key: cord-0694491-ro2voemd
authors: Ozturk, Ayfer
title: Stigmatization spreads faster than the virus. Viruses do not discriminate, and neither should we.” Combatting the stigmatization surrounding coronavirus disease (COVID‐19) pandemic
date: 2021-04-30
journal: Perspect Psychiatr Care
DOI: 10.1111/ppc.12815
sha: 97491e99bd3e7ebab92f1cb7a9ab4c05cb91f15d
doc_id: 694491
cord_uid: ro2voemd

Infectious diseases are one of the most important problems of the last century. Epidemics have caused the stigmatization of managers, healthcare professionals, and those likely to be infected throughout history. Although many infectious diseases caused stigmas both in the past and today, a new name is added to the list of epidemics in various regions in the world each year and the masses become alerted. The latest disease added to the list is the new coronavirus (COVID‐19). Today, because of the COVID‐19 pandemic, which has influenced the whole world, the risk of social stigmatization reappears. In this context, it is very important to take the necessary measures to prevent stigmatization and to plan the interventions.

Throughout human history, health problems periodically emerge that suddenly enter the world and concern all of humanity. 1 One of these is the new coronavirus (COVID- 19) disease, which emerged in China and has spread very rapidly in many countries, causing an acute infectious lung inflammation epidemic. 2,3 COVID-19, which is caused by the new coronavirus, has turned into a pandemic and is a serious threat to humans worldwide. 4 The World Health Organization (WHO) China Representative Office reported cases of lung inflammation of unknown etiology in Wuhan city in Hubei Province, China in December, 2019. 4, 5 The possibilities of other coronaviruses, influenza, and other such diseases were ruled out by laboratory diagnostics. 5 On January, 2020, the agent that caused the disease was identified as a new type of coronavirus (2019-nCoV), which was not previously detected in humans. 6 Thereupon, the disease caused by the 2019-nCoV virus was called COVID-19. The WHO declared this disease a pandemic on March, 2020. 7,8 COVID-19 has become a global health threat in a short time. As of January 2021, there are more than 100 million confirmed cases globally, 9 with two million in Turkey alone, reported by Ministry of Health. 10 The current global pandemic inevitably has consequences for mental health, as shown through previous health crises. 11 Psychological reactions of the people in pandemics are commonly associated with emotional distress, which plays an important role in the course of the disease. During these periods, psychological disorders can be triggered and exacerbated by pandemic stress factors, and the pandemic can have long-lasting psychological effects on individuals. 12 Similar to previous epidemic diseases, the effects of COVID-19, as a medical condition, on the physical health of people was affected directly and indirectly by the disease as well as the effects of the reaction of society to the consequences of this disease and pandemic on psychological health are inevitable. 13, 14 Supporting the previously conducted studies, current studies associate the COVID-19 pandemic process with many serious psychological problems and regard it as a threat to the well-being of the individual. 15 In addition to the disease itself, other factors play a role in anxiety and other psychological disorders that occur during pandemic periods. Other uncertainties associated with the course of the disease are also important factors that cause anxiety and psychological distress 12, 16 in pandemics. The COVID-19 outbreak continues with considerable uncertainty around the world. Because international responses and decisions vary, the interregional processes are operating differently. 16 Uncertainty, fear, and anxiety about a disease can cause social stigmatization of people, places, or things. 17, 18 People belonging to a particular nationality, population, or region may experience discrimination even if their risk of contracting the virus is not high. 19 Similarly, stigmas and discrimination may occur when people associate a disease such as COVID-19 with a particular population or nationality, even though all the people in the relevant population or region do not carry a risk of disease. People who are out of the COVID-19 quarantine may be exposed to stigmatization even if they no longer carry, or are at risk of spreading the virus. [17] [18] [19] 2 | OUTBREAKS AND STIGMATIZATION: WHY HAS COVID-19 BROUGHT STIGMA WITH IT?

According to the WHO, health-related social stigma occurs when there is negativity associated with a group of people who share characteristics or have been affected by a disease. 20 This negativity may manifest as discrimination, treating the person differently, stereotypes/labels, or decreased status of the person. This can be distressing for those with the disease and their caregivers, family, friends, and communities. Those without the disease that possess similar characteristics as the targeted group might also be subjected to social stigma. 21 Mentioning infectious diseases with stigmas is not a new situation. Infectious diseases have serious social consequences and they have become one of the stigmatizing medical issues in modern history. Epidemics have caused the stigmatization of managers, healthcare professionals, and those who carry the disease or are likely to be infected throughout history. 22, 23 Other infectious diseases have also been associated with social stigma, discrimination, and exclusion 24,25 (e.g., influenza A [H1N1], bubonic plague, Asiatic flu, cholera, Ebola virus disease, Zika virus, HIV, tuberculosis, SARS, and MERS). 26 In the past, people who were infected with syphilis were cursed by the people, leprosy disease was regarded as an "evil" sent by God, and the plague was considered a punishment for people's sinful behaviors. 27 More recently, after returning to society, survivors of the 2013-2016 West Africa Ebola outbreak encountered ostracization and unemployment. 28 There have been many infectious diseases causing stigmas both in the past and today.

