Race, Rurality, and Suicidality in Children and Adolescents

Abstract

Introduction:

Suicide is among the leading causes of death in U.S. youth. Rural residency is a risk factor, but suicide variability by race/ethnicity is more nuanced. Early detection of suicidal ideation and intent are key components of prevention, but to the authors’ knowledge, few prior studies have examined how rurality and race interact on youth suicidality. This study examined suicidality between White non-Hispanic vs. non-White or Hispanic youth, as well as those who lived in rural vs. non-rural areas.

Methods:

Cross-sectional analyses were conducted using data from youth age 5–17 years who had complete capture of their medical care in a Wisconsin healthcare system. Suicidality was extracted from medical records by screening for diagnoses indicative of suicidal attempt or ideation between 2017 and 2022. Race/ethnicity and rural residence were extracted from administrative records. Analyses were done in 2023.

Results:

The sample included 27,392 rural and 20,370 non-rural youth, with suicidality observed in 2% of participants. There was a significant interaction between rural residence and race/ethnicity (p = 0.015). Non-White or Hispanic youth in rural areas had the highest risk of suicidality at 75 (CI: 57, 97) per 10,000. Non-White or Hispanic youth in non-rural areas had the lowest risk of suicidality at 38 (CI: 28, 52) per 10,000.

Conclusions:

Racial/ethnic minority youth who lived in rural areas were more likely to experience suicidality as compared to their non-rural counterparts. Larger prospective studies are needed to identify causal elements of the rural environment that may hasten racial disparities in youth suicidality.

Introduction

The U.S. has the seventh highest rate of adolescent suicides in 35 developed nations,¹ and suicide is among the leading causes of mortality across all U.S. youth.² Suicide rates are ~50% higher in rural U.S. adolescents and young adults relative to their suburban and urban counterparts.³ Data on suicides by race/ethnicity in youth, however, are more nuanced. Youth suicides are highest among Native Americans, with Asian, African American, and Hispanic groups lowest.^{4, 5}

Increased youth suicides are a public health concern, but epidemiologic factors are only partially understood. Early identification of suicidal ideation and attempt are key components of preventing mortality,⁶ but few prior studies have examined how rural residence and race/ethnicity interact to influence youth suicidality. This study examined suicidality between White non-Hispanic vs. non-White or Hispanic youth, as well as those in rural vs. non-rural areas.

Methods

Using data from the Wisconsin National Children’s Center for Rural and Agricultural Health and Safety surveillance system,⁷ a cross-sectional analysis was conducted. The source population included patients of the Marshfield Clinic Health System (MCHS; Marshfield, WI) in north-central Wisconsin. The sample included individuals who, between 01/01/2017 and 12/31/2022: (1) were age 5–17, (2) had ≥ 1 MCHS medical encounter, and (3) had reasonably complete capture of their medical care within MCHS data systems, as evidenced by residency in the Marshfield Epidemiologic Study Area,⁷ medically-homed to MCHS, or a member of MCHS’s Security Health Plan of Wisconsin. The upper age bound was constrained by the age of the cohort under surveillance and the lower age bound was based on the youngest cohort member with suicidality. Procedures were approved by the MCHS Institutional Review Board, with wavers of informed consent and HIPAA authorization.

Race and ethnicity were extracted from MCHS electronic health records (EHR) using standard categories. Given the limited diversity of the source population, race/ethnicity was combined into two discrete groups, including White non-Hispanic vs. non-White or Hispanic. This approach helped avoid low statistical power in less common race/ethnicity groups. Rural residence was defined by Rural Urban Commuting Area scores based on each participant’s residential ZIP code, which considers population density and commuter volume to metropolitan areas using U.S. Census data.⁸

