E Jaramillo Tuberculosis and Stigma

Journal of Health Psychology
http://hpq.sagepub.com Tuberculosis and Stigma: Predictors of Prejudice Against People with Tuberculosis
Ernesto Jaramillo J Health Psychol 1999; 4; 71 The online version of this article can be found at: http://hpq.sagepub.com/cgi/content/abstract/4/1/71
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Tuberculosis and Stigma: Predictors of Prejudice Against People with Tuberculosis
Journal of Health Psychology Copyright 1999 SAGE Publications London, Thousand Oaks and New Delhi, [13591053(199901)4:1] Vol 4(1) 7179; 005483
ERNESTO JARAMILLO
Fundacion CIDEIM, Cali, Colombia
Abstract
Tuberculosis is a main cause of mortality and morbidity in developing countries. Although diagnostic and curative means are well known, they are not always available and affordable. Also, the disease has a worldwide stigma, which adds to the suffering. A survey exploring the correlates of prejudice, as an attitudinal component of this stigma, was carried out in Cali, Colombia. Results show that scientically unfounded beliefs about the transmission of the disease are the main signicant predictor of the instrumental function of this attitude. Health education and, arguably, more successful control programmes could help to reduce the social isolation suffered by people with tuberculosis.
e r n e s t o j a r a m i l l o ( m d, Universidad del Valle, Cali, ph d, University of London) is a research associate at the School of Public Health, Universidad del Valle, and at the Fundacion CIDEIM, Cali, Colombia.
a c k n o w l e d g e m e n t s. I am thankful to Drs Antonio Irurita and Carlos A. Hernandez of the Secretariat of Public Health in Cali, who facilitated the access to data for this article. I am thankful also to doctors I. Plewis for statistical advice, E. Thomas and S. Mindel for comments and editorial advice, and two anonymous reviewers for their helpful critiques. A scholarship of Colciencias enabled me to write this article. c o m p e t i n g i n t e r e s t s: None declared.
Keywords
a d d r e s s. Correspondence should be directed to: e r n e s t o j a r a m i l l o m d, ph d. Fundacion CIDEIM, Avenida 1-N 3-03, Cali, Colombia. [email: cideim@cali.atcol.net.co]
health education, prejudice, stigma, tuberculosis

