All-Cause Mortality Disparities Persist Among Black, White Men Living in Rural US

From 1968 to 2016, differences among Black and White older adults’ mortality rates have narrowed in urban areas throughout the United States. However, data show a considerable widening in the mortality rate among Black and White men living in rural counties. Results from the cross-sectional study of more than 3000 counties were published in JAMA Network Open.

As coronavirus disease 2019 (COVID-19) continues to spread among the nation’s vulnerable populations, exposing years’ worth of racial and economic health disparities, researchers hope these new findings will aid in understanding the intersectional factors associated with the disparities, potentially informing future public health and clinical interventions.

“Population-based mortality rates are important indicators of overall health status,” researchers write. “Mortality rates may reflect underlying disparities in access to health care, quality of care, racial and geographical variations, and other socioeconomic factors associated with health.”

Geographic, Racial Mortality Disparities

Using mortality data from the CDC WONDER database, investigators assessed sex-specific age-adjusted all-cause mortality rates of older Black and White adults living in rural and urban counties. The database contains information collected by the CDC’s National Center for Health Statistics, while researchers added in data from the Area Health Resources Files of the US Health Resources and Services Administration between 1992 and 2014. These files include county-level socioeconomic characteristics, such as per capita income, unemployment rates, and poverty rates.

Codes from the US Department of Agriculture Economic Research Service’s 2013 Rural-Urban Continuum were used to classify counties based on level on urbanization: urban counties, rural counties adjacent to an urban county, and rural counties not adjacent to an urban county.

Individuals 65 years and older across 3131 US counties were included in the final analysis.

In 1968, a total of 3076 counties (19,240,437 adults ≥65 years; 11,100,000 women [57.69%]; 1,484,747 Black individuals [7.74%]) were identified. Of the included counties, 1138 were urban, 1018 were rural adjacent, and 922 were rural nonadjacent.

In comparison, a total of 3087 counties (46,400,000 adults ≥65 years; 25,800,000 women [55.72%]; 4,447,733 Black individuals [9.60%]) were identified in 2016. Of those, 1163 were urban, 1020 were rural adjacent, and 904 were rural nonadjacent.

Data showed that between 1968 and 2016:

• Mortality rates per 100,000 persons decreased from 8801 to 5477 deaths (38%) among Black men and from 6380 to 3960 deaths (38%) among Black women.
• Mortality rates decreased from 9063 to 4896 deaths (46%) among White men and from 6175 to 3760 deaths (39%) among White women.
• The mortality rate among Black men decreased from 8715 to 5368 deaths (38%) in urban counties, from 8924 to 6458 deaths (28%) in rural-adjacent counties, and from 9500 to 6941 deaths (27%) in rural-nonadjacent counties.
• The mortality rate among White men decreased from 9063 to 4751 deaths (48%) in urban counties, from 9113 to 5338 deaths (41%) in rural-adjacent counties, and from 8971 to 5229 deaths (42%) in rural-nonadjacent counties.

However, the racial mortality gap increased among men living in rural counties after 1980.

• Compared with White men, approximately 1200 more deaths per 100,000 Black men occurred in urban counties in 2004, and 1900 more deaths per 100,000 Black men occurred in rural-adjacent areas in 2007.
• Compared with White women, approximately 650 more deaths per 100,000 Black women occurred in urban areas, and 782 more deaths per 100,000 Black women occurred in rural-adjacent counties in 2002.
• After controlling for county-level socioeconomic characteristics, in the mid-2000s the racial gap remained highest and continued to increase in rural-nonadjacent counties (1122 more deaths per 100,000 Black men compared with White men).
• Between 1992 and 2014, compared with urban counties, rural-adjacent and rural-nonadjacent counties had lower per capita income, higher unemployment rates, lower median household income, higher poverty rates, a higher proportion of adults 65 years and older, and less diversity.

In the past half century, the racial mortality gap has varied greatly, but the increasing racial mortality gap for men in rural counties indicates the need for further research into these disparities, researchers argue.

Rural vs Urban Health Disparities

Historically, the disparity gap in urban vs rural mortality has been attributed to factors like unintentional injuries, cardiovascular disease, chronic obstructive pulmonary disease, and lung cancer, which make up 70% of the overall gap, authors write.

However, between 1999 and 2016, suicide rates among people living in rural counties were 25% higher than those in major metropolitan areas, NBC reported in September 2019.

