Investigating trends in rural health outcomes: a research agenda

Geoforum 30 (1999) 203±221

www.elsevier.com/locate/geoforum

Critical review

Investigating trends in rural health outcomes: a research agenda Gary Higgs * Department of City and Regional Planning, University of Wales, Cardi€, P.O. Box 906, Cardi€, CF1 3YN, UK Received 11 June 1998; in revised form 28 April 1999

Abstract Recent research has highlighted the nature of spatial inequalities in health experience in the UK providing evidence of increasing spatial polarisation. However, these studies have tended to be largely concerned with variations in health in urban settings. Recent economic trends, particularly in the agricultural sector, have focused attention on the socio-economic status of rural populations. With a number of notable exceptions, relatively few studies have been concerned explicitly with issues of rural health. The aims of this paper are to ®rstly, review recent research which has begun to challenge the notion that rural populations are necessarily healthier than their urban compatriots and secondly, to identify a number of possible explanations for the trends identi®ed in these studies. Variations are examined in relation to methodological problems, socio-economic trends in rural areas, changing accessibility to primary and secondary health care and lifestyle/behavioural factors. A research agenda is presented whereby these types of factors can be further investigated through an integrated approach to studying health variations within rural areas. Finally, the paper concludes by suggesting that more research is needed to investigate the main determinants of health experience and health status in a range of rural settings. Ó 1999 Elsevier Science Ltd. All rights reserved. Keywords: Health inequalities; Rural health; Accessibility to services; Socio-economic changes in rural areas; Rural lifestyles

1. Introduction The recently published report of the Independent Inquiry into Inequalities in Health chaired by Sir Donald Acheson has summarised much of the evidence for inequalities of health in England and identi®ed priority areas for future policy development in order to reduce such inequalities across a range of Government departments (Acheson Report, 1998). Recent research has highlighted the nature, and extent, of spatial inequalities in health experience in the UK providing evidence of increasing spatial polarisation (Dorling, 1997). Similar trends were found in Wales at the small area level with widening disparities in mortality experience between a‚uent and deprived areas during the 1980s (Higgs et al., 1998; Senior et al., 1998). This follows a long line of research which has analysed geographical health inequalities at inter- and intra-national scales (for example, Charlton and Murphy, 1997; Drever and Whitehead, 1995; McLoone and Boddy, 1994; Phillimore et al., 1994; Townsend et al., 1988). Furthermore there is evidence of variations in health status at more *

E-mail: HiggsG@cardi€.ac.uk

localised scales; for example, Jones and CurtisÕs (Jones and Curtis, 1998) study of the spatial trends in standardised mortality and morbidity in London showing intra-urban contrasts. The divergence in trends between areas that have seen a relative (and in some instances absolute) deterioration in health status in the last four or ®ve decades and those that have experienced an improvement, has drawn attention to those areas which are generally perceived to have higher than average levels of material deprivation, i.e. predominantly urban areas of the country (for example, Glasgow, McCarron et al., 1994). This has provided the focus for recent research projects, including a number under the ESRC Health Variations Research Programme (Phase 1), in which area e€ects on the health of individuals are under investigation. Furthermore the increasing realisation of widening inequalities, and the need to narrow the health gap, has formed the basis for action plans such as those outlined in the GovernmentÕs consultation papers on public health in England (Department of Health, 1998) and Wales (Welsh Oce, 1998). To date, much of the research that has been conducted has analysed health inequalities between areas based on a gradation of socio-economic conditions. Often this has concentrated on health di€erentials within

0016-7185/99/$ - see front matter Ó 1999 Elsevier Science Ltd. All rights reserved. PII: S 0 0 1 6 - 7 1 8 5 ( 9 9 ) 0 0 0 2 1 - 4

204

G. Higgs / Geoforum 30 (1999) 203±221

urban settings. Less research has been conducted on di€erences in health experiences, and in particular the linkages between aspects of poverty and health status, within rural areas. Cox (1995) noted a similar disparity of research e€ort in general practice issues between urban and rural areas. This has led some to suggest, that Ôlittle substantial research has been done into speci®c and di€erent health needs in the rural areasÕ and that ÔBritain, in this respect, lags behind other developed countriesÕ (Simmons, 1997; p. 80). Furthermore, this comes at a time of a downturn in the economic fortunes of many rural areas as a result of trends in the agricultural industry arising from factors such as changes in the Common Agricultural Policy (CAP) and the impacts of the BSE Crisis. More recently, important research initiatives have challenged the notion that rural areas are necessarily more a‚uent than urban areas, pointed to the causes of such trends and identi®ed signi®cant pockets of rural disadvantage based on a whole host of socio-economic measures (e.g. Shucksmith et al., 1996a). However, to date, relatively less attention has been focused on the impacts of these forces on health outcomes in rural areas. The contrast with North America where there appears to be more published research relating to the geography of rural health (for example, Gesler and Ricketts, 1992; Health Services Research, 1989; Ricketts et al., 1994), more funding for research centres speci®cally established in order to study facets of rural health1 and, indeed, a journal speci®cally dedicated to providing an outlet for such research initiatives, is particularly apparent. With a number of notable exceptions (for example, those reviewed in Section 2, few studies have been speci®cally concerned with exploring spatial and temporal trends in health status in rural areas of the UK and with trying to account for variations noted, for example, in wider scale studies of health inequalities as they relate to rural areas. Shucksmith et al. (1996a) quoting work from Fearn (1987) suggests that there are two main factors why rural health issues have received relatively scant attention. Firstly, there is the perceived notion that people in rural areas are generally ÔhealthierÕ than those in urban areas. As recently as 1987, Eyles comments on the basis of the area mortality data of the Registrar GeneralÕs decennial supplements that, ÔIn the most general terms, it appears that the popular image of healthy country life is correctÕ (Eyles, 1987; p. 110). A second set of explanations as to why rural health issues have not received similar attention to those of

1 See, for example, those listed at http://home.rednet.co.uk/ homepages/irh/linx.html

urban areas, stems from the notion that there is a generally equitable health service in rural areas in the UK which leads to a even distribution of health care. Because the physical distances involved in accessing health facilities are less than in countries such as the United States and Australia, access is perceived to be less problematic. Fearn questions both these assumptions and points to evidence to suggest that the perceived health advantages of rural areas are far from uniform. In this treatise, changes in primary health care in rural areas, in the light of increased centralisation of health facilities, has led to problems of di€erential accessibility for certain social groups to such services. Following on from these ®ndings, a major impetus for research in this area is the concern amongst health authorities serving rural populations that resource allocation mechanisms have in the past failed to incorporate rural dimensions to need which take into account supply side factors and the fact that there are higher costs involved in providing health services in sparsely populated areas. This, in turn, has led to a number of studies which have explored the development of alternative indicators based on, for example, measures such as population sparsity, population distance from GPÕs or service utilisation patterns (see Carr-Hill and Sheldon, 1992; Hale, Rita and Associates, 1996; Watt and Sheldon, 1993 for reviews of such research). Given these concerns, there is the distinct likelihood that rural health issues may well rise up the political agenda and this paper is a preliminary attempt to ®rstly, review the relatively limited research on rural health in the UK and secondly, to use the more extensive literature available from North America, in particular, in order to present a research agenda whereby some of the major gaps in knowledge can be addressed. Whilst acknowledging the di€erent systems of health care availability between the UK and North America, and the implications this has for access to services, for example, it is suggested that many of the problems associated with rural health are similar. The aim is to highlight a number of areas where substantial research is required to try to account for trends in rural health. The rest of this paper is structured as follows: in Section 2, I provide a brief review of previous studies which have explored the di€erences in health outcomes between urban and rural areas. Inevitably, the majority of such studies have focused on di€erences in mortality ± totals and by cause of death ± although reference is made to other studies which have looked at di€erences in, for example, long-term illness between such areas. As well as the variations between urban and rural areas, such studies have drawn attention to the need to investigate spatial variations in health within rural areas with di€ering socio-economic and geographical characteristics. These have emphasised the need to take into account the levels of deprivation within rural areas to

G. Higgs / Geoforum 30 (1999) 203±221

fully elucidate the in¯uence of rural factors per se. In Section 3, a number of strands of research are outlined which have focused on trying to account for such trends. Firstly, it is suggested that the actual de®nition of what constitutes a ÔruralÕ area can have an important in¯uence on the ®ndings from such studies. The nature of the health indicators used and methodological constraints, such as the problem of small numbers of cases, are also key considerations. The potential in¯uence of factors such as access to services, socio-economic restructuring in rural areas and behavioural (lifestyle) factors on spatial variations in health outcomes are explored in turn. The latter, in particular, is a relatively under-researched theme in rural studies and in Section 4, a research agenda is presented whereby this work could be taken further. A series of questions are posed which could be addressed in order to gain further insights into the nature of potential in¯uencing factors. Finally, some brief concluding remarks are made and attention drawn to the policy relevance of such research in rural contexts. 2. Existing evidence of rural health variations 2.1. Variations between urban and rural areas 2.1.1. Introduction Research in the UK has been primarily focused on the di€erences in health outcomes between rural and urban areas in terms of mortality (e.g. Britton et al., 1990; Phillimore and Reading, 1992), morbidity (e.g. Charlton et al., 1994; Congdon, 1995) and on birth weight and childrenÕs height (e.g. Reading et al., 1993, Charlton, 1996; Larson et al., 1997). Several studies have emphasised the need to incorporate a range of health measures in order to fully gauge the extent of urban±rural health variations. Mackenbach (1993), for example, used three measures ± perceived general health, prevalence of chronic conditions and mortality ± to demonstrate the in¯uence of the degree of urbanisation on health outcomes in the Netherlands. Rural areas were shown to have better than average health status on all three indicators, although other factors such as age, marital status, level of education and gender had to be taken into account. Senior (1998) noted higher ward level prevalence of limiting long-term illness in rural areas of Wales than in England highlighting the importance of taking into account local context and the types of cultural factors which may have in¯uenced responses to the question relating to long-term illness in the 1991 Census. Bentham et al. (1993) found that rural areas had lower rates of long-term illness than urban areas but, for wards which are more distant from hospital locations, standardised morbidity for the under 75

205

age group were seen to be higher, emphasising the importance of factors such as accessibility. The importance of taking into account the exact nature of rural areas was emphasised by Verheij (1996). In a review of literature published since the mid-1980s regarding variations in mental health, physical health and well-being in urban and rural areas, he questions the widespread notion of healthier rural communities by suggesting that, after controlling for demographic factors and di€erences in socio-economic characteristics, the tendency towards better perceived health in rural areas disappears. Sobal et al. (1996), in a study of rural± urban di€erences in obesity levels in the United States, highlight two main strands of sociological explanation for observed trends; namely the determination, or contextual, and composition perspectives. The former tries to account for any variations in health outcomes or status by emphasising inherent di€erences in rural and urban areas per se. Here the very characteristics of rural areas vis-a-vis urban areas, potentially related to economic, employment and lifestyle patterns, are seen as a major determinant of the health experiences of individuals living in these areas. In the composition perspective, explanations for trends are sought in terms of the socio-demographic pro®les of rural and urban areas. In particular the age, gender, race and socio-economic composition of residents are used to account for any variations in health status. Thus, in this perspective, any relationship between degree of urbanicity and the health outcome under investigation is explained by the variations in the social make-up of the relevant populations. As the research reviewed in the following sections reveal, the challenge for researchers in this ®eld is therefore to devise methodologies whereby the relevance of the two perspectives can be fully explored. The aim here is to provide a critical review of previous studies before providing a research agenda whereby some of these themes can be advanced. In the absence of data sets at appropriate geographical or temporal scales, much of the research carried out, to date, has focused on the use of mortality data, either based on crude death rates or standardised mortality ratios (SMRs), which permit a comparison of overall death rates for di€erent populations whilst taking into account the di€erences in age structure of those populations. Such studies are reviewed in the next two sections, ®rstly for all causes and secondly, for speci®c causes of death. 2.1.2. Variations between urban and rural areas ± all cause mortality Mortality rates are lower in rural areas than in urban areas; however, this is not uniform and several studies have emphasised the importance of taking into account the geographical and socio-economic characteristics of such areas (Miller et al., 1987; Dorling, 1995). A

