Urban Health in Tanzania: Questioning the Urban Advantage

How are health inequalities articulated across urban and rural spaces in Tanzania? This research paper explores the variations, differences, and inequalities, in Tanzania’s health outcomes—to question both the idea of an urban advantage in health and the extent of urban–rural inequalities in health. The three research objectives aim to understand: what are the health differences (morbidity and mortality) between Tanzania’s urban and rural areas; how are health inequalities articulated within Tanzania’s urban and rural areas; and how are health inequalities articulated across age groups for rural–urban Tanzania? By analyzing four national datasets of Tanzania (National Census, Household Budget Survey, Demographic Health Survey, and Health Demographic Surveillance System), this paper reflects on the outcomes of key health indicators across these spaces. The datasets include national surveys conducted from 2009 to 2012. The results presented showcase health outcomes in rural and urban areas vary, and are unequal. The risk of disease, life expectancy, and unhealthy behaviors are not the same for urban and rural areas, and across income groups. Urban areas show a disadvantage in life expectancy, HIV prevalence, maternal mortality, children’s morbidity, and women’s BMI. Although a greater level of access to health facilities and medicine is reported, we raise a general concern of quality and availability in health services; what data sources are being used to make decisions on urban–rural services, and the wider determinants of urban health outcomes. The results call for a better understanding of the sociopolitical and economic factors contributing to these inequalities. The urban, and rural, populations are diverse; therefore, we need to look at service quality, and use, in light of inequality: what services are being accessed; by whom; for what reasons?     

Residential mobility within England and urban-rural inequalities in mortality

This study is situated within the international literature on geographic health inequalities between urban and rural areas. Using data from the Office for National Statistics Longitudinal Study (ONS LS), this paper assesses the role of residential mobility within England between 1981 and 2001 in explaining geographic inequalities in all-cause mortality between urban and rural Local Authority Districts at the end of the period (deaths occurring between 2001 and 2005). First, the pattern of directly age-standardised death rates (2001-2005) in urban and rural areas of residence in 2001 is examined and compared with the pattern that would have been seen if the observed death/survival of individuals had occurred in their original place of residence in 1981, or in 1991. Secondly, logistic regression is applied to examine whether individuals' residential mobility between urban and rural areas predict the risk of mortality, adjusting for people's socio-demographic characteristics. Findings show that, for this sample, residential mobility 1981-2001 accounts for about 30% of the urban-rural inequalities in mortality observed at the end of the period. LS members who were residentially mobile between urban and rural areas were relatively healthier than long-term urban residents, with better mortality outcomes among rural in-migrants. In age-stratified analysis, LS members of working age (20-64 years) moving out of rural areas, and LS members of retirement age (65 years and older) moving into rural areas, were shown to be healthier. Processes of selective migration in and out of rural areas in England are complex and may partly explain urban-rural health inequalities. In terms of varying mortality risk, findings also highlight the possible marginalisation and disadvantage of sub-groups of the rural population.     

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.     

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.     

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.     

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 multilevel analysis of the effects of rurality and social deprivation on premature limiting long term illness

STUDY OBJECTIVE: To examine the geographical variation in self perceived morbidity in the south west of England, and assess the associations with rurality and social deprivation. DESIGN: A geographically based cross sectional study using 1991 census data on premature Limiting Long Term Illness (LLTI). The urban-rural and intra-rural variation in standardised premature LLTI ratios is described, and correlation and regression analyses explore how well this is explained by generic deprivation indices. Multilevel Poisson modelling investigates whether Customized Deprivation Profiles (CDPs) and area characteristics improve upon the generic indices. SETTING: Nine counties in the south west of England PARTICIPANTS: The population of the south west enumerated in the 1991 census. MAIN RESULTS: Intra-rural variation is apparent, with higher rates of premature LLTI in remoter areas. Together with high rates in urban areas and lower rates in the semi-rural areas this indicates the existence of a U shaped relation with rurality. The generic deprivation indices have strong positive relations with premature LLTI in urban areas, but these are a lot weaker in semi-rural and rural locations. CDPs improve upon the generic indices, especially in the rural settings. A substantial reduction in unexplained variation in rural areas is seen after controlling for the level of local isolation, with higher isolation, at the wider geographical scale, being related to higher levels of LLTI. CONCLUSIONS: This study highlights the need to treat rural areas as heterogeneous, although this has not been the tendency in health research. Generic deprivation indices are unlikely to be a true reflection of levels of deprivation in rural environments. The importance of CDPs that are specific to the area type and health outcome is emphasised. The significance of physical isolation suggests that accessibility to public and health services may be an important issue, and requires further research.     

