20

IJPHN

Relationship of Age, Gender, and History of Comorbid Diseases in TB Patients

toward Self-Stigma TB in Surakarta
Ignes Widowati*, Balgis, Sri Mulyani

Public Health Department of Medical Faculty Sebelas Maret University, Surakarta, Indonesia

*Corresponding Author:
Ignes Widowati
E-mail: [email protected]

Abstract
Tuberculosis (TB) infection in Indonesia has not been completely eradicated. It is challenging for those
who suffer from TB to be away from self-stigma. This study aimed to determine the relationship between
age factors, gender, and a history of comorbid diseases related to self-stigma. This was a cross sectional
study using a Tuberculosis Stigma Assessment questionnaire. Total 50 respondents were obtained by
purposive sampling technique. Inclusion criteria are TB patients or former patients aged 18 years to the
elderly, male and female, without or having a history of comorbidities (HIV & DM). Quantitative-
qualitative analysis, univariate and bivariate tests using Pearson Correlation and Chi Square were
employed. Based on the Pearson correlation test there were no relationships between age and stigma,
adolescent (p = 0.506), adult (p = 0.732), and elderly (p = 0.539),. Through Chi Square test, there was no
relationship between the gender and stigma (p=0.520) . Likewise, a history of comorbid disease with TB
stigma which p-value 0.537 did not show any relationship. Quantitatively, 78% of respondents were
stigmatized, where respondents tend to be shy and not open about their TB status. There were 78% of
respondents were stigmatized but no significant relationships between age, gender, and history of comorbid
diseases on TB self-stigma.

Keywords : Self-stigma; TBC; age; gender; comorbid diseases.

Abstrak
Infeksi Tuberkulosis (TBC) di Indonesia belum tereradikasi sempurna. Penderita TBC seringkali sulit
terlepas dari self-stigma. Penelitian ini bertujuan untuk mengetahui hubungan faktor usia (remaja, dewasa,
dan lansia), jenis kelamin, dan riwayat penyakit komorbid dalam memengaruhi self-stigma. Penelitian
cross sectional study menggunakan kuisioner Tuberculosis Stigma Assessment. Sebanyak 50 responden
didapatkan dengan teknik purpossive sampling. Kriteria inklusi penderita atau mantan TBC usia 18 tahun
hingga lansia, pria dan wanita, serta tanpa komorbid atau memiliki riwayat komorbid (HIV & DM).
Dilakukan analisa kuantitatif – kualitatif, uji Univariat serta Bivariate dengan teknik Pearson Korelasi dan
Chi Square. Berdasarkan uji korelasi pearson tidak terdapat hubungan antara usia dengan stigma, usia
remaja (p= 0,506), usia dewasa (p=0,732), dan lansia (p=0,539). Melalui uji Chi Square tidak ada
hubungan antara jenis kelamin dengan stigma (p-value 0.520). Begitu pula riwayat penyakit komorbid
dengan stigma TB dengan p-value 0.537 juga tidak menunjukkan hubungan. Secara kuantitatif sebanyak
78% responden terstigma, dimana responden cenderung malu dan tidak terbuka tentang status TBCnya.
Terdapat 78% responden terstigma namun tidak terdapat hubungan signifikan antara faktor usia, jenis
kelamin, dan riwayat penyakit komorbid terhadap self-stigma TBC.

Kata kunci: Self-stigma; TBC; usia; jenis kelamin; penyakit komorbid

Indonesian Journal of Public Health Nutrition October 2021, Vol. 2 Issue 1 page 20 - 33
 21

Introduction several conditions such as the presence

of comorbid diseases further add to the
Infectious disease Tuberculosis (TB)
stigma of the community, eventually TB
prevalence is still in the top rank in the
sufferers tend to close themselves and be
infectious diseases’ problems in
isolated. This also makes people
Indonesia which has not been completely
reluctant to check themselves for fear of
eradicated. According to WHO data in
being stigmatized by the community, so
2018, Indonesia was ranked 5th in the
that the discovery of TB cases in
highest number of TB and TB/MDR
Indonesia and Surakarta in particular is
cases, while Indonesia's TB-HIV cases
still low.
were ranked 7th in the world (1). In
In a study of Age and Race
2019, Indonesia's position rose to the
Differences of Self Esteem which data
third rank after China and India with an
collected using Rosenberg’s Scale of
estimated 845,000 TB cases while the
Global self esteem that measured vary in
number of notified TB cases was
time told that age significantly correlated
543,874 (2).
with self-esteem (4) where fluctuated
Tuberculosis has negative impacts
self-esteem condition over the age could
on health also reduces the patient's
influencing self-stigma level among
immunity makes their condition get
patients. While in TBC-Related Stigma
worse, even turn to other complications
study in Dalian China, a cross sectional
such as HIV/AIDS, malnutrition, and is
survey where data collected using
closely related to history of comorbid
questionnaire to measure stigma that was
diseases such as Diabetes Mellitus. In
designed by relevant literature and
addition, TBC impacts on social life,
consultations with experts in related
creates community stigma even results
fields revealed that female patients were
social isolation. The existence of this
more likely to have high level of stigma
stigma becomes a burden for TB
than men where they were discriminated,
sufferers which causes many patients do
social exclusion, and influencing marital
not want to be found out if they have TB
prospect (5). Also in patients who having
as fear of being stigmatized. This leaves
TBC and comorbidities such as HIV,
many patients undiagnosed and becomes
could worsen their self-stigma level (6).
a source of transmission for others so
Due to the problems and the
that the TB problem in Indonesia is not
resulting impact, it is necessary to
resolved.
remove the stigma. Therefore, the
Beside stigma from other people
researchers wanted to conduct research
(enacted stigma), there also (self-stigma)
on the relationship between age, gender,
which appear from theirselves, where
and history of comorbid disease in TB
they devaluate, ashamed, think
patients in dealing with TB stigma in the
negatively about something that has
Surakarta community. The purpose of
happened to them or due to external
this study was to examine how far the
stigma (3). There are several factors
factors of age, gender, and history of this
could affect the response of TB sufferers
comorbid disease affect the response of
in facing stigma, namely are age, gender,
TB patients in dealing with stigma, then
level of education and knowledge about
find out how these TB sufferers respond
TB, access to health, history of comorbid
to stigma and find out what stigma they
diseases, and so on. These factors could
have received.
impact on the patient's psychological
condition, healing progress, and
motivation to recover. In addition,

