Causes of Geographic Divergence in American Mortality Between 1990 and 2015: Health Behaviors, Health Care Access and Migration

项目摘要/摘要 该项目旨在找出造成地理不平等死亡率水平和趋势的因素。 横跨美国的城乡连续体和地区。居住地的城市化程度是 本身是社会经济地位(SES)和获得保健服务机会的重要分层层面； 在现有的关于SES预期寿命梯度的研究中，它在很大程度上被忽视了。大型中心 大都会地区及其郊区的预期寿命在 1990年至2015年是2010年至2015年期间仅有的预期寿命增长的地区。通过 相比之下，较小的地铁和非地铁在1990至2010年间的改善要慢得多， 实际上在2010年至2015年间经历了预期寿命的下降。假设的具体机制 造成城乡死亡率不平等的原因包括：(1)健康行为和行为风险因素；(2) 卫生保健的获得和质量，以及(3)国内和国际移徙。确定……的贡献 这三种机制中的每一种都加剧了这些不平等的程度和扩大了这些不平等 2015年，我们使用了三个独特的、受限使用的数据集(国家健康访谈调查、国家 纵向死亡率研究和美国社区数据库中的死亡率差异)联合 有重要的统计数据和几个地区一级的数据集，涵盖了各种背景因素。这些 受限使用数据集包含有关死亡原因、地理位置和迁移的详细信息，并且它们 在以前的研究中没有用来确定死亡率差异或导致这些差异的机制 横跨城乡连续体。我们将采用多种方法，包括标准 人口统计方法，删除原因的生命表，量化吸烟的间接估计方法- 归因死亡率和离散时间风险模型既适用于聚合数据，也适用于个人数据。我们的 严格和彻底地评估行为风险因素对死亡率不平等的贡献 城乡连续体和区域通过关注多重行为和原因改进了先前的研究。 死亡(相对于单一行为或潜在原因)，使用多种方法，并解释 生活过程中吸烟等行为对死亡率的影响。移民对死亡率不平等的影响 到目前为止，几乎没有人关注这一问题。然而，考虑到移民到美国的数量增加， 有选择地迁移到县内不同地区和大都市区/非大都市区，以及健康 移民的优势，移民很可能在扩大生活中的地理不平等方面发挥重要作用 期望值。该项目是第一个量化国际和国内移民对 美国境内的死亡率差异。我们还将研究SES(教育和收入)如何 预期寿命的不平等在城乡连续体中存在差异，并确立了日益加剧的不平等 在美国，与其他高收入国家相比，我们的预期寿命不足。

PROJECT SUMMARY/ABSTRACT This project aims to identify factors responsible for levels and trends in geographic inequalities in mortality across the urban-rural continuum and regions of the United States. Urbanicity of one’s place of residence is itself an important stratifying dimension of socioeconomic status (SES) and access to health care services, and it has been largely overlooked in existing studies of SES gradients in life expectancy. Large central metropolitan areas and their suburbs, which experienced remarkable improvements in life expectancy between 1990 and 2015, were the only areas to have experienced life expectancy gains between 2010 and 2015. By contrast, smaller metros and non-metros experienced much slower improvements between 1990 and 2010, and actually experienced life expectancy declines between 2010 and 2015. Specific mechanisms hypothesized to contribute to urban-rural mortality inequalities include: (1) health behaviors and behavioral risk factors, (2) health care access and quality, and (3) domestic and international migration. To identify the contribution of each of these three mechanisms to the magnitudes of and widening in these inequalities between 1990 and 2015, we use three unique, restricted-use datasets (the National Health Interview Survey, the National Longitudinal Mortality Study, and the Mortality Disparities in American Communities database) in conjunction with vital statistics and several area-level datasets covering a wide array of contextual factors. These restricted-use datasets contain detailed information on cause of death, geography, and migration, and they have not been used in prior studies to identify mortality differences or mechanisms driving these differences across the urban-rural continuum. We will employ multiple methodological approaches including standard demographic methods, cause-deleted life tables, indirect estimation methods for quantifying smoking- attributable mortality, and discrete-time hazard models applied to both aggregate and individual-level data. Our rigorous and thorough assessment of the contribution of behavioral risk factors to mortality inequalities across the urban-rural continuum and regions improves on prior studies by focusing on multiple behaviors and causes of death (versus a single behavior or underlying cause), employing multiple methods, and accounting for the life course effects of behaviors like smoking on mortality. Migration’s impacts on mortality inequalities have received little attention to date. However, given the increased volume of migration to the United States, selective migration into different regions and metro/non-metro areas within the county, and the health advantages of migrants, migration is likely to play an important role in widening geographic inequalities in life expectancy. This project is the first study to quantify the impact of both international and domestic migration on mortality differentials within the United States. We will also examine how SES (education and income) inequalities in life expectancy vary across the urban-rural continuum and establish how growing inequality within the United States contributes to our life expectancy shortfall relative to other high-income countries.