COVID-19 stigmatization after the development of effective vaccines: Vaccination behavior, attitudes, and news sources

Don C Des Jarlais; Sarah Lieff; Margaux Grivel; Gabriella Meltzer; Jasmin Choi; Chenziheng Allen Weng; Jonathan P Feelemyer; Virginia W Chang; Lawrence Yang

doi:10.1371/journal.pone.0283467

. 2023 Apr 27;18(4):e0283467. doi: 10.1371/journal.pone.0283467

COVID-19 stigmatization after the development of effective vaccines: Vaccination behavior, attitudes, and news sources

Don C Des Jarlais ^1,^2,^*, Sarah Lieff ², Margaux Grivel ², Gabriella Meltzer ², Jasmin Choi ², Chenziheng Allen Weng ³, Jonathan P Feelemyer ⁴, Virginia W Chang ^2,^4,^‡, Lawrence Yang ^2,^5,^‡

Editor: Ismail Ayoade Odetokun⁶

PMCID: PMC10138268 PMID: 37104270

Abstract

Objective

To compare COVID-19 stigmatization at two pandemic time points (1) August 2020—during lockdowns and prior to vaccine rollout, and (2) May 2021—during vaccine rollout, when approximately half of U.S. adults were vaccinated.

Methods

Comparison of COVID19-related stigmatization and associated factors in two national internet surveys conducted in August 2020 (N = 517) and May 2021 (N = 812). Factors associated with endorsing stigmatization were identified using regression analysis. The main outcomes included endorsement of stigmatization and behavioral restrictions towards persons with COVID-19 and towards persons of Chinese descent. A previously developed “stigmatizing attitudes and behavioral restrictions” scale was adapted to measure the intersection of negative attitudes toward COVID-19 disease and negative attitudes toward persons of Chinese descent.

Results

COVID-19 related stigmatization declined significantly from August 2020 to May 2021. Many factors were associated with stigmatizing in both surveys: full time employment, Black race, Hispanic ethnicity, worry about contracting COVID-19, probable depression, and Fox News and social media as sources of information (all positively associated), and self-assessed knowledge about COVID-19, contact with Chinese individuals, and publicly funded news as sources (all negatively associated). Positive attitudes toward vaccination were associated with stigmatization.

Conclusions

COVID-19 related stigmatization reduced substantially over these two points in the pandemic, with many continuities in the factors associated with stigmatizing. Despite the reduction in stigmatizing, however, some stigmatizing attitudes for both COVID-19 and Chinese individuals remained.

Introduction

Control of infectious diseases often requires identifying persons who have been exposed to or contracted the disease and then placing restrictions on their behavior. Isolation of active cases and quarantine of persons who have been exposed are two examples of such identification and behavioral restrictions. While such identification and restrictions may be critical for controlling the disease, they may also lead to stigmatization of persons with the disease and social groups associated with the disease.

A critical distinction between good public health practice and stigmatization is that in good public health practice, the persons undergoing behavioral restrictions are treated with dignity, respect, and support, while in stigmatization, persons are often treated with hostility and contempt. A second critical distinction is the public health behavioral restrictions are evidence-based, while stigmatization is often based in exaggerated fears and pre-existing negative attitudes towards specific social groups. Stigmatization can cause substantial psychological, social, physical, and economic harm to individuals and groups that are stigmatized [1–3].

Stigmatization may also lead to avoiding medical care, attempting to hide disease and exposures, and to hiding membership in groups associated with the disease, all of which may contribute to further transmission [4]. The negative consequences of infectious disease related stigmatization may be particularly likely if the stigmatization reinforces existing negative social stereotypes of the groups associated with the disease [5, 6].

Early in the SARS-CoV-2/COVID-19 epidemic, there was considerable stigmatization of persons with COVID-19 and persons of Chinese descent (and in particular persons from Wuhan) [7]. Some political leaders in the United States (U.S.) linked the SARS-CoV-2 virus to China through the use of derogatory terms such as “China virus,” “Wuhan virus,” and “Kung flu” [8]. This terminology clearly linked the disease to persons of Chinese nationality and the linkage occurred in parallel with an over 150% increase in anti-Asian hate crimes reported in the U.S. in 2020–2021 compared to the previous year and reports of Asians experiencing direct and indirect racial hostility [9–11]. Other countries have also reported anti-Chinese/anti-Asian sentiment associated with COVID-19; examples including Australia [12], Europe [13] and South Korea [14].

Highly effective vaccines that greatly reduce serious illness and deaths from COVID-19 have been developed and made widely available in the U.S. Approximately 62% of adults in the U.S. had received at least one dose of a vaccine by the time of our second data collection (late May 2021) and 77.6% had received at least one dose as of May 3, 2022, a year later [15].

The development and partial implementation of the vaccines, however, has been followed by intense controversy [16–19]. The controversy has often been fed by the considerable amount of misinformation and disinformation about COVID-19 that has been disseminated in the U.S., often through social media platforms [20–23].

In this study, we used non-random national internet samples to compare the COVID-19 stigmatization U.S. at two different points in the epidemic. The first survey was conducted in August 2020, when various lockdowns had been implemented [24]. The second survey occurred in May 2021, a time when approximately half of U.S. adults had received at least one dose of a COVID-19 vaccine, and the Centers for Disease Control and Prevention (CDC) had just announced guidance that fully vaccinated persons no longer needed to wear masks in most settings [25]. This time period also coincided with increasing public polarization over the vaccines [26, 27]. We consider two primary questions in the comparison of the two surveys: 1) Did the overall frequency of stigmatization change? and 2) Did the factors associated with expressing stigmatization remain the same or change? Identifying changes and consistencies in stigmatization within a rapidly changing pandemic may provide insights into the nature of disease-related stigmatization and possibly for preparing for future epidemics and pandemics. The Health Belief Model (HBM) is used to interpret the findings [28, 29]. This model is frequently used in health communications, in which the perceived threat (seriousness and susceptibility) of the disease is emphasized as a rationale for engaging in protective behaviors. The “protective behaviors” may include avoiding contact with and placing behavioral restrictions on persons with the disease. However, given the controversies around the vaccines and the mis- and dis-information about the vaccines, we did not attempt to use the HBM to predict how stigmatization and how the correlates of stigmatization might have changed from pre- to post development of the vaccines.

Methods

Data collection

Amazon’s Mechanical Turk (MTurk) is a crowdsourcing platform that provides access to an on-demand and diverse global workforce, an estimated 225,000 of which are U.S.-based [30]. Through MTurk, researchers and other “requesters” can post tasks that workers can complete if they meet pre-specified criteria. Participants in this study were eligible to complete the online survey if they were at least 18 years of age, had previously completed at least 500 MTurk tasks, and had approval ratings greater than or equal to 90% for previously completed MTurk tasks. The first survey was launched on August 5, 2020, during a period of intense lockdowns and social distancing. The second survey was launched on May 21, 2021, soon after the CDC announced new guidance that fully vaccinated persons no longer needed to wear masks or practice social distancing outdoors or in most indoor settings, excluding health care facilities, while flying or taking public transit, and in congregate settings [25]. Persons who had not been vaccinated, however, were still advised to wear masks in almost all situations outside of private homes. The May 2021 survey included all the items in the August 2020 survey, and additional items about having been vaccinated and intentions to become vaccinated.

Data quality was assessed using two attention checks requiring participants to select a specific response option and a time-to-completion analysis. Given the significant outliers, we implemented a minimum acceptable time to complete the survey of one standard deviation below the whole sample mean (151.562 seconds for the August 2020 survey, 182.897 seconds for May 2021 survey), and a maximum cutoff score of 1,000 seconds for the August 2020 survey and 1,400 seconds for the May 2021 survey. Of the 1,606 respondents between the two surveys, a final sample of 1,312 (August 2020 N = 517; May 2021 N = 812) was retained for this analysis. Entries were excluded due to failed attention checks (N = 51), unacceptable completion times (N = 64), and having incomplete data (N = 179).

Study variables

As a primary purpose of the 2021 survey was to compare COVID-19 related stigmatization at two points in the pandemic—during initial lockdown vs. after vaccine rollout—we used many of the items from the 2020 survey in the 2021 survey. Table 1 presents the major COVID-19 related items in our two surveys.

Table 1. List of different COVID-19 related questions and variables and recoding schemes for analysis.

