Rural residents in the US often face greater premature mortality and poorer health outcomes compared with their counterparts located in urban areas. Despite changing demographics and changes in populations, rural public health, according to the CDC, continues to be a concern and efforts to address preventable premature deaths continue to require attention.
A report demonstrated that higher percentages of potentially preventable deaths within nonmetropolitan areas compared with metropolitan areas in the US. A CDC Morbidity and Mortality Weekly Report used mortality data to estimate the number and percentage of deaths from the 5 leading causes of death—heart disease, cancer, unintentional injury, chronic lower respiratory disease (CLRD), and stroke—that could have been prevented if all states had similarly low death rates. Additionally, the report also estimates the disparities in premature mortality from the 5 causes of death that occurred in rural areas during 2010 to 2022 in the US.
For this analysis, mortality data for US residents from the National Vital Statistics System were used to calculate preventable premature deaths by urban-rural county classification from the 5 leading causes of death from 2010 to 2022. For consistency, COVID-19-related deaths were excluded from the analysis. Individuals older than 80 at the time of death were not included in the analysis, which is consistent with the average life expectancy for the US population in 2010 (about 79 years of age).
Further, age groups varied by the cause of death, most of which were 10-year age gaps However, the youngest age group ranged from 0 to 9 years in the unintentional injury group and the largest gap was 0 to 49 years in the CLRD and cerebrovascular disease groups because, according to the authors, these deaths are rare in younger individuals. In addition, for each age group and cause of death, the death rates of the 3 states with the lowest rates from 2008 through 2010 were averaged to create benchmark rates that were used to represent the lowest death rates achievable by states at the beginning of the study period. Benchmarks were applied to both nonmetropolitan and metropolitan counties, and were not adjusted for other characteristics that may influence death rates (eg, race, socioeconomic status, or urbanicity).
Additionally, rural and urban categories were identified using the National Center for Health Statistics 2013 urban-rural county 6-point classification system: large central metropolitan/most urban (1), large fringe metropolitan (2), medium metropolitan (3), small metropolitan (4), micropolitan (5), and noncore/most rural (6). Preventable premature deaths were calculated individually for the 2 nonmetropolitan categories (numbers 5 and 6 on the scale) and the 4 metropolitan categories (numbers 1 through 4 on the scale).
The findings indicated that rural residents—notably those living in noncore/most rural counties—experienced higher rates of preventable premature deaths during the duration of the analysis, with disparities in premature deaths varying depending on the cause of death. Despite the disparities observed in the findings, they were not limited to place of residence. Additionally, all-cause premature deaths were often associated with other demographic factors, including sex, race, or ethnicity.
Cancer-related deaths decreased through the study’s duration (21% to 0.3%) regardless of county classification; however, the decreases in urban locations were larger than those observed in rural counties. Additionally, the preventable premature deaths from cancer in noncore/most rural communities in 2022 (18.1%) was very similar to that shown in large central metropolitan counties 2010 (17.9%).
Key Takeaways
- Persistent Disparities Between Rural and Urban Counties: The findings of the study highlight a trend of ongoing health disparities between rural and urban populations in the US. Rural areas, particularly those considered noncore/most rural counties, continue to experience disproportionately higher rates of premature mortality, suggesting that existing efforts to address health inequities have not been effective in narrowing the gap between rural and urban communities.
- Trends Varied Across Causes of Death: The study reveals diverse trends in preventable premature deaths across different causes, indicating the complex nature of health disparities. While some causes, such as heart disease and cancer, show overall declines in preventable deaths, others, like unintentional injuries and chronic lower respiratory disease, demonstrate fluctuations or increases over time. The variations suggest that different health conditions may be influenced by unique sets of factors, such as lifestyle behaviors, access to health care, socioeconomic status, and environmental determinants.
- Further Research and Action: The analysis emphasizes the need for continued research and action to address the underlying factors contributing to preventable premature deaths in rural areas. By including demographic, social, and environmental determinants of health disparities, researchers can gain a better understanding of what may be driving these inequities and identify targeted strategies for intervention. The study also shows the importance of comprehensive public health initiatives aimed at improving access to health care services, promoting healthy behaviors, addressing socioeconomic inequalities, and addressing environmental hazards in rural communities.
Preventable premature deaths related to heart disease had decreased from 2010 (33.5%) through 2019 (28.8%), but increased in 2020 through June 2022 (33.6%). Notably, increases from 2020 to June 2022 occurred across all county categories, except for large central metropolitan counties, which experienced a decrease from 2020 (32.9%) to 2021 (30.1%). Preventable premature deaths related to heart disease were highest in rural counties during 2022 (micropolitan: 45.8%; noncore/most rural: 49.4%).
Unintentional injury deaths increased from 2010 to 2019 (38.8% to 53.8%) and continued to increase significantly to 2021, but there was a slight decrease through June 2022 (63.5%). Percentages in rural areas were higher than in urban areas, however, increases in preventable premature deaths from unintentional injury during 2010 through 2022 were significantly for nearly all categories, except for micropolitan.
The percentage of preventable premature deaths related to CLRD decreased from 2010 through 2022 (38.6% to 25.5%), and the percentage of preventable premature deaths varied widely when stratified by rural-urban county category; however, all categories except for noncore/most rural experienced decreases. Disparities increased when large central metropolitan percentages decreased in 2010 (23.4%) to 2022 (0%), but the rural percentages ranged between 50.7% and 54.8% during 2022.
Preventable premature deaths because of stroke decreased from 2010 (32.4%) through 2019 (26.4%), and then increased through June 2022 (33.9%). Further, each rural-urban category experienced increased from 2019 to June 2022; however, noncore/most rural counties experience slight decreases from 2021 to June 2022, and rural counties had the highest percentages from January to June 2022 (micropolitan: 42.0%; noncore/most rural: 40.9%). According to the investigators, stroke-related preventable premature deaths in 2022 were most prevalent in southern states.
Limitations of the study include the application of benchmarks to all urban-rural county categories, the inability to entirely categorize deaths to population size or geographic locations (risk factors do not occur randomly in populations and are related to outside factors), and the estimates of preventable premature deaths using benchmarks may not accurately reflect improvements in mortality that occurred in later years. Further, the investigators note that even trying to exclude COVID-19 from data, some deaths may still have been increased due to COVID-19 and the pandemic. Additionally, some death misclassifications may have occurred and deaths due to pandemic-related effects—such as reduced access to emergency care or life-saving treatments—may have been limited because of COVID-19.
The authors note that reporting the trend within preventable premature deaths can highlight differences over time and can help better understand any underlying social, environmental, or structural risk factors. Additionally, they emphasize that more detailed analyses that include race, age, and ethnicity, preventable deaths among individuals aged 80 years and older, and preventable premature deaths related to other causes should be conducted.
Reference
García, MC, Rossen, LM, Matthews, K, et al. Preventable Premature Deaths from the Five Leading Causes of Death in Nonmetropolitan and Metropolitan Counties, United States, 2010–2022. MMWR Surveill Summ 2024;73(No. SS-2):1–11. doi:10.15585/mmwr.ss7302a1.
