Socioeconomic Inequality in Chronic Complications of Type 2 Diabetes Mellitus in Iran: Concentration Index and Decomposition Approach
,
Abstract
Background: In Iran, evidence regarding the impact of socioeconomic (SES) inequality on the progression and complications of type 2 diabetes mellitus (T2DM) are sparse and needs growing body of research. SES is a complex construct and its impact on the health outcomes should be evaluated in an efficient and flexible way. The purpose of this study is to examine SES inequality in chronic complications among T2DM patients using methods of decomposing inequality.
Methods: This cross-sectional study included patients with T2DM receiving care at the diabetes clinic in Hamadan City, Iran, between April and September 2023. Demographic, SES, diabetic related factors were obtained from medical records and face-to-face interviews. A binary logistic regression model was utilized to investigate the relationship between diabetes complications and independent variables. The concentration index (CI) and decomposition approach were used to evaluate SES inequality and determine the contribution of each factor to inequality.
Results: A total of 530 patients (61.6% females and 54.9% less than 60 years) were included. In the study population, 22.3%, 9.5%, and 4.7% had retinopathy, kidney failure, and diabetic foot ulcers, respectively. The CI for retinopathy, kidney failure, and foot ulcers were [(CI: -0.273, p<0.001), (CI: -0.089, p<0.001), (CI: -0.122, p<0.001), respectively]. Factors with the greatest contribution to SES inequality for retinopathy were economic status (44.6%), duration of T2DM (24.5%), age (18.7%), and healthy lifestyle (12.5%), for kidney failure were economic status (33.8%), hypertension (22.5%), education level (21.3%), and HbA1c value (13.5%), and for foot ulcers were economic status (78.7%), duration of T2DM (33.6%), HbA1c value (17.2%) hypertension (7.4%).
Conclusion: This study demonstrated that SES inequality in chronic complications of T2DM with greatest contribution for economic status. It is recommended that policymakers and health professionals consider the main causes of SES inequality in the chronic complications of T2DM when developing health strategies.
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7. Fowler MJ. Microvascular and macrovascular complications of diabetes. Clinical diabetes. 2008;26(2):77-82.
8. Ansari P, Akther S, Khan JT, Islam SS, Masud MSR, Rahman A, et al. Hyperglycaemia-linked diabetic foot complications and their management using conventional and alternative therapies. Applied Sciences. 2022;12(22):11777.
9. Dewi F, Hinchliffe RJ. Foot complications in patients with diabetes. Surgery (Oxford). 2020;38(2):108-13.
10. Mounirou BA, Adam ND, Yakoura AK, Aminou MS, Liu YT, Tan LY. Diabetic retinopathy: an overview of treatments. Indian Journal of Endocrinology and Metabolism. 2022;26(2):111-8.
11. Rema M, Premkumar S, Anitha B, Deepa R, Pradeepa R, Mohan V. Prevalence of diabetic retinopathy in urban India: the Chennai Urban Rural Epidemiology Study (CURES) eye study, I. Investigative ophthalmology & visual science. 2005;46(7):2328-33.
12. DeFronzo RA, Reeves WB, Awad AS. Pathophysiology of diabetic kidney disease: impact of SGLT2 inhibitors. Nature Reviews Nephrology. 2021;17(5):319-34.
13. Adler AI, Stevens RJ, Manley SE, Bilous RW, Cull CA, Holman RR, et al. Development and progression of nephropathy in type 2 diabetes: the United Kingdom Prospective Diabetes Study (UKPDS 64). Kidney international. 2003;63(1):225-32.
14. Haire-Joshu D, Hill-Briggs F. The next generation of diabetes translation: a path to health equity. Annual review of public health. 2019;40:391-410.
15. Mahdavi M, Parsaeian M, Farzadfar F, Mohamadi E, Olyaeemanesh A, Takian A. Inequality in prevalence, awareness, treatment, and control of hypertension in Iran: the analysis of national households’ data. BMC Public Health. 2022;22(1):2349.
