Background During past disease outbreaks, healthcare workers (HCWs) have been stigmatized (e.g., shunned, ostracized) by members in their community, for fear that HCWs are sources of infection. There has been no systematic evaluation of HCW stigmatization during the COVID-19 pandemic.
Methods Non-HCW adults from the United States and Canada (N = 3551) completed an online survey, including measures of HCW stigmatization, COVID Stress Syndrome, and avoidance.
Results Over a quarter of respondents believed that HCWs should have severe restrictions placed on their freedoms, such as being kept in isolation from their communities and their families. Over a third of respondents avoided HCWs for fear of infection. Participation in altruistic support of HCWs (i.e., evening clapping and cheering) was unrelated to stigmatizing attitudes. Demographic variables had small or trivial correlations with HCW stigmatization. People who stigmatized HCWs also tended to avoid other people, avoid drug stores and supermarkets, and avoid leaving their homes. Factor analysis suggested that HCW stigmatization is linked to the COVID Stress Syndrome.
Conclusion Fear and avoidance of HCWs is a widespread, under-recognized problem during the COVID-19 pandemic. It is associated with the COVID Stress Syndrome and might be reduced by interventions targeting this syndrome.
Behind the facade of altruistic cheering and clapping for HCWs, there are important, under-recognized, and widespread stigmatizing attitudes toward healthcare providers. Our research suggests that many respondents in the community have grossly exaggerated estimates of the odds that HCWs are carriers of SARSCoV2. That is, almost a third (32 %) of respondents believed that HCWs are likely to have COVID-19 (Table 1). This stands in marked contrast to the research on COVID-19, which shows that the typical HCW is highly unlikely to be infected with SARSCoV2. American data (collected from February-April, 2020) shows that the majority of reported COVID-19 cases (89 %) were not HCWs (CDC COVID-19 Response Team, 2020). Canadian research shows that HCWs as a group (i.e., regardless of whether they specifically care for COVID-19 patients) have a risk of only 0.14 % of developing COVID-19, as compared to 0.10 % in the general population (COVID-19 Scientific Advisory Group, 2020). The higher prevalence was due, in part, to HCWs having a higher prevalence of testing for COVID-19 as compared to non-HCWs (15 % vs. 3%; COVID-19 Scientific Advisory Group, 2020). Among HCWs, the risk of being infected specifically as part of their occupations was only .01 % (COVID-19 Scientific Advisory Group, 2020). This is consistent with research conducted in the Netherlands, which found that HCWs are more likely to acquire COVID-19 in the community, rather than in hospital settings (Kluytmans-van den Bergh et al., 2020). That is, just like non-HCWs, HCWs were most likely to be infected in the community rather than in hospital settings. Therefore, there is no sound basis for the attitudes of many of our participants, who believed that HCWs should be separated from their communities or families
Globally, HCWs have a higher risk of acquiring COVID-19 as compared to non-HCWs (Koh, 2020), but even so, the majority (97 %) of HCWs have not been infected (COVID-19 Scientific Advisory Group, 2020). Although HCWs working with COVID-19 patients (e.g., in intensive care units) are at greater risk of exposure to SASCoV2, these workers are effectively protected by personal protective equipment (e.g., face masks, gloves, visors), which reduces the risk of infection to minimal levels (Liu et al., 2020). To illustrate, even among frontline HCWs in Wuhan, China (January-February, 2020), working in high-risk settings (i.e., clinics devoted to COVID-19), the incidence of COVID-19 was only 0.55 % (Lai et al., 2020). In other words, even in high risk settings, the overwhelming majority of HCWs (99.45 %) did not develop COVID-19. As observed by Cheng, Wong, and Yuen (2020), “this relatively low infection rate is reassuring, as it suggests that personal protect equipment, if available, can protect frontline HCWs directly caring for patients with COVID-19” (p. 1).
Although HCWs are at increased risk of infection with SARSCoV2 as compared to the general public, to our knowledge no health authority or government has recommended that HCWs be isolated from their communities or families during the COVID-19 pandemic. Indeed, such harsh measures would unnecessarily compound the stress already experienced by HCWs. Yet, our study revealed that a remarkably high percentage of Canadians and Americans expressed harsh attitudes about isolating HCWs, even to the point of believing that they should be denied access to their families.
How do these unrealistic attitudes arise? In some important ways, the COVID-19 pandemic had largely been a hidden pandemic, at least at the time of data collection (May 6–19, 2020). During the 1918 influenza pandemic, people were widely exposed to deaths in their communities, and the sight of coffins, hearses, and funerals were commonplace (Crosby, 2003). This has not been the case during the COVID-19 pandemic, where exposure to sickness and death has been, for the majority of people, a largely abstract experience in which fatalities are simply reported in the news media, rather than personally experienced. The majority of our respondents (84 %) did not even personally know anyone who had been diagnosed with COVID-19. HCW stigmatization was unrelated to whether the respondent personally knew anyone who had been infected by SARSCoV2 (r = .02, p > .10). Exposure to dramatic images of fatalities from the news media, along with dramatic news images of HCWs tending to the sick and dying, can cause the viewing public to overestimate the personal risk of infection (Taylor, 2019). In this context, many people in the present study held unrealistic attitudes about the dangers of coming into contact with HCWs.
