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Fear and Stigma: The Epidemic within the SARS Outbreak

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Because of their evolving nature and inherent scientific uncertainties, outbreaks of emerging infectious diseases can be associated with considerable fear in the general public or in specific communities, especially when illness and deaths are substantial. Mitigating fear and discrimination directed toward persons infected with, and affected by, infectious disease can be important in controlling transmission. Persons who are feared and stigmatized may delay seeking care and remain in the community undetected. This article outlines efforts to rapidly assess, monitor, and address fears associated with the 2003 severe acute respiratory syndrome (SARS) epidemic in the United States. Although fear, stigmatization, and discrimination were not widespread in the general public, Asian-American communities were particularly affected.
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Because of their evolving nature and inherent scientif-
ic uncertainties, outbreaks of emerging infectious diseases
can be associated with considerable fear in the general
public or in specific communities, especially when illness
and deaths are substantial. Mitigating fear and discrimina-
tion directed toward persons infected with, and affected by,
infectious disease can be important in controlling transmis-
sion. Persons who are feared and stigmatized may delay
seeking care and remain in the community undetected.
This article outlines efforts to rapidly assess, monitor, and
address fears associated with the 2003 severe acute respi-
ratory syndrome (SARS) epidemic in the United States.
Although fear, stigmatization, and discrimination were not
widespread in the general public, Asian-American commu-
nities were particularly affected.
P
ublic health strategies that deal with rapidly evolving
disease outbreaks of new and emerging infectious dis-
eases require a delicate balance between protecting the
public’s health and initiating exclusionary practices and
treatments that can lead to fear and stigmatization of, and
discrimination against, specific populations. The outbreak
of severe acute respiratory syndrome (SARS) illustrates
these difficulties. SARS spontaneously appeared in the
southern province of Guangdong, People’s Republic of
China, in November 2002 (1,2). By July 2003, the epidem-
ic, had spread to more than 30 countries with 8,427 cumu-
lative probable cases and 916 deaths and was identified as
a global threat to health (1). In the United States, 418 cases
were reported with 74 classified as probable SARS; no
deaths occurred (1). As with many disease outbreaks, sci-
entific information and data related to the disease changed
almost hourly, as public health scientists and practitioners
responded to the worldwide outbreak, which was coupled
with widespread fear (3,4).
SARS-related Fear, Stigmatization,
and Discrimination
While persons, agencies, and governments sought to
identify modes of transmission, strategies for disease con-
tainment, and treatment for SARS, fear spread unchecked
throughout the global community. Fear of SARS arose
from the underlying anxiety about a disease with an
unknown cause and possible fatal outcome (5).
Stigmatization of potential SARS patients emerged early
in the outbreak, as global media reported dramatic stories
from Asia in print media, television, and the Internet.
Headlines from the English-language press heightened the
fear. “Concern is mounting over the continuing spread of
the deadly SARS virus. Some experts say it could have a
similar impact to the 1918 flu epidemic that killed 50 mil-
lion—or the current world HIV crisis,” wrote the British
Broadcasting Corporation from London, England (6).
“China has threatened to execute or jail for life anyone
who deliberately spreads the killer SARS virus,” stated the
Cable News Network from Beijing, China (7).
Studies have shown that during serious disease out-
breaks, when the general public requires immediate infor-
mation, a subgroup of the population that is at potentially
greater risk of experiencing fear, stigmatization, and dis-
crimination will need special attention from public health
professionals (8–10). The recent SARS outbreak was a
classic example of such an outbreak.
Fear is further fueled when infection control techniques
and restrictive practices such as quarantine and isolation
are employed to protect the public’s health (11,12). While
exclusionary practices based upon the best available scien-
tific evidence may be scientifically and ethically sound for
one population, those same practices may not be sound for
all populations (5,11). During the SARS outbreak, some
persons became fearful or suspicious of all people who
Fear and Stigma: The Epidemic
within the SARS Outbreak
Bobbie Person,* Francisco Sy,* Kelly Holton,*† Barbara Govert,* Arthur Liang,* and the NCID/SARS
Community Outreach Team
1
358 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 10, No. 2, February 2004
EMERGENCE OF SARS
*Centers for Disease Control and Prevention, Atlanta, Georgia,
USA; and †Northrop Grumman Mission Systems, Atlanta,
Georgia, USA
1
Community Outreach Team: Brenda Garza, Deborah Gould,
Meredith Hickson, Marian McDonald, Cecilia Meijer, Julia Smith,
Liza Veto, Walter Williams, Laura Zauderer
looked Asian, regardless of their nationality or actual risk
factors for SARS, and expected them to be quarantined.
