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ORIGINAL ARTICLE Table of Contents  
Ahead of print publication
Stigma among COVID-19 patients in South India-A cross-sectional study


1 School of Social Work, IGNOU, New Delhi, India
2 Department of Sociology and Social Work, CHRIST (Deemed to be University), Bengaluru, Karnataka, India
3 Department of Social Work, Central University of Karnataka, Kalaburagi, Karnataka, India
4 Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
5 Department of Clinical Psychology, Institute of Psychiatry, Kolkata, West Bengal, India

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Date of Submission17-Dec-2021
Date of Acceptance19-Feb-2022
Date of Web Publication12-May-2022
 

  Abstract 


Background: COVID-19 has a significant biopsychosocial impact on the lives of people who are infected, with the stigma associated with the illness being one of the major issues. However, the level of stigma based on demographics, gender differences, hospital-based or home-based care is yet to be explored. Hence, this study aimed to infer the level of stigma between these groups in the urban district of south India.
Materials and Methods: This cross-sectional study recruited 50 participants who were recently infected with COVID-19 and were receiving either hospital or home-based care. The stigma was assessed using a standardized questionnaire which has four domains. MannWhitney U test was conducted to analyze the data.
Results: Median age is 54 years and the majority of the participants are male (74%). The mean score of enacted stigma subscale was 4.48, disclosure fear was 2.34, internalized stigma was 2.82, perceived externalized stigma was 7.32 and the total stigma mean score was 17. The perceived externalized stigma subscale was higher in males (7.57 ± 5.96) when compared to females 6.62 ± 5.53. Total stigma scores were higher for males 17.2 ± 10.1 when compared to females 16.2 ± 10.5. The total stigma score was more (17 ± 10.3) among home isolated COVID patients as compared to hospitalized patients (16.9 ± 10.2).
Conclusion: Increased levels of stigma among COVID-19 patients have various important psychosocial implications. This study highlights the need for larger prospective cohort studies to further understand stigma in the context of COVID-19.

Keywords: COVID-19, home isolation, hospital care, stigma


How to cite this URL:
Shetty KV, Amaresha AC, Bamney U, Rajkumar RP, Srivastava P, Mahesh G. Stigma among COVID-19 patients in South India-A cross-sectional study. Arch Ment Health [Epub ahead of print] [cited 2022 Nov 29]. Available from: https://www.amhonline.org/preprintarticle.asp?id=345139





  Introduction Top


COVID Infected people suffer from influenza-like symptoms, such as fever, shortness of breath, sore throat, fatigue, and erythematous rash.[1],[2] In severe cases patients develop acute respiratory distress syndrome leading to multiple organ failure and death.[3] The impact is more severe in elderly people and people with comorbidities such as respiratory disorder, cardiovascular disorder, hypertension, and diabetes.[4] A large population of people is found to be asymptomatic however they are reported to transmit the virus as well.[5]

During the pandemic, the everyday habits of people have shifted abruptly. Besides their anxieties and unhappiness, people tend to have increased levels of impatience.[6] Social stigma is a societal process that excludes the persons who are thought to be a possible source of sickness or a threat to society's effective social existence.[7] The stigma attached to COVID-19 puts the lives of patients, healthcare personnel, and survivors of the disease in jeopardy.[8] Because of a perceived link to disease, persons may be labeled, stereotyped, discriminated against, treated separately, and/or lose status during an outbreak.[9]

The epidemic of coronavirus illness has resulted in social stigma and discrimination against anyone who is thought to have come into contact with the virus.[10] In the case of the COVID-19 pandemic, the virus's invisibility aided the development of a cultural risk assessment by enabling “trait-based attributions drawn from social categories and stigma associated with out-group members.[11] The widespread ignorance and incorrect assumptions about COVID-19 that are driven by rumors circulating in the news and spreading through social media could be one of the primary causes of stigma.[12] It establishes a contrast between “normal and acceptable” and “tainted and unwanted.” Race, culture, sex, and health are all common sources of social stigma.[13]

