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 Table of Contents  
INVITED PERSPECTIVE/COMMENTARY
Year : 2021  |  Volume : 37  |  Issue : 1  |  Page : 14-18

“Feared and Avoided”: Psychosocial effects of stigma against health-care workers during COVID-19


Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India

Date of Submission15-Sep-2020
Date of Decision31-Oct-2021
Date of Acceptance18-Dec-2020
Date of Web Publication31-Mar-2021

Correspondence Address:
Debanjan Banerjee
Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_319_20

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How to cite this article:
Vani P, Banerjee D. “Feared and Avoided”: Psychosocial effects of stigma against health-care workers during COVID-19. Indian J Soc Psychiatry 2021;37:14-8

How to cite this URL:
Vani P, Banerjee D. “Feared and Avoided”: Psychosocial effects of stigma against health-care workers during COVID-19. Indian J Soc Psychiatry [serial online] 2021 [cited 2021 Jun 19];37:14-8. Available from: https://www.indjsp.org/text.asp?2021/37/1/14/312875




  Background Top


The coronavirus disease-2019 (COVID-19) pandemic has been wreaking havoc all over the world in recent times. In the wake of high rates of transmissibility and infection rates, vaccines still in development, evolving information on treatment strategies, widespread deficiency of drugs and hospital equipment, and being physically restricted and monitored, the health-care professionals have been at the receiving end of both the physiological effects of the outbreak and its consequences. The fear of an unknown illness has led to the health care workers (HCWs) being discriminated and defamed in various parts of the world.[1] The transmission rate of COVID-19 is much more than its earlier congeners like the severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome, leading to a rapid spread of the infection throughout the globe.[2] Understandably, all the frontline workers are at increased risk of infection. In addition, the HCWs (physicians, nurses, and paramedical staff), especially those working directly with the COVID-19 patients, are much more vulnerable. Besides devastating lives and livelihood globally, the risk to the HCWs has always been on the forefront. Data from the Amnesty International showed that over 3000 HCWs had died from COVID-19 from 63 countries, including India, the lack of personal protective equipment (PPE) being one of the major reasons. The extrapolated data are obviously the “tip of the iceberg,” as sporadically numerous pandemic-related deaths have been reported all over within the HCW community. The Indian Medical Association announced the demise of 196 doctors in the line of COVID-19 duty as of August 9 and has appealed to the central government for help, support, life insurance facilities, and better protection in the line of their work.[3] The fear of infection and mortality, occupational hazards of contamination, guilt, and concern of transmitting to the family members and stigma surrounding the same affect them regularly. All these factors combined with professional issues such as chronic stress, trauma, and burnout can lead to an array of mental health problems in the HCWs. Stigma, discrimination, and prejudice against them can only amplify and complicate these psychosocial issues. This can affect their professional quality of life (QOL), increase the job-related demands, worsen sleep quality, impair interpersonal relationships, and reduce self-esteem, all of which can worsen coping during the ongoing crisis.[4] A multipronged approach involving intervention such as counseling, psychotherapy, support, training, and providing up-to-date information is suggested to combat these issues in a timely manner so that the mental health of these frontline warriors be protected during these dangerous times.[4] Keeping this in background, this article glances at the problem statement of stigma against the HCWs and ways of mitigating the same.


  Global Problem Situation Top


Pandemics have been an integral part of human existence, from the Black Plague, small pox, Ebola, and the Spanish flu of 1918 that have killed millions over the centuries. The world has been reeling under the grasp of yet another unique virus infection, namely COVID-19 which has led to major public health challenges. It has been said that the spread started from Wuhan, China, at the end of 2019 and in a span of few months has spread to all countries. Although 70%–80% of the population may be asymptomatic or mildly symptomatic respiratory disease, 20%–30% of the people suffer from severe and life-threatening complications and death.[2] Globally, the case number has crossed the 45 million mark as per the current World Health Organization (WHO) estimate, with most countries in the community transmission stage of the pandemic with a case fatality rate varying from <0.1% to over 25% across nations.[5],[6] In a bid to control the caseload, countries all over the world have implemented lockdowns and quarantine measures. The emergence of this outbreak has led to socioeconomic crises, unemployment, migrant crisis, glaring deficits in health care, and mental health challenges on a global scale.[7] What started with an unidentified pneumonia has eventually turned into an intriguing illness plaguing the world with rising cases and fatalities each day.


  Psychosocial Effects on the Health-Care Workers Top


HCWs have been on the frontline of the current COVID-19 pandemic that has been sweeping across the world. From long duty hours, unavailability of PPEs and drugs, increasing caseload, perceived lack of support from the administration, absence of proper information channels, government apathy, and nascent policies and regulations, the HCWs have been going through complex and complicated times.[3],[4],[8] Multiple factors such as stress in the workplace, feelings of helplessness due to the rising mortality rate, worry and guilt about exposing their families and loved ones to possible risk of infection and the social stigma of possibly being a viral carrier has adversely affected the mental health and self efficacy of the HCWs.

