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Widening Rural–Urban Disparities in Life Expectancy, U.S., 1969–2009

  • Gopal K. Singh
    Correspondence
    Address correspondence to: Gopal K. Singh, PhD, USDHHS, Health Resources and Services Administration, Maternal and Child Health Bureau, 5600 Fishers Lane, Room 18-41, Rockville MD 20857
    Affiliations
    USDHHS (Singh), Health Resources and Services Administration, Maternal and Child Health Bureau, Rockville, Maryland
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  • Mohammad Siahpush
    Affiliations
    Department of Health Promotion, Social and Behavioral Health (Siahpush), University of Nebraska Medical Center, Omaha, Nebraska
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      Background

      There is limited research on rural–urban disparities in U.S. life expectancy.

      Purpose

      This study examined trends in rural–urban disparities in life expectancy at birth in the U.S. between 1969 and 2009.

      Methods

      The 1969–2009 U.S. county-level mortality data linked to a rural–urban continuum measure were analyzed. Life expectancies were calculated by age, gender, and race for 3-year time periods between 1969 and 2004 and for 2005–2009 using standard life-table methodology. Differences in life expectancy were decomposed by age and cause of death.

      Results

      Life expectancy was inversely related to levels of rurality. In 2005–2009, those in large metropolitan areas had a life expectancy of 79.1 years, compared with 76.9 years in small urban towns and 76.7 years in rural areas. When stratified by gender, race, and income, life expectancy ranged from 67.7 years among poor black men in nonmetropolitan areas to 89.6 among poor Asian/Pacific Islander women in metropolitan areas. Rural–urban disparities widened over time. In 1969–1971, life expectancy was 0.4 years longer in metropolitan than in nonmetropolitan areas (70.9 vs 70.5 years). By 2005–2009, the life expectancy difference had increased to 2.0 years (78.8 vs 76.8 years). The rural poor and rural blacks currently experience survival probabilities that urban rich and urban whites enjoyed 4 decades earlier. Causes of death contributing most to the increasing rural–urban disparity and lower life expectancy in rural areas include heart disease, unintentional injuries, COPD, lung cancer, stroke, suicide, and diabetes.

      Conclusions

      Between 1969 and 2009, residents in metropolitan areas experienced larger gains in life expectancy than those in nonmetropolitan areas, contributing to the widening gap.

      Introduction

      Life expectancy is an important health indicator and a key measure of human development globally.
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      Since 1990, reducing health inequalities and increasing life expectancy have been the two most important overarching goals for the U.S., as specified in its national health initiative, Healthy People.
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      Life expectancy estimates are routinely available for gender and broad racial/ethnic groups in the U.S.
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      Many U.S. studies have analyzed spatial–temporal patterns in mortality,
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      Increasing inequalities in all-cause and cardiovascular mortality among U.S. adults aged 25–64 years by area socioeconomic status, 1969–1998.
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      Singh GK, Kogan MD. Widening socioeconomic disparities in U.S. childhood mortality, 1969–2000. Am J Public Health 2007;97(9):1658–65.

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      Changing area socioeconomic patterns in U.S. cancer mortality, 1950–1998, part I: all cancers among men.
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      • Hankey B.F.
      Changing area socioeconomic patterns in U.S. cancer mortality, 1950–1998, part II: lung and colorectal cancers.
      and a few studies have reported differentials in life expectancy according to SES or area-based deprivation level.
      • Singh G.K.
      • Siahpush M.
      Widening socioeconomic inequalities in U.S. life expectancy, 1980–2000.
      • Lin C.C.
      • Johnson N.J.
      Decomposition of life expectancy and expected life-years lost by disease.
      • Olshansky S.J.
      • Antonucci T.
      • Berkman L.
      • et al.
      Differences in life expectancy due to race and educational differences are widening, and many may not catch up.
      Estimates of U.S. life expectancy according to urbanization level are limited, particularly analysis of trends in life expectancy among rural and urban populations over time.
      • Murray C.J.L.
      • Kulkarni S.
      • Ezzati M.
      New perspectives on U.S. health disparities.
      Although substantial disparities in life expectancy exist among gender, racial/ethnic, and socioeconomic groups in the U.S., it is important to know the magnitude and causes of life expectancy disparities been rural and urban areas for the purposes of social planning and public health decision making.
      Life expectancy is a summary index of mortality that can be used to document both absolute and relative inequalities in survival between rural and urban populations.
      • Singh G.K.
      • Siahpush M.
      Widening socioeconomic inequalities in U.S. life expectancy, 1980–2000.
      It manifests the effects of excess mortality risks during infancy, childhood, youth, working ages, and old age as well as those from major chronic and communicable diseases. The aim of this study is to examine changes in the extent of rural–urban inequalities in U.S. life expectancy between 1969 and 2009. A county-based rural–urban variable was linked to national mortality data to examine the extent to which differences in life expectancy among U.S. men and women in metropolitan and nonmetropolitan areas have changed during the past 4 decades. For the most recent time period, life expectancies at birth were derived for metropolitan and nonmetropolitan areas stratified by race, gender, and income. Rural–urban disparities were decomposed in life expectancy attributable to excess mortality in specific age groups and causes of death.

      Methods

      The 1969–2009 national vital statistics mortality database was used to analyze temporal rural–urban inequalities in U.S. life expectancy.
      National Center for Health Statistics
      Health, U.S., 2010, with special feature on death and dying.
      • Minino A.M.
      • Murphy S.L.
      • Xu J.Q.
      • Kochanek K.D.
      Deaths: final data for 2008.
      • Kochanek K.D.
      • Xu J.Q.
      • Murphy S.L.
      • Minino A.M.
      • Kung H.C.
      Deaths: final data for 2009.
      • Minino A.M.
      • Murphy S.L.
      Death in the U.S., 2010.
      • Singh G.K.
      • Siahpush M.
      Widening socioeconomic inequalities in U.S. life expectancy, 1980–2000.

      National Center for Health Statistics. National Vital Statistics System, mortality multiple cause-of-death public use data file documentation. Hyattsville MD: USDHHS, 2012; www.cdc.gov/nchs/nvss/mortality_public_use_data.htm

      Because the national mortality database does not allow direct computation of life expectancies for people in rural and urban areas, the 1974, 1983, 1993, and 2003 rural–urban continuum variables were linked to the age-, gender-, race-, and county-specific mortality statistics from 1969–1980, 1981–1989, 1990–1998, and 1999–2009, respectively, to derive life expectancy estimates.
      • Singh G.K.
      • Siahpush M.
      • Williams S.D.
      Changing urbanization patterns in U.S. lung cancer mortality, 1950–2007.
      • Singh G.K.
      • Azuine R.E.
      • Siahpush M.
      Widening socioeconomic, racial, and geographic disparities in HIV/AIDS mortality in the U.S., 1987–2011.

