Unravelling the extent of inequalities in health across urban and rural areas: Evidence from a national sample in England

Studies of inequalities in health between rural and urban settings have produced mixed and sometimes conflicting results, depending on the national setting of the study, the level of geographic detail used to define rural areas and the health indicators studied. By focusing on morbidity data from a national sample of individuals, this study aims to examine the extent of inequalities in health between urban and rural areas, as well as inequalities in health across rural areas of England. Multilevel analyses for poor self-rated health, overweight and obesity, and common mental disorders are reported for a sample of 30,776 individuals aged 18 years and older (obtained from the Health Survey for England years 2000–2003 combined) and distributed across 3645 small areas classed in four categories: two groups of urban areas (Greater London area or ‘other cities’) and two types of rural settings (semi-rural areas or villages). Results show that rural dwellers were significantly less likely than residents of urban areas to report their health as being fair or poor and to report common mental disorders, independent of their socio-demographic characteristics. However, as for urban settlements, there were significant variations in health across semi-rural areas and across villages, indicating the presence of health inequalities within rural settings in England. These inequalities were not fully explained by the individual composition of the areas or by the available measures of area socioeconomic conditions, indicating that in rural contexts more specific factors may have significance for health. Different policies and services for health promotion and care may need to be targeted to different types of rural areas.     

Biopsychosocial imperatives from the rural perspective

Rural health issues are examined within a biopsychosocial framework by addressing three questions: what is meant by ‘rural’? what are rural health needs? what factors must be considered in understanding and addressing these needs?Probably the single most important characteristic distinguishing rural from urban areas is low population density. This factor is particularly important in terms of its impact on (1) communication and transportation patterns, (2) one's ‘sense of community’ and (3) the availability of specialized services and complex organizations and institutions.For statistical purposes two different definitional dichotomies exist: rural-urban and metropolitan-nonmetropolitan. Although the rural and nonmetropolitan populations are not conterminous, approximately the same percentage of the nation's population is included in each of the two categories. A serious misconception is that of equating agriculture with rurality. While most farmers live and work in rural areas only a small fraction of rural Americans are engaged in agriculture.In terms of health needs, infant mortality tends to be higher in nonmetropolitan than in metropolitan areas; and limitation of activity due to chronic conditions is more likely to occur among the nonmetropolitan than the metropolitan population. Similarly, the percent of people who perceive their health as either ‘fair’ or ‘poor’ is higher for the nonmetropolitan population. On the other hand, the incidence of acute conditions and disability days per person per year are lower for the nonmetropolitan population than for the metropolitan population. Limited data on mental health suggest that the halcyon picture of country life may be grossly distorted.Understanding and addressing rural health needs involves a close look at the social, economic and medical systems operating in rural America. Income and employment levels, and their interrelationship to nutrition, housing and transportation generally find rural areas at a disadvantage. Although attitudes and values between rural and urban populations differ, it is all too easy to exaggerate these differences. The areas of sharpest differences have to do with issues of morality, religion and political philosophy. Problems in the availability and accessibility of medical services—especially specialized services—continue to plague rural areas.Recently, the most important dynamic in rural areas has been the rapid population growth associated with urban-to-rural migration. Another important characteristic of rural America is its diversity. Greater diversity likely exists among rural areas than among urban areas. For example, some rural areas have medical systems that are as sophisticated as those found in most urban areas.Failing to recognize and appreciate the diversity within the rural sector may be the greatest impediment to designing and implementing effective public policies for dealing with rural health needs. Considerable research, recent books, the creation of statewide offices of rural health and the work of national organizations have been helpful in alleviating the misunderstanding which surrounds rural America, its health care needs and the ways to best address those needs.     

