measuring socio-economic inequality in utilization of type 2 diabetes services

doi:10.21203/rs.3.rs-4617605/v1

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Research Article

measuring socio-economic inequality in utilization of type 2 diabetes services

https://doi.org/10.21203/rs.3.rs-4617605/v1

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Introduction: Health inequities are important issue; this study was conducted in order to measuring socio-economic inequality in utilization of type 2 diabetes services.

Methods: This study is an explanatory sequential mixed method that was conducted in two Quantitative and Qualitative phases. In the Quantitative part, type 2 diabetes patients referred to health centers, hospitals and diabetes clinics in Isfahan and Khuzestan provinces were selected through available samples. Using the Concentration Index(CI) approach, the existence of inequality in utilization of type 2 diabetes services was examined. In the next step, in order to analyze the inequality, the inequality contribution of each of the determining factors was determined by concentration index analysis method. Next step, we conducted in-depth interviews with key experts in the field of health to extracted effective solutions.

Results: most of the samples were 1306 (65.3%) men. The most age group involved was799 people (40%) over 60 years. concentration index value in outpatient services was 0.31 (p<0.05), inpatient services -0.10 (p>0.05), and pharmaceutical services 0.11 (p<0.05). This means that there was a disparity in the use of outpatient and drug services for type 2 diabetic patients, while the disparity in inpatient services is not significant.

Variables contributing to inequality for outpatient services were health status (33.54%), basic insurance (27.43%) and socio-economic status (24.08%), also in pharmaceutical services, health status variable (22.20%), basic insurance (13.63%) and socio-economic status (34.35%) contributed to socio-economic inequality in utilizing from services related to type 2 diabetes patients. Also, the experts' point of view for solutions to reduce socio-economic inequalities in Iran were classified in 3 main themes (socio-economic status, health status, basic insurance) and 29 sub-themes.

Conclusion: According to the results, it is suggested that targeted health interventions for the poor patient, and the efforts towards outpatient and medicinal items insurance coverage for type 2 diabetic patients. Improving the status of variables affecting of socio-economic inequality in type 2 diabetic patients and improving the status of the country's health system, strengthening the package of basic health insurance utilization.

inequality

socio-economic state

utilization

type 2 diabetes

concentration index

Type 2 Diabetes (T2D) Mellitus is one of the most prevalent diseases and leading causes of years of life lived with disease worldwide(1). Diabetes is the fourth leading cause of death in most countries (2). Diabetes has the highest Burden of Disease (GBD) of non-communicable diseases worldwide(3). Just over 1 in 10 in the world have diabetes(4). There has been a rising trend in T2D prevalence turning it into a growing global epidemic. As recently estimated by the International Diabetes Federation, the number of people diagnosed worldwide will increase from 463 million in 2019 to 700 million in 2045 leading to a 51% increase in 26 years (5, 6).

However, the relatively high prevalence of T2D is not distributed equally among different socioeconomic groups.

According to the report of the Non-Communicable Diseases Research Center and Steps Information (STEPs) in the period of 2016, The prevalence of diabetes in Isfahan province is 201,366 (12.3%) in women and 185,784 (11%) in men, and in Khuzestan province it is 183,256 (13.9%) in women and 189,204 (14.1%) in men.

The national average prevalence of diabetes is 10.6% in Iran, so the situation of two provinces of Khuzestan is higher than the national average of diabetes(7).

Socioeconomic inequalities exist in T2D, with individuals from lower socioeconomic status (SES) groups being more affected (8). Not only are there socioeconomic variations in the prevalence of T2D, but also disease management, chronic complications (9), and mortality(10). Lack of knowledge on the disease condition and also unavailability of healthcare services worsen the health outcomes. Timely intervention and medication are required to prevent complications, but most patients are unable to access quality healthcare to manage diseases (11). Previous studies have found out that people prefer hospitals service based on their income, socioeconomic condition, and health status. Patients choose healthcare services for diabetes depending upon the quality of care provided to them(12). observational data over 40 years have shown consistent—and often heart-wrenching differences in diabetes outcomes across populations, where populations at socioeconomic disadvantage, in terms of lower education and income levels, experience less access to care and preventive services,(13). lower rates of diagnosis, poorer health behaviors and control, (14) worse cardio metabolic outcomes, (15) and shorter life expectancy as compared with more advantaged populations of higher socioeconomic status(16). These findings suggest that diabetes is not a purely biological issue; its onset and progression are heavily influenced by the broader socioeconomic context(17). According to the results of studies conducted on socioeconomic inequality in non-communicable diseases and socioeconomic inequality in the use of health care services (18–26). and considering that type 2 diabetes is among the priorities of Iran(27).

This study used the cumulative index approach (6). and decomposition, to identify and determine the contribution of effective factors in inequality and provide solutions that reduce socioeconomic inequality in utilizing from services for type 2 diabetic patients through interviews with experts and experts regarding interventions related to reducing inequality in diabetic patients and how to implement them. Therefore, by using the findings of the quantitative section and applying the opinions of experts (qualitative section of the study), the policy entry points and priorities regarding the reduction of inequality in diabetic patients were better identified.

The study is an explanatory sequential mixed method, which was conducted in two phases, quantitative and qualitative, respectively. In the quantitative phase, socio-economic inequality in utilization from services in type 2 diabetes patients in Isfahan and Khuzestan provinces was measured and the contributing variables in this inequality were determined.

According to the results obtained in the quantitative part, a qualitative method was conducted in the second phase of the study. Then, the solutions to reduce the inequality in the variables that contribute to the inequality in utilization from the services of type 2 diabetic patients were identified through interviews with key experts in health. next step, to achieve the fourth goal, to identify strategies to reduce inequality in utilization from services in type 2 diabetes patients in different countries of the world, a scoping review study was conducted.

The statistical population of the research

The target population includes patients with type 2 diabetes in Isfahan and Khuzestan provinces.

inclusion and exit criteria

diabetic patients Information referred to diabetes management and control centers, health and treatment centers, and hospitals was collected through available samples.

include criteria was people whose diabetes confirmed by the centers providing services to diabetic patients and the exclude criteria was patients whose diabetes was not confirmed by the service centers.

