Although tuberculosis (TB) stigma has been widely reported in South Asia and elsewhere, few interventions have been introduced to reduce it. Whilst it is recognised that stigma interventions need to address the fundamental causes of stigma and that their design needs to be theory-driven, causal theories to explain TB stigma are lacking. In this thesis I present the development of causal theories to explain manifestations of TB stigma and identify theory-driven approaches to addressing TB stigma in South Asia.
Causal theories to explain TB stigma were developed using a multi-country comparative approach, involving qualitative methods and the principles of grounded theory, alongside a realist conceptualisation of causality. Qualitative data was collected through 73 interviews with people with TB, their family members and health care providers in three rural and two urban sites in Bangladesh, Nepal and Pakistan, and through eight focus group discussions conducted in three of the sites.
Three manifestations of TB stigma, for which causal theories were developed, were identified from the data: reduced marriage prospects, the perception that people with TB are hated, and the attribution of blame for the course and reoccurrence of TB. All three manifestations are rooted in different psychological processes and it is between these manifestations and their roots that the realist causal theories lie. The mechanisms and contexts which explain how, for whom and in what circumstances TB stigma becomes manifest provide the theory that can be used to underpin approaches to addressing TB stigma. These approaches focus on influencing the legitimacy of rejection, hatred and blame, on reducing vulnerability to TB, on empowering people with TB, and on mainstreaming TB stigma and pre-empting the changing nature of its manifestations.
