Expert Commentary

Rural-urban health care disparities: Research roundup

This roundup brings together a sampling of recent studies that highlight health-related differences between rural and urban areas.

Vernon, FL Family Health Center
(Royalbroil/Wikimedia Commons)

For researchers attempting to understand rural America, health is increasingly an area of interest. Rural areas tend to have fewer resources for health care than urban areas. This roundup brings together a sampling of studies published in the past year that highlight health-related differences between rural and urban areas. The included studies touch on disparities in cancer screening and diagnosis, fertility rates, mortality rates and more. Some of the studies also address what works to lessen differences. For example, a dementia disparities study connects increases in rural educational attainment to gains in cognitive function.


Rural–Urban Disparities in Stage of Diagnosis Among Cancers with Preventive Opportunities
Zahnd, Whitney E.; et al. American Journal of Preventive Medicine, May 2018.

This study attempts to unpack why rural populations tend to have higher cancer mortality rates despite lower incidence rates overall.

The main finding:

  • Rural populations tended to have lower rates of early stage cancers and higher rates of distant stage cancers. This was true for all “stageable” cancers, including for cancers with opportunities for prevention, such as human papillomavirus-associated cancers.

Rural-Urban Disparities in Access to Breast Cancer Screening: A Spatial Clustering Analysis: Disparities in Breast Cancer Screening
Chandak, Aastha; et al. The Journal of Rural Health, June 2018.

Do rural and urban patients have the same access to breast cancer screening? This study looks at cancer registry data, screening rates and the location of mammography facilities in Nebraska from 2008 to 2012 to answer that question.

Key findings:

  • Population centers in urban areas in Nebraska were closer to mammography centers than population centers in rural areas. According to the paper, “Proximity to mammography centers was measured as the shortest straight‐line distance between the population‐weighted centroid of the census tract and the closest mammography center.”
  • Urban areas also had higher screening rates and lower rates of late-stage diagnosis of breast cancer.
  • “The evidence from this study points to geographic disparities in access to screening for breast cancer. Mitigating the access issues that rural women face would require interventions specifically targeted to rural populations.”

Rural-Urban Differences in Human Papillomavirus Knowledge and Awareness among US Adults
Mohammed, Kahee A.; et al. Preventive Medicine, April 2018.

This study, which analyzes data from 10,147 respondents participating in the Health Information National Trends Survey 2013–2017, finds:

  • Rural adults are less likely than their urban peers to have heard of HPV and the vaccine.
  • They’re also less likely to understand how HPV is transmitted, and its link to cervical cancer.
  • Rural and urban adults both had low knowledge of HPV’s links to oral, anal and penile cancers.

Association Between Loss of Hospital-Based Obstetric Services and Birth Outcomes in Rural Counties in the United States
Kozhimannil, Katy B.; et al. JAMA, March 2018.

One area of health care that in recent years has suffered dramatic losses in rural areas is obstetric services. Researchers at the University of Minnesota and Yale theorized that changes in access to care could have effects on preterm birth rates, which are linked to increased risk of infant mortality. Researchers looked at data collected between 2004 and 2014 on births occurring in 1,086 rural counties in the United States. This encompassed almost 5 million births. The scholars compared the rates of out-of-hospital births, births in hospitals without obstetric units and preterm deliveries for counties that had in-hospital obstetric services and those that did not.

Key findings:

  • Over the 10 years studied, 179 counties lost in-hospital obstetric services.
  • Loss of obstetric services in rural counties not adjacent to urban areas was linked to a 0.7 percentage point increase in out-of-hospital births, a 3 percentage point increase in births in a hospital without an obstetric unit, and a 0.7 percentage point increase in preterm births in the year following the closure compared to counties where women continued to have access to in-hospital obstetric services.
  • Loss of obstetric services in rural counties that were adjacent to urban areas was linked to a 1.8 percentage point increase in births in a hospital without an obstetric unit.
  • Pregnant women went for prenatal visits less often in rural counties that lost obstetric services.

Worsening Rural-Urban Gap in Hospital Mortality
Villapiano, Nicole; et al. The Journal of the American Board of Family Medicine, November 2017.

This study looks at over 4 million hospitalizations from 2008 and nearly 4 million hospitalizations from 2013 to compare changes in mortality rates by location and over time.

Key findings:

  • The odds that urban patients would die in the hospital decreased from 2.51 percent in 2008 to 2.27 percent in 2013.
  • Rural patients didn’t see a similar decline from 2008 to 2013; their hospital mortality rate stayed constant at 2.66 percent.
  • Even after adjusting for other factors, patients in rural areas still had a greater probability of dying in the hospital than their urban peers.

Differences in Obesity Prevalence by Demographic Characteristics and Urbanization Level Among Adults in the United States, 2013-2016
Hales, Craig M.; et al. JAMA, June 2018.

This study looks at the prevalence of obesity from 2013 to 2016 across urban and rural areas in the United States. The nationally representative sample included 10,792 adults.

