Year after year, southern states consistently rank among the worst in the U.S. for health and wellness.

This is not a new trend. The rankings have changed little over the last quarter century. What’s causing residents of Mississippi, Alabama and Louisiana and other southern states to live such short lives, while experiencing higher rates of cancer, diabetes and heart disease?

As a researcher who’s worked on state health promotion in Hawaii and Texas, it’s clear to me that there are a variety of factors behind people’s poor health in southern states – and none will be an easy fix.

Premature deaths

People in southern states die earlier from a variety of chronic conditions than people in the rest of the U.S. Infectious diseases including whooping cough, salmonella and chlamydia are high across the south, particularly in Louisiana and the Carolinas.

According to America’s Health Rankings, an annual report by the nonprofit United Health Foundation, someone living in Kentucky is 55 percent more likely to die from cancer than a person living in Utah. A resident of Mississippi is 85 percent more likely to die of cardiovascular disease than someone living in Minnesota. If you live in West Virginia, you are more than twice as likely to have diabetes as someone living in Colorado.

Overall, premature death occurs almost twice as often in many of the southern states compared to Minnesota and California.

A July study found a 20-year difference in life expectancy by county, with most of the counties with lower life expectancy located in the Southeast. The life expectancy gap is also growing year to year.

Unhealthy lifestyles

Health behaviors also contribute quite strongly to the development of chronic diseases.

People living in many areas in the south are twice as likely to be smokers and be sedentary than people living in Utah. Every southern state except Florida has an adult obesity rate higher than 30 percent. This lack of fitness has led to the highest rates of injury in the Army basic training across the region.

Poor lifestyle behaviors don’t explain everything, though. For example, West Virginia and Kentucky have very high rates of drug overdose deaths related to the opioid epidemic. However, rates in many southern states – including Mississippi, Georgia and Arkansas – are lower than the rest of the country.

What is causing these poor health outcomes? As a public health researcher, I look to the physical and social conditions in which people live, including education levels, access to health care, air and water quality, housing, culture and many other factors. These can be the root causes of health and illness.

All of these states are relatively poor, with Kentucky, Alabama, West Virginia, Arkansas and Mississippi having the lowest household median incomes in the county. However, this doesn’t tell the whole story. Idaho, for example, is ranked 40th in household income and 14th in health.

Education is often viewed as an important indicator of health – but Alabama, Kentucky, Tennessee and Missouri are all in the top 10 for high school graduation rates.

Air pollution – which is linked to heart attacks, bronchitis and asthma – falls somewhere in the middle for most southern states. Violent crime tends to be higher, with the exception of Mississippi.

Of the 26 states have comprehensive statewide indoor air smoking bans, none are in the South.

According to Walkscore, a site that calculates the walkability of cities, nine of the least walkable cities in the U.S. are in the South. Only one, Miami, is in the top 10.

Limited access to care

It can be hard to find a health care provider in the South. Georgia, Alabama, Arkansas and Mississippi all fall in the bottom 10 for the number of primary care physicians per capita. Mental health providers and dentists are also in short supply across the South. In fact, Alabama only has 85 mental health care providers per 100,000 people. Compare that to 547 per 100,000 in Massachusetts.

Lack of routine health care can lead to an increase in preventable hospitalizations. For instance, a diabetic who is routinely seen by a physician can avoid more serious complications that lead to hospitalizations. Infant mortality and low birth weight babies are prevalent across the region.

Funding for public health differs across the region, with West Virginia providing more per capita than any other state and Missouri spending a fifth of that. The uninsured population is also a mix, with Kentucky and West Virginia having low rates and Mississippi, Florida, Georgia and Oklahoma having some of the highest.

Regional strategies

In the end, the data is clear: Americans living in the southern United States live shorter, sicker lives. The region needs a comprehensive strategy to improve health.

At Texas A&M, we’ve banded together with 13 universities in the Southeastern Conference to discuss ideas that can reach communities outside the universities.

One of our initial ideas is to leverage the mass gatherings around football games to promote positive health activities. The largely rural makeup of these states along with attendance at football games exceeding 78,000 people per game provides a unique southern strategy to change health in these states.

However, no single intervention will change several decades of poor health.

Jay Maddock is affiliated with the Champions for Health in the South Initiative.