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

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.

Figure 1

Differences in achievement of diabetes performance measures among rural versus urban (reference category) populations. Results are generated from survey-weighted multivariable Poisson regression models with robust SEs adjusted for clustering at the level of the primary sampling unit and inclusion of covariates of rural versus urban residence and age. Age is included as a continuous variable using restricted cubic splines with five knots at the following percentiles: 5, 27.5, 50, 72.5, and 95% (29). Error bars indicate 95% CIs. BP, blood pressure; med, medication.

Figure 2

Diabetes performance measures among rural versus urban populations. A: Age-adjusted proportion of individuals with diabetes achieving performance measures are calculated as predictive margins from survey-weighted multivariable Poisson regression models with robust SEs adjusted for clustering at the level of the primary sampling unit and inclusion of covariates of rural versus urban residence and age. Estimates underlying the figure are presented in Supplementary Material. Error bars indicate 95% CIs. B: Population of individuals achieving and not achieving performance measures are calculated using a hypothetic country with the same rural-urban demographics as the pooled sample and a population of 10 million individuals. Estimates underlying the figure are presented in Supplementary Material. BP, blood pressure.

Figure 3

Differences in achievement of diabetes performance measures among rural versus urban (reference category) populations by sex. Results are generated from sex-stratified survey-weighted multivariable Poisson regression models with robust SEs adjusted for clustering at the level of the primary sampling unit and inclusion of covariates of rural versus urban residence and age. Error bars indicate 95% CIs. BP, blood pressure; med, medication.