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IJE Advance Access originally published online on August 4, 2009
International Journal of Epidemiology 2009 38(5):1285-1296; doi:10.1093/ije/dyp224
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Published by Oxford University Press on behalf of the International Epidemiological Association © The Author 2009; all rights reserved.
The online version of this article has been published under an open access model. Users are entitled to use, reproduce, disseminate, or display the open access version of this article for non-commercial purposes provided that: the original authorship is properly and fully attributed; the Journal and Oxford University Press are attributed as the original place of publication with the correct citation details given; if an article is subsequently reproduced or disseminated not in its entirety but only in part or as a derivative work this must be clearly indicated. For commercial re-use, please contact journals.permissions@oxfordjournals.org

Is it better to be rich in a poor area or poor in a rich area? A multilevel analysis of a case–control study of social determinants of tuberculosis

Ricardo Arraes de Alencar Ximenes1,2,*, Maria de Fátima Pessoa Militão de Albuquerque1,3, Wayner V Souza3, Ulisses R Montarroyos1, George T N Diniz3, Carlos F Luna3 and Laura C Rodrigues4

1 Departamento de Medicina Tropical, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil.
2 Departamento de Clinica Medica, Universidade de Pernambuco, Recife, Pernambuco, Brazil.
3 Núcleo de Saúde Coletiva, Centro de Pesquisa Ageu Magalhães, FioCruz, Recife, Pernambuco, Brazil.
4 Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK.

* Corresponding author. Universidade Federal de Pernambuco-Medicina Tropical, Av. Professor Moraes Rego, s/n, Recife, Pernambuco 50670420, Brazil. E-mail: ricardo.ximenes{at}pq.cnpq.br


  Abstract

Background Tuberculosis is known to have socio-economic determinants at individual and at area levels, but it is not known whether they are independent, whether they interact and their relative contributions to the burden of tuberculosis.

Methods A case–control study was conducted in Recife, Brazil, to investigate individual and area social determinants of tuberculosis, to explore the relationship between determinants at the two levels and to calculate their relative contribution to the burden of tuberculosis. It included 1452 cases of tuberculosis diagnosed by the tuberculosis services and 5808 controls selected at random from questionnaires completed for the demographic census. Exhaustive information on social factors was collected from cases, using the questionnaire used in the census. Socio-economic information for areas was downloaded from the census. Multilevel logistic regression investigated individual and area effects.

Results There was a marked and independent influence of social variables on the risk of tuberculosis, both at individual and area levels. At individual level, being aged ≥20, being male, being illiterate, not working in the previous 7 days and possessing few goods, all increased the risk of tuberculosis. At area level, living in an area with many illiterate people and where few households own a computer also increased this risk; individual and area levels did not appear to interact. Twice as many cases were attributable to social variables at individual level than at area level.

Conclusions Although individual characteristics are the main contributor to the risk of tuberculosis, contextual characteristics make a substantial independent contribution.

Keywords Tuberculosis, social determinants, multilevel, Brazil, poverty

Accepted 6 May 2009


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Commentary: Socio-economic determinants of tuberculosis in Recife, Brazil
Int. J. Epidemiol., October 1, 2009; 38(5): 1295 - 1296.
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