Socioeconomic status and the risk for colonization or infection with priority bacterial pathogens: a global evidence map
Authors: Blackmon Sarah , Avendano Esther , Nirmala Nanguneri , Chan Courtney W. , Morin Rebecca A. , Balaji Sweta , McNulty Lily , Alemu Argaw Samson , Doron Shira , Nadimpalli Maya L. 
Published: April 2024

Low socioeconomic status (SES) is thought to exacerbate risks for bacterial infections, but global evidence for this relationship has not been synthesized. We systematically reviewed the literature for studies describing participants’ SES and their risk of colonization or community-acquired infection with priority bacterial pathogens. Fifty studies from 14 countries reported outcomes by participants’ education, healthcare access, income, residential crowding, SES deprivation score, urbanicity, or sanitation access. Low educational attainment, lower than average income levels, lack of healthcare access, residential crowding, and high deprivation were generally associated with higher risks of colonization or infection. There is limited research on these outcomes in low- and middle-income countries (LMICs) and conflicting findings regarding the effects of urbanicity. Only a fraction of studies investigating pathogen colonization and infection reported data stratified by participants’ SES. Future studies should report stratified data to improve understanding of the complex interplay between SES and health, especially in LMICs.

Putting research into context

With community-acquired antimicrobial resistance (AMR) on the rise, it is important to understand the factors that exacerbate colonization and infection with priority pathogens that are increasingly antimicrobial-resistant, particularly in the context of the social determinants of health. Previous studies have found that poverty exacerbates the risk of colonization/infection with community-acquired antimicrobial-resistant pathogens; however, other indicators of socioeconomic status (SES) including educational attainment or access to healthcare require further investigation. A comprehensive search of the scientific literature was conducted in MEDLINE (Ovid), MEDLINE Epub Ahead of Print, In-Process, In-Data-Review & Other Non-Indexed Citations, and Daily (Ovid), Global Health (Ovid), Embase (Elsevier), Cochrane Database of Systematic Reviews (Wiley), Cochrane Central Register of Controlled Trials (Wiley), and Web of Science Core Collection from inception through January 2022. All searches were based on an initial MEDLINE search developed and utilizing MeSH terminology and related keywords for the following concepts: Community-Acquired Infections, Outpatients, Ambulatory Care, Socioeconomic Factors, Health Status Disparities, Healthcare Disparities, Continental Population Groups, Ethnic Groups, Gram-Negative Bacteria, and individual ESKAPE pathogens.

ADDED VALUE OF THIS STUDY

This scoping review found sufficient evidence to support future systematic reviews and meta-analyses evaluating the relationship between SES and risks for colonization or infection with community-acquired bacterial pathogens that are increasingly antimicrobial-resistant. We identified 50 published papers from 14 countries reporting outcomes by participants’ education, healthcare access, income, residential crowding, SES deprivation score, urbanicity, or sanitation access. Low educational attainment, lower than average income levels, lack of healthcare access, residential crowding, and high deprivation were generally associated with higher risks of colonization and infection.

IMPLICATIONS OF ALL THE AVAILABLE EVIDENCE

This review identified several gaps in the current literature describing relationships between SES and risks for colonization/infection with community-acquired bacterial pathogens. First, we identified few studies from LMICs, despite LMICs having the highest burden of AMR. Only a fraction of published studies reported data stratified by SES, as SES is more often controlled for rather than analyzed as an exposure of interest in bacterial colonization and infection studies. Of the studies that did report results stratified by SES, few examined collinearity between reported SES characteristics, making it challenging to assess the most important exposures driving or mediating observed associations. Future studies should report data stratified by SES characteristics or SES deprivation scores to allow for a better understanding of the complex interplay between SES and health, especially in LMICs.