Some Americans did not understand that quarantine and
isolation practices appropriate for SARS-affected areas in
Asia, where community transmission was a concern, were
practices that were not appropriate in the United States
where the disease was not community acquired. For exam-
ple, some persons, who had recently traveled to areas
where SARS was spreading, isolated themselves, even
though they had no symptoms and had not been exposed to
someone with SARS.
Mitigating Fear, Stigmatization, and
Discrimination through Strategic
Community Outreach
Fear of being socially marginalized and stigmatized as
a result of a disease outbreak may cause people to deny
early clinical symptoms and may contribute to their failure
to seek timely medical care (5). Such fear can ultimately
increase stigmatization when cases are identified at a later
date (11). Stigmatization associated with discrimination
often has social and economic ramifications that intensify
internalized stigmatization and feelings of fear (13).
Containing fear, which is integral to the public health
management of a new and emerging disease such as SARS,
is best accomplished by a behavioral strategy that address-
es the needs of a segment of the population at risk of
becoming stigmatized and discriminated against. This strat-
egy works best as a complement to a larger public health
education and communication campaign. Typically during
outbreaks, initial risk communication is targeted to front-
line public health professionals through vehicles such as the
Morbidity and Mortality Weekly Report. Initial communi-
cation provides information on case definitions and labora-
tory-testing strategies, as well as interim guidelines for
infection control and other critical issues. Communication
strategies for the general public most frequently involve tel-
evision sound bites, press conferences with dignitaries and
health officials, and targeted release of information to mass
media outlets such as newspapers and Internet sites (14).
Although these risk communication activities are critical
for keeping the general public informed during an outbreak,
they can fail to meet the personal needs of the affected pop-
ulation and the general public.
Methods
During the first week of April 2003, the National
Center for Infectious Diseases (NCID) at the Centers for
Disease Control and Prevention (CDC) formed a 14-mem-
ber, multidisciplinary NCID/SARS Community Outreach
Team as part of its emergency response to the global SARS
outbreak. While other NCID/CDC response teams dealt
with laboratory investigations, surveillance, communica-
tion, and clinical infection control practices, the
Community Outreach Team worked to implement rapid
public health strategies to document, monitor, and assist in
ameliorating specific problems associated with fear,
stigmatization, and discrimination attributed to the SARS
outbreak in the United States.
In creating a rapid public health intervention to mitigate
behaviors and practices associated with SARS-related fear,
the team recognized the need to address the experiences of
persons at greatest risk for experiencing SARS-related fear,
stigma, and discrimination. The team monitored stigmatiz-
ing ideas and behaviors in the general population and the
media, particularly toward Asian Americans, who were dis-
proportionately reporting fear, stigmatization, and discrim-
ination compared to the general public. The team began
working with Asian-American communities to develop a
culturally tailored intervention that 1) promoted communi-
ty understanding of the facts related to the transmission and
prevention of SARS; 2) contributed to the strengthening of
community resiliency and capacity to mitigate fear, stigma-
tization, and discrimination; and 3) encouraged appropriate
health-seeking behaviors for those who may have been
exposed to SARS and were experiencing early symptoms.
The team also worked to dispel myths; keep the general
public better informed; prevent discrimination against
SARS-affected communities; and provide guidance for
institutions, agencies, and organizations hosting interna-
tional visitors from SARS-affected countries.
Rapid Situational Assessment
During the first 3 weeks of April 2003, the
NCID/SARS Community Outreach Team conducted a
rapid situational analysis to determine the impact of
SARS-related fear, stigmatization, and discrimination
within the Asian-American community in the United
States. The team carried out the following activities:
1) facilitated group discussions with key opinion leaders
within the Asian community in the United States; 2) col-
lected and monitored the CDC Public Response Service
data; 3) collected and monitored Asian-language newspa-
pers, Internet sites, and other information sources;
4) reviewed polling data and other communication infor-
mation; 5) conducted community visits, panel discussions,
and media interviews; 6) solicited information from state
and regional minority health liaisons nationwide; 7) devel-
oped ongoing relationships with the Asian-American
communities; particularly in major metropolitan areas
throughout the United States; and 8) determined new data-
gathering strategies as needed.
Group Discussions
The team conducted group interviews through telecon-
ferences with national, state, and local influential leaders
Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 10, No. 2, February 2004 359
PERSPECTIVE PREPAREDNESS AND RESPONSE
in the Asian-American community throughout the United
States. The team also conducted group interviews with
chambers of commerce and trade association members,
school officials and representatives, state public health
department staff, academicians at universities, mental
health professionals, and others. The 11 teleconferences
the team conducted reached more than 70 persons who
represented more than 50 agencies, organizations, and
communities. The goals of the group interviews were the
following: 1) determine the impact of SARS-related fear
on the Asian community; 2) document examples of fear,
stigmatization, and discrimination; 3) determine strategies
for identifying and reaching “hidden populations”;
4) develop partnerships with leaders and community mem-
bers of the affected populations; 5) determine the needs of
affected populations; and 6) respond appropriately to those
needs through a targeted intervention with activities and
Asian-language materials.
