Urban-rural Differences Research Articles

Rural-urban differentials in undernutrition among women in India: Evidence from a decomposition approach.

Background: Global healthcare and nutrition policies have not eliminated the pressing public health issue of undernutrition, which remains a paramount public health concern in countries like India, coinciding with overweight and obesity, in the form of dual burden of malnutrition. Aim: This study delves into the rural-urban differential in undernutrition among reproductive-aged women in India for targeted policy interventions and to achieve universal health coverage. Methods: Data from the recent iteration of the National Family Health Survey (NFHS-5; 2019-21) were utilized to examine the factors influencing rural-urban differentials in women's undernutrition. A set of logistic regression and Fairlie's decomposition analysis are employed to identify the associated covariates and understand the factors driving these differentials. Results: The analysis reveals that rural women are significantly more vulnerable to undernutrition compared to urban counterparts, with factors such as education, wealth status, age, and dietary diversity playing key roles. The decomposition analysis of the rural-urban gap revealed that the variables considered in the study accounted for approximately 75% of the disparity. The difference in household wealth between rural and urban areas contributed about 63% of the explained gap, followed by educational status (16%), age group (11%), dietary diversity (8%), religion (5%), and media exposure (4%). Conclusion: The findings underscore the importance of targeted interventions addressing socio-economic inequalities to mitigate undernutrition among women in India. Enhancing access to education, improving economic opportunities, promoting dietary diversity, and challenging cultural norms are crucial steps towards achieving equitable nutritional outcomes and reducing the existing rural-urban disparity.

The very long-term risk of stroke after acute coronary syndrome and geographic differences. The ABC-10* study on heart disease

Abstract Background Little is known about the very long-term risk of stroke among acute coronary syndrome (ACS) survivors. Methods In this prospective study, we enrolled 535 ACS patients admitted to hospitals in three Italian provinces, discharged alive and followed for 24 years or death. The patient's residency was classified into three urban and three nearby rural areas. Results All patients completed the follow-up (6142 Perso-years). 85 (16%) patients suffered an acute stroke. Patients median age was 67 years, 70% were male, and 318 patients were residing in rural areas. Patients who had a stroke and those who had not shared most of the demographic and clinical characteristics. The incidence rate of overall stroke was 14/1000 person-year. Cox analyses showed older age (HR 3.13;95%CI 2.31-4.26), male gender (HR 1.88;95%CI 1.20-2.95), baseline diabetes (HR 2.25 95%CI 1.37-3.69), heart failure (HR 2.69;95%CI 1.71-4.24), and higher albumin/creatinine ratio (HR 1.75;95%CI 1.33-2.30) were all associated with an increased risk of stroke. while higher baseline eGFR, reperfusion, statin and beta-blockers treatment during follow-up were associated with a decreased risk; HR (0.55 (95%CI 0.42-0.72), 0.45(95%CI 0.29-0.71), 0.21(95%CI 0.13-0.34), and 0.37(95%CI 0.23-0.57), respectively). In the multivariate analysis, only older age (HR1.55;95%CI 1.08-2.21; p=0.02) was an independent predictor of stroke while statin treatment was independently associated with a lower risk (HR 0.35;95% CI 0.21-0.58; p<0.0001). However, all these variables did not predict the risk of stroke in competing risk regression analysis where death was treated as the competing event. A sub-analysis of the 43 patients who had a fatal stroke (FS) revealed 7/1000 person-year FS IR. The Cox regression and competing risk analyses of predictors of FS showed similar results. Interestingly, we observed an association between geographic areas of residence and the long-term FS risk as the risk increased going from rural to urban (HR 2.08;95%CI 1.14-3.80; p=0.02) areas and from north to middle and south provinces (HR 1.47;95%CI 1.00-2.15; p=0.04) in the univariate Cox regression analysis. Results kept true using multivariate Cox and Competing risk regression models. Conclusion This analysis reveals the significant urban-rural difference in the very long–term risk of fatal stroke among unselected ACS patients which highlights the importance of implementing a preventive policy based on area-specific knowledge.

The interaction between Indigenous identity and rural residency in dementia prevalence among Ecuadorian older adults.

