Differences in Late‐Stage Diagnosis,Treatment, and Colorectal Cancer‐Related Death Between Rural and Urban African Americans and Whites in Georgia

Purpose: Disparities in health outcomes due to a diagnosis of colorectal cancer (CRC) have been reported for a number of demographic groups. This study was conducted to examine the outcomes of late‐stage diagnosis, treatment, and cancer‐related death according to race and geographic residency status (rural vs urban). Methods: This study utilized cross‐sectional and follow‐up data from the Surveillance, Epidemiology, and End Results (SEER) Program for all incident colon and rectal tumors diagnosed for the Atlanta and Rural Georgia Cancer Registries for the years 1992‐2007. Findings: Compared to whites, African Americans had a 40% increased odds (OR, 1.40; 95% CI, 1.30‐1.51) of late‐stage diagnosis, a 50% decreased odds (OR, 0.50; 95% CI, 0.37‐0.68) of having surgery for colon cancer, and a 67% decreased odds (OR, 0.33; 95% CI, 0.25‐0.44) of receiving surgery for rectal cancer. Rural residence was not associated with late stage at diagnosis or receipt of treatment. African Americans had a slightly increased risk of death from colon cancer (HR, 1.11; 95% CI, 1.00‐1.24) and a larger increased risk of death due to rectal cancer (HR, 1.24; 95% CI, 1.14‐1.35). Rural residents experienced a 15% increased risk of death (HR, 1.15; 95% CI, 1.01‐1.32) due to colon cancer. Conclusions: Further investigations should target African Americans and rural residents to gain insight into the etiologic mechanisms responsible for the poorer CRC outcomes experienced by these 2 segments of the population.     

The Influence of Rural Versus Urban Residence on Utilization and Receipt of Care for Chronic Low Back Pain

Purpose : (1) To describe demographic and health‐related characteristics among rural/urban residents with chronic low back pain (LBP); (2) To determine if the utilization of diagnostics and treatments differs between rural and urban residents with chronic LBP; and (3) To determine the association between rural/urban residence and health care provider usage and if associations differ by race or gender. Methods : A 2006 cross‐sectional telephone survey of a representative sample of North Carolina residents. Subjects with chronic LBP were questioned regarding their health and health care use. Wald and chi‐square tests were used to determine differences between demographic and health‐related characteristics of rural/urban residents. Logistic regression was used to determine the association between rural/urban residence and health care provider use. Differences in race or gender were explored with stratified analysis with a P < .10. Findings : 588 residents of North Carolina with self‐reported chronic LBP sought care from a provider in the previous year. In bivariate analyses, when compared to urban residents, rural residents were younger, more likely to be uninsured, reported significantly higher levels of disability, and reported more depression/sadness. Rural residents were less likely to receive care from a rheumatologist (adjusted odds ratio [aOR] 0.47 [95% CI, 0.22‐0.99]). Rural blacks were less likely to receive care from a physical therapist when compared to urban blacks (aOR 0.26 [95% CI, 0.07‐0.87]). Conclusion : Despite similarities of high provider use, imaging and therapeutics, when compared to urban residents, rural residents reported higher levels of functional limitation and depression.     

Rural Residence and Hispanic Ethnicity: Doubly Disadvantaged for Diabetes?

CONTEXT: Hispanics are at increased risk for diabetes, while rural residents have historically had decreased access to care. PURPOSE: To determine whether living in a rural area and being Hispanic confers special risks for diagnosis and control of diabetes. METHODS: We analyzed the Third National Health and Nutrition Examination Survey (1988-1994). Hispanics and non-Hispanic white adults were classified according to rural/urban residence to create 4 ethnicity-residence groups. Investigated outcomes were previously diagnosed and undiagnosed diabetes. Among those with diagnosed diabetes, we investigated control of glucose, hypertension, and lipids. FINDINGS: The prevalence of diagnosed diabetes was greatest for rural residents, especially for rural Hispanics (8.2%) versus that for urban whites (4.6%), rural whites (6.5%), or urban Hispanics (4.5%), (P < .01). However, urban Hispanics were most likely to have undiagnosed diabetes at 3.7%, versus 2.3% of rural whites, 2.8% of urban whites, and 2.7% of rural Hispanics (P = .04). Among people with diagnosed diabetes, there was no difference in glycemic control between the 4 groups. Rural Hispanics with diagnosed diabetes had the greatest prevalence of elevated systolic blood pressure at 45%, compared to 37% of urban whites, 29% of rural whites, 28% of urban Hispanics (P = .01). In regression models controlling for potential confounders, there were no differences among urban and rural whites and Hispanics in the likelihood of undiagnosed diabetes or in glycemic control for those with diagnosed diabetes. CONCLUSIONS: Initiatives that target Hispanic health, and especially diabetes, should acknowledge rural/urban Hispanic health differences.     