Five major recommendations were derived from the
facilitated group discussions with key informants: 1) devel-
op simple, tailored SARS prevention messages; 2) develop
SARS information materials in various Asian languages; 3)
disseminate SARS information through multiple and cul-
turally appropriate channels, including (but not limited to)
community visits, town hall meetings, and health education
and communication channels to complement mass media
messages; 4) establish partnerships with local Asian-
American community–based organizations to educate the
community; and 5) ensure that CDC would continue to pro-
vide leadership and coordination in preventing and control-
ling SARS. The relationships developed during these group
discussions allowed team members to monitor and docu-
ment ongoing stigmatizing situations related to the disease
outbreak in real time and to deal more effectively with
intentional and unintentional discrimination.
CDC Public Response Service
CDC operates the Public Response Service (CDC PRS)
under contract with the American Social Health
Association. This contract provides hotline service to the
general public requesting information via telephone and
email about bioterrorism and other disease emergencies,
including SARS. The NCID/SARS Community Outreach
Team worked with the CDC PRS to track a daily sample of
incoming SARS-related calls, specifically noting questions
associated with fear, stigmatization, and discrimination
directed toward the Asian-American community. This sys-
tem allowed the team to help determine specific answers to
frequently asked questions for hotline staff and to develop
simple, prerecorded Asian-language messages. Passive
data collection of SARS fear-related concerns began on
April 29, 2003. During May 2003, 7,327 SARS-related
calls were received; 4,013 (54.7%) of these calls were pas-
sively sampled. Of these sampled calls, an average of 10%
of callers expressed concerns related to fear, stigmatiza-
tion, and discrimination. A caller could express more than
one concern. Major concerns included the following: fear
of buying Asian merchandise (187 calls); working with
Asians (83 calls); living near Asians (45 calls); going to
school with Asians (41 calls); and more generic issus such
as being on a cruise ship or airplane (77 calls); and church,
school, or workplace issues (65 calls). Most SARS calls
related to transmission, symptoms, and treatment of dis-
ease and travel advisories.
Asian-Language Information Sources
One critical component of the team’s activities was
determining where members of the Asian-American com-
munity were getting SARS-related information. Team
members monitored English-language and Asian-language
electronic, print, and television media coverage and infor-
mal chat rooms in the United States and other countries to
stay abreast of changing information about the nature of
the SARS outbreak that could influence fear, stigmatiza-
tion, and discrimination. The assessment showed that many
people within the Asian-American community were getting
information from Asian-language newspapers, television,
and Internet sites directly from China, Hong Kong, Taiwan,
and other Asian areas—usually hours ahead of information
providers in the United States. The information provided
by these Asian-language sources was often inconsistent
with newspaper, television, and Internet coverage in the
United States, thus creating fear and suspicion that the
United States government might not be telling the truth
about the outbreak in this country. Independent content-
analysis research conducted by InterTrend
Communications (San Francisco, CA) compared four of
the most popular Chinese language newspapers in the
United States with two popular national mainstream
English-language newspapers from March 21 to April 3,
2003 (15). InterTrend data showed that 1) Chinese-lan-
guage newspapers were more likely to highlight SARS
news related to the Chinese community in the United States
or from China more prominently than mainstream English-
language newspapers; and 2) Chinese-language newspa-
pers were more likely to have articles on SARS, including
featured in-depth articles, than mainstream English-lan-
guage U.S. national newspapers (15). These findings sup-
ported the team’s initial assessment (based on an informal
convenience sample of Asian-language papers).
General email inquiries sent to the CDC communica-
tions center and information from public health profes-
sionals, health providers, and community members led the
team to SARS-related Internet sites that contained rumors
and inaccurate information, which added to general misun-
derstanding, confusion, and fear. Even legitimate public
360 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 10, No. 2, February 2004
EMERGENCE OF SARS
health Internet sites from different parts of the world pro-
vided disparate information as the outbreak unfolded, fur-
thering uncertainty and fear in the United States. The team
also monitored Internet sites that supported community
fears as they promoted home remedies, medicinal cures,
and inappropriate and unnecessary protective equipment.
Monitoring the information sources of the affected popula-
tion was a critical activity, allowing the team to separate
fact from fiction with accuracy and timeliness and address
salient issues and concerns during community visits.