While recognizing the acknowledged difference in dementia prevalence between Indigenous and non-Indigenous populations, most previous studies were conducted in the Global North. This study aims to examine the relationship between Indigenous ethnic identity and dementia status with a special focus on urban-rural differences among older adults in Ecuador. Data came from Ecuador's Survey of Health, Welfare, and Aging (SABE), derived from a probability sample of households in Ecuador. The final sample comprised 4,984 adults aged 60 or older. Dementia status was assessed through three indicators: low scores on a cognitive assessment, the number of difficulties in instrumental activities of daily living (IADL), and self-reported dementia diagnosis. Logistic regression and multivariate decomposition analyses were utilized. Indigenous participants, even after adjusting for sociodemographic and health-related factors, exhibited a higher likelihood of having dementia compared to their non-Indigenous counterparts. Among Indigenous participants, those residing in rural areas had higher likelihood of having dementia status, while there was no significant urban-rural difference observed among non-Indigenous participants. Rural residency and covariates explain 91.0% of the observed difference in dementia prevalence between Indigenous and non-Indigenous older adults. Indigenous older adults who are living in rural areas are at particularly high risk of having dementia largely because they have presently recognized modifiable risk factors. These findings underscore the urgent need to prioritize provisions of appropriate and equitable service related to dementia for Indigenous People living in rural areas outside high-income countries.

Frequency of internet use, economic income, and health of the population—comparative analysis of urban and rural areas based on Chinese General Social Survey

People’s health is one of the important supports for China’s economic development. This study uses the 2021 Chinese General Social Survey (CGSS) data to empirically test the impact of residents’ Internet use frequency and economic income on residents’ health level, and analyzes the differences between urban and rural areas. The empirical test results show that, firstly, the frequency of Internet use can promote the health level of residents, and the promotion effect of Internet use frequency on the health level of rural residents is higher than that of urban residents; Secondly, economic income has a positive promoting effect on the health level of the entire sample of residents, but in urban samples, the regression between economic income and residents’ health level is not significant. Third, in the heterogeneity test of region, gender and age, it is found that the impact of residents’ Internet use frequency and economic income on residents’ health level also has urban–rural differences. Based on this, this study suggests that the government can continue to make efforts to further promote the health level of residents by improving the Internet penetration rate, strengthening the use of Internet skills, carrying out Internet professional skills training and promoting the high-quality development of Internet content.

Rural–urban differences in dental opioid prescribing among adolescent/young adult and adult Medicaid beneficiaries

Rural–urban differences in dental opioid prescribing among adolescent/young adult and adult Medicaid beneficiaries

Exploring the determinants of fertility rates in Ethiopia: a decomposition analysis using count regression models with a focus on urban and rural residence, based on the 2019 Ethiopian demographic health survey

IntroductionFertility refers to the biological capacity to reproduce and have children. It is a key aspect of reproductive health influenced by various factors. Therefore, this study aims to explore the determinants of fertility rates based on urban and rural settings in Ethiopia.MethodA stratified two-stage cluster sampling approach was used, employing data from the 2019 Ethiopian Mini Demographic and Health Survey (https://dhsprogram.com). The study comprised 8,885 women aged 15 to 49 years. The study employed Stata 17, and the data was described using descriptive statistics. Associations were examined using decomposition analysis and negative binomial regression. The Incidence Rate Ratio and p-value were used to determine the statistical significance of the variables examined.ResultsThe negative binomial regression found that factors such as maternal age (IRR, 1.08, P-value,0.00), living in rural (IRR,1.09, P-value,0.00), being Muslim (IRR,1.13, P-value,0.00), being from other religious groups (IRR,1.16, P-value,0.00), having six up to nine household members (IRR,1.24, P-value,0.00), having greater than nine household member(IRR,1.14, P-value,0.04), having one child under five year (IRR,1.35, P-value,0.00), having two children under five year (IRR,1.77, P-value,0.00), and having more than two under five years (IRR,1.99, P-value,0.00), being currently pregnant (IRR,1.08, P-value,0.00), use of contraceptive(IRR,1.13, P-value,0.00) are positively associated with bearing more children. On the other hand, completing primary education (IRR,0.84, P-value,0.00), secondary education (IRR,0.61, P-value,0.00), being from the richest household (IRR = 0.94, P-value,0.00), and being single/divorced and widowed (IRR,0.49, P-value,0.00) are negatively associated with having more children because their IRR is less than one. The decomposition analysis also demonstrated that marital status has a stronger negative correlation with fertility in rural compared to urban settings. Additionally, the number of children under five exerts a greater influence on fertility in urban areas.Conclusionthe study found significant rural-urban differences in the factors shaping fertility in Ethiopia. While demographics like maternal age, education, and wealth influenced fertility in both settings, the relationships varied in nature and magnitude. To address this, Policymakers should develop targeted fertility programs that address the unique needs and challenges faced by rural and urban populations.

