The Quality of Life and Perceived Stigma of Tuberculosis Patients in India

https://doi.org/10.33698/NRF0199 Atinderbir Kaur, Bindu K, Prabhjot Saini, Monika Sharma, Jasbir Kaur

Abstract : Tuberculosis is a disease with social implications due to stigma attached to it. It further prolongs delay in seeking proper care leading to physical, psychological and social disabilities and dehabilitation. This study was conducted with an objective to assess Quality of life (QOL) and perceived stigma of tuberculosis patients. This prospective study was conducted on 100 tuberculosis patients selected by convenience sampling technique in selected DOTS clinics of district Ludhiana, Punjab. WHOQOL-BREF (World Health Organization- Quality Of Life ) was used as research instrument to assess Quality of life and EMIC (Modified Explanatory Model Interview Catalogue) developed by WHO-TDR (World Health Organization- Tropical Disease Research) to assess the Perceived stigma among the subjects. Data was collected by self- report method by pen & paper i.e. tool was translated into Hindi, Punjabi and explained to patients. After taking informed consent patient himself put information into it under guidance of researcher.Explanation about different sections in the question was provided by the researcher during face to face conversation.

The findings revealed that all (100%) TB patients were stigmatized, (99% were somewhat stigmatized while 1% were highly stigmatized). 96% of the subjects showed average Quality of life. The highest mean quality of life score was recorded in physical domain of health (69%) followed by social domain (68%) and psychological domain (66.33%). There was a negative correlation of perceived stigma with quality of life (r= – 0.11, p=0.268). Adults (36-45 yrs), never married and recently diagnosed patients showed better Quality of life (p<0.05). Younger adults (18-25 years), females, unmarried, migrants and lower-middle class were found to be more stigmatized (p<0.05). The study concludes that despite the ability to cure TB, the stigma among patients still remains a problem which has an impact on QOL. Therefore, it is recommended that nurses need to supplement the efforts in communication and education of public about TB to reduce stigma experienced by TB patients and play a supportive and curative role to optimize better QOL.

Keywords

Perceived stigma, Quality of Life, Tuberculosis Patients.

Correspondence at

 Mrs. Prabhjot Saini

Professor

DMCH College of Nursing DMC & Hospital, Ludhiana.

Introduction

Tuberculosis has been recognized as a scourge of humanity since antiquity.1 Tuberculosis (TB) remains a major global health problem. Despite the availability of a cheap and effective treatment, tuberculosis still accounts for millions of cases of active disease and deaths worldwide. Though India is the second-most populous country in the world one fourth of the global incident TB cases occur in India annually. As per WHO Global TB Report 2015, out of the estimated global annual incidence of 9.6 million TB cases, 2.2 million were estimated to have occurred in India. There were also 0.22 million TB deaths in India2.

Tuberculosis is a disease with social implications due to the stigma attached to it. It has been seen that apart from physical symptoms, TB patients face various problems that are social and economic in nature.3 The social stigma is recognized as an important barrier for successful care of people affected by tuberculosis. Tuberculosis has been and is still considered as a ‘dirty disease’, ‘a death penalty’ or as affecting ‘guilty people’.4,5 Health-related stigma describes a social concept that has an enormous impact on the lives of people that suffer from a certain health conditions.6 According to Rensen et al. (2010), stigma is interrelated and may have an impact on the self-efficacy of the affected person, his or her participation in the community, personal well-being and self-esteem.7 Affected persons may feel disappointed in themselves for contracting the particular disease or condition, feel embarrassed, guilty and inferior compared to others.8-11 Khan et al. (2000) showed that most of the poor patients preferred private practitioners. The patients were reluctant to disclose their disease but the same time they were facing some social as well as economic problem.12 Women more often Though in medical practice, the method of assessing patient health status and disease is by laboratory or clinical tests but it becomes impossible to separate the disease from the individual’s personal and social context, especially in chronic and progressive diseases. Therefore, for a comprehensive assessment of patients’ health status, it is very much essential to assess the overall impact of TB on health and patients’ perception of well-being, besides routine clinical, radiological and bacteriological assessments. This assessment can be done by measuring the Quality of Life (QOL) that has several dimensions 15.