On the Spatial Inequalities of Institutional Versus Home Births in Ghana: A Multilevel Analysis

Spatial inequalities related to the choice of delivery care have not been studied systematically in Sub-Saharan Africa where maternal and perinatal health outcomes continue to worsen despite a range of safe motherhood interventions. Using retrospective data from the 1998 and 2003 Demographic and Health Surveys, this paper investigates the extent of changes in spatial inequalities associated with type of delivery care in Ghana with a focus on rural-urban differentials within and across the three ecological zones (Savannah, Forest and Coastal). More than one-half of births in Ghana continue to occur outside health institutions without any skilled obstetric care. While this is already known, we present evidence from multilevel analyses that there exist considerable and growing inequalities, with regard to birth settings between communities, within rural and urban areas and across the ecological zones. The results show evidence of poor and disproportionate use of institutional care at birth; the inequalities remained high and unchanged in both urban and rural communities within the Savannah zone and widening in urban communities of the Forest and Coastal zones. The key policy challenges in Ghana, therefore, include both increasing the uptake of institutional delivery care and ensuring equity in access to both public and private health institutions.     

A rural advantage? Urban-rural health differences in northern England.

Rural health inequalities have been relatively neglected in recent years. The data assembled for a large study of health and deprivation in the Northern Region of England have been reanalysed to examine three questions. How wide are rural health inequalities compared with those in urban areas? Is health intrinsically better in rural areas, given comparable deprivation or affluence? Is the association between health and wealth weaker in rural than in urban areas? It is shown that, although health inequalities are wider in urban areas, this corresponds to wider socio-economic divisions: at equivalent levels of wealth, health measures are similar. This relationship breaks down, however, when the most remote rural areas are compared with matching localities in conurbations, for in this case rural areas have a clear advantage. We go on to show that the apparent weakness of the association between health and wealth in rural areas is largely an artefact; the association becomes stronger when the units of population (electoral wards) are enlarged to resemble more closely those in urban contexts. The comparability of rural and urban forms of deprivation is discussed in the light of these results.     

Service Use of Rural and Urban Medicaid Beneficiaries Suffering From Depression: The Role of Supply

Despite the prevalence and consequence of depression in rural areas, the literature on treating depression in rural areas is relatively scarce and inconclusive. The use of mental health services by rural people suffering from depression and the role that supply may play in explaining these differences are not well understood. Understanding these issues for rural Medicaid beneficiaries is important as Medicaid managed carefor physical and behavioral health care is expanded to rural areas. This study compares the mental health service use of rural and urban Medicaid beneficiaries, ages 18 to 64, in Maine suffering from depression and examines what influence mental health and primary care supply have in explaining observed differences. Two models are used to estimate the use of ambulatory mental health services: (1) a logit likelihood estimate of whether a beneficiary uses any outpatient mental health services for depression; (2) an ordinary least squares regression estimating the number of annualized ambulatory mental health care visits among users. Rural beneficiaries suffering from depression have lower utilization than urban beneficiaries. Rural and urban Aid for Families with Dependent Children (AFDC)--and Supplemental Security Income (SSI)--beneficiaries suffering from depression rely more on mental health than on general health care providers to receive ambulatory mental health care. Rural beneficiaries (AFDC and SSI) rely relatively more on general health care providers than urban beneficiaries. Multivariate analysis suggests that mental health supply and patient-level factors, but not primary care supply, account for utilization differences. This article describes the need to better understand factors limiting participation of primary care providers and to study the role of supply across multiple states.     

Rural, Urban and Suburban Comparisons of Preventive Services in Family Practice Clinics

Numerous studies have compared health services provided in rural and urban areas, and overall they have found that utilization is lower in rural areas. A significant factor in lower utilization is that rural residents have less access to health services. Much less is known about rural and urban utilization differences once a patient has access to a service provider. This paper focuses on preventive services received when a patient is already in a clinic. Using data from an in-depth qualitative study of 16 family practice clinics in Nebraska, comparisons of physician-specific preventive service rates are made across three geographic categories: rural, urban and suburban. Results from a one-way multivariate analysis of variance show that preventive services rates for nine services examined were as high or higher in rural areas, suggesting that rural health services do not lag for patients with access.     

