COVID-19-related stigma towards doctors in India: an online cross-sectional study

Background: The coronavirus disease 2019 (COVID-19) pandemic has led to worry and panic in the minds of people all over the world. Consequently, doctors and other frontline healthcare workers have become a target of stigma in the society. In spite of the Indian government appreciating doctors and healthcare workers with gestures, such as an aerial floral salute and asking the citizens to maintain a positive attitude toward doctors, several people are looking down at doctors as probable virus carriers and treating them as a potential threat to the general public. Aims: To assess stigma and discrimination faced by doctors during the COVID-19 pandemic and their psychological wellbeing. Materials and methodology: A cross-sectional study was conducted on doctors, with convenience sampling technique used to collect data. The study tools were presented in Google forms, and the link was circulated by an exponential non-discriminative snowballing method through doctors’ WhatsApp groups across several states of the country. The study tools included participant information sheet, informed consent form, sociodemographic proforma, a self-designed questionnaire related to stigma and discrimination, and the World Health Organization (Five) Well-Being Index (WHO-5). Results: Three hundred and fifty-six (69.94%) out of 509 doctors reported that they had experienced stigma from the society and their families. 95.5% doctors reported that they are proud of their profession despite experiencing stigma. 58.2% doctors reported that they have received appreciation from the society for their work. 5.6% doctors reported that stigma had a serious impact on their wellbeing. Conclusion: The study results show that majority of doctors are facing stigma and discrimination. Addressing stigma and discrimination faced by doctors and other frontline healthcare workers is significant in fighting this pandemic.


INTRODUCTION
Stigma is conceptualised as having three different elements.First, misinformation regarding the stigmatised condition, seen as ignorance.Second, a negative outlook towards a stigmatised individual or group, seen as prejudice.Third, the behavioural manifestation of stigma, that is, discrimination, which occurs when a person or a group of people with such views act out.[1] Stigma linked to the coronavirus disease 2019 (COVID-19) pandemic is a potential threat to the functioning of healthcare workers and also, lives of patients.With the rising number of cases, more number of healthcare providers are involved to manage the disaster.Since, they have been playing a chief role dealing with the pandemic, they are constantly confronting various challenges within, and also, outside their workplaces.[2] Unfortunately, those working in healthcare facilities on a regular basis with diagnosed COVID-19 cases may often get shunned.They get labelled or lose their noble status because of stigma attached with the pandemic.[3] The doctors' white coat, once well-thoughtout as a revered cloth, has now in the times of pandemic, got a tag as a symbol of infection and irreverence.[4] Media descriptions in India, have revealed that frontline healthcare workers dealing with COVID-19 patients have been facing considerable ostracism in the society.[5] For example, an unruly mob incident was reported in Central India, when doctors and healthcare workers dressed in full protective suits entered a locality to quarantine contacts of a confirmed COVID-19 patient, but ran for their lives.[6] Despite consistent efforts of the Indian Government at raising awareness, and the doctors and healthcare workers relentlessly working with shortage of personal protective equipment (PPE), risking their own lives, and staying away from their families, members of the public may look down at doctors as potential virus carriers and treating them as a threat to the society.
There are myriads of adverse effects of stigma on an individual and society.While one can foresee the negative impact of stigma on a person's psychological wellbeing, this has not been much researched in context of doctors experiencing stigma, and more so, during public health crisis such as the current COVID-19 pandemic.The wellbeing of doctors in a public health crisis remains paramount given the level of individual and organisational efficiency required at such times.In addition to the stigma associated with pandemics such as this, one would also need to be wary of the stigma that can go along with psychiatric morbidities, such as depression and anxiety which the pandemic can bring about.[7] In this study, we attempted to explore the stigma and discrimination faced by doctors during the current pandemic and their psychological wellbeing.

