ORIGINAL ARTICLE Disparities in the Use of Diabetes Screening in Appalachia Jennifer M. Lobo, PhD; 1 Roger Anderson, PhD; 1 George J. Stukenborg, PhD; 1 Anthony McCall, MD; 2 Hyojung Kang, PhD; 3 Fabian Camacho, MS; 1 & Min-Woong Sohn, PhD 1 1 Department of Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, Virginia 2 Internal Medicine, School of Medicine, University of Virginia, Charlottesville, Virginia 3 Department of Systems and Information Engineering, University of Virginia, Charlottesville, Virginia Funding and Disclosures: The authors gratefully acknowledge the financial support from the Agency for Healthcare Research and Quality (R01HS018542). The paper presents the findings and conclusions of the authors; it does not necessarily represent the Agency for Healthcare Research and Quality. For further information, contact: Min-Woong Sohn, PhD, Department of Public Health Sciences, School of Medicine, University of Virginia, Hospital West, 3rd Floor, Rm 3181, Charlottesville, VA 22908-0717; e-mail: msohn@virginia.edu. doi: 10.1111/jrh.12247 Abstract Purpose: The Appalachian region presents disproportionately high rates of chronic disease compared to the rest of the United States. Early diagnosis of diabetes through screening is an important step in reducing diabetes compli- cations. This study examines disparities in the use of diabetes screening in Ap- palachia. Methods: We analyzed 2009 and 2010 Behavioral Risk Factor Surveillance System data for 96,111 adults aged 45 years from 11 Appalachian states. Based on economic status, Appalachian counties were grouped into distressed (least affluent), at-risk, transitional, and competitive (most affluent). Logistic regression analyses were used to estimate the statistical significance and effect size of factors associated with diabetes screening. Results: Competitive counties had the highest rate of diabetes screening (65.4%). At-risk counties had the lowest rate (60.3%), about 7.8% lower compared to competitive counties (P < .001). After adjusting for socioeco- nomic factors, differences in screening rates between county economic levels in Appalachia were not statistically significant. Among respondents 65 years, at-risk counties had an 8.1% lower screening rate compared to competitive counties; this difference was not adequately explained by differences in socioe- conomic factors. Screening rates in distressed and transitional counties were not significantly different from competitive counties in unadjusted or adjusted models. Conclusions: At-risk counties had significantly lower screening rates than competitive counties. They should receive more policy attention similar to that received by distressed counties. Social policies that improve socioeconomic sta- tus and educational attainment, and health policies that reduce barriers to ac- cess to care may reduce disparities in diabetes screening rates in the less afflu- ent Appalachian counties. Key words Appalachia, diabetes, health disparities, rural, screening. Approximately 8% of the US population, or 25 million individuals, reside in the Appalachian region, an area made up of 420 contiguous counties spanning 13 states. Of these counties, 42% are designated as rural compared to 20% of counties in the nation overall. 1 Appalachia suf- fers from some of the most extreme geographic varia- tion in health outcomes in the United States, as shown in studies considering the diagnosis of diabetes, 2,3 and screening, diagnosis, and treatment of breast cancer. 4-6 The Appalachian Regional Commission (ARC) recognizes disproportionately high rates of chronic disease in this re- gion as a special area of concern in its strategic objectives for 2011-2016. 1 The CDC recognized the seriousness of diabetes dispar- ities in the region and has instituted a diabetes prevention project since the early 2000s. 7,8 In addition, screening for The Journal of Rural Health 00 (2017) 1–9 c  2017 National Rural Health Association 1