Quirey Parker Elle, Klabbers Gonnie
Queen's University Belfast, Belfast, UK.
Maastricht University, Maastricht, Netherlands.
J Urban Health. 2025 Sep 4. doi: 10.1007/s11524-025-00989-6.
It is widely acknowledged that child mortality rates have been higher in rural than urban areas in sub-Saharan Africa (SSA); a phenomenon appreciated as the urban advantage. However, since at least the 1980s, this urban advantage has been narrowing, and in some cases reversing across SSA. While existing studies have primarily focused on establishing this relationship, few clearly define what constitutes urban or rural, with authors using different operationalizations. Even fewer explore the underlying drivers of change. Rural and urban health outcomes are associated with both the social determinants of health and the wider political economy of health systems. This study aims to elucidate the factors underpinning the narrowing urban advantage in by examining how such factors are differentially distributed and operate across urban and rural contexts. A scoping search was conducted for English-language peer-reviewed published articles after 1990 on urban and rural child health disparities in SSA. Databases used included PubMed, Embase, and Web of Science. Overall, 21 articles were included in the scope of this review. This review adhered to PRISMA-ScR guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews). This review examines the extent to which urban areas in SSA continue to confer a survival advantage in child mortality, and the mechanisms underlying shifts in this trend. Four key categories of determinants-environmental, healthcare-related, sociodemographic, and disease/morbidity-related-consistently emerge across the literature, though their significance and strength vary across rural and urban settings. Notably, the review identifies a growing influence of intra-urban inequality, driven by informal urbanization and the expansion of slums, as a central factor in the narrowing urban advantage. The operationalization of urbanicity and rurality was inconsistent across studies, and rigid geographical classifications often obscured important spatial and contextual nuances. These findings underscore the limitations of conventional rural-urban comparisons and highlight the need for more nuanced frameworks that reflect the complex, evolving landscape of urban poverty and child health in SSA. The spatial reconfiguration of urban poverty appears to be modifying the distribution of child health risks in manners not captured by traditional urban-rural comparisons. Future research should focus on employing an urban continuum in demographic research, accounting for intra-urban inequities within the context of rapid urbanization processes which are altering the urban health landscape, and reshaping the social determinants of child mortality across the urban-rural spectrum.
人们普遍认为，撒哈拉以南非洲（SSA）农村地区的儿童死亡率高于城市地区；这一现象被视为城市优势。然而，至少自20世纪80年代以来，这种城市优势一直在缩小，在某些情况下，整个撒哈拉以南非洲地区的这种优势甚至发生了逆转。虽然现有研究主要集中在确立这种关系上，但很少有研究明确界定什么构成城市或农村，作者们使用的操作定义各不相同。更少的研究探讨变化的潜在驱动因素。农村和城市的健康结果与健康的社会决定因素以及卫生系统更广泛的政治经济状况都有关联。本研究旨在通过考察这些因素在城市和农村环境中如何不同地分布和起作用，来阐明城市优势缩小背后的因素。对1990年以后发表的关于撒哈拉以南非洲城市和农村儿童健康差距的英文同行评审文章进行了范围界定检索。使用的数据库包括PubMed、Embase和科学网。总体而言，本综述纳入了21篇文章。本综述遵循PRISMA-ScR指南（系统评价和元分析扩展的范围界定综述的首选报告项目）。本综述考察了撒哈拉以南非洲城市地区在儿童死亡率方面继续具有生存优势的程度，以及这一趋势转变的潜在机制。在整个文献中，始终出现四个关键类别的决定因素——环境、医疗保健相关、社会人口统计学和疾病/发病率相关——尽管它们在农村和城市环境中的重要性和强度各不相同。值得注意的是，该综述发现，由非正规城市化和贫民窟扩张驱动的城市内部不平等的影响日益增加，是城市优势缩小的一个核心因素。城市化和农村化的操作定义在各项研究中不一致，严格的地理分类往往掩盖了重要的空间和背景细微差别。这些发现强调了传统城乡比较方法的局限性，并突出了需要更细致入微的框架，以反映撒哈拉以南非洲城市贫困和儿童健康复杂且不断演变的状况。城市贫困的空间重新配置似乎正在以传统城乡比较方法未涵盖的方式改变儿童健康风险的分布。未来的研究应侧重于在人口研究中采用城市连续体概念，在快速城市化进程改变城市健康状况并重塑城乡范围内儿童死亡率的社会决定因素的背景下，考虑城市内部的不平等问题。
