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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 21  |  Issue : 2  |  Page : 77-82

Stigma and discrimination among doctors toward health-care staff working at COVID-19 sites


1 Senior Resident, Department of Psychiatry, M.P. Shah Medical College, Jamnagar, Gujarat, India
2 Associate Professor, Department of Preventive and Social Medicine, M.P. Shah Medical College, Jamnagar, Gujarat, India
3 Resident Doctor, Department of Psychiatry, M.P. Shah Medical College, Jamnagar, Gujarat, India

Date of Submission11-Oct-2020
Date of Acceptance27-Nov-2020
Date of Web Publication14-Jan-2021

Correspondence Address:
Dr. Parveen Kumar
2nd Floor Trauma Building, Department of Psychiatry, M.P. Shah Medical College, Jamnagar- 361 008, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AMH.AMH_48_20

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  Abstract 


Background: Different infectious disease outbreaks such as bubonic plague, Asiatic flu, cholera, Middle East respiratory syndrome, and Ebola have been associated with polarization, racism, blame, and resultant psychological distress. Health-care providers involved in managing the COVID-19 crisis face challenges such as stigma and discrimination.
Aim: The current study is aimed to explore stigma and discrimination related to COVID-19 among healthcare workers.
Methods: A cross-sectional study was carried out during April and May 2020. Doctors working at health-care facility were approached and requested to fill semi-structured pro forma containing the following parts: (1) Demographic details of participants, (2) Brief Illness Perception Questionnaire 5 (BIPQ-5), (3) Physical Distance and Discrimination Questionnaire, (4) Avoidance Questionnaire, (5) feeling thermometer toward a person having COVID, HIV, TB, Swine flu.
Statistical Analysis: Data entry and analysis was performed using Microsoft excel and SPSS 26 version software. Independent t-test was used to compare the mean and standard deviation of the BIPQ score, physical distance, and discrimination questionnaire score with various demographic variables and avoidance questionnaire.
Results: A total of 323 doctors participated in the study. Out of which 51.39% reports that it is necessary to avoid persons and 30.60% have a problem if a person eats in mess/canteen when working in COVID-19 care. Participants living with family members have statistically significant (P < 0.001) a higher score on the BIPQ, and Physical Distancing and Discrimination Questionnaire. A significant positive correlation (r = 0.162, P = 0.004) of brief illness of perception with physical distancing and discrimination score.
Conclusion: The study found a high threat perception of COVID-19 as well as stigma and discrimination within health-care staff. The stigma and discrimination for COVID-19 are more than other illnesses such as swine flu, tuberculosis, and HIV. This can result in the work compliance and management strategies of health-care workers.

Keywords: COVID-19, discrimination, healthcare staff, stigma


How to cite this article:
Chanpa NB, Kotecha I, Kumar P, Tiwari DS, Vasavada DA, Bhatt RB. Stigma and discrimination among doctors toward health-care staff working at COVID-19 sites. Arch Ment Health 2020;21:77-82

How to cite this URL:
Chanpa NB, Kotecha I, Kumar P, Tiwari DS, Vasavada DA, Bhatt RB. Stigma and discrimination among doctors toward health-care staff working at COVID-19 sites. Arch Ment Health [serial online] 2020 [cited 2021 Apr 14];21:77-82. Available from: https://www.amhonline.org/text.asp?2020/21/2/77/306869




  Introduction Top


From time to time, there have been multiple outbreaks which challenged the health sectors throughout the history which included different infectious disease outbreaks such as bubonic plague, Asiatic flu, cholera, Middle East respiratory syndrome, and Ebola. They have been associated with polarization, racism, blame, and resultant psychological distress.[1] One such is observed recently, which is Novel Coronavirus. There are lots of factors which are not being considered and caused the spread of COVID-19. Out of which one is insufficient knowledge about the transmission of SARS-CoV-2 and protective measures such as wearing face masks in public is associated with anxiety. On January 30, 2020, the World Health Organization declared the outbreak of the 2019 novel coronavirus (COVID-19) as a public health emergency of international concern. Health-care providers involved in managing the COVID-19 crisis are increasing with an increase in the number of cases and facing challenges, including stigma and discrimination.[2]