Sample size and sampling method

The information of diabetic patients referred to diabetes management and control centers, health and treatment centers and hospitals by socio-economic checklist and utilization questionnaire, the number and percentage of the sample was assigned to each center based on the number of hospital beds and the population covered by the centers. The questioner asked patients who had long-term history of type 2 diabetes (more than 5 years) and whose disease was confirmed by specialist doctors and had outpatient and inpatient records. According to Vahedi et al.'s study (124), the sample size was calculated with a confidence interval of 95% and test power of 99%, and p1 (outpatients utilization ratio) = 67% and p2 (inpatients utilization ratio) = 81%.

$$n=\frac{{\left({z}_{1-\frac{\propto }{2}}+{z}_{1-\beta }\right)}^{2}({p}_{1}\left(1-{p}_{1}\right)+{p}_{2} \left(1-{p}_{2}\right))}{{({p}_{1}-{p}_{2})}^{2}}$$

$$n=\frac{{\left(1.96+2.8\right)}^{2}(0.67\left(1-0.67\right)+0.81 \left(1-0.81\right))}{{(0.67-0.81)}^{2}}=433.5\cong 434$$

Due to lack of sufficient literacy and lack of understanding of the questions or non-cooperation of the patients, 15% was added to reduce the sample size, as a result: The number of samples was 2000 in the two provinces of Khuzestan and Isfahan. 500 patients referred to the inpatient department and 500 patients referred to the outpatient department in each province.

Data collection

To design the research tool (questionnaire) at the beginning after reviewing the studies on the utilization of health services in Iran, the questionnaire pattern was specified. A panel of 5 experts (2 people PhD in health and medical services management, 1-person health policy, 1-person internal specialist, 1-person health care) to find the level of difficulty, the degree of incompatibility, the ambiguity of terms or the existence of insufficiency in the meanings of words and The list of services provided to type 2 diabetic patients was completed.

Finally, the utilization questionnaire included a total of 70 questions, which are divided into: 29 questions related to the list of outpatient service needs to be provided to type 2 diabetic patients, 12 questions related to the list of drug needs provided to diabetic patients, 29 questions related to the list of inpatient service needs for patients Type 2 diabetes was designed.

The process of completing the questionnaire (how to ask questions)

After completing the stages of preparing the questionnaire and the volume and method of sampling, the way of asking questions and questioning was determined. Questioners were asked from patients who had a history of long-term type 2 diabetes (more than 5 years) and were approved by endocrinologist and internal medicine doctors and had outpatient and inpatient records. Also, to ensure the patients' need for outpatient, pharmaceutical and hospitalization services, the information in the patients' outpatient records was checked. The questions were asked by a trained questioner. In this method, the questioners talked directly with the respondents in person (face to face) and wrote their answers in questionnaire. The questioners explained the concepts and objectives of the questions to the respondent and received clear and real answers from the respondent. the ethical ethics for communicating with the respondents was adjusted.

The respondent was assured that the information and data would be preserved The questioners gained the trust and cooperation of the respondents.

Validity and reliability

The questionnaire was given to 20 type 2 diabetic patients to determine face validity. Then using the formula, face validity was calculated. (Impact Score = Frequency(%)×Importance)

Content Validity Ratio (CVR) responses were calculated with the formula. And they were adapted to Lash's table (132). Numbers higher than 0.42 were accepted.

Content Validity Index (Content Validity Index) responses were calculated with the content validity index of Basel and Waltz (133). The total agree points for each item were divided by the total number of experts.

The resulting values less than 0.7 were rejected. Between 0.7 and 0.79 should be revised and values greater than 0.79 were acceptable.

To check the reliability of the questionnaire, Cronbach's alpha method was calculated separately for outpatient, inpatient and pharmaceutical services.

Research variables

the study variables were classified based on the research objectives. Statistical control method was used to check confounding and moderating variables. After collecting the data, possible confounding factors were included as control variables in the regression model. Therefore, the effect of the confounding variable was controlled. Therefore, any effect that the potential confounding variable had on the dependent variables was shown in the regression results.

1. The first phase of research (quantitative study):

Construction of socio-economic status variable

In the quantitative part, the measurement of socioeconomic inequality in utilization from services related to type 2 diabetes patients and its analysis was done by socio-economic checklist and research tool (questionnaire), according to the number of hospital beds and the patient covered by the centers. People whose diabetes was confirmed by centers providing services to diabetic patients were included in the study.

Data

The information that was asked from the type 2 diabetic patients through the socio-economic checklist includes the following: home ownership, an Iranian car, a foreign car, a motorcycle, a smart phone, a normal refrigerator, a freezer side refrigerator, a washing machine, a dishwasher, a microwave, a laptop, Normal TV, LED_Plasma_LCD, vacuum cleaner, internet network, infrastructure level, landline phone, bathroom, kitchen, sanitary toilet.

According to the descriptive statistical results, the variables with low standard deviation were removed from the factor analysis model.

missing data (missing value): considering that the information of the socio-economic checklist and service utilization questionnaire was collected from the patients' self-reported information,

When receiving incomplete information from patients and the number of missing data was high, the sample was removed and another patient was substituted.

Using principal component analysis (PCA) method

At this stage, the following items were considered: Categorical variables should be converted into dichotomous variables. Because by converting the classes to a quantitative scale, their meaning is lost. Choosing the number of main components: The number of components can be determined in several ways; The method of previous criterion or hypothesis that the researcher determines the number during the analysis, Keyser's test, which is the most common method, selects components whose eigenvalue is greater than one.

The third method is a graphical method that, like the second method, uses eigenvalues to select the appropriate number of components. This method is known as pebble test (135).

The variance for each principal component represents the percentage of variation in the data that is explained by that component.

Classification of patient to economic groups

In this study, cut-off points were used to assign people to economic groups. In this method, people were grouped into 5 economic quintiles or 5 economic groups, including the poorest, poorer, middle, rich, and richest based on the factor scores assigned to them.

$$xtile quint \left[aw=hweigt\right]=score1, nq\left(5\right)$$

Measuring socio-economic inequality

Cumulative index approach was used measure socioeconomic inequality in utilization from services related to type 2 diabetes patients.

