Rural-urban Health Research Articles

County Reclassifications and Rural-Urban Mortality Disparities in the United States (1970-2018).

Objectives. To demonstrate how inferences about rural-urban disparities in age-adjusted mortality are affected by the reclassification of rural and urban counties in the United States from 1970 to 2018.Methods. We compared estimates of rural-urban mortality disparities over time, produced through a time-varying classification of rural and urban counties, with counterfactual estimates of rural-urban disparities, assuming no changes in rural-urban classification since 1970. We evaluated mortality rates by decade of reclassification to assess selectivity in reclassification.Results. We found that reclassification amplified rural-urban mortality disparities and accounted for more than 25% of the rural disadvantage observed from 1970 to 2018. Mortality rates were lower in counties that reclassified from rural to urban than in counties that remained rural.Conclusions. Estimates of changing rural-urban mortality differentials are significantly influenced by rural-urban reclassification. On average, counties that have remained classified as rural over time have elevated mortality. Longitudinal research on rural-urban health disparities must consider the methodological and substantive implications of reclassification.Public Health Implications. Attention to rural-urban reclassification is necessary when evaluating or justifying policy interventions focusing on geographic health disparities.

Effect of Rural and Marginal Urban Health Service on the physicians' perception of primary health care in Peru.

To determine the effect of the Rural and Marginal Urban Health Service (SERUMS) on the physicians' perception of work in the primary health care (PHC) setting and its associated factors. A secondary data analysis of a sample of physicians who performed the SERUMS in 2016 was carried out. To evaluate the variable of interest, the scale "Perception of work in the PHC setting" was used, higher scores indicated a negative perception of work in the PHC setting. A baseline survey (before the SERUMS) and a follow-up survey (8-12 months after starting the SERUMS) were applied and differences in both scores were evaluated. Of the 780 respondents, 215 (27.6%) completed the baseline and follow-up survey. The average score increased considerably (from 3.4 to 6.7; p < 0.001), which shows a negative perception of work in the PHC setting after participating in the SERUMS. Of the three parts of the survey, the one regarding perceptions by the physicians working in the PHC and the one about perceptions of medical work in the PHC setting increased the perception scores. No sociodemographic variables were found to be associated with the change in scores. Physicians' perception about work in the PHC setting deteriorated after participating in the SERUMS. Therefore, strategies to encourage physicians' interest in working at this level of healthcare should be promoted.

Why is the Rural to Urban Migration Rate in India so Low? An Empirical Analysis

Little research has examined the relationship between rural to urban migration, urbanization, and economic growth in India. While urbanization is a key driver for economic growth in many countries, the rural to urban migration rate in India is low, potentially due to a lowering of the gap between urban-rural health, infrastructure, employment opportunities, and economic conditions. Using panel data models, I investigate the relevant determinants of rural to urban migration at the state level in India from 1991 to 2011. Panel data analysis suggests that higher per capita state income and a lower difference between urban to rural literacy rates encourage rural to urban migration. In this context, I suggest that urban job creation, improved urban infrastructure, and management of urban poverty and income inequality are essential to promoting rural to urban migration in India.

A Century Later: Rural Public Health's Enduring Challenges and Opportunities.

The US public health community has demonstrated increasing awareness of rural health disparities in the past several years. Although current interest is high, the topic is not new, and some of the earliest public health literature includes reports on infectious disease and sanitation in rural places. Continuing through the first third of the 20th century, dozens of articles documented rural disparities in infant and maternal mortality, sanitation and water safety, health care access, and among Black, Indigenous, and People of Color communities. Current rural research reveals similar challenges, and strategies suggested for addressing rural-urban health disparities 100 years ago resonate today. This article examines rural public health literature from a century ago and its connections to contemporary rural health disparities. We describe parallels between current and historical rural public health challenges and discuss how strategies proposed in the early 20th century may inform current policy and practice. As we explore the new frontier of rural public health, it is critical to consider enduring rural challenges and how to ensure that proposed solutions translate into actual health improvements. (Am J Public Health. 2020;110:1678-1686. https://doi.org/10.2105/AJPH.2020.305868).

