Content of this journal is licensed under a Abstract
Aim:
The aim of this study was to examine the relationship between feelings of stigma in tuberculosis (TB) patients and the social support provided by their household contacts, who are family members.
Methods:
This cross-sectional study aimed to examine the relationship between feelings of stigma in TB patients and the social support provided by their household contacts in southern Türkiye (81 patients and 81 household contacts). The data were collected between May and August 2022 using Individual Information Forms, the Tuberculosis-Related Stigma Scale, and the Provided Social Support Scale.
Results:
Although household contacts with higher education and income provided more social support (p < .05), these characteristics did not predict stigma levels among patients (p > .05). A low level of social support provided to TB patients by their household contacts was associated with more feelings of stigma, from both patient perspective and community perspective (p < .05).
Conclusion:
Household contacts should be encouraged to develop positive behavioral changes toward TB. Awareness of household contacts should be raised about the importance of social support in TB by health professionals. Thus, by increasing the social support provided to TB patients through household contacts, patients’ feelings of stigma can be reduced.
Keywords: Household contact, social support, stigma, tuberculosis
What is already known on this topic?
Tuberculosis (TB) is a highly stigmatized disease globally, and this stigma has been associated with adverse outcomes.
Social support, particularly from household members, is regarded as an important aspect in improving treatment outcomes and quality of life for TB patients.
Theoretical approaches suggest that social support may serve as a valuable resource for patients to cope with the stress of disease, potentially reducing negative psychosocial effects like stigma.
What this study adds on this topic?
Lower levels of social support provided by household contacts were significantly associated with higher levels of TB-related stigma.
Household contacts with higher education and income provide more support.
A support gap in family care highlights the need to train household contacts, which can reduce TB-related stigma.
Introduction
Tuberculosis (TB) is one of the diseases that is the leading cause of death worldwide. According to the Global TB report, 10.8 million new TB cases were diagnosed in 2023 (World Health Organization, 2024). Data from the Ministry of Health of the Republic of Türkiye show that 8925 patients were diagnosed with TB in 2020. Comparing data from 2005 to 2020, although the incidence of TB patients in Türkiye has decreased, the number of contacts has increased (Republic of Türkiye Ministry of Health, 2022). Because TB is easily transmitted through the respiratory tract, people who share the same environment with patients become contacts of the infected person. Although isolation measures are a frequently used method to reduce the number of contacts, they also reduce patients’ social relationships and social support (Saqib et al., 2019).
Social support is defined as material and spiritual assistance provided by one’s spouse, family, and friends to a person in a stressful and challenging circumstance (Aktaş & Sertel-Berk, 2012). A thematic review of 17 articles emphasizes that social support is beneficial in TB disease in terms of treatment adherence, psychological well-being, motivation to recover, quality of life, prevention of TB transmission, successful TB treatment, and self-efficacy to recover (Syamsir et al., 2024). In a study conducted in Nepal, it was also determined that social support increases the treatment success rate of patients by 1.2 times (Baral et al., 2014). Despite this, it highlights the importance of family members in providing social support; various risk factors reduce the social support received by TB patients. A study of 220 TB patients in China found that those who were single, widowed, or divorced, and had fewer family members, had lower social support scores (Chen et al., 2016). It is known that isolation measures implemented after a TB diagnosis can lead to job losses and that this can also disrupt family communication (Aytac et al., 2025; Lohiniva et al., 2016). Moreover, a deficit in social support not only diminishes this family communication but also constitutes a significant risk factor for adverse psychological consequences (Chen, et al., 2021).
Among these adverse psychological consequences, stigma stands out as particularly detrimental. Previous studies report stigma prevalence ranging from 30% to over 69.3% among TB patients globally, with factors such as disease severity, HIV co-infection, gender, and socioeconomic status frequently identified as correlates (Baskaran et al., 2023; Datiko et al., 2020). In a study conducted in Türkiye, it was found that TB patients were exposed to a very high level of stigma (Aytac et al., 2025). Stigma discredits individuals and lowers their social status, showing at multiple levels through community perceptions and actions, family reactions, and the internalization of negative beliefs by patients themselves (self-stigma) (Datiko et al., 2020). Stigmatized individuals tend to develop attitudes that reduce their efforts to seek social support, such as avoidance of interpersonal relationships, embarrassment, disgust, and guilt as they feel unworthy (Bayraktar & Khorshtd, 2017).
