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Problem/ConditionHigher rates of death in nonmetropolitan areas (often referred to as rural areas) compared with metropolitan areas have been described but not systematically assessed.Period Covered1999–2014Description of SystemMortality data for U.S. residents from the National Vital Statistics System were used to calculate age-adjusted death rates and potentially excess deaths for nonmetropolitan and metropolitan areas for the five leading causes of death. Age-adjusted death rates included all ages and were adjusted to the 2000 U.S. standard population by the direct method. Potentially excess deaths are defined as deaths among persons aged <80 years that exceed the numbers that would be expected if the death rates of states with the lowest rates (i.e., benchmark states) occurred across all states. (Benchmark states were the three states with the lowest rates for each cause during 2008–2010.) Potentially excess deaths were calculated separately for nonmetropolitan and metropolitan areas. Data are presented for the United States and the 10 U.S. Department of Health and Human Services public health regions.ResultsAcross the United States, nonmetropolitan areas experienced higher age-adjusted death rates than metropolitan areas. The percentages of potentially excess deaths among persons aged <80 years from the five leading causes were higher in nonmetropolitan areas than in metropolitan areas. For example, approximately half of deaths from unintentional injury and chronic lower respiratory disease in nonmetropolitan areas were potentially excess deaths, compared with 39.2% and 30.9%, respectively, in metropolitan areas. Potentially excess deaths also differed among and within public health regions; within regions, nonmetropolitan areas tended to have higher percentages of potentially excess deaths than metropolitan areas.InterpretationCompared with metropolitan areas, nonmetropolitan areas have higher age-adjusted death rates and greater percentages of potentially excess deaths from the five leading causes of death, nationally and across public health regions.Public Health ActionRoutine tracking of potentially excess deaths in nonmetropolitan areas might help public health departments identify emerging health problems, monitor known problems, and focus interventions to reduce preventable deaths in these areas.

In spite of the increasing number of young women infected with HIV in the United States, little is known about the reproductive and mothering experiences of these women. The purpose of the grounded-theory research discussed in this article was to describe the reproductive and mothering experiences of HIV-positive women. Twenty HIV-positive women participated in 31 in-depth interviews. The grounded-theory method was used for data analysis. A communication pattern known in the psychiatric literature as a double bind was discovered to be a basic social psychological problem that affected the women's experiences with reproduction and mothering. An understanding of the power and influence of these double binds permits health care professionals to plan patient-centered programs and to individualize care specifically for HIV-positive women.

To test the hypothesis that physical inactivity is associated with increased stroke risk in women and men, the authors analyzed data from a longitudinal cohort study with three follow-up data collection waves. In the Nation Health and Nutrition Examination Survey I (NHANES I) Epidemiologic Follow-up Study, 7,895 white persons and black persons aged 45-74 years were examined in 1971-1975 as part of NHANES I. Included in this analysis were 5,852 persons without a history of stroke (fatal and nonfatal) or missing data. The average follow-up was 11.6 years (maximum, 16.4 years). Incident stroke (fatal or nonfatal) was the main outcome measure. Events were ascertained from cause of death information coded from death certificates and from discharge diagnoses coded from hospital and nursing home records during the follow-up period (1971 through 1987). Participants were asked to characterize their level of habitual physical activity as low, moderate, of high. The relative risk for stroke was estimated by Cox proportional hazards regression analysis, comparing persons reporting low with those reporting high physical activity at baseline and persons in the upper with those in the lower tertile of resting pulse rate. There were 249 incident cases of stroke identified in white women, 270 in white men, and 104 in blacks. In white women aged 65-74 years, low nonrecreational activity was associated with an increased risk of stroke (relative risk = 1.82,95% confidence interval 1.10-3.02) after adjusting for the baseline risk factors of age, smoking, history of diabetes, history of heart disease, education, systolic blood pressure, serum total cholesterol, body mass index, and hemoglobin concentration. Similar associations were seen for men and for blacks and for low recreational activity in women. A higher resting pulse rate was associated with an increased risk of stroke in blacks but not in whites. A consistent association of reported low physical activity with an increased risk of stroke was observed in white women. Regular physical activity may be of benefit in preventing stroke in women as well as men.