206

G. Higgs / Geoforum 30 (1999) 203±221

number of studies have been conducted which have challenged the notion of a generally healthier rural population and have revealed a more complex pattern of health trends. Schneider and GreenbergÕs (Schneider and Greenberg, 1992) study of causes of death in the United States for the period 1939±1981 for the 35±64 age group, highlights the need to account for factors such as rural poverty in order to gain some insight into such variations. By using income levels at the state level, they were able to demonstrate the relationship between poverty and higher death rates. The fact that, by its very nature rural poverty is likely to be spatially heterogeneous, suggests that the health experience will vary within rural areas. Cli€ord et al. (1986), for example, in their study of urban±rural di€erences, stressed the importance of taking into account the demographic pro®les of areas and found that di€erences almost disappeared following adjustment for age and gender. A study of mortality patterns in North Carolina (1950± 1980) revealed a decline in di€erentials between urban and rural areas, the extent of which was dependent on age, race and degree of urbanicity (Cli€ord and Brannon, 1985). Gesler et al. (1992) present evidence to suggest that the incidence of some chronic conditions is higher amongst people residing in rural areas in the United States. This, in turn, can be partly explained in terms of the higher percentage of elderly people in rural areas. Schneider and Greenberg (1992) note a convergence of mortality rates for some cancers between urban and rural states in the US which can be largely accounted for, in their opinion, by an improvement in the diagnosis and earlier reporting in the latter, by higher inter-regional migration rates within the United States and by an increasing homogeneity of lifestyles. But they also note a divergence in the rates for certain forms of cancers, e.g. female lung cancer, between urban and rural areas. This, and the fact that trends were slightly di€erent according to gender, suggests that accounting for trends in health status of urban and rural populations is far from straightforward. Beck et al. (1996), for example, draw attention to the higher risks from stress related and cardiovascular disease for rural women in an Appalachian survey compared to their urban counterparts which, in turn, could be related to socio-economic status and ®nancial barriers to, for example, cancer screenings. Again the geographical setting and socio-demographic factors have to be taken into account when comparing trends and the researchers suggest that there may well be a unique set of health problems speci®c to their study area which may not be replicable to other rural settings. Their study also suggests that, depending on the nature of such rural-urban circumstances, di€erent trends may be evident for different causes of death and that more pro®table insights may be achieved by looking at variations in speci®c cause mortality.

2.1.3. Variations between urban and rural areas ± cause of death breakdown In the UK several studies have been concerned with examining urban-rural di€erentials in health status by cause of death. Because of the lower numbers of deaths in rural areas there may be problems with the statistical reliability of such trends. However, a number of recent studies suggest that variations between rural and urban areas in terms of overall mortality statistics may hide statistically signi®cant spatial trends in mortality by speci®c cause of death. Shucksmith et al. (1996a) noted that there are signi®cant rural±urban contrasts in cause of mortality; with the latter having high death rates from respiratory diseases and certain forms of cancer whilst the former have a greater proportion of deaths from accidents with farm accidents, in particular, being a major cause of injuries (and deaths). In CharltonÕs (Charlton, 1996) study of cause of death for 0±74 year olds for clusters of local authority districts, rural areas had the lowest mortality for all causes of death except for injury and poisoning. Dorling (1995) found that, in the late 1980s, death rates from heart disease, strokes, cancers and respiratory diseases were generally lower, and those from trac accidents and suicide were higher, in rural areas. Furthermore, such ®ndings marked a continuation of trends from the 1920sÕ onwards in England and Wales (e.g. for coronary heart disease by Britton (1990) and lung cancer by Howe (1981)) and would appear to suggest that the health advantages of living in rural areas are relatively long-standing. A review of previous studies of health status in urban and rural areas revealed that, in the majority of cases, incidence rates of cancer were higher in urban areas, although the extent of the di€erences were seen to vary according to factors such as gender, being greater for men for most cancers (Verheij, 1996). He also observed exceptions to these trends for some cancers, e.g. leukaemia, as evidenced in the literature. Doll (1991), in an international study of 13 countries, also found higher rates of incidence for both males and females in urban areas for 23 of 26 types of cancer, the extent of the urban excess varying by type. This was related to variations in the lifestyle behaviour ± diet, smoking, and alcohol consumption amongst others ± between urban and rural residents. Howe (1981), however, found no signi®cant urban-rural distinctions between death rates from, for example, gastric cancer. Britton (1990) noted that trends for breast and prostate cancer were reversed with predominantly rural counties appearing to have higher than expected mortality rates. Di€erences have also been found for colorectal cancer survival rates between women in rural and urban areas in France (Launoy et al., 1992), suggesting a possible adverse e€ect of rural residence (partly caused, it was postulated, by delays in diagnosis in rural women). Monroe et al. (1992), in a review of previous studies of cancer mortality patterns

G. Higgs / Geoforum 30 (1999) 203±221

in the US, suggest that although the majority of such studies have found higher rates in urban areas, there was some evidence to suggest that the types of cancer and the socio-economic circumstances of the individuals involved need to be taken into account prior to extrapolation of such ®ndings to other areas. A number of studies have focused on the di€erences in cancer incidence rates between areas of varying population densities (e.g. Howe et al., 1993; Nasca et al., 1992). Skin cancer rates, for example, may not have such a distinct urban-rural di€erentiation. Greenberg (1983) notes a convergence of rural mortality rates for some cancers with those of urban areas in the United States although this was not consistent across age or gender groups (for example, the di€erence between urban and rural rates of white female lung cancer mortality actually increased from 1950 to 1975 related to higher smoking rates in the former). Similar trends were noted in The Netherlands with some evidence of a convergence of rates for men for tobacco-related cancers between urban and rural areas, but none for other cancers, which were accounted for by di€erences in lifestyle factors (Schouten et al., 1996). Another focus for research has been studies of mental illness, psychiatric disorders and suicide rates in rural communities. Verheij (1996), for example, on the basis of a review of current published studies, questions the assumption that there are higher levels of mental illness in urban areas. In particular, the in¯uence of factors such as unemployment on levels of depression were seen to vary according to the nature of the urban±rural setting. Two potential reasons for this were postulated; namely that the higher levels of social support and the potential for informal employment opportunities in rural areas could mean that the potential impact of unemployment takes on a di€erent signi®cance in rural areas. Against this is the social stigmatisation of unemployment, suggesting that the linkages between such factors and the incidence of depression are far from straightforward. A number of studies have speci®cally focused on the in¯uence of these factors on suicide rates by di€ering occupational groups (Charlton, 1995; Kelly et al., 1995). Recent evidence from Wales suggests that rural authorities tended to have higher than average suicide rates (Monaghan, 1998). Such trends need to be considered in the light of recent evidence which suggests that there has been an increase in mortality from suicides for men aged 20±64 during the 1970s and 1980s across all social groups except Social Class I (Drever and Bunting, 1997). Kelly et al. (1995) examined variations in suicide rates between 1982 and 1992 by both occupation and geography in the UK. They found that such rates tend to be highest in the 15±44 age group especially for men and that a higher rate of suicide existed for farmers and farm workers than expected.

207

Furthermore, a quarter of such deaths in this occupational class occurred in the 65±74 age group. Saunderson and Langford (1996) have looked at completed suicides at the district level in England and Wales for the age groups 15±24, 25±44 and 45±64. Using a comparison of a ÔtraditionalÕ approach based on SMRs and empirical Bayesian estimates, they found that in addition to the high rates in some of the larger urban areas, there appeared to be many high risk agricultural areas particularly in North and mid Wales, North Yorkshire and the West Country. Potential reasons for these ®ndings include the recent ®nancial pressure on farmers as a result of factors such as the changes to the common agricultural policy and the reduction in subsidies, the implications of the recent BSE crisis, easy access to ®rearms, the physical and social isolation some individuals experience in rural communities (especially elderly single men), and the need for increased counselling services in the light of recent policy developments (Watt, 1995; Malmberg et al., 1997). Similar trends have been noted in other developed countries (e.g. in Australia by Dudley et al., 1997). The trend in deaths by suicide in rural areas have also been related to accessibility to, and take-up of, psychiatric care which tends to be lower in rural areas (Kelly et al., 1995). This suggests that di€erences between urban and rural areas may be partly attributable to sociocultural factors. Trends the UK appear, however, to be spatially uneven and worthy of further analysis at the small area level. 2.2. Variations within rural areas Previous studies inevitably have tended to focus on the di€erences between urban and rural areas in terms of overall health experience. A common theme running through such research is the importance of adjusting for variations in age, sex and (in some circumstances) race in rural areas when trying to account for rural±urban di€erences in death rates. This, in turn, may hide differential health experience within such areas which could potentially account for such trends. It is the view of some researchers that a simple urban±rural dichotomy is inappropriate and that, on the basis of existing evidence, it is far too simplistic to conclude that rural populations are healthier than those of urban areas or that inequalities in health due to socio-economic status, age or deprivation levels are less marked than that of urban areas (Payne et al., 1996). Given that geographical variation in mortality rates are closely related to spatial trends in socio-economic deprivation in the population and the fact that deprivation levels will vary within rural areas this may not be entirely unexpected. In such circumstances the interaction between region, deprivation levels and urban/rural status will complicate resultant trends in health status (Dolk et al., 1995).

208

G. Higgs / Geoforum 30 (1999) 203±221

Despite this, there remain few studies that have focused primarily on intra-rural variations in health status. Bentham (1984), through a study of variations in SMRs and a measure of rurality at the district level in England and Wales, found that mortality rates tend to vary according to remoteness of rural areas, with more remote areas having higher than expected rates. Similar trends were noted at the sub-district level for the county of Norfolk (Bentham and Haynes, 1985), namely that rates tended to be low for those rural areas bordering main towns but were higher for more remote rural communities. The need to take into account the socio-economic settings of rural areas in such studies was also reiterated in the Phillimore and Reading (1992) study of deprivation and mortality for 678 wards in the Northern Region of England. In particular, the need to incorporate measures of distance to nearest urban areas has led some to propose the development of a Ôrural remoteness indexÕ which takes into account the distance of residents to GP services, for example, and which can then, in turn, be correlated with health measures such as SMR (Haynes and Bentham, 1982). Thus in the latter study for rural areas of Norfolk, higher SMRs were noted where the rural remoteness index is highest ± possibly a result of inaccessibility to doctors surgeries. The important point to be stressed is that the nature of the relationship between health and measures of rurality will be highly dependent on the nature of the rural area ± what Phillimore and Reading (1992; p. 291) refer to as Ôintra-rural distinctionsÕ. Their research suggests that the relationship between deprivation and ill-health is somewhat di€erent in rural and urban contexts. The importance of also taking into account the age pro®le of the population in rural areas was also revealed in rural±urban comparisons of mortality in the US using the National Longitudinal Mortality Study (Smith et al., 1995). Crude mortality rates (prior to any age-standardisation) tend to be higher in the former. However, analysis of such rates for persons aged 55 years and older, revealed that between the ages of 55 and 74 there does appear to be a disparity in mortality rates between rural and urban areas, but that this ceases to be the case over the age of 75. In this age group, other socio-demographic factors such as marital status and educational attainment were deemed more in¯uential contributors to mortality rates. This led the authors to suggest that, Ôthe protective e€ect of rural residence declines in older age cohortsÕ (Smith et al., 1995; p. 274). Congdon (1995) found higher illness rates (% rate for males aged 45±49) in Ônon-metropolitanÕ East Anglia than ÔmetropolitanÕ London, but suggested that, when deprivation levels were accounted for, Ôa‚uent metropolitan wards have lower illness levels than deprived rural wardsÕ (Congdon, 1995; p. 331). Interestingly,

