Stigma against health care providers caring for COVID-19 patients in Turkey

Abstract

Health care providers (HCPs) worldwide have been a common target for stigmatization during widespread infections, such as COVID-19. The purpose of this study is to highlight the prevalence of stigmatization during the COVID-19 pandemic among HCPs in Turkey using the Stigma COVID-19 HCPs instrument (S19-HCPs). Descriptive design. The S19-HCPs is a self-administered, web-based survey (24 items) developed previously. The internal consistency of the S19-HCPs’ Turkish version was satisfactory (α = 0.79). Test-retest correlations were all statistically significant for the Turkish version of the instrument (ICC = 0.90, p0.01). Most study participants were 20–30 years old (77%); among the respondents, 66% had worked in a COVID-19-designated facility. Stigma against HCPs is highly prevalent in Turkey. The outcomes of this study revealed substantial levels of HCP stigmatization in Turkey irrespective of their motivation to work with COVID-19 patients. Education, media, and awareness campaigns might play a critical role in addressing global stigmatization issues.

Keywords:

• social stigma
• COVID-19
• S19-HCPs
• health personnel
• Turkey

1. Introduction

In December 2019, acute severe respiratory syndrome coronavirus-2 (SARS-CoV-2), the virus that led to COVID-19, was identified in Wuhan, Hubei Province, China (WHO, 2020). Since then, it has spread to over 200 countries, with more than 223 million confirmed cases and more than 4.9 million confirmed deaths (by 1 November 2021). Nurses, physicians, and other health care providers (HCPs) are on the front lines as part of a great effort to save as many lives as possible. HCPs have been honored as the fighters of this pandemic in public. Managers and the public have seized social media to extend their gratitude to HCPs. Nevertheless, many reports of stigmatization among HCPs have surfaced around the world (Adiukwu et al., 2020; Lan et al., 2021; Nashwan, Abujaber, Nashwan, Abujaber et al., 2021; Nashwan, Villar et al., 2021; Taylor et al., 2020; Villar et al., 2021). HCPs have always been the target of stigmatization during prevalent infections (Taylor et al., 2020). Stigma against mental illness, noncontagious (e.g., cancers) diseases, and contagious illnesses, such as human immunodeficiency virus (HIV), Ebola virus disease (EVD), tuberculosis (TB), and severe acute respiratory syndrome (SARS), is widespread and well researched (Earnshaw & Quinn, 2012). People are generally suspicious of unfamiliar HCPs, which is the case for COVID-19, a new illness. Many factors regarding this disease remain unknown, and social stigma against HCPs who care for COVID-19 patients is expected (Bagcchi, 2020). Throughout history, the term “stigma” has been used to describe physical marks designed to expose something uncommon and bad about a given psychological status (Anderson, 2014). In recent times, stigma has been defined as unfavorable, discriminatory thoughts, feelings, and behaviors toward people with specific characteristics that are perceived as unpleasant and threatening (Anderson, 2014; Adiukwu et al., 2020; Bagcchi, 2020; Brewis et al., 2020; Earnshaw & Quinn, 2012). Stigma has many forms and faces, including fear of infection, blame, stereotypes, social judgment, lack of awareness, fear of social consequences, and prejudice (Prasad et al., 2020), which was particularly evident in the misleading information regarding the COVID-19 pandemic and its link to specific racial and ethnic groups, e.g., “Wuhan” or “Chinese” virus. In contrast, insufficient and indeterminate research on COVID-19 transmission and prevention measures combined with COVID-19 news and briefs increased anxiety among the public, causing doubt in health care services (Prasad et al., 2020). Frontline HCPs have been the targets of stigma, social isolation, and discrimination in their workspace surroundings and their social environment during the pandemic. Frontline HCPs caring for COVID-19 patients can suffer from stigma, which negatively impacts their focus and efficiency in making sound decisions (Singh & Subedi, 2020). Furthermore, the impact of stigma is not limited to the psychological well-being of health care providers; it can also affect their professional competence to provide quality care to the population during the pandemic period (Singh & Subedi, 2020; Villa et al., 2020).

