According to an investigation into rural health conducted by the Canadian Population Health Initiative, the health status of rural Canadians is systematically worse than it is for urban Canadians, for most, but not all, outcomes [1, 2]. This report demonstrated that urban-rural differences in health status, in morbidity and mortality from most illnesses, and health behaviours remain even after controlling for socio-economic status, suggesting that something about rural life in itself accounts for these differences.
The report also clearly illustrated the major differences in socio-economic status between urban and rural Canadians. For example, in remote areas of Canada approximately 50 percent of the population has little formal education compared to a figure of approximately 25 percent in urban regions. This underscores the fact that any analyses comparing health outcomes between residents in rural and urban areas must take into account the large differences in labour market, income, and educational status. When investigating health outcomes across the rural/urban continuum, it is important to be able to control for confounding by various measures of socio-economic status and/or conduct studies among sub-populations that are similar across regions.
Non-work injury, except perhaps in the case of motor vehicle trauma, remains under-investigated in studies of rural health. There is evidence that in the case of motor vehicle trauma, that in North America, both injuries and fatalities occur in higher proportion and with greater severity in rural compared to urban areas [3, 4]. For non-work injury outcomes such as assault, medical misadventure, and accidental poisoning, there is little understanding of differences across rural and urban places.
In recent years a growing body of evidence has been generated investigating occupational and community influences on a wide range of health outcomes using a large cohort of British Columbian sawmill workers and their children [5–16]. The present study explores differences between urban and rural sawmill worker members of this cohort in hospitalization for non-work injury.
Because the nature and organization of work in sawmills located in rural and urban regions of the province is fairly similar and because educational requirements and wages paid have been similar throughout the province, the cohort members are a homogeneous group. As well, there is information, for cohort members, on potential socio-economic confounders. Using this cohort in investigations of rural/urban differences in health, provides a unique opportunity to compare health outcomes within a relatively homogeneous population of workers for which variables are available to further control for socio-economic confounding.
The aim of the study was to explore the relationship between rural and urban residency and migration between rural and urban places and the risk of hospitalization for non-work related injury among BC sawmill workers
Literature Review
This literature review is divided into four sections. In the first section we review the Canadian literature on rural/urban differences in motor vehicle and other vehicular accidents. Because there is no available Canadian research on rural/urban differences in accidental poisonings and non-work injuries, in the second section we review the, although limited, international literature on this topic. In the third section we review the limited Canadian literature on rural/urban differences in assault. Finally, in the fourth section, we review the international literature on rural/urban differences in medical misadventure.
Motor Vehicle Trauma
Across North America injuries and fatalities due to motor vehicle trauma occur in higher proportion and greater severity in rural compared to urban areas [3, 4]. According to Transport Canada in 2002, 63.2% of all fatal crashes occurred on rural roadways [17]. In Alberta in 2002, nearly 75% of fatal crashes occurred in rural areas [17–19]. These studies also illustrated that speeding and not wearing seat belts were more prevalent in rural than in urban areas.
In Alberta, rural residents and men were more likely to sustain spinal injuries, mainly due to vehicle accidents [20]. Using data from the Canadian Institute for Health Information (CIHI), Macpherson et al. [19] investigated all Canadian children hospitalized due to bicycling-related injuries (1994-1998, n = 9367). The average annual incidence rate for bicycle-related head injuries in children was 18.5 per 100, 000 for children living in rural compared with 10.9 in urban areas, 15.5 in mixed urban and 17.4 in mixed rural areas. Logistic regression, controlling for age, sex, socio-economic status (SES), collision with a motor vehicle, and the presence of provincial helmet legislation, suggested that this variation may be explained by differences in bicycling exposure, helmet use, hospital admission criteria, or road environments across geographic areas.
A population-based study of motor vehicle trauma among children and youth in Alberta examined police report data for the period from 1997 to 2002 [21]. Across all age and sex strata, both hospitalization and fatality rates were significantly higher in rural compared with urban regions. After adjusting for age, sex, and calendar year, the relative risk for motor vehicle trauma hospitalization (rural versus urban) was 3.0 (95% CI: 2.8, 3.2), and for fatality, 5.4 (95% CI: 4.2, 6.9).
Accidental poisoning and Other non-work injuries
The research on rural/urban differences in accidental poisoning and non-work injuries in Canada is non-existent. However, a limited number of researchers in other countries have examined this topic. Boland and colleagues [22] conducted a study of urban/rural differences in mortality and hospital admission rates for non-work injuries in the Republic of Ireland. Central Statistics Office mortality data from 1980-2000 were used to calculate standardized mortality ratios (SMRs) in residents of urban and rural areas, and standardized hospital admission ratios (SARs) in urban and rural residents were calculated using hospital admission data (Hospital In-Patient Enquiry) from 1993-2000. The overall rate of non-work injury mortality was significantly higher among rural residents (SMR 103.0, 95% CI 101-105), and also for deaths related to drowning, accidents and injury from machinery, and firearms. Among rural residents SARs were significantly higher for injuries from falls, being struck by or against an object, fire or burns, and accident and injury from machinery.
A cross-sectional study of poisoning of children aged 0-4 years based on crude rates of hospitalizations in Australia during the financial year 1996-97 found significantly higher rates among children living in rural and remote areas compared with those living in metropolitan areas [23]. Rate differentials increased with geographical remoteness.
A UK study calculated SMRs using data from the longitudinal study of the Office of Population Censuses and Surveys, a quasi-random 1% sample of the population of England and Wales [24]. In general, the results demonstrated a striking similarity between metropolitan and non-metropolitan areas, for deaths from accident, violence, and poison.
Assault
A 1991 Canadian study on domestic homicide involving firearms [25] showed that almost half (49%) of domestic homicides occurred in rural areas (i.e., places with a population less than 10,000), even though rural residences account for only 23% of the population. However, consistent with previous research, urban dwellers report higher rates of personal victimization--including sexual assault, robbery, assault, break and enter, motor vehicle/parts theft and vandalism--than those from rural areas. Urban residents reported a total personal victimization rate over 40% higher than that of rural dwellers (199 versus 138 per 1,000) [26].
Estimates of the rates of violence against women in rural Canada are few [27]. The Statistic Canada General Social Survey found no variation in reported rates of spousal violence between urban and rural men and women [28]. However, in rural areas, 2% of women and 1% of men reported spousal violence in the past 12 months by their current partners, compared to 1% of women and 2% of men in urban areas. Notably though, availability of services that address domestic violence, including health services, is lower in rural areas. This may reduce reporting rates for rural citizens [27]. In a cross-sectional survey in a rural health region in Alberta, among 526 women, 5% of women reported experiencing physical assault in the last 12 months and 23% reported experiencing sexual assault in their lifetime, indicating that rates of spousal abuse in rural regions are moderately high [29].
Medical Misadventure
There is a lack of research on how patient safety and quality of care differ between rural and urban settings [30]. A review of the limited available research, mainly from the United States, suggests that patient safety events and medical errors may be less likely to occur in rural than in urban hospitals [31]. For example, Romano et al. [32] conducted a study of patient safety in the U.S. [33]. They found that the incidence of most Patient Safety Incidents was highest at urban teaching hospitals. The Harvard Medical Practice Study, conducted in acute care hospitals in New York State in 1984 also showed significantly lower medical injury rates in rural compared to metropolitan hospitals [34].