Results
Rapid Situational Response
Based on its rapid situational assessment, the team was
able to develop interventions to assist in mitigating fear,
stigmatization, and discrimination. Team members carried
out the following activities: 1) advised other SARS emer-
gency response teams on how to minimize the risk of stig-
matizing groups in their own communications by focusing
messages on the virus and the relevant behavioral risk fac-
tors; 2) assisted with developing culturally tailored health
education materials; and 3) conducted community visits,
panel discussions, and media interviews to positively influ-
ence negative behaviors occurring in communities. These
visits and other contacts with the Asian-American commu-
nity allowed CDC to develop ongoing relationships and
helped the team determine new data-gathering strategies.
Targeted Health Education Materials
During a disease outbreak, information changes rapidly
as scientific evidence is collected and analyzed. Vital com-
ponents of the team’s activities were prioritizing and trans-
lating existing information and guidance documents and
developing health education materials to address the spe-
cific needs of the Asian-American community. An in-
house translation service did not exist, and the rapidly
evolving scientific evidence challenged the turnaround
time for developing, translating, and disseminating infor-
mation. The team worked to identify priority documents
for translation and to ensure Asian-language translation for
Web and print products tailored to the Asian-American
community. To ensure accurate translations, CDC con-
tracted with professional translation services and had all
documents back-translated. Web-based information on
SARS included documents in traditional Chinese, simpli-
fied Chinese, Korean, Vietnamese, and Japanese, as well
as French and Spanish. The team also created brief, record-
ed educational hotline messages in Chinese and
Vietnamese. The main messages for people in the United
States were the following: 1) the risk of SARS is low;
2) severe cases of SARS have been uncommon, and there
have been no deaths in the United States; 3) methods for
disease prevention in the general public are like those of
other viral diseases; and 4) although no evidence of com-
munity spread currently exists, continued vigilance,
aggressive case management, and infection control are
needed.
Community Field Visits
Team members conducted field visits to Asian commu-
nities in Boston; New York City; Oakland, California; San
Francisco; Washington, D.C.; Edison, New Jersey; and
Los Angeles to respond to the direct needs of the commu-
nities and gather information. The team met with commu-
nity leaders, toured the communities, informally gathered
further information, and gave community SARS presenta-
tions in seven cities, reaching approximately 500 persons.
Through community visits, the team was able to 1) provide
the latest in evidence-based information on SARS with
Asian-language education materials; 2) dispel misconcep-
tions, myths, and rumors; 3) act as a catalyst for bringing
together a broad spectrum of organizations and persons in
the community to create local networks to promote com-
munity resiliency; and 4) provide credibility and reassur-
ance to those who felt vulnerable. Speakers also presented
a public health model for mitigating fear, stigmatization,
and discrimination that could be instituted by public health
officials, clinicians, and community members. Through
open discussion sessions and informal information gather-
ing in the community, the team found that SARS-related
stigmatization was occurring more frequently within the
Asian community than from outsiders directed toward the
Asian community. The team also found that those persons
with SARS-like symptoms who used traditional herbal
physicians and pharmacies were less likely to be referred
to, or seek out, public health officials, suggesting that fur-
ther research into strategies to reach this population is
needed. Conducting community visits also showed that
CDC was responding to the needs of the community at risk
for SARS-related fear, stigmatization, and discrimination
and was modeling positive behaviors to the public.
Discussion
Other infectious disease epidemics have been associat-
ed with specific ethnic groups. Fear, stigmatization, and
discrimination plagued Russian Jewish immigrants when
the 1892 outbreaks of typhus fever and cholera in New
York City were traced to Russian Jewish immigrants from
Eastern Europe (8). In the spring of 1900, the Chinatown
community in San Francisco was faced with extreme dis-
crimination due to an outbreak of bubonic plague, the
“black death,” attributed to rats transported on a ship from
Hong Kong (9). In 1993 an outbreak of hantavirus infec-
tion in the Four Corners area (where the borders of four
states—Arizona, New Mexico, Utah, and Colorado—
Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 10, No. 2, February 2004 361
PERSPECTIVE PREPAREDNESS AND RESPONSE
meet) of the United States was initially referred to by
reporters as a Navajo disease, which led to severe fear,
stigmatization, and discrimination of Native Americans in
the region (10). Previous scientific studies have shown that
fear associated with stigmatization and discrimination has
negatively affected public health efforts with chronic con-
ditions and diseases such as mental illness, HIV/AIDS,
tuberculosis, leprosy, and epilepsy (16–20). More recently,
stigmatization associated with fear and the AIDS epidem-
ic negatively influenced voluntary testing, counseling, and
treatment of those infected with the disease (21). Health
providers have also seen reluctance by recent refugees and
immigrants to get tested and treated for tuberculosis
because of possible social stigmatization (22). The poten-
tial of being labeled at-risk for having or transmitting a
stigmatizing condition such as SARS creates fear and anx-
iety, and an entire population of people can be at risk for
becoming stigmatized in society (23).
