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We aimed to characterise how poverty and interrelated personal risk factors increase tuberculosis risk in Peru to inform the design of locally appropriate, person-centred, equity-oriented interventions.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      We undertook a case-control study among people aged 15\u00a0years and over in 32 communities in Peru between 2016 and 2019. Cases (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u20092337) were people diagnosed with any form of tuberculosis. Controls (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u2009981) were people living in randomly selected households in the same communities. We derived measures of household poverty from three dimensions (physical, human, and financial capital) and investigated the associations between these; personal risk factors more specifically linked to health (e.g. smoking); and tuberculosis. We used logistic regression to calculate adjusted odds ratios (a\n                      <jats:italic>OR<\/jats:italic>\n                      ), 95% confidence intervals (95%\n                      <jats:italic>CI<\/jats:italic>\n                      ), and population attributable fractions (PAF). A directed acyclic graph was used to inform the analytical approach.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Household poverty was strongly associated with tuberculosis (a\n                      <jats:italic>OR<\/jats:italic>\n                      \u2009=\u20093.1; 95%\n                      <jats:italic>CI:<\/jats:italic>\n                      2.3\u20134.2 for people from the \u2018poorer\u2019 versus \u2018less poor\u2019 half of households). There was a non-linear social gradient across deciles of household poverty, with odds of tuberculosis increasing exponentially as poverty deepened (a\n                      <jats:italic>OR<\/jats:italic>\n                      \u2009=\u200912.6; 95%\n                      <jats:italic>CI:<\/jats:italic>\n                      6.8\u201323.2 for the \u2018poorest\u2019 decile versus the \u2018least poor\u2019 decile). Overall, tuberculosis burden could be halved by reducing poverty in the \u2018poorer\u2019 half of households to the level of the \u2018less poor\u2019 half (PAF\u2009=\u200947%; 95%\n                      <jats:italic>CI:<\/jats:italic>\n                      40\u201354). For key personal risk factors, we estimated PAF for alcohol excess (PAF\u2009=\u200912.3%, 95%\n                      <jats:italic>CI:<\/jats:italic>\n                      7.2\u201317.2); underweight (PAF\u2009=\u200910.3%, 95%\n                      <jats:italic>CI:<\/jats:italic>\n                      8.7\u201311.8); smoking (PAF\u2009=\u20098.8%, 95%\n                      <jats:italic>CI:<\/jats:italic>\n                      3.8\u201313.5); HIV (PAF\u2009=\u20095.7%, 95%\n                      <jats:italic>CI:<\/jats:italic>\n                      4.6\u20136.7); and diabetes (PAF\u2009=\u20094.6%, 95%\n                      <jats:italic>CI:<\/jats:italic>\n                      3.3\u20136.0). We also identified other important risk factors including previous tuberculosis (PAF\u2009=\u200914.8%, 95%\n                      <jats:italic>CI:<\/jats:italic>\n                      11.6\u201317.9); incarceration (PAF\u2009=\u20099.5%, 95%\n                      <jats:italic>CI:<\/jats:italic>\n                      6.8\u201312.1); and lower social capital (PAF\u2009=\u20094.1%, 95%\n                      <jats:italic>CI:<\/jats:italic>\n                      2.6\u20135.6). Most personal risk factors, particularly education and substance misuse, tuberculosis exposures (e.g. incarceration and homelessness), and undernutrition, exhibited a social gradient across quintiles of household poverty and were more prevalent in people living in poorer households (Cochran-Armitage test for linear trend\n                      <jats:italic>P<\/jats:italic>\n                      \u2009&lt;\u20090.001 for variables showing these social gradients).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Interventions addressing multidimensional household poverty and interrelated personal risk factors could substantially reduce tuberculosis burden. Our results provide an evidence base for designing person-centred, equity-oriented interventions; and support more effective implementation of poverty reduction and social protection within the global tuberculosis response.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s40249-025-01324-6","type":"journal-article","created":{"date-parts":[[2025,6,19]],"date-time":"2025-06-19T21:23:26Z","timestamp":1750368206000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":14,"title":["The social determinants of tuberculosis: a case-control study characterising pathways to equitable intervention in Peru"],"prefix":"10.1186","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-3033-2367","authenticated-orcid":false,"given":"Matthew J.","family":"Saunders","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rosario","family":"Montoya","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Luz","family":"Quevedo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eric","family":"Ramos","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sumona","family":"Datta","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carlton A.","family":"Evans","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2025,6,20]]},"reference":[{"key":"1324_CR1","unstructured":"Global tuberculosis report 2024. 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Ethical approvals included the Callao Ministry of Health, Peru; Asociaci\u00f3n Ben\u00e9fica PRISMA, Peru; and Imperial College London, UK. All participants gave their written informed consent and, in the case of minors (aged under 18 years), assent, to participate.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"The authors declare that they have no competing interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"53"}}