Assessing the association between elements of health inequalities and the risk of bacterial infection in high-income countries: a systematic scoping review
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Introduction There is sufficient evidence to support the notion that the rate of infection is higher in vulnerable groups than in the wider population. This scoping review sought to further elucidate the relationship between health inequalities and the risk of bacterial infections in high-income countries. Methods Factors associated with health inequalities were defined as socioeconomic status and deprivation (employment status, income levels, deprivation categories); protected characteristics (age, gender, ethnicity, sexual orientation, disability); inclusion health groups (migration status, sex workers, people who inject drugs, the homeless) and geography (urban or rural dwelling). The published literature search was conducted on Embase, Google and Medline with a grey literature search also conducted. Exclusion criteria were defined as papers that were either published pre-2010, set in low- or middle-income countries, or that covered viral, parasitic, or fungal pathogens. Key pathogens and infections to include were determined by review of the UK antimicrobial resistance (AMR) National Action Plan. Results The search yielded 343 papers; of which, 70 were eligible for review. The most frequently reported infections were sexually transmitted infections (STIs), infectious diseases e.g. Mycobacterium tuberculosis and sexually transmitted blood-borne infections. Most papers reviewed cited multiple health inequalities, most notably ethnicity (21/70), race (18/70), age (14/70), sex (13/70) and socio-economic status and deprivation and inclusion health groups (sex workers and people experiencing drug and alcohol dependence). Conclusion Evidence has emerged highlighting an important association between factors commonly associated with health inequalities and the increased risk of bacterial infections within high-income countries. Notably, ethnic populations, members of the LGBTQ+ community, people experiencing homelessness and those of a poor socioeconomic status are at a higher risk of bacterial infection.
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Line 168 Italicise microbe name Line 175 I find the reporting of P values from other literature sources, in the absence of the statistical details unhelpful. I would advise these are removed, as going into depth about the statistics is out of the scope of this manuscript. Line 191-193 either needs citations, rewriting to reflect the general understanding of this topic (instead of non-existent literture) or removal. Line 204 the use of “aboriginals” is not appropriate. The authors should use “indigenous people”. Line 321 “One could suggest” please rephrase into scientific language. Line 331. Missing full stop. Line 337 missing bracket Line 372 define minority stress theory Line 383 P Value - either fully explain and provide details, or simply say it’s significant Line 385, again, One could infer is not scientific. What does the evidence …
Line 168 Italicise microbe name Line 175 I find the reporting of P values from other literature sources, in the absence of the statistical details unhelpful. I would advise these are removed, as going into depth about the statistics is out of the scope of this manuscript. Line 191-193 either needs citations, rewriting to reflect the general understanding of this topic (instead of non-existent literture) or removal. Line 204 the use of “aboriginals” is not appropriate. The authors should use “indigenous people”. Line 321 “One could suggest” please rephrase into scientific language. Line 331. Missing full stop. Line 337 missing bracket Line 372 define minority stress theory Line 383 P Value - either fully explain and provide details, or simply say it’s significant Line 385, again, One could infer is not scientific. What does the evidence indicate?? This review must cite primary sources when information from them is included in the manuscript. It is not appropriate to use popular science writing or press releases in place of primary sources. This relates specifically to references 95 and 100. 95 should be https://www.gov.uk/government/statistics/drug-misuse-findings-from-the-2013-to-2014-csew/drug-misuse-findings-from-the-201314-crime-survey-for-england-and-wales#estimates-of-illicit-drug-use-by-ethnicity-and-sexual-orientation and 100 should be https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(16)30514-X/fulltext . The authors must comb through all references and ensure they are the appropriate citations. Same comment for reference 101. There is no reference provided for 116. To cite government reports, please include a DOI and date accessed. E.g. references 113, 114, 115. A google search for reference 104 lands on a page not found.
