Social Isolation, Social Exclusion and Access to Resources: Mapping the Gendered Impact of TB-related Stigma Among TB Patients in Eastern Cape Province, South Africa

Social Isolation, Social Exclusion and Access to Resources: Mapping the Gendered Impact of TB-related Stigma Among TB Patients in Eastern Cape Province, South Africa | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Social Isolation, Social Exclusion and Access to Resources: Mapping the Gendered Impact of TB-related Stigma Among TB Patients in Eastern Cape Province, South Africa Andrew Medina-Marino, Lindsey de Vos, Joseph Daniels This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5409926/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 13 You are reading this latest preprint version Abstract Background Stigma and isolation among people living with tuberculosis (PLWTB) is well documented. Poorly understood are the gendered pathways by which TB-related stigma results in isolation or impacts access to resources during one’s illness-to-health journey. Methods We interviewed PLWTB receiving treatment at government clinics in Buffalo City Metro, South Africa. Semi-structured guides explored: TB symptom experiences; access-to-care; treatment motivation; key supporters; and access to mental and tangible resources (MTRs) during illness. Open coding was done inductively, with MTR domains informed by the Network-Individual-Resource Model. Findings were analyzed through a cyclic iterative and deductive process using social isolation and exclusion as interpretive lenses. Memos and pathway mapping examined gendered differences in stigma, isolation, and access to networked MTRs. Results One-hundred forty-two PLWTB (Men = 93; Women = 61) were interviewed. PLWTB described pervasive TB stigma and isolation. Women described self-isolating in response to enacted and anticipated stigma. Men described active exclusion by friends and family. Women’s maintenance of familial ties facilitated access to MTRs while ill. Men’s systematic exclusion reduced their agency to access resources. Men and women described regaining of physical strength and recovery of social networks, but also the sustained post-treatment stigma impact. Conclusions We identified gendered pathways through which TB stigma and isolation affect access to MTRs. For women, stigma led to social isolation, but familial networks maintained access to MTRs, fostering resilience. Men experienced social exclusion, reduced agency to access MTRs, and increased vulnerability during illness. Findings can guide gender-responsive interventions to reduce the impact of TB stigma on health outcomes. tuberculosis stigma gender qualitative South Africa Figures Figure 1 BACKGROUND Globally, an estimated 10.6 million people developed TB in 2022, of those, 55% were adult men, 33% were adult women and 12% were children.[ 1 ] Compared to women, men are at increased risk for poor outcomes along the TB care cascade and TB-related mortality.[ 1 – 4 ] Though women bear a lower burden of TB disease, TB exacerbates the gendered health inequalities and vulnerability that women face globally, which increases their risk of poor TB outcomes.[ 5 – 7 ] A host of social determinants, including stigma, gender norms and practices, social support, and access to tangible (e.g., food, money, transportation) and mental (i.e., self-efficacy, coping mechanisms, resiliency) resources are known to influence both men and women’s risk for poor treatment outcomes.[ 8 – 12 ] However, elucidating gender-specific dimensions in how men and women experience TB illness, particularly TB-related stigma and isolation, is necessary to inform gender-responsive interventions to improve men and women’s TB-related health outcomes and quality of life during their illness-to-health journey.[ 9 , 10 , 13 , 14 ] Stigmatization of people with TB are driven by a combination of misconceptions, cultural beliefs, social dynamics and judgement, and fear of contagion, all of which results in distinctive acts of exclusion beyond advised TB protocols.[ 15 – 20 ] Perceived and real signs and symptoms of TB, especially cough and weight loss, may thus bring about prolonged isolation stemming from self-imposed or enforced isolation by others.[ 17 , 19 ] Such acts include self-withdrawal due to perceived social repercussions and community stigma [ 17 , 20 ], not sharing utensils with others and being excluded from social and familial events and networks, all of which can impact a patient’s quality of life and resiliency.[ 7 , 17 , 21 – 23 ] Although there are similarities in how men and women experience TB-related stigma, few studies report higher TB stigma or vulnerability among men.[ 14 , 24 ] Much more often, women are reported to experience higher stigma burden due to gender and cultural norms that increase women’s vulnerability and social inequities, especially in highly patriarchal societies that further impose barriers to accessing health services.[ 5 , 15 , 22 , 25 , 26 ] Stigmatizing perceptions can further impact men and women’s health-care seeking behavior, retention in care and preferences for TB care and treatment delivery.[ 14 , 21 , 25 , 27 – 32 ] The ability of individuals living with TB to navigate stigma during their illness-to-health journey is influenced by psychosocial support and access to resources.[ 9 , 33 – 35 ] Support networks, including partners, family, healthcare providers and community members, offer essential provisions like emotional support, food and means to access healthcare.[ 23 , 34 , 36 – 38 ] Alternatively, unsupportive networks can restrict or block access to resources through isolation and exclusion. This may result in reduced resiliency to cope with TB illness,[ 33 ] an inability to practice optimal health behaviors, and negatively impact the quality of life of those living with TB, all of which have a direct impact on treatment adherence and completion.[ 12 , 19 , 20 , 37 , 39 ] A complex interplay between stigma and gender, and their intersecting impact on resource access and support, have been described for other health conditions.[ 16 , 40 – 42 ] Given that men and women’s TB illness and treatment experiences may vary greatly due to social and cultural variations, including existing gender norms [ 43 – 45 ], we explored how men and women living with TB in South Africa experience stigma and isolation, and how these impact their social networks and access to resources during treatment. METHODS This qualitative sub-study was nested within a larger, mixed-methods, prospective cohort study (NIH R21AI148852; https://reporter.nih.gov/project-details/10085625 ), which sought to identify gender-specific and gender-neutral preferences for a male-centered TB care and support intervention. Study Framework This study was guided by the Network-Individual-Resource Model (NIRM), and concepts of isolation and stigma.[ 46 – 49 ] The NIRM takes an ecological approach to behaviour change, and articulates how access to and exchanges of resources between an individual and their networks positively and negatively influence health behaviors and outcomes.[ 46 , 50 ] The NIRM conceptualizes resources into Mental (e.g., personal agency, attitudes, perceived norms, social support, social capital) and Tangible (e.g., income, access to food, physical health, transport), operationalized at the individual and network levels.[ 46 ] The NIRM postulates that networks can mitigate risk and enhance coping mechanisms by providing relevant resources. The NIRM argues that network memberships are often sustained by trust, which can be jeopardized by stigma. When stigma acts to isolate individuals from participating in networks, access to resources may become restricted. This hinders one's ability to effectively cope with stressors and increases their vulnerability to poor outcomes.[ 33 ] In this context, we used the NIRM to explore and describe pathways by which stigma influences access to resources. To more fully integrate stigma into the NIRM, we used current literature and guidance documents to define stigma types (e.g., anticipated, enacted, internalized), and how these different types of stigmas may contribute to isolation.[ 49 , 51 – 53 ] Furthermore, we applied the concepts of social isolation and social exclusion, related but distinct concepts that refer to different experiences in the realm of social relationships, as interpretive lenses to more fully explore how these pathways to isolation may influence resource access and vulnerabilities while ill with TB.[ 47 , 48 ] Specifically, social isolation refers to the objective state of being physically separated from or having minimal social contact with others; social isolation can be voluntary (i.e., retreating from social interactions to minimize stigmatization or to minimize infecting others) or involuntary (i.e., weakness due to illness; geographic remoteness).[ 47 , 48 ] In comparison, social exclusion is often a result of societal structures, discrimination, or prejudice, and refers to the process through which individuals or groups are marginalized, denied access to resources, opportunities, or participation in social activities.[ 47 , 48 ] Study Setting This study was conducted in Buffalo City Metropolitan (BCM) Health District, Eastern Cape Province, South Africa. Eastern Cape Province is historically under-resourced and lacks the mature research infrastructure of historically advantaged areas of Durban, Johannesburg and Cape Town. Since 1990, Eastern Cape has ranked last among South Africa’s nine provinces in its Human Development Index score.[ 54 , 55 ] In 2019, the estimated HIV prevalence in Eastern Cape Province was 20.2% (95% CI: 19.7%-20.9%) among those aged 15–49 years.[ 56 , 57 ] That same year, BCM had an estimated TB incidence of 876 per 100,000 population (male incidence = ~ 1072 per 100,000 population; female incidence = ~ 540 per 100,000 population).[ 58 ] In 2018, the last year in which data were published, BCM had a drug-susceptible TB (DS-TB) treatment success rate of 71.2% (the lowest in South Africa), a loss-to-care (LTC) rate of 17.6% (second highest in South Africa), and a TB client death rate of 6.3%.[ 59 ] Participant Recruitment From March 2021 through January 2022, study staff were embedded in 15 of 79 primary and community health clinics throughout BCM, including: 1) urban, peri-urban and rural clinics, and 2) clinics with catchment areas including formal and informal settlement housing. In collaboration with clinic TB nurses, TB patients were identified and screened for eligibility by study staff. Inclusion criteria included: 1) age ≥ 18 years; 2) currently living in BCM; and 3) currently engaged in or initiating treatment for DS-TB. All eligible individuals were invited to learn about the study, consecutively recruited, consented and administered a study questionnaire by study staff at time-of-enrollment. Participants were prospectively followed and purposively invited for an in-depth interview (IDI) based on their progression along the TB treatment cascade (i.e., currently on treatment; missed ≥ 15 days of a treatment refill visit; recently completed treatment). The study attempted to recruit an equal number of male and female TB patients. Data Collection Semi-structured interview protocols were developed to examine the following domains: experiences and perspectives of TB symptoms; access to clinical care and services; individual motivations for treatment; disclosure decision-making; social and familial network support during TB illness; perspectives of other men and women’s TB experiences; and probing for tangible and mental resources accessed during their TB illness and treatment journey. Open-ended questions in line with these domains further explored changes in the behaviors and dynamics of their social and familial networks, experiences with anticipated, enacted and internalized stigma, judgment, the ability to access support, perceived impacts of their illness on their lifestyle and relationships, and experiences of isolation and network membership exclusion. Interviews were scheduled with participants either telephonically or via home visits. Interviews were conducted in a participant’s preferred language (English or IsiXhosa), and in a private location agreeable to the study participant. Interviews were audio-recorded and lasted approximately 60–90 minutes. The gender of the interviewers was matched to those of participants. Data collection was monitored and refined through a review of initial interviews, weekly team meetings, and refresher trainings. Interview recordings were transcribed, translated into English (from isiXhosa) where needed, and reviewed by a second team member for quality control. Data Analysis A subset of transcripts was read and open-coded by the study team using an inductive approach. Codes relating to TB illness experiences and mental and tangible resources, as defined by NIRM, were identified and consolidated into a codebook. The codebook was then applied to all the transcripts using Dedoose (Version 9.0.17, Los Angeles, CA: SocioCultural Research Consultants, LLC), with coding iteratively assessed and discussed to ensure consensus and inter-coder reliability. Codes were subsequently organized into the following domains: 1) family and community environment; 2) TB symptom experiences; 3) clinic experiences; 4) mental and tangible resources that are either within one’s control (i.e. self-support) or sought/accessed/lost from others; 5) resiliency and vulnerability; 6) judgment (self/others); 7) discriminatory actions and 8) the social impacts of TB and isolation. Ongoing analysis was conducted throughout data collection and refined through a cyclic iterative process. Isolation constructs, gender and the NIRM were used as a deductive interpretive lens to elucidate the relationships between and intersections of stigma, isolation, social networks, and the mental and tangible resources accessed, lost or needed while participants were transversing the TB treatment journey.[ 46 – 48 ] Frequency analysis, memos, and pathway diagrams were leveraged to assess the relationships between mental and tangible resources during TB treatment. Matrices to compare men and women’s TB illness experiences were developed through an inductive approach. TB-stigma literature reviews and weekly study team discussions with study investigators further confirmed findings of the interrelationships of TB stigma, social networks and resource accessibility. The concepts of social isolation and social exclusion were then used to further help understand isolation experiences and pathways, and their dynamic relationship with stigma (i.e., anticipated, enacted and internalized). We further inductively examined changes in participants’ behaviors and social networks over time to determine how social networks were maintained, dissolved, and/or re-established as participants progressed along their illness-to-health journey. Ethics Ethics approval was obtained from Human Research Ethics Committee of the Faculty of Health Sciences, University of Cape Town (Ref no. : 673/2019) (Medina-Marino, PI) with an institutional reliance agreement by Arizona State University (Daniels, PI). Study approval was provided by the Eastern Cape Provincial Department of Health (Ref no.: EC202010_023). All participants provided written informed consent. Recording of interviews was voluntary. Interview participants were provided a small snack and R150 (~ $ 8 USD) for their time. Study staff, both male and female, were trained in qualitative research, interviewing techniques, human subject’s protection, and good clinical practice. Participant Representation In-text quotes are attributed to participants by their study ID number, gender, and age. RESULTS Participant Characteristics (Table 1 ) We conducted IDIs with 142 TB patients with a median age of 37 (IQR: 30–46) years. Of those, 86 (60.6%) were men, 48 (33.8%) self-reported a previous history of TB and 69 (48.6%) self-reported living with HIV. A larger proportion of men reported having a previous history of TB disease compared to women (37.2% vs. 28.6%). In comparison, a larger proportion of women reported living with HIV compared to men (67.9% vs. 36.1%), reflecting the gendered inequities and high HIV co-infection rates in South Africa. Compared to women, men were more likely to report being unemployed (72.1% vs. 58.9%) during TB treatment, living alone (29.0% vs. 16.1%) and being the primary household breadwinner (48.8% vs. 30.4%). Table 1 Sociodemographic characteristics of interviewed TB patients (N = 142) Characteristic (n/%) Men (n = 86) Women (n = 56) Total (N = 142) Age (median, IQR) 38 (31–48) 33 (27.5–44) 37 (30–46) Relationship Status Single 57 (66.3) 38 (67.9) 95 (66.9) Married or Living together 26 (30.2) 11 (19.6) 37 (26.1) Divorced, separated, or widowed 3 (3.5) 7 (12.5) 10 (7.0) Employment Status Unemployed (actively or inactively looking) 62 (72.1) 33 (58.9) 95 (66.9) Working for pay 7 (8.1) 6 (10.7) 13 (9.2) Self-employed 7 (8.1) 4 (7.1) 11 (7.8) Student 1 (1.2) 4 (7.1) 5 (3.5) Other 9 (10.5) 9 (15.3) 18 (12.7) Primary Household Breadwinner 42 (48.8) 17 (30.4) 59 (42.2) Monthly household Income < R 2 000 (~ $ 135) 58 (67.4) 34 (60.7) 92 (64.8) Completed secondary education 20 (23.3) 18 (32.1) 38 (26.8) Live alone 25 (29.0) 9 (16.1) 34 (23.8) Had TB in the past Never 54 (62.8) 40 (71.4) 94 (66.2) Yes, less than 2 years 11 (12.8) 3 (5.4) 14 (9.9) Yes, more than 2 years 21 (24.4) 13 (23.2) 34 (23.9) HIV Status (self-reported) Positive 31 (36.1) 38 (67.9) 69 (48.6) Negative 48 (55.8) 15 (26.8) 63 (44.4) Not disclosed/Don’t know 7 (8.1) 3 (5.4) 10 (7.0) Symptom Onset and Stigma Markers Both men and women described anticipating and experiencing stigma due to their TB status and clinic attendance. Visible weight loss was a particularly potent marker of TB illness that triggered negative comments and judgement. Women expressed significant concern for being gossiped about. This often resulted from visible weight loss or behaviors perceived to be associated with TB disease: “I don’t like it when people talk about my weight, you know it makes me feel like there’s something I am not doing right, well in this case I knew that there’s something that I’m not doing right.” [75, Female, 30 years] “I was thinking about what people will say [at the clinic]. People [would] be watching me when they pass by while I was sitting there [at the clinic]. I thought maybe they think I have TB because I drink a lot or smoke all those awful things like maybe they are judging me…” [292, Female, 23 years] These women reveal the connections between negative comments, causal attribution and