Place‐Based Inequality in US Suicide Mortality During the First Pandemic Year: Rural–Urban Divergence and Later Vaccination Uptake
Matias GayABSTRACT
Objective
This study aims to quantify rural–urban divergence in US suicide mortality during 2020 and assess how a subsequent ecological vaccination‐uptake marker and county‐level population composition relate to that divergence.
Methods
We linked CDC WONDER deaths and denominators for 2018–2021 across six 2013 NCHS urbanization categories. The original analysis included 242 state‐by‐urbanization cells and modeled the log 2020‐to‐pooled‐2018–2019 crude‐rate ratio. In a strictly matched 239‐cell sensitivity sample, models were adjusted for pre‐pandemic age, sex, racial/ethnic, and socioeconomic composition, with and without state fixed effects. A population‐offset Poisson panel, official CDC age‐adjusted benchmarks, and missing‐data sensitivity analyses evaluated robustness.
Results
An index of 100 represents each category's mean 2018–2019 crude rate. In 2020, the index was 93.0 in large central metropolitan and 102.2 in noncore rural areas (state‐bootstrap difference 9.27 points; 95% interval 5.40–13.23). The original vaccination‐uptake association attenuated after categorical urbanization adjustment ( β = −0.0231 before; β = −0.0125 after). In the 239‐cell analysis, the ordinal rurality coefficient was positive with population‐composition controls ( β = 0.0156; 95% CI 0.0038–0.0274) but uncertain after state fixed effects ( β = 0.0049; 95% CI −0.0207 to –0.0306). The fully adjusted Poisson model was likewise uncertain ( β = 0.0093; 95% CI −0.0179 to –0.0365).
Conclusions
The first pandemic year coincided with unequal mortality changes across US urbanization categories, also visible in national age‐adjusted CDC data. Neither a pandemic‐specific independent rurality effect nor a causal role for subsequent vaccination uptake was established. State‐level differences and the pre‐pandemic trend constrain explanatory claims.