Urban-rural differences in preferences for traditional Chinese medicine services among chronic disease patients: a discrete choice experiment

BackgroundWith the increasing prevalence of chronic diseases, the demand for medical services from chronic disease patients has become diversified and personalized. The advantages and role of traditional Chinese medicine in the prevention and treatment of chronic diseases gradually emerging. The preferences and willingness to pay for traditional Chinese medicine services (TCMS) among patients with chronic diseases, as well as any disparities between urban and rural patients, have not been examined in past studies.ObjectiveThis study aimed to investigate the preferences of chronic disease patients for TCMS, explore the value/importance that patients place on different treatment attributes, and evaluate whether there are urban-rural differences in their preferences and willingness to pay for TCMS.MethodsA total of 317 patients from Jiangsu Province, China participated in a discrete choice experiment that elicited the preferences for TCMS. The choice questions were constructed by six attributes: out-of-pocket (OOP) cost, institution, medical provider, treatment method, treatment duration, treatment efficacy. Mixed logit models were used to estimate the stated preference and marginal willingness to pay for each attribute.ResultsThe choice preferences of chronic disease patients for TCMS in this study were influenced by the four attributes: institution, treatment method, and treatment efficacy, and OOP cost. Improvements in treatment efficacy were the most concerning, followed by being treated in traditional Chinese medicine (TCM) hospital. Patients were willing to pay more to get better treatment outcomes. Compared with primary care institutions, patients were willing to pay more for treatment in TCM hospitals. The preferences for economic attribute (OOP cost) varied between urban and rural areas, and rural patients tended to favor scenarios that imposed a lower economic burden on them.ConclusionThe chronic disease patients’ preferences for TCMS were determined mainly by treatment efficacy but also by institution, treatment method and OOP cost. The urban-rural difference in preference identified in this study highlights that effective policy interventions should consider the characteristics of patients’ demand in different regions.

Rural residency, rural resentment, and attitudes toward public land management in the United States

ABSTRACT Disparate urban and rural lived experiences contribute to the geographic divide in American politics. We expect this to be especially true for environmental politics because of urban-rural differences in exposure to natural resources. We demonstrate that Americans are broadly supportive of public lands and that ruralites are slightly more supportive of public land management compared to the non-rural. However, a crucial exception to general rural attitudes is highly resentful ruralites are uniquely and dramatically unsupportive of public lands and direct their resentment at the federal government especially. This research clarifies the nationalized nature of the urban-rural divide by highlighting that the preferences of resentful rural Americans are in stark contrast to the rest of society, even the rest of rural America. Nevertheless, when a minority’s unpopular opinions on the management of America’s natural resources overshadow more moderate and modal positions it fuels fringe movements like the Sagebrush Rebellion.

Association between obesogenic environments and childhood overweight/obesity across the United States: Differences by rurality.