	Original Scale Scores	Recoded Variable
Stigmatizing Attitudes and Behavioral Restrictions (SABR) Scale items
1. Requiring Americans with COVID-19 to wear identification tags	1. Agree Strongly 2. Agree Somewhat 3. Disagree Somewhat 4. Disagree Strongly	1. “No Stigma” if answered “disagree” to all SABR items 2. “Any Stigma” if answered agree to any SABR items
2. The government announcing it will execute people who knowingly spread COVID-19
3. Avoiding areas in the United States that are heavily populated by Chinese individuals
4. Forcing all Chinese people to be medically checked for COVID-19
5. Not allowing Chinese people to enter the United States
Contact with Persons Questions
Have you ever known somebody who had COVID-19	1. Definitely Yes 2. Probably Yes 3. Probably No 4. Definitely No	1. Contact (1,2) 2. No Contact (3,4)
Have you ever known somebody who became seriously ill or died from COVID-19
Have you ever known somebody who identifies as Chinese?
Experience of Discrimination related to COVID-19
Have you experienced stigmatization or discrimination related to COVID-19?	1. Yes, a lot 2. Some 3. No	1. Yes, a lot/Some (1,2) 2. No (3)
Have you experienced stigmatization or discrimination because of your race/ethnicity	1. Yes, a lot 2. Some 3. No	1. Yes, a lot/Some (1,2) 2. No (3)
Vaccination Behavior and Intentions
Have you been or are you in the process of being vaccinated against COVID-19, and if not, do you intend to receive a COVID-19 vaccination in the future	1. Vaccinated 2. Definitely will get vaccinated 3. Probably will get vaccinated 4. Probably will not get vaccinated 5. Definitely will not get vaccinated	1. Vaccinated (1) 2. Definitely/probably will get vaccinated (2,3) 3. Probably will not get vaccinated (4) 4. Definitely will not get vaccinated (5) Further combined as 1.Pro-vaccines (1, 2, 3) and 2. Anti-vaccines (4, 5)
Other COVID-19 related questionnaire items
Do you have any of the underlying conditions, such as diabetes, being overweight, heart disease, lung/breathing diseases, that could make COVID-19 disease more severe	1. Yes 2. No	1. Yes if answered for any condition 2. No if answered no for all conditions
Probable current depression	1. PHQ score	1. Yes if PHQ score of 5 or more 2 No if PHQ score of less than 5
How worried are you about contracting COVID-19?	3. Not at all worried 4. Somewhat worried 5. Very worried	1. Not at all worried (1) 2. Somewhat/very worried (2,3)
How much have you heard about COVID-19? (Self-assessed knowledge)	1. Not much 2. Some 3. A great deal	1. Not much/Some knowledge (1,2) 2. A great deal of knowledge (3)
News Sources	1. Facebook 2. Twitter 3. NPR 4. PBS 5. CNN 6. MSNBC 7. ABC 8. CBS 9. NBC 10. Other News source 11. New York Times 12. Fox News	1. Social Media (1,2) 2. Publicly-funded News (These are stations funded through government sources and donations) (3,4) 3. Commercial TV News (These are stations funded through advertising) (5–9) 4. Other news source (10)

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New York Times (11) and Fox News (12) were retained as separate news variables because of prior research indicating their importance in the coverage of COVID-19 news [33–35]

Primary outcome

The primary outcome of interest was COVID-19 related stigmatization, measured with the Stigmatizing Attitudes and Behavioral Restrictions (SABR) Scale. This SABR scale was adapted from a 2003 study comparing stigmatization of SARS-1 and HIV/AIDS [31]. Despite the many differences in the epidemiology of SARS-1 and HIV/AIDS (in modes of transmission, in case fatality rates, geographic areas of concentration, social groups with which the diseases were associated, total numbers of cases) there were strong similarities in the patterns of responses to the SABR items for SARS-1 and HIV/AIDS.

Responses to all of the individual SABR items were significantly correlated across the two diseases, and many of the same factors were associated with stigmatizing both SARS-1 and HIV/AIDS. These associated factors included education, income, race/ethnicity, greater worry about contracting the disease, less knowledge of the disease, and mental health problems [31].

Exploratory factor analysis of the August 2020 survey showed a strong single general factor explaining approximately 71% of the variance, with all items loading 0.6 or greater onto this factor. Reliability for this scale was excellent (Cronbach’s alpha = 0.90). This SABR scale should be considered as measuring the intersection of stigmatization of COVID-19 and stigmatization of persons of Chinese descent. It was not intended to capture all aspects of stigmatization of either the disease or of the social group.

Contact with persons with or associated with COVID-19 and with Chinese persons

These items were adapted from stigma research [32] suggesting that personal contact would decrease stigmatization.

Experiences of discrimination related to COVID-19 and race/ethnicity

We included questions on having experienced stigmatization to examine whether experiencing stigmatization might lead to empathy for persons associated with COVID-19 and less stigmatizing or might lead to resentment and increased stigmatizing.

Preferred news source

These items were used in the 2020 survey and were strongly associated with stigmatization in that survey. That preferred news sources are associated with beliefs about COVID-19 has been noted in many previous studies [36–38].

Lack of hypotheses

We did not formulate hypotheses for our two major research questions (whether the prevalence of stigmatization or the correlates of stigmatization would change after development of vaccines) because we believed that the amount of polarization, mis- and dis-information about the vaccines precluded straightforward application of any theoretical framework.

Statistical analysis

Cross tabulations and chi square tests assessed bivariate relationships between the August 2020 and May 2021 surveys and demographic characteristics, vulnerabilities to and experiences with COVID-19, and the SABR scale, with p-values of less than 0.05 used to detect statistically significant differences. We calculated crude odds ratios to examine associations of possible predictor variables with the COVID-19 SABR items using univariate logistic regression. All predictors and covariates were moved into multivariable logistic regression models to estimate adjusted odds ratios. The vaccination status/vaccination intentions variable formed a continuum from positive to very negative attitudes toward vaccination, and the Cochran-Armitage test for trend was used to assess relationships with COVID-19 related attitudes and experiences and the SABR items.

As noted below, there were modest differences in the demographic characteristics of the respondents in the two surveys. We thus used demographic characteristics as control variables in all multivariable analyses.

Analyses were performed in STATA version 17 [39]. The study was approved by the New York University Institutional Review board. All participants provided written informed consent after reading a summary of the study, but before beginning the survey.

Results

Table 2 presents the demographic characteristics of respondents in the two surveys. There were modest differences in the demographic characteristics of the participants in the two surveys. Participants in the May 2021 survey were moderately older, less likely to be non-Hispanic Black or Hispanic, and less likely to have college degrees.

Table 2. Sample characteristics for Waves 1 (N = 517) and 2 (N = 812).

	Wave 1		Wave 2		p-value
	N = 517		N = 812		p-value
	N	%	N	%
Gender
Female	186	36.0	324	39.9	0.15
Male	331	64.0	488	60.1
Age
18–24 years	26	5.0	26	3.2	0.04
25–34 years	242	46.8	332	40.9
35–44 years	149	28.8	253	31.2
45–54 years	55	10.6	110	13.6
55+	45	8.7	91	11.2
Race
NH White	295	57.1	542	66.8	<0.001
NH Black	69	13.4	65	8.0
Hispanic	137	26.5	151	18.6
Asian	16	3.1	54	6.7
Employment
No employment	44	8.5	89	11.0	0.33
Part-time	61	11.8	89	11.0
Full-time	412	79.7	634	78.1
Education
High School or Below	55	10.6	93	11.5	0.01
Some College	71	13.7	161	19.8
College Degree (BA/BS)	317	61.3	433	53.3
Graduate School	74	14.3	125	15.4

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Table 3 presents endorsements of the five SABR items in the two surveys. In the May 2021 survey, there was less endorsement of the SABR items, including for the scale as a whole and for each of the individual items. All the differences in the SABRs were in the direction of less stigmatization in the May 2021 survey.

Table 3. Endorsements of the five SABR items for Waves 1 (N = 517) and 2 (N = 812).

