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. 2021 Feb 2;23(2):1525–1531. doi: 10.1007/s40200-020-00713-y

Geographical, gender and age inequalities in non-communicable diseases both at national and provincial levels in Iran

Nima Fattahi 1, Sina Azadnajafabad 1, Esmaeil Mohammadi 1, Arya Aminorroaya 1, Shahabeddin Rezaei 1, Erfan Ghasemi 1, Negar Rezaei 1,2, Shohreh Naderimagham 1,2,✉, Bagher Larijani 2,✉, Farshad Farzadfar 1,2
PMCID: PMC11599513  PMID: 39610535

Abstract

Over 80% of deaths due to non-communicable diseases (NCDs) occur in low and middle-income countries, indicating an inequality in the health care system around the world. Conducted studies at provincial level in developed countries have shown that mortality rates due to this group of diseases are higher in the populations with lower education, income, and social class. NCDs account for 71.3% of total world deaths in 2016 and 79.2% of total deaths in Iran in the same year. Improving the health of Iranian population and reducing the number of communicable diseases over the past decades have made NCDs as a major health problem in Iran. In this study, we describe the status of most lethal NCDs in the country at national and provincial level. In addition, study on the inequality of deaths due to NCDs at provincial level in Iran showed that there is a considerable difference between different provinces. Furthermore, there is an age inequality so that mortality of main NCDs increased dramatically after the age of 70. Therefore, health policy makers and decision makers should adopt appropriate policies to reduce gender, geographic and age disparities to reduce gender and inter-provincial inequalities in Iran.

Keywords: Inequality, Iran, Non-communicable diseases

Introduction

Uneven distribution of deaths due to non-communicable diseases (NCDs) is one of the most important points about them, since more than 80% of deaths occur in low- and middle-income countries, indicating an inequality in the health care system around the world [1–4]. People in these countries have less access to care and treatment of NCDs which leads to worse prognosis and shorter survival rate of patients. One of the important issues about inequality in treatment of NCDs in different countries is the rate of treatment coverage for different patients. While two-thirds of patients with hypertension and diabetes in developed countries such as the United States and South Korea receive treatment, less than 50% of patients in low and middle-income countries receive remedy [1]. Studies on the inequality in NCDs within countries are limited and often have performed in developed countries. Studies about NCDs at the provincial level in developed countries have shown that mortality rates due to these diseases are higher in the population with lower education, income, and social class [1, 2]. The male to female mortality rate of NCDs varies from 0.7 to 1 [5–9]. A study in Iran at national and provincial level predicted that the age standardized mortality rate of NCDs by 2030 and the results showed that cancer in the southern, northern and central provinces will be declined. On the other hand, cardiovascular diseases in the southeast, north-west and central provinces of Iran will be reduced. Chronic respiratory diseases will be more common in southern provinces and industrial cities. Diabetes-related deaths are also high in most provinces, but higher in the southern, central and northern provinces [2, 10].

Nowadays, epidemiological and demographic changes around the world have made NCDs and their related risk factors as a priority of the health systems, in this regard, World Health Organization (WHO) has devoted Sustained Development Goals (SDGs) target 3.4 to reducing NCDs premature mortality rate [2, 11]. NCDs account for 79.2% of total deaths and 74% of total burden of diseases in Iran as a middle-income country [1, 12]. Improving primary health care in recent years in this country resulted in better health of children and reduction in maternal mortality rate. Additionally, life expectancy increased from 66 years to 78 years between 1990 and 2013. Improving the health of Iranians and reducing the number of communicable diseases over the years has made NCDs as a major health problem in Iran [11, 13, 14].

In this study, we aimed to help policymakers to have a clear picture about gender, age and within-provincial inequalities of the main NCDs including cardiovascular disease, cancer, diabetes and kidney diseases, neurologic and chronic respiratory diseases in Iran. Therefore, related health authorities may have appropriate decision makings and resource allocation considering these inequalities.

Overview

The results of, The National and Subnational Burden of Diseases, Injuries, and Risk Factors (NASBOD) study, which is a systematic effort for estimating the magnitude of health loss due to diseases, injuries and risk factors, at national and subnational level, showed that cardiovascular diseases, diabetes and kidney disease, cancer and chronic respiratory diseases were the four leading causes of death due to NCDs in 2015 in Iran [5]. On the other hand, results of the Global Burden of Disease (GBD) study which is the most comprehensive worldwide observational epidemiological study to date in 2017 indicate that cardiovascular diseases, cancers, diabetes and kidney disease and neurological diseases had the highest mortality rate due to NCDs in that year [15]. The details are explained below.