these trends were not mirrored in premature mortality (per 1000 males aged between 45 and 64) and infant mortality (per 1000 births). When population density is used to grade wards within urban and rural settings, a clear gradient was evident between the high density and low density wards in a‚uent and deprived urban areas for chronic ill-health. This is also the case for rural deprived and a‚uent wards but for middle aged deaths and infant mortality there appears no gradient with density and, as Congdon suggests there may indeed be an increase in rates for these two indicators for less dense, more remote wards indicating that Ôthe more remote rural areas have a middle-aged mortality disadvantage as compared to less remote rural wardsÕ (p. 331). This then replicates some of the ®ndings of Bentham (1984) and suggests that although there is a general health advantage to living in rural areas, the relationship is not uniform and that there may well be instances, for certain health indicators, of poorer health outcomes for low density, more remote, wards in rural settings even where the social structure replicates those of denser wards. In addition, there may be instances where urban±rural di€erentials are masked by di€ering levels of deprivation between, and within, rural areas ± as found in Patterson and WaughÕs (Patterson and Waugh, 1992) study of variations in childhood diabetes in Scotland where deprivation was seen to confer a larger protective e€ect in urban areas. These ®ndings have been replicated in other studies in which less signi®cant relationships were found between deprivation levels and health outcomes for rural areas suggesting a di€erential impact of deprivation on health in urban and rural settings. Phillimore and Reading (1992) categorised wards in the Northern Region of England into four groups namely those in conurbations, larger towns, small towns and rural areas and examined the relationships between health and deprivation for the most a‚uent and most deprived 10% of wards (based on the Townsend deprivation score, an index which combines indicators of unemployment, lack of car, not being an owner occupier and overcrowding) within each of these four broad groups. No signi®cant di€erence existed between SMRs (0±64) for the most a‚uent deciles between the four settings but this was not mirrored in the trends for the most deprived 10%. For the latter a distinct trend from conurbations (highest SMRs) to rural areas (lowest SMRs) were noted. The ratio of deprived:a‚uent decile SMRs were also larger for urban areas suggesting a wider inequality than in rural contexts. However, one of the most important ®ndings of this research was that when comparing SMRs for those wards in non-rural situations which matched the poorest decile of rural wards on material deprivation scores, very little di€erence was noted and the rural health advantage disappeared. This led the researchers to suggest that,

G. Higgs / Geoforum 30 (1999) 203±221

209

Ô(t)his evidence runs counter to the view that health is inherently better in rural areas, for it suggests that, in localities of equivalent a‚uence or deprivation, there is little to choose between the di€erent settingsÕ (Phillimore and Reading, 1992; p. 294).

section presents some potential explanatory factors for such trends.

Part of the explanation in their view was that some of the rural wards shared many of the socio-economic characteristics of the urban classi®ed wards, i.e. they were dominated largely by the coal mining industry and consisted largely of pit villages. In such cases, it is dif®cult to disentangle the in¯uence of urban ± rural variations on health status from that due to the general socio-economic characteristics of such areas. By comparing the SMRs for remote rural areas with those of wards of comparable deprivation scores in a‚uent conurbations, they found SMRs, for the 0±64 age group, 13% below the national average for the former set of wards suggesting a health advantage to living in remote rural areas in their study area. Dolk et al. (1995) found that although mortality tended to be higher for urban areas for the majority of regions of the UK for all deprivation quintiles in the period 1982±1985, the extent of the advantage varied. They also noted that trends for rural areas in Wales were actually reversed except for the most a‚uent quintile in which mortality rates were seen to revert back to being lower for rural areas. In summary, the published literature on rural±urban contrasts in health outcomes seems to suggest that the relationship between such di€erentials and socio-economic circumstances, as evidenced by standard deprivation indicators, is far from straightforward. In particular, the nature of compounding factors on health status and the diculties in isolating the in¯uences of individual contributory factors, often leads to contradictory ®ndings and precludes more wider generalisation. Any study of this nature, which aims to examine health variations, will need to incorporate indicators at a variety of scales in order to account for spatial trends (Curtis and Jones, 1998). Furthermore, it is the contention of researchers such as Verheij (1996) that it is important to take into account the characteristics of the individuals included in such studies in order to examine the interaction between the individual and the environment and to fully elucidate the in¯uence of the degree of urbanicity on health status. A number of approaches, both qualitative and quantitative, have been used to study the in¯uence of such factors on health variations. Statistical approaches, for example, include the use of multi-level methods, which permit an analysis of both compositional and contextual in¯uences and draw attention to the need for hierarchically structured data (Shouls et al., 1996; Duncan et al., 1998). The aim of this section has been to provide an overview of variations in health status and experiences of individuals in di€erent geographical settings. The next

Previous studies, that have focused on spatial and temporal trends in health inequalities, have tended to adopt a socio-economic model of health based on the main determinants of health status. Dahlgren and Whitehead (1991), for example, have identi®ed a series of layers with each in¯uencing health to a greater or lesser degree, depending on individual, community and socio-economic circumstances and which are, in turn, subject to di€erent levels of intervention in attempts to reduce inequalities. At the individual level, they identify the importance of age, sex and constitutional factors as well as those of individual behavioural and lifestyle factors. Whilst the latter are capable of being modi®ed through changes in behavioural patterns, the former remain ®xed. The ability of individuals to modify their way of life in rural contexts will, however, be disproportionately dependent on external factors such as the economic forces which lead to rationalisation of services which, in turn, are likely to di€erentially impact on those social groups without access to private transport. Such individuals may be dependent to varying degrees on the types of social and community networks which are widely perceived to exist in rural areas. Where such networks break down, potentially as a result of sociodemographic changes in rural areas, there will be inevitable constraints in the choices available to some rural residents. The next layer in the socio-economic model of health relates to the impacts of varying working and living conditions, educational opportunities, environmental factors and access to services and goods. Again, there are speci®c rural dimensions which can be drawn out relating to access to essential primary care services and limited information opportunities in some rural areas which can potentially in¯uence health status and warrant further study. Over-riding many of these factors, and interacting to varying degrees with them, is the pervading socio-economic, cultural and environmental climates within society (Dahlgren and Whitehead, 1991). Variations in these inter-related layers of determinants are the underlying causes of health inequalities through their impacts on both the health status, and health experiences, of individuals. This section of the paper aims to adopt this socio-economic model in order to ®rstly, identify the various strands of research as evidenced in the literature on rural health and secondly, to draw attention to a number of relatively under-researched themes in rural health studies. Before considering such in¯uences, a number of methodological constraints, which need to be taken into account before comparing the ®ndings from such studies, are described.

3. Investigating rural health trends

210

G. Higgs / Geoforum 30 (1999) 203±221

3.1. Methodological constraints There is a body of literature that suggests that any rural±urban health di€erential could potentially be an artefact ®rstly, of the methods by which ÔruralÕ areas are de®ned and identi®ed, and secondly, that other methodological problems such as the inadequacies of using (urban-biased) indicators of disadvantage in rural contexts could have a signi®cant impact on such ®ndings. The relevance of these criticisms for studies of rural health are elaborated on below. Problems persist in a number of cases with regard to the precise nature of the data used to discern trends in urban±rural health outcomes. Watt et al. (1993, 1994) draw attention to such methodological constraints, including di€erences over the precise de®nition of the term rural. Previous studies have used measures of ÔruralityÕ based on clustering techniques using a range of census based variables (e.g. Cloke, 1977; Wallace et al., 1995) or distance from health-related services or those based on land use (Charlton, 1996). De®ning rural and rurality has tended to preoccupy a great deal of rural geography literature in the last two decades in particular. Despite this, as Ilbery (1998, p. 2) has commented, Ôthere remains little chance of reaching an agreement on what is meant by the term ruralÕ. Invariably, studies that have noted a di€erence in urban±rural health status or in variations in access to services, have not incorporated discussions as to the implications of the de®nition of rurality used to discern trends. Despite this a number of studies have explored the signi®cance of changes in the de®nitions of rural areas on such ®ndings. Hartley et al. (1994), for example, in a study of urban and rural di€erences in access to health care in relation to insurance characteristics in Minnesota, found no signi®cant di€erence in the results according to the de®nition of rural used. Others have noted a signi®cant di€erence in results. Hewitt (1992) expresses such concerns from a North American perspective. As she comments, ÔDichotomous measures of urbanity and rurality mask key distinctions between urban and rural areas as well as wide variations within particular rural areas (Hewitt, 1992; p. 53). This may be particularly problematic where the spatial units under consideration are coarse. This was recognised in a recent Scottish Oce (1996) socio-economic pro®le of local authority districts which classi®ed rural areas as those with a population density of less than one person per hectare. This classi®cation appeared both to include urban areas within rural districts and to exclude rural areas which happen to fall in otherwise urban districts and was thus highly dependent on the spatial scale employed. Clearly, therefore, a number of key

research questions need to be posed at the outset of such research regarding the nature of the criteria used to de®ne such areas. Any comprehensive study of rural± urban health di€erences needs to consider the potential signi®cance of variations in approaches. These may include those based on: · population totals (e.g. the US Bureau of Census categorises towns with over 2500 population as urban and the rest, rural (Ricketts, 1994)); · measures of population density/sparsity (Phillimore and Reading, 1992); · socio-economic characteristics at the small area level, including economic activity (e.g. levels of employment in forestry/agriculture); · degree of isolation from urban areas, e.g. based on drivetimes from major centres above a speci®ed population; · some measure of access to services; · degree of urbanisation. Each of these measures can be criticised, for example, a measure of population density takes no account of the distribution of population within areas and may be biased by the presence of towns within rural areas. For any de®nition of rural, there is no logical breakpoint for any measure of population total/sparsity, level of access or economic activity or geographical isolation, suggesting that any categorisation is likely to be arti®cial. Often a combination of these measures is used; Hewitt (1992), for example, explores the use of measures based on several of these techniques in studies of rural health. Rural±urban continuum codes for Metropolitan and Non-metropolitan counties (also known as the Beale codes), for example, use a combination of total population size, settlement size and adjacency to metropolitan areas to classify counties in the United States (Butler, 1990). The criteria used to de®ne rural can have an important bearing on the ®ndings of such research. Clearly, it is important that any study focusing on urban±rural health di€erentials takes this on board and fully justi®es the de®nition of rurality used in a clear and objective manner. A second group of methodological constraints relates to the measures used to describe trends in health experience. Whilst the in¯uence of rural residence per se is dicult to elucidate without recourse to data on individual life circumstances, including migration histories, and health status, very little detailed longitudinal data of this nature is available. In most instances researchers are faced with using cross sectional data to provide snapshots of urban±rural contrasts in health. In addition, in the absence of data relating to illnesses, researchers have often had to resort to using mortality data which may not necessarily be a good indicator of the general health of people living in rural areas. The use of statistical information relating to death in such studies is subject to a number of methodological reservations (see, for exam-