Child Nutritional Status by Rural/Urban Residence: A Cross‐National Analysis

Purpose: Rural children in developing countries have poor health outcomes in comparison with urban children. This paper considers 4 questions regarding the rural/urban difference, namely: (1) do individual‐level characteristics account for rural/urban differences in child nutritional status; (2) do community‐level characteristics account for rural/urban differences net of individual‐level characteristics; (3) does type of residence alter the influence of individual characteristics; and (4) does the rural/urban difference vary across national contexts? Method: Analysis is based on Demographic and Health Survey data from 35 developing countries. Multilevel regression is used to examine rural/urban differences in nutritional status net of individual, community and national determinants of health status. Findings: Rural children have a substantially higher risk of poor nutrition. Much of this disadvantage is because of socioeconomic disadvantage, reproductive norms favoring early and more rapid childbearing, and lack of access to modern medicine. Rural residence also structures the nature of the relationships between socioeconomic status, access to medical care, and nutrition. Finally, the rural/urban gap declines as countries develop. Conclusion: Rural/urban differences in child nutritional status are substantial, and some—but not all—of the differences are attributable to socioeconomic status, access to medical care, and reproductive norms.     

Adequate Access to Posthospital Home Health Services: Differences Between Urban and Rural Areas

The health care environment in rural areas changed dramatically in the 1980s. Policy-makers are concerned that these changes have reduced access to care among residents of rural areas. This study measures adequate access to Medicare home health services and determines whether it differs for urban and rural beneficiaries. Adequate access to care is measured by whether a patient with a specific health condition received a level of skilled services predetermined as appropriate for that condition. The predetermined levels of care were developed in an earlier study and were found to correlate with adverse outcomes. This study focused on patients with diabetes mellitus and surgical hip procedures to concentrate on access to skilled nursing services and physical therapy services. To conduct the analysis, a data base was constructed that included both patient utilization and health status data, drawing on three different data sources: Medicare hospital claims data, Medicare home health bill record data, and home health plan of treatment data from patients' utilization review forms (forms 485 and 486). The analysis samples consisted of 404 patients with diabetes and 876 patients who had surgical hip procedures. Significant differences were found between urban and rural areas in access to home health services. The largest differences were found in access to physical therapy services, but differences in access to skilled nursing services also exist. The data suggest that the availability of skilled care services may cause these differences.     

Urban primary health care in Africa: a comparative analysis of city-wide public sector projects in Lusaka and Dar es Salaam

Since the 1980s, a number of health system interventions in Sub-Saharan Africa have targeted urban areas, reflecting increasing attention to the contextual contrasts between urban and rural health settings. This article compares attempts in two projects-in Zambia and Tanzania-to strengthen urban primary health care in the public sector and make it more inclusive in a dual sense: making quality services more accessible to the poor; and fostering community involvement in health care and health-related activity. The paper reveals that the projects have produced many similar outcomes (both positive and negative), despite differences in their managerial arrangements. After identifying issues that may need to be considered in other health initiatives, the discussion revisits the urban/rural dimension of health care in relation to three key aspects: the by-passing of primary services, community participation and inter-sectoral action.     

Migration and young women's access to maternal healthcare in sub-Saharan Africa

Pregnant young women have increased risk of poor maternal health outcomes and frequently have low rates of skilled maternal healthcare utilization. Migrant youth may suffer even poorer use of maternal health services given the disruption of migration, changes in social support, and potential difficulties in obtaining care in a new community. Using a sample of 46,905 women aged 15–24 from 27 Demographic and Health Surveys collected across sub-Saharan Africa from 2003 to 2009, I examine variation in use of skilled maternal healthcare, looking at three aspects of migration: place, disruption, and adaptation. I find evidence of a significant advantage in migrating to urban versus rural areas, suggesting that there is an urban advantage in maternal healthcare regardless of migrant stream. I find no evidence of positive adaptation on maternal healthcare use, but show that rural-rural migrants experience negative adaptation after longer duration of residence. There are lingering positive effects of this urban advantage for urban-rural migrants, who, despite a dearth of healthcare facilities in rural areas, maintain high use of maternal healthcare well after migration.     

