BD is a chronic and recurrent multisystemic disorder that leads to functional limitations, especially among young employed males (26). This condition has adverse socioeconomic and psychological effects, as supported by numerous investigations exploring its clinical presentations, geographical prevalence, and associated complications (3, 5, 27, 28).
In the current study, most of the patients (55.5%) were male, similar to another study by Davatchi et al. in Iran that reported 55.8% of the patients were male (29). In the literature, studies presented diverse findings, with specific studies indicating a higher occurrence in males while others indicated a higher occurrence in females (1, 27). In the present study, most of the patients were from urban areas (90.5%), which supports previous reports (30–32). However, it may be related to urban residents’ better access to this clinic. In the current study, 77% of participants did not attend higher education, and this is in line with other studies that reported 87% and 76.4% of patients do not have higher education (6, 33). Nevertheless, it contradicts other studies that reported most of the responder patients (44.9%-78.10%) had university or college education (4, 5, 31). Marital status was as follows: married for most of the patients (74%), single for 19% of the patients, and divorced or widowed for 7% of BD patients. This finding aligns with other studies that reported most of the patients were married (20, 30, 34). In the present study, 55.00% of patients had no occupation; in other studies on BD, it was reported as 27.8–48.5% (6, 14, 30, 32).
SES is a composite measure that combines economic and sociological indicators, including an individual's income, level of education, occupation, wealth, and access to resources. Various studies have shown that rheumatological diseases are related to SES (16–19, 35, 36). However, few studies have been done in the field of BD (12, 14, 28).
In the present study, the frequency of genders among different SES groups did not show a significant difference, which is consistent with another study by Ashman et al. (28). Lab tests (ESR, HLA-B5, HLA-B51, and HLA-B27) demonstrated no relation to the SES. In addition, the differences in the rate of Pathergy test, and BD manifestations at the time of diagnosis and during the illness were insignificant among different SES groups, except for the frequency of ocular involvement relapse and prevalence of cataracts. Low SES had a negative effect on occurring relapse, whereas moderate SES had a protective effect. Nevertheless, the duration of employment and having an occupation for at least one year had no influence. Furthermore, patients with low SES experienced a higher rate of cataracts. No study has been published to date regarding the relationship between SES and the recurrence of ocular symptoms, as well as the rate of cataracts in BD. Nevertheless, there have been studies conducted within the field of cataracts in general that have demonstrated that the economic level exhibits a direct correlation with the occurrence and progression of cataracts (37–41). Consequently, it is anticipated that the disparities in cataract occurrence observed in the present study among diverse SES groups may be due to the effect of SES on all types of cataracts, regardless of their etiology, and not associated with BD itself.
No similar studies were found in the field of BD to compare other results. However, in a study by Yalçındağ, BD patients diagnosed with uveitis, in comparison to patients experiencing other non-infectious uveitis, demonstrated a significantly low level of education and SES (14). Park et al. discovered that BD patients with lower SES had a greater frequency of emergency room visits in Korea. Further, no discrepancies were found in hospitalization rates or surgery rates. It is noteworthy to mention that the categorization of SES in their study was derived only from the type of insurance. They suggest that the lack of access to specialized office-based medical care, specifically gastroenterology services, may be a contributing factor to these findings. However, there were no disparities noted in the usage of immunomodulators or biological agents (8). Pehlivan and colleagues assessed the impact of hygiene and living conditions on neuro-Behcet's disease (NBD), multiple sclerosis (MS), and headaches (as a control group representing the general population). The authors did not establish a specific index for SES to make comparisons among the patient groups; instead, they opted to evaluate each feature independently. It was discovered that there were no significant disparities in terms of sex, age, and rural origins among the NBD, MS, and headache groups. Nevertheless, NBD patients exhibited markedly lower levels of education and income and considerably inferior living conditions and hygiene habits in comparison to both MS and headache patients. Additionally, it was reported that they resided near cattle pens, utilized dried cow dung as a fuel source, dwelled in earth-based houses lacking a sewage system, were born at home, and had a history of intestinal parasites. The frequency of bathing and tooth-brushing was significantly lower among NBD patients as opposed to both MS and headache patients. As a result, the authors posited that the unsatisfactory living conditions and hygiene practices of individuals with BD may contribute to the etiology of this particular disease (12).