MATERIALS AND METHODOS
This was an online cross-sectional study for which convenience sampling technique was used to collect data.The study was mostly a hypothesis generating one, rather than a testing one due to limited existing studies around stigma in doctors.The sample size was determined by doing a pilot study on 33 doctors, obtained by forwarding the tools/ questionnaires and awaiting responses over two full days.Of these, seven doctors reported stigma, showing a prevalence of 21.2%.This necessitated a sample of 350 participants for the main study.After obtaining necessary permission from the institutional ethics committee, the study tools were presented in Google forms and the link was circulated by an exponential non-discriminative snowballing method.Doctors receiving the message were requested to complete the survey, and then, forward the link to doctors from various states of the country through WhatsApp groups.The survey link was circulated starting from 9 July 2020 and after the sample size requirement was met, it was closed on 18 July 2020.
The study tools/questionnaires consisted of the following sections: 1.A participant information sheet describing details of the study, its purpose with a form for informed consent.2. Sociodemographic proforma containing questions to collect sociodemographic details of doctors.3. Questionnaire for stigma and discrimination: Selfdesigned, face validated questionnaire to assess stigma and discrimination during the COVID-19 pandemic-As no specific questionnaire was available to study stigma and discrimination towards doctors during pandemic times, a study specific survey response questionnaire was designed to assess the stigma and discrimination faced by doctors during the present COVID-19 pandemic.This was face validated through discussion with experts including psychiatrists.The questionnaire consists of ten questions with yes or no answers, developed using cues from print and digital media across the country related to stigma and discrimination against doctors faced in the society.Nine questions are related to stigma and discrimination faced by doctors in different situations and one question on appreciation from the society.A screening question before the questionnaire asks if participants experienced stigma in any sort of situation, and only those who experienced it could continue to answer the nine questions related to stigma and the subsequent World Health Organization (Five) Well-Being Index (WHO-5).[8] 4. WHO-5: Wellbeing of doctors was measured using WHO-5.[8] It consists of five statements rated on a sixpoint Likert scale in which, one has to choose how they have been feeling over the past two weeks.High scores indicate better wellbeing; the total score ranging from zero to 25.A score below 13 indicates poor wellbeing, and is an indication for testing for depression under the tenth revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10).[9] While the scale has not been validated in an Indian setting, it has adequate validity both as a screening tool for depression and wellbeing, and has been used in a number of countries and across a wide range of studies.[10] The Cronbach α for the scale has been found to be 0.91.WHO-5 has a sensitivity/specificity of 0.79/0.79 in detecting depression at a cut-off score of 13. [11] It was also mentioned in the beginning of this online form that these questions in the wellbeing index needed to be answered in relation to the COVID-19 pandemic and its impact.
Those who did not provide consent to participate and those with pre-existing mental illnesses were excluded from the study.The participant information section in the beginning of the online study questionnaire mentioned that the study is not appropriate for participants with preexisting mental illnesses and hence, should not participate in the same.All statistical analysis was performed by using Statistical Package for the Social Sciences version 16.0 (SPSS 16.0) and Microsoft (MS) Excel 2007.Descriptive statistical analysis was done where the quantitative and qualitative variables were expressed in frequencies and percentages.

RESULTS
Responses received were from states of Andhra Pradesh, Telangana, Tamil Nadu, Delhi, Odisha, Gujarat, Karnataka, and Assam.A total of 509 responses were received; out of which, 356 (69.94%) doctors affirmed that they experienced stigma from the society or family, and further answered specific questions related to stigma (questions one to nine).95.5% doctors reported that they did not feel ashamed of their profession despite experiencing stigma.All participants (509) answered a tenth question that was positively framed (to capture positive experiences in their role as a doctor during the COVID-19 pandemic).58.2% doctors reported that they have received praise and appreciation from the society for their work (tenth question).Table 1 represents various demographic variables, Table 2 represents stigma and discrimination survey responses, Table 3 represents demographic variables for WHO-5 score <13 and Figure 1 represents psychological wellbeing amongst doctors.

