Rural and urban differences in mortality among Americans 55 years and older: analysis of the National Longitudinal Mortality Study

Divorce and Death: A Meta-Analysis and Research Agenda for Clinical, Social, and Health Psychology

Divorce is a relatively common stressful life event that is purported to increase risk for all-cause mortality. One problem in the literature on divorce and health is that it is fragmented and spread across many disciplines; most prospective studies of mortality are based in epidemiology and sociology, whereas most mechanistic studies are based in psychology. This review integrates research on divorce and death via meta-analysis and outlines a research agenda for better understanding the potential mechanisms linking marital dissolution and risk for all-cause mortality. Random effects meta-analysis with a sample of 32 prospective studies (involving more than 6.5 million people, 160,000 deaths, and over 755,000 divorces in 11 different countries) revealed a significant increase in risk for early death among separated/divorced adults in comparison to their married counterparts. Men and younger adults evidenced significantly greater risk for early death following marital separation/divorce than did women and older adults. Quantification of the overall effect size linking marital separation/divorce to risk for early death reveals a number of important research questions, and this article discusses what remains to be learned about four plausible mechanisms of action: social selection, resource disruptions, changes in health behaviors, and chronic psychological distress.

The effects of rurality on mental and physical health

The effects of rurality on physical and mental health are examined in analyses of a national dataset, the Community Tracking Survey, 2000-2001, that includes individual level observations from household interviews. We merge it with county level data reflecting community resources and use econometric methods to analyze this multi-level data. The statistical analysis of the impact of the choice of definition on outcomes and on the estimates and significance of explanatory variables in the model is presented using modern econometric methods, and differences in results for mental health and physical health are evaluated.

Urban neighborhood context and mortality in late life

OBJECTIVE

To examine the contextual effects of urban neighborhood characteristics on mortality among older adults.

METHOD

Data are from the Study of Assets and Health Dynamics Among the Oldest Old (AHEAD). Death is assessed between the baseline assessment (1993) and the first follow-up interview (1995). Neighborhood data are from the 1990 Census.

RESULTS

The log odds of dying between the two time points are higher in high proportion Hispanic neighborhoods, net of individual-level sociodemographic variables, but this effect is partly mediated by individual-level health. The log odds of dying are significantly (p < .05) lower in affluent neighborhoods, controlling for all individual-level variables and neighborhood proportion Hispanic.

DISCUSSION

There are survival-related benefits of living in an affluent urban neighborhood, which we posit may be manifested through the diffusion of innovations in health care and health-promotion activities.

Is sprawl associated with a widening urban-suburban mortality gap?

This paper examines whether sprawl, featured by low development density, segregated land uses, lack of significant centers, and poor street connectivity, contributes to a widening mortality gap between urban and suburban residents. We employ two mortality datasets, including a national cross-sectional dataset examining the impact of metropolitan-level sprawl on urban-suburban mortality gaps and a longitudinal dataset from Portland examining changes in urban-suburban mortality gaps over time. The national and Portland studies provide the only evidence to date that (1) across metropolitan areas, the size of urban-suburban mortality gaps varies by the extent of sprawl: in sprawling metropolitan areas, urban residents have significant excess mortality risks than suburban residents, while in compact metropolitan areas, urbanicity-related excess mortality becomes insignificant; (2) the Portland metropolitan area not only experienced net decreases in mortality rates but also a narrowing urban-suburban mortality gap since its adoption of smart growth regime in the past decade; and (3) the existence of excess mortality among urban residents in US sprawling metropolitan areas, as well as the net mortality decreases and narrowing urban-suburban mortality gap in the Portland metropolitan area, is not attributable to sociodemographic variations. These findings suggest that health threats imposed by sprawl affect urban residents disproportionately compared to suburban residents and that efforts curbing sprawl may mitigate urban-suburban health disparities.

Marital status and health: exploring pre-widowhood

BACKGROUND

Health and function vary by marital status across the life-course, but little is known about older adults approaching spousal loss (pre-widowed).

