EUGLOREH project
THE STATUS OF HEALTH IN THE EUROPEAN UNION:
TOWARDS A HEALTHIER EUROPE

FULL REPORT

PART III - HEALTH CAUSES, FACTORS AND DETERMINANTS

10. HEALTH DETERMINANTS

10.5. LIVING AND WORKING ENVIRONMENT

10.5.2. Urban and rural populations

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10.5.2. Urban and rural populations

 

10.5.2.1. Introduction

 

When looking into urban-rural differences, a key challenge is always represented by the definition of “urban” and “rural”. First of all, these areas are not separated from each other, as in spatial terms rural areas somewhere border with and transform into urbanized areas. The definition of urban and rural areas, however, can relate to a number of variables, such as the population size in relation to space, the provision of services and infrastructures or the distance from urban centres. In many cases it seems easier to defineurbanism” and then label as “rural” what does not fall under “urban”. Still, recent study results indicate that the dualism between rural and urban areas may be more an imagination shaped by perceptions and stereotypes, as modern developments in societies and the urban-rural dynamics work towards the reduction of the existing quantitative differences (Eurofound, 2006). In the same way, the OECD (2007) has considered not only two types of settlement categories (urban versus rural), but also defined an intermediate category to catch settlement structures that cannot be easily considered as urban or rural based on the profile of the respective settlements. The OECD data show that in a number of countries, this intermediate category covers a substantial part of settlements and population. In addition, it indicates a lower level or urbanisation in the EU than suggested by other statistics: in many member states, urban settlements account for less than one third of all settlements. The data of such a categorization using three different categories are therefore much different than the data discussed in the introduction above, which only considered two categories of urban versus rural settlements structures.

 

Figure 10.5.2.1. Population distribution per settlement structure in 2003 for selected EUGLOREH countries

 

Thereby, any comparison of the health status of urban and rural populations strongly depends on how – in a given studyurban and rural are defined (Johnson-Webb et al., 1997), and needs to consider that in poorer countries the differences between urban and rural populations may be expressed to a larger degree than in well-developed countries.

The divergence between urban and rural settlements introduces a variety of mechanisms that influence health status and mortality of the population, such as the provision of health care. Key dimensions of variation between urban and rural settlement are for example the demographic structure of populations, or their exposure to environmental conditions.

 

10.5.2.2. Data sources

 

The data in this chapter is mostly taken from scientific publications and reports produced by international Institutions (e.g. Un Habitat, EUROSTAT, WHO, UNECE; OECD, Eurofound, EURIPA, the Institute of Rural Health (UK) and a number of research and review articles which will be referenced as they are used.

Many of the data presented in this chapter are based on sources which will be updated regularly (such as EUROSTAT and OECD), or will issue future reports on similar subjects (Eurofound, Institute of Rural Health, EURIPA etc.)

Gaps of evidence emerge when it comes to the comparison of dataespecially disease prevalence data, which is less available than data on health service provision – between urban and rural setting, as well as adequate data from some of the new EU members state. Due to these limitations, the health data on disease prevalence mostly come from national studies and therefore needs to be interpreted with caution, as they are not representative on European scale.

 

 

10.5.2.3. Data description and analysis.

 

Demographic and contextual variations

Pan-European studies indicate that there is very little difference in the gender distribution, while for what concerns age, there is a general trend that irrespective of the country, the rural population is some years older than the urban population (Eurofound, 2006). The OECD (2007) stated that especially younger people migrate into urban areas, which leaves an increasing portion of the elderly in rural areas. In most countries, therefore, the dependency rates (the ratio of the elderly population to the working age population) are higher in rural areas, with implications for the provision of adequate heath care and other services as the area’s populations age. The difference of the elderly dependency rate between urban and rural areas is higher in Southern countries of the EU (Spain: 22% in urban versus 33% in rural areas; Portugal: 21% versus 33%; Greece: 22% versus 29%; but also in France: 21% versus 30%). There is however a high difference also in Sweden (21% versus 29%) and a rather small difference for Italy (27,5% versus 30%). However, in Hungary, the Czech Republic and Poland, the elderly dependency rate is slightly lower in rural than in urban areas (OECD, 2007).

