Original Research | Published: 11 July 2024
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Psychosocial health stigma related to COVID-19 disease among COVID-19 patients in Jordan: a comparative study

https://doi.org/10.1136/bmjph-2023-000165

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Abstract

Objective Beyond its effects on physical health, COVID-19 psychosocial stigma has emerged as a result of this global crisis, making people feel ashamed, alone and discriminated against. This comparative study aims to assess the psychosocial health stigma of COVID-19, and to evaluate the perceived stigma according to the sociodemographic variables during the pandemic in Jordan.

Method A study in Jordan compared stigma between 112 COVID-19 patients (52 males and 60 females) and 118 healthy controls (56 males and 62 females), with participants ranging from 18 to over 60 years old in both groups.

Results According to the data, 27% of COVID-19 patients had high-level stigma, with total stigma scores ranging from 46 to 111 and a mean of 80.23 (SD=12.79). Quartile results showed 50% scored 80, 25% over 88 and 75% over 78, indicating moderate stigma within a 0–160 range. On the other hand, the total scores of stigma among the healthy controls ranged from 40 to 112, with a mean of 78.55 (SD=12.41). 30.3% report high levels of stigma. Quartile results showed 50% scored 78, 25% over 85 and 75% over 71, indicating moderate stigma. No significant stigma score difference was found between patients and controls (t=1.09, p=0.28). No significant correlation with demographics, except among medical workers (t=−3.32, p=0.001).

Conclusion The study revealed negligible differences in stigma between the two groups, but greater stigma among medical field workers highlighting the need for integrated community and policy support to fight stigma.

What is already known on this topic

  • Stigmatisation during pandemics impacts survivors and health workers’ mental health.

What this study adds

  • No significant stigma differences between COVID-19 patients and controls.

  • Data timing, with rising vaccinations, might explain stigma shift.

How this study might affect research, practice or policy

  • Implementing policies protecting healthcare workers from stigma.

  • Understanding the growth of stigma is critical for successful responses.

Introduction

In December 2019, a pneumonia of unknown cause emerged in Hubei Province of China. The name SARS-CoV-2 was given to the disease on 7 January 2020.1 The WHO emphatically declared the COVID-19 outbreak a public health emergency of international concern on 30 January 2020. In March, the WHO characterised COVID-19 as a pandemic.2 Pandemics are not just biological crises; they can also have psychosocial effects, such as anxiety, stress, mass panic, fear and the rise of stigma. Notably, at times it appears that the spread of societal stigma is outpacing the infection itself.3 Stigma is a social label that prevents people from fully accepting their surroundings. It is a feature that socially discredits an individual or a group.4 Throughout history, epidemics have stigmatised managers, healthcare professionals, and those vulnerable to get infected. The COVID-19 has been added to the list.5 An analysis of 50 eligible publications, which included data from 92 722 people and included diseases such as SARS, H1N1, MERS, Zika, Ebola and COVID-19, revealed an overall stigma rate of 34% across all groups. Stigmatisation differed among patient groups, the broader public and healthcare staff.6 In Sri Lanka, one-third of COVID-19 patients experienced widespread discrimination due to disease-related stigma. This varied from societal exclusion and the dissemination of disinformation to work issues such as job termination and refused re-entry. These situations led to more social isolation, unwillingness to seek medical care, and pressures on ties within the affected families.7

