Growth and Persistence of Place-Based Mortality in the United States: The Rural Mortality Penalty

Overview

Journal Am J Public Health

Specialty Public Health

Date 2018 Nov 30

PMID 30496008

Citations 119

Authors

Arthur G Cosby

M Maya McDoom-Echebiri

Wesley James

Hasna Khandekar

Willie Brown

Heather L Hanna

Affiliations

Soon will be listed here.

Abstract

Objectives: To examine 47 years of US urban and rural mortality trends at the county level, controlling for effects of education, income, poverty, and race.

Methods: We obtained (1) Centers for Disease Control and Prevention WONDER (Wide-ranging ONline Data for Epidemiologic Research) data (1970-2016) on 104 million deaths; (2) US Census data on education, poverty, and race; and (3) Bureau of Economic Analysis data on income. We calculated ordinary least square regression models, including interaction models, for each year. We graphed standardized parameter estimates for 47 years.

Results: Rural-urban mortality disparities increased from the mid-1980s through 2016. We found education, race, and rurality to be strong predictors; we found strong interactions between percentage poverty and percentage rural, indicating that the largest penalty was in high-poverty, rural counties.

Conclusions: The rural-urban mortality disparity was persistent, growing, and large when compared to other place-based disparities. The penalty had evolved into a high-poverty, rural penalty that rivaled the effects of education and exceeded the effects of race by 2016. Public Health Implications. Targeting public health programs that focus on high-poverty, rural locales is a promising strategy for addressing disparities in mortality.

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References

Case A, Deaton A . Mortality and morbidity in the 21 century. Brookings Pap Econ Act. 2017; 2017:397-476. PMC: 5640267. DOI: 10.1353/eca.2017.0005. View

Diez Roux A . Investigating neighborhood and area effects on health. Am J Public Health. 2001; 91(11):1783-9. PMC: 1446876. DOI: 10.2105/ajph.91.11.1783. View

Singh G, Siahpush M, Williams S . Changing urbanization patterns in US lung cancer mortality, 1950-2007. J Community Health. 2011; 37(2):412-20. PMC: 3296001. DOI: 10.1007/s10900-011-9458-3. View

Singh G, Siahpush M . Widening rural-urban disparities in all-cause mortality and mortality from major causes of death in the USA, 1969-2009. J Urban Health. 2013; 91(2):272-92. PMC: 3978153. DOI: 10.1007/s11524-013-9847-2. View

Stein E, Gennuso K, Ugboaja D, Remington P . The Epidemic of Despair Among White Americans: Trends in the Leading Causes of Premature Death, 1999-2015. Am J Public Health. 2017; 107(10):1541-1547. PMC: 5607670. DOI: 10.2105/AJPH.2017.303941. View

James W, Cossman J . Long-Term Trends in Black and White Mortality in the Rural United States: Evidence of a Race-Specific Rural Mortality Penalty. J Rural Health. 2016; 33(1):21-31. DOI: 10.1111/jrh.12181. View

Befort C, Nazir N, Perri M . Prevalence of obesity among adults from rural and urban areas of the United States: findings from NHANES (2005-2008). J Rural Health. 2012; 28(4):392-7. PMC: 3481194. DOI: 10.1111/j.1748-0361.2012.00411.x. View

Rossen L, Hedegaard H, Khan D, Warner M . County-Level Trends in Suicide Rates in the U.S., 2005-2015. Am J Prev Med. 2018; 55(1):72-79. PMC: 6038117. DOI: 10.1016/j.amepre.2018.03.020. View

Fenelon A . Geographic Divergence in Mortality in the United States. Popul Dev Rev. 2014; 39(4):611-634. PMC: 4109895. DOI: 10.1111/j.1728-4457.2013.00630.x. View

10.

Ingram D, Franco S . 2013 NCHS Urban-Rural Classification Scheme for Counties. Vital Health Stat 2. 2014; (166):1-73. View

11.

Cosby A, Neaves T, Cossman R, Cossman J, James W, Feierabend N . Preliminary evidence for an emerging nonmetropolitan mortality penalty in the United States. Am J Public Health. 2008; 98(8):1470-2. PMC: 2446448. DOI: 10.2105/AJPH.2007.123778. View

12.

Case A, Deaton A . Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century. Proc Natl Acad Sci U S A. 2015; 112(49):15078-83. PMC: 4679063. DOI: 10.1073/pnas.1518393112. View

13.

Murray C, Kulkarni S, Michaud C, Tomijima N, Bulzacchelli M, Iandiorio T . Eight Americas: investigating mortality disparities across races, counties, and race-counties in the United States. PLoS Med. 2006; 3(9):e260. PMC: 1564165. DOI: 10.1371/journal.pmed.0030260. View

14.

Lawrence E, Hummer R, Harris K . The Cardiovascular Health of Young Adults: Disparities along the Urban-Rural Continuum. Ann Am Acad Pol Soc Sci. 2017; 672(1):257-281. PMC: 5501485. DOI: 10.1177/0002716217711426. View

15.

Cossman J, James W, Cosby A, Cossman R . Underlying causes of the emerging nonmetropolitan mortality penalty. Am J Public Health. 2010; 100(8):1417-9. PMC: 2901280. DOI: 10.2105/AJPH.2009.174185. View

16.

Singh G, Daus G, Allender M, Ramey C, Martin E, Perry C . Social Determinants of Health in the United States: Addressing Major Health Inequality Trends for the Nation, 1935-2016. Int J MCH AIDS. 2018; 6(2):139-164. PMC: 5777389. DOI: 10.21106/ijma.236. View

17.

Chetty R, Stepner M, Abraham S, Lin S, Scuderi B, Turner N . The Association Between Income and Life Expectancy in the United States, 2001-2014. JAMA. 2016; 315(16):1750-66. PMC: 4866586. DOI: 10.1001/jama.2016.4226. View

18.

James W . All rural places are not created equal: revisiting the rural mortality penalty in the United States. Am J Public Health. 2014; 104(11):2122-9. PMC: 4202986. DOI: 10.2105/AJPH.2014.301989. View

19.

Garcia M, Faul M, Massetti G, Thomas C, Hong Y, Bauer U . Reducing Potentially Excess Deaths from the Five Leading Causes of Death in the Rural United States. MMWR Surveill Summ. 2017; 66(2):1-7. PMC: 5829929. DOI: 10.15585/mmwr.ss6602a1. View