Data from a recent study conducted in Maryland also found that from 2003 to 2018, 28.4% of gun suicides in the state of Maryland resulted from long guns. That proportion jumps to 51.6% in rural counties, compared with just 16.8% in the state’s urban counties.

“Coupled with the fact that attempt survivors rarely die in subsequent attempts, and most suicide decedents have no history of a past attempt, access to highly lethal means has been recognized as one of the most important contributors to high rates of completed suicide,” researchers said. Although the majority (82%) of all firearm suicide decedents were non-Hispanic Whites, the study found men were 2.4 times more likely to commit suicide via long gun than women.

Furthermore, in 2019, 19 hospitals in rural America closed—the most in a decade—and at present, 1 in 4 is in danger of closing. Shortages of supplies and staff, in addition to long physical distances between patients and care centers, also serve as limitations for individuals living in secluded areas.

As rural areas tend to adopt more conservative social and economic policies, individual states’ actions can heavily impact life expectancy and health outcomes in their respective populations. For example, 75% of hospitals at risk of closure in 2019, as well as most that have closed in the past 10 years, were in non–Medicaid expansion states such as Texas, Oklahoma, and Alabama.

An additional study found that life expectancy trends in the United States "paint a troubling portrait of life and death,” and state policies play an important role in the stagnation and recent decline in life expectancy.

Using 45 years’ worth of data, researchers ranked state policies on a liberal to conservative continuum, where liberal policies were defined as “expanding state power for economic regulation and redistribution, or for protecting marginalized groups, or restricting state power for punishing deviant social behavior.”

Analyses found:

1. If all states’ policies were identical to Connecticut’s in 2014, (Connecticut made the largest shift toward liberal policies from 1970 to 2014), US life expectancy would be 2 and 1.3 years longer among women and men, respectively.
2. If all states’ policies were identical to Oklahoma in 2014 (it saw the greatest shift toward conservative policies) US life expectancy would be an estimated 1 and 0.5 years shorter among women and men, respectively.
3. If the status quo is maintained, thereby allowing the current policy direction of states to continue, results would yield minimal improvements in longevity (0.4 and 0.3 years higher among women and men, respectively).

Racial Health Disparities

Compounding the issues already limiting optimal health outcomes in rural America, data show older Black adults have higher rates of cardiovascular mortality and die of cancer, kidney disease, stroke, and cardiovascular disease at higher rates than their White counterparts.

JAMA researchers also note the stroke-associated mortality rate in Black adults was twice that of White adults, while the age-adjusted mortality rate for stroke was higher in Black men compared with Black women. A higher incidence of disabling chronic conditions was also observed among Black adults compared with White adults.

In addition to limited access to care in rural settings, further associations between all-cause mortality in this population “may include the risk of encountering health care stereotypes and racial and age discrimination, which may be more pronounced in rural health care settings,” authors write.

For example, a 2016 study found implicit racial bias helped to entrench false beliefs on pain perceptions and treatment among Black Americans. While individuals with medical training were less likely to endorse false beliefs—such as that Black individuals have thicker skin or heal more quickly—researchers found higher endorsements of these beliefs among people without medical training. Participants with medical training (medical students and residents) endorsed 11.55%, on average, of false beliefs, whereas laypeople endorsed 22.43% of the false beliefs on average.

Marginalized populations, such as the homeless or people of color, are more likely to be presumed to be noncompliant with their medication, but they’re also more likely to be presumed to be medication seeking or having an ulterior motive other than trying to receive needed care, the study states.

However, authors of the current study caution that results cannot establish a causal relationship among mortality rate, rurality, and race and can only inform a statistical association. Due to the lack of Census tract geocodes, researchers were also not able to analyze national mortality data at geographic levels smaller than counties. Because of the compositional heterogeneity of counties, authors point out the association of poverty level with mortality is likely to be underestimated for both the rural and urban areas included in the study.

“Notably, the current mortality rate of Black men living in rural areas is similar to that of White men living in urban and rural areas in the mid-1980s,” researchers conclude. “Controlling for income and unemployment rate, the current adjusted mortality rate of Black men in rural areas is higher than that of White men more than 2 decades ago.”

Reference

Ferdows NB, Aranda MP, Baldwin JA, et al. Assessment of racial disparities in mortality rates among older adults living in US rural vs urban counties from 1968 to 2016. JAMA Netw Open. 2020;3(8):e2012241. doi:10.1001/jamanetworkopen.2020.12241