self-blame. Male patients also described their fear of negative comments which they attribute to their weight loss and poor health: P: I felt judged, and on my way to clinic people were looking at my weight. Some even asked why I have lost so much weight and that didn’t sit well with me. I: Who did you feel was judging you? Other patients, clinic staff? P: No, it was friends [87, Male, 37 years] “I get embarrassed. Maybe let’s say we are chilling at a certain place. Let me make an example. Let’s say I’m on my way to town. We’re sitting in a taxi with people, or any other place you can think of, or maybe I’m visiting a friend at his home, but any place I don’t normally go to, I do feel embarrassed like [in my mind, I think], ‘Ey. People will start asking questions here about my loss of weight’ and other things that I won’t be comfortable to talk about. So, I end up not going to these places because I’m ashamed and scared” [41, Male, 35 years] These quotes highlight men and women’s shared experiences of negative or unwanted comments about their weight loss, and describe the psychological impact (e.g., shame, embarrassment or self-blame) of having TB. Both men and women also anticipate being stigmatized as their TB-related symptoms become visible, or as they start to attend clinic for their TB treatment. The fear of encountering questions or being forced into uncomfortable discussions about visible health changes led both men and women to avoid or not participate in certain social situations. Stigma and Gendered Pathways to Isolation Both women and men describe isolation as a manifest experience while ill with TB. However, women discuss enduring social isolation, while men describe being excluded by others (i.e., social exclusion). Women: Self-isolation and avoidance Women revealed how they refrained from venturing outside their homes due to the comments they received after exhibiting TB symptoms. These comments and unwarranted judgment predominantly emanated from their social networks and friends: “I was not all right. I felt judged when people asked me about my weight. I avoided leaving the house” [238, Female, 39 years] “…So, she [a friend] would say bad things about me. Then I would notice the mood, but some people would tell me straight up that “[friend’s name] is saying this and that about you”. I ended up avoiding them because they had bad attitude towards me. I isolated myself and lived in my shack with my boyfriend ” [347, Female, 30 years] Judgmental comments and negative remarks were sources of discomfort, and engendered self-consciousness. The latter participant [347, Female, 30 years] closely observed shifts in the behavior and mood of others, leading to avoidance of her friends. As a result of experienced mistreatment and altering social dynamics, female patients conveyed feelings of shame and disappointment in friends that resulted in avoidant behaviors: “It made me very sad [when others noticed her weight loss]. I was ashamed I couldn’t even leave the house. People were talking. My neighbor (pointing to the right wall) was the first person to notice my weight loss.” [116, Female, 31 years] “I even distance myself from people because they are no longer coming to visit me anymore and I told myself I will leave them. I: So you told yourself to stay at home? P: Yes. I: How did you expect people to treat you after they noticed these symptoms? P: At least friends were supposed to support each other, not judging before you know anything. Maybe they are judging because they have no knowledge, and they are scared.” [124, Female, 31 years] This female patient [124, Female, 31 years] described a desire for empathy and support from friends, instead of friends who are quick to judge or project fear due to their lack of knowledge. Overall, women described conscious decisions to distance themselves and/or self-isolate to shield themselves from adverse comments and community stigma. Men: Wanting to engage, but being excluded Men often described how they were excluded from social interactions by friends once stigma markings became obvious or their TB status became known. Specifically, men describe how friends would ‘distance themselves’ and exclude them from social events or community spaces due to their TB-related symptoms or illness. Several men use emotive language to describe how much these types of experiences impacted them: “…they were far from me. They didn’t even want to come and see me. Even when I take a walk during the day and go to them, they would not want me anywhere near them. Maybe if I had gone [there] with something to eat, they would not want to share with me.” [125, Male, 36 years] “I had to stop a lot of things, and I was not able to go to places that I used to go [to]. Places I used to go and smoke at, and they [friends] used to distance themselves from me as if I was going to infect them. It was painful to me, but I saw where they were coming from” [45, Male, 36 years] Men described continually trying to socially engage with friends but were constantly excluded. They describe how their exclusion was driven by the fear of infection, and how their exclusion exacerbated feelings of loneliness: “Like even today, some people treat me bad. Some people think the worst of me. That I can give them TB anytime because I cough and… I don’t know man. I just want to go and walk away from this place and not even worry about people anymore. Like living on my own strictly. I feel like that, I feel lonely .” [15, Male, 38 years] This man describes the emotional toll of being socially excluded, and the pain and loneliness he experiences. They even expressed a desire to remove themselves from this situation, due to this forced disconnection from others. The Role of Family in Mitigating or Exacerbating Stigma and Isolation In general, women and men described profoundly different experiences with their families when ill with TB. Specifically, most women spoke of stable, reliable support from family members, while many men described friction with and hostility from their families and dissolution of romantic relationships. Women: Familial support and access to resources Women often described a high level of trust to disclose their TB illness to family members due to the perception that family do not gossip or divulge one’s illnesses in a negative manner. Familial acceptance was particularly important when women self-isolated to avoid community stigmatization: “My friends distanced themselves from me, so I was lonely. I was talking only with my family and since I was not the first person to get ill in the family, they were fine with it.” [59, Female, 20 years] “I expected that they [household members] would just be upset and not talk about it, but they understood. I just trusted them, and I knew if I told a friend they would go around and divulge it in the streets. It is better to talk to the one at home” [106, Female, 30 years] These women describe the impacts of illness on social connections and the pivotal role their families played. Familial support was a crucial counterbalance to community stigmatization that could have otherwise discouraged or demotivated them during treatment: “She [my mother] said to me ‘my child, when you have TB people like to gossip. They like to say that “oh [that] one has HIV.’ Then she said to me ‘don’t be scared, don’t be afraid. You will overcome this TB, you overcome it the first time you can overcome it the second time’…” [12, Female, 30 years] “There are people who spread rumors. You have to tell yourself that you do not live for people. They cannot change who you are and there is nothing more important than your family. If you get support from your family, an outsider's support is not that important than your family’s support. The only thing that will make you to give up is if your family doesn't welcome you, but I think family is the most.” [23, Female, 42 years] In addition to family members providing mental and emotional support, women described how they continued to access tangible resources via familial networks: “I: Who supported you during this time? P: My aunt I: What type of support did she provide? P: She gave me all the support I needed – money, advice, motivation, food, and shelter. She did everything for me.” [59, Female, 20 years] “Okay when I found out that I had TB, I came home and told my family that I have TB. They didn’t judge me or distance themselves, but supported me and also changed the food we eat to healthy food for me. They did that so that I can quickly recover.” [75, Female, 30 years] These women highlighted the importance of their family networks in accessing tangible (e.g., money, food, and shelter) and mental (e.g., motivation, emotional support, companionship) resources crucial for combating loneliness and sustaining resiliency during their TB illness-to-health journey. Men: Friction, blame and loss of familial support In addition to being socially excluded by friends, many men described being judged and excluded by their families. Judgement often arose from behaviors perceived to be related to contracting TB (e.g., drinking alcohol, smoking, partying). Furthermore, several men described strained or dissolution of romantic relationships while ill with TB. After those [TB] symptoms, it was hectic at home, especially [with] my mom and uncles. My mom is short-tempered and when she would scold me, she would use that I have TB against me and say that I bring over friends that have TB [326, Male, 46 years] ”It is painful on my family’s side only because my mother was someone who loved [me]. But when I had TB, I have never seen her, she doesn’t even call. And my sister is the one who changed when she found out that I have TB. She [sister] didn’t give any [support] except the ones I told you, and the cereals she bought me once. She never bought them, and she never came again to check up on me. Eh! I wish my sister, and my mother would have supported me, because when I was working, I was doing everything for her, my mother. Now she is living well in the villages, and she has money, but I am not looking for her money, but I wanted her to support me especially with food because I was really struggling with getting food, because I was not working, and my girlfriend was not working as well.” [138, Male, 38 years] These men described how their families accused them of putting them at risk for TB, distanced themselves and stopped providing then with any type of support. Men further explained how retention of familial support would have helped them overcome existing challenges, including food and economic insecurity. Familial judgment and exclusion also engendered self-blame for having TB. In extreme cases, though not unique, several men described being physically locked in rooms by family members due to perceived safety concerns. This deprived these men of basic needs such as access to a bathroom: “…I decided to move back to my shack and my elder brother he was just giving me the bad look when I [would] walk with friends. But [he] asked me ‘why [do] you have this [TB]?’ and I said it[s] because of alcohol, walking at night, cigarette and weed… My sister chased me to stay in my room and close[d] the door because of [my] coughing sometimes. I wanted to go to the toilet, but I [couldn’t] because my door was locked. So, I [would] just open [a] window and take out my penis or I take [a] bucket, so I didn’t like [these] things” [199, Male, 31 years] Interestingly, only men spoke about dissolution of their romantic relationships because of their illness. Although women had relationships, no relationship dissolution was reported because of their TB. For instance, the following men describe the end of their marriage or relationship with a girlfriend: “…at the clinic, my wife’s sister was a nurse and heard I was taking my [TB] treatment at [another clinic]. She said she knows I am taking treatment, and I can no longer be with her sister. And I ended up losing her [wife], and she said she no longer wants marriage. It really hurt me.” [237, Male, 40 years] …Ey brother, I lost most of them [women] because of my health… she [girlfriend] did not notice that I am not okay, but she heard rumors, she distanced herself. I was not okay, I tried to explain but she already heard a lot, it was [too] late for me [7, Male, 26 years] Social losses and ill-health also translated into internalized negative feelings and emasculation as described by this patient: …[interacting] with men I don't know what to say because I don't even feel like a man anymore. I feel too weak to be a man because I can't even provide for myself. How would a man like me provide for a woman? That's why I don't even have a girlfriend anymore because I know that I can't even provide for myself. [15, Male, 38 years] Men described how their TB illness affected their physical strength and sexual performance and attributed these factors to the dissolution of their romantic relationships. Overall, men’s severely strained familial relationships or loss of romantic partners exacerbated their isolation and drastically reduced their ability to access the necessary resources and support they needed when ill with TB. Regaining Health and Re-establishing (Altered) Social Networks Most patients described feeling better within three months after initiating TB treatment. This was often associated with increased appetite and an improved sense of being: “I felt better after two months, and on the third month I could notice I was better now. I was eating too much day and night”. [83, Male, 47 years] Improved health and strength were associated with both men and women re-establishing connections with those that had socially excluded them. However, for some these connections were irreparably altered. Both men and women described social re-engagement once others perceived or observed them to have regained health. However, concerns lingered about the stability and nature of these re-established connections: “…they [friends at college] were still acting funny, but it took them a long time to accept me, until they saw that I was gaining back my weight. Even though I showed them my clinic book, they still had doubts at first” [248, Female, 25 years]. “I lost a lot of people; they thought I had COVID so they were protecting themselves. I: How did all this make you feel? P: It made me feel sad. It’s not like I’m the only person with TB around here. So, I didn’t understand why they were treating me this way. I: And when you got better, how did people treat you? P: I went back to work right after I felt stronger. And after that, everything went back to normal. You know how people are when they see that you can work again and make money” [Male, 87, 37 years] These individuals experienced initial hesitation from others, which persisted despite presenting clinical information to friends. Re-establishment of social networks took time and only happened once they regained their strength and resumed their roles in society. Unfortunately, other men and women described either a lack of agency to reconnect with lost relationships, or an active decision to reject those that were not there when they needed them: P: …no I cut it off with all my friends. I cut them off… I: What stopped you from discussing that you got TB with your friends? P: Because they couldn’t help and [weren’t] motivating me” [Male, 14, 32 years] “The ones that isolated me are still isolating me. In the community I no longer have friends. People I was friends with disappeared, also at church and the ones I see are the ones I did not go to church with. I was visited by the ones from Thursday service instead of the Saturday service.” [Female, 207, 56 years] "P: They see you as a weak person I: You also mentioned that you do not have friends anymore P: Yeah, nobody comes to me anymore –none of my friends.” [15, Male, 38 years] Lack of support or motivation during illness led some individuals to sever ties with absent friends. Others described feeling abandoned even when they regained their health. Regardless of whether original connections were permanently altered, re-established or lost, both men and women had to actively navigate or redefine their social connections. These experiences highlight the long-term social sequalae of TB, even when someone successfully completed their treatment or regained their health DISCUSSION Our findings substantiate a broader body of literature describing the ubiquity of TB-related stigma, with isolation being a manifest experience of stigma.[ 4 , 10 , 14 , 15 , 60 ]. However, there has been limited exploration or mapping of the pathways through which isolation occurs or functions during TB illness and treatment. While experiences of social isolation and social exclusion are reported in the TB literature,[ 7 , 17 , 18 , 21 , 61 , 62 ] ours is the first to describe and delineate distinct, gendered pathways by which TB stigma facilitates social isolation or social exclusion (Fig. 1 ). By applying the NIRM in conjunction with isolation concepts and stigma types, we further describe how familial networks mediated access to resources, and in turn mitigated or exacerbated women and men’s isolation. In this context, we show how families promoted women’s resiliency while magnifying men’s vulnerability when ill with TB. In our study, men and women experienced distinct pathways towards isolation in response to TB stigma (Fig. 1 ). Both men and women reported that observable weight-loss was the main trigger for their anticipated and experienced stigma, which has often been associated with HIV.[ 63 , 64 ] However, women described withdrawing more quickly from their social networks, while men continued seeking social interactions until they were forcibly excluded. Specifically, men reported being socially excluded by their peers due to fear of infection and by family members due to judgment and behaviour blame. In contrast, women engaged in social isolation as a protective measure against negative comments and judgements from others. These findings highlight gendered differences in how men and women are impacted by and respond to stigma, with women exhibiting a protective response and men losing agency. Familial networks and support have been well described as crucial to promoting resiliency during one’s illness-to-health journey.[ 37 , 39 , 65 ] In our study, women’s familial networks emerged as a crucial buffer against social isolation by proving emotional support and material resources, thus helping them cope with and navigate their TB illness and treatment, and facilitating resiliency (Fig. 1 ). This may flow from that fact that in high HIV burden communities, women act as caregivers, head households, and economic contributors to their families, reinforcing their importance within the family structure and encouraging familial support when ill.