Lazarus and Folkman’s Transactional Model of Stress and Coping model offers a powerful conceptual framework for understanding how social support can mitigate negative psychological consequences such as stigma. According to this model, a chronic and stigmatized disease such as TB can be considered a significant stressor for the individual. The patient’s capacity to cope depends on their available resources, among which social support from others can serve as a crucial benefit. This support may positively influence the patient’s cognitive appraisal of the illness, potentially reducing its negative psychological impact (Biggs et al., 2017).
Although social support can originate from various sources, this study specifically focuses on support provided by household contacts due to their unique position in the TB care context. During treatment, patients often experience reduced contact with broader social networks due to the infectious nature of the disease and necessary precautions (Saqib et al., 2019). Consequently, household members become the primary and most immediate source of daily support. However, in a study conducted in Türkiye, it was found that 64.8% of patients experienced negative effects in their communication with family and close circles after being diagnosed with TB (Aytac et al., 2025). This dramatic inconsistency between the expected critical role of household support and the prevalence of reported negative family interactions indicates a significant gap between the support needed and the support actually provided. Furthermore, studies examining the direct relationship between the level and types of supportive behaviors actually exhibited by household members and patient outcomes such as stigma are limited, particularly in the Turkish context. Therefore, to bridge this gap, this study aims to specifically examine the relationship between TB patients’ feelings of stigma and the social support provided by their household contacts in Türkiye.
Research Questions
What is the perceived level of stigma among TB patients?
What is the level of social support provided to TB patients by their household contacts?
Is there a significant relationship between the perceived level of stigma in TB patients and the level of social support provided by their household contacts?
Do the individual characteristics of patients and household contacts affect the levels of stigma and provided social support?
Methods
Study Design
This study was designed as a cross-sectional, descriptive study.
Sample
This study was conducted between May and August 2022 at a TB dispensary in a city located in southern Turkiye. Patients with Patients with tuberculosis and their household contacts, who were family members, meeting the inclusion criteria were included in the sample via a convenience sampling method. Patients with tuberculosis who volunteered to participate in the study, were 18 years old and older, had neither communication nor comprehension difficulties, had been diagnosed with TB within the last 6 months, and had no diagnosis of any psychiatric disease were included in the study. Household contacts who were willing to participate in the study, were 18 years old and older, had neither communication nor comprehension difficulties, lived in the same house with a patient diagnosed with TB within the last 6 months, and had no diagnosis of any psychiatric disease were included in the study. G*Power 3.1.9.7 program was used to calculate the required minimum sample size at the beginning of the study. A prior power analysis revealed that 76 participants were sufficient to determine a moderate effect size (ƒ2 = 0.15) with 80% power in a model containing 3 predictors. A subsequent analysis of the findings showed that Model 1 reached 99% and Model 2 reached 98% statistical power (N = 81). For each TB patient included in the study, a household contact relative was also included. In households with more than one eligible household contact relative, priority was not given to any particular family role (e.g., spouse, parent, or child); instead, the participating household relative was selected based on their availability and willingness to participate on the data collection day. The plan was to exclude the patient from the study if a household contact relative refused to participate. Of the eligible participants, four TB patients refused to participate, while no household contacts declined. The study was completed with a total of 162 participants, including 81 TB patients and 81 household contacts.
Data Collection
Data collection forms were administered separately to both patients and household contacts via face-to-face interviews in the TB dispensary. To minimize the potential for social bias, data were collected ensuring confidentiality. Only the participant and the researcher were present in the data collection environment. Participants were informed that their personal information would be kept confidential. For the data collection, the “Individual Information Form for Patients” and the “Tuberculosis-related Stigma Scale” were applied to the TB patients. The “Individual Information Form for Household Contacts” and the “Provided Social Support Scale (PSSS)” were applied to the household contacts. The data collection process lasted for approximately 20 minutes for each TB patient and household contact.
