Abstract
Racial health disparities are well documented and pervasive across the United States. Evidence suggests there is a "rural mortality penalty" whereby rural residents experience poorer health outcomes than their urban counterparts. However, whether this penalty is uniform across demographic groups and U.S. regions is unknown. To assess how rural-urban differences in mortality differ by race (Black vs. White), U.S. region, poverty status, and how rural-urban status is measured. Age-standardized mortality rates (ASMRs)/100,000 by U.S. county (2015-2019) were obtained by race (Black/White) from the CDC Wonder National Vital Statistics System (2015-2019) and were merged with county-level social determinants from the US Census Bureau and County Health Rankings. Multivariable generalized linear models assessed the associations between rurality (index of relative rurality [IRR] decile, rural-urban continuum codes, and population density) and race-specific ASMR, overall, and by Census region and poverty level. Overall, average ASMR was significantly higher in rural areas than urban areas for both Black (rural ASMR = 949.1 per 100,000vs. urban ASMR = 857.7 per 100,000) and White (rural ASMR = 903.0 per 100,000vs. urban ASMR = 791.6 per 100,000) populations. The Black-White difference was substantially higher (p < 0.001) in urban than in rural counties (65.1 per 100,000vs. 46.1 per 100,000). Black-White differences and patterns in ASMR varied notably by poverty status and U.S. region. Policies and interventions designed to reduce racial health disparities should consider and address key contextual factors associated with geographic location, including rural-urban status and socioeconomic status.
Published Version
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