1. Economic Dislocation and Landscapes of Despair: Rural-Urban & Within-Rural Differences in Non-Hispanic White Premature Mortality
Shannon M. Monnat
Lerner Chair for Public Health Promotion and Associate Professor of Sociology
Senior Research Associate, Center for Policy Research
Maxwell School of Citizenship and Public Affairs
Syracuse University
March 21-22, 2018, Washington, DC
Rural Policy Research Initiative
Rural Poverty: Fifty Years after The People Left Behind
Acknowledgements: USDA ERS Cooperative Agreement ( ); Institute for New Economic Thinking (INO ); SU Lerner Center for Public Health Promotion; USDA Agricultural Experiment Station Multistate Research Project: W4001: Social, Economic, and Environmental Causes and Consequences of Demographic Change in Rural America.

2. Objectives
Track distribution of counties by rates of drug, alcohol, and suicide mortality ( ) by rural-urban and poverty status.
Analyze relationships between poverty and mortality by metro status.
Data
County Mortality Rates: National Center for Health Statistics restricted multiple cause of death mortality files, (NH whites, age 25-64, counties w/NHW pop >2,000)
County Economic and Demographic Measures: 2000 U.S. Census & American Community Survey

3. Mortality Rates, (NHW 25-64), 2000-2016
Rates are age-adjusted
Drugs
Alcohol
Suicide

4. Mortality Rates, (NHW 25-64), 2014-16
All-Cause Mortality
Drugs
Alcohol
Suicide
Rates are age-adjusted

5. Percentage of Counties with NHW (age 25-64) Mortality Rates >30, by Metro Status
Rates in highest in urban fringe
Increased most in urban fringe & medium/small metro
Nonmetro
Rates in highest in micro & rural
Increased most in medium/small metro
Rates in highest in micro & rural
Increased most in medium/small metro

6. Relationship between Poverty and NHW (age 25-64) Mortality Rates
Similar patterns when plotting NHW poverty in
Rates are age-adjusted; analyses exclude counties with <2000 NHW pop; error bars represent 95% confidence intervals

7. Persistent vs. New Poverty (NHW 18-64) – based on 15%+ poverty rates
Rates are age-adjusted; analyses exclude counties with <2000 NHW pop

8. Persistent Poverty vs. New Poverty and Mortality
Rates are age-adjusted; analyses exclude counties with <2000 NHW pop; error bars represent 95% confidence intervals

9. Regression Results – NHW (age 25-64) Mortality Rates 2014-16
Persistent Poverty vs. Non-Poverty
B (RSE)
New Poverty vs. Non-Poverty
Drug Mortality Rates,
Model 1
5.13 (1.35)
2.40 (0.89)
Model 2
Alcohol Mortality Rates,
3.10 (0.84)
1.69 (0.57)
Suicide Mortality Rates,
4.14 (1.04)
1.16 (0.70)
Model 1: spatial autoregressive model with state fixed effects & robust standard errors (RSE), model controls for metro status, 2000 % NH black, % Hispanic, % age 65+, % veterans, % vacant housing, % separated divorced, change in each measure (2000 to ), and population loss 2000 to
Model 2: adds 2000 % unemployed/not in labor force, % age 25+ w/4-year college degree, and change in these two measures 2000 to
Bolded values indicate statistical significance at p<.05;
B=difference in #deaths per 100,000 population

10. Regression Results – NHW (age 25-64) Mortality Rates 2014-16
Persistent Poverty vs. Non-Poverty
B (RSE)
New Poverty vs. Non-Poverty
Drug Mortality Rates,
Model 1
5.13 (1.35)
2.40 (0.89)
Model 2
2.99 (1.45)
1.65 (0.91)
Alcohol Mortality Rates,
3.10 (0.84)
1.69 (0.57)
1.86 (0.93)
1.40 (0.93)
Suicide Mortality Rates,
4.14 (1.04)
1.16 (0.70)
4.16 (1.15)
1.05 (0.73)
Model 1: spatial autoregressive model with state fixed effects & robust standard errors (RSE), model controls for metro status, 2000 % NH black, % Hispanic, % age 65+, % veterans, % vacant housing, % separated divorced, change in each measure (2000 to ), and population loss 2000 to
Model 2: adds 2000 % unemployed/not in labor force, % age 25+ w/4-year college degree, and change in these two measures 2000 to
Bolded values indicate statistical significance at p<.05;
B=difference in #deaths per 100,000 population

11. Regression Results – Change in NHW Mortality Rates, 2000-02 to 2014-16
Model 1: spatial autoregressive model with state fixed effects & robust SEs, controls for mortality rate in , metro status, 2000 % NH black, % Hispanic, % age 65+, % veterans, % vacant housing, % separated divorced, change in each measure (2000 to ), and population loss 2000 to ;
Model 2: adds 2000 % unemployed/not in labor force, % age 25+ w/4-year college degree, and change in these two measures 2000 to
Persistent Poverty vs. Non-Poverty
B (RSE)
New Poverty vs. Non-Poverty
Change in Drug Mortality Rates
Model 1
4.55 (1.33)
1.61 (0.88)
Model 2
2.61 (1.43)
0.90 (0.90)
Change in Alcohol Mortality Rates
2.67 (0.84)
1.53 (0.57)
1.54 (0.93)
1.27 (0.59)
Change in Suicide Mortality Rates
4.14 (1.04)
1.16 (0.70)
4.16 (1.15)
1.05 (0.73)
Bolded values indicate statistical significance at p<.05;
B=difference in #deaths per 100,000 population

12. Regression Results by Metro Status –NHW (age 25-64) Mortality Rates, 2014-16
Drugs: Higher in persistent poverty; not explained by employment/education composition
Alcohol: Higher in new poverty; explained by employment/education
Suicide: poverty not associated
NONMETRO
Drugs: Higher in both persistent and new poverty; explained by employment/education composition
Alcohol: Higher in persistent; explained by employment/education
Suicide: Higher in persistent; not explained by employment/education

13. Nonmetro NHW (age 25-64) Mortality Means by Region, 2014-16

14. Nonmetro NHW (age 25-64) Mortality Means by Region, 2014-16

15. Summary Drug epidemic not disproportionately rural:
NHW (age 25-64) drug mortality rates higher in metro counties
Largest increases since 2000 in urban fringe and medium/small metro.
But, rural areas may have more challenges dealing with it.
Heterogeneity: very high rates in some nonmetro counties (i.e., Appalachia, southwest), very low in others.
Don’t forget about the other “deaths of despair”:
Alcohol & suicide mortality rates higher in nonmetro counties; largest increases since 2000 in medium/small metro.
Poverty more strongly associated with drug mortality rates than with alcohol and suicide mortality rates.
Poverty (especially persistent poverty) more strongly associated with drug mortality in nonmetro than metro counties.
Driven by counties in Midwest and South.
May be function of employment and education composition.

16. Shannon Monnat smmonnat@maxwell.syr.edu
Thank you.
Shannon Monnat