 

With age being one of the major health determinants, this already indicates a higher demand for health and care services within rural settings. Finally, there is evidence on educational differences, with rural residents being 1.3 times more often without secondary education than urban dwellers (Eurofound, 2006).

Rural areas show decreasing dependency on agricultural activities and – in some areas – even a boosting activity in the service sector. Even in highly rural areas, occupation in agriculture is usually not higher than 20% (Eurofound, 2006). Still, there is a difference in health-related living conditions as urban residents tend to complain much more about environmental exposures and lack of amenities. Unpublished data from the 1st European Quality of Life Survey (Eurofound, 2006) indicate that this is a trend visible in all European countries and relates to problems such as air pollution, water quality, noise exposure and access to green and recreational areas (Figures 10.5.2.2-10.5.2.4).

 

Figure 10.5.2.2. Complaints by residents on environmental conditions

 

Figure 10.5.2.3. Complaints due to air pollution in urban and rural settings

 

Figure 10.5.2.4. Complaint about access to recreational / green spaces in urban and rural setting

 

Health data

 

A variety of national studies and research projects reveal sometimes conflicting evidence on the health differences between urban and rural settings. Data from international studies, collected with similar tools and methodologies, seem to be scarce. For existing national studies confounding factors such as age distribution are often not adequately considered and the definition of “urban” and “rural” is not comparable. Therefore, it is difficult to evaluate the available data on a European scale.

 

Not much data is available on mortality differences and life expectancy in urban and rural settings. However, a recent OECD publication on the diversities of the regions provides data for a range of EU countries (OECD, 2007). In general, the aggregated data of the EU countries covered shows a clear difference between urban and rural settings. The difference is more strongly expressed for males who have increased mortality rates in rural areas and decreased mortality rates in urban areas. For females, there is a similar trend but it is much less evident. However, there are striking gender differences for individual countries. For example, in Spain and Greece there is an increased mortality in females irrespective of the settlement category, while in Germany the mortality increase and decrease is occurring in opposite settlement categories for males and females.

 

Figure 10.5.2.5. Correlation of age-adjusted standard mortality rate with urban and rural settlements, males

 

Figure 10.5.2.6. Correlation between age-adjusted mortality rates with urban and rural settlements, females

 

One of the few national studies undertaken indicates that – for Northern Ireland - there was an increasing prevalence of poor health from rural to urban areas (O`Reilly et al., 2007).

 

Table 10.5.2.1. Variations in cause specific mortality in Northern Ireland for people aged 25-74 per area of residence

 

For self-reported limiting long-term illness, the Odds Ratio was at 0.93 for intermediate settings and at 0.81 for rural settings when compared to cities. The data were rather similar (0.94 and 0.81, respectively) also for low self-reported health status. Mortality rates were about 22% higher in cities than in most rural areas. Differences in death rates between rural and city areas were evident for most of the major causes of death but were greater for respiratory disease and lung cancer.

 

For Lithuania, the national mortality report for 2006 indicated that mortality rates are considerably higher for rural settings (16.4 deaths per 1.000 populations versus 11.57 in urban settings), a trend identified in most countries and most recognized in the older population.

 

Figure 10.5.2.7. Life expectancy by gender in urban and rural settings in Lithuania, 2006

 

Figure 10.5.2.8. Mortality rates in urban and rural settings in Lithuania, 2006

 

Looking into the future, the data for life expectancy indicate that for children born in 2006, the average life expectancy of male children is one year higher (66.4 years) in urban settings than in rural settings (63.5 years). For female children, the difference is 2 years (77.8 years in urban and 75.7 years in rural settings).

Although the gender difference is much stronger than the urban-rural dichotomy, the data identifies inequities in mortality and life expectancy which clearly bring disadvantages to the rural population. Similar (although varying) trends are found for other EU countries, indicating that the population composition as well as its health status and health service accessibility may be different between urbanized and rural parts of the same country.

