Journal of Urban Health

, Volume 91, Issue 2, pp 272–292 | Cite as

Widening Rural–Urban Disparities in All-Cause Mortality and Mortality from Major Causes of Death in the USA, 1969–2009

  • Gopal K. SinghEmail author
  • Mohammad Siahpush


This study examined trends in rural–urban disparities in all-cause and cause-specific mortality in the USA between 1969 and 2009. A rural–urban continuum measure was linked to county-level mortality data. Age-adjusted death rates were calculated by sex, race, cause-of-death, area-poverty, and urbanization level for 13 time periods between 1969 and 2009. Cause-of-death decomposition and log-linear and Poisson regression were used to analyze rural–urban differentials. Mortality rates increased with increasing levels of rurality overall and for non-Hispanic whites, blacks, and American Indians/Alaska Natives. Despite the declining mortality trends, mortality risks for both males and females and for blacks and whites have been increasingly higher in non-metropolitan than metropolitan areas, particularly since 1990. In 2005–2009, mortality rates varied from 391.9 per 100,000 population for Asians/Pacific Islanders in rural areas to 1,063.2 for blacks in small-urban towns. Poverty gradients were steeper in rural areas, which maintained higher mortality than urban areas after adjustment for poverty level. Poor blacks in non-metropolitan areas experienced two to three times higher all-cause and premature mortality risks than affluent blacks and whites in metropolitan areas. Disparities widened over time; excess mortality from all causes combined and from several major causes of death in non-metropolitan areas was greater in 2005–2009 than in 1990–1992. Causes of death contributing most to the increasing rural–urban disparity and higher rural mortality include heart disease, unintentional injuries, COPD, lung cancer, stroke, suicide, diabetes, nephritis, pneumonia/influenza, cirrhosis, and Alzheimer’s disease. Residents in metropolitan areas experienced larger mortality reductions during the past four decades than non-metropolitan residents, contributing to the widening gap.


Mortality Cause of death Rural–urban Metropolitan Decomposition Race Poverty Inequality Trend USA 



The views expressed are the authors’ and not necessarily those of the Health Resources and Services Administration or the US Department of Health and Human Services.

Human Subjects Review

No IRB approval was required for this study, which is based on the secondary analysis of public-use federal databases.