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JOURNAL OF HEALTH PSYCHOLOGY 4(1)
t u b e r c u l o s i s ( T B ), is one of the main causes of mortality in developing countries (Raviglione, Dye, Schmidt, Kochi, & WHO Global Surveillance and Monitoring Project, 1997). It is an air-transmitted bacterial disease affecting mainly the lungs. After acquiring the infection there is a 10 percent lifetime risk of developing the disease, usually as a result of immunosuppressive events such as undernutrition, cancer or ageing, and a 10 percent risk during the rst year of HIV infection (Murray, Styblo, & Rouillon, 1993). The strategy used to control TB is based on diagnosis and curative treatment of sources of infection. However, poor quality of health care services, inadequate adherence to the guidelines for diagnosis and treatment by patients and health care workers, HIV infection and poverty are considered the main factors that limit the success of this strategy (Enarson et al., 1995). While most of these factors are of a structural nature (Farmer, 1996) some sociobehavioural aspects, such as the worldwide stigma attached to the disease, also contribute to the worsening of the quality of life of people with tuberculosis (PWT) (Hudelson, 1996; Jaramillo, in press). Stigma is dened as an attribute giving discredit to and spoiling the identity of the bearer (Goffman, 1968). This quite complex aspect of social life has been analysed mainly from the perspectives of sociology (Williams, 1987) and social psychology (Jones et al., 1984). Sociologists and psychologists agree that stigma is a result of the way in which people experience their social life, and plays a function helping people to cope with the challenges of daily life. From the psychological point of view, the study of the stigma attached to some diseases focuses on prejudice, the attitude behind the discriminative behaviour (Crandall & Moriarty, 1995). A neofunctionalist approach to understanding prejudice in physical illnesses distinguishes instrumental and symbolic functions (Crandall & Glor, 1997). The instrumental function refers to the implications, in terms of material advantages and disadvantages, deriving from the relation of the individual with the attitude object. The symbolic function refers to the gains or losses in the process of reafrming personal values that are produced by interacting with the attitude object (Eagly & Chaiken, 1993). An instrumental function of the prejudice against
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TB is, for example, fear of infection. A symbolic function is, for example, the aversion of poverty. While some reports on the discrimination against PWT based on qualitative research would suggest a greater inuence of the symbolic than of the instrumental function, some others suggest the opposite, which is the case in Cali, Colombia (Jaramillo, 1995, 1998). By far the most common form of discrimination towards PWT in Cali is isolation from physical and social contact with their peers, in order to avoid infection. As a result, loss of employment and even divorce after diagnosis are not uncommon, and avoidance of sharing meals and food utensils, is commonly practised while PWT are receiving medical treatment. The stigma attached to TB has been explored by social scientists (Hudelson, 1996) and medical historians (Bryder, 1988), and has been further explored from a discourse analysis perspective (Sontag, 1977). However, it has been barely studied from a psychological perspective. This article aims to identify the correlates of the instrumental function of the prejudice against PWT in Cali. The main hypothesis to be tested is that peoples beliefs about mechanisms of TB transmission are the main predictor of the prejudice against PWT. This hypothesis derives from qualitative research formerly carried out in Cali (Jaramillo, 1995). The fact that instrumental function is more susceptible to change through social and educational interventions makes this type of research particularly relevant in the context of the needs of PWT in less developed countries. Data for this article were taken from the baseline survey for the impact evaluation of a health promotion initiative for TB control carried out in Cali in 1994 (Duque, 1994).
Methods
Sample