城乡居民艾滋病相关知识和态度的现状调查

目的了解城乡居民艾滋病相关知识和态度的现状,为有针对性地开展城乡居民艾滋病健康教育工作提供参考依据。方法采用多阶段抽样方法,在辽宁省和湖北省抽取农村居民和城市居民2160人进行问卷调查,共收回有效问卷2130份,其中农村居民1067份,城市居民1063份。结果农村居民艾滋病知识平均知晓率为73.57%,城市居民为80.52%,农村居民知识知晓率显著低于城市居民(P<0.01);44.91%农村居民和40.36%城市居民将减少或断绝与艾滋病感染者的来往;22.84%农村居民和15.78%的城市居民不允许感染者继续工作和学习,29.94%农村居民和29.11%城市居民介意和艾滋病患者一起吃饭,城乡居民对艾滋病感染者的态度构成有统计学差异(P<0.05或P<0.01)。结论城乡居民对艾滋病知识有较高知晓率,我国的艾滋病防治工作取得了初步成效,但对艾滋病感染者的歧视态度仍较为严重。     

Rurality and Other Determinants of Early Colorectal Cancer Diagnosis in Nebraska: A 6-Year Cancer Registry Study, 1998-2003

ABSTRACT:  Background: There are no studies of rurality, and other determinants of colorectal cancer (CRC) stage at diagnosis with population-based data from the Midwest. Methods: This retrospective study identified, incident CRC patients, aged 19 years and older, from 1998-2003 Nebraska Cancer Registry (NCR) data. Using federal Office of Management and Budget classifications, we grouped patients by residence in metropolitan, micropolitan nonmetropolitan, or rural nonmetropolitan counties (non-core based statistical areas). In univariate and multivariate logistic regression analyses, we examined the association of the county classification and of other determinants with early (in situ/local) versus late (regional/distant) stage at CRC diagnosis. Results: Of the 6,561 CRC patients identified, 45% were from metropolitan counties, 24% from micropolitan nonmetropolitan counties and 31% from rural nonmetropolitan counties, with 32%, 38%, and 33%, respectively, being diagnosed at an early stage. Multivariate analysis showed micropolitan nonmetropolitan residents were significantly more likely than rural nonmetropolitan residents to be diagnosed at an early stage (adjusted OR, 1.22; 95% CI: 1.05-1.42, P < .05). However, rural nonmetropolitan and metropolitan residents did not significantly differ in the likelihood of early diagnosis. Residents with Medicare rather than those with private insurance (P < .0001), married rather than unmarried residents (P < .01), and residents with rectal cancer rather than those with colon cancer (P < .0001) were more likely to be diagnosed at an early stage. Conclusions: Early CRC diagnosis needs to be increased in rural (non-core) non-metropolitan residents, unmarried residents, and those with private insurance.     

