The Growing Divide in the Composition of Public Health Delivery Systems in US Rural and Urban Communities, 2014–2018.

Objectives. To examine changes in the scope of activity and organizational composition of public health delivery systems serving rural and urban US communities between 2014 and 2018. Methods. We used data from the National Longitudinal Survey of Public Health Systems to measure the implementation of recommended public health activities and the network of organizations contributing to these activities in a nationally representative cohort of US communities. We used multivariable regression models to test for rural–urban differences between 2014 and 2018. Results. The scope of recommended activities implemented in rural areas declined by 3.4 percentage points between 2014 and 2018, whereas it increased by 1.4 percentage points in urban areas. The rural–urban disparity in scope of activities grew by a total of 4.8 percentage points (P <.05) over this time. The disparity in network density grew by 2.3 percentage points (P <.05). Conclusions. Urban public health systems have enhanced their scope of activities and organizational networks since 2014, whereas rural systems have lost capacity. These trends suggest that system improvement initiatives have had uneven success, and they may contribute to growing rural–urban disparities in population health status. [ABSTRACT FROM AUTHOR]