	Wave 1		Wave 2		p-value
	N = 517		N = 812		p-value
Should people avoid areas in the United States heavily populated by Chinese?
Agree/Strongly agree	248	48.0	269	33.1	<0.001
Disagree/Strongly disagree	269	52.0	543	66.9
Should all Chinese by forcibly checked for COVID-19?
Agree/Strongly agree	235	45.5	242	29.8	<0.001
Disagree/Strongly disagree	282	54.6	570	70.2
Should Chinese not be allowed to enter the United States?
Agree/Strongly agree	261	50.5	253	31.2	<0.001
Disagree/Strongly disagree	256	49.5	559	68.8
Should Americans with COVID-19 be required to wear identification tags?
Agree/Strongly agree	257	49.7	288	35.5	<0.001
Disagree/Strongly disagree	260	50.3	524	64.5
Should people who knowingly spread COVID-19 be executed?
Agree/Strongly agree	235	45.5	262	32.3	<0.001
Disagree/Strongly disagree	282	54.6	550	67.7
Have you experienced stigmatization or discrimination because of your race/ethnicity?
Yes, a lot/some			298	36.7
No			514	63.3
COVID Stigma (5-item composite)¹
Some stigma	341	66.0	377	46.4	<0.001
No stigma	176	34.0	435	53.6

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¹ COVID Stigma 5-item composite includes the following items

Should Americans with COVID-19 be required to wear identification tags?

Should people who knowingly spread COVID-19 be executed?

Should people avoid areas in the United States heavily populated by Chinese?

Should all Chinese be forcibly checked for COVID-19?

Should Chinese not be allowed to enter the United States?

The changes in stigmatization occurred within the context of changes in many other aspects of the COVID-19 pandemic. Table 4 presents information on experiences with and potential vulnerabilities to COVID-19 among the respondents. There were multiple differences in the responses to these survey items. Participants in the May 2021 survey were less likely to be worried about contracting COVID-19, more likely to assess themselves as knowledgeable, more likely to report contact with persons who had COVID-19, less likely to report probable depression, and less likely to report social media as a source of information.

Table 4. COVID-19 related experiences and vulnerabilities for Waves 1 (N = 517) and 2 (N = 812).

	Wave 1		Wave 2		p-value
	N = 517		N = 812		p-value
	N	%	N	%
COVID Knowledge
Some	89	17.2	107	13.2	0.04
A great deal	428	82.8	705	86.8
COVID Worry
Somewhat/very worried	459	88.8	620	76.4	<0.001
Not at all worried	58	11.2	192	23.7
Do you have any of the underlying conditions, such as diabetes, overweight, heart disease, lung/breathing diseases, that could make COVID-19 disease more severe?
Yes			309	38.0
No			503	62.0
Contact with Chinese
Contact	390	75.4	648	79.8	0.06
No contact	127	24.6	164	20.2
Contact with COVID
Contact	288	55.7	634	78.1	<0.001
No contact	229	44.3	178	21.9
Contact with Severe COVID
Contact			352	43.4
No contact			460	56.7
Depression
Probable depression	342	66.2	430	53.0	<0.001
No probable depression	175	33.9	382	47.0
Social Media News
Yes	381	73.7	536	66.0	0.003
No	136	26.3	276	34.0
Public Funded News
Yes	144	27.9	183	22.5	0.03
No	373	72.2	629	77.5
Commercial TV News
Yes	344	66.5	556	68.5	0.46
No	173	33.5	256	31.5
New York Times
Yes	206	39.9	307	37.8	0.46
No	311	60.2	505	62.2
Fox News
Yes	196	37.9	287	35.3	0.34
No	321	62.1	525	64.7
Vaccination intention (N = 816)
Positive/Vaccinated			713	87.4
Negative			103	12.6

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We then conducted a bivariable logistic regression of the odds of stigmatizing in the May 2021 survey compared to the odds of stigmatizing in the August 2020 survey. The OR was 0.45 (95% CI 0.36–0.56). We also conducted a multivariable logistic regression to control for the demographic and “vulnerabilities and experiences” variables in our survey; the adjusted OR was 0.52 (95% CI 0.37–0.72) showing that the reduction in endorsing SABR items remained significant after controlling for the other variables in our survey. The odds for endorsing at least one SABR item were 48% lower in the May 2021 survey compared to the August 2020 survey. (Full data available from the first author).

Factors associated with endorsing SABRs in August 2020 and May 2021 surveys

We used logistic regression to identify factors associated with the SABR scale in the two surveys. Table 5 presents the bivariable and multivariable models for each of the two surveys. Overall, there were many variables that were significant in at least one of the regressions and substantial similarities in the factors that were significantly associated with the SABR scale across the two surveys. The variables significantly associated with stigmatization in both surveys were: full time employment, Black race, Hispanic ethnicity, worry about contracting COVID-19, probable depression, Fox News and social media as preferred sources of information (all positively associated), and self-assessed knowledge about COVID-19, contact with Chinese individuals, and publicly funded news as preferred sources (all negatively associated).

Table 5. Logistic regression results for associations with COVID-19 stigma for Waves 1 (N = 517) and 2 (N = 812).

	Wave 1 (N = 517)		Wave 2 (N = 816)
Outcome	Crude ORs	Adjusted ORs	Crude ORs	Adjusted ORs
	OR (95% CI)	OR (95% CI)	OR (95% CI)	OR (95% CI)
Age (Ref: 18–24 years old)
25–34 years	1.14 (0.47, 2.74)	0.81 (0.26, 2.55)	0.93 (0.42, 2.08)	0.54 (0.20,1.47)
35–44 years	0.70 (0.28, 1.71)	0.77 (0.23, 2.56)	0.80 (0.36, 1.79)	0.33 (0.20,1.47)
45–54 years	0.72 (0.27, 1.95)	0.78 (0.21, 2.89)	0.47 (0.20, 1.12)	0.26 (0.12,0.95)
55+ years	0.51 (0.18, 1.41)	0.81 (0.20, 3.22)	0.40 (0.16, 0.97)	0.74 (0.08,0.79)
Male Gender (Ref: Female)	1.85 (1.27, 2.69)	1.99 (1.19, 3.34)	1.22 (0.92, 1.61)	1.45 (0.97,2.18)
Race/Ethnicity (Ref: White Race)
Non-Hispanic Black	3.45 (1.84, 6.48)	3.68 (1.58, 8.59)	1.84 (1.09, 3.08)	1.19 (0.60,2.37)
Hispanic	7.15 (3.99, 12.81)	3.95 (1.84, 8.46)	7.82 (5.00, 12.21)	3.26 (1.82,5.85)
Asian	0.68 (0.25, 1.88)	2.10 (0.61, 7.20)	1.65 (0.94, 2.90)	1.46 (0.73,2.93)
Education (Ref: High School or less)
Some College	0.54 (0.26, 1.12)	0.50 (0.20, 1.25)	0.74 (0.41, 1.35)	0.55 (0.27,1.11)
College Degree	3.68 (2.04, 6.63)	2.01 (0.95, 4.28)	3.64 (2.21, 6.02)	1.83 (0.98,3.40)
Graduate School	3.47 (1.65, 7.31)	1.90 (0.70, 5.14)	4.77 (2.65, 8.60)	2.55 (1.18,5.52)
Employment (Ref: Unemployed)
Part-Time Employment	2.45 (1.11, 5.42)	1.51 (0.50, 4.59)	3.61 (1.75, 7.48)	2.92 (1.25,6.81)
Full-Time Employment	3.65 (1.92, 6.93)	1.26 (0.53, 3.00)	6.35 (3.45, 11.66)	2.85 (1.42,5.71)
COVID-19 Related Questions
Some/a lot of COVID-19 worry (Ref: No worry)	2.12 (1.22, 3.68)	1.04 (0.49, 2.23)	7.19 (4.70, 11.01)	3.17 (1.89,5.32)
A great deal COVID-19 Knowledge (Ref: Some Knowledge)	0.37 (0.21, 0.65)	0.85 (0.40, 1.81)	0.14 (0.08, 0.24)	0.49 (0.12,0.43)
Contact with COVID-19 (Ref: No contact)	1.04 (0.72, 1.50)	0.98 (0.58, 1.66)	0.52 (0.37, 0.73)	0.48 (0.30,0.80)
Contact Chinese Individuals (Ref: No contact)	0.24 (0.14, 0.42)	0.56 (0.28, 1.15)	0.23 (0.16, 0.34)	0.36 (0.21,0.63)
Probable Depression (Ref: No depression)	5.97 (4.00, 8.92)	3.63 (2.12, 6.21)	6.35 (4.66, 8.65)	3.37 (2.25,5.05)
Positive Vaccine Intentions or Vaccinated (Ref: Negative Intentions)			3.11 (1.94, 5.00)	2.17 (1.18,3.99)
Having any chronic conditions			2.91 (2.17, 3.90)	1.35 (0.87,2.08)
COVID-19 Related News Sources
New York Times News Source (Ref: No)	1.08 (0.74, 1.57)	1.14 (0.67, 1.95)	1.17 (0.88, 1.55)	1.04 (0.69,1.57)
Fox News Source (Ref: No)	5.13 (3.25, 8.10)	4.82 (2.69, 8.63)	4.88 (3.57, 6.66)	3.56 (2.33,5.42)
Social Media (Ref: No)	4.24 (2.81, 6.41)	2.22 (1.29, 3.83)	4.40 (3.18, 6.09)	1.98 (1.29,3.02)
Public News (Ref: No)	0.19 (0.12, 0.28)	0.27 (0.15, 0.47)	0.31 (0.22, 0.45)	0.33 (0.20,0.55)
Commercial News (Ref: No)	0.83 (0.56, 1.22)	0.66 (0.36, 1.20)	1.07 (0.79, 1.44)	1.02 (0.67,1.55)

