Association of community sociodemographic and tuberculosis-related factors with variability in community-level tuberculosis stigma in South Africa: an ecological analysis from the MISSED TB Outcomes study

OBJECTIVE: Tuberculosis (TB) stigma is a critical barrier to timely diagnosis and treatment, yet few studies have quantified community-level TB stigma or its variability across geographic contexts. This study describes methods for capturing community-level TB stigma and examines stigma variability and correlations with community-level sociodemographic and TB-related factors across urban, periurban and rural communities. DESIGN: Ecological study. SETTING: 93 demarcated study communities in Buffalo City Metropolitan Health District, Eastern Cape, South Africa. PARTICIPANTS: 3869 heads of household, age ≥18 years, were surveyed in a geographically clustered random sample of households across the 93 study communities. PRIMARY OUTCOME MEASURES: Validated scales were used to measure perceived TB stigma. Community levels of TB stigma were generated by aggregating individual responses within each study community. RESULTS: Median community TB stigma scores varied significantly by community location: compared with urban communities, rural communities had lower TB stigma scores (beta=-0.235; 95% CI -0.362 to -0.108) while periurban communities had higher scores (beta=0.136; 95% CI 0.017 to 0.254). Community TB stigma was positively associated with community HIV stigma, with the strongest associations in urban (beta=0.977 (95% CI 0.634 to 1.321) and rural (beta=0.816 (95% CI 0.186 to 1.446) communities. No associations were observed between TB stigma and TB prevalence, TB knowledge or household demographics after adjusting for community location. CONCLUSIONS: TB stigma varied meaningfully across communities and was associated with urbanicity and HIV stigma. Stigma is a complex social process and there may be many other factors shaping TB stigma at the community level. Future research and stigma-reduction interventions should consider local contexts and community-level determinants beyond individual demographics, TB knowledge or community TB burden.