[ 40 , 66 – 69 ] Furthermore, South African women often rely on strong female networks, particularly in households where men migrate for work, offering them a buffer during illness.[ 39 , 66 , 67 , 69 ] This contrasts with studies from Southeast Asia, where women experience significant social exclusion, neglect from family members, and rejection by husbands, reflecting a combination of cultural, social, and economic factors.[ 7 , 14 , 18 , 70 ] In India and Bangladesh, traditional gender norms often render women more dependent on male family members, leading to neglect or exclusion when they cannot fulfil domestic roles [ 71 – 73 ]. In these countries, TB-related stigma often intersects with marital and reproductive expectations, causing women to be rejected by their husbands or in-laws [ 18 , 61 , 73 , 74 ]. Furthermore, women in Southeast Asia, who are often part of joint family systems, may be more vulnerable to rejection when TB is seen as a financial or social burden [ 37 , 74 ]. Overall, these contextual factors highlight why familial support for women with TB may differ significantly between South Africa and Southeast Asian countries. Men in our study experienced overt rejection and social exclusion by both peers and family, resulting in distinct challenges and resource insecurity while ill with TB (Fig. 1 ). Their social exclusion is likely a result of gender norms around masculinity and health, where illness is equated to weakness and seeking help is perceived as a threat to their social status.[ 13 , 43 , 75 ] This exclusion extended to romantic relationships, where men reported experiencing estrangement or dissolution,[ 14 , 24 ] a dynamic not reported by any women in our study. The lack of trust and support from female caregivers, a crucial element for treatment adherence, further exacerbated men’s exclusion, leaving them with diminished access to essential mental and tangible resources.[ 13 ] Consequently, men’s prioritization of work over health, often framed as a negative aspect of masculinity,[ 11 , 13 , 43 , 76 ] may instead represent a survival strategy to retain social and economic resources that they know could be lost or difficult to re-establish, thus compromising their survival during and after illness. This may also explain why men, unlike women, resisted self-isolation in response to community stigmatization, as maintaining their social status within existing social and family networks preserves access to necessary resources. [ 10 , 15 , 24 ] The differences in how men and women navigate stigma may also reflect their respective roles in accessing and contributing to social networks. Specifically, while women benefit from relatively stable and enduring familial networks, men rely more on broader, yet often more fragile, peer networks that are more easily disrupted by illness.[ 46 , 66 , 77 , 78 ] As a result, when illness undermines men’s ability to meet social expectations or contribute to these networks, they are more likely to experience social exclusion and a resultant loss of resources.[ 46 , 79 ] Both men and women in our study described a gradual reintegration into social networks as their health improved, but this reintegration was neither immediate nor universally successful. The findings suggest that the impacts of social exclusion and isolation extend beyond the symptomatic phase of TB, with some patients facing sustained social challenges even during and after treatment. This persistent exclusion has been previously reported in TB-related stigma literature,[ 7 ] and highlights the need for ongoing support during the recovery phase to facilitate reintegration into social networks and mitigate long-term stigma effects. STRENGTHS AND LIMITATIONS Our use of an extensive qualitative dataset (142 in-depth interviews), representing a diverse range of experiences along the entire TB care cascade, allowed for a more comprehensive exploration of the nuanced experiences related to TB stigma, and the gendered pathways to isolation and dynamics of accessing resources.Further, the findings underscore socio-cultural factors that may be specific to the study setting, highlighting the complex interplay of gender norms, stigma, and social determinants that differ between countries and global regions. While the cross-sectional design offers a snapshot of the impact and lingering effect of stigma, a deeper exploration of these dynamics is needed. Future research using longitudinal or serial interviews could further illuminate how relationships and access to resources evolve over time. CONCLUSIONS Findings reveal women and men’s distinct and gendered experience of social isolation and exclusion, respectively, during TB illness that impacts access to key resources for treatment support.[ 4 , 30 , 32 , 60 , 79 ] This work underscores the critical role of familial networks in buffering or exacerbating the impact of stigma on individuals' TB journeys, well-being and health outcomes. Responsive interventions such as peer support for men [ 23 , 80 ] and familial support models for women [ 46 ] may in turn improve treatment outcomes for men and women. Abbreviations BCM Buffalo City Metropolitan Health District DS TB-Drug-susceptible tuberculosis IDI In-depth interview LTC Loss-to-care MTRs Mental and tangible resources NIRM Network-Individual-Resource Model PLWTB People living with tuberculosis Declarations Ethics approval and consent to participate Ethics approval was obtained from Human Research Ethics Committee of the Faculty of Health Sciences, University of Cape Town (Ref no.: 673/2019) (Medina-Marino, PI) with an institutional reliance agreement by Arizona State University (Daniels, PI). Study approval was provided by the Eastern Cape Provincial Department of Health (Ref no.: EC202010_023). All participants provided written informed consent. Recording of interviews was voluntary. Interview participants were provided a small snack and R150 (~ $ 8 USD) for their time. Study staff, both male and female, were trained in qualitative research, interviewing techniques, human subject’s protection, and good clinical practice. Consent for publication Not applicable Competing interests The authors declare that they have no competing interests that are relevant to this paper. Funding The study was funded by the U.S. National Institutes of Health (NIH) under award R21AI148852 to AMM and JD, with additional support provided by NIH awards R34HL170819 to AMM and JD and R01AI150485 to AMM. Author Contribution AMM: Conceptualization, Methodology, Validation, Writing – Original Draft, Visualization, Supervision, Funding Acquisition.: LDV: Formal analysis, Project administration, Data curation, Writing – Original Draft, Visualization.: JD: Conceptualization, Methodology, Validation, Formal Analysis, Writing – Original Draft, Supervision, Funding acquisition. Acknowledgement This study was conducted with the support and permission of the Eastern Cape Province and Buffalo City District Department of Health. Authors would like to especially thank the project manager Ralph Mawarire and FPDs senior field workers for their contributions to the interviews and the participants who agreed to be interviewed about their experiences relating to TB and treatment. We thank and acknowledge Mr. Seluleko Ngcobo for supporting literature review activities, and Dr. Aaron Kipp and Dr. Amrita Daftary for their critical review and support during manuscript development. We further thank the Foundation for Professional Development and Desmond Tutu Health Foundation qualitative research team for their contributions to the analysis. Data Availability Due to the sensitive and confidential nature of qualitative interview data these will not be publicly available. Data used for this analysis may be available upon reasonable request and based on a data-sharing agreement with the corresponding author. References Global Tuberculosis Report 2023. Geneva: World Health Organization; 2023. Mlotshwa M, Abraham N, Beery M, Williams S, Smit S, Uys M, et al. Risk factors for tuberculosis smear non-conversion in Eden district, Western Cape, South Africa, 2007–2013: a retrospective cohort study. BMC Infect Dis. 2016;16(1):365. Kubjane M, Cornell M, Osman M, Boulle A, Johnson LF. Drivers of sex differences in the South African adult tuberculosis incidence and mortality trends, 1990–2019. Sci Rep. 2023;13(1):9487. Horton KC, MacPherson P, Houben RMGJ, White RG, Corbett EL. Sex Differences in Tuberculosis Burden and Notifications in Low- and Middle-Income Countries: A Systematic Review and Meta-analysis. Metcalfe JZ, editor. PLoS Med. 2016;13(9):e1002119. Daftary A, Furin J, Zelnick JR, Venkatesan N, Steingart K, Smelyanskaya M, et al. TB and women: a call to action. int j tuberc lung dis. 2020;24(12):1312–5. Osman M, Van Schalkwyk C, Naidoo P, Seddon JA, Dunbar R, Dlamini SS, et al. Mortality during tuberculosis treatment in South Africa using an 8-year analysis of the national tuberculosis treatment register. Sci Rep. 2021;11(1):15894. Long NH, Johansson E, Diwan VK, Winkvist A. Fear and social isolation as consequences of tuberculosis in VietNam: a gender analysis. Health Policy. 2001;58(1):69–81. Hargreaves JR, Boccia D, Evans CA, Adato M, Petticrew M, Porter JDH. The Social Determinants of Tuberculosis: From Evidence to Action. Am J Public Health. 2011;101(4):654–62. Craig GM, Daftary A, Engel N, O’Driscoll S, Ioannaki A. Tuberculosis stigma as a social determinant of health: a systematic mapping review of research in low incidence countries. International Journal of Infectious Diseases. 2017;56:90–100. Chikovore J, Pai M, Horton KC, Daftary A, Kumwenda MK, Hart G, et al. Missing men with tuberculosis: the need to address structural influences and implement targeted and multidimensional interventions. BMJ Glob Health. 2020;5(5):e002255. Muttamba W, Omongot S, Najjingo I, Nuwarinda R, Buregyeya E, Del Barrio MO, et al. Using intersectional gender analysis to identify challenges in tuberculosis care at four health care facilities in Uganda. Infect Dis Poverty [Internet]. 2024 Jan 5 [cited 2024 Sep 17];13(1). Available from: https://idpjournal.biomedcentral.com/articles/ 10.1186/s40249-023-01171-3 Sebothoma KJ, Peu MD, Moagi MM, Mshunqane N. Experiences of families living with tuberculosis patients in the North West province, South Africa. Health SA Gesondheid [Internet]. 2024 May 6 [cited 2024 Jul 21];29. Available from: http://www.hsag.co.za/index.php/hsag/article/view/2530 Daniels J, Medina-Marino A, Glockner K, Grew E, Ngcelwane N, Kipp A. Masculinity, resources, and retention in care: South African men’s behaviors and experiences while engaged in TB care and treatment. Social Science & Medicine. 2021;270:113639. Krishnan L, Akande T, Shankar AV, McIntire KN, Gounder CR, Gupta A, et al. Gender-Related Barriers and Delays in Accessing Tuberculosis Diagnostic and Treatment Services: A Systematic Review of Qualitative Studies. Tuberculosis Research and Treatment. 2014;2014:1–14. Courtwright A, Turner AN. Tuberculosis and Stigmatization: Pathways and Interventions. Public Health Rep. 2010;125(4_suppl):34–42. Stangl AL, Earnshaw VA, Logie CH, van Brakel W, C. Simbayi L, Barré I, et al. The Health Stigma and Discrimination Framework: a global, crosscutting framework to inform research, intervention development, and policy on health-related stigmas. BMC Med. 2019;17(1):31. Redwood L, Fox GJ, Nguyen TA, Bernarys S, Mason P, Vu VA, et al. Good citizens, perfect patients, and family reputation: Stigma and prolonged isolation in people with drug-resistant tuberculosis in Vietnam. Reassignment PM, editor. PLOS Glob Public Health. 2022;2(6):e0000681. Mukerji R, Turan JM. Exploring Manifestations of TB-Related Stigma Experienced by Women in Kolkata, India. Annals of Global Health. 2018;84(4):727. Foster I, Biewer A, Vanqa N, Makanda G, Tisile P, Hayward SE, et al. “This is an illness. No one is supposed to be treated badly”: community-based stigma assessments in South Africa to inform tuberculosis stigma intervention design. BMC Global Public Health. 2024;2(1):41. Zimmerman E, Smith J, Banay R, Kau M, Garfin AMCG. Behavioural barriers and perceived trade-offs to care-seeking for tuberculosis in the Philippines. Global Public Health. 2022;17(2):210–22. Cremers AL, de Laat MM, Kapata N, Gerrets R, Klipstein-Grobusch K, Grobusch MP. Assessing the Consequences of Stigma for Tuberculosis Patients in Urban Zambia. Kumar A, editor. PLoS ONE. 2015;10(3):e0119861. Mbuthia GW, Nyamogoba HDN, Chiang SS, McGarvey ST. Burden of stigma among tuberculosis patients in a pastoralist community in Kenya: A mixed methods study. Marotta C, editor. PLoS ONE. 2020;15(10):e0240457. Paz-Soldán VA, Alban RE, Jones CD, Oberhelman RA. The provision of and need for social support among adult and pediatric patients with tuberculosis in Lima, Peru: a qualitative study. BMC Health Serv Res. 2013;13(1):290. Miller C, Huston J, Samu L, Mfinanga S, Hopewell P, Fair E. ‘It makes the patient’s spirit weaker’: tuberculosis stigma and gender interaction in Dar es Salaam, Tanzania. Int J Tuberc Lung Dis. 2017;21(11):S42–8. Onifade DA, Bayer AM, Montoya R, Haro M, Alva J, Franco J, et al. Gender-related factors influencing tuberculosis control in shantytowns: a qualitative study. BMC Public Health. 2010;10(381):11. Oshi DC, Oshi SN, Alobu IN, Ukwaja KN. Gender-related factors influencing women’s health seeking for tuberculosis care in Ebonyi, Nigeria. J Biosoc Sci. 2016;48(1):37–50. Cramm JM, Finkenflügel HJ, Møller V, Nieboer AP. TB treatment initiation and adherence in a South African community influenced more by perceptions than by knowledge of tuberculosis. BMC Public Health. 2010;10(1):72. Cramm JM, Nieboer AP. The relationship between (stigmatizing) views and lay public preferences regarding tuberculosis treatment in the Eastern Cape, South Africa. Int J Equity Health. 2011;10(1):2. Teo AKJ, Singh SR, Prem K, Hsu LY, Yi S. Duration and determinants of delayed tuberculosis diagnosis and treatment in high-burden countries: a mixed-methods systematic review and meta-analysis. Respir Res. 2021;22(1):251. Murray EJ, Bond VA, Marais BJ, Godfrey-Faussett P, Ayles HM, Beyers N. High levels of vulnerability and anticipated stigma reduce the impetus for tuberculosis diagnosis in Cape Town, South Africa. Health Policy and Planning. 2013;28(4):410–8. Kerkhoff AD, Mwamba C, Pry JM, Kagujje M, Nyangu S, Mateyo K, et al. A mixed methods study on men’s and women’s tuberculosis care journeys in Lusaka, Zambia—Implications for gender-tailored tuberculosis health promotion and case finding strategies. Yi S, editor. PLOS Glob Public Health. 2023;3(6):e0001372. DeSanto D, Velen K, Lessells R, Makgopa S, Gumede D, Fielding K, et al. A qualitative exploration into the presence of TB stigmatization across three districts in South Africa. BMC Public Health. 2023;23(1):504. Nasir A, Hassan II, Ma’ruf A, Suharno NE, Goenharto S, Purwanto CR, et al. Coping efforts made: Psychological burden of people living with tuberculosis due to social stigma in society. A qualitative phenomenology study. Sumari-de Boer IM, editor. PLoS ONE. 2024;19(7):e0303331. Oga-Omenka C, Wakdet L, Menzies D, Zarowsky C. A qualitative meta-synthesis of facilitators and barriers to tuberculosis diagnosis and treatment in Nigeria. BMC Public Health. 2021;21(1):279. Andom AT, Gilbert HN, Ndayizigiye M, Mukherjee JS, Lively CT, Nthunya J, et al. Understanding barriers to tuberculosis diagnosis and treatment completion in a low-resource setting: A mixed-methods study in the Kingdom of Lesotho. Fauk NK, editor. PLoS ONE. 2023;18(5):e0285774. Skinner D, Claassens M. It’s complicated: why do tuberculosis patients not initiate or stay adherent to treatment? A qualitative study from South Africa. BMC Infect Dis [Internet]. 2016 Dec [cited 2021 May 13];16(1). Available from: http://bmcinfectdis.biomedcentral.com/articles/ 10.1186/s12879-016-2054-5 Addo J, Pearce D, Metcalf M, Lundquist C, Thomas G, Barros-Aguirre D, et al. Living with tuberculosis: a qualitative study of patients’ experiences with disease and treatment. BMC Public Health. 2022;22(1):1717. Barrett P, Hale B, Butler M. Family Care and Social Capital: Transitions in Informal Care [Internet]. Springer Dordrecht; 2014. Available from: https://doi.org/10.1007/978-94-007-6872-7c Mbokazi N, Van Pinxteren M, Murphy K, Mair FS, May CR, Levitt NS. Ubuntu as a mediator in coping with multimorbidity treatment burden in a disadvantaged rural and urban setting in South Africa. Social Science & Medicine. 2023;334:116190. Viisainen K, Baumgart Dos Santos M, Sunderbrink U, Couto A. Gender and stigma in antiretroviral treatment adherence in Mozambique: A qualitative study. Vijayasingham L, editor. PLOS Glob Public Health. 2024;4(7):e0003166. McKenzie SK, Oliffe JL, Black A, Collings S. Men’s Experiences of Mental Illness Stigma Across the Lifespan: A Scoping Review. Am J Mens Health. 2022;16(1):155798832210747. Sorsdahl K, Stein DJ, Myers B. Negative attributions towards people with substance use disorders in South Africa: Variation across substances and by gender. BMC Psychiatry. 2012;12(1):101. Chikovore J, Hart G, Kumwenda M, Chipungu G, Desmond N, Corbett EL. TB and HIV stigma compounded by threatened masculinity: implications for TB health-care seeking in Malawi. int j tuberc lung dis. 2017;21(11):26–33. da Silva TC, Pinto ML, Orlandi GM, Figueiredo TMRM de, França FO de S, Bertolozzi MR. Tuberculosis from the perspective of men and women. Rev esc enferm USP. 2022;56:e20220137. Bajema KL, Kubiak RW, Guthrie BL, Graham SM, Govere S, Thulare H, et al. Tuberculosis-related stigma among adults presenting for HIV testing in KwaZulu-Natal, South Africa. BMC Public Health. 2020;20(1):1338. Johnson BT, Redding CA, DiClemente RJ, Mustanski BS, Dodge B, Sheeran P, et al. A Network-Individual-Resource Model for HIV Prevention. AIDS Behav. 2010;14(S2):204–21. Huisman M, Tilburg TG van. Chapter 7 - Social exclusion and social isolation in later life. In: Ferraro KF, Carr D, editors. Handbook of Aging and the Social Sciences (Ninth Edition) [Internet]. Ninth Edition. Academic Press; 2021. p. 99–114. (Handbooks of Aging). Available from: https://www.sciencedirect.com/science/article/pii/B9780128159705000073 Barry B. Social exclusion, social isolation and the distribution of income. In: Understanding Social Exclusion. London: Oxford University Press; 2022. p. 13–29. Link BG, Phelan JC. Conceptualizing Stigma. Annu Rev Sociol. 