Protecting the health of the public while preventing
stigmatization of segments of the population during a rap-
idly evolving disease outbreak is complex. The team’s
experience during the recent SARS outbreak demanded
anticipatory insight, perceptive planning, and a rapid
response to a targeted audience with specific cultural per-
spectives and influences. It also required us to recognize
the distinctive features of SARS in a medical, social, and
cultural context. Weiss states, “Preventing fear and stigma-
tization depends on controlling or treating the target health
problem, countering tendencies of those who stigmatize
others, and supporting those who are stigmatized through
emotional support and social policies” (11).
The data collected during the rapid situational assess-
ment were critical in guiding activities of the team. Both
the data and the data collection process assisted the team in
establishing interpersonal relationships with community
leaders, determining priority needs, identifying responsi-
ble intervention strategies, and developing effective com-
munication channels. The team was able to better under-
stand community perceptions and attitudes by identifying
the communities’ trusted sources of information. When
conducting community visits, the team was able to address
discordant information, myths, and rumors; provide simple
Asian-language messages and materials; and act as a cata-
lyst to build community resiliency and prepare for the pos-
sibility of future emerging diseases. The team was also
able to keep CDC/NCID leaders informed and to intervene
when they identified discriminatory policies, practices,
and actions that were inconsistent with evidence-based
public health recommendations and guidelines.
Quelling fear-driven stigmatization and discrimination
during the SARS outbreak required tailored intervention
strategies carried out by the SARS Community Outreach
Team. These activities complemented traditional risk com-
munication for the general public. To be effective, behav-
ioral intervention approaches, messages, and materials had
to be salient for the affected population, in this case Asian-
American communities within the United States. Further,
these interventions aimed at promoting an accurate under-
standing of the epidemic both in the general population
and within the affected community, that is, the dynamic
nature of the outbreak and its cause, treatment options, and
prevention strategies. Through interpersonal connections,
the team members worked to promote reassurance and
enhance community resiliency.
Public health professionals must understand the neces-
sary balance needed to protect the public’s health with
appropriate exclusionary practices, while at the same time
preventing fear, stigmatization, and discrimination of spe-
cific segments of the population. As we prepare for the
next new or reemerging disease outbreak, we should also
be preparing to deal with the fear epidemic that will likely
accompany it. By developing effective behavioral and
health education strategies and providing timely attention
to the special needs of affected populations, we can ensure
that, no matter what the infectious disease, we can limit the
associated epidemic of fear and stigmatization.
Acknowledgments
We thank the following CDC staff members who volun-
teered their time to translate critical information into multiple
languages during the SARS outbreak: Feng Chai, Rachanee
Cheingsong, Feng Xiang Gao, Wenlin Huang, Han Li, Wenkai Li,
Xiaofang Li, Timothy Lim, Gang Liu, Yuko Mizuno, Christine
Huong Montgomery, Xuanthao Ngo, Doan Quang, Yang Xia, and
Yingtao Zhou.
Ms. Person is a senior behavioral scientist in the National
Center for Infectious Diseases, Centers for Disease Control and
Prevention. Her research interests focus on health and behavior,
with a specific interest in cross-cultural behavioral interventions
for the prevention and control of infectious disease.
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Address for correspondence: Bobbie Person, Chief, Health Education and
Behavioral Science Office of Health Communication, National Center for
Infectious Diseases, Centers for Disease Control and Prevention, 1600
Clifton Road, Mailstop C14, Atlanta, GA 30333, USA; fax: 404-371-
5490; email: bperson@cdc.gov
Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 10, No. 2, February 2004 363
PERSPECTIVE PREPAREDNESS AND RESPONSE
... The outbreak of infectious diseases induces widespread anxiety (3). During the SARS outbreak in 2003, empirical studies on psychological responses of the general population to epidemics were reported (4)(5)(6). ...
... Pregnant women are particularly affected, as they are naturally concerned about the safety of their fetus and tend to overestimate the risk of contracting the disease (5,9). Elevated stress level in pregnant women during the SARS outbreak was precipitated by the infection and the epidemic itself, quarantine, economic fallout, and lack of social and family support (3). Previous trauma and recent stressful life events were associated with anxiety and depression in perinatal period (3,10), yet it impacts pregnancy and postpartum stages differently (11). ...