Indonesian Journal of Public Health Nutrition October 2021, Vol. 2 Issue 1 page 20 - 33
 22

Methods communities may know that I

have TB
This study was an analytical
X6 : I am scared to tell others I have TB
observational study with a cross
because they may thin I also suffer
sectional study approach using
HIV/AIDS
purpossive sampling techique to collect
X7: I feel guilty about suffering fromTB
the data. This study was conducted in 11
because it is a burden for my
community health centers representing 5
family
sub-districts in Surakarta. The data of
X8 : I choose carefully to anyone to talk
both TBC active patients and former
about TB that I suffered (only tell
TBC patients who were diagnosed from
to certain people)
2018 until 2021 were collected and
X9 : I am afraid to tell about my TB to
selected depend on specified criteria. TB
my family
or former TBC patients aged 18 years old
Beside the statements there are four
untuil elderly, women and men, without
Likert Scale to measure self-stigma’s
comorbidities or having comorbidities
level of respondents ( 1= strongly
(we only focus on HIV and DM) were
disagree, 2= disagree, 3 = agree, 4=
included. Total subjects were 80
strongly agree). The B section contains
respondents, which 30 respondents were
of 7 questions to ask whether
used for questionnaire validity and
respondents have ever felt or obtained
reliability test, while 50 respondents for
community stigma and where
study analysis.
repondents obtained the stigma. Last, the
The instrument data collection
C section contains of 3 descriptive
using Tuberculosis Stigma Assessment
question to let respondents tell about
which is developed by Stop TB
their TBC treatment and stigma
Partnership by Van Rie that we has
experiences in detailed description.
translated them to Bahasa Indonesia.
Beside those sections, sociodemographic
This assessment or questionnaire has 3
characteristic form was added, involving
sections (A, B, and C) which each of
questions demographic characteristics
them contains separate measurement
(age, gender, work, education, and
tools. The A section contains 9
income rate per month) also data of
statements to measure how do
current TBC status. The cronbach alpha
respondents thoughts and feel about their
was 0,720 , so this assessment is reliable
TBC conditions, as illustrated in Figure
to used.
1 as X1-X9 to describe each point
We collected the data by online to
statement in section A. X1-X9 are
prevent the coronavirus spreading, thus
written to describe each statement in
we contacted respondents’ phone
questionnaire . There are:
number one by one then sent the
X1:I feel hurt because of other reactions
questionnaire in the form of googleform.
toward my TB condition.
The instruction and informed consent
X2: I have lost/have been shunned by
was available inside gform, so
friends or relatives when I tell
respondents who refused to participate
about my TB
were excluded from this study. We
X3: I feel alone
guided the respondents to help them
X4: I am afraid to tell other people
answer the questions to minimalize miss-
(outside family members) that I
interpretation.
have TB
Data obtained from the sample were
X5: I am afraid to go to TB
analyzed using SPSS 25.0 version.
clinic/hospital because

Indonesian Journal of Public Health Nutrition October 2021, Vol. 2 Issue 1 page 20 - 33
 23