2001;27:363–85. Pellowski JA, Barnett W, Kuo CC, Koen N, Zar HJ, Stein DJ. Investigating tangible and mental resources as predictors of perceived household food insecurity during pregnancy among women in a South African birth cohort study. Social Science & Medicine. 2017;187:76–84. Meershoek A, Zwerling A, Daftary A, Citro B, Smyth C, Lewis D, et al. TB Stigma Measurement Guidance [Internet]. KNCV Challenge TB; 2018. Available from: www.challengetb.org Liamputtong P, Rice ZS. Stigma, discrimination, and social exclusion. In: Handbook of social inclusion: Research and practices in health and social sciences. Cham, Switzerland: Springer Nature Switzerland AG; 2022. p. 113–28. Earnshaw VA, Chaudoir SR. From Conceptualizing to Measuring HIV Stigma: A Review of HIV Stigma Mechanism Measures. AIDS Behav [Internet]. 2009 Dec [cited 2024 Sep 17];13(6). Available from: http://link.springer.com/ 10.1007/s10461-009-9593-3 Smits J, Permanyer I. The Subnational Human Development Database. Sci Data. 2019;6:190038. Global Data Lab. Subnational Human Development Index - South Africa [Internet]. Global Data Lab; [cited 2023 Jul 1]. Available from: https://globaldatalab.org/shdi/shdi/ZAF/ Johnson L, Dorrington R. Thembisa version 4.6: National and Provincial Model Outputs [Internet]. Thembisa; 2023. Available from: https://www.thembisa.org/content/downloadPage/ProvOutput4_6 Johnson LF, Dorrington RE, Moolla H. Progress towards the 2020 targets for HIV diagnosis and antiretroviral treatment in South Africa. Southern African Journal of HIV Medicine [Internet]. 2017;18(1). Available from: https://sajhivmed.org.za/index.php/hivmed/article/view/694 TB Online Surveillance Dashboard [Internet]. South African National Institute of Communicable Diseases. [cited 2020 Aug 29]. Available from: http://www.nicd.ac.za/tb-surveillance-dashboard/ Massyn N, Day C, Ndlovu N, Padayachee T. District Health Barometer 2019/20 [Internet]. Durban: Health Systems Trust; 2020 Dec [cited 2021 Oct 26]. Available from: https://www.hst.org.za/publications/District%20Health%20Barometers/DHB%202019-20%20Complete%20Book.pdf Chang SH, Cataldo JK. A systematic review of global cultural variations in knowledge, attitudes and health responses to tuberculosis stigma. int j tuberc lung dis. 2014;18(2):168–73. Karim F, Chowdhury AMR, Islam A, Weiss MG. Stigma, Gender, and their Impact on Patients with Tuberculosis in Rural Bangladesh. Anthropol Med. 2007;14(2):139–51. Tadesse S. Stigma against Tuberculosis Patients in Addis Ababa, Ethiopia. Kumar A, editor. PLoS ONE. 2016;11(4):e0152900. Ashaba C, Musoke D, Tsebeni Wafula S, Konde-Lule J. Stigma among tuberculosis patients and associated factors in urban slum populations in Uganda. Afr H Sci. 2021;21(4):1640–50. Daftary A. HIV and tuberculosis: The construction and management of double stigma. Social Science & Medicine. 2012;74(10):1512–9. Petros De Guex K, Augustino D, Mejan P, Gadiye R, Massong C, Lukumay S, et al. Roadblocks and resilience: A qualitative study of the impact of pediatric tuberculosis on Tanzanian households and solutions from caregivers. Global Public Health. 2023;18(1):2196569. Majombozi Z. Care, Contagion and the Good Mother: Narratives of Motherhood, TB and Healing. Anthropology Southern Africa. 2019;42(4):290–301. O’Laughlin B. Missing men?: the debate over rural poverty and women-headed households in Southern Africa. The Journal of Peasant Studies. 1998;25(2):1–48. Knight L, Hosegood V, Timæus IM. Obligation to family during times of transition: care, support and the response to HIV and AIDS in rural South Africa. AIDS Care. 2016;28(sup4):18–29. Phillips LH. ‘I am Alone. I am a Woman. What are my Children going to Eat?’ Domestic Workers and Family Networks. South African Review of Sociology. 2011;42(2):29–44. Gosoniu GD, Ganapathy S, Kemp J, Auer C, Somma D, Karim F, et al. Gender and socio-cultural determinants of delay to diagnosis of TB in Bangladesh, India and Malawi. Int J Tuberc Lung Dis. 2008;12(7):8. Atre SR, Kudale AM, Morankar SN, Rangan SG, Weiss MG. Cultural concepts of tuberculosis and gender among the general population without tuberculosis in rural Maharashtra, India. Tropical Med Int Health. 2004;9(11):1228–38. Indra DM, Buchignani N. Rural landlessness, extended entitlements and inter-household relations in south Asia: A Bangladesh case. Journal of Peasant Studies. 1997;24(3):25–64. Barua M, Van Driel F, Jansen W. Tuberculosis and the sexual and reproductive lives of women in Bangladesh. Daftary A, editor. PLoS ONE. 2018;13(7):e0201134. Hatherall B, Newell JN, Emmel N, Baral SC, Khan MA. “Who Will Marry a Diseased Girl?” Marriage, Gender, and Tuberculosis Stigma in Asia. Qual Health Res. 2019;29(8):1109–19. Brown J, Sorrell J, Raffaelli M. An exploratory study of constructions of masculinity, sexuality and HIV/AIDS in Namibia, Southern Africa. Culture, Health & Sexuality. 2005;7(6):585–98. Mahalik JR, Burns SM, Syzdek M. Masculinity and perceived normative health behaviors as predictors of men’s health behaviors. Soc Sci Med. 2007;64(11):2201–9. Sileo KM, Reed E, Kizito W, Wagman JA, Stockman JK, Wanyenze RK, et al. Masculinity and engagement in HIV care among male fisherfolk on HIV treatment in Uganda. Culture, Health & Sexuality. 2019;21(7):774–88. Naigino R, Miller AP, Ediau M, Anecho A, Senoga U, Tumwesigye NM, et al. Stakeholder perspectives on the Kisoboka intervention: A behavioral and structural intervention to reduce hazardous alcohol use and improve HIV care engagement among men living with HIV in Ugandan fishing communities. Drug and Alcohol Dependence. 2023;253:111011. Makgopa S, Cele LP, Mokgatle MM. Pre-Diagnosis Health Seeking Behaviors and Experiences Post-Diagnosis, among Men Diagnosed with Tuberculosis in a District of Gauteng Metropolitan City, South Africa: In-Depth Interviews. IJERPH. 2022;19(20):13635. Medina-Marino A, Bezuidenhout D, Ngcelwane N, Cornell M, Wainberg M, Beyrer C, et al. Qualitative Identification of Intervention Preferences to Support Men’s Engagement and Retention in TB Care in South Africa. Am J Mens Health. 2022;16(5):155798832211293. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5409926","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":382921901,"identity":"a02b1360-aee3-4db1-8ca5-af89b17538a5","order_by":0,"name":"Andrew Medina-Marino","email":"data:image/png;base64,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","orcid":"","institution":"Desmond Tutu HIV Foundation","correspondingAuthor":true,"prefix":"","firstName":"Andrew","middleName":"","lastName":"Medina-Marino","suffix":""},{"id":382921902,"identity":"fb9160c2-22c2-4c65-bfb5-619987ad3a75","order_by":1,"name":"Lindsey de Vos","email":"","orcid":"","institution":"Desmond Tutu HIV Foundation","correspondingAuthor":false,"prefix":"","firstName":"Lindsey","middleName":"","lastName":"de Vos","suffix":""},{"id":382921903,"identity":"bf42441e-c75b-45b9-a5d8-66e45288bb6e","order_by":2,"name":"Joseph Daniels","email":"","orcid":"","institution":"Arizona State University","correspondingAuthor":false,"prefix":"","firstName":"Joseph","middleName":"","lastName":"Daniels","suffix":""}],"badges":[],"createdAt":"2024-11-07 12:38:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5409926/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5409926/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":70694004,"identity":"c1813ff8-77b0-4fb8-a139-240f109f3078","added_by":"auto","created_at":"2024-12-05 17:07:02","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":86244,"visible":true,"origin":"","legend":"\u003cp\u003eGendered Pathways and Impact of Stigma and Isolation Men and Women’s Health Journeys When Ill with TB\u003c/p\u003e","description":"","filename":"Figure1GenderedPathwaysandImpactofStigma.png","url":"https://assets-eu.researchsquare.com/files/rs-5409926/v1/10de0c4768f608340588ad22.png"},{"id":70694005,"identity":"bcb1824d-363a-49a5-8224-a30160dada31","added_by":"auto","created_at":"2024-12-05 17:07:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":855738,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5409926/v1/90b5f228-4250-4e6b-ac90-5b3011b35b64.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Social Isolation, Social Exclusion and Access to Resources: Mapping the Gendered Impact of TB-related Stigma Among TB Patients in Eastern Cape Province, South Africa","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eGlobally, an estimated 10.6\u0026nbsp;million people developed TB in 2022, of those, 55% were adult men, 33% were adult women and 12% were children.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] Compared to women, men are at increased risk for poor outcomes along the TB care cascade and TB-related mortality.[\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] Though women bear a lower burden of TB disease, TB exacerbates the gendered health inequalities and vulnerability that women face globally, which increases their risk of poor TB outcomes.[\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] A host of social determinants, including stigma, gender norms and practices, social support, and access to tangible (e.g., food, money, transportation) and mental (i.e., self-efficacy, coping mechanisms, resiliency) resources are known to influence both men and women\u0026rsquo;s risk for poor treatment outcomes.[\u003cspan additionalcitationids=\"CR9 CR10 CR11\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] However, elucidating gender-specific dimensions in how men and women experience TB illness, particularly TB-related stigma and isolation, is necessary to inform gender-responsive interventions to improve men and women\u0026rsquo;s TB-related health outcomes and quality of life during their illness-to-health journey.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eStigmatization of people with TB are driven by a combination of misconceptions, cultural beliefs, social dynamics and judgement, and fear of contagion, all of which results in distinctive acts of exclusion beyond advised TB protocols.[\u003cspan additionalcitationids=\"CR16 CR17 CR18 CR19\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] Perceived and real signs and symptoms of TB, especially cough and weight loss, may thus bring about prolonged isolation stemming from self-imposed or enforced isolation by others.[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] Such acts include self-withdrawal due to perceived social repercussions and community stigma [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], not sharing utensils with others and being excluded from social and familial events and networks, all of which can impact a patient\u0026rsquo;s quality of life and resiliency.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] Although there are similarities in how men and women experience TB-related stigma, few studies report higher TB stigma or vulnerability among men.[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] Much more often, women are reported to experience higher stigma burden due to gender and cultural norms that increase women\u0026rsquo;s vulnerability and social inequities, especially in highly patriarchal societies that further impose barriers to accessing health services.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] Stigmatizing perceptions can further impact men and women\u0026rsquo;s health-care seeking behavior, retention in care and preferences for TB care and treatment delivery.[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan additionalcitationids=\"CR28 CR29 CR30 CR31\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe ability of individuals living with TB to navigate stigma during their illness-to-health journey is influenced by psychosocial support and access to resources.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan additionalcitationids=\"CR34\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] Support networks, including partners, family, healthcare providers and community members, offer essential provisions like emotional support, food and means to access healthcare.[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan additionalcitationids=\"CR37\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] Alternatively, unsupportive networks can restrict or block access to resources through isolation and exclusion. This may result in reduced resiliency to cope with TB illness,[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] an inability to practice optimal health behaviors, and negatively impact the quality of life of those living with TB, all of which have a direct impact on treatment adherence and completion.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eA complex interplay between stigma and gender, and their intersecting impact on resource access and support, have been described for other health conditions.[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan additionalcitationids=\"CR41\" citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e] Given that men and women\u0026rsquo;s TB illness and treatment experiences may vary greatly due to social and cultural variations, including existing gender norms [\u003cspan additionalcitationids=\"CR44\" citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e], we explored how men and women living with TB in South Africa experience stigma and isolation, and how these impact their social networks and access to resources during treatment.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eThis qualitative sub-study was nested within a larger, mixed-methods, prospective cohort study (NIH R21AI148852; \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://reporter.nih.gov/project-details/10085625\u003c/span\u003e\u003cspan address=\"https://reporter.nih.gov/project-details/10085625\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e), which sought to identify gender-specific and gender-neutral preferences for a male-centered TB care and support intervention.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Framework\u003c/h2\u003e \u003cp\u003eThis study was guided by the Network-Individual-Resource Model (NIRM), and concepts of isolation and stigma.[\u003cspan additionalcitationids=\"CR47 CR48\" citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e] The NIRM takes an ecological approach to behaviour change, and articulates how access to and exchanges of resources between an individual and their networks positively and negatively influence health behaviors and outcomes.[\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e] The NIRM conceptualizes resources into \u003cem\u003eMental\u003c/em\u003e (e.g., personal agency, attitudes, perceived norms, social support, social capital) and \u003cem\u003eTangible\u003c/em\u003e (e.g., income, access to food, physical health, transport), operationalized at the individual and network levels.[\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e] The NIRM postulates that networks can mitigate risk and enhance coping mechanisms by providing relevant resources. The NIRM argues that network memberships are often sustained by trust, which can be jeopardized by stigma. When stigma acts to isolate individuals from participating in networks, access to resources may become restricted. This hinders one's ability to effectively cope with stressors and increases their vulnerability to poor outcomes.[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] In this context, we used the NIRM to explore and describe pathways by which stigma influences access to resources. To more fully integrate stigma into the NIRM, we used current literature and guidance documents to define stigma types (e.g., anticipated, enacted, internalized), and how these different types of stigmas may contribute to isolation.[\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan additionalcitationids=\"CR52\" citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e] Furthermore, we applied the concepts of social isolation and social exclusion, related but distinct concepts that refer to different experiences in the realm of social relationships, as interpretive lenses to more fully explore how these pathways to isolation may influence resource access and vulnerabilities while ill with TB.[\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] Specifically, social isolation refers to the objective state of being physically separated from or having minimal social contact with others; social isolation can be voluntary (i.e., retreating from social interactions to minimize stigmatization or to minimize infecting others) or involuntary (i.e., weakness due to illness; geographic remoteness).[\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] In comparison, social exclusion is often a result of societal structures, discrimination, or prejudice, and refers to the process through which individuals or groups are marginalized, denied access to resources, opportunities, or participation in social activities.[\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Setting\u003c/h3\u003e\n\u003cp\u003eThis study was conducted in Buffalo City Metropolitan (BCM) Health District, Eastern Cape Province, South Africa. Eastern Cape Province is historically under-resourced and lacks the mature research infrastructure of historically advantaged areas of Durban, Johannesburg and Cape Town. Since 1990, Eastern Cape has ranked last among South Africa\u0026rsquo;s nine provinces in its Human Development Index score.[\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e] In 2019, the estimated HIV prevalence in Eastern Cape Province was 20.2% (95% CI: 19.7%-20.9%) among those aged 15\u0026ndash;49 years.[\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e] That same year, BCM had an estimated TB incidence of 876 per 100,000 population (male incidence\u0026thinsp;=\u0026thinsp;~\u0026thinsp;1072 per 100,000 population; female incidence\u0026thinsp;=\u0026thinsp;~\u0026thinsp;540 per 100,000 population).[\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e] In 2018, the last year in which data were published, BCM had a drug-susceptible TB (DS-TB) treatment success rate of 71.2% (the lowest in South Africa), a loss-to-care (LTC) rate of 17.6% (second highest in South Africa), and a TB client death rate of 6.3%.