Common mental health and psychosocial challenges that the HCWs face on daily basis are:[8]

  • Anxiety, depression, and posttraumatic stress symptoms
  • Poor coping strategies
  • Issues of being in isolation and quarantine
  • Physical and mental fatigue
  • Stress and loneliness
  • Risk of moral injury
  • Public stigma, discrimination, and self-stigma
  • Worry and responsibilities about loved ones
  • Possible guilt for spreading infection
  • Uncertainties in workplace and future.


In a review of the mental health problems faced by the HCW during the COVID-19 pandemic, Spoorthy et al.[8] highlighted the role of stigma, place, and department of work which were correlated with increased stress, anxiety, depressive symptoms, and insomnia. Further, these psychological problems were also related to poor social support, social exclusion, decreased self-efficacy, and reduced help-seeking for the HCWs. The need to prioritize mental health care for the HCWs using a multidisciplinary approach was suggested by the authors. The “Health-Stigma-Discrimination model” for the vulnerable minorities can be applied to this frontline population as well where increased risk of exposure to the infection in the line of work and societal attributional biases form the drivers of stigma, which further facilitate and perpetuate self-stigma.[9] This can lead to internal misrepresentations of the “perceived discrimination” that can worsen the psychological status, prevent social inclusion, impair work efficiency and QOL, as well as reduce help-seeking behavior in the HCWs.

Studies done in Wuhan, China, the epicenter of the epidemic, showed that HCWs experienced anxiety, depression, and insomnia symptoms with a lack of social support that can probably lead to devastating effects in sleep quality and self-efficacy.[10],[11] Those working in high-risk settings and interact with critical patients also displayed posttraumatic stress symptoms.[12] Levels of distress have also been noted to be positively correlated with lack of control over events and proper up-to-date information.[13] This can in turn can also lead to a vicious cycle of guilt and self-stigma.


  Stigma against Health-Care Workers Top


”Stigma” is defined as the process of negatively correlating the attributes of certain individuals which are then devalued and discredited.[14] This negative association has led to discrimination based on race, religion, region, gender, and sexual orientation as well as illnesses. This inherent nature of a human to fear an unknown affliction or an abnormality has evolved over time to protect them from life-threatening diseases and has programmed them to stay away as a part of natural selection.[15] These psychological adaptations of self-protection have morphed into negative emotions and cognitions which translate to avoidance, stereotyping, and other discriminatory behaviors.[16] As Zhong Nanshan, president of the Chinese Medical Association, once said during the 2003 SARS outbreak, “The psychological fear (of a disease) is more fearful than the disease itself.”[17]

The close proximity of working with infected individuals has led to significant stigmatization of the HCWs among the society. Accused of being the “carriers of contagion,” many have been turned out of their apartments and verbally as well as physically abused.[18],[19] The fear of marginalization due to the potential contraction of the virus also has led to riots and physical harm to the health professionals in specific pockets of regions leading to difficulties in sample collection and contact tracing. Hence, it is only natural for these fears to dictate the beliefs and attitudes of the health professionals as well.

It is this anxiety that has perhaps led to patients to be turned away from hospitals and clinics, ambulances refusing to ferry patients, providing less accurate care. This is similar to the 1994 Surat plague outbreak when 80% of the private physicians left the city forsaking their Hippocratic oath.[20] Related incidents were noted during the SARS outbreak when growing resentment among the staff on having to work on being chosen for the job in isolation wards/intensive care units led to refusal to work shifts.[21]

A recent study by Ramaci et al.[4] shows that stigma has a positive correlation to fatigue and negative outcomes such as burnout, and inversely impacts work satisfaction among HCWs. Being ostracized in one's line of work can have consequences such insomnia, lack of concentration, lethargy, and depression which causes a fall in the standard of care. Mental Health concerns arising out of being sidelined and isolated in the society can also lead to further self-stigma since many HCWs would rather not acknowledge professional psychological or psychiatric help. This can in turn lead to a higher risk of suicidality and stress.[22] Since stigmatized attitudes can have adverse effects on professional and personal QOL and emotional well-being, it becomes crucial to prioritize the same. Dispelling stigma through adequate training, provision of adequate protective gear, and dispelling misinformation have proven effective through multilevel activities while working with patients with human immunodeficiency virus/acquired immunodeficiency syndrome, and Ebola.[23] A recent systematic review by Banerjee et al.[24] related to the impact of the COVID-19 pandemic on the psychosocial health and mental well-being in the South Asian countries reported the poorer quality of sleep, chronic stress, perceived stigma, and increased psychological distress in the frontline HCWs of these countries. In the same article, the Indian Psychiatric Society (IPS) also advocates the need for multidisciplinary strategies at all levels (individual, society, and administrative) to improve the QOL of the frontline workers and fight the discrimination toward them. The IPS recognizes the unique plight of the frontline HCWs during the COVID-19 and has called for mental health promotion among them together with community participation in mitigating both the societal and self-stigma. Liaison with the media and the government will be vital to spread this message among all classes of society. Large-scale pandemics frequently give rise to xenophobic sentiments and a recent Indian study has shown this xenophobia to increase the “fear of coronavirus” during the pandemic that can be mitigated through collectivism and positivism.[25] Further, the rise of misinformation and disinformation during COVID-19 has transformed it into a “digital infodemic” that along with increased use of social media can lead to faulty interpretations of “facts” related to the spread, pathogenesis, and duration of infection. The cognitive biases and emotional overtones associated with the psychology of misinformation can further increase fear, rumor mongering, stigma, and avoidance of the frontline COVID-19 workers, including the HCWs.[26]


