Rural-Urban Cardiovascular Health Disparities: A Literature Review

Introduction: The Rural-Urban Health Divide

Hughes, Watanabe-Galloway, Schnell, and Soliman (2015) studied the differences in colorectal cancer screening rates between rural and urban populations in Nebraska. Their investigation into the reasons behind this gap revealed several noteworthy findings, some of which were unexpected. The authors found that rural residents were more likely to believe that colorectal cancer cannot be prevented, and therefore did not feel that screening was worthwhile. A higher percentage of rural residents also identified cost as a barrier, while perceived embarrassment and perceived unpleasantness were indicators found more frequently among rural residents. The study suggests that cultural factors play a meaningful role in the rural-urban divide.

However, the study also found that people who had a personal doctor were more likely to receive screenings. This indicates that physician density can play a significant role — people without a regular doctor are less likely to receive advice to pursue screenings or to obtain referrals. These factors can contribute to lower screening rates and, consequently, higher rates of morbidity among rural populations.

An Icelandic study (Haraldsdottir, Gudmundsson, Thorgeirsson, Lund, & Valdimarsdottir, 2017) regarding cardiovascular disease arrived at similar conclusions. The authors found that rural areas had a higher prevalence of preventable risk factors. They also found that hospital discharges were more frequent in rural areas, which may have contributed to higher mortality rates. The underlying causes of higher discharge rates were not examined in that study, but the implication is that shorter hospital stays may be more common among rural residents — particularly when the hospital is not located in their community — potentially depriving them of the full range of diagnostic testing they would have received with a longer stay.

Lifestyle and Socioeconomic Factors in Cardiovascular Disease

Amponsah, Tabi, and Gibbison (2015) examined cardiovascular disease in rural Georgia. As in the Icelandic study, they found that lifestyle factors contributed to the gap in health outcomes. Rural residents in their study generally had lower socioeconomic status, and lower socioeconomic status is associated with higher rates of cardiovascular disease. This adds to the body of evidence that health disparities between rural and urban residents are at least partly attributable to lifestyle differences.

Bo Nielsen, Leppin, Gyrd-Hansen, Ejg Jarbøl, Søndergaard, Veldt Larsen, and Larsen (2017) conducted a study in Denmark to examine potential gaps in preventative care as a contributing factor to the rural-urban outcome divide. As in many other studies, socioeconomic factors were linked to lifestyle choices that in turn increased the likelihood of cardiovascular disease. In their study, rural residents were more likely to smoke, maintain poor diets, and abstain from exercise.

Campbell, Manns, Weaver, Hemmelgarn, King-Shier, and Sanmartin (2017) conducted a study in Canada that was not specifically framed around the rural-urban question. They found, however, that the correlation between lower socioeconomic status and higher rates of cardiovascular disease held in their data. They specifically cited financial barriers to accessing medications and healthy food as reasons why people with lower incomes faced higher rates of cardiovascular disease. While this study removes the rural-urban dynamic from the argument, it lends further support to the link between socioeconomic status and greater incidence of cardiovascular disease.

Access to Care: Physicians, Specialists, and Transportation

In South Carolina, rural residents face additional barriers, including several that are not directly linked to socioeconomic status. Barriers identified in that context include lack of health insurance, lack of knowledge, misperceptions, fear, and limited accessibility — all cited as reasons why rural South Carolinians do not participate in clinical trials (Kim, Tanner, Friedman, Foster, & Bergeron, 2014). A reasonable argument can be made that these same factors apply to other forms of health care as well.

Syed, Gerber, and Sharp (2013) examined transportation barriers faced by rural residents. Analyzing 61 different studies, they found that transportation barriers were frequently cited as issues by rural patients. This form of analysis does not seek to validate the view that transportation is a barrier — only to document that patients themselves identify it as one. The authors found the strongest association among people with lower incomes and those who were uninsured or underinsured. The former group may find traveling for care to be a legitimate financial burden; the latter group may be unable to pay for care but cite other reasons for not seeking it. There are unanswered questions that would require examining the constituent studies in greater detail to resolve fully.

