Annals of Clinical and Analytical Medicine Original Research The Stigmatizing Effect of Tuberculosis Disease Stigma in Tuberculosis Disease Burcu Korkut1, Nergiz Sevinç2 Department of Community Health Center, Karabuk Provincial Health Directorate 2 Department of Public Health, Faculty of Medicine, Karabuk University, Karabuk, Turkey 1 Abstract Aim: This study aimed to measure the level of stigmatization using tuberculosis-related stigma (TRS) scale in healthy individuals and in patients with tuberculosis (TB) and to evaluate the factors affecting stigmatization. Material and Methods: This cross-sectional survey study included healthy individuals (aged 18-75 years) admitted to Community Health Centre and patients with TB (aged 18-75 years) admitted to Tuberculosis Control Dispensary in Karabuk City of Turkey between July 2021 and October 2021. A questionnaire consisting of two parts, in which the first part included questions about sociodemographic characteristics and the second part included questions of Tuberculosis-Related Stigma (TRS) scale for the assessment of level of stigmatization, was applied to both healthy individuals and patients with TB using a face-to-face survey technique. Results: The study included 360 healthy individuals (mean age: 45.46±12.90 years, female 65.3%) and 120 patients with TB (mean age, 41.15±16.42 years, male 60.8%). The mean total TRS scale score in healthy individuals was 18.60±4.18; those aged 36-53 years, those who were employed, and those living in the village had significantly higher TRS scale scores (p<0.05 for all). The mean total TRS scale score in TB patients was 19.72±3.20; those aged 18-35 years, single patients, those employed, and those with high- income level had significantly higher TRS scale scores (p<0.05 for all). Discussion: The current study revealed that the level of stigma was higher in patients with TB. Additionally, it was thought that preventing stigma in TB patients would positively affect the treatment process. Keywords Stigma, Tuberculosis, Survey DOI: 10.4328/ACAM.20825 Received: 2021-08-19 Accepted: 2021-11-27 Published Online: 2021-12-02 Printed: 2022-01-01 Ann Clin Anal Med 2022;13(1):104-108 Corresponding Author: Burcu Korkut, Karabük Provincial Health Directorate Community Health Center, 5000 Houses 75. Year District, 20. Cad, No:4, 78020, Karabük, Turkey. E-mail: dr.burcutezcan@hotmail.com P: +90 537 063 16 27 Corresponding Author ORCID ID: https://orcid.org/0000-0002-0296-9144 Annals of Clinical and Analytical Medicine 104 Stigma in Tuberculosis Disease Introduction Tuberculosis (TB) is a worldwide public health crisis. According to the 2019 report of the World Health Organization (WHO), TB affects around ten million people globally each year and is one of the top ten causes of mortality (available at: https://www. who.int/publications/i/item). The incidence of TB is 0.044% in Asia, 0.025% in Africa, 0.0029% in the Americas, and 0.0025% in Europe [1]. According to the Tuberculosis Control Dispensary (TCD) 2019 report, the incidence of TB in Turkey was 15.3%; 60.9% of the patients had pulmonary TB, 57.7% were males, 33.3% were over 65 years old, and 7.8% were relapse cases (available at: https://hsgm.saglik.gov.tr/depo/birimler / tuberkuloz_db/raporlar). The causative agent of TB is Mycobacterium tuberculosis which is usually transmitted through the air. Among people with TB infection, 5-15% are at risk of developing TB at some point in their lives [2]. The disease affects the lungs at a rate of 6570% [3]. Some diseases such as acquired immunodeficiency syndrome (AIDS), diabetes mellitus, chronic renal failure, some types of cancers, drug and alcohol addiction, tobacco use, and silicosis can lead to TB by impairing the immune system [4]. Unintentional emotions, thoughts, and actions of healthy individuals in society against people diagnosed with infectious diseases, such as TB, aimed at reducing their social status and standing, are referred to as “stigmatizing” behaviors [5]. It is known that 27-80% of patients with TB worldwide are subject to stigmatization in their family, social and work environment. Psychological trauma caused by stigmatizing behaviors can lead individuals to quit their job, divorce, dropout of education, and suicide [6]. It has been noted that some patients with TB who have the fear of stigmatization conceal their disease, start their treatment late, or do not receive treatment at all, which all result