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Introduction
Infectious disease outbreaks are associated with negative psychological and social consequences comparable to their biological outcomes1. Among these consequences, one of the most impactful is stigma-discrimination, as it affects health-related outcomes and is a barrier to accessing health services2. These negative social attitudes and behaviors affect various segments of society, such as patients, families, and healthcare provides2.
During the rapid spread of SARS-CoV-2 infection, it has been observed that health systems have faced a critical overload on human resources4, which are mainly due to psychological distress4 associated with the so-called stigma-discrimination complex (SDC)5,6.
Stigma is defined as a characteristic or trait attributed to someone or something and usually implies a negative connotation7. This trait represents a discrediting label that makes stigmatized people feel alienated from society, and labelling can turn into pigeonholing and stereotyping, leading to discrimination and loss of status8.
In the context of the COVID-19 pandemic, people are stigmatized because of a perceived link to the disease, shaping the concept of COVID-19-related stigma, particularly affecting health care workers (HCWs)9.
In infectious disease outbreaks, fear and misinformation are variables that explain stigmatization10,11. SDC interferes with the diagnosis and treatment process by disrupting communication, individual identity, and sense of free will12. People who feel stigmatized tend to avoid certain behaviors perceived to increase stigma, such as refusing to be tested for COVID-19, because a positive result may be the label, they consider stigmatizing13.
Stigma is a barrier to effective infectious disease prevention and control mechanisms and can affect the stigmatized group and a wide range of people around them with a particular impact on HCWs4,14. For example, perceived stigma discourages infected persons and affects health professionals themselves15 and can be an additional stressor4.
Complementarily, negative attitudes may affect care-seeking and increase the collateral damage of COVID-196. More than 200 COVID-19-related attacks on HCWs have been documented16. In these incidents, HCWs experienced social isolation, public insults or harassment, refusal to use public transport and eviction from the housing. These violent behaviors in the pandemic context towards HCWs shape a specific stigmatization process called Coronavirus Disease-Related Stigma-Discrimination-Complex-towards Health Care Workers (CDRSDCHCW)17,18.
These stigmatization experiences negatively influence HCWs' performance, job satisfaction, self-efficacy and general well-being4,19. Besides, it is crucial to consider that SDC tends to persist over time, easier to consolidate than to eradicate1,20.
Therefore, CDRSDCHCW should be rigorously addressed by healthcare professionals, providers, and health authorities21. Having a valid and reliable instrument to measure CDRSDCHCW17 could improve the identification of the phenomenon and associated variables and allow public health decision-makers to design informed and effective interventions. Despite the potential impact on the quality of life of HCWs, CDRSDCHCW and its associated factors have not been sufficiently investigated22.
This study aimed to determine the frequency and explore variables associated with stigma discrimination complex related to COVID-19 towards health care workers during the pandemic in a sample of emerging-age university adults in Mexico.
Materials and method
Study design and participants
A cross-sectional study was carried out. An online questionnaire was sent to students at the. A sample of at least 384 participants was expected since this sample size was calculated for low prevalences of the dependent variable of 10%, with a margin of error of 3%, or as high as 50%, with a margin of error of 5%, in both cases with a 95% confidence level23. This number of participants would explore some associations with acceptable confidence intervals24. Students between 18 and 29 years of age (emerging age) were included25.
Measures
The research questionnaire included demographic variables (age, gender, marital status, education level, occupation, marital status and income level), religiosity, fear of coronavirus disease and stigma-discrimination related to coronavirus disease towards HCWs.
Stigma-discrimination complex related to coronavirus disease towards health care workers
It was quantified with the Stigma-Discrimination Scale Related to Coronavirus Disease towards Health Care Workers. This tool is a five-item instrument with a dichotomous response pattern17, which resulted from a process of adaptation of the Tuberculosis Stigma Scale26. The instrument presents a unidimensional structure with acceptable internal consistency, Kuder-Richardson coefficient of 0.6717. Each affirmative response is assigned one point; overall scores can be between 0 and 5. Scores between 0 and 2 were classified as low stigma-discrimination related to coronavirus disease, and scores between 3 and 5 were classified as high stigma-discrimination according to the research group's criteria. In the present study, the Kuder-Richardson test was 0.68.
Religiosity
Religiosity was quantified with the Francis 4-item short scale of attitude towards Christianity (Francis-4). This instrument consists of four items exploring attitude towards God, Jesus and prayer. The items offer five response options from completely disagree to completely agree, scored from zero to four, with overall scores between 0 and 16. This instrument has shown excellent dimensionality and internal consistency in previous studies27. Global scores between 0 and 12 were rated as low religiosity and those between 13 and 16 as high religiosity, based on previous studies in Colombia17. In the present study, the scale showed a Cronbach's alpha of 0.97.
Fear of coronavirus disease
It was quantified with the five-item version of the Fear of COVID-528, adapted and validated by the research team in the general Colombian population original 7-item Fear of COVID-19 Scale29. The Fear of COVID-5 has four response options that are scored from 0 to 3. The Spanish version of this instrument has shown adequate internal consistency, Cronbach's alpha of 0.7530. In the present study, the scale showed a Cronbach's alpha of 0.78. The scale allows total scores between 0 and 15. Scores equal to or higher than four were categorized as high fear related to COVID-19, like a similar study in a Colombian population31.