Individual Information Form for Patients
The information on the age, gender, income level, marital status, and household conditions of the patients was determined in this form, which the researchers prepared by reviewing the relevant literature (Bayraktar & Khorshtd, 2017; Chen, et al., 2021; Karakaş et al., 2022; Yilmaz & Dedeli, 2016). A pilot study was conducted to determine the validity of the form. The prepared form was examined by three patients and was evaluated to determine whether the questions were understood correctly. Following these suggestions, the final version of the form was created. Data from three patients who participated in the pilot study were not used in the present study.
Tuberculosis-Related Stigma Scale
The TB-related Stigma Scale, developed by Van Rie et al. in 2008, is a tool used to assess the level of stigma associated with the TB disease (Van Rie et al., 2008). The scale has two subscales. These subscales enable the assessment of stigma from both patient and community perspectives. Each item in the scale, composed of a total of 23 items, has a 4-point Likert response. The responses are rated as strongly disagree (0), disagree (1), agree (2), or strongly agree (3). A higher score on the scale indicates a higher level of stigma (minimum = 1, maximum = 50). Beşer et al. (2018) conducted a study of the validity and reliability of the scale in Türkiye. The Cronbach’s α value of the Turkish version of the scale was 0.83 for the community perspective and 0.89 for the patient perspective (Beser et al., 2018). In the present study, the Cronbach’s alpha value of the scale was 0.89 for the community perspective and 0.88 for the patient perspective. Permission was obtained electronically from the responsible author to use the Turkish version of the scale.
Individual Information Form for Household Contacts
The information on the age, gender, income level, marital status, and household conditions of the household contacts was determined in this form, which the researchers prepared by reviewing the relevant literature (Bayraktar & Khorshtd, 2017; Chen, et al., 2021; Karakaş et al., 2022; Yilmaz & Dedeli, 2016). A pilot study was conducted to determine the validity of the form. The prepared form was examined by three household contacts and was evaluated to determine whether the questions were understood correctly. Following these suggestions, the final version of the form was created. Data from three household contacts who participated in the pilot study were not used in the present study.
Provided Social Support Scale
Aktaş and Sertel-Berk (2012) conducted a Turkish validity and reliability study of the 25-item final version of the scale developed by Barrera, Sandler, and Ramsay in 1981 (Barrera et al., 1981). Scale items are rated between 1 (never) and 5 (almost every day) points. A higher score on the scale indicates a higher level of social support provided. While the scale is being assessed, the mean values calculated by dividing the total scores by the number of items are used. The scale consists of three subscales: emotional support, material support, and informational support. The Cronbach’s α value was found to be 0.91 for the overall PSSS (Aktaş & Sertel-Berk, 2012). In the present study, the Cronbach’s α value of the scale was found to be 0.98 for the overall PSSS. Permission was obtained electronically from the responsible author to use the Turkish version of the scale.
Ethical Considerations
For the study, approval from the Clinical Trials Ethics Committee of Gaziantep University (Document no: 2021/415, Date: February 7, 2022) and permission from Gaziantep Provincial Directorate of Health (Date: April 6, 2022, Number: 95) were obtained. Verbal informed consent was obtained from all patients and their household contacts included in this study.
Data Analysis
Statistical analyses were conducted using IBM SPSS Statistics for Windows, Version 25.0 (IBM Corp.; Armonk, NY, USA).For descriptive statistics, the frequencies, percentages, means, and standard deviations were used, and the Shapiro‒Wilk test was used to check whether the continuous variables were normally distributed. Independent Student’s t-test and analysis of variance (ANOVA) were used to analyze the differences among categorical variables. For post-hoc analyses following significant ANOVA results, Bonferroni adjustment was applied to control for type I error across multiple pairwise comparisons. Pearson’s correlation test was used to assess the correlation between the scale scores.
Simple linear regression analyses were conducted to examine whether provided social support significantly predicted TB-related stigma. Preliminary analyses including all three subscales of the PSSS (emotional, material, and informational support) revealed severe multicollinearity, with all variance inflation factor values exceeding 10. Therefore, the total score of the PSSS was used as the independent variable in the final models to avoid statistical artifacts and better represent the overall construct of social support. In the first model, the total score of the PSSS was entered as the independent variable, with the community perspective subscale of the TB-related Stigma Scale as the dependent variable. In the second model, the total provided social support score predicted the patient perspective subscale of the stigma measure. In addition, demographic variables that showed significant differences in scale scores were also included in the regression models. The significance of the regression models was assessed using the F-test, while the significance of individual predictors was evaluated with t-tests. The statistical significance level was accepted as p < .05.