in high mortality [7]. Concealing the disease due to fear of stigmatization makes it impossible to take social measures for preventing transmission, accelerates the spread of the disease, and causes an increase in TB incidence [8]. Thus, for reducing morbidity and mortality rates in TB and for preventing its transmission to healthy individuals, early diagnosis and starting timely treatment are critical [9]. It is of great importance to raise awareness of populations towards TB about modes of transmission, disease duration, precautions to be taken, treatment process, and the importance and necessity of regular use of medicines [10]. It is thought that studies on this topic would play an essential role in reducing transmission, providing positive treatment outcomes, and increasing motivation, hope, and quality of life for individuals with TB. Accordingly, the current study aimed to measure the level of TB-related stigmatization using the TBrelated stigma (TRS) scale in healthy individuals and in patients with TB and to evaluate the factors affecting stigmatization. Material and Methods This cross-sectional survey study was conducted in Karabuk Province of Turkey between July 2021 and October 2021 on newly diagnosed TB patients (n=123, aged 18-75 years), who were admitted to the TCD, and on healthy individuals (n=367, aged 18-75 years), who were admitted to the Community Health Center (CHS). Resistant cases in which the infection did not 105 | Annals of Clinical and Analytical Medicine become negative despite more than six months of therapy and those having relapses were excluded. The healthy group was formed from those having a family member diagnosed with TB and/or working in a health-related field. All participants were included in the study without being sampled. Ten participants (7 healthy participants and 3 patients with TB) who incorrectly completed the study questionnaire were excluded. The study was approved by the Ethics Committee of Non-Interventional Clinical Researches of Karabuk University (No: E-77192459050.99-48904 Subject: 2021/608) and Karabuk Governorship Provincial Health Directorate (No: 98024045-604.01.02). All participants were informed about the study and their written informed consent was obtained. A questionnaire consisting of two parts was applied to both healthy individuals and patients with TB using a face-toface survey technique. In the first part of the questionnaire, all participants were asked seven general questions about sociodemographic characteristics. In the second part, healthy individuals were asked 11 questions forming factor 1, and TB patients were asked 12 questions forming factor 2 of the Tuberculosis-Related Stigma (TRS) scale. Tuberculosis-Related Stigma (TRS) scale The TRS scale was first developed by Van Rie et al. [11], and the validity and reliability analysis of the Turkish version of the scale was performed by Küçük Şapçıoğlu (Küçük Şapcıoğlu E. Validity and reliability study of the tuberculosis-related stigma scale in Turkish population [Thesis]. İzmir: Ege University Institute of Health Sciences; 2012). Both factors of the TRS scale are 4-point Likert type scales, and each statement in the scale is scored from 0 to 3 (for positive questions: 0 points for “strongly disagree”, 1 point for “disagree”, 2 points “agree”, and 3 points for “strongly agree”). There are no reverse-scored questions on the scale. For both factor 1 and factor 2 of the TRS scale, higher scores indicate higher levels of stigma and/ or stigmatization. The lowest and highest scores obtained from the TRS scale were 0 and 33, respectively, for factor 1 (healthy individuals) and 0 and 36 for factor 2 (patients with TB). Cronbach’s alpha coefficients for factor 1 and factor 2 of the TRS scale were 0.88 and 0.82, respectively (Küçük Şapcıoğlu E. Validity and reliability study of the tuberculosis-related stigma scale in Turkish population [Thesis]. Izmir: Ege University Institute of Health Sciences; 2012). Statistical Analysis Data analyses were performed using the IBM SPSS Statistics for Macintosh, Version 25 (IBM Corp., Armonk, NY, USA). Descriptive statistics were expressed as frequency, percentage, mean, and standard deviation, minimum-maximum (min-max). The Kolmogorov-Smirnov test was used to test the normality of quantitative data. The Mann-Whitney U and Kruskal-Wallis tests were used to determine whether the dependent variables fit the normal distribution. Statistical