This approach was used for quantify and compare the degree of socioeconomic inequalities in health variables (28, 29).

Choosing the right regression model

Because the outcome variables of the study were dichotomous (yes, no), to obtain the regression coefficients, a suitable regression model was performed using GLM.

Classification of research variables:

Classification of research variables for services where inequality has been proven.

According to the conceptual framework of the study, the research variables were classified into two structural determinants, intermediary determinants.

The variables were classified into two categories: The first category of structural determinants includes: socio-economic status, education. The second category of intermediate determinants includes: age, sex, health status, marital status, place of residence, basic insurance, supplementary insurance.

Descriptive findings

Table 1. shows the demographic information of type 2 diabetes patients in the study population. Most of the type 2 diabetic patients, 1253 (62.6%) referring to health and treatment centers and diabetes clinics, were from the urban community. A high proportion of the sample 1306 (65.3%) were men. The most age group involved in type 2 diabetes in this study was 799 people (40%) over 61 years old. Most of the patients were married, 1828 (91.4%).

Table 1

Frequency distribution of demographic information of type 2 diabetic patients
Variables		Frequency	Percentage
sex	Female	694	34.7
sex	male	1306	65.3
age	20–30	60	3
	31–40	383	19.2
	41–50	470	23.5
	51–60	288	14.4
	> 61	799	40
Marital status	Single	172	8.6
Marital status	married	1828	91.4
location	City	1253	62.6
	margin	449	22.5
	Village	298	14.9
job	Unemployed	21	1.1
	housewife	464	23.2
	seasonal worker	133	6.7
	manual worker	399	20
	Employee	283	14.1
	the employer	33	1.7
	Retired	667	33.4
education	illiterate	70	3.5
	elementary	415	20.8
	Secondary education	346	17.3
	diploma	620	31
	Associate Degree	235	11.8
	Masters	213	10.7
	Masters	91	4.6
	doctorate	10	0.5
insurance	health Service	620	31
	social security	800	40
	other	580	29
Supplementary insurance	yes	530	26.5
Supplementary insurance	no	1470	73.5

2. The results of the first phase of the research (quantitative part):

Results of principal component analysis using PCA

First, in order to enter the variables into the PCA model, it is necessary to measure the mean and standard deviation of the asset variables, and the assets that have a very high or very low standard deviation are removed from the analysis process and are not included in the PCA model. The table below shows the mean and standard deviation of the asset variables.

Table 2

Asset variables entered into the PCA model
Variables	Mean	SD
Home ownership	0.53	0.49
Iranian car	0.73	0.44
Foreign car	0.05	0.22
motorcycle	0.11	0.32
Smart mobile	0.68	0.46
Normal refrigerator	0.66	0.47
Fridge freezer side	0.36	0.48
laundry	0.8	0.39
dish washing	0.11	0.32
Microwave	0.43	0.49
Laptop	0.36	0.48
Normal TV	0.26	0.44
LED_Plasma_LCD	0.74	0.43
vacuum cleaner	0.95	0.19
Internet network	0.19	0.39

Table 2. shows the variables that were removed from the PCA model due to high and low standard deviation.

Table 3

Asset variables omitted from the PCA model
Variables	Mean	SD
The surface of the infrastructure	2.87	0.98
Landline phone	0.7	0.94
Bathroom	0.99	0.05
kitchen	0.99	0.05
sanitary toilet	0.99	0.06

In Table 4. Four components whose eigenvalue is higher than one have been identified. The following table shows the factor loadings of all variables of each component. The factor load is the correlation between the main components and variables, which varies between 1 and − 1. The socio-economic variable that was created in this study according to the PCA model and the variables loaded on the first component (variables marked in blue) which include (Iranian car, smart mobile, washing machine, microwave, laptop, LED_Plasma_LCD)) Was. The rest of the variables are also loaded on three other factors.

Table 4. Assets loaded on components

In this study, cut-off points were used to assign people to economic groups.

In this method, the amount of factor scores (socio-economic status score) assigned to people are sorted from small to large and separated into 20% parts. 20% of people who are in a high socio-economic status as rich, 20% of people who are in a very low socio-economic status as the poorest group, 20% who are in a low socio-economic status as the poor group and the rest Between these two groups, they are placed as the middle group. Frequency distribution of the economic status of sample people in Table 5. It is clear.

Table 5

Frequency distribution of determinants of household economic status
Variable	frequency	percentage	Cumulative relative
the poorest	418	20.9	20.9
Poor	431	21.55	42.45
medium	362	18.10	60.55
rich	394	19.7	80.25
the richest	395	19.75	100
Total	2000	100

From the results of cumulative index, probability value and cumulative curve, we found that the inequality in outpatient services with cumulative index is 0.3171 (P < 0.05) and by Wagstaff method 0.3174 (P < 0.05) and pharmaceutical services with cumulative index 0.1125 (P < 0.05) by Erreygers method and 0.1145 (P < 0.05) by Wagstaff method and it is significant and according to the table, the cumulative index number is positive, which means that the rich utilization from outpatient and pharmaceutical services more than the poor. While in inpatient services, it shows a probability value greater than 0.05. The cumulative curve in the use of inpatient services in type 2 diabetes patients cuts the line of equality, which indicates that the inequality is not noticeable.

Table 6

Cumulative indicators and percentage changes for utilization from outpatient, inpatient and pharmaceutical services
Services	Cumulative index		standard error		p-value
Services	Normalize by Erreygers	Normalize by Wagstaff	Normalize by Erreygers	Normalize by Wagstaff	Normalize by Erreygers	Normalize by Wagstaff
Outpatient services	3171/0	3174/0	0242/0	0243/0	0.0001	0.0001
Inpatient services	-0/104	-0/105	0251/0	0252/0	0.09	0.09
Pharmaceutical services	1125/0	1145/0	0249/0	0253/0	0.0001	0.0001

The results of the second phase of the research (qualitative part):

The results of the second phase of the research (qualitative part): The questioners asked the experts about the solution to reduce the inequality in utilization from the services of type 2 diabetic patients in the identified variables (socio-economic status, health status, basic insurance).