Prevalence of Obesity Among Adults From Rural and Urban Areas of the United States: Findings From NHANES (2005‐2008)

Purpose: Rural residents have higher rates of chronic diseases compared to their urban counterparts, and obesity may be a major contributor to this disparity. This study is the first analysis of obesity prevalence in rural and urban adults using body mass index classification with measured height and weight. In addition, demographic, diet, and physical activity correlates of obesity across rural and urban residence are examined. Methods: Analysis of body mass index (BMI), diet, and physical activity from 7,325 urban and 1,490 rural adults in the 2005‐2008 National Health and Nutrition Examination Survey (NHANES). Findings: The obesity prevalence was 39.6% (SE = 1.5) among rural adults compared to 33.4% (SE = 1.1) among urban adults (P= .006). Prevalence of obesity remained significantly higher among rural compared to urban adults controlling for demographic, diet, and physical activity variables (odds ratio = 1.18, P= .03). Race/ethnicity and percent kcal from fat were significant correlates of obesity among both rural and urban adults. Being married was associated with obesity only among rural residents, whereas older age, less education, and being inactive was associated with obesity only among urban residents. Conclusions: Obesity is markedly higher among adults from rural versus urban areas of the United States, with estimates that are much higher than the rates suggested by studies with self‐reported data. Obesity deserves greater attention in rural America.     

Mental Health Differences Between Rural and Urban Men Living with HIV Infection in Various Age Groups

Despite the disproportionate increase in rural, Southern residents and older persons during the third era of the HIV/AIDS epidemic, no known study has examined whether older, rural men living with HIV infection face a double jeopardy and have poorer psychosocial profiles than other subgroups of men. We investigated whether area of residence (rural, urban), age (young, middle-age, old), and the interaction of residence and age would be related to mental health factors by using two measurement methods to categorize rural and urban residence (US Census Bureau classification and The Office of Rural Health Policy’s, Rural Urban Commuting Area Codes [RUCAs]). We conducted 2–3 hour-long, face-to-face interviews with all but 43 patients who met the study criteria and kept their clinic appointments at three different types of healthcare facilities (i.e., VA, university clinic, public health department) over a 20-month period. The sample consisted of 226 men living in the southeastern US. Rural and urban men of various age groups did not differ in socioeconomic factors, travel distance to clinics, use of medications, satisfaction with care, types of severe stressors, and confidentiality concerns. Using two methods to categorize area of residence, we found that rural men as compared to urban men had similar levels of total stress, AIDS-related stress, social support, active coping and avoidance coping, but higher rates of risk for depression. Rural men had higher levels of non-AIDS-related stress only when the US Census Bureau’s categorization was used, which highlights the importance of carefully selecting and describing methods to categorize rural versus urban residence.     

辽宁省城乡居民艾滋病相关知识和态度现况调查

目的了解城乡居民艾滋病相关知识和态度的现状。方法采用多阶段抽样方法，对沈阳市、鞍山市、锦州市1075人城乡居民进行问卷调查。结果城乡居民艾滋病相关知识平均知晓率为83．56％。其中，城市居民平均知晓率为85．13％，农村居民平均知晓率为81．95％，经t检验，城乡居民平均知晓率差异有统计学意义（P〈0．05）。结论农村居民较城市居民艾滋病相关知识知晓率低，且对艾滋病病毒感染者的歧视态度较严重。     

Clinical and demographic predictors of late-stage cervical cancer

BACKGROUND: Despite increasingly widespread use of the Papanicolaou smear, almost half of all women with invasive cervical cancer are diagnosed at a late stage (regional or distant). Little is known about factors associated with late-stage diagnosis of cervical cancer. OBJECTIVE: To examine the relationship of age, race, education level, income level, smoking, marital status, health insurance type, comorbidity, and residence in an urban or rural setting to late stage at diagnosis of cervical cancer. METHODS: Incident cases of invasive cervical cancer occurring in 1994 in Florida were identified from the state tumor registry (N = 852). Cases were linked with state discharge abstracts and the 1990 US census. Multiple logistic regression was used to determine the relationship between predictor variables (age, race or ethnicity, marital status, smoking status, education level, income level, insurance type, comorbidity, and urban vs rural residence) and the odds of late-stage diagnosis. RESULTS: Age, marital status, and insurance type were associated with late-stage diagnosis. Each additional year of age was associated with a 3% increased odds of late-stage diagnosis (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.02-1.05; P<.001). Being unmarried was associated with a 63% increased odds of late-stage diagnosis (OR, 1.63; 95% CI, 1.18-2.25; P=.003). Being uninsured was associated with a 60% increased odds of late-stage diagnosis (OR, 1.60; 95% CI, 1.07-2.38; P=.02). Having commercial health maintenance organization insurance was associated with a 46% decreased odds of late-stage disease (OR, 0.54; 95% CI, 0.30-0.96; P=.04). Race, education level, income level, smoking status, comorbidity, and urban residence were not associated with stage at diagnosis. CONCLUSIONS: Women with cervical cancer who are elderly, unmarried, and uninsured are more likely to be diagnosed at a late stage. These women should be targeted for cervical cancer education and screening programs.     