Univariate analysis were done to know Meanwhile in table 2, talked about

frequencies and percentages of frequency distribution of respondents in
sociodemographic data and each this study. A total of 50 respondents were
variables. Bivariate analysis using grouped into 4 age categories, namely:
pearson correlation and chi-square test adolescent age (17-25 years), adult age
were performed to examine the (26-45 years), pre-elderly age (46-55
significance correlation between each years), and elderly age (56->65 years). ,
variables. In addition we presented where the most were adult respondents
quantitative and qualitative analyses to as many as 25 people, dominated by
examine the findings of this study. women as many as 28 people. This is in
accordance with WHO which stated that
the majority of TB patients are adults of
Results
productive age (7). However, for the
Sociodemographic data of gender dominance of the respondents in
respondents were presented in table 1, this study were women, it’s not in
including data on recent education, accordance with several research
occupation, income, latest diagnosis, and journals such as in Sari, 2018 and Aryal,
treatment status at the time of the study. et.al, 2012 where TB respondents were
The majority of respondents in this study more likely to be male due to smoking
received the latest education equivalent risk factors, work environment factors,
to high school as many as 23 people. The and the possibility of drinking alcoholic
most jobs undertaken by respondents beverages (8,9). The majority of TB
were factory workers as many as 10 respondents here were without
people, while the income of most comorbidities, but for respondents with
respondents were below the minimum TB-DM there were 7 people while TB-
wage for Surakarta city. When we asked HIV was 1 person only who agree to
the respondents, majority of patients had participate. Based on the scores from the
recovered or were called ex-TB as many STP TB Van Rie questionnaire, the most
as 32 people, on average, they had respondents scored above 18, so 39
finished treatment during the last year. people were classified as stigmatized
while 11 people were not stigmatized.

able 1. Sociodemographic Characteristics

Characteristics Frequencies Percentages
Gender
Female 28 56%
Male 22 44%
Age
18-25 9 18%
26-45 25 50%
46-55 12 24%
>56 4 8%
Education
Uneducated 8 16%
Elementary school 11 22%
High school 23 46%
Bachelor 4 8%

Indonesian Journal of Public Health Nutrition October 2021, Vol. 2 Issue 1 page 20 - 33
 24

Work
Salesman 6 12%
Business 3 6%
Factory workers 10 20%
Drivers 3 6%
Teacher 4 8%
Employee 8 16%
Odd job 1 2%
Student 2 4%
Retired 1 2%
Unemployed 8 16%
Income
No income 9 18%
< Rp.2.500.000 27 54%
Rp. 2.500.000 3 6%
>Rp. 2.500.000 7 14%
Current Diagnose
Pulmonary TBC 15 30%
Extra-pulmo TBC 2 4%
MDR-TBC 1 2%
Recovered 32 64%
Treatment Status
Completed >1 year ago 13 26%
Already done this past year 25 50%
Undergoing treatment 12 24%
Comorbidities
Diabetes Mellitus 7 14%
HIV 1 2%
Without comorbid 39 78%
Others 3 8%
Self-Stigma
Not stigmatized 11 22%
Stigmatized 39 78%
Total 50 100%

Table 2. Relationship between Age (Adolescent, Adult, and Elderly), Gender, and
Comorbidities in TB Patients toward Self-Stigma TB in Surakarta
Independent variable Dependent variable Correlation P-value (sig.)
coefficient

Adolescent Self-stigma -0,256 0,506 a

Adult -0,072 0,732 a
Elderly 0,160 0,539 a

Gender Self-stigma 0,520b

Comorbidities
(HIV& DM) Self-stigma 0,537b
a = Pearson correlation; b = Chi Square

Indonesian Journal of Public Health Nutrition October 2021, Vol. 2 Issue 1 page 20 - 33
 25

Table 3. The results of the quantitative scores of respondents' answers to the questionnaire
Categories Stigmatized Non stigmatized Frequencies
Age Group
Adolescent (18-25 y.o) 9 0 9
Adult (26-45 y.o) 17 8 25
Elderly (>46 y.o) 13 3 16
Gender
Female 22 5 27
Male 17 6 23
Comorbidities
DM 5 2 7
HIV 1 0 1
Total 39 11 50

X9 8% 74% 16% 2%

X8 2% 42% 36% 20%

X7 4% 52% 38% 6%

X6 2% 80% 14% 4%

X5 6% 86% 8% 0%

X4 0% 42% 48% 10%

X3 8% 76% 12% 4%

X2 12% 76% 10% 2%

X1 4% 76% 16% 4%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Strongly disagree Disagree Agree Strongly agree

Figure 1. Percentage of respondents' answers to each item of the questionnaire questions

The results of the Pearson test for the In the bivariate test of adolescent age
adolescent age group, p value = 0.506, the (18-25 years) there was no relationship
adult age group, p = 0.732, and the elderly between adolescent age and self-stigma.
group p = 0.539. All three had p-value According to the previous theory, Neff and
more than 0.05, so it can be concluded that McGehee (2010), during adolescence
the age variable for adolescents, adults, there were several distinct pressures, such
and the elderly were not significant with as pressures when searching for self-
self-stigma. Besides, gender and identity, pressures for academic
comorbidities obtained p-value 0.520 and performance, need to be popular, the
0,537, where both are greater than 0.05 so desire to be accepted, feeling fit in an
there were no relationship between the two appropriate social group, role and
variables. environmental conditions that cause social
pressure to make adolescent emotional
Relationship between age and self- tension higher where this could affect self-
stigma of TB patients esteem (10). As Maharjan, et.al, 2019 said
self-esteem was related to self-stigma, the