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As noted in the Introduction, COVID-19 vaccines had been available for several months in the U.S. prior to the May 2021 survey. Approximately half the U.S. adult population had received at least one inoculation by the time of the May 2021 data collection. We therefore used our “vaccination status/vaccination intentions” variable for further analyses of the May 2021 survey data. As shown in Table 5, pro-vaccine attitudes (vaccinated, definitely will get vaccinated and probably will get vaccinated) versus anti-vaccines (probably will not get vaccinated and definitely will not get vaccinate) were associated with endorsing stigmatization.

Table 6 presents the SABR items by the vaccination status/intentions variable. The SABR scale as a whole and all the individual SABR items showed significant differences across vaccination status/intentions. The direction of the differences was consistent in that being vaccinated and having positive intentions to be vaccinated were associated with a greater likelihood of endorsing an individual SABR item. The “definitely will not get vaccinated” group was distinctive in their low likelihood of endorsing any of the SABR items.

Table 6. SABRs by vaccine intentions for Wave 2, N = 812.

	Vaccinated		Definitely/Probably will vaccinate		Probably will not be vaccinated		Definitely will not be vaccinated		p-value
	N = 557		N = 152		N = 50		N = 53		p-value
	N	%	N	%	N	%	N	%
COVID Stigma (5-item composite)¹
Some stigma	277	49.7	75	49.3	15	30.0	10	18.9	<0.001
No stigma	280	50.3	77	50.7	35	70.0	43	81.1
Should people avoid areas in the United States heavily populated by Chinese?
Agree/Strongly agree	203	36.5	56	36.8	6	12.0	4	7.6	<0.001
Disagree/Strongly disagree	354	63.6	96	63.2	44	88.0	49	92.5
Should all Chinese by forcibly checked for COVID-19?
Agree/Strongly agree	190	34.1	44	29.0	6	12.0	2	3.8	<0.001
Disagree/Strongly disagree	367	65.9	108	71.1	44	88.0	51	96.2
Should Chinese not be allowed to enter the United States?
Agree/Strongly agree	192	34.5	49	32.2	7	14.0	5	9.4	<0.001
Disagree/Strongly disagree	365	65.5	103	67.8	43	86.0	48	90.6
Should Americans with COVID-19 be required to wear identification tags?
Agree/Strongly agree	221	39.7	55	36.2	9	18.0	3	5.7	<0.001
Disagree/Strongly disagree	336	60.3	97	63.8	41	82.0	50	94.3
Should people who knowingly spread COVID-19 be executed?
Agree/Strongly agree	205	36.8	48	31.6	6	12.0	3	5.7	<0.001
Disagree/Strongly disagree	352	63.2	104	68.4	44	88.0	50	94.3

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Table 7 presents the relationships of the vaccination status/intention variable with selected “COVID-19 experiences and vulnerabilities” items that were associated with endorsing/not endorsing the SABR scale. There were significant relationships between the vaccination status/intentions variable and COVID-19 worry, less knowledge, having underlying conditions, and contact with severe COVID-19 cases and probable depression.

Table 7. Selected COVID-19 experiences and vulnerabilities by vaccine intentions, Wave 2, N = 812.

	Vaccinated		Definitely/Probably will vaccinate		Probably will not be vaccinated		Definitely will not be vaccinated		p-value
	N = 557		N = 152		N = 50		N = 53		p-value
	N	%	N	%	N	%	N	%
COVID Knowledge
Some	79	14.2	20	13.2	5	10.0	3	5.7	0.31
A great deal	478	85.8	132	86.8	45	90.0	50	94.3
COVID Worry
Somewhat/very worried	449	80.6	125	82.2	30	60.0	16	30.2	<0.001
Not at all worried	108	19.4	27	17.8	20	40.0	37	69.8
Do you have any of the underlying conditions, such as diabetes, overweight, heart disease, lung/breathing diseases, that could make COVID-19 disease more severe?
Yes	253	45.4	37	24.3	12	24.0	7	13.2	<0.001
No	304	54.6	115	75.7	38	76.0	46	86.8
Contact with Severe COVID
Contact	275	49.4	53	34.9	15	30.0	9	17.0	<0.001
No contact	282	50.6	99	65.1	35	70.0	44	83.0
Depression
Probable depression	305	54.8	83	54.6	22	44.0	20	37.7	0.06
No probable depression	252	45.2	69	45.4	28	56.0	33	62.3

Open in a new tab

Discussion

As noted in the Introduction, the primary purposes for the comparison of the pre- versus post-vaccine development surveys were to assess 1) whether the frequency of endorsing COVID-19 related stigmatization changed, and 2) whether the factors associated with endorsing COVID-19 related stigmatization changed.

Reduction in stigmatization

There was a substantial decrease in stigmatization, both in the crude odds ratio and in the multivariable adjusted odds ratio. This can be seen as a cause for some optimism with respect to decreasing COVID-19 related stigmatization in the US.

Continuity in factors associated with endorsing stigmatizing attitudes

The second major finding from the comparison of the 2020 and 2021 surveys were the multiple factors associated with stigmatization in both surveys. These included full time employment, Black race, Hispanic ethnicity, worry about contracting COVID-19, probable depression, and Fox News and social media as preferred sources of information (all positively associated), and self-assessed knowledge about COVID-19, contact with Chinese individuals, and publicly funded news as preferred sources (all negatively associated).

The Health Belief Model and the SABR scale

The Health Belief Model (HBM) posits that greater perceived threat of a disease—specifically greater perceived severity and greater perceived susceptibility—will lead to greater motivation to actions that would reduce the threat of the disease [29]. Endorsing behavioral restrictions on persons with or associated with a threatening disease would thus be a straightforward prediction from the model.

A number of the factors associated with stigmatization in Table 4 are consistent with the HBM. For example, worry about contracting COVID-19 and having underlying conditions that would increase the likelihood of severe disease were positively associated with stigmatizing. Greater perceived knowledge (less uncertainty) about COVID-19 and more experience with COVID-19 were negatively associated with stigmatizing. The changes between the two surveys were also generally consistent with the HBM. For example, worry decreased between the surveys and stigmatization also decreased.

Vaccination behaviors and intentions

The biggest change across the two surveys was the emergence of vaccination behavior and new attitudes towards vaccination, At the time of the second survey, being vaccinated or intending to be vaccinated was positively associated with endorsing stigmatizing attitudes and behavioral restrictions. At first, this may appear counterintuitive. Public health officials might have hoped that being vaccinated would greatly allay worries about contracting COVID-19. There are, multiple possible reasons for the finding.

First, our data should not be interpreted as showing an effect that vaccination did not reduce stigmatization. We did not have data from the same individuals prior to and after vaccination so that we cannot infer causation at the individual level.

The prevalence of stigmatization among all respondents in the 2020 survey was 66.0%, and the prevalence of stigmatization among respondents in the 2021 survey was 46.4%. (See Table 3). Thus, there was a net reduction of approximately 20% in survey participants endorsing stigmatizing attitudes and behavioral restrictions between the 2020 and 2021 surveys. In the 2021 survey 557/812 (69%) of the participants were vaccinated. It is possible that the 20% reduction in the prevalence of stigmatizing all came from the 31% of 2021 participants who were not vaccinated, but it would seem more likely that there was also a net reduction in endorsing stigmatization among the 2021 participants who were vaccinated.

Second, there are several plausible reasons for why those had been vaccinated might still have been quite concerned about contracting COVID-19 at the time of the second survey. The vaccines were never presented as completely effective. At the time the second survey, the CDC was still recommending that vaccinated persons wear masks in many public settings [25]. Also, the vaccinated persons did have higher prevalence of underlying conditions, more personal experience with severe cases of COVID-19, and less self-perceived knowledge (greater uncertainty) about COVID-19, all of which could contribute to the threat value of COVID-19 and lead to endorsing stigma and behavioral restrictions even if one was vaccinated.

