背景:疟疾仍然是撒哈拉以南非洲(SSA)的主要负担。虽然已经证明了贫困和疟疾之间的联系,需要对社会经济地位(SEP)影响疟疾风险的明确机制有更清晰的认识,以指导设计更全面的干预措施来缓解疟疾风险.本系统综述概述了SSA疟疾社会经济差异中介的当前证据。
方法:我们搜索了PubMed和WebofScience的随机对照试验,队列,2000年1月1日至2022年5月31日以英文发表的病例对照和横断面研究。在对所包括的研究的参考列表进行回顾后,确定了进一步的研究。我们纳入了以下研究:(1)对SEP与疟疾感染之间的因果途径的危险因素进行了正式的中介分析,或(2)使用标准回归模型将这些潜在的中介因素作为SEP与疟疾之间关联的混杂因素进行了调整。至少有两名独立审稿人对这些研究进行了评估,进行数据提取,并评估偏见的风险。对纳入的研究进行了系统概述。
结果:我们在SSA中确定了来自20个国家的41篇文章,以纳入最终审查。其中,30项研究采用横断面设计,和26发现疟疾风险的社会经济不平等。三项正式的调解分析表明,调解粮食安全的证据有限,住房质量,和以前的抗疟药使用。Housing,教育,杀虫剂处理过的蚊帐,在其余的研究中,营养被强调为可以独立于SEP预防疟疾,暗示调解的潜力。然而,方法上的限制包括使用横截面数据,混淆调整不足,测量SEP和疟疾的异质性,以及通常低质量或中等质量的研究。没有研究考虑暴露介质相互作用或考虑可识别性假设。
结论:很少有研究进行正式的中介分析以阐明SEP与疟疾之间的通路。研究结果表明,粮食安全和住房可能是更可行的(结构性)干预目标。使用精心设计的纵向研究和改进的分析进行进一步的研究将阐明当前对SEP和疟疾之间途径的稀疏证据,并为有效干预的更多潜在目标提供证据。
BACKGROUND: Malaria remains a major burden in sub-Saharan Africa (SSA). While an association between poverty and malaria has been demonstrated, a clearer understanding of explicit mechanisms through which socioeconomic position (SEP) influences malaria risk is needed to guide the design of more comprehensive interventions for malaria risk mitigation. This systematic
review provides an overview of the current evidence on the mediators of socioeconomic disparities in malaria in SSA.
METHODS: We searched PubMed and Web of Science for randomised controlled trials, cohort, case-control and cross-sectional studies published in English between January 1, 2000 to May 31, 2022. Further studies were identified following reviews of reference lists of the studies included. We included studies that either (1) conducted a formal
mediation analysis of risk factors on the causal pathway between SEP and malaria infections or (2) adjusted for these potential mediators as confounders on the association between SEP and malaria using standard regression models. At least two independent reviewers appraised the studies, conducted data extraction, and assessed risk of bias. A systematic overview is presented for the included studies.
RESULTS: We identified 41 articles from 20 countries in SSA for inclusion in the final
review. Of these, 30 studies used cross-sectional design, and 26 found socioeconomic inequalities in malaria risk. Three formal
mediation analyses showed limited evidence of
mediation of food security, housing quality, and previous antimalarial use. Housing, education, insecticide-treated nets, and nutrition were highlighted in the remaining studies as being protective against malaria independent of SEP, suggesting potential for mediation. However, methodological limitations included the use of cross-sectional data, insufficient confounder adjustment, heterogeneity in measuring both SEP and malaria, and generally low or moderate-quality studies. No studies considered exposure mediator interactions or considered identifiability assumptions.
CONCLUSIONS: Few studies have conducted formal
mediation analyses to elucidate pathways between SEP and malaria. Findings indicate that food security and housing could be more feasible (structural) intervention targets. Further research using well-designed longitudinal studies and improved analysis would illuminate the current sparse evidence into the pathways between SEP and malaria and adduce evidence for more potential targets for effective intervention.