An unexpected side effect of public health education efforts in Brazil

Understanding of tuberculosis is associated with higher, not lower, stigmatization of TB patients in Brazil, according to a new "Insights" report from Vanderbilt's Latin American Public Opinion Project (LAPOP) titled "Blaming the Victim: Knowledge of Tuberculosis is Associated with Greater Stigma in Brazil."

This puzzling finding reported by Vanderbilt postdoctoral researcher Mollie Cohen and graduate student Heather Ewing is based on data collected from LAPOP's 2016/17 AmericasBarometer survey. Marshall Eakin, professor of history; Timothy Sterling, David E. Rogers Professor of Medicine and director of the Vanderbilt Tuberculosis Center, and Elizabeth Zechmeister, Cornelius Vanderbilt Professor of Political Science and director of LAPOP, also contributed to the report.

Community education is often a key component of most public health campaigns. By empowering a community to recognize and understand a serious health condition, they should be more likely to be vigilant about transmission, recognize the need for treatment and support those who are ill. In Brazil, high knowledge of tuberculosis has a surprising negative relationship to stigma: Brazilians who are more knowledgeable are more likely to stigmatize those with the disease.

Brazilians with more formal education in general assign much less stigma to TB than those with less. Brazilians in regions with higher incidence of the disease, the southeast and northeast, also reported less stigma.

"Studies consistently show that individuals with higher educational attainment express less stigma in surveys; one reason is that they are more likely to know and give socially acceptable responses to survey questions," said Cohen.

Those with darker skin were more likely to express stigma than those with lighter skin. Likewise, urban dwellers were more likely to express stigma to TB, as were the young.

Disease stigma impacts more than the social wellbeing of the patient and their family. Patients who perceive stigma are less likely to seek diagnosis and treatment, which leads to a number of public health concerns—patients get sicker, they infect more people and the health care facilities that treat them experience decreased revenue and risk closure, which negatively impacts those who do want to be treated.

The researchers caution that these findings should not be generalized to all public health campaigns, but rather that messaging matters.

"This work points to the need for future research to identify what kinds of messages might be most effective at minimizing stigma, and under what circumstances," they write.