Social stigma is the negative association between a person and a group who share common characteristics. People are labeled, stereotyped, and treated separately, leading to a negative effect on those with the disease, their family, caregivers, friends, and community.[3] Social stigma is experienced with many illnesses, including mental illness, leprosy, HIV AIDS, Tuberculosis, and Influenza. Social stigma is a normal behavior experienced with the above-mentioned diseases, and institutional segregation can further increase it.[4],[5]

Due to incomplete information and fear associated with COVID-19 health-care professionals also face difficulties in the workplace.[6] Increasing cases, mortality, social isolation, stigma, and discrimination put them at high risk of psychological problems.[7] Discrimination is faced at multiple places such as by staff at hotels and difficulties in finding places to live.[8] People working in COVID-19 health-care facilities are treated as untouchable. Even health-care workers involved in non-COVID are facing discrimination through different behaviors such as refusing to serve them food in some cafeterias and people not renting out premises to them.

Stigmas are also widely documented in health-care facilities, ranging from outright denial of care, sub-standard care, physical and verbal abuse, and passing care off to their colleagues. Health-care workers may also be living with stigmatizing conditions and may conceal their health from colleagues. Stigma reduction is not a routine part of the training of health-care workers.[9] The current study aimed to explore stigma and discrimination related to COVID-19 among health-care workers.


  Methods Top


A cross-sectional study was carried out to assess the stigma and discrimination related to COVID-19 among health-care workers working at Jamnagar, Gujarat from April to May 2020. Doctors working at health-care facility were approached and requested to fill semi-structured pro forma containing the following parts: (1) Demographic details of participants, (2) brief illness perception questionnaire 5 (BIPQ-5)[10] physical distance and discrimination questionnaire[11] avoidance questionnaire feeling thermometer toward a person having COVID, HIV, TB, Swine flu.[12] All the questionnaires used in the study were in the public domain. The questionnaire was pre-tested on 25 participants, and difficulties faced by them in few words were corrected. Participants who gave consent for participation were included in the study. Ethical approval was taken from the institutional ethical committee.

Material

Demographic details

Demographic details include age, gender, residential area, marital status, living with family or not, history of COVID-19 infection to self and family members, family education.

Brief illness perception questionnaire 5

This scale consists of five items and is used for the assessment of perception about COVID-19 illness. The test provides an overall representation of the illness and the participant's response were recorded on a linear scale ranging from 0 to 10. The overall score ranges from 0 to 50, which represents the higher the score, the greater the perception of illness as a threat. This questionnaire explains different processes such as how people perceive threats to their health, how different mental representations and associated emotions were generated, how they start a different plan of action for the regulation of threat and copying. The internal consistency coefficient with a Cronbach's alpha of the scale was 0.66.[10]

Physical distance and discrimination questionnaire

To mitigate the stop, the spread of the Novel Coronavirus a four-item questionnaire is used to assess physical distance and discrimination. This assessment includes questions such as “I would not shake hand with health-care workers involved in taking care of COVID-19 patients,” “I would not hug health care workers who are involved in taking care of COVID-19 patients,” “I would not sit in the same room where health-care workers involved in taking care of COVID-19 patients were included.” Participant's responses were recorded on a linear scale ranging from 0 to 7 (0 = strongly disagree and 7 = strongly agree). A higher score represents more discrimination and physical distance.[11]

Avoidance questionnaire

Questions such as do you feel to avoid persons if they are involved in the care of COVID-19 patients to protect yourself? Do you have a problem if people involved in taking care of COVID-19 patients eat in your mess/canteen with all necessary precautions? These questions were used to assess avoidance towards those who were working in COVID-19 health-care facilities. Participant's responses were recorded as “Yes” and “No.”

