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      Uneven stigma loads: Community interpretations of public health policies, ‘evidence’ and inequities in shaping Covid-19 stigma in Vietnam

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          Abstract

          The infectious spread of COVID-19 has been accompanied by stigma in both global and local contexts, sparking concern about its negative effect on individuals, communities, and public health responses. The changing epidemiological context of the COVID-19 epidemic and evolving public health responses during the first year of the pandemic (2020) in Vietnam serve as a case study to qualitatively explore the fluidity of stigma.

          We conducted in-depth interviews with 38 individuals, (13 cases, 9 close contacts, and 16 community members) from areas affected by local outbreaks. Thematic analysis was conducted iteratively.

          Our analysis indicates that the extent and impacts of COVID-19-related stigma were uneven. Adapting the clinical term 'viral load' as a metaphor, we describe this variation through the wide range of 'stigma load' noted in participants' experiences. Individuals encountering more acute stigma, i.e. the highest 'stigma load', were those associated with COVID-19 at the start of the local outbreaks. These intensively negative social responses were driven by a social meaning-making process that misappropriated an inaccurate understanding of epidemiological logic. Specifically, contact tracing was presumed within the public consciousness to indicate linear blame, with individuals falsely considered to have engaged in 'transgressive mobility', with onward transmission perceived as being intentional. In contrast, as case numbers grew within an outbreak the imagined linearity of the infection chain was disrupted and lower levels of stigma were experienced, with COVID-19 transmission and association reframed as reflecting an environmental rather than behavioural risk.

          Our findings demonstrate the role of public health policies in unintentionally creating conditions for stigma to flourish. However, this is fluid. The social perceptions of infection risk shifted from being individualised to environmental, suggesting that stigma can be modified and mitigated through attending to the productive social lives of public health approaches and policies.

          Highlights

          • Those associated with COVID-19 experienced variable degrees of stigma - 'stigma load'.

          • Those linked to COVID-19 at the start of outbreaks experienced highest stigma load.

          • Misinterpretation of public health strategies contributed to blaming discourses.

          • Stigma receded when risk framed as environmental not behavioural.

          • Fluidity of stigma suggests potential to allay stigmatising effect of interventions.

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          Most cited references48

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          Stigma during the COVID-19 pandemic

          Healthcare workers and patients who have survived COVID-19 are facing stigma and discrimination all over the world. Sanjeet Bagcchi reports. Stigma associated with COVID-19 poses a serious threat to the lives of healthcare workers, patients, and survivors of the disease. In May 2020, a community of advocates comprising of 13 medical and humanitarian organisations including, among others, the International Committee of the Red Cross, the International Federation of the Red Cross and Red Crescent Societies, the the International Hospital Federation, and World Medical Association issued a declaration that condemned more than 200 incidents of COVID-19 related attacks on healthcare workers and health facilities during the ongoing pandemic. According to the declaration, “The recent displays of public support for COVID-19 responders are heartwarming, but many responders are nevertheless experiencing harassment, stigmatization and physical violence.” In a Mar 18, 2020 statement, WHO also unveiled that “some healthcare workers may unfortunately experience avoidance by their family or community owing to stigma or fear. This can make an already challenging situation far more difficult.” Several incidents of stigmatization of healthcare workers, COVID-19 patients, and survivors have come up during this pandemic across the world. For instance, in Mexico, doctors and nurses were found to use bicycles, as they were reportedly denied access to public transport and were subjected to physical assaults. Similarly, in Malawi, healthcare workers were reportedly disallowed from using public transport, insulted in the street, and evicted from rented apartments. In India, media reports revealed that doctors and medical staff dealing with COVID-19 patients faced substantial social ostracism; they were asked to vacate the rented homes, and were even attacked while carrying out their duties. With respect to social stigma of COVID-19 patients, there was an incident where a pregnant woman was reportedly abandoned by her family in India, after she gave birth to a child at a hospital in Maharashtra state, and was found positive for SARS-CoV-2. In some cases, COVID-19 survivors in India were stalked in social media. A COVID-19 survivor in Harare, Zimbabwe, got surprised, according to a media report, when the road in front of his house was named as “corona road” and some people even preferred to avoid the road fearing the possibilities of infection. “COVID-19 pandemic has created an unprecedented panic in the minds of people in India and several other countries”, says Diptendra Kumar Sarkar, a professor of surgery and Covid-19 strategist affiliated to the Institute of Post Graduate Medical Education Research (Kolkata, India). According to him, healthcare workers in India have become a natural target in the society, which is why they are suffering mental stress. Many of them faced social isolation, because of their job, and some had even faced near lynching situations, he points out. “Such a situation of social isolation may be linked to the high infectivity of the virus”, he suggests. Rahuldeb Sarkar, a respiratory medicine consultant at the Medway Maritime Hospital (Kent, UK) adds that, in countries such as India and Mexico, healthcare workers have to face substantial stigma during the pandemic as a result of the fear (about the infection) of the general public. “People do not have clear idea about modes of transmission of the virus”, he says. “Social stigma in COVID-19 pandemic is attributable to unscientific belief and improper understanding of common masses”, says Asis Manna, a professor of microbiology at the Infectious Diseases and Beliaghata General Hospital (Kolkata, India). According to him, some people believe that healthcare staff working in a hospital are a potential source of infection. This baseless belief extends to drivers of ambulances, family members of COVID-19 patients, and also patients discharged from the hospital after cure, he notes. However, in USA and UK, the doctors' experience of COVID-19 related stigma is different. “In the USA, we have had several instances where healthcare workers have faced harassment at public places because they have been perceived as at higher risk of transmission”, says Anish Ray, a consultant pediatrician at the Cook Children's Medical Center (TX, USA). However, according to Sarkar put, “In the UK, we were fortunate not to have stigma around healthcare workers' possibility of catching COVID. Instead of turning on against us, our neighbors truly appreciated the work we have been doing”. To tackle social stigma derived from COVID-19, WHO speaks of creating an environment where open discussion among people and healthcare workers is possible. “How we communicate about COVID-19 is critical in supporting people to take effective action to help combat the disease and to avoid fuelling fear and stigma”, WHO says, in a statement. “All efforts must be taken to scientifically destigmatise COVID-19 instead of statutory sermons by law makers”, urges Sarkar. “Proper health education targeting the public appears to be the most effective method to prevent social harassments of both healthcare workers and COVID-19 survivors”, says Ray. “It would also help create a proper environment to work as a team to contain this pandemic”, he stresses. © 2020 Flickr - Harsha K R 2020 Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.
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            Challenges and opportunities in examining and addressing intersectional stigma and health