The sample was randomly selected using a frame built by Analizar Mercadeo Ltd, a company specializing in public surveys in Cali. This company was also hired by the evaluators of the health promotion initiative to undertake the eldwork (Duque, 1994). This frame was drawn on updated maps of the city depicting the number of blocks and houses per block. The sample was stratied by socio-economic status
JARAMILLO: PREJUDICE AND TUBERCULOSIS
in order to make it more representative of the population. Once the blocks for the respective strata were identied, a random numbers table was used to select the houses from which the respondents were selected by the interviewers. Since the interest for this research was to assess the attitudes of those at risk of developing a transmissible form of pulmonary TB, only one individual per household among those aged 15 years or over was randomly selected for face-toface interview according to the procedure described by Kish (1965). If the selected resident declined to be interviewed, the interviewer chose the next household. The interviewers, who had completed secondary school education at least, had previous experience of surveys dealing with health issues, and attended a training session where the aims of this survey were explained in detail. The eldwork was conducted during the evenings, which is, by empirical evidence, the best strategy for achieving an insignicantly low non-response rate, as was the case here (less than 5 percent in all the strata of the sample).
Instrumentation
The whole survey consisted of 24 questions (testretest reliability of 0.71). The main topics addressing the survey were sources of information on TB, lay notions of causality of the disease, beliefs about the mechanisms of transmission, and feelings and prejudice against PWT. Behavioural, sources of information, and sociodemographic variables were selected to examine their role in predicting the prejudice. Since the perceived severity of the disease is another important factor inuencing the instrumental attitude towards physical illnesses, this was also included as a variable.
PWT. The scale has an internal consistency of 0.70 (Cronbachs alpha). Although the prejudice towards PWT was operationalized as an attitude having a cognitive (beliefs about mechanisms of TB transmission) and an affective (feelings evoked by PWT) component, the scale for the latter was not considered for this analysis because of its low internal consistency (0.50 of Cronbachs alpha). Instead of the scale, the individual items were used as independent variables. The cognitive component was assessed with four items of a 5-point Likert-type scale (see Appendix). Responses to items were summed so that the higher the score achieved, the more scientically founded were the beliefs about mechanisms of TB transmission, that is, the more in line with the epidemiological evidence. Scientically founded beliefs are that TB is not transmitted by sharing meals or cutlery, by kisses, hugs, sexual relationships, or by working/studying with PWT. The scale has an internal consistency of 0.62 (Cronbachs alpha). Items assessing the feelings evoked by PWT were 3-point Likert-type scales. The higher the score of the item, the more positive the feeling. Positive feelings were those of solidarity with PWT and not of fear, pity, anger or loathing. The perceived severity of the disease was measured by asking the interviewees if they considered TB to be a curable disease.
Sociodemographic variables
Gender, age, education and socio-economic status were the sociodemographic variables considered for the analysis. Place of residence was chosen in this research as an indicator of socioeconomic status since previous research has demonstrated that in Cali this is a statistically signicant factor for predicting the income, family and educational background of people (Mohan, 1994).
Behavioural variables
The degree of prejudice against PWT was measured with a ve 3-point Likert-type social distance scale (intention to engage in physical and social contact with PWT). Responses to items were summed so that the higher the score, the more socially acceptable were the PWT considered by the respondents surveyed, that is, the more willing the respondents were to engage in social contact by sharing meals, working/ studying or by physical contact such as hugging, kissing or having sexual relationships with
Source of information variables