TB-related stigma is a matter of practical concern because it contributes to suffering as component of the so-called hidden burden of disease and it may interfere with treatment and control.16 It is clear that the burden of disease is huge indicating that the effect of disease is manifold. This indicates that the effect of disease needs to be studied not just on physical dimensions but all other dimensions as they also have a great impact on treatment and overall well-being of patients. Therefore, The study aims to deepen our understanding of TB-related perceived stigma and its impact on quality of life among tuberculosis patients. Hence the study was conducted with the objective to to assess Quality of life (QOL) and perceived stigma of tuberculosis patients. than men, face very different and sometimes extreme reactions to TB and stigma, this fear can promote denial, undermining self- esteem and ultimately prevent timely diagnosis and effective treatment of TB.13 The stigma associated with the disease, prolongs delay in seeking proper care and thereby it leads to physical, psychological and social disabilities and dehabilitation. The quality of life of such patients decline rapidly. 14

Material and Methods

A descriptive research design was used on 100 TB patients selected by convenience sampling technique in selected DOTS clinics such as DMC & Hospital, Haibowal Kalan, Haibowal khurdh, Kundanpuri, and Gurunanak pura of Ludhiana city, Punjab, India. Tuberculosis patients receiving DOTS therapy at least from 3 months, age more than or equal to 18 years were included in the study and patients having any other chronic illness, pregnant women were excluded. The tool was divided into 4 parts: Part I- Socio- demographic characteristics, Part II- Disease profile, Part III- Modified Explanatory Model Interview Catalogue (EMIC) to assess perceived stigma among TB patients and Part IV- WHOQOL-BREF to assess Quality of life (QOL). Data was obtained by self report method.

Modified Explanatory Model Interview Catalogue (EMIC) developed by WHO/TDR (2002) was used to assess Perceived stigma. The catalogue consisted of 18 questions to assess Perceived stigma among tuberculosis patients. Items were rated as “Yes”, “Possibly”, “Uncertain” & “No” and scored as 3, 2,1&0 respectively. The subjects were categorized into No stigma (‘0′ score), Somewhat stigmatized (1-32 score) and highly stigmatized (33-54 score). Quality of Life was assessed by using a pre-designed, pre-tested questionnaires; WHOQOL-BREF, the questionnaire composed of four domains Physical, Psychological, Social, and Environmental. The questionnaire consists of total 26 Likert-type items out of which 24 are formulated into separate subscales: physical (seven items), psychological (six items), social (three items) and environmental (eight items) domains. Subjects were asked to respond to each item with a score of 1-5. A high score indicate better Quality of life. The level of Quality of life was categorized as per the scores into Good (89-120), Average (57-88) and Poor (24-56). Reliability of tool of standardized tool was predetermined. Informed consent was taken from them before filling the Questionnaire. Ethical clearance was obtained from institutional ethical committee of DMC & Hospital, Ludhiana. Analysis of the data was done in accordance with the objectives of the study. Calculations were carried out with the help of Microsoft excel and SPSS. The various statistical measures used for analysis were frequency distribution, measures of central tendency (mean), measures of dispersion (standard deviation) t-test and ANOVA test applied to find out the statistical significance.

Results

Sample Characteristics

Table 1 shows the mean age of 100 subjects was 34 ± 14.97 years. One third of subjects (36%) were of age group of 18-25 years followed by 27% in the category of 26- 39 years and > 45 years, 10% were of age group of 36-45 years. Urban (78%) subjects outnumbered the rural subjects. Two third of the patients were married (64%). More than half (54%) of the subjects were males and 46% were females. Majority of the subjects (64%) were married while 35% were never married and only 1% was in widower category. One third of subjects (34%) were educated up to elementary level followed by 27% up to secondary level, 20% graduates and above and only 19% were illiterate. More than half of subjects (55%) were found to be working whereas 45% were not working. Near about 1/3rd (35%) constituted of laborers, followed by 30% housewives, 11% students, 7% shop- keepers and only 2 % on government jobs. Majority of them (69%) belongs to Hindu religion and remaining 31% belongs to Sikh religion. More than 3/4th (78%) belong to urban habitat and 22% belongs to rural habitat. Majority (80%) of them belonged to state Punjab, whereas 20% were migrants. Near about half (48%) belong to upper- middle class, 37% belongs to middle class, 13% belongs to lower-middle class and only 2% belongs to upper class.

Table 1: Frequency distribution

Table 2 reveals that 19% of them were

of sample characteristics

N=150

having family history of tuberculosis. Furthermore 87% were having tuberculosis from <1 year, 76% suffered from pulmonary tuberculosis, 85% belonged to category 1 and 87% of tuberculosis patients did not receive/attend any counseling regarding tuberculosis.

