TB Stigma in Nigeria: A Health Stigma and Discrimination Framework Analysis

Author(s): Michael Kunnuji, Obioma Chijioke- Akaniro, George Eluwa, Emperor Ubochioma, Russell Armstrong, Chukwuma Anyaike

Background:

Nigeria is a country with a high burden of TB with low treatment coverage and high TB mortality. TB stigma is a major barrier to accessing TB care and a challenge to an effective response. This study adopted the health stigma and discrimination framework of Stangl and colleagues to explore the drivers and facilitators of TB stigma, TB stigma marking, manifestations of TB stigma, and outcomes.

Methods:

The study analysed qualitative open-ended responses on TB stigma experience provided by a total of 2,061 survey respondents comprising 1,404 persons with TB, 337 caregivers of PWTB, 125 community representatives, and 195 healthcare providers. Survey respondents were drawn from 18 states, three from each of the geopolitical zones of Nigeria. The qualitative data were coded deductively using domains in the Stangl et al. framework.

Result:

We found TB stigma to be widespread in Nigeria, driven largely by fear of infection and death. TB stigma intersects with gender discrimination, and HIV stigma and stigma are associated with deviation from sexual norms. TB stigma manifestations include internalized stigma, secondary stigma and perceived stigma, with common experiences such as avoidance behavior, shaming, blaming and insulting PWTB.

Conclusion:

TB stigma is widespread in Nigeria and is driven largely by fear of infection and death. TB stigma has both health- related (delayed diagnosis, poor treatment adherence and treatment completion) and non-health-related impacts (social exclusion, mental health and poverty), and TB stigma should be given priority in National TB programmes in Nigeria and globally if the incidence and prevalence of TB must be reduced. TB stigma intersects with gender discrimination, and HIV stigma, and stigma associated with deviation from sexual norms. It manifests in different forms, including internalized stigma, secondary stigma and perceived stigma, often finding expression in avoidance behavior, shaming, blaming and insulting PWTB. The study concludes that improving Nigeria’s TB response requires improving community-level TB knowledge as well as improving TB knowledge among non-TB healthcare providers who often stigmatize TB care providers in facilities.