Discussion

The present study revealed that stigma in patients with COVID-19 is not an individual or minor problem, but rather comprises a very serious social issue. According to our analysis, three major themes were found: (1) fear and exclusion (2) discrimination, and (3) loneliness. It is understandable that there is confusion, anxiety, and fear about this unknown and rapidly transmitted disease among the public. However, this does not justify the deprivation of COVID-19 patients and even their families from their human and social rights (28, 29).
In the current pandemic, there has been a lot of social stigma and discrimination against individuals perceived to have been in contact with the potentially deadly viral agent (5, 13) responsible for COVID-19. This is not a new issue, as Davtyan et al. found that there were forms of stigma in the Ebola outbreak that were similar to those reported in HIV/AIDS studies (30). Also, Karamouzian and Hategekimana pointed to the fear and stigma of Ebola as a barrier to preventing the disease from spreading (31). A study by Faraq et al. also reflected stigmatization during the Middle East respiratory syndrome (MERS) pandemic in Qatar (32). However, we believe that stigmatization in this pandemic has been much more severe.
In line with our findings, other studies have shown that social exclusion has created barriers between COVID-19 patients and society, influencing the physical and mental health and overall well-being of those who become afflicted (33, 34). The study of Ernel et al. (2020) showed that negative social stigma is mostly due to rejection and fear of acquiring COVID-19. Some researchers have referred to a solid sense of anxiety endured by the population (35-37). Other researchers (38) have theorized the relationship between the disease and the prevalence of anxiety. This is while some have addressed the exceptional state of social lockdown, self-isolation orders, and strict quarantine measures, emphasizing the importance of the potentially neglected mental health outcomes of the pandemic (39). Not only does the situation alter the attitudes of individuals but also it transforms and reassembles their emotions, beliefs, and values (13). In addition, living habits and daily behaviors are affected strongly by the COVID-19 outbreak (40).
Stigma may influence the actions of those who are stigmatized. Many of the participants in the present study described their social experiences with the central concept of discrimination. Discrimination is in fact a state of differentiation and stereotyping at the community level where an individual is made to feel that he or she does not belong to a certain class. In other words, in the process of social discrimination, a symbolic social order assigns an individual to a class that they do not belong to according to the individual’s own criteria and according to those of society in its normal state. The individual experiences verbal indifference, even from relatives and loved ones. Such discrimination also gives rise to a sense of injustice, which has been reflected in many studies in the field of COVID-19 associated stigma. Repetitive reports, across the globe, admit consensually the fact that fear and anxiety about the virus has led to social stigma and discrimination (15). Addressing fear, loneliness, and discrimination toward COVID-19 patients should be a priority for public health professionals (41, 42). Cooperation between all sections of society in dealing with negative social stigma is essential but represents a serious challenge (43).
It seems that stigma and its psychosocial complications have been substantially embedded within the context of COVID-19 disease. Patients have found the atmosphere of being rejected by those around them to be quite disturbing. The absence of others from the scene has added psychological and social strains to their health problems. Our interviewees described literally or figuratively the unique feeling of being made to realize that you have to distance yourself from others. This unique feeling brings about a sense of rejection that increases the suffering of the patient. Feeling rejected may extend over time, with the individual feeling the stigma even after being assured by their doctor that they are no longer infectious (continuation of rejection ).
Fear and rejection intervene and intersect with the meaning units of the third theme. A child’s conceptual network may be disturbed in its mirror stage, as described in Lacan’s psychoanalytic theories under the influence of Freud. Normally, in the epistemological network of the individual, there is an overall conceptual framework that lacks any deep gaps (44, 45). Here, when a person acquires COVID-19 and is faced with rejection from those around them, their conceptual framework is disrupted. The loneliness that comes with rejection is considered as a harm in the patient’s cognitive network as they expect the company of loved ones but instead become the subject of stigma and are avoided, similar to that which occurs in the mirror stage in a child’s mental system. Phenomenologically, this experience is rather unique, with a reflection of it being available from the personal accounts and reflections of those afflicted during the pandemic (46, 47). The social stigma of disease and stereotyping seen in the current pandemic should trigger radical changes to help patients in terms of their social and psychological wellbeing.
In their 2020 study, Grover et al. demonstrated an urgent need to understand and address the mental health issues of patients with COVID-19 during hospitalization or quarantine. Uncertainty about the illness, limited support from family, and fear of death of oneself or loved ones give rise to severe psychological stress, making mental health assessments and the provision of mental health support crucial (48). Brans et al. (2020) showed that from the start of the COVID-19 pandemic, feelings of fear have encompassed patients. There are concerns that fear and stigma may be more severe during the current pandemic relative to other infectious disease outbreaks.
In line with the literature, the findings of the present study revealed that the stigma caused by COVID-19 at the individual level may lead to delay or refusal of care, non-compliance with containment measures and treatment, and physical and psychological stress. In addition, Ren et al. (2020) showed that stigma is associated with problems in diagnosing and controlling the disease, feelings of rejection and loneliness, and increased mortality and complications, consequently exerting negative effects on public health (49). Persistent discrimination and false beliefs associated with the disease may become major barriers to effective public health interventions such as vaccinations. Many studies have rightly pointed out that for an infectious disease prevention program to be effective, the stigma associated with it must be actively addressed. Therefore, addressing the fears, loneliness, and discrimination felt by those afflicted with COVID-19 should be a priority for public health professionals (41, 42).
Combating COVID-19 associated stigma requires evidence-based cultural strategies. Lessons learned from successful experiences of dealing with past epidemics as well as WHO guidelines for dealing with such social stigma can help inform public health campaigns in fighting this issue. While emphasizing the importance of words, the WHO recommends that people afflicted with the disease should not be addressed as ”COVID-19 cases” or “COVID-19 victims”. Furthermore, the patients’ families should not be addressed using terms like ”COVID-19 suspects” or ”suspicious cases”, and conversations about the patients should not include the use of phrases such as ”carriers and transmitters of the disease” or ”contaminants of others”. These recommendations are because such words implicitly indicate intentional transmission and put blame on the patient, reinforcing attitudes of stigmatization and labeling (50, 51).
This study included a number of limitations, mostly revolving around the telephone-based nature of the interviews. Firstly, telephone interviews may possibly result in shorter conversations with the interviewee compared to face-to-face interviews. Secondly, the physical and spatial conditions of the interviewees may have varied at the time of the interview, possibly affecting the findings. Finally, it seemed to be more difficult to gain a patient’s trust in a telephone interview relative to a face-to-face interview. Nonetheless, telephone-based interviews seemed to be more appropriate considering the urgent health situation caused by the current pandemic.