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28. Association AD. 12. Older Adults: Standards of Medical Care in Diabetes—2020. Diabetes care. 2020;43(Supplement_1):S152-S62.
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30. Wagstaff A, Van Doorslaer E, Watanabe N. On decomposing the causes of health sector inequalities with an application to malnutrition inequalities in Vietnam. Journal of econometrics. 2003;112(1):207-23.
31. Kakwani N, Wagstaff A, Van Doorslaer E. Socioeconomic inequalities in health: measurement, computation, and statistical inference. Journal of econometrics. 1997;77(1):87-103.
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33. Funakoshi M, Azami Y, Matsumoto H, Ikota A, Ito K, Okimoto H, et al. Socioeconomic status and type 2 diabetes complications among young adult patients in Japan. PloS one. 2017;12(4):e0176087.
34. Arambewela MH, Somasundaram NP, Jayasekara HBPR, Kumbukage MP, Jayasena PMS, Chandrasekara CMPH, et al. Prevalence of chronic complications, their risk factors, and the cardiovascular risk factors among patients with type 2 diabetes attending the diabetic clinic at a tertiary care hospital in Sri Lanka. Journal of diabetes research. 2018;2018(1):4504287.
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36. Rotimi C, Daniel H, Zhou J, Obisesan A, Chen G, Chen Y, et al. Prevalence and determinants of diabetic retinopathy and cataracts in West African type 2 diabetes patients. Ethnicity & disease. 2003;13:110-7.
37. Al-Rubeaan K, Al Derwish M, Ouizi S, Youssef AM, Subhani SN, Ibrahim HM, et al. Diabetic foot complications and their risk factors from a large retrospective cohort study. PloS one. 2015;10(5):e0124446.
38. Younis BB, Shahid A, Arshad R, Khurshid S, Ahmad M, Yousaf H. Frequency of foot ulcers in people with type 2 diabetes, presenting to specialist diabetes clinic at a Tertiary Care Hospital, Lahore, Pakistan. BMC Endocrine Disorders. 2018;18:1-6.
39. Sortsø C, Lauridsen J, Emneus M, Green A, Jensen PB. Social inequality in diabetes patients' morbidity patterns from diagnosis to death - A Danish register-based investigation. Scandinavian journal of public health. 2018;46(1):92-101.
40. Ponesai N, Anderson C, Mufuta T, Gombe N, Lucia T, Donewell B. Risk factors for diabetic complications among diabetic patients, Chirumanzu District, Zimbabwe, 2011. Austin J Public Health Epidemiol. 2015;2(2):1-7.
41. Akın S, Bölük C. Prevalence of comorbidities in patients with type–2 diabetes mellitus. Primary care diabetes. 2020;14(5):431-4.
42. Petrie JR, Guzik TJ, Touyz RM. Diabetes, hypertension, and cardiovascular disease: clinical insights and vascular mechanisms. Canadian Journal of Cardiology. 2018;34(5):575-84.
43. Tatsumi Y, Ohkubo T. Hypertension with diabetes mellitus: significance from an epidemiological perspective for Japanese. Hypertension Research. 2017;40(9):795-806.
44. Rwegerera GM, Masaka A, Pina- Rivera Y, Moshomo T, Gaenamong M, Godman B, et al. Determinants of glycemic
control among diabetes mellitus patients in a tertiary clinic in Gaborone, Botswana: findings and implications. Hospital practice. 2019;47(1):34-41.
45. Bachmann M, Eachus J, Hopper C, Davey Smith G, Propper C, Pearson N, et al. Socio‐economic inequalities in diabetes complications, control, attitudes and health service use: a cross‐sectional study. Diabetic Medicine. 2003;20(11):921-9.
46. Kalyango JN, Owino E, Nambuya AP. Non-adherence to diabetes treatment at Mulago Hospital in Uganda: prevalence and associated factors. African health sciences. 2008;8(2):67- 73.
47. Maric-Bilkan C. Sex differences in micro-and macro-vascular complications of diabetes mellitus. Clinical Science. 2017;131(9):833-46.