  1. 1.
    National Center for Health Statistics. Health, United States, 2010 with special feature on death and dying. Hyattsville: US Department of Health and Human Services; 2011.Google Scholar
  2. 2.
    US Department of Health, Education, and Welfare. Vital statistics of the United States 1950, volume I. Washington, DC: US Government Printing Office; 1954.Google Scholar
  3. 3.
    Grove RD, Hetzel AM. Vital statistics rates in the United States, 1940–1960. National Center for Health Statistics. Washington, DC: US Government Printing Office; 1968.Google Scholar
  4. 4.
    Kitagawa EM, Hauser PM. Differential mortality in the United States: a study in socioeconomic epidemiology. Cambridge, UK: Harvard University Press; 1973.Google Scholar
  5. 5.
    Singh GK. Area deprivation and widening inequalities in US mortality, 1969–1998. Am J Public Health. 2003; 93(7): 1137–43.PubMedCentralPubMedCrossRefGoogle Scholar
  6. 6.
    Singh GK, Siahpush M. Increasing inequalities in all-cause and cardiovascular mortality among US adults aged 25–64 years by area socioeconomic status, 1969–1998. Int J Epidemiol. 2002; 31(3): 600–13.PubMedCrossRefGoogle Scholar
  7. 7.
    US Department of Health and Human Services. Healthy people 2020. (2013). Accessed September 25, 2013.
  8. 8.
    US Department of Health and Human Services. Tracking Healthy People 2010. Washington, DC: US Government Printing Office; 2000.Google Scholar
  9. 9.
    US Department of Health and Human Services. Healthy people 2010: midcourse review. Washington, DC: US Government Printing Office; 2006.Google Scholar
  10. 10.
    Minino AM, Murphy SL, Xu JQ, Kochanek KD. Deaths: final data for 2008. Natl Vital Stat Rep. 2011; 59(10): 1–127.PubMedGoogle Scholar
  11. 11.
    Kochanek KD, Xu JQ, Murphy SL, Minino AM, Kung HC. Deaths: final data for 2009. Natl Vital Stat Rep. 2011; 60(3): 1–167.Google Scholar
  12. 12.
    Minino AM, Murphy SL. Death in the United States, 2010. NCHS Data Brief. 2012; 99(10): 1–8.PubMedGoogle Scholar
  13. 13.
    Ezzati M, Friedman AB, Kulkarni SC, Murray CJ. The reversal of fortunes: trends in county mortality and cross-county mortality disparities in the United States. PLoS Med. 2008; 5(4): e66.PubMedCentralPubMedCrossRefGoogle Scholar
  14. 14.
    Cullen MR, Cummins C, Fuchs VR. Geographic and racial variation in premature mortality in the U.S: analyzing the disparities. PLoS One. 2012; 7(4): e32930.PubMedCentralPubMedCrossRefGoogle Scholar
  15. 15.
    Cheng ER, Kindig DA. Disparities in premature mortality between high- and low-income US counties. Prev Chronic Dis. 2012;9:E75.Google Scholar
  16. 16.
    Singh GK, Siahpush M. Increasing rural–urban gradients in US suicide mortality, 1970–1997. Am J Public Health. 2002; 92(7): 1161–7.PubMedCentralPubMedCrossRefGoogle Scholar
  17. 17.
    Singh GK, Siahpush M, Williams SD. Changing urbanization patterns in US lung cancer mortality, 1950–2007. J Community Health. 2012; 37(2): 412–20.PubMedCentralPubMedCrossRefGoogle Scholar
  18. 18.
    Singh GK. Rural–urban trends and patterns in cervical cancer mortality, incidence, stage, and survival in the United States, 1950–2008. J Community Health. 2012; 37(1): 217–23.PubMedCrossRefGoogle Scholar
  19. 19.
    Singh GK, Williams SD, Siahpush M, Mulhollen A. Socioeconomic, rural–urban, and racial inequalities in US cancer mortality: part 1—all cancers and lung cancer and part II—colorectal, prostate, breast, and cervical cancers. J Cancer Epidemiol. 2011; 107497: 1–27. doi: 10.1155/2011/107497.CrossRefGoogle Scholar
  20. 20.
    Singh GK, Azuine RE, Siahpush M. Widening socioeconomic, racial, and geographic disparities in HIV/AIDS mortality in the United States, 1987–2011. Adv Prev Med. 2013; 657961: 1–13. doi: 10.1155/2013/657961.CrossRefGoogle Scholar
  21. 21.
    Gillum RF, Mehari A, Curry B, Obisesan TO. Racial and geographic variation in coronary heart disease mortality trends. BMC Publ Health. 2012; 12: 410.CrossRefGoogle Scholar
  22. 22.
    Cossman JS, Cossman RE, James WL, Campbell CR, Blanchard TC, Cosby AG. Persistent clusters of mortality in the United States. Am J Public Health. 2007; 97(12): 2148–50.PubMedCentralPubMedCrossRefGoogle Scholar
  23. 23.
    National Center for Health Statistics. National vital statistics system, mortality multiple cause-of-death public use data file documentation. Hyattsville: US Department of Health and Human Services. (2012). Accessed September 25, 2013.
  24. 24.
    Butler MA, Beale CL. Rural–urban continuum codes for metro and nonmetro counties, 1993. Washington, DC: Economic Research Service, US Department of Agriculture; 1994. Staff report 9425.Google Scholar