Rural-Urban Disparities in Cardiovascular Disease Mortality Among Middle-Age Men in China.

Rural-urban health disparities are still poorly understood, due to a considerable gap in knowledge, while a looming heart disease and stroke epidemic in China has caused global concern. This report attempts to fill in the knowledge gaps to examine if rural-urban disparities in heart disease and stroke mortality have widened, which population cohorts have experienced the greatest mortality growth and disparities, and if rurality still matters in China. Age-specific data from 2002 to 2016 published in the China Health Yearbooks were analyzed with the Joinpoint Regression Program. The results reveal that China faces a fast growing cardiovascular disease epidemic with widening rural-urban disparities. Rural death rates have grown higher than urban rates along with fast rising rural mortality, and the fastest increasing rates are found among rural men in younger age groups. These findings inspire further research into the causes of the disparities.

Impact of urban-rural health insurance integration on health care: Evidence from rural China

In recent years, Chinese local governments have experimented with integrating the social health insurance system segmented between rural and urban areas to unify the administration, policy, and funds of various health insurance programs. In this study, we take advantage of the staggered implementation of the urban-rural health insurance integration across cities over time to examine the impacts of the integration on rural residents' health care utilization and health outcomes. Based on an original city-year level policy dataset and the China Health and Retirement Longitudinal Study (CHARLS) for the years 2011, 2013, and 2015, we find that the integration significantly increases the middle-aged and older rural residents' inpatient care utilization and this positive effect is particularly salient in poor areas. Moreover, we find that the positive policy effect of integration is attributed to enhanced health insurance benefits, such as a higher reimbursement rate for inpatient care. However, the integration has limited impacts on the middle-aged and older rural residents' health outcomes. This study reveals the partial success of urban-rural health insurance integration to reduce health care inequality in China.

Advancing Rural Cancer Control Research: National Cancer Institute Efforts to Identify Gaps and Opportunities.

Cancer mortality rates are approximately 8% higher in rural populations and mortality rates are falling more slowly in rural communities, resulting in widening rural-urban health disparities in the United States. The NCI has a long history of supporting health disparities research, including research to understand the health needs, strengths, and opportunities in rural communities. However, the portfolio analysis described in this article underscores the need to significantly accelerate rural cancer control research in partnership with state and local communities. This commentary outlines NCI's efforts over the last four years to address gaps in rural cancer control research and improve cancer prevention, control, and care delivery in rural populations. Future directions, challenges, and opportunities are also discussed.

EHealth and Telemedicine in India: An Overview on the Health Care Need of the People

We have reached far ahead today when it comes to the telemedicine technology which was first installed in Boston in 1967 that made a regular interaction between physicians and patients at distant locations. Being a developing and lower-middle income country, currently India faces shortage of doctors, nurses &amp; midwives, and healthcare infrastructure. Around 70% of Indian population lives in remote and rural villages lacking access to basic healthcare facilities. In such situations telemedicine plays a great role in providing quality and affordable healthcare to India’s poorest people, and is expected to bridge the rural-urban health divide. Whether telemedicine technology meets its objective to provide adequate healthcare services to the poor remote and rural population is matter of great concern. This article aims to provide an overview on this issue.

Distributional analysis of rural-urban household healthcare expenditure differentials in developing countries: evidence from Ghana

Purpose Equity in access to and use of healthcare resources is a global development agenda. Policymakers’ knowledge of the sources of differences in household healthcare spending is crucial for effective policy. This paper aims to investigate the differences in the determinants of household healthcare expenditure across space and along selected quantiles of healthcare expenditure in Ghana. The determinants of rural-urban healthcare expenditure gap are also explored. Design/methodology/approach Data was obtained from the sixth round of the Ghana Living Standards Survey (GLSS 6) conducted in 2013. An unconditional quantile regression (UQR) and a decomposition technique based on UQR, adjusted for sample selection bias, were applied. Findings The results indicate that differences in the determinants of household healthcare expenditure across space and along quantiles are driven by individual-level variables. Besides, the rural-urban health expenditure gap is greatest among households in the lower quantiles and this gap is largely driven by differences in household income per capita and percentage of household members enrolled on health insurance policies. Originality/value The findings show that there are differences in the determinants of household health expenditure along with the income distribution, as well as between rural and urban localities, which would call for targeted policies to address these inequalities.

