Introduction

A new strain of coronavirus emerged toward the close of 2019 in Wuhan, China, giving rise to the coronavirus disease 2019 (COVID-19) and spreading a wave of concern across China (1). This health issue soon became a pandemic, placing an immense burden on populations all around the world (2). According to data from the World Health Organization (WHO), Iran is one of the countries that has been highly affected by COVID-19 (3). Kalantary H. et al. showed that in Iran, up to one-third of patient deaths due to COVID-19 occurred in individuals aged over 70 years, while the highest recovery rate was seen in those aged between 30-39 years (4).
One of the key issues raised from the start of a pandemic is social stigma (5). The notion of stigma is defined as “a social process that results in devaluation and discrediting” (6). According to Echoing Goffman, stigma creates a dichotomy between the states of “being normal and acceptable” and the state of “being tainted and undesirable’ or a dichotomy between “normal” and “undesirable” states in general. It is usually associated with an attribute that is deeply discrediting, reducing an individual “from a whole and usual person” to a “tainted, discounted one” (6, 7). In the process of stigmatization, people involved in the phenomena of the social world are pushed to the margins of society (8). Stigma may not only affect the mental health (9) and behavior of those who are stigmatized but also can change and reconstruct their feelings and beliefs (10, 11). Furthermore, stigma can cause depression in the short or long term due to the social disrespect that accompanies it (12).
Since the commencement of the COVID-19 crisis, infected individuals have at times been labeled, stereotyped, and discriminated against. Such stigma can represent a critical issue, threatening both the personal and social life of healthcare workers, patients, and survivors (5). Ramaci T. et al. showed that the social stigma associated with COVID-19 had a high impact on healthcare workers’ psychological and physical demands, professional quality of life, and self-esteem in Italy (13). Moreover, several reports have claimed that some people refuse to bury the corpses of COVID-19 victims in Egypt (14). Gradually, the issue of COVID-19 associated stigma went beyond personal and social aspects and turned into an international stigma against races and countries. For example, anti-Asian stigma was generated by certain groups and even politicians considering the supposed geographical origin of the disease (15). Stigma and discrimination lead to social exclusion, which affects mental health (16). Stigma does not stop at illness: it marks those who are ill, their families across generations, institutions that provide treatment, psychotropic drugs, and mental health workers (17). The stigma associated with COVID-19 poses a serious threat to the lives of all those involved directly or indirectly with the disease (5). The effects of COVID‐19‐related stigma on the health and social lives of individuals and societal functioning are enormous (18). The study conducted by Banks L. et al . showed that poverty exacerbation due to COVID-19 could represent a key social problem among individuals who reside in low and middle-income countries. The mentioned study revealed that people with disabilities faced several personal, economical, and social challenges in the COVID-19 period, with the researchers concluding that social protection and financial support are necessary for protecting such individuals from social stigma (19). Moreover, the study of Gupta J et al. revealed that some protective measures against COVID-19 had negative social effects on low-income individuals (including those residing in poor areas) due to inadequate access to health facilities and lack of financial support. Moreover, the study claimed that some of these social effects may be stronger than the negative health effects of COVID-19 (20). On the other hand, frustration and anxiety were reported as the predominant social theme among the population, particularly among healthcare workers on the front-lines of COVID-19 management (21, 22).
To the best of our knowledge, few studies are available on COVID-19 associated stigma in Iran, especially ones that are qualitative in nature. Therefore, this study was conducted to assess COVID-19 associated stigma among the Iranian population through a qualitative survey.
Methods
Study design, participants and samplling
The present work was a qualitative study that was conducted in January and February 2021. The study area was the Fars, Yazd, and Khorasan provinces. Data were obtained through interviews with 24 individuals who had fully recovered from COVID-19 after treatment. The snowball sampling method was employed, and sampling was continued until achieving data saturation. Table 1 shows the characteristics of the participants in the study (Table 1).
[Table 1 here]
Data collection
The interview protocol was based on the following questions:
The semi-structured interviews were transcribed after being conducted via telephone by an expert sociologist. The use of telephone interviews in qualitative research has proved useful in recent decades (23, 24). The transcribed data were analyzed via conventional content analysis (25). For this purpose, the data were read several times by the researchers to obtain an overview of what the participants were talking about. Then, condensed meaning units were labeled by formulating codes that were subsequently grouped into categories. The interviews were analyzed with the aim of bringing the categories to the highest level of abstraction, i.e., arriving at specific themes. The reflexive method was used during this process. Researchers went back and forth several times between the data and the generated themes in order to arrive at the most appropriate themes.

