Journal of epidemiology and community health · 2025
Associations of municipality-level income and racial segregation with individual-level tuberculosis treatment outcomes in Brazil: a nationwide cohort study (2010-2019).
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Hall Qanisha, Sousa Filho José Firmino de, Guimarães Joanna Mn, Malta Deborah C, Romero-Sandoval Natalia Cristina, Hargreaves Sally, Kerr Ligia, Santos Gervasio F, Brickley Elizabeth B, Paixão Enny S, Barreto Maurício L, Pescarini Julia M, Unit on the Social and Environmental Determinants of Health Inequalities (SEDHI)
Аннотация
BACKGROUND: Residential segregation is considered a social determinant of health, but there is limited evidence of its impact on tuberculosis (TB). We investigated the associations between municipality-level income and racial segregation and TB treatment outcomes in Brazil.
METHODS: We studied nationwide registries of new TB cases between 1 January 2010 and 31 December 2019. TB treatment was dichotomised as unfavourable (ie, loss to follow-up, modification of treatment regimen, treatment failure and death) and favourable (ie, cured/treatment completion). We assessed individuals' municipality-level income and racial segregation (ie, dispersion of household heads earning ≤half versus those earning >half minimum wage; and of household heads identifying as black or brown/mixed race (Pardo/a) versus white). Logistic regression adjusted for sociodemographic and clinical variables was used to estimate the OR of experiencing an unfavourable treatment outcome associated with segregation overall and by self-identified race/ethnicity.
RESULTS: Individuals living in highly economically and racially segregated municipalities (fifth versus first quintiles) were more likely to have an unfavourable TB treatment outcome (income segregation: adjusted OR 1.34 (95% CI 1.31 to 1.37); racial segregation: 1.13 (0.94 to 1.36)). Living in municipalities of higher income segregation (third, fourth and fifth quintiles) was associated with higher unfavourable TB treatment outcomes in all self-identified racial groups (fifth quintile: white 1.25 (0.96 to 1.64); black 1.42 (1.15 to 1.74); brown/mixed 1.37 (1.20 to 1.56); Asian=1.30 (1.00 to 1.69) and Indigenous 1.37 (1.00 to 1.87)).
CONCLUSIONS: Living in highly income and racially segregated environments is associated with unfavourable TB treatment outcomes for all self-identified races in Brazil. TB programmes should account for segregation as a barrier to TB treatment completion.
METHODS: We studied nationwide registries of new TB cases between 1 January 2010 and 31 December 2019. TB treatment was dichotomised as unfavourable (ie, loss to follow-up, modification of treatment regimen, treatment failure and death) and favourable (ie, cured/treatment completion). We assessed individuals' municipality-level income and racial segregation (ie, dispersion of household heads earning ≤half versus those earning >half minimum wage; and of household heads identifying as black or brown/mixed race (Pardo/a) versus white). Logistic regression adjusted for sociodemographic and clinical variables was used to estimate the OR of experiencing an unfavourable treatment outcome associated with segregation overall and by self-identified race/ethnicity.
RESULTS: Individuals living in highly economically and racially segregated municipalities (fifth versus first quintiles) were more likely to have an unfavourable TB treatment outcome (income segregation: adjusted OR 1.34 (95% CI 1.31 to 1.37); racial segregation: 1.13 (0.94 to 1.36)). Living in municipalities of higher income segregation (third, fourth and fifth quintiles) was associated with higher unfavourable TB treatment outcomes in all self-identified racial groups (fifth quintile: white 1.25 (0.96 to 1.64); black 1.42 (1.15 to 1.74); brown/mixed 1.37 (1.20 to 1.56); Asian=1.30 (1.00 to 1.69) and Indigenous 1.37 (1.00 to 1.87)).
CONCLUSIONS: Living in highly income and racially segregated environments is associated with unfavourable TB treatment outcomes for all self-identified races in Brazil. TB programmes should account for segregation as a barrier to TB treatment completion.