DISCUSSION
In the current study, 69.94% of doctors reported that they have experienced stigma from the society and family during the pandemic, which seems to be far higher than expected and goes against the notion of a noble profession that the practise of medicine is.In general, doctors do not experience stigma from the society; however, during the current COVID-19 pandemic, social stigma against doctors is quite high.This is mainly because of the fear and panic the pandemic has triggered in people's minds, and when fear is so acute, the rational thinking in individuals is lost and this may make persons to think that everyone is infectious, especially those dealing with patients.
On WHO-5 scale, 5.6% of the doctors scored below 13, indicating that stigma could be one of the important factors impacting psychological wellbeing (Figure 1 and Table 3).Loss of wellbeing leads to mental health issues, such as anxiety and depressive disorders.One silver lining in the current study is that despite facing stigma, 95.5% doctors reported that they are proud of their profession.58.2% of the total sample reported that they received appreciation for the services they are rendering to the society during these difficult times (Table 2).This probably is reflective of the fact that professional satisfaction of the doctor goes much beyond perceived stigma, and the appreciation and gratitude expressed by patients predominates, and on the whole, providing them with a rewarding experience.
Fear, worry, distress, and anxiety linked to a disease may cause a particular disliking of people of certain countries leading to a condition called xenophobia, and in turn, to social stigma.[12] Racism, discrimination, and emotions of hostility are often caused by fear, anxiety, and uncertainty, and these emotions in an individual are high during pandemic times resulting in the creation of victims based on deformed perceptions of risk.Like the 1918 influenza pandemic which was called as Spanish flu, despite the fact that it was not originated from Spain.It became known around the world as the Spanish flu because of the news coverage around it, while the Spanish people called it French flu.[13] Doctors face many ethical dilemmas while doing duties during pandemic times, such as whether to give ventilator support to a terminally ill patient who will not make it or to someone who is less critical, and how to balance between doing duties and concerns of contracting illness and spreading it to families and friends.Doctors and other healthcare providers do not have the choice of staying inside their homes, be with their families and be safe, unlike many other professionals.They have the responsibility to go out of their homes to contain the spread of coronavirus, to treat people who are affected by the virus, and also, attend regular medical and surgical emergencies.Doctors cannot abandon responsibilities towards patients; it is against the Hippocratic Oath they take during their graduation.What needs to stop is social stigma and discrimination against doctors during the COVID-19 pandemic, such as doctors being called as contagion of the disease, physical assaults, verbal abuses, all of which will only make the pandemic crisis worse.

Limitations
Although doctors from different states across the country participated in the research, still the participation is low.The assessment of stigma and discrimination towards doctors is limited to the survey questionnaire and other aspects of stigma were not covered.The survey questionnaire that was used in the study was only face validated, the questionnaire being dichotomous in nature, with yes or no options, neutral answers were not measured.The questionnaire was circulated on WhatsApp on a convenient sampling basis, and therefore has limitations around generalisability.[14] Also, the government response towards the pandemic would have varied from state to state.Since the distribution of doctor's responses from individual states was not known, it was not possible to evaluate the state wise differences of the impact of the pandemic.Also, the questions were framed to capture mostly discrimination, and internalised or perceived stigma was not evaluated.However, considering the situation, as no scale is available to measure stigma and discrimination towards doctors during pandemics, this was a rapid and feasible methodology to get a view of doctors facing stigma and discrimination from the society during the pandemic.Association with the variables such as age, gender, clinical experience of the doctor, nature of workplace, etc. which could have an impact on stigma was not done in the study could be a limitation.The association between stigma and wellbeing of doctors was also not looked into.

Conclusion
The study results show that majority of the doctors are facing some or other discrimination, with some of them having significant impact on their emotional wellbeing.Doctors in these times need better recognition and appreciation from the public authorities and the society.This is more important in a country as ours that is already facing a severe shortage of hospitals, doctors, protective gears, medical equipment, and stigma will only make things worse.

Future directions
Government authorities, local leaders, celebrities, and administrative officials should take initiative in speaking out against negative behaviours and statements, and debunking myths of the disease.Stigma and discrimination towards frontline workers may be mitigated by raising awareness on print and digital media and highlighting the role of doctors and other healthcare workers in containing the pandemic.In this context, bigger studies looking into stigma towards doctors across India by a medical body such as the Indian Medical Association and the Indian Psychiatric Society are the way forward.With the pandemic likely to have a big impact on health at an individual and population level over a long period, there is a need for validated scales to capture the psychological impact of COVID-19 in future.[15]