            Background ‘Intersectional stigma’ is a concept that has emerged to characterize the convergence of multiple stigmatized identities within a person or group, and to address their joint effects on health and wellbeing. While enquiry into the intersections of race, class, and gender serves as the historical and theoretical basis for intersectional stigma, there is little consensus on how best to characterize and analyze intersectional stigma, or on how to design interventions to address this complex phenomenon. The purpose of this paper is to highlight existing intersectional stigma literature, identify gaps in our methods for studying and addressing intersectional stigma, provide examples illustrating promising analytical approaches, and elucidate priorities for future health research. Discussion Evidence from the existing scientific literature, as well as the examples presented here, suggest that people in diverse settings experience intersecting forms of stigma that influence their mental and physical health and corresponding health behaviors. As different stigmas are often correlated and interrelated, the health impact of intersectional stigma is complex, generating a broad range of vulnerabilities and risks. Qualitative, quantitative, and mixed methods approaches are required to reduce the significant knowledge gaps that remain in our understanding of intersectional stigma, shared identity, and their effects on health. Conclusions Stigmatized identities, while often analyzed in isolation, do not exist in a vacuum. Intersecting forms of stigma are a common reality, yet they remain poorly understood. The development of instruments and methods to better characterize the mechanisms and effects of intersectional stigma in relation to various health conditions around the globe is vital. Only then will healthcare providers, public health officials, and advocates be able to design health interventions that capitalize on the positive aspects of shared identity, while reducing the burden of stigma.
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              Health-related stigma.

              The concept of stigma, denoting relations of shame, has a long ancestry and has from the earliest times been associated with deviations from the 'normal', including, in various times and places, deviations from normative prescriptions of acceptable states of being for self and others. This paper dwells on modern social formations and offers conceptual and theoretical pointers towards a more convincing contemporary sociology of health-related stigma. It starts with an appreciation and critique of Goffman's benchmark sensitisation and traces his influence on the personal tragedy or deviance paradigm dominant in the medical sociology from the 1970s. To allow for the development of an argument, the focus here is on specific types of disorder--principally, epilepsy and HIV--rather than the research literature as a whole. Brief and critical consideration is given to attempts to operationalise or otherwise 'measure' health-related stigma. The advocacy of a rival oppression paradigm by disability theorists from the 1980s, notably through re-workings of the social model of disability, is addressed. It is suggested that we are now in a position to learn and move on from this paradigm 'clash'. A re-framing of notions of relations of stigma, signalling shame, and relations of deviance, signalling blame, is proposed. This framework, and the positing of a variable and changing dynamic between cultural norms of shame and blame--always embedded in social structures of class, command, gender, ethnicity and so on--is utilised to explore recent approaches to health stigma reduction programmes.
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                Author and article information

                Contributors
                Journal
                SSM Popul Health
                SSM Popul Health
                SSM - Population Health
                Elsevier
                2352-8273
                13 October 2022
                December 2022
                13 October 2022
                : 20
                : 101270
                Affiliations
                [a ]Woolcock Institute of Medical Research, Ha Noi, Viet Nam
                [b ]Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
                [c ]Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
                [d ]Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
                Author notes
                [] Corresponding author. Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia. sarah.bernays@ 123456sydney.edu.au
                Article
                S2352-8273(22)00249-X 101270
                10.1016/j.ssmph.2022.101270
                9558770
                36267122
                972608ed-3cdc-4b75-8da7-bd42c47ea761
                © 2022 The Authors

                This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

                History
                : 10 December 2021
                : 30 August 2022
                : 12 October 2022
                Categories
                Regular Article

                covid-19,stigma,public health policies,qualitative,inequity,vietnam

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