COVID-19 Linked Social Stigma Among Arab Survivors: A Cross-Sectional Experiences from the Active Phase of the Pandemic

Figures & data

Table 1 Inclusion & Exclusion Criteria

	Inclusion Criteria	Exclusion Criteria
1	Must be diagnosed with COVID-19	Not infected with COVID-19
2	Must be 18 years or older	Less than 18 years of age
3	Able to speak Arabic or English	Cognitive impairment and Unable to give written consent.
4	Resident or Citizen of KSA	Not a resident of KSA / staying outside KSA

Table 2 Lawshe’s Content Validity Ratios (CVR) for an Item and Content Validity Index (CVI) Value

Lawshe’s Content Validity Ratios (CVR) for an item and a Content Validity Index (CVI) value
	Expert 1	Expert 2	Expert 3	Expert 4	Expert 5	CVR
Question 1	x	x	x	x	x	1
Question 2	x	x	x	x	x	1
Question 3	x	x	x	x	x	1
Question 4	x	x	x	x	x	1
Question 5	x	x	x	x	x	1
Question 6	x	x	x	x	x	1
Question 7	x	x	x	x	x	1
Question 8	x	x	x	x	x	1
Question 9	x	x	x	x	x	1
Question 10		x	x	x	x	0.6
Question 11	x	x	x	x	x	1
Question 12	x	x	x	x	x	1
Question 13	x	x	x	x	x	1
Question 14	x	x		x	x	0.6
Question 15	x	x	x	x		0.6
CVR(Critical) for a panel size (N) of 5 is 1.					CVI	0.8

Table 3 Descriptive Analysis of the Data Collected

		Frequency, (%)	Enacted Sigma		Disclosure Concerns		Internalized Stigma		Externalized Stigma		Total Stigma
			Mean	SD	Mean	SD	Mean	SD	Mean	SD	Mean	SD
Age (in years)	18–27	338 (70.1%)	7.88	3.53	4.8	2.8	6.39	3.98	18.19	8.04	37.28	15.52
	28–37	61 (12.7%)	8.18	2.98	4.66	2.38	5.79	2.91	18.75	7.82	37.38	13.03
	38–47	42 (8.7%)	8.26	2.88	4.33	1.97	6.24	2.96	19.33	7.77	38.17	14.20
	48–57	27 (5.6%)	7.67	3.89	3.67	1.98	5.85	3.11	18.44	9.68	35.63	18.01
	58 and above	14 (2.9%)	7	3.7	3.79	2.29	5.5	3.32	15.71	9.07	32.0	17.39
Gender	Male	158 (32.7%)	7.47	3.31	5.22	2.67	6.94	3.67	20.85	7.96	41.84	15.68
	Female	324 (67.2%)	8.83	3.5	4.37	2.59	5.9	3.69	17.06	7.89	34.82	14.58
Education	High School	148 (30.7%)	7.47	3.27	4.43	2.6	6.15	3.65	17.02	8.21	35.07	15.65
	Bachelors	309 (64.1%)	8.15	3.52	4.77	2.72	6.22	3.72	18.74	7.95	37.91	15.17
	Masters	17 (3.5%)	8.29	2.71	4.53	1.58	7.65	4.32	18.76	8.75	39.24	14.62
	Doctorate	8 (1.7%)	6.38	3.54	4.38	2.13	5.63	2.92	24.13	7.45	40.50	12.99
Occupation	Unemployed	261 (54.1%)	7.67	3.62	4.57	2.81	5.96	3.8	17.34	7.96	35.58	15.46
	Self Employed	82 (17.0%)	8.11	3.53	4.91	2.66	6.8	3.86	19.32	8.89	39.15	16.40
	Private	44 (9.1%)	7.8	2.34	4.14	2.13	6.11	3.32	18.14	6.53	36.18	12.00
	Government	94 (19.5%)	8.53	3.17	4.9	2.35	6.63	3.47	20.21	8.14	40.28	14.73
Marital Status	Single	155 (32.2%)	8.02	3.47	4.8	2.76	6.35	3.87	18.16	8.07	37.36	15.46
	Married	300 (62.2%)	7.73	3.43	4.5	2.42	6.08	3.49	18.27	8.14	36.57	15.12
	Divorced	27 (5.6%)	7.85	3.15	3.85	2.36	5.96	3.14	20	8.31	37.67	14.79
Residence	Living alone	77 (16%)	8.62	3.55	4.88	2.69	7.19	3.95	18.83	8.57	39.53	16.90
	Living with family	405 (84%)	7.78	3.4	4.61	2.63	6.06	3.64	18.2	8.02	36.67	14.94
	Range of score(s): min - max		5–15		5–10		5–15		7–35		15–75
Mean Time since discharge		13.17 days (Range: 7–21 days), Std Dev: 6.14 days

Figure 1 Score distribution to stigma questionnaire by the study participants.

Figure 2 Distribution of scores (a).Depicted as a histogram (b). Normal Q-Q plot of the total score as against stigma questionnaire.