Feeling thermometers toward person having COVID, HIV, TB, Swine-flu

Feeling thermometers are often used to measure greater endorsement of prejudice towards others with the diseases. Here feeling thermometers were used to measure what participants feel towards a person suffering from different infections such as (COVID, HIV, AIDS, and H1N1). Participant's responses were recorded on 100-pointer linear scales ranging from very negative to very positive (100). Lower scores reflect colder (or less positive) feelings toward the measured group. Participants' effect toward others with cancer, HIV/AIDS, and H1N1 was measured using feeling thermometers. Participant's responses to the question “How do you feel towards people who have cancer (HIV/AIDS/H1N1)?” were recorded on 100-pointer linear scales ranging from very negative to very positive (100).[12]

Statistical analysis

Data entry and analysis was performed using Microsoft excel and Epi-info software (Centers for Disease Control and Prevention (CDC),Piedmont, North Carolina, United State). The sociodemographic profile has been expressed in terms of frequency and percentage. An independent t-test was used to compare the mean and standard deviation of the BIPQ score, physical distance, and discrimination questionnaire score with various demographic variables and avoidance questionnaire. Pearson correlation was used to find the relation between brief illness of perception with physical distancing and discrimination score. The mean and standard deviation of participant's feeling thermometers score was compared across different illnesses (COVID-19, swine flu, HIV, tuberculosis).


  Results Top


A total of 323 doctors participated in the study, of which 59.1% were male and 40.9% were female. Most participants belonged to the Hindu religion (89.1%). [Table 1] shows the demographic details of the participants.
Table 1: Demographic details of participants* (n=323)

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The mean score of participants on the brief illness of perception was 28.97 ± 5.78 and 17.60 ± 5.19 physical and discrimination questionnaires. Out of a total of 51.39% (n = 166) reports that it is necessary to avoid persons and 30.60% (n = 99) have a problem if a person eats in mess/canteen when working in COVID-19 care. [Table 2] shows that participants who feel that it is necessary to avoid persons who are involved in the care of COVID-19 patients to protect themselves have a higher score on the brief illness of perception score as well as physical and discrimination questionnaire. Which was found to be statistically significant with (P = 0.01) and (P < 0.001), respectively, as denoted by independent t-test.
Table 2: Relation of participants response to avoidance questions with brief illness perception score and physical distance and discrimination score* (n=323)

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[Table 2] shows that participants who have a problem if people involved in taking care of COVID-19 patients eat in their mess/canteen with all necessary precautions have a statistical high score on the physical and discrimination questionnaire (P < 0.001), while no statistical relation with the brief illness of perception score (P = 0.25) which was denoted by independent t-test.

[Table 3] shows that participants living with family members have a higher score on the BIPQ, Physical Distance, and Discrimination Questionnaire. Both the differences were found to be statistically significant (P < 0.001) as denoted by an independent t-test.
Table 3: Relation of demographic variable with brief illness perception score and physical distance and discrimination score* (n=323)

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There was no statistical significance observed between other demographic details with the BIPQ score, Physical Distance and, Discrimination Questionnaire as observed on independent t-test.

[Table 4] shows that the mean score of feeling towards different illnesses was lowest in COVID-19 as compared to others, which shows that participants have a more negative feeling toward COVID-19 sufferer that other illnesses such as swine flu, tuberculosis, and HIV.
Table 4: Comparison of participants mean and standard deviation towards person suffering from different illness* (n=323)

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[Figure 1] shows a small positive, statistically significant correlation (r = 0.162, P = 0.004) of brief illness of perception with physical distancing and discrimination scores, as denoted by the Pearson correlation test. As the perception of threat toward illness increases, physical distancing, and discrimination also increases.
Figure 1: Scatter plot between brief illness perception score and physical distancing and discrimination score

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  Discussion Top


The current study observed that participants have more negative feelings toward COVID-19 than other illnesses such as swine flu, tuberculosis, and HIV. The results of the study found that COVID-19 was stigmatized at the height of the pandemic. Similar findings were also demonstrated at the time of the H1N1 pandemic. People held decreased effect or increased prejudice and more negatively toward people with H1N1 than people with HIV/AIDS.[12] This may be due to various medical misinformation and unverifiable content regarding COVID-19 through these platforms create panic, fear, and anxiety among people.[13] With that media coverage and public opinion about suspending programs like airline programs as compared to the actual need for public health.[14] The information about the risk of infection presented through sensational media (various audio-visual channels) reporting in a manner to influence people's perception.[15]

