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.     

The effects of auditive and visual settings on perceived restoration likelihood

Research has so far paid little attention to how environmental sounds might affect restorative processes. The aim of the present study was to investigate the effects of auditive and visual stimuli on perceived restoration likelihood and attitudes towards varying environmental resting conditions. Assuming a condition of cognitive fatigue, all participants (N = 40) were presented with images of an open plan office and urban nature, each under four sound conditions (nature sound, quiet, broadband noise, office noise). After the presentation of each setting/sound combination, the participants assessed it according to restorative qualities, restoration likelihood and attitude. The results mainly showed predicted effects of the sound manipulations on the perceived restorative qualities of the settings. Further, significant interactions between auditive and visual stimuli were found for all measures. Both nature sounds and quiet more positively influenced evaluations of the nature setting compared to the office setting. When office noise was present, both settings received poor evaluations. The results agree with expectations that nature sounds and quiet areas support restoration, while office noise and broadband noise (e.g. ventilation, traffic noise) do not. The findings illustrate the significance of environmental sound for restorative experience.     

Characterization of Rural Mental Health Service Systems

This paper explores two mental health systems in rural North Carolina that provide services to people with severe mental disorders. Recent findings show rural people with mental disorders receive less mental health care than their urban counterparts. This study asks whether rural service systems differ from urban systems in the way that their services are coordinated and structured. A popular conception is that public mental health systems in the United States are uncoordinated with many services provided outside the mental health sector. Rural service providers are seen as even more dependent on nonspecialized mental health providers than their urban counterparts. While many rural service barriers are attributed to the rural environment, little is known about rural service systems and how their organization might contribute to or negate barriers to care. Social network methods were used in this study to compare two rural with four urban systems of care. Findings confirm that mental health systems fit the de facto hypothesis, but that rural systems differ in ways not anticipated by the hypothesis. Rather than being more dependent on nonmental health agencies, rural mental health agencies are more interdependent.     

Rural-Urban Differences in Health Insurance Coverage and Patterns Among Working-Age Adults in Kentucky

Context: Past studies show that rural populations are less likely than urban populations to have health insurance coverage, which may severely limit their access to needed health services. Purpose: To examine rural-urban differences in various aspects of health insurance coverage among working-age adults in Kentucky. Methods: Data are from a household survey conducted in Kentucky in 2005. The respondents include 2,036 individuals ages 18-64. Bivariate analyses were used to compare the rural-urban differences in health insurance coverage by individual characteristics. Logistic regression analyses were used to examine the independent impact of rural-urban residence on the various aspects of health insurance coverage, while controlling for the individuals’ health status and sociodemographic characteristics. Findings: The overall rate of working-age adults with health insurance did not differ significantly between the rural and urban areas of Kentucky. However, there were significant rural-urban differences in insurance for specific types of health care and in patterns of insurance coverage. Rural adults were less likely than urban adults to have coverage for vision care, dental care, mental health care, and drug abuse treatment. Rural adults were also less likely to obtain insurance through employment, and their current insurance coverage was, on average, of shorter duration than that of urban adults. Conclusions: In Kentucky, the overall health insurance rate of working-age adults is influenced more by employment status and income than by whether these individuals reside in rural or urban areas. However, coverage for specific types of care, and coverage patterns, differ significantly by place of residence.     

Attraction and retention of qualified health workers to rural areas in Nigeria: a case study of four LGAs in Ogun State, Nigeria