The present study found evidence that the fear and avoidance of HCWs is part of a broader pattern of stigmatization. That is, people who tend to stigmatize (fear and avoid) HCWs also tend to stigmatize foreigners (i.e., are xenophobic, as assessed by the COVID Stress Scales) and also tend to avoid drug stores and pharmacies and, by extension, avoid retail workers in those stores. A question for further investigation concerns the breadth and boundaries of fear and avoidance. People with a high degree of fear and avoidance of HCWs may also tend to avoid other groups of people, for fear that the latter might be vectors of disease (e.g., children or sickly-looking people). Indeed, previous research concerning perceived vulnerability to disease suggests that people who are highly fearful of infection even stigmatize (e.g., avoid) people who only remotely have features suggestive of ill health (e.g., people who are old, disabled, or obese) (Schaller & Park, 2011). An issue for further research is whether HCW stigmatization is associated with stigmatization of people who have been infected with, and recovered from SARSCoV2. People who recovered from SARS were stigmatized (shunned, avoided) (Taylor, 2019) and there is concern that survivors of COVID-19 may be similarly stigmatized (World Health Organization, 2020). It remains to be determined whether this is part of a broader tendency to stigmatize people who are associated in some way with illness, and whether it is associated with the COVID Stress Syndrome.
Shunning, ostracism, and avoidance have been notable features of past pandemics and outbreaks, such as during the SARS outbreak (Taylor, 2019). Historians of pandemics have noted that survivors, public health officials, and political leaders tend to forget the lessons learned from previous pandemics (Crosby, 2003). The problem of pandemic-related stigmatization of HCWs is a lesson we have not learned. Cheering for HCWs is not enough. What is needed are clear, sensible, public education campaigns concerning the risks that HCWs pose to the public (see also Bhaumik, Moola, Tyagi, Nambiar, & Kakoti, 2020; Centers for Disease Control & Prevention, 2020).
The present study offers some clues about how to address the problem of HCW stigmatization. Correlational and factor analysis in this study indicates that the tendency to stigmatize HCWs is associated with the COVID Stress Syndrome. Previous research shows that the severity of this syndrome is correlated with the tendency to overestimate health risks in general (Taylor et al., 2020a, b). Thus, the fear and avoidance of HCWs is part of a broader tendency to overestimate health threats. Given that HCW stigmatization is linked to the COVID Stress Syndrome, it is possible that treating this syndrome might lead to a reduction in excessive fears of HCW, thereby reducing stigmatization. This could be done by means of cognitive-behavioral interventions or educational programs (Taylor & Asmundson, 2004; Taylor, 2019). Whether this is beneficial remains to be investigated in future research.
The present study has various strengths and limitations. In terms of strengths, the sample was large and, to our knowledge, this was the first systematic study to empirically investigate HCW stigmatization during COVID-19. In terms of limitations, the study was cross-sectional, conducted several months into the pandemic, and so it is possible that the attitudes and behaviors of respondents may change over time. Our assessment was limited to the self-report of attitudes and behaviors, rather than direct observational assessments of actual behaviors. Nevertheless, the findings are in keeping with studies conducted during the SARS outbreak (Bai et al., 2004; Koh et al., 2005). Further research into the largely unrecognized and under-appreciated issue of HCW stigmatization is needed to better understand and overcome this important societal problem.
There are many different avenues for further investigation. Future research is needed to evaluate the replicability and generalizability of the findings obtained in the present study. Research could be conducted to determine whether the findings are replicated using different methods to assess stigmatization. As part of this, alternative methods could be used to assess the respondents’ estimations of the odds that HCWs are infected with SARSCoV2. Respondents could be asked, for example, to estimate the percentage of HCWs in their community that are currently infected with SARSCoV2, and this percentage could be compared with local prevalence statistics. The temporal stability of the tendency to stigmatize HCWs also needs to be investigated. Pandemics are dynamic events, in which psychological reactions change over time and circumstance (Taylor, 2019). The tendency to stigmatize HCWs could be trait-like or it might fluctuate, depending on whether the person feels personally threatened with infection. Alternatively, the tendency to stigmatize HCWs could have trait-like qualities (i.e., a baseline tendency to stigmatize) that are exacerbated and expressed when the person perceives that they are threatened with infection. Research on the perceived vulnerability to disease supports this combined trait and state conceptualization. That is, there is an enduring tendency (trait) for people to perceive themselves to be vulnerable to disease, and this vulnerability can be exacerbated when the person is exposed to health threats, which has been shown to increase their tendency to stigmatize people who have superficial characteristics suggestive of poor health (e.g., the elderly, obese, or disabled) (Schaller & Park, 2011). Answers to these and related questions will help address the under-recognized and significant issue of pandemic-related HCW stigmatization.
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