ReviewA systematic literature review of health disparities among rural people with epilepsy (RPWE) in the United States and Canada
Introduction
Epilepsy is the second-most burdensome neurologic disorder worldwide in disability adjusted-life years [1] and affects an estimated 3.4 million people, or 1.2% of the U.S. population [2]. One 2004 study estimated the economic impact of epilepsy to be approximately $9.5 billion in direct medical care costs in the United States alone [3]. For patients, the financial burden of epilepsy is just one consequence of this chronic condition. One in five people with epilepsy (PWE) have cognitive limitations, and 30–50% will struggle with major depressive disorder. Driving restrictions are placed on those with seizures, and, as such, 45.7% of those with active epilepsy face work limitations or are unable to work [4]. Furthermore, these restrictions may be exacerbated by other factors, including enhanced stigma, lower socioeconomic status, and poor quality of life [5].
The U.S. Bureau of the Census defines “rural” as all population, housing, and territory not included within urbanized areas or urban clusters [6]. By this definition, 19.3% of the U.S. population lives in a rural area. As a group, rural populations possess significant health disparities compared to urban populations [7], [8], [9]. Rural communities have more uninsured residents under 65, lower median household incomes, higher percentage of children living in poverty, and higher rates of all-cause mortality [7]. Rural-dwelling individuals experience increased travel time, distance and, consequently, perceived difficulty in obtaining care [10], [11]. At the patient-level, rural-dwellers have lower educational levels, earn less income and are more likely to be unemployed [12].
Elucidating the impact of health disparities on rural-dwelling people with epilepsy (RPWE) is warranted given epilepsy’s prevalence and cost to society, as well as the mounting evidence regarding a rural–urban healthcare gap. Insights into these discrepancies can help inform policy and practice interventions aiming to improve outcomes for RPWE. In this systematic literature review, we assess and describe the original research on health disparities in RPWE in the United States and Canada by analyzing population definitions, study designs, and conclusions on health outcomes. We expect that the results of this analysis will help identify gaps in the literature and provide guidance for further study. We hypothesized that RPWE in the United States and Canada experienced more health disparities compared to urban-dwelling PWE.
Section snippets
Search strategy
In collaboration with a university research librarian (AS), six electronic databases (Pubmed, Cochrane, PsychInfo, Web of Science, Scopus and Ovid) were searched for original research on the health outcomes of RPWE compared to other groups of PWE. For this study, we used the definition of health disparity by Carter-Pokras and Baquet as, “differences in health outcomes and their determinants between segments of the population, as defined by social, demographic, environmental, and geographic
Study identification and description
The article-selection process is summarized in Fig. 1b. Initial search results included 2093 articles, of which 54 were selected for full-text review. Five articles met our inclusion/exclusion criteria [16], [17], [18], [19], [20]. One further article was added during hand-search [21]. Table 1 presents the results of the data extraction from the six papers. All six included articles were observational studies (four cohort studies and two cross-sectional studies) that directly compared rural and
Discussion and future directions
Area of residence can affect health at the person level (i.e., lack of routine care, lifestyle, behavior) or the environmental level (i.e., health care shortages, access to care, poverty) [24]. Sixty-five percent of rural areas are considered health professional shortage areas [25]. Consequently, people in rural areas have fewer overall visits to a physician and less referrals to specialists [25], [26], [27]. Given the significant health disparities of the rural population as a whole, one might
Conclusions
Our present study did not find sufficient evidence to conclusively confirm or refute the hypothesis that RPWE face or experience worse health disparities than similar urban populations of PWE. Limitations may include an overall paucity of studies, and a causality dilemma among rurality, lower SES, and epilepsy, which makes it difficult to tease out the effects of rural-dwelling alone. This review adds to the growing literature suggesting that the health disparities experienced by PWE may be a
Funding sources
This publication is a product of a Health Promotion and Disease Prevention Research Center supported by Cooperative Agreement Number 6 U48DP006389 from the Centers for Disease Control and Prevention (CDC). The findings and conclusion in the report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Support was received from the Institute for Clinical and Translational Science at the University of Iowa and the
Declaration of Competing Interest
Dr. Sajatovic has received research grants from Otsuka, Alkermes, Janssen, Reuter Foundation, Woodruff Foundation, Reinberger Foundation, National Institutes of Health (NIH), Centers for Disease Control and Prevention (CDC) and International Society of Bipolar Disorders in the past 3 years; is a consultant for Bracket, Otsuka, Sunovion, Neurocrine, Supernus and Health Analytics; has received royalties from Springer Press, Johns Hopkins University Press, Oxford Press and UpToDate; and has
References (30)
- et al.
Tracking Psychosocial Health in Adults with Epilepsy—Estimates from the 2010 National Health Interview Survey
Epilepsy Behav
(2014) - et al.
Illness severity and propensity to travel along the urban-rural continuum
Health Place
(2007) - et al.
Mortality in people with epilepsy: A statewide retrospective cohort study
Epilepsy Res
(2016) - et al.
Socioeconomic variables explain rural disparities in US mortality rates: Implications for rural health research and policy
SSM Popul Health
(2018) - et al.
Health-care access among adults with epilepsy: The U.S. National Health Interview Survey, 2010 and 2013
Epilepsy Behav
(2016) - GBD 2017 DALYs and HALE Collaborators. Global, regional, and national disability-adjusted life-years (DALYs) for 359...
- et al.
National and state estimates of the numbers of adults and children with active epilepsy - United States, 2015
MMWR Morb Mortal Wkly Rep
(2017) - et al.
Economic impact of epilepsy in the United States
Epilepsia
(2009) - et al.
Socioeconomic status, health care use, and outcomes: persistence of disparities over time
Epilepsia
(2011) - Ratcliffe M, Burd C, Holder K, Fields A. Defining rural at the U.S. Census Bureau. Available from:...
Rural Health Snapshot
The disparity called rural health: what is it, and what needs to be done?
Aust J Rural Health
Growth and persistence of place-based mortality in the United States: the rural mortality penalty
Am J Public Health
How adults’ access to outpatient physician services relates to the local supply of primary care physicians in the rural southeast
Health Serv Res
National and regional prevalence of self-reported epilepsy in Canada
Epilepsia
Cited by (5)
Disparities in the nationwide distribution of epilepsy centers
2021, Epilepsy and BehaviorCitation Excerpt :Despite epilepsy surgery’s unequivocal superiority to medical therapy for drug-resistant epilepsy (DRE), many disparities limit its utilization.[1] Prior literature has shown a strong association between socioeconomic status and epilepsy prevalence, particularly in rural populations.[2,3] A 2018 review by Nathan et al., outlined major factors influencing health disparities in epilepsy care, using the acronym FACETS (fear of treatment, access to care, communication barriers, education, trust between patient and physician, and social support).[4]
What is the price of residence in rural areas for patients with epilepsy?
2023, Neurological ResearchSocioeconomic disparities in epilepsy care
2022, Current Opinion in Neurology