Differences in Selected HIV Care Continuum Outcomes Among People Residing in Rural,Urban, and Metropolitan Areas—28 US Jurisdictions

Purpose

The HIV care continuum is used to monitor success in HIV diagnosis and treatment among persons living with HIV in the United States. Significant differences exist along the HIV care continuum between subpopulations of people living with HIV; however, differences that may exist between residents of rural and nonrural areas have not been reported.

Methods

We analyzed the Centers for Disease Control and Prevention's National HIV Surveillance System data on adults and adolescents (≥13 years) with HIV diagnosed in 28 jurisdictions with complete reporting of HIV‐related lab results. Lab data were used to assess linkage to care (≥1 CD4 or viral load test ≤3 months of diagnosis), retention in care (≥2 CD4 and/or viral load tests ≥3 months apart), and viral suppression (viral load <200 copies/mL) among persons living with HIV. Residence at diagnosis was grouped into rural (<50,000 population), urban (50,000‐499,999 population), and metropolitan (≥500,000 population) categories for statistical comparison. Prevalence ratios and 95% CI were calculated to assess significant differences in linkage, retention, and viral suppression.

Findings

Although greater linkage to care was found for rural residents (84.3%) compared to urban residents (83.3%) and metropolitan residents (81.9%), significantly lower levels of retention in care and viral suppression were found for residents of rural (46.2% and 50.0%, respectively) and urban (50.2% and 47.2%) areas compared to residents of metropolitan areas (54.5% and 50.8%).

Conclusions

Interventions are needed to increase retention in care and viral suppression among people with HIV in nonmetropolitan areas of the United States.     

The Vermont Model for Rural HIV Care Delivery: Eleven Years of Outcome Data Comparing Urban and Rural Clinics

Context: Provision of human immunodeficiency virus (HIV) care in rural areas has encountered unique barriers. Purpose: To compare medical outcomes of care provided at 3 HIV specialty clinics in rural Vermont with that provided at an urban HIV specialty clinic. Methods : This was a retrospective cohort study. Findings: Over an 11-year period 363 new patients received care, including 223 in the urban clinic and 140 in the rural clinics. Patients in the 2 cohorts were demographically similar and had similar initial CD4 counts and viral loads. There was no difference between the urban and rural clinic patients receiving Pneumocystis carinii prophylaxis (83.5% vs 86%, P= .38) or antiretroviral therapy (96.8% vs 97.5%, P= .79). Both rural and urban cohorts had similar decreases in median viral load from 1996 to 2006 (3,876 copies/mL to <50 copies/mL vs 8,331 copies/mL to <50 copies/mL) and change in percent of patients suppressed to <400 copies/mL (21.4%-69.3% vs 16%-71.4%, P= .11). Rural and urban cohorts had similar increases in median CD4 counts (275/mm³-350/mm³ vs 182 cells/mm³-379/mm³). A repeated measures regression analysis showed that neither fall in viral load (P= .91) nor rise in CD4 count (P= .64) were associated with urban versus rural site of care. Survival times, using a Cox proportional hazards model, were similar for urban and rural patients (hazard ratio for urban = 0.80 [95% CI, 0.39-1.61; P= .53]). Conclusions: This urban outreach model provides similar quality of care to persons receiving care in rural areas of Vermont as compared to those receiving care in the urban center.     

