Tuberculosis and social aspects in a Brazilian state of high vulnerability: a systematic review

Abstract

ABSTRACT Objectives: to synthesize evidence on social, economic, territorial, and healthcare access factors associated with the occurrence and outcomes of tuberculosis in Maranhão. Methods: a mixed-methods systematic review, registered in PROSPERO and conducted in accordance with PRISMA 2020. The search was carried out in May 2025 using the SPIDER strategy. Original studies published between 2014 and 2025, in Portuguese, English, or Spanish, were included; duplicates and studies not focused on the target population were excluded. Methodological quality and risk of bias were assessed using the Mixed Methods Appraisal Tool. Results: of the 94 studies identified, 12 were included. Four thematic axes were identified: spatial distribution and risk areas; sociodemographic vulnerabilities; organization and access to health services; and treatment conditions and social protection. Structural inequalities were associated with higher incidence, treatment abandonment, and barriers to diagnosis. Conclusions: the persistence of tuberculosis in Maranhão is related to social and territorial vulnerabilities, requiring intersectoral policies, strengthening of primary healthcare, and monitoring of social indicators.