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.     

Revealing mental health status in Iran's capital: putting equity and efficiency together

Information about urban health is often based on averages, while to better understand health status in urban areas, inequality should also be included. In this paper, we applied an achievement index approach in order to surmount this defect and to examine mental health status in Iran's capital, Tehran. The data we required for this study were taken from the Urban Health Equity Assessment and Response Tool (Urban HEART) survey which was conducted in Tehran in 2007, covering people aged 15 and above. The concentration index, which is a commonly used measure of socioeconomic inequalities in health, was extended to enable the combination of inequality and averages and the formation of a mental health achievement index. Values from the standard concentration indices showed that mental disorders are concentrated disproportionately among the poor in Tehran. An extension of the standard concentration indices revealed that, in most of Tehran's districts, the mental health of populations in the poorest quintile is much worse than that of other groups. In addition, when we computed the achievement index and ranked districts according to this index, the ranking was different from the ranking by averages. These findings imply that mental health varies significantly across the economic groups of the population in Tehran and that efficiency-oriented strategies which target average level of mental health alone are not sufficient to improve mental health of all people especially mental health of the poor. Equity-oriented strategies which target the mental health inequalities should be considered as well.     

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.     

Prevalence, pattern and determinants of mental disorders in rural Bangladesh

OBJECTIVES: Very few studies have examined mental health morbidity in Bangladesh. This community-based study of rural Bangladesh in 2000-2001 estimated the burden of mental morbidity among rural people of working age. STUDY DESIGN AND METHODS: Community surveys were conducted with one respondent from each household of three selected villages in the service provision area of a non-profit public health organization. General Health Questionnaire 60 (GHQ-60) was used as a screening tool in Stage I, and clinical examination by a Western-trained psychiatrist was undertaken for concurrent validation in Stage II. RESULTS: The overall prevalence of psychiatric disorders in this rural area was 16.5%. Depressive disorders and anxiety disorders constituted about one-half and one-third of the total cases, respectively. A significantly higher prevalence of mental disorders was found in the economically poor respondents, those over 45 years of age, and women from large families. CONCLUSION: There is a high prevalence of psychiatric disorders in rural Bangladesh. These findings should aid the planning of locally relevant and appropriate mental healthcare programmes. There is an urgent need for a national mental healthcare policy that strengthens primary mental healthcare services.     

The restorative benefits of walking in urban and rural settings in adults with good and poor mental health

People differ in their potential for psychological restoration but there is little evidence on the role of varying mental health state or settings in the process. This paper reports two quasi-experiments which compare the restorative benefits of walking in urban and rural settings in two groups of adults with good and poor mental health. Two aspects of restoration are examined, firstly mood, the other using personal project techniques (Little, 1983) to capture an under-explored aspect of cognitive restoration through reflection on everyday life tasks. Results are consistent with a restorative effect of landscape: the rural walk was advantageous to affective and cognitive restoration in both health groups when compared to an urban walk. However, beneficial change took place to a greater extent in the poor health group. Differential outcomes between health groups were found in the urban setting, which was most advantageous to restoration in the poor mental health group. This study extends restorative environments research by showing that the amount of change and context for restoration can differ amongst adults with variable mental health.     

Immunization in urban areas: issues and strategies.

In the past, immunization programmes have focused primarily on rural areas. However, with the recognition of the increasing numbers of urban poor, it is timely to review urban immunization activities. This update addresses two questions: Is there any need to be concerned about urban immunization and, if so, is more of the same kind of rural EPI activity needed or are there specific urban issues that need specific urban strategies? Vaccine-preventable diseases have specific urban patterns that require efficacious vaccines for younger children, higher target coverage levels, and particular focus to ensure national and global eradication of poliomyelitis. Although aggregate coverage levels are higher in urban than rural areas, gaps are masked since capital cities are better covered than other urban areas and the coverage in the poorest slum and periurban areas within cities is as bad as or worse than that in rural areas. Difficult access to immunization services in terms of distance, costs, and time can still be the main barrier in some parts of the city. Mobilization and motivation strategies in urban areas should make use of the mass media and workplace networks as well as the traditional word-of-mouth strategies. Use of community health workers has been successful in some urban settings. Management issues concern integration of the needs of the poor into a coherent city health plan, coordination of different health providers, and clear lines of responsibility for addressing the needs of new, urbanizing areas.     