 

A recent survey on the quality of life coordinated by the Eurofound collected data on the self-reported health status of all EU members and candidate countries. For most countries, the data show that rural residents more often define their health status as poor. However, within the EU15, there is a balanced general picture,  while the problems are more expressed in the new member States.

 

Figure 10.5.2.9. Self-reported health in urban and rural settings

 

In addition, the survey asked for the prevalence of long-standing illnesses and disabilities that affect health. The results are presented here below and indicate that this is also a bigger challenge in rural settings, although there is a balanced result for the member States that joined the EU in 2004.

 

Figure 10.5.2.10. Long-standing illness and disability in urban and rural settings

 

Continuing the case of long-standing illnesses, Lopez-Abuin et al. (2005) state that in rural areas there is a greater prevalence of chronic diseases which is posing a challenge to rural health services. Mostly, this increased demand is related to a greater number of elderly patients. In contrast, a Dutch study showed that in the Netherlands, the urban population shows more health problems, a higher prevalence of chronic conditions and more overweight cases (Verheij et al., 1998). This result may, however, be affected by the high urbanization level in the Netherlands, which may result in much less remote rural areas than in other countries. More detailed data available from the Netherlands compares the prevalence of health problems between urban and rural residents, showing that e.g. for female citizens, there are increased health demands in rural areas based on increased prevalence of trauma, pregnancies, infections, chronic diseases, acute somatic symptoms and neoplasms (NIVEL, 2006). However, for rural females less problems were noticed for what concerned social issues, family planning and preventive actions.

 

Figure 10.5.2.11. Health problems in urban and rural citizens in the Netherlands

 

For male residents, the chart below indicates that many infections tend to be more prevalent in rural settings.

 

Figure 10.5.2.12. Infection prevalence in urban and rural male citizens in the Netherlands

 

A rural health profile of the UK (North West UK) stated that rural populations face broadly the same range of illnesses, health issues, lifestyle choices and medical interventions as those living in urban areas (Wood, 2004). Even more, the Rural White Paper of the UK government in 2000 stated that the health of rural residents is as good or better than the national average, in terms of birth weight, incidence of long term illness and longevity (DETR, 2000). However, this statement is not coherent with the fact that healthcare practitioners in rural areas need to deal more often with chronic diseases such as heart disease, stroke and mental illness (BMA, 2005).

 

Evidence from Bulgaria suggests that within rural settings, the stroke incidence per 100.000 citizens is much higher than in urban settings (Male: 909 in rural versus 597 in urban places; Female: 667 in rural versus 322 in urban places). Four-week case mortality was also significantly higher in villages and rural settings, reaching 48% compared to the 35% of urban places (Powles et al, 2002).

 

Within Germany, data from children health surveys indicate that for most health indicators (birth weight, bronchitis, allergies, cold and cough), children in rural areas score significantly better than children in urban settings (Du Prel et al., 2006). A UK-study shows the same result for birth weight, indicating that urban new-borns are substantially disadvantaged compared to their rural counterparts. Another survey on health care indicators in England identified rural patients as associated to better health outcomes (e.g. all-cause mortality and avoidable mortality) and reduced cases of hospitalization (Gulliford et al, 2004).

For asthma, data from Sweden showed a similar prevalence for girls in rural and urban settings (8.5%), while for boys the prevalence was higher in urban (14.2%) than in rural settings (11.7%) (Roel et al., 2005).

 

For Scotland, surveys found that patients distant from the nearest cancer centre have poorer survival after diagnosis for prostate and lung cancer, and that, in general terms, more remote patients are less likely to have their stomach, breast and colorectal cancer diagnosed at all (Campbell et al., 2000). Research has linked barriers to medical service access also with poorer health outcomes from other diseases such as asthma (Jones and Bentham, 1997) and thrombolysis (Rawles et al, 1998), often because the disease is at a more advanced stage by the time diagnosis occurs.

 

With regard to zoonoses, rural settings have always shown increased levels of these infections. However, for some animal-triggered diseases, such as tick-borne diseases, there is now an increasing risk also in some rather urbanized communities (Wood, 2004).

