Open Access Research BMJ Open: first published as 10.1136/bmjopen-2017-020406 on 30 March 2018. Downloaded from Urban–rural differences in the prevalence of diabetes mellitus among 25–74 year-old adults of the Yangon Region, Myanmar: two cross- sectional studies Wai Phyo Aung,1,2 Aung Soe Htet,1,3 Espen Bjertness,1 Hein Stigum,1 Virasakdi Chongsuvivatwong,4 Marte Karoline Råberg Kjøllesdal1 To cite: Aung WP, Htet AS, ABSTRACT Strengths and limitations of this study Bjertness E, et al. Urban–rural Objectives To investigate the association between urban– differences in the prevalence of rural location and the occurrence of diabetes mellitus (DM) ► The study followed the internationally recommend- diabetes mellitus among 25–74 in the Yangon Region, and to estimate the proportion of year-old adults of the Yangon ed WHO STEP protocol. urban and rural participants already diagnosed with DM, Region, Myanmar: two cross- ► A national reference laboratory was used for the in- and of those, the proportion under treatment and under sectional studies. BMJ Open vestigation of fasting plasma glucose. control. 2018;8:e020406. doi:10.1136/ ► Both urban and rural areas were included. bmjopen-2017-020406 Design Two cross-sectional studies, using the WHO STEPs ► Because the results were from only one region of methodology. Myanmar, the results might not be generalised to the ► Prepublication history for Setting The Yangon Region of Myanmar, urban and rural this paper is available online. entire Myanmar population. areas. To view these files, please visit the journal online (http:// dx. doi. Participants Men and women, aged 25–74 years, included during the study period from September– org/ 10. 1136/ bmjopen- 2017- of a country’s health transition.1 2 The advan- 020406). November 2013 (urban) and 2014 (rural areas) (n=1372). Institutionalised people, physically and mentally ill person, tages of urbanisation include better access Received 2 November 2017 to healthcare services, education and social monks and nuns were excluded. 2 http://bmjopen.bmj.com/ Revised 29 December 2017 Results The age-standardised prevalence of DM was services. On the other hand, adverse changes Accepted 16 February 2018 12.1% in urban and 7.1% in rural areas (p=0.039). such as nutrition transition with an increase in In urban areas, the prevalence of DM was lowest in the consumption of saturated fats and sugar the highest educational groups (p<0.001). There were and a more sedentary lifestyle are reported no differences in DM prevalence between gender or worldwide.3 The net effect of urbanisation income levels. In rural areas, those who were physically is an epidemiological transition towards inactive had a low intake of fruit and vegetable and were increasing rates of obesity and non-commu- overweight/obese had a higher DM prevalence than others. nicable diseases (NCDs), including diabetes In a logistic regression, the OR for DM in rural compared on September 29, 2021 by guest. Protected copyright. mellitus (DM) type II. with urban areas was 0.38 (0.22, 0.65), adjusted for sociodemographic variables and behavioural risk factors. According to the WHO, DM was the sixth 1Department of Community most important cause of global deaths in In urban areas, 43.1% of participants had the experience 4 Medicine and Global Health, of receiving blood glucose measurements by a doctor or 2015. In 2017, there were 146 million people Institute of Health and Society, health worker, and 61.5% of all cases of DM were already with DM in rural areas, while 274 million University of Oslo, Oslo, Norway 5 2Occupational and diagnosed, 78.7% were under treatment and 45.8% were people lived with DM in urban areas. The Environmental Health Division, under control. The corresponding proportions in rural areas global prevalence of DM is estimated to Department of Public Health, were 26.4%, 52.4%, 78.1% and 32.0%, respectively. increase from 8.8% in 2015 to 10.4% in 2040, Ministry of Health and Sports, Conclusion The prevalence of DM in the Yangon Region equaling 642 million people.5 In the WHO Yangon, Myanmar was high, and significantly higher in urban than in South-East Asia Region (SEAR), the number 3International Relations Division, rural areas. More health services are needed to serve of people living with DM increased from 17 Ministry of Health and Sports, this population with a large proportion of undiagnosed 6 Yangon, Myanmar to 96 million between 1980 and 2014. Half 4 diabetes. Preventive measures to halt and reduce the Epidemiology Unit, Prince of prevalence of DM are urgently needed. of the world’s people with diabetes are now Songkla University, Songkla, living in the SEAR and the Western Pacific Thailand Region.6 Correspondence to INTRODUCTIOn In Myanmar, the prevalence of behavioural Dr Wai Phyo Aung; Urbanisation influences lifestyle and socio- and metabolic risk factors for NCD, such as waiphyoaung77@ gmail. com economic position and is one of the drivers heavy alcohol