[\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]\u003c/p\u003e\n\u003ch3\u003eParticipant Recruitment\u003c/h3\u003e\n\u003cp\u003eFrom March 2021 through January 2022, study staff were embedded in 15 of 79 primary and community health clinics throughout BCM, including: 1) urban, peri-urban and rural clinics, and 2) clinics with catchment areas including formal and informal settlement housing. In collaboration with clinic TB nurses, TB patients were identified and screened for eligibility by study staff. Inclusion criteria included: 1) age\u0026thinsp;\u0026ge;\u0026thinsp;18 years; 2) currently living in BCM; and 3) currently engaged in or initiating treatment for DS-TB. All eligible individuals were invited to learn about the study, consecutively recruited, consented and administered a study questionnaire by study staff at time-of-enrollment. Participants were prospectively followed and purposively invited for an in-depth interview (IDI) based on their progression along the TB treatment cascade (i.e., currently on treatment; missed\u0026thinsp;\u0026ge;\u0026thinsp;15 days of a treatment refill visit; recently completed treatment). The study attempted to recruit an equal number of male and female TB patients.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eSemi-structured interview protocols were developed to examine the following domains: experiences and perspectives of TB symptoms; access to clinical care and services; individual motivations for treatment; disclosure decision-making; social and familial network support during TB illness; perspectives of other men and women\u0026rsquo;s TB experiences; and probing for tangible and mental resources accessed during their TB illness and treatment journey. Open-ended questions in line with these domains further explored changes in the behaviors and dynamics of their social and familial networks, experiences with anticipated, enacted and internalized stigma, judgment, the ability to access support, perceived impacts of their illness on their lifestyle and relationships, and experiences of isolation and network membership exclusion.\u003c/p\u003e \u003cp\u003eInterviews were scheduled with participants either telephonically or via home visits. Interviews were conducted in a participant\u0026rsquo;s preferred language (English or IsiXhosa), and in a private location agreeable to the study participant. Interviews were audio-recorded and lasted approximately 60\u0026ndash;90 minutes. The gender of the interviewers was matched to those of participants. Data collection was monitored and refined through a review of initial interviews, weekly team meetings, and refresher trainings. Interview recordings were transcribed, translated into English (from isiXhosa) where needed, and reviewed by a second team member for quality control.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eA subset of transcripts was read and open-coded by the study team using an inductive approach. Codes relating to TB illness experiences and mental and tangible resources, as defined by NIRM, were identified and consolidated into a codebook. The codebook was then applied to all the transcripts using Dedoose (Version 9.0.17, Los Angeles, CA: SocioCultural Research Consultants, LLC), with coding iteratively assessed and discussed to ensure consensus and inter-coder reliability. Codes were subsequently organized into the following domains: 1) family and community environment; 2) TB symptom experiences; 3) clinic experiences; 4) mental and tangible resources that are either within one\u0026rsquo;s control (i.e. self-support) or sought/accessed/lost from others; 5) resiliency and vulnerability; 6) judgment (self/others); 7) discriminatory actions and 8) the social impacts of TB and isolation.\u003c/p\u003e \u003cp\u003eOngoing analysis was conducted throughout data collection and refined through a cyclic iterative process. Isolation constructs, gender and the NIRM were used as a deductive interpretive lens to elucidate the relationships between and intersections of stigma, isolation, social networks, and the mental and tangible resources accessed, lost or needed while participants were transversing the TB treatment journey.[\u003cspan additionalcitationids=\"CR47\" citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] Frequency analysis, memos, and pathway diagrams were leveraged to assess the relationships between mental and tangible resources during TB treatment. Matrices to compare men and women\u0026rsquo;s TB illness experiences were developed through an inductive approach. TB-stigma literature reviews and weekly study team discussions with study investigators further confirmed findings of the interrelationships of TB stigma, social networks and resource accessibility. The concepts of social isolation and social exclusion were then used to further help understand isolation experiences and pathways, and their dynamic relationship with stigma (i.e., anticipated, enacted and internalized). We further inductively examined changes in participants\u0026rsquo; behaviors and social networks over time to determine how social networks were maintained, dissolved, and/or re-established as participants progressed along their illness-to-health journey.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eEthics\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eEthics approval\u003c/strong\u003e \u003cp\u003e was obtained from Human Research Ethics Committee of the Faculty of Health Sciences, University of Cape Town (Ref no. : 673/2019) (Medina-Marino, PI) with an institutional reliance agreement by Arizona State University (Daniels, PI). Study approval was provided by the Eastern Cape Provincial Department of Health (Ref no.: EC202010_023). All participants provided written informed consent. Recording of interviews was voluntary. Interview participants were provided a small snack and R150 (~\u003cspan\u003e$\u003c/span\u003e8 USD) for their time. Study staff, both male and female, were trained in qualitative research, interviewing techniques, human subject\u0026rsquo;s protection, and good clinical practice.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipant Representation\u003c/h3\u003e\n\u003cp\u003eIn-text quotes are attributed to participants by their study ID number, gender, and age.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eParticipant Characteristics (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/h2\u003e \u003cp\u003eWe conducted IDIs with 142 TB patients with a median age of 37 (IQR: 30\u0026ndash;46) years. Of those, 86 (60.6%) were men, 48 (33.8%) self-reported a previous history of TB and 69 (48.6%) self-reported living with HIV. A larger proportion of men reported having a previous history of TB disease compared to women (37.2% vs. 28.6%). In comparison, a larger proportion of women reported living with HIV compared to men (67.9% vs. 36.1%), reflecting the gendered inequities and high HIV co-infection rates in South Africa. Compared to women, men were more likely to report being unemployed (72.1% vs. 58.9%) during TB treatment, living alone (29.0% vs. 16.1%) and being the primary household breadwinner (48.8% vs. 30.4%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e Sociodemographic characteristics of interviewed TB patients (N\u0026thinsp;=\u0026thinsp;142)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eCharacteristic (n/%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMen (n\u0026thinsp;=\u0026thinsp;86)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWomen (n\u0026thinsp;=\u0026thinsp;56)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTotal (N\u0026thinsp;=\u0026thinsp;142)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAge (median, IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (31\u0026ndash;48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e33 (27.5\u0026ndash;44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e37 (30\u0026ndash;46)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eRelationship Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57 (66.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38 (67.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95 (66.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarried or Living together\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26 (30.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (19.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e37 (26.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDivorced, separated, or widowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (3.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10 (7.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eEmployment Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnemployed (actively or inactively looking)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e62 (72.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33 (58.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95 (66.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWorking for pay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7 (8.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (10.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13 (9.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelf-employed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7 (8.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11 (7.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStudent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (1.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (3.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9 (10.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (15.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18 (12.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003ePrimary Household Breadwinner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42 (48.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17 (30.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e59 (42.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eMonthly household Income\u0026thinsp;\u0026lt;\u0026thinsp;R 2 000 (~\u003cspan\u003e$\u003c/span\u003e135)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58 (67.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e34 (60.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e92 (64.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eCompleted secondary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (23.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18 (32.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38 (26.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eLive alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (29.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9 (16.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e34 (23.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eHad TB in the past\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54 (62.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40 (71.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e94 (66.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes, less than 2 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11 (12.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (5.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14 (9.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes, more than 2 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21 (24.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (23.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e34 (23.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eHIV Status (self-reported)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31 (36.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38 (67.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e69 (48.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e48 (55.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (26.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e63 (44.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot disclosed/Don\u0026rsquo;t know\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7 (8.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (5.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10 (7.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eSymptom Onset and Stigma Markers\u003c/h2\u003e \u003cp\u003eBoth men and women described anticipating and experiencing stigma due to their TB status and clinic attendance. Visible weight loss was a particularly potent marker of TB illness that triggered negative comments and judgement.\u003c/p\u003e \u003cp\u003eWomen expressed significant concern for being gossiped about. This often resulted from visible weight loss or behaviors perceived to be associated with TB disease:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I don\u0026rsquo;t like it when people talk about my weight, you know it makes me feel like there\u0026rsquo;s something I am not doing right, well in this case I knew that there\u0026rsquo;s something that I\u0026rsquo;m not doing right.\u0026rdquo;\u003c/em\u003e [75, Female, 30 years]\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I was thinking about what people will say [at the clinic]. People [would] be watching me when they pass by while I was sitting there [at the clinic]. I thought maybe they think I have TB because I drink a lot or smoke all those awful things like maybe they are judging me\u0026hellip;\u0026rdquo;\u003c/em\u003e [292, Female, 23 years]\u003c/p\u003e \u003cp\u003eThese women reveal the connections between negative comments, causal attribution and self-blame. Male patients also described their fear of negative comments which they attribute to their weight loss and poor health:\u003c/p\u003e \u003cp\u003e \u003cem\u003eP: I felt judged, and on my way to clinic people were looking at my weight. Some even asked why I have lost so much weight and that didn\u0026rsquo;t sit well with me.\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eI: Who did you feel was judging you? Other patients, clinic staff?\u003c/h2\u003e \u003cp\u003e \u003cem\u003eP: No, it was friends\u003c/em\u003e [87, Male, 37 years]\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I get embarrassed. Maybe let\u0026rsquo;s say we are chilling at a certain place. Let me make an example. Let\u0026rsquo;s say I\u0026rsquo;m on my way to town. We\u0026rsquo;re sitting in a taxi with people, or any other place you can think of, or maybe I\u0026rsquo;m visiting a friend at his home, but any place I don\u0026rsquo;t normally go to, I do feel embarrassed like [in my mind, I think], \u0026lsquo;Ey. People will start asking questions here about my loss of weight\u0026rsquo; and other things that I won\u0026rsquo;t be comfortable to talk about. So, I end up not going to these places because I\u0026rsquo;m ashamed and scared\u0026rdquo;\u003c/em\u003e [41, Male, 35 years]\u003c/p\u003e \u003cp\u003eThese quotes highlight men and women\u0026rsquo;s shared experiences of negative or unwanted comments about their weight loss, and describe the psychological impact (e.g., shame, embarrassment or self-blame) of having TB. Both men and women also anticipate being stigmatized as their TB-related symptoms become visible, or as they start to attend clinic for their TB treatment. The fear of encountering questions or being forced into uncomfortable discussions about visible health changes led both men and women to avoid or not participate in certain social situations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eStigma and Gendered Pathways to Isolation\u003c/h2\u003e \u003cp\u003eBoth women and men describe isolation as a manifest experience while ill with TB. However, women discuss enduring social isolation, while men describe being excluded by others (i.e., social exclusion).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eWomen: Self-isolation and avoidance\u003c/h2\u003e \u003cp\u003eWomen revealed how they refrained from venturing outside their homes due to the comments they received after exhibiting TB symptoms. These comments and unwarranted judgment predominantly emanated from their social networks and friends:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I was not all right. I felt judged when people asked me about my weight. I avoided leaving the house\u0026rdquo;\u003c/em\u003e [238, Female, 39 years]\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;So, she [a friend] would say bad things about me. Then I would notice the mood, but some people would tell me straight up that \u0026ldquo;[friend\u0026rsquo;s name] is saying this and that about you\u0026rdquo;. I ended up avoiding them because they had bad attitude towards me. I isolated myself and lived in my shack with my boyfriend\u003c/em\u003e\u0026rdquo; [347, Female, 30 years]\u003c/p\u003e \u003cp\u003eJudgmental comments and negative remarks were sources of discomfort, and engendered self-consciousness. The latter participant [347, Female, 30 years] closely observed shifts in the behavior and mood of others, leading to avoidance of her friends. As a result of experienced mistreatment and altering social dynamics, female patients conveyed feelings of shame and disappointment in friends that resulted in avoidant behaviors:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;It made me very sad [when others noticed her weight loss]. I was ashamed I couldn\u0026rsquo;t even leave the house. People were talking. My neighbor (pointing to the right wall) was the first person to notice my weight loss.\u0026rdquo;\u003c/em\u003e [116, Female, 31 years]\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I even distance myself from people because they are no longer coming to visit me anymore and I told myself I will leave them.\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eI: So you told yourself to stay at home?\u003c/h2\u003e \u003cp\u003e \u003cem\u003eP: Yes.\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eI: How did you expect people to treat you after they noticed these symptoms?\u003c/h2\u003e \u003cp\u003e \u003cem\u003eP: At least friends were supposed to support each other, not judging before you know anything. Maybe they are judging because they have no knowledge, and they are scared.\u0026rdquo;\u003c/em\u003e [124, Female, 31 years]\u003c/p\u003e \u003cp\u003eThis female patient [124, Female, 31 years] described a desire for empathy and support from friends, instead of friends who are quick to judge or project fear due to their lack of knowledge. Overall, women described conscious decisions to distance themselves and/or self-isolate to shield themselves from adverse comments and community stigma.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eMen: Wanting to engage, but being excluded\u003c/h2\u003e \u003cp\u003eMen often described how they were excluded from social interactions by friends once stigma markings became obvious or their TB status became known. Specifically, men describe how friends would \u0026lsquo;distance themselves\u0026rsquo; and exclude them from social events or community spaces due to their TB-related symptoms or illness. Several men use emotive language to describe how much these types of experiences impacted them:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;they were far from me. They didn\u0026rsquo;t even want to come and see me. Even when I take a walk during the day and go to them, they would not want me anywhere near them. Maybe if I had gone [there] with something to eat, they would not want to share with me.