Abstract
Background
COVID-19 related stigma has been identified as a critical issue since the beginning of the pandemic. We developed a valid and reliable questionnaire to measure COVID-19 related enacted stigma, inflicted by the non-infected general population. We applied the questionnaire to measure COVID-19 related enacted stigma among Tehran citizens from 27 to 30 September 2020.
Methods
A preliminary questionnaire with 18 items was developed. The total score ranged from 18 to 54; a higher score indicated a higher level of COVID-19 related stigma. An expert panel assessed the face and content validity. Of 1637 randomly recruited Tehran citizens without a history of COVID-19 infection, 1064 participants consented and were interviewed by trained interviewers by phone.
Results
Item content validity index (I-CVI), Item content validity ratio (I-CVR), and Item face validity index (I-FVI) were higher than 0.78 for all 18 items. The content and face validity were established with a scale content validity index (S-CVI) of 0.90 and a scale face validity index (S-CVI) of 93.9%, respectively. Internal consistency of the questionnaire with 18 items was confirmed with Cronbach’s alpha of 0.625. Exploratory factor analysis revealed five latent variables, including “blaming”, “social discrimination”, “dishonor label”, “interpersonal contact”, and “retribution and requital attitude”. The median of the stigma score was 24 [25th percentile: 22, 75the percentile: 28]. A large majority (86.8%) of participants reported a low level of stigma with a score below 31. None of the participants showed a high level of stigma with a score above 43. We found that the higher the educational level the lower the participant’s stigma score.
Conclusion
We found a low level of stigmatizing thoughts and behavior among the non-infected general population in Tehran, which may be due to the social desirability effect, to the widespread nature of COVID-19, or to the adaptation to sociocultural diversity of the large city.
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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.
Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Abbreviations
- COVID-19:
-
Coronavirus disease of 2019
- WHO:
-
World health organization
- SARS:
-
Severe acute respiratory syndrome
- HIV/AIDS:
-
Human immunodeficiency virus/Acquired immunodeficiency syndrome
- CVI:
-
Content validity index
- I-CVI:
-
Content validity index of each item
- S-CVI:
-
Scale content validity index
- CVR:
-
Content validity ratio
- I-CVR:
-
Content validity ratio of each item
- FVI:
-
Face validity index
- I-FVI:
-
Face validity index for each item
- S-FVI:
-
Face validity index for scale
- KMO:
-
Kaiser-Meyer-Olkin
- PAF:
-
Principal axis factoring
- SPSS:
-
Statistical package for the social sciences
- IQR:
-
Interquartile range
- SD:
-
Standard deviation
- No:
-
Number
- P:
-
P value
- vs:
-
Versus
- U.S.A.:
-
United States of America
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Acknowledgements
We thank Dr. Mohammadreza Hojat for hel** us with develo** the questionnaire. Furthermore, we appreciate the social and cultural deputy office at Tehran Municipality for hel** us with data gathering, including interview with Tehran citizens on phone call to filling out the questionnaires.
GT is supported by the National Institute for Health Research (NIHR) Applied Research Collaboration South London at King’s College London NHS Foundation Trust, and by the NIHR Asset Global Health Unit award. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care. GT is also supported by the Guy’s and St Thomas’ Charity for the On Trac project (EFT151101), and by the UK Medical Research Council (UKRI) in relation to the Emilia (MR/S001255/1) and Indigo Partnership (MR/R023697/1) awards.
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Contributions
MF: Conceptualization, Methodology, Formal analysis, Interpretation, Writing original draft, Investigation, and Project administration. HNo: Methodology, Formal analysis, Data curation, Interpretation, and Writing original draft. AARR: Conceptualization, Methodology, Writing. review and editing. AMA: Writing original draft, and Investigation. MRJY: Supervision, Methodology, and Writing. review and editing. HSh: Methodology, and Writing. review and editing. HNa: Project administration, and Writing. review and editing. ShKh: Investigation, and Writing. review and editing. AB: Investigation, and Writing. review and editing. MFat: Visualization of the results, Data curation, and Writing. review and editing. EG: Investigation, and Writing. review and editing. FSM: Investigation, and Writing. review and editing. HRB: Conceptualization, Writing. review and editing. GT: Interpretation, Writing. review and editing. AHJN: Conceptualization, Methodology, Interpretation, Writing. review and editing, Supervision, and Acquisition of the non-cash support for data collection. The author(s) read and approved the final manuscript.
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The institutional review board and ethics committee of Kerman University of Medical Sciences (KMU) approved this study. The ethic approval code is “IR.KMU.REC.1399.090”. All authors confirmed that all parts of the study were carried out in accordance with Declaration of Helsinki guidelines and regulations. The surveys were anonymous. The interviewers explained the purpose and method of the study to all interviewees and obtained the oral informed consent on the phone. The institutional review board and ethic committee approved the oral informed consent on the phone due to restrict COVID-19 rules and regulations for social isolation and the necessity of no internet-based approach to include more diverse population regardless of access to the internet-based social media or communication tools. Address: Deputy for research affairs, Kerman University of Medical Sciences, Haft Bagh-e-Alavi Highway, Kerman, 7616911320, Iran. Tell: + 983432263815.
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Faghankhani, M., Nourinia, H., Rafiei-Rad, A.A. et al. COVID-19 related stigma among the general population in Iran. BMC Public Health 22, 1681 (2022). https://doi.org/10.1186/s12889-022-14039-2
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DOI: https://doi.org/10.1186/s12889-022-14039-2