Childhood obesity is more prevalent in rural compared to urban communities and may be related to urban-rural differences in environmental factors known to affect obesity. However, understanding of how environmental factors impact childhood obesity in rural settings remains limited. This study aimed to address this gap by exploring the relationship between obesogenic environments and childhood overweight/obesity rates, including variations across the urban-rural continuum. This study analyzed data for counties in the United States (N = 3140). Linear regression models were employed to examine the relationship between the Childhood Obesogenic Environment Index, which consisted of ten variables from a variety of sources associated with physical activity and healthy eating, and childhood overweight/obesity rates estimates derived from the 2016 National Survey of Children's Health. County rurality was categorized using Rural-Urban Continuum Codes and a moderation analysis was conducted to identify potential variations by rurality. There was a significant positive association between the COEI and childhood overweight/obesity rates nationally, with notable variations across the urban-rural continuum for specific index components. Neighborhood walkability showed a significant positive association across rurality, indicating that childhood overweight/obesity rates were higher in less walkable communities. Full-service restaurants exhibited an inverse relationship with childhood overweight/obesity rates across all RUCC levels. These results underscore the obesogenic environmental factors associated with childhood overweight/obesity rates nationally and how they vary across the urban-rural continuum. This study highlights the importance of considering these variations when designing interventions to address childhood obesity.

Clinical characteristics, in-hospital management, and outcomes among patients hospitalized for acute ischemic stroke in rural versus urban hospitals in China: A nationwide hospital-based study.

Efforts to improve rural stroke care have intensified in China. However, high-quality comprehensive data on the differences in care and outcomes between rural and urban hospitals are limited. We analyzed data on patients with acute ischemic stroke hospitalized in the China Stroke Center Alliance hospitals from 2015 to 2022. The in-hospital management measures assessed included nine acute and five discharge management measures. Outcomes evaluated included death or discharge against medical advice (DAMA), major adverse cardiovascular events (MACE), disability at discharge, and in-hospital complications. We enrolled 1,583,271 patients with acute ischemic stroke from 1930 hospitals, comprising 1086 (56.3%) rural sites with 735,452 patients and 844 (43.7%) urban sites with 847,891 patients. Patients in rural hospitals demonstrate suboptimal management measures compared to those in urban hospitals, including lower rates of intravenous recombinant tissue plasminogen activator within 4.5 h (26.0% vs 28.3%; difference: -2.3% (-2.5% to -2.0%)), endovascular treatment (0.6% vs 1.9%; difference: -1.3% (-1.3% to -1.2%)), vessel assessment (88.5% vs 92.0%; difference: -3.5% (95% confidence interval (CI): -3.6% to -3.4%)), and anticoagulants for atrial fibrillation at discharge (42.9% vs 47.7%; difference: -4.8% (95% CI: -5.4% to -4.2%)). Overall, the rural-urban disparity in in-hospital outcomes was small. Rural patients had a slightly higher rate of in-hospital death/DAMA (9.0% vs 8.0%; adjusted odds ratio (OR): 1.22 (95% CI: 1.20-1.23); adjusted risk difference (aRD): 1.3% (95% CI: 1.2%-1.4%)) and a slightly lower rate of complications (10.9% vs 13.0%; aOR: 0.83 (95% CI: 0.82-0.84); aRD: -1.3% (95% CI: -1.3% to -1.3%)). No notable rural-urban differences were observed in MACE and disability at discharge. Patients in rural hospitals demonstrated suboptimal management measures and had higher rates of in-hospital death/DAMA compared to those in urban hospitals. Prioritizing the allocation of health resources to rural hospitals is essential to improve healthcare quality and outcomes. The data supporting the findings of this study are available from the corresponding author upon reasonable request.

A novel approach to improve population mapping considering facility-based service capacity and land livability

Social sensing data, including points-of-interest (POI) and mobile position, are important data sources for population mapping. However, existing studies using POI data disregard the heterogeneity in facility size among the same type of POI and urban–rural differences. Moreover, mobile position data face biased issues. This study presents a hybrid model that considers facility-based service capacity (FSC) and land livability to map fine-scale population distributions. Based on extracting the FSC index by integrating POI, mobile phone positioning (MPP), and road network data, the district-level census population was disaggregated into 100-m grids using a random forest model. Subsequently, a regression equation was developed from the land use data to correct the estimated residuals. The results showed that the hybrid model exhibited considerably smaller errors than those of the POI density-based method and direct mapping of MPP (RMSE = 5,393.31, 7,348.91, and 7,824.76, respectively), effectively reducing population misallocation in extreme-density regions. Compared to WorldPop and LandScan datasets and a comparative model, our method reduced the RMSE by 30–60%, proving the effectiveness of integrating various social sensing and remote sensing data for improving population mapping. This study improves on an existing method as a thought-provoking step toward advancement in fine-scale population mapping research.

