Food insecurity, not stigma, linked to worse mental health in Botswana TB patients

Tuberculosis (TB) and HIV both carry powerful social stigma, and when someone has both conditions the stigma can overlap and intensify. Researchers led by Sanghyuk S. Shin set out to understand how TB-related and HIV-related stigma relate to two common mental health problems—depression and anxiety—among people newly diagnosed with TB in Botswana. They also wanted to know whether men and women experience these links differently. To find out, the team enrolled 180 people with TB at 12 health centers in Gaborone. About 35.6% of participants were women (64 people) and 55.0% (99 people) were living with HIV. The study measured depression and anxiety and asked participants about their experiences of stigma from different angles, then used statistical models to see whether higher stigma scores were associated with worse mental health. The research focused on real-world factors affecting people early in their TB treatment experience and tested whether gender changed the relationships between stigma and mental health.

The study used standard, named questionnaires to measure mental health and stigma: depression was assessed with the PHQ-9, anxiety with the ZUNG Self-Rating Anxiety Scale, TB stigma with the Van-Rie TB-related Stigma Scale (from both patient and community perspectives), and HIV stigma with an HIV-related Stigma Scale. The team analyzed the data using linear regression and tested moderation by gender with interaction terms. In models adjusted for confounders, the links between depression and stigma did not reach statistical significance: TB-related stigma from the patient perspective (β = 0.12, p = 0.065), TB-related stigma from the community perspective (β = 0.03, p = 0.7), and HIV-related stigma (β = 0.07, p = 0.4). Likewise, models for anxiety showed no evidence of association with TB- or HIV-related stigma in final models: patient perspective (β = 0.04, p = 0.7), community perspective (β = −0.11, p = 0.4), and HIV-related stigma (β = 0.24, p = 0.14). The analyses did find that food insecurity was positively associated with worse mental health outcomes, and that male gender was associated with lower depression and anxiety scores. There was no evidence that gender changed (moderated) the relationship between stigma and mental health.

These findings suggest a more complicated picture than the simple expectation that more stigma always equals worse mental health. In this sample of people recently diagnosed with TB in Gaborone, Botswana, stigma measures did not show clear, statistically significant associations with depression or anxiety once other factors were taken into account. Instead, lack of reliable food and material resources emerged as a measurable driver of poorer mental health. That does not mean stigma is unimportant: stigma may still affect lives in ways the study’s measures did not fully capture, or it may influence other outcomes such as care seeking and social support. For policy and practice, the study points to the value of integrating social and economic support into TB care. Strengthening TB programs to address food insecurity and broader financial and material needs could have immediate benefits for mental health among people with TB and people with TB and HIV, even while stigma-reduction efforts continue.