A Retrospective Analysis Examining the Impact of Educational Attainment and Social Determinants of Health on...

Rifampicin-resistant tuberculosis (RR-TB) remains a major public health challenge in TB-endemic regions. While social determinants of health affect infectious disease outcomes, their impact on RR-TB remains poorly understood. This study evaluated the relationship between educational attainment, social disadvantage, and RR-TB outcomes.

We conducted a retrospective cohort study using data from 4 Centre for the AIDS Programme of Research in South Africa RR-TB clinical trials. Social vulnerability was measured using an exploratory Social Disadvantage Score (SDS) that incorporated education, employment, and incarceration. We used a latent class analysis (LCA) to identify classes with shared social vulnerability indicators. Associations with treatment outcomes were assessed using Cox regression models, with the exploratory SDS, its component indicators, and derived latent classes as predictors.

Education was not independently associated with unfavorable treatment outcomes (adjusted hazard ratio [aHR] = 1.39, 95% confidence interval [CI]: 0.96-1.99, P = .077), whereas a history of incarceration doubled the hazard (aHR = 2.05, 95% CI: 1.33-3.16, P < .001). Restricting subsequent models to the subcohort with collected employment data, unemployment increased the hazard of unfavorable outcomes (aHR = 1.84, 95% CI: 1.20-2.82, P = .005). Using the same subcohort, increasing cumulative social disadvantage showed a strong dose-response relationship, with a 5-fold higher hazard for 3 disadvantages (aHR = 5.85, 95% CI: 2.73-12.56, P < .001). Latent class analysis revealed that Class 2 (moderate socioeconomic advantage) had a significantly higher hazard of unfavorable outcomes (aHR = 1.82, 95% CI: 1.19-2.79, P = .006).

Cumulative social risk score was associated with unfavorable RR-TB outcomes, supporting further evaluation of targeted support for disadvantaged populations.