Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute, Respiratory Division, McGill University, Montreal, QC, Canada.
Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute, Respiratory Division, McGill University, Montreal, QC, Canada.
Lancet Glob Health. 2019 Jan;7(1):e68-e80. doi: 10.1016/S2214-109X(18)30435-2.
Indigenous peoples worldwide carry a disproportionate tuberculosis burden. There is an increasing awareness of the effect of social determinants and proximate determinants such as alcohol use, overcrowding, type 1 and type 2 diabetes, substance misuse, HIV, food insecurity and malnutrition, and smoking on the burden of tuberculosis. We aimed to understand the potential contribution of such determinants to tuberculosis in Indigenous peoples and to document steps taken to address them.
We did a systematic review using seven databases (MEDLINE, Embase, CINAHL, Global Health, BIOSIS Previews, Web of Science, and the Cochrane Library). We identified English language articles published from Jan 1, 1980, to Dec 20, 2017, reporting the prevalence of proximate determinants of tuberculosis and preventive programmes targeting these determinants in Indigenous communities worldwide. We included any randomised controlled trials, controlled studies, cohort studies, cross-sectional studies, case reports, and qualitative research. Exclusion criteria were articles in languages other than English, full text not available, population was not Indigenous, focused exclusively on children or older people, and studies that focused on pharmacological interventions.
Of 34 255 articles identified, 475 were eligible for inclusion. Most studies confirmed a higher prevalence of proximate determinants in Indigenous communities than in the general population. Diabetes was more frequent in Indigenous communities within high-income countries versus in low-income countries. The prevalence of alcohol use was generally similar to that among non-Indigenous groups, although patterns of drinking often differed. Smoking prevalence and smokeless tobacco consumption were commonly higher in Indigenous groups than in non-Indigenous groups. Food insecurity was highly prevalent in most Indigenous communities evaluated. Substance use was more frequent in Indigenous inhabitants of high-income countries than of low-income countries, with wide variation across Indigenous communities. The literature pertaining to HIV, crowding, and housing conditions among Indigenous peoples was too scant to draw firm conclusions. Preventive programmes that are culturally appropriate targeting these determinants appear feasible, although their effectiveness is largely unproven.
Indigenous peoples were generally reported to have a higher prevalence of several proximate determinants of tuberculosis than non-Indigenous peoples, with wide variation across Indigenous communities. These findings emphasise the need for community-led, culturally appropriate strategies to address smoking, food insecurity, and diabetes in Indigenous populations as important public health goals in their own right, and also to reduce the burden of tuberculosis.
Canadian Institutes of Health Research.
全球土著人民承受着不成比例的结核病负担。人们越来越意识到社会决定因素和直接决定因素（如饮酒、过度拥挤、1 型和 2 型糖尿病、药物滥用、艾滋病毒、粮食不安全和营养不良以及吸烟）对结核病负担的影响。我们旨在了解这些决定因素对土著人民结核病的潜在贡献，并记录为解决这些问题而采取的步骤。
我们使用七个数据库（MEDLINE、Embase、CINAHL、全球卫生、BIOSIS Previews、Web of Science 和 Cochrane 图书馆）进行了系统评价。我们确定了自 1980 年 1 月 1 日至 2017 年 12 月 20 日发表的英语文章，报告了全球土著社区中结核病直接决定因素的流行情况以及针对这些决定因素的预防方案。我们纳入了任何随机对照试验、对照研究、队列研究、横断面研究、病例报告和定性研究。排除标准是语言不是英语的文章、全文不可用、人群不是土著、专门针对儿童或老年人以及专门针对药物干预的研究。
在确定的 34255 篇文章中，有 475 篇符合纳入标准。大多数研究证实，土著社区中直接决定因素的流行率高于一般人群。在高收入国家的土著社区中，糖尿病比在低收入国家更为常见。饮酒的流行率在一般情况下与非土著人群相似，但饮酒模式往往不同。吸烟率和无烟烟草消费在土著人群中通常高于非土著人群。在大多数评估的土著社区中，粮食不安全状况普遍存在。在高收入国家的土著居民中，药物使用比低收入国家更为常见，而且在不同的土著社区中差异很大。关于艾滋病毒、拥挤和住房条件的文献对于土著人民来说太少，无法得出明确的结论。针对这些决定因素制定的文化上适宜的预防方案似乎可行，尽管其有效性在很大程度上尚未得到证实。
与非土著人民相比，土著人民普遍报告有更高的几种结核病直接决定因素的流行率，而且在不同的土著社区之间差异很大。这些发现强调了需要以社区为基础、采取文化上适宜的策略来解决土著人群中的吸烟、粮食不安全和糖尿病问题，因为这些问题本身就是重要的公共卫生目标，也可以减轻结核病的负担。
加拿大卫生研究院。