  The Way Forward: Strategies for Mitigation of Distress Top


There is a need for multidisciplinary intervention in the face of ongoing stigma and other work demands so that the much-needed mental health needs among HCWs be met. There is thus an immense need to add mental health support networks in the hospitals itself so that the HCWs do not feel alone and feel confidant of seeking help.[27]

Studies during the SARS outbreak showed that formal and informal psychological support to staff telephonically and electronically, especially to those in quarantine, has shown immense benefit in reducing the worry among HCWs.[28] Involving the staff in group interviews to help deal with the potential risks and stressors in workplace may help to reduce the fear among them.[21] Training sessions involving information as to how to protect themselves in the workplace. ensuring ample time and space to rest, engaging in leisure activities in between shifts, peer support and self-resilience will help HCWs mentally and physically prepare themselves for facing these challenging times.[29],[30] At the same time, clear and up-to-date communication is necessary from the side of authorities so that the fear of uncertainty is dispelled.[31] Other key elements crucial to protecting the mental health of HCWs include acknowledging the difficult work being done by the HCWs and thereby building resilience, evaluating absenteeism, and assessing for any distress, constant monitoring of those in high-risk environments, and discussion with the team about emotional and personal perspectives on patients such as the Schwartz rounds model.[32]

Furthermore, programs such as “Time to Change” have been devised to actively tackle mental health problems in the workplace and the stigma through support and self-help activities.[33]

The Psychological First Aid model proposed by McCabe et al.[34] describes various steps to alleviate these feelings of distress and fear which can in turn lead to feeling isolated and discriminated. The salient aspects of this consensus-derived, empirically supported, and evidence-based model involve:

  • To provide an outlet for emotional expression so as to ensure emotional well-being and stability
  • To be connected to these individuals through friends, family, and religious groups, etc
  • To provide information about stress and coping strategies useful for reducing distress and increasing the QOL so that enduring consequences such as posttraumatic stress disorder, and depression be prevented.


Wong et al. had found that the most effective coping strategies that helped HCWs were those such as positive reframing, planning, and problem–solving, whereas methods of coping include venting, behavioral disengagement, and self-distraction as these defocused from the actual problem and its possible solutions.[13],[35]

  • To alleviate distress through providing guidance, distraction techniques, relaxation methods, and also through cognitive restructuring and psychotherapy.


All these strategies will benefit in mitigating the aftereffects of feeling discriminated against as well as feeling of self-blame, guilt, and self-stigma. The media plays an important role to improve the knowledge–attitude–practice gap of the general public through information–education–communication activities using public figures. This helps reducing stigma and discrimination toward the frontline workers.

By acknowledging and publicizing the work of frontline health workers in a positive light, terming the HCWs as “heroes” of the pandemic not only builds their morale but also motivates the community to respect their efforts more leading to more acceptability in the community. The frequent comparison with the frontline army during a war might be a good analogy to start with; however, the “war against COVID-19” is long lasting and far from over. Despite the understanding of the service provided by the HCWs during these difficult times, nationwide discrimination and violence toward HCWs continued to exist which prompted the Government of India released an ordinance in April 2020 to the Epidemic Disease Act (1897) that makes any act of violence against a health personnel cognizable and nonbailable with imprisonment and fine.[36]A global system of surveillance is also required and the data added to the WHO Surveillance System of Attacks on Healthcare can measure to prevent such attacks be planned and implemented.[37] Naming the HCWs as “Corona warriors” and merely patronizing them might help in publicizing their efforts but does little in improving public awareness about their efforts and challenges.


  Conclusion Top


With a lack of proven treatments, vaccinations still in development and a general deficiency in preparedness for such a large-scale pandemic in most nations; it is only understandable that the most feared will be the most avoided. The stress of working in an environment caring for an insidious illness and filled with uncertainties has to be recognized and the burden of stigma be mitigated among the HCWs for a better QOL. This requires the concerted effort of the authorities at all levels and creation of multidisciplinary mental health teams so that timely interventions can be planned for the benefit of the frontline mental health-care professionals. Preparedness for pandemics is important, both resource-wise and at psychological levels. Legislations to improve policies related to the care of HCWs and modify public perceptions about them can help to shape ways for such futuristic crises. As discussed, they are at risk both to the physiological effects of the virus as well as the psychosocial consequences. Arguably, the holistic care of the workforce who fights the virus is important for the public health as well. The pandemic is still widening its clutches. Systematic research into the mental health issues and stigma faced by the HCWs will help to shape interventions, especially their lived experiences during the ongoing struggle. When the world faces a global crisis, collectivism and optimism help to navigate the course. It is a collective responsibility at all levels of stakeholders to support, understand, empathize, and care for the HCWs not only during the fight against the ongoing viral outbreak but also the postpandemic aftermath.



 
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