When exploring the impact of SES on health, it is imperative to consider the role of health-related QoL. It encompasses physical, mental, and social well-being. Many studies have shown an association between QoL and SES (42–48). However, these associations are rarely discussed on their own in the field of BD (4–8). BD patients who had moderate QoL experienced a decline in their QoL over the years (4, 5), especially patients with lower educational achievements (4). Some of the BD manifestations were found to have a negative impact on QoL; for instance, arthropathy and neurological problems emerged as the most prominent symptoms with a sustained adverse effect on QoL over time (4). Other effective manifestations are pathergy reaction, uveitis, genital ulceration, erythema nodosum, thrombophlebitis, and gastrointestinal involvement (4, 33). Interestingly, worse QoL outcomes were observed in BD patients who were unemployed and received beneficial support. It should be noted that the severity of symptoms experienced by patients suffering from this affliction has been found to exert a detrimental influence on their capacity to sustain gainful employment (4). It was found that ocular and neurological involvement, poor SES, and lower QoL are the primary factors contributing to the societal impact of BD, as indicated by decreased productivity (by more days off from work or school) (5). It might be because of the worse physical functioning, bodily pain, physical difficulty, and general health perception that were reported in patients with NBD compared to healthy controls (7). The relationship between disease activity and physical function limitation was also found in patients with fatigue, oral ulceration, and joint involvement. Moreover, patients with erythema nodosum exhibited lower social function scores, and patients with thrombophlebitis experienced lower physical function (33). Besides all these problems, BD patients with neurological and ocular manifestations have the highest mean annual total direct and indirect cost compared to patients with other manifestations and experience higher productivity loss compared to those with mucocutaneous joint disease. (6)
According to a study conducted by Sut et al., BD’s costs associated with medication, para-clinic tests, and hospitalization were found to be higher than the costs attributed to productivity loss. Medication alone accounted for 79% of the total direct costs, placing a heavy burden on patients. Additionally, the lack of financial support hindered many patients’ access to expensive biological agents (6). The financial burden of BD shows the importance of the SES in providing proper treatment and management. BD is a complex immune-mediated disease that requires the consideration of multiple factors for effective management, including treatment adherence (49). Therefore, failure to meet this requirement might result in severe consequences. Few studies investigated the relationship between BD symptoms, adherence, and the role of patients’ budgets (30, 31, 50). In a systematic review of systematic reviews by Mathes et al., unemployment and treatment costs can decrease adherence. However, the amount of income and financial status have no contribution (51). Although studies on the role of BD patients’ financial status are controversial, for instance, Cinar et al. and Zayed et al. found no occupational influences on BD. On the other hand, Khabbazi et al. discovered more adherence among unemployed patients (however, the sample size of unemployed patients was only 11, and their young age may have introduced bias into the conclusion) (30, 31, 49). Moreover, the impact of medication costs was not found to be significant in the study by Khabbazi et al., in contrast to the systematic review by Mathes et al. (51). This disparity may be because medications used for BD treatment are covered by government insurance in Iran. Besides, self-financed BD patients and patients with low income appeared to be less adherent (30, 31). Indeed, BD patients’ resident area and level of education did not affect adherence (30, 49).
However, Zayed et al. and Khabbazi et al. (30, 31) found no association between treatment adherence and clinical characteristics such as disease severity and complications, and this might challenge the idea that non-adherence is the reason for the high relapse of ocular involvement and cataracts in low SES patients in our study. Unfortunately, one of the studies found in the field of adherence in BD investigated cataracts or the recurrence of ocular symptoms and their relation to adherence. Although other researchers discovered that patients with both oral ulcers and ocular involvement had higher treatment adherence compared to those with isolated oral ulcers (50).
Limitations
It is possible that the selection of patients based on visiting the BD clinic diminished the prevalence rates of vascular, neurological, and different types of ocular involvements and had an impact on the analysis. The high rate of insured patients, because of low-cost insurance prepared by the government, might lead to different rates of clinic visits and medication costs compared to other countries. However, this is the first original study investigating the relationship between BD manifestations and SES, which can inspire more relevant efforts on this matter. Another advantage of this study is that the BD symptoms were confirmed and recorded by a physician, unlike some other studies.