Macrodetermined racial inequalities in diagnostic testing among tuberculosis patients in Brazil

• Published in: Public health (London) Vol. 167; pp. 103 - 110
• Main Authors: Jacobs, M.G., Pelissari, D.M., Diaz-Quijano, F.A.
• Format: Journal Article
• Language: English
• Published: Netherlands Elsevier Ltd 01.02.2019; Elsevier Science Ltd
• Subjects: Brazil; Clinical outcomes; Confidence intervals; Culture; Decision making; Dependent variables; Diagnosis; Diagnostic systems; Diagnostic tests; Geographic distribution; Geographical distribution; Geopolitics; Health care; Health care access; Health disparities; Health inequalities; HIV; Human immunodeficiency virus; Independent variables; International relations; Medical diagnosis; Medical tests; Patients; Public policy; Race; Racial groups; Racial inequality; Regional variations; Regression analysis; Regression models; Statistical analysis; Surveillance systems; Tests; Tuberculosis; Brazil; Brazil; Tuberculosis; Diagnosis; HIV; Race; Health inequalities
• ISSN: 0033-3506; 1476-5616
• DOI: 10.1016/j.puhe.2018.11.003

To estimate the association between tuberculosis (TB) patients' race and patients’ access to diagnostic testing in Brazil. In addition, we evaluated if the associations could be explained by a geographic codistribution between racial groups and diagnostic testing. It is a cross-sectional study based on secondary data from a national surveillance system of new TB cases diagnosed in 2015. We evaluated the association between TB patients’ race (independent variable) and the HIV testing and TB mycobacterial culture providing (dependent variables) with logistic regression models. We used multilevel models to consider different geopolitical levels (region, state and municipality). In addition, we used conditional logistic regressions matched by health-care unit. All models were adjusted by individual covariates associated with the outcomes. Compared with non–Afro-Brazilian patients, Afro-Brazilian patients had significantly lower odds to have had HIV testing [odds ratio (OR): 0.72; 95% confidence interval (CI): 0.69–0.75] and mycobacterial culture performed (OR: 0.74; 95% CI: 0.71–0.77). However, these statistically significant negative associations between Afro-Brazilian racial category and testing disappeared when patients were considered as nested in geopolitical contexts or matched for health-care unit. Afro-Brazilian TB patients had lower probability to have HIV test and mycobacterial culture performed. However, these associations seem to be macrodeterminated by the geographic distribution of both racial groups and diagnostic testing. Our findings can support the formulation of public policies aiming to mitigate regional disparities as a strategy to improve racial equity in access to healthcare. The approach presented can be applied in a range of scenarios to identify disparities, localize its source and support decision-making. •Afro-Brazilian TB patients had less HIV testing performed than non–Afro-Brazilian TB patients.•Afro-Brazilian TB patients had less mycobacterial culture performed than non–Afro-Brazilian patients.•Racial inequalities in testing are explained by regional differences.•Other characteristics of patient and disease also determine testing provision.