Research validity

Given its significance, we attempted to ensure the validity of the work by following the model of Lincoln and Guba (26). To this end, designing a suitable qualitative research model, selecting the right participants, choosing accurate interview questions, and employing appropriate methods for data analysis were the most important concerns of our research group. We used member check (27) during the data analysis process as one way to see if the categories and themes reached were satisfactory. Assessing the transferability of concepts and themes was also one of our priorities. Ultimately, our research group aimed to base the concepts and themes on the actual data rather than relying on individual preconceptions and assumptions.

Study ethics

The protocol of the study was approved by the Ethics Committee of Shiraz University of Medical Sciences (Ethics code: IR.SUMS.REC.1399.419). Informed consent was obtained from all participants. Patients were also assured that their personal information would remain confidential with the researchers.
Results
Data analysis revealed that the experience of affliction with COVID-19 was quite difficult for the study participants. This was particularly prominent in the first two waves of the disease in Iran, where the participants were under severe psychological pressures. Fear of transmitting the disease to other family members, fear of illness and death, rejection by family members, and loneliness comprised the most common experiences. The three main themes developed were fear and rejection, discrimination, and loneliness (Table 2).
[Table 2 here]

Fear and rejection

Right from the start, affliction with COVID-19 creates a pervasive fear among patients and more so among those around them. Such fear arises when the test returns positive, and the patients implicitly or explicitly start noticing dramatic changes in the behaviors of those around them as the fear is accompanied by rejection. The most common experience of the study participants was the behavioral changes that they witnessed in those around them after declaring positive test for COVID-19. These changes are shaped by a combination of fear, concern, suspense, and compassion, though mostly being due to fearing affliction with the disease. Usually, fear first arises in those around the person, such as first-degree relatives or colleagues. The behavior that stems from fear is understandable to the patient. On the one hand, the patient gives the right to those around him, and on the other hand, witnessing such extreme fear adds to their concerns. Rejection begins with the initial distancing from the patient. ”Testing positive” here means fear, concern, anxiety, rejection, and seclusion. The person understands these meanings from the behaviors and attitudes of those around them and attempts to manage them, where ensuring the well-being of those around them is the most important solution. The person realizes that those around them are reluctant to approach them and may be trying to main their distance. In this situation, everyone is afraid of illness and death, which are seen to be embodied by the patient. The fear is such that even patients in the COVID-19 ward were afraid of one another. Moreover, four participants drew similarities to stigmatized concepts such as AIDS, leprosy, and al 11Mythological demons of childbirth that interfere with human reproduction., meaning that the atmosphere of fear is intense to such an extent that it is as if the patient has contracted such negatively perceived diseases.
See, the disease was so scary that I remember, for instance, when my test result returned positive, everyone around me became anxious even though I didn’t have a very bad feeling (participant 6). It seems that you have AIDS or leprosy because a very discomforting feeling touches you and everyone tries to distance themselves from you (participant 5).
The most important psychosocial issue concerning COVID-19 is that this fear and rejection may continue even after disease resolution. A miner still spoke of feeling fear and rejection. He believed that 14 months after the start of the COVID-19 pandemic, laborers in cities such as Mashhad, Tehran, and Tabriz who go on leave to their towns and villages still are avoided by others upon returning.
You know, we’re still scared. We are afraid of those who return after going on leave. We assume that they were gone due to testing positive, or that they are returning from another area with the virus (participant 1).
The atmosphere of fear and rejection made some prefer to hide the disease, especially in the first and second waves. The stigmatization of COVID-19 sufferers and victims represented the main reason for such concealment. One of the participants, a 34-year-old single man, described telling a friend to keep it secret after he tested positive.
When I tested positive, I didn’t tell anyone. No one in the neighborhood was aware of my disease. I didn’t even tell my family members, except for my cousin, whom I told so that if my situation worsened, he would be prepared to take me to the hospital (participant 4).