The Hashemite Kingdom of Jordan has a population of 11 million. According to Jordan’s Ministry of Health data, the total number of confirmed cases of COVID-19 was 173 154, with 14 105 deaths recorded until the first half of August 2022.8 The first case was confirmed on March 2. Since then, the Kingdom of Jordan has managed the crisis well, instituting stringent laws that restrict social interactions and isolate those who are affected in designated hospitals.9 Jordanians blamed the rapid transmission to people referred to as ‘super-spreaders’, who frequently used humour as a coping technique to allay disease-related anxieties.10 Unfortunately, despite the measures taken, rumours and social stigma related to COVID-19 have been on the rise worldwide. Therefore, it is important to highlight the psychosocial health stigma among COVID-19 patients, as it has negative consequences. These consequences include delays in seeking care or not seeking care or, in some cases, patients not seeking care at all, leading to unmanageable symptoms and a lack of access to healthcare.11 Studies have indicated that stigma, both internal and external, significantly impacted COVID-19 patients’ psychological well-being. In addition to these negative consequences, these stigmatising experiences may also lead to several additional challenges, such as economic difficulties.12 13 Global health communication has a significant impact on public perceptions of illnesses and related psychological difficulties. Therefore, creating a thorough approach to lessen stigma is essential. The procedure should engage every relevant parties such as the government, the media, local government agencies and hospitals.14 Research on COVID-19 stigma is vital since Jordan merges many cultural norms, societal expectations and medical practices. Understanding how Jordanians perceive and react to stigma, which is shaped by their traditions and beliefs, is useful in addressing this issue. As a result, the research’s reach goes beyond Jordan’s boundaries, providing insights that may improve how similar issues are handled globally. By examining a specific case, we can learn lessons that are more applicable both locally and worldwide.

Study questions

  1. Is there a significant difference in the total stigma levels between COVID-19 patients and healthy controls?

  2. Is there a significant difference in the level of stigma related to COVID-19 based on age, social status, educational level and financial status?

  3. How does the level of stigma related to COVID-19 vary between different genders and between individuals working in the medical field compared with those who do not?

  4. Which demographic factors (age, gender, social status, educational level, financial status and work in the medical field) are significant predictors of the stigma level associated with COVID-19?

Methods

Design

A comparative study design was used to investigate the differences in the stigma levels between COVID-19 patients and healthy controls and also the correlation between COVID-19 related stigma and the sociodemographic variables of the study participants.

Study sites and settings

Jordan has multiple health service providers: public sector, private sector and Royal Medical Services. The current study was conducted at Al-Rashid Hospital between 26 June 2021 and early November 2021. Al-Rashid Hospital is one of the private hospitals in Amman, Jordan. The researchers attempted to recruit samples from other settings, were unsuccessful due to inconsistent adherence to COVID-19 precautions, which are not always met. Al-Rashid Hospital has been authorised by the Ministry of Health to conduct PCR (COVID-19) tests since the onset of the pandemic.

Patient involvement

At all stages of our study design, data collection and results, we involved patients and the public as a part in our research. Prior to the adoption of the final questionnaire format, we piloted the questionnaires among a diverse group of people to ‘sense-check’ the research objectives and maintained ongoing relationships with our participants throughout the study period. Participants helped us to understand their experiences and views of psychosocial stigma towards COVID-19 during the pandemic, which helped us to refine our questionnaire. We provided participants with detailed information on how we would protect their data and respect their privacy. We informed those who participated in our research about the results. This is important for us in order to respect their time and commitment as well as open lines of communication help us to ensure that any findings are accurately reported and most importantly, used to alleviate the burden of psychological stigma of COVID-19. The importance of this study lies in involving the patients and public in each stage from the start to completion and dissemination. It encompasses our commitment to conducting research which is ethical, impactful and meaningful to the target population.

Sampling

The study’s reference population includes all eligible individuals identified through positive COVID-19 (rRT-PCR) test results who consented to participate. The control group consisted of visitors to the hospital’s emergency and radiology departments who fulfilled the study’s eligibility requirements. To estimate the necessary sample size, we conducted an analysis on the difference between two independent means using G*Power.15 This analysis was designed to calculate an adequate sample size for a one-tailed test with a medium effect size (d=0.50), a statistical power of 0.80 and a significance level of alpha=0.05, resulting in a required sample size of 102. 10% was added to cover the dropout; therefore, the total sample size was 112 participants; the slight discrepancy in the sample size for the healthy controls was due to logistical considerations and the availability of willing participants during the research period, even though the initial sample size calculation focused primarily on the patient group.