Third, as part of the increasing polarization over the vaccines, there were increasing news stories raising doubts about the effectiveness of the vaccines and concerns about the potential harmful side effects associated with being vaccinated, which could have increased the perceived threat of COVID-19 among those who had been vaccinated [40].

Each of these factors would be consistent with the basic premise of the Health Belief Model that greater perceived threat of COVID-19 would be likely to motivate endorsing stigmatizing attitudes and behavioral restrictions on persons who associated with COVID-19.

News sources

There has been varying coverage of COVID-19 among different news sources in the U.S., with some sources taking an approach based on science while others have taken a more xenophobic and anti-scientific approach. Specific news sources, particularly Fox News, significantly downplayed the COVID-19 pandemic, particularly in the early stages (late 2020-early 2021) and were skeptical of much of the scientific expertise surrounding the virus and transmission of COVID-19 [41, 42].

However, Fox News also spread many xenophobic messages about COVID-19. Fox News frequently referred to COVID-19 as the “Chinese Coronavirus” which acted to reinforce the negative stereotypes of Asian Americans. For examples, Fox News carried stories that the Chinese government “intentionally” released the COVID-19 virus [43–45]

These xenophobic stories likely contributed to some of the associations seen in the analysis related to Chinese individuals (questions 3–5 in the SABR scale items). While Fox News did downplay the importance of COVID-19 as a disease, which would be associated with lower stigmatization of persons associated with the disease, Fox News also emphasized the association of COVID-19 with China, which would have increased stigmatization of Chinese persons. In our sample, the xenophobic, anti-Chinese effect appears to have been much stronger that the downplay of COVID-19 effect.

Potential causal pathways

Many of the odds ratios in the univariable logistic regressions were attenuated in the multivariable regression models, suggesting complex associations, with many variables having both direct and indirect associations with endorsing stigmatizing attitudes and behavioral restrictions. Having longitudinal individual-level data would be useful in developing a full conceptual model of causal pathways (with specification of confounders, mediators, and moderators) for endorsing stigmatizing attitudes and behavioral restrictions. Ideally, individual-level data would be matched with significant developments in the pandemic: initial concern and lockdowns, development of vaccines, political polarization of vaccination and mask mandates, emergence of multiple variants, and emergence of “pandemic fatigue.”

The SABR scale

The SABR scale was originally developed for studying stigmatization of SARS-1 and AIDS. These were serious diseases; the case fatality rate for SARS-1 was about 14% [46] and until the development of the “cocktail” antiretroviral treatments for AIDS, its case fatality rate was over 90% [47].

HIV infection was (and still is) lifelong. At the time we first used the scale for COVID-19, August 2020, the case fatality rate was unknown, but the numbers of COVID-19 deaths in the US were quite high, approximately 450–500 per day [48].

We are currently updating the SABR scale to increase its applicability to less serious infectious diseases, such as COVID-19, which now has a very low case fatality rate.

The data in this report provide evidence for multiple aspects of construct validity for the scale. Higher worry about contracting COVID-19 was associated with greater likelihood of endorsing stigmatizing attitudes and behavioral restrictions on persons with or associated with COVID-19 which may be considered construct validity for attitudes. The scale also had construct validity for experiences, with previous exposure to severe cases of COVID-19 and having underlying conditions associated with greater endorsement of stigmatizing attitudes and behavioral restrictions. The scale also had construct validity for behavior—as deciding that one would definitely not get vaccinated can be considered behavior—and was associated with very low SABR scale scores.

The scale also showed construct validity with stigmatization theory [14] as greater contact with persons of Chinese descent as associated with less endorsement of stigmatization and behavioral restrictions of persons of Chinese descent.

This short scale cannot be considered as a comprehensive measure of the stigmatization of an infectious disease associated with a socially devalued group, but there is substantial evidence for its construct validity.

Future research

While many of the relationships in our data are generally consistent with the Health Belief Model, we would not propose that this model can generate a full understanding of the causal pathways leading to stigmatization of COVID-19. As noted in the introduction, COVID-19 stigmatization was added to existing anti-Asian/anti-Chinese stigmatization in the U.S. and was followed by a large increase in anti-Asian hate crimes [9]. We conceived of our scale as measuring the intersection of anti-Chinese stigmatization and anti-COVID-19 stigmatization and not to measure separate components. Future research should involve adapting the scale to changes in knowledge about COVID-19, for example it clearly has a much lower case-fatality rate than SARS-1 or AIDS, but there is also the potential for symptoms persisting over long periods of time (long COVID-19) [49].

The scale also needs to be complemented with measures of factual knowledge of COVID-19, the sources of accurate, mis- and disinformation and of group affiliations. And as noted above, individual level longitudinal data, tied to developments in the epidemiology, psychology, and politics of the pandemic, are needed.

Limitations

Several limitations of this study should be mentioned. First, we did not have a nationally representative sample in either survey. We did, however, control for demographic characteristics in our multivariable analyses. Second, we did not have the same respondents in both surveys, so we were unable to study changes in attitudes and stigmatization at the individual level. Third, we had only a single item measuring knowledge of COVID-19 and this was based on self-assessment. We were not able to assess the factual content of the respondents’ self-assessed knowledge. Having an accurate assessment of the respondents’ knowledge of COVID-19 and of the vaccines might be quite important in assessing relationships between news sources and stigmatizing.

These limitations are important, but we believe that our data do show an important reduction in endorsing stigmatizing attitudes and behavioral restrictions, the general applicability of the Health Belief Model, and the importance of different media as preferred news sources. The development and politicization of the vaccines has led to an additional layer of complexity in the stigmatization of persons who have COVID-19 and groups who are associated with COVID-19.

Conclusions

There was a very substantial reduction in the endorsement of stigmatizing attitudes and behavioral restrictions between the August 2020 and May 2021 surveys. Many of the factors associated with stigmatizing were significant in both surveys. The development and partial implementation of effective vaccines did not eliminate stigmatizing and added new complexity to the patterns of stigmatization.

Generating enough public concern about a new threat to health to lead people to take appropriate actions while minimizing stigmatization of persons having or associated with the disease is always a difficult public health communication task. Achieving this balance may be especially difficult in a context of widespread mis- and disinformation, a variety of competing news sources, political polarization, and the potential for hate crimes.

Supporting information

S1 Checklist. Clinical studies checklist.

(DOCX)

Click here for additional data file.^{(35.2KB, docx)}

S2 Checklist. Strobe checklist for cohort observational studies.

(DOCX)

Click here for additional data file.^{(32.5KB, docx)}

S1 File. IRB approval from New York University.

(PDF)

Click here for additional data file.^{(94KB, pdf)}

Acknowledgments

We would like to thank the participants who provided the survey information that was used in this report from MTURK workers.

Data Availability

There are important ethical and legal restrictions to publicly sharing the data from this manuscript, and we will note this in the updated data availability statement. Our survey contains Personal Health Information (PHI) which is protected under the Health Insurance Portability and Accountability Act (HIPPA), such as vaccination status and whether the individual suffers from any of the “underlying conditions” that would be likely to make a COVID infection more severe, as well as demographic characteristics. Providing public access to the data used in our analyses could threaten loss of the confidentiality of PHI, and was not to be permitted according to our proposal submitted to the IRB. Access to the data can be provided through an approved Data Use Agreement between our institution (New York University) and the institution with which the user is affiliated. Persons wanting to access the data should communicate with the NYU IRB (email contact: irbinfo@nyulangone.org) to initiate a Data Use Agreement.

Funding Statement

This work was supported by New York University and was funded through a research grant from New York University’s Anti-Racism Center (20-61518-G1336-MC1039).

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PLoS One. doi: 10.1371/journal.pone.0283467.r001

Decision Letter 0

Maria Elisabeth Johanna Zalm

15 Aug 2022

PONE-D-22-15278COVID-19 Stigmatization after the Development of Effective Vaccines: Vaccination Behavior, Attitudes, and News SourcesPLOS ONE

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Reviewer #1: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

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Reviewer #1: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Although they briefly reference the Health Beliefs model (p. 9), the current study is atheoretical and does not provide any explanation for mechanisms contributing to why and how stigma manifests and plays itself out. There are several excellent theoretical frameworks for stigma—by Rachel Smith and also by Rebecca Meisenbach, for example. This would add to the investigative strength of the current manuscript. The measurement is minimal but it is good that they compare data obtained during two point in time approximately 10 months apart.

