Background Tuberculosis (TB) remains a public health problem in the UK-born population of England, including among young adults. Ecological studies indicate that deprivation is an important risk factor for TB, but there are few recent individual-level studies in high income countries that have investigated the association between poverty-related social determinants of health inequality (SDH) and TB.
Our objective was to measure the association between individual socio-economic status and social determinants of health, and TB, taking into account the clustering of social risk factors in individuals, and to estimate the potential population impact on TB rates.
Methods Secondary analyses of a nationwide case-control study conducted among UK-born White adults aged 23 to 38 years at diagnosis of their first TB episode, and randomly selected age and sex frequency-matched community controls. Data on some SDH (education, household overcrowding, tobacco smoking, alcohol use, drugs use, and history of homelessness and prison) were collected in face-to-face interviews. Statistical analyses, using logistic regression models, was informed by a theoretical causal framework (Directed Acyclic Graph) of plausible inter-relationships between the measured social factors.
Results Overall, 681 TB cases and 1183 controls were recruited. The risk of TB was about four times higher in subjects whose formal education was up to GCSE O-levels or less compared to those with at least a university degree (OR=3.94; 95%CI: 2.74; 5.67), after controlling for other TB risk factors (age, sex, BCG vaccination and stays in Africa or Asia for 33 months). After simultaneously adjusting for these risk factors and all measured social determinants, higher TB risk was also independently associated with tobacco smoking, use of drugs (especially injectable drugs - OR=5.67; 95%CI: 2.68; 11.98), history of homelessness and deprivation in the area of residence. Population Attributable Fraction (PAF) estimates suggested that tobacco use and class-A drug use were, respectively, responsible for 18% and 15% of TB cases in the target population.
Conclusion The results provide insight into some of the mechanisms through which deprivation increases the risk of TB in the general population in England and support the argument for improved approaches to TB control efforts, such as integrated health and social services in high-risk young adult populations.
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