Indonesian Journal of Public Health Nutrition October 2021, Vol. 2 Issue 1 page 20 - 33
 26

lower the self-esteem, the higher the self- factors, friend support, environment,
stigma. Thus during puberty, where socio-culture, and community norms that
emotions fluctuated, adolescents were applied in the area (14). So besides being
vulnerable to have low self-esteem (11) so influenced by age (intrinsic), extrinsic
they were vulnerable about self-stigma. could be the answers. As in the study of
However, the results of this study did not Abdisa, et.al, 2020 which examined self-
agree with the theories above. stigma in Mental Illness patients, the
Meanwhile, the bivariate test for results showed that family, friend, and
adults (26-45 years old) toward self- environmental support significantly
stigma also showed no significant affected self-stigma, where patients who
relationship. This did not correlate with received social support tended to have a
previous theories, such as in Jahja, 2011 good prognosis and avoid by self-stigma
where adults began to stabilize their (15).
emotions and showed authority so they
could be wiser, think longer, and were not Relationship between gender and self-
easily influenced by stigma (12). In stigma of TB patients
addition, from research by Shaw, et.al,
2011 said at the age of young adults (25 There was no significant relationship
years) experience increasing of self- between gender and self-stigma of TB
esteem and when entering the age of mild patients in bivariate analysis which
life (45 years), self-esteem tended to be showed p value = 0.520 539 (greater than
stable which could affect adults in 0.05). According to the gender difference
responding stigma (4). hypothesis, that were, physically and
Likewise in the elderly who did not psychologically, men and women had their
show any significant relationship between own characteristics, differences in
the self-stigma of tuberculosis, which was emotional management between men and
not in accordance with the theory of women affected their mindset, how to
Eisdofer, 1997 in Johana 1994 which said express emotions, and how they behave,
in the elderly there was a degenerative thus influencing the perspective on stigma.
process, the body was weakened and In the study of Mirowsky and Ross,
susceptible to disease especially if the 2000 women reported more symptoms
elderly were exposed to Tuberculosis and when experiencing distress, depression,
the stigma of society, it would be easier to and anxiety than men (16). In addition,
make them down and lose motivation. men had a habit of hiding what they felt
Self-esteem in the elderly also began to more than women who were more
decline (4) . In the study of Griffiths, et.al, expressive of their emotions so easy for
2008 it was also found that self-stigma was self-stigma to occur (17). However, the
significantly higher in older patients (13) , results of this study did not agree with the
but the above study did not agree with the research above, because self-stigma can be
results of this study. influenced by extrinsic factors as
The conclusion of this study was previously described. According to, Jing
adolescents, adults and the elderly were Teo et.al.2020 explained TB patients had
not significant with self-stigma. courage to face their illness because of
According to Widiyatun, 1999 self-stigma family support, friends, and other TB
was influenced by intrinsic factors such as survivor made them stronger in facing
age, gender, maturity level, experience, stigma (18).
physical condition and mental health, as In addition, there were social factors
well as extrinsic factors including family could affect the stigma of TB patients,

Indonesian Journal of Public Health Nutrition October 2021, Vol. 2 Issue 1 page 20 - 33
 27

where TB respondents who lived in urban participants in this study due to since
areas had higher average stigma value than pandemic strikes, TBC findings in all
those who lived in rural areas, as in urban health centers were decreased also some
areas respondents more secretive, did not respondents refused to participate,
want others to know if they were suffering therefore the number of respondents was
from TB than residents of rural areas who quite small. TB-DM and TB-HIV
were more indifferent to TB (19), as is the respondents in this study, namely 7 people
case with research by Mushtaq, et.al. 2011 (TB-DM) and 1 person (TB-HIV), the
which said the majority of TB respondents results might not be significant. Although
in urban areas felt embarrassed if they some journals, especially those with TB-
were found to have TB compared to HIV, said to have higher levels of anxiety
respondents in rural areas (20). Stigma in and were significantly associated with
TB patients was also more prevalent in stigma (23) and TB-HIV sufferers felt
respondents of working age (20-50 years more embarrassed and often criticized for
old) because respondents often felt afraid suffering from HIV which was considered
and embarrassed if their coworkers know to be contagious (18).
about their TB disease and frequently In addition to the lack of research
stigmatized (shunned) by coworkers if respondents, there could be other external
caught (21). factors affected self-stigma, as in the study
of Botchsway, et.al. 2021 regarding stigma
in people with diabetes in Ghana found
Relationship History of Comorbid there was no significant difference
Diseases (HIV & DM) with Self-stigma between patients with low stigma or high
of TB patients stigma, one of which was influenced by
the factor of family support (social
Bivariate analysis between comorbid support) where respondents with low self-
disease variables (HIV & DM) and self- stigma were significantly positively
stigma showed no significant relationship. correlated with the presence of high social
In our hypothesis, comorbid diseases (HIV support. Height (24) .
& DM) had a relationship with self-stigma From the table 3 could be seen as a whole
as TB patients with comorbidities felt based on the results of the questionnaire
negative impacts, both physically (sick) scores, respondents with stigmatized
and the stigma imposed on them, patients scores were much higher than non-stigma
tended to feel burdened, tended to be alone scores. In the age category, both the
and blame themselves. As research by category of adolescents, adults, and the
Yuyun et al, 2011 said most of the HIV elderly, the stigmatized scores more than
respondents were still afraid of their HIV those who were not stigmatized. In the
status being known by others due to afraid gender category, women scored more
of being stigmatized and ostracized by stigmatized than men, and 5 people with
society (6). Likewise, DM sufferers who comorbid DM were stigmatized and 1
felt the psychological impact since being person with HIV.
diagnosed with Diabetes Mellitus, where If a comparison was made, according
every day he lives with DM, of course the to the questionnaire score as many as 78%
patient would feeling discouraged, of respondents were stigmatized, but in the
stressed or even depressed (22). SPSS, analysis test the relationship
However, the results of the analysis of between independent variables and self-
this study did not agree with the theory stigma was not proven to be significant.
above, because it could be affected by This could be due to the fact that the
several factors. First, lack number of