OBJECTIVE

To explore health and function by marital status focusing on the pre-widowed and to examine factors associated with shorter time to spousal loss. PARTICIPANTS, DESIGN, AND MEASUREMENTS: We used 3 years of data from African American and white community-dwelling older adults in the UAB Study of Aging (N = 1000). Participants were categorized as "continuously married" (married at baseline and 3 years), "widowed" (widowed at baseline), "single" (never married/divorced); and "pre-widowed" (married at baseline and widowed within 3 years). Assessments included sociodemographic characteristics, and measures of depression, anxiety, life-space mobility, and self-reported health. chi(2) and analysis of variance (ANOVA) were used to examine baseline differences. Using Cox regression, we explored factors having independent and significant associations with shorter time to spousal loss among married older adults.

RESULTS

There were significant differences by marital status category for sociodemographic factors, health, and function. Pre-widows differed from other categories by sociodemographic characteristics as well as levels of depression, anxiety and self-reported health. Among married older adults, being female and having lower self-reported health at baseline were independent significant hazards for shorter time to widowhood; while rural residence and providing spousal care were independent significant hazards for a longer progression to widowhood.

CONCLUSIONS

Health deficits associated with spousal bereavement may be evident earlier in the marital transition than previously thought, warranting attention to the health of elderly persons whose spouses have chronic/life-limiting conditions.

An examination of urban versus rural mortality in China using community and individual data

OBJECTIVE

Urban/rural residence is a critical health determinant and one researchers have historically found to distinguish health experiences. In this study, we investigated variations in older adult mortality across urban and rural areas of China and assessed mechanisms driving an urban advantage through a series of socioeconomic and health service covariates measured at individual and community levels.

METHODS

We employed 15 years of mortality data from the China Health and Nutrition Survey. We calculated average annual age-specific death rates and used combinations of covariates to examine Cox proportional hazards models. We employed the 2000 Chinese Census and the 2002 Demographic Yearbook descriptively to assess reliability and provide an alternative source for mortality variation.

RESULT

Hazard ratios and standardized death rates showed rural mortality to be about 30% higher than urban mortality. Cadre status, amenities within the community, and average wage within the community are important determinants of mortality, and adjusting for these covariates reduced the urban advantage.

DISCUSSION

There is great differentiation in economic and social life between urban and rural China, and this appears to be negatively influencing survival chances of older adults in rural areas. The policy implications are fairly clear: Investment in rural China is needed to reduce health inequalities.

Primary care consultation, hospital admission, sick leave and disability pension owing to neck and low back pain: a 12-year prospective cohort study in a rural population

Background

Neck and low back pain are common musculoskeletal complaints generating large societal costs in Western populations. In this study we evaluate the magnitude of long-term health outcomes for neck and low back pain, taking possible confounders into account.

Method

A cohort of 2,351 Swedish male farmers and rural non-farmers (40–60 years old) was established in 1989. In the first survey, conducted in 1990–91, 1,782 men participated. A 12-year follow-up survey was made in 2002–03 and 1,405 men participated at both times. After exclusion of 58 individuals reporting a specific back diagnosis in 1990–91, the study cohort encompassed 1,347 men. The health outcomes primary care consultation, hospital admission, sick leave and disability pension were assessed in structured interviews in 2002–03 (survey 2). Symptoms and potential confounders were assessed at survey 1, with the exception of rating of depression and anxiety, which was assessed at survey 2. Multiple logistic regression generating odds ratios (OR) with 95% confidence intervals (95% CI) was performed to adjust the associations between reported symptoms and health outcomes for potential confounders (age, farming, workload, education, demand and control at work, body mass index, smoking, snuff use, alcohol consumption, psychiatric symptoms and specific back diagnoses during follow up).

Results

Of the 836 men reporting current neck and/or low back pain at survey 1, 21% had had at least one primary care consultation for neck or low back problems, 7% had been on sick leave and 4% had disability pension owing to the condition during the 12 year follow up. Current neck and/or low back pain at survey 1 predicted primary care consultations (OR = 4.10, 95% CI 2.24–7.49) and sick leave (OR = 3.22, 95% CI 1.13–9.22) after potential confounders were considered. Lower education and more psychiatric symptoms were independently related to sick leave. Lower education and snuff use independently predicted disability pension.