Human exposure to allergenic pollens: a comparison between urban and rural areas

Background

Pollinosis is found more frequently in urban areas than in rural environments. This could be partly related to the different types of pollen exposure in these dissimilar areas. The objective of this study was to compare the distribution of pollen in these environments across an urbanization gradient.

Methods

Daily pollen abundances were obtained in France using Hirst-type sensors. Sampling was conducted from January to June in 2003 and 2006 in a rural area, a semi-rural area and in two urban areas, which were characterized by several urbanization criteria.

Results

Total allergenic pollen abundance was higher in rural and semi-rural areas than in urban areas irrespective of the sampling year. Multivariate analyses showed that pollen exposures differed according to the type of area and were strongly explained by the urbanization gradient. Grass, ash, birch, alder, hornbeam, hazel and plantain pollen quantities exceeded the allergy threshold more often in rural settings than in urban areas. In urban areas, only plane pollen quantities exceeded the allergy threshold more often than in rural areas.

Conclusions

Allergenic pollen exposure is higher in rural areas than in urban areas, and the most abundant pollen in each area did not originated from the same taxa. This result should be taken into account in epidemiological studies comparing allergies in rural and urban areas to adapt the panel of pollen extracts for human environmental exposure. In addition, this study highlights that some ornamental trees produce a large number of allergenic pollens and provide new sources of aeroallergens.     

Trends in mental health inequalities in urban Canada

ObjectivesCanadians do not all enjoy equal levels of health. The presence of income-related health inequalities has been well established in Canada, but there is a lack of consistent reporting of mental health inequalities in Canada’s largest cities. This study reports the prevalence and inequalities in mental health outcomes at the city, provincial, and national levels over time.MethodsSelf-reported poor mental health, life stress, and physician-diagnosed self-reported mood and anxiety disorder from the Canadian Community Health Survey were pooled over five-year intervals and combined with neighbourhood income information from the Canadian Census. First, prevalence rates were calculated for each interval at the neighbourhood level for urban communities. Second, the distributions of these neighbourhood rates were summarized at the city level and for Canada as a whole using overall prevalence rates and concentration indices of inequality. Finally, trends in these city- and country-level outcomes were also explored.ResultsAt the national level, starting from 2001 to 2005, the prevalence of poor mental health (27.9%), mood disorder (7.3%), and anxiety disorder (6.8%) had significantly increased by 2011–2015. Inequalities were present in 2001–2005 and worsened over time. The prevalence rate at the national level of life stress was 66.6% in 2001–2005 and decreased over time.ConclusionThe large and increasing values of inequalities and the difference in prevalence rates and inequalities in cities highlight the necessity for mental disorder-specific data and for city-level analysis of inequalities. The next steps in reducing inequalities involve deconstructing the health inequalities, and continued monitoring.     

Inequalities in mortality and illness in Trent NHS Region.

BACKGROUND: The Department of Health is encouraging health authorities to improve health status by tackling health inequalities. We defined ward level spatial health variations in Trent National Health Service Region, England, investigated urban and rural inequalities, and examined the relationship with deprivation, to identify the extent of small area health inequalities and to establish whether a quantifiable difference exists between urban and rural health as affected by deprivation. METHOD: A small area ecological study design was adopted and ward level (n=591) standardized ratios were calculated (population aged <75, n=3,900,000) for specific causes of death and limiting long-term illness. A classification was devised to assess ward health inequalities according to an urban-rural dimension. Deprivation was measured using the Townsend Index and the relationship with mortality and illness was analysed using Pearson product moment correlation. RESULTS: Wide variations in mortality and illness were evident at ward level, being widest for accident mortality (standardized mortality range 0-508). Stroke mortality accounted for the largest proportion of wards with standardized mortality ratios over 125 (36.2 per cent). Relative deprivation correlated strongly with limiting long-term illness (r=0.82) and all-cause mortality (r=0.68) across Trent, and in both urban and rural environments. CONCLUSION: The study set health inequalities within a regional context for Trent as an initiative to coincide with the Government's proposed health strategy for the next few years. Wide health inequalities were evident in Trent and the association between deprivation and health was of a similar magnitude in urban and rural wards. This small area approach allows health authorities access to ward level information in order to inform key debate on tackling health inequalities and distributing resources in relation to need.     

