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

1990 年至 2015 年间美国死亡率地理差异的原因：健康行为、医疗保健获取和移民

• 批准号: 9754755
• 负责人: IRMA T. ELO
• 金额: $ 33.43万
• 依托单位: UNIVERSITY OF PENNSYLVANIA
• 依托单位国家: 美国
• 财政年份: 2018
• 资助国家: 美国
• 起止时间: 2018-08-15 至 2023-03-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9754755
• 关键词: AIDS/HIV problem; Accounting; Address; Affect; Age; Alcohol consumption; American; Area; Attention; Automobile Driving; Behavior; Behavioral; Cause of Death; Characteristics; Communities; Country; County; Data; Data Set; Databases; Development; Differential Mortality; Dimensions; Education; Ethnic Origin; Geography; Hazard Models; Health; Health behavior; Healthcare Systems; Heterogeneity; Homicide; Income; Individual; Inequality; Internal Migrations; International; International Migrations; Life Cycle Stages; Life Expectancy; Life Experience; Life Tables; Light; Link; Methodology; Methods; Migrant; National Health Interview Survey; Obesity; Overdose; Pattern; Performance; Pharmaceutical Preparations; Play; Policies; Population; Quality of Care; Race; Risk Factors; Role; Rural; Site; Smoking; Socioeconomic Status; Suicide; Time; United States; Violence; Vital Statistics; attributable mortality; contextual factors; discrete time; experience; falls; geographic difference; health care availability; health care quality; health care service; improved; metropolitan; migration; mortality; mortality disparity; peer; residence; rural area; socioeconomics; suburb; trend

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.

项目概要/摘要 该项目旨在确定造成死亡率地域不平等水平和趋势的因素 跨越美国城乡连续体和地区的居住地的城市性。 本身就是社会经济地位（SES）和获得医疗保健服务的重要分层维度，以及 现有的 SES 梯度对大型中心预期寿命的研究在很大程度上忽视了这一点。 大都市区及其郊区的预期寿命显着提高 1990 年和 2015 年是 2010 年至 2015 年期间预期寿命有所延长的唯一地区。 相比之下，较小的都市圈和非都市圈在 1990 年至 2010 年间的进步要慢得多， 2010 年至 2015 年间，人们的预期寿命实际上有所下降。 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) 医疗保健的获取和质量，以及 (3) 国内和国际移民的贡献。 这三种机制中的每一种都对 1990 年至 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 纵向死亡率研究和美国社区死亡率差异数据库）结合 包含生命统计数据和涵盖广泛背景因素的多个地区级数据集。 限制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 之前的研究尚未用于确定死亡率差异或驱动这些差异的机制 我们将采用包括标准在内的多种方法论。 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适用于总体数据和个体数据。 对行为风险因素对死亡率不平等的影响进行严格而彻底的评估 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，并解释 吸烟等行为对死亡率的生命历程影响 移民对死亡率不平等的影响。 然而，鉴于美国移民数量的增加，迄今为止，这一问题还没有受到多少关注。 有选择性地迁移到县内的不同地区和都市区/非都市区，以及健康状况 移民的优势，移民可能在扩大生活中的地理不平等方面发挥重要作用 该项目是第一个量化国际和国内移民对预期影响的研究。 我们还将研究 SES（教育和收入）的差异。 预期寿命的不平等在城乡连续体中存在差异，并确定了日益加剧的不平等是如何产生的 与其他高收入国家相比，美国的预期寿命缩短了。