10.5.2. Urban and rural populations
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 define “urbanism” 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.
Population distribution per settlement structure in 2003 for selected EUGLOREH
Thereby, any comparison of the health status of urban and
rural populations strongly depends on how – in a given study – urban 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
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,
Gaps of evidence emerge when it comes to the comparison of
data – especially 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.
description and analysis.
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,
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
Complaints by residents on environmental conditions
Complaints due to air pollution in urban and rural settings
Complaint about access to recreational / green spaces in urban and rural
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.
Correlation of age-adjusted standard mortality rate with urban and rural
Correlation between age-adjusted mortality rates with urban and rural
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
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
Life expectancy by gender in urban and rural settings in
Mortality rates in urban and rural settings in Lithuania,
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
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.
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.
Long-standing illness and disability in urban and rural
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.
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.
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,
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
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).
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
Table 10.5.2.3. Problems accessing health services
in urban and rural areas (2006)
population reporting problems
countries with high GDP
Belgium, Denmark, Finland, France, Germany, Ireland, Italy, Luxembourg, The
Netherlands, Sweden, United Kingdom
countries with intermediate GDP
Czech Republic, Greece, Malta, Portugal, Slovenia, Spain
countries with low GDP
Hungary, Latvia, Lithuania, Poland, Slovakia
countries and Turkey
from: European Foundation for the Improvement of Living and Working Conditions
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
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.
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.
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