Results
Comparison of Stigma and Provided Social Support According to Demographic Variables
According to the data presented in Table 1, the mean scores of the participants on the TB Stigma Scale and the PSSS were analyzed. Accordingly, the mean score of TB patients on the community perspective subscale of the stigma scale was 33.82 ± 6.75, while the mean score on the patient perspective subscale was 33.64 ± 6.23. Regarding the PSSS, the mean score for household contacts for emotional support was 1.78 ± 0.65, for material support 1.79 ± 0.64, for informational support 1.76 ± 0.67, and the total mean score of the scale was 1.78 ± 0.64.
Table 1.
Participants’ TB Stigma Scale and PSSS Scores (N = 81)
| Mean | Standard Deviation | Minimum | Maximum | |
|---|---|---|---|---|
| TB stigma scale | ||||
| Community perspective | 33.82 | 6.75 | 16.67 | 50.00 |
| Patient perspective | 33.64 | 6.23 | 16.67 | 50.00 |
| PSSS | ||||
| Emotional support | 1.78 | 0.65 | 1.00 | 5.00 |
| Material support | 1.79 | 0.64 | 1.00 | 4.00 |
| Informational support | 1.76 | 0.67 | 1.00 | 5.00 |
| Total | 1.78 | 0.64 | 1.00 | 5.00 |
Note: PSSS = Provided social support scale.
Table 2 shows the scores of the patients on the TB-related stigma scale and other data related to their individual characteristics. The mean age of the TB patients was 42.68 ± 17.04 (years), 56.8% were female, 72.8% were married, 43.2% had a high school education or higher, 74.1% had an income less than their expenses, and 79% had a nuclear family type. The individual characteristics of the TB patients were not significantly associated with their stigma scores (p > .05) (Table 2). As an exploratory analysis, Table 3 presents the associations between household contacts’ individual characteristics and their PSSS scores. The mean age of the household contacts was 44.89 ± 13.54 (years), 56.8% were male, 93.8% were married, 44.4% had primary education, 75.3% had an income lessthan their expenses, and were partners (66.7%). Household contacts with at least a high school education (F = 4.731, p = .012 for emotional; F = 3.999, p = .022 for material; F = 4.285, p = .017 for informational; F = 4.486, p = .014 for total support) and those with higher income than expenses (F = 8.732, p = .003 for emotional; F = 8.955, p < .001 for material; F = 10.045, p < .001 for informational; F = 9.452, p < .001 for total support) reported significantly higher scores on all aspects of PSSS (Table 3).
Table 2.
Individual Characteristics and TB Stigma Scale Scores of the TB Patients (N = 81)
| Characteristics | n (%) | Community Perspective | Patient Perspective | |||
|---|---|---|---|---|---|---|
| (Mean ± SD) | Statistics | (Mean ± SD) | Statistics | |||
| Age (mean ± SD) | 42.68 ± 17.04 | |||||
| Gender | Female | 46 (56.8) | 34.09 ± 5.88 | t = .412p = .681 | 33.70 ± 5.99 | t = .088p = .93 |
| Male | 35 (43.2) | 33.46 ± 7.83 | 33.57 ± 6.62 | |||
| Marital status | Married | 59 (72.8) | 33.95 ± 6.78 | t = .282p = .779 | 33.29 ± 6.00 | t = −.840p = .403 |
| Single | 22 (27.2) | 33.47 ± 6.82 | 34.60 ± 6.87 | |||
| Presence of children | Yes | 54 (66.7) | 33.16 ± 7.48 | t = −1.238p = .219 | 32.84 ± 6.28 | t = −1.646p = .104 |
| No | 27 (33.3) | 35.13 ± 4.87 | 35.24 ± 5.93 | |||
| Education level | Literate | 18 (22.2) | 35.19 ± 7.54 | F = .823p = .443 | 34.49 ± 6.48 | F = 1.423p = .247 |
| Primary school | 28 (34.6) | 32.63 ± 6.83 | 32.04 ± 5.88 | |||
| High school and higher | 35 (43.2) | 34.07 ± 6.29 | 34.48 ± 6.30 | |||
| Employment status | Employed | 31 (38.3) | 33.14 ± 7.36 | t = −.713p = .478 | 34.14 ± 6.53 | t = .564p = .575 |
| Unemployed | 50 (61.7) | 34.24 ± 6.39 | 33.33 ± 6.08 | |||
| Perceived household income level | Income less than expenses | 60 (74.1) | 33.71 ± 6.75 | F = .428p = .654 | 33.68 ± 6.15 | F = 1.553p = .218 |
| Income equal to expenses | 18 (22.2) | 33.59 ± 7.24 | 32.56 ± 6.43 | |||
| Income more than expenses | 3 (3.7) | 37.37 ± 3.81 | 39.35 ± 5.26 | |||
| Type of family | Nuclear family | 64 (79) | 33.78 ± 6.95 | t = -.094p = .925 | 33.59 ± 6.28 | t = −.134p = .893 |
| Extended family | 17 (21) | 33.96 ± 6.16 | 33.82 ± 6.21 | |||
Note: SD = Standard deviation; TB = Tuberculosis.