Table 4 One-Sample t-Test for Each Domain

Domain	Overall Mean	t	df	p-value
Enacted Stigma	7.92	31.39	480	<0.001
Disclosure Concerns	4.65	21.96	480	<0.001
Internalized Stigma	6.24	19.14	480	<0.001
Externalized Stigma	18.30	30.57	480	<0.001
Total Stigma	37.13	31.72	480	<0.001

Table 5 Descriptive Analysis of the Domain and Corresponding Responses

Items / Questions	Strongly Agree		Agree		Neutral		Disagree		Strongly Disagree
	N	%	N	%	N	%	N	%	N	%
1. People have hurt me by their reaction on learning about my COVID-19 positivity.	139	28.9%	71	14.8%	115	23.9%	65	13.5%	91	18.9%
2. I am very careful in telling people that I have had COVID-19 disease.	195	40.5%	89	18.5%	90	18.7%	44	9.1%	63	13.1%
3. Having had COVID-19 disease makes me feel that I am a bad person.	257	53.4%	87	18.1%	62	12.9%	36	7.5%	39	8.1%
Total Enacted Stigma: Domain Mean: 2.64, SD: 1.52, Median: 3, 25th Percentile:1, 75th Percentile: 4
4. Most people are afraid of a person who has had COVID-19 disease.	99	20.6%	51	10.6%	79	16.4%	88	18.3%	164	34.1%
5. People known to me would be uncomfortable around COVID-19 disease survivor.	164	34.1%	64	13.3%	108	22.5%	87	18.1%	58	12.1%
Total Disclosure Concerns: Domain Mean: 2.32, SD: 1.41, Median: 2, 25th Percentile:1, 75th Percentile: 3
6. People’s reaction to me being a COVID-19 survivor forced me to restrict my socializing.	120	24.9%	56	11.6%	85	17.7%	94	19.5%	126	26.2%
7. I worry about people telling others that I have had COVID-19 disease.	208	43.2%	84	17.5%	87	18.1%	44	9.1%	58	12.1%
8. Having had COVID-19 disease makes me feel guilty.	226	47.0%	68	14.1%	84	17.5%	54	11.2%	49	10.2%
Total Internalized Stigma: Domain Mean: 2.08, SD: 1.33, Median: 1, 25th Percentile:1, 75th Percentile: 3
9. Most people who have had COVID-19 disease face rejection by others.	152	31.6%	68	14.1%	116	24.1%	66	13.7%	79	16.4%
10. People known to me would reject COVID-19 disease survivors.	176	36.6%	72	15.0%	101	21.0%	73	15.2%	59	12.3%
11. I lost friend(s) because I had COVID-19 disease.	258	53.6%	71	14.8%	67	13.9%	38	7.9%	47	9.8%
12. Having had COVID-19 disease made me feel that I am not as good a person as others.	246	51.1%	93	19.3%	72	15.0%	27	5.6%	43	8.9%
13. Most people think that a person who has had COVID-19 disease is disgusting.	201	41.8%	104	21.6%	88	18.3%	39	8.1%	49	10.2%
14. People known to me would treat COVID-19 disease survivor as an outcast.	225	46.8%	63	13.1%	89	18.5%	49	10.2%	55	11.4%
15. People known to me would not want COVID-19 disease survivors around their children.	178	37.0%	65	13.5%	84	17.5%	59	12.3%	95	19.8%
Total Externalized Stigma: Domain Mean: 2.61, SD: 1.48, Median:3, 25th Percentile:1, 75th Percentile: 4
Overall Stigma score: 37.12, SD: 15.2, Median: 37, 25th Percentile: 25, 75th Percentile: 47, Minimum: 15, Maximum: 75,

Table 6 Predictors of COVID-19 Perceived Stigma

	Moderate/High		Low		Chi-Square	Significance	Likelihood Ratio
	N	(%)	N	(%)	X2	p-value	Value	p-value
Gender
Male	93	19.3%	65	13.5%	21.731	<0.001	21.704	<0.001
Female	118	24.5%	206	42.7%
Nationality
Non-Saudi	19	3.9%	8	1.7%	8.219	0.004	8.251	0.004
Saudi	192	39.8%	263	54.6%
Marital Status
Single	129	26.8%	171	35.5%	0.318	0.853	0.316	0.854
Married	69	14.3%	86	17.8%
Divorced	13	2.7%	14	2.9%
Age Group
Young	142	29.5%	196	40.7%	1.431	0.232	1.426	0.232
Mature	69	14.3%	75	15.6%
Residence Status
Rural	83	17.2%	86	17.8%	3.011	0.083	3.003	0.083
Urban	128	26.6%	185	38.4%
Educational Levels
High	154	32.0%	180	37.3%	2.403	0.121	2.419	0.12
Low	57	11.8%	91	18.9%
Occupation
Employed	116	24.1%	104	21.6%	13.71	0.001	14.113	0.001
Unemployed	95	19.7%	166	34.4%
Living Status
Alone	35	7.3%	42	8.7%	0.105	0.746	0.105	0.746
With Family	176	36.5%	229	47.5%
Relatives / Family suffering from Covid-19
Yes	172	35.7%	234	48.5%	3.06	0.217	3.416	0.181
No	38	7.9%	37	7.7%
Income Level
Low	123	25.5%	190	39.4%	8.215	0.016	8.566	0.014
High	87	18.0%	81	16.8%