Table 7

Solutions to reduce socio-economic inequalities in utilization from services for type 2 diabetic patients according to experts
theme	Sub-theme	suggestions
Socio-economic status	Attention to socio-economic status	− Paying attention to the socio-economic situation in planning − Paying attention to the socio-economic situation in providing resources − Paying attention to the socio-economic situation in targeting services
	Improving of socio-economic status	− Improving the socioeconomic conditions of households − Strengthening social support and employment structures − Attention to the financial and economic problems of households − Employment generation − Supporting the poor through proper distribution of subsidies
	area Planning	− Identifying of vulnerable areas and socio-economic crisis − Focusing on policies related to vulnerable groups and areas − Localization of programs compiled in the ministry for some deprived and less privileged areas − Attention to geography in planning
	Attention to deprived and vulnerable areas	− Increasing access to services in marginal and remote areas and vulnerable areas − Deprivation of deprived and vulnerable villages and areas − Distribution of expert personnel to underprivileged areas and villages in the form of passing the commitment period − Providing active services on the outskirts of cities and deprived areas − Paying attention to the rapid growth of marginal and deprived areas and planning to serve them
	Providing a complete information platform	− Identifying of households with poor economic status − Data-based programming
	Promote a systemic approach	− Mutual recognition of systems and their cooperation to achieve desired results − Improving the systemic, comprehensive and long-term view of the socio-economic variables affecting the state of the health system − Improving the proportional distribution of resources and facilities in the provinces of the country − Focusing on the implementation of designated programs
	Attention to socio-economic factors in providing services	− Making healthcare workers aware of the impact of social and economic factors − Formulation of programs to provide special services for specific socio-economic groups − Special attention to specific regions of the country according to its environmental conditions and social context
	decreasing the costs of health services	− Providing cost-effective services for patients − Trying to reduce the indirect costs of providing services − Providing diabetes services based on demand and need in the desired area
	Financial support	− Subsidy for the treatment and care of type 2 diabetic patients − Government subsidy for low-income households − Financial protection of type 2 diabetic patients in public hospitals − Designing a financial support package for patients − Increasing insurance coverage
	Cooperation	− Sustainable intersectoral cooperation − Holistic approach − Joint efforts
	Equitable distribution of health resources	− Paying attention to the free periodic care service packages for diabetic patients − Increasing access to services by developing the network system − Leveling of services − Distribution of specialist doctors, physical health resources (such as hospitals, active beds and pharmacies) in the cities
	Attention to studies in the field of health	− Sensitizing of relevant authorities by presenting the results of studies in the field of reducing inequality − Using the results of studies in planning and policies
	Improving the status of statistics and information	− Accurate determination of the level of households in the country and even the level of the city − Implementation of programs to accurately determine the socio-economic quotient of households
	Free service coverage	− utilizing from outpatient and pharmaceutical services by all type 2 diabetic patients in the country − Implementation of free care programs for type 2 diabetic patients − Providing services to type 2 diabetic patients (both rich and poor) regardless of their financial status or place of residence.
health status	Empowerment of society	− Identifying of households with poor health status − Institutionalizing a healthy lifestyle in type 2 diabetic patients − Informing patients about diagnostic and treatment measures − Planning and optimal use of social media for health promotion − Strengthening mass media in raising the level of information and awareness of patients − Media support − Health education to informants and patients
	Health policy	− Creating policies that support health − Creation of healthy and protected environments − Making it possible to express complaints and grievances
	Monitoring the implementation of self-care programs	− Monitoring the implementation of individual self-care programs − Monitoring the implementation of organizational self-care programs − Monitoring the implementation of social self-care programs
	Improving the quality of diabetes services	− Standardization of care for type 2 diabetic patients − Improving evaluation systems for quality care at different levels − Improvement of continuous monitoring systems
	Providing care services for diabetic patients	− Implementation of community-based screening programs − Outcome-based treatment goals for type 2 diabetic patients − Providing information about the ratio and distribution of undiagnosed diabetics among social and economic strata − Using popular mass media to inform about how to provide services − Risk-based positive health care action − Health care management and control for type 2 diabetic patients − Long-term follow-up of diabetes complications − Providing rehabilitation services for vulnerable and injured diabetic patients
	Structure	− Creating a scientific and practical structure in the country's health sector − Paying attention to and improving the status of the referral system − Improve old equipment and facilities
	service providers	− Improve diabetes management skills for providers and physicians through training − Financial and non-financial incentives for service providers − Trying to motivate employees to provide better services − Efforts to improve skills through in-service training for employees
	Promote of interdepartmental cooperation	− Identifying of partners and stakeholders − Attracting interdepartmental cooperation − Facilitating interdepartmental cooperation and coordination − Designing and implementing interdepartmental projects − Formation of interdepartmental project teams
Basic insurance	Financing	− Proper collection of resources − Creating a suitable tariff system − Strengthening the financing system for collection, aggregation and purchase of services − Creating appropriate financial partnership − Solving problems related to per capita and tariff in the country − Better implementation of the subsidy targeting program − Making the financing system fair − Creating a suitable system for identifying poor people
	coordination	− Strengthening coordination between organizations − Strengthening the coordination of the insurance package with primary care levels and supplementary levels − Strengthen coordination between cost, population and depth of service
	Management factors	− Management stability − Non-dependence of programs and policies on individuals − Improvement of supervision and control − Monitoring the correct implementation of the electronic file
	Implementation factors	− Commitment to law enforcement − Creating a single database − Accurate estimation of people without insurance coverage − Establishing a monitoring and evaluation system
	Political factors	− Emphasizing the discussion of insurance in the constitution − Balance of power and strengthening coordination between the ministers of health and welfare − The need for political pressure to merge insurance funds − Strategic policies
	Structural factors	− Creating a single insurance structure − Creating a proper closed review process − Designing a suitable service package for diabetic patients
	cultural factors	− Trying to correct closed behavior − Efforts to increase people's awareness − Trying to increase people's participation − Trying to increase people's satisfaction

in cumulative index and cumulative curves analysis, we found there is a socio-economic inequality in the use of outpatient and pharmaceutical services for type 2 diabetic patients; It means that the rich utilization from outpatient and medical services more than the poor. While the disparity in inpatient services was not significant.