Their participants are largely thirty something, employed, educated White males who likely read Fox News and were active on social media. Interesting commentary on Mturk, I guess. It is also interesting that they had some Asians in their samples.

Mturk is a good data source. It would have been good to obtain larger samples in both waves given the affordability of data collection on Mturk. Their comparative time frame is also appropriate. I also like that they included attention checks esp. with an Mturk master sample which does a lot of survey work.

SABR has some extreme items potentially traumatizing/harming participants arousing their bias

e.g. ‘wearing an identification tag’ (as in Nazi Germany)

execute people who knowingly spread COVID

These measures are extremes of stigma measurement.

It is alarming to me that in Wave 2, 39.7% of people who were vaccinated agreed that people with COVID should have to wear identification tags and 36.8% of vaccinated individuals believed people who knowingly spread COVID should be executed.

The opposite was true for people who refused to be vaccinated.

What did the researchers do at the end of this study to address the potential inflammation of prejudice elicited by these SABR items and the potential harm their study could have caused?

Many IRBs require that researchers when they ask questions capable of inflaming prejudice also do something to reduce it at the conclusion of the survey.

What suggestions do they have for minimizing stigmatization?

This is where a theory might have come into play.

The discussion of anti-Asian hate crimes at the end of this study is somewhat disjointed and comes out of nowhere. They ask a question did you ever experience prejudice/stigma?

They really do not develop this. Not really clear how this fits into their study. They need to make the connection more apparent.

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Reviewer #1: No

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PLoS One. 2023 Apr 27;18(4):e0283467. doi: 10.1371/journal.pone.0283467.r002

Author response to Decision Letter 0

7 Oct 2022

Review Response for PLOS One Paper

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Response: We would like to thank the editor and the reviewer for their thoughtful comments on the first submission We believe that we have appropriately addressed all of the comments and that the paper has been substantially improved as a result.

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Response: We have reviewed the formatting information for the manuscript above and have made changes as necessary

Author Response: We have updated the information to Methods section to note that the study was approved by the New York University IRB and that affirmative indication of informed consent was required before the survey could be started. The participant was not asked to provide their name in order to protect confidentiality. The study did not include minors.

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Response: We have clarified the role of the funders in the updated manuscript and have added the necessary information to the funding source information previously stated in the original submission. We have also added the necessary information on the funding source update in the updated cover letter submitted in the revised files.

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Response: There are important ethical and legal restrictions to publicly sharing the data from this manuscript, and we will note this in the updated data availability statement. Our survey contains Personal Health Information (PHI) which is protected under the Health Insurance Portability and Accountability Act (HIPPA), such as vaccination status and whether the individual suffers from any of the “underlying conditions” that would be likely to make a COVID infection more severe, as well as demographic characteristics. Providing public access to the data used in our analyses could threaten loss of the confidentiality of PHI, and was not to be permitted according to our proposal submitted to the IRB.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

3. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #1: Yes

4. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: Yes

5. Review Comments to the Author

Response: We thank the reviewer for those comments. Smith had been cited in the Introduction to the first submission. In the Discussion section of the revised manuscript we provide more detail on the work of Meisenbach and Smith. We did find their work to be very helpful and thank the reviewer for asking that this work be included in the revised manuscript.

Response: We thank the reviewer for the positive comments.

SABR has some extreme items potentially traumatizing/harming participants arousing their bias

e.g. ‘wearing an identification tag’ (as in Nazi Germany)

execute people who knowingly spread COVID

These measures are extremes of stigma measurement.

The opposite was true for people who refused to be vaccinated.

What did the researchers do at the end of this study to address the potential inflammation of prejudice elicited by these SABR items and the potential harm their study could have caused?

Many IRBs require that researchers when they ask questions capable of inflaming prejudice also do something to reduce it at the conclusion of the survey.

Response: First, we would like to thank the reviewer for these thoughtful comments.

The SABR scale has been reviewed by multiple times by multiple IRBs, including those of the Beth Israel Medical Center and of New York University, since it was first developed in 2003. All of the reviews concluded that the use of the scale was “minimal risk,” that the risk of harm was no greater than the risks in “everyday life.” (See NIH definition: "Minimal risk" means that the probability and magnitude of harm or discomfort anticipated in the research are not greater in and of themselves than those ordinarily encountered in daily life or during the performance of routine physical or psychological examinations or tests.)

The reviewer is quite correct that the SABR scale contains several extreme items. However, there has been considerable public discussion of these items. For example, during the AIDS epidemic, several state legislatures considered making deliberately infecting other persons with HIV a capital offense. There was also public discussion of requiring persons with AIDS to wear some form of badge indicating that they were infected with HIV, and of legislation that would require persons with HIV infection to inform their sexual partners that they had HIV. None of these restrictions were considered ethical or likely to be effective, so that they were not implemented, but they clearly could have been encountered by persons following the news.

More recently, there has been discussion of forcibly confining persons with COVID to their residences, which has occurred in some countries. Forcibly confining someone to their residence may be more draconian than making them wear a badge indicating that they have COVID

Finally, if one considers the internet and cable networks to be part of things “ordinarily encountered in daily life,” our dry questionnaire items are certainly much less inflammatory that the emotional rhetoric in these “aspects of daily life.”

We do recognize that several of the SABR items are extreme, but along with our IRB, do not believe that that are more inflammatory many items in the news or on the internet.

We are considering whether to remove the extreme items in the SABR scale or add additional material at the end of the survey to address possible adverse responses to the scale and other items in the questionnaire in our future research. However, we agree with our IRBs that the present research is “minimal risk” and that the informed consent is appropriate.

What suggestions do they have for minimizing stigmatization?

This is where a theory might have come into play.

Response: We would like to thank the reviewer for this suggestion. We have added new material, specifically linked to theories of stigmatization, the revised Discussion section, where we include theoretical concepts from Meisenbach and Smith.

The discussion of anti-Asian hate crimes at the end of this study is somewhat disjointed and comes out of nowhere. They ask a question did you ever experience prejudice/stigma?

They really do not develop this. Not really clear how this fits into their study. They need to make the connection more apparent.

Response: We agree that the mention of continuing anti-Asian hate crimes in the Discussion is “somewhat disjointed” and “appears to come “out of nowhere.” We agree that the comment on continuing anti-Asian hate crimes was “disjointed.” We asked a question about experiencing COVID-related stigmatization, but did not ask about experiencing hate crimes. We have omitted this reference to the continuation of anti-Asian hate crimes in the revision.

We would again like to thank the editor and the reviewers for their thoughtful and constructive comments on the first submission. We believe that we have appropriately addressed all of the comments and that the manuscript has been substantially strengthened as a result.

PLoS One. doi: 10.1371/journal.pone.0283467.r003

Decision Letter 1

Pieter-Paul Verhaeghe

22 Nov 2022

PONE-D-22-15278R1COVID-19 Stigmatization after the Development of Effective Vaccines: Vaccination Behavior, Attitudes, and News SourcesPLOS ONE

Dear Dr. Des Jarlais,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. I think the paper improved already a lot. However, one of the reviewers still has some major concerns, especially with respect to the current interpretation of the news sources. In addition, there are also quite a few minor comments that should be addressed. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Jan 06 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

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We look forward to receiving your revised manuscript.

Kind regards,

Pieter-Paul Verhaeghe

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #2: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #1: Yes

Reviewer #2: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: Yes

Reviewer #2: Yes

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6. Review Comments to the Author

Reviewer #1: (No Response)

Reviewer #2: I like the idea and implementation of the paper, but I have a number of points that should be addressed by the authors in a revision.

In general, the paper requires a bit of a language revision. By example in the last paragraph of the intro they talk about three primary questions but only two are raised and there are some typos in the paper such as on page 22 or in the headline ‘Casual Pathways’, which I suppose should be causal.

I see that they have revised the point of anti-Asian hate crime, but by mentioning it in the abstract they create the impression that they did their own analysis on it.

Overall, I like the introduction, but I wonder if the authors can broaden the context to see if the findings would apply to other countries than the US; e.g., was anti-Asian sentiment present in other countries as well.

I also think that the authors have to be more convincing when they argue for the applicability of the SABR scale. I do think that there are major differences between characteristics of the HIV and Covid-19 disease. This applies to the subsection ‘Primary outcome’ where it is stated that there were ‘strong similarities in the patterns of stigmatization’, but what does this even mean? I also agree with the other referees that the question on executing people is phrased much too strong for the context of Covid-19 and that in general these questions could have been closer to realistic restrictions, though I concur that this is based on an ex-post view from today.