INTRTODUCTION: A shortage of health workers is a major problem for Nigeria, especially in rural areas where more than 70% of the population live. At the primary care level, trained community health officers provide services normally reserved for doctors or medical specialists. The community health officers must therefore be supported and motivated to provide effective quality healthcare services. This study aimed to determine factors that will attract and retain rural and urban health workers to rural Nigerian communities, and to examine differences between the two groups. METHODS: A cross-sectional survey measured health workers' work experience, satisfaction with, and reasons for undertaking their current work; as well as reasons for leaving a work location. Data were also gathered on factors that attract health workers to rural settings and also retain them. RESULTS; Rural health workers were generally more likely to work in rural settings (62.5%) than their urban counterparts (16.5%). Major rural motivators for both groups included: assurances of better working conditions; effective and efficient support systems; opportunities for career development; financial incentives; better living conditions and family support systems. The main de-motivator was poor job satisfaction resulting from inadequate infrastructure. Rural health workers were particularly dissatisfied with career advancement opportunities. More urban than rural health workers expressed a wish to leave their current job due to poor job satisfaction resulting from poor working and living conditions and the lack of career advancement opportunities. CONCLUSIONS: Motivational factors for attraction to and retention in rural employment were similar for both groups although there were subtle differences. Addressing rural health manpower shortages will require the development of a comprehensive, evidence-based rural health manpower improvement strategy that incorporates a coordinated intersectoral approach, involving partnership with a range of stakeholders in rural health development.     

Social capital and health in rural and urban communities in South Australia

Objective : This paper seeks to compare the relationships between social capital and health for rural and urban residents of South Australia.
Methods : Using data from a South Australian telephone survey of 2,013 respondents (1,402 urban and 611 rural), separate path analyses for the rural and urban samples were used to compare the relationships between six social capital measures, six demographic variables, and mental and physical health (measured by the SF-12).
Results : Higher levels of networks, civic participation and cohesion were reported in rural areas. Education and income were consistently linked with social capital variables for both rural and urban participants, with those on higher incomes and with higher educational achievement having higher levels of social capital. However, there were also differences between the rural and urban groups in some of the other predictors of social capital variables. Mental health was better among rural participants, but there was no significant difference for physical health. Social capital was associated with good mental health for both urban and rural participants, but with physical health only for urban participants. Higher levels of social capital were significantly associated with better mental health for both urban and rural participants, but with better physical health only for urban participants.
Conclusions and implications : The study found that social capital and its relationship to health differed for participants in rural and urban areas, and that there were also differences between the areas in associations with socioeconomic variables. Policies aiming to strengthen social capital in order to promote health need to be designed for specific settings and particular communities within these.     

Veterans Health Administration and Medicare Outpatient Health Care Utilization by Older Rural and Urban New England Veterans

CONTEXT: Older veterans often use both the Veterans Health Administration (VHA) and Medicare to obtain health care services. PURPOSE: The authors sought to compare outpatient medical service utilization of Medicare-enrolled rural veterans with their urban counterparts in New England. METHODS: The authors combined VHA and Medicare databases and identified veterans who were age 65 and older and enrolled in Medicare fee-for-service plans, and they obtained records of all their VHA services in New England between 1997 and 1999. The authors used ZIP codes to designate rural or urban residence and categorized outpatient utilization into primary care, individual mental health care, non-mental health specialty care, or emergency room care. FINDINGS: Compared with their urban counterparts, veterans living in rural settings used significantly fewer VHA and Medicare-funded primary care, specialist care, and mental health care visits in all 3 years examined (P<.001 for all). Compared with urban veterans, veterans living in rural settings used fewer VHA emergency department services in 1998 and 1999 but more Medicare-funded emergency department visits in 1997. The authors found some evidence of substitution of Medicare for VHA emergency visits in rural veterans, but no other evidence of like-service substitution. Rural veterans were more reliant on Medicare for primary care and on VHA services for specialty and mental health care. CONCLUSIONS: These findings suggest that rural access to federally funded health care is restricted relative to urban access. Older veterans may choose different systems of care for different health care services. With poor access to primary care, rural veterans may substitute emergency room visits for routine care.     

Children's mental health care: differences by race/ethnicity in urban/rural areas

This study examines racial/ethnic disparities in children's mental health and the receipt of mental health services, and whether those disparities differ between urban and rural areas. We find no significant difference between racial/ethnic groups in the prevalence of child mental health problems in either urban or rural areas. However, there are disparities in the use of mental health services. Hispanic children and Black children in urban areas receive less mental health care than their White counterparts, and the disparity persists for Hispanic children in rural areas, even after controlling for other relevant factors. Initiatives to improve access to mental health care for racial/ethnic minorities should recognize these disparities, and address the lack of culturally appropriate services in both urban and rural areas. In addition, outreach should raise awareness among parents, teachers, and other community members concerning the need for mental health services for minority children.     

