Socioeconomic and regional inequalities in health-related quality of life in Bhutan: a nationally representative cross-sectional study

Background: Bhutan lacks comprehensive data on health-related quality of life (HRQoL) despite its growing population and rising disease burden. This study provides the first national and subnational assessment of HRQoL inequalities and their determinants in Bhutan's general population. Methods: We analysed data from 11 340 adults aged ≥15 years from the 2023 Bhutan National Health Survey, a nationally representative cross-sectional survey. We assessed health status using the EuroQol 5-Dimension 5 Level (EQ-5D-5L) descriptive system and the EuroQol Visual Analogue Scale (EQ-VAS). We used regression analyses to examine factors associated with HRQoL and individual EQ-5D-5L dimensions, as well as concentration, slope, and relative indices of inequality to assess national and subnational socioeconomic disparities. Results: Pain/discomfort was the most commonly reported EQ-5D-5L problem (38%; 95% confidence interval (CI) = 36, 40), followed by mobility limitations and anxiety/depression (both 14%; 95% CI = 13, 15). The mean EQ-5D-5L score was 0.95 (standard deviation (SD) = 0.10), and the mean EQ-VAS score was 77.06 (SD = 17.44). HRQoL was lower among women, older respondents, those with lower education, unemployed individuals, rural residents, and those with poorer dietary habits. In regression analyses, older age and rural residence were consistently associated with higher odds of reported problems, while higher education was protective across all EQ-5D-5L dimensions. Higher household expenditure was generally associated with higher EQ-5D and EQ-VAS scores, but the richest quintile also had higher odds of reporting problems in several individual dimensions. Inequality analyses showed larger disparities by education and area of residence than by wealth, with broadly similar patterns across gender groups and across EQ-5D and EQ-VAS scores. Conclusions: Significant socioeconomic, geographic, and behavioural disparities in HRQoL exist in Bhutan, with inequalities more pronounced by education and area of residence than by wealth. Targeted interventions for less-educated and rural populations, alongside efforts to promote healthier diets, are needed to help mitigate these inequities.