Introduction: Differences in health between urban and rural areas of Canada are well documented. Canadian rural communities are remarkably heterogeneous in terms of social, economic, and geographic characteristics. There is reason to believe that there is also considerable heterogeneity in health within rural Canada but existing literature has not given this adequate consideration. This article describes heterogeneity in health along the urban-rural continuum, both between and within categories of rural areas. Factors that may explain observed variations are then examined.
Methods: The study population included all adult (>18 years) respondents on the Canadian Community Health Survey Cycle 1.1, linked to census subdivision-level data from the corresponding Canadian Census. Study areas were classified according to Metropolitan Influenced Zones (MIZ), which group rural areas based on their degree of connectivity with nearby urban areas. Dichotomized Health Utilities Index (HUI) scores were the outcome variable. Random-intercept logistic regression models investigated the associations of HUI with individual and area characteristics. To describe between-area variation in health, the proportion of the total variation accounted for by the area random effect (the intra-class correlation coefficient [ICC]) was estimated. To aid interpretation of the magnitude of the effect of area relative to other variables in the models, the ICC was also expressed as a median odds ratio (MOR), or the median amount by which the probability of disability will change for an individual who moves from one area to another.
Results: On a descriptive level, poorer health was observed in more remote rural areas, but the size of estimated effects for categories of rural areas was generally small compared with effects of other individual and area variables, and with the degree of heterogeneity between areas. The composition of rural areas is important in order to understand patterns in health. Individual income, education, and employment, and area characteristics such as Francophone or Aboriginal populations, and migration patterns help explain the gradient in health by MIZ, but considerable heterogeneity in health within categories of MIZ remains. In models stratified by MIZ, significant between-area heterogeneity was observed in all models, with MORs ranging from 1.18 to 1.53.
Conclusion: It was observed that heterogeneity in health among rural areas is substantial, and generally larger than the effect of rurality, itself, on health. More attention is needed to understand the characteristics of Canada's heterogeneous rural communities, and the different processes by which disparities in health emerge and persist. The findings suggest that a focus on rurality alone, emphasizing urban versus rural disparities, or even continuum-based approaches like MIZ, may be less informative than finding ways to classify and examine different types of rural areas according to factors relevant to health.