\u0026rdquo;\u003c/em\u003e [125, Male, 36 years]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I had to stop a lot of things, and I was not able to go to places that I used to go [to]. Places I used to go and smoke at, and they [friends] used to distance themselves from me as if I was going to infect them. It was painful to me, but I saw where they were coming from\u0026rdquo;\u003c/em\u003e [45, Male, 36 years]\u003c/p\u003e \u003cp\u003eMen described continually trying to socially engage with friends but were constantly excluded. They describe how their exclusion was driven by the fear of infection, and how their exclusion exacerbated feelings of loneliness:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Like even today, some people treat me bad. Some people think the worst of me. That I can give them TB anytime because I cough and\u0026hellip; I don\u0026rsquo;t know man. I just want to go and walk away from this place and not even worry about people anymore. Like living on my own strictly. I feel like that, I feel lonely\u003c/em\u003e.\u0026rdquo; [15, Male, 38 years]\u003c/p\u003e \u003cp\u003eThis man describes the emotional toll of being socially excluded, and the pain and loneliness he experiences. They even expressed a desire to remove themselves from this situation, due to this forced disconnection from others.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eThe Role of Family in Mitigating or Exacerbating Stigma and Isolation\u003c/h2\u003e \u003cp\u003eIn general, women and men described profoundly different experiences with their families when ill with TB. Specifically, most women spoke of stable, reliable support from family members, while many men described friction with and hostility from their families and dissolution of romantic relationships.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eWomen: Familial support and access to resources\u003c/h2\u003e \u003cp\u003eWomen often described a high level of trust to disclose their TB illness to family members due to the perception that family do not gossip or divulge one\u0026rsquo;s illnesses in a negative manner. Familial acceptance was particularly important when women self-isolated to avoid community stigmatization:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;My friends distanced themselves from me, so I was lonely. I was talking only with my family and since I was not the first person to get ill in the family, they were fine with it.\u0026rdquo;\u003c/em\u003e [59, Female, 20 years]\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I expected that they [household members] would just be upset and not talk about it, but they understood. I just trusted them, and I knew if I told a friend they would go around and divulge it in the streets. It is better to talk to the one at home\u0026rdquo;\u003c/em\u003e [106, Female, 30 years]\u003c/p\u003e \u003cp\u003eThese women describe the impacts of illness on social connections and the pivotal role their families played. Familial support was a crucial counterbalance to community stigmatization that could have otherwise discouraged or demotivated them during treatment:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;She [my mother] said to me \u0026lsquo;my child, when you have TB people like to gossip. They like to say that \u0026ldquo;oh [that] one has HIV.\u0026rsquo; Then she said to me \u0026lsquo;don\u0026rsquo;t be scared, don\u0026rsquo;t be afraid. You will overcome this TB, you overcome it the first time you can overcome it the second time\u0026rsquo;\u0026hellip;\u0026rdquo;\u003c/em\u003e [12, Female, 30 years]\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;There are people who spread rumors. You have to tell yourself that you do not live for people. They cannot change who you are and there is nothing more important than your family. If you get support from your family, an outsider's support is not that important than your family\u0026rsquo;s support. The only thing that will make you to give up is if your family doesn't welcome you, but I think family is the most.\u0026rdquo;\u003c/em\u003e [23, Female, 42 years]\u003c/p\u003e \u003cp\u003eIn addition to family members providing mental and emotional support, women described how they continued to access tangible resources via familial networks:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I: Who supported you during this time?\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eP: My aunt\u003c/h2\u003e \u003cdiv id=\"Sec22\" class=\"Section3\"\u003e \u003ch2\u003eI: What type of support did she provide?\u003c/h2\u003e \u003cp\u003e \u003cem\u003eP: She gave me all the support I needed \u0026ndash; money, advice, motivation, food, and shelter. She did everything for me.\u0026rdquo;\u003c/em\u003e [59, Female, 20 years]\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Okay when I found out that I had TB, I came home and told my family that I have TB. They didn\u0026rsquo;t judge me or distance themselves, but supported me and also changed the food we eat to healthy food for me. They did that so that I can quickly recover.\u0026rdquo;\u003c/em\u003e [75, Female, 30 years]\u003c/p\u003e \u003cp\u003eThese women highlighted the importance of their family networks in accessing tangible (e.g., money, food, and shelter) and mental (e.g., motivation, emotional support, companionship) resources crucial for combating loneliness and sustaining resiliency during their TB illness-to-health journey.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eMen: Friction, blame and loss of familial support\u003c/h2\u003e \u003cp\u003eIn addition to being socially excluded by friends, many men described being judged and excluded by their families. Judgement often arose from behaviors perceived to be related to contracting TB (e.g., drinking alcohol, smoking, partying). Furthermore, several men described strained or dissolution of romantic relationships while ill with TB.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eAfter those [TB] symptoms, it was hectic at home, especially [with] my mom and uncles. My mom is short-tempered and when she would scold me, she would use that I have TB against me and say that I bring over friends that have TB\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e[326, Male, 46 years]\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026rdquo;It is painful on my family\u0026rsquo;s side only because my mother was someone who loved [me]. But when I had TB, I have never seen her, she doesn\u0026rsquo;t even call. And my sister is the one who changed when she found out that I have TB. She [sister] didn\u0026rsquo;t give any [support] except the ones I told you, and the cereals she bought me once. She never bought them, and she never came again to check up on me.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eEh! I wish my sister, and my mother would have supported me, because when I was working, I was doing everything for her, my mother. Now she is living well in the villages, and she has money, but I am not looking for her money, but I wanted her to support me especially with food because I was really struggling with getting food, because I was not working, and my girlfriend was not working as well.\u0026rdquo;\u003c/em\u003e [138, Male, 38 years]\u003c/p\u003e \u003cp\u003eThese men described how their families accused them of putting them at risk for TB, distanced themselves and stopped providing then with any type of support. Men further explained how retention of familial support would have helped them overcome existing challenges, including food and economic insecurity.\u003c/p\u003e \u003cp\u003eFamilial judgment and exclusion also engendered self-blame for having TB. In extreme cases, though not unique, several men described being physically locked in rooms by family members due to perceived safety concerns. This deprived these men of basic needs such as access to a bathroom:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;I decided to move back to my shack and my elder brother he was just giving me the bad look when I [would] walk with friends. But [he] asked me \u0026lsquo;why [do] you have this [TB]?\u0026rsquo; and I said it[s] because of alcohol, walking at night, cigarette and weed\u0026hellip;\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eMy sister chased me to stay in my room and close[d] the door because of [my] coughing sometimes. I wanted to go to the toilet, but I [couldn\u0026rsquo;t] because my door was locked. So, I [would] just open [a] window and take out my penis or I take [a] bucket, so I didn\u0026rsquo;t like [these] things\u0026rdquo;\u003c/em\u003e [199, Male, 31 years]\u003c/p\u003e \u003cp\u003eInterestingly, only men spoke about dissolution of their romantic relationships because of their illness. Although women had relationships, no relationship dissolution was reported because of their TB. For instance, the following men describe the end of their marriage or relationship with a girlfriend:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;at the clinic, my wife\u0026rsquo;s sister was a nurse and heard I was taking my [TB] treatment at [another clinic]. She said she knows I am taking treatment, and I can no longer be with her sister. And I ended up losing her [wife], and she said she no longer wants marriage. It really hurt me.\u0026rdquo;\u003c/em\u003e [237, Male, 40 years]\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026hellip;Ey brother, I lost most of them [women] because of my health\u0026hellip; she [girlfriend] did not notice that I am not okay, but she heard rumors, she distanced herself. I was not okay, I tried to explain but she already heard a lot, it was [too] late for me\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e[7, Male, 26 years]\u003c/p\u003e \u003cp\u003eSocial losses and ill-health also translated into internalized negative feelings and emasculation as described by this patient:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026hellip;[interacting] with men I don't know what to say because I don't even feel like a man anymore. I feel too weak to be a man because I can't even provide for myself. How would a man like me provide for a woman? That's why I don't even have a girlfriend anymore because I know that I can't even provide for myself.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e[15, Male, 38 years]\u003c/p\u003e \u003cp\u003eMen described how their TB illness affected their physical strength and sexual performance and attributed these factors to the dissolution of their romantic relationships. Overall, men\u0026rsquo;s severely strained familial relationships or loss of romantic partners exacerbated their isolation and drastically reduced their ability to access the necessary resources and support they needed when ill with TB.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eRegaining Health and Re-establishing (Altered) Social Networks\u003c/h2\u003e \u003cp\u003eMost patients described feeling better within three months after initiating TB treatment. This was often associated with increased appetite and an improved sense of being: \u0026ldquo;I felt better after two months, and on the third month I could notice I was better now. I was eating too much day and night\u0026rdquo;. [83, Male, 47 years] Improved health and strength were associated with both men and women re-establishing connections with those that had socially excluded them. However, for some these connections were irreparably altered.\u003c/p\u003e \u003cp\u003eBoth men and women described social re-engagement once others perceived or observed them to have regained health. However, concerns lingered about the stability and nature of these re-established connections:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;they [friends at college] were still acting funny, but it took them a long time to accept me, until they saw that I was gaining back my weight. Even though I showed them my clinic book, they still had doubts at first\u0026rdquo;\u003c/em\u003e [248, Female, 25 years].\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I lost a lot of people; they thought I had COVID so they were protecting themselves.\u003c/em\u003e \u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eI: How did all this make you feel?\u003c/h2\u003e \u003cp\u003e \u003cem\u003eP: It made me feel sad. It\u0026rsquo;s not like I\u0026rsquo;m the only person with TB around here. So, I didn\u0026rsquo;t understand why they were treating me this way.\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eI: And when you got better, how did people treat you?\u003c/h2\u003e \u003cp\u003e \u003cem\u003eP: I went back to work right after I felt stronger. And after that, everything went back to normal. You know how people are when they see that you can work again and make money\u0026rdquo;\u003c/em\u003e [Male, 87, 37 years]\u003c/p\u003e \u003cp\u003eThese individuals experienced initial hesitation from others, which persisted despite presenting clinical information to friends. Re-establishment of social networks took time and only happened once they regained their strength and resumed their roles in society. Unfortunately, other men and women described either a lack of agency to reconnect with lost relationships, or an active decision to reject those that were not there when they needed them:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eP: \u0026hellip;no I cut it off with all my friends. I cut them off\u0026hellip;\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003eI: What stopped you from discussing that you got TB with your friends?\u003c/h2\u003e \u003cp\u003e \u003cem\u003eP: Because they couldn\u0026rsquo;t help and [weren\u0026rsquo;t] motivating me\u0026rdquo;\u003c/em\u003e [Male, 14, 32 years]\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The ones that isolated me are still isolating me. In the community I no longer have friends. People I was friends with disappeared, also at church and the ones I see are the ones I did not go to church with. I was visited by the ones from Thursday service instead of the Saturday service.\u0026rdquo;\u003c/em\u003e [Female, 207, 56 years]\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"P: They see you as a weak person\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eI: You also mentioned that you do not have friends anymore\u003c/h2\u003e \u003cp\u003e \u003cem\u003eP: Yeah, nobody comes to me anymore \u0026ndash;none of my friends.\u0026rdquo;\u003c/em\u003e [15, Male, 38 years]\u003c/p\u003e \u003cp\u003eLack of support or motivation during illness led some individuals to sever ties with absent friends. Others described feeling abandoned even when they regained their health. Regardless of whether original connections were permanently altered, re-established or lost, both men and women had to actively navigate or redefine their social connections. These experiences highlight the long-term social sequalae of TB, even when someone successfully completed their treatment or regained their health\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eOur findings substantiate a broader body of literature describing the ubiquity of TB-related stigma, with isolation being a manifest experience of stigma.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. However, there has been limited exploration or mapping of the pathways through which isolation occurs or functions during TB illness and treatment. While experiences of social isolation and social exclusion are reported in the TB literature,[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e] ours is the first to describe and delineate distinct, gendered pathways by which TB stigma facilitates social isolation or social exclusion (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). By applying the NIRM in conjunction with isolation concepts and stigma types, we further describe how familial networks mediated access to resources, and in turn mitigated or exacerbated women and men\u0026rsquo;s isolation. In this context, we show how families promoted women\u0026rsquo;s resiliency while magnifying men\u0026rsquo;s vulnerability when ill with TB.\u003c/p\u003e \u003cp\u003eIn our study, men and women experienced distinct pathways towards isolation in response to TB stigma (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Both men and women reported that observable weight-loss was the main trigger for their anticipated and experienced stigma, which has often been associated with HIV.[\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e] However, women described withdrawing more quickly from their social networks, while men continued seeking social interactions until they were forcibly excluded. Specifically, men reported being socially excluded by their peers due to fear of infection and by family members due to judgment and behaviour blame. In contrast, women engaged in social isolation as a protective measure against negative comments and judgements from others. These findings highlight gendered differences in how men and women are impacted by and respond to stigma, with women exhibiting a protective response and men losing agency.\u003c/p\u003e \u003cp\u003eFamilial networks and support have been well described as crucial to promoting resiliency during one\u0026rsquo;s illness-to-health journey.[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e] In our study, women\u0026rsquo;s familial networks emerged as a crucial buffer against social isolation by proving emotional support and material resources, thus helping them cope with and navigate their TB illness and treatment, and facilitating resiliency (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). This may flow from that fact that in high HIV burden communities, women act as caregivers, head households, and economic contributors to their families, reinforcing their importance within the family structure and encouraging familial support when ill.[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan additionalcitationids=\"CR67 CR68\" citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e] Furthermore, South African women often rely on strong female networks, particularly in households where men migrate for work, offering them a buffer during illness.