It seems that this is justifiable because due to the necessity and importance of inpatient services and the urgent need of diabetics for inpatient services when complications of type 2 diabetes occur, in general, all classes, whether rich or poor, are forced to use inpatient services.

On the other hand, due to the provision of subsidized inpatient care services after the implementation of the health system transformation plan, the use of inpatient services by disadvantaged groups has increased, which has reduced the inequality in the use of inpatient services. The findings of the study by Vahedi et al. It is consistent with our study (30).

In the study by Sözmen et al. It showed that in Turkey's HTP plan in 2016, the main contributors to the use of inpatient services were patients from the weak socio-economic group and green card holders. Green Card is an insurance plan that provides subsidized healthcare services for disadvantaged groups (31). Therefore, the participation of the public sector in providing subsidized inpatient services can facilitate access to inpatient services and deal with socio-economic inequalities in the use of inpatient services. However, policy makers must ensure the sustainability of these interventions. The results of the present study clarify the tendency of managers to give priority to the coverage of care services and the control and prevention of diabetes complications that lead to hospitalization and long-term bed occupancy. Therefore, due to the complications of treating complications caused by diabetes such as diabetic ulcer problems, cardiovascular, kidney, vision, etc., there is a need for specialized care to control the condition of type 2 diabetic patients and prevent the occurrence of irreversible complications that lead to hospitalizations. It is long-term and occupying a hospital bed is mandatory in the health system. Without defining a comprehensive and comprehensive service package, it will be impossible to encourage and motivate patients to receive free services, as well as to establish a suitable referral system and continuous follow-up of identified patients. Type 2 diabetic patients need primary care services with an emphasis on education and empowerment to control the disease and evaluate the occurrence of complications to prevent the complications of the disease.

The results of the present study are consistent with the results of many studies that confirmed the existence of inequality in the provision of outpatient and pharmaceutical services in type 2 diabetic patients. xu et al. In a study of horizontal trends of inequality in utilization from health care in rural China, they found that there was inequality in utilization from outpatient services(32).

Tapager et al. In a study aimed at investigating the justice in access to diabetes treatment, they found that even in a health system with global comprehensive coverage, there is health care inequality in the access to preventive and therapeutic services(33).

Vahedi et al., in a study aimed at investigating socio-economic inequalities in the use of medical services in Iran, showed that the inequality in the use of outpatient medical services increased in the studied years, while the inequality in the use of inpatient services decreased(30).

Barnard et al. In a study in England aimed at investigating social and economic inequality in diabetic patients, they found that socio-economic inequality is seen in access to health care(34).

Forozan et al. In the purposeful study "Analysis of inequality in the use of outpatient health services in households living in Tehran, they stated that due to the positive inequality indicators, the status of utilization from health services is more concentrated in the privileged groups (inequality in favor of the rich) therefore the existence of social inequality -Economy is confirmed in outpatient health services(35). Mulyanto et al. In a study aimed at measuring socioeconomic inequalities in utilization from type 2 diabetes management and control services in Indonesia, they showed that there was socioeconomic inequality in utilization from pharmaceutical and outpatient services(36).

In the study by Gesuita et al. With the aim of measuring the social and economic inequalities of diabetes care in Italy, they showed that outpatient services are not evenly distributed in the regional territory (37). In the study of Sorts et al., with the aim of investigating socioeconomic inequality in the use of health care by diabetic patients in Denmark, they showed that the pattern of use of services differs among patients with different socioeconomic status, especially in outpatient and rehabilitation services (38). Also, in a study conducted by Nooraiee et al. with the aim of determining the factors related to the use of various health and treatment services, they also confirmed the social and economic inequality in outpatient health services (39). Wang et al. conducted a study aimed at investigating social and economic factors and inequality in the prevalence and treatment of diabetes among middle-aged and elderly people in China, which evaluated the factors affecting inequality with regard to the prevalence of diabetes and drug treatment among middle-aged and elderly Chinese adults. To estimate socio-economic factors and inequalities in the prevalence and treatment of diabetes, logistic regression models and cumulative index have been used. The results showed that the inequality of receiving antidiabetic drugs was observed among the rich in urban and rural areas. Social and economic factors have significantly affected the possibility of receiving medicine (40). In a study conducted by Heltberg et al. aimed at measuring social inequalities in diabetes care: a study of the general population in Denmark, they showed that social and economic inequality were related to the drug treatment of type 2 diabetic patients(41). In this study, part of the outpatient services reported with a significant inequality index are periodically provided to type 2 diabetic patients in the first levels of the health system to control the disease state and prevent the occurrence of disease complications.

In the national program for the control of type 2 diabetes (42), the need for periodical care at the first level of the May health system is emphasized for type 2 diabetic patients once every one to six months, which includes: nutrition visit, weight measurement, determination BMI, food plan presentation, blood pressure measurement, diabetic foot visit, liver disease check, liver enzyme tests, cancer check, pancreatic cancer check, liver cancer check, thyroid cancer check, breast cancer check, check The presence of colon cancers, checking the presence of other cancers, routine tests of diabetic patients, lipid tests. In a study conducted by Amini et al. with the aim of descriptive phenomenology of the reasons for the reduction in the consumption of free health service packages in type 2 diabetic patients in Ahvaz, they found that the reasons for the reduction in the consumption of the service package in diabetic patients were classified into three themes, which included 13 It was a sub-theme and 57 codes. Themes included individual, access, and structural factors. In addition, the sub-themes were lack of awareness, poor health literacy, adverse patient experience, problems using services, cultural barriers, verbal miscommunication, low trust, geographical barriers, time barriers, financial problems, lack of human resources, poor service delivery. And organizational factors were barriers to participation(43).