 

Looking into mental health, for example, a representative study from the UK indicated that mental state of mind is worse in urban areas, with social pathologies such as alcohol and drug dependence being more prevalent in urban settings. The authors conclude that higher stress and less stable social conditions in urban areas may be a causal factor (Paykel et al., 2000). In comparison, isolation is more typical for rural settings, and suicide rates have increased (Wood, 2004).

 

For what concerns smoking, as one of the most important examples of lifestyle factors, data from Germany suggests that smoking is more spread within urbanized than rural settlements (OR = 1.56), and that heavy smokers also tend to be urban dwellers (Völzke et al., 2006). Other behavioral factors for which data is available regard the prevalence of sexually transmitted infections (STIs). A large Dutch survey (Van Bergen et al., 2006) brought about that the occurrence of STIs is strongly increased by urbanization levels:

 

Table 10.5.2.2. Percentage and total number of selected STI episodes in general practice according to level of urbanisation and deprived area score

 

The data clearly show that for quite a number of health effects, rural citizens may have a considerable advantage compared to urban residents. A meta-review carried out in New Zealand (based on 232 studies / papers etc.) came up with similar conflicting evidence on the question whether rural citizens are more or less healthy, indicating that this is strongly related to the type of disease. In the US, the National Rural Health Association (NRHA) states that despite only one third of car accidents occur in rural areas, they account for two thirds of deaths attributed to this sort of accidents. This problem of car traffic accidents being more severe and leading to more serious consequences has also been identified within the UK (Wood, 2004).

Health service access

 

One major problem of national health systems in rural and less populated areas is the provision of adequate health services. According to Eurofound (2006), access to and distance from medical care facilities (GP, hospital or medical centre) still represents a challenge for the less-developed EU countries.

 

 

Table 10.5.2.3. Problems accessing health services in urban and rural areas (2006)

 

 

Country group

Countries

% population reporting problems

EU countries with high GDP

Austria, Belgium, Denmark, Finland, France, Germany, Ireland, Italy, Luxembourg, The Netherlands, Sweden, United Kingdom

Rural:    20

Urban:   18

EU countries with intermediate GDP

Cyprus, Czech Republic, Greece, Malta, Portugal, Slovenia, Spain

Rural:    27

Urban:   24

 

EU countries with low GDP

Estonia, Hungary, Latvia, Lithuania, Poland, Slovakia

Rural:    34

Urban:   17

 

2006-Accession countries and Turkey

Bulgaria, Romania, Turkey

Rural:    58

Urban:   47

 

EU25

 

Rural:    23

Urban:   20

 

 

 

Adapted from: European Foundation for the Improvement of Living and Working Conditions (2006)

 

 

The distribution of reported problems clearly indicates a trend that less developed countries have increased problems with the accessibility of medical services, and that this challenge is much more expressed in rural settings. Such findings are in agreement with EUROSTAT publications as well (EUROSTAT, 2003). Thereby, current evidence questions the equity of urban and rural citizens with regard to the provision of medical services.

Lopez-Abuin et al. (2005) have listed the main barriers to effective rural emergency practice, most of which are related to distance to services, lack of specialists and special consultations / equipment, and the need for services out-of-hour times. The British Medical Association (BMA, 2005) identified four specific characteristics of rural health practice:

increased emergency/minor casualty work 
difficulties associated to distance and travel          
specific rural illness, e.g. zoonoses 
difficulties in obtaining cover for absence and out-of-hours work.

 

The BMA therefore suggests that different approaches to healthcare provision may be required for rural settings as urban health systems do not translate well into rural areas (BMA, 2005).

 

10.5.2.4. Control tool and policies

 

Depending on the type of disease, there are different findings on the variations of morbidity and mortality in urban and rural regions. Therefore, it is very difficult to make a general statement answering the question whether rural or urban residents are more or less affected by poor health. In addition, it needs to be kept in mind that any interpretation of such mortality and morbidity differences implies to consider the demographic differences as well, i.e. account all analysis for the age of the respective population group. Thereby, more precise statements on the urban and rural differences of health status are only possible for specific diseases or disease groups, such as sexually transmitted infections or road accident injuries (see also Section 8.3.1.)

