key: cord-313480-268xf8i9
authors: Ransing, Ramdas; Ramalho, Rodrigo; de Filippis, Renato; Isioma Ojeahere, Margaret; Karaliuniene, Ruta; Orsolini, Laura; da Costa, Mariana Pinto; Ullah, Irfan; Grandinetti, Paolo; Gashi Bytyçi, Drita; Grigo, Omityah; Mhamunkar, Aman; El Hayek, Samer; Essam, Lamiaa; Larnaout, Amine; Shalbafan, Mohammadreza; Nofal, Marwa; Soler-Vidal, Joan; Pereira-Sanchez, Victor; Adiukwu (FA), Frances
title: Infectious Disease Outbreak Related Stigma and Discrimination during the COVID-19 Pandemic: Drivers, Facilitators, Manifestations, and Outcomes across the World
date: 2020-07-27
journal: Brain Behav Immun
DOI: 10.1016/j.bbi.2020.07.033
sha: 
doc_id: 313480
cord_uid: 268xf8i9

nan

Being part of a social minority (e.g. migrants, people of color or Asian descent in Western countries) is not itself a risk factor for contracting Coronavirus disease-2019 (COVID-19). However, certain groups of people across the world are being targeted by COVID-19 related stigma (COS) and discrimination, what constitutes a growing concern(Bagcchi, 2020). There is an urgent need to better understand it, as it may pose as a barrier for accessing testing and health care and for maintaining treatment adherence (Stangl et al., 2019) . It is very likely that COS is the consequence of multiple socioecological drivers (e.g., fear, misinformation) and facilitators (e.g., racism, poverty) (Logie, 2020) . In this letter, we attempt to explore COS related factors based on the real-life experiences of a group of psychiatrists from thirteen countries using the health stigma and discrimination framework (HSDF) (Stangl et al., 2019) . We categorized these experiences as per the process domains (such as drivers, facilitators) and these process domains along with examples/responses are depicted in figure 1.0.

In the majority of represented countries, COS was associated with similar drivers, (e.g., fear associated with the infection or the quarantine), beliefs (supra-natural or religious), and blame to self or others for contracting the disease, as well as guilt and shame. Common facilitators of COS were not being aware of one's rights not to be discriminated against due to lack of education or lack of legislation or policies addressing discrimination or lack of enforcement. Infodemic (i.e. excessive circulation of misinformation) acted both as a driver and facilitating factor for COS (Ransing et al., 2020a) . Unfortunately, most contributors in our group reported that these drivers and facilitators were inadequately addressed in their countries. In certain cases, the reinforcement of negative stereotypes and prejudice, plus social processes of labeling, further fueled already existing social inequalities, which were then reinforced by some public health enforcement measures (e.g., arresting people for breaching quarantine) (Clissold et al., 2020; Logie and Turan, 2020).

Most of the authors reported that people with current or past COVID-19 and their relatives, social minorities (depending on the country, it could include people from Asian descent or black races, and immigrants) and healthcare workers (HCWs) deployed in COVID-19 services have experienced and continue to experience COS. This has led to some HCWs and affected populations to suffer a range of stigma experiences and practices. These people have experienced, and are experiencing, discrimination such as the refusal of housing, verbal abuse or gossip, and social devaluation. Also, their family members or friends are experiencing 'secondary' or 'associative' stigma. Likewise, older people, people with premorbid illnesses, and marginalized people are experiencing more stigmatizing experiences and may not favor treatment due to scarcity of medical resources.

Furthermore, it may have led to diminishing access to health care and uptake of testing, delayed treatment and poor adherence to treatment, decreased acceptability of HCWs in their communities, and overall decreased resilience (i.e. power to challenge stigma). These outcomes may jeopardize their health and wellbeing. They also are influencing outcomes for organizations and institutions, including laws and policies, the availability and quality of health services, law enforcement practices, and social protections. Moreover, it may increase already existing social inequalities by leading to further unemployment and poverty, and impede several social processes such as social integration. For example, documented and undocumented immigrants, refugees, ethnic and religious minorities, people recovered from COVID-19, and marginalized populations may experience socio-economic exclusion due to rapid policy changes such as VISA restriction in some countries. Also, people who have experienced criminalization (due to breaching public health measures) may find reduced access to employment, housing, and healthcare, and may be exposed exacerbated risks for suicide and violence in the pandemic and post-pandemic period To contribute to reducing COS and its negative impact, we collated recommendations for developing interventions using the HSDF (Table 1 ) (Stangl et al., 2019) . We suggest that any adopted interventions should address drivers and facilitators, without disregarding underlying social and health inequities. They should be multi-component, multi-level (Logie and Turan, 2020), and directed towards broader social, cultural, political, and economic factors. More importantly, they should focus on empowering and strengthening communities. Also, these efforts require long term investments in transforming values, laws, rights, and policies (Logie, 2020) . There is a pressing need to collect more systematic data to identify the complex factors related to COS and to improve our understanding of the way it intersects with social and health disparities, to identify gaps where new interventions or programs are required, and to develop appropriate strategies or improve existing programs addressing this problem (Table 1 ).