城乡基层医疗人员对气候变化及其健康风险认知的差异

目的探究基层医疗人员对气候变化及其健康风险认知的城乡差异。方法采用分层随机整群抽样,抽取广东省21家城区和10家乡镇基层医疗卫生机构的医疗人员进行问卷调查,收集其基本信息和对气候变化及其健康风险的认知情况,通过卡方检验、秩和检验和logistic逐步回归分析探究气候变化认知的城乡差异。结果63.8%(468/733)的基层医疗卫生人员认同气候变化正在发生,55.4%(406/733)的人认为气候变化主要归因于人类活动。城区卫生人员对气候变化正在发生的认同程度高于乡镇,而城区与乡镇对气候变化发生原因的认知差异不明显。城区人员在高温热浪的健康风险认知上略高于乡镇,而对于气候变化与传染病关联的认知略低于乡镇,但差异不具有统计学意义。乡镇人员识别气候变化脆弱人群的能力略高于城区,差异具有统计学意义。此外,职称级别越高越能感知气候变化健康风险;临床医生相比于护士和公共卫生人员更认同气候变化正在发生且更能识别其发生原因。结论城区基层医疗卫生人员在气候变化正在发生的认同程度上略高于乡镇,但是乡镇医疗卫生人员比城区的更能识别脆弱人群。城区与乡镇基层医疗卫生人员对气候变化及其健康风险认知均不容乐观,应积极采取措施提升风险认知以增强其应对气候变化健康风险的能力。     

Differences in health-related quality of life in rural and urban veterans

OBJECTIVES: We sought to determine whether disparities in health-related quality of life exist between veterans who live in rural settings and their suburban or urban counterparts. METHODS: We determined health-related quality-of-life scores (physical and mental health component summaries) for 767109 veterans who had used Veterans Health Administration services within the past 3 years. We used rural/urban commuting area codes to categorize veterans into rural, suburban, or urban residence. RESULTS: Health-related quality-of-life scores were significantly lower for veterans who lived in rural settings than for those who lived in suburban or urban settings. Rural veterans had significantly more physical health comorbidities, but fewer mental health comorbidities, than their suburban and urban counterparts. Rural-urban disparities persisted in all survey subscales, across regional delivery networks, and after we controlled for sociodemographic factors. CONCLUSIONS: When compared with their urban and suburban counterparts, veterans who live in a rural setting have worse health-related quality-of-life scores. Policymakers, within and outside the Veterans Health Administration, should anticipate greater health care demands from rural populations.     

Rural-urban comparison of contextual associations with self-reported mental health status

Ample evidence documents the association between individual-level risk factors and mental health status; relatively less is known about associations between features of the context in which individuals live and their mental health. The objective of this study is to assess differences in associations between contextual characteristics of both rural and urban settings and mental health status measured by the mental health component of the SF-12. Using state-representative data, we observed significant rural/urban differences in the association of mental health status with availability of health care resources but no significant associations in other contextual domains. Lack of overlap in contextual associations suggests that contextual influence operates differently in rural and urban settings and that interventions to improve mental health may not translate across settings.     

Health and Well-Being of Childbearing Women in Rural and Urban Contexts

As part of the national focus on women's health issues, it is important to identify those health-related characteristics of rural women that distinguish them from women living in urban settings. The aim of this study was to compare rural and urban childbearing women on socioeconomic characteristics, perceived stress, health-related practices, illness symptoms, parenting confidence, and body weight. One hundred sixty-five midwestern women responded to a health survey sent to them six months after childbirth. Rural women were younger and less educationally and economically advantaged compared to urban women. Before adjusting for these differences, rural women were less self-actualized, more interpersonally isolated, and reported less healthy nutrition than urban women. These differences disappeared when socioeconomic differences were adjusted. Rural and urban mothers did not differ in most other areas, including perceived stress, parenting confidence, and body weight. Compared to national norms, the perceived stress levels of both rural and urban mothers were significantly higher than a probability sample of U.S. women. Findings support the role of socioeconomic factors as contributing to risk of poor health promotion among rural childbearing women.     