      National Center for Health Statistics. National Vital Statistics System, mortality multiple cause-of-death public use data file documentation. Hyattsville MD: USDHHS, 2012; www.cdc.gov/nchs/nvss/mortality_public_use_data.htm

      • Butler M.A.
      • Beale C.L.
      Rural–urban continuum codes for metro and nonmetro counties, 1993.

      Economic Research Service, U.S. Department of Agriculture. Rural–urban continuum codes; www.ers.usda.gov/data-products/rural-urban-continuum-codes.aspx.

      • Bureau of Health Professions
      Area resource file, 2009–10, technical documentation.
      • Singh G.K.
      • Williams S.D.
      • Siahpush M.
      • Mulhollen A.
      Socioeconomic, rural–urban, and racial inequalities in U.S. cancer mortality, part 1: all cancers and lung cancer, and part II: colorectal, prostate, breast, and cervical cancers.
      The rural–urban continuum variable classifies all U.S. counties into nine distinct groups according to decreasing urbanization levels or increasing levels of rurality, based on the population size of the counties and their proximity to metropolitan areas.
      • Singh G.K.
      • Siahpush M.
      • Williams S.D.
      Changing urbanization patterns in U.S. lung cancer mortality, 1950–2007.

      Economic Research Service, U.S. Department of Agriculture. Rural–urban continuum codes; www.ers.usda.gov/data-products/rural-urban-continuum-codes.aspx.

      • Bureau of Health Professions
      Area resource file, 2009–10, technical documentation.
      • Singh G.K.
      • Williams S.D.
      • Siahpush M.
      • Mulhollen A.
      Socioeconomic, rural–urban, and racial inequalities in U.S. cancer mortality, part 1: all cancers and lung cancer, and part II: colorectal, prostate, breast, and cervical cancers.
      For computing life expectancy and cause-specific mortality rates, the nine rural–urban continuum categories were collapsed into five groups: large metropolitan county-group, medium metropolitan county-group, small metropolitan county-group, urban nonmetropolitan county-group, and rural nonmetropolitan county-group (Table 1).
      • Singh G.K.
      • Siahpush M.
      • Williams S.D.
      Changing urbanization patterns in U.S. lung cancer mortality, 1950–2007.
      • Singh G.K.
      • Azuine R.E.
      • Siahpush M.
      Widening socioeconomic, racial, and geographic disparities in HIV/AIDS mortality in the U.S., 1987–2011.
      • Singh G.K.
      • Williams S.D.
      • Siahpush M.
      • Mulhollen A.
      Socioeconomic, rural–urban, and racial inequalities in U.S. cancer mortality, part 1: all cancers and lung cancer, and part II: colorectal, prostate, breast, and cervical cancers.
      The broad metropolitan category included large metropolitan counties with population ≥1 million and smaller metropolitan counties of population <250,000. The nonmetropolitan category included small urban towns of population <20,000 and rural towns with a population of <2500, which may or may not be adjacent to a metropolitan area.
      • Singh G.K.
      • Siahpush M.
      • Williams S.D.
      Changing urbanization patterns in U.S. lung cancer mortality, 1950–2007.

      Economic Research Service, U.S. Department of Agriculture. Rural–urban continuum codes; www.ers.usda.gov/data-products/rural-urban-continuum-codes.aspx.

      • Bureau of Health Professions
      Area resource file, 2009–10, technical documentation.
      • Singh G.K.
      • Williams S.D.
      • Siahpush M.
      • Mulhollen A.
      Socioeconomic, rural–urban, and racial inequalities in U.S. cancer mortality, part 1: all cancers and lung cancer, and part II: colorectal, prostate, breast, and cervical cancers.
      Metropolitan and nonmetropolitan areas accounted for 83.4% and 16.6% of the total U.S. population in 2007, respectively.
      • Singh G.K.
      • Siahpush M.
      • Williams S.D.
      Changing urbanization patterns in U.S. lung cancer mortality, 1950–2007.
      • Bureau of Health Professions
      Area resource file, 2009–10, technical documentation.
      Table 1Selected socioeconomic, demographic, and health characteristics for five rural–urban continuum categories, 2000–2009, % unless otherwise noted
      CharacteristicAll metro countiesMetro countiesAll nonmetro countiesNonmetro counties
      Large
      Counties in metropolitan areas with 1 million population or more
      Medium
      Counties in metropolitan areas of 250,000–1,000,000 population
      Small
      Counties in metropolitan areas with less than 250,000 population
      Urban
      Urban nonmetropolitan counties
      Rural
      Rural counties with no places with a population of 2,500 or more
      Number of counties, 20071,0904143253512,0511,381670
      Average population size, 2007230,825390,379185,28084,80424,38932,4747,724
      Total U.S. population, 200783.4253.5819.969.8716.5814.871.72
      High school diploma or more, 2005–200985.0585.0385.3384.6681.7181.8780.34
      College graduates, 2005–200929.5331.7326.7423.2317.2817.5415.05
      Median family income ($), 2005–200967,24870,98362,35856,82850,40650,83546,681
      Poverty rate, 2005–200912.9212.1813.7515.2416.4416.3717.05
      Income disparity,
      Income disparity was defined as 100*ratio of number of households with <$15,000 income to number of households with ≥$75,000 income
      2005–2009
      40.6834.0948.0161.6995.1891.57126.52
      White-collar occupation, 2005–200961.7563.5059.7056.4350.7350.9348.92
      Unemployment rate, 2005–20094.714.794.584.504.404.444.05
      Minority population,
      Consists of black, American Indian, Asian/Pacific Islander, and Hispanic populations
      2005–2009
      35.7040.7528.6822.4918.0318.4814.16
      Immigrant population, 2005–200914.1217.549.045.863.643.832.00
      Households with no car and >1 mile to grocery store, 20061.831.452.412.804.194.035.52
      Population with low-income and >1 mile to grocery store, 20068.215.6811.4615.4123.3322.3032.15
      Medically underserved counties,
      Underserved areas for primary medical care services
      2007
      38.5735.5940.0040.7044.3535.6062.39
      Underserved for mental health services, 200739.0337.2932.3147.2979.2476.6384.63
      Chronically poor counties,
      ≥20% of the county population was poor in each of the four censuses: 1970, 1980, 1990, and 2000
      1970–2000
      4.221.944.926.2716.5715.5618.66
      Counties with population losses,
      Population declining between the 1980 and 1990 and between the 1990 and 2000 censuses
      1980–2000
      6.335.085.538.5525.8919.4139.26
      Violent crime rate,
      Rate per 100,000 population
      2005
      529.13584.29450.41390.47243.68256.35138.03
      Voting rate in presidential election,
      Percent of population aged ≥18 years
      2004
      55.2054.3256.9456.4556.7456.1162.06
      Population aged <65 lacking health insurance, 200617.8318.1117.1817.6817.4717.1620.18
      Number of doctors per 10,000 population, 200730.0432.2826.9124.2212.1812.905.92
      Number of nurses per 10,000 population, 200741.4339.4744.3546.1530.1931.7216.91
      Obesity prevalence among adults aged ≥18, 2006–200825.3024.5226.2727.5928.5828.5329.01
      Diabetes prevalence among adults aged ≥18, 2006–20088.498.308.739.059.779.7110.26
      Source: Data derived from the 2009–2010 Area Resource File, 2005–2009 American Community Survey, 2010 USDA Food Environment Atlas, and Census Bureau’s 2007 County and City Data Book
      a Counties in metropolitan areas with 1 million population or more
      b Counties in metropolitan areas of 250,000–1,000,000 population
      c Counties in metropolitan areas with less than 250,000 population
      d Urban nonmetropolitan counties
      e Rural counties with no places with a population of 2,500 or more
      f Income disparity was defined as 100*ratio of number of households with <$15,000 income to number of households with ≥$75,000 income
      g Consists of black, American Indian, Asian/Pacific Islander, and Hispanic populations
      h Underserved areas for primary medical care services
      i ≥20% of the county population was poor in each of the four censuses: 1970, 1980, 1990, and 2000
      j Population declining between the 1980 and 1990 and between the 1990 and 2000 censuses
      k Rate per 100,000 population
      l Percent of population aged ≥18 years
      Life expectancy estimates were derived for twelve 3-year time periods, 1969–1971, 1972–1974,…2002–2004, and one 5-year period, 2005–2009. These time periods were used because of the availability and confidential restrictions of county-level mortality data.
      • Kochanek K.D.
      • Xu J.Q.
      • Murphy S.L.
      • Minino A.M.
      • Kung H.C.
      Deaths: final data for 2009.

