Unmasking hidden disparities: a comparative observational study examining the impact of different rurality classifications for health research in Aotearoa New Zealand

Abstract

ObjectivesExamine the impact of two generic—urban–rural experimental profile (UREP) and urban accessibility (UA)—and one purposely built—geographic classification for health (GCH)—rurality classification systems on the identification of rural–urban health disparities in Aotearoa New Zealand (NZ).DesignA comparative observational study.SettingNZ; the most recent 5 years of available data on mortality events (2013–2017), hospitalisations and non-admitted hospital patient events (both 2015–2019).ParticipantsNumerator data included deaths (n=156 521), hospitalisations (n=13 020 042) and selected non-admitted patient events (n=44 596 471) for the total NZ population during the study period. Annual denominators, by 5-year age group, sex, ethnicity (Māori, non-Māori) and rurality, were estimated from Census 2013 and Census 2018.Primary and secondary outcome measuresPrimary measures were the unadjusted rural incidence rates for 17 health outcome and service utilisation indicators, using each rurality classification. Secondary measures were the age-sex-adjusted rural and urban incidence rate ratios (IRRs) for the same indicators and rurality classifications.ResultsTotal population rural rates of all indicators examined were substantially higher using the GCH compared with the UREP, and for all except paediatric hospitalisations when the UA was applied. All-cause rural mortality rates using the GCH, UA and UREP were 82, 67 and 50 per 10 000 person-years, respectively. Rural–urban all-cause mortality IRRs were higher using the GCH (1.21, 95% CI 1.19 to 1.22), compared with the UA (0.92, 95% CI 0.91 to 0.94) and UREP (0.67, 95% CI 0.66 to 0.68). Age-sex-adjusted rural and urban IRRs were also higher using the GCH than the UREP for all outcomes, and higher than the UA for 13 of the 17 outcomes. A similar pattern was observed for Māori with higher rural rates for all outcomes using the GCH compared with the UREP, and 11 of the 17 outcomes using the UA. For Māori, rural–urban all-cause mortality IRRs for Māori were higher using the GCH (1.34, 95% CI 1.29 to 1.38), compared with the UA (1.23, 95% CI 1.19 to 1.27) and UREP (1.15, 95% CI 1.10 to 1.19).ConclusionsSubstantial variation in rural health outcome and service utilisation rates were identified with different classifications. Rural rates using the GCH are substantially higher than the UREP. Generic classifications substantially underestimated rural–urban mortality IRRs for the total and Māori populations.

Connecting - Fellows Take Action: An International Rural Collaboration

“…This global focus further connects our fellowship. We recognise our rural communities are confronted with numerous barriers and reduced access to healthcare, impacting on their health and well-being (Whitehead et al, 2022) including an increase in health disparities and inequities (Whitehead et al, 2023). We also recognise there is limited agreement and understanding of conceptualising and defining the global 'rural' (Whitehead et al, 2022) related to community socio-cultural, demography, and unique rural encounters affecting vulnerable, minority and Indigenous populations, situated in geographical rural landscapes.…”

What does it mean to be an allied health professional working in rural Aotearoa New Zealand? A qualitative study

“…1 Nineteen percent of Aotearoa New Zealand's population live in rural areas. 2 These areas have overall higher proportions of indigenous Māori, lower socioeconomic status, and poorer health outcomes than urban areas. [2][3][4] Furthermore, there is considerable variation between rural communities both in the range of healthcare services that are locally available and in the way in which they are organised.…”

“…2 These areas have overall higher proportions of indigenous Māori, lower socioeconomic status, and poorer health outcomes than urban areas. [2][3][4] Furthermore, there is considerable variation between rural communities both in the range of healthcare services that are locally available and in the way in which they are organised. 5 The distinct scopes of practice allied health professionals need to practise successfully in the rural environment has received international recognition.…”

“…Healthcare in the rural setting is characterised by unique and complex challenges faced by patients, professionals, and services 1 . Nineteen percent of Aotearoa New Zealand's population live in rural areas 2 . These areas have overall higher proportions of indigenous Māori, lower socioeconomic status, and poorer health outcomes than urban areas 2–4 .…”

Rural–urban variation in the utilisation of publicly funded healthcare services: an age-stratified population-level observational study

“…The GCH has "unmasked" rural-urban differences in health outcomes that were obscured when other rural-urban classifications were used. 7 Mortality disparities identified by the GCH differ considerably across age bands, with younger rural residents having higher mortality rates than their urban peers, but older rural residents having mortality rates similar to or slightly lower than their urban peers. 8 Rural Māori have consistently poorer health outcomes than rural non-Māori, frequently exceeding the ethnic inequities observed in the urban context.…”