‘It makes the patient's spirit weaker': tuberculosis stigma and gender interaction in Dar es Salaam, Tanzania

SETTING: Dar es Salaam, Tanzania. OBJECTIVES: To describe tuberculosis (TB) related stigma and to understand how it interacts with gender to affect access to care. DESIGN: Eight focus group discussions were held among 48 TB patients and their household members, and a thematic content analysis was carried out. RESULTS: The main components of stigma were fear, self-isolation, ostracization, loss of status in the community, and discrimination by providers. Participants described the cultural context in which stigma operated as characterized by a general lack of health knowledge, cultural beliefs about TB, and engendered beliefs about disease in general. Both genders described some similar effects of stigma, including relationship difficulties and specifically challenges forming new relationships, but many effects of stigma were distinct by gender: women described challenges including assumptions about promiscuity and infidelity, as well as rejection by partners, while men described survival challenges. Stigma acted as a barrier to care through a cyclical pattern of stigma and fear, leading to health-seeking delays, with resulting continued transmission and poor health outcomes that further reinforced stigma. CONCLUSION: TB-related stigma is prevalent in this setting and operates differently for men and women. Interventions designed to increase case detection must address stigma and its interaction with gender.