  25. 25.
    Economic Research Service, US Department of Agriculture. Rural–urban continuum codes.–urban-continuum-codes.aspx. Accessed September 25, 2013.
  26. 26.
    Bureau of Health Professions. Area resource file, 2009–10, technical documentation. Rockville: Health Resources and Services Administration; 2010.Google Scholar
  27. 27.
    Singh GK, Azuine RE, Siahpush M, Kogan MD. All-cause and cause-specific mortality among US youth: socioeconomic and rural–urban disparities and international patterns. J Urban Health. 2012; 90(3): 388–405.CrossRefGoogle Scholar
  28. 28.
    US Census Bureau. Census of population and housing 1990: summary tape file 3A on CD-ROM. Washington, DC: US Department of Commerce; 1992.Google Scholar
  29. 29.
    US Census Bureau. Summary file 3, technical documentation, 2000 census of population and housing. Washington, DC: US Department of Commerce; 2005.Google Scholar
  30. 30.
    US Census Bureau. The 2009 American community survey. Washington, DC: US Census Bureau. (2010). Accessed September 25, 2013.
  31. 31.
    SAS Institute Inc. SAS/STAT user’s guide, version 9.1: the GENMOD procedure. Cary: SAS Institute Inc.; 2004.Google Scholar
  32. 32.
    Reese BF. Motor vehicle accident deaths in the United States, 1950–67. National Center for Health Statistics. Washington, DC: US Government Printing Office; 1970.Google Scholar
  33. 33.
    Massey JT. Suicides in the United States, 1950–1964. National Center for Health Statistics. Washington, DC: US Government Printing Office; 1967.Google Scholar
  34. 34.
    DesMeules M, Pong R, Leagce C, et al., eds. How healthy are rural Canadians? An assessment of their health status and health determinants. Ottawa, Canada: Canadian Institute for Health Information; 2006.Google Scholar
  35. 35.
    Legace C, Desmeules M, Pong RW, Heng D. Non-communicable disease and injury-related mortality in rural and urban places of residence: a comparison between Canada and Australia. Can J Public Health. 2007; 98(Suppl 1): S62–9.Google Scholar
  36. 36.
    Gartner A, Farewell D, Dunstan F, Gordon E. Differences in mortality between rural and urban areas in England Wales, 2002–04. Health Stat Q. 2008; 39: 6–13.PubMedGoogle Scholar
  37. 37.
    Gartner A, Farewell D, Roach P, Dunstan F. Rural/urban mortality differences in England and Wales and the effect of deprivation adjustment. Soc Sci Med. 2011; 72(10): 1685–94.PubMedCrossRefGoogle Scholar
  38. 38.
    US Department of Agriculture. Food environment atlas. Washington, DC: Economic Research Service, USDA. (2012). Accessed September 25, 2013.
  39. 39.
    Schiller JS, Lucas JW, Ward BW, Peregoy JA. Summary health statistics for U.S. adults: National Health Interview Survey, 2010. Vital Health Stat. 2012; 10(252): 1–207.Google Scholar
  40. 40.
    National Center for Health Statistics. The national health interview survey, questionnaires, datasets, and related documentation: 1976 public use data file. Hyattsville US Department of Health and Human Services. (2009). Accessed September 25, 2013.
  41. 41.
    Benson V. Marano MA Current estimates from the National Health Interview Survey, 1995. Vital Health Stat. 1998; 10(199): 1–428.Google Scholar
  42. 42.
    Adekoya N. Motor vehicle-related death rates—United States, 1999–2005. MMWR Morb Mortal Wkly Rep. 2009; 58(7): 161–5.Google Scholar
  43. 43.
    Health Resources Services Administration Maternal and Child Health Bureau. The Health and well-being of children in rural areas: a portrait of the nation, 2007. Rockville, Maryland: US Department of Health and Human Services; 2011.Google Scholar
  44. 44.
    Singh GK, Siahpush M, Kogan MD. Rising social inequalities in US childhood obesity, 2003–2007. Ann Epidemiol. 2010; 20(1): 40–52.PubMedCrossRefGoogle Scholar
  45. 45.
    Singh GK, Siahpush M, Kogan MD. Disparities in children’s exposure to environmental tobacco smoke in the United States, 2007. Pediatrics. 2010; 126(1): 4–13.PubMedCrossRefGoogle Scholar
  46. 46.
    Shaw M, Dorling D, Gordon D, Davey SG. The widening gap: health inequalities and policy in Britain. Bristol, England: Policy Press; 1999.Google Scholar

Copyright information

© The New York Academy of Medicine (outside the USA) 2013

Authors and Affiliations

  1. 1.Maternal and Child Health Bureau, Health Resources and Services AdministrationUS Department of Health and Human ServicesRockvilleUSA
  2. 2.Department of Health Promotion, Social and Behavioral HealthUniversity of Nebraska Medical CenterOmahaUSA

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