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This manuscript would benefit from more fully realising the potential of the scoping review methodology. While the review appears to me to be methodologically sound (I'm aware reviewer 1 is more of an expert), its synthesis remains largely descriptive, confirming well-established associations between health inequalities and certain bacterial infections particularly STIs and tuberculosis in high-income settings. However, it lacks the conceptual depth and innovation expected of a scoping review. The inclusion of a broader range of sources, such as government reports and policy documents, would enhance the manuscript's utility. Most importantly, although the review identifies evidence gaps, it does not prioritise them or translate them into a structured future research agenda. To strengthen its contribution, the authors are encouraged to …
This manuscript would benefit from more fully realising the potential of the scoping review methodology. While the review appears to me to be methodologically sound (I'm aware reviewer 1 is more of an expert), its synthesis remains largely descriptive, confirming well-established associations between health inequalities and certain bacterial infections particularly STIs and tuberculosis in high-income settings. However, it lacks the conceptual depth and innovation expected of a scoping review. The inclusion of a broader range of sources, such as government reports and policy documents, would enhance the manuscript's utility. Most importantly, although the review identifies evidence gaps, it does not prioritise them or translate them into a structured future research agenda. To strengthen its contribution, the authors are encouraged to reflect more critically on what this review adds to the field and to frame new conceptual questions that could advance academic discourse and public health practice.
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Comments to Author
I have concerns for rigour in this this work was conducted and reported. This includes clarity of purpose, the application of the stated methodology, and the accurate presentation of findings from the literature. I don't understand how starting position stated as "Conversely, few papers have assessed the association between health inequalities and the risk of bacteria infection in high-income countries." and then undertaking a review on these publications - where in fact 70 were found. It sounds like the original premise is poorly stated and might be edited? Or did it mean few reviews? Although then as I understand it the authors consider the prior number to be zero rather than "few". The selection criteria state that there was a focus on "key organisms of relevance to antibiotic resistance" but the …
Comments to Author
I have concerns for rigour in this this work was conducted and reported. This includes clarity of purpose, the application of the stated methodology, and the accurate presentation of findings from the literature. I don't understand how starting position stated as "Conversely, few papers have assessed the association between health inequalities and the risk of bacteria infection in high-income countries." and then undertaking a review on these publications - where in fact 70 were found. It sounds like the original premise is poorly stated and might be edited? Or did it mean few reviews? Although then as I understand it the authors consider the prior number to be zero rather than "few". The selection criteria state that there was a focus on "key organisms of relevance to antibiotic resistance" but the work is presented as factors associated with bacterial infections. At other times the bacterial is dropped such as the discussion - which starts with reference to infections in general. Clarity about what is being studied should run through the paper, match the selection criteria, and should be describe the same consistent topic across the paper. Similarly the impact statement describes this work as "systematically exploring the complex interplay between socioeconomic and demographic factors and the risk of bacterial infections". The imitations note that "this study considered several factors associated with health inequalities but did not assess the interplay between them" Results: Under the heading "Level of income" the text refers to exchanging sex for money and peoples understanding of the extent of this and risk of STI. Neither of these is necessarily level of income. Similarly the statement about Helicobacter pylori among "African American populations compared to white American population" is placed in a section headed Migrants. This isn't a comparison between migrants and non-migrants. The text "However, this relationship was not consistent across all racial groups as black females with college-levels of education had significantly higher predicted probabilities of having an STI (12.4% self-reported; 13.4% assay-diagnosed) compared with white females who had less than a high school diploma." Presents data that does not necessarily support the conclusion of this finding not being consistent across "racial groups". A consistent association with education within ethnic group but an impact of ethnic group greater than that of education could also produce this finding. Looking up reference 42 as I was surprised that a PWID paper had a bacterial infection focus this paper has no data on bacterial infections or any infections. I don't understand how this made it into the review or that the conclusion stated here that "PWID, such as illicit fentanyl, were at increased risk for injection-related infectious diseases" is justified by the paper focus and conclusions. In addition to this paper not supporting the statement made, looking at the inclusion criteria there isn't a basis for this paper having been included as it makes no reference to any of the specific bacterial infections. Reference 52 is cited to state "that male sex was associated with a higher incidence of infectious diseases in infant populations". This paper does not study the incidence of infectious disease but rather deaths associated with infection. Table 2 extracts correct information but the text then states something different. Overall I haven't confidence that this work is conducted and reported with a rigour and precision that makes it an addition to the published literature.
Please rate the quality of the presentation and structure of the manuscript
Very poor
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
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