significance was set at a p-value of <0.05 for all analysis methods. Results This cross-sectional, survey study included 360 healthy individuals (mean age, 45.46±12.90 years, female 65.3%) and 120 patients with TB (mean age, 41.15±16.42 years, male 60.8%). The distribution of healthy individuals and patients Stigma in Tuberculosis Disease Table 1. Distribution of healthy individuals and patients with tuberculosis according to their sociodemographic characteristics Introductory Characteristics Healthy individuals (n=360) n % Individuals with tuberculosis (n=120) n % Age 18-35 81 22.5 48 40.0 36-53 176 48.9 35 29.2 54-86 103 28.6 37 30.8 Gender Female 235 65.3 47 39.2 Male 125 34.7 73 60.8 Marital status Married 270 75.0 55 45.8 Single 51 14.2 32 26.7 Divorced/Widow 39 10.8 33 27.5 Educational Status Illiterate 0 0.1 12 10 Primary School Graduate 12 3.3 28 23.3 Secondary School Graduate 25 6.9 31 25.8 High School Graduate 76 21.1 32 26.7 University Graduate 247 68.6 17 14.2 Unemployed 142 39.4 79 65.8 Employee 218 60.6 41 34.2 Low 32 8.8 65 54.2 Middle 248 68.9 51 42.5 High 80 22.2 4 3.3 12 3.3 56 46.7 35.8 Occupation Introductory Characteristics Healthy individuals (n=360) (18.60± 4.18) Mean ±SD p Age 18-35 18.79± 4.93 36-53 19.07 ± 4.10 54-86 17.66 ± 4.40 KW*=8.599 p=0.014 Gender Female 44,19±12,6 Male 47,84±13,1 z**=-1.053 p=0.297 Marital status Married 18.51±4.17 Single 18.90±5.78 Divorced/Widow 18.84±4.10 KW*=1.312 p=0.519 Educational Status Primary School Graduate 19.50±2.15 Secondary School Graduate 19.36±6.12 High School Graduate 18.11±5.05 University Graduate 18.63±4.08 KW*=4.341 p=0.114 Occupation Unemployed 17.53±4.71 Employee 19.30±4.07 KW*=20.312 p=0.002 Income Level Income Level Place of Residence Village Table 2. Tuberculosis-Related Stigma scale scores of the healthy individuals (n=360) Town 95 264 43 Province 253 70.3 21 17.5 Total 360 100.0 120 100.0 with TB according to their sociodemographic characteristics is presented in Table 1. The mean TRS scale score was 18.60±4.18 (min-max, 9.029.0) in healthy individuals. In these individuals, while sex, marital status, educational level, and income level did not have a significant effect on the level of stigmatization (p>0.05, Table 2), age, employment status, and place of residence had significant effects (p<0.05; Table 2). In patients with TB, the mean TRS scale score was 19.72±3.20 (min-max, 14.0±27.0). In patients with TB, while age, marital status, employment status, and income level had a significant effect (p<0.05, Table 3), sex and educational status did not affect the level of stigmatization (p>0.05, Table 3). Mean TRS scale scores of TB patients who experienced guilt (21.55±1.66), anxiety (22.00±1.26), fear (19.37±2.20), and sadness (19.03±2.35) were significantly higher than the mean score of those without these feelings (17.66±1.58, 18.34±2.15, 16.76±1.98, and 16.00±.00, respectively) (p<0.05, Table 3). However, no significant difference was determined between the mean scores of patients with and without the feeling of loneliness (19.02±2.60 and 18.26±1.55, respectively; p>0.05; Table 3). 106 | Annals of Clinical and Analytical Medicine Low 19.62±4.64 Middle 18.32±4.44 High 19.07±4.20 KW*=3.494 p=0.174 Place of Residence Village 21.00 ±3.69 Town 19.48±5.00 Province 18.16±4.13 KW*=8.169 p=0.017 TRS: Stigma Related to Tuberculosis SD: Standard Deviation; KW*: Kruskal Wallis-H test; z**: Mann-Whitney U coefficient; p<0.05 was considered significant. Discussion In the current study, which evaluated the stigma levels of healthy individuals and patients with TB, the TRS scale score was found as 18.60±4.18 and 19.72±3.20 in healthy individuals and in patients with TB, respectively. Accordingly, the stigma level was determined as moderate in both groups. In the study conducted in a university hospital by Bayraktar and Khorshtd (2017) the stigma level in healthy individuals was reported as low with a mean TRS scale score of 13.87±6.26 [12]. In the current study, the stigma level was lower due to the fact that healthy individuals included in the study might also have relatives diagnosed with TB. Wynne et al. (2014) studied 360 healthy individuals in Uganda and found that 47% of them had highly stigmatizing attitudes towards patients with TB [13]. Bati et al. (2013) studied 422 healthy individuals with TB in rural areas in Ethiopia and found that 59.2% of healthy individuals had high levels of stigma towards TB patients [14]. The