基于误差空间模型城乡居民医疗保健消费影响因素的实证分析

目的探讨影响城乡居民医疗保健消费的主要因素及两者差异。方法利用误差空间自回归模型,对2009年我国31个省域城乡居民医疗保健消费支出的影响因素进行实证分析。结果出院病人医药费、地方财政卫生支出、受教育年限是影响城镇居民消费的主要因素,而个人纯收入、地方财政卫生支出、受教育年限是影响农村居民消费的主要因素;地方财政卫生支出、受教育年限对城乡居民医疗保健消费的作用方向相反。结论要区别对待城乡居民的健康需求。     

2000-2018年我国城乡居民医疗保健支出公平性变化研究

目的:了解我国城乡及地区间医疗保健支出现状及差异性,分析我国城乡居民医疗保健支出的公平性,为我国医药卫生体制改革提供科学参考。方法:收集2000—2018年城乡医疗保健支出、人均可支配收入及人均纯收入等相关数据,采用集中指数和集中曲线对我国城乡医疗保健支出进行公平性分析。结果:2010—2018年城镇居民人均医疗保健支出(实际值)年平均增长速度为3.55%,农村居民人均医疗保健支出(实际值)年平均增长速度为10.00%。2000—2017年我国城镇居民人均医疗保健支出集中指数呈下降趋势,其中2006年出现最大值为0.1332,除2015—2017年外,其余年份差异均具有统计学意义(P<0.05);2000—2017年我国农村居民人均医疗保健支出集中指数呈下降趋势,2004年出现最大值为0.2522,差异均具有统计学意义(P<0.05)。结论:我国城乡人均医疗保健支出逐年增加,全国和各地区城乡人均医疗保健支出差距较大。我国城乡人均医疗保健支出存在不公平性,城镇人均医疗保健支出优于农村人均医疗保健支出,公平性逐渐趋好。     

Stunting and Anemia in Children from Urban Poor Environments in 28 Low and Middle-income Countries: A Meta-analysis of Demographic and Health Survey Data

Child malnutrition remains a global concern with implications not only for children’s health and cognitive function, but also for countries’ economic growth. Recent reports suggest that global nutrition targets will not be met by 2025. Large gaps are evident between and within countries. One of the largest disparities in child malnutrition within counties is between urban and rural children. Large disparities also exist in urban areas that have higher rates of child malnutrition in the urban poor areas or slums. This paper examines stunting and anemia related to an urban poverty measure in children under age 5 in 28 low and middle-income countries with Demographic and Health Survey data. We used the United Nations Human Settlements Programme (UN-HABITAT) definition to define urban poor areas as a proxy for slums. The results show that in several countries, children had a higher risk of stunting and anemia in urban poor areas compared to children in urban non-poor areas. In some countries, this risk was similar to the risk between the rural and urban non-poor. Tests of heterogeneity showed that these results were not homogeneous across countries. These results help to identify areas of greater disadvantage and the required interventions for stunting and anemia.     

Health-seeking behaviour and rural/urban variation in Kazakhstan

This paper seeks to analyse the findings of an extensive household survey, uncovering interesting evidence of variation in health-seeking behaviour across rural and urban areas due, it is suggested, to differences in real costs, quality of care, and perceptions of the value of health and health care. It is shown that, ceteris paribus, urban households in Kazakhstan are more likely to consult, to be admitted to hospital, to report illness, and will spend relatively more on health care.The data suggest the need for further qualitative study into the factors underlying these patterns leading to strategies to increase the quality, acceptability and affordability of rural health services. This is important given the decline in health indicators such as life expectancy in Kazakhstan and the increased burden on households of funding health care in a time of economic insecurity and deterioration of public services.     