      National Center for Health Statistics. National Vital Statistics System, mortality multiple cause-of-death public use data file documentation. Hyattsville MD: USDHHS, 2012; www.cdc.gov/nchs/nvss/mortality_public_use_data.htm

      Age-, gender-, and county-specific deaths for these time periods were obtained using the national mortality database,
      • Minino A.M.
      • Murphy S.L.
      • Xu J.Q.
      • Kochanek K.D.
      Deaths: final data for 2008.
      • Kochanek K.D.
      • Xu J.Q.
      • Murphy S.L.
      • Minino A.M.
      • Kung H.C.
      Deaths: final data for 2009.

      National Center for Health Statistics. National Vital Statistics System, mortality multiple cause-of-death public use data file documentation. Hyattsville MD: USDHHS, 2012; www.cdc.gov/nchs/nvss/mortality_public_use_data.htm

      whereas age-, gender-, and county-specific population estimates for the same time periods served as denominators for computing age-specific mortality rates.
      • Kochanek K.D.
      • Xu J.Q.
      • Murphy S.L.
      • Minino A.M.
      • Kung H.C.
      Deaths: final data for 2009.

      U.S. Census Bureau. Census of population and housing, 1990: Summary Tape File 3A on CD-ROM. Washington DC: U.S. Department of Commerce, 1992.

      • U.S. Census Bureau
      Summary file 3, technical documentation. 2000 Census of Population and Housing.
      Each of the 3141 counties in the mortality database was assigned one of the five rural–urban continuum categories or one of the two metropolitan–nonmetropolitan categories. Life-table estimates were calculated by the standard life-table methodology by converting observed age-specific mortality rates (for 19 age groups: <1 year, 1–4, 5–9, …, 80–84, and ≥85 years) into life-table probabilities of dying.
      • Singh G.K.
      • Siahpush M.
      Widening socioeconomic inequalities in U.S. life expectancy, 1980–2000.
      • Namboodiri K.
      • Suchindran C.M.
      Life table techniques and their applications.
      • Preston S.H.
      • Heuveline P.
      • Guillot M.
      Demography: measuring and modeling population processes.
      Infant mortality rate was used to approximate the probability of dying in the first year of life.
      • Singh G.K.
      • Siahpush M.
      Widening socioeconomic inequalities in U.S. life expectancy, 1980–2000.
      Because metropolitan and nonmetropolitan areas differ substantially in their sociodemographic characteristics, rural–urban differences in life expectancy were examined by stratifying analyses according to race and area-poverty level for 1969–1971 and 2005–2009. For income-specific analyses, county-level poverty data from the 1990 and 2000 censuses were linked with county-level mortality statistics for 1969–1971 and 2005–2009, respectively.

      Economic Research Service, U.S. Department of Agriculture. Rural–urban continuum codes; www.ers.usda.gov/data-products/rural-urban-continuum-codes.aspx.

      U.S. Census Bureau. Census of population and housing, 1990: Summary Tape File 3A on CD-ROM. Washington DC: U.S. Department of Commerce, 1992.

      • U.S. Census Bureau
      Summary file 3, technical documentation. 2000 Census of Population and Housing.
      Five area-poverty groups were used: <5.00% (i.e., <5% of the population below the poverty line in a county); 5.00%–9.99%; 10.00%–14.99%; 15.00%–19.99%; and ≥20%.
      Descriptive sociodemographic data for rural–urban groups were derived from the American Community Survey, the Area Resource File, the U.S. Department of Agriculture (USDA) Food-Environment Atlas, and the County and City Data Book.
      • Bureau of Health Professions
      Area resource file, 2009–10, technical documentation.