Table 3.
Individual Characteristics and PSSS Scores of TB Household Contacts
| Characteristics | n (%) | Emotional Support | Material Support | Informational Support | PSSS Total | |||||
|---|---|---|---|---|---|---|---|---|---|---|
| (Mean ± SD) | t/F; p | (Mean ± SD) | t/F; p | (Mean ± SD) | t/F; p | (Mean ± SD) | t/F; p | |||
| Age (Mean ± SD) | 44.89 ± 13.54 | |||||||||
| Gender | Female | 35 (43.2) | 1.87 ± 0.64 | t = 1.141p = .257 | 1.89 ± 0.66 | t = 1.234p = .221 | 1.87 ± 0.70 | t = 1.187p = .239 | 1.88 ± 0.65 | t = 1.199p = .234 |
| Male | 46 (56.8) | 1.71 ± 0.65 | 1.71 ± 0.62 | 1.69 ± 0.65 | 1.70 ± 0.64 | |||||
| Marital status | Married | 76 (93.8) | 1.81 ± 0.64 | t = 1.732p = .087 | 1.81 ± 0.64 | t = 1.586p = .117 | 1.80 ± 0.67 | t = 1.758p = .083 | 1.81 ± 0.64 | t = 1.715p = .09 |
| Single | 5 (6.2) | 1.30 ± 0.56 | 1.35 ± 0.52 | 1.26 ± 0.57 | 1.30 ± 0.55 | |||||
| Presence of Children | Yes | 65 (80.2) | 1.76 ± 0.66 | t = −.521p = .604 | 1.76 ± 0.65 | t = −.731p = .467 | 1.74 ± 0.69 | t = −.736p = .464 | 1.75 ± 0.66 | t = -.657p = .513 |
| No | 16 (19.8) | 1.86 ± 0.61 | 1.89 ± 0.61 | 1.88 ± 0.60 | 1.87 ± 0.59 | |||||
| Education level | Literatea | 11 (13.6) | 1.43 ± 0.60 | F = 4.731p = .012*c > a | 1.44 ± 0.64 | F = 3.999p = .022*c > a | 1.40 ± 0.64 | F = 4.285p = .017*c > a | 1.43 ± 0.62 | F = 4.486p = .014*c > a |
| Primary schoolb | 36 (44.4) | 1.67 ± 0.55 | 1.69 ± 0.57 | 1.66 ± 0.61 | 1.67 ± 0.56 | |||||
| High school and higherc | 34 (42) | 2.01 ± 0.69 | 1.99 ± 0.66 | 1.99 ± 0.69 | 2.00 ± 0.67 | |||||
| Employment status | Employed | 42 (51.9) | 1.78 ± 0.65 | t = .01p = .992 | 1.78 ± 0.62 | t = −.126p = .91 | 1.76 ± 0.64 | t = −.071p = .943 | 1.77 ± 0.63 | t = −.057p = .955 |
| Unemployed | 39 (48.1) | 1.78 ± 0.66 | 1.79 ± 0.67 | 1.77 ± 0.71 | 1.78 ± 0.67 | |||||
| Perceived household income level | Income less than expenses | 61 (75.3) | 1.68 ± 0.58 | F = 8.732p < .001**c > a, c > b | 1.69 ± 0.58 | F = 8.955p < .001**c > a, c > b | 1.66 ± 0.59 | F = 10.045p < .001**c > a, c > b | 1.68 ± 0.58 | F = 9.452p < .001**c > a, c > b |
| Income equal to expenses | 17 (21) | 1.91±0.56 | 1.89 ± 0.52 | 1.88 ± 0.57 | 1.90 ± 0.54 | |||||
| Income more than expenses | 3 (3.7) | 3.10 ± 1.05 | 3.13 ± 1.02 | 3.24 ± 1.11 | 3.15 ± 1.06 | |||||
| Relationship to TB patient | Mother | 9 (11.1) | 1.97 ± 0.77 | F = 1.157p = .332 | 2.01 ± 0.78 | F = .891p = .450 | 1.98 ± 0.90 | F = .957p = .417 | 1.99 ± 0.81 | F = 1.025p = .386 |
| Father | 8 (9.9) | 1.82 ± 0.79 | 1.83 ± 0.72 | 1.79 ± 0.86 | 1.82 ± 0.78 | |||||
| Partner | 54 (66.7) | 1.80 ± 0.62 | 1.79 ± 0.62 | 1.78 ± 0.63 | 1.79 ± 0.61 | |||||
| Child | 10 (12.3) | 1.45 ± 0.52 | 1.54 ± 0.57 | 1.47 ± 0.50 | 1.48 ± 0.53 | |||||
