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Factors Behind Some Women's Falling Life Span: Q&A

A study published Monday in the journal Health Affairs suggests life span for women in some parts of the country is actually falling, a finding that generated a lively discussion among Wall Street Journal readers. On Wednesday, The Wall Street Journal spoke with the authors of the study— David Kindig, a health-sciences professor at the University of Wisconsin's Population Health Institute, and Erika Cheng, a Ph.D candidate at the university—about what factors may be behind the result. Here is an edited excerpt:

The Wall Street Journal: What motivated you to conduct this study in the first place?

David Kindig: I'm not sure if you're familiar with the County Health Rankings, but it's a project funded by the Robert Wood Johnson Foundation that we work on here at the Population Health Institute. Each year, it releases the health outcomes of every county in the country, and they're incredibly useful. But they really only discuss how we're doing right now at this moment. They don't deal with change or improvement over time. So I asked Erika to gather some data, and when she came to me with these numbers about women, I was shocked. We dug right in. That was 2½ years ago.

WSJ: What were your expectations?

DK: You know, we thought there might be something going on, but we never expected these findings. We knew that females live longer than men, in general at all levels, but if you'd have told me one gender would worsen more than the other, I would have said no way, because why would it be? Nations and states tend to improve. Sure, at the county level, things work a little differently, but on a national or regional level, you almost never see absolute worsening.

Erika Cheng: I might have expected men to have improved more than women because women tend to do better in health studies, so maybe there'd be less room for them to improve. But we certainly didn't expect the opposite to be true, for women to be doing worse. You expect health to improve over time. You just do. So it was shocking for both of us to find that it wasn't true for females.

WSJ: Were you surprised by the results? What caught you off guard?

EC: For me, it was the sheer number of counties where women were doing worse and the degree. They weren't just doing a little bit worse; it was significant decline.

DK: We were surprised to find out how big a role social determinants played in our research, such as family income, graduation rates and smoking. These things are often not as appreciated as medical determinants, such as the rates of preventable hospitalization, the number of primary-care facilities per county, and so on. Those are important too, of course, but we found the social determinants to be significantly associated with the decline. To see that come through this national data set and underscore it was fascinating.

The obvious question is: why? We thought it would be interesting to involve our readers, so we picked out some of the most common explanations put forward in the comments section of the article on the Wall Street Journal website, and asked the study's authors to respond to them.

Reader comment: Diet, obesity and fast food. Those with money suffered less because it costs more to feed yourself well, and better-educated people make more-informed food choices.

DK: We agree that diet is a factor, and also agree that we absolutely can't look at diet independently. Education is huge, because you need a certain level of education to know which choices to make about diet. Listen, some places out there are food deserts. People couldn't buy certain foods even if they wanted to. But again, that's less about dietary choices and more about income. So it's not as simple as just pointing at fast-food restaurants and blaming them for not serving more fruits and vegetables, because there's other factors at play. What about our choice? And how do we learn to make good choices? How much does the good choice cost? Is it available in our neighborhood? You get the idea.

EC: David's right. The important thing is to understand that its multiple factors. It's diet, but it's not diet on its own. It's a bunch of things working together.

Reader comment: This is most likely stress-related, as more women joined the workforce on a full-time basis at the time the data began.

EC: I think this is a fascinating topic. Unfortunately, we didn't dig too far into stress because it's very difficult to measure at the county level, but we both agree that it is highly likely that stress plays a role here. Absolutely.

DK: I think stress is undoubtedly a factor here. Living in a small, rural place has its stresses. Being a working mother has its stresses. Not having the resources you need at your fingertips or the education required to earn more money, these are all things that certainly involve stress.

The study found that the association of smoking with mortality was slightly stronger in women than in men. ENLARGE

Reader comment: Obviously, smoking is the biggest contributor to declining female life spans. Smoking rates have declined in men.

DK: Smoking was the thing we were absolutely not surprised to find as a huge factor. When people ask what factors were more important for women than men, it's smoking. The association of smoking with mortality was slightly stronger in women. It was the one little hint we had for the gender differences. Women took up smoking later and are quitting later than men.

WSJ: Of all the above factors, why do you think the decline in women's life span is happening?

DK: Well, I would note that those factors affect everybody in every region. Its not like southern women die more from smoking than women in other places, it's a confluence of these factors coming together, kind of in a perfect storm, in certain parts of the south and west. What that means is that those policy makers, legislators and business leaders are going to have to do more. They have a steeper hill to climb. And on our part as researchers, we have to really ramp up our data so that we're confident enough to act on it.

WSJ: What else piqued your interest during this study?

EK: We think the concept of migration is important and something that deserves follow-up research. We tried to control for population changes—whether people moved away from certain counties or into them—but it was difficult to determine how long these people that are reported as dying in certain counties had lived there, and where they came from. I'm not sure where the male-female angle would be, but I think migration is definitely relevant.

WSJ: To what extent do you think accessibility to health care plays a role?

DK: It wasn't significant in this study compared to other factors, but access to health care is of course critical. It's a two-way story, you know? This study should not be interpreted to say that health care doesn't matter, but it also shouldn't be interpreted to say that smoking and graduation rates don't matter. They're both important. We just found that in this study, one was more important than the other.

WSJ: The data seem to suggest the problem is occurring particularly in low-population, rural areas of the country.

DK: That might be an over-interpretation because it's not only small and rural places. Low density was a factor, but it was weak compared to the smoking, education and income factors. There are significant-sized counties that are also having higher death rates, as well, so it isn't that broad.

WSJ: Where can our readers turn for more information?

DK: Check out the County Health Rankings. They provide your area's smoking rates, graduation rates, insurance rates and so on. When we re-report that data at the state level, officials use those rankings to say, "OK, what do we need to work on?" It's important information. And I want to emphasize that it varies by county. There are counties in Utah with fine smoking rates that have a long way to go in terms of graduation. We see this as a tool for people to come together and figure out what they need to work on and what they're doing well on.

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