Exploration of village health centres in Northern and Central China: A qualitative study.

China faces issues associated with urban-rural health inequities. This study explores functions of village health centres through a community perspective. Four research questions were asked, including: (a) What are the functions of village health centres? (b) How is medication administered in village health centres? (c) What are the roles of village doctors? (d) What are the evaluation mechanisms of village health centres? In-depth interviews and field observations are used in the study. Nine rural villages in two provinces in Northern and Central China. A total of 93 people across were interviewed. Village health centres are primarily responsible for providing public health services and essential medical care. In addition, village health centres also function as a social venue of a rural community. A centralised medication scheme augments these processes through supplying health centres with affordable medications. Village doctors are expected to take the needs and preferences of their patients into consideration when creating care plans, and must establish trusting rapport with patients by upholding their unique values. This results in care that is convenient, accessible, and person-centred. Village health centres are evaluated through a 2-step process which has direct effects on the amount of government subsidy received. Village health centres have multi-faceted functions in rural Chinese communities. Overall, the benefits of village health centres include convenient and timely access to care for rural residents. Improvements can be made in certain areas, such as streamlining provincial medication schemes and adopting a strengths-based model of evaluation.

Trends in Hospital Mortality for Uninsured Rural and Urban Populations, 2012-2016.

Rural-urban health disparities have received increasing scrutiny as rural individuals continue to have worse health outcomes. However, little is known about how insurance status contributes to urban-rural disparities. This study characterizes how rural uninsured patients compare to the urban uninsured, determines whether rurality among the uninsured is associated with worse clinical outcomes, and examines how clinical outcomes based on rurality have changed over time. We conducted a retrospective cohort study of the 2012-2016 National Inpatient Sample hospital discharge data including 1,478,613 uninsured patients, of which 233,816 were rural. Admissions were broken into 6 rurality categories. Logistic regression models were used to determine the independent association between rurality and hospital mortality. Demographic and clinical characteristics differed significantly between rural and urban uninsured patients: rural patients were more often white, lived in places with lower median household income, and were more often admitted electively and transferred. Rurality was associated with significantly higher in-hospital mortality rates (1.44% vs 1.89%, OR 1.32, P<.001). This association strengthened after adjusting for medical comorbidities and hospital characteristics. Further, disparities between urban and rural mortality were found to be growing, with the gap almost doubling between 2012 and 2016. Rural and urban uninsured patients differed significantly, specifically in terms of race and median income. Among the uninsured, rurality was associated with higher in-hospital mortality, and the gap between urban and rural in-hospital mortality was widening. Our findings suggest the rural uninsured are a vulnerable population in need of informed, tailored policies to reduce these disparities.

Rural-urban mortality inequalities in four Nordic welfare states.

In the Nordic countries, there are ambitious welfare policies that might reduce rural-urban health disparities. Aim: To investigate the effect of population density on health in four Nordic countries. Methods: The health outcomes analysed were life expectancy and potential years of life lost. The effect of population density was appraised as the difference in life expectancy/ potential years of life lost by a 10-fold increase of population density. Results: In Finland, Norway and Sweden, mortality rates were consistently higher in less densely populated municipalities. These disparities increased over time. Conclusions: The welfare efforts to offset rural-urban disparities have mostly not been sufficient.

Rural and urban differences in health system performance among older Chinese adults: cross-sectional analysis of a national sample