Eligibility criteria

The research explores two groups. The ‘patient’ group included individuals with a confirmed COVID-19 diagnosis who are at least 18 years old, literate, possess the ability to communicate verbally and voluntarily participated after their recovery, sharing experiences and perceptions regarding virus-related stigma. In contrast, the ‘healthy control’ group included individuals without a prior positive COVID-19 diagnosis, ensuring a valid comparison with the patient group. The inclusion criteria for this control require participants to be at least 18 years old, possess the ability to communicate verbally and have a willingness to participate without having been previously diagnosed with COVID-19. The study’s investigation of these diverse groups intends to shed light on the many experiences and perceptions of pandemic-related stigma, so contributing to a more complete understanding of its psychosocial impacts.

Data collection procedure

A list was generated comprising individuals diagnosed positive for COVID-19 who agreed to participate in the study. Eligible participants, as determined by the randomisation paper,16 were included as cases until a total of 112 were enrolled. Additionally, 118 control participants were randomly chosen from the general section of the hospital based on study eligibility criteria. Once recovered from the disease, questionnaires were sent to these cases, followed by phone interactions to clarify any related queries. On average, participants took approximately 10 min to complete the questionnaire.

The anonymity and confidentiality of the participants were among the foremost priorities when gathering data. We ensured that the responses provided by participants would stay anonymous by providing a unique identification to each questionnaire in order to protect their identities. The whole time the data was being collected, rigorous adherence to COVID-19 safety standards was maintained. At different points during the study, people chose not to participate for a variety of reasons. Initially, some individuals were excluded from the study due to age or health restrictions. Later, others chose not to participate, citing personal reasons or scheduling conflicts. Additionally, a few participants who initially joined later dropped out or ceased participating, and several faced difficulties in completing follow-up activities due to logistical issues or significant life events.

Measurements

This study measured stigma using a stigma questionnaire adapted from the Berger HIV stigma scale.17 The forward and backward translation method was used to translate the questionnaire from English into Arabic. Psychiatrists and psychologists modified the questionnaire to include the WHO’s instruction for COVID-19 social distancing, and some items were modified to cover the period after recovery from COVID-19. The final questionnaire had 31 items. The questionnaire has two main components: demographic data information and the Berger HIV stigma scale. The first section consists of sociodemographic characteristics including age, gender, marital status, educational level, income and if the participant is a medical field worker.

The second section consists of four subscales: (a) personalised stigma, (b) negative self-image, (c) disclosure concerns and (d) concerns about the public attitude. Each item used a 4-point Likert scale. Given that the public recognised COVID-19 as ‘coronavirus disease’, this term was used in the questionnaire. A pilot study with 22 individuals (10% of the total sample size) was conducted. These subjects were chosen at random and followed the same inclusion and exclusion criteria as the main study. An expert panel examined face validity. The content validity index (CVI) was determined for each item, and all CVIs were more than 0.75. Cronbach’s alpha reliability coefficients were determined to be at least 0.60 for all subscales.

Data analysis

Data entry and statistical analysis were conducted using SPSS V.26 (IBM, 2019). In addition, a descriptive analysis was performed, including frequencies, percentages, ranges, means and SD.

Inferential analysis (t-test), one-way analysis of variance (ANOVA), and multiple linear regressions were used to measure the differences and relationships between the mean scores of the different variables. In this study, the level of statistical significance was set at p≤0.05 for all analyses. To answer the specific research questions, one-way ANOVA, and multiple linear regression were used.

Results

Of the 230 completed questionnaires, 112 were from patients and 118 from healthy controls. The response rate was 76% for cases, 69% for controls, and a combined total of 73% for both cases and controls, with demographic details outlined in table 1.

Table 1
|
Demographic variables for COVID-19 cases and controls

Total stigma and its dimensions

Note that items with the lowest mean indicate the strongest feeling of stigma.

Personalised stigma

For infected individuals, personalised stigma scores ranged from 13 to 43 with a mean of 29.35 (SD=5.54). With the quartile equation, 50% scored 30, 25% reached 33 or more and 75% achieved at least 26. Conversely, healthy controls exhibited scores between 13 and 44, averaging 28.29 (SD=5.47); with the quartile evaluation, 50% scored 28, 25% exceeded 31 and 75% scored 25 or higher (online supplemental table W1).