A new name is added to the list of epidemics in various regions of the world each year and the masses become alerted. The last name added to the list was COVID-19.

The level of stigma associated with COVID-19 is based on three main factors: As it is new and has no cure, the disease may also be stigmatized. 29 The disease is new and there are many aspects that are not yet known, we are often afraid of the unknown, and it is easy to associate this fear with "others." The fact that people are confused, worried, and afraid is, therefore, understandable. Unfortunately, these factors also fuel harmful stereotypes. 20 Discriminatory discourses, superstitions, and unfounded information about whether various ethnic groups and races will be affected by the disease have spread faster than the epidemic in the media and social media since the first days of the disease. Conspiracy theories about the emergence of the disease also target some governments to strengthen discrimination. 22 In addition, the public health response to COVID-19 itself may increase stigma and cause discrimination. 30 COVID-19 has led diverse groups of people to experience stigma and discrimination. 30 Healthcare workers caring for patients with COVID-19, people who have recovered from COVID-19, those in lower socioeconomic groups, and those with specific religious and racial identities experience this discrimination. [33] [34] [35] Discriminatory and stigmatizing discourses and behaviors directed toward Asians, especially the Chinese, at the beginning of the outbreak targeted many people and groups as the disease spread worldwide, especially those traveling to risky areas, the elderly, emergency teams, and healthcare professionals, and individuals infected or quarantined who survived and their relatives. 19 As a result, COVID-19 has led to the reinforcement of pre- 

Stigmas can make individuals feel isolated from and even abandoned by society. 20 The stigma carries serious consequences, including fueling fear, pessimism, hopelessness, weakness, social withdrawal, inadequacy, helplessness, anger, and intolerance directed at other people, feelings of guilt, shame, regret, sadness, self-pity, anger, internalized emotions, selfdoubt, overwhelmed feelings, negative self-talk, unrealistic expectations, and perceived sense of failure. 20, 22, 30, 37, 38 People may feel sad, hurt, and angry when their friends and other members of their community avoid them over the fear of being infected with COVID-19. 20 In such cases, they may feel anxieties and fears regarding the future, intense anger toward the people surrounding them, and a desire to hurt themselves may emerge. Anxiety symptoms, social withdrawal, pessimism, hopelessness, inadequacy, helplessness, and guilt may trigger mental illnesses. 20, 22 More importantly, stigmas can cause potential patients to avoid accessing the healthcare system with the concern of exclusion by others and continue to spread infection instead. 29 The fear of discrimination can cause two detrimental clinical and public health consequences: symptomatic patients delaying healthcare (prognostic deterioration) and underidentification of infectious individuals (increasing viral transmission to susceptible contacts). 39 Thus, stigmatized people are more likely to be reluctant to seek treatment, leading to delayed treatment and increased morbidity and mortality. 30 Studies on past pandemics have shown that stigmas harm the tests and treatment efforts regarding the disease. 40 A delayed diagnosis is associated with more severe illness, particularly for the elderly and other vulnerable groups, whereas delayed reporting of an infectious patient can accelerate community spread of COVİD-19. 41

It is very important to plan interventions to prevent social stigma for risky groups during the process of combating COVID-19. 42 Knowing the facts, sharing them with those around you, and awareness can help reduce this stigmatization. 19, 22, 40 People with more personal resources (income, education, and social support) and good mental health have increased knowledge regarding emerging infectious diseases, are less worried, and less likely to stigmatize others. 41 Education, clear and honest communication, and nondiscriminatory language could improve the knowledge, attitudes, and behaviors associated with COVID-19 and reduce related social stigma. 43 National, regional and local healthcare services that communicate transparently and work reliably and efficiently can also alleviate fears amongthe community and reduce stigmatisation and social discrimination 44 The WHO defines an infodemic, characterized by an overabundance of news, mixing facts, rumors, and fake news, as too much information, including false or misleading information, about COVID-19. The WHO notes that it is a key driver of social stigma in our time. 45, 46 The WHO also states that an infodemic can cause panic and fear in societies, make the fight against the disease difficult, and increase stigmatization.

