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

项目总结/摘要 该项目旨在查明造成死亡率地域不平等的程度和趋势的因素 在美国的城乡结合部和地区。一个人居住地的城市化程度是 本身是社会经济地位和获得保健服务的一个重要分层维度， 在现有的关于社会经济地位梯度对预期寿命的影响的研究中，它在很大程度上被忽视了。大型中央 大都市地区及其郊区，在2000年至2005年期间， 1990年和2015年，是2010年至2015年期间预期寿命增长的唯一地区。通过 相比之下，1990年至2010年期间，较小的地铁和非地铁的改善速度要慢得多， 在2010年到2015年之间，人们的预期寿命实际上有所下降。假设的具体机制 造成城乡死亡率不平等的因素包括：（1）健康行为和行为危险因素，（2） 卫生保健的获得和质量，以及（3）国内和国际移民。为了确定 这三种机制中的每一种都对1990年至1999年期间这些不平等的程度和扩大产生了影响。 2015年，我们使用了三个独特的、限制使用的数据集（国家健康访谈调查、国家健康调查和国家健康调查）。 纵向死亡率研究和美国社区死亡率差异数据库） 人口动态统计数据和几个地区一级的数据集涵盖了广泛的背景因素。这些 限制使用的数据集包含有关死因、地理和迁移的详细信息， 在以前的研究中还没有用于确定死亡率差异或驱动这些差异的机制 在城市和农村的连续体中。我们将采用多种方法，包括标准 人口统计学方法，原因删除生命表，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适用于总体和个人水平的数据。我们 严格和彻底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种行为和原因改进了先前的研究 死亡（相对于单一行为或根本原因），采用多种方法，并占 吸烟等行为对死亡率的影响。移徙对死亡率不平等的影响 至今很少受到关注。然而，鉴于移民到美国的人数增加， 有选择地迁移到县内不同地区和大都市/非大都市地区， 虽然移民有许多优势，但移民可能在扩大生活中的地理不平等方面发挥重要作用。 期待该项目是第一个量化国际和国内移民对人口增长的影响的研究。 美国国内的死亡率差异。我们还将研究SES（教育和收入） 预期寿命的不平等在城乡之间各不相同， 与其他高收入国家相比，美国国内的贫困导致了我们的预期寿命缩短。

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.