      U.S. Census Bureau. The 2009 American Community Survey. Washington DC: U.S. Census Bureau, 2010; www.census.gov/acs/www/

      U.S. Department of Agriculture. Food environment atlas. Washington DC: Economic Research Service, USDA, 2012; ers.usda.gov/data-products/food-environment-atlas/documentation.aspx

      CDC. Behavioral Risk Factor Surveillance System. Atlanta GA: CDC, 2012; www.cdc.gov/brfss/

      U.S. Census Bureau. County and city data book, 2007. Washington DC: U.S. Government Printing Office, 2011; www.census.gov/statab/www/ccdb.html

      Inequalities in life expectancy across gender and time periods were measured by the absolute difference in life expectancy between metropolitan and nonmetropolitan areas. Additionally, for the 2005–2009 period, life expectancy estimates were computed for metropolitan and nonmetropolitan areas stratified by income/poverty level and race/ethnicity. Absolute differences in life expectancy in 2005–2009 between metropolitan and nonmetropolitan areas were decomposed additively by age groups and into major underlying causes of death using Arriaga’s and the standard life-table decomposition methods.
      • Preston S.H.
      • Heuveline P.
      • Guillot M.
      Demography: measuring and modeling population processes.
      • Arriaga E.E.
      Measuring and explaining the change in life expectancies.
      • Das Gupta P.
      Standardization and decomposition of rates: a user’s manual. Current population reports, P23–186.
      Life-table survival function was used to analyze trends in survivorship for metropolitan and nonmetropolitan areas by age, poverty status, and race. Age-adjusted rates of mortality from major causes of death were computed in 1990–1992 and 2005–2009 to supplement life expectancy trend analysis.