贵州省部分地区城镇和农村青壮年居民艾滋病相关知识、态度和信念研究

目的了解贵州省城镇居民和农村青壮年居民艾滋病相关知识水平和态度,为艾滋病防治工作提供依据。方法采用与规模大小成比例(PPS)的两阶段分层抽样法选择了583名城镇居民和429名农村居民,由调查员对调查对象进行一对一的问卷调查。问卷内容包括人口学信息、艾滋病一般知识、艾滋病传播知识、艾滋病预防知识、对艾滋病和艾滋病人的态度和其他关于艾滋病的信念等,随后对两类人群的部分结果进行了比较。结果城镇居民的艾滋病知识平均得分为15.48分,农村居民的艾滋病知识平均得分为9.75分(总分22分)。城镇居民的艾滋病知识水平高于农村居民,农村居民比城镇居民对艾滋病和感染者更具歧视性。两类人群对艾滋病知识存在很多误区。与艾滋病知识水平相关的因素主要有居住在示范区、文化程度、性别及职业。结论应采用多种方式开展艾滋病宣传教育,提高城镇居民和农村居民的艾滋病知识知晓率,减少歧视。     

Access to and Use of Eye Care Services in Rural Arkansas

Context: Rural residents are more likely to be uninsured and have low income.
Purpose: To determine if rural residents in Arkansas have decreased access to eye care services and use them less frequently than urban residents.
Methods: Data from the 2006 Visual Impairment and Access to Eye Care Module from the Arkansas Behavioral Risk Factor Surveillance System (BRFSS) were used in the analysis. Adults age 40 years and older were included (n = 4,289). Results were weighted to reflect the age, race, and gender distribution of the population of Arkansas. Multiple logistic regression was used to adjust for demographic differences between rural and urban populations.
Findings: Significantly fewer rural residents (45%) reported having insurance coverage for eye care services compared with residents living in urban areas (55%). Rural residents were less likely (45%) than urban residents (49%) to have had a dilated eye exam within the past year. Among residents aged 40-64, those from rural areas were more likely than their urban counterparts to report cost/lack of insurance as the main reason for not having a recent eye care visit.
Conclusions: In 2006, rates of eye care insurance coverage were significantly lower for rural residents while use of eye care services differed slightly between rural and urban residents. Rural residents in Arkansas age 40-64 would benefit from having increased access to eye care insurance and/or low cost eye care services.     

The Metabolic Syndrome: Are Rural Residents at Increased Risk?

Purpose: The purpose of this study was to estimate the differences in prevalence of metabolic syndrome and its individual components across rural‐urban populations, as well as to determine the risk factors associated with metabolic syndrome and examine how they contribute toward rural‐urban disparity. Methods: Data came from the 1999‐2006 National Health and Nutrition Examination Survey, restricting to 6,896 participants aged 20 years or more with complete information. Metabolic syndrome was defined using the National Cholesterol Education Program's Adult Treatment Panel III criteria. Residence was measured at the census tract level using the Rural‐Urban Commuting Area Codes. We estimated the prevalence of metabolic syndrome and its components by residence. Multiple logistic regression models were used to examine urban‐rural differences after adjusting for sociodemographic, health, dietary, and lifestyle factors. Results: The prevalence of metabolic syndrome was higher in rural than urban residents (39.9% vs 32.8%), among both men (39.7% vs 33.3%) and women (40.2% vs 32.3%, respectively). The age and sex adjusted OR for metabolic syndrome in rural as compared to urban residents was 1.23 (95% CI, 1.02‐1.49), which was attenuated to 1.06 (95% CI, 0.90‐1.25) after adjusting for covariates. Older age, lower physical activity, higher screen time, higher meat intake, and skipping breakfast were associated with increased odds of metabolic syndrome. Conclusion: Rural dwelling was associated with higher prevalence of metabolic syndrome among adults in the Unites States, which can be attributed to the differences in demographic composition and obesity‐related behavioral factors between urban and rural residents.     