Indonesian Journal of Public Health Nutrition October 2021, Vol. 2 Issue 1 page 20 - 33
 28

number of respondents who represented The following presents the data based
each variable in this study was quite small, on Figure 1 which the percentage of
so could not represent the actual respondents' answers to the questionnaire
relationship between the two variables. As from items X1-X9, dominant respondents
in the adolescent age category which only answered agree on items X4, X7, and X8.
got 9 people, and in the comorbid disease In item X4 with the question "I am afraid
variable where TB-DM was only 7 people to tell other people (outside family
and TB-HIV was only 1 person. So even members) that I have TB", the most
though the score was stigmatized, could respondents answered point 3 (agree) and
not show any relationship. the second most was point 2 (disagree).
In the other hand, there were external
factor could made no significant results The followings were a description of the
among independent variables, which there patient's answers agree:
were no treatment differences
(psychological treatment to reduce self- “...And because I'm ashamed, it's also impossible
stigma) among variables ages (adolescent, to tell my friends/others that I'm sick with TB, I'm
afraid of being shunned. So I don't expose my TB,
adult, and elderly) , gender (woman and only to my family. I am very careful and afraid to
men), and comorbid disease of Diabetes relate to other people” (DA, 21 years old)
Mellitus, except for HIV where the TB-
HIV patients will get more attention and “I didn't tell my parents and in-laws for fear of
monitoring both physical and mental being worried because I was old. I don't tell my
big family and neighbors, only my wife and
health. The public health center have some children who know." (Jo, 39 years old)
programs to controlling both self-stigma in
patients also community stigma, such as, However, there are also patients who did
conduct counseling when starting TB not agree:
treatment also during medical control, but
most of public health center give same "I am an open person, so everyone knows that I
counseling treatment to TB patients, which have tuberculosis and no one stays away. I just
no spesific differences on stigma TB have fun and don't think negatively" (SL, 25 years
treatment toward those independent old)
variables, so this could be another reason
From the description above,
this relationship was not significant.
many respondents choose to only talked
The discussion contained a discussion
about TB to certain people because they
that connected and compared the research
were afraid of being shunned, ostracized,
results with the theory being tested and the
and fear to be a burden on their minds.
results of previous research. The
However, some patients also did not mind
discussion could end by mentioning the
telling their condition, it could be
limitations of the study and suggestions for
influenced by the personality factor of
further research.
someone who were open or believed that
In this questionnaire there were 9
people around support them.
question items which include questions
In item X7 with the question "I
with points using a Likert scale system (1
feel guilty about suffering from TB
= strongly disagree, 2 = disagree, 3 =
because it is a burden to my family" the
agree, 4 = strongly agree) accompanied by
most respondents gave a score of 2
questions with description answered for
(disagree) as much as 52% and a score of
respondent shared their opinion about the
3 (agree) 38%. Here's the description:
experience of stigma. The following were
a review of respondents' answers.

Indonesian Journal of Public Health Nutrition October 2021, Vol. 2 Issue 1 page 20 - 33
 29

"I also feel very guilty about suffering from are really close and can be trusted." (D, 22 years
tuberculosis, because at home I live with mother old)
only, I as the breadwinner for family while my
mother is sick, so I feel guilty for suffering from “Never tell my neighbors because I am afraid that
tuberculosis." (Mu, 20 years old) the neighbors will know it (as I live in the
village)” (F, 26 years old)
“I feel guilty how come I got TB” (Madam, 51
years old) "I don't get stigmatized for being picky about
stories about TB, so only certain people know."
"I feel guilty that I got TB, maybe because I (Su, 52 years old)
smoked and met a lot of people at work.
Meanwhile at home, my cousin is still young, it's a However, there are also patients who
shame if he catches it, so I keep my distance and
wear mask also my own spoon." (SL, 25 years
disagree with this statement:
old)
"My family and neighbors are supportive; there's
However, there are also those who no avoiding and I don't cover up." (De, 43 years
old)
disagree with this statement:
"The neighbors around here are supportive
"I don't feel bad talk/fear/guilt because my people, they don't isolate/dissolve them, they even
principle of being sick is from Allah (God), so I support them so they can get better." (Aug, 41
just accept it and treat it until it heals." (So, 51 years old)
years old)