The outcome was medically-attended suicidality, which was extracted from the EHR. International Classification of Diseases version 10 diagnostic codes indicative of suicidal attempt or ideation (presenting to MCHS urgent/emergency, inpatient, or outpatient settings) were screened for. Per Healthcare Cost and Utilization Project Clinical Classification Software,⁹ diagnostic codes that mapped to suicidal ideation and intentional self-harm (5.13) were combined, and individuals with any code for suicidality between 2017 and 2022 were categorized as cases. These codes confirm suicidality in 95% of identified cases.¹⁰

Associations between race, rurality, and suicidality were analyzed using multivariable logistic regression. All models included an interaction term for race and rural residency, along with several a priori specified covariates, including sex, age (quartiles) at last follow-up, health insurance, suicidality prior to 2017–2022, major depression (EHR codes), and number of county residents per mental healthcare provider.¹¹

Results

The sample included 27,392 rural (57%) and 20,370 non-rural (43%) youth. Age and sex differences were negligible between rural and race/ethnicity groups, but there were dissimilarities in health insurance and number of mental healthcare providers (Table 1). Non-White or Hispanic youth were much more likely to have public-assisted health insurance, and there was a much lower ratio of mental healthcare providers to residents of rural areas.

Table 1.

Characteristics of north-central Wisconsin youth age 5–17 years who lived in rural vs. non-rural areas, 2017–2022.

Characteristics	Rural, White non-Hispanic (n = 23,502)	Rural, non-White or Hispanic (n = 3,890)	Non-rural, White non-Hispanic (n = 16,293)	Non-rural, non-White or Hispanic (n = 4,077)
Age, frequency (%)
5–8 years	6,806 (29%)	1,205 (31%)	4,548 (28%)	1,224 (30%)
9–11 years	5,259 (22%)	987 (23%)	3,508 (22%)	943 (23%)
12–13 years	5,653 (24%)	939 (24%)	3,988 (24%)	978 (24%)
14–17 years	5,784 (25%)	849 (22%)	4,249 (26%)	932 (23%)
Sex, frequency (%)
Female	11,441 (49%)	1,936 (50%)	7,878 (48%)	2,005 (49%)
Male	12,061 (51%)	1,954 (50%)	8,415 (52%)	2,072 (51%)
Health insurance, frequency (%)
Private	7,895 (34%)	571 (16%)	5,660 (35%)	437 (11%)
Public-assisted	15,180 (65%)	3,244 (83%)	10,436 (64%)	3,582 (88%)
None or unknown	427 (2%)	75 (2%)	197 (1%)	58 (1%)
Number of county residents for each mental healthcare provider, mean ±SD	1,009.5 ±543.9	1,137.0 ±603.6	657.5 ±384.6	478.5 ±270.7
Major depression, frequency (%)	855 (4%)	137 (4%)	653 (4%)	121 (3%)
Suicidality prior to 2017–2022, frequency (%)	6 (0%)	3 (0%)	3 (0%)	3 (0%)

Suicidality was observed in 2% (n=845) of all youth, with 67% of cases age 14–17 years and 68% female. Crude suicidality case counts by rural residence and individual race/ethnicity categories are outlined in Table 2. In the multivariable model, there was a significant interaction between rural residence and race/ethnicity (p = 0.015; model not shown). To illustrate this association, model-estimated risks of suicidality are summarized in Figure 1. Non-White or Hispanic youth who lived in rural areas had the highest risk of suicidality at 75 (CI: 57, 97) per 10,000. In contrast, non-White or Hispanic youth who lived in non-rural areas had the lowest risk of suicidality at 38 (CI: 28, 52) per 10,000. White non-Hispanic youth, both rural and non-rural, had similar, mid-range risk of suicidality. All covariates were significant.

Table 2.

Number of suicidality cases by rural residence and race/ethnicity groups in north-central Wisconsin youth age 5–17 years.

