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

Author:

Flood David123ORCID,Geldsetzer Pascal45,Agoudavi Kokou6,Aryal Krishna K.7,Brant Luisa Campos Caldeira89,Brian Garry10,Dorobantu Maria11,Farzadfar Farshad12,Gheorghe-Fronea Oana1113,Gurung Mongal Singh14,Guwatudde David15,Houehanou Corine16,Jorgensen Jutta M. Adelin17,Kondal Dimple1819,Labadarios Demetre20,Marcus Maja E.21,Mayige Mary22,Moghimi Mana12,Norov Bolormaa23,Perman Gastón24,Quesnel-Crooks Sarah25,Rashidi Mohammad-Mahdi12,Moghaddam Sahar Saeedi26,Seiglie Jacqueline A.27,Bahendeka Silver K.2829,Steinbrook Eric30,Theilmann Michaela31,Ware Lisa J.3233,Vollmer Sebastian21,Atun Rifat3435,Davies Justine I.363738,Ali Mohammed K.3940,Rohloff Peter241,Manne-Goehler Jennifer4243

Affiliation:

1. 1Division of Hospital Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI

2. 2Center for Indigenous Health Research, Wuqu’ Kawoq, Tecpán, Guatemala

3. 3Research Center for the Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama, Guatemala City, Guatemala

4. 4Division of Primary Care and Population Health, Stanford University, Stanford, CA

5. 5Chan Zuckerberg Biohub, San Francisco, CA

6. 6Togo Ministry of Health, Lome, Togo

7. 7Public Health Promotion and Development Organization, Kathmandu, Nepal

8. 8Serviço de Cardiologia e Cirurgia Cardiovascular, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil

9. 9Departamento de Clínica Médica, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil

10. 10The Fred Hollows Foundation New Zealand, Auckland, New Zealand

11. 11University of Medicine and Pharmacy Carol Davila, Bucharest, Romania

12. 12Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran

13. 13Cardiology Department, Emergency Hospital Bucharest, Bucharest, Romania

14. 14Health Research and Epidemiology Unit, Ministry of Health, Thimphu, Bhutan

15. 15Department of Epidemiology and Biostatistics, School of Public Health, Makerere University, Kampala, Uganda

16. 16Laboratory of Epidemiology of Chronic and Neurological Diseases, Faculty of Health Sciences, University of Abomey-Calavi, Cotonou, Benin

17. 17Department of Public Health, University of Copenhagen, Copenhagen, Denmark

18. 18Public Health Foundation of India, Gurugram, India

19. 19Centre for Chronic Disease Control, New Delhi, India

20. 20Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa

21. 21Department of Economics and Centre for Modern Indian Studies, University of Göttingen, Göttingen, Germany

22. 22National Institute for Medical Research, Dar es Salaam, Tanzania

23. 23Division of Nutrition, National Center for Public Health, Ulaanbaatar, Mongolia

24. 24Department of Public Health, Instituto Universitario Hospital Italiano de Buenos Aires, Buenos Aires, Argentina

25. 25Non-Communicable Diseases, Caribbean Public Health Agency, Port of Spain, Trinidad and Tobago

26. 26Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran

27. 27Diabetes Unit, Massachusetts General Hospital, Boston, MA

28. 28Saint Francis Hospital Nsambya, Kampala, Uganda

29. 29Uganda Martyrs University, Kampala, Uganda

30. 30University of Michigan Medical School, Ann Arbor, MI

31. 31Heidelberg Institute of Global Health, Heidelberg University and University Hospital, Heidelberg, Germany

32. 32South African Medical Research Council–Wits Developmental Pathways for Health Research Unit, Faculty of Health Sciences, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa

33. 33Department of Science and Innovation–National Research Foundation Centre of Excellence in Human Development, University of the Witwatersrand, Johannesburg, South Africa

34. 34Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA

35. 35Department of Global Health and Social Medicine, Harvard Medical School, Harvard University, Boston, MA

36. 36Institute of Applied Health Research, University of Birmingham, Birmingham, U.K

37. 37Centre for Global Surgery, Department of Global Health, Stellenbosch University, Stellenbosch, South Africa

38. 38Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa

39. 39Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA

40. 40Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, GA

41. 41Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA

42. 42Division of Infectious Diseases, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA

43. 43Medical Practice Evaluation Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA

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.

Funder

Harvard Catalyst

National Institute of Diabetes and Digestive and Kidney Diseases

National Institutes of Health

NIDDK

National Center for Advancing Translational Sciences of the National Institutes of Health

National Clinician Scholars Program at the University of Michigan Institute for Healthcare Policy & Innovation

Publisher

American Diabetes Association

Subject

Advanced and Specialized Nursing,Endocrinology, Diabetes and Metabolism,Internal Medicine

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