“My husband always supports me in reminding

From the description above, that
me to take medicine and maintain my diet, so I respondents were scared to tell about TB
feel motivated.” (Ro, 31 years old) (only tell certain people) because they
were afraid of being shunned, ostracized,
From the respondents' descriptions, and getting bad words. However,
they guilty for suffering from TB because respondents who disagree have a reason
they felt sorry for family members who that the patient felt his family and their
lived in the same house as the respondent environment (neighbors/friends) won’t
due to fear of being infected. However, isolate the respondent.
some respondents disagree because
respondents received support from their
families so they were motivated, some Discussion
were sincere and resigned that all the This research study aims to see the
illnesses they suffered were God's destiny form of self-stigma that occurs in TB
so there was nothing to regret. patients in Surakarta associated with age,
Finally, the X8 item. with the gender, and history of comorbid disease
statement "I choose carefully to anyone to with 50 respondents as subjects where
talk about the TB that I suffer (only tell quantitatively obtained 39 or 78%
certain people)" the most patients respondents were stigmatized. This result
answered point 2 (disagree) as much as was bigger than the findings in the TBC
42% and the second most was point 3 self-stigma study in Cambodia that used a
(agree) as much as 36% with the following similar questionnaire which stigmatized
description: percentage of more than 50%18] . The
results showed there was no significant
“During the time I was sick with TB, I was afraid relationship between age, gender, and
to tell other people, afraid to be
shunned/discussed negatively. So my family and I
comorbid disease (HIV & DM) variables
don't tell anyone, even if we only tell people who on self-stigma, but quantitatively 78% of
respondents were stigmatized. This

Indonesian Journal of Public Health Nutrition October 2021, Vol. 2 Issue 1 page 20 - 33
 30

section will combine discussion of In addition, in Abioye, et.al, 2011 also

quantitative with qualitative findings. explained many TB patients covered their
The answers and scores given by TB status from the community in
respondents to the 9 questions above vary anticipation of external stigma, and some
greatly. Some gave an agree score to all who told their TB status are stigmatized
question items, some only gave a score of (23). Whereas in TB-HIV patients,
3 (agree) to 2-3 items, some even gave respondents never told others they had
only 1 item a agree score, but even though HIV, for fear of being discriminated, as in
only 1 out of 9 items was given a score of Cremers, 2015 where TB-HIV sufferers
agree, the total score was quantitative were associated with immoral behavior
already stigmatized. Therefore, the (25). The existence of self-stigma caused
answers and scores of respondents vary sufferers to fear being a source of
widely. However, from the nine items transmission and being discriminated
above, the item that was chosen by the against/bullying from the community.
most respondents with a score of agreeing However, by not telling other people, most
was the question item no. 4 “I am afraid to of the respondents did not feel stigmatized
tell other people (outside family members) from the community, according to the
that I have TB”, item no. 7 “I feel guilty qualitative discussion as many as 80% of
for suffering from TB because I am a people did not feel stigmatized because no
burden to my family” and item no. 8 “I one else knew the respondent had TB.
choose carefully to tell anyone about my Furthermore, 44% of respondents felt
TB (only tell certain people)”. guilty for suffering from TB as they felt
Respondents of adolescent, adult, and were a burden on their family. As it’s
elderly age, both female and male, and a known TB was highly contagious (26)
history of comorbid DM and HIV, each made sufferers afraid of transmitting it to
dominantly answered agree on item no. 4, their families, besides many sufferers
7, and 8. Thus, in this study, the dominant couldn’t work during treatment so their
TB respondents felt stigmatized (self- income for family needs was reduced, as
stigma) due to closing themselves off from Courtwright research, 2010 that TB
the outside environment because of shame sufferers, especially men, often lose their
and fear of being stigmatized by society. jobs due to TB (27). But on the other hand,
In item no.4, 58% of respondents 80% of respondents in this study received
answered agree if they were afraid to tell positive support from their families,
other people (outside family members) therefore even though they felt guilty, their
that they had TB. According to the families still supported their treatment,
respondent's confession, they were scared where family support and closest people
other people would find out about their TB played an important role in supporting the
status because they would be being treatment and recovery of TB patients
shunned, given a negative stigma from (28).
society, or even losing their job. Thus Finally, 56% of respondents chose
many respondents were silent (not telling) carefully to tell anyone about TB (only
to other people except family/close friends told certain people). The majority of TB
who can be trusted. Some of them even did sufferers only told their TB status to the
not admit that they had TB when asked. closest people, such as family, lovers,
This was similar to the research of close friends, close relatives, or people
Mushtaq, 2011 where the majority of TB who had an interest in knowing about their
respondents, especially those living in condition (29). Due to TB sufferers scared
Urban areas covered his TB status (20). of being negatively stigmatized by others