Different than for health status, a more precise conclusion is possible for the provision of health services in rural settings. Based on the reviewed evidence, it seems that rural residents are disadvantaged by a less extensive provision of health services compared to the urban settlers. This lack of access to services is a frequent problem identified by almost all publications and reports, and draws the attention of policy-makers more on the lack of health services than on the lack of good health. Several reports even identify the lack of services as a causal factor for increased morbidity and/or mortality based on the less accessible and less sophisticated health services in rural settings, while in many cases lower rural disease prevalence rates could also be related to a lack of monitoring and reduced identification (thereby leading to an under-reporting of diseases in rural settings). However, little information is available on the validity of the reported data.

In brief, there is an increasing recognition of the relevance of rural health services, but there are no clear European trends for most of the available health indicators that would distinguish between urban and rural settings. The results and findings discussed in this chapter therefore strongly depend on the country of origin, the specific health outcome and the definition of rural areas used to compare the data. A valid and consistent review of rural and urban health conditions in the EU, however, does not exist.

 

There seems to be no European policy tools that directly focus on the development, improvement or stabilization of rural health services. However, to some extent, health and health services may be part of general European policy and regional development tools such as cohesion strategies, InterReg programmes, and regional integration policy tools and community initiative programmes such as PHARE or TACIS. The main objective of these initiatives may – to a varying extent – also provide limited benefits and capacities for rural health service development as part of overall regional development schemes. However, the existence and the practical impact of such side-effects of economic integration initiatives remains unclear.

 

10.5.2.5. Future developments

 

Although the terminology of urban versus rural settings remains fuzzy, it is evident that rural areas are quickly changing and that differences in urban places may become more and more obsolete in several EU countries. Still, it remains to be seen to what extent this may reduce the existing differences described above. Most of the more detailed data is however only available on a national scale, and there is not yet a clear picture on the European dimension of urban-rural differences in population health. Therefore, one of the important tasks for the future is to collect or categorize data on health status and health services per settlement categories in order to provide evidence on the urban-rural health variations and to inform health policies on priorities and trends.

 

10.5.2.6. References

 

British Medical Association (2005): Healthcare in a rural setting. BMA Board of Science.
Available at: http://www.bma.org.uk/ap.nsf/AttachmentsByTitle/PDFrural/$FILE/rural.pdf (accessed on 16 January 2008)  

Campbell NC et al. (2000): Rural factors and survival from cancer: analysis of Scottish cancer registration. British Journal of Cancer. 82, 1863-1866.

 

Department of the Environment, Transport and the Regions (DETR) (2000): Our Countryside: the future. A fair deal for rural England. The Stationary Office Limited.

 

Du Prel, X et al. (2006): Preschool children's health and its association with parental education and individual living conditions in East and West Germany. BMC Public Health 2006, 6:312

[http://www.biomedcentral.com/1471-2458/6/312] (accessed on 19 September 2007)

 

Eurofound (2006): First European Quality of Life Survey: Urban-rural differences. Luxembourg.

 

Eurostat (2003): Eurostat Yearbook 2003. The statistical guide to Europe. Luxembourg.

 

Gulliford MC et al. (2004): Availability and structure of primary medical care services and population health and health care indicators in England. BMC Health Services Research 2004, 4:12.

[http://www.biomedcentral.com/1472-6963/4/12] (accessed on 19 September 2007)

 

Johnson-Webb KD, Baer LD, Gesler WM (1997): What is rural? Issues and considerations. Journal of Rural Health. 13(3), 253-256.

 

Jones A, Bentham G. (1997): Health service accessibility and deaths fromasthma in 401 local authority districts in England and Wales 1988-1992. Thorax, 52(3), 218-22.

