Elsevier

Epilepsy & Behavior

Volume 122, September 2021, 108181
Epilepsy & Behavior

Review
A systematic literature review of health disparities among rural people with epilepsy (RPWE) in the United States and Canada

https://doi.org/10.1016/j.yebeh.2021.108181Get rights and content

Highlights

  • Epilepsy can be burdensome for patients, families, health systems, and society.

  • Health disparities of people with epilepsy can be worsened by living in rural areas.

  • Demographics and socioeconomic status drive the poor outcomes, not rurality per se.

  • Prospective studies with standard definitions of rural are needed.

Abstract

Background

Epilepsy is a leading cause of global disease burden, with people with epilepsy (PWE) experiencing adverse health outcomes related to the psychiatric comorbidities and socioeconomic consequences of the disorder. Rural populations are more likely to be impoverished or uninsured, which could impact health outcomes for rural-dwelling PWE (RPWE).

Aims

This systematic literature review identified original research studying health disparities and outcomes among RPWE in the United States and Canada to (1) characterize the disparities faced by RPWE and (2) elucidate the effects of these disparities upon clinical outcomes.

Methods

We performed a systematic search of six electronic databases: Pubmed, Cochrane, PsychInfo, Web of Science, Scopus, and Ovid. Articles considered were original research reports conducted in Canada or the United States before August 2020. A modified Newcastle Ottawa Scale was used to assess the quality of the included studies.

Results

Our search returned 2093 articles that examined the health disparities of RPWE, of which six met criteria for this review. Outcome measures of health disparity included in these papers were mortality (2; 33%), use of health resources (2; 33%), and epilepsy prevalence (2; 33%). Only one paper (16%) concluded that RPWE experienced worse health outcomes relative to urban-dwelling PWE, while 5 (84%) found no difference.

Conclusion

Our study did not find sufficient evidence that RPWE in the US and Canada experience significant health disparities compared to similar urban populations of PWE. More research using prospective studies and datasets allowing better characterization of rurality is required.

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

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