Is Living in a Rural Area Good for Your Respiratory Health?

Results From a Cross-sectional Study in Scotland

Lisa Iversen, MSc; Philip C. Hannaford, MD; David B. Price, FRCGP; David J. Godden, MD


CHEST. 2005;128(4):2059-2067. 

In This Article

Materials and Methods

Ethical approval for the study was granted by the Multi-Centre Research Ethics Committee for Scotland and by the Local Research Ethics Committees of the 57 volunteer general practices (22 rural and 35 urban) throughout Scotland that participated in the study.

When we began the study, there was no agreed simple definition of rurality in Scotland that could be used for epidemiologic research. We defined, therefore, rurality in terms of family practice (general practice). Using the National Health Service in Scotland, Information and Statistics Division classification at that time, rural practices were those that received rural practice payments for one third or more of their registered patients.[17] These payments are made by the government to compensate practitioners for the scattered nature of their registered patients, principally for the increased time and expense spent visiting patients a minimum of 4.8 km from the practice center, and for the limited number of patients on their lists. Adjustments are made to the payments if a practice covers an area where there are concentrations of patients, eg, in a village. Practices were invited to participate in the study through existing primary care research networks and by a letter sent to a random selection of general practices on the Scottish mainland.

Each practice identified a random sample of 80 registered adults, stratified by age (16 to 50 years, >50 years) and sex. Each person was allocated a unique identification number by the practices so that confidentiality could be preserved. Questionnaire packs were mailed to the individuals by the practices on our behalf, between October 2001 and October 2002. The practices sent an identical reminder pack to nonrespondents 3 to 6 weeks after the initial mailing. Following the mailing of reminders, practices were asked to provide aggregated details of the age and sex of nonrespondents.

The questionnaire pack included a letter from the general practice, a letter from the research team, a patient information sheet, a questionnaire, and a consent form. The questionnaire pack was piloted on 100 patients from two practices, and minor amendments were made. The final questionnaire collected selfreported data on age; gender; socioeconomic factors; smoking habits; selected illnesses (major respiratory and atopic diseases, and other major chronic conditions including heart disease, diabetes and depression), based on items included in another respiratory study[18]; respiratory symptoms (cough, phlegm, wheeze, breathlessness), based on questions modified from the Medical Research Council (MRC) 1986 Respiratory Symptoms Questionnaire[19]; use of medicines and health services; the generic health status measure (the Short Form-36 [SF-36])[20]; and the respiratory-specific quality of life measure (the Airways Questionnaire 20 [AQ20]).[21,22]

The SF-36, which was completed by all respondents, contains 36 items that measure eight health domains: physical functioning, social functioning, role limitations due to physical problems, role limitations due to emotional problems, mental health, energy and fatigue, pain, and general perception of health. Generic measures of health status are designed to incorporate a range of aspects of health status.[23] The AQ20 measures quality of life in both asthma and COPD patients,[22,24] and was particularly attractive for use in a postal questionnaire due to its low respondent burden, requiring < 3 min to complete the 20 items.[22]

Data were entered into Microsoft Access (Microsoft; Redmond, WA), and data analysis was completed using statistical software (SPSS for Windows, version 9.01; SPSS; Chicago, IL). The analysis explored the relationship between the location of the participants' general practice (rural or urban), used as a proxy measure of whether respondents lived in rural or urban areas, and different health outcomes. Differences in the characteristics of respondents from rural and urban practices were assessed using the χ2 test. Univariate associations between the prevalence of self-reported illness and symptoms, and rural/urban practice location were examined by binary logistic regression. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were then calculated allowing for gender, age group (generally 16 to 24 years, 25 to 34 years, 35 to 44 years, 45 to 54 years, 55 to 64 years, 65 to 74 years, and > 75 years, but collapsed for some analyses); smoking (current, former, never smoked > 100 cigarettes); Carstairs Morris deprivation category (Depcat) based on postal code (Depcat 1–2, Depcat 3–4, Depcat 5–7; higher values indicating less affluence)[25]; and employment (employed, not employed, retired, student, or unable to work due to illness). In the United Kingdom, the term chronic bronchitis is often used to describe COPD,[26] so we grouped together respondents who reported having chronic bronchitis, COPD, or emphysema. We suspected that some of the respondents who reported chronic bronchitis might be misreporting acute bronchitis; therefore, we looked at the overlap among the three conditions and the age distribution of the respondents.

In order to examine whether there were differences in the severity of respiratory disease between rural and urban practice groups, we investigated the medicines used by respondents who reported having asthma. These respondents were categorized into one of three treatment groups based on British Thoracic Society guidelines[27]: those using inhaled short-acting β2-agonists only; those using inhaled short-acting β2-agonists and a regular inhaled steroid; and those using short-acting β2-agonists and other add-on therapies. The association between treatments used and location was assessed using the χ2 test.

The eight SF-36 domain scores for each respondent could range between 0 (worst) and 100 (best health state). Since the scores were not normally distributed, median scores (and the interquartile range [IQR]) were calculated for each domain. Mann-Whitney U tests compared the SF-36 scores of respondents with each respiratory condition or symptom living in rural or urban practice locations. Since multiple testing may find a statistically significant result by chance,[28] we used the more stringent value of 1% (p < 0.01) for statistical significance. Responses to the AQ20 questions were summed to give a total score between 0 (least) and 20 (most impaired health state). Median AQ20 scores and IQRs were calculated for respondents reporting asthma, chronic bronchitis, COPD/emphysema, and selected symptoms of these conditions. The scores of respondents living in rural and urban practice locations were compared using the Mann-Whitney U test.


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