Coastal proximity and mental health among urban adults in England: The moderating effect of household income

After adjusting for covariates, self-reported general health in England is higher among populations living closer to the coast, and the association is strongest amongst more deprived groups. We explored whether similar findings were present for mental health using cross-sectional data for urban adults in the Health Survey for England (2008–2012, N ≥25,963). For urban adults, living ≤1 km from the coast, in comparison to >50 km, was associated with better mental health as measured by the GHQ12. Stratification by household income revealed this was only amongst the lowest-earning households, and extended to ≤5 km. Our findings support the contention that, for urban adults, coastal settings may help to reduce health inequalities in England.     

Health, mental health, substance use, and service utilization among rural and urban incarcerated women.

Incarcerated women commonly report health, mental health, and substance use problems, yet there is limited research on service utilization before incarceration, particularly among women from urban and rural areas. This study includes a stratified random sample of 100 rural and urban incarcerated women to profile the health, mental health, substance use, and service utilization; examine the relationship between the number of self-reported problems and service utilization; and examine self-reported health and mental health problems in prison as associated with preincarceration health-related problems and community service utilization. Study findings suggest that health and mental health problems and substance use do not differ significantly among rural and urban women prisoners. However, there are differences in service utilization -- particularly behavioral health services including mental health and substance abuse services; urban women report more service utilization. In addition, rural women who reported using needed community services before prison also reported fewer health problems in prison. Implications for correctional and community treatment opportunities in rural and urban areas are discussed.     

Community Priorities for Healthy Eating in Older Adults

Community planners such as policymakers and health care and nutrition service providers can create an “age-friendly” environment to support healthy eating in older residents by addressing the highest priorities that enable older adults to improve their dietary intake through different food-related community settings. To identify and prioritize these factors that facilitate behavioral change (enablers) and behavioral settings important for older adult nutrition based on the social ecological model, nutrition and aging professionals (n?=?30) from two rural (West Virginia, Iowa) and two urban (Massachusetts, New York) city/county regions (communities) participated in an online or live focus group discussion and completed an analytic hierarchy process survey online. Overall, the most important perceived enablers were accessibility and cost, followed by transportation and social support, but their relative importance varied by community. Participants from all communities considered congregate meal sites and food banks among the most important behavioral settings. Participants from most communities considered food stores to be important and also highlighted other settings unique to the area, such as senior housing, neighborhood, and farmers’ markets. By targeting interventions to address the most notable enablers and behavioral settings specific to their community, planning groups can enhance their older residents’ ability to achieve optimal nutritional health.     

城乡老年慢性病患者抑郁状况及影响因素分析

目的：探究老年慢性病患者的抑郁现状及影响因素的城乡差异比较,为实施早期预防和干预措施提供理论依据。方法：选取2018年中国健康与养老追踪调查数据库中共4 547名老年慢性病患者作为研究对象,采用简版流调中心抑郁量表(CESD-10)进行评分。结果：城乡老年慢性病患者抑郁状况的差异有统计学意义(χ²=78.119,P<0.05),其中农村组抑郁发生率为44.0%,城镇组为29.5%。回归分析显示,城乡老年慢性病患者抑郁共有的危险因素是女性、西部、睡眠时间较短、自评健康状况较差、躯体生活自理能力受损、工具性日常生活活动能力受损;城镇组特有的保护因素是受教育程度初中、高中及以上,城镇组特有的危险因素是共患3种及以上慢性病;农村组特有的保护因素是有配偶、家庭月生活支出1 000～5 000元,农村组特有的危险因素是共患2种慢性病。结论：农村老年慢性病患者与城镇相比,抑郁发生率更高,应重点关注高危群体的心理健康,开展有针对性的心理疏导工作,以改善其抑郁状况。     