... Elevated stress level in pregnant women during the SARS outbreak was precipitated by the infection and the epidemic itself, quarantine, economic fallout, and lack of social and family support (3). Previous trauma and recent stressful life events were associated with anxiety and depression in perinatal period (3,10), yet it impacts pregnancy and postpartum stages differently (11). Psychometric evidence of the Perceived Stress Scale has shown that pregnant women are more associated with depression with certain risk factors, namely unemployment, lower education level, perceived stress in the last month, and recent life adversity (12). ...
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Aim The present study aimed to investigate the construct structure behind the psychosocial response, behavioral response, prenatal depression, and post-traumatic stress disorder (PTSD) in pregnant women during the COVID-19 pandemic in China. Method The validated Chinese version of the Edinburgh Postnatal Depression Scale (EPDS), PTSD CheckList (PCL)-6, and two newly established scales for COVID-19-related psychological and behavioral responses were used. Structural equation modeling (SEM) analysis was applied to evaluate the structural relationships of psychological and behavioral responses during the COVID-19 pandemic. Results Of the 1,908 mothers who completed the questionnaires, 1,099 met the criteria for perinatal depression, and 287 were positively screened for PTSD, where 264 women exceed the cut-off points for both. Pregnant women with full-time or part-time jobs tended to have the lowest scores of EPDS (10.07 ± 5.11, P < 0.001) and stress levels (23.85 ± 7.96, P = 0.004), yet they were more likely to change their behavior in accordance with the COVID-19 outbreak (13.35 ± 3.42, P = 0.025). The structural model fit the data (χ ² = 43.260, p < 0.001) and resulted in satisfactory fit indices (CFI = 0.984, TLI = 0.959, RMSEA = 0.072, and χ ² /d f = 10.815), all path loadings were significant ( p < 0.05). The SEM indicates that the level of QoL was attributable to the occurrence of PND, leading to PTSD, and COVID-19 related behavioral and psychological responses. Conclusion The inter-relationships between the COVID-19-related psychosocial and behavioral responses have been assessed, indicating that the pandemic increased the burden of perinatal depression. Psychoeducation, as well as other psychological interventions, may be needed to alleviate the COVID-19-based anxiety and increase their engagement in protective behaviors.
... Stigma was further exacerbated by infection control techniques and restrictive practices such as quarantine, isolation and lockdown, deployed to protect global health 3 . Similar experiences of stigma in the past have been reported during the outbreak of severe acute respiratory syndrome (and Ebola virus) 4,5 . ...
... Social stigma against the people who had contracted or suspected to have disease/infection during an epidemic is not a new phenomenon. This was also observed during the epidemic of severe acute respiratory syndrome (Person et al., 2004), H5N1 (Barrett & Brown, 2008) towards people being treated for mental ill-health (Trani et al., 2015), HIV and AIDS (Bharat, 2011). Society usually exhibited a hatred attitude or behaviour in a fear of contracting the infection/disease (Cohn, 2012). ...
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... As some infectious diseases including severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), and Ebola virus disease are rapidly transmitted through personal contacts with infected individuals, stigmatization of the infected individuals with these diseases has occurred in their societies [1][2][3]. As a result, the stigmatization of the infected individuals during the outbreak of these infectious diseases has become a critical social issue. ...
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... It was also observed that social media penetrated much better than other ground level activities and campaigns of health awareness by Government (Dubey et al. 2016). It has been observed in a significant number of researches that people tend to spend more time online during the pandemic in order to access much needed information, feel less lonely, participate in the discussion and exchange their opinions (Person et al. 2004;WHO 2019;Nabity-Grover et al. 2020). The chances of spreading rumours, fake news, social stigma and distorted information cannot be ignored in places like India where the population is very huge; internet and mobile phones have become reasonably affordable for every segment and usage of social media is growing very rapidly among public. ...
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... Poyraz et al. pointed out that the risk of PTSD among COVID-19 survivors with long-term symptoms was 5 times higher than that in those without long-term symptoms [42]. In addition, the study found that 16.2% of the public believed that SARS patients could possibly transmit the virus 18 months after infection, and some groups discriminated against SARS patients [43], adversely affecting the positive help-seeking behavior and mental psychology of SARS patients [44]. According to a survey on stigmatization among COVID-19-infected persons, most patients felt stigmatized and discriminated against, and social discrimination and long-term symptoms may contribute to the existence of long-term mental and mental health conditions [45]. ...
