The Effects of Socioeconomic Status on Health in Rural and Urban America

Abstract

THE ELECTORAL MAP OF 2000-WITH ITS COASTAL BLUE EDGES AND POINtillist urban centers set against great swaths of red-told many political and economic stories. Attitudes toward rural life often reveal a complex mixture of affection and disdain, ideas about neighborliness and isolation, simplicity and provincialism. In his recent essay, "One Nation, Slightly Divisible," David Brooks argues that the differences between rural and urban America may be merely superficial, exemplified in consumer preferences such as Wal-Mart vs Pottery Barn. 1 Although I agree with his assertion that the two locales possess unique "sensibilities," there are important differences in rural vs urban health care. While 20% of Americans live in rural areas, only 9% of the nation's physicians practice there. Poverty-a principal health risk factor in any geographic locale-is more prevalent in rural areas and is often related to increased rates of chronic disease and greater numbers of uninsured citizens. 2 Rural residents have fewer physicians and nurses per capita and increased transportation barriers; they visit a physician less often and later in the course of their illness than do urban residents. 2 This issue of MSJAMA explores the question of whether there are two US health care delivery systems, one urban and one rural. Differences between urban and rural health care exist on a continuum defined by many variables. Susan Blumenthal and Jessica Kagen provide an epidemiologic background in which to consider important differences and markers between rural and urban health. Hilda Heady explores some of the monetary inequities embodied in rural vs urban reimbursement policies. Terry Meden and colleagues describe how distance from a tertiary care center may be related to decisions about mastectomy for rural women with stages I and II breast cancer. Although Roe vs Wade made abortion legal in the United States, this right may be moot in many rural settings. Trude Bennett explores some of these barriers to prenatal care, family planning, surgical contraception, and other reproductive health care services in rural areas. To address the chronic geographic maldistribution of physicians, Howard Rabinowitz and Nina Paynter outline the constructs that inform medical students' decision to become generalists or specialists and correlatively to practice in a rural vs an urban setting. These inequities in rural vs urban health care delivery are based in structural, economic, and cultural differences. Through increased awareness, research, education, and preventive public health measures, congress, and ultimately communities and the health care providers who serve them, may begin to lessen the degrees of difference.

Disparities in the application of adjuvant radiotherapy after breast‐conserving surgery for early stage breast cancer

“…As a result, delivery of oncology services to rural patients typically does not improve over time, and in fact as evidence‐based recommendations become more complicated with layering and tailoring of therapies, the rate of appropriate adjuvant treatment may actually decline 7, 35. Because approximately 20% of the US population lives in an area qualified as rural,26 disparities similar to that found in our study may have broad‐based implications for the country as a whole.…”

Inequalities in access to cancer treatment: an analysis of cross-regional patient mobility in Greece

“…Nevertheless, total or partial absence of oncology-specific substructures in large geographical areas seriously undermines equality in access to health services [33], especially for people with limited financial ability [34,35]. Therefore, the present misallocation of oncology-specific resources, which leads to increased patient mobility, creates "two tier" cancer patients based on ability to pay.…”

Community Size as a Factor in Health Partnerships in Community Parks and Recreation, 2007

“…These findings indicate that smaller communities (which are most likely rural) are disadvantaged regarding their ability to develop and implement partnerships with health organizations. This is especially troubling since poverty, obesity, chronic disease, and uninsured rates are higher in rural areas than suburban and urban areas (26,27). Not only do very small communities engage in partnership less, they have fewer organizations to partner with and they must serve a significantly larger geographic area (49.1 miles for rural vs 0.5 miles in urban areas) (28).…”