Unveiling the causal effects of China’s minimum living standard guarantee on household transportation expenditures: A causal forest analysis

We investigate the causal effects of China’s Minimum Living Standard Guarantee (MLSG, also called Dibao) subsidy on household transportation expenditures. Utilizing data from the Chinese Social Survey, we employ a combination of the propensity score matching (PSM), causal forest (CF) and marginal treatment effect model (MTE) methodologies to rigorously estimate the subsidy’s effects. The PSM allows us to mitigate selection bias by matching MLSG recipients with comparable non-recipients. While the causal forest captures the heterogeneity of treatment effects across various household profiles. The result of MTE indicate that observable and essential heterogeneity are present to influence the effect of their subsidies, which present the consistent with PSM and CF. The causal mediation analysis indicates the mediating mechanism that MLSG impacts on household transportation expenditures, while also revealing significant variations among different regions. The study not only refines our understanding of the MLSG’s effects on household spending but also offers novel insights into applicational advancements by incorporating machine-learning techniques for policy evaluation. These results have important implications for policy formulation and refinement, particularly in the urban-rural differences.

Urbisphere-Berlin Campaign: Investigating Multiscale Urban Impacts on the Atmospheric Boundary Layer

Abstract For next-generation weather and climate numerical models to resolve cities, both higher spatial resolution and subgrid parameterizations of urban canopy–atmosphere processes are required. The key is to better understand intraurban variability and urban–rural differences in atmospheric boundary layer (ABL) dynamics. This includes upwind–downwind effects due to cities’ influences on the atmosphere beyond their boundaries. To address these aspects, a network of >25 ground-based remote sensing sites was designed for the Berlin region (Germany), considering city form, function, and typical weather conditions. This allows investigation of how different urban densities and human activities impact ABL dynamics. As part of the interdisciplinary European Research Council Grant urbisphere, the network was operated from autumn 2021 to autumn 2022. Here, we provide an overview of the scientific aims, campaign setup, and results from 2 days, highlighting multiscale urban impacts on the atmosphere in combination with high-resolution numerical modeling at 100-m grid spacing. During a spring day, the analyses show systematic upwind-city-downwind effects in ABL heights, largely driven by urban–rural differences in surface heat fluxes. During a heatwave day, ABL height is remarkably deep, yet spatial differences in ABL heights are less pronounced due to regionally dry soil conditions, resulting in similar observed surface heat fluxes. Our modeling results provide further insights into ABL characteristics not resolved by the observation network, highlighting synergies between both approaches. Our data and findings will support modeling to help deliver services to a wider community from citizens to those managing health, energy, transport, land use, and other city infrastructure and operations.

Rural-urban and regional variations in aspects of caregiving, support services and caregiver health in the USA: evidence from a national survey

ObjectivesDue to substantial regional variability in available caregiving services and supports, culture and health status among informal caregivers in the USA, the study objective was to explore how rural-urban differences...

Exploring Rural-Urban Differences in the Receipt of Nonelective Cancer-specific Gastrointestinal Surgery Using a Multilevel Mixed-Effects Approach

BackgroundRural communities constitute a populace marked by various social challenges influencing health outcomes. As such, nonelective surgeries for cancer may have a disproportionate impact on rural populations. We explored patient and county-level factors contributing to differences in the receipt of nonelective cancer-specific surgery between rural and urban residents. MethodsThis retrospective study included adult patients captured in the SEER-Medicare data between January 2008 and December 2015 with an incident stage I-IV cancer of the stomach, liver/intrahepatic bile duct, pancreas, gallbladder/other biliary origin, or small intestine who underwent a cancer-specific surgery. The primary outcome was nonelective cancer-directed surgery among rural versus urban residents. We conducted a multivariable mixed-effects logistic regression model to adjust for confounders while accounting for county-level clustering. ResultsThe sample included 10,136 patients who underwent a surgical intervention; 2,941 (29%) were nonelective. The incidence of nonelective surgery was lower among rural compared tourban patients [351 (27%) and 2590(29%); p= 0.05]. There was no statistically significant difference in the unadjusted and adjusted odds of nonelective surgery between rural and urban residents [OR 0.88, 95% CI (0.76-1.03); p= 0.11] and [aOR 0.86, 95% CI (0.72-1.02); p= 0.080]. Additionally, high social vulnerability index counties or Black race was significantly associated with increase odds of nonelective surgery [aOR 1.33, 95% CI (1.07-1.65); p=0.009] and [aOR 1.49, 95% CI (1.26-1.77); p<0.0001], respectively. ConclusionThis study found no difference in the odds of receiving nonelective surgery for GI foregut cancers between rural and urban populations. However, Black race and high SVI were associated with higher odds of the receipt of nonelective surgery. Further research is warranted to explore if disparities in clinical outcomes exist despite the comparable likelihood of receiving nonelective surgery between rural and urban communities.