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According to previous studies, mental status in 1-year COVID-19 survivors might range from 6–43%. Longer-term psychological consequences in recovered COVID-19 subjects are unknown, so we analyzed longer-term quality of life and mental status in recovered COVID-19 subjects at 2 years after infection. Among 144 recovered COVID-19 subjects in the Taizhou region, 73 and 45 completed face-to-face follow-ups at the first year and second year after infection, respectively, with a 61.7% follow-up rate. The questionnaire, which was administered at both follow-ups, included questions about quality of life, psychological health, and post-traumatic stress disorder (PTSD). The Mann–Whitney U test was used to the differences of each scale between the first and second year. Among the 45 people who completed both follow-up visits, the incidence of psychological problems was 4.4% (2/45) in the first year, and no new psychological abnormalities were observed in the second year. Quality of life improved, while the General Health Questionnaire (GHQ-12) and Impact of Event Scale—Revised (IES-R) scores did not improve over time. The incidence of mental disorders was lower than those in previous studies. Multidisciplinary management for COVID-19 in this study hospital may have reduced the frequency to a certain extent. However, among those with mental health problems, such problems may exist for a long time, and long-term attention should be given to the psychological status of recovered COVID-19 subjects.
Stigma among healthcare workers during the coronavirus disease 2019 (COVID-19) pandemic is an issue that requires immediate attention, as it may otherwise lead to the collapse of healthcare systems. In this study, we developed the COVID-19-related stigma scale for healthcare workers (CSS-HCWs) and assessed its reliability and validity. Data were collected online from 500 participants, including physicians and nurses involved in COVID-19 care. The first item of the draft scale was developed based on a literature review and qualitative study. The draft scale consisted of 24 items, which were rated on a six-point Likert scale. Descriptive statistics were calculated and the data distribution was analyzed. To assess the scale’s validity and reliability, structural validity was evaluated through an exploratory factor analysis. Criterion-related validity was examined through a correlation analysis using the E16-COVID19-S, a COVID-19 scale developed for physicians in Egypt. Reliability was evaluated by examining the scale’s stability and internal consistency. The findings revealed that the stigma scale was a valid and reliable instrument. The final scale consisted of 18 items across three domains: personal stigma, concerns of disclosure and others, and family stigma. In conclusion, the scale is a valid and reliable instrument that can measure COVID-19-related stigma among healthcare workers.
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Introduction: Given the high coverage of the mass media and its significant influence in communicating evidence-based health information, the aim of this study was to describe the misnomer in COVID-19 communication across the media in Nigeria. Methods: This was a review of newspaper articles that had been published between 1st February and 31st May 2020. Quantitative content analysis was used to describe and analyze the themes which characterized media representations of the COVID-19 outbreak in Nigeria. Identification of codes and themes was done by the researchers and were used to broadly categorize the data obtained into ‘general’ and ‘thematic’ categories. Coding for the general category included 14 news media outlets during the first three months of COVID-19 pandemic in Nigeria. Codes for the thematic category included: Description of COVID-19 in Nigeria, Assurances on COVID-19 containment in Nigeria, Support for COVID-19 management, COVID-19 education, Treatment of COVID-19, and the effects of COVID-19 in Nigeria. Results: In all, 289 news articles met the inclusion criteria and were thus analyzed. The reporting was as follows: Description of COVID-19 (18.3%), Assurances of readiness and containment (13.5%), COVID-19 education (25.3%), Support for management of Coronavirus in Nigeria (14.9%), Treatment of COVID-19 in Nigeria (13.8%), and Effects of COVID-19 (14.2%). Overall, 64 (22.1%) of COVID-19 information across the media was fake news; 35 (12.2%) pertained to the “Description of COVID-19” theme, while 29 (9.9%) pertained to the “Treatment of COVID-19” theme. Discussion: To facilitate accurate reporting of detailed information by the news media, a collaboration between health agencies and news media outlets should be enhanced to curtail false information ravaging the society.
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In 1892, a record-breaking year for immigration to the United States, New York City was struck by two devastating epidemics - typhus fever and cholera. The typhus epidemic was traced to one particular boat carrying East European Jews; the cholera epidemic was more widespread, prompting President Benjamin Harrison to temporarily halt immigration. In response, local and national health authorities specifically targetted the immigrant Jews from Eastern Europe, ordering them removed not only from incoming ships but also from their new homes in New York and dispatching them to nearby quarantine islands - where "coffin corner" awaited those who succumbed. In "Quarantine!" Howard Markel traces the course of these two epidemics, day by day, from the point of view of those involved - the public health doctors who diagnozed and treated the victims, the newspaper reporters who covered the stories, government officials who established and enforced policy, and, most importantly, the immigrants themselves. Drawing on rarely cited stories from the Yiddish-American press, immigrant diaries and letters, and official accounts, Markel follows the immigrants on their journey from a squalid and precarious existence in Russia's Pale of Settlement, to the steerage steamer, to New York's Lower East Side, to the city's quarantine islands. Along the way, Markel explains how quarantine policy was shaped both by medical opinions and popular perceptions of disease. He explores the complex political, economic and social battles that guide or obstruct a community's quarantine efforts, as well as the extent to which a person's ethnicity frames the social response. And he shows how Gilded Age Americans, alarmed by the rising tide of immigrants, found in "undesirable" aliens a scapegoat for all that was ailing a rapidly growing nation. "At present", Markel concludes, "the isolation of quarantine of people with specific contagious diseases is neither an antiquated practice nor a theoretical discussion. It remains an occasional reality of public health control". At a time of renewed anti-immigrant sentiment and the threat of newly emerging infectious diseases, "Quarantine!" provides an historical context for considering similar problems that face American society today.