      Results

      Table 1 presents selected sociodemographic and health characteristics by urbanization level. SES is generally inversely related to levels of rurality, with higher poverty and lower education and income levels found in nonmetropolitan than metropolitan areas. Metropolitan and urban areas had a higher proportion of minority and immigrant populations, whereas nonmetropolitan and rural areas were more likely to be medically underserved. Rural and nonmetropolitan areas were also more likely to be characterized by unfavorable built-environmental characteristics (such as inadequate public transportation and lower access to grocery stores) that put their residents at higher risks of obesity, physical inactivity, and poor diet and reflected in higher obesity and diabetes prevalence in rural areas (Table 1).
      Life expectancy varied substantially by time period, gender, and metropolitan/nonmetropolitan area, ranging from 66.6 years for men in nonmetropolitan areas in 1969–1971 to 81.3 years for women in metropolitan areas in 2005–2009 (Table 2). In 1969–1971, the overall life expectancy was 0.4 years longer in metropolitan than in nonmetropolitan areas (70.9 vs 70.5 years). By 2005–2009, the absolute difference in life expectancy had increased to 2.0 years (78.8 vs 76.8 years). The rural–urban gap in life expectancy widened over time for both men and women. Compared to their metropolitan counterparts, men in nonmetropolitan areas experienced a shorter life expectancy by 0.6 years in 1969–1971, 1.0 years in 1996–1998, and 2.1 years in 2005–2009. For women, the absolute difference in life expectancy between metropolitan and nonmetropolitan areas increased from –0.1 years in 1969–1971 to 0.6 years in 1996–1998 and 1.6 years in 2005–2009.
      Table 2Life expectancy at birth (in years) in metropolitan and nonmetropolitan areas, U.S., 1969–2009
      YearMetro areaNonmetro areaMetro areaNonmetro areaMetro areaNonmetro areaMetro and nonmetro difference in life expectancy
      Both gendersBoth gendersMalesMalesFemalesFemalesBoth gendersMalesFemales
      1969–197170.970.567.266.674.774.80.40.6−0.1
      1972–197471.871.368.067.375.675.70.50.7−0.1
      1975–197773.172.869.368.877.077.20.30.5−0.2
      1978–198073.873.770.069.777.678.00.10.3−0.4
      1981–198374.574.570.970.578.178.50.00.4−0.4
      1984–198674.874.871.271.078.378.60.00.2−0.3
      1987–198975.175.071.571.478.578.70.10.1−0.2
      1990–199275.875.572.371.979.279.10.30.40.1
      1993–199576.075.572.672.279.379.00.50.40.3
      1996–199876.976.073.972.979.779.10.91.00.6
      1999–200177.276.274.573.379.879.01.01.20.8
      2002–200477.876.375.173.580.379.21.51.61.1
      2005–200978.876.876.274.181.379.72.02.11.6
      Source: Based on data from the U.S. National Vital Statistics System, 1969–2009
      Note: The 1974, 1983, 1993, and 2003 rural–urban continuum codes were used to compute life expectancy estimates in metropolitan (metro) and nonmetropolitan (nonmetro) areas from 1969–1980, 1981–1989, 1990–1998, and 1999–2009, respectively.
      Between 1969–1971 and 2005–2009, metropolitan residents experienced larger gains in life expectancy than nonmetropolitan residents, which contributed to the widening gap. For men in nonmetropolitan areas, life expectancy increased by 0.28 years annually between 1969 and 2009, whereas it increased by 0.33 years annually for men in metropolitan areas during the same time period. The average annual increases for women in nonmetropolitan and metropolitan areas were 0.18 and 0.24 years, respectively.
      Consistent with the life expectancy trends, compared to metropolitan areas, all-cause mortality in nonmetropolitan areas was 2% higher in 1990–1992 but 13% higher in 2005–2009. Between 1990 and 2009, relative risk of mortality in nonmetropolitan areas increased from 1.05 to 1.13 for cardiovascular diseases (CVD); from 1.49 to 1.50 for unintentional injuries; from 1.07 to 1.26 for chronic obstructive pulmonary disease (COPD); from 1.01 to 1.17 for lung cancer; from 1.04 to 1.17 for diabetes; and from 1.15 to 1.34 for suicide.
      Life expectancy was inversely related to levels of rurality (Figure 1). In 2005–2009, those in large metropolitan areas had a life expectancy of 79.1 years, compared with 76.9 years in small urban towns and 76.7 years in rural areas.
      Figure thumbnail gr1
      Figure 1Life expectancy at birth (years) by levels of urbanization, U.S., 2005–2009
      Although life expectancy decreased with increasing area-poverty rates, the association between poverty and life expectancy was stronger in nonmetropolitan areas (Table 3). Those in the most affluent nonmetropolitan areas had a life expectancy of 80.6 years, 6.2 years longer than those living in high-poverty nonmetropolitan areas. Rural–urban disparities in life expectancy existed within each area-poverty group, with the disparity being most pronounced in higher area-poverty groups. In areas with poverty rates ≥20%, metropolitan residents had a life expectancy of 77.7 years, 3.3 years longer than nonmetropolitan residents.
      Table 3Life expectancy (in years) by metropolitan status, poverty level, and race/ethnicity, U.S., 2005–2009
      MetroNonmetroMetroNonmetroMetroNonmetroMetropolitan and nonmetropolitan difference in life expectancy
      Both gendersBoth gendersMalesMalesFemalesFemalesBoth gendersMalesFemales
      Poverty rate in 2000 (%)
       <580.780.678.778.182.682.90.10.6−0.3
       5–9.9979.678.877.276.381.981.30.80.90.6
       10–14.9978.377.475.674.780.980.10.90.90.8
       15–19.9977.875.974.973.180.678.81.91.81.8
       ≥2077.774.474.471.280.777.73.33.23.0
       Low−high poverty areas
      Difference in life expectancy between low-poverty areas (poverty rate <5%) and high-poverty areas (poverty rate ≥20%)
      3.06.24.36.91.95.2
      Race/ethnicity and poverty
       All whites79.277.276.774.581.680.02.02.21.6
       All blacks74.272.870.669.477.476.01.41.21.4
       All American Indians/AN85.874.882.871.688.578.111.011.210.4
       All Asians and Pacific Islanders86.984.984.282.389.387.32.01.92.0
       All Hispanics83.182.280.379.785.985.00.90.60.9
       Affluent whites79.978.877.676.382.181.41.11.30.7
       Affluent blacks76.176.773.274.578.779.3−0.6−1.3−0.6
       Affluent American Indians/AN85.777.383.675.187.679.58.48.57.1
       Affluent Asians and Pacific Islanders87.284.689.5
       Affluent Hispanics86.283.888.5
       Poor whites78.875.475.972.481.778.63.43.53.1
       Poor blacks74.071.669.767.777.875.22.42.02.6
       Poor American Indians/AN72.668.676.8
       Poor Asians and Pacific Islanders86.783.589.6
       Poor Hispanics81.079.877.676.884.282.91.20.81.3
       All whites−all blacks
      Difference in life expectancy between all whites and all blacks
      5.04.46.15.14.24.0
       Affluent whites−affluent blacks
      Difference in life expectancy between affluent whites (poverty rate <10%) and affluent blacks (poverty rate <10%)
      3.82.14.41.83.42.1
       Poor whites−poor blacks
      Difference in life expectancy between poor whites (poverty rate ≥20%) and poor blacks (poverty rate ≥20%) AN, Alaska Natives
      4.83.86.24.73.93.4
      Note: Life expectancy estimates for non-Hispanic whites were similar to those for whites.
      a Difference in life expectancy between low-poverty areas (poverty rate <5%) and high-poverty areas (poverty rate ≥20%)
      b Difference in life expectancy between all whites and all blacks
      c Difference in life expectancy between affluent whites (poverty rate <10%) and affluent blacks (poverty rate <10%)
      d Difference in life expectancy between poor whites (poverty rate ≥20%) and poor blacks (poverty rate ≥20%)AN, Alaska Natives
      Rural–urban disparities in life expectancy existed for all racial/ethnic groups, particularly among American Indians/Alaska Natives who, on average, live 11 years longer in metropolitan than in nonmetropolitan areas (Table 3). When stratified by gender, race/ethnicity, and income, life expectancy in 2005–2009 ranged from 67.7 years among poor black men in nonmetropolitan areas to 89.6 among poor Asian/Pacific Islander women in metropolitan areas (Table 3). Differences in age-specific survivor functions for race and income groups in Figure 2 indicate that the rural poor in 2005–2009 had survival experiences similar to those of affluent metropolitan residents in 1969–1971, and rural blacks in 2005–2009 experienced survival probabilities that urban whites enjoyed in 1969–1971.
      Figure thumbnail gr2
      Figure 2Survivorship by age, poverty status, race, and metropolitan/nonmetropolitan area, U.S., 1969–2009
      Excess infant, child, and youth mortality in rural areas contributed to 0.25 years or 12.9% of the total urban–rural gap (1.95 years) in life expectancy in 2005–2009 (Table 4). More than 87% of the life expectancy gap can be attributed to excess mortality among those aged ≥25 years in rural areas. Unintentional injuries (26.7%); heart disease (20.5%); COPD (8.2%); lung cancer (8.2%); stroke (5.1%); suicide (5.1%); diabetes (3.1%); sudden infant death syndrome (SIDS) and ill-defined conditions (3.1%); pneumonia/influenza (2.1%); kidney diseases (2.1%); colorectal cancer (1.5%); Alzheimer’s disease (1.5%); and birth defects (1.5%) accounted for most of the urban–rural gap in life expectancy (Table 4). On the other hand, because of lower homicide and HIV/AIDS mortality in rural areas, the contribution of homicide and HIV/AIDS to the total urban–rural life expectancy gap was negative.
      Table 4Decomposition of life expectancy at birth by age and cause of death, U.S., 2005–2009
      Age and cause of deathOverall gap between metro and nonmetro areasGap between affluent metro and poor nonmetro areas
      Absolute contribution (years)Percentage contributionAbsolute contribution (years)Percentage contribution
      All ages and all causes1.95100.06.27100.0
      Age group (years)
       <10.063.10.345.4
       1–140.073.60.193.0
       15–240.126.20.294.6
       25–440.4322.11.5124.1
       45–640.5226.72.4338.8
       ≥650.7437.91.5023.9
      Cause of death
       Cardiovascular diseases0.5226.71.7828.4
       Heart disease0.4020.51.4423.0
       Stroke0.105.10.233.7
       Hypertension0.000.00.061.0
       All cancers combined0.2814.40.7011.2
       Lung cancer0.168.20.314.9
       Colorectal cancer0.031.50.081.3
       Prostate cancer0.010.50.081.3
       Breast cancer−0.01−0.50.040.6
       Cervical cancer0.010.50.040.6
       Chronic lower respiratory diseases/COPD0.168.20.284.5
       Diabetes mellitus0.063.10.264.1
       Influenza and pneumonia0.042.10.121.9
       Nephritis/kidney diseases0.042.10.142.2
       Chronic liver disease and cirrhosis0.021.00.111.8
       HIV/AIDS−0.04−2.10.071.1
       Infectious/parasitic diseases excluding HIV/AIDS0.010.50.152.4
       Alzheimer's disease0.031.50.030.5
       Birth defects0.031.50.061.0
       Perinatal conditions−0.01−0.50.111.8
       SIDS and ill-defined conditions0.063.10.162.6
       Unintentional injuries0.5226.71.0316.4
       Suicide0.105.10.111.8
       Homicide−0.06−3.10.193.0
       All other causes0.199.70.9715.5
      Source: Based on data from the U.S. National Vital Statistics System
      COPD, chronic obstructive pulmonary disease; SIDS, sudden infant death syndrome
      Infant mortality contributed to 0.34 years or 5.4% of the life expectancy gap (6.27 years) between affluent metropolitan and poor nonmetropolitan areas (Table 4). Excess mortality among the rural poor aged 45–64 years accounted for 38.8% of the life expectancy gap. CVD, unintentional injuries, and cancer accounted for 56% of the life expectancy difference between urban rich and rural poor; moreover, homicide and HIV/AIDS contributed positively to the life expectancy gap.

