American Diabetes Association
HPACC_rural-urban_appendices_-_2022_04_20.pdf (1.01 MB)

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

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posted on 2022-06-30, 17:20 authored by David Flood, Pascal Geldsetzer, Kokou Agoudavi, Krishna K. Aryal, Luisa Campos Caldeira Brant, Garry Brian, Maria Dorobantu, Farshad Farzadfar, Oana Gheorghe-Fronea, Mongal Singh Gurung, David Guwatudde, Corine Houehanou, Jutta M Adelin Jorgensen, Dimple Kondal, Demetre Labadarios, Maja E. Marcus, Mary Mayige, Mana Moghimi, Bolormaa Norov, Gastón Perman, Sarah Quesnel-Crooks, Mohammad-Mahdi Rashidi, Sahar Saeedi Moghaddam, Jacqueline A. Seiglie, Silver Bahendeka Karaireho, Eric Steinbrook, Michaela Theilmann, Lisa J. Ware, Sebastian Vollmer, Rifat Atun, Justine I. Davies, Mohammed K. Ali, Peter Rohloff, Jennifer Manne-Goehler



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.


The pooled sample from 42 countries included 840,110 individuals (35,404 with diabetes). Compared to urban populations with diabetes, rural populations had approximately 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% to 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% to 39%) lower relative risk of cholesterol control. Rural women with diabetes had lower achievement of performance measures relating to control than urban women, while among men differences were small.

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.



DF was supported by a Pilot and Feasibility Grant funded by the Michigan Center for Diabetes Translational Research (NIH Grant P30-DK092926) and fellowship funding from the Veterans Health Administration and National Clinician Scholars Program at the University of Michigan. PG was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under award number KL2TR003143. JAS was supported by grant number T32DK007028 from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and by grant number 5KL2TR002542–03 (Harvard Catalyst). JMG was supported by grant K23 DK125162 from the NIDDK.


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