G. Higgs / Geoforum 30 (1999) 203±221

ple, Curtis and Taket, 1996; Chapter 4). The relatively small numbers of deaths in rural areas, especially from relatively rare causes, often precludes analysis at the small area level with any degree of statistical reliability and this has meant that researchers are faced with reaggregating areas or averaging data over time in order to statistically verify trends. The suggestion is that, in the absence of data relating to good health, trends in the self-reported limiting long-term illness variable from the 1991 Census of Population (Payne et al., 1996) or variations in survival from, for example, cancer (Monroe et al., 1992) which are not necessarily re¯ected in variations in mortality rates, could form more appropriate measures of poor health during the lifetime of rural populations. Only relatively recently have databases become available for some areas which could be potentially used to enhance such studies, for example GP morbidity databases, but these tend to be based on sample surveys and, to date, have not been used to address rural health issues per se. A third group of methodological problems relates to the exact nature of the deprivation measures used to link material factors with health trends. This draws attention to the need to control for the di€erences in urban and rural populations through measures of the socio-economic status of the population in order to evaluate the signi®cance, or otherwise, of the settings themselves. A number of the studies reviewed in this paper have proposed the use of deprivation indicators in this regard. However, there have been few attempts to incorporate rurality measures into such indicators and the types of variables used tend to re¯ect measures of urban, as opposed to rural, poverty (Dunn et al., 1998). For example, Townsend et al. (1988) found a weaker relationship between an index of deprivation, based on amongst other variables levels of car ownership, and health in rural areas. Phillimore and Reading (1992), in comparing urban and rural health, suggest that household tenure and car ownership di€erentials may be weaker discriminators of wealth in rural settings. The appropriateness, or otherwise, of such measures will also depend on the nature of the rural area, and may be a more suitable measure of deprivation in those rural areas which share similar socio-economic characteristics to small and large towns. In contrast, they may be unsuitable in measuring the circumstances of more rural, remote, areas where factors such as physical and social isolation and declining levels of service provision can form a major component of deprivation. This is compounded by the heterogeneous nature of deprivation in rural wards and more pro®table analysis could be performed on smaller spatial units (enumeration districts) or by grouping wards on the basis of similar material deprivation scores in order to get around the small number problems. Phillimore and Reading (1992; p. 296) have done this for wards in Northumberland and found

211

that Ôthe ostensibly weaker relationship between health and wealth in rural areas of the Northern Region, ..., is to great extent an artefact of the small populations of many rural wardsÕ. The indicators used to study the changing relationship between material deprivation and ill-health at the individual and area level have tended to be those derived from census variables which are biased towards urban areas (Townsend et al., 1988; Morris and Carstairs, 1991). EylesÕs (Eyles, 1987) more general critique of the use of area-based methods in such studies, can be seen to be even more applicable to rural areas, where disadvantage is much less likely to have distinct spatial manifestations and is more dispersed in nature. The use of crude indicators in ÔexplainingÕ health di€erentials in such settings is therefore particularly problematic (MacIntyre et al., 1993). Studies such as Cloke et al.Õs (Cloke et al., 1994) Rural Lifestyles research has shown that ÔhiddenÕ deprivation exists in the countryside and plainly this may have health implications for individuals living in such areas which cannot be gauged from areabased measures based on urban-biased census measures (Shucksmith et al., 1996a; Doogan et al., 1997). In such circumstances, it is important to ascertain whether trends in mortality by urban±rural breakdown are real and not an artefact of the methodology employed. Ideally those studies based ®rstly, on classifying wards and then secondly, on comparing mortality trends on the basis of average health outcomes for clusters of small areas should involve an analysis of the sensitivity of the results to minor modi®cations of the classi®cations. In summary, a number of methodological constraints need to be taken into account when comparing the health status of residents of rural and urban areas. At the most basic level this relates to the de®nition of rural employed; more problematic is the deprivation or socioeconomic classi®cation used to categorise areas which may have di€erent meaning when applied to rural settings. There is the inherent danger that spatial variations in health inequalities are purely an artefact of the methods used. Even accounting for such e€ects, however, the evidence does point to rural±urban di€erentials in some measures of health status. In the next three sections, a number of research strands are identi®ed from the existing literature which may go some way to explaining such trends. 3.2. Socio-economic changes in rural areas A number of researchers have stressed the importance of changes in socio-economic characteristics, and in particular the role of migration, on variations in health outcomes in rural areas. Given the well-rehearsed argument that socio-economic status has a signi®cant bearing on health di€erentials, any changes of this nature can be expected to have implications for health

212

G. Higgs / Geoforum 30 (1999) 203±221

outcomes. The in¯uence of di€erent population structures between urban and rural areas on health status has formed the basis for a number of studies in North America and the UK (e.g. Hayward et al., 1997; Mainous and Kohrs, 1995). However, there has been relatively little research on the implications of migration for patterns of health inequalities. Bentham (1984) examined mortality rates within di€erent types of rural area and found that SMRs were highest in the more remote rural areas of East Anglia and linked trends in mortality to socio-demographic trends in such areas and the relative inaccessibility to services such as surgeries in rural areas. In particular, rates of migration of young people and the consequent ÔageingÕ of the population structure at the district level led Bentham (1984; p. 224) to suggest that Ômortality rates tend to be highest and to be deteriorating most where population decline has been greatestÕ. Another factor in these trends could, in BenthamÕs view, be the tendency for those out-migrants from such areas to be more highly skilled, healthier and more socially mobile with consequent impacts on social class (and hence health) variations within rural areas. The importance of taking into account the age structures of migrants was emphasised by Bentham (1988) who found, amongst elderly groups, it was the unhealthy who were more inclined to move and consequently areas with high levels of out-migration of these groups were becoming healthier. Coggon et al. (1990) examined the implications of migration on patterns of mortality for stomach cancer and highlighted the need to consider the characteristics of the areas individuals migrate from as well as the characteristics of the migrants themselves. In addition the distance of migration may be a signi®cant factor in such variations, with longer distance migrants tending to have lower mortality levels (Britton, 1990). Evidence from Northern England, however, suggests that there are generally lower mortality rates in more rural, remote, communities (Phillimore and Reading, 1992). One plausible explanation relates to the nature of social networks in rural areas. Rural areas are perceived to have more supportive social networks than urban areas (Amato and Zuo, 1992). It can be postulated that within communities that are experiencing larger levels of inward migration, there may well be areas which have witnessed a breakdown in such relations ± possibly in tandem with changes in family structures ± which may, in turn, have implications in terms of health outcomes through a decline in the levels of social interaction. In contrast, rural areas that have witnessed lower rates of counter-urbanisation may well retain the traditional community values and social networks and may, in turn, be more advantaged in terms of health outcomes. The movement of the elderly, in particular, to larger towns within rural areas where medical services are often better could, perversely, lead to higher mortality and morbid-

ity levels in areas that are generally well served (Bentham, 1988). Previous analysis suggests that mortality levels for migrants are dependent, to a large extent, on the nature of the socio-economic conditions of the areas of residence and the characteristics of the individual migrants making generalisation more dicult. Research conducted in The Netherlands by Verheij et al. (1998), for example, emphasised the need to take into account the e€ect of selective migration on urban±rural health variations, by using longitudinal datasets to compare the health status of migrants with that of the populations that remain in urban or rural areas. Their results suggest that, after controlling for demographic and socio-economic characteristics, no signi®cant di€erences in health status existed between urban-out and urban-in migrants and that ÔstayersÕ are healthier than ÔmoversÕ. They also found variations in trends by age pro®les especially with regard to younger healthier age groups but, as they suggest, the absolute numbers of migrants needs to be very high if the implications of such trends are to be gauged from aggregate statistics. In summary, as Bentham (1984) suggests, the overriding result of migratory trends may well be to complicate the relationship between mortality and area of residence but more research is needed to see if these ®ndings are replicated in other geographical settings. Despite recent lifestyles based analysis in England (Cloke et al., 1994), Wales (Cloke et al., 1997) and Scotland (Shucksmith et al., 1996b), which has drawn attention to the nature of socio-economic changes in rural areas and recent texts which have examined the cultural and socio-political importance of migration into rural areas (e.g. Boyle and Halfacree, 1998), the impact of such trends on the health status of rural communities has remained a relatively under-researched theme. 3.3. Access and utilisation of primary and secondary health care A third avenue of research concerning urban±rural variations in health outcomes relates to contrasting accessibility to, and utilisation of, primary and secondary health care. A number of research projects have focused on the changing accessibility of residents in rural areas to hospitals (e.g. Haynes and Bentham, 1979a) and GPs (Williams et al., 1980). Such research has been particularly prevalent in North America, largely because of the large travelling distances involved, and has focused on the utilisation of services by rural and urban residents. Although rates were generally lower for people living in rural areas, Gesler and Ricketts (1992) highlight a number of studies in which the gap in utilisation rates were seen to be narrowing largely as a response to improvements in physician±population ratios and changes in health insurance coverage by rural residents. HaynesÕ (Haynes, 1991) study of variations in self-reported

G. Higgs / Geoforum 30 (1999) 203±221

morbidity and health service utilisation for di€erent socio-economic groups in di€erent areas of the UK, drew attention to the importance of such factors as access to private transport and the fact that poorer groups with lower levels of personal mobility were often at a disadvantage in terms of access to health services. It is widely recognised that there will be some commonality between the factors in¯uencing utilisation rates in both urban and rural contexts. Benzeval and Judge, for example, note the respective importance of health status, demographic and socio-economic factors (including factors such as car ownership) in determining hospital (Benzeval and Judge, 1994) and GP (Benzeval and Judge, 1996) utilisation rates. Such studies draw attention to the importance of taking into account factors such as the availability of health care facilities, the (in)ability of consumers of health care to pay for such services (Beck et al., 1996) and the failure to recognise that health care is needed (Comer and Mueller, 1995). Clearly, any comprehensive study of changing access to services will need to take on board such factors. This section considers the compounding in¯uence of distance on accessibility through variations in the availability of health services in rural contexts. The emphasis is on the role of physical access to facilities; the importance of more informal social networks and the compounding in¯uence of social isolation is considered later. There is a relatively wide ranging literature on the importance of changing access and utilisation of medical care in rural areas (see Fielder, 1981 and Moscovice, 1989 for reviews of the primary and secondary health sectors, respectively). Such studies have focused on the relationship between access to services and the utilisation of such services (or what Fielder refers to as the study of ÔpotentialÕ and ÔactualÕ utilisation respectively). Others have primarily focused on the relationship between access to health services for those physically and socially isolated groups living in remote rural areas and health outcomes. These suggest that the relationship between the provision of health care and health status is complicated by a whole host of factors besides distance, not least of which is the compounding in¯uence of variations in socio-economic conditions (see Joseph and Phillips, 1984, for a fuller review of such studies). The implication that health status for resident populations will improve with a concomitant improvement in health facility coverage clearly ignores the in¯uence of factors such as socio-economic status on health behaviour. Nevertheless, a number of studies have been carried out which provide evidence for the importance of studying the impacts of declining provision of primary and secondary care on potentially vulnerable social groups in rural areas. Much of this research has focused on North America where the disparities between urban and rural areas in terms of the supply of physicians, and the fact that fewer alternatives are available within rural