BackgroundDespite improvement in health outcomes over the past few decades, China still experiences striking rural-urban health inequalities. There is limited research on the rural-urban differences in health system performance in China.MethodWe conducted a cross-sectional analysis to compare health system performance between rural and urban areas in five key domains of the health system: effectiveness, cost, access, patient-centredness and equity, using data from the WHO Study on Global AGEing and adult health (SAGE), China. Multiple logistic and linear regression models were used to assess the first four domains, adjusting for individual characteristics, and a relative index of inequality (RII) was used to measure the equity domain.FindingsCompared to urban areas, rural areas had poorer performance in the management and control of hypertension and diabetes, with more than 50% lower odds of having breast (AOR = 0.44; 95% CI: 0.30, 0.64) and cervical cancer screening (AOR = 0.49; 95% CI: 0.29, 0.83). There was better performance in rural areas in the patient-centredness domain, with more than twice higher odds of getting prompt attention, respect, clarity of the communication with health provider and involvement in decision making of the treatment in inpatient care (AOR = 2.56, 2.15, 2.28, 2.28). Although rural residents incurred relatively less out-of-pocket expenditures (OOPE) for outpatient and inpatient services than urban residents, they were more likely to incur catastrophic expenditures on health (AOR = 1.30; 95% CI 1.16, 1.44). Wealth inequality was found in many indicators related to the effectiveness, costs and access domains in both rural and urban areas. Rural areas had greater inequalities in the management of hypertension and coverage of cervical cancer (RII = 7.45 vs 1.64).ConclusionOur findings suggest that urban areas have achieved better prevention and management of non-communicable disease than rural areas, but access to healthcare was equivalent. A better understanding of the causes of the observed variations is needed to develop appropriate policy interventions which address these disparities.

Rural-urban health disparities for mood disorders and obesity in a midwestern community.

Prior studies indicate greater disease burden for obesity among rural compared with urban residents but no differences for mood disorder based on geographic location. Recent attention has focused on the need to examine regional rural-urban disparities in disease burden. We focused on mood disorders and obesity prevalence within three southeastern Minnesota counties served by the Mayo Clinic Center for Translational Science Award, in Rochester, Minnesota, as these were top priorities identified in community health needs assessments. Cross-sectional study to assess the association of rural-urban locality on 5-year (2009-2014) prevalence of mood disorder and obesity obtained using the Rochester Epidemiological Project medical records linkage system, among subjects residing in three mixed rural-urban counties on April 1, 2014. Multivariable analyses adjusted for demographics, socioeconomic status using an individual housing-based measure, and counties. The study cohort (percent rural location) included 91,202 (15%) for Olmsted, 10,197 (51%) in Dodge, and 10,184 (57%) in Wabasha counties. On multivariate analysis, 5-year prevalence of mood disorders and obesity was significantly greater for urban compared with rural residents, after adjusting for confounders; odds ratios (95% confidence intervals): 1.21 (1.17-1.26), P < 0.001, and 1.05 (1.01-1.10), P = 0.016, respectively. Observed effects were not modified in additional models adjusted for health care utilization (HCU; ≥1 general medical examination visit and flu vaccination). Rural-urban health disparities for burden of mood disorders and obesity are independent of socioeconomic status and HCU in a Midwestern community. It is important to assess potential regional heterogeneity of rural-urban disparities on health outcomes.

Impact of Urban-Rural Health Insurance Integration on Health Care: Evidence from Rural China

In recent years, Chinese local governments have experimented with integrating the social health insurance system segmented between rural and urban areas to unify the administration, policy, and funds of various health insurance programs. In this study, we take advantage of the staggered implementation of the urban-rural health insurance integration across cities over time to examine the impacts of the integration on rural residents' health care utilization and health outcomes. Based on an original city-year level policy dataset and the China Health and Retirement Longitudinal Study (CHARLS) for the years 2011, 2013, and 2015, we find that the integration significantly increases the middle-aged and older rural residents' inpatient care utilization and this positive effect is particularly salient in poor areas. Moreover, we find that the positive policy effect of integration is attributed to enhanced health insurance benefits, such as a higher reimbursement rate for inpatient care. However, the integration has limited impacts on the middle-aged and older rural residents' health outcomes. This study reveals the partial success of urban-rural health insurance integration to reduce health care inequality in China.

Trends and socio-economic disparities in catastrophic health expenditure and health impoverishment in China: 2010 to 2016.