higher level of stigma associated with infectious diseases in the countries with a low level of education, such as Uganda and Ethiopia, can be explained by the fact that stigma is more common in underdeveloped societies. Crispim et al. (2017) assessed the stigma of TB patients and found a scale score of 83.1±0.2 [15]. The reason for the differences in stigmatization scores in the literature is thought to be due to the fact that Stigma in Tuberculosis Disease Table 3. Tuberculosis-Related Stigma scale scores of the patients with tuberculosis (n=120) Introductory Characteristics Individuals with tuberculosis (n=120) (19.72 ± 3.20) Mean ±SD p Age 18-35 21.08 ± 3.15 36-53 18.88 ± 3.39 54-86 18.75 ± 2.44 KW*=13.803 p=0.001 Gender Female 19.23 ± 2.92 Male 20.04 ± 3.35 z**=-1.057 p=0.291 Marital status Married 19.49 ± 2.63 Single 22.87 ± 2.18 Divorced/Widow 17.06 ± 2.12 KW*=56.502 p=0.000 Educational Status Primary School Graduate 17.66 ± 2.99 Secondary School Graduate 18.57 ± 2.09 High School Graduate 20.03 ± 3.28 University Graduate 20.25 ± 3.61 KW*=6.632 p=0.085 Occupation Unemployed 18.74 ± 2.31 Employee 19.00 ± 2.58 KW* =34.399 p=0.000 Income Level Low 19.24 ± 3.35 Middle 20.07 ± 2.95 High 23.00 ± .000 KW*=7.937 p=0.019 Place of Residence Village 19.14 ± 3.32 Town 19.83 ± 3.41 Province 21.04 ± 1.85 KW*=9.251 p=0.010 Feelings About Their Illness Guilt No 17.66 ± 1.58 Yes 21.55 ± 1.66 Anxiety z**=-7.654 p=0.000 . No 18.34 ± 2.15 Yes 22.00 ± 1.26 Fear z**=-5.299 p=0.000 . No 16.76 ± 1.98 Yes 19.37 ± 2.20 Loneliness z**=-4.720 p=0.000 . No 18.26 ± 1.55 Yes 19.02 ± 2.60 Sadness z**=-1.676 p=0.094 . No 16.00 ± .000 Yes 19.03 ± 2.35 z**=-3.823 p=0.000 TRS: Stigma Related to Tuberculosis; SD: Standard Deviation; KW*: Kruskal Wallis-H test; z**: Mann-Whitney U coefficient; p<0.05 was considered significant. different scales are used in the studies and the studies are carried out in different geographical regions and cultural environments. Bayraktar and Khorshtd (2017) measured the level of stigma in TB patients and found that the mean TRS scale score was 11.08±5.50 [12]. In our study, the stigma score in TB patients was found to be moderate (19.72±3.20), and TB patients were observed to feel more stigmatized. Öztürk (2018) used the Stigma Scale in Patients with Tuberculosis (SSPT) and found a mean score of 69.6±12.6 [5]. In our study, when examining 107 | Annals of Clinical and Analytical Medicine patients with TB, the mean TRS scale score was 19.72±3.20 (min-max, 14.0±27.0). Açıkel and Pakyüz (2015) found that the stigma score of the patients with pulmonary TB was above average (83.79±7.42) in 74.4% of the patients [16]. Baltacı et al. (2021) used SSPT and determined the stigma score of 53.6% of TB patients to be above average (71.86±10.13) [17]. The SSPT developed by Sert (2010) (Sert H. Determination of stigma levels and affecting factors in patients with tuberculosis [Doctoral Thesis]. Istanbul Marmara University Institute of Health Sciences; 2010) was used in the studies by Öztürk [5], Açıkel and Pakyüz [16] and Baltacı [17]. In all three studies, more than half of the participants with TB reported that they experienced high levels of stigma due to TB. The higher stigma scores found in these studies compared to our results could have resulted from the difference in socio-demographic characteristics such as residence place, educational level, employment status, and gender of the participants. Crispim et al. (2017) used the Brazilian version of the TRS scale and reported the stigma score of TB patients as 62.7±0.2 [15]. Both healthy and TB individuals participated in this research, and it was found that the stigma level of the ill individuals was higher than that of the individuals with tuberculosis. On the other hand, in the present study, stigma scores were higher in individuals with TB likely due to ethnic differences. Jittimanee et al. (2009) found that 65% of the human immunodeficiency virus (HIV)-infected TB patients experienced high levels of stigma in Thailand [18]. Stigmatization of AIDS patients ranks first and TB patients ranks second worldwide. It is thought that this situation arises from the lack of knowledge about infectious diseases in society; the factors such as ways of transmission, duration, and methods of protection against these diseases. We think that TB patients being co-infected with HIV significantly increase the rate of stigmatization. In the current study, the evaluation