Cardiovascular diseases (CVD)

According to the GBD study, cardiovascular diseases caused 285.33 (95%UI: 256.79–301.53) age standardized mortality per 100,000 people in 2017 in Iran [15]. On the other hand, NASBOD study 2015 showed that cardiovascular diseases caused 170.16 deaths per 100,000 people, accounting for 37% of all deaths in Iran [5, 16, 17]. The mortality rates in males and females in 2015, were 177.41 and 162.80 per 100,000 people, respectively. In general, the male to female ratio of mortality in this country was 1.09 in 2015(Table 1). It should be noted that the mortality rate of this group of diseases was relatively constant from 2000 to 2015 [5, 18]. At provincial level, the highest and the lowest cardiovascular age standardized mortality rates in Iran were 239.63 (95% UI: 186.36–306.91) and 115.29 (95% UI: 86.46–153.37) per 100,000 people respectively. In this regard, the ratio of the highest to the lowest age standardized mortality rates due to CVDs in Iran was about 2.07 in 2015(Fig. 1) (Table 1). It should be noted that the mortality rate in males was higher than females in all provinces [19, 20]. Evaluating age pyramid in 2015 shows that there is a significant increase in 70+ years age group comparing with lower ages so that the mortality rate in 70+ years age group males (2695.56) to 50–69 years age group males (351.12) is 7.6 and in 70+ years female (2752.64) to 50–69 years females (234.01) is 11.7 [5](Table 1).

Table 1.

geographical, gender, and age inequality in non-communicable diseases mortality in Iran

Disease Male to female mortality rate 70+ years age group to 50–69 years age group Highest to lowest mortality rate among different provinces of Iran
Male Female
Cardiovascular diseases 1.09 7.6 11.7 2.07
Cancers 1.53 4.7 3.7 2.05
Diabetes mellitus 0.74 5.1 6.41 4.41
Chronic respiratory diseases 1.40 7.6 9.6 2.28
Neurological diseases 1.04 11.6 12.7 2.78
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Fig. 1.

Fig. 1

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Cardiovascular diseases related age-standardized death rate in different provinces of Iran, 2015

Cancers

According to the GBD study 2017, the age standardized mortality rate due to cancers was 96.22 (95%UI:88.14–102.21) per 100,000 people [15, 21]. The results of NASBOD study 2015 showed that the mortality rate due to all cancers was 45.49 per 100,000 people in Iran, meaning that cancers accounted for 10% of all deaths in this country [22–26]. The mortality rate due to all cancers in males and females were 55.09 and 35.83 per 100,000 people respectively and the males to females cancers ratio was 1.53 in that year (Table 1), although mortality rates due to all cancers have generally declined from 2000 to 2015 [5, 6, 27]. In general, the highest and the lowest cancer age standardized mortality rates were 61.24 (95%UI: 43.79–87.91) and 29.87 (95%UI: 21.27–43.13) per 100,000 people, respectively. The highest to the lowest cancer mortality rates in 2015 was 2.05 in Iran (Fig. 2) (Table 1). It should be noted that the mortality rate due to cancer in males was more than females in all provinces of this country [28, 29]. Evaluating age pyramid in 2015 shows that there is a significant increase in 70+ years age group comparing with lower ages so that the mortality rate in 70+ years age group males (633.06) to 50–69 years age group males (133.99) is 4.7 and in 70+ years female (331.66) to 50–69 years females (89.23) is 3.7 [5] (Table 1).

Fig. 2.

Fig. 2

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Cancer related age-standardized death rate in different provinces of Iran, 2015

Diabetes and kidney diseases

According to the GBD study, age-standardized mortality rates due to diabetes and kidney diseases was 43.27 (95%UI: 38.88–45.96) per 100,000 in 2017 in Iran [15]. The results of NASBOD study 2015 showed that the mortality rate due to diabetes mellitus was 9.04 per 100,000 persons in both sexes in Iran. Mentioned item was 10.38 and 7.72 per 100,000 in women and men respectively. Therefore, the male to female mortality rates ratio in 2015 was 0.74 [5, 30, 31] (Table 1). It is also worth noting that the incidence of diabetes and kidney diseases related deaths at both national and provincial levels increased from 1990 to 2015 [32]. The highest and the lowest age-standardized mortality rates due to diabetes mellitus in Iran in 2015 were 16.82 (95% UI: 12.46–22.53) and 3.81 (95% UI: 2.66–5.39) respectively. The highest to the lowest ratio is 4.41 [32](Fig. 3) (Table 1). Evaluating age pyramid in 2015 shows that there is a significant increase in 70+ years age group comparing with lower ages so that the mortality rate in 70+ years age group males (97.21) to 50–69 years age group males (19.01) is 5.11 and in 70+ years female (141.13) to 50–69 years females (22.36) is 6.31 [5] (Table 1).