Therefore, preventing an infodemic in digital and physical environments is emphasized. 46 Within this context, the importance of individuals' ability to obtain accurate information from reliable sources about preventative measures, life-saving actions, and early screening and treatment is paramount. Gently correcting discriminatory or untrue information and preventing its dissemination when noticed, disseminating the correct information that the virus can spread in any society, race, and religious group, and, therefore, promoting an accepting, understanding, and supportive approach to the groups with a high risk of contamination is highlighted. 17, 18, 20 Descriptions and expressions used in the media in the process of combating the epidemic, as well as the collective consciousness that these definitions will create, can direct stigmatizing attitudes, especially toward risky groups, after COVID-19. 42 According to the WHO, any attitude developed toward the disease ranging from words to different definitions used to prevent stigmatization is important. The WHO emphasizes the importance of the expressions used and notes that the words and definitions used for COVID-19 can trigger and increase stigmatization. They suggest appropriately using the expressions, such as case definition and isolation, that are used to describe the disease and its process. Otherwise, crucial stages, such as clinical tests and quarantine, can be harmed. Individuals in society, health professionals, and the media have important roles. 20 Accordingly, the organization suggests that people who are positive for COVID-19 should not be described as "COVID-19 cases," "victims," "COVID-19 families," or "sick," instead, expressions such as "people with COVID-19," "people receiving treatment for COVID-19," "people recovered from COVID-19," "people who lost their lives due to infection of COVID-19," or "people with a possible diagnosis of COVID-19" should be used. 20, 22 In this process, health professionals should share correct information about the spread of the virus, respect and protect the privacy of patients and persons with a potential contact, raise awareness about COVID-19 without increasing fear, and be sensitive to images shared on social media. In line with these attitudes, the importance of not reinforcing stereotypes in society is emphasized. 17, 18, 20 In addition, it is very important for health professionals to educate the public by correcting incorrect or missing information.

Stigma in health refers to the negative or discriminatory attitudes toward the person or group diagnosed with a particular disease, the areas where the disease occurs. Today, because of the COVID-19 pandemic, which has influenced the whole world, the risk of social stigmatization reappears. It is stated that the vast majority of individuals subjected to stigma may adopt social prejudices and stereotypical thoughts themselves over time. Accordingly, as a result of this situation, thoughts of harming both self and others around including feelings of intense anger may emerge via guilt, shame and concerns about the future, and thus, this may threaten psychological health. In this context, it is very important to take the necessary measures to prevent stigmatization and to OZTURK | 3 plan the interventions. 42 The psychosocial consequences of an outbreak cannot be separated from the global health crisis; they reinforce each other in a continuing cycle. Stigmatization is more than a negative consequence of pandemics. Stigmas should be considered a biosocial phenomenon in the context of an infectious disease. It may become both a contributing factor to the spread of the epidemic and disease of its own. Therefore, the social harm that spreads with the disease should also be taken into consideration when dealing with COVID-19. Otherwise, we may face the risk of promoting social antagonism, which has the potential to accelerate the spread of the disease. 47 While psychological interventions have been applied in several ways during the spread of the COVID-19 virus, a public approach is required to overcome its common psychological effects. Hence, it is extremely important to establish a public system to verify the validity of the information published by the media. In addition, the media should take responsibility for the dissemination of misleading and sensational titles that promote stigmatization. Communities and mental health units should always strive to improve their social support systems and prevent stigmas related to the disease. A targeted mental health strategy for different communities, including those under quarantine and healthcare workers, could be useful as well. 29 It is extremely important that mental health professionals provide the necessary support to those who are exposed to the disease and the caregivers. Special efforts should be made for vulnerable communities, such as infected people, their families, and colleagues, communities of people with a previous mental/physical condition, and healthcare teams and aid workers, including the nurses and doctors, who work directly with the infected people or those in quarantine. Nurses and physicians should also understand what this experience means to each patient. They should provide sensitive, appropriate, and effective care for each patient by providing and planning holistic care for the infected and sick people.

In conclusion, society, health professionals, and the media have important roles in the process of fighting against stigmatization.

This crisis has implications for psychiatric-mental health nurses, as the consequences of COVID-19 can result in mental health problems among both the general public and nursing workforce. 48 Psychiatric-mental health nurses should work to promote optimum mental health outcomes for both the general public and nursing workforce in light of COVID-19.

While the physiological consequences of COVID-19 cannot be overlooked, it is critical that psychiatric-mental health nurses advocate to assure that mental health consequences of COVID-19 are also given commensurate attention. Promoting mental health during COVID-19 may be challenging due to the stigma associated with mental health problems; however, psychiatric-mental health nurses are well-positioned to fulfill leadership roles throughout the care continuum in response to COVID-19. It is clear that psychiatric-mental health nurses must act now as leaders in addressing and mitigating COVID-19-related mental health consequences.

The author declares that there are no conflict of interests.

Ayfer Ozturk, conceived, designed, wrote and edited the manuscript.

https://orcid.org/0000-0002-3092-0671

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