performed on the emotional states of the TB patients revealed that 30% of the patients felt guilty, 13.3% felt anxious, 56.7% felt fearful, 93.3% felt sad, and 75% felt lonely. The mean TRS scale scores of TB patients who experienced guilt (21.55±1.66), anxiety (22.00±1.26), fear (19.37±2.20), and sadness (19.03±2.35) were significantly higher than the mean score of those without these feelings (17.66±1.58, 18.34±2.15, 16.76±1.98, and 16.00±.00, respectively). Bayraktar and Khorshtd (2017) found that among individuals with TB, 33.9% experienced guilt, 12.8% experienced anxiety, 14.7% experienced fear, 44% experienced sadness, 5.5% experienced pessimism, and 9.2% experienced anger [12]. Moreover, Ünalan et al. (2008) determined that 75.5% of their patients experienced acceptance, 43.4% experienced sadness, and 28.6% experienced fear, pessimism, anxiety, and anger [19]. In addition, Dhingra and Khan (2010) demonstrated that 60% of 1977 patients in India experienced anxiety, pessimism, restlessness, and anger [20]. According to Datiko et al. (2020), individuals stigmatized owing to TB had pessimistic feelings such as fear, anxiety, loneliness, and sadness in Ethiopia. Although the rates of emotions arising from stigma in TB patients differ from the results of the current study, they are similar in content. The difference in the percentage of feelings is thought to depend on factors such as education level, income level, place of residence, level Stigma in Tuberculosis Disease of knowledge about TB, isolation from the social environment, abandonment, or job loss [10]. In the current study, 60.8% of our patients were male. Similarly, in the study by Datiko et al. (2020) on stigmatization in TB in Ethiopia, the rate of male patients was 57.8% [10]. The average age of TB patients in the current study was 44.86±16.3 years, and 40% of the patients were aged between 18-35 years. In a study on stigmatization of TB patients by Baltacı et al. (2021), it was found that the mean age of patients was 46.96±14.21 years, and the age range was between 34-47 years [17]. The current study and other available studies indicate that TB is common in similar gender, mean age, and age range. Additionally, in the current study, 54.2% of TB patients reported their financial situation as “poor”. In their study, Bayraktar and Khorshtd (2017) found that 69.7% of TB patients described their economic status as moderate [12]. The difference between the studies may be due to the differences in socioeconomic levels and self-report of income levels by the patients. In our study, the residential area where the TB disease was the most prevalent was urban (53.3%). Similarly, Mis and Karasungur (2016) also reported that 52.1% of their TB patients lived in the city center in Van Province [21]. These findings may be due to the fact that people living in the city centre do not register at health centers due to the fear of stigmatization, and thus they are late for treatment. The evaluation of the educational level of the TB patients in the current study revealed that the literacy rate was 90%. Similarly, Bayraktar and Khorshtd (2017) found the literacy rate to be 89.1% [12]. Based on the above-mentioned data, to the best of our knowledge, the findings of the sociodemographic characteristics of TB patients in other studies are mainly similar to the findings obtained in the current study. The current study was conducted in a single center and TB patients did not want to participate in the survey due to fear of stigma, all of which can be considered limitations of the study. The lack of sufficient number of studies on the level of stigma in healthy individuals can be considered a strength of the study. Conclusion The present study demonstrated that the level of stigma towards TB individuals was higher in TB patients than in healthy individuals with both groups having moderate levels. The average TRS scale scores of individuals diagnosed with TB who experienced feelings of guilt, anxiety, fear, and sadness were significantly higher than those who did not experience these feelings. While age, employment status, and place of residence had significant effects on stigma level in healthy individuals, age, marital status, employment status, and income level had significant effects on stigma level in patients. The adverse effects of stigmatization were identified in the current study and it was emphasized that individuals diagnosed with TB should