India has witnessed a major problem of social stigma and discrimination due to the fear associated with infection. The current study found a higher threat perception of COVID-19 illness and more physical distancing and discrimination towards persons working in health care facilities. As the perception of threat toward illness increases, physical distancing and discrimination also increase. The high rates may be due to changes in human behavior during COVID-19 as a rapidly quantifying measure of physical distancing to stop transmission of disease and high perception of infection spread to them, leading to more physical distancing and discrimination. As from one of the incidents reported in India Today, a 25-year-old nurse employed with the Intensive Care Unit (ICU) of a major government hospital was locked inside her room by her hostel warden since March 24, 2020, in south Delhi's Hauz Khas area.[16] Discrimination toward illness is not uncommon in health-care providers. A study by Ross and Goldner in a review of literature found that health-care professionals had a stigmatizing attitude toward a person having a mental illness.[9] A study by Dong et al. on stigma discrimination among health-care providers toward persons suffering from HIV observed negative attitudes and cognition.[17] A review of literature of studies from different parts of the world by Nyblade et al. focusing on HIV-related stigma among health care facilities found high stigma and fear of casual contact due to lack of awareness and fear of infection.[18] Study by Coreil et al. among health professionals from South Florida observed a high degree of anticipated perceived stigma toward tuberculosis.[19]

The current study observed that health-care professionals try to avoid people working at COVID care at places such as mess or canteen even after taking proper care. Similarly, Tandon report that anyone who is involved in providing care to COVID-19 cases treated as untouchable, health-care providers are being labeled and discriminated at different places.[6] These results may be due to fear of infection of respiratory disease. The current study also found that participants living with their family members have more infection threat. The finding may be correlated as participants felt chances of the spread of infection to their family members from them.

The current study found no difference in stigma and discrimination between those who got infected due to COVID-19 and non-infected. The results may be due to non-clear evidence about how many cycles of COVID-19 a country may face.[6] However, some research from Disease Control and Prevention South center reports that patients recovered from COVID-19 did shed viral material, but they were not infectious and cannot transmit to others.[20] Study by Ramaci et al. among 260 health-care workers (HCWs) from Italy report a high impact of stigma on worker's outcome which can result in work compliance and management strategies relating to pandemic risk for HCWs.[21]

Accurate information plays a key role in making appropriate decisions and to fight public health crisis but providing accurate information only may not help counteract COVID-19 stigma and discrimination.[22] This can be done by responsible media coverage, organizing lectures for health-care staff, providing pamphlets, fact-checking various sources of information and labeling them as incorrect through government intervention, and setting up a precedent by punishing those spreading malicious rumors intentionally, appreciating and rewarding the efforts of COVID health-care staff who are putting their and their loved ones lives at risk by working in the grueling epidemic. These are some of the measures which will help in decreasing discrimination among health-care staff and in the general population toward COVID-19 staff.


  Conclusion Top


The study found a high threat perception of COVID-19 as well as stigma and discrimination within health-care staff. The stigma and discrimination for COVID-19 are more than other illnesses such as swine flu, tuberculosis, and HIV. This may be due to various misinformation, and rumors spreading through digital media. This can result in the work compliance and management strategies of health-care workers. Responsible media coverage, organizing lectures for health-care staff, providing pamphlets, fact-checking various sources of information, and labeling them as incorrect are measures that will help in decreasing discrimination among health-care staff.

Limitation and future scope

The study contains self-reported data that could be biased in the direction of both over-reporting and under-reporting. The study included only doctors, and further studies should include other medical professionals such as nurses and other paramedical staff. The study was conducted at a single center; a multi-centric approach would reflect general trends better. Due to the cross-sectional nature of the study, it is difficult to preclude any causal interpretations; longitudinal studies are required to better elucidate causality.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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