Spatial patterns of electoral support in the 2023 general election in Poland

RESEARCH OBJECTIVE: This article focuses on identifying the spatial patterns of electoral support for the main political actors, and searching for adequate determinants that explain this distribution of support, based on the results of the 2023 general election in Poland. THE RESEARCH PROBLEM AND METHODS: Is there a relationship between the basic morphological features of the voting space in Poland and the hierarchy of the settlement structure, along with the arrangement of regions associated with the country’s historical and political heritage? The methods used in the study include analysis of descriptive statistics, estimation of spatial autocorrelation, discriminant analysis, and cartographic methods. PROCESS OF ARGUMENTATION: The research process involves a two-stage procedure: 1) identifying a general picture of spatial variation in electoral support for selected groupings, and basic clustering patterns of electoral support; and 2) estimating links between the observed patterns of support and their presumed determinants; that is, the country’s settlement hierarchy and historical-political divisions. RESEARCH RESULTS: The spatial variability of the support indicators is characterised by a distinctive territorial distribution, based on the units of the settlement system and the boundaries of former historical divisions. The nature of this linkage indicates the changing layout of the voting space, associated with the increasing polarisation of citizens’ political preferences. CONCLUSIONS, INNOVATIONS, AND RECOMMENDATIONS: The current pattern of urban-rural differentiation is related to the different preferences of metropolitan (over 20,000 inhabitants) and rural or small-town (up to 20,000 inhabitants) communities. The east-west heterogeneity of Poland’s voting space is increasing due to similarities of preferences among the inhabitants of former Austrian and Russian Poland, on the one hand, and Prussian Poland and the Recovered Territories, on the other.

Greenspace coverage vs. enhanced vegetation index: Correlations with surface urban heat island intensity in different climate zones

The two greenspace indicators, greenspace coverage (GC) and enhanced vegetation index (EVI), have been widely used in studies on surface urban heat island intensity (SUHII). However, GC, which is more practical for urban planning, has not been as extensively involved in cross-regional SUHII studies as EVI. This study investigated 233 Chinese cities spanning three climate zones to examine how the correlations between SUHII and GC differ from those between SUHII and EVI across different climate zones. Our findings reveal that SUHII is more closely associated with the urban-rural differences in greenspace (ΔGC and ΔEVI) than with the urban values of GC and EVI. ΔGC shows potential for inter-city SUHII studies and outperforms ΔEVI in mild temperate climate zones (Cw and Cf). In the snow with dry winter climate zone (Dw), the correlation between SUHII and ΔEVI peaks at −0.795, exceeding that of ΔGC at −0.653. The cooling effects of greenspace diminish progressively from Dw to Cw to Cf, with the same ΔGC corresponding to higher SUHII in Cf than in Cw and Dw. These results underscore the necessity to develop targeted acceptable SUHII standards and GC thresholds for different climate zones to guide greening-based cooling measures.

Education Equity in Urban-Rural Differences in China: Take Teacher Team Building as An Example

China's educational equity has received widespread attention from society, and all regions of the country have adopted positive policies to adjust and improve the fairness of the education system. However, in the existing education system, there are still deficiencies in the allocation of educational resources and teachers in different regions, such as the eastern and western regions, and coastal and inland areas. Certainly, urban and rural areas are the same. This paper analyzes the role of teachers for students, society, and even the country, as well as the differences in urban and rural educational resources and fairness. This paper analyzes the importance of teachers for both urban and rural students, which further illustrates the importance of fair allocation of teacher resources for the development of students. Based on this, this paper proposes the following suggestions: carry out urban-rural educational cooperation develop diversified education, and cultivate excellent local teachers to reduce the fairness problems in urban and rural areas.

