Social isolation, social exclusion, and access to mental and tangible resources: mapping the gendered impact of tuberculosis-related stigma among men and women living with tuberculosis in Eastern Cape Province, South Africa

BACKGROUND: In 2022, an estimated 10.6 million people developed tuberculosis (TB) globally, with men bearing a greater burden of disease compared to women. In South Africa specifically, men experience higher risks of poor outcomes and TB-related mortality than women. Stigma and isolation among people living with tuberculosis (PLWTB) are well documented. The gendered pathways through which TB-related stigma leads to isolation or impacts access to resources during one's illness-to-health journey are poorly understood. METHODS: We interviewed PLWTB receiving treatment at government clinics in Buffalo City Metro Health District, Eastern Cape Province, South Africa. Semi-structured guides explored TB symptom experiences, access to care, treatment motivation, key supporters, and access to mental and tangible resources (MTRs) during illness. Open coding was done inductively, with MTR domains informed by the Network-Individual-Resource Model. Findings were analyzed through a cyclic, iterative, and deductive process using social isolation and exclusion as interpretive lenses. Memos and pathway mapping examined gendered differences in stigma, isolation, and access to networked MTRs. RESULTS: One hundred forty-two PLWTB (men = 86; women = 56) were interviewed. PLWTB described pervasive TB stigma and isolation. Women described self-isolating in response to enacted and anticipated stigma. Men described active exclusion by friends and family. Women's maintenance of familial ties facilitated access to MTRs while ill. Men's systematic exclusion (e.g., deliberate or forced by peers or family) reduced their agency to access resources. Men and women described regaining physical strength and recovery of social networks through treatment, but also the sustained impacts of post-treatment stigma. CONCLUSIONS: We identified gendered pathways through which TB stigma and isolation affect access to MTRs. For women, stigma led to social isolation, but familial networks helped maintain access to MTRs, fostering resilience. Men experienced social exclusion, reduced agency to access MTRs, and increased vulnerability during illness. Findings can guide gender-responsive interventions to reduce the impact of TB stigma on health outcomes.