Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2019 Jan;109(1):155-162.
doi: 10.2105/AJPH.2018.304787. Epub 2018 Nov 29.

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

Arthur G Cosby  1 , M Maya McDoom-Echebiri  1 , Wesley James  1 , Hasna Khandekar  1 , Willie Brown  1 , Heather L Hanna  1
Affiliations

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

Arthur G Cosby et al. Am J Public Health. 2019 Jan.

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.

PubMed Disclaimer

Figures

FIGURE 1—
FIGURE 1—
Trends in Rural and Urban Age-Adjusted (All-Cause) Mortality for the United States: Centers for Disease Control and Prevention WONDER, 1970–2016 Note. Results are from 47 annual ordinary least squares regression models of race, education, income, poverty, and rural residence regressed on age-adjusted all-cause mortality for the contiguous United States.
FIGURE 2—
FIGURE 2—
Standardized Parameter Estimates of Place-Based Social Determinants of Mortality: Centers for Disease Control and Prevention WONDER, US Census Bureau, Bureau of Economic Analysis, 1970–2016 Note. Results are from 47 annual ordinary least squares regression models of race, education, income, poverty, rural residence, and rural × poverty regressed on age-adjusted all-cause mortality for the contiguous United States.
FIGURE 3—
FIGURE 3—
Standardized Parameter Estimates of Place-Based Social Determinants of Mortality: Centers for Disease Control and Prevention WONDER, US Census Bureau, Bureau of Economic Analysis, 1970–2016 Note. Poverty > 15% in rural high poverty; poverty ≤ 15% in rural low poverty.
FIGURE 4—
FIGURE 4—
Trends in Age-Adjusted All-Cause Mortality Rates for Rural, High-Poverty Counties; Rural, Low-Poverty Counties; Urban, High-Poverty Counties; and Urban, Low-Poverty Counties: United States, Centers for Disease Control and Prevention WONDER, 1970–2016
See this image and copyright information in PMC

References

    1. Cosby AG, Neaves TT, Cossman RE et al. Preliminary evidence for an emerging nonmetropolitan mortality penalty in the United States. Am J Public Health. 2008;98(8):1470–1472. - PMC - PubMed
    1. Haines MR. The urban mortality transition in the United States, 1800–1940. Ann Demogr Hist (Paris) 2001;101(1):33–64.
    1. Murray CJ, Kulkarni SC, Michaud C Eight Americas: investigating mortality disparities across races, counties, and race-counties in the United States. PLoS Med. 2006;3(9):1513–1524. [Erratum in PLoS Med. 2006;3(9):1513–1524] - PMC - PubMed
    1. Centers for Disease Control and Prevention. 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 - PubMed
    1. James WL. All rural places are not created equal: revisiting the rural mortality penalty in the United States. Am J Public Health. 2014;104(11):2122–2129. - PMC - PubMed

Publication types

MeSH terms