Fig. 3.

Fig. 3

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Diabetes mellitus related age-standardized death rate in different provinces of Iran, 2015

Chronic respiratory diseases

According to the GBD study, the age-standardized mortality rate due to chronic respiratory diseases in Iran was 27.93 (95%UI 24.01–29.93) per 100,000 people [15, 33]. On the other hand, the results of the NASBOD study 2015 indicated that this rate was 22.71 per 100,000 people, accounting for 5 % of total mortality in 2015 in Iran [33, 34]. The mortality rate due to this group of diseases was 26.50 In males and 18.89 in females per 100,000 people. The males to females mortality rate proportion was 1.40 (Table 1). It should be noted that from 1990 to 2015, mortality rate due to chronic respiratory diseases have generally increased throughout the country [35]. The highest age-standardized mortality rate due to these diseases at provincial level was 29.96(23.92–37.97) per 100,000 and the lowest one was 13.14(10.14–17.07) per 100,000 people. The ratio of the highest to the lowest mortality rate was 2.28 [9](Fig. 4) (Table 1). Evaluating age pyramid in 2015 shows that there is a significant increase in 70+ years age group comparing with lower ages so that the mortality` rate in 70+ years age group males (387.91) to 50–69 years age group males (50.53) is 7.67 and ASDR in 70+ years female (288.12) to 50–69 years females (29.98) is 9.6 [5] (Table 1).

Fig. 4.

Fig. 4

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Chronic respiratory related age-standardized death rate in different provinces of Iran, 2015

Neurologic disorders

According to the GBD study, the age-standardized mortality rate due to Neurologic disorders in Iran was 20.77 (95%UI: 9.1–46.58) per 100,000 people. The NASBOD study 2015 showed that the mortality rate due to neurological disorders was 14.90 per 100,000 people in Iran. Mentioned rate in males and females was 15.50 and 14.30 per 100,000 persons respectively, and the ratio of males to females mortality rate was 1.04 [7, 8, 36] (Table 1). At provincial level, the highest and the lowest age-standardized mortality rate were 26.80 (95%UI: 17.16–42.54) and 9.64 (95%UI: 5.31–18.72) per 100,000 people. The ratio of the highest to the lowest mortality rate of neurological disorders at the provincial level was 2.78 [37–39](Fig. 5) (Table 1). Evaluating age pyramid in 2015 shows that there is a significant increase in 70+ years age group comparing with lower ages so that the mortality rate in 70+ years age group males (227.79) to 50–69 years age group males (19.58) is 11.6 and ASDR in 70+ years female (212.80) to 50–69 years females (16.76) is 12.7 [5] (Table 1).

Fig. 5.

Fig. 5

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Neurological disorders related age-standardized mortality rate in different provinces of Iran, 2015

Conclusion

In general, the male to female mortality rate due to NCDs varies from 0.7 to 1.5. Therefore, it can be concluded that there is an inequality in NCDs mortality rate between genders, which can be due to the physiological differences between two sexes to unequal utilization of health services [1]. On the other hand, there is an inter-provincial difference in the country. The range of the highest to the lowest mortality rates of different NCDs varies from 2.3 in diabetes and kidney diseases to 3.2 in cancers. Many factors are contributing to inequality, including the economic and physical barriers against accessing health services as well as the quality of health services provided in different areas of the country and inequality in the screening, diagnosis, and treatment of NCDs [2]. In addition to gender and province there is a wide age inequality so that all of the mentioned diseases from age 70 onwards the morbidity and mortality of the disease increases dramatically. There are some essential requirements to address inequalities in NCDs, including preventive and therapeutic programs as well as progressive social policies and effective and strong leadership, inter-sectoral cooperation, and effective observation at both national and sub-national levels. Provided data in this study helps policymakers adjust their policies to reduce inequalities across the country as well as between sexes and different age groups.

Availability of data and materials

All data is available through GBD VIZHUB and vizit. Report.

Authors’ contributions

All authors have made a significant contribution to the manuscript and accept the responsibility for the study protocol and the presented results.

Compliance with ethical standards

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Footnotes

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Contributor Information

Shohreh Naderimagham, Email: shohrehnaderimagham@yahoo.com.

Bagher Larijani, Email: larijanib@tums.ac.ir.

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