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


Of the 4,560 questionnaires mailed, 142 were returned not delivered, 28 individuals had left the practice, 7 had died, 2 were overseas; and 5 questionnaires were completed by children. The corrected response rate was 60% (2,603 of 4,376 questionnaires). More individuals registered with a rural practice responded than those with an urban practice: 65% vs 56% (p < 0.001). Respondents were more likely to be women (55% vs 45%, p < 0.001) and older than nonrespondents; mean age was 52 years vs 47 years, respectively (p < 0.001).

Table 1 shows the characteristics of respondents by location. Most respondents were white (2,573 of 2,582 respondents). There were no differences between rural and urban respondents in terms of gender, age, education, or smoking status. Respondents from rural practices were more likely to be retired or otherwise not employed, and less likely to be not working because of illness or disability than urban respondents (p < 0.001). Respondents from rural practices were more likely to be in the middle Depcat (3– 4) and less likely to be in the most deprived group (Depcat 5–7) than those from urban practices (p < 0.001).

The unadjusted OR for any self-reported chest illness, asthma, eczema/dermatitis, and rheumatic troubles/arthritis was significantly lower among participants from rural areas than for those from urban areas ( Table 2 ). After adjustment, only the ORs for any self-reported chest illness, asthma, and eczema/ dermatitis remained statistically significant. We found a large overlap between respondents reporting COPD or emphysema but did not find an overlap in the reporting of chronic bronchitis and COPD or emphysema. A small proportion of the respondents who reported chronic bronchitis, COPD, or emphysema were < 45 years old (13.5%; 34 of 251 respondents). Most of this younger group reported having chronic bronchitis, with only one respondent indicating COPD and none reporting emphysema.

More respondents reported symptoms than specific diagnoses. The prevalence of respiratory symptoms was generally lower among participants from rural practices than urban practices. Fewer respondents from rural areas reported breathlessness than those from urban areas, and if this symptom occurred were more likely to report mild symptoms ( Table 3 ). After adjustment, respondents from rural locations were significantly less likely than those from urban locations to report persistent cough and phlegm, being disabled from walking due to breathlessness because of a reason other than lung disease, and various types of wheeze. In particular, respondents from rural practices were less likely to report symptoms suggestive of asthma (attacks of wheeze or whistling in the chest during the previous 12 months, and attacks of shortness of breath with wheeze).

Among respondents reporting asthma, we found no differences between location and types of medications used: inhaled short-acting β2 only (20.6% rural vs 22.0% urban); those using inhaled short-acting β2 and a regular inhaled steroid (42.3% rural vs 42.2% urban); and those using short-acting β2 and other add-on therapies (37.1% rural vs 35.8% urban) [p = 0.764].

The median SF-36 scores for the respondents reporting different respiratory conditions and selected symptoms are shown in Table 4 . The respondents who did not have any of the respiratory or other chronic conditions had the highest SF-36 scores. For each of the conditions and symptoms, we found impairments to most aspects of health status with the exception of the median SF-36 score for role limitations due to emotional problems. Respondents reporting asthma had particularly low SF-36 scores in energy and fatigue, and general health perception domains. Those reporting COPD/emphysema had the lowest SF-36 scores of all conditions assessed, with low median scores in all of the domains especially for physical functioning, role limitations due to physical problems, and due to emotional problems.

Respondents who reported persistent cough and phlegm had similar scores to those reporting wheeze symptoms. Their scores were low in the energy and fatigue, pain, and general health perception aspects of health status.

When there were significant differences between the SF-36 scores of the two groups, the SF-36 scores of respondents living in rural areas were higher (ie, indicating better health status) than those of their urban counterparts (data not shown). There were no differences for respondents with reported asthma. Rural participants reporting chronic bronchitis had better pain scores than those from urban practices (p < 0.001). The median scores for role limitations from physical problems (p = 0.009), mental health (p = 0.001), and energy and fatigue (p = 0.001) of rural respondents reporting COPD/emphysema were higher (signifying better health status) than those for urban participants with this condition.

There were more rural/urban differences found for symptoms, particularly for cough and phlegm, where the domain scores for energy and fatigue, pain, and general health perception were significantly higher among respondents from rural practices than from those from urban practices. Of all the conditions and symptoms assessed, a significant rural/ urban difference in the perception of general health domain was only found for cough and for phlegm.

Most respondents who reported a respiratory condition or symptom completed the respiratory-specific quality of life questionnaire ( Table 5 ). The distribution of the total AQ20 scores for individuals with asthma was skewed toward the milder end of quality of life impairment when compared with the scores of respondents with COPD/emphysema (data not shown). Median AQ20 scores were generally lower representing better quality of life among respondents from rural practices than from urban practices. AQ20 scores were significantly lower for respondents from rural practices for COPD/emphysema and for persistent cough and phlegm, when compared to those from urban practices.


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