Rural-Urban Differences in Diabetes Care and Control in 42 Low- and Middle-Income Countries: A Cross-sectional Study of Nationally Representative Individual-Level Data

• Type of Material: Article
• Authors: David Flood, University of Michigan; Pascal Geldsetzer, Stanford University; Kokou Agoudavi, Togo Ministry of Health; Krystal K. Aryal, Public Health Promotion and Development Organization; Luisa Campos Caldeira Brant, Universidade Federal de Minas Gerais; Garry Brian, The Fred Hollows Foundation New Zealand; Maria Dorobantu, University of Medicine and Pharmacy Carol Davila; Farshad Farzadfar, Tehran University of Medical Sciences; Oana Gheorghe-Fronea, University of Medicine and Pharmacy Carol Davila; Mongal Singh Gurung, Ministry of Health, Thimphu Bhutan; David Guwatudde, Makerere University; Corine Houehanou, University of Abomey-Calavi; Jutta M. Adelin Jorgensen, University of Copenhagen; Dimple Kondal, Public Health Foundation of India; Demetre Labadarios, Stellenbosch University; Maja E. Marcus, University of Göttingen; Mary Mayige, National Institute for Medical Research, Dar es Salaam Tanzania; Mana Moghimi, Tehran University of Medical Sciences; Bolormaa Norov, National Center for Public Health, Ulaanbaatar Mongolia; Gastón Perman, Instituto Universitario Hospital Italiano de Buenos Aires; Sarah Quesnel-Crooks, Caribbean Public Health Agency; Mohammad-Mahdi Rashidi, Tehran University of Medical Sciences; Sahar Saeedi Moghaddam, Tehran University of Medical Sceinces; Jacqueline A. Seiglie, Massachusetts General Hospital; Silver K. Bahendeka, Uganda Martyrs University; Eric Steinbrook, University of Michigan Medical School; Michaela Theilmann, Heidelberg University and University Hospital; Lisa J. Ware, University of Witwatersrand; Sebastian Vollmer, University of Göttingen; Rifat Aftun, Harvard University; Justine I. Davies, University of Birmingham; Mohammed K Ali, Emory University; Peter Rohloff, Center for Indigenous Health Research; Jennifer Manne-Goehler, Harvard Medical School
• Language: English
• Date: 2022-06-30
• Publisher: American Diabetes Association
• Publication Version: Final Published Version
• Copyright Statement: © 2022, American Diabetes Association
• License: Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International
• Final Published Version (URL): https://doi.org/10.2337%2Fdc21-2342
• Title of Journal or Parent Work: Diabetes Care
• Volume: 45
• Issue: 9
• Start Page: 1961
• End Page: 1970
• Grant/Funding Information: D.F. was supported by a Pilot and Feasibility Grant funded by the Michigan Center for Diabetes Translational Research (National Institutes of Health [NIH] grant P30-DK092926) and fellowship funding from the Veterans Health Administration and National Clinician Scholars Program at the University of Michigan. P.G. was supported by the National Center for Advancing Translational Sciences of the NIH under award number KL2TR003143. J.A.S. was supported by grant T32DK007028 from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and by grant 5KL2TR002542–03 (Harvard Catalyst). J.M.-G. was supported by grant K23 DK125162 from the NIDDK.
• Keywords: diabetes; income inequality; rural health
• Research Categories: Health Sciences, Public Health; Health Sciences, Health Care Management

Abstract

OBJECTIVE Diabetes prevalence is increasing rapidly in rural areas of low- and middle-income countries (LMICs), but there are limited data on the performance of health systems in delivering equitable and effective care to rural populations. We therefore assessed rural-urban differences in diabetes care and control in LMICs. RESEARCH DESIGN AND METHODS We pooled individual-level data from nationally representative health surveys in 42 countries. We used Poisson regression models to estimate age-adjusted differences in the proportion of individuals with diabetes in rural versus urban areas achieving performance measures for the diagnosis, treatment, and control of diabetes and associated cardiovascular risk factors. We examined differences across the pooled sample, by sex, and by country. RESULTS The pooled sample from 42 countries included 840,110 individuals (35,404 with diabetes). Compared with urban populations with diabetes, rural populations had ∼15–30% lower relative risk of achieving performance measures for diabetes diagnosis and treatment. Rural populations with diagnosed diabetes had a 14% (95% CI 5–22%) lower relative risk of glycemic control, 6% (95% CI −5 to 16%) lower relative risk of blood pressure control, and 23% (95% CI 2–39%) lower relative risk of cholesterol control. Rural women with diabetes had lower achievement of performance measures relating to control than urban women, whereas among men, differences were small. CONCLUSIONS Rural populations with diabetes experience substantial inequities in the achievement of diabetes performance measures in LMICs. Programs and policies aiming to strengthen global diabetes care must consider the unique challenges experienced by rural populations.