COVID 19 does not only affect physical health, it impacts mental health as well. Studies have reported that COVID 19 patients experience anxiety, phobia, and depressive symptoms.[14],[15],[16],[17] A recent study from China reported that the general population experience moderate to severe depression, anxiety, and stress symptoms during the pandemic.[16] The psychological distress in psychiatric patients has also been reported to have increased as they are unable to access their usual treatment.[18]

With an exponential increase in the number of cases, several countries resorted to imposing lockdown and India being one of them. On March 22, 2020, the Government of India requested its citizens to observe “Janata Curfew,” a self-imposed curfew for a day.[19] Post this curfew a full lockdown was imposed by the Indian Government for 21 days as a preventive strategy.[20] After this announcement, mass movement across the country took place which is said to be the largest movement since the partition of India in 1947.[21] All educational institutions, shopping centers, offices, factories, local markets, and all modes of transport were completely halted except for emergency services. The government extended lockdown till May 31st, 2020 post which the unlock phase began with gradual ease in restrictions.[22]

Although the lockdown proved to be an effective strategy for maintenance of social distancing, it came with its disadvantages including significant mental health issues like depression, anxiety, fear, loneliness, sleep disturbances, frustration, anger outbursts, etc.[23] Indians are said to be more social, engaging in several religious festivals and get-togethers throughout the year.[24] Inability to socialize was thus a major source of stress across all age groups. The uncertain nature of disease along with loss of freedom and being separated from closed ones due to lockdown are also thought to cause psychological disturbances in people.[25] The lockdown also impacted daily wage laborers and mass movement of migrant workers took place across the states. However, in contrast, a recent study in India reported a positive impact on the relationships between the people during the pandemic.[26]

As discussed, the COVID 19 brought the major psychosocial issue in the forefront such as-stigma. Dudley[27] defined stigma as “stereotypes or negative views attributed to a person or a group of people when their characteristics or behavior are viewed as different from or inferior to societal norms.” There are three levels of stigma namely social stigma, self-stigma, and professional stigma. Social stigma is a belief held by a major portion of the society against a stigmatized person, for example believing a COVID survivor to be infectious and avoiding him/her at any cost even postrecovery. A few models have been proposed to understand the social stigma. The sociocultural model explains stigma as a justification for social injustice by labeling the stigmatized person as inferior and the motivational model highlights basic psychosocial needs. The social cognitive model explains stigma using the cognitive framework.[28]

The survivors and their family members were discriminated against and stigmatized during their course of illness and even postrecovery. COVID-positive patients were abandoned by families and some were forced to vacate their rented places. The stigma has contributed significantly to the spread of the virus as people out of fear of being stigmatized avoid disclosing the symptoms and refuse to undergo testing.[27] The survivors reported the loss of friends, reduced social communication, verbal abuse, and being unfriended from social media.[29] Survivors also reported being fired from their private jobs.[8] The job loss increases their frustration, guilt, and depression.[30] Stigma is not just held by society. The stigmatized person can internalize the stigma as well. COVID 19 saw cases of suicide in patients due to self-stigma.[31] Hence, the present study is intended to explore stigma among COVID-19 patients in India. Furthermore, there is a lack of studies exploring the comparison between gender, place of care such as hospital care and home isolation, and domicile such as rural and urban. This study explores differences in stigma among these demographic groups. This will help us not only to understand the risk groups for stigma but also to design and provide demographic-specific interventions.


  Materials and Methods Top


Study design

The present study adopted a descriptive cross-sectional research design to understand the differences in COVID-19 related stigma among the gender (male vs. female), place of care (hospital vs. home isolation), and domicile (rural vs. urban).