Key finding:

  • The authors found that obesity and severe obesity were significantly more prevalent among adults living in nonmetropolitan statistical areas compared with their counterparts living in large metropolitan statistical areas.

Urban-Rural Differences in Aerobic Physical Activity, Muscle Strengthening Exercise, and Screen-Time Sedentary Behavior: Urban-Rural Differences in Physical Activity
Robertson, Michael C.; et al. The Journal of Rural Health, September 2018.

This study considers whether the increased risk of premature mortality and other health problems that rural populations face might stem from differences in physical activity levels. They looked at the levels of aerobic physical activity (e.g., brisk walking, bicycling, swimming), leisure-time muscle strengthening (e.g., weight lifting or circuit training), and screen-time sedentary behavior (like watching TV or surfing the web) reported by rural and urban residents in a nationally representative survey of 14,188 people.

Key findings:

  • Urban and rural residents had similar levels of aerobic physical activity.
  • However, rural residents engaged in less leisure-time muscle strengthening than urban residents.
  • Rural residents engaged in less sedentary screen-time than their urban counterparts.

Secular Trends in Dementia and Cognitive Impairment of U.S. Rural and Urban Older Adults
Weden, Margaret M.; et al. American Journal of Preventive Medicine, February 2018.

This study looks at data from over 16,000 U.S. adults to analyze whether there are differences between rural and urban populations with respect to the incidence of dementia and cognitive impairment.

Key findings:

  • While rural residents were more likely to have dementia than their urban counterparts in 2000, the relative risk decreased over time and was no longer statistically significant by 2010.
  • The authors find that receiving more years of education reduced the rural-urban divide with respect to dementia and cognitive impairment.
  • The authors conclude, “Larger gains in rural adults’ cognitive functioning between 2000 and 2010 that are linked with increased educational attainment demonstrate long-term public health benefits of investment in secondary education.”

Trends in Fertility and Mother’s Age at First Birth Among Rural and Metropolitan Counties: United States, 2007–2017
Ely, Danielle M.; Hamilton, Brady E. National Center for Health Statistics Data Brief, October 2018.

These are the latest data from the U.S. Center for Disease Control and Prevention’s National Vital Statistics System on fertility rates across the country. Fertility rates consist of the estimated number of lifetime births expected per 1,000 women, based on age-specific birth rates in a given year.

Here are the key trends:

  • Across the U.S., fertility rates are declining. This is more pronounced in metropolitan areas – small or medium and large metropolitan counties saw 16 and 18 percent declines in fertility rates from 2007 through 2017, respectively. But rural counties are also experiencing declining fertility rates – from 2007 through 2011, the fertility rate went down 9 percent. Between 2011 and 2017, it did not change significantly.
  • Fertility rates declined for white, black, and Hispanic women from 2007 to 2017. Hispanic women saw the largest declines.
  • Average maternal age is increasing across the board, but mothers in metropolitan areas are waiting even longer to have their first children than rural mothers. For rural mothers, the average age at first birth went from 23.2 years in 2007 to 24.5 in 2017. In large metropolitan counties, the average age was 25.9 in 2007 and 27.7 in 2017. So, when comparing mothers in rural and large metropolitan counties, the difference in mean maternal age at first birth increased from 2.7 to 3.2 years.

Rural–Urban Differences in Risk Factors for Motor Vehicle Fatalities
Henning-Smith, Carrie; Kozhimannil, Katy B. Health Equity, September 2018.

Rural areas have higher rates of motor vehicle fatalities than their urban counterparts – it’s a difference of 22 per 100,000 people versus 14 per 100,000, according to this study, which looks at 2017 County Health Rankings data for its analysis.

The authors found the following variables were associated with higher rates of motor vehicle fatalities:

  • Higher rates of physical inactivity within a county
  • Higher rates of individuals without health insurance
  • Having a large percentage of people of the same race or ethnicity
  • And having larger percentages of younger or older adults.

Decomposing Mortality Disparities in Urban and Rural U.S. Counties
Spencer, Jennifer C.; et al. Health Services Research, May 2018.

Rural counties have lower life expectancies than urban counties. This study tries to understand why this is the case, examining county-level economic, demographic and regional characteristics to understand how these factors play into this disparity.

Key findings:

  • “We find that the growing urban/rural mortality gap can be more than explained by differences in county demographics, economics, and geographic distribution at each decade from 1980 to 2010.”
  • “On comparing the sources of explained difference over time, we find that economic characteristics represent a large but relatively constant portion of the explained differences while demographic characteristics, most notably the importance of foreign‐born and Hispanic populations [in urban areas], appear to be increasing over time.”
  • “The increasing benefit for foreign‐born relative to native‐born Americans has been attributed to several factors, including shifting demographics of the immigrant population toward Hispanics and Asians, and increasingly low rates of obesity and smoking relative to U.S. populations.”


This photo, taken by RoyalBroil and obtained from Wikimedia Commons, is being used under a Creative Commons license. No changes were made.

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