Race, rural residence, and control of diabetes and hypertension

PURPOSE: African Americans are at increased risk for diabetes mellitus and hypertension, and rural residents have historically had decreased access to care. It is unclear whether living in a rural area and being African American confers added risks for diagnosis and control of diabetes and hypertension. The purpose of this study was to examine the prevalence of diagnosed diabetes and hypertension, as well as control of both conditions, among rural and urban African Americans and whites. METHODS: We conducted an analysis of the Third National Health and Nutrition Examination Survey (1988-1994). Non-Hispanic African Americans and non-Hispanic white adults 20 years and older were classified according to rural or urban residence (n = 11,755). Investigated outcomes were previously diagnosed diabetes mellitus and hypertension and control of diabetes and hypertension. RESULTS: The prevalence of diagnosed diabetes was 4.5% for urban whites, 6.5% for rural whites, 6.0% for urban African Americans, and 9.5% for rural African Americans. Among patients with diagnosed diabetes, 33% of rural whites, 43% of urban whites, 45% of urban African American, and 61% of rural African Americans had glycosylated hemoglobin (HbA(1c)) levels of 8% or higher (P < .01). Among patients with diagnosed hypertension, 11% of rural whites, 13% of urban whites, 20% of urban African Americans, and 23% of rural African Americans had diastolic blood pressure greater than 90 mmHg (P < .01). In regression models controlling for relevant variables, including body mass index, health status, access to care, education, income, and insurance, compared with rural African Americans, rural and urban whites were significantly more likely to have better glycemic control and diastolic blood pressure control. Urban African Americans also had better diabetes control than rural African Americans. CONCLUSIONS: In this nationally representative sample, rural African Americans are at increased risk for a lack of control of diabetes and hypertension.     

Urban/Rural Differences in Decision Making and the Use of Advance Directives Among Nursing Home Residents at Admission

CONTEXT: Advance directives promote patient autonomy and encourage greater awareness of final care options while reducing physician and family uncertainty regarding patient preferences. PURPOSE: To investigate differences in decision making authority and the use of advance directives among nursing home residents admitted from urban and rural areas. METHODS: A total of 551,208 admission assessments in the Minimum Data Set were analyzed for all residents admitted to a nursing facility in 2001. Using the Rural Urban Commuting Areas (RUCA) methodology and ZIP code of primary residence before admission, these residents were classified into 4 urban/rural areas. FINDINGS: Residents from rural areas were significantly more likely to have executed a durable power of attorney for health care or for financial decisions than residents admitted from the other areas, with the largest differences observed between residents admitted from urban and rural areas. Almost 6 residents in 10 from urban areas had no advance directives in place at admission compared with only 4 residents in 10 admitted from rural areas. CONCLUSIONS: Health providers and social workers in both rural and urban areas should advise patients about the value of advance directives.     

Similar secondary stroke prevention and medication persistence rates among rural and urban patients

Purpose: Rural residents are less likely to obtain optimal care for many serious conditions and have poorer health outcomes than those residing in more urban areas. We determined whether rural vs urban residence affected postdischarge medication persistence and 1 year outcomes after stroke. Methods: The Adherence eValuation After Ischemic Stroke‐Longitudinal (AVAIL) study is a multicenter registry of stroke patients enrolled in 101 hospitals nationwide. Medications were recorded at hospital discharge and again after 3 and 12 months. Persistence was defined as continuation of prescribed discharge medications. Participants were categorized as living in rural or urban settings by cross‐referencing home ZIP code with metropolitan statistical area (MSA) designation. Findings: Rural patients were younger, more likely to be white, married, smokers, and less likely to be college graduates. There was no difference in stroke type or working status compared to urban patients, and there were minor differences in comorbid conditions. There were no differences based on rural vs urban residence in medication persistence at 3 or 12 months postdischarge and no differences in outcomes of recurrent stroke or rehospitalization at 12 months. Conclusion: Despite differences in patient characteristics, there was no difference in medication persistence or outcomes between rural and urban dwellers after hospitalization for ischemic stroke or transient ischemic attack (TIA).     

