title: Assessing the consequences of stigma for tuberculosis patients in urban Zambia.
abstract: BACKGROUND
  Stigma is one of the many factors hindering tuberculosis (TB) control by negatively affecting hospital delay and treatment compliance. In Zambia, the morbidity and mortality due to TB remains high, despite extended public health attempts to control the epidemic and to diminish stigma.
  
  
  OBJECTIVE
  To enhance understanding of TB-related stigmatizing perceptions and to describe TB patients' experiences of stigma in order to point out recommendations to improve TB policy.
  
  
  METHODS
  We conducted a mixed method study at Kanyama clinic and surrounding areas, in Lusaka, Zambia; structured interviews with 300 TB patients, multiple in-depth interviews with 30 TB patients and 10 biomedical health workers, 3 focus group discussions with TB patients and treatment supporters, complemented by participant observation and policy analysis of the TB control program. Predictors of stigma were identified by use of multivariate regression analyses; qualitative analysis of the in-depth interviews, focus group discussions and participant observation was used for triangulation of the study findings.
  
  
  RESULTS
  We focused on the 138/300 patients that described TB-related perceptions and attitudes, of whom 113 (82%) reported stigma. Stigma provoking TB conceptions were associated with human immunodeficiency virus (HIV)-infection, alleged immoral behaviour, (perceived) incurability, and (traditional) myths about TB aetiology. Consequences of stigma prevailed both among children and adults and included low self-esteem, insults, ridicule, discrimination, social exclusion, and isolation leading to a decreased quality of life and social status, non-disclosure, and/or difficulties with treatment compliance and adherence. Women had significantly more stigma-related problems than men.
  
  
  CONCLUSIONS
  The findings illustrate that many TB patients faced stigma-related issues, often hindering effective TB control and suggesting that current efforts to reduce stigma are not yet optimal. The content and implementation of sensitization programs should be improved and more emphasis needs to be placed on women and children.
authors: Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Faculty of Social and Behavioural Science, Department of Sociology and Anthropology, University of Amsterdam, Amsterdam, The Netherlands.
authors: Anne Lia
authors: AL
authors: Cremers
authors: Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
authors: Myrthe Manon
authors: MM
authors: de Laat
authors: Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; The National TB/Leprosy Control Programme, Lusaka, Zambia; University of Zambia-University College London (UNZA-UCL) program, Lusaka, Zambia.
authors: Nathan
authors: N
authors: Kapata
authors: Faculty of Social and Behavioural Science, Department of Sociology and Anthropology, University of Amsterdam, Amsterdam, The Netherlands.
authors: Rene
authors: R
authors: Gerrets
authors: Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands; Division of Epidemiology, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
authors: Kerstin
authors: K
authors: Klipstein-Grobusch
authors: Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
authors: Martin Peter
authors: MP
authors: Grobusch
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002648:Child; D002675:Child, Preschool; D005260:Female; D017144:Focus Groups; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007223:Infant; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D011788:Quality of Life; D057545:Social Stigma; D014376:Tuberculosis / Q000523:psychology*; D014505:Urban Population; D055815:Young Adult; D015024:Zambia