In the study of Schouten et al. in Ghana, they found that cultural beliefs are one of the barriers to diabetic health care (44). A study by Babaei Hyderabadi in 2017 showed that local traditions and customs are the reason for non-receipt of services by diabetic patients in scheduled appointments (45). Various studies have suggested programs to help health providers better understand different cultural contexts and modern health care practices (46).In Bidarpoor study, he showed that low trust was one of the important reasons for not receiving outpatient services from comprehensive medical service centers (47). In the research of Babaei et al., it was shown that the problem of transportation is one of the reasons for non-receipt of services by diabetic patients(45). In addition, in Khan study, most of the patients who could not visit the doctor on the day of the appointment stated lack of access to transportation as the main reason(48).

In the study of Sharifi and Bidarpour, it was found that physical accessibility and long distance from the place are important reasons for diabetic patients (47, 49). Another reason for the low uptake in our study was time barriers, which included: long waiting time, inappropriate working hours of the health care center, which have been mentioned in other studies(45, 47, 50).

Waiting time is defined as the time between the patient's registration on the waiting list and the period the patient spends at any point of the service before treatment (51). It has been shown in various studies that the long waiting time has an adverse effect on the patient's willingness to return to health and treatment centers, which greatly reduces the use of health and treatment services (52). Various studies have shown that vulnerable patient groups, such as those with low income, lack of health insurance, or debt, are at increased risk of not receiving care and services provided by health centers (53, 54). Improving the coverage of health services and the highest standard of health depends on their accessibility, acceptability and quality (55).

The healthcare workforce consists of a wide range of healthcare workers who provide healthcare services. The lack of health providers, doctors, specialists and part-time doctors and the unavailability of free medical tests in other developing countries were among the reasons for not receiving them (56). In addition, Hyderabadi and his colleagues, absence of employees at work, lack of follow-up of patients, improper communication between patients and doctors, "service providers" was one of the reasons for non-attendance and non-receipt of service by patients in scheduled appointments. Referral, lack of equipment and lack of motivation of employees emphasized (45). Poorly motivated health workers can have a negative impact on individual facilities and the entire health system. Some experts believe that the low wages and bad working conditions of healthcare workers are among the factors that demotivate employees in this sector of the health system (57). Another part of outpatient services that is reported with a significant inequality index is outpatient services that are provided by the second level (public and private hospitals, internal clinics, diabetes clinics and polyclinics) and the third level (superspecialized centers). Which includes: neuropathy visit, neuropathy electromyography, retinopathy visit, retinopathy treatment, laser retinopathy, nephropathy visit, nephropathy diagnostic tests, cardiovascular visit, echocardiography/cardiovascular ECG.

We also found that the cumulative index of cheap drugs such as: anti-diabetic pills including: metformin, gliclazide or glibenclamide, some blood pressure drugs and aspirin is negative, and this means that the consumption of these medicinal items by the poor is more than the rich.

Also, the use of expensive and specialized combination drugs to control type 2 diabetes, including: antidiabetic pills: pioglitazone, linagliptin, combination drugs including: metformin/sitagliptin, metformin/linagliptin, empagliflozin/linagliptin, empagliflozin/linagliptin/metformin, Novomix, other anti-triglyceride drugs, cardiovascular drugs including: Metoral, pregabalin, vitamins including: B1, B12, D, other neuropathy drugs and spironolactone are positive nephropathy drugs, that is, it is used by the rich more than the poor.

On the other hand, medicinal items for which no significant disparity was reported include: antidiabetic pills including: sitagliptin, empagliflozin, acarbose, combined drugs including: metformin/Empagliflozin Human insulin (medium-acting) including: NPH, Jugular, N/R, analog insulin (long-acting) including: Lantus, Lumire, Togeo, analog insulin (rapid-acting) including: Noverpid, Epidra, Lispro. Antihypertensive drugs include: losartan, valsartan, amlodipine, diltiazem, hydrochlorothiazide, atenolol, lipid-lowering drugs for cholesterol control: atrostatin, rosovastatin, others, triglyceride control drugs: gemfibrozil, fenofibrate, cardiovascular drugs: Acevix, nitroglycerin, Prosmil (Lasix)), others, neuropathy drugs: gabapentin, nephropathy drugs: pentoxifylline. According to the announcement of the version of the incurable package in January 2022 by the Ministry of Health of Iran, diabetes medications including all types of insulin used by patients as well as anti-diabetic tablets sitagliptin, empagliflozin, acarbose and some combined drugs were included in the incurable package and the possibility of utilization from the fund It was available for eligible patients(58). Which was consistent with the results of the present study for the equal utilization of the poor and the rich from some medicinal items and the non-significance of these items. Therefore, it is very important to survey doctors, specialists and assess the needs of type 2 diabetic patients before designing a package of pharmaceutical services and coverage of pharmaceutical items by policy makers and managers, health planners for the scientific and executive guidance of type 2 diabetes control programs. The results of the cumulative index analysis showed that the socio-economic status variable had the largest share (24.8%) in the use of outpatient services and (34.35%) the share in the use of pharmaceutical services for type 2 diabetic patients. This means that if the socio-economic status is equally distributed among type 2 diabetic patients from different socio-economic groups, the disparity in utilization from outpatient and pharmaceutical services in type 2 diabetic patients should be reduced by 24 and 34%. The results of the analysis were consistent with the results of many studies in the world:

Sarker et al. In a study aimed at socio-economic inequalities in diabetes and pre-diabetes among Bangladeshi adults, they stated that both diabetes and pre-diabetes were significantly related to the socio-economic status of the respondents (p 0.001) (59).

Briggs et al. In a study aimed at investigating the social and economic factors that determine health and diabetes: a scientific study found that the physical environment, nutritional status, healthcare and treatment, and socioeconomic status, inequality in living and working conditions, and people's living environment have a direct effect on biological outcomes and It has a behavior related to the prevention and control of type 2 diabetes (60). Safiuddin et al. In a study aimed at investigating socio-economic inequalities in type 2 diabetes among working, non-working and pensioners, they found that groups with lower socioeconomic status are more affected by type 2 diabetes (6).

