Perspective on health inequalities
In their introduction the authors hypothesise that there is an association between poverty and Tuberculosis (TB) in Recife, Brazil, and that this is mediated by accommodation crowding, malnutrition and “other socially determined factors”. However this paper does not include a nutrition variable, and the authors don’t clarify which other social factors they believe are important. They examine numerous possible socioeconomic position (SEP) variables without defining a priori which is of primary interest. They are clear that they believe health inequalities stem from social inequalities at both individual and group levels, and thus we must assume they are considering poverty in relative, rather than absolute terms.
The authors were able to show at an area level that a combined measure of computer ownership and literacy captured the effect of all other SEP variables. This model is based on statistical significance in multivariate analysis, and does not appear to have theoretical underpinnings. However, in the discussion the authors state that this shows “education… is related to all other aspects of poverty”. Given this explicit assumption it is unclear why other education measures were not considered a priori.
It is important to note that the paper does not answer the question posed in the title. It shows that being of low SEP (by the exposure measures discussed), is associated with having TB. To answer the question about effects of relative deprivation, rates of TB in various areas need to be compared, with each census area graded in terms of poverty. This measure of area poverty should then be included in multivariate analysis controlling for individual-level SEP....
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...ota Population Center, Minneapolis. University of Minnesota. http://catalog.ihsn.org/index.php/catalog/359/data_dictionary.
9. Howe LD, Galobardes B, Matijasevich A, Gordon D, Johnston D, et al. (2012) Measuring socio-economic position for epidemiological studies in low-and middle-income countries: a methods of measurement in epidemiology paper. International journal of epidemiology 41: 871-886.
10. Howe L, Hargreaves J, Huttly S (2008) Issues in the construction of wealth indices for the measurement of socio-economic position in low-income countries. Emerging Themes in Epidemiology 5: 1-14.
de Alencar Ximenes, RA, de Fatima Pessoa Militao de Albuquerque, M, Souza, WV et al. (2009). 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. Int J Epidemiol 38(5): 1285-1296
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