      Discussion

      Life expectancy in the U.S. has increased consistently during the past 4 decades, albeit at a modest pace, rising from 70.8 years in 1970 to 78.7 years in 2010.
      National Center for Health Statistics
      Health, U.S., 2010, with special feature on death and dying.
      • Minino A.M.
      • Murphy S.L.
      • Xu J.Q.
      • Kochanek K.D.
      Deaths: final data for 2008.
      • Kochanek K.D.
      • Xu J.Q.
      • Murphy S.L.
      • Minino A.M.
      • Kung H.C.
      Deaths: final data for 2009.
      • Minino A.M.
      • Murphy S.L.
      Death in the U.S., 2010.
      In contrast to the consistent improvements in overall life expectancy, this study reveals substantial and increasing urban–rural disparities in U.S. life expectancy over time, with the gap widening from 0.4 years in 1969–1971 to 2.0 years in 2005–2009. Racial disparities in life expectancy were very marked in both metropolitan and nonmetropolitan areas. Life expectancy of blacks was 5 years shorter in metropolitan areas and 4.4 years shorter in nonmetropolitan areas, compared to their white counterparts. Considering race/ethnicity, gender, and poverty simultaneously, the inequalities are even more dramatic, with poor black men in nonmetropolitan areas experiencing about 22 years shorter life expectancy than poor Asian/Pacific Islander women in metropolitan areas. Remarkably, the rural poor and rural blacks currently experience life expectancy and survival probabilities that urban rich and urban whites enjoyed nearly 4 decades earlier.
      With inequalities in all-cause mortality and mortality from several major causes of death on the rise, rural–urban disparities in U.S. life expectancy are not expected to diminish for the foreseeable future.
      • Singh G.K.
      Area deprivation and widening inequalities in U.S. mortality, 1969–1998.
      • Singh G.K.
      • Siahpush M.
      Increasing inequalities in all-cause and cardiovascular mortality among U.S. adults aged 25–64 years by area socioeconomic status, 1969–1998.
      • Singh G.K.
      • Siahpush M.
      Increasing rural–urban gradients in U.S. suicide mortality, 1970–1997.
      • Singh G.K.
      • Siahpush M.
      • Williams S.D.
      Changing urbanization patterns in U.S. lung cancer mortality, 1950–2007.
      • Singh G.K.
      • Siahpush M.
      Widening socioeconomic inequalities in U.S. life expectancy, 1980–2000.
      • Singh G.K.
      • Williams S.D.
      • Siahpush M.
      • Mulhollen A.
      Socioeconomic, rural–urban, and racial inequalities in U.S. cancer mortality, part 1: all cancers and lung cancer, and part II: colorectal, prostate, breast, and cervical cancers.
      Existence of such marked and growing rural–urban disparities in U.S. life expectancy runs counter to the goals of the national health initiative that calls for elimination of health inequalities by 2020.
      The decomposition analysis showed that unintentional injuries, CVD, COPD, and lung cancer accounted for 70% of the overall rural–urban gap in life expectancy and 54% of the life expectancy gap between the urban rich and rural poor in 2005–2009. Interestingly, rural–urban disparities in mortality from these major causes of death also widened between 1990 and 2009.
      Rural–urban patterns in life expectancy shown here are consistent with a previous study that showed large disparities in life expectancy among various U.S. population or geographic groups.
      • Murray C.J.L.
      • Kulkarni S.
      • Ezzati M.
      New perspectives on U.S. health disparities.
      In this study, rural blacks and whites had lower life expectancy than their urban counterparts, and blacks in poor rural South or in high-risk urban environments had at least 15 years lower life expectancy than Asians.
      • Murray C.J.L.
      • Kulkarni S.
      • Ezzati M.
      New perspectives on U.S. health disparities.
      Urbanization patterns in U.S. life expectancy are consistent with those for Canada and Australia, where life expectancies also decrease in relation to increasing levels of rurality.
      Australian Institute of Health and Welfare
      Australia’s health 2012. AIHW Cat. No. 156.
      • Australian Institute of Health and Welfare
      Rural, regional and remote health: indicators of health status and determinants of health. AIHW Cat. No. PHE 97.
      In 1999–2001, life expectancy for Canadian men in remote rural areas was 74.0 years, compared with 76.8 years in urban areas.
      In 2002–2004, Australian men living in remote areas had a life expectancy of 72.1 years, compared with 79.0 years for those in major cities. Life expectancy of Australian women was 6.2 years shorter in remote areas than in central cities.
      Australian Institute of Health and Welfare
      Australia’s health 2012. AIHW Cat. No. 156.
      • Australian Institute of Health and Welfare
      Rural, regional and remote health: indicators of health status and determinants of health. AIHW Cat. No. PHE 97.
      Rural–urban patterns differed for Scotland, where men and women in rural areas had, respectively, 3.6 and 2.0 years longer life expectancy than their urban counterparts in 2007–2009.
      General Register Office for Scotland
      Life expectancy in special areas (urban/rural, deprivation and community health partnership) within Scotland, 2007–2009.
      Rural–urban patterns in England were similar to those for Scotland. For English men and women, life expectancy in rural areas during 2001–2007 was 78.6 and 82.4 years; the respective figures for urban areas were 76.5 and 81.0 years.
      • Kyle L.
      • Wells C.
      Variations in life expectancy between rural and urban areas of England, 2001–2007.
      Consistent with the U.S. pattern, life expectancy differences between rural and urban areas of England were widest in the most-deprived quintiles.
      • Kyle L.
      • Wells C.
      Variations in life expectancy between rural and urban areas of England, 2001–2007.
      This study has limitations. Life expectancy estimates for Hispanics, Asian/Pacific Islanders, and American Indians/Alaska Natives should be interpreted with caution as vital statistics–based mortality rates for these groups tend to be underestimated by 5%, 7%, and 30%, respectively.
      • Kochanek K.D.
      • Xu J.Q.
      • Murphy S.L.
      • Minino A.M.
      • Kung H.C.
      Deaths: final data for 2009.
      • Arias E.
      • Schauman W.S.
      • Eschbach K.
      • et al.
      The validity of race and Hispanic origin reporting on death certificates in the U.S.
      • Arias E.
      • Eschbach K.
      • Schauman W.S.
      • et al.
      The Hispanic mortality advantage and ethnic misclassification on U.S. death certificates.
      Second, the use of the 1990 census data to define area-poverty groups in 1969–1971 is a limitation. Third, the socioeconomic measure, county-level poverty rate, could vary greatly across neighborhoods or census tracts within a given county.
      • Singh G.K.
      • Siahpush M.
      Widening socioeconomic inequalities in U.S. life expectancy, 1980–2000.
      • Singh G.K.
      • Williams S.D.
      • Siahpush M.
      • Mulhollen A.
      Socioeconomic, rural–urban, and racial inequalities in U.S. cancer mortality, part 1: all cancers and lung cancer, and part II: colorectal, prostate, breast, and cervical cancers.
      Unfortunately, census-tract geocodes are not available in the national mortality database.
      • Kochanek K.D.
      • Xu J.Q.
      • Murphy S.L.
      • Minino A.M.
      • Kung H.C.
      Deaths: final data for 2009.
      • Singh G.K.
      • Siahpush M.
      Widening socioeconomic inequalities in U.S. life expectancy, 1980–2000.