Disclosure concern

For infected individuals, disclosure concern scores ranged from 8 to 29 with a mean of 21.04 (SD=5.54). Using the quartile equation, 50% had scores of 22, 25% scored 23 or higher and 75% scored 19 or above. For healthy controls, scores ranged from 11 to 43 with a mean of 20.26 (SD=3.83); 50% had scores of 20, 25% scored 23 or higher and 75% had scores of 18 or more (online supplemental table W2).

Negative self-image

For infected individuals, negative self-image scores ranged from 8 to 22 with a mean of 15.42 (SD=3.08). Using the quartile equation, 50% had scores of 15, 25% scored 17 or higher and 75% scored 14 or above. For healthy controls, scores ranged from 7 to 22 with a mean of 15.46 (SD=2.77); 50% had scores of 15, 25% scored 17 or higher and 75% had scores of 14 or more (online supplemental table W3).

Concerns with public attitudes

For infected individuals, concerns with public attitudes scores ranged from 6 to 20 with a mean of 14.42 (SD=3.67). Using the quartile equation, 50% had scores of 15, 25% scored 17 or higher and 75% scored 12 or above. For healthy controls, scores ranged from 7 to 20 with a mean of 14.54 (SD=3.15); 50% had scores of 14, 25% scored 16 or higher and 75% had scores of 12 or more (online supplemental table W4).

Total stigma

For individuals infected with the disease, stigma scores spanned from 46 to 111, averaging at 80.23 (SD=12.79). Using the quartile equation, 50% of these participants scored 80 or above, 25% scored 88 or higher and 75% scored at least 78, pointing towards a moderate intensity of stigma feelings. Conversely, among the healthy controls, scores were found to lie between 40 and 112 with a mean score of 78.55 (SD=12.41). Again, using the quartile equation, 50% of these participants marked scores of 78 or more, a quarter scored 85 or beyond and 75% had scores surpassing 71. This suggests a moderate level of stigma feelings across both groups. The data analysis (table 2) revealed that there was no significant difference between those who got the disease and those who did not in all the variables: personalised stigma, disclosure concerns, negative self-image, concerns about public attitudes and total stigma level.

Table 2
|
The total stigma

Difference in stigma level related to age, social status and educational level

Using a one-way ANOVA test at alpha <0.05, we explored stigma differences related to age, social status, educational level and financial status. After confirming all parametric test assumptions, all variables displayed a normal distribution (skewness: −2 to +2, kurtosis: −7 to +7) and equality of variances.

Analysis revealed that there was no significant difference in stigma related to age, social status, educational level and financial status variables. The F values and p values are as follows: (F=0.43, p=0.73), (F=0.18, p=0.91), (F=0.34, p=0.85); (F=1.05, p=0.37) respectively.

Difference in stigma level related to gender and working in the medical field

Using an independent t-test (alpha<0.05), stigma levels were tested based on gender and working in the medical field. The variables met normal distribution criteria (skewness: −2 to +2, kurtosis: −7 to +7). While no gender-based stigma variance was detected (t=−0.87, p=0.39), a significant difference was found between those working in the medical field and those outside (t=−3.32, p=0.001). In particular, non-medical participants reported a higher stigma mean of 81.22 (SD=12.64) compared with 75.45 (SD=11.63) for medical professionals, this suggests that medical professionals experience higher levels of stigma.

Predictors related to COVID-19 stigma

We conducted multiple linear regressions to predict the stigma level based on age, gender, social status, educational level, financial status and medical fieldwork. Analysis (table 3) revealed that stigma level was significantly predicted among those working in the medical field.

Table 3
|
Predictors of stigma

Additional tables that provide extended analyses of the data discussed in this paper are available in the online supplemental appendix, see online supplemental tables W1–W4.