Giorgi et al. also found that obligatory lockdowns, social isolation regulations, and sickness anxiety all had an impact on both residents’ and employees’ mental health. Health care personnel are more prone to experience mental health problems associated with health emergencies. This review lays the groundwork for a deeper comprehension of the mental health of employees throughout the epidemic (Giorgi et al., 2020). Moreover, COVID-19 has impacted mental health globally, as described by Vindegaard et al. However, little information is available on how psychological affect, stress levels, anxiety levels, and depression levels have changed during the epidemic. The establishment of a mental health organization is a key component to prevent psychological effects (Vindegaard & Benros, 2020). Based on empirical research, Preti et al. recommended that the adverse impacts of epidemic/pandemic breakouts on the mental health of HCWs be addressed. The assessment of coping mechanisms and resilience should be encouraged, as should the establishment of online support services. Frontline HCWs should also receive special consideration (Preti et al., 2020).

This study aims to highlight the prevalence of stigmatization during the COVID-19 pandemic against HCP in Turkey using the Stigma COVID-19 HCPs (S19-HCPs). In addition, the findings of this study will serve as a foundation for future stigma-fighting initiatives and proper educational programs.

2. Methods

An observational cross-sectional design, including a self-managed web-based survey, was used to achieve the study objectives. The S19-HCPs was developed and validated by the research team (including experts from the mental health services) based on the available literature. The internal consistency of the English and Arabic S19-HCPs was satisfactory (α = 0.79 and 0.74, respectively). The two-week test-retest correlations were all statistically significant (ICC = 0.91 and 0.89, respectively; AJ Nashwan et al., 2021). The psychometric measures were tested in Turkish via back-to-back translation by the 2nd and 3rd authors who speak both English and Turkish fluently. The internal consistency of the S19-HCPs’ Turkish version was satisfactory (α = 0.79). Test-retest correlations were all statistically significant for the Turkish versions of the tool (ICC = 0.90; Carmines & Zeller, 1979).

The participating institutions sent the questionnaire via an official corporate email. Data collection from a convenient sample of HCPs started on May 2021 and continued until July 2021 (the sample size was determined by the total number of registered nurses in Turkey). In addition, participants were invited to complete an anonymous, voluntarily web-based questionnaire (QSurvey<SUP>TM</SUP>). At the end of the first part of the web-based questionnaire, two options, “I agree to participate in the study” and “I do not want to participate in the study”, were created. The participants who selected the latter option were excluded from the study. With this method, informed consent was obtained from the participants.

3. Ethical approval

The Ethics Committee approved the study from Ondokuz Mayis University (OMU) (Ref Number 2021/358). Therefore, the study information page was provided along with the questionnaire explaining the expectations and research procedure.

4. Results

Descriptive statistics were used to explain the HCPs’ characteristics. The largest group of study participants was aged 20–30 yrs (77%), followed by participants aged between 31–40 yrs (15%) and participants aged 41–50 yrs (5%); the smallest group of participants was aged 51+ yrs (2%). Furthermore, more than half of the cohort was female (78%), and 21% were male. Most participants were nurses (49%), followed by physicians (18%) and allied health professionals (19%). The majority had less than 5 years of experience in the health care field (62%), followed by participants with 6–10 years of experience (approximately 26%). Among the respondents, 66% had worked either in a COVID-19 designated facility or a quarantine center, and 87% claimed that they had received training for COVID-19-related stigma and discrimination, infection control, comprehensive disease prevention, and patients’ informed consent and confidentiality (Table 1).

Table 1. Characteristics of the participants

	n	%
Age
20–30 yrs	234	77.7
31–40 yrs	46	15.3
41–50 yrs	16	5.3
51+	5	1.7
Gender
Male	64	21.3
Female	237	78.7
Occupation
physician	96	31.9
nurse	149	49.5
allied health	56	18.6
Years of experience in health care
1–5 yrs	187	62.1
6–10 yrs	79	26.2
11–20 yrs	28	9.3
21+	7	2.3
Working in a COVID-19 designated facility
Yes	200	66.4
No	101	33.6
Training status
Yes	264	87.7
No	37	12.3

The above table and bar diagram state that in the domains of stigma, the attitude of study participants toward patients with COVID-19 was high, with a mean score of 2.39, and the mean score for following the precautions against COVID-19 was 1.8. The third highest mean score was 1.743 and indicated how well the HCPs were perceived by society (Table 2 and 3).