Tatulashvili et al. In a systematic study aimed at socio-economic inequalities and type 2 diabetes complications, they stated that among the 28 included studies, the clearest relationship between socioeconomic status and diabetes complications, especially retinopathy (in 9 out of 14 studies) and cardiopathy (in 8 studies) of 9 studies). Individual and regional economic and social status was associated with increased risk of complications (4). in a study aimed at investigating the relationship between inequality and the prevalence of diabetes and its risk factors in Sri Lanka: a low-middle income country, DeSilva et al. stated that there is a variable relationship between socioeconomic status and the prevalence of diabetes and its risk factors (61).

Regarding the variable impact of socio-economic factors on inequality, it is consistent with the results of some studies in other countries. For example, in the studies conducted including Leo and his colleagues in 2016 in Portugal (62), the study by Martens and his colleagues in 2021 in the United States (180), the study by Wang and his colleagues in 2018 in China (40), the study by Li and his colleagues In 2016 in China (63), the study by Heltberg and his colleagues in 2017 in Denmark (41) showed that the economic status of households had the greatest impact or contribution to socio-economic inequality in the use of health services by diabetic patients.

In this regard, we interviewed the suggestions of 12 experts, experts and health managers regarding the ways to improve the socio-economic status in Iran. The proposed solutions to improve the socio-economic status and reduce the inequality in utilization from the services of type 2 diabetic patients are:

Many experts introduced addressing socio-economic determinants in resource planning and service targeting as the main solution to reduce inequality in utilization from outpatient and pharmaceutical services for type 2 diabetes patients.

In the study by Moradi et al. conducted in Kurdistan and found that socio-economic factors should be considered when planning interventions to control type 2 diabetes (248). Also, in a study conducted by Godlawalti et al, mentioned the planning based on the socioeconomic factors of diabetic patients (64). Sikio et al, found that if socio-economic factors are considered in the planning, provision of resources and targeting of the organization of local health services, It is possible to increase the utilization of patients from health services (65).

In some studies, the improvement of the socio-economic conditions of households was mentioned as the proposed solution to increase the utilization of health services in type 2 diabetic patients (65, 66).

In confirmation of the solution of identifying vulnerable areas and social economic crisis and focusing on policies related to vulnerable groups and areas, a study by Leo and his colleagues in the northern region of Portugal aimed at investigating health inequalities in diabetes mellitus and high blood pressure found that the prevalence of type 2 diabetes and high blood pressure The order was 6.16% and 19.35%, which was different in the neighborhoods. This prevalence was significantly associated with low education level, low birth weight, unemployment and low income rates; And they stated that there is a need for policy making and identifying deprived areas and targeting these areas (62).

Increasing access to services in marginal and remote areas and vulnerable areas was one of the strategies that the interviewees emphasized a lot in order to reduce the inequality in utilization from the services related to type 2 diabetes patients and improve the socio-economic status. In confirmation of this solution, many studies in the world mentioned this solution in their articles (33, 36, 66–68).

Also, in many studies, it was pointed out the deprivation of deprived and vulnerable villages and areas (69–72).

In order to confirm the strategy of identifying households with poor economic status,

some studies were consistent of the strategy expressed by the interviewees (73).

Many experts emphasized the promotion and thinking of the systemic approach as the main solution to face inequality in the field of health and to improve the social and economic situation.

In a study conducted by Urswin et al., they pointed to investing in systems thinking and knowledge of data systems and upstream determinants of diabetes and health inequalities that can provide great value to this field (66). also, many studies have proposed the provision of special services for socio-economic groups in the results of studies (66, 74, 75).

in this study were proposed the solotion reduce the costs of health services to improve the socio-economic status of type 2 diabetic patients, solutions

In the study of Shrivastava et al. aimed at the social and economic factors related to diabetes and its management in India, they found that there is an urgent need to strengthen the health care delivery system to create awareness and prevention, early diagnosis, management, providing cost-effective services and services related to diabetic patients, with There is a focus on low SES people and women (76).

Barwah and his colleagues in the results of the study of the challenges of diabetes management in India: focusing on regional inequalities in India, granting treatment subsidies to type 2 diabetic patients who have a poor socioeconomic status will reduce inequality which were consistent with the results of this study (77).

In this study, to improve the socioeconomic status of diabetic patients, it was pointed out the need for sustainable intersectoral cooperation and joint efforts and a holistic approach. In other studies, intersectoral cooperation has been presented as a solution to improve inequality. Torslev et al. In a study aimed at providing a long-term protocol for health promotion and prevention of type 2 diabetes among people living in an ethnically and socioeconomically diverse neighborhood in Copenhagen, Denmark. They showed that sustainable inter-sectoral cooperation and partnership between related government institutions, private companies and civil society organizations is effective in improving the socio-economic status and promoting health (78).

In this study, the solutions for the fair distribution of health resources to achieve the goal of reducing social and economic inequality in utilization from health services for type 2 diabetic patients were discussed, that confirmed in many studies(79, 80).

In the study by Wu et al. With the aim of investigating the socio-economic situation and the prevalence of diabetes in China, they showed that strategies for the prevention and monitoring of the prevalence of diabetes should be established in China, (81) which was consistent with the solution presented by the experts in this study to focus on free periodical care service packages for diabetic patients. From the results of cumulative index analysis, we found that the variable of health status had the largest share (23.43%) in the use of outpatient services and the largest share (28.72%) in the use of pharmaceutical services for type 2 diabetic patients. In other words, if the health status is equally distributed among type 2 diabetic patients of different socio-economic groups, the inequality in utilization from outpatient and pharmaceutical services in type 2 diabetic patients should be reduced by 23% and 28%, respectively. These findings with the findings of the study by Barnard et al. which was done in England is consistent. In their study, the largest share of inequality was related to the health status of diabetic patients. They found that significant differences in health status between groups, populations, or individuals result from unequal distribution of social, environmental, and economic conditions (34).

Also, many studies have emphasized on institutionalizing and educating healthy lifestyle for type 2 diabetic patients which were consistent with the results of this study(82).

In this study, the creation of health-supporting policies, the creation of health-supporting and protected environments, and the possibility of expressing complaints and grievances were proposed as solutions in the field of health policy to improve the health status of type 2 diabetic patients, which were consistent with the solutions presented in other studies(83).