Discussion

Individuals and communities have experienced psychological distress as a result of the stigma associated with COVID-19. A comprehensive evaluation of 248 publications published between 2020 and 2021 found significant influences on COVID-19 stigma. These included mistrust of the government, a lack of public comprehension, and the spread of misinformation.18 Our study classified COVID-19 stigma as low, moderate or high. The study found that patients’ experiences with stigma varied: 26.1% reported low levels of stigma, 46.8% reported moderate levels and a remarkable 27% reported high levels. During the pandemic, patients, communities and medical professionals were particularly concerned about stigma. This is a severe problem since stigmatisation may have a negative impact on their well-being and potentially deter them from seeking medical care in subsequent time.19 Stigma seems to be a typical negative experience that many pandemic survivors go through. demonstrating a trend that crosses several health contexts and geographical areas. Consider the Ebola outbreak that struck West Africa in 2014–2016 were reported to have faced signoficant stigma when they returned to their hometowns.20 Abuhammad et al21 measured the prevalence of stigmatisation among Jordanian population towards those with COVID-19; the level of stigmatisation towards those who had contact with infected individuals was 64%.

Our study showed that there were no significant differences in stigma level between the diseased and controls. Ahmed Suleiman et al22 reported similar findings related to total stigma. They demonstrated that stigma associated with tuberculosis (TB) did not differ between TB patients and controls in Gezira State. Both groups exhibited a modest level of stigma. On the contrary, a high level of stigmatisation was found in another study among COVID-19 survivors compared with the healthy controls in China.23 Our study results highly correlate with the time of the study when around 4 million people had taken the vaccine.8 As our collective understanding of the disease grew, the community perspective began to shift over time. In light of this, findings from many studies revealed that individuals who overcame COVID-19 faced a noticeably higher degree of social stigma during the pandemic’s early days compared with its later stages24 as observed by Sun et al25 who noted that COVID-19 patients in China felt better after being diagnosed in the middle and late phases of the disease despite the fear, denial and stigma they experienced at the onset of the disease. The research highlighted that after vaccination, the number of people experiencing COVID-19 related discrimination dropped from 79.76% to 62.26%, indicating a decline of 21.94%, similar to a longitudinal study in Jamnagar, India, involving 420 COVID-19 survivors from June 2020 to February 2021 found that participants experienced stigma. Although stigma persisted after 6 months, there was a statistically significant reduction in overall stigmatisation during that time period.26 The availability of vaccines may have influenced these outcomes. Vaccines can provide a sense of security while perhaps reducing anxiety and negative attitudes toward the infection. This sense of security may minimise stigma for both individuals who have and have not contracted the virus. Observing how these perceptions may alter as vaccination becomes more generally available necessitates additional analysis and research, which will provide us with new approaches to dealing with health-related stigmas in the future.

Based on our findings, there was no significant association between COVID-19 stigma and other sociodemographic or COVID-19-related characteristics of the study sample except for those working in the medical field. We found no significant difference between males and females in terms of overall stigma levels. This is similar to an Indonesian study27 and a study done in Saudi Arabia.28 This is in contrast with a comparative study conducted in China, among COVID-19 survivors and healthy controls in terms of gender. Males had higher level of stigma than females.23 Moreover, in this study, there were no significant differences in stigma in relation to age, marital status, educational level and income. A study done by Al Eid et al29 is similar and aligns with this study. Yet, according to Bhatnagar et al,30 those people who were self-employed and between 46 and 60 years had the highest stigma incidence compared with other age group. In a study from Tunisia involving 346 COVID-19 infected participants, individuals with low socioeconomic status had higher level of social stigma.31 A Jordanian study by Abuhammad et al21 began in June 2020 and ended in August 2020, found that the prevalence of stigma toward those infected with COVID-19 is about 65%; gender, income, and academic position are being predictors of stigma toward both COVID-19 patients and their contacts. A systematic literature review of 248 articles from 2020 to 2021, identified key factors contributing to COVID-19 stigma, including low public knowledge, widespread disinformation and a lack of trust in the government, emphasising the need for preventive and treatment actions.18 Stigma emerges as a societal phenomenon that separates individuals perceived as potential carriers of disease, thereby threatening the smooth functioning of social activities and life’s normalcy.32