213

areas, has formed the basis for a number of studies into rural health care provision (Fielder, 1981). Joseph and Bantock (1984), for example, noted a widening disparity of access in Ontario, Canada during the period 1901± 1981 as a result of the increasing centralisation of general practitioners services into larger villages and towns and away from smaller hamlets and villages. This, they suggested, could be accounted for, to a certain extent, by the redistribution of rural populations, the increased mobility of residents of rural areas through access to private transport and changes in health care delivery itself. Contrary to this, Comer and Mueller (1995) found, through interviews with 6000 residents in a variety of urban and rural settings in Nebraska, that rural residents reported more visits to physicians such that the relationship between access and distance in this particular state did not mirror national surveys. This led the researchers to suggest that, Ôif anything, rural areas have greater access, and this is true when variations in health status is taken into considerationÕ (Comer and Mueller, 1995; p. 133). This, in turn, highlighted the importance of taking into account the localised nature of urban± rural di€erences in health status, incomes and health insurance ± each of which can contribute to problems of access. Such ®ndings may also mask problems in areas which have experienced a shortage of physicians. Furuseth (1998) has reviewed a number of studies from the United States which have shown that closures in rural hospitals and clinics especially in the late 1980s has led to restricted access to health facilities for rural vis-a-vis urban residents. Where distances to care are greater (as in some rural areas), access to these services is likely to be an important in¯uencing factor on health care utilisation (Joseph and Phillips, 1984). Although as Fielder (1981, p. 129) suggests Ôaccess is not to be equated with the use of servicesÕ, di€erences in health service utilisation need to be considered in the light of accessibility issues. The problem faced by researchers in this ®eld is to try to develop measures of accessibility to such services. Ideally, we would require time series data at the individual patient level relating to utilisation patterns for primary and secondary health care. Such data is lacking for large areas, so that researchers are often faced with using alternative measures. However, there are methodological problems with using data such as consultation rates, for example, in order to establish the signi®cance of such factors. Doogan et al. (1997), for example, noted low rates for a rural county in Wales (Powys) but suggests that low attendance at a GP clinic in rural areas could, in theory, be symptomatic of a healthy society or alternatively could suggest that some residents in such areas have lower than average accessibility to GPs depending on factors such as availability of services, the perceived quality of the service provided and access to private transport opportunities. The impacts of the

214

G. Higgs / Geoforum 30 (1999) 203±221

closure of some branch surgeries in mid-Wales and the move towards larger, and fewer, practices and the resultant impacts on health care utilisation, remains a relatively under-researched theme (see Section 4). Poorer access to facilities in more remote areas may well account for the relationships between mortality trends and ÔremotenessÕ (Bentham, 1984; Bentham and Haynes, 1985). Previous studies have drawn attention to the importance of distance in in¯uencing demand for primary health services by exploring the signi®cance of distance as a barrier to care in rural areas (e.g. Parkin, 1979; Haynes and Bentham, 1982; Joseph and Bantock, 1982). Jones et al. (1998), for example, noted a decline in consultation rates with distance away from a surgery for self-reported asthmatics in rural Norfolk. Hicks (1990) suggests, using US case study data, that lower utilisation rates for health services cannot necessarily be explained by di€erences in health status between urban and rural areas and that there are other factors that may be important in accounting for variations in such rates. Zijtho€ et al. (1994) explore a number of factors which may be of signi®cance in determining health service utilisation. These include the nature of social and informal networks, varying attitudes to doctors, occupational status and the levels of social support, in addition to the role of distance. Similar trends have been found with regard to access to hospitals (e.g. Haynes and Bentham, 1979b) with distance acting as an inhibiting factor in the use of hospital services. Although such studies stress the need to take into account contributory factors other than distance (such as income, education, employment status, age, gender, individual perceptions and the scope of services provided by hospitals) when accounting for the use of medical facilities, a number have noted distinct urban±rural di€erences in geographical accessibility. Love and Lindquist (1995), for example, found access to hospitals o€ering geriatric services di€ered substantially for the elderly population that lived outside metropolitan statistical areas in the state of Illinois. Walsh et al. (1997) similarly found that residents of some rural areas in North Carolina were ÔunservedÕ by existing hospitals. Jones and Bentham (1997), in a study of deaths from asthma in England and Wales (1988±1992) at the LA district level, note that, after controlling for socio-economic status, there was a tendency for mortality to rise with distance from hospitals. As Watt et al. (1994, p. 18) suggest however, Ô(w)hat is not clear from the studies is the degree to which decreased use of primary care with increasing distance represents unmet needÕ. There has been relatively less research on the implications of access to, or provision of, health services on health status. With respect to the former, Bentham and Haynes (1985) studied the relationship between health outcomes and distance from facilities and found a low level of take-up of health facilities with distance. In

particular an examination of the rates of GP consultation revealed that Ôpersonal mobility a€ects the use of GP services in a rural area, in addition to the e€ect of remoteness in the services themselves (Bentham and Haynes, 1985; p. 236). Certain groups within such communities, namely the elderly, unemployed and those without access to a car will thus be di€erentially disadvantaged and have the lowest consultation rates (Haynes and Bentham, 1982; Evans and Neate, 1986; Haynes, 1991; Watt et al., 1994). Kohrs and Mainous (1996) have explored the relationship between health status and areas underserved in terms of primary care physicians and found no signi®cant di€erences in health status for a survey of residents in medically underserved areas (MUAs) compared with those of non-shortage areas in Kentucky. In contrast to studies which have focused on the potential impacts of the quantity and spatial location of medical services for health outcomes, few researchers have analysed the impacts of variable quality of provision in rural areas (Watt et al., 1994). As Monroe et al. (1992, p. 219) suggest in relation to cancer studies, Ô(R)esearchers should attempt to unravel the relationship between geographic access to specialised cancer care, including cancer prevention activities, and cancer outcome in order to detect emerging di€erences in health status of rural populations that may be associated with inferior accessÕ. Doogan et al. (1997) noted lower than average cancer registration rates for both men and women in a predominantly rural health authority in Wales as well as a higher rate of death from breast and colorectal cancer. This, in turn, raises important concerns regarding access to specialist cancer units. Do residents of rural areas Ôhave less access to, or utilisation of, early cancer detection programs than their urban counterpartsÕ ? (Monroe et al., 1992; p. 219). If so, to what extent can variations in such programs, over and above the variations in take-up by the di€erent socioeconomic status of patients, account for spatial trends in survival rates ? Research has been carried out in the United States to examine the relationship between such factors as the stage of disease at diagnosis for cancers and the availability of screening programs, and di€erential accessibility to health facilities (see, for example, Li€ et al., 1991). Greenberg (1984) used a study of cancer mortality rates in rural America to suggest that survival rates in urban areas had improved relative to rural areas partly as a result of di€erential access to facilities as well as a convergence of risk enhancing factors. Another research question relates to the precise role played by the availability of, and access to, information (Giarchi, 1990). Evidence from studies of breast cancer screening rates in rural America are mixed. Monroe et al. (Monroe et al., 1992) review of the published literature found no discernible di€erences in breast cancer

G. Higgs / Geoforum 30 (1999) 203±221

screening rates. Bentham et al. (1995) examined the factors a€ecting the non-response to cervical screening programs in Norfolk including a measure of physical isolation based on distance from a doctorÕs surgery and access to a bus route. The incorporation of this rural remoteness indicator was not seen, however, to be statistically signi®cant leading the researchers to suggest that factors such as the absence/presence of a female GP in the practice, the nature of the practice itself and deprivation levels of the areas in which patients reside were of more importance in determining rates of uptake. Further research, using network analysis in a Geographical Information System (GIS) framework has re®ned such analysis by taking into account patient distribution, hospital or GP characteristics, and transport/network information to measure accessibility and to model the implications of changes in the healthcare delivery system (Hirsch®eld et al., 1995; Love and Lindquist., 1995; Walsh et al., 1997). Such techniques allow researchers the potential to address cross-boundary ¯ows of patients to health facilities but are highly dependent on accurate data on service provision being made available at a suitably disaggregate level. In addition, to provide a fully comprehensive picture, information is also required on the quality of provision available to residents of rural areas. This theme is returned to in Section 4. 3.4. Lifestyle and behavioural factors A fourth strand of research is concerned with investigating the role of lifestyle or behavioural factors, such as diet, smoking and lack/absence of exercise, on di€erences in health outcomes. In contrast to some of the research strands identi®ed above, the analysis of lifestyle trends in rural areas, and their implications for health status of rural residents, remains a relatively under-researched theme. Only recently, as the importance of such factors have become acknowledged, have some of the datasets needed to explore the signi®cance of lifestyle factors in rural contexts been created. An example is the 1984/85 Health and Lifestyle Survey of England, Wales and Scotland, a survey of 9000 people in a range of social and environmental settings in which respondents were asked about their health and lifestyles and their attitudes towards health, although the survey had no information, for example, on the use of health services (Blaxter, 1990). Preliminary analysis from this study seemed to suggest that in Ôrural/resort areasÕ, perceived illness was lower across most age/sex groups for all social classes and that health di€erences between classes were small. Furthermore, an analysis by regional breakdowns revealed insigni®cant di€erences between rural areas, suggesting that Ôrural areas were equally healthy, whether in the North or SouthÕ (Blaxter, 1990, p. 86). Behavioural patterns were then compared for

215

rural and urban areas in order to try to partly account for such trends. One of the overall conclusions was that the broad socio-economic circumstances and the external environment, as well as the psychosocial well-being of individuals, are more signi®cant determinants of health than healthy (or unhealthy) behaviours. The challenge for researchers is to try to measure the extent to which variations in such circumstances are contributing to trends in rural±urban health di€erentials. The majority of published research in this area, to date, is available from North America. GreenbergÕs (Greenberg, 1987) study, for example, in the United States seems to contradict the perception of better health-related behaviours in rural areas. His analysis of di€erences in behavioural risk factors between individual respondents in four states, categorised by those living in predominantly urban, moderately urban and rural counties, revealed that urban±rural contrasts in the four factors under consideration (smoking, obesity, hypertension and sedentary lifestyles) were small, and that Ôwhen there are di€erences they usually indicate better behavioural practices in urban areasÕ (Greenberg, 1987; p. 148). As Greenberg emphasises it is important to take into account factors such as age and occupation within such settings and future changes in social pro®les as a result of population migration. This work also drew attention to the importance of factors such as the level of educational attainment in partly in¯uencing such trends in behavioural risk patterns. However, the greater risk for the younger (18±34) age groups in rural states, especially for males, led Greenberg (1987, p. 149) to suggest that should these di€erences widen further then Ôurban/rural di€erences in chronic diseases among males will tilt in favour of lower rates in urban areasÕ. As if to reiterate GreenbergÕs concerns with taking into account the unique set circumstances of rural areas within individual studies, however, Johnson et al. (1995) found, in a study of health-promoting behaviour in Canada that, after controlling for such factors as age, sex, income and education, residents of rural areas were more likely to engage in some types of healthier behaviour than those of large cities. For others, for example smoking rates, there appeared no signi®cant di€erence between residents in such settings. BlaxterÕs (Blaxter, 1990) analysis of dietary trends based on speci®c food habits revealed that, contrary to the perceived notion that residents of rural areas have better diets, there were di€erent trends according to age, sex and social class with non-manual men in the 40±59 age group in Ôrural/resortÕ areas, for example, having poorer diets on these criteria. There were no signi®cant di€erences between rural and urban areas for females however. One set of contributory factors to a poor diet in some rural areas may be the lack of access to particular types of food. The decline in village shops and reduced public transport provision evident in the

216

G. Higgs / Geoforum 30 (1999) 203±221

various Rural Development Commission (1992, 1995) surveys could further impact on such dietary trends. Research in Scotland suggests that people in remote communities, especially those lacking private transport, were not in a position to improve their diet (Clark et al., 1995). Factors such as lower disposable income, lack of access to certain fresh goods, higher food costs, etc. were all seen to impact on the dietary patterns of individuals. Guy (1991), however, found no signi®cant di€erence in the availability of ÔhealthyÕ food between stores in rural regions of Wales when compared to urban areas although there was evidence to suggest that shoppers in the latter would need to travel further to access the widest range of groceries. With regard to prices, his research suggested that, after accounting for types of store, there was no major regional variations in the price of food items between urban and more remote areas. Clearly, the ®ndings from this research needs to be replicated in other rural areas prior to generalisation, especially in the light of more recent changes such as the decline in the provision of shops noted above. The implications of such changes on dietary behaviour, however, remains a relatively under-researched theme in rural health studies (see Section 4). One of the few studies carried out, to date, which has looked at the relationship between urban±rural residence and obesity levels in the United States, seems to suggest that any di€erence in the relative weight of people in rural and urban areas could be explained by di€erences in sociodemographic pro®les, although there was some evidence that residents of rural areas were more likely to be overweight than their urban counterparts (Sobal et al., 1996). This, in the view of the researchers, would provide some credence to the importance of the composition perspective noted in previous studies. Clearly, this research needs to be extended to see how replicable such ®ndings are to other social groups and rural settings in order to fully examine the underlying behavioural determinants of such trends and the implications of, for example, migration patterns on urban±rural variations. Another behavioural factor is the prevalence of smoking. Schneider and Greenberg (1992) put forward the higher smoking rates in rural areas as one reason why there were higher rates of cancer and heart disease in rural areas of the United States. GreenbergÕs study (1987) suggests that there are important age and gender di€erences to take into account in studies of smoking rates in that, for example, elderly women in rural states were seen to smoke less than women of a similar age category in urban states. However, the di€erences in rates between females in younger age groups were not statistically signi®cant. Evidence from the Health and Lifestyle Survey suggests that similar trends exist in the UK with generally higher smoking rates in urban areas but with stronger class di€erences for women in rural areas.