Table 2. COVID-19 stigma against the study participants

	Mean X± ss	Min-max
Fear of contracting COVID-19	1.413 ± 0.814	0.1–3.1
Following precautions to prevent COVID-19 infection	1.079 ± 0.353	0.0–1.8
Willingness to care for COVID-19 patients	1.743 ± 0.556	0.8–3.0
Perception of the caregivers of patients with COVID-19	1.720 ± 0.684	1.0–4.0
Satisfaction with the COVID-19 center’s provisions for safety	0.797 ± 0.498	0.0–2.0
Attitude toward the patient with COVID-19	2.390 ± 0.486	1.3–3.8

Table 3. Association between the age, gender, occupation, years of health care experience of the participants, participants’ working status and COVID-19 stigma

	Fear of contracting COVID-19	Following precautions to prevent COVID-19 infection	Willingness to care COVID-19 patients	Perception of the caregivers of patients with COVID-19	Satisfaction with the COVID-19 center’s provisions for safety	Attitude toward the patient with COVID-19
Age
20–30 yrs	159.94	160.50	148.09	143.19	153.69	151.87
31–40 yrs	115.43	111.57	183.04	188.35	139.74	158.38
41–50 yrs	116.13	95.06	89.81	161.50	127.94	156.06
51+	171.30	248.20	188.00	139.20	202.50	26.40
Chi-square p	13.056 0.005	27.378 0.000	15.535 0.001	11.175 0.011	4.073 0.254	11.002 .012
Gender
Male	155.05	178.46	136.67	139.84	165.50	181.90
Female	149.91	143.58	154.87	154.01	147.08	142.66
Chi-square p	0.177 0.674	8.834 0.003	2.236 0.135	1.400 0.237	2.376 0.123	10.577 0.001
Occupation of the participants
Physician	133.99	171.30	116.04	113.17	137.86	140.05
Nurse	181.22	154.34	179.75	168.66	157.55	155.39
Allied health	99.74	107.32	134.44	168.86	156.09	158.10
Chi-square p	41.260 0.000	21.340 0.000	34.273 0.000	27.873 0.000	3.393 0.183	2.344 0.310
Years of health care experience
1–5 yrs	157.14	154.95	145.51	133.20	152.54	149.27
6–10 yrs	155.87	154.42	163.09	182.39	145.04	156.01
11–20 yrs	95.25	95.68	151.21	179.96	155.00	180.54
21+	154.93	228.14	160.43	156.43	161.07	22.43
Chi-square p	12.744 0.005	18.909 0.000	2.388 0.496	22.209 0.000	0.612 0.894	19.448 0.000
Working status at COVID-19 facility
Yes	171.83	162.81	168.99	156.11	159.55	155.38
No	109.76	127.62	115.39	140.89	134.07	142.32
Chi-square p	34.298 0.000	11.977 0.001	25.829 0.000	2.148 0.143	6.054 0.014	1.560 0.212
Participants training status regarding COVID-19
Yes	153.04	153.14	154.94	151.06	152.67	153.68
No	136.43	135.73	122.92	150.54	139.09	131.91
Chi-square p	1.188 0.276	1.418 0.234	4.457 0.035	0.001 0.972	0.831 0.362	2.096 0.148

4.1. Fear of contracting COVID-19

Statistically significant differences in the fear of contracting COVID-19 were found when stratifying participants by age, occupation, years of experience in health care, and the working status of HCPs at the COVID-19 facility or quarantine centers. The HCPs aged 51+ years, nurses and other HCPs, and HCPs with 1–5 years of health care experience showed a high fear of contracting covid. The HCPs who worked in a COVID-19 designated facility or quarantine centers also had a high level fear of contracting COVID-19.

4.2. Following precautions to prevent COVID-19

Statistically significant differences in following precautions to prevent COVID-19 were found when stratifying participants by age, occupation, years of experience in health care, and working status. HCPs aged 51+ yrs., physicians, HCPs with 21 and above yrs. of health care experience, and HCPs who worked in a COVID-19 designated facility or quarantine centers all showed high levels of following these precautions.