A better connection between anti-Chinese sentiments in the introduction and how this leads to their inclusion in the SABR scale would be appreciated.

In the list of variables in Table 1, the rows on ‘experience of discrimination’ are not explained in the text. The authors also seem to explain the relevance of some variables by referring to results in the analyses of the survey (such as on page 9 on the knowledge on the disease); please limit this to the results section and focus on theoretical explanations why these variables should be included. And for consistency in the introduction of the categories of variables, all should state the expectation how they affect stigmatization, for some such as the vaccination behavior this is missing.

With regard to the comparison of the sample characteristics in Table 2, I don’t understand why only for some the p-value is provided; also mention in the text that you rely on p-values.

I don’t think that the answer to the main research question (1) is well presented in Table 3. The change in the SABR scale appears in the middle of the long table and I suggest to present it separately. I also suggest to look at heterogeneities in the change to make it more informative; this could also inform the subsequent analysis on the determinants. What groups within the sample does one expect to change their sentiment the most?

On page 13 the authors talk about variables ‘most strongly and consistently associated with stigmatization’, what is the objective criteria for this statement?

The authors rightfully put the health belief model into the focus. It would be great if they could link vaccination earlier to the theory; indeed, following their reasoning I was surprised about the effect of vaccination on stigmatization.

On page 19 they talk about ‘parallel changes’ in variables, what does that mean?

I’m not convinced by the section on ‘News sources’. First, they should explain the tv stations to readers who are not familiar with the US television market. Then, their reference to papers that talk about the association of Fox news and Covid-19 is not correct; as far as I see it, none of the referenced papers address Fox news (page 20). Indeed, there is a good literature on Fox news and Covid-19, but it finds exactly opposite results to the present paper. Fox news downplayed the risks of Covid-19 (Gollwitzer et al. 2020, Ash et al. 2020 and others), which according to the health belief model of the authors should lead to less stigmatization of Covid-19 cases and not more.

And lastly, I wonder how in the contribution section the participation in another paper should matter for the contribution in the current one.

Ash, E., Galletta, S., Hangartner, D., Margalit, Y. and Pinna, M. The Effect of Fox News on Health Behavior During COVID-19 (June 27, 2020). Available at SSRN: http://dx.doi.org/10.2139/ssrn.3636762

Gollwitzer, A., Martel, C., Brady, W.J. et al. Partisan differences in physical distancing are linked to health outcomes during the COVID-19 pandemic. Nat Hum Behav 4, 1186–1197 (2020). https://doi.org/10.1038/s41562-020-00977-7

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

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PLoS One. 2023 Apr 27;18(4):e0283467. doi: 10.1371/journal.pone.0283467.r004

Author response to Decision Letter 1

19 Dec 2022

First we would like to thank the reviewers for their thorough review and comments on the draft. We have made several changes and the updated draft has been improved. Below please find specific responses to comments left by the reviewers.

Author Response: We have gone through the paper in the revision and have corrected the language. We thank the reviewer for these comments.

I see that they have revised the point of anti-Asian hate crime, but by mentioning it in the abstract they create the impression that they did their own analysis on it.

Author response: We have removed the reference to anti-Asian hate crimes from the abstract in order to avoid the impression that we conducted analyses of anti-Asian hate crimes.

Author response: We appreciate the positive comments about the Introduction. There has been Anti-Asian sentiment in other locations outside of the US, although the US has been one of the main locations where this has been documented. In response to the reviewer comment, we have added references and note several countries that have reported these sentiments, including locations in Australia, Europe, and East Asia (i.e., South Korea).

Author response: We agree that HIV/AIDS and COVID-19 are very different diseases.

The SABR scale was originally developed to assess potential similarities in the stigmatization of HIV/AIDS and SARS-1, which are also very different diseases (in terms of routes of transmission, total number of cases, geographic areas of concentration, social groups with which the disease has been associated, case fatality rate, etc.). Despite these differences, there were strong similarities in the patterns of patterns of stigmatization for SARs-1 and HIV/AIDS. All of the individual SABR items were significantly correlated for these two diseases, and many of the same factors were associated with stigmatizing both SARS-1 and HIV/AIDS. These associated factors included education, income, race/ethnicity, worry about contracting the disease, knowledge of the disease, and mental health problems. (Des Jarlais et al, 2003)

This information on similar patterns of stigmatization show by the SABR scale across the very different diseases of SARS-1 and HIV/AIDS has now been included in the Methods section. As noted in the Methods section, we believe that the scale measures the intersection between stigmatization of a serious infectious disease and stigmatization of an associated social group that is devalued in the larger society.

I also agree with the other referees that the question on executing people is phrased much too strong for the context of Covid-19 and that in general these questions could have been closer to realistic restrictions, though I concur that this is based on an ex-post view from today.

Author response: The question of executing persons who intentionally spread the disease came from public calls in the 1980s and 1990s in the US for executing persons who intentionally transmitted AIDS. The question was included in our 2020 survey because we wanted to use exactly the same SABR scale used in the 2003 paper comparing SARS-1 and HIV/AIDS. We repeated the same SABR scale in the 2021 survey because we wanted to assess possible change in stigmatization after the development of the effective vaccines and changing the scale would have interfered with the comparison.

We agree with the reviewers that this question of executing people intentionally transmitting COVID-19 is probably too harsh, and have removed it from the scale in our continuing research. However, consider a case in which person A, who is infectious with COVID-19, intentionally transmits COVID-19 to person B, who is elderly and has multiple underlying conditions. We suspect many people in the US would consider this to be a case of attempted homicide.

A better connection between anti-Chinese sentiments in the introduction and how this leads to their inclusion in the SABR scale would be appreciated.

Author response: The anti-Chinese items in the SABR scale were in the original use of the scale for assessing stigmatization of SARS-1, which was highly concentrated in China and associated with Chinese persons. The same holds for the origin of COVID-19 (SARS-CoV-2).

In the list of variables in Table 1, the rows on ‘experience of discrimination’ are not explained in the text.

Author response: With respect to this comment, we have removed the data on the two items on experiencing discrimination related to race/ethnicity and to COVID-19 from the current report. These items were not in the 2020 survey, and thus not relevant to the comparison of the 2020 survey to the 2021 survey, nor are they closely linked to the Health Belief Model, which is the primary theoretical focus for the present paper. They were included as exploratory items in the 2021 survey to explore possible similarities in racial/ethnic discrimination and COVID-19 discrimination. Our preliminary analyses have led us to believe that we need more data on the specifics of COVID-19 discrimination (was it in response to severe COVID-19 disease or non-serious disease, or even in the absence of actual disease), and larger numbers of Black and Asian subjects (only 6% of subjects were Black and 6% were Asian) for meaningful analyses. Additionally, we need to consider the possibility that some respondents may have perceived discrimination because of their reluctance to be vaccinated. The imposition of vaccine mandates, which were publicly discussed at the time of the survey, could have created such a perception of discrimination.

The authors also seem to explain the relevance of some variables by referring to results in the analyses of the survey (such as on page 9 on the knowledge on the disease); please limit this to the results section and focus on theoretical explanations why these variables should be included. And for consistency in the introduction of the categories of variables, all should state the expectation how they affect stigmatization, for some such as the vaccination behavior this is missing.

Author response: Almost all of the variables in Table 2 were taken from the 2003 SARS-1 HIV/AIDS study, and then repeated in the August 2020 survey. This is now clarified in the Methods section.

With respect to the present report, our primary research questions were 1) Did the prevalence of stigmatization change after the introduction of effective vaccines? and 2) Did the correlates of stigmatization change after the introduction of the vaccines? We must emphasize that we did not have theory-based “expectations” for the answers to these two questions. Expectations would necessarily have been derived from a theoretical analysis of the effects of the vaccines, of the effects of the increasing political polarization that accompanied the introduction of the vaccines, of the continuing controversies over the origins of the virus, of the continuing increases in the deaths from the disease, and of the effects of the increase in mis- and dis-information about the vaccines. We would not have much confidence in developing “expectations” from this complex situation.

We have now clarified in the Methods section (see page 10) that we did not have expectations or hypotheses as to whether the introduction of the vaccines might lead to 1) a change in the prevalence of stigmatization or 2) changes in the correlates of stigmatization after the introduction of the vaccines.