Our experiences suggest that COS is a global phenomenon. To address it, we need to amplify our collective ability to respond effectively through global collaborations in cross-disciplinary research and policy efforts. Our experiences, put together through HSDF, provides an opportunity to explore the COS, to suggest efficient and effective interventions with the perspectives of clinicians, policymakers, researchers, and project implementers rather than focusing on an individual's experiences These developed interventions may appropriately address the complex realities of affected and vulnerable populations. Further, we suggest that COS researchers should standardize the measures, compare outcomes, and build more effective cross-cutting interventions (Ransing et al., 2020b) .

HIV: Human immunodeficiency virus SARS: Severe acute respiratory syndrome MERS: Middle East respiratory syndrome

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Pandemics and prejudice

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Ethnic disparities in hospitalisation for COVID-19 in England: The role of socioeconomic factors, mental health, and inflammatory and pro-inflammatory factors in a community-based cohort study

Lessons learned from HIV can inform our approach to COVID-19 stigma

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Mental Health Interventions during the COVID-19 Pandemic: A Conceptual Framework by Early Career Psychiatrists

Can COVID-19 related mental health issues be measured? Brain, Behavior, and Immunity S0889159120309326

Factors associated with COVID-19 outbreak-related suicides in India

The Health Stigma and Discrimination Framework: a global, crosscutting framework to inform research, intervention development, and policy on health-related stigmas

Figure 1: Analysis of the stigmatization process for COVID-19 using Health Stigma and Discrimination Framework

The authors wish to thank the Early Career Psychiatrists Section of the World Psychiatric Association (WPA) for being a supportive network that allowed to connect early career psychiatrists from different countries to work together on this initiative.

Facilitato Fear:infection, quarantine, isolation, to be hospitalized, to enter Beliefs: people with COVID-19 or recovered from it have Blaming self or others for

No awareness about one's rig education, poverty, and already existing discriminat into a hospital, social exclusion, losing job due to quarantine or a positive report. Conspiracy against health system compromised immunity and contact with them is dangerous (high infectiousness), the infection cannot be treated or recovered from. contracting the disease, guilt, and shame for being COVID-19 positive.Beliefs: Religious, cultural or supernatural beliefs a Lack of regulation: Unenforced protective laws re health care workers (HCWs), etc.); discrimination b law.

Intersecting stigma Gender (female), race (e.g. Black), ethnicity (e.g. Asian descent).Health conditions: e.g. diabetes, hypertension, alcohol abuse, smoking, flu like symptoms, respiratory diseases, mental illness.Occupation or settings: health care workers, people wo residing in COVID-19 affected regions.

Experiences: loss of social status and reputation (individual and family), employment discrimination, internalization of stigma, perceived stigma, experienced stigma, secondary stigma, restrictions in social participation, e.g. problems in getting or securing/keeping a job/work, problems with friendships, problems in using public facilities, and concealment.Practices: discriminatory attitudes, stereotypes, stigmatiz with COVID-19, social rejection, avoidance, poor heal stigma for HCWs providing care to people living with CO healthcare, Exaggerated media presentations of COVID-1 Potential outcomes Affected Population : 1. Concealment of contact with people with COVID-19 or people with COVID-19 concealing symptoms causing a delay in accessing, engaging in, and completing treatment, poor treatment adherence, and poor treatment outcomes. 2. Delayed screening and treatment-seeking. 3. Financial burden, risk of increasing the burden of disease. 4. Vulnerability to mental illness such as depression, low self-esteem, and self-efficacy. Strong experiences of anticipated and perceived stigma.

1. HCWs avoid working in COVID-19 services, and thu well-qualified staff. 2. People with upper-respiratory-tract infections or peop sent to COVID-19 units, which could lead to overburde turnover of staff. 3. Underutilization of healthcare resources, delay, and av

Reduced mental wellbeing, poor quality of life due to mental illness and increased COVID-19 related mortality, morbidity, and susceptibility to comorbid infection.

Increased prevalence of mental illness such (e.g. depression and anxiety), attempted suicide, reduced capacity of the health care system.

Aggravated poverty due to loss of income, employment.

Prolonged transmission of the virus increases in the number of people with COVID-19. 

• Intervention should consider enacted, felt-normative, internalized, and anticipated stigma. • Consider legal, policy approach to reducing some discrimination (e.g.providing houses to HCWs). However, some (e.g. verbal abuse or gossip) are difficult to address . • Reduce the participation barriers (e.g., addressing access barriers posed by COVID-19 caregiving and/or healthcare provider).