Abstract
BACKGROUND: Adherence to video directly observed treatment (VDOT) remains inconsistent, with some patients frequently missing video submissions. Stigma associated with tuberculosis (TB) may influence patients' engagement with VDOT, leading to non-adherence. This study examines the effect of baseline TB-related stigma on missed VDOT submissions as a marker of patient engagement throughout treatment among patients with TB. METHODS: This study was a secondary analysis of 71 patients with TB from the DOT Selfie Randomized clinical trial (RCT) in Kampala, Uganda (July 2020-October 2021). It focused on the association between baseline TB-related stigma and missed video submissions during six months of VDOT. Stigma was measured using a 13-item tool covering self-, anticipated, and public stigma. Self-stigma is when individuals believe and internalize negative views about TB, causing shame and avoiding care. Public stigma involves harmful attitudes and discrimination from others, leading to isolation. Anticipated stigma is the fear of being judged or treated unfairly if one's TB status becomes known. Four negative binomial regression models adjusted for HIV status, alcohol use, household size, marital status, and TB severity were used to estimate adjusted incidence rate ratios (aIRR) with their 95% confidence intervals (CIs) using STATA 14.2. RESULTS: The study included 71 patients with TB with a mean age of 33 years (SD = 12), and 36 (51%) were female. TB-related stigma was highly prevalent, with 51% (95% CI: 39-62) experiencing high levels of overall stigma. The prevalence of public stigma was 97% (95% CI: 90-100), self-stigma was 80% (95% CI: 22-45), and anticipated stigma was 68% (95% CI: 55-78). High overall stigma was significantly associated with an increase in the rate of missed VDOT videos (aIRR = 1.9; 95% CI: 1.1-3.5). Similarly, patients who reported anticipated stigma missed twice as many VDOT videos as those without anticipated stigma (aIRR: 2.1; 95% CI: 1.2-3.8). There was no significant association between self and public stigma and missed videos. CONCLUSION: TB-related stigma, particularly the anticipated fear of judgment, undermines VDOT adherence monitoring. Interventions such as early screening for stigma, patient counselling, and community education are essential to improving outcomes.