Discrimination

Another key experience among the participants was discrimination, which they saw either in themselves or in their relatives. Fear and exclusion lead to the construction of an atmosphere of discrimination. Several participants described their experiences with occupational discrimination. At the beginning of the pandemic, when intense fear prevailed throughout society, occupational discrimination became prominent. In the workplace, anyone who coughed or sneezed was labeled as infected or suspicious, leading to their rejection by others. Notably, people who became infected continued to experience a sense of discrimination even after returning to work. The discrimination seems to be involuntary; it may be a social compulsion influenced by the atmosphere of fear, where the pandemic appears to have led to such discrimination against COVID-19 patients.
My father was hospitalized and died in a COVID-19 ward for unknown reasons. You can’t imagine the calamity that we went through. There was no one to participate in the funeral, and I was deprived of seeing my father for a final farewell, which is something that will forever hurt me (participant 22). I went to a company for a job interview. The employer asked me to pull my mask down. I said that I am suspicious [for COVID-19]. He asked what I was doing there, and told me to leave immediately and to come back later. In my current workplace, my co-workers told the employer to prevent me from coming to work (participant 17).
Another form of discrimination was familial discrimination, where the atmosphere of fear and rejection would prevent family members from paying appropriate attention to a person with or suspected of COVID-19. The family is not interested in communicating with or caring for the individual, treating him or her in such a way that they come to the conclusion that they must minimize their expectations from the family.
I saw my family behaving in such a way as if I no longer had a place in the house … they would treat me differently than other family members. That’s why I moved out; I found living apart to be better. I’ve lived apart from them ever since (participant 8).
Social discrimination also occurs in social interactions between healthy individuals and suspects or sufferers, their families, and families who have lost members due to COVID-19. In these situations, minimal contact is made with these individuals, and even condolences are sparingly given. These people are also kept away from social spaces when others know them. Perhaps the reason for all this social discrimination is that people are afraid that as soon as they enter into a conversation with these people, they may be infected or will be forced to visit the affected person or family.
In our neighborhood, I remember that no one would even reply to the greeting of the first person who became infected; people would pass by him swiftly as if he had all sorts of faults. An old man fell victim to COVID-19. When he died, even the way that people offered their condolences to the family differed from the usual (participant 4). Someone had willed for their body to be taken to the family village after their death. However, the villagers blocked the ambulance from entering the village. Ultimately, the person was buried in a desert nearby the village (participant 23).

Loneliness

One of the prominent themes among those with the experience of affliction with COVID-19 was the intense feeling of loneliness. The first issue associated with loneliness is the loss of social and psychological support from loved ones, which was experienced by over one-third of the participants. In fact, families were in a state of fear and rejection. In these situations, family members usually inadvertently change their behavior toward the sufferers. Furthermore, some participants described that the family members would specifically expose the sufferer to severe social pressure in demanding that they follow the protocols during isolation. Many participants who stayed home in self-quarantine and sent their family members elsewhere experienced extreme loneliness. The absence of the closest loved ones such as the spouse, children, or parents on the one hand and the fear and concern of illness and death on the other created an overwhelming situation. In a house with multiple family members, the patient was typically imprisoned within a room and given food and medicine. Our participants described that the infected or suspected person was constantly warned by those around them. While some had sent their family members to live apart from them, others were made to feel abandoned as their family members themselves had made such a move. It seems that the most difficult experiences were described by those who had to suddenly live alone.
As soon as I got sick, my parents left me alone and went to the village. I became very sad. My sister would visit every day and put the food behind the door; she wouldn’t even stop a moment to talk to me (participant 11). My older sister kept calling and saying that if mom and dad got sick, it would be my fault (participant 17).
Another category of loneliness is a sort of biological-physical experience related to the first theme, i.e., fear and rejection. In this situation, the sufferer is dominated by the components of fear, worry, uncertainty, feeling dirty, and feeling like they have a terrible illness, giving rise to an unpleasant feeling of disgust toward the individual’s own body. Any physical symptom reinforces this feeling of self-disgust, also strengthening the fear of getting worse and dying.
Due to the way my colleagues would treat me, I would be left feeling dirty. It was a very, very bad feeling (participant 17). It was as if I had leprosy; it was a very unique situation (participant 5). When you test positive, it’s like you have al… it’s not a good feeling (participant 1).
The final category of the loneliness theme reflects the most important phenomenon that patients experience in the COVID-19 era, which is being distant from friends, family, and society. In addition to the difficulties embedded in the disease process, the absence of first-degree relatives from around the patient creates a psychologically challenging condition. Constantly thinking about loneliness, continuous worrying, fear of disease progression and death, and the absence of a first-degree relative cause a kind of loneliness that is extremely troubling for the individual. The sufferer feels a deep sense of loneliness – as if it’s the end of the world and there is no one left to come to their aid.
I realized something during this period: it is because of this loneliness that people get sicker and lose their spirit, or even pass away. Living alone is not part of human nature, and this phenomenon itself can hurt people a lot (participant 21). Psychologically, I felt completely torn apart for a while. Everyone avoided me and whoever had contracted the disease after seeing me even a long time beforehand would blame me. They would even call me up to condemn me (participant 20).