1. Rural/urban mortality differences and the effect of deprivation adjustment in England and Wales
Dissertation project for Masters in Public Health HSQ article
Andrea Gartner,
Health information and intelligence analyst,
Wales Centre for Health, Cardiff

2. The project
ONS suggested the work (Myer Glickman and Prof. David Fone,Cardiff University)
Previous work on WCfH publication “A profile of rural health in Wales”
Supervisors: Prof. Frank Dunstan and Dr. Daniel Farewell, Cardiff University
ONS provided mortality data access and HSQ article arrangements (HSQ 39 autumn 2008)
WCfH study leave

3. Is there a difference in mortality between rural and urban areas of England and Wales?
Investigate variation amongst rural/urban sub-classes (compare rates for all-cause mortality)
Examine differences between rural and urban areas whilst adjusting for deprivation (Logistic regression analysis for all-causes and six specific causes)
(3. Investigate rural/urban differences in relationship of mortality and deprivation)

4. Challenges with rural/urban analysis
Definition of “rural” varies in literature
Large variation in rural health outcomes – poor results hidden by averages (Haynes & Gale,2000;)
Deprivation measures thought to be more urban-centred (Farmer et al.,2001; Christie & Fone,2003)
Migration
Few published studies on the topic
IMD/WIMD different

5. Rural or urban?
Six rural/urban classes of at LSOA level (2004 classification)
20% of population in England live in a rural area (35% in Wales)

6. All-cause mortality rates 2002-2004 by rural/urban class
Rural “Village and dispersed” tend to have lowest rates
Source: ONS

7. Rural/urban distribution of deprivation (WIMD 2005)
-> Urban areas are classed as more deprived

8. Regression analysis: models
Logistic regression model fitted with variables age and rurality
Second model with variables age, rurality and five deprivation measures
Townsend Index of Deprivation
Index of Multiple deprivation 2004 (IMD), Welsh Index of Multiple deprivation (WIMD)
(W)IMD excluding health domain
(W)IMD Employment domain
(W)IMD Income domain
Run separately for male/female, England/Wales, causes and deprivation measures (168 runs)

9. Regression analysis: output
Estimated odds ratio for rurality variable relative to urban (95% confidence interval, significance value)
Interpreted as risk ratio of mortality
England male
Before adj
After adj. IMD excl.
All causes
0.85* (15%)
0.96* (4%)
Lung cancer
0.73* (27%)
0.89* (11%)
Suicide (15+)
0.90* (10%)
1.11* (11% higher)
*Statistically significant (p-value< 0.05)

10. Rural/urban rates similar for…
Male before
Male after
Female before
Female after
All causes
0.90*
0.95*
0.92*
0.96*
Cancer
0.91*
0.95
0.94
0.98
Circulatory
0.93*
0.96
1.00
*Statistically significant (p-value< 0.05)
** Odds ratio rural relative to urban, Wales , before and after adjustment for WIMD
Rural/urban differences narrowed
Deprivation accounted for much of the difference

11. Rural rates lower for… Largest rural/urban differences before
Male before
Male after
Female before
Female after
Lung cancer
0.85*
0.93
0.78*
0.87
Respiratory disease
0.87*
0.96
* Statistically significant (p-value< 0.05)
** Odds ratio rural relative to urban, Wales , before and after adjustment for WIMD
Largest rural/urban differences before
Deprivation accounted for some of the difference, but still substantial diff.

12. Rural rates higher for…
Male before
Male after
Female before
Female after
Accidents
1.14
1.27*
1.06
1.11
Suicides (pattern unclear )
0.96
1.04
1.16
1.27
* Statistically significant (p-value< 0.05)
** Odds ratio rural relative to urban, Wales , before and after adjustment for WIMD
Rural/urban differences widened to substantial difference (accidents)
Suicides unclear/not stat. significant

13. Conclusions
Effect of adjustment similar for five deprivation measures (Wales effect smaller)
Association between mortality and deprivation similar in rural and urban areas
Large differences for some causes are of significant public health concern
Deprivation adjustment removed many initital rural/urban mortality differences
Rural populations were not inevitably “healthier” than urban populations

14. Any comments or questions?