Note: PSSS = Provided Social Support Scale; SD = Standard deviation; TB = Tuberculosis.
*p < .05.
**p < .001.
Superscript letters (a, b, c) indicate the respective categories of the variables for post-hoc pairwise comparisons.
Correlations and Regressions
When the relationship between the scale scores of the participants was examined, a negative and moderately significant correlation was found between the scores they obtained from all the subscales of the PSSS and their stigma scale scores (p < .05) (Table 4). Scatter plots and trend lines were created to illustrate the results of the relationship between feelings of stigma and provided social support (Figure 1).
Table 4.
Correlation Between TB-Related Stigma and Provided Social Support Subscales
| 1 | 2 | 3 | 4 | 5 | 6 | ||
|---|---|---|---|---|---|---|---|
|
r | 1 | |||||
|
r | 0.700* | 1 | ||||
|
r | −0.578* | −0.450* | 1 | |||
|
r | −0.571* | −0.444* | 0.962* | 1 | ||
|
r | −0.581* | −0.502* | 0.970* | 0.953* | 1 | |
|
r | −0.584* | −0.469* | 0.992* | 0.984* | 0.986* | 1 |
Note: PSSS = Provided Social Support Scale; SD = Standard deviation; TB = Tuberculosis.
*p < .001; r, Pearson’s correlation coefficient.
Figure 1.
Scatter plots of the Relationship Between Feelings of Stigma and Provided Social Support Scale.
Simple linear regression analyses revealed that provided social support was a significant negative predictor of stigma from both community perspective (β = −0.613, p < .001) and patient perspective (β = −0.437, p < .001). The model for community perspective explained 34.6% of the variance in stigma scores, while the model for patient perspective explained 23.7% of the variance (Table 5).
Table 5.
Linear Regression Analyses Predicting TB-Related Stigma from Provided Social Support (N = 81)
| Model 1 | B | SE | β | t | p | R | R2 | Adjusted R2 | F |
|---|---|---|---|---|---|---|---|---|---|
| Community perspective | 43.977 | 2.499 | 17.597 | <.001* | .589 | .346 | .321 | 13,602(p< .001*) | |
| Education level of household contact | −0.023 | .965 | −0.002 | −0.024 | .981 | ||||
| Perceived household income level by household contact | 1.024 | 1.290 | 0.080 | 0.793 | .430 | ||||
| Provided social support scale | −6.425 | 1.072 | −0.613 | −5.992 | <.001* | ||||
| Model 2 | |||||||||
| Patient perspective | 41.955 | 2.491 | 16.843 | <.001* | .487 | .237 | .207 | 7975(p < .001*) | |
| Education level of household contact | 0.565 | .962 | 0.063 | 0.587 | .559 | ||||
| Perceived household income level by household contact | −1.632 | 1.286 | −0.139 | −1.269 | .208 | ||||
| Provided social support scale | −4.224 | 1.069 | −0.437 | −3.952 | <.001* |
Note: R2 = Effect size; SE = Standard error; TB = Tuberculosis.