Table 2: Distribution of tuberculosis patients as per clinical profile.

N=100

Variable	n (%)
Duration of illness (in years)
<1	87
1-2	07
>2	06
Disease category
Pulmonary	76
Extra-pulmonary*	24
Treatment category
Category 1 (new cases)	85
New sputum smear-positive	59
New sputum smear-negative	04
New extra-pulmonary	22
Category 2 (previously treated cases)	15
Sputum smear-positive relapse	04
Sputum smear-positive failure	01
Sputum smear positive after default	02
Others**	08
Counseling regarding tuberculosis
received/attended
Yes	13
No	87

 

Sample characteristics n (%) Age ( years)* 18-25 36 26-35 27 36-45 10 >45 27 Gender Male 54 Female 46 Habitat Rural 22 Urban 78 Marital status Married 64 Never married 35 Widow/widower 01 Educational status Illiterate 19 Elementary 34 Secondary 27 Graduation and above 20 Working Status Working** 55 Non working 45 Religion Sikh 31 Hindu 69 Native place Punjab 80 Other states*** 20 Socio-economic status (as per Udai Pareek scale) Upper class 02 Upper- middle class 48 Middle class 37 Lower-middle class 13

*Mean Age: 34 ± 14.97 years

**Other states: Uttar Pradesh, Bihar, Himachal Pradesh

*Extra-pulmonary cases include: Abdominal tuberculosis, skeletal tuberculosis, pleural tuberculosis,

tuberculosis lymphadenitis.

**Others include patients who are Sputum Smear- Negative or who have Extra-pulmonary disease who can have recurrence.

Perceived Stigma among TB patients

Table 3 reveals that all the TB patients were stigmatized where 99% were somewhat stigmatized (17.80±5.76) while only 1% was highly stigmatized (35.00+

00).

Quality of Life

96% of tuberculosis patients showed average Quality of life with mean score 75.11± 16.90 where as only 4% of tuberculosis patients had good Quality of life with mean score 89.00± 00. Hence it shows that maximum of tuberculosis patients had average Quality of life. (Table 3)

Table 3: Distribution of tuberculosis patients as per level of Perceived stigma

N=150

Attributes	n	Mean ± SD	Mean %
Level of Perceived stigma
Somewhat stigmatized (1-32)	99	17.80 ± 5.76	32.96
Highly stigmatized (33-54)	01	35.00 ± 00	64.81
Level of Quality of life
Average (57-88)	96	75.11± 16.90	62.59
Good (89-120)	04	89.00± 00	74.16

 

 

Table 4 shows the distribution of Perceived stigma score according to different category. 72% of subjects desired to keep people from knowing about their disease. Maximum subjects (99%) discussed their problem with the person they consider closest to them. About 1/3rd (37%) thought less about themselves because of the disease. 43% of subjects feel ashamed or embarrassed of having tuberculosis. 79% believed that their disease will cause adverse effect on others. 63% of the respondents thought that others have avoided them because of the disease and only 6% of the patient felt that some people refuse to visit their home because of tuberculosis. Only 2 % felt that neighbors, colleagues or others in your community will think less of patient’s family because of this

problem. Very less subjects (11%) felt that this problem might cause social problems for their children in the community. Half of subjects (50%) had an opinion of anticipating difficulty in getting married despite cure. 98% felt that their spouse will support them over the course of treatment. About 1/3rd of subjects (31%) said that their partner refuse sex due to tuberculosis. Only 9% of the patient felt that they will have other problem in their marriage even after cure. 6% of the subjects were asked to stay away from work. Very less subjects (7%) felt that even if they don’t (or didn’t) have any other health problems, people are likely to think they do because of your tuberculosis. All the subjects (100%) expect family support that their family will remain with them and be supportive over the course of treatment.