The source of information was considered particularly relevant for the analysis of the instrumental function of the prejudice, due to the fact that this function is more likely to be affected by new information. Formal and informal networks of communication were the two main categories selected for exploring what sources people used for obtaining information about TB. Formal
73
networks were considered to be the mass media organizations (local and national newspapers, television and radio broadcasting networks), health care institutions and centres of formal and non-formal education. Friends and relatives, and their direct contact with PWT were considered as informal networks.
using Epi Info 6.02 software (Centers for Disease Control and Prevention & World Health Organization, 1994). All the other statistical procedures were performed using SPSS 6.0 for Windows (SPSS, 1993).
Results
Table 1 shows the characteristics of the population and of the sample in terms of gender, age, educational level and socio-economic status. The sample is representative of the population of Cali for sex and for age, except for the age groups 45 to 54 and 55 to 64 years, which were signicantly over-represented. The low socioeconomic group was signicantly over-represented in the sample due to the way in which the stratication of the sample was performed. Because of the difculties the interviewers
Statistical analysis
Goodness-of-t chi-square test was performed to assess the representativeness of the survey samples for the whole population. Differences in scores between the categories of ordinal variables were tested by one-way analysis of variance (ANOVA). Categorical variables were dummy coded before performing a multiple linear regression in order to identify those variables predicting the prejudice towards PWT. Goodness of t chi-square tests were performed
Table 1. Sociodemographic characteristics of the population of Cali aged 15 years and over (1994), and of the respondents interviewed Characteristics Population of Cali aged 15 (N 1,230,045a) n Gender Female Male Age (years) 1524 2534 3544 4554 5564 65 Education Primary or less Secondary Higher Other Socio-economic status High Upper middle Lower middle Low
a
Respondents interviewed (N 399) n 210 198 115 88 74 59 38 25 89 232 67 11 40 99 136 124 % 50.4 49.6 28.8 22.1 18.5 14.8* 9.5** 6.3 22.3 58.1 16.8 2.8 10.0 24.8 34.1 31.1***
% 54.8 45.2 33.10 26.38 17.12 10.90 6.92 5.57 11.3 27.2 37.6 20.1
673,898 556,147 407,191 324,560 210,540 134,155 85,133 68,466 197,616 475,667 657,553 351,511
Source: Duque (1994) * Goodness of t 2 6.21; d.f. 1; p < .05 ** Goodness of t 2 4.20; d.f. 1; p < .05 *** Goodness of t 2 29.94; d.f. 1; p < .0000
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Table 2. Distribution of mean scores of the scale measuring the prejudice against people with tuberculosis, according to sociodemographic variables in Cali, 1994 Variable Scores for the scale measuring prejudice (N 399) Mean Gender Female Male Age (years) 1524 2534 3544 4554 5564 65 Education Primary or less Secondary Higher Other Socio-economic status High Upper middle Lower middle Low t (means) 1.7 8.46 8.91 F 5.61 9.57 8.50 8.54 8.59 7.97 7.04 F .51 8.42 8.81 8.61 8.81 F 3.45 7.85 8.38 8.69 9.20 SD p .09 2.55 2.68 p .000 2.67 2.41 2.57 2.74 2.51 2.01 p .67 2.17 2.71 2.9 2.56 p .01 2.34 2.89 2.46 2.58
experienced in interviewing those living in very rich areas (high rates of people declining to be interviewed) and very poor areas (insecurity), people belonging to these socio-economic strata were not adequately represented. All the respondents interviewed stated having heard of TB or having some idea about what TB is, but only 86 percent (343/399) of the interviewees thought that it was curable. Sources of information mentioned by the respondents were mass media (television, radio and newspapers) (99 percent; 397/399), health care and educational institutions (27 percent; 111/399), friends and relatives (28 percent; 113/399), and direct contact with PWT (14.5 percent; 58/399). A one-way ANOVA test showed no signicant differences in the scale measuring prejudice (F .39; p .88) nor in the scale measuring beliefs about TB transmission (F .76; p .59) according to the source of information about TB. Table 2 shows the scores achieved by the respondents interviewed in the social distance scale used to measure the prejudice toward PWT. A one-way ANOVA procedure was used
to test differences between groups. It shows signicant differences for age (F 5.61; p < .000) and socio-economic status (F 3.45; p .01). The polynomial linear test showed a signicant rising pattern for socio-economic status (F 3.45, p .017) and a descending one for age (F 5.61, p .0001). That is, the higher the socio-economic status and the older the respondents, the higher their prejudice against PWT. Table 3 shows the scores achieved by the respondents interviewed when asked about their beliefs about mechanisms of TB transmission, the cognitive component of the prejudice. Oneway ANOVA showed signicant differences between the categories of age (F 6.76; p < .0000) and socio-economic status (F 4.61; p .003). The polynomial linear test showed a signicant rising pattern for socio-economic status (F 7.38; p .007) and a descending one for age (F 27.02; p < .0000). That is, the higher the socio-economic status and the older the respondents surveyed, the less scientically founded were their beliefs about how TB is transmitted.