*p < .001.
Discussion
In the past, TB was considered a dirty disease affecting sinners. Despite current recognition of TB as an infectious disease, persistent misconceptions in society continue to foster stigma, leading patients to perceive themselves as guilty, unworthy, or impure (Datiko et al., 2020). This stigmatization induces various psychological, social, and behavioral disorders. Additionally, this situation negatively affects the treatment adherence of patients (Aggarwal, 2019). Within Türkiye, existing evidence documents moderate stigma levels (Yilmaz & Dedeli, 2016) and widespread deterioration in family communication after diagnosis (Aytac et al., 2025). This critical finding can be explained through a psychosocial mechanism based on Lazarus and Folkman’s Transactional Model of Stress and Coping (Biggs et al., 2017). According to this model, a diagnosis of TB is a major stressor, and household social support is a critical coping resource. This model is consistent with a recent study that identified stigmatization as a psychological reaction to fear and illness among patients with chronic disease (Balaban & Potas, 2024).
The primary aim of this study was to examine the relationship between TB patients’ feelings of stigma and the social support provided by their household contacts. The present findings clearly demonstrate a significant negative relationship, in which lower levels of provided social support are associated with higher levels of stigma from both a community and a patient perspective. A study conducted in Türkiye found a significant negative correlation between stigmatization and social support among TB patients (Polat et al., 2024). A similar study conducted in South Africa determined that low social support among individuals diagnosed with TB was associated with high stigma (Bresenham et al., 2020). The results of this study confirm these international and national evidences, showing that lower enacted support correlates with higher stigma; however, the present study includes a significant methodological difference. While other studies have examined social support perceived by TB patients, this study examined social support provided by household contacts. This methodological difference aimed to determine the core behaviors of household contacts regarding the social support needed by patients. The low social support scores in the present study indicate that household contacts are not providing adequate social support to TB patients.
In exploratory analyses, the present study found that household contacts with higher education and income provided more support, although social support scores were low. Although these results are descriptive and require replication, they suggest that socioeconomic factors may influence the capacity to provide support. It is known that household contacts may fail to provide adequate social support to TB patients due to various personal barriers. One qualitative study reported that a patient who was unable to work and experienced income loss due to TB stated that his or her family refused to talk to him or her and that he or she suffered from family conflict (Lohiniva et al., 2016). This aligns with findings from Pakistan, where family support was closely related to available household resources (Saqib et al., 2019). Actually, the diagnosis, treatment, and follow-up of TB in Türkiye are provided free of charge by the Ministry of Health (Republic of Türkiye Ministry of Health, 2022). Additionally, the Ministry of Family and Social Services provides financial aid to patients with certain conditions to meet the loss of the labor force and increase care costs. However, these aids are provided only to those who apply. Patients who have not been informed about applying for aid or are not eligible for the aid are not able to benefit from it (Republic of Türkiye Ministry of Family and Social Services, 2023). It may be useful to inform both TB patients and their household contacts to access public social aid to reduce the destructive cost of the disease and its psychosocial burden, such as stigma.
Despite the clear impact of socioeconomic factors on support capability, the regression analysis conducted in the present study determined that the socioeconomic characteristics of household contacts were not predictors of perceived stigma among TB patients, both from a community perspective and a patient perspective. The situation shows that socioeconomic variables frequently impact social support; however, the perceived stigma experienced by patients with TB is primarily caused by a lack of personal support, rather than the identity of household contacts or the resources they have.
Another important finding of this study is that there is no significant relationship between individual patient characteristics and perceived stigma, from both community perspective and patient perspective. This study found no significant difference between the level of stigma among TB patients and age or gender; this result is consistent with a previous study conducted in Türkiye which similarly revealed no significant difference in stigma based on gender (Yiğit Açıkel & Çinar Pakyüz, 2015). Similarly, no significant difference was found between patients’ education and income levels and perceived stigma. This finding is partially consistent with the international literature; for example, a study from Nepal reported no significant association between education level and TB-related stigma, but noted that higher income was associated with lower stigma (Aryal et al., 2012). The absence of such a relationship in our study may be attributed to the relatively homogeneous socioeconomic profile of the sample or to the possibility that stigmatization can operate independently of individual socioeconomic status within the Turkish cultural context. The lack of significant differences among these individual characteristics suggests that the experience of TB-related stigma may be a powerful social phenomenon rather than one determined solely by individual characteristics, highlighting the potential importance of external, modifiable factors such as social environment and support in shaping perceptions of stigma.