Conclusion

Few individuals with neck or low back pain were on sick leave or were granted a disability pension owing to neck or low back problems during 12 years of follow up. Symptoms at baseline independently predicted health outcomes. Educational level and symptoms of depression/anxiety were important modifiers.

Knowledge of rural nurses' aides about end-of-life care

Currently, little is known about the role of nurses' aides (NAs) in rural long-term care facilities or their impact on the process of death and dying in rural healthcare environments. Focus groups with NAs were held in 6 rural counties located in 5 states to assess attitudes and perceptions about end-of-life care and training needs. Key informants from 8 states and the District of Columbia added to the understandings. Nurses' aides (N = 63) and key informants (N = 21) worked in a variety of rural settings that provide end-of-life care (ie, nursing homes, hospitals, hospices, home healthcare agencies). Five themes about the needs of rural NAs around end-of-life care were identified in the focus groups, and 4 themes emerged from key informant interviews. A prototype computer-based training module on communication about end-of-life issues was developed, tested, and found useful and compelling.

Urban and rural differences in mortality and causes of death in historical Poland

The purpose of this paper is to document and interpret urban-rural differences in mortality in the past. To this end, we used data on mortality in Wielkopolska, Poland, in the 19th century and at the beginning of the 20th century. The data on mortality in rural areas (N = 1,173,910 deceased), small towns (N = 573,903 deceased), and Poznań, the capital of the Wielkopolska region (N = 86,352 deceased), were gathered from original Prussian statistical yearbooks (Preussische Statistik). Causes of death were also analyzed (rural areas, N = 449,576 deceased; small towns, N = 238,365 deceased; Poznań, N = 61,512 deceased). Mortality measures such as crude death rate (CDR), infant death rate (IDR), and neonatal and postneonatal death rates were calculated. Life tables were constructed for both stationary and stable population models and measures of the opportunity for natural selection calculated (Crow's index I(m), potential gross reproduction rate R(pot), and biological state index I(bs)). Relative frequencies of leading causes of death were computed. Stratification depending on the place of residence was evident in all mortality measures as well as in the values of the life tables and the measures of the opportunity for natural selection, but it was reverse of what is observed today in developed countries. In Poznań (a large industrial city), the mortality situation was the least favorable. It was caused by large population density, lack of water supply and sewage systems (up to 1896), and bad working conditions. The values of CDR ranged between 26.89-31.46, and IDR between 190.6-280.5. Newborn life expectancy (for a stable population model) was 31.6 years, I(m) = 0.79, R(pot) = 0.85, and I(bs) = 0.47. The most common causes of death were tuberculosis, other diseases of the respiratory and circulatory systems, dysentery and diarrhea, and cancer. These diseases were less common in rural areas, so they had the most favorable values of mortality measures (CDR between 22.87-27.32, IDR between 181.8-219.4, life expectancy of newborn e(0) = 42.12, I(m) = 0.55, R(pot) = 0.93, I(bs) = 0.60). Infectious diseases (other than tuberculosis), frailty at birth, and frailty in old age were the most frequent causes of death in rural areas. Small towns (population <20,000) had a mortality intermediate between city and rural areas.

Disentangling contextual effects on cause-specific mortality in a longitudinal 23-year follow-up study: impact of population density or socioeconomic environment?

BACKGROUND

Various studies have investigated urban/rural differences in cause-specific mortality. A separate body of literature has analysed effects of socioeconomic environment on mortality. Almost no studies have attempted to disentangle effects of population density and socioeconomic environment on mortality, beyond the effects of individual characteristics.

METHODS

Considering all individuals living in the region of Scania, Sweden, from 1970-93, we performed 10 year mortality follow-ups on (i) individuals aged 55, (ii) individuals aged 65, and (iii) individuals aged 75 years at baseline. Cox multilevel models adjusted for individual factors allowed us to investigate the independent effects of population density and median income in the parish of residence on mortality from ischaemic heart disease (IHD), lung cancer, and chronic obstructive pulmonary disease (COPD) among individuals who had lived in the same parish for at least 10 years prior to mortality follow-up.