In summary, the close match between the distribution of unhealthy behaviour such as high smoking rates, poor diet and alcohol consumption, and deprivation levels as evidenced for example, in a study of health variations in Cornwall (Payne et al., 1996), would seem to highlight the need to take into account lifestyle factors. In the past, such studies have been hampered by a lack of suitable data sets with which to assess variations in dietary, smoking and exercise patterns. The best estimates of these factors, at present, could be through the use of sample surveys of lifestyles such as those coordinated by Health Promotion Wales (Health Promotion Wales, 1998). However, this does require some measure of rurality to be added to the sample data so that any variations between urban and rural areas can be examined. The importance of enhancing these data sets in order to fully examine health variations is explored in more detail in the next section. 4. A rural health research agenda Curtis and Jones (1998) explore a number of alternative theoretical perspectives on health and space which could be used to explore contextual e€ects in studies of health inequalities in di€erent geographical settings. They describe the advantages of using a combination of theoretical approaches in order to account for such e€ects. Furthermore, they go on to use these theoretical frameworks to describe the health advantages and disadvantages of living in rural areas in relation to four alternative landscape perspectives (ecological, materialist, consumption and therapeutic). For example, theories of landscapes of consumption and materialist landscapes could form the basis of a strand of research based on identifying the implications of reductions in health facilities and a withdrawal of public transport opportunities in rural areas, and their relationship to health variations (Curtis and Jones, 1998; p. 665). The aim here is to adopt some of these theoretical frameworks in order to describe a number of strands of research which would appear worthy of further study given the gaps in the literature identi®ed in the previous section. Many of these are clearly inter-related, for example, the need to study the relationship between socioeconomic status and access to, and utilisation of, health care, or the relationship between psychosocial factors and socio-economic status through, for example, studies of behavioural or lifestyle trends. The exact nature of many of these linkages has formed the basis for numerous wide ranging studies of socio-economic di€erentials in health (see, for example, Williams, 1990). In this paper, I am speci®cally concerned with trying to elucidate the types of factors that are uniquely in¯uencing the health status of residents of rural areas by

G. Higgs / Geoforum 30 (1999) 203±221

proposing a research agenda whereby this work could be taken forward. This needs to tie in at least two main strands of literature. Firstly, evidence from locality based studies and the lifestyles research alluded to earlier suggests that the types of socio-economic changes that are taking place in rural areas may well impact on the nature of social and community networks in rural areas. In particular, it can be postulated that one of the main outcomes of migration trends, such as the movement of (mainly younger) family members out of rural areas, has been to erode such ties and to increase the levels of social isolation felt by longer stay residents of such areas. This, in turn, can be related to a second broad literature which has looked at the importance of social ties and networks in terms of health outcomes and has investigated the impacts of psychosocial factors on health (e.g. Williams, 1990; Wilkinson, 1996). More research is needed to assess the importance of such factors in rural areas, given that in WilkinsonÕs view Ôpsychosocial factors provide the primary links between material disadvantage and healthÕ ? (Wilkinson, 1996; p. 164). Trends in rural areas could provide an ideal Ôtest-bedÕ for such theories especially given the types of socio-economic restructuring that have been documented in the previous section. The impacts of such trends on perceived levels of social support and their subsequent impact on health status remains very much an under-researched theme. The bene®cial impacts on health of increased social contact and support was highlighted by Wilkinson as being a key component of psychosocial in¯uences. The same sets of factors are often cited to help explain lower mortality rates in rural areas (Smith et al., 1995). In such contexts, an important research strand relates to the impacts of changing social integration in rural areas on health outcomes especially through their in¯uence on social networks. Previous research has emphasised the need to take into account variations in health status within rural communities. A study in rural Cornwall found di€erences in health status were linked to socio-economic characteristics of communities but also demonstrated the in¯uence of factors which may be unique to living in a rural area (Payne et al., 1996). Interesting comparisons could be made between the health status of areas, such as Cornwall, which have proportionately large numbers of (largely elderly) in-migrants, and other rural areas which have not experienced such levels of counterurbanization, in order to gauge the impacts of these socio-demographic factors. The relative in¯uence of socio-economic restructuring on health trends vis- a-vis that due to changes in material circumstances or declining service provision (in particular access to GPs or hospitals) should form the basis of future research initiatives in this area. Previous research has also highlighted distinct di€erences in health status in rural areas in relation to

217

gender, for example in studies in the United States (Beck et al., 1996), and further research is required to see if such ®ndings are replicated in other rural settings. Another research strand concerns the need to account for urban±rural variations in health outcomes in relation to lifestyle and behavioural patterns in order to establish the importance of di€erences in lifestyle determinants of health in rural and urban settings. Are there, for example, speci®c aspects of living in a rural area, over and above that of individual household lifestyle experiences, that could account for such trends? Previous research has alluded to the linkages between health status and unhealthy lifestyles (e.g. poor diet, smoking, alcohol abuse) in both urban and rural contexts. However, there may be factors that are unique to rural areas, which present diculties for health promotion agencies faced with modifying such behaviour. There may well be unique sets of circumstances which are in¯uencing such patterns in rural areas (e.g. the centralisation and rationalisation of public services, changes in primary care delivery, demographic, cultural and economic trends). Some potentially useful surveys have been conducted regarding the health status of the population which could be used in this regard ± for example the 1995 Welsh Health Survey which was used to gather information for a sample of 28,000 individuals on diagnosed illnesses, perceived health status and lifestyle circumstances (Welsh Oce, 1996). The addition of some measure of ÔruralityÕ for individual cases would enable the breakdown of such trends by geographical setting. However, limited comparisons can be made regarding urban±rural trends because data has been presented for health authority areas and not disaggregated to ®ner spatial scales. More work is also needed to examine urban±rural di€erentiation in cancer rates and to relate such trends to, for example, behavioural and environmental factors. Are there other risk-enhancing, or alternatively health promoting, lifestyles in urban areas, for example? There is a relative lack of information, certainly within the UK, on dietary trends in rural areas in relation to, for example, changing access to village shops and declining public transport opportunities. Another research question relates to the extent to which limited access to leisure opportunities by some member of rural communities contributes to health outcomes. Rural populations are often assumed to be potentially healthier given access to outdoor recreational opportunities, but there may be a whole host of factors which may limit the take-up of such facilities. Following on from such concerns, another broad range of research questions relates to future trends in rural services. There is evidence from rural Wales, for example, that rural areas are facing a shortage of doctors, dentists, pharmacists and nurses (Western Mail, 1998). Whilst some of the contributory factors

218

G. Higgs / Geoforum 30 (1999) 203±221

in¯uencing such trends are reasonably well known (Macleod, 1995), the implications, if any, for the health experiences of rural residents are worthy of further study. In relation to primary and secondary care delivery, a number of other research questions need to be addressed to examine the health implications of increasing centralisation and specialisation in GP provision into larger villages and towns within rural areas, the health implications of closing branch surgeries (even for those with basic facilities) and rural hospitals or reducing the range of services provided and the relationship between the shortage of some primary care services and health status in rural areas. Furthermore, the impacts of changes in the provision of such services may interact with the types of socio-economic processes taking place in rural areas to complicate the overall picture of health status. Recently, some research has been conducted which has evaluated the impacts of new developments in health care delivery, such as trends in telemedicine and telehealth, on the improvement of rural health care services (Preston et al., 1992) and an extension of this research to other rural settings could well prove pro®table. 5. Conclusions Research, much of which is reviewed in this paper, suggests that urban±rural di€erentials in health patterns are worthy of further study. Studies, to date, have stressed the importance of taking into account the exact nature, settings and socio-economic circumstances of individuals and households before extrapolation to other rural areas. Against this, is the perceived notion that rural areas are inherently much healthier places to live than urban areas. Such a notion, as evidenced, in this paper is far too simplistic in that, for some measures of health status, the well-rehearsed trends in health advantage are actually reversed. Even after accounting for social disadvantage, such groups are at a health disadvantage compared to residents of urban areas. Such ®ndings, in addition to the types of methodological problems highlighted in Section 3 of the paper, have led some to suggest that, Ô(I)nadequate research makes it dicult to say whether country people on the whole are healthier or less healthy than their urban counterpartsÕ (Simmons, 1997; p. 82) There is a need for more in-depth studies within predominantly rural areas along the lines of that conducted in West Cornwall (Payne et al., 1996) and rural Norfolk (Bentham et al., 1993). Both these studies concluded that a more pro®table research angle would be to look at di€erences within rural areas, for example in relation to health care utilisation, in order to try to

elucidate why di€erences between a‚uent and deprived groups exist within such communities and to try to alleviate such disparities. This recognises that there are a complex set of inter-related factors that are contributing to overall health status and that any study of this nature needs to control for variations in the socio-demographic pro®le of these areas. A primary aim of this paper has been to try to identify, through an exploration of the relevant literature, a number of research stands that are worthy of further study. Although, this is by no means a complete agenda, by brie¯y reviewing the current status of health research in rural areas and by drawing attention to gaps in our knowledge, the aim has been to ®rstly, pose a number of research questions which would seem to be worthy of addressing in any comprehensive study of health inequalities and secondly, to provoke discussion on the determinants of health status in rural areas. As this review has illustrated much work has been carried out by medical geographers, amongst others, to provide evidence for the spatial patterns and inequalities evident in the urban±rural continuum, less on trying to account for such trends. More research is needed to establish the types of factors that are unique to rural areas that may be impacting on health experience and health status. Studies from North America suggest there are signi®cant di€erences in perceptions of health status between the urban and rural poor, with the latter reporting a lower level of health than the former even after accounting for di€erences in factors such as age, sex and employment status (e.g. Amato and Zuo, 1992). Tentative explanations for these trends were suggested in terms of poorer access to facilities and the social stigma associated with poverty in rural areas. Despite this, the authors caution against misinterpreting these results ± there were no signi®cant di€erences, for example, in the levels of depression or happiness between the urban and rural poor. Clearly, more research needs to be undertaken to see how replicable these results are to other urban±rural settings. The current economic trends that are severely impacting on some groups in rural communities and the consequent social stress caused by factors such as lack of job security, recent trends in the agricultural industry, low wage levels and inaccessible housing opportunities, has raised the pro®le of rural health issues. Wide ranging health studies to address some of the research questions posed in this paper would, therefore, appear to be particularly timely and long overdue. References Acheson Report, 1998. Report of the Independent Inquiry into Inequalities in Health, Chaired by Sir Donald Acheson. The Stationary Oce, London.