consumption, tobacco use, Aung WP, et al. BMJ Open 2018;8:e020406. doi:10.1136/bmjopen-2017-020406 1 Open Access BMJ Open: first published as 10.1136/bmjopen-2017-020406 on 30 March 2018. Downloaded from a sedentary lifestyle, obesity and hypertension, is high A multistage cluster sampling was used. First, six town- among 15–64 year-old citizens in 2009.7 In 2012, NCDs ships from urban areas and six townships from rural led to 59% of total deaths in Myanmar.8 In 2004, the prev- areas were randomly selected among 45 townships of alence of DM in residents between the ages of 25 and 64 the Yangon Region. In the second stage, we listed all the years in the Yangon Region was 8.1%.9 In 2014, the wards (urban township units) in the six selected urban national prevalence of DM in the same age range was townships and all the villages (rural township units) in 10.5%.10 Despite an increase in the prevalence of NCDs, the six selected rural townships. Based on the unit of there is still a limited amount of research on NCDs and its wards and villages, five wards from each selected urban risk factors in Myanmar. township and five villages from each selected rural town- If poorly controlled, DM may lead to long-term compli- ship were randomly selected. The total number of wards cations, such as diabetes retinopathy, lower limb amputa- and villages was 60. From each selected ward and village, 6 tion, renal failure and cardiovascular diseases. Diabetes 26–27 households were randomly chosen. After selecting retinopathy is particularly prevalent among people with households, we listed the eligible household members, 11 a long duration of DM and a low socioeconomic status. and one was randomly invited to participate in this study. Controlling DM significantly reduces the risk of cardio- The data collection was done during the daytime on the 12 vascular diseases in patients with DM. Moreover, the first day, and the blood sample collection was done the rate of amputation in patients with DM is reduced up to next morning. If the selected respondent was away from 13 40%–60% if DM is properly controlled. the home during the data collection time, we made an This study aims to investigate the association between appointment with him/her the next day, most often right urban–rural location and the occurrence of DM in after the blood sample collection was done. There were 25–74 year-old male and female citizens of the Yangon 1608 invitees in this study, with an equal distribution of Region, and to estimate the proportion of urban and rural gender (804 from urban and 804 from rural areas). The participants already diagnosed with DM, and of those, the total number of participants who accomplished STEPs 1 proportion under treatment and under control. and 2 were 1486, with 755 (94%) from urban areas and 731 (91%) from rural areas. For all three STEPs, 693 Population and methods (86%) from urban areas and 679 (83%) from rural areas Based on the WHO STEPwise approach for the surveil- 14 were accomplished. The primary reasons given for not lance of NCDs risk factors, this study is a house- participating in STEPs 1 and 2 were ‘not willing’ and ‘not hold-based, cross-sectional study in urban and rural areas having time’, while ‘afraid to be involved in the blood of selected townships in the Yangon Region conducted sampling procedure’ was the primary reason for STEP 3. from September to November 2013 and 2014, respec- Thirteen pregnant women (3 urban and 10 rural) were tively. The survey had all three STEPs,: (1) questionnaires excluded because maternal physiological changes in http://bmjopen.bmj.com/ related to sociodemographic characteristics, dietary and pregnancy might impact on the estimates. There were no sedentary lifestyle habits and history of DM, (2) physical differences between those who completed STEPs 1 and 2 measurements of height and weight and (3) laboratory only and all 3 STEPS, in terms of age, location and educa- investigation for fasting plasma glucose (FPG). tional level. Sampling Men and women between the ages of 25 and 74 partic- Data collection and measurement ipated in the study. Buddhist monks and nuns, institu- The questionnaires were translated into the Myanmarian 14 on September 29, 2021 by guest. Protected copyright. tionalised people and military persons were not invited, language from the WHO STEPs Instruments V.2.1. while people who were judged to be too physically or Data were collected by the principle investigator and mentally ill to participate were not eligible. According to four research assistants (medical doctors). The research the WHO sample size calculator for the STEP survey,14 assistants were recruited via the Myanmar Medical Asso- with a level of marginal error of 0.05, a design effect ciation, and underwent a 2-day training with technical of 1.5 and an expected response rate of 80%, we would input from the Department of Medical Research (Lower need a sample of 500 in each study (urban and rural) Myanmar).