With regard to the comparison of the sample characteristics in Table 2, I don’t understand why only for some the p-value is provided; also mention in the text that you rely on p-values.

Author response: In Table 2, there are p-values provided for each of the variables included in the responses. For some variables, such as education, there were multiple response categories but only an overall single statistical test was used to test for a difference between the 2020 and the 2021 surveys. We have updated the manuscript to mention p-values were used to detect statistical significance in the comparisons made.

Author Response: We have reworked this section of the results and have split Table 3 into Table 3A and 3B. This allows us to separately present the data on reduction of stigmatization in Table 3A and the changes in the Health Belief Model related factors associated with stigmatization in Table 3B. We would like to thank the reviewer for calling attention to the need to present these results with greater clarity.

We are not sure what the reviewer means by “groups within the sample does one expect to change the most?” This question is worded in terms of future change, and we do not have expectations about changes in the future. If the reviewer is asking about past change (from the 2020 survey to the 2021 survey), we would first have to mention that we do not have data on the same individuals in the two surveys, so that we cannot identify individuals who did and did not change. To us, the biggest group-level change was the emergence of the vaccination/vaccination intentions groups, with 69% of the 2021 survey respondents reporting that they had received at least one immunization by May 2021. We would assume that many of those who did get vaccinated were those who in August 2020 were worried about contracting COVID-19. And we suspect that many who did get vaccinated did reduce their worry (see page 20 of the Discussion), however, getting vaccinated clearly did not eliminate being worried about contracting COVID-19 (see Table 5A)

On page 13 the authors talk about variables ‘most strongly and consistently associated with stigmatization’, what is the objective criteria for this statement?

Author Response: This wording was based on our assessment of the size of the ORs and whether a variable was associated with stigmatization in both surveys. We have changed the wording to simply note: “The variables significantly associated with stigmatization in both surveys were: full time employment, Black race, Hispanic ethnicity, worry about contracting COVID-19, probable depression, self-assessed knowledge about COVID-19, contact with Chinese individuals, and Fox News, social media and publicly-funded news as sources of information,” in Results, p.14.

Author Response: We now mention the Health Belief Model in the introduction as an explanatory framework for the results.

However, as emphasized in the Discussion, page 21 paragraph 3, we cannot assess the “effect” of vaccination at the individual level because we do not have pre-vaccination data on the prevalence of stigmatization among the individuals who did get vaccinated.

We suspect that vaccination was probably associated with a reduction in the prevalence of stigmatization among those who were vaccinated. As noted in Discussion, p. 21, there was a large reduction in the prevalence of stigmatization between the two surveys, from 66% endorsing at least one SABR item in 2020 to 46% endorsing at least one SABR item in 2021.

Approximately 69% of the respondents in the 2021 survey reported being vaccinated for COVID-19; assuming that prior to the vaccine rollout, those that went on to be vaccinated had similar rates of stigmatizing as those who did not receive the vaccine in 2020, the large reduction in overall stigmatizing in the 2021 survey likely included reduced stigmatizing not only among the unvaccinated, but among those who did receive the COVID-19 vaccine as well.

On page 19 they talk about ‘parallel changes’ in variables, what does that mean?

Author response: We have updated the language in this section to specifically discuss the changes among the variables and have removed the term “parallel changes.” We now note the changes in HBM related variables occurred consistent with the model. For example, on p. 19, we note that “The changes between the two surveys were also generally consistent with the HBM. For example, worry decreased between the surveys and stigmatization also decreased.

I’m not convinced by the section on ‘News sources’. First, they should explain the tv stations to readers who are not familiar with the US television market.

Author response: We have added more information in Table 1 to denote the revenue models for the different types of TV stations. We further described how some of these news sources are perceived in the U.S. context, specifically during the COVID-19 pandemic. We provided examples of how some of these news sources played a role in spreading information during the COVID-19 pandemic.

Then, their reference to papers that talk about the association of Fox news and Covid-19 is not correct; as far as I see it, none of the referenced papers address Fox news (page 20). Indeed, there is a good literature on Fox news and Covid-19, but it finds exactly opposite results to the present paper. Fox news downplayed the risks of Covid-19 (Gollwitzer et al. 2020, Ash et al. 2020 and others), which according to the health belief model of the authors should lead to less stigmatization of Covid-19 cases and not more.

Author Response: While we agree with the reviewer that Fox News downplayed the virus and the COVID-19 epidemic as a whole and blamed much of the worrying on “unwarranted hysteria.” We would also note that Fox News continually engaged in xenophobic language during their newscasts.

Fox News frequently referred to COVID-19 as the “Chinese Coronavirus” that acted to reinforce the negative stereotypes of Asian Americans. For example, Fox News carried stories that the Chinese government “intentionally” released the COVID-19 virus, and/or intentionally leaked the virus from the Wuhan lab: 1) Dorman S. Chinese virologist: China's government 'intentionally' released COVID-19. Fox News. 2020., 2) Connelly Eileen AJ. Explosive study claims to prove Chinese scientists created COVID New York Post. 2021, and 3) Blanton D. Fox News Poll: Majority believes COVID-19 leaked from lab in China. Fox News. 2020.

These xenophobic stories likely contributed to some of the associations seen in the analysis related to Chinese individuals (questions 3-5 in the SABR scale items). While Fox News did downplay the importance of COVID-19 as a disease, which would be associated with lower stigmatization of persons associated with the disease, Fox News also emphasized the association of COVID-19 with China, which would have increased stigmatization of Chinese persons as measured by the SABR scale. In our sample, the xenophobic, anti-Chinese effect appears to have been much stronger that the downplaying of COVID-19 effect.

And lastly, I wonder how in the contribution section the participation in another paper should matter for the contribution in the current one.

Author Response: We have reworded this section so that only co-authors of the present paper are noted in the Contribution section. The present paper contains data from two surveys, so that we wanted to acknowledge the efforts of the researchers who contributed to the initial publication of the first survey results.

Again, we would like to thank reviewer for the careful reading and constructive comments that have substantially improved the manuscript.

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PLoS One. doi: 10.1371/journal.pone.0283467.r005

Decision Letter 2

Ismail Ayoade Odetokun

1 Feb 2023

PONE-D-22-15278R2COVID-19 Stigmatization after the Development of Effective Vaccines: Vaccination Behavior, Attitudes, and News SourcesPLOS ONE

Dear Dr. Des Jarlais,

Please submit your revised manuscript by Mar 18 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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Ismail Ayoade Odetokun, DVM, Ph.D.

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PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Reviewer #1: (No Response)

Reviewer #2: The paper has improved a lot and the authors address the suggestions well. I have only a few minor points

The section on the Methods – description of Table 1 is still a little confusing. The authors start talking about the different variables in table 1, but then shift to the ‘lack of hypotheses’ before returning to variables on ‘preferred news sources’. Please follow the order of the table, and afterwards address the other issues such as hypotheses and the statistical analysis. And if I’m not mistaken, all variable categories in Table 1 are addressed, but the ‘Experience of Discrimination related to Covid-19’ is not.

Please briefly explain the ‘Health Belief Model’ when it is mentioned for the first time in the main text (under the heading ‘Other Covid-19 related questions’). The authors do this later in the discussion section, but it helps the unfamiliar reader to know about it beforehand

The authors added a good discussion on ‘Vaccination behavior and intentions’. I wonder though if the costs of vaccination to the individual (the potential side effects of vaccines on health that were reported on in the media) could be an explaining factor for the stigmatization if one assumes that infected persons are less likely to be vaccinated.

On language and formatting: please don’t underline words or sentences, and please refrain from using terms such as ‘extreme’ in ‘extremely useful’

Once the authors have addressed the above points, I’m happy to see the paper as fit for publication.

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PLoS One. 2023 Apr 27;18(4):e0283467. doi: 10.1371/journal.pone.0283467.r006

Author response to Decision Letter 2

8 Feb 2023

February 6, 2023

Re: Revision Assignment for PONE-D-22-15278R2, EMID:29430ed9bc6288a5

We would like to thank the reviewer for reviewing the most recent draft and the comments below. We have addressed these points in the updated draft and believe that the paper has been strengthened as a result. Following are responses to each of the individual comments from the review. Thank you.

Author Response: We have modified the updated draft to move the hypothesis section lower in the paper after the description of Table 1 and before the Statistical Analysis section to allow for continuity with respect to the description of the elements of Table 1. We have added a sentence describing the “Experience of Discrimination related to COVID-19 to the Methods section where the variables are described.

Author response: The first mention of the