Understanding Inequities in Child Vaccination Rates among the Urban Poor: Evidence from Nairobi and Ouagadougou Health and Demographic Surveillance Systems

Studies on informal settlements in sub-Saharan Africa have questioned the health benefits of urban residence, but this should not suggest that informal settlements (within cities and across cities and/or countries) are homogeneous. They vary in terms of poverty, pollution, overcrowding, criminality, and social exclusion. Moreover, while some informal settlements completely lack public services, others have access to health facilities, sewers, running water, and electricity. There are few comparative studies that have looked at informal settlements across countries accounting for these contextual nuances. In this paper, we comparatively examine the differences in child vaccination rates between Nairobi and Ouagadougou’s informal settlements. We further investigate whether the identified differences are related to the differences in demographic and socioeconomic composition between the two settings. We use data from the Ouagadougou and Nairobi Urban Health and Demographic Surveillance Systems (HDSSs), which are the only two urban-based HDSSs in Africa. The results show that children in the slums of Nairobi are less vaccinated than children in the informal settlements in Ouagadougou. The difference in child vaccination rates between Nairobi and Ouagadougou informal settlements are not related to the differences in their demographic and socioeconomic composition but to the inequalities in access to immunization services.     

国内外卫生服务城乡发展一体化的模式与经验启示

城乡卫生一体化既是一个城乡综合的医疗卫生事业的发展过程,又是城乡卫生统筹发展的一个终极目标.立足“人人享有基本卫生保健”的目标,这要求政府打破城乡居民身份界限,为城乡居民提供享有其需要的、政府能够承担的基本医疗卫生服务的机会和原则,逐步实现基本医疗卫生服务均等化,缩小城乡居民基本医疗卫生服务的差距,提高全体居民健康水平.总结了一些国内外卫生服务城乡一体化发展的模式和经验,以期为其他地区推进卫生城乡一体化提供参考.     

Life expectancy gap between the Francophone majority and Anglophone minority of a Canadian population

Language is an important determinant of health, but analyses of linguistic inequalities in mortality are scant, especially for Canadian linguistic groups with European roots. We evaluated the life expectancy gap between the Francophone majority and Anglophone minority of Québec, Canada, both over time and across major provincial areas. Arriaga’s method was used to estimate the age and cause of death groups contributing to changes in the life expectancy gap at birth between 1989–1993 and 2002–2006, and to evaluate patterns across major provincial areas (metropolitan Montréal, other metropolitan centres, and small cities/rural areas). Life expectancy at birth was greater for Anglophones, but the gap decreased over time by 1.3 years (52% decline) in men and 0.9 years (47% decline) in women, due to relatively sharper reductions in Francophone mortality from several causes, except lung cancer which countered reductions in women. The life expectancy gap in 2002–2006 was widest in other metropolitan centres (men 5.1 years, women 3.2 years), narrowest in small cities/rural areas (men 0.8 years, women 0.7 years), and tobacco-related causes were the main contributors. Only young Anglophones <40 years in small cities/rural areas had mortality higher than Francophones, resulting in a narrower gap in these areas. Differentials in life expectancy favouring Anglophones decreased over time, but varied across areas of Québec. Tobacco-related causes accounted for the majority of the current life expectancy gap.     