4.3. Willingness to care for COVID-19 patients

Statistically significant differences in the willingness to care for COVID-19 patients were found when stratifying participants by age, gender, occupation, years of health care experience, and working status. HCPs aged 50+ yrs, female HCPs, nurses, HCPs with 6–10 years of health care experience and HCPs who worked in a COVID-19 designated facility or quarantine centers all showed a high willingness to care for these patients.

4.4. Perception of the caregivers of patients with COVID-19

The analysis revealed statistically significant perceptual differences in HCPs of different age groups, years of experience in health care, and working status while caring for COVID-19 patients. Specifically, HCPs aged between 31–40 years with a high level of experience felt that they are perceived well while caring for patients with COVID-19, while HCPs with 6–10 years of experience feel that they are perceived adequately while caring for patients with COVID-19. HCPs who did not work in a COVID-19 designated facility or quarantine centers felt they were perceived poorly.

4.5. Satisfaction with the COVID-19 center’s provisions for safety

The HCPs’ working status at the COVID-19 facility or quarantine centers and occupation significantly correlated with their satisfaction with the safety provisions at the COVID-19 centers. HCPs who worked in a COVID-19 designated facility or quarantine centers reported high satisfaction, and nurses reported the highest level of satisfaction.

4.6. Attitudes toward patients with COVID-19

Gender and years of health care experience significantly correlated with the attitude of HCPs toward patients with COVID-19 infection. Specifically, female HCPs indicated a low attitude, whereas HCPs with 11–20 years of experience reported a high attitude.

5. Discussion

The study’s purposes were fulfilled by analyzing the prevalence of stigmatization during the COVID-19 pandemic among 301 HCPs using the self-developed COVID-19 HCP instrument (S19-HCPs) in Turkey. The demographic profiles state that participants were primarily young adult and female HCPs involved in nursing, medicine, and dentistry. In general, participants had five years of experience, had been appointed to work in a COVID-19 facility, and completed the training on COVID-19 stigma, discrimination, infection control, universal precautions, patient informed consent, and confidentiality. Our study identified a high level of fear of being infected among HCPs. Nevertheless, the level of willingness to care for patients with COVID-19 was high, as was the perception of HCPs who cared for these patients. Conversely, satisfaction with provisions for safety from COVID-19 and attitude toward patients was comparatively moderate among genders but high among nurses, especially younger nurses.

COVID-19 has increased fear among the public and HCPs working with patients with COVID-19. Being infected and infecting loved ones with COVID-19, who may die from the disease, leads to a great sense of loss of control; according to a global survey of health care professionals and the public (Mertens et al., 2020), fear may also have been caused by reduced physical and environmental well-being (Harper et al., 2020). Caring for COVID-19-infected patients poses a serious occupational health risk for health care workers (Khan et al., 2014; Nashwan, Abujaber, Mohamed et al., 2021). HCPs working in countries where COVID-19 is on the rise have a higher level of fear.

Pandemic information is essential for HCPs’ willingness to care for patients (Nashwan, Abujaber, Mohamed et al., 2021). HCPs need to seek accurate, verified and valid information. Unfortunately, malicious and false information that can mislead HCPs is abundant on the internet. Sources of information must be carefully screened and verified by HCPs (Bhagavathula et al., 2020). Appropriate protection can only be achieved when coupled with education and experience on the same premise, and the management of COVID-19 patients requires extensive training and practice to reduce the risk of being infected by HCPs. Study findings suggest that health care workers who are trained to care for COVID-19 patients are more confident about being deployed to COVID-19 centers than those who are not directly assigned to deal with COVID-19 patients (Ran et al., 2020). In addition to physical training and preparation, most health care institutions have started introducing concepts related to stigma, discrimination, informed consent, and confidentiality as a part of their training and orientation programs. These programs resulted from the number of reported discrimination cases against health care workers worldwide during the peak of the COVID-19 pandemic. HCPs are assaulted, threatened, and removed from their homes in India, the USA and Australia (McKay et al., 2020). In terms of the perception of caregivers of COVID-19 patients, health care professionals who are adults between the ages of 31–40, working as nurses, and trained in the care of COVID-19 patients feel that they are well perceived by their caregivers (Bhanot et al., 2020).

