The development and validation of a novel COVID19 stigma scale among healthcare workers (COVISS-HCWs)

The coronavirus disease which emerged in the year 2019, (COVID-19) is caused by the novel severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) [1]. The disease has assumed pandemic proportions leading to the death of over 6 million people worldwide [1]. Limited knowledge about the disease and lack of effective means of control may result in feelings of fear and anxiety of catching the infection, its symptoms, and complications. Fear of the disease may lead to negative behaviors against persons who have the disease or may have it [2]. Public health strategies dealing with rapidly growing disease outbreaks such as COVID-19 require a delicate balance between maintaining precautionary measures for infection control such as physical distancing while alleviating the possible psychological harms of such measures [3].

The psychological repercussions of lockdowns and physical distancing policies have been well documented [4]. These, however, may be aggravated by the stigma of carrying the infection or being around those who have it. According to the World Health Organization (WHO), stigma is defined as “the negative association between a person or group of people who share certain characteristics and a specific disease” [5]. Stigma might be expressed verbally or through discriminatory behaviors such as isolation, refusal to provide service, bullying, and harassment. Stigma may also affect individuals dealing with those infected with the disease, such as caregivers, family members, or those in the same community. Importantly, healthcare providers may also face stigmatization. This, along with the well-documented high rates of anxiety and depression among this group, may compromise their well-being and hence, may even threaten disease control [6]. Studying stigma against patients with infectious diseases such as human immunodeficiency virus (HIV), and tuberculosis (Tb) is prevalent. However, studies regarding stigma against healthcare providers taking care of those patients are limited. In March 2020, the WHO Department of Mental Health and Substance Use developed a series of suggestions that can be used to support the psychosocial well-being of different groups during the outbreak [7]. According to Roy et al., stigma is associated with many health conditions. In contrast, awareness may minimize the stigma and facilitate acceptance of the healthcare workers in the general population [7]. To date, only two studies documented stigmatization using a specific questionnaire against healthcare workers dealing with COVID-19 patients [8, 9]. The aim of this study is to design and validate a stigma scale specific to COVID-19 and investigate correlates of stigma among healthcare workers dealing with COVID-19 patients in Syria. Through a novel questionnaire tailored to the COVID-19 context, we studied feelings of perceived harm, shyness and inferiority, and avoidance among healthcare workers in five major public hospitals in Damascus, the capital of Syria. The validity and reliability of this questionnaire are presented in this manuscript. In addition, we aimed to investigate whether the experience of stigma correlates with demographic or workplace variables and whether it relates to a healthcare worker’s attitude towards COVID-19 vaccines.

Stigma develops towards diseases in situations where a person is considered to be the cause of disease, incurable or degenerative, when the disease seems to cause adverse effects for others, and when it has visible signs on the patient’s body. These situations are compatible with many diseases such as tuberculosis, leprosy, HIV/AIDS, H1N1 and severe acute respiratory syndrome (SARS). During the SARS outbreak, HCWs were prevented from interacting outside and inside the hospital with their colleagues. Furthermore, habits that require mask removal such as eating, and drinking were done alone or outside the hospital [20]. In addition, HCWs had concerns about their safety, transmitting the disease to family members, stigmatization, and social isolation. On the other hand, the relationship between patients and staff became blurred as they experienced a strong emotional identification with their colleagues who were now infected which increased anxiety regarding their competence and skills [20]. One study reported that HCWs realize that their work is less valued due to the stigma that comes from close dealing with HIV-infected patients [21]. While currently, during the COVID-19 pandemic, HCWs in Mexico and Malawi were found to use bicycles, as they were prevented from using public transportation and were subjected to physical abuse [22]. In India, doctors and nurses dealing with COVID-19 patients faced social stigmatization as they were fired from their rented homes and were even attacked during their duties [22]. Recently, COVID-19 joined the list of diseases that trigger stigmatization. However, this disease has different pathologies and spreads relatively faster than many other diseases, which is likely to cause more panic among community members. As in the case with previous outbreaks, HCWs during COVID-19 are at the frontline confronting the pandemic and may face stigmatization. Experiencing stigma negatively affects HCWsʼ psychological status which may reflect on their medical performance and influences the spread of disease. According to the WHO, HCWs treating COVID-19 are considered as a stigma-vulnerable group during the pandemic along with travelers to infected countries and symptomatic patients [23, 24]. Considering the widespread nature and continuing relevance of COVID-19 and its associated stigma, it is important to develop a COVID-19-specific stigma scale in order to evaluate the prevalence of stigma during the pandemic. A universal, reliable, and valid scale for evaluating presence of COVID-19 stigma among HCWs is still lacking. The main objective of the current study, that included 700 HCWs from five of Damascus’s dedicated COVID-19 hospitals, was to develop the COVID-19 Stigma Scale (COVISS-HCWs) in order to investigate the prevalence of COVID-19-associated stigma among HCWs and its possible predictive factors. Accordingly, we developed and divided COVISS-HCWs items into two subscales (harmfulness, and inferiority, and avoidance) depending on EFA. Confirmatory factor analysis (CFA) resulted in reducing COVISS from 14 to 11 items. Importantly, responses to all items and all subscales highly correlated with the overall scale indicating COVISS-HCWs reliability. We found that 69 HCW (9.86% were stigmatized according to our validated score. Few studies reported varying proportions of COVID-19 stigma using non-validated stigma tools among Indonesian, Egyptian, Burkina Faso, Nigerian, and Ethiopian physicians that were 21.9%, 31.2%, 66%, 67%, and 88% respectively [25‐27]. Furthermore, Adalberto et al. suggested non- validated scale to determine COVID-19 stigma-discrimination toward HCWs [28]. In general, studies that attempted to use a definite validate COVID-19 stigma scale involved either non-HCWs such as general population and recovered infected patients or a particular group of HCWs except the Vietnamese and Egyptian studies [9, 29‐32].The later attempted to adapt the SARS stigma scale to form a valid scale for assessing the presence of covid-19 among physicians [9].