RESULTS

In females, as in males, after adjustment for individual and contextual socioeconomic status, we found a dose-response association between population density and mortality from lung cancer and COPD in all age groups investigated, and from IHD especially in the youngest age group. Overall, the population density effect was the strongest on lung cancer mortality. Median income had an additional impact only in 2 out of 16 subgroups of age x gender x cause of death.

CONCLUSIONS

In our region-wide study conducted at the parish level, contextual disparities in mortality were dominated by the population density effect. However, it may be unwise to conclude that truly contextual effects exist on mortality, before identification of plausible mediating processes through which urbanicity may influence mortality risk.

Mapping high or low mortality places across time in the United States: a research note on a health visualization and analysis project

This research note reports progress in visualizing and analyzing United States mortality data at the county level. The data visualization technique employed here may be applicable to other research situations. We dichotomized the range of mortality rates into high or low mortality counties, mapped them, and explored the clustering of high or low mortality rate counties across both space and time. We find visual evidence that high or low mortality counties spatially cluster together during individual periods of time (5 years). We find further visual evidence that there is a spatial persistence over time (30 years) of these counties with high or low mortality. This evidence leads us to conclude that relatively high or low mortality is anchored over time within a spatial region and population, suggesting that research efforts may be focused on these clusters to assess local causes of high or low mortality rates. Future research will examine the permanence of the resident population (i.e., population mixing), characteristics of the resident population, and characteristics of their place of residence over time.

Age, menopause and hormone replacement therapy influences on cardiovascular risk factors in a cohort of middle-aged Chilean women

OBJECTIVE

To determine the prevalence of obesity and other cardiovascular risk factors (RF) in middle-aged women, to correlate them with each other, and to describe the prevalence of such a RF and their changes with aging, menopause and Hormone Replacement Therapy (HRT) in a cohort of Chilean workers.

MATERIAL AND METHOD

In 1991-1992 cardiovascular RFs were assessed in 467 women between 40 and 59 who were not taking HRT at that time. Five years later these women were re-evaluated.

RESULTS

Sedentarism (87.2%), dyslipidemias (71.5%), high blood pressure (13.5%), obesity (13.1%), smoking (12.4%) and diabetes (2.8%) were the more prevalent RF. These RF become more prevalent with age. In the second control, 5 years later, hypertension (20.9%), obesity (27.3%), smoking (20.8%) and diabetes (5.9%) were observed increased. Dyslipidemia did not changed, although triglyceride levels rose from 125.9+/-56.4 to 136.8+/-63.5 mg/dl (P<0.01). Sedentarism dropped to 58.8%. Menopause did not deteriorate any of these RF. The use of HRT increased during the 5-years follow-up from 3.8 to 35%, and related to its use a decrease in LDL-cholesterol and an increase in HDL-cholesterol levels were detected.

CONCLUSION

Middle-aged women included in this cohort have a high prevalence of RF; these deteriorate with age, but no with menopause. HRT improves the lipid profile.

Excess mortality among urban residents: how much, for whom, and why?

OBJECTIVES

The goals of this study were to estimate prospective mortality risks of city residence, specify how these risks vary by population subgroup, and explore possible explanations.

METHODS

Data were derived from a probability sample of 3617 adults in the coterminous United States and analyzed via cross-tabular and Cox proportional hazards methods.

RESULTS

After adjustment for baseline sociodemographic and health variables, city residents had a mortality hazard rate ratio of 1.62 (95% confidence interval [CI] = 1.21, 2.18) relative to rural/small-town residents; suburbanites had an intermediate but not significantly elevated hazard rate ratio. This urban mortality risk was significant among men (hazard rate ratio: 2.25), especially non-Black men, but not among women. Among Black men, and to some degree Black women, suburban residence carried the greatest risk. All risks were most evident for those younger than 65 years.

CONCLUSIONS

The mortality risk of city residence, at least among men, rivals that of major psychosocial risk factors such as race, low income, smoking, and social isolation and merits comparable attention in research and policy.

