Self-identified rurality in a nationally representative population in the US

Introduction: In the US, health services research most often relle on Rural-Urban Commuting Area (RUCA) classification codes to measure rurality. This measure is known to misrepresent rurality and does not rely on individual experiences of rurality associated with healthcare inequities. We aimed to determine a patient- centered RUCA-based definition of rurality. Methods: In this cross-sectional study, we conducted an online survey asking US residents, "Do you live in a rural area? and the rationale for their answer. We evaluated the concordance between their self-identified rurality and their ZIP code-derived RUCA designation of rurality by calculating Cohen's kappa (K) statistic and percent agreement. Results: Of the 774 participants, 456 (58.9%) and 318 (41.1%) Individuals had conventional urban and rural RUCA classifications, respectively. There was only moderate agreement between perceived rurality and rural RUCA classification (K=0.48; 95% confidence interval (CI)=0.42-0.54). Among people living within RUCA 2-3 defined urban areas (n=51), percent agreement was only 19.6%. Discordance was driven by their perception of the population density, proximity to the nearest neighbor, proximity to a metropolitan area, and the number of homes in their area. Based on our results, we reclassified RUCA 2-3 designations as rural, resulting in an increase in overall concordance (K=0.56; 95%CI=0.50-0.62), Discussion: Patient-centered rural-urban classification is required to effectively evaluate the impact of rurality on health disparities. This study presents a more patient-centric RUCA-based classification of rurality that can be easily operationalized in future research in situations in which self-reported rural status is missing or challenging to obtain. Conclusion: Reclassification of RUCA 2-3 as rural represents a more patient-centric definition of rurality.