Urban–Rural Differences in Mental and Physical Health among Primary Care Patients with Multiple Chronic Conditions: A Secondary Analysis from a Randomized Clinical Trial
1Department of Medicine, University of Vermont, Burlington, VT 05405, USA
2Department of Psychiatry, University of Vermont, Burlington, VT 05405, USA
3Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, Portland, OR 97201, USA
*Author to whom correspondence should be addressed.
Int. J. Environ. Res. Public Health 2022, 19(23), 15580; https://doi.org/10.3390/ijerph192315580
Purpose: Rural health disparities are largely
attributable to access to healthcare, socioeconomic status, and health
behaviors. Little is known about the persistence of these disparities
when differences in access to care are eliminated. We sought to
investigate urban–rural differences in physical and mental health in
primary care patients with demonstrated access to primary care. Methods:
We obtained cross-sectional survey responses from a multicenter
randomized controlled trial on 2726 adult primary care patients with
multiple chronic medical or behavioral conditions from 42 primary care
practices in 13 states. Study outcomes include measures of mental health
including: The Patient-Reported Outcomes Measurement Information System
(PROMIS-29®), General Anxiety Disorder-7 (GAD-7), and
Patient Health Questionnaire-9 (PHQ-9), as well as physical health
including: the PROMIS-29® and the Duke Activity Status Index
(DASI). Urban–rural residence was indicated by census-tract Rural Urban
Commuting Areas of the participant’s home address. Differences in mental
and physical health outcomes attributable to rurality were assessed
using multilevel models with a random intercept for census-tract.
Results: After adjustment for demographic and neighborhood
characteristics, urban residents had significantly worse generalized
anxiety disorder (GAD-7) (ß = 0.7; 95% CI = 0.1, 1.3; p = 0.027), depression (PHQ-9) (ß = 0.7; 95% CI = 0.1, 1.4; p = 0.024), and functional capacity (DASI) (ß = −0.4; 95% CI = −0.5, −0.2; p
< 0.001) compared to rural residents. Urban residents also had
significantly worse anxiety and depression as measured by the PROMIS-29® compared to their rural counterparts. There were no urban–rural differences in the other PROMIS-29®
subdomains. Conclusions: Among adults with demonstrated access to care
and multiple diagnosed chronic conditions, rural residents had better
mental health and functional capacity than their urban counterparts.
This finding is not consistent with prior research documenting rural
health disparities and should be confirmed.
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