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Table 3. Distribution of mean scores of beliefs on mechanisms of tuberculosis transmission according to sociodemographic variables in Cali, 1994 Variable Scores for beliefs about TB transmission (N 399) Mean Gender Female Male Age (years) 1524 2534 3544 4554 5564 65 Education Primary or less Secondary Higher Other Socio-economic status High Upper middle Lower middle Low t (means) 1.56 10.21 9.64 F 6.76 11.32 9.84 9.96 8.78 8.18 9.08 F 2.32 9.58 10.32 9.22 8.72 F 4.61 8.15 10.18 9.70 10.54 SD p .12 3.72 3.70 p < .0000 4.01 3.47 3.82 3.14 2.87 2.54 p .07 3.77 3.74 3.64 2.10 p .003 3.66 3.49 3.31 4.15
The predominant feelings evoked by PWT were of solidarity, fear and pity rather than loathing or blaming. Strong feelings of solidarity (82.2 percent; 328/399), pity (42.4 percent; 169/399), fear (25.3 percent; 101/339), loathing (3.5 percent; 14/399) and anger (2.0 percent; 8/399) were reported by the interviewees. A one-way ANOVA test showed signicant differences only for pity according to age (F 3.20, p .007). A polynomial test for linearity showed a signicant increasing trend for age (F 12.6, p .004) for decreasing levels of pity. Bivariate analysis was performed in order to explore how the beliefs about TB transmission, cognitive component of the feelings evoked by PWT, sources of information about the disease, and the sociodemographic variables correlate with the attitude toward PWT (Table 4). Beliefs about TB transmission, age, gender, socio-economic status, and the level of fear and pity were all signicantly correlated with the attitude, as were being female, though weakly. In order to exclude any spurious association between those variables which correlated sig76
nicantly with the prejudice against PWT, and to identify those independent predictors of this attitude, a multiple linear regression was performed. The scores representing the prejudice against PWT and the independent variables full the normality assumptions for regression analysis. Categorical variables were dummy coded. A stepwise procedure was chosen for performing the regression. Only eight variables, those with p < 0.05, were allowed to enter the equation. A Bonferroni correction was performed to compensate for the well-known tendency of stepwise regression to increase the chance of type I error (Kleinbaum, Kupper, Muller, & Nizam, 1997). The results of the regression show that the prejudice against PWT can be predicted from the age, level of fear of PWT, and the beliefs about its transmission held by the respondents (see Table 5). The older the respondents and the more fearful they are of PWT, the less scientifically founded their beliefs about TB transmission. This model explains 26 percent of the variance of the attitude towards PWT (Table 5). However, the instrumental functions of prejudice alone explain 23 percent of the variance
Table 4. Correlation between independent variables and the prejudice against people with tuberculosis in Cali, 1994 Independent variable Cognitive components of the attitude Beliefs about TB transmission Exposure to cough of PWT Curability of TB Feelings towards PWT (affective component of the attitude) Fear Pity Loathing Anger Solidarity Sociodemographic variables Gender Age Educational level Socio-economic status Sources of information on TB Television Radio Newspapers Contact with PWT Friends/relatives Health care and educational institutions * p < .05; ** p < .00; *** p < .000 Prejudice against PWT .44*** .12** .05 .27*** .11* .06 .05 .04 .08* .23*** .001 .16** .02 .07 .04 .04 .05 .11*
(F 57.82; p < .000), that is, the cognitive component of the attitude ( .40, t 8.87, p < .000) and the fear of PWT ( .17, t 3.71, p .0002).
Discussion
The study reported in this article aimed to explore the correlates of the prejudice against PWT, as the attitudinal aspect of the stigma
attached to TB in Cali. It was hypothesized from previous qualitative research carried out in this city (Jaramillo, 1995) that this attitude was heavily inuenced by a cognitive basis (beliefs about mechanisms of TB transmission). This study shows that, in fact, having scientically unfounded beliefs about TB transmission and being fearful of PWT are signicant predictors of prejudice, according to a linear regression model that explains 23 percent of whole vari-
Table 5. Results of the multiple regression of variables predicting the prejudice towards people with tuberculosis in Cali, 1994 Predictor variables R2 .26; SE 2.26; F 28.00; p .000 B SE B .36 .16 .13 .12 .10 p pa
Beliefs about TB transmission .25 .03 Fear of PWT .55 .14 Age .22 .07 Socio-economic status .32 .12 Educational and health care institutions as source of information on TB .62 .26
a
.000 .000 .0002 .0016 .005 .04 .008 .06 .02 1.6
With Bonferroni correction

