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.