Table 7 Thematic Analysis of Open-Ended Questions and Free-Text Comments

Participants Quotes	Interpretative Theme	Overarching Themes
Self-coping strategies	Faith and spiritual practice	Prayers, optimism, and faith in God help me overcome all COVID-19 matters and consequences.
		Even if my people let me down, God will not let me down and leave me alone for sure.
	Negative and realistic expectations	I had COVID-19, a source of harmful and fatal infections; I expected to be abandoned.
		I have to be realistic and realize the negative attitude towards me; I always remind myself about the negative consequences of COVID-19.
	Withdraw behaviours	I keep myself alone and isolated. I did not go to any events or be social with others.
		Being alone is better than seeing people run away from you.
	Ignoring	Ignore people and negative attitudes to avoid negative feelings.
		Ignore all media and news, turn off social media app notifications, and avoid negotiations.
	Hide the COVID-19 diagnosis and act normally.	I did not tell anybody about my positive results, tried to treat my symptoms at home, and went to work usually. Then, all had COVID-19 at work, so I would not be isolated or discriminated against.
		I hid my COVID-19 diagnosis from my family and friends without informing them about where I travel or what disease I have.
	Mindfulness	Reading inner strength and practicing mindfulness and breathing exercises helped overcome COVID-19.
		Yoga and meditation are excellent practices for clearing my mind, releasing my tension and negative feelings, and tolerating the negative attitudes of others.
Contextual Challenges during COVID-19	Media Factors	The negative social and traditional media information can lead to negative perceptions of ourselves.
		Exposure to COVID-19 has shaped mental and social attitudes.
		Media misinformation and false allegations lead to stigma.
	Policy conflicts	I think the uncertainty and self-stigma are attributed to confusing policies and information.
		The health COVID-19 policies implemented and forced to follow are associated with crime and significant financial fines.
		I lost trust in HCPs and felt insecure due to contradictory information.
	In direct stigmatization by HCPs	HCPs closed my flat and stigmatized us, isolating us for two weeks.
		When I was in the hospital, HCPs avoided talking or coming close to me. I felt that I was rejected and discriminated against even by HCPs
		The inappropriate attitude of MOH staff, such as sealing my apartment while we were inside and preventing us from going outside, caused neighbors to abandon us, leading to fear.
	Lack of formal education and healthcare support	HCPs were confused and overwhelmed by COVID-19 and focused on warning the infected more than supporting the infected.
		Health agencies should have listened to our needs.
Preferences for self-coping and support strategies to promote health and social re-integration	Self-care	I prefer to maintain my daily routine and, following a healthy lifestyle, perform exercise, especially in the initial days of reintegration.
		I like to keep my own space and have a spiritual practice. Having a particular time praying and performing my religious customs was very beneficial.
		Yoga and meditation were beneficial in releasing all tensions and negative feelings.
	Harm reduction	Avoiding self-isolation and hiding my medical information and COVID-19 test results helped prevent stigmatization.
		I was keen to increase adherence to health instructions and guidelines to protect family members and loved ones.
		I advise anyone to follow the health guidelines and personal protective equipment for the COVID-19 response and reduce its complications.
		Control thoughts and emotions to manage negative feelings and emotions.
		Reducing social activity and avoiding adverse reactions were helpful.
		There is no point in having aggressive responses or trying to defend yourself or explain your case. Ignore all and have your own space.
	Resilience	I am still young and was confident that my body’s immune system could fight COVID-19.
		Confidence in God’s help to overcome COVID-19
		I was confident in my ability to cope with COVID-19.
		I should be mindful of people’s fears and reactions to COVID-19, even if they make uncertain conclusions.
	Peer support	Having a group discussion with other COVID-19 patients is beneficial
		The peer support group provides a safe space to express concerns.
	Social interventions	The community should be more open and allow infected people to express their feelings.
		Media contaminates people’s minds with fear, doubts, and false information. The community should accept and respect all infected people and support them in reintegrating.
		Working society should support infected workers to find emotional healing.
		Please use community institutions to establish peer support groups for infected people and their family members.
	Organizational interventions	Plans and interventions for dealing with this stigma should be a part of national preventive strategies for this pandemic.
		Controlling the media is essential. Social media analysts can help identify potential stigma hotspots.
		MOH public messaging directly combats the stigmatization of individuals or groups and aids in addressing the stigma associated with the disease
		National psychological crisis intervention and health education should be established to help people reintegrate into society and reduce social stigma.
		Online stigma programs can reduce stigma and help people understand the negative impact of stigma.

Figure 3 Preferences stigma interventions for recovery and integrations following the COVID-19 surge.