[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e] This contrasts with studies from Southeast Asia, where women experience significant social exclusion, neglect from family members, and rejection by husbands, reflecting a combination of cultural, social, and economic factors.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e] In India and Bangladesh, traditional gender norms often render women more dependent on male family members, leading to neglect or exclusion when they cannot fulfil domestic roles [\u003cspan additionalcitationids=\"CR72\" citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e]. In these countries, TB-related stigma often intersects with marital and reproductive expectations, causing women to be rejected by their husbands or in-laws [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e]. Furthermore, women in Southeast Asia, who are often part of joint family systems, may be more vulnerable to rejection when TB is seen as a financial or social burden [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e]. Overall, these contextual factors highlight why familial support for women with TB may differ significantly between South Africa and Southeast Asian countries.\u003c/p\u003e \u003cp\u003eMen in our study experienced overt rejection and social exclusion by both peers and family, resulting in distinct challenges and resource insecurity while ill with TB (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Their social exclusion is likely a result of gender norms around masculinity and health, where illness is equated to weakness and seeking help is perceived as a threat to their social status.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e] This exclusion extended to romantic relationships, where men reported experiencing estrangement or dissolution,[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] a dynamic not reported by any women in our study. The lack of trust and support from female caregivers, a crucial element for treatment adherence, further exacerbated men\u0026rsquo;s exclusion, leaving them with diminished access to essential mental and tangible resources.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] Consequently, men\u0026rsquo;s prioritization of work over health, often framed as a negative aspect of masculinity,[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e] may instead represent a survival strategy to retain social and economic resources that they know could be lost or difficult to re-establish, thus compromising their survival during and after illness. This may also explain why men, unlike women, resisted self-isolation in response to community stigmatization, as maintaining their social status within existing social and family networks preserves access to necessary resources. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] The differences in how men and women navigate stigma may also reflect their respective roles in accessing and contributing to social networks. Specifically, while women benefit from relatively stable and enduring familial networks, men rely more on broader, yet often more fragile, peer networks that are more easily disrupted by illness.[\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e, \u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e, \u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e] As a result, when illness undermines men\u0026rsquo;s ability to meet social expectations or contribute to these networks, they are more likely to experience social exclusion and a resultant loss of resources.[\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eBoth men and women in our study described a gradual reintegration into social networks as their health improved, but this reintegration was neither immediate nor universally successful. The findings suggest that the impacts of social exclusion and isolation extend beyond the symptomatic phase of TB, with some patients facing sustained social challenges even during and after treatment. This persistent exclusion has been previously reported in TB-related stigma literature,[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] and highlights the need for ongoing support during the recovery phase to facilitate reintegration into social networks and mitigate long-term stigma effects.\u003c/p\u003e\n\u003ch3\u003eSTRENGTHS AND LIMITATIONS\u003c/h3\u003e\n\u003cp\u003eOur use of an extensive qualitative dataset (142 in-depth interviews), representing a diverse range of experiences along the entire TB care cascade, allowed for a more comprehensive exploration of the nuanced experiences related to TB stigma, and the gendered pathways to isolation and dynamics of accessing resources.Further, the findings underscore socio-cultural factors that may be specific to the study setting, highlighting the complex interplay of gender norms, stigma, and social determinants that differ between countries and global regions. While the cross-sectional design offers a snapshot of the impact and lingering effect of stigma, a deeper exploration of these dynamics is needed. Future research using longitudinal or serial interviews could further illuminate how relationships and access to resources evolve over time.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eFindings reveal women and men\u0026rsquo;s distinct and gendered experience of social isolation and exclusion, respectively, during TB illness that impacts access to key resources for treatment support.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e] This work underscores the critical role of familial networks in buffering or exacerbating the impact of stigma on individuals' TB journeys, well-being and health outcomes. Responsive interventions such as peer support for men [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e] and familial support models for women [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e] may in turn improve treatment outcomes for men and women.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBCM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBuffalo City Metropolitan Health District\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTB-Drug-susceptible tuberculosis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIDI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIn-depth interview\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLTC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLoss-to-care\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMTRs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMental and tangible resources\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNIRM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNetwork-Individual-Resource Model\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePLWTB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePeople living with tuberculosis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003e Ethics approval was obtained from Human Research Ethics Committee of the Faculty of Health Sciences, University of Cape Town (Ref no.: 673/2019) (Medina-Marino, PI) with an institutional reliance agreement by Arizona State University (Daniels, PI). Study approval was provided by the Eastern Cape Provincial Department of Health (Ref no.: EC202010_023). All participants provided written informed consent. Recording of interviews was voluntary. Interview participants were provided a small snack and R150 (~\u003cspan\u003e$\u003c/span\u003e8 USD) for their time. Study staff, both male and female, were trained in qualitative research, interviewing techniques, human subject\u0026rsquo;s protection, and good clinical practice.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests that are relevant to this paper.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003e The study was funded by the U.S. National Institutes of Health (NIH) under award R21AI148852 to AMM and JD, with additional support provided by NIH awards R34HL170819 to AMM and JD and R01AI150485 to AMM.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAMM: Conceptualization, Methodology, Validation, Writing \u0026ndash; Original Draft, Visualization, Supervision, Funding Acquisition.: LDV: Formal analysis, Project administration, Data curation, Writing \u0026ndash; Original Draft, Visualization.: JD: Conceptualization, Methodology, Validation, Formal Analysis, Writing \u0026ndash; Original Draft, Supervision, Funding acquisition.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003e This study was conducted with the support and permission of the Eastern Cape Province and Buffalo City District Department of Health. Authors would like to especially thank the project manager Ralph Mawarire and FPDs senior field workers for their contributions to the interviews and the participants who agreed to be interviewed about their experiences relating to TB and treatment. We thank and acknowledge Mr. Seluleko Ngcobo for supporting literature review activities, and Dr. Aaron Kipp and Dr. Amrita Daftary for their critical review and support during manuscript development. We further thank the Foundation for Professional Development and Desmond Tutu Health Foundation qualitative research team for their contributions to the analysis.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eDue to the sensitive and confidential nature of qualitative interview data these will not be publicly available. Data used for this analysis may be available upon reasonable request and based on a data-sharing agreement with the corresponding author.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGlobal Tuberculosis Report 2023. Geneva: World Health Organization; 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMlotshwa M, Abraham N, Beery M, Williams S, Smit S, Uys M, et al. Risk factors for tuberculosis smear non-conversion in Eden district, Western Cape, South Africa, 2007\u0026ndash;2013: a retrospective cohort study. BMC Infect Dis. 2016;16(1):365.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKubjane M, Cornell M, Osman M, Boulle A, Johnson LF. Drivers of sex differences in the South African adult tuberculosis incidence and mortality trends, 1990\u0026ndash;2019. Sci Rep. 2023;13(1):9487.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHorton KC, MacPherson P, Houben RMGJ, White RG, Corbett EL. Sex Differences in Tuberculosis Burden and Notifications in Low- and Middle-Income Countries: A Systematic Review and Meta-analysis. Metcalfe JZ, editor. PLoS Med. 2016;13(9):e1002119.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDaftary A, Furin J, Zelnick JR, Venkatesan N, Steingart K, Smelyanskaya M, et al. TB and women: a call to action. int j tuberc lung dis. 2020;24(12):1312\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOsman M, Van Schalkwyk C, Naidoo P, Seddon JA, Dunbar R, Dlamini SS, et al. Mortality during tuberculosis treatment in South Africa using an 8-year analysis of the national tuberculosis treatment register. Sci Rep. 2021;11(1):15894.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLong NH, Johansson E, Diwan VK, Winkvist A. Fear and social isolation as consequences of tuberculosis in VietNam: a gender analysis. Health Policy. 2001;58(1):69\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHargreaves JR, Boccia D, Evans CA, Adato M, Petticrew M, Porter JDH. The Social Determinants of Tuberculosis: From Evidence to Action. Am J Public Health. 2011;101(4):654\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCraig GM, Daftary A, Engel N, O\u0026rsquo;Driscoll S, Ioannaki A. Tuberculosis stigma as a social determinant of health: a systematic mapping review of research in low incidence countries. International Journal of Infectious Diseases. 2017;56:90\u0026ndash;100.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChikovore J, Pai M, Horton KC, Daftary A, Kumwenda MK, Hart G, et al. Missing men with tuberculosis: the need to address structural influences and implement targeted and multidimensional interventions. BMJ Glob Health. 2020;5(5):e002255.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMuttamba W, Omongot S, Najjingo I, Nuwarinda R, Buregyeya E, Del Barrio MO, et al. Using intersectional gender analysis to identify challenges in tuberculosis care at four health care facilities in Uganda. Infect Dis Poverty [Internet]. 2024 Jan 5 [cited 2024 Sep 17];13(1). Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://idpjournal.biomedcentral.com/articles/\u003c/span\u003e\u003cspan address=\"https://idpjournal.biomedcentral.com/articles/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s40249-023-01171-3\u003c/span\u003e\u003cspan address=\"10.1186/s40249-023-01171-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSebothoma KJ, Peu MD, Moagi MM, Mshunqane N. Experiences of families living with tuberculosis patients in the North West province, South Africa. Health SA Gesondheid [Internet]. 2024 May 6 [cited 2024 Jul 21];29. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.hsag.co.za/index.php/hsag/article/view/2530\u003c/span\u003e\u003cspan address=\"http://www.hsag.co.za/index.php/hsag/article/view/2530\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDaniels J, Medina-Marino A, Glockner K, Grew E, Ngcelwane N, Kipp A. Masculinity, resources, and retention in care: South African men\u0026rsquo;s behaviors and experiences while engaged in TB care and treatment. Social Science \u0026amp; Medicine. 2021;270:113639.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKrishnan L, Akande T, Shankar AV, McIntire KN, Gounder CR, Gupta A, et al. Gender-Related Barriers and Delays in Accessing Tuberculosis Diagnostic and Treatment Services: A Systematic Review of Qualitative Studies. Tuberculosis Research and Treatment. 2014;2014:1\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCourtwright A, Turner AN. Tuberculosis and Stigmatization: Pathways and Interventions. Public Health Rep. 2010;125(4_suppl):34\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStangl AL, Earnshaw VA, Logie CH, van Brakel W, C. Simbayi L, Barr\u0026eacute; I, et al. The Health Stigma and Discrimination Framework: a global, crosscutting framework to inform research, intervention development, and policy on health-related stigmas. BMC Med. 2019;17(1):31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRedwood L, Fox GJ, Nguyen TA, Bernarys S, Mason P, Vu VA, et al. Good citizens, perfect patients, and family reputation: Stigma and prolonged isolation in people with drug-resistant tuberculosis in Vietnam. Reassignment PM, editor. PLOS Glob Public Health. 2022;2(6):e0000681.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMukerji R, Turan JM. Exploring Manifestations of TB-Related Stigma Experienced by Women in Kolkata, India. Annals of Global Health. 2018;84(4):727.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFoster I, Biewer A, Vanqa N, Makanda G, Tisile P, Hayward SE, et al. \u0026ldquo;This is an illness. No one is supposed to be treated badly\u0026rdquo;: community-based stigma assessments in South Africa to inform tuberculosis stigma intervention design. BMC Global Public Health. 2024;2(1):41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZimmerman E, Smith J, Banay R, Kau M, Garfin AMCG. Behavioural barriers and perceived trade-offs to care-seeking for tuberculosis in the Philippines. Global Public Health. 2022;17(2):210\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCremers AL, de Laat MM, Kapata N, Gerrets R, Klipstein-Grobusch K, Grobusch MP. Assessing the Consequences of Stigma for Tuberculosis Patients in Urban Zambia. Kumar A, editor. PLoS ONE. 2015;10(3):e0119861.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMbuthia GW, Nyamogoba HDN, Chiang SS, McGarvey ST. Burden of stigma among tuberculosis patients in a pastoralist community in Kenya: A mixed methods study. Marotta C, editor. PLoS ONE. 2020;15(10):e0240457.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePaz-Sold\u0026aacute;n VA, Alban RE, Jones CD, Oberhelman RA. The provision of and need for social support among adult and pediatric patients with tuberculosis in Lima, Peru: a qualitative study. BMC Health Serv Res. 2013;13(1):290.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiller C, Huston J, Samu L, Mfinanga S, Hopewell P, Fair E. \u0026lsquo;It makes the patient\u0026rsquo;s spirit weaker\u0026rsquo;: tuberculosis stigma and gender interaction in Dar es Salaam, Tanzania. Int J Tuberc Lung Dis. 2017;21(11):S42\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOnifade DA, Bayer AM, Montoya R, Haro M, Alva J, Franco J, et al. Gender-related factors influencing tuberculosis control in shantytowns: a qualitative study. BMC Public Health. 2010;10(381):11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOshi DC, Oshi SN, Alobu IN, Ukwaja KN. Gender-related factors influencing women\u0026rsquo;s health seeking for tuberculosis care in Ebonyi, Nigeria. J Biosoc Sci. 2016;48(1):37\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCramm JM, Finkenfl\u0026uuml;gel HJ, M\u0026oslash;ller V, Nieboer AP. TB treatment initiation and adherence in a South African community influenced more by perceptions than by knowledge of tuberculosis. BMC Public Health. 2010;10(1):72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCramm JM, Nieboer AP. The relationship between (stigmatizing) views and lay public preferences regarding tuberculosis treatment in the Eastern Cape, South Africa. Int J Equity Health. 2011;10(1):2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTeo AKJ, Singh SR, Prem K, Hsu LY, Yi S. Duration and determinants of delayed tuberculosis diagnosis and treatment in high-burden countries: a mixed-methods systematic review and meta-analysis. Respir Res. 2021;22(1):251.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMurray EJ, Bond VA, Marais BJ, Godfrey-Faussett P, Ayles HM, Beyers N. High levels of vulnerability and anticipated stigma reduce the impetus for tuberculosis diagnosis in Cape Town, South Africa. Health Policy and Planning. 2013;28(4):410\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKerkhoff AD, Mwamba C, Pry JM, Kagujje M, Nyangu S, Mateyo K, et al. A mixed methods study on men\u0026rsquo;s and women\u0026rsquo;s tuberculosis care journeys in Lusaka, Zambia\u0026mdash;Implications for gender-tailored tuberculosis health promotion and case finding strategies. Yi S, editor. PLOS Glob Public Health. 2023;3(6):e0001372.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDeSanto D, Velen K, Lessells R, Makgopa S, Gumede D, Fielding K, et al. A qualitative exploration into the presence of TB stigmatization across three districts in South Africa. BMC Public Health. 