48. Bruce M, Mallika MV. Prevalence of complications of diabetes among patients with diabetes mellitus attending a tertiary care centre in Tamil Nadu. International Journal Of Community Medicine And Public Health. 2019.
49. Naseer S, Malkera A, Khan N, Siddiqui AH, Khan SA, Ali S, et al. Prevalence of diabetic complications in urban and rural population of Punjab. Pakistan Journal of Medical & Health Sciences. 2022;16(03):69-.
50. Hwang J, Rudnisky C, Bowen S, Johnson JA. Income-related inequalities in visual impairment and eye screening services in patients with type 2 diabetes. Journal of Public Health. 2016;38(4):e571-e9.
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53. Sortsø C, Lauridsen J, Emneus M, Green A, Jensen PB. Social inequality in diabetes patients’ morbidity patterns from diagnosis to death–A Danish register-based investigation. Scandinavian journal of public health. 2018;46(1):92-101.
54. Larranaga I, Arteagoitia J, Rodriguez J, Gonzalez F, Esnaola S, Pinies J, et al. Socio‐economic inequalities in the prevalence of Type 2 diabetes, cardiovascular risk factors and chronic diabetic complications in the Basque Country, Spain. Diabetic Medicine. 2005;22(8):1047-53.
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58. Mansouri A, Emamian MH, Zeraati H, Hashemi H, Fotouhi A. Economic inequality in presenting vision in Shahroud, Iran: two decomposition methods. International journal of health policy and management. 2018;7(1):59.
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60. Morasae EK, Forouzan AS, Majdzadeh R, Asadi-Lari M, Noorbala AA, Hosseinpoor AR. Understanding determinants of socioeconomic inequality in mental health in Iran's capital, Tehran: a concentration index decomposition approach. International journal for equity in health. 2012;11:1-13.
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2. Bygbjerg IC. Double burden of noncommunicable and infectious diseases in developing countries. Science. 2012;337(6101):1499-501.
3. WHO. Diabetes 2023 [Available from: https://www.who.int/health-topics/ diabetes#tab=tab_1.
4. Sun H, Saeedi P, Karuranga S, Pinkepank M, Ogurtsova K, Duncan BB, et al. IDF Diabetes Atlas: Global, regional and country-level diabetes prevalence estimates for 2021 and projections for 2045. Diabetes research and clinical practice. 2022;183:109119.
5. Ganasegeran K, Hor CP, Jamil MFA, Loh HC, Noor JM, Hamid NA, et al. A systematic review of the economic burden of type 2 diabetes in Malaysia. International journal of environmental research and public health. 2020;17(16):5723.
6. Liu Z, Fu C, Wang W, Xu B. Prevalence of chronic complications of type 2 diabetes mellitus in outpatients-a cross-sectional hospital based survey in urban China. Health and quality of life outcomes. 2010;8:1-9.
7. Fowler MJ. Microvascular and macrovascular complications of diabetes. Clinical diabetes. 2008;26(2):77-82.
8. Ansari P, Akther S, Khan JT, Islam SS, Masud MSR, Rahman A, et al. Hyperglycaemia-linked diabetic foot complications and their management using conventional and alternative therapies. Applied Sciences. 2022;12(22):11777.
9. Dewi F, Hinchliffe RJ. Foot complications in patients with diabetes. Surgery (Oxford). 2020;38(2):108-13.
10. Mounirou BA, Adam ND, Yakoura AK, Aminou MS, Liu YT, Tan LY. Diabetic retinopathy: an overview of treatments. Indian Journal of Endocrinology and Metabolism. 2022;26(2):111-8.
11. Rema M, Premkumar S, Anitha B, Deepa R, Pradeepa R, Mohan V. Prevalence of diabetic retinopathy in urban India: the Chennai Urban Rural Epidemiology Study (CURES) eye study, I. Investigative ophthalmology & visual science. 2005;46(7):2328-33.
12. DeFronzo RA, Reeves WB, Awad AS. Pathophysiology of diabetic kidney disease: impact of SGLT2 inhibitors. Nature Reviews Nephrology. 2021;17(5):319-34.
