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.