Patterns and predictors of noninstitutional health care utilization by older adults in rural and urban America

Noninstitutional long-term care is not often included in policy studies or recommendations in the United States even though there have been recent efforts to include this type of care in health reform proposals. This study was designed to provide insight into the patterns and predictors of noninstitutional medical, home-, and community-based services utilization by older adults in rural and urban America. The National Long Term Care Survey (NLTCS) was used to explore the relationship between residential setting and subsequent noninstitutional services utilization. Weighted logistic regression procedures for complex survey designs were used to guide the analysis. Living in the Northeast and residence in moderately densely populated areas (towns, small cities, and suburbs) were significant positive predictors of subsequent medical, home-, and community-based services utilization. Because some differentials were found in access to and use of services by regional and geographic setting, policy-makers need to develop alternative strategies to eliminate inequities in the distribution of noninstitutional long-term care services in more remote areas.

Effect of hospital type, insurance type, and gender on the treatment of cardiovascular disease in middle-aged adults

The cost and duration of cardiovascular care was studied for 4,804 episodes of hospitalization in patients between 45 and 64 years of age. Men were more likely than women to be treated in urban medical centers for shorter, more expensive hospital care; women were more likely to be treated in rural hospitals for longer, less expensive care. Cost of treatment per day was not dependent on the type of insurance, but Medicaid claims (which represent low income patients) were associated with greater lengths of stay.

Rural women's satisfaction and stress as family health care gatekeepers

Women shoulder much of the responsibility for their families' health care, making women's satisfaction with available services an important issue for their families and for women's personal stress levels. Lack of services and resulting stress may be acute for rural women, the focus of this study. In a state-wide survey, fewer than one-half of rural women were satisfied with the health services available; dissatisfaction was a strong determinant of women's stress over health care issues. Rural women are at risk for a pile-up of stressors that could impede their ability to care for themselves and their families.

Effect of a transient, geographically localised economic recovery on community health and income studied with longitudinal household cohort interview method

STUDY OBJECTIVE

The main purpose of the study was to determine whether the health or economic status of a cohort of residents in an economically troubled geographical area changed between 1990 and 1993.

DESIGN

Longitudinal, single cohort, interview survey method with the key variables of health status and economic status. Quasi-experimental pre-post design with economic rebound as the intervention.

SETTING

A relatively low income geographical area in a rural, mountainous region before and after an economic rebound. In 1990, the local economy and health care system collapsed because of the closure of a series of manufacturing plants; outward migration from the area peaked. Between 1990 and 1993, new industries opened, and state and private community assistance programmes intervened, resulting in an economic rebound, migration into the area, and marked growth of the health service sector.

PARTICIPANTS

A 2% sample of residents of households, using a combination of random, stratified, and clustered sampling. Residents included in the study had lived within the area throughout the 1990-1993 period of the study.

MAIN RESULTS

Stable, non-migrating residents had a statistically significant 7% reduction in health status between 1990 and 1993, as measured by a composite of subjective and objective measures. The non-migrating residents also had a significant decrease in average household income ($14,700 in 1990 and $12,400 in 1993 in constant 1990 dollars) during the strong economic expansion, and therefore did not participate in or receive direct economic benefit from the expansion. There was a rapid population increase during the expansion, attributable to inward migrants who were younger and healthier than existing residents. The decline in health for the non-migrating residents was tentatively attributed to either direct or indirect effects of the decline in family income.

CONCLUSIONS

Local economic development accompanied by expanded health care services availability can leave existing area residents poorer and less healthy, and this problem may be masked by an abundance of healthier, wealthier inward migrants.

Lay health advisors: a strategy for getting the word out about breast cancer

Transforming natural helpers into lay health advisors (LHAs) is a complex undertaking. Using the North Carolina Breast Cancer Screening Program (NC-BCSP) as a case study, this article describes the steps involved in developing, implementing, and evaluating an LHA intervention, considering factors that make the LHA approach appropriate for the NC-BCSP's population, setting, and health focus. The authors review five phases of implementation (start-up, training, LHA activities, follow-up, resource mobilization) and discuss the NC-BCSP's evaluation strategies and tools in light of difficulties involved in assessing natural helping processes and impact. Program challenges related to resource needs, identification of natural helpers, and LHA monitoring and support also are considered. The authors describe ways in which one large group of older, rural, African American LHAs are helping establish countywide partnerships between health care providers, agencies, and local communities that support and sustain individual changes in health behavior.