Indonesian Journal of Public Health Nutrition October 2021, Vol. 2 Issue 1 page 20 - 33
 31

and treated unfavorably , made them Because there are still many TB
tended to close themselves off and hide respondents who have self-stigma that
their identity (8). masks the identity of the condition
In addition to the three items above, as suffered from the surrounding community,
many as 20% of respondents were found efforts are needed to overcome self-
to have been hurt due to being stigmatized stigma. There needs empowerment in
from outside, where as much as 2.4% relation to their TB status, such as
received stigma at home, 3.7% received counseling by health workers and
stigma at work and hospitals/health discussion forums between patients and
centers, and 12.2% received stigma at their families to support TB patients on a
home. Respondents said they were regular and scheduled basis.
shunned at work and by their neighbors In addition, it is necessary to educate
because they were afraid of being infected, the community about knowledge of TB
as well as being discriminated against by disease and the impact of stigma on TB
health workers when they wanted to check sufferers, hope the community will be
at the health center. aware the importance to eliminate
Due to still many TB respondents who negative stigma towards TB sufferers. If
have self-stigma that masks the identity of this is carried out comprehensively, both
the condition suffered from the community stigma and self-stigma for TB
surrounding community, efforts are sufferers would be eliminated and help
needed to overcome self-stigma in TB reduce TB cases in Indonesia.
patients because the resulting
consequences could worsen treatment Acknowledgment
results, trigger greater transmission, and
The researcher expresses gratitude to
facilitate the occurrence of multiresistant
Allah SWT, the Almighty God, with
drug TBC. Therefore to eliminate self-
whose permission this research can be
stigma, it is necessary to empower them
completed properly. Then the researcher
with regard to their TB status, such as
would like to thank the parents who
counseling by health workers and
always give their prayers and give the best
discussion forums between patients and
for the researcher. In addition, to dr. Balgis
their families to support TB patients (30) .
and Mrs. Mulyani as supervisors who
guide the author so this research could be
Conclusion better. And lastly, thanks to fellows for the
motivation given.
The results showed there was no
relationship between adolescent age (p-
References
value 0.506), adult age (p-value 0.732),
elderly age (p-value 0.539), gender (p- 1. World Health Organtization (WHO).
value 0.520), and history of comorbid Global TB Report 2018. Paris : France.
diseases (p-value 0.520). p-value 0.537) 2. World Health Organtization (WHO).
toward TB self-stigma. However, in Global TB Report 2019. Paris : France.
quantitative terms, 78% of respondents felt 3. Alison J Gray, MRCPsych. Stigma In
stigmatized where the dominant Psychiatry. Journal of The Royal
respondents tended to feel ashamed and Society of Medicine 2002; 95(2): 72–
cover up their TB status from the 76.
surrounding environment in order to avoid
community stigma. 4. Shaw, B. A., Krause, N., Liang, J. and
Bennett, J. Tracking changes in social

Indonesian Journal of Public Health Nutrition October 2021, Vol. 2 Issue 1 page 20 - 33
 32

relations throughout late life. Journals perkembangan remaja. Jakarta:

