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.
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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.
US Department of Health, Education, and Welfare. Vital statistics of the United States 1950, volume I. Washington, DC: US Government Printing Office; 1954.
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.
Kitagawa EM, Hauser PM. Differential mortality in the United States: a study in socioeconomic epidemiology. Cambridge, UK: Harvard University Press; 1973.
Singh GK. Area deprivation and widening inequalities in US mortality, 1969–1998. Am J Public Health. 2003; 93(7): 1137–43.
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.
US Department of Health and Human Services. Healthy people 2020. http://www.healthypeople.gov/2020/default.aspx (2013). Accessed September 25, 2013.
US Department of Health and Human Services. Tracking Healthy People 2010. Washington, DC: US Government Printing Office; 2000.
US Department of Health and Human Services. Healthy people 2010: midcourse review. Washington, DC: US Government Printing Office; 2006.
Minino AM, Murphy SL, Xu JQ, Kochanek KD. Deaths: final data for 2008. Natl Vital Stat Rep. 2011; 59(10): 1–127.
Kochanek KD, Xu JQ, Murphy SL, Minino AM, Kung HC. Deaths: final data for 2009. Natl Vital Stat Rep. 2011; 60(3): 1–167.
Minino AM, Murphy SL. Death in the United States, 2010. NCHS Data Brief. 2012; 99(10): 1–8.
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.
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.
Cheng ER, Kindig DA. Disparities in premature mortality between high- and low-income US counties. Prev Chronic Dis. 2012;9:E75.
Singh GK, Siahpush M. Increasing rural–urban gradients in US suicide mortality, 1970–1997. Am J Public Health. 2002; 92(7): 1161–7.
Singh GK, Siahpush M, Williams SD. Changing urbanization patterns in US lung cancer mortality, 1950–2007. J Community Health. 2012; 37(2): 412–20.
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.
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.
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.
Gillum RF, Mehari A, Curry B, Obisesan TO. Racial and geographic variation in coronary heart disease mortality trends. BMC Publ Health. 2012; 12: 410.
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.
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. http://www.cdc.gov/nchs/nvss/mortality_public_use_data.htm (2012). Accessed September 25, 2013.
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.
Economic Research Service, US Department of Agriculture. Rural–urban continuum codes. http://www.ers.usda.gov/data-products/rural–urban-continuum-codes.aspx. Accessed September 25, 2013.
Bureau of Health Professions. Area resource file, 2009–10, technical documentation. Rockville: Health Resources and Services Administration; 2010.
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.
US Census Bureau. Census of population and housing 1990: summary tape file 3A on CD-ROM. Washington, DC: US Department of Commerce; 1992.
US Census Bureau. Summary file 3, technical documentation, 2000 census of population and housing. Washington, DC: US Department of Commerce; 2005.
US Census Bureau. The 2009 American community survey. Washington, DC: US Census Bureau. http://www.census.gov/acs/www/ (2010). Accessed September 25, 2013.
SAS Institute Inc. SAS/STAT user’s guide, version 9.1: the GENMOD procedure. Cary: SAS Institute Inc.; 2004.
Reese BF. Motor vehicle accident deaths in the United States, 1950–67. National Center for Health Statistics. Washington, DC: US Government Printing Office; 1970.
Massey JT. Suicides in the United States, 1950–1964. National Center for Health Statistics. Washington, DC: US Government Printing Office; 1967.
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.
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.
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.
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.
US Department of Agriculture. Food environment atlas. Washington, DC: Economic Research Service, USDA. http://ers.usda.gov/data-products/food-environment-atlas/documentation.aspx (2012). Accessed September 25, 2013.
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.
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. http://www.cdc.gov/nchs/nhis/quest_data_related_1996_prior.htm (2009). Accessed September 25, 2013.
Benson V. Marano MA Current estimates from the National Health Interview Survey, 1995. Vital Health Stat. 1998; 10(199): 1–428.
Adekoya N. Motor vehicle-related death rates—United States, 1999–2005. MMWR Morb Mortal Wkly Rep. 2009; 58(7): 161–5.
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.
Singh GK, Siahpush M, Kogan MD. Rising social inequalities in US childhood obesity, 2003–2007. Ann Epidemiol. 2010; 20(1): 40–52.
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.
Shaw M, Dorling D, Gordon D, Davey SG. The widening gap: health inequalities and policy in Britain. Bristol, England: Policy Press; 1999.
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.
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Singh, G.K., 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 91, 272–292 (2014). https://doi.org/10.1007/s11524-013-9847-2
- Cause of death