Stigma, Gender, and their Impact on Patients with Tuberculosis in Rural Bangladesh

Abstract

In addition to marginalization by poverty and ethnicity, gender is likely to contribute to vulnerability to TB-related stigma affecting women. Stigma often contributes to psychosocial problems and emotional suffering, and it may hinder help seeking and treatment adherence. TB-related stigma and its gender-specific features have not been carefully studied in Bangladesh, and such research is needed to reduce adverse effects of stigma. This study assessed and compared stigma in women and men, and identified crosscutting and gender-specific features of TB-related stigma. To assess stigma and the context of TB-related illness experience, meaning and help seeking behavior from patients' perspectives, a cultural epidemiological study administered a locally adapted semi-structured EMIC interview to 50 women and 52 men with pulmonary TB in rural Bangladesh. Indicators of TB-related stigma were assessed individually and collectively in a validated index. They were compared by sex, and illness narratives elaborated features of stigma with reference to features of TB. The study showed that six indicators of TB-related stigma were more prominent in accounts of women and two were more prominent in men's interviews. Gender differences appeared somewhat less after adjusting for other sociodemographic variables, and age was most significantly inversely related to stigma. Features of stigma more prominent in the accounts of women included feeling shamed or embarrassed, thinking less of themselves and feeling that others refused to visit or avoided them. Men were less likely to disclose their condition to a confidant, stay away from work or report that their spouse refused sex because of TB. Effective public health information and counselling sensitive to gender-specific features of stigma are needed to protect TB patients from the adverse impact of avoidable stigma. Further research is needed to clarify effects of gender-specific features of felt and enacted stigma on help seeking and treatment adherence.

A systematic review of global cultural variations in knowledge, attitudes and health responses to tuberculosis stigma

“…52 Attitudes toward tuberculosis TB is experienced as embarrassing and shameful in Congo, 5 Zambia, 53 This 'dirty' disease is believed to affect poor people; patients with TB feel less respected by others or inferior in Ethiopia 23 and Viet Nam, 6 with women in Bangladesh feeling shame and rejected by others. 7 Discrimination was reported in South Africa, 47 Indonesia 8 and Nepal. 4 In Brazil, TB is perceived as diffi cult and isolating, changing a person's perception of themselves.…”

“…58 Health care workers fear infection when interacting with those with TB; shun, avoid, and advocate the segregation of patients with TB at home and in hospitals 59 31 Women are faced with adverse consequences more often than men; coughing up sputum in public by women is culturally frowned upon, resulting in enormous suffering. 72 Men are less likely to disclose their condition, stay away from work or report that their spouse refused sex because of TB; women report feeling ashamed or embarrassed, think less of themselves and feel that others refuse to visit them or avoid them 7 …”

“…55 Men and women report feeling different levels of stigmatization and social and economic consequences (Appendix Table A.7). 7,9,16,31,35,45,72,73,75,[79][80][81][82][83][84][85] Four factors related to sex differences in TB stigma were found: 1) fi nancial dependence of women on men to obtain treatment in Pakistan, 35 2) low priority of women's health in Peru, 83 3) social isolation of women in Bangladesh 31 and Viet Nam, 9 and 4) decreased marital prospects in Malawi, 16 Pakistan, 35 and India. 16,28 In Viet Nam, women worried more than men about the social consequences of the disease, 84 and women perceived more TB stigma than men in Kosovo 82 and India.…”

“…2,3 Individuals with TB and their families can experience prejudice and negative attitudes, such as shame, blame and a sense of judgment. [4][5][6][7][8] Enacted TB stigma refers to exclusion, rejection or devaluation by others against patients and their families based on beliefs of social unacceptability or inferiority. 9 Perceived TB stigma refers to patient and family fears of inferiority stemming from the anticipation of an adverse judgment related to a TB diagnosis.…”

Social, Historical and Cultural Dimensions of Tuberculosis

“…Because the 'self' of an individual is not necessarily located in the individual body per se, but rather located in the person's cultural and social relations. For example, unequal gender relations may mean the experience of stigma by female TB patients is worse than their male counterparts (Long et al, 1999;Karim et al, 2007).…”