13. Adler AI, Stevens RJ, Manley SE, Bilous RW, Cull CA, Holman RR, et al. Development and progression of nephropathy in type 2 diabetes: the United Kingdom Prospective Diabetes Study (UKPDS 64). Kidney international. 2003;63(1):225-32.
14. Haire-Joshu D, Hill-Briggs F. The next generation of diabetes translation: a path to health equity. Annual review of public health. 2019;40:391-410.
15. Mahdavi M, Parsaeian M, Farzadfar F, Mohamadi E, Olyaeemanesh A, Takian A. Inequality in prevalence, awareness, treatment, and control of hypertension in Iran: the analysis of national households’ data. BMC Public Health. 2022;22(1):2349.
16. Dray-Spira R, Gary-Webb TL, Brancati FL. Educational disparities in mortality among adults with diabetes in the US. Diabetes care. 2010;33(6):1200-5.
17. Agardh E, Allebeck P, Hallqvist J, Moradi T, Sidorchuk A. Type 2 diabetes incidence and socio-economic position: a systematic review and meta-analysis. International journal of epidemiology. 2011;40(3):804-18.
18. Smith BT, Lynch JW, Fox CS, Harper S, Abrahamowicz M, Almeida ND, et al. Life-course socioeconomic position and type 2 diabetes mellitus: The Framingham Offspring Study. American Journal of Epidemiology. 2011;173(4):438-47. 19. Ortiz MS, Cabieses B, Oyarte M, Repetto P. Disentangling socioeconomic inequalities of type 2 diabetes mellitus in Chile: A population-based analysis. PloS one. 2020;15(9):e0238534.
20. Ha R, Jung-Choi K. Area-based inequalities and distribution of healthcare resources for managing diabetes in South Korea: a cross-sectional multilevel analysis. BMJ open. 2022;12(2):e055360.
21. Lee YH. Socioeconomic differences among community-dwelling diabetic adults screened for diabetic retinopathy and nephropathy: The 2015 Korean Community Health Survey. PloS one. 2018;13(1).
22. Rahman M, Nakamura K, Hasan SM, Seino K, Mostofa G. Mediators of the association between low socioeconomic status and poor glycemic control among type 2 diabetics in Bangladesh. Scientific reports. 2020;10(1):6690.
23. Sharafi M, Bahramali E, Farjam M, Rezaeian S, Afrashteh S, Amiri Z. Socioeconomic inequality in noncommunicable diseases: Results from a baseline Persian cohort study. Medical Journal of the Islamic Republic of Iran. 2021;35:78.
24. Darvishi A, Nikkhah A, Mahmudimanesh M, Balajam NZ, Shafiee G, Heshmat R. Socioeconomic inequalities in type 2 diabetes mellitus: a study based on a population-based survey in Iran. BMC Public Health. 2024;24(1):926.
25. Janssen F, Trias-Llimós S, Kunst AE. The combined impact of smoking, obesity and alcohol on life-expectancy trends in Europe. International Journal of Epidemiology. 2021;50(3):931-41.
26. WHO. Obesity and overweight 2024 [Available from: https://www.who.int/ news-room/fact-sheets/detail/obesity-and-overweight.
27. Kosha A, Najmi M, Hezaveh A M, Mughithi A, Mutlaq A G, Yara Ahmadi S, et al. The set of basic interventions for non-communicable diseases of Iran's primary health care system "Irapen" (executive instructions and educational content for doctors): Mojasameh; 2017.
28. Association AD. 12. Older Adults: Standards of Medical Care in Diabetes—2020. Diabetes care. 2020;43(Supplement_1):S152-S62.
29. Wagstaff A, O'Donnell O, Van Doorslaer E, Lindelow M. Analyzing health equity using household survey data: a guide to techniques and their implementation: World Bank Publications; 2007.
30. Wagstaff A, Van Doorslaer E, Watanabe N. On decomposing the causes of health sector inequalities with an application to malnutrition inequalities in Vietnam. Journal of econometrics. 2003;112(1):207-23.