be isolated from society as long as they are contagious and should follow treatment regularly. In addition, basic information was provided to end social isolation after eliminating the contagion, emphasizing both the individualistic and societal importance of the issue. TB patients experiencing guilt, fear, and sadness should receive psychological counseling from health care professionals. It is considered useful for instructors to favor active education methods such as roleplaying from an early age so that healthy individuals can 108 | Annals of Clinical and Analytical Medicine empathize with stigmatized TB patients. Scientific Responsibility Statement The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article. Animal and human rights statement All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article. Funding: None Conflict of interest None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission. References 1. Harding E. WHO global progress report on tuberculosis elimination. Lancet Respir Med. 2020; 8(1):19. 2. Kim P, Shah SN, Rustomjee R, Gandhi N, Mathema B, Dowdy D, et al. What We Know About Tuberculosis Transmission: An Overview. J Infect Dis. 2017; 216(6):629–35. 3. Conradie F, Diacon AH, Ngubane N, Howell P, Everitt D, Crook AM, et al. Treatment of Highly Drug-Resistant Pulmonary Tuberculosis. N Engl J Med. 2020; 382(10):893-902. 4. Ayaz E, Haliloğlu M. What is your radiological diagnosis? Istanbul Journal of Pediatric Infection. 2019; 13(3): 174-6. 5. Öztürk FÖ. Stigma Concept and Tuberculosis. International Refereed Journal of Nursing Studies. 2018; 13:136-48. 6. Şimşek H, Özmen D, Çetinkaya AÇ. Evaluation of Internalized Stigma in Tuberculosis Patients. International Refereed Journal of Nursing Research. 2016; 7:159-73. 7. Yin X, Yan S, Tong Y, Peng X, Yang T, Lu Z, et al. Status of Tuberculosis-Related Stigma and Associated Factors: A Cross-Sectional Study in Central China. Trop Med Int Health. 2018; 23(2): 199-205. 8. 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. Int J Infect Dis. 2017; 56: 90-100. 9. 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): 42–8. 10. Datiko DG, Jerene D, Suarez P. Stigma matters in ending tuberculosis: Nationwide survey of stigma in Ethiopia. BMC Public Health. 2020; 20(1): 1-10. 11. Van Rie A, Sengupta S, Pungrassami P, Balthip Q, Choonuan S, Kasetjaroen Y, et al. Measuring stigma associated with tuberculosis and HIV/AIDS in southern Thailand: exploratory and confirmatory factor analyses of two new scales. Trop Med Int Health. 2008; 13(1): 21–30. 12. Bayraktar D, Khorshtd L. Examination of Stigma of Tuberculosis in Healthy and Sick Individuals. Journal of Psychiatric Nursing. 2017; 8(3): 129–36. 13. Wynne A, Richter S, Jhangri GS, Alibhai A, Rubaale T, Kipp W. Tuberculosis and human immunodeficiency virus: exploring stigma in a community in western Uganda. AIDS Care. 2014; 26: 940–6. 14. Bati J, Legesse M, Medhin G. Community’s knowledge, attitudes and practices about tuberculosis in Itang Special District, Gambella Region, South-Western Ethiopia. BMC Public Health. 2013; 13(1): 1-9. 15. Crispim JA, da Silva LMC, Yamamura M, Popolin MP, Ramos ACV, Arroyo LH, et al. Validity and reliability of the tuberculosis-related stigma scale version for Brazilian Portuguese. BMC Infect Dis. 2017; 17(1): 510. 16. Acikel YG, Pakyuz CS. Evaluating the stigma on patients with tuberculosis. J Florence Nightingale Nurs. 2015; 23(2): 136–45. 17. Baltacı B, Arslan S, Nemnezı̇ S, Demı̇rel Y. Analysis of Stigma and Discrimination in Tuberculosis Patients. Journal of Izmir Chest Hospital. 2021; 35(1): 11-21. 18. Jittimanee SX, Nateniyom S, Kittikraisak W, Burapat C, Akksilp S, Chumpathat N, et al. Social stigma and knowledge of tuberculosis and HIV among patients with both diseases in Thailand. PLoS One. 2009; 4(7): 6360. 19. Ünalan D, Baştürk M, Ceyhan O. The relationship between tuberculosis and life events and the perception of the disease. Journal of Inonu University Faculty of Medicine 2008; 15(4): 249–55. 20. Dhingra VK, Khan S. A sociological study on stigma among TB patients in Delhi. Indian J Tuberc. 2010; 57(1): 12–18. 21. Mis L, Karasungur R. Factors Affecting Tuberculosis Incidence in Van Province in 2010-2011. Journal of Cumhuriyet University Institute of Health Sciences. 2016; 1(2): 53-62. How to cite this article: Burcu Korkut, Nergiz Sevinç. The Stigmatizing Effect of Tuberculosis Disease. Ann Clin Anal Med 2022;13(1):104-108