The social determinants of tuberculosis: from evidence to action

Abstract

Growing consensus indicates that progress in tuberculosis control in the low- and middle-income world will require not only investment in strengthening tuberculosis control programs, diagnostics, and treatment but also action on the social determinants of tuberculosis. However, practical ideas for action are scarcer than is notional support for this idea. We developed a framework based on the recent World Health Organization Commission on Social Determinants of Health and on current understanding of the social determinants of tuberculosis. Interventions from outside the health sector-specifically, in social protection and urban planning-have the potential to strengthen tuberculosis control.

FIGURE 1

Risk factors for different stages of TB pathogenesis and epidemiology. Note. BCG = bacillus Calmette-Guerin; MDR = multidrug resistant; TB = tuberculosis. ^a TB infection and disease rates are often reported to be higher among Black Africans and Hispanics than among Whites. ^b Increased TB risk associated with contact with a case of TB depends on the infectivity of the source case, the degree of exposure to the case by the susceptible person, and the degree of susceptibility of a person to infection. ^c It is unclear whether this observation can be explained by differences in case finding or whether it is due to different susceptibility to TB among sexes. TB disease tends to be more common among males.^d Migrants’ increased risk of TB in many settings may result from higher exposure to TB in country of origin or experience of worse socioeconomic living conditions compared with residents.

FIGURE 2

Conceptual framework and strategic entry points for intervention outside the health care sector. Note. SES = socioeconomic status; TB = tuberculosis. Gray boxes indicate entry points for intervention.Source. Adapted with permission from Elsevier. Source. Reproduced from Lonnroth et al.