5.1. Satisfaction with the COVID-19 center’s provisions for safety

Male nurses with 21+ years of experience who were trained in COVID-19 quarantine centers were highly satisfied with the safety precautions of the COVID-19 centers. This satisfaction indicates the participants assigned COVID-19 treatment facility regularly procured PPE and effectively managed, understood and implemented infection protocols. Conversely, HCPs heavily trust personal protective equipment to protect themselves while taking care of COVID-19 patients (Ranney et al., 2020). HCPs displayed a positive attitude toward patients, which was highest among nurses, younger HCPs, and those trained in COVID-19 facilities. The stigma of COVID-19 in society was also evident in the workplace and facilities serving infected patients. The attitudes and perceptions of HCPs toward the disease state may affect the quality of care given to their patients. Knowledge is inadequate and attitudes are low among HCPs coping with COVID-19 patients (Bashir et al., 2020; Bhagavathula et al., 2020; Nashwan, Abujaber, Mohamed et al., 2021; Ran et al., 2020). Although all knowledge sources oppose discrimination in countries around the world, such as India, cases of misinformed individuals have caused an uproar among frontline workers to observe their call for better treatment and to end discrimination (Bhanot et al., 2020; Singh & Subedi, 2020).

A study from Nigeria revealed that stigmatization against frontline health care workers (FHCW) has proven to be a significant obstacle when doing their job. The psychological toll taken by FHCWs may influence the caliber of the services they provide. The study demonstrates the need to spread knowledge and awareness about the current pandemic. The government and society need to recognize and value the work made by FHCWs (Kwaghe et al., 2021). Another study from India found that during the COVID-19 pandemic, more than half of frontline HCWs at the Department of Anesthesia and Critical Care faced significant social stigma, with the subgroup concerned with public opinion experiencing the most stigma. The degree of stigma correlated with the HCW’s age, male gender, job title, level of education, and marital status (Jain et al., 2021). Moreover, Sorokin et al. found that medical staff who have direct contact with a coronavirus infection have a considerable rise in stress. The epidemic jeopardizes the mental health of the most talented and youthful specialists. Stigmatizing reactions, which are more common among nurses and paramedical staff, are not directly related to the dangers of infection (Sorokin et al., 2020). While this rapid systematic review focuses on the crucial elements that can help identify HCWs who are most vulnerable to psychological distress during pandemics, it recommends that early treatments and continuing monitoring be given to HCWs who are at risk for increasing distress. The relationships between risk and resiliency characteristics and distress need to be studied over time. Possible connections between elements and the effect of these connections on the persistence of discomfort are currently unknown (Sirois & Owens, 2021).

6. Limitations

The research was conducted over several months, and the pandemic and the participants’ perceptions may have changed over time. Therefore, the research findings were limited to the self-reporting of the participants rather than direct observational evaluations.

7. Conclusion

The previous research results show that overall, participants enjoyed positive recognition by their communities, despite perceived high levels of stigmatization. Moreover, participants were highly motivated to care for COVID-19 patients. Nevertheless, hidden fears of discrimination persist among HCPs. Therefore, the fear of contracting COVID-19 was significant among participants when grouped by age, work status, and training status. Precautions are followed strictly by HCPs who are trained in caring for COVID-19 patients. Briefly, respondents have a high level of willingness to care for COVID-19 patients, are perceived positively by caregivers and relatives, are highly satisfied with the safety precautions implemented by their respective facilities, and have a high positive attitude toward COVID-19 patients. These determinants reflect the overall development of protocols consequential to COVID-19 care one year after the emergence of the illness.

Availability of data and material

All data generated during this study are included in this published article.

Authors’ contributions

AJN, MK and IAA: Research design, Data collection, Literature search, Manuscript preparation. AJN: Formal Analysis. All authors read and approved the final manuscript.

Declarations Ethics approval

The Ethics Committee approved all study activities of the following centers:

• Turkey

  • Ondokuz Mayis University (OMU) (Ref Number 2021/358)

Acknowledgements

The publication of this article was funded by the Qatar National Library.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This study received no grant or funding.