      National Center for Health Statistics. National Vital Statistics System, mortality multiple cause-of-death public use data file documentation. Hyattsville MD: USDHHS, 2012; www.cdc.gov/nchs/nvss/mortality_public_use_data.htm

      • Singh G.K.
      • Williams S.D.
      • Siahpush M.
      • Mulhollen A.
      Socioeconomic, rural–urban, and racial inequalities in U.S. cancer mortality, part 1: all cancers and lung cancer, and part II: colorectal, prostate, breast, and cervical cancers.
      Given the compositional heterogeneity of counties, the association of poverty with life expectancy reported here is likely to be underestimated in both metropolitan and nonmetropolitan areas.
      • Singh G.K.
      • Siahpush M.
      Widening socioeconomic inequalities in U.S. life expectancy, 1980–2000.
      • Singh G.K.
      • Williams S.D.
      • Siahpush M.
      • Mulhollen A.
      Socioeconomic, rural–urban, and racial inequalities in U.S. cancer mortality, part 1: all cancers and lung cancer, and part II: colorectal, prostate, breast, and cervical cancers.
      Rural–urban inequalities in life expectancy are consistent with disparities in other health measures.
      • Schiller J.S.
      • Lucas J.W.
      • Ward B.W.
      • Peregoy J.A.
      Summary health statistics for U.S. adults: National Health Interview Survey, 2010.
      • Coben J.H.
      • Tiesman H.M.
      • Bossarte R.M.
      • Furbee P.M.
      Rural–urban differences in injury hospitalizations in the U.S., 2004.
      Residents of rural and nonmetropolitan areas also report considerably higher prevalence of self-assessed fair/poor health, psychological distress, disability, functional limitation, injuries, hypertension, and physical inactivity than their urban counterparts.
      • Schiller J.S.
      • Lucas J.W.
      • Ward B.W.
      • Peregoy J.A.
      Summary health statistics for U.S. adults: National Health Interview Survey, 2010.
      • Coben J.H.
      • Tiesman H.M.
      • Bossarte R.M.
      • Furbee P.M.
      Rural–urban differences in injury hospitalizations in the U.S., 2004.
      Moreover, the rural–urban inequalities in health determinants appear to have increased over time, as rural residents currently fare worse in these health indicators than urban residents, compared to 2 decades ago.
      • Schiller J.S.
      • Lucas J.W.
      • Ward B.W.
      • Peregoy J.A.
      Summary health statistics for U.S. adults: National Health Interview Survey, 2010.

      National Center for Health Statistics. The National Health Interview Survey, questionnaires, datasets, and related documentation: 1976 public use data file. Hyattsville MD: USDHHS, 2009; www.cdc.gov/nchs/nhis/quest_data_related_1996_prior.htm

      • Benson V.
      • Marano M.A.
      Current estimates from the National Health Interview Survey, 1995.
      The health of U.S. children is also less favorable in rural than in urban areas.
      Health Resources and Services Administration, Maternal and Child Health Bureau
      The health and well-being of children in rural areas: a portrait of the nation 2007.
      • Singh G.K.
      • Siahpush M.
      • Kogan M.D.
      Rising social inequalities in U.S. childhood obesity, 2003–2007.
      • Singh G.K.
      • Siahpush M.
      • Kogan M.D.
      Disparities in children’s exposure to environmental tobacco smoke in the U.S., 2007.
      The rural–urban gap in child health is likely to extend into youth and adult ages, a scenario that does not bode well for any future efforts to reduce the rural–urban gap in life expectancy.
      Temporal rural–urban inequalities in life expectancy may partly reflect inequalities in behavioral and healthcare factors. Rural areas have higher smoking and obesity prevalence and lower access to health services.
      • Bureau of Health Professions
      Area resource file, 2009–10, technical documentation.
      • Schiller J.S.
      • Lucas J.W.
      • Ward B.W.
      • Peregoy J.A.
      Summary health statistics for U.S. adults: National Health Interview Survey, 2010.
      • Casey M.M.
      • Call K.T.
      • Klingner J.M.
      Are rural residents less likely to obtain recommended preventive healthcare services?.
      • Okon N.J.
      • Fogle C.C.
      • McNamara M.J.
      • et al.
      Statewide efforts to narrow the rural–urban gap in acute stroke care.
      Rural–urban patterns in smoking behavior have changed over the past 4 decades. Smoking prevalence among U.S. adults in 1976 was 37.8% for people living in central cities, 36.5% for people living outside the central cities in metropolitan areas, and 25.1% for people living on rural farms.
      • Singh G.K.
      • Siahpush M.
      • Williams S.D.
      Changing urbanization patterns in U.S. lung cancer mortality, 1950–2007.

      National Center for Health Statistics. The National Health Interview Survey, questionnaires, datasets, and related documentation: 1976 public use data file. Hyattsville MD: USDHHS, 2009; www.cdc.gov/nchs/nhis/quest_data_related_1996_prior.htm

      Contemporary data indicate changing rural–urban patterns in smoking.
      • Singh G.K.
      • Siahpush M.
      • Williams S.D.
      Changing urbanization patterns in U.S. lung cancer mortality, 1950–2007.
      • Schiller J.S.
      • Lucas J.W.
      • Ward B.W.
      • Peregoy J.A.
      Summary health statistics for U.S. adults: National Health Interview Survey, 2010.
      In 2010, smoking prevalence was 16.9% in large metropolitan areas, 19.7% in small metropolitan areas, and 26.9% in nonmetropolitan areas.
      • Schiller J.S.
      • Lucas J.W.
      • Ward B.W.
      • Peregoy J.A.
      Summary health statistics for U.S. adults: National Health Interview Survey, 2010.
      Changing urbanization patterns in smoking are also confirmed by the long-term shifts and reversal of U.S. lung cancer mortality patterns.
      • Singh G.K.
      • Siahpush M.
      • Williams S.D.
      Changing urbanization patterns in U.S. lung cancer mortality, 1950–2007.
      Until the 1970s, lung cancer mortality was significantly higher in metropolitan areas, whereas it is currently higher in rural and nonmetropolitan areas.
      • Singh G.K.
      • Siahpush M.
      • Williams S.D.
      Changing urbanization patterns in U.S. lung cancer mortality, 1950–2007.
      Obesity prevalence is higher in rural areas, which have seen a more rapid rise in obesity prevalence than urban areas during the past 3 decades. In 1976, adults living in large metropolitan areas had an obesity prevalence of 9.2%, compared with 9.5% in nonmetropolitan areas.