The scale consists of 16-item, each item had four possible responses distributed as 1–4 Likert scale points, allocated into three subscales personalized stigma (8 items); concerns of disclosure and public attitudes (5 items); and negative experiences (3 items) with Cronbach’s α for the three subscales 0.90, 0.66, and 0.78 respectively and 0.90 for overall scale [9]. In this study, we adapted some questions from Nyblade HIV and TB stigma scales to fit Covid 19 HCWs [11, 12].Whereas, the other questions were developed by our team to Covid 19 HCWs. Our final novel questionnaire consists of 11 items only, each item had five possible responses and distributed as 1–5 Likert scale points which is more precise than 1–4 Likert scale points, allocated into two subscales harmfulness and inferiority (7 items); and avoidance (4 items) with Cronbach’s α for the two subscales 0.87 (very good), and 0.85 (very good), respectively and 0.909 for overall scale. The Egyptian study depends on the SARS stigma scale that developed its scale from Berger HIV scale which is developed to assess stigma among infected HIV patients not particularly to assess stigma among HCWs [9, 33, 34]. While we adapted some questions from Nyblade HIV and TB stigma scales that designed their scales to assess stigma among HCWs [11, 12]. Another small study included only 61 Vietnamese HCWs attempted to develop validated scale that administrated in Vietnamese language, while in this study the scale was administrated in English language to increase its utility in the world [32]. However, the published scale was different from the SARS HIV and tuberculosis stigma scale which we used to develop the COVISS-HCWs scale [11, 12, 33]. The first subscale concerns harmfulness and inferiority, and the second subscale was avoidance faced by HCWs due to communication behaviors. Responses to all items and all subscales highly correlated with the overall scale. Further analysis of validity measures allow us to conclude that the final model displayed good convergent but mixed divergent validity [35]. In this study, financial status significantly correlated with experiencing stigma as it appears in 32,3% of low-income participants, which is nearly similar to other studies conducted in low-income countries (37%) [36]. This can be explained that low-income countries are more likely to attend stress and as a result they may have huge psychological pressure on population as well as HCWs. In addition, HCWs who have less contact with COVID-19 patients were less stigmatized than others who had occasional contact, and also less than who had daily close contact with them, 7.5%, 14.6% and 19.4% respectively. This result is similar to other studies which end up with 3.5 times stigmatization when HCWs deal with COVID-19 inpatients [25]. Stigma aggravates stress, post-traumatic stress syndrome, burnout syndrome, inability to concentrate and make decisions, negative self-image and concerns about the public attitude in addition to feeling guilty and avoiding communication with friends and family members [4, 32, 37‐39]. As a result, inability to work properly and cope with the various situations was seen in the presence of HCWs stigmatization and mental health damage [40, 41]. Our findings show that HCWs are being stigmatized and need to have help from health policy makers and officials. Moreover, it is essential to provide effective psychiatric, physical, ethical and social support from their families, friends and health professionals after quarantine or hospitalization to get over the negative consequences. This may reduce the long-term mental effects of the disease [42].

This is the first validated scale to evaluate COVID19 stigma rates among health care workers using only 11-items. The scale was adapted from others that were specifically developed and validated for HCWs, with additional questions that we tailored to fit the COVID19 context. However, our study is cross-sectional, hence it demonstrated associations but not causal relations between the studied elements. It was also based on a self-reported questionnaire, not direct observation. Therefore, responder bias cannot be excluded, and findings may be biased by social desirability to prove HCWs distress during the pandemic. Moreover, resident doctors represented the vast majority of our specimen which may represent a specific group of HCWs, and thus may limit the generalizability of our findings to all HCWs.

Stigma towards HCWs in COVID-19 pandemic is a widespread phenomenon in countries all over the world. It should be identified with its categories harmfulness and inferiority, and avoidance. 9.86% of HCWs were stigmatized. COVISS-HCWs demonstrated very good internal consistency and construct validity among this sample of Syrian's HCWs. These satisfactory properties make the COVISS-HCWs suitable for utilize by health care providers.