Data analysis
Frequencies and percentages for qualitative variables and measures of central tendency and dispersion for quantitative variables [mean (M), standard deviation (SD), median (Me) and interquartile range (IQR)] were described according to the distribution of the data. For the analysis, CDRSDCHCW was considered the dependent variable, while demographic variables, religiosity, and high fear of COVID-19 were considered independent variables. For variables associated with CDRSDCHCW, prevalence ratios (PR) with their 95% confidence intervals (95% CI) were calculated. Subsequently, significant variables in the bivariate analysis, those that met the Hosmer-Lemeshow criteria32 and those with biological plausibility with the outcome, were entered into a generalized linear model with a binomial distribution and log link function to calculate adjusted PR (aPR)33 explaining the association between covariates and CDRSDCHCW. The analysis was completed in Jamovi version 1.2.27.0.
Results
1,054 students participated (M=20.7; SD=2.2; Me=20; RIC=19-22). Categorical findings and population characteristics are presented in Table 1.
Table 1 Demographical characteristics of sample
Scores for religiosity were observed between 0 and 16 (M=8.53; SD=5.45; Me=9; and RIC=4-12); for fear of coronavirus disease, they were between 0 and 15 (M=2.35; SD=2.51; Me=2; and RIC=0.25-3); for stigma-related discrimination between 0 and 5 (M=0.92; SD=1.26; Me=0; and RIC=0-1).
In this study, 12.4% (n=131) of participants scored for high stigma-discrimination. A statistically significant association was found between CDRSDCHCW and the high fear of COVID-19. See Table 2.
Discussion
In the present study, 12.6% of Mexican emerging-age students reported high CDRSDCHCW and associated high fear of COVID-19. The high frequency of CDRSDCHCW observed is similar to that found in other studies that have reported high levels of COVID-19-related stigma towards health professional11,30,34. These findings could be explained by the fact that SARS-CoV-2 is more contagious than other stigmatized diseases35. The perception of a global pandemic experience combined with economic crisis scenarios1 could also explain the high stigmatization level.
The development of stigma/discrimination is related to cultural, educational, religious, personal, economic, and environmental variables36. Thus, in the present study, a statistically significant association was observed between high CDRSDCHCW and a high level of fear of COVID-19. These results are compared with similar studies where fear of contagion is a variable that generates prejudice, stereotypes, and discrimination11,30. Indeed, HCWs around the world, in both low- and middle-income countries, face SDC, mediated mainly by fear of infection34. However, the association between CDRSDCHCW and other variables may take on a different connotation according to methodological issues. For example, in a sample of 91 COVID-19 survivors in India, perceived stigma was significantly higher in men than women; enacted stigma and internalized stigma were associated with a high education and occupation level20. In this study, Dar et al. measured stigma using a stigma questionnaire adapted from the Ebola-related stigma questionnaire derived from the Berger HIV stigma scale37. However, unlike our study, the stigma assessment in this sample did not target stigmatization experiences directed towards HCWs but was instead a general stigma measure, explaining the differences in associations with the present study.
Another predictor of the stigma that we included in this study was religiosity, although no statistical association with CDRSDCHCW was found. The influence of religiosity on COVID-19 management, especially in developing countries, may generate certain practices that are deleterious to established precautionary measures against the disease; furthermore, the belief that life and death are controlled by the "Almighty", which is also configured as a religious stigma that may impact precautionary measures against COVID-1938. This observation suggests that the relationship between stigma and religiosity is more complex and may be mediated by other types of variables not explored in this study.
The cross-sectional nature of this study limits the strength of the associations assessed, and it is not possible to make causal relationships between variables. On the other hand, social desirability bias may have limited participants' responses for fear of being stigmatized, although to reduce this, we tried to preserve maximum confidentiality. The results are not generalizable to the Mexican university population, as the convenience sample was restricted to a single university. The study's quantitative nature does not allow us to explore other manifestations of the stigmatization process related to COVID-19 so that qualitative studies would enrich the state of knowledge in this area.
Implications
CDRSDCHCW could disrupt patient identification and surveillance and generate considerable negative impacts on pandemic control and management2. Therefore, predicting the stigma-related consequences of COVID-19 is essential in planning prevention measures. Consistent with previous data4, this study's findings suggest that the CDRSDCHCW study can provide insight into the stigmatization process associated with emerging infectious diseases and the possible consequences of such stigmatization.
The Knowledge of the frequency and correlates of CDRSDCHCW provides valuable information for designing interventions to reduce social stigma towards HCWs9,37. In this perspective, an inclusive and rights-based policy approach to address COVID-19 should not only focus on eliminating the disease or interrupting transmission but also address stigma and intersecting vulnerabilities, as well as the conditions that promote or perpetuate stigma39. Consequently, to be equitable and practical, the global response to COVID-19 requires that stigma becomes a higher priority on the public health agenda.
COVID-19-related stigmatization towards health workers among emerging-age adult university students in Mexico is considerable and is associated with a high level of fear of COVID-19. These results highlight the importance of establishing intervention programmes that address COVID-19-related stigma towards health professionals and their potential consequences.