G. Higgs / Geoforum 30 (1999) 203±221 Amato, P.R., Zuo, J., 1992. Rural poverty, urban poverty and psychological well-being. The Sociological Quarterly 33 (2), 229±240. Beck, R.W., Jijon, C.R., Edwards, J.B., 1996. The relationships among gender, perceived ®nancial barriers to care, and health status in a rural population. Journal of Rural Health 12 (3), 188±196. Bentham, C.G., 1984. Mortality rates in the more rural areas of England and Wales. Area 12, 219±226. Bentham, C.G., 1988. Migration and morbidity: implications for geographical studies of disease. Social Science and Medicine 26, 49±54. Bentham, C.G., Haynes, R., 1985. Health, personal mobility and the use of health services in rural Norfolk. Journal of Rural Studies 1 (3), 231±239. Bentham, C.G., Gale, S., Haynes, R., Lovett, A., Brainard, J., 1993. Analysis of small area statistics on morbidity, mortality and deprivation for resource allocation in East Anglia. Health and Environment Research Group Working Paper. School of Environmental Science, University of East Anglia, Norwich. Bentham, C.G., Hinton, J., Haynes, R., Lovett, A., Bestwick, C., 1995. Factors a€ecting non-response to cervical cytology screening in Norfolk, England, Social Science and Medicine 40 (1), 131±135. Benzeval, M., Judge, K., 1994. The determinants of hospital utilisation: Implications for resource allocation in England. Health Economics 3, 105±116. Benzeval, M., Judge, K., 1996. Access to health-care in England ± continuing inequalities in the distribution of GPs. Journal of Public Health Medicine 18 (1), 33±40. Blaxter, M., 1990. Health and Lifestyles. Tavistock, London; Routledge & Kegan Paul, London. Boyle, P., Halfacree, K. (Eds.), 1998. Migration into Rural Areas: Theories and Issues. Wiley, Chichester. Britton, M., 1990. Geographic variation in mortality, 1979±83. In: Britton, M. (Ed.), Mortality and Geography, OPCS Series DS No. 9. HMSO, London, pp. 17±26. Britton, M., Fox, A.J., Godblatt, P., Jones, D.R., Rosato, M., 1990. The in¯uence of socio-economic and environmental factors on geographic variation in mortality. In: Britton, M. (Ed.), Mortality and Geography, OPCS Series DS No. 9. HMSO, London, pp. 57± 78. Butler, M.A., 1990. Rural±urban continuum codes for metro and nonmetro counties, AGES 9028, US Department of Agriculture. Carr-Hill, R., Sheldon, T., 1992. Rationality and the use of formulas in the allocation of resources to health care. Journal of Public Health Medicine 14 (2), 117±126. Charlton, J., 1995. Trends and patterns in suicide in England and Wales. International Journal of Epidemiology 24 (1), S45±S52. Charlton, J., 1996. Which areas are the healthiest? Population Trends 83, 17±24. Charlton, J.R., Murphy, M. (Ed.), 1997. The Health of Adult Britain 1841±1994, DS No. 12. H.M.S.O. London. Charlton, J., Wallace, M., White, I., 1994. Long term illness: results from the 1991 Census. Population Trends 75, 18±25. Clark, G., MacLellan, M., McKie, L., Skerratt, S., 1995. Food availability and food choice in remote and rural areas. Health Education Board for Scotland, University of Aberdeen. Cli€ord, W.B., Brannon, Y.S., 1985. Rural-urban di€erentials in mortality. Rural Sociology 50 (2), 210±224. Cli€ord, W.B., Miller, M.K., Stoker, C.S., 1986. Rural±urban di€erences in mortality in the United States, 1970±1990. In: Jahr, D., Johnson, W., Wimberly, R.C. (Eds.) New Dimensions in Rural Policy: Building Upon our Heritage. US Government Printing Oce, Washington, DC, pp. 63±70. Cloke, P., 1977. An index of rurality for England and Wales. Regional Studies. 11, 31±46. Cloke, P., Milbourne, P., Thomas, C., 1994. Lifestyles in rural England. A Research Report to the Department of the Environment and the Economic and Social Research Council and the Rural Development Commission.

219

Cloke, P., Goodwin, M., Milbourne, P., 1997. Rural Wales: Community and Marginalization. University of Wales Press, Cardi€. Coggon, D., Osmond, C., Barker, D.J.P., 1990. Stomach cancer and migration within England and Wales. British Journal of Cancer 61, 573±574. Comer, J., Mueller, K., 1995. Access to health care: Urban±rural comparisons from a Midwestern agricultural state. Journal of Rural Health 11 (2), 128±136. Congdon, P., 1995. The impact of area context on long term illness and premature mortality: an illustration of multi-level analysis. Regional Studies 29 (4), 327±344. Cox, J., 1995. Rural general practice in the United Kingdom. Occasional Paper 71. The Royal College of General Practitioners, London. Curtis, S., Jones, I.R., 1998. Is there a place for geography in the analysis of health inequality? Sociology of Health and Illness 20 (5), 645±672. Curtis, S., Taket, A., 1996. Health and Societies: Changing Perspectives. Arnold, London. Dahlgren, G., Whitehead, M., 1991. Policies and Strategies to promote social equity in health. Institute of Futures Studies, Stockholm. Department of Health, 1998. Our healthier nation: A contract for health. The Stationary Oce, London. Dolk, H., Mertens, B., Kleinschmidt, I., Walls, P., Shaddick, G., Elliott, P., 1995. A standardisation approach to the control of socio-economic confounding in small area studies of environment and health. Journal of Epidemiology and Community Health 49 (2), S9±S14. Doll, R., 1991. Urban and rural factors in the etiology of cancer. International Journal of Cancer 47 (6), 803±810. Doogan, K., Gordon, D., Payne, S., Smith, R., 1997. Rural deprivation in Powys: the European context. School for Policy Studies, University of Bristol. Dorling, D.F., 1995. A New Social Atlas of Britain. Wiley, Chicester. Dorling, D.F., 1997. Death in Britain: how local mortality rates have changed: 1950s to 1990s. Report to the Joseph Rowntree Foundation. Drever, F., Bunting, J., 1997. Patterns and trends in male mortality. In: Drever, F., Whitehead, M. (Eds.), Health Inequalities, Series DS No. 15. H.M.S.O. London, pp. 95±107. Drever, F., Whitehead, M., 1995. Mortality in regions and local authority districts in the 1990s: exploring the relationship with deprivation. Population Trends 82, 19±26. Dudley, M., Kelk, N., Florio, T., Howard, J., Waters, B., Haski, C., Alcock, M., 1997. Suicide among young rural Australians 1964± 1993: a comparison with metropolitan trends. Social Psychiatry and Psychiatric Epidemiology 32 (5), 251±260. Duncan, C., Jones, K., Moon, G., 1998. Context, composition and heterogeneity: using multi-level models in health research. Social Science and Medicine 46 (1), 97±117. Dunn, J., Hodge, I., Monk, S., Kiddle, C., 1998. Developing Indicators of Rural Disadvantage. Rural Research Report No. 36. Rural Development Commission, London. Evans, D., Neate, S., 1986. Policies for access to health care and their outcome in Leicestershire. In: Lowe, P., Bradley, T., Wright, S. (Eds.), Deprivation and Welfare in Rural Areas. Geobooks, Norwich, pp. 213±225. Eyles, J., 1987. The Geography of the National Health. Croom Helm, London. Fearn, R., 1987. Rural health care: a British success or a tale of unmet need? Social Science and Medicine 24, 263±274. Fielder, J.L., 1981. A review of the literature on access and utilisation of medical care with special emphasis on rural primary care. Social Science and Medicine 15, 129±142. Furuseth, O., 1998. Service provision and social deprivation, Chapter 11. In: Ilbery, B. (Ed.), The Geography of Rural Change. Longman, Harlow.

220

G. Higgs / Geoforum 30 (1999) 203±221

Giarchi, G., 1990. Distance decay and information deprivation: health implications for people in rural isolation. In: Abbott, P., Payne, G. (Eds.), New Directions in the Sociology of Health. Falmer, London, pp. 57±69. Gesler, W.M., Hartwell, S., Ricketts, T.C., Rosenberg, M.W., 1992. Introduction. In: Gesler, W.M., Ricketts, T.C. (Eds.), Health in Rural North America. Rutgers Univ. Press, London, pp. 1±22. Gesler, W.M., Ricketts, T.C. (Eds.), 1992. Health in Rural North America. Rutgers Univ. Press, London. Greenberg, M.R., 1983. Urbanisation and Cancer Mortality. Oxford Univ. Press, New York. Greenberg, M.R., 1984. Changing cancer mortality patterns in the rural United States. Rural Sociology 49, 143±153. Greenberg, M.R., 1987. Urban/rural di€erences in behavioural risk factors for chronic diseases. Urban Geography 8 (2), 146±151. Guy, C.M., 1991. Urban and rural contrasts in food prices and availability ± a case study in Wales. Journal of Rural Studies 7 (3), 311±325. Hale, Rita and Associates, 1996. Fair shares for rural areas? an assessment of public resource allocation systems. Rural Research Report No. 22. Rural Development Commission, London. Hartley, D., Quam, L., Lurie, N., 1994. Urban and rural di€erences in health insurance and access to care. Journal of Rural Health 10 (2), 98±108. Haynes, R., 1991. Inequalities in health and health service use: evidence from the General Household Survey. Social Science and Medicine 33 (4), 361±368. Haynes, R., Bentham, G., 1979a. Community hospitals and rural accessibility. Saxon House, Farnborough. Haynes, R., Bentham, G., 1979b. Accessibility and the use of hospitals in rural areas. Area 11, 186±191. Haynes, R., Bentham, G., 1982. The e€ects of accessibility on GP consultations; out patient attendanceÕs and in-patient admissions in Norfolk, England. Social Science and Medicine 16, 561±569. Hayward, M.D., Pienta, A.M., McLaughlin, D.K., 1997. Inequality in menÕs mortality: the socio-economic status gradient and geographic context. Journal of Health and Social Behaviour 38 (4), 313±330. Health Promotion Wales, 1998. Lifestyle changes in Wales: results from the Health in Wales survey, 1985±1996. Technical Report No. 27. HPW, Cardi€. Health Services Research, 1989. Special Issue: a rural health services research agenda 23 (6). Hewitt, M., 1992. De®ning Rural areas: impact on health care policy and research. In: Gesler, W.M., Ricketts, T.C. (Eds.), Health in Rural North America. Rutgers Univ. Press, London, pp. 25±54. Hicks, L.L., 1990. Availability and accessibility of rural health care. The Journal of Rural Health 6 (4), 485±505. Higgs, G., Senior, M., Williams, H., 1998. Spatial and temporal variation of mortality and deprivation. I Widening health inequalities.. Environment and Planning A 30, 1661±1682. Hirsch®eld, A., Brown, P.J.B., Bundred, P., 1995. The spatial analysis of community health services on Wirral using Geographic Information Systems. Journal of the Operational Research Society 46, 147±159. Howe, G.M., 1981. Mortality from selected malignant neoplasms in the British Isles: The spatial perspective. Social Science and Medicine 15, 199±211. Howe, H.L., Keller, J.E., Lehnherr, M., 1993. Relation between population density and cancer incidence, Illinois, 1986±1990. American Journal of Epidemiology 138 (1), 29±36. Ilbery, B., 1998. Dimensions of rural change, Chapter 1. In: Ilbery, B. (Ed.), The Geography of Rural Change. Longman, Harlow. Johnson, J.L., Ratner, P.A., Bottor€, J.L., 1995. Urban±rural di€erences in the health-promoting behaviours of Albertans. Canadian Journal of Public Health 86 (2), 103±108.

