摘要：Objectives. I investigated mortality disparities between urban and rural areas by measuring disparities in urban US areas compared with 6 rural classifications, ranging from suburban to remote locales. Methods. Data from the Compressed Mortality File, National Center for Health Statistics, from 1968 to 2007, was used to calculate age-adjusted mortality rates for all rural and urban regions by year. Criteria measuring disparity between regions included excess deaths, annual rate of change in mortality, and proportion of excess deaths by population size. I used multivariable analysis to test for differences in determinants across regions. Results. The rural mortality penalty existed in all rural classifications, but the degree of disparity varied considerably. Rural–urban continuum code 6 was highly disadvantaged, and rural–urban continuum code 9 displayed a favorable mortality profile. Population, socioeconomic, and health care determinants of mortality varied across regions. Conclusions. A 2-decade long trend in mortality disparities existed in all rural classifications, but the penalty was not distributed evenly. This constitutes an important public health problem. Research should target the slow rates of improvement in mortality in the rural United States as an area of concern. Recent research has identified a new trend in rural–urban, macrolevel mortality disparities in the United States, called the rural mortality penalty. 1,2 Historically, there has been a penalty associated with urban places; however, in recent decades, a reversal has occurred. Beginning in the mid-1980s, rural and urban mortality rates diverged, and the gap between them has grown for more than 2 decades. According to previous publications that introduced the rural mortality penalty, the rural United States is an aggregation of 6 nonmetropolitan designations distinguished by population size and adjacency to an urban area; this is a typology used in many previous studies. 3,4 This research uncovers the disproportionate mortality burden across these rural classifications. Throughout the 19th and early 20th centuries, there was a mortality penalty associated with urban areas. 5 The urban mortality penalty was largely attributed to the spread of contagious and infectious disease, 6,7 poor water quality, 8 and inadequate sewage disposal 9 in densely populated areas. 10,11 The first half of the 20th century transformed urban cities because of public works projects that improved water quality and sanitation 8 and public health advancements that included vaccinations, quarantines, physical examinations, health education, workplace safety, food quality, and controlling medication. 5 The result was unprecedented improvements in urban health from 1900 to 1940, highlighted by a 40% decline in mortality, an increased life expectancy from 47 to 63 years, 8,12 and generally equivalent rural and urban mortality rates. 5 This pattern persisted until the mid-1980s, when the rural mortality penalty emerged. Public health advances, however important, did not encompass all determinants of mortality. The major determinants of mortality in the rural United States exist at the individual, structural, or contextual levels. Individual-level determinants include use of self-care, 13,14 low satisfaction of care, 14,15 lack of a regular source of care, 15,16 and lifestyle and behaviors. 17,18 Structural and contextual determinants include poverty, 15 high rates of female-headed households, 19 degree of urbanization, 15 age structure of the population, 20,21 income inequality, 22 high rates of chronic illnesses, 23 access to care, 13,15,24,25 physician and hospital shortages, 26–28 and unique cultural characteristics, 29,30 including an identity of resiliency. 31 Furthermore, macrolevel restructuring because of immigration and suburbanization has occurred in many rural communities. These changes create diverse economic opportunities, 19,32–34 populations, 34–37 and changing demographic characteristic structures. 34,37 Traditional social, racial, and ethnic boundaries have blurred, 34–37 and the cultural gap between rural and urban places has shrunk, 34,37 changing how we understand the dynamics among demographic, social, and economic processes, resources, constraints, and health policies in people’s pursuit of better health. 37 Innovative research investigating regional disparities in health outcomes has been published in the last decade, but there remains a gap in understanding intrarural differences. A recent study of life expectancy found widening disparities across rural–urban categories over a 40-year period, with poor rural Blacks having the lowest survival probability. 38 Another regional study of mortality, titled “Eight Americas” uncovered disparities in life expectancy, mortality, health insurance, and health care utilization by regions based on race, county, population density, race-specific county level per capita income, and homicide rate. 39,40 This work highlighted the complexity of “place” and its role in eliminating health disparities across population segments. 41 The rural United States is complex, and is often treated as a “nonurban” residual category lacking a clear conceptualization of poverty, opportunity structure, and other social processes. 42–44 With the emergent rural mortality penalty, it is paramount to understand the context and conditions unique to the rural part of the country. 29,30 I sought to uncover differing mortality profiles and determinants across rural regions.