One of the biggest challenges in cardiovascular care is that treatment must be highly individual-centered and personal. In particular, preventative care must meet these requirements, as each patient needs an individualized health plan to effectively manage cardiovascular risk (Harrington & Heidenreich, 2015). Rural residents who experience the worst cardiovascular outcomes are often those who face the greatest obstacles: they do not receive the preventative care they need, nor the individualized care required to manage their heart health effectively.

One study that offers a counterpoint to many of these findings is Choo, McGeary, Farman, Greyling, Cross, and Leslie (2014), who found that in rural Scotland, referral rates between rural and urban patients were not significantly different. However, this is a single study, and findings applicable in Scotland may not translate to other countries, where health care practices and systems differ considerably. That said, it is valuable to know that rural location need not inherently pose barriers to care, and that system-level factors can mitigate geographic disadvantage.

References

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Allenby, A., Kinsman, L., Tham, R., Symons, J., Jones, M., & Campbell, S. (2016). The quality of cardiovascular disease prevention in rural primary care. Australian Journal of Rural Health, 24(2), 92–98. doi:10.1111/ajr.12224

Amponsah, W. A., Tabi, M. M., & Gibbison, G. A. (2015). Health disparities in cardiovascular disease and high blood pressure among adults in rural underserved communities. Online Journal of Rural Nursing & Health Care, 15(1), 185–208. doi:10.14574/ojrnhc.v15i1.351

Bo Nielsen, J., Leppin, A., Gyrd-Hansen, D., Ejg Jarbøl, D., Søndergaard, J., Veldt Larsen, P., & Larsen, P. V. (2017). Barriers to lifestyle changes for prevention of cardiovascular disease — a survey among 40–60-year-old Danes. BMC Cardiovascular Disorders, 17, 1–8. doi:10.1186/s12872-017-0677

Campbell, D. T., Manns, B. J., Weaver, R. G., Hemmelgarn, B. R., King-Shier, K. M., & Sanmartin, C. (2017). Financial barriers and adverse clinical outcomes among patients with cardiovascular-related chronic diseases: A cohort study. BMC Medicine, 15, 1–13. doi:10.1186/s12916-017-0788-6

Choo, W. K., McGeary, K., Farman, C., Greyling, A., Cross, S. J., & Leslie, S. J. (2014). Utilisation of a direct access echocardiography service by general practitioners in a remote and rural area — distance and rurality are not barriers to referral. Rural & Remote Health, 14(4), 1–6.

Haraldsdottir, S., Gudmundsson, S., Thorgeirsson, G., Lund, S. H., & Valdimarsdottir, U. A. (2017). Regional differences in mortality, hospital discharges and primary care contacts for cardiovascular disease. Scandinavian Journal of Public Health, 45(3), 260–268. doi:10.1177/1403494816685341

Harrington, R. A., & Heidenreich, P. A. (2015). Team-based care and quality: A move toward evidence-based policy. Journal of the American College of Cardiology, 66, 1813–1815.

Hughes, A., Watanabe-Galloway, S., Schnell, P., & Soliman, A. (2015). Rural-urban differences in colorectal cancer screening barriers in Nebraska. Journal of Community Health, 40(6), 1065–1074. doi:10.1007/s10900-015-0032-2

Kim, S., Tanner, A., Friedman, D., Foster, C., & Bergeron, C. (2014). Barriers to clinical trial participation: A comparison of rural and urban communities in South Carolina. Journal of Community Health, 39(3), 562–571. doi:10.1007/s10900-013-9798-2

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Syed, S., Gerber, B., & Sharp, L. (2013). Traveling towards disease: Transportation barriers to health care access. Journal of Community Health, 38(5), 976–993. doi:10.1007/s10900-013-9681-1