Table 4: Responses of TB patients as per EMIC

N=150

Items	Yes (%)	Possibly (%)	Uncertain (%)	No (%)
1.    Desire to keep others from knowing	72	12	00	16
2.    Disclose to confident	99	00	01	00
3.    Think less of yourself	37	22	04	37
4.    Shamed or Embarrassed	43	22	01	34
5.    Others would think less of you	33	26	28	13
6.    Adverse effect on others	79	08	02	11
7.    Others have avoided you	63	22	00	15
8.    Others refuse to visit	06	07	17	70
9.    Others would think less of patient’s family	02	04	11	83
10. Problems for your children	11	05	10	74
11. Problem getting married despite cure	50	16	15	19
12. Expectations of support from spouse	98	00	00	02
13. Partner refuses sex due to tuberculosis	31	03	16	50
14. Problem in ongoing marriage	09	03	10	78
15. Problem for the relative to marry	00	01	04	95
16. Obstracised from work	06	00	06	88
17. Presumed other health problems	07	03	28	62
18. Expectations of support from family	100	00	00	00

 

Table 5 depicts that subjects showed better Quality of life for physical domain and worse Quality of life for environmental domain. The highest mean quality of life score was recorded in physical domain of health (69%) with mean score 24.15 ± 3.24,

followed by social domain (68%) with mean score 10.20 ± 1.23 and psychological domain (66.33%) with mean score 19.90 ±

2.39 and least affected domain was environmental domain (61.05%) with mean score 24.42 ± 2.83.

Table 5: Mean quality of life among tuberculosis patients

N=150

Domains of QOL	Mean ± S.D	Max. score	Mean%	Rank
Physical	24.15 ± 3.24	35	69.00	1
Psychological	19.90 ± 2.39	30	66.33	2
Social	10.20 ± 1.23	15	68.00	3
Environmental	24.42 ± 2.83	40	61.05	4
Total	78.67± 7.27	120	65.55

*higher the score better the quality of life

 Table 6 depicts there was a negative correlation (r= -0.11, p=0.268) of perceived stigma (78.67 ± 7.27) with quality of life

(18.15 ± 5.73) indicating that higher the perceived stigma lower is the quality of life.

Table 6: Relationship between Quality of life and Perceived stigma.

N=150

Variables	Mean ± S.D	Max. score	Mean%	r-statistics
Quality of life Perceived stigma	78.67 ± 7.27 18.15 ± 5.73	120 54	65.55 33.61	r = -0.11 df = 01 p= 0 .26NS

 

Table 7 depicts the relationship of perceived stigma with domains of quality of life. There was a weak positive correlation (r= 0.13) of perceived stigma (18.15 ± 5.73) with physical domain of quality of life (figure

1) indicating that perceived stigma weakly effects physical domain of QOL. There was a weak negative relationship of  perceived

NS = Non Significant

 stigma with Psychosocial domain (r=-0.07) (Figure 2), Social domain (r= -0.09), (figure

3) and Environmental domain (r= -0.33) quality of life (figure 4) indicating that higher the perceived stigma lower is the quality of life in terms of psychosocial, social and environmental domains.

Table 7: Relationship of perceived stigma with Domains of Quality of life

N=150

Domains of QOL	Quality of Life Mean ± SD	Percieved stigma Mean ± SD	r- statistics
Physical	24.15 ± 3.24	18.15 ± 5.73	0.13
Psychological	19.90 ± 2.39	18.15 ± 5.73	-0.07
Social	10.20 ± 1.23	18.15 ± 5.73	-0.09
Environmental	24.42 ± 2.83	18.15 ± 5.73	-0.33

X Value                                                                                       X Value

Fig 1: Correlation of perceived stigma (X axis) with physical domain of quality of Life (Y axis)

Fig 2: Correlation of perceived stigma (X axis) with psychosocial domain of quality of Life (Y axis)

X Value

Fig 3: Correlation of perceived stigma (X axis) with Social domain of quality of Life (Y axis)

X Value

Fig 4: Correlation of perceived stigma (X axis) with environmental domain of quality of Life (Y axis)

Table 8 reveals association of quality of life with socio demographic data subjects. Adults of age group 36-45 years were having significantly better quality of life than patients of other age groups. (p=0.048), Male (p=0.12), Never married (p=0.017), secondary education and above (p=0.009), Working (p=0.059), Hindu religion

(p=0.016), rural subjects (p=0.20), Punjab residents (p=0.23), lower-middle class and those who have been recently diagnosed with tuberculosis (< 2 years) were found having better quality of life than their counterparts.

Table 8: Association of Quality of life among tuberculosis patients with socio demographic variables.

