Community variability in TB-related stigma in South Africa: an ecologic analysis from the MISSED TB Outcomes Study

Background: Tuberculosis (TB) stigma is a critical barrier to timely diagnosis and treatment. Although stigma originates within communities, few studies have quantified community-level TB stigma or its variability across geographic contexts. This study describes methods for capturing community-level TB stigma and examines stigma variability across 93 urban, peri-urban, and rural communities in Buffalo City Metropolitan Health District, South Africa. Methods: As part of the MISSED TB Outcomes Study, heads of household (HoHs) were surveyed in a geographically clustered random sample of households across demarcated study communities. Validated scales were used to measure perceived community-level TB stigma, HIV stigma, and TB/HIV knowledge. Demographic data, including self-reported household TB and HIV history, were also captured. Community-level data, including TB and HIV stigma, were generated by aggregating individual responses within each study community. Associations between TB stigma and other community-level variables were analyzed using robust linear regression. Results: Surveys were completed by 3,869 households across 93 communities. Median community TB stigma scores varied significantly by community location, with rural communities reporting the lowest stigma and peri-urban communities the highest. TB stigma was positively associated with HIV stigma across all community types, with the strongest associations in urban and rural communities. No associations were observed between TB stigma and TB prevalence, TB knowledge, or household demographics after adjusting for community location. Conclusions: TB stigma varied meaningfully across communities and was influenced by urbanicity and HIV stigma. These findings suggest that stigma-reduction interventions must be tailored to local contexts and consider community-level determinants beyond individual knowledge or TB burden. The identified variability in TB stigma will inform future multilevel analyses of the TB care cascade in South Africa.