To investigate trends and socio-economic disparities in the catastrophic health expenditure (CHE) and health impoverishment in China after major reform of the health system and to examine the impacts of the chronic disease on CHE and impoverishment. We obtained data from four rounds of the China Family Panel Studies 2010-2016, with a sample size of 14960 households. We defined CHE as the point at which annual household health payments exceeded 40% of annual capacity to pay. Impoverishment is measured by the $1.90 per day poverty line. Multivariate logistic regression models were performed to identify impacts of the family member with chronic disease on CHE and impoverishment. Between 2010 and 2016, the incidence of CHE in China decreased from 19.37% to 15.11% and from 7.39% to 5.14% for health impoverishment; however, the decrease in level of impoverishment was less in rural areas (from 6.16% down to 3.03%) than in urban areas (from 8.46% down to 7.81%). The gap between impoverishment rates across the income quartiles is growing. Multivariable analysis showed that households with two or more members suffering chronic diseases were significantly more likely to incur CHE (aOR: 2.46, 95% CI: 1.93-3.13) and impoverishment (aOR: 2.66, 95% CI: 1.87-3.78) than households with no members suffering chronic diseases, after adjusting for sociodemographic covariates. Important advances have been made in achieving greater financial protection for Chinese citizens. Nevertheless, greater attention to the poor households with chronic disease members is needed. Policymakers in China should focus on optimising integrated rural-urban health insurance by expanding the current benefit packages and strengthening poverty alleviation efforts.

Primary health institutions preference by hypertensive patients: effect of distance, trust and quality of management in the rural Heilongjiang province of China

BackgroundTraditional “inverted triangle” healthcare resources allocation model in China has wasted a lot of health resources. The Chinese health reform began to strengthens the role of the primary health institutions in delivering primary health care especially in rural areas in the background of large development gap between urban-rural health and rapid growth in the incidence of chronic diseases in rural. We take hypertensive patients as an example, to verify the effect of policy implementation through distribution characteristics of rural primary health institutions preference of hypertensive patients and explore the influencing factor that promoting rationalized use of medical care for patients with chronic disease as well as rational allocation of health resources in rural areas.MethodsA cross-sectional survey was conducted in Heilongjiang, a province in northeastern China by using a self-designed questionnaire. Stratified cluster sampling was used to choose 484 hypertensive patients from two villages in Heilongjiang province in 2010.ResultsAbout 88.4% of respondents reported preferred primary health institutions (83.5% preferred village clinics and 4.9% preferred township hospitals), 49.4% of respondents knew hypertension management administered by primary health institutions, 53.5% received hypertension education from primary care physicians, more than half of respondents reported that they didn’t receive telephone interviews and family visits from primary care physicians over the past 6 months. Residence closer to the primary health institutions (OR = 10.360), trust in village doctors (OR = 7.323), elders (OR = 3.001), and asked for return visits by primary health physicians (OR = 2.073) promote preferences for primary health institutions.Conclusions: Accessibility to primary healthcare and doctor-patient trust stimulate patients to choose the primary health institutions. Primary health institutions should improve general approach to hypertension management and enhance the ability of providing basic public health services.

Pattern of ocular morbidity in school children and its association with academic achievement

Background: Ocular morbidity describes any eye disease regardless of resultant visual loss. India is plagued by ocular morbidities in school going children. Refractive error is considered to be the major cause of visual impairment. The objectives of the present study were to compare the pattern of ocular morbidity in urban and rural school children, to study the association of academic achievement with ocular morbidity in study population and to suggest appropriate recommendations for addressing the problem of ocular morbidity in school children.Methods: A cross sectional study was conducted in the 9 primary and 5 junior high schools of field practice areas of Rural Health Training Centre and Urban Health Training Centre respectively, under Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh from September 2005 to August 2006.Results: Prevalence of ocular morbidity in the present study was 23.3%. Maximum prevalence of 28.7% of ocular morbidity was seen in the age group of 14-16 years. Prevalence of ocular morbidity was found to be 100 (51.6%) in males and 64 (40.1%) in females. 29.3% of the 164 school children having ocular morbidity showed poor academic achievement compared to 18.7% of the 541 children not having ocular morbidity and the association was found to be statistically significant.Conclusions: Refractive error was one of the major causes of ocular morbidity among school going children but most of them were of mild degree. Ocular morbidity was found to affect the academic achievement of school going children.