Socioeconomic inequalities in self-assessed health and mental health in Barcelona, 2001-2016

ObjectivePrevious research has found persistent socioeconomic inequalities in health outcomes at the national level, with different patterns after the economic crisis. However, inequalities in urban areas are also important. This study analyses socioeconomic inequalities in self-assessed health and mental health in the city of Barcelona.MethodRepeated cross-sectional design using quinquennial data from the Barcelona Health Surveys carried out in 2001, 2006, 2011 and 2016 for the population older than 22 years. Robust Poisson regressions models were used to compute socioeconomic gradients and relative (RII) and slope indexes of inequality (SII) by occupational social class, with stratification by sex. RII and SII were also obtained with further adjustment by employment situation.ResultsA consistent socioeconomic gradient was found for all years except for 2011. Relative and absolute inequalities followed a V-shape, showing a drop during the economic crisis but widening thereafter to recover pre-crisis figures for self-assessed health and widening for mental health, in both relative and absolute terms in 2016. Adjustment for employment situation reduces inequalities but a large part of these inequalities remains, with variability across years.ConclusionsThe lasting effects of the 2008 economic crisis and the austerity programmes imposed since then may have contributed to the persistence of socioeconomic inequalities in self-assessed health and the widening of those for mental health.     

The contribution of smoking and obesity to income-related inequalities in health in England

Reducing avoidable inequalities in health is a priority in many health care systems, including the NHS in Great Britain. Evidence suggests that lifestyle factors may play a role in explaining socioeconomic inequalities in health. In this paper we measure the contribution of smoking and obesity to income-related inequality in health. We use the corrected concentration index to measure inequality across time and areas of England, and decomposition methods to quantify directly the contribution of smoking and obesity to income-related inequality. Instrumental variables regression is used to test the endogeneity of smoking and obesity. We use data from nine rounds of the Health Survey for England (1998–2006). The results show that there are significant income-related health inequalities in England, that the extent of the inequality varies by area, and that in some areas it has increased over time. Nationally, smoking and obesity make a significant but modest contribution to income-related inequality in health (2.3% and 1.2%, respectively). Despite the reduction in smoking prevalence, the contribution of smoking has slightly increased over time, due to its increasing concentration among the poor and its negative effect on health. While the prevalence of obesity is increasing, it is more equally distributed across society. The prevalence of these problems varies between areas, and so does the contribution they make to income-related inequalities in health.     

Determinants of child malnutrition during the 1999 economic crisis in selected poor areas of Indonesia

There is empirical evidence at the national level that suggests the 1999 Indonesian economic crisis impact was very heterogeneous both between urban and rural areas and across regions. A cross sectional study of the nutritional status of children and its determinants was performed in urban poor areas of Jakarta, and rural areas of Banggai in Central Sulawesi, and Alor-Rote in East Nusa Tenggara. Two-stage cluster sampling was used to obtain 1078 households with under-five children in the urban poor area of Jakarta, and 262 and 631 households with under-five children each for the rural areas of Banggai and Alor-Rote, respectively. Data collection for both studies was performed from January 1999 to June 2001. The study shows that wasting affected more children in the urban poor areas of Jakarta than in the other study areas. On the other hand, stunting and anemia were significantly more severe among children 6-59 months of age in the rural area of Alor-Rote compared to the other study areas. The high prevalence of infectious diseases was significantly related to the higher prevalence of wasting in the study areas of Jakarta and Banggai, and also significantly related to the higher prevalence of stunting and anemia in the study area of Alor-Rote. To avert this kind of health impact of a economic downturn, there is a need to improve the nutritional and health status of under-five children and their mothers through the existing health care system, provide basic health services and improve the capacity of health staff across Indonesia as part of the decentralization process.     

Inequality decomposition and geographic targeting with applications to China and Vietnam

How far are income‐related inequalities in the health sector due to gaps between poor and less poor areas, rather than due to differences between poor and less poor people within areas? This note sets out a method for answering this question, and illustrates it with two empirical examples. The disproportionate accrual of health subsidies to Vietnam's better‐off is found to be largely due to the fact that richer provinces have larger per capita subsidies, while pro‐rich inequalities in health insurance coverage in rural China are found to be largely due to the fact that better‐off villages have been more successful at preventing the collapse of their insurance schemes. Copyright © 2005 John Wiley & Sons, Ltd.