 

Lopez-Abuin JM, Garcia-Criado EI and Chacon-Manzano CM (2005): Proposals for improvement of emergency rural health care. Rural and Remote Health 5, on-line article n. 323, available from http://www.rrh.org.au

 

Ministry of Health of New Zealand (2007): UrbanRural Health Comparisons: Key results of the 2002/03 New Zealand Health Survey. Wellington: Ministry of Health.

 

National Rural Health Association (no date given): What`s different about rural health care? [http://www.nrharural.org/about/sub/different.html] (accessed on 12 April 2007)

 

Netherlands Institute of Health Services Research (NIVEL) (2006): The use of Electronic Medical Recording in General Practice as a tool for studying urban/rural health and health care utilization differences. Presentation held by Jouke van der Zee et al. (Netherlands Institute of Health Services Research, Utrecht) at the Rural Health Conference, Lodi, Italy in 2006.

 

OECD (2007): OECD Regions at a Glance: 2007 Edition. OECD, Paris.

[http://www.oecd.org/document/61/0,3343,en_2649_37429_38690301_1_1_1_37429,00.html] (accessed on January 23, 2008)

 

O'Reilly G, O'Reilly D, Rosato M, Connolly S (2007): Urban and rural variations in morbidity and mortality in Northern Ireland. BMC Public Health, 7:123.

[http://www.biomedcentral.com/1471-2458/7/123] (accessed on 19 September 2007)

 

Paykel E.S. (2000): Urban-rural mental health differences in Great Britain: findings from the National Morbidity Survey. Psychological Medicine 30:269-280.

 

Powles, J et al. (2002): Stroke in urban and rural populations in North-East Bulgaria:

incidence and case fatality findings from a 'hot pursuit' study. BMC Public Health 2002, 2:24.

 

Statistics Lithuania (2007): Causes of deaths 2006. Vilnius, 2007.

 

UN-HABITAT (2007): Urbanization: A Turning Point.   [http://www.unhabitat.org/downloads/docs/Press_SG_visit_Kibera07/SG%205.pdf] (article online, accessed on 2 August 2007).

 

Roel E et al. (2005): Clinically diagnosed childhood asthma and follow-up of symptoms in a Swedish case control study. BMC Family Practice 2005, 6:16.

[http://www.biomedcentral.com/1471-2296/6/16] (accessed on 19 September 2007)

 

Rawles J et al. (1998): Call to needle times after acute myocardial infarction in urban and rural areas in Northeast Scotland: prospective observational study. BMJ, 317: 576-8.

 

Van Bergen JEAM et al. (2006): Prevalence of STI related consultations in general practice: results from the second Dutch National Survey of General Practice. British Journal of General Practice; 56: 104109.

 

Verheij RA et al. (1998): Urban-rural variations in health in The Netherlands: does selective migration play a part? Journal of Epidemiology and Community Health 52:487-493.

 

Völzke H et al. (2006): Urban-rural disparities in smoking behaviour in Germany. BMC Public Health 2006, 6:146

[http://www.biomedcentral.com/1471-2458/6/146] (accessed on 19 September 2007)

 

Wood J (2004): Rural Health and Healthcare: a North West perspective. Public Health Information Report, North West Public Health Observatory, Lancaster, UK.

[http://www.nwpho.org.uk/reports/ruralhealth.pdf] (accessed on 12 November 2007)

 

10.5.2.7. Acronyms

 

BMA

British Medical Association

DETR

Department of the Environment, Transport and the Regions

EEA

 European Environment Agency

EU

 European Union

EURIPA

 European Rural and Isolated Practitioners Association

Eurofound:

European Foundation for the Improvement of Living

EUROSTAT

Statistical Office of the European Communities

GDP

 Gross Domestic Product

GP

 General Practitioner

NIVEL

Netherlands Institute of Health Services Research

NRHA

National Rural Health Association

OECD

Organization for Economic Co-operation and

PHARE

Poland and Hungary: Assistance for Restructuring their

RCT

 Randomized controlled trial

STI

 Sexually transmitted infections

TACIS

Technical Aid to the Commonwealth of Independent States

UK

United Kingdom

UN-HABITAT

The United Nations Human Settlements Programme

US

United States