Jones, A.P., Bentham, C.G., 1997. Health service accessibility and deaths from asthma in 401 local authority districts in England and Wales, 1988±1992. Thorax 52 (3), 218±222. Jones, A.P, Bentham, G., Harrison, B.D.W., Jarvis, D., Badminton, R.M., Wareham, N.J., 1998. Accessibility and health service utilisation for asthma in Norfolk, England. Journal of Public Health Medicine 20 (3), 312±317. Jones, I., Curtis, S., 1998. Health Chapter 9. In: Pacione, M. (Ed.), BritainÕs Cities: Geographies of Division in Urban Britain. Routledge & Kegan Paul, London. Joseph, A.E., Bantock, P.R., 1982. Measuring potential physical accessibility to general practitioners in rural areas: a method and case study. Social Science and Medicine 16, 85±90. Joseph, A.E., Bantock, P.R., 1984. Rural accessibility of general practitioners: the case of Bruce and Grey Counties, Ontario, 1901± 1981. Canadian Geographer 28, 226±239. Joseph, A.E., Phillips, D.R., 1984. Accessibility and Utilisation: Geographical Perspectives on Health Care Delivery. Harper & Row, New York. Kelly, S., Charlton, J., Jenkins, R., 1995. Suicide deaths in England and Wales, 1982±1992: the contribution of occupation and geography. Population Trends 80, 16±25. Kohrs, F.P., Mainous, A.G., 1996. Is health status related to residence in medically underserved areas? Evidence and implications for policy. Journal of Rural Health 12 (3), 218±224. Larson, E.H., Hart, L., Rosenblatt, R.A., 1997. Is non-metropolitan residence a risk factor for poor birth outcome in the US? Social Science and Medicine 45 (2), 171±188. Launoy, G., Coutour, X.L., Gignoux, M., Pottier, D., Dugleux, G., 1992. In¯uence of rural environment on diagnosis, treatment, and prognosis of colorectal cancer. Journal of Epidemiology and Community Health 46, 365±367. Li€, J.M., Chow, W., Greenberg, R.S., 1991. Rural±urban di€erences in stage at diagnosis: possible relationship to cancer screening. Cancer 67, 1454±1459. Love, D., Lindquist, P., 1995. The geographical accessibility of hospitals to the aged: A geographic information systems analysis within Illinois. Health Services Research 29 (6), 629±651. MacIntyre, S., MacIver, S., Soomans, A., 1993. Area, class and health: should we be focusing on places or people? Journal of Social Policy 22, 213±234. Mackenbach, J.P., 1993. Inequalities in health in The Netherlands according to age, gender, marital status, level of education, degree of urbanisation, and region. European Journal of Public Health 3, 112±118. Macleod, J.A.J., 1995. Recruitment to rural practice, Chapter 13. In: Cox, J. (Ed.). Rural General Practice in the United Kingdom. Occasional Paper 71. The Royal College of General Practitioners, London, pp. 43±45. Mainous, A.G., Kohrs, F.P., 1995. A comparison of health status between rural and urban adults. Journal of Community Health 20 (5), 423±431. Malmberg, A., Hawton, K., Simkin, S., 1997. A study of suicide in farmers in England and Wales. Journal of Psychosomatic Research 43 (1), 107±111. McCarron, P.G., Davey-Smith, D., Womersley, J., 1994. Deprivation and mortality in Glasgow: increasing di€erentials from 1980 to 1992. British Medical Journal 309, 1481±1482. McLoone, P., Boddy, F.A., 1994. Deprivation and mortality in Scotland, 1981 and 1991. British Medical Journal 309, 1465±1470. Miller, M.K., Stokes, C.S., Cli€ord, W.B., 1987. A comparison of the rural±urban mortality di€erential for deaths from all causes, cardiovascular disease and cancer. Journal of Rural Health 3 (2), 23±34. Monaghan, S., 1998. An Atlas of Health Inequalities between Welsh Local Authorities. Welsh Local Government Association, Cardi€.

G. Higgs / Geoforum 30 (1999) 203±221 Monroe, A.C., Ricketts, T.C., Savitz, L.A., 1992. Cancer in rural versus urban populations: a review. The Journal of Rural Health 8 (3), 212±220. Morris, R., Carstairs, V., 1991. Which deprivation? A comparison of selected deprivation indexes.. Journal of Public Health Medicine 13 (4), 318±326. Moscovice, I.S., 1989. Rural hospitals: a literature synthesis and health services research agenda. Health Services Research 23 (6), 891±930. Nasca, P.C., Mahoney, M.C., Wolfgang, P.E., 1992. Population density and cancer incidence di€erentials in New York State, 1978± 1982. Cancer Causes and Control 3 (1), 7±15. Parkin, D., 1979. Distance as an in¯uence on demand in general practice. Epidemiology and Community Health 33, 96±99. Patterson, C.C., Waugh, N.R., 1992. Urban/rural and deprivational di€erences in incidence and clustering of childhood diabetes in Scotland. International Journal of Epidemiology 21 (1), 108±117. Payne, S., Henson, B., Gordon, D., Forrest, R., 1996. Poverty and Deprivation in West Cornwall in the 1990s. Statistical Monitoring Unit, School for Policy Studies, University of Bristol. Phillimore, P., Reading, R., 1992. A rural disadvantage? Urban±rural health di€erences in Northern England. Journal of Public Health Medicine 14, 290±299. Phillimore, P., Beattie, A., Townsend, P., 1994. Widening inequality of health in northern England, 1981±1991. British Medical Journal 308, 1125±1128. Preston, J., Brown, F.W., Hartley, B., 1992. Using telemedicine to improve health care in distant areas. Hospital and Community Psychiatry 43 (1), 25±32. Reading, R., Raybould, S., Jarvis, S., 1993. Deprivation, low birth weight and childrenÕs height: a comparison between rural and urban areas. British Medical Journal 307, 1458±1462. Ricketts, T.C., 1994. A focus on rural and regional health care delivery. In: Ricketts, T.C., Savitz, L.A., Gesler, W.M., Osborne, D.N. (Eds.), Geographic Methods for Health Services Research: A Focus on the Rural±Urban Continuum. University Press of America, London, pp. 11±37. Ricketts, T.C., Savitz, L.A., Gesler, W.M., Osborne, D.N., 1994. Geographic Methods for Health Services Research: A Focus on the Rural±Urban Continuum. University Press of America, London. Rural Development Commission, 1992. 1991 Survey of Rural Services. RDC, London. Rural Development Commission, 1995. 1994 Survey of Rural Services. RDC, London. Saunderson, T.R., Langford, I.H., 1996. A study of the geographical distribution of suicide rates in England and Wales 1989±1992 using Emprical Bayes Estimates. Social Science and Medicine 43 (4), 489±502. Schneider, D., Greenberg, M.R., 1992. Death rates in rural America 1939±1981: convergence and poverty. In: Gesler, W.M., Ricketts, T.C. (Eds.), Health in Rural North America. Rutgers Univ. Press, London, pp. 55±68. Schouten, L.J., Meijer, H., Huveneers, J.A.M., Kiemeney, L.A.L., 1996. Urban±rural di€erences in cancer incidence in The Netherlands, 1989±1991. International Journal of Epidemiology 25 (4), 729±736. Scottish Oce, 1996. Scottish rural life update: a revised socioeconomic pro®le of rural Scotland. HMSO, Edinburgh. Senior, M.L., 1998. Area variations in self-perceived limiting long term illness in Britain, 1991: is the Welsh experience exceptional? Regional Studies 32 (3), 265±280.

221

Senior, M.L., Williams, H.C.W.L., Higgs, G., 1998. Spatial and temporal variation of mortality and deprivation 2. Statistical modelling.. Environment and Planning A 30, 1815±1834. Shouls, S., Congdon, P., Curtis, S., 1996. Geographic variation in illness and mortality: the development of a relevant area typology for SAR districts. Health and Place 2 (3), 139±155. Shucksmith, M., Roberts, D., Scott, D., Chapman, P., Conway, E., 1996a. Disadvantage in rural areas, RDC Rural Research Report no. 29. RDC, Salisbury. Shucksmith, M., Chapman, P., Clark, G.M., 1996b. Rural Scotland Today: The best of both worlds? Avebury, Aldershot. Simmons, M., 1997. Landscapes ± of Poverty: Aspects of rural England in the late 1990Õs, Lemos and Crane, London. Smith, M.H., Anderson, R.T., Bradham, D.D., Longino, C.F., 1995. Rural and urban di€erences in mortality among Americans 55 years and older: analysis of the National Longitudinal Mortality Study. The Journal of Rural Health 11 (4), 274±285. Sobal, J., Troiano, R.P., Frongillo, E.A., 1996. Rural±urban di€erences in obesity. Rural Sociology 61 (2), 289±305. Townsend, P., Phillimore, P., Beattie, A., 1988. Health and Deprivation: Inequality and the North. Croom Helm, London. Verheij, R.A., 1996. Explaining urban±rural variations in health: a review of interactions between individual and environment. Social Science and Medicine 42 (6), 923±935. Verheij, R.A., vandeMheen, H.D, Bakker, D.H., Groenewegen, P.P., Mackenbach, J.P., 1998. Urban±rural variations in health in The Netherlands: does selective migration play a part? Journal of Epidemiology and Community Health 52, 487±493. Wallace, M., Charlton, J., Denham, C., 1995. The new OPCS area classi®cations. Population Trends 79, 15±30. Walsh, S.J., Page, P.H., Gesler, W.M., 1997. Normative models and healthcare planning: network-based simulations within a geographic information system environment. Health Services Research 32 (2), 243±260. Watt, I., 1995. Health needs of rural residents. In: Rural General Practice in the UK. Occasional Paper No. 71. Royal College of General Practitioners, London. Watt, I., Sheldon, T., 1993. Rurality and resource allocation in the UK. Health Policy 26, 19±27. Watt, I., Franks, A., Sheldon, T., 1993. Rural health and health care. British Medical Journal 306, 358±359. Watt, I., Franks, A., Sheldon, T., 1994. Health and health care of rural populations in the UK: is it better or worse. Journal of Epidemiology and Community Health 48, 16±21. Welsh Oce, 1996. Welsh Health Survey 1995. Government Statistical Service, Cardi€. Welsh Oce, 1998. Better Health ± Better Wales. Cm 3922. The Stationary Oce, London. Western Mail, 1998. Country life too hard for new doctors, 9th March 1998, p. 1. Wilkinson, R.G., 1996. Unhealthy Societies: The A‚ictions of Inequality. Routledge & Kegan Paul, London. Williams, D.R., 1990. Socio-economic di€erentials in health: a review and redirection. Social Psychology Quarterly 53 (2), 81±99. Williams, R., Bloor, M., Horobin, G., Taylor, R., 1980. Remoteness and disadvantage: ®ndings from a survey of access to health services in the Western Isles. Scottish Journal of Sociology 4 (2), 105±124. Zijtho€, P., Verheij, R., de Bakker, D., 1994. Urban±rural variations in health and health services utilisation: an annotated bibliography. NIVEL Bibliography No. 50. Netherlands Institute of Primary Health care, Utrecht.