title: Widening rural-urban disparities in all-cause mortality and mortality from major causes of death in the USA, 1969-2009.
abstract: 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.
authors.affiliation: Maternal and Child Health Bureau, Health Resources and Services Administration, US Department of Health and Human Services, 5600 Fishers Lane, Room 18-41, Rockville, MD, 20857, USA, gsingh@hrsa.gov.
authors.forename: Gopal K
authors.initials: GK
authors.lastname: Singh
authors.forename: Mohammad
authors.initials: M
authors.lastname: Siahpush
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D002423:Cause of Death / Q000639:trends*; D002648:Child; D002675:Child, Preschool; D005006:Ethnicity / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008875:Middle Aged; D009026:Mortality / Q000639:trends*; D011203:Poverty / Q000706:statistics & numerical data; D012424:Rural Population / Q000706:statistics & numerical data* / Q000639:trends; D012737:Sex Factors; D012959:Socioeconomic Factors; D014481:United States / Q000453:epidemiology; D014505:Urban Population / Q000706:statistics & numerical data* / Q000639:trends; D055815:Young Adult