Urban-rural disparities in mortality due to stroke subtypes in China and its provinces, 2015-2020.

Death burden of stroke is severe in China with over one-third rural residents, but there is still a lack of specific national and high-quality reports on the urban-rural differences in stroke burden, especially for subtypes. We aimed to update the understanding of urban-rural differences in stroke deaths. This is a descriptive observational study. Data from the national mortality surveillance system, which covers 323.8 million with 605 disease surveillance points (DSPs) across all 31 provinces, municipalities, and autonomous regions in China. All deaths from stroke as the underlying cause from 2015 to 2020 according to DSPs. Crude mortality rate and age-standardized mortality rate (ASMR) were estimated through DSPs. Average annual percentage change was used to explain the change in mortality rate. From 2015 to 2020, the majority of deaths from all stroke subtypes occurred in rural areas. There were significant differences between the changes of urban and rural ASMRs. On the whole, the changes in urban areas were evidently better, and the ASMR differences were basically expanding. Stroke ASMR in urban China decreased by 15.5%. The rural ASMR of ischemic stroke (IS) increased by 12.9%. The rural and urban ASMRs of intracerebral hemorrhage decreased by 24.9% and 27.4%, and those of subarachnoid hemorrhage decreased by 29.5% and 40.4%, respectively. The highest ASMRs of all stroke subtypes and the increasing trend of IS ASMR make rural males the focus of stroke management. The death burden of stroke varies greatly between urban and rural China. Rural residents face unique challenges.

Rural-Urban Disparities in Hospital Services and Outcomes for Children With Medical Complexity

Limited availability of inpatient pediatric services in rural regions has raised concerns about access, safety, and quality of hospital-based care for children. This may be particularly important for children with medical complexity (CMC). To describe differences in the availability of pediatric services at acute care hospitals where rural- and urban-residing CMC presented for hospitalization; identify rural-urban disparities in health care quality and in-hospital mortality; and determine whether the availability of pediatric services at index hospitals or the experience of interfacility transfer modified rural-urban differences in outcomes. This retrospective cohort study examined all-payer claims data from Colorado, Massachusetts, and New Hampshire from 2012 to 2017. Analysis was conducted from May 2023 to July 2024. Participants included CMC younger than 18 years residing in these states and hospitalized during the study period. Rural or urban residence was determined using Rural-Urban Commuting Area codes. Hospitals were categorized as children's hospitals or general hospitals with comprehensive, limited, or no dedicated pediatric services using American Hospital Association survey data. Interfacility transfers between index and definitive care hospitals were identified using health care claims. In-hospital mortality, all-cause 30-day readmission, medical-surgical safety events, and surgical safety events were operationalized using Agency for Healthcare Research and Quality measure specifications. Among 36 943 CMC who experienced 79 906 hospitalizations, 16 525 (44.7%) were female, 26 034 (70.5%) were Medicaid-insured, and 34 008 (92.1%) were urban-residing. Rural-residing CMC were 6.55 times more likely to present to hospitals without dedicated pediatric services (rate ratio [RR], 6.55 [95% CI, 5.86-7.33]) and 2.03 times more likely to present to hospitals without pediatric beds (RR, 2.03 [95% CI, 1.88-2.21]) than urban-residing CMC, with no significant differences in interfacility transfer rates. In unadjusted analysis, rural-residing CMC had a 44% increased risk of in-hospital mortality (RR, 1.44 [95% CI, 1.03-2.02]) with no significant differences in other outcomes. Adjusting for clinical characteristics, the difference in in-hospital mortality was no longer significant. Index hospital type was not a significant modifier of observed rural-urban outcomes, but interfacility transfer was a significant modifier of rural-urban differences in surgical safety events. In this cohort study, rural-residing CMC were significantly more likely to present to hospitals without dedicated pediatric services. These findings suggest that efforts are justified to ensure that all hospital types are prepared to care for CMC.