Liver fibrosis severity in chronic hepatitis B is associated with area-level rather than individual socioeconomic disadvantage: a nationwide multicentre study in Türkiye

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BACKGROUND: Socioeconomic disadvantage may influence the chronic hepatitis B (CHB) care continuum and the stage at which clinically relevant liver disease is recognised. However, evidence linking both individual- and area-level socioeconomic disadvantage to histologically assessed liver fibrosis in CHB remains limited. We examined whether socioeconomic disadvantage at the individual and area levels was associated with liver fibrosis severity in adults with CHB in Türkiye. METHODS: In this nationwide multicentre observational study, adults with CHB who underwent liver biopsy in routine care between 1 January 2019 and 31 December 2024 across 24 centres in Türkiye were screened. Clinical and histopathological data were obtained retrospectively from medical records, while socioeconomic data were collected after biopsy through structured face-to-face interviews. Fibrosis was staged using the Ishak system. Individual socioeconomic indicators and province-level categories of the socioeconomic development index (SEDI) were examined. The primary analysis used ordinal logistic regression. Supportive analyses included multivariable logistic regression, 1:1 propensity score matching with conditional logistic regression, overlap weighting, likelihood-ratio tests for interaction, chi-square or Fisher's exact tests, Kruskal-Wallis tests, and Wilcoxon rank-sum tests, with Benjamini-Hochberg adjustment for post-hoc comparisons. RESULTS: The analytic cohort included 956 adults, of whom 53.7% were male. Mild fibrosis (Ishak 0-2) was present in 73.1%, moderate fibrosis (3-4) in 21.7%, and advanced fibrosis/cirrhosis (5-6) in 5.2%. In multivariable ordinal regression, higher fibrosis stage was associated with older age at biopsy (adjusted OR = 1.12 per 10-year increase, 95% CI: 1.02-1.24; P = 0.019), longer travel time to a centre capable of CHB follow-up (adjusted OR = 1.53 per category, 95% CI: 1.30-1.79; P < 0.001), longer duration of residence in the current place of residence (adjusted OR = 1.21 per 5-year increase, 95% CI: 1.03-1.42; P = 0.023), and lower residential socioeconomic development (adjusted OR = 1.97 per one-level decrease, 95% CI: 1.82-2.15; P < 0.001). In matched and overlap-weighted comparisons of SEDI 6 versus SEDI 1, the corresponding estimates were OR = 26.00 (95% CI: 8.21-82.37; P < 0.001) and OR = 24.75 (95% CI: 8.96-68.36; P < 0.001), respectively. CONCLUSIONS: Liver fibrosis severity in adults with CHB was associated more consistently with area-level socioeconomic disadvantage of the current place of residence than with birthplace socioeconomic context or most individual socioeconomic indicators. These findings support a social epidemiological interpretation in which place-based disadvantage may be more closely linked to fibrosis severity at clinical presentation, potentially through unequal access to timely follow-up and specialist assessment.

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