      National Center for Health Statistics. The National Health Interview Survey, questionnaires, datasets, and related documentation: 1976 public use data file. Hyattsville MD: USDHHS, 2009; www.cdc.gov/nchs/nhis/quest_data_related_1996_prior.htm

      By 2010, the obesity prevalence had risen to 25.9% in large metropolitan areas and to 33.2% in nonmetropolitan areas.
      • Schiller J.S.
      • Lucas J.W.
      • Ward B.W.
      • Peregoy J.A.
      Summary health statistics for U.S. adults: National Health Interview Survey, 2010.
      Widening rural–urban inequalities in life expectancy shown here may reflect increasing inequalities between metropolitan and nonmetropolitan areas in upstream social-structural factors such as material living conditions, social integration, and distribution of other valued social resources (e.g., spending on public safety, social and welfare services, education, affordable housing, and job creation).
      • Singh G.K.
      • Siahpush M.
      Increasing inequalities in all-cause and cardiovascular mortality among U.S. adults aged 25–64 years by area socioeconomic status, 1969–1998.
      • Singh G.K.
      • Siahpush M.
      Increasing rural–urban gradients in U.S. suicide mortality, 1970–1997.
      • Singh G.K.
      • Siahpush M.
      Widening socioeconomic inequalities in U.S. life expectancy, 1980–2000.
      Although absolute differences between rural–urban areas in income and wealth increased markedly between 1970 and 2009, substantial inequalities in poverty, unemployment, and healthcare access have persisted.
      • Bureau of Health Professions
      Area resource file, 2009–10, technical documentation.

      U.S. Census Bureau. The 2009 American Community Survey. Washington DC: U.S. Census Bureau, 2010; www.census.gov/acs/www/

      For example, the median family income in 1970 was $2892 less for nonmetropolitan residents than metropolitan residents.
      • Bureau of Health Professions
      Area resource file, 2009–10, technical documentation.
      The income gap increased to $16,842 in 2009. In 1970, 10.9% of nonmetropolitan residents had a college degree, compared with 17.7% of metropolitan residents. The education deficit grew in 2009, as 17.3% of nonmetropolitan residents and 29.5% of metropolitan residents had a college degree. In 1970, the poverty rate was 12.9% in metropolitan areas and 17.1% in nonmetropolitan areas.
      • Bureau of Health Professions
      Area resource file, 2009–10, technical documentation.
      In 2009, the poverty gap was similar.
      • Bureau of Health Professions
      Area resource file, 2009–10, technical documentation.

      U.S. Census Bureau. The 2009 American Community Survey. Washington DC: U.S. Census Bureau, 2010; www.census.gov/acs/www/

      Marked improvements in socioeconomic conditions are vital to ensuring further gains in life expectancy and reduced mortality rates in rural areas, as they have remained disadvantaged over the past 4 decades in terms of socioeconomic conditions, economic and educational opportunities, provision of health services, access to essential goods and services, and transportation.
      • Singh G.K.
      • Siahpush M.
      Increasing rural–urban gradients in U.S. suicide mortality, 1970–1997.
      • Singh G.K.
      • Siahpush M.
      • Williams S.D.
      Changing urbanization patterns in U.S. lung cancer mortality, 1950–2007.
      • Bureau of Health Professions
      Area resource file, 2009–10, technical documentation.
      • Singh G.K.
      • Williams S.D.
      • Siahpush M.
      • Mulhollen A.
      Socioeconomic, rural–urban, and racial inequalities in U.S. cancer mortality, part 1: all cancers and lung cancer, and part II: colorectal, prostate, breast, and cervical cancers.
      Some federal programs suggest shifting public health resources from smaller, rural states to larger, more densely populated states to reduce the national disease burden. Although such a strategy may reduce the public health burden at the national level, it may lead to even greater rural–urban disparities in health and life expectancy as important resources need to be shifted away from rural residents who remain at a higher risk of mortality from major chronic conditions and injuries. Behavioral and social-policy interventions such as smoking reduction, anti-obesity measures, and improved healthcare access have the potential to reduce health inequalities between rural and urban areas.
      • Singh G.K.
      • Siahpush M.
      Widening socioeconomic inequalities in U.S. life expectancy, 1980–2000.
      • Singh G.K.
      • Williams S.D.
      • Siahpush M.
      • Mulhollen A.
      Socioeconomic, rural–urban, and racial inequalities in U.S. cancer mortality, part 1: all cancers and lung cancer, and part II: colorectal, prostate, breast, and cervical cancers.
      However, reducing inequalities in education, poverty, unemployment, housing, transportation, and labor market opportunities—the underlying social determinants of health inequalities—must be an important policy goal for narrowing the rural–urban gap in life expectancy.
      • Singh G.K.
      Area deprivation and widening inequalities in U.S. mortality, 1969–1998.
      • Singh G.K.
      • Siahpush M.
      Increasing inequalities in all-cause and cardiovascular mortality among U.S. adults aged 25–64 years by area socioeconomic status, 1969–1998.
      • Singh G.K.
      • Siahpush M.
      Widening socioeconomic inequalities in U.S. life expectancy, 1980–2000.
      • Singh G.K.
      • Williams S.D.
      • Siahpush M.
      • Mulhollen A.
      Socioeconomic, rural–urban, and racial inequalities in U.S. cancer mortality, part 1: all cancers and lung cancer, and part II: colorectal, prostate, breast, and cervical cancers.
      • Shaw M.
      • Dorling D.
      • Gordon D.
      • Davey Smith G.
      The widening gap: health inequalities and policy in Britain.

      Acknowledgments

      The views expressed are the authors’ and not necessarily those of the Health Resources and Services Administration or the USDHHS.
      No financial disclosures were reported by the authors of this paper.

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