31. Kakwani N, Wagstaff A, Van Doorslaer E. Socioeconomic inequalities in health: measurement, computation, and statistical inference. Journal of econometrics. 1997;77(1):87-103.
32. Erreygers G. Correcting the concentration index. Journal of health economics. 2009;28(2):504-15.
33. Funakoshi M, Azami Y, Matsumoto H, Ikota A, Ito K, Okimoto H, et al. Socioeconomic status and type 2 diabetes complications among young adult patients in Japan. PloS one. 2017;12(4):e0176087.
34. Arambewela MH, Somasundaram NP, Jayasekara HBPR, Kumbukage MP, Jayasena PMS, Chandrasekara CMPH, et al. Prevalence of chronic complications, their risk factors, and the cardiovascular risk factors among patients with type 2 diabetes attending the diabetic clinic at a tertiary care hospital in Sri Lanka. Journal of diabetes research. 2018;2018(1):4504287.
35. Voigt M, Schmidt S, Lehmann T, Köhler B, Kloos C, Voigt UA, et al. Prevalence and Progression Rate of Diabetic Retinopathy in Type 2 Diabetes Patients in Correlation with the Duration of Diabetes. Experimental and clinical endocrinology & diabetes : official journal, German Society of Endocrinology [and] German Diabetes Association. 2018;126(9):570-6.
36. Rotimi C, Daniel H, Zhou J, Obisesan A, Chen G, Chen Y, et al. Prevalence and determinants of diabetic retinopathy and cataracts in West African type 2 diabetes patients. Ethnicity & disease. 2003;13:110-7.
37. Al-Rubeaan K, Al Derwish M, Ouizi S, Youssef AM, Subhani SN, Ibrahim HM, et al. Diabetic foot complications and their risk factors from a large retrospective cohort study. PloS one. 2015;10(5):e0124446.
38. Younis BB, Shahid A, Arshad R, Khurshid S, Ahmad M, Yousaf H. Frequency of foot ulcers in people with type 2 diabetes, presenting to specialist diabetes clinic at a Tertiary Care Hospital, Lahore, Pakistan. BMC Endocrine Disorders. 2018;18:1-6.
39. Sortsø C, Lauridsen J, Emneus M, Green A, Jensen PB. Social inequality in diabetes patients' morbidity patterns from diagnosis to death - A Danish register-based investigation. Scandinavian journal of public health. 2018;46(1):92-101.
40. Ponesai N, Anderson C, Mufuta T, Gombe N, Lucia T, Donewell B. Risk factors for diabetic complications among diabetic patients, Chirumanzu District, Zimbabwe, 2011. Austin J Public Health Epidemiol. 2015;2(2):1-7.
41. Akın S, Bölük C. Prevalence of comorbidities in patients with type–2 diabetes mellitus. Primary care diabetes. 2020;14(5):431-4.
42. Petrie JR, Guzik TJ, Touyz RM. Diabetes, hypertension, and cardiovascular disease: clinical insights and vascular mechanisms. Canadian Journal of Cardiology. 2018;34(5):575-84.
43. Tatsumi Y, Ohkubo T. Hypertension with diabetes mellitus: significance from an epidemiological perspective for Japanese. Hypertension Research. 2017;40(9):795-806.
44. Rwegerera GM, Masaka A, Pina- Rivera Y, Moshomo T, Gaenamong M, Godman B, et al. Determinants of glycemic
control among diabetes mellitus patients in a tertiary clinic in Gaborone, Botswana: findings and implications. Hospital practice. 2019;47(1):34-41.
45. Bachmann M, Eachus J, Hopper C, Davey Smith G, Propper C, Pearson N, et al. Socio‐economic inequalities in diabetes complications, control, attitudes and health service use: a cross‐sectional study. Diabetic Medicine. 2003;20(11):921-9.
46. Kalyango JN, Owino E, Nambuya AP. Non-adherence to diabetes treatment at Mulago Hospital in Uganda: prevalence and associated factors. African health sciences. 2008;8(2):67- 73.