Interestingly, individuals working in the medical field have a higher stigma level than those not working in the medical field. In the literature, a study conducted during the second wave of the COVID-19 pandemic in Egypt, from February 2021 to April 2021 on workers at Cairo University hospitals showed that two-thirds of the participants had moderate-to-severe COVID-19-related stigma.33 Consequently, stigma was more prevalent among physicians and medical residents than other professional and employment categories in both Iran34 and Bangladesh.35 In Taiwan, out of 357 identified as physicians while 1064 identified as nurses had varying degrees of stigma as well as observable burnout symptoms. Burnout symptoms were strongly connected to COVID-19 stigma, career, and presently providing care for patients who were either confirmed or suspected to have the disease.36An increase in participants’ perceptions of social stigma was connected to a drop in compassion satisfaction and an increase in compassion fatigue and burnout.37 Often, healthcare workers are more exposed to blame and negativity because they are directly taking care of patients. They often encounter more avoidant and negative behaviours from people in their community, which can be hard on their mental well-being, especially during the COVID-19 crisis. A study of healthcare workers conducted during the COVID-19 pandemic in Taiwan discovered an important association between higher rates of suicidal ideation and insomnia and increased fear of the virus. Furthermore, increased resilience was observed to significantly reduce the incidence of insomnia.38 Another study in this context discovered that 25.6% of patients had depressive symptoms, 44.6% had insomnia, 15.4% experienced post-traumatic stress disorder symptoms, 30.6% had anxiety symptoms and 23.4% felt anxious. This underlines the significant mental health challenges faced by Taiwanese frontline healthcare professionals, emphasising the critical need for targeted mental health interventions.39

Limitations

Our study’s findings have implications for a wide range of practical applications and academic areas. According to research, our understanding of COVID-19 stigma has to be updated to account for its evolving characteristics during the pandemic and to better future investigations. The self-reported questionnaire has some drawbacks, such as honesty while answering it. Rather than being truthful, the participants may choose the answer they find more sociallyacceptable. The generalisability of our study’s findings is limited. The study was conducted in a specific hospital in Jordan, therefore it may not accurately represent all COVID-19 patients and healthy individuals in the country. Furthermore, while the sample size we chose was enough for our study, it may not be representative of Jordan’s total demographics and backgrounds. Our study focused on a specific period of the pandemic, and the situation could have evolved over time. Finally, some people who did not meet our criteria or elected not to participate were excluded, which could introduce bias. Further research in different locations and timeframes is required for broader applicability.

Recommendations for practice, research and policy

Our study’s findings have implications for a wide range of practical applications and academic areas. According to research, our understanding of COVID-19 stigma has to be updated to account for its evolving characteristics during the pandemic and to better future investigations.

It is critical for healthcare workers to be prepared with, and carefully follow, methods supported by extensive research in order to establish an environment of understanding and respect, therefore reducing the incidence of stigma linked with the pandemic. Speaking out against the stereotyping of groups of people who are stigmatised because of COVID-19 should be done through the media. The COVID-19 pandemic has severely impacted the health systems of the majority of nations. The Ministry of Health and legislators should work together to create initiatives to combat stigma associated with COVID-19.

They should also evaluate the consequences for healthcare providers and ensure that the regulations put in place are long-term effective. The aim is clear: addressing the complexity of stigma in this unprecedented period requires a creative and dynamic strategy. Frontline healthcare workers deserve to be publicly recognised and honoured for their dedication and efforts during the pandemic.

Conclusion

Stigma distances individuals, hindering them from accessing necessary support and understanding, making those affected feel isolated and often stopping them from getting the help they need. Our research found that, even with the increased vaccinations in Jordan, the feelings of COVID-19 stigma were comparable for both those who had the virus and those who did not. However, the ongoing feelings of fear, loneliness and doubt signal a bigger problem in our society. In Jordan, professionals working in the medical field, particularly those on the front lines of our fight against COVID-19, face serious stigma, highlighting the critical need to strengthen supportive settings and address misconceptions about those who maintain our public health. Thus, it is critical to discuss this and work to clear up any misunderstandings. By doing so, we may assist people come together and reduce the overall impact of the pandemic on our community’s well-being. Ultimately, stigma is viewed as a hidden burden on communities. As a result, efforts must be made now to raise community awareness of the COVID-19 stigma. Raising awareness can help to reduce the spread of a disease that has a significant economic, social and death burden.