Huge poor-rich inequalities in maternity care: an international comparative study of maternity and child care in developing countries

OBJECTIVE: Progress towards the Millennium Development Goals for maternal health has been slow, and accelerated progress in scaling up professional delivery care is needed. This paper describes poor-rich inequalities in the use of maternity care and seeks to understand these inequalities through comparisons with other types of health care. METHODS: Demographic and Health Survey (DHS) data from 45 developing countries were used to describe poor-rich inequalities by wealth quintiles in maternity care (professional delivery care and antenatal care), full childhood immunization coverage and medical treatment for diarrhoea and acute respiratory infections (ARI). FINDINGS: Poor-rich inequalities in maternity care in general, and professional delivery care in particular, are much greater than those in immunization coverage or treatment for childhood illnesses. Public-sector inequalities make up a major part of the poor-rich inequalities in professional delivery attendance. Even delivery care provided by nurses and midwives favours the rich in most countries. Although poor-rich inequalities within both rural and urban areas are large, most births without professional delivery care occur among the rural poor. CONCLUSION: Poor-rich inequalities in professional delivery care are much larger than those in the other forms of care. Reducing poor-rich inequalities in professional delivery care is essential to achieving the MDGs for maternal health. The greatest improvements in professional delivery care can be made by increasing coverage among the rural poor. Problems with availability, accessibility and affordability, as well as the nature of the services and demand factors, appear to contribute to the larger poor-rich inequalities in delivery care. A concerted effort of equity-oriented policy and research is needed to address the huge poor-rich inequalities in maternity care.     

Rural and Urban Differences in Sexual Behaviors Among Adolescents in Florida

The national teen birth rate is higher in rural compared to urban areas. While national data suggest rural areas may present higher risk for adverse sexual health outcomes among adolescents, it is unknown whether there are differences within the state of Florida. Overall, Florida has poorer sexual health indicators for adolescents compared to national rates. The purpose of this study was to assess differences in sexual behaviors among Florida adolescents by rural–urban community location. This study includes baseline data from a randomized controlled trial conducted in Florida high schools. Of the 6316 participants, 74% were urban and 26% were rural. Participants responded to questions on sexual behaviors, sexual behavior intentions, and demographics. We estimated the effect of rural–urban status on risk outcomes after controlling for demographic variables using generalized linear mixed models. More teens from rural areas reported ever having sex (24.0%) compared to urban teens (19.7%). No significant differences were observed for most of sexual behaviors assessed. Nonetheless, urban participants were less likely to intend to have sex without a condom in the next year compared to rural participants (aOR?=?0.76, 95% CI 0.63–0.92). Overall, there were no major differences in sexual behaviors between rural and urban adolescents in Florida. However, sexual intentions differed between rural and urban adolescents; specifically, rural adolescents were more likely to intend to have sex without a condom in the next year compared to urban adolescents. Understanding the specific disparities can inform contraception and sexual health interventions among rural youth.     

Socioeconomic and Geographical Disparities in Under-Five and Neonatal Mortality in Uttar Pradesh,India

As a part of the Millennium Development Goals, India seeks to substantially reduce its burden of childhood mortality. The success or failure of this goal may depend on outcomes within India’s most populous state, Uttar Pradesh. This study examines the level of disparities in under-five and neonatal mortality across a range of equity markers within the state. Estimates of under-five and neonatal mortality rates were computed using five datasets, from three available sources: sample registration system, summary birth histories in surveys, and complete birth histories. Disparities were evaluated via comparisons of mortality rates by rural–urban location, ethnicity, wealth, and districts. While Uttar Pradesh has experienced declines in both rates of under-five (162–108 per 1,000 live births) and neonatal (76–49 per 1,000 live births) mortality, the rate of decline has been slow (averaging 2 % per annum). Mortality trends in rural and urban areas are showing signs of convergence, largely due to the much slower rate of change in urban areas. While the gap between rich and poor households has decreased in both urban and rural areas, trends suggest that differences in mortality will remain. Caste-related disparities remain high and show no signs of diminishing. Of concern are also the signs of stagnation in mortality amongst groups with greater ability to access services, such as the urban middle class. Notwithstanding the slow but steady reduction of absolute levels of childhood mortality within Uttar Pradesh, the distribution of the mortality by sub-state populations remains unequal. Future progress may require significant investment in quality of care provided to all sections of the community.