If perception were reality, the most dangerous places to live would be major urban areas, where crimes like homicide are supposedly high.
Perception is not reality.
A new study in the Annals of Emergency Medicine shows that if people are going to die by an injury, they much more likely are in the country.
Sage Meyers, a pediatric emergency medicine physician and the lead author of the study at the University of Pennsylvania's Perelman School of Medicine, was surprised when she saw the results.
"The media tends to present injury deaths that are more sensational, and people tend to have a more emotional reaction to injuries that are intentional, especially homicide, and therefore hold these closer in their mind," she said. "Here we were able to look at all injury-related deaths together to realize that when you consider 'safety' to be the risk of serious injury to yourself, you are safer in an urban county than outside of an urban county, which tends to be contrary to what people would initially believe."
The study may make people think more about the safety of where they live, but it also may inform how emergency-care resources are allocated and how campaigns to reduced injuries can be targeted more effectively, Meyers said.
By analyzing more than a million injury deaths that occurred between 1999 and 2006, the study showed that the risk of injury death was 22 percent higher in the most rural counties than in the most urban counties.
This is looking at all injury deaths together — intentional (such as homicide and suicide) and unintentional (such as motor vehicle crashes, falls and other accidents). But if you compare unintentional injury death to homicide, people are 15 times more likely to die because of an unintentional injury than be murdered. The risk of those unintentional deaths rests heavily in rural areas where the risk of injury death is 40 percent higher than the most urban areas.
"I think that we were struck by how much higher the risk of unintentional injury death was as compared to homicide and suicide," Meyers says. "This really drove our findings, as unintentional injury rates are much higher in rural areas as compared to urban. Any differences in homicide and suicide are dwarfed by the risk of unintentional injury. "
Homicide rates were significantly higher in urban counties, according to the study. The more rural the county, the fewer homicides. Although suicide rates were higher in the most rural counties, the study said the differences were not significant.
The most common way people died from injuries involved automobile crashes. There were 27.61 deaths per 100,000 people in most rural areas and 10.58 per 100,000 in most urban areas.
Part of the reason automobile deaths may be higher in rural areas could be related to higher speeds, increased risk taking, disregarding of traffic laws and longer distances to medical care, the study says.
Initial analysis in the study, however, indicates that access to trauma care has little effect on the numbers of injury deaths.
Other dangers in rural settings include injury deaths by machinery and environmental injuries such as exposure to the elements. One area where rural areas do better than cities is in falls among the elderly. Older people are more likely to fall in cities and get hurt than in rural areas. The study did not look at the possible reasons for this difference.
As part of the study, the researchers looked at the differences in how various groups fared in urban versus rural areas.
Rural areas with the most educated people were less safe than rural areas with lower percentages of educated people.
Rural areas with the highest percentages of black inhabitants had much lower risk of injury death than rural areas with fewer black inhabitants. The study ventured a few hypothesis for this difference. Blacks have a lower rate of suicide, and given the higher rate of suicide in rural areas, this would have an impact. The study also speculated that it could be that rural communities with more blacks may be farther from highways where the highest percentages of rural injury deaths take place.
The opposite was true for Latinos. The more Latinos in a rural area, the larger the risk of injury death.
"As these were not the focus of the study, but secondary analyses, we did not look further into why these differences exist," Myers said. "But they are ripe for further study."
Another area for study — or implementation, is to take the broader results and target rural areas for injury-prevention intervention.
"There is no need to use the same technique or deliver the same message across the rural-urban spectrum if you know the differences in what specific injuries that people are at risk for in rural areas or urban areas, and at what ages," Myers says. "You can target your interventions to those specific injuries, in the age groups that are most at risk."
For example, a campaign about fall injuries among older Americans would be more effective if targeted to urban elderly, she says.
And perhaps, because of this study, a city's Chamber of Commerce may advertise someday about how people should consider leaving the dangerous countryside and coming to the relatively safer city.