County-Level Poverty Is Equally Associated With Unmet Health Care Needs in Rural and Urban Settings


  • Lars E. Peterson MD, PhD,

    1. Department of Family Medicine, Medical University of South Carolina, Charleston, South Carolina
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  • David G. Litaker MD, PhD

    1. Departments of Medicine, Epidemiology and Biostatistics; and Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio
    2. Mannheim Institute of Public Health, Social and Preventive Medicine, Mannheim, Germany
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  • This study was supported, in part, by NIH/AHRQ Training Grant N0. 2 T32 HS00059 (LP), and VA IIR 06-091 and 1R25T CA111898 (DL). The authors wish to express their appreciation to Drs. Duncan Neuhauser, Robert Binstock, and Aloen Townsend for their insightful comments on earlier versions of this manuscript. For further information, contact: Lars Peterson, MD, PhD, 9228 Medical Plaza Drive, N. Charleston, SC 29406; e-mail


Context: Regional poverty is associated with reduced access to health care. Whether this relationship is equally strong in both rural and urban settings or is affected by the contextual and individual-level characteristics that distinguish these areas, is unclear.

Purpose: Compare the association between regional poverty with self-reported unmet need, a marker of health care access, by rural/urban setting.

Methods: Multilevel, cross-sectional analysis of a state-representative sample of 39,953 adults stratified by rural/urban status, linked at the county level to data describing contextual characteristics. Weighted random intercept models examined the independent association of regional poverty with unmet needs, controlling for a range of contextual and individual-level characteristics.

Findings: The unadjusted association between regional poverty levels and unmet needs was similar in both rural (OR = 1.06 [95% CI, 1.04-1.08]) and urban (OR = 1.03 [1.02-1.05]) settings. Adjusting for other contextual characteristics increased the size of the association in both rural (OR = 1.11 [1.04-1.19]) and urban (OR = 1.11 [1.05-1.18]) settings. Further adjustment for individual characteristics had little additional effect in rural (OR = 1.10 [1.00-1.20]) or urban (OR = 1.11 [1.01-1.22]) settings.

Conclusions: To better meet the health care needs of all Americans, health care systems in areas with high regional poverty should acknowledge the relationship between poverty and unmet health care needs. Investments, or other interventions, that reduce regional poverty may be useful strategies for improving health through better access to health care.