Background

The Coronavirus disease 2019 (COVID-19) spread rapidly as far as the World Health Organization (WHO) officially declared a global pandemic on March 11, 2020 [1]. By January 2022, it has caused at least 5,502,856 death [2]. The ongoing COVID-19 pandemic has led to chaotic social interactions like COVID-19 related stigmatizing behavior and discrimination. COVID-19 related stigma targets patients, their families, and some communities [3, 4]. For example, incidents of stigmatization towards healthcare workers, COVID-19 patients, and survivors have been reported across the world [5,6,7,8]. As we know, health related stigma may deter people from adopting healthy behaviors like delay appropriate healthcare-seeking, which results in an increased psychological, social, economic, and physical burden of any disease [9,10,11,15, 30,59].

The highest rate of enacted stigma was reported from India, which was followed by Jordan China, Lebanon, the U.S.A/Canada, and Egypt regardless of the measuring tool was used (Items versus scale). In contrary to our findings, more than half of Lebanese and Jordanians demonstrated a moderate level of stigma and discrimination using a scale. However, it may be expected that due to geographical and cultural proximity, the prevalence of stigma in those countries should have been similar to ours. That may be because we did not include the rural population in our study; however, the participants of those studies were from both urban and rural populations. That may be also due to the difference between the sampling method of the studies: probability sampling versus non-probability sampling [35, 54]. Comparing Wang’s study with Zhang’s and Zhao’s, we noted that the prevalence of the stigma was dropped by half or more while the scale was used instead of an item to measure the COVID-19 related enacted stigma [31, 36, 37]. The prevalence of stigma in Zhao’s study, followed by Zhang’s, in China is the most similar one to our findings [36, 37]. The Jordanian, Chinese, and Lebanese general population indicated a mild to moderate level of stigma, which supported our findings among the Iranian general population [35,36,37, 54].

Moreover, previous studies mostly supported our findings of the correlates of COVID-19 related stigma among the general population. For instance, Zhang et al. reported that older age and lower level of education were significantly associated with higher stigma scores [36]. Haddad et al. also indicated that having a history of COVID-19 in the family and having direct contact with suspected or confirmed COVID-19 cases played the role of an ameliorating factor for the general population and reduced the stigma discrimination score [54]. Conversely, Zhao et al. detected that participants with master’s degrees or higher endorsed a higher level of stigma toward recovered patients. They also confirmed no significant differences among different ages regarding the level of stigma [37].

This study has several limitations. For instance, due to an inevitable factor of subjectivity when trying to assess stigma, it has a probability that respondents provide responses affected by social desirability factors, even though they were anonymous [60]. Moreover, non-response bias is a prevalent sampling bias in survey studies. People who refused to answer the questions or dropped out from a study may systematically differed from those who completely answer the stigma survey because we asked about an embarrassing information. We used some strategies to avoid sampling bias especially non-response bias. We defined the target population and sampling frame. We also match the sampling frame to the target population as much as possible. For example, we used a stratified random sampling method. We used a software randomly generated a phone number with the city code of Tehran. Two third of the numbers were the mobile numbers and one-third of those were the landline numbers. It followed the proportion of the communication method used by our population. Moreover, our statistic confirmed that the distribution of the participants followed the same pattern of the distribution of the inhabitants across 22 districts of the city. In addition, our survey was designed short enough by experts and trained staff to make data collection simple. We also used data collection by phone using a trained staff to develop a proper relationship with respondents to encourage them to cooperate, and make sure the respondents that any information given is completely confidential and anonymous [61]. Besides, 5.point Likert scale was preferred to use for rating each item in our questionnaire but we had to use 3.choice scale i.e. agree, neither agree nor disagree, and disagree rating scale due to improving understandability in oral communications. Since we administered our questionnaire by phone, we had to use an easily communicable, easily understandable, and a concise questionnaire to have an acceptable rate of participants’ attention and accurate answers. We believe that low Cronbach alpha for social discrimination dimension and dishonor dimension was due to these limitations. In addition, we included only urban population in our study due to executive limitation. Stigma against healthcare workers was not included in the context of this questionnaire. Moreover, since stigma is a dynamic concept and dependent on culture, social norms, rules, and conditions in each society, stigma varies by time and place. That scale was designed in the cultural and social context of Iran at the beginning of the pandemic. Although for the purpose of publication, two bilingual physicians translated these questionnaires to English, then two independent translators back-translated them to Persian. Finally, the translations were confirmed by questionnaire developers, we highly recommend to re-evaluate and adapting our questionnaire to other social and cultural contexts across the globe before use. Conversely, there are several strengths in our study. For instance, we developed a new valid and reliable scale to exclusively and specifically measure COVID-19 related stigma, imposed by the general population. Besides, we had a sample representative of urban population of Iran due to stratified random sampling method and using the residents of Tehran, as the most diverse city of Iran, for sampling frame. We also used both mobiles and landlines to overcome the limitations of random-digit dial telephone surveys. Moreover, we recruited participants from all districts of Tehran city based on the population of each district to match the sociodemographic characteristics of the sample with the those of population. Furthermore, we extracted the behaviors, thoughts, or attitudes that had made the COVID-19 related stigma in our community.

Conclusion

Since COVID-19 related stigma and discrimination are a widespread and disturbing issue in a pandemic, it requires acknowledgment, screening, and prompt intervention to counteract it. Our questionnaire can play an essential role in screening the presence of the enacted stigma among non-infected general population, comprehending the different dimensions of that type of stigma from general population’s perspectives, and extracting the factors inspiring the prevention strategies. It is expected that the policymakers plan interventions and concerted actions to reduce and eradicate this health risk. We suggest that they target seniors, low. Educated communities, and female homemakers, students and out of work communities to enhance the impact of their interventions. We also suggest to focus on blaming and dishonoring mechanisms to better address the destigmatization in our society. It seems that our community needs a widespread and strong clarification about the lack of relationship between an infectious pandemic divine retribution and requital, and guilt.