Trends in the educational gradient of mortality among US adults aged 45 to 84 years: Bringing regional context into the explanation

Objectives: We investigated trends in the educational gradient of US adult mortality, which has increased at the national level since the mid-1980s, within US regions. Methods: We used data from the 1986-2006 National Health Interview Survey Linked Mortality File on non-Hispanic White and Black adults aged 45 to 84 years (n = 498 517). We examined trends in the gradient within 4 US regions by race-gender subgroup by using age-standardized death rates. Results: Trends in the gradient exhibited a few subtle regional differences. Among women, the gradient was often narrowest in the Northeast. The region's distinction grew over time mainly because low-educated women in the Northeast did not experience a significant increase in mortality like their counterparts in other regions (particularly for White women). Among White men, the gradient narrowed to a small degree in the West. Conclusions: The subtle regional differences indicate that geographic context can accentuate or suppress trends in the gradient. Studies of smaller areas may provide insights into the specific contextual characteristics (e.g., state tax policies) that have shaped the trends, and thus help explain and reverse the widening mortality disparities among US adults.