77
ance of the attitude towards PWT. Although the symbolic component of prejudice against PWT was not specically explored in this research, some ndings give support to the hypothesis that it plays a minor role. In fact, the predominant feelings towards PWT were solidarity, fear and pity rather than anger, loathing or blame. This is quite understandable once the fact that PWT are rarely blamed for having the disease and the lay causality model of TB (that it is composed of several factors such as poverty, bacterial infection, bad hygiene, exposure to changes in temperature, etc) are taken into account (Jaramillo, 1995, 1998). The importance of the instrumental component in the attitude against PWT in Cali might then be consistent with previous research showing that the contagiousness and the severity of physical illnesses are the main predictors of prejudice, even in those cases where the symbolic aspects of the attitude may be relevant (Crandall & Moriarty, 1995). A further multiple regression analysis (where sources of information and sociodemographic variables were included with the cognitive component of the prejudice towards PWT) showed that being older was also a signicant predictor of prejudice towards PWT, in a model that explains 26 percent of the whole variance. Higher levels of prejudice amongst older people can be due to their higher chances than young people of having had direct contact with PWT, and longer exposure to the lay beliefs about TB transmission. The interaction of TB with HIV infection may exacerbate the stigmatization suffered by those with both diseases. This interaction was not explored because of the relatively low prevalence of AIDS among TB patients in Cali at the time of this inquiry (Corral, 1994). Although the means for tackling the TB epidemic appear to be straightforward from a biomedical perspective, in the less developed countries the issue is more complex. Making the resources for early diagnosis and treatment available and affordable would demonstrate that TB is controllable. People having this new experience of the disease, combined with health education replacing unfounded beliefs with scientically based information, could eventually reduce the burden of the stigma and help to improve the quality of life of PWT.
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Appendix
1. Scale assessing beliefs about mechanisms of TB transmission. What are the chances of getting infected with TB through sharing cutlery with PWT? kissing PWT? sexual relationship with PWT? studying/working with PWT? (response categories: 1 absolutely sure; 2 very probable; 3 dont know/dont answer; 4 very improbable; 5 not possible.) 2. Questions assessing affects towards PWT. How intense are these feelings with respect to PWT? fear loathing anger sorrow (response categories: 1 very strong; 2 some/ dont know/dont answer; 3 none.) 3. Social distance scale for assessing the prejudice towards PWT. Would you be able to kiss PWT? share meals with PWT? have sex with PWT? work/study with PWT? hug PWT? (response categories: 1 strongly disagree; 2 dont know/dont answer; 3 strongly agree.)
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Enarson, D., Grosset, J., Mwinga, A., Hersheld, E., OBrien, R., Cole, S., & Reichman, L. B. (1995). The challenge of tuberculosis: Statements on global control and prevention. Lancet, 346, 809819. Farmer, P. (1996). Social scientists and the new tuberculosis. Social Science and Medicine, 44(3), 347358. Goffman, E. (1968). Stigma: Notes on the management of spoiled identity. Harmondsworth: Penguin. Hudelson, P. (1996). Gender differentials in tuberculosis: The role of socio-economic and cultural factors. Tubercle and Lung Disease, 77, 391400. Jaramillo, E. (1995). Knowledge, attitudes and practices of lay people about tuberculosis in Cali, Colombia. Tubercle and Lung Disease, 76 (Suppl. 2), 106. Jaramillo, E. (in press). Tuberculosis control in less developed countries: Can culture explain the whole picture? Tropical Doctor. Jaramillo, E. (1998). Pulmonary tuberculosis and health seeking behaviour: How to get a delayed diagnosis in Cali, Colombia. Tropical Medicine and International Health, 3(2): 138144. Jones, E., Farina, A., Hastorf, A., Markus, H., Miller, D., & Scott, R. (1984). Social stigma:
The psychology of marked relationships. New York: W. H. Freeman. Kish, L. (1965). Survey Sampling. New York: Wiley. Kleinbaum, D. G., Kupper, L. L., Muller, K. E., & Nizam, A. (1997). Applied regression analysis and multivariate methods (3rd ed.). Pacic Grove, CA: Duxbury Press. Mohan, R. (1994). Understanding the developing metropolis: Lessons from the city study of Bogota and Cali, Colombia. New York: Oxford University Press. Murray, C., Styblo, K., & Rouillon, A. (1993). Tuberculosis. In D. Jamison, W. Mosley, A. Measham, & J. Bobadilla (Eds.), Disease control priorities in developing countries (pp. 233259). New York: Oxford Medical Publishers. Raviglione, M., Dye, C., Schmidt, S., Kochi, A., & WHO Global Surveillance and Monitoring Project. (1997). Assessment of worldwide tuberculosis control. Lancet, 350, 624629. Sontag, S. (1977). Illness as metaphor. Harmondsworth: Penguin Books. SPSS (1993). Statistical Package for Social Sciences. Chicago, IL. Williams, S. (1987). Goffman, interactionism, and the management of stigma in everyday life. In G. Scambler (Ed.), Sociological theory and medical sociology (pp. 134164). London: Tavistock.
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Journal of Health Psychology

Tuberculosis and Stigma: Predictors of Prejudice Against People with Tuberculosis

health education, prejudice, stigma, tuberculosis

JOURNAL OF HEALTH PSYCHOLOGY 4(1)

JARAMILLO: PREJUDICE AND TUBERCULOSIS

Source of information variables

JOURNAL OF HEALTH PSYCHOLOGY 4(1)

JARAMILLO: PREJUDICE AND TUBERCULOSIS

JOURNAL OF HEALTH PSYCHOLOGY 4(1)

JARAMILLO: PREJUDICE AND TUBERCULOSIS

With Bonferroni correction

JOURNAL OF HEALTH PSYCHOLOGY 4(1)

JARAMILLO: PREJUDICE AND TUBERCULOSIS

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