Trends and socioeconomic disparities in financial risk protection in China 2010–16: a repeated cross-sectional analysis

BackgroundIn 2009, China launched a new health system reform with the goal of achieving universal health coverage by 2020. This study aimed to assess the trends and socioeconomic disparities in financial risk protection in China, and to explore the influence of chronic diseases on catastrophic health expenditure and impoverishment due to health payments. MethodsWe used data from the China Family Panel Studies 2010–16, with a sample size of 14 960 households. We defined catastrophic health expenditure as the point at which annual household health payments exceeded 40% of annual capacity to pay. Impoverishment was defined as earning below the poverty line of $1·90 per day. We used multivariate logistic regression models to identify the effects of the costs incurred by a family member with chronic disease on catastrophic health expenditure and impoverishment. Ethics permission and approval were obtained from the Peking University Biomedical Ethics Review Committee (IRB00001052-14010). FindingsBetween Aug 13, 2010 and June 28, 2016, the incidence of catastrophic health expenditure in China decreased from 19·37% (95% CI 17·91–20·93) to 15·11% (14·09–16·12), and from 7·34% (6·54–8·14) to 5·14% (4·53–5·74) for health impoverishment; however, the decrease in impoverishment was less in rural areas (from 8·46% to 7·81%) than in urban areas (from 6·16% to 3·03%) in 2010–16 (p<0·0001). The gap between the prevalence of impoverishment across the income quartiles has grown. Multivariable analysis showed that households with two or more people with chronic diseases were significantly more likely to incur catastrophic health expenditure (odds ratio 2·46 [95% CI 1·93–3·13]) and impoverishment (2·66 [1·87–3·78]) compared with households with no people with chronic diseases, after adjusting for sociodemographic covariates. InterpretationImportant advances have been made in improving financial protection for Chinese citizens. Nevertheless, increased attention to poor and rural households with people with chronic diseases is needed. Policymakers in China should focus on optimising integrated rural–urban health insurance by expanding the existing benefit packages. Moreover, increased efforts to alleviate poverty should be continued through further development of China's medical assistance system for poor people. FundingNone.

Disparities in outcomes associated with rural-urban insurance status in China among inpatient women with stroke: a registry-based cohort study.

Despite a few studies have demonstrated sex differences in stroke care and outcomes, limited research has explored insurance-related disparities in outcomes, particularly among women stroke patients. The aim was to determine whether rural-urban health insurance status affect the stroke treatment, process of care, and 1-year clinical outcomes for inpatient ischemic stroke in women. Women patients with acute ischemic stroke (AIS) covered by New Rural Cooperative Medical Scheme (NRCMS) and urban resident/employee-based basic medical insurance scheme (URBMI/UEBMI) were abstracted from the China National Stroke Registry II (CNSR II). Shared frailty model in the Cox model or generalized estimating equation with consideration of the hospital's cluster effect were used to assess the associations between rural-urban insurance status and quality of care during hospitalization and 1-year stroke outcomes including all-cause death, 1-year recurrence, and 1-year disability. A total of 5,707 women patients enrolled from 219 hospitals in CNSR II were analyzed. Compared with 2,880 women patients covered by URBMI/UEBMI, 2,827 women patients covered by NRCMS were younger (65.7 versus 68.9 years), less likely to have vascular risk factors, awareness and treatment of hypertension and dyslipidemia prior to stroke. Women covered by NRCMS were more likely to receive early antithrombotics, discharge antithrombotics, lipid-lowering drugs, but less likely to receive antihypertensive medication than those covered by URBMI/UEBMI. One-year all-cause mortality and stroke recurrence were both significantly higher in women patients with NRCMS than those with URBMI/UEBMI [adjusted hazard ratio (95% confidence interval): 1.40 (1.06-1.84) and 1.38 (1.04-1.83), separately]. AIS women patients with rural-urban insurance status demonstrated remarkable differences in age, stroke risk factors, awareness and treatment, the process of care, and 1-year stroke recurrence and mortality. Healthcare policymakers need to focus their attention on these disparities and take proper steps to improve primary healthcare service in rural areas.