			Rurala						Non-rural
Cases	White (n=25,516)	Hispanic (n=2,145)	Black or African American (n=633)	Asian (n=363)	Native American or Alaskan Native (n=863)	Native Hawaiian or Pacific Islander (n=104)	White (n=17,796)	Hispanic (n=1,125)	Black or African American (n=895)	Asian (n=1,946)	Native American or Alaskan Native (n=226)	Native Hawaiian or Pacific Islander (n=50)
Suicidality, frequency (%)	472 (1.8%)	54 (2.5%)	22 (3.5%)	2 (0.6%)	20 (2.3%)	2 (1.9%)	299 (1.7%)	22 (2.0%)	26 (2.9%)	9 (0.5%)	4 (1.8%)	2 (4.0%)

^aBecause race/ethnicity categories are not mutually exclusive, individual participants could be in multiple race/ethnicity categories, and the sum of all race/ethnicity counts exceed the total sample size. Likewise, the sum of all suicidality case counts in this Table exceed that observed in the sample.

Figure 1.

Estimated prevalence of medically-attended suicidality in north-central Wisconsin youth age 5–17 years, by rural residence and race/ethnicity, 2017–2022. The final model included an interaction term for race and rural residency, and was adjusted for age, sex, health insurance, prior suicidality, major depression, and number of county residents per mental healthcare provider.

Discussion

This is one of the few studies to examine the impact of race and rurality on medically-attended suicidality in youth. White non-Hispanic youth had a similar risk of suicidality regardless of residence. Non-White or Hispanic youth, however, had significantly greater risk of suicidality in rural areas, and half the risk of suicidality in non-rural areas. This was consistent with prior cluster analyses observing higher risks of suicide in rural African American youth.⁵

Rural factors can hasten racial disparities in many ways,¹² and youth suicidality in this study was consistent with prior research showing lower self-rated health among most rural adult racial/ethnic minorities.¹³ This may be driven by socioeconomic factors such as parental education and household income, which were unavailable in this study, but known to be lower in rural, racial/ethnic minority groups.^{12, 13} Payer mix was heavily influenced by race/ethnicity in this study, as considerably fewer non-White or Hispanic youth had private health insurance. In rural communities, the lack of mental healthcare or social services, particularly those oriented toward diverse residents, could also contribute to youth suicidality.¹² More research is needed on clinical implications, but rural providers could likely improve healthcare quality by incorporating more frequent mental health screenings in racial minority patients. There have also been some successful regional efforts to decrease suicides in Native American youth.¹⁴

Conversely, non-White or Hispanic youth who lived in non-rural areas had the lowest risk of suicidality. Reasons are speculative, but could reflect residual confounding. This study sample was too small to analyze suicidality by specific race/ethnicity groups. The collapsed non-White or Hispanic category obscured the racial compositions of rural and non-rural areas. For example, the study non-rural group had lower proportions of Native Americans and higher proportions of Asians. These two groups, respectively, have the highest and (among the) lowest rates of youth suicide in the U.S.^{4, 5} Such patterns were similar in this study, and suicidality case counts were lower in non-rural areas for nearly all race/ethnicity groups.

Limitations

Strengths of this study included the defined population and objective EHR marker of suicidality. However, this approach yields an undercount, as it is limited to youth with medically-attend suicidality. In addition, generalizability is restricted by the north-central Wisconsin source population, which is less diverse than many parts of the U.S. This required a collapsed race/ethnicity exposure to preserve statistical stability, which limits more granular conclusions concerning health equity.¹⁵ As suicide risk can vary by specific groups,^{4, 5} race/ethnicity data should be analyzed in greater detail using larger datasets. In addition, familial differences in mental healthcare seeking, and mediating roles of various mental health disorders, should be compared by race/ethnicity groups in rural and non-rural areas.¹⁶

Conclusions

Compared to their rural counterparts, racial/ethnic minority youth who lived in non-rural areas were less likely to experience suicidality. This highlights the need for larger, prospective studies to identify causal elements of the rural environment that drive racial disparities in youth suicidality. This could inform future clinical interventions and social solutions to youth suicide prevention.