2023;23(1):504.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNasir A, Hassan II, Ma\u0026rsquo;ruf A, Suharno NE, Goenharto S, Purwanto CR, et al. Coping efforts made: Psychological burden of people living with tuberculosis due to social stigma in society. A qualitative phenomenology study. Sumari-de Boer IM, editor. PLoS ONE. 2024;19(7):e0303331.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOga-Omenka C, Wakdet L, Menzies D, Zarowsky C. A qualitative meta-synthesis of facilitators and barriers to tuberculosis diagnosis and treatment in Nigeria. BMC Public Health. 2021;21(1):279.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAndom AT, Gilbert HN, Ndayizigiye M, Mukherjee JS, Lively CT, Nthunya J, et al. Understanding barriers to tuberculosis diagnosis and treatment completion in a low-resource setting: A mixed-methods study in the Kingdom of Lesotho. Fauk NK, editor. PLoS ONE. 2023;18(5):e0285774.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSkinner D, Claassens M. It\u0026rsquo;s complicated: why do tuberculosis patients not initiate or stay adherent to treatment? A qualitative study from South Africa. BMC Infect Dis [Internet]. 2016 Dec [cited 2021 May 13];16(1). Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://bmcinfectdis.biomedcentral.com/articles/\u003c/span\u003e\u003cspan address=\"http://bmcinfectdis.biomedcentral.com/articles/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12879-016-2054-5\u003c/span\u003e\u003cspan address=\"10.1186/s12879-016-2054-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAddo J, Pearce D, Metcalf M, Lundquist C, Thomas G, Barros-Aguirre D, et al. Living with tuberculosis: a qualitative study of patients\u0026rsquo; experiences with disease and treatment. BMC Public Health. 2022;22(1):1717.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarrett P, Hale B, Butler M. Family Care and Social Capital: Transitions in Informal Care [Internet]. Springer Dordrecht; 2014. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/978-94-007-6872-7c\u003c/span\u003e\u003cspan address=\"10.1007/978-94-007-6872-7c\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMbokazi N, Van Pinxteren M, Murphy K, Mair FS, May CR, Levitt NS. Ubuntu as a mediator in coping with multimorbidity treatment burden in a disadvantaged rural and urban setting in South Africa. Social Science \u0026amp; Medicine. 2023;334:116190.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eViisainen K, Baumgart Dos Santos M, Sunderbrink U, Couto A. Gender and stigma in antiretroviral treatment adherence in Mozambique: A qualitative study. Vijayasingham L, editor. PLOS Glob Public Health. 2024;4(7):e0003166.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcKenzie SK, Oliffe JL, Black A, Collings S. Men\u0026rsquo;s Experiences of Mental Illness Stigma Across the Lifespan: A Scoping Review. Am J Mens Health. 2022;16(1):155798832210747.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSorsdahl K, Stein DJ, Myers B. Negative attributions towards people with substance use disorders in South Africa: Variation across substances and by gender. BMC Psychiatry. 2012;12(1):101.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChikovore J, Hart G, Kumwenda M, Chipungu G, Desmond N, Corbett EL. TB and HIV stigma compounded by threatened masculinity: implications for TB health-care seeking in Malawi. int j tuberc lung dis. 2017;21(11):26\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eda Silva TC, Pinto ML, Orlandi GM, Figueiredo TMRM de, Fran\u0026ccedil;a FO de S, Bertolozzi MR. Tuberculosis from the perspective of men and women. Rev esc enferm USP. 2022;56:e20220137.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBajema KL, Kubiak RW, Guthrie BL, Graham SM, Govere S, Thulare H, et al. Tuberculosis-related stigma among adults presenting for HIV testing in KwaZulu-Natal, South Africa. BMC Public Health. 2020;20(1):1338.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohnson BT, Redding CA, DiClemente RJ, Mustanski BS, Dodge B, Sheeran P, et al. A Network-Individual-Resource Model for HIV Prevention. AIDS Behav. 2010;14(S2):204\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuisman M, Tilburg TG van. Chapter 7 - Social exclusion and social isolation in later life. In: Ferraro KF, Carr D, editors. Handbook of Aging and the Social Sciences (Ninth Edition) [Internet]. Ninth Edition. Academic Press; 2021. p. 99\u0026ndash;114. (Handbooks of Aging). Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.sciencedirect.com/science/article/pii/B9780128159705000073\u003c/span\u003e\u003cspan address=\"https://www.sciencedirect.com/science/article/pii/B9780128159705000073\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarry B. Social exclusion, social isolation and the distribution of income. In: Understanding Social Exclusion. London: Oxford University Press; 2022. p. 13\u0026ndash;29.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLink BG, Phelan JC. Conceptualizing Stigma. Annu Rev Sociol. 2001;27:363\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePellowski JA, Barnett W, Kuo CC, Koen N, Zar HJ, Stein DJ. Investigating tangible and mental resources as predictors of perceived household food insecurity during pregnancy among women in a South African birth cohort study. Social Science \u0026amp; Medicine. 2017;187:76\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeershoek A, Zwerling A, Daftary A, Citro B, Smyth C, Lewis D, et al. TB Stigma Measurement Guidance [Internet]. KNCV Challenge TB; 2018. Available from: www.challengetb.org\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiamputtong P, Rice ZS. Stigma, discrimination, and social exclusion. In: Handbook of social inclusion: Research and practices in health and social sciences. Cham, Switzerland: Springer Nature Switzerland AG; 2022. p. 113\u0026ndash;28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEarnshaw VA, Chaudoir SR. From Conceptualizing to Measuring HIV Stigma: A Review of HIV Stigma Mechanism Measures. AIDS Behav [Internet]. 2009 Dec [cited 2024 Sep 17];13(6). Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://link.springer.com/\u003c/span\u003e\u003cspan address=\"http://link.springer.com/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10461-009-9593-3\u003c/span\u003e\u003cspan address=\"10.1007/s10461-009-9593-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmits J, Permanyer I. The Subnational Human Development Database. Sci Data. 2019;6:190038.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGlobal Data Lab. Subnational Human Development Index - South Africa [Internet]. Global Data Lab; [cited 2023 Jul 1]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://globaldatalab.org/shdi/shdi/ZAF/\u003c/span\u003e\u003cspan address=\"https://globaldatalab.org/shdi/shdi/ZAF/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohnson L, Dorrington R. Thembisa version 4.6: National and Provincial Model Outputs [Internet]. Thembisa; 2023. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.thembisa.org/content/downloadPage/ProvOutput4_6\u003c/span\u003e\u003cspan address=\"https://www.thembisa.org/content/downloadPage/ProvOutput4_6\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohnson LF, Dorrington RE, Moolla H. Progress towards the 2020 targets for HIV diagnosis and antiretroviral treatment in South Africa. Southern African Journal of HIV Medicine [Internet]. 2017;18(1). Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://sajhivmed.org.za/index.php/hivmed/article/view/694\u003c/span\u003e\u003cspan address=\"https://sajhivmed.org.za/index.php/hivmed/article/view/694\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTB Online Surveillance Dashboard [Internet]. South African National Institute of Communicable Diseases. [cited 2020 Aug 29]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.nicd.ac.za/tb-surveillance-dashboard/\u003c/span\u003e\u003cspan address=\"http://www.nicd.ac.za/tb-surveillance-dashboard/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMassyn N, Day C, Ndlovu N, Padayachee T. District Health Barometer 2019/20 [Internet]. Durban: Health Systems Trust; 2020 Dec [cited 2021 Oct 26]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.hst.org.za/publications/District%20Health%20Barometers/DHB%202019-20%20Complete%20Book.pdf\u003c/span\u003e\u003cspan address=\"https://www.hst.org.za/publications/District%20Health%20Barometers/DHB%202019-20%20Complete%20Book.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChang SH, Cataldo JK. A systematic review of global cultural variations in knowledge, attitudes and health responses to tuberculosis stigma. int j tuberc lung dis. 2014;18(2):168\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKarim F, Chowdhury AMR, Islam A, Weiss MG. Stigma, Gender, and their Impact on Patients with Tuberculosis in Rural Bangladesh. Anthropol Med. 2007;14(2):139\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTadesse S. Stigma against Tuberculosis Patients in Addis Ababa, Ethiopia. Kumar A, editor. PLoS ONE. 2016;11(4):e0152900.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAshaba C, Musoke D, Tsebeni Wafula S, Konde-Lule J. Stigma among tuberculosis patients and associated factors in urban slum populations in Uganda. Afr H Sci. 2021;21(4):1640\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDaftary A. HIV and tuberculosis: The construction and management of double stigma. Social Science \u0026amp; Medicine. 2012;74(10):1512\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePetros De Guex K, Augustino D, Mejan P, Gadiye R, Massong C, Lukumay S, et al. Roadblocks and resilience: A qualitative study of the impact of pediatric tuberculosis on Tanzanian households and solutions from caregivers. Global Public Health. 2023;18(1):2196569.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMajombozi Z. Care, Contagion and the Good Mother: Narratives of Motherhood, TB and Healing. Anthropology Southern Africa. 2019;42(4):290\u0026ndash;301.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO\u0026rsquo;Laughlin B. Missing men?: the debate over rural poverty and women-headed households in Southern Africa. The Journal of Peasant Studies. 1998;25(2):1\u0026ndash;48.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKnight L, Hosegood V, Tim\u0026aelig;us IM. Obligation to family during times of transition: care, support and the response to HIV and AIDS in rural South Africa. AIDS Care. 2016;28(sup4):18\u0026ndash;29.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePhillips LH. \u0026lsquo;I am Alone. I am a Woman. What are my Children going to Eat?\u0026rsquo; Domestic Workers and Family Networks. South African Review of Sociology. 2011;42(2):29\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGosoniu GD, Ganapathy S, Kemp J, Auer C, Somma D, Karim F, et al. Gender and socio-cultural determinants of delay to diagnosis of TB in Bangladesh, India and Malawi. Int J Tuberc Lung Dis. 2008;12(7):8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAtre SR, Kudale AM, Morankar SN, Rangan SG, Weiss MG. Cultural concepts of tuberculosis and gender among the general population without tuberculosis in rural Maharashtra, India. Tropical Med Int Health. 2004;9(11):1228\u0026ndash;38.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIndra DM, Buchignani N. Rural landlessness, extended entitlements and inter-household relations in south Asia: A Bangladesh case. Journal of Peasant Studies. 1997;24(3):25\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarua M, Van Driel F, Jansen W. Tuberculosis and the sexual and reproductive lives of women in Bangladesh. Daftary A, editor. PLoS ONE. 2018;13(7):e0201134.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHatherall B, Newell JN, Emmel N, Baral SC, Khan MA. \u0026ldquo;Who Will Marry a Diseased Girl?\u0026rdquo; Marriage, Gender, and Tuberculosis Stigma in Asia. Qual Health Res. 2019;29(8):1109\u0026ndash;19.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrown J, Sorrell J, Raffaelli M. An exploratory study of constructions of masculinity, sexuality and HIV/AIDS in Namibia, Southern Africa. Culture, Health \u0026amp; Sexuality. 2005;7(6):585\u0026ndash;98.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMahalik JR, Burns SM, Syzdek M. Masculinity and perceived normative health behaviors as predictors of men\u0026rsquo;s health behaviors. Soc Sci Med. 2007;64(11):2201\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSileo KM, Reed E, Kizito W, Wagman JA, Stockman JK, Wanyenze RK, et al. Masculinity and engagement in HIV care among male fisherfolk on HIV treatment in Uganda. Culture, Health \u0026amp; Sexuality. 2019;21(7):774\u0026ndash;88.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNaigino R, Miller AP, Ediau M, Anecho A, Senoga U, Tumwesigye NM, et al. Stakeholder perspectives on the Kisoboka intervention: A behavioral and structural intervention to reduce hazardous alcohol use and improve HIV care engagement among men living with HIV in Ugandan fishing communities. Drug and Alcohol Dependence. 2023;253:111011.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMakgopa S, Cele LP, Mokgatle MM. Pre-Diagnosis Health Seeking Behaviors and Experiences Post-Diagnosis, among Men Diagnosed with Tuberculosis in a District of Gauteng Metropolitan City, South Africa: In-Depth Interviews. IJERPH. 2022;19(20):13635.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMedina-Marino A, Bezuidenhout D, Ngcelwane N, Cornell M, Wainberg M, Beyrer C, et al. Qualitative Identification of Intervention Preferences to Support Men\u0026rsquo;s Engagement and Retention in TB Care in South Africa. Am J Mens Health. 2022;16(5):155798832211293.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-global-and-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [BMC Global and Public Health](https://bmcglobalpublichealth.biomedcentral.com/)","snPcode":"44263","submissionUrl":"https://submission.springernature.com/new-submission/44263/3","title":"BMC Global and Public Health","twitterHandle":"@BMC_GPH","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"tuberculosis, stigma, gender, qualitative, South Africa","lastPublishedDoi":"10.21203/rs.3.rs-5409926/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5409926/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eStigma and isolation among people living with tuberculosis (PLWTB) is well documented. Poorly understood are the gendered pathways by which TB-related stigma results in isolation or impacts access to resources during one\u0026rsquo;s illness-to-health journey.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe interviewed PLWTB receiving treatment at government clinics in Buffalo City Metro, South Africa. Semi-structured guides explored: TB symptom experiences; access-to-care; treatment motivation; key supporters; and access to mental and tangible resources (MTRs) during illness. Open coding was done inductively, with MTR domains informed by the Network-Individual-Resource Model. Findings were analyzed through a cyclic iterative and deductive process using social isolation and exclusion as interpretive lenses. Memos and pathway mapping examined gendered differences in stigma, isolation, and access to networked MTRs.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOne-hundred forty-two PLWTB (Men\u0026thinsp;=\u0026thinsp;93; Women\u0026thinsp;=\u0026thinsp;61) were interviewed. PLWTB described pervasive TB stigma and isolation. Women described self-isolating in response to enacted and anticipated stigma. Men described active exclusion by friends and family. Women\u0026rsquo;s maintenance of familial ties facilitated access to MTRs while ill. Men\u0026rsquo;s systematic exclusion reduced their agency to access resources. Men and women described regaining of physical strength and recovery of social networks, but also the sustained post-treatment stigma impact.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eWe identified gendered pathways through which TB stigma and isolation affect access to MTRs. For women, stigma led to social isolation, but familial networks maintained access to MTRs, fostering resilience. Men experienced social exclusion, reduced agency to access MTRs, and increased vulnerability during illness. Findings can guide gender-responsive interventions to reduce the impact of TB stigma on health outcomes.\u003c/p\u003e","manuscriptTitle":"Social Isolation, Social Exclusion and Access to Resources: Mapping the Gendered Impact of TB-related Stigma Among TB Patients in Eastern Cape Province, South Africa","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-05 17:06:57","doi":"10.21203/rs.3.rs-5409926/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-01-14T07:57:06+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-12-18T19:05:26+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-12-18T16:14:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"178781644588115466356986714677290054533","date":"2024-12-05T14:46:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"285530284104450073895483971731671944062","date":"2024-12-04T17:33:07+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-12-03T15:15:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"250386859848271788851412485996848661383","date":"2024-12-03T13:38:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"91831174738826632850523145019058126247","date":"2024-11-20T12:11:21+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-11-18T12:07:17+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-11-13T07:22:19+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-11-11T10:39:18+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-11-11T10:29:45+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Global and Public Health","date":"2024-11-07T12:23:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-global-and-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [BMC Global and Public Health](https://bmcglobalpublichealth.biomedcentral.com/)","snPcode":"44263","submissionUrl":"https://submission.springernature.com/new-submission/44263/3","title":"BMC Global and Public Health","twitterHandle":"@BMC_GPH","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"47b89fde-3260-4d39-96b1-62993cb7ef1a","owner":[],"postedDate":"December 5th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-05-06T12:53:21+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-05 17:06:57","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5409926","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5409926","identity":"rs-5409926","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}