In recent years there has been a renewal of interest in geographic characteristics within public health, particularly in the areas of international health and community development. Past research has documented a difference between urban and rural health care, usually expressed in terms of healthcare access and utilization, cost, and geographic distribution of providers and services.(1) Recently, however, a new research focus has begun to direct its attention toward differences in population health, public health, environmental health, and the differences between urban and rural health behaviors. By utilizing a framework that examines determinants of health, researchers can identify environment-specific factors that may contribute to different health outcomes for urban and rural residents.
This focus on the environmental and social determinants of health has accompanied a rapid change in rates of urban populations across the world. The rapid urbanization of the 20th century reflects changes in global political, economic, and social forces.(2) Thus, the health of urban populations has changed as cities have evolved. As more people worldwide live in cities, it is imperative to understand how urban living affects population health. Does urban living negatively affect health? Can urban living enhance population health and well-being? This article first examines determinants of heath in urban versus rural contexts and then outlines several emerging problems caused by rapid urbanization.
The social environment: Urban environments are more likely to see large disparities in socioeconomic status, higher rates of crime and violence, the presence of marginalized populations (e.g., sex workers) with high risk behaviors, and a higher prevalence of psychological stressors that accompany the increased density and diversity of cities.(3),(4),(5)
The physical environment: In densely populated urban areas, there is often a lack of facilities and outdoor areas for exercise and recreation. In addition, air quality is often lower in urban environments which can contribute to chronic diseases such as asthma.(6) In the developing world, urban dwellers often live in large slums which lack basic sanitation and utilities such as water and electricity. Lack of basic infrastructure can exacerbate rates of infectious disease and further perpetuate the cycle of poverty.
Access to health and social service: Persons of lower socioeconomic status and minority populations are more likely to live in urban areas and are more likely to lack health insurance(7). Thus, these populations face barriers to care, receive poorer quality care, and disproportionately use emergency systems. Other commonly represented populations in cities are undocumented immigrants and transient populations. The high prevalence of individuals without health insurance or citizenship creates a greater burden on available systems. This often leads to vast disparities in health care outcomes as well as a two-tiered health care system where insured individuals have access to preventive and routine health care while marginalized populations utilize “safety-net” emergency room care.
The social environment: In the United States, rural elders have significantly poorer health status than urban elders.(8) Also, rural residents smoke more, exercise less, have less nutritional diets, and are more likely to be obese than suburban residents.(9) “Health educators are increasingly aware of the need for culturally sensitive approaches to modifying unhealthy behavior, but few rural health researchers and policymakers are asking the relevant cultural question, ‘Why does rural residence (culture, community, and environment) reinforce negative health behaviors?’ ”(10) In fact, many of the major public health problems faced in rural areas (e.g., obesity, tobacco use, failure to use seat belts) are not likely to respond to an increased presence of general practitioners, physician specialists, or physician extenders. Instead, these challenges call for a social perspective with a focus on prevention and a healthy lifestyle.
Despite negative health behaviors, many aspects of rural social life contribute to positive health outcomes. “Rural areas frequently have strengths including dense social networks, social ties of long duration, shared life experiences, high quality of life, and norms of self-help, and reciprocity”.(11) Addressing the needs of rural areas requires building upon the positive aspects of rural life while addressing the health, public health, infrastructure, and economic needs of rural areas.
Similar issues exist in the developing world. A recent World Bank report “Las Casas Maternas en Nicaragua” reported that 60% of adolescent pregnant women are from rural areas. The problem of youth pregnancy stems from the larger issues of rural versus urban access to education, health services, and employment.(12) Furthermore, rural areas in Nicaragua have higher levels of unemployment and poverty, and lower levels of education. The national average of people without adequate education is 18% while in rural areas that number jumps to 25%.
The physical environment: Rural women in the United States, especially less educated women, are more sedentary than urban women.(13) Rural individuals are less likely to report sidewalks, streetlights, high crime, access to facilities, and frequently seeing others exercise in their neighborhood. While poor air quality and crime rates are likely to be less of an issue in rural areas, insufficiencies in the built environment make it difficult for rural residents to exercise and maintain healthy habits.
Access to health and social service: Evidence indicates that rural residents have limited access to health care(14) and that rural areas are underserved by primary care physicians.(15) In the developing and developed world, many rural individuals must travel substantial distances for primary medical care, requiring significantly longer travel times to reach care than their urban counterparts.(16) Furthermore, some rural areas have a higher proportion of uninsured and individually insured residents than urban areas.(17)
More than 50% of the world’s population now lives in urban areas.(18) Urbanization implies “considerable changes in the ways in which people live, how they earn their livelihoods, the food which they eat, and the wide range of environmental factors to which they are exposed.”(19) There is an underlying assumption that urban populations will be healthier than their rural counterparts and that urbanization equates with modernization. However, this is rarely true. Research about the features of urban areas that influence health has been relatively sparse but often indicates increased health hazards.(20)
A past conception regarding rural versus urban health was the idea of an “epidemiological transition” that occurs when populations move from underdeveloped areas to urban ones. With the onset of modernization it was thought that the burden of disease would shift from infectious to chronic causes. In the past, most deaths were caused by infectious diseases, degenerative diseases, and violence; thus, people did not often live long enough to be afflicted by chronic causes of death such as heart disease and diabetes. While this transition does exist in some extent, today it is more appropriate to talk about a “double burden” of disease, both infectious and chronic.
This double burden is often present in areas that have experienced rapid urbanization. Throughout most of human history, populations were not large enough to sustain highly transmissible infectious diseases for long periods of time. Now, however, this is no longer the case. Because people are living closer to one another in often unsanitary environments, the potential for infectious disease transmission is much higher. In addition to higher rates of infectious diseases, rapid urbanization has led to poor living and working conditions, and thus more chronic diseases. For example, poor urban individuals who live in moldy apartments are more likely to be afflicted with asthma. Furthermore, overworked factory employees are more likely to suffer from work-related injuries and environmental pollution.
To understand urban health and the phenomenon of urbanization, we must shift our focus away from disease outcomes and toward urban exposures, namely, the characteristics of the urban context that influence health and well-being. This can include methods relevant to the study of urban health including epidemiology, health policy, and urban planning. In addition, practical issues for developing healthy cities should be addressed, such as preventive strategies, the provision of health services, and education.
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(3) Department of Commerce, Bureau of the Census. Qualifying urban areas for census 2000. Federal Register Part 7. May 1, 2002.
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(10) Hartley DA. Rural health disparities, population health, and rural culture. Am J Public Health. 2004;94:1675–1678.
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(12) Milton, Angela. Rural Vs. Urban Access to Health Services. Accessed September 14, 2009.
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(14) Office of Program Development. Study of Models to Meet Rural Health Care Needs. Rockville, MD: Health Resources and Service Administration, 1992. Publication No. HRS 240-89-0037.
(15) Kletke PR, Marder WD, Willke RJ. A projection of the primary care physician population in metropolitan and nonmetropolitan areas. Primary Care Research: Theory and Methods. AHCPR conference proceedings, Washington DC: Agency for Health Care Policy and Research; 1991:261-269.
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(17) Hartley, D., L. Quam, and N. Lurie. Urban and rural differences in health insurance and access to care. Journal of Rural Health. 1994; 10 (2): 98-108.
(18) State of the world population 2007: unleashing the potential of urban growth. New York: United Nations Population Fund, 2007.
(19) Phillips DR, 1993. Urbanization and human health. Parasitology106(Suppl): 93–107.
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