47. Maric-Bilkan C. Sex differences in micro-and macro-vascular complications of diabetes mellitus. Clinical Science. 2017;131(9):833-46.
48. Bruce M, Mallika MV. Prevalence of complications of diabetes among patients with diabetes mellitus attending a tertiary care centre in Tamil Nadu. International Journal Of Community Medicine And Public Health. 2019.
49. Naseer S, Malkera A, Khan N, Siddiqui AH, Khan SA, Ali S, et al. Prevalence of diabetic complications in urban and rural population of Punjab. Pakistan Journal of Medical & Health Sciences. 2022;16(03):69-.
50. Hwang J, Rudnisky C, Bowen S, Johnson JA. Income-related inequalities in visual impairment and eye screening services in patients with type 2 diabetes. Journal of Public Health. 2016;38(4):e571-e9.
51. Tao X, Li J, Zhu X, Zhao B, Sun J, Ji L, et al. Association between socioeconomic status and metabolic control and diabetes complications: a cross-sectional nationwide study in Chinese adults with type 2 diabetes mellitus. Cardiovascular diabetology. 2016;15:1-10.
52. Kim SH, Lee SY, Kim CW, Suh YJ, Hong S, Ahn SH, et al. Impact of socioeconomic status on health behaviors, metabolic control, and chronic complications in type 2 diabetes mellitus. Diabetes & metabolism journal. 2018;42(5):380-93.
53. Sortsø C, Lauridsen J, Emneus M, Green A, Jensen PB. Social inequality in diabetes patients’ morbidity patterns from diagnosis to death–A Danish register-based investigation. Scandinavian journal of public health. 2018;46(1):92-101.
54. Larranaga I, Arteagoitia J, Rodriguez J, Gonzalez F, Esnaola S, Pinies J, et al. Socio‐economic inequalities in the prevalence of Type 2 diabetes, cardiovascular risk factors and chronic diabetic complications in the Basque Country, Spain. Diabetic Medicine. 2005;22(8):1047-53.
55. Tatulashvili S, Fagherazzi G, Dow C, Cohen R, Fosse S, Bihan H. Socioeconomic inequalities and type 2 diabetes complications: a systematic review. Diabetes & metabolism. 2020;46(2):89-99.
56. Lynch J, Smith GD, Harper SA, Hillemeier M, Ross N, Kaplan GA, et al. Is income inequality a determinant of population health? Part 1. A systematic review. The Milbank Quarterly. 2004;82(1):5-99.
57. Frohlich KL, Ross N, Richmond C. Health disparities in Canada today: Some evidence and a theoretical framework. Health policy. 2006;79(2-3):132-43.
58. Mansouri A, Emamian MH, Zeraati H, Hashemi H, Fotouhi A. Economic inequality in presenting vision in Shahroud, Iran: two decomposition methods. International journal of health policy and management. 2018;7(1):59.
59. Rijken M, Spreeuwenberg P, Schippers J, Groenewegen PP. The importance of illness duration, age at diagnosis and the year of diagnosis for labour participation chances of people with chronic illness: results of a nationwide panel-study in the Netherlands. BMC public health. 2013;13:1-13.
60. Morasae EK, Forouzan AS, Majdzadeh R, Asadi-Lari M, Noorbala AA, Hosseinpoor AR. Understanding determinants of socioeconomic inequality in mental health in Iran's capital, Tehran: a concentration index decomposition approach. International journal for equity in health. 2012;11:1-13.
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| Files | ||
| Issue | Vol 10 No 3 (2024) | |
| Section | Articles | |
| Keywords | ||
| Concentration index;×Decomposition;×Diabetes;×Inequities;×Diabetes Complications;×Socioeconomic status× | ||
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This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. |
How to Cite
1.
Mafakheri S, Ayubi E, Borzouei S, Ramezani Doroh V, Khazaei S. Socioeconomic Inequality in Chronic Complications of Type 2 Diabetes Mellitus in Iran: Concentration Index and Decomposition Approach. JBE. 2025;10(3):374-395.