N=100

Variables	N	Mean ± S.D	F/t value	p value
Age (in years)
18-25	36	79.36 ± 5.30	2.73	0.048*
26-35	27	79.89 ± 6.28
36-45	10	81.50 ± 3.65
> 45	27	75.48 ± 10.18
Gender
Male	54	79.70 ± 6.86	1.55	0.124NS
Female	46	77.46 ± 7.62
Marital status
Married	65	77.40 ± 8.03	2.43	0.017*
Never married	35	81.02 ± 4.86
Educational status
Illiterate	19	74.21 ± 8.86	4.08	0.009*
Elementary	34	78.26 ± 6.26
Secondary	27	81.00 ± 6.13
Graduation and above	20	80.45 ± 6.50
Working status
Working	55	79.91 ± 6.92	1.90	0.059NS
Not working	45	77.16 ± 7.48
Religion
Sikh	31	76.06±8.67	2.46	0.016*
Hindu	69	79.84±6.27
Habitat
Rural	22	80.41 ± 6.94	1.27	0.20NS
Urban	78	78.18 ± 7.33
Native place
Punjab	80	79.09 ± 7.51	1.15	0.253NS
Other state	20	77.00 ± 6.09
Socio-economic status
Upper-class	02	79.50 ± 6.36	2.05	0.056NS
Upper-middle class	48	80.50 ± 6.73
Middle class	37	77.59 ± 7.99
Lower-middle class	13	74.85 ± 5.58
Duration of illness (in yrs)
<1	87	79.15 ± 6.91	4.73	0.011*
1-2	07	80.00 ± 5.94
>2	06	70.17 ± 9.49

*higher the score better the quality of life                        NS = Non Significant, * significant at p<0.05

Table 9 shows the association of Perceived stigma among tuberculosis patients with socio- demographic variables. It depicts that mean score for Perceived stigma was found to be high among subjects of age 18-25 years (p=0.001). The mean score for Perceived stigma was more among females (19.78 ± 5.13) than males (16.76 ± 5.90) (p=0.008). Perceived stigma was found to be more among those who were never married (20.22 ± 4.38) (p=0.007), not working

(19.33 ± 5.514) (p=0.062), Sikh religion (19.26

± 5.76) (p=0.016), urban inhabitants (18.37 ± 5.58) (p=0.470), migrant population (20.50 ±

6.37) (p=0.04), lower-middle class (22.08 ± 2.81) (p=0.001). Hence it is concluded that there was a significant association of Perceived stigma among subjects in younger age group, female, never married, migrant population, lower socio economic status (p<0.05).

Table 8: Association of Quality of life among tuberculosis patients with socio demographic variables.

N=100

Sample characteristics	N	Mean ± S.D	F/t value	p value
Age (years)*
18-25	36	21.11 ± 4.11	7.43	0.001*
26-35	27	18.07 ± 5.62
36-45	10	14.80 ± 5.13
>45	27	15.52 ± 6.17
Gender
Male	54	16.76 ± 5.90	2.70	0.008*
Female	46	19.78 ± 5.13
Habitat
Rural	22	17.36 ± 6.32	0.72	0.470NS
Urban	78	18.37 ± 5.58
Marital status
Married	64	17.03 ± 6.09	2.74	0.007*
Never married/Single	36	20.22 ± 4.38
Educational status
Illiterate	19	18.84 ± 5.11	0.718	0.543NS
Elementary	34	18.85 ± 5.49
Secondary	27	16.85 ± 6.08
Graduation & above	20	18.05 ± 6.32
Working Status
Working**	55	17.18 ± 5.78	1.88	0.062NS
Non working	45	19.33 ± 5.51
Religion
Sikh	31	19.26 ± 5.76	1.29	0.19NS
Hindu	69	17.65 ± 5.69
Native place
Punjab	80	17.56 ± 5.45	0.72	0.04*
Other states	20	20.50 ± 6.37
Socio-economic status
Upper class	02	19.50 ± 6.36	5.687	0.001*
Upper- middle class	48	16.00 ± 6.00
Middle class	37	19.49 ± 5.10
Lower-middle class	13	22.08 ± 2.81

Maximum score = 54

 Minimum score = 00

NS = Non Significant

* significant at p<0.05

Discussion

Tuberculosis is not only a health problem but a social, economic, and political disease. It manifests itself wherever there is neglect, exploitation, illiteracy and widespread violation of human rights. Despite the fact that the TB can be cured with medication, it still carries social stigma due to perceived consequences of infection. TB not only affects the patient’s physical health but also social, economical and psychological well-being. Keeping in view these dimensions, TB compel health professionals to make a comprehensive assessment of patient’s health and this can be made by measuring the Quality of life of the patient because it’s too difficult to split the disease form patient’s quality of life.