Study setting and participants

The study comprised 50 COVID-19 patients who were under the state-run secondary care mental health hospital of Northern Karnataka which is also a research institution. The center has been designated as a counseling center for home isolated COVID-19 patients. The institution has set up a COVID-19 treatment care center and also it was receiving the list of home isolated patients from the district authority for counseling daily. The participants were selected from a cohort of patients who were either hospitalized for COVID-19 care or patients who are in home isolation and were monitored by the secondary care hospital. The inclusion criteria followed were: (1) Patients hospitalized for COVID-19 treatment or under the home isolation but monitored by hospital irrespective of the severity; (2) Consented to participate in the research; (3) Who could understand Kannada, English, and Hindi language.

Tools for data collection

Sociodemographic schedule

An interview schedule was prepared to collect the sociodemographic variables such as age, gender, marital status, religion, education, occupation, family type, residence, mode of treatment including medical and psychological variables.

The stigma questionnaire

The stigma questionnaire used in this study was from the HIV[32] and Ebola[33] related. This tool was modified by Dar et al. in 2020[29] for assessing stigma among COVID patients in Kashmir, India. The tool consists of 15 items which include 4 subscales such as Enacted stigma, Internalized stigma, Perceived external stigma, and Disclosure fears. Each item was rated on a 4-point Likert scale (0: strongly disagree, 1: disagree, 2: agree, 3: strongly agree). Scores would be summed, with higher scores indicating greater experiences of stigma. The scale has excellent internal consistency with the Cronbach “α” score of 0.92.

Ethical considerations

Ethical approval for this research was obtained from the (Institutional Review Board number: DIMHANS/H.E.R.C/10/2020–21). The participants and their caregivers have explained the aim and nature of the study. The voluntary participation, anonymity, and confidentiality of data were ensured to all the participants. Oral consent was sought from all the study participants and it was recorded. Participants who have reported psychological concern throughout the interviews received COVID-related supportive counseling as well as instruction on problem-solving techniques, coping mechanisms, and ways to accept their current feelings. Other issues expressed by the respondents were addressed and appropriately referred to.

Data collection

The data were collected from study participants through telephonic interviews post their discharge from the hospital. The first author collected the data between January 2021 and May 2021.

Statistical analysis

The data were computed in MS-excel and exported to Jamovi (Version 1.6.23) for statistical analysis. The frequency and percentile, mean and median, standard deviation, and range were conducted for demographic details and stigma scores. Since the stigma data were not normally distributed on the Shapiro-Wilks test and graphical methods the nonparametric inferential statistical test such as Mann–Whitney U-test (Mann-U) was conducted to compare the median scores between male and female, hospital care and home isolation, and rural and urban participants.


  Results Top


[Table 1] shows that the median age is 54 years. The annual family income in rupees is Rs. 100,000 and the median number of family members tested with COVID positive is one. Also, the table shows that the majority of the participants are male (74%), married (64%), religion by Hindu (82%). The majority were educated up to 12th grade (48%), farmers (32%), and half of them belong to urban areas (50%). The treatment model was predominantly hospital based (58%).
Table 1: Sociodemographic details of coronavirus disease-2019 patients

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[Table 2] summarizes the mean and standard deviation and also median and range of stigma scores. The mean score of enacted stigma subscale was 4.48, disclosure fears were 2.34, internalized stigma was 2.82, perceived externalized stigma was 7.32 and total stigma mean score was 17. The study reveals that the mean score of the perceived externalized stigma subscale was (7.32) high compared with other subscales of the stigma scale. COVID Survivors experienced the highest score in all the six questions of the perceived externalized stigma subscale (Most people think that a person who has had coronavirus disease was disgusting, afraid of a person who has had coronavirus disease, rejected when others find out, treat someone who has had coronavirus disease as an outcast, reject someone who has had coronavirus disease uncomfortable and not want someone who has had coronavirus disease around their children). The total stigma score was little more than the cut-off score. However, none of the above scores are statistically significant.
Table 2: Descriptive statistics of domains of stigma

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[Table 3] indicates the gender-wise comparison on stigma scores. The perceived externalized stigma subscale was higher among males (7.57 ± 5.96) when compared to females 6.62 ± 5.53. Total stigma scores were higher for males 17.2 ± 10.1 when compared to females 16.2 ± 10.5. However, none of the above scores were statistically significant concerning gender-wise analysis.
Table 3: Gender comparison on stigma scores