Are slum dwellers at heightened risk of HIV infection than other urban residents? Evidence from population-based HIV prevalence surveys in Kenya

In 2008, the global urban population surpassed the rural population and by 2050 more than 6 billion will be living in urban centres. A growing body of research has reported on poor health outcomes among the urban poor but not much is known about HIV prevalence among this group. A survey of nearly 3000 men and women was conducted in two Nairobi slums in Kenya between 2006 and 2007, where respondents were tested for HIV status. In addition, data from the 2008/2009 Kenya Demographic and Health Survey were used to compare HIV prevalence between slum residents and those living in other urban and rural areas. The results showed strong intra-urban differences. HIV was 12% among slum residents compared with 5% and 6% among non-slum urban and rural residents, respectively. Generally, men had lower HIV prevalence than women although in the slums the gap was narrower. Among women, sexual experience before the age of 15 compared with after 19 years was associated with 62% higher odds of being HIV positive. There was ethnic variation in patterns of HIV infection although the effect depended on the current place of residence.     

Late HIV presentation among AIDS cases in Australia, 1992-2001

OBJECTIVE: To describe time trends and demographic, exposure and clinical factors associated with late HIV presentation among notified AIDS cases diagnosed in Australia in 1992-2001. METHODS: AIDS cases, diagnosed in Australia and notified to the National AIDS Registry, were included in the analysis. AIDS cases newly diagnosed with HIV infection within three months of AIDS diagnosis were defined as cases of late HIV presentation. RESULTS: The percentage of AIDS cases with late HIV presentation increased significantly from 18% in 1992-96 to 33.1% in 1997 (adjusted odds ratio (AOR)=1.79, p<0.005) and to 49.6% in 2001 (AOR=3.01, p<0.005). Older age, having been born in Asia, a HIV exposure history of heterosexual contact or an 'other/undetermined' exposure and a diagnosis of PCP only or of multiple AIDS illnesses, were associated with late HIV presentation among AIDS cases diagnosed in 1992-96 and in 1997-2001, and among overseas-born cases diagnosed in 1992-2001. In 1997-2001, a low CD4+ cell count was also associated with late HIV presentation. Among homosexually active men diagnosed with AIDS in 1997-2001, older age, a diagnosis of PCP or multiple AIDS illnesses and a low CD4+ cell count were associated with late HIV presentation. CONCLUSION: Predictors of late HIV presentation have remained substantially unchanged over time and among population subgroups, suggesting a need for innovation in HIV/AIDS testing and counselling strategies.     

Self-reported patterns of health services utilisation: an urban-rural comparison in South Australia

Objective: To compare self‐reported patterns of health service utilisation among residents of urban and rural South Australia. Design, setting and main outcome measures: Secondary analysis of data generated by computer‐assisted telephone interviews of 7377 adults done in 1995–6. Respondents were asked if they had used each of 18 different health services during the previous 12 months. Residence was classified in three ways: (1) capital city versus rest of the state, (2) by the Rural, Remote and Metropolitan Areas classification (RRMA) and (3) by the Accessibility and Remoteness Index for Australia classification (ARIA). Results: General practitioner services were most frequently used, by approximately 89% of respondents. Only 4% reported not using any service. Comparing capital city with rest of the state, modest but statistically significant differences in utilisation (P < 0.01) were measured for nine services. In eight of these nine, utilisation was higher among rural residents. Analysing by RRMA, eight services were reportedly used differently and seven of these were the same as those identified from the capital city versus rest of state comparison. Across the five ARIA categories, six previously identified services were reported as being used differentially. Overall, rural residents had a higher than expected rate of moderate and high level of health service use. Conclusions: Self‐reported use of a range of health services was broadly similar across urban and rural South Australia, with most cases of higher use were reported from rural areas rather than urban areas. Similar results were obtained when residence was classified in the three different ways. What is already known on this subject: It is widely reported that the health status of and access to health services for rural Australians is worse than their urban counterparts. However, while this is clearly the case for some conditions and some groups, further data is needed to understand rural–urban health differentials better. Few explicit comparisons of different methods of classifying rurality (RRMA, ARIA and capital city vs. the rest) have been published. What does this study add: This study demonstrates that the self‐reported utilisation of a wide range of health services in South Australia is no worse, and is often greater, among rural residents compared to those in Adelaide. The same conclusions are reached irrespective of the method of classifying rurality.