of Gerontology: Psychological Salemba Medika; 2010.
Sciences and Social Sciences 2011;
62B, 2, S90–9. 13. Kathleen M Griffiths,Helen
5. Chen, et.al. Tuberculosis-related Christensen, Anthony F Jorm.
Stigma and It’s Determinants in Predictors of Depression Stigma.
Dalian, Northeast China: a cross- BMC Psychiatry 2008; 8(25).
sectional study. BMC Public Health
14. Widayatun TR. Behavioral science.
2021; 21(6).
Jakarta: CV. Sagung Seto. 1999.
6. Yuyun, Y, Rini,S.H dan
15. Eba Abdisa, Ginenus Fekadu, Shimelis
Aryastami.N.K. Faktor - Faktor
Girma, Tesfaye Shibiru, Temesgen
Pendukung Kepatuhan Orang Dengan
Tilahun, Habib Mohamed, Aaga
HIV/AIDS (Odha) Dalam Minum
Wakgari, Amsalu Takele, Milkias
Obat Antiretroviral Di Kota Bandung
Abebe,Reta Tsegaye. Self-stigma and
Dan Cimahi. Pusat Teknologi
medication adherence among patients
Intervensi Kesehatan Masyarakat,
with mental illness treated at Jimma
Badan Litbangkes, Pusat Humaniora,
University Medical Center, Southwest
Pemberdayaan Masyarakat dan
Ethiopia. International Journal of
Kebijakan Kesehatan, Badan
Mental Health System 2020;14(56).
Litbangkes Buletin Peneliti Kesehatan
16. Mirowsky, J., & Ross, C. E. Social
2011; 42(2): 72 - 83 73. Bandung.
causes of psychological distress. New
7. World Health Organtization (WHO).
York: Aldine de Gruyter 2003.
Global TB Report 2014. Paris : France.
17. Hsiu-Lan Cheng, Cixin Wang, Ryon C.
8. Sari Yunita. Gambaran Stigma Diri
McDermott, Matthew Kridel, Jamey
Klien Tuberkulosis Paru (TB Paru)
Leeanne Rislin. Self-Stigma, Mental
Yang Menjalani Pengobatan Di
Health Literacy, and Attitudes Toward
Puskesmas Malingping. Media Ilmu
Seeking Psychological Help. Journal
Kesehatan 2018; 7(1).
of Counseling and Development 2018;
9. Aryal S., Badhu, A., Pandey, S.,
(96) : DOI: 10.1002/jcad.12178.
Bhandari, A., Khatiwoda, P.,
18. Jing Teo,et.al. Characterizing and
Khatiwada, P., & Giri, A. Stigma
Measuring Tuberculosis Stigma in the
related to Tuberculosis among patients
Community: A Mixed-Methods Study
attending DOTS clinics of Dharan
in Cambodia. Open Forum Infectious
Municipality. Kathmandu Univ Med J
Diseases 2020; 7(10)
2012;37(1)48-52.
19. Oladele, et.al. A Comparative Study of
10. Neff, K. D., dan McGehee, P. Self-
Knowledge, Attitude, and
Compassion and Psychological
Determinants of Tuberculosis-
Resilience Among Adolescent and
Associated Stigma in Rural and Urban
Young Adults’. Self and Identity 2010.
Communities of Lagos State, Nigeria.
11. Bach & Szivos., S. E. Social Tuberculosis Research and Treatment
comparison, stigma and 2020; doi: 10.1155/2020/1964759
mainstreaming: the self-esteem of 20. Mushtaq ,et.al. Urban-rural Inequities
young adults with a mild mental in Knowledge, Attitudes and Practices
handicap. Mental Handicap Research Regarding Tuberculosis in Two
2010; 6(3): 217-236. DOI: Districts of Pakistan's Punjab
10.1111/j.1468-3148.1993.tb00054.x. Province. International Journal of
Equity in Health 2011; 8(4)
12. Jahja. Pertumbuhan dan 21. Fischer, A. H., Rodriguez Mosquera, P.

Indonesian Journal of Public Health Nutrition October 2021, Vol. 2 Issue 1 page 20 - 33
 33

M., van Vianen, A. E. M., & Manstead, Puskesmas Gang Sehat. Jurnal
A. S. R. Gender and Culture Mahasiswa dan Peneliti Kesehatan
Differences in Emotion. Emotion 2015; 2(3).
2004; 4(1): 87–94. 29. E A Dodor. The Feelings and
https://doi.org/10.1037/1528- Experiences of Patients with
3542.4.1.87 Tuberculosis in the Sekondi-Takoradi
22. American Association of Diabetes Metropolitan District: Implications for
Educator. AADE7 self-care behaviors TB Control Efforts. Ghana Medical
2014. Available at : Journal 2012; 46(4): 211–218.
https://www.diabeteseducator.org/pati 30. Dedeh Husnaniyah, Mamat Lukman,
entresources/ diakses pada 18 Raini Diah Susanti. Faktor-Faktor
September 2019 Yang Berpengaruh Terhadap Harga
23. Abioye, et.al Socio-demographic Diri (Self Esteem) Penderita
determinants of stigma among patients Tuberkulosis Paru Di Wilayah Eks
with pulmonary tuberculosis in Lagos, Kawedanan Indramayu. The
Nigeria. African Health Science 2011, Indonesian Journal of Health Science
11(1) 2017; 9(1).
24. Marian Botchway, PhD, MPH1,
Rachel E. Davis, PhD, MPH2, Anwar
T. Merchant, ScD,MPH, DMD,
Lambert T. Appiah, MD4, Spencer
Moore, PhD, MPH. Diabetes-Related
Stigma And Its Influence On Social
Networks, Social Support, And Hba1c
In Ghana. Original
Report:Stigma,Discrimination,Health
Disparities 2021; 31(1):57-66.
DOI:10.18865/ed.31.1.57
25. Cremers,et.al. Assessing the
Consequences of Stigma for
Tuberculosis Patients in Urban
Zambia. PLoS ONE 2015; 10(3):
e0119861.
26. Helper Sahat P. Manalu. Faktor-Faktor
Yang Mempengaruhi Kejadian Tb
Paru Dan Upaya Penanggulangannya.
Jurnal Ekologi Kesehatan 2010; 9(4).
27. Courtwright, A., & Turner, A. N.
Tuberculosis and
Stigmatization:Pathways and
Interventions. Public Health Reports
2010; 125(Suppl 4), 34±42.
28. Muhardiani, Mardjan, Abrori.
Hubungan Antara Dukungan
Keluarga, Motivasi Dan Stigma
Lingkungan Dengan Proses
Kepatuhan Berobat Terhadap
Penderita Tb Paru Di Wilayah Kerja

Indonesian Journal of Public Health Nutrition October 2021, Vol. 2 Issue 1 page 20 - 33