A multilevel analysis of the eVects of rurality and social deprivation on premature limiting long term illness

Study objective—To examine the geographical variation in self perceived morbidity in the south west of England, and assess the associations with rurality and social deprivation. Design—A geographically based cross sectional study using 1991 census data on premature Limiting Long Term Illness (LLTI). The urban-rural and intra-rural variation in standardised premature LLTI ratios is described, and correlation and regression analyses explore how well this is explained by generic deprivation indices. Multilevel Poisson modelling investigates whether Customised Deprivation Profiles (CDPs) and area characteristics improve upon the generic indices. Setting—Nine counties in the south west of England Participants—The population of the south west enumerated in the 1991 census. Main results—Intra-rural variation is apparent, with higher rates of premature LLTI in remoter areas. Together with high rates in urban areas and lower rates in the semi-rural areas this indicates the existence of a U shaped relation with rurality. The generic deprivation indices have strong positive relations with premature LLTI in urban areas, but these are a lot weaker in semi-rural and rural locations. CDPs improve upon the generic indices, especially in the rural settings. A substantial reduction in unexplained variation in rural areas is seen after controlling for the level of local isolation, with higher isolation, at the wider geographical scale, being related to higher levels of LLTI. Conclusions—This study highlights the need to treat rural areas as heterogeneous, although this has not been the tendency in health research. Generic deprivation indices are unlikely to be a true reflection of levels of deprivation in rural environments. The importance of CDPs that are specific to the area type and health outcome is emphasised. The significance of physical isolation suggests that accessibility to public and health services may be an important issue, and requires further research. (J Epidemiol Community Health 2001;55:44–51) The problems of widening inequalities in health and health care need in the UK have been recognised since the Black Report first demonstrated them in the 1980s. The Acheson Report has confirmed their persistence and the government is now committed to tackling them. Most research and policy making has focused on urban deprivation, but there is growing concern about the health and health care problems of deprived rural residents. It is increasingly recognised that the concept of the rural idyll is a myth and that many rural communities face particular problems that impinge on health including poor employment opportunities, low pay, lack of aVordable housing, inaccessible public and health care services exacerbated by the declining availability of rural transport. Moreover, those who have most diYculties accessing health services tend to need them most, for example the elderly, disabled and lone parents. Census based deprivation indices are widely used at the area level as proxy measures for the socioeconomic status of the population and hence health care need. It has been suggested, however, that the components of these indices are biased towards urban areas and therefore poor measures of the extent of rural deprivation. For example, one of the core components of a number of indices is car ownership. In rural locations public transport is relatively inaccessible and consequently cars are basic necessities. The cost of running and maintaining these cars may further impoverish poor families. Accessibility diYculties are frequently cited as major concerns for deprived rural dwellers but these are not considered in the generic indices. 9 There is little empirical research on the relation between deprivation indices and health outcomes in rural areas in the UK. The definitions of rurality, level of analysis and geographical coverage used in the studies that do exist vary greatly, making comparisons and the formation of conclusions diYcult. There are indications, however, that the often assumed gradient of increasing health status with decreasing urbanisation may not persist for the remoter rural areas. 11 This paper first examines urban/rural and intra-rural variations in health in the south west of England using the Limiting Long Term Illness (LLTI) measure. It then analyses the association of LLTI with generic measures of deprivation, custom built deprivation measures and areal characteristics. The relations are examined separately within diVerent geographical settings, in particular exploring the determinants of intra-rural variation. J Epidemiol Community Health 2001;55:44–51 44 Department of Social Statistics, University of Southampton, Southampton S Barnett I Diamond Health Care Research Unit, University of Southampton, Southampton General Hospital, Southampton SO16 6YD P Roderick Department of Geography, University of Southampton, Southampton D Martin