Comparing Across Health Indices: Differences by Rurality, Missingness, and Associations With Health Outcomes

Area-level indices of vulnerability, deprivation, prosperity, and the like are increasingly being applied in policy, reimbursement methods, and resource allocation. Measures captured within these indices are often described as reflecting the social determinants of health, social risk factors, health-related social needs, and similar constructs. Examples of such indices include the Prosperity Index, Social Vulnerability Index, Social Deprivation Index, Opportunity Index, and many others. However, the underlying evidence base lacks a sufficient focus on rurality to inform such uses and to understand their implications for rural communities. The purpose of this study was to compare the area-level indices and score missingness by measures of rurality. Further, researchers examined associations between indices and health-related outcomes of interest. This study provided policymakers and researchers with a deeper understanding of how indices compare and their relationships with health outcomes in rural communities. Findings could guide the selection and application of area-level indices in policy, practice, and research with considerations for any potential differential findings in rural communities.

This study utilized publicly available data and a quantitative, cross-sectional design to compare scores and missingness of indices by rurality and associations with health outcomes of interest. Researchers selected indices that meet several criteria including: national in scope, created for a general purpose, publicly available or can be calculated using publicly available data and methodologies, available either at the census tract or county-level, and updated since 2019. Researchers conducted bivariate and multivariate analyses of the associations between indices and health outcomes, and differences by rurality. Given that counties are the primary spatial unit for operational levels of emergency management and public health statistics in the U.S., researchers conducted these analyses on a subset of indices available at the county-level. Health outcomes of interest were related to cost, quality, access to care, or health status. Examples included Medicare expenditures and utilization, insurance coverage, mortality rates, and supply of health care providers. These analyses used multivariate linear and logistic regression, and spatial analyses such as spatial lag/error regression were considered. To better describe relationships between indices and health outcomes, researchers conducted analyses to detect the potential mediating role of rurality (e.g., formal mediation analyses or stratified analyses).

Publications

• An Assessment of Area-Level Vulnerability and Resilience Indices by Geography: A Rural-Urban Comparison
  Journal Article
  ETSU/NORC Rural Health Research Center
  Date: 07/2025
  Area-level vulnerability and resilience indices are widely used to address health needs by informing resource allocation and policy. Researchers found that indices differ from each other and by rurality, contributing to the growing body of evidence to inform the use and improvement of these indices.