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[Table 4] reveals the treatment mode-wise comparison on stigma scores. The total stigma score was more (17 ± 10.3) among home-isolated COVID patients as compared to hospitalized patients (16.9 ± 10.2). However, there was no statistically significant difference between hospital care versus home isolation on enacted stigma (Mann-U = 280; P = 0.63), disclosure fears (Mann-U = 295; P = 0.85), internalized stigma (Mann-U = 225; P = 0.10), perceived externalized stigma (Mann-U = 262; P = 0.399); and total stigma (Mann-U = 294; P = 0.84).
Table 4: Comparison of mode of treatment on stigma scores

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[Table 5] reveals domicile comparison on stigma score. The total stigma scores were higher (18.8 ± 11.2) for COVID infected patients with rural background in comparison to urban background (18.8 ± 11.2) patients. However, there is no statistically significant difference between urban versus rural patients on enacted stigma (Mann-U = 293; P = 0.70), disclosure fears (Mann-U = 277; P = 0.48), internalized stigma (Mann-U = 266; P = 0.35), perceived externalized stigma (Mann-U = 242; P = 0.17); and total stigma (Mann-U = 251; P = 0.23).
Table 5: Domicile comparison on stigma scores

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  Discussion Top


The results showed that there are no significant differences in stigma scores between demographic groups. However, we could see higher means on stigma scores for the male gender, persons with home isolation, and rural background.

There are some previous studies on the gender comparison on effects of COVID-19. They found that women experience more psychological impact than men.[34] Gender-related differences in the psychological impact of confinement as a consequence of COVID-19 in Spain.[35] However, in the present study, men experienced higher stigma as compared to women. This needs further exploration because the sample of the study is not comparable to conclude. But a previous study reports a greater psychological impact for women than men.[36] This could be attributed to the increase in household and childcare activities during a COVID-19 pandemic and which is supported by other studies conducted by Carlson et al., and Carli.[37],[38]

The place of treatment is also associated with stigma among COVID-19 patients. It was seen that patients who are isolated at home and treated are having more stigma than those who are treated at hospitals. Though there are no reports to explain this phenomenon, we could speculate that due to various interventions provided to the patients at the hospital the stigma scores may reduce.[39] Since the current study was conducted in a secondary care mental health hospital which has a qualified multi-disciplinary team that addresses the stigma, health, and mental issues. This could be possibly one reason for the hospital care group having fewer stigma scores in comparison to the participants who were isolated at home.

In middle-income countries like India, there is a disparity of health-care services among rural and urban. The rural communities especially are marginalized for health-care services. There is a lack of knowledge and misconceptions regarding the COVD-19 among the rural population.[12] This corroborates with the present study where rural patients had higher overall stigma scores as compared to the urban population.

The results of this study need to be interpreted with caution because of the smaller sample size due to high refusal rates, fear of further stigma, and safety precautions. Furthermore, the data collection was restricted to only a secondary mental health center which is a major limitation for the generalization of the findings. Further community-based surveys with longitudinal methods are to be conducted to see the changes in stigma among recovered COVID-19 patients. This will help us to understand the patterns of changes in stigma prospectively. The other implications of the study are that the rural population should be addressed through various community campaigns to target the attitudinal or stigma-related issues because the stigma has detrimental effects on the treatment-seeking behaviors among the rural population. Although there are contradictory observations on stigma for gender, it would be good to explore the gender differences systematically with future studies.


  Conclusion Top


Irrespective of the gender, place of treatment, and residence there is a presence of stigma among COVID-19 patients. This could require multi-disciplinary psychosocial interventions to address the stigma and its ill effects.

Acknowledgments

The authors are grateful to the District administration, Dahrwad, Karnataka, India for providing COVID patients list for tele counseling.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Correspondence Address:
Kannappa V Shetty,
School of Social Work, IGNOU, New Delhi
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/amh.amh_189_21




 
 
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