Children with Special Health Care Needs Program: Urban/Rural Comparisons

The purposes of this study were to: (1) describe both the urban and rural clients who received services from the Indiana Children with Special Health Care Needs program (CSHCN) including both demographic and clinical characteristics; (2) conduct a health care needs assessment of the CSHCN program clients in both urban and rural areas; and (3) measure the perceived quality and adequacy of the CSHCN program services. A survey instrument was developed and mailed to all 6,459 families who participated in the Indiana CSHCN program from July 1, 1990 to June 30, 1991. Of the 2,722 questionnaires used in the analysis, 1,624 clients (59.7%) resided in urban counties and 1,098 (40.3%) resided in rural counties. The most frequently noted conditions for program eligibility were asthma, ear infections, hearing impairments, heart defects, and convulsions and seizures. Asthma had greater prevalence among the urban clients while cleft lip/palate, epilepsy, and heart defects were more common among the rural clients. The majority of program clients perceived their medical needs as being met. However, significant numbers of clients perceived unmet needs for mental health services, support groups, information about community services, resources to pay for uncovered medical expenses, and respite care. Of the 23 listed services, five were reported at significantly lower rates by rural clients as not being met: regular medical care, recreation, child care/day care, parent support group services, and speech therapy. Quality of medical services was generally perceived as being "excellent or good," while services related to information about community programs, child's rights in school, resources available to pay for uncovered medical expenses, as well as communication between the treatment center and the child's school were more often rated as "fair or poor." A smaller proportion of rural clients rated physician care and availability of staff nurses as fair or poor. A larger percentage of the rural group reported that access to treatment center location was fair or poor, compared to the urban group. Overall, the evaluation of the Indiana CSHCN program has shown that the non-medical care component seems to be in need of change, especially in the area of information and communication. Attention needs to be focused on providing more family support such as respite or child care and support groups, better information and communications, and improved availability of mental health services to better enable the CSHCN program to meet its objectives.     

A prospective study of morbidity and mortality rates among farmers and rural and urban nonfarmers

Farmers are known to have lower morbidity and mortality rates than the mean for other occupational groups in the general population. Whether this is due to the urban-rural health gradient or to occupational factors related to farming is not clear. To explore this issue, we conducted a prospective study of farmers and matched rural and urban referents. Official hospital admission and mortality data for the years 1989-1996 were obtained. The relative risk of being admitted to hospital were 10% higher among rural and urban referents than among the farmers. The biggest differences were seen for mental and cardiovascular disorders. The odds of dying during follow-up did not differ between the two rural groups but were doubled among urban referents. In conclusion, the lower morbidity and mortality rates among farmers are partly due to the urban-rural health gradient but in addition salutogenic factors linked to farming seem to be active.     

Rural-Urban Disparities in Health-Related Quality of Life Within Disease Categories of Veterans

ABSTRACT:  Context: Compared to their urban counterparts, rural veterans have been found to have lower health-related quality of life. Purpose: To determine whether these disparities persist when examining disease categories of rural and urban veterans. Methods: We obtained survey data on 748,216 veterans who were current or anticipated Veterans Health Administration patients. Using International Classification of Diseases (ICD)-9CM codes, we determined whether these veterans had diagnoses that fell into any of 30 physical health disease categories, and we used ZIP codes to determine whether veterans lived in rural or urban settings. We compared rural to urban prevalence of disease categories as well as urban to rural health-related quality-of-life physical health component summary scores (PCS) and mental health component summary scores (MCS) for each disease category. Findings: Physical diagnoses were significantly more prevalent in the rural veteran population for most disease categories examined. For every disease category examined, PCS were significantly lower for veterans who lived in rural, compared to urban, settings ( P < .001 for all); rural veterans also experienced lower MCS for all disease categories although differences were modest. Differences persisted after controlling for sociodemographic factors. Conclusions: Compared to the urban veteran population, within disease categories, the rural veteran population experiences higher disease prevalence and lower physical and mental quality-of-life scores. Policymakers should anticipate greater health care demands from the rural veteran population and work to meet that demand.