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There is limited research on rural–urban disparities in U.S. life expectancy.
This study examined trends in rural–urban disparities in life expectancy at birth in the U.S. between 1969 and 2009.
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.
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.
Between 1969 and 2009, residents in metropolitan areas experienced larger gains in life expectancy than those in nonmetropolitan areas, contributing to the widening gap.
Life expectancy is an important health indicator and a key measure of human development globally.
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.
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.
The 1969–2009 national vital statistics mortality database was used to analyze temporal rural–urban inequalities in U.S. life expectancy.
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.
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.
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).
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.
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.
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.
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.
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.
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.
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.
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
Metro and nonmetro difference in life expectancy
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.
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
Metropolitan and nonmetropolitan difference in life expectancy
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.
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 death
Overall gap between metro and nonmetro areas
Gap between affluent metro and poor nonmetro areas
Absolute contribution (years)
Absolute contribution (years)
All ages and all causes
Age group (years)
Cause of death
All cancers combined
Chronic lower respiratory diseases/COPD
Influenza and pneumonia
Chronic liver disease and cirrhosis
Infectious/parasitic diseases excluding HIV/AIDS
SIDS and ill-defined conditions
All other causes
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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).
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.
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.
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.
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.
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.