In confirmation of the solution proposed by the interviewees, other studies also pointed to the improvement of self-care programs for type 2 diabetic patients, (84).

In this study, were mentioned strategies to promote and improve the quality of services in order to improve the health status of type 2 diabetes patients,

Esadi et al. stated that we recommend public health strategies to improve health literacy and increase public awareness of diabetes (85).

In this study order to provide care services for type 2 diabetic patients, many solutions were presented by the interviewees, Huang et al. found that people with lower income have visual impairment compared to people with higher income. There are more. The main contribution to the observed income inequality in visual impairment was related to age and marital status. Regarding eye screening services, patients with higher income used more eye screening and preventive eye screening services. The main factors for increased use were income, having private health insurance, and patient experience in discussing diabetes complications with health professionals. When formulating health and treatment policies in order to minimize and reduce the observed inequalities, the implementation of eye damage screening programs for diabetic patients should be considered (86). Also, in the study of Burge et al., treatment goals based on results are mentioned as a way to improve the health status of diabetes mellitus patients(27).

Improving diabetes management skills for providers and doctors through training, financial and non-financial incentives for service providers, trying to motivate employees to provide better services, trying to improve skills through in-service training for employees are some of the things that the interviewees suggested. In this regard, other studies also mentioned efforts to motivate service providers, such as the study by Shekelle and his colleagues with the aim of measuring social and economic inequalities in diabetes index scores: poor quality or poor criteria? In the UK, they noted that some evidence suggests that in the UK, financial incentives, such as those in the new GP contract, are helping to reduce (though not eliminate) these disparities and inequalities(87). The reference to financing in the statements of experts in order to improve the basic insurance status of type 2 diabetic patients is also confirmed in other studies. Mutyambizi et al. In study h with aimed of measuring socio-economic inequalities and the determinants of catastrophic health expenditure and poverty for diabetes care in South Africa, they found that health financing interventions among diabetic patients should especially target poor women (88). According to experts' statements, improving management factors such as managerial stability, non-dependence of programs and policies on individuals, improving monitoring and control, monitoring the correct implementation of the electronic file will improve the status of basic insurance and promote the utilization of health services in type 2 diabetic patients. In this regard, many studies pointed to management factors in dealing with the inequality of type 2 diabetic patients (81, 85, 89). According to the interviewees, trying to correct cultural factors such as behavior modification, increasing awareness, participation and satisfaction of people is one of the methods that improve the performance of insurance companies. In many cases, studies pointed to the modification of behavior and increasing awareness in order to reduce inequality and increase the utilization of health services (4, 36, 63). In developing countries, studies show that most inequalities are caused by a lack of education and health literacy, and most studies have emphasized the promotion of public education and the promotion of health literacy and increasing access and proximity to health facilities for solutions (45, 52, 90–93). While in developed countries, most of the studies emphasized the improvement of comprehensive perspectives in strategies, racial differences and development of digital infrastructures (30, 66, 67, 81, 94, 95).

According to the results of the study, targeted and appropriate healthcare interventions for the poor as well as efforts to cover everyone with outpatient care and coverage of commonly used medicinal items should be considered. Specialized care is needed to control the condition of type 2 diabetic patients and prevent irreversible complications that lead to long-term hospitalizations and occupying hospital beds. It is necessary to define a comprehensive service package with an emphasis on education for disease control to encourage patients to receive free services, and it is also necessary to establish a proper referral system and continuous follow-up of identified patients in the health system. Improving the status of variables affecting the creation of socio-economic inequality in type 2 diabetic patients can become the basis for the growth of the indicators of the country's health system. It is recommended that targeted insurance coverage for low-income type 2 diabetic patients in society, enrichment of basic insurance benefit packages and facilitating access to needed health and medical services can be effective plans to deal with the disparity of the outpatient department and pharmaceutical items for type 2 diabetic patients. Appropriate interventions and changes in the implementation of policies to reduce social and economic inequalities in type 2 diabetes are needed. This emphasizes the effective collaboration between researchers and policy makers, managers, doctors, health experts, other institutions and related communities to improve the social and economic status of patients.

Ethics approval and consent to participate

This study received the required ethics approval from the Research Ethics Committee of Isfahan University of Medical Sciences, Isfahan, Iran with ethics code: IR.MUI.NUREMA.REC.1401.033. Furthermore, all methods were carried out in accordance with relevant guidelines and regulations in the Ethics approval and informed consent to participate section under declarations in the manuscript. Also, written informed consent of all participants was acquired, and they were assured of confidentiality and data anonymity.

Consent for publication

Not applicable.

Availability of data and materials

All data are available from the corresponding authors upon reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

no funding.

Authors' contributions

LG contributed in concept, and wrote the manuscript draft; MAR abstracted and analyzed the articles, and critically revised the manuscript; AT conceived of the study, participated in its design and contributed in analyzing . SK developed the original idea and analyzed data. All authors read and approved the final article.

Acknowledgments

We would like to thank all interviewees and experts of comprehensive health centers for their gentle contribution.

Financial support and sponsorship
This study was funded by Isfahan University of Medical Sciences, Isfahan, Iran, as a PhD thesis with research code no.: 3400867.

Conflict of interest

There are no conﬂicts of interest.

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No competing interests reported.

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measuring socio-economic inequality in utilization of type 2 diabetes services

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Version 1

Abstract

Introduction

Materials and methods

The statistical population of the research

inclusion and exit criteria

Sample size and sampling method

Data collection

The process of completing the questionnaire (how to ask questions)

Validity and reliability

Research variables

1. The first phase of research (quantitative study):

Construction of socio-economic status variable

Data

Using principal component analysis (PCA) method

Classification of patient to economic groups

Measuring socio-economic inequality

Choosing the right regression model

Classification of research variables:

Descriptive findings

2. The results of the first phase of the research (quantitative part):

Results of principal component analysis using PCA

The results of the second phase of the research (qualitative part):

Discussion

Conclusion

Declarations

References

Additional Declarations

Status:

Version 1