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When learning of a positive HIV test, individuals face a host of psychological and social stresses. HIV-related stigma is associated with psychological distress and can interfere with coping, adjustment, and management of HIV disease. Effective management of HIV disease requires timely testing for HIV infection so that persons who are infected can learn of their serostatus and gain access to care, therefore benefiting from available treatment options. This article discusses the impact that HIV-related stigma has on HIV testing and care. Specifically, problems associated with delays in testing, disclosure of seropositive status, and implications for health care are presented.
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To identify newly arrived Vietnamese refugees' beliefs about tuberculosis (TB) and TB education needs. In 1994, the New York State Health Department and the Centers for Disease Control and Prevention conducted a survey of 51 newly arrived adult Vietnamese refugees in two New York counties. After being trained in interview methods, two bilingual researchers asked 32 open-ended questions on the causes of TB, TB treatment, and the disease's impact on work and social relationships. Respondents correctly viewed TB as an infectious lung disease with symptoms such as cough, weakness, and weight loss. Hard manual labor, smoking, alcohol consumption, and poor nutrition were believed to be risk factors. Many respondents incorrectly believed that asymptomatic latent infection is not possible and that infection inevitably leads to disease. Nearly all respondents anticipated that having tuberculosis would adversely impact their work, family, and community activities and relationships. Targeted patient education is needed to address misconceptions about TB among Vietnamese refugees and to help ensure adherence to prescribed treatment regimens.
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This report provides interim recommendations for prevention and control of hantavirus infections associated with rodents in the southwestern United States. It is based on principles of rodent and infection control and contains specific recommendations for reducing rodent shelter and food sources in and around the home, recommendations for eliminating rodents inside the home and preventing them from entering the home, precautions for preventing hantavirus infection while rodent-contaminated areas are being cleaned up, prevention measures for persons who have occupational exposure to wild rodents, and precautions for campers and hikers.
Several conclusions about measuring adherence can be drawn. Probably the best approach is to use multiple measures, including some combination of urine assays, pill counts, and detailed patient interviews. Careful monitoring of patient behavior early in the regimen will help predict whether adherence is likely to be a problem. Microelectronic devices in pill boxes or bottle caps have been used for measuring adherence among patients with tuberculosis, but their effectiveness has not been established. The use of these devices may be particularly troublesome for some groups such as the elderly, or precluded for those whose life styles might interfere with their use such as the homeless or migrant farm workers. Carefully designed patient interviews should be tested to determine whether they can be used to predict adherence. Probably the best predictor of adherence is the patient's previous history of adherence. However, adherence is not a personality trait, but a task-specific behavior. For example, someone who misses many doses of antituberculosis medication may successfully use prescribed eye drops or follow dietary recommendations. Providers need to monitor adherence to antituberculosis medications early in treatment in order to anticipate future problems and to ask patients about specific adherence tasks. Ongoing monitoring is essential for patients taking medicine for active tuberculosis. These patients typically feel well after a few weeks and either may believe that the drugs are no longer necessary or may forget to take medication because there are no longer physical cues of illness. Demographic factors, though easy to measure, do not predict adherence well. Tending to be surrogates for other causal factors, they are not amenable to interventions for behavior change. Placing emphasis on demographic characteristics may lead to discriminatory practices. Patients with social support networks have been more adherent in some studies, and patients who believe in the seriousness of their problems with tuberculosis are more likely to be adherent. Additional research on adherence predictors is needed, but it should reflect the complexity of the problem. This research requires a theory-based approach, which has been essentially missing from studies on adherence and tuberculosis. Research also needs to target predictors for specific groups of patients. There is clear evidence of the effect on adherence of culturally influenced beliefs and attitudes about tuberculosis and its treatment. Cultural factors are associated with misinformation about the medical aspects of the disease and the stigmatization of persons with tuberculosis. Culturally sensitive, targeted information is needed, and some has been developed by local tuberculosis programs.(ABSTRACT TRUNCATED AT 400 WORDS)