A multilevel analysis of the effects of rurality and social deprivation onpremature limiting long term illness

Study objective-To examine the geographical variation in self perceived mor bidity in the south west of England, and assess the associations with rural ity and social deprivation. Design-A geographically based cross sectional study using 1991 census data on premature Limiting Long Term Illness (LLTI). The urban-rural and intra-r ural variation in standardised premature LLTI ratios is described, and corr elation and regression analyses explore how well this is explained by gener ic deprivation indices. Multilevel Poisson modelling investigates whether C ustomised Deprivation Profiles (CDPs) and area characteristics improve upon the generic indices. Setting-Nine counties in the south west of England Participants-The population of the south west enumerated in the 1991 census . Main results-Intra-rural variation is apparent, with higher rates of premat ure LLTI in remoter areas. Together with high rates in urban areas and lowe r rates in the semi-rural areas this indicates the existence of a U shaped relation with rurality. The generic deprivation indices have strong positiv e relations with premature LLTI in urban areas, but these are a lot weaker in semi-rural and rural locations. CDPs improve upon the generic indices, e specially in the rural settings. A substantial reduction in unexplained var iation in rural areas is seen after controlling for the level of local isol ation, with higher isolation, at the wider geographical scale, being relate d to higher levels of LLTI. Conclusions-This study highlights the need to treat rural areas as heteroge neous, although this has not been the tendency in health research. Generic deprivation indices are unlikely to be a true reflection of levels of depri vation in rural environments. The importance of CDPs that are specific to t he area type and health outcome is emphasised. The significance of physical isolation suggests that accessibility to public and health services may be an important issue, and requires further research.