The present study revealed that 96% had average Quality of life where as only 4% of subjects had good Quality of life and none of them were having poor quality of life. Masood Sarwar Awanet et al. (2012) reported that in Pakistan heath-related quality of life was poor among tuberculosis patients, where the mean score was below 50%.17

Present study revealed that the mean percentage score was highest in physical domain 69%, followed by 68%, 66.33% and 61% for social domain, psychological domain, and environmental domain respectively concluding that TB patients had better Quality of life in Physical domain and worst in Environmental domain. Similar findings were reported by Adeyeye et al. in Nigeria revealing that the highest mean transformed quality of life score was recorded in social relationship domain of health (70.80±18.12) while the lowest was in the environmental domain

(66.33±15.20). The mean transformed quality of life scores in the other domains of health included 67.40±22.20 and 66.75±16.60 in physical and psychological domains respectively.18

Present study revealed that all the subjects were stigmatized with the TB disease where 99% were somewhat stigmatized and only 1% were highly stigmatized. Similar study was conducted by Aryal et al. which showed that among 60 TB patients attending DOTS clinic of Dharan Municipality, Nepal, 63.3% of the subjects were stigmatized whereas 36.7% of subjects were non-stigmatized.19

Patients in age group 36-45 showed better QOL that other age groups (p=0.048). These findings are supported by a study conducted by Olufunke O. Adeyeye et al.(2014) in Nigeria which revealed that with the exemption of the environmental domain of health, younger age group (<50 years) had superior health -related quality of life in all other domains of health (p<0.001).18

Men showed better QOL as compared to women (p>0.05), the patients residing in rural area were having better QOL as compare to those residing in urban area (p>0.05). In contrast to these findings, Masood Sarwar Awan et. al. (2012) showed that among 120 TB patients of Sargodha district female patients were enjoying better QOL as compared to male and rural patient’s quality of life scores were better than urban patients (p<0.05).17

The subjects who were never married had better QOL that married subjects (p=0.017). These findings are supported by study conducted by Demet Unalan (2008) in Turkey which also revealed that the QOL scores were the highest in unmarried cases and lowest in widowed cases in the active group in all dimensions of QOL (p<0.05).20

The study also showed that patients with higher education and less duration of illness had better QOL as compared to other categories (p<0.05). Duyan et al. (2005) found that better HRQOL was correlated with higher income, higher education, better housing conditions, better social security, and closer relationships with family members and friends(p<0.05).21 Olufunke

1. Adeyeye et al. (2014) showed that the independent predictors of low quality of life scores were low monthly income, advancing duration of the illness, concomitant illnesses, unemployment, advancing age and male gender (p<0.05).18 The present study also revealed that patients in age group 18-25 (21.11 ± 4.11) experienced more stigma and this was statistically significant (p=0.008). Female patients were found to have more stigma (19.78 ± 5.13) as compared to male patients (p=0.001). The patients who were never married were found to be more stigmatized (20.22 ± 4.38) (p=0.007). A study conducted by Weiss MG et.al. (2013) supported these findings which revealed that females were more stigmatized than males. Being never married was also associated with greater stigma. Increasing age was associated with less stigma among tuberculosis patients (p<0.05).22 The study also showed that there was significant association of stigma with native place. (p=0.04) which showed that patients who belongs to other states were more stigmatized (20.50 ± 6.37) as compared to patients who belongs to Punjab state. The study findings also showed that there was association between Perceived stigma and socio economic status as well. The patients under lower-middle class were more stigmatized with mean score 22.08 ± 2.81 (p=0.001). On the contrary the a study conducted by V. K. Dhingra (2003) showed that there was an immense stigma observed at society level with 60% of the patients hiding their disease (p<0.05) from the friends or neighbours and this was found to have statistically significant difference with more stigma among middle and upper middle class when compared to lower middle class and lower class. It was concluded that still there is presence of immense stigma at societal level which effects the Quality of life among tuberculosis patients. Therefore, it is recommended that nurses need to supplement the efforts in communication and education of public about complete cure of TB to reduce stigma experienced by TB patients and play a supportive and curative role to optimize better QOL.

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