The evidence frequently emphasizes the importance of social support in reducing the physical, emotional, and financial burdens associated with chronic illnesses (Bustamante et al., 2018; Kong et al., 2019; Yang & D’Arcy, 2022). This study revealed that household contacts provide very low social support to TB patients, which is associated with increased feelings of stigma among patients with TB. In Turkish culture, where family unity is extremely important, failing to provide the expected support may have additional symbolic importance, increasing the patient’s feelings of stigma (Demirci, 2022). This cultural dimension helps to clarify why the social support evaluated in this study is so significantly associated with stigma findings.
Study Limitations
This study has several limitations. The sample was recruited from a single TB dispensary in southern Türkiye, a region with a relatively low socioeconomic level, which limits the generalizability of the findings to other settings or socioeconomic groups. In household contacts with more than one eligible contact, no specific family role was prioritized; the participating contact was selected based on availability and willingness to participate. This non-standardized procedure may have introduced selection bias, as social support may differ by family role. The relatively modest sample size of 81 couples, despite sufficient post hoc power (98%–99%), may affect the stability of the regression coefficients and limit generalizability. Furthermore, for some demographic subgroups (e.g., marital status and income level), the small sample size may have further limited the statistical power to detect significant associations. Although we took measures to ensure confidentiality, the use of face-to-face interviews for data collection introduces the potential for social desirability bias, where participants may have underreported stigma or over-reported supportive behaviors. Given these limitations, participants from different socioeconomic levels can be included in the sample in future studies.
Conclusion and Recommendations
In this study, the relationship between feelings of stigma in TB patients and the social support provided by their household contacts was examined. The study results revealed that TB patients had a high level of stigma and that the social support provided by household contacts was low. As a secondary result, household contacts with higher education and income levels tended to provide more social support. More importantly, it was determined that the low level of social support provided by household contacts was associated with feelings of stigma in TB patients, from both community perspective and patient perspective.
These findings have direct implications for nursing practice and public health interventions while also highlighting critical importance for future research. Nurses, who are at the forefront of TB care, are vital in implementing family-centered interventions. To enhance the social support provided by household contacts, these interventions should include structured training to eliminate TB transmission myths, training in positive communication and emotional support techniques, and active facilitation of access to existing social assistance programs to alleviate the economic stress that hinders households’ supportive capacity. Future research should systematically explore the underlying causes of inadequate social support provided by household contacts. Furthermore, interventional studies are needed to develop that effectively inform families about social assistance opportunities and promote permanent, positive behavioral changes against TB. Thus, by guiding household contacts to understand the critical importance of social support, nurses can implement concrete actions that reduce stigma and improve patient outcomes.
Funding Statement
This work was supported by the Department of Scientific Research and Projects of Kilis 7 Aralık University, Türkiye [grant numbers 2022/MAP/002].
Footnotes
Artificial Intelligence Usage Statement: The authors declared that no Artificial Intelligence tool was used in the preparation of the manuscript.
Ethics Committee Approval: Ethical committee approval was received from the Ethics Committee of University of Gaziantep (Approval no: 2021\415, Date: February 7, 2022).
Informed Consent: Verbal informed consent was obtained from patients and household contacts who participated in this study.
Peer-review: Externally peer-reviewed.
Acknowledgements: The authors would like to thank all of the patients and household contacts who participated in this study.
Author Contributions: Concept – U.D.; Design – U.D., S.A., M.S.; Supervision – U.D.; Resources – U.D.; Materials – U.D., S.A.; Data Collection and/or Processing – S.A.; Analysis and/or Interpretation – U.D., M.S.; Literature Search – U.D.; Writing Manuscript – U.D.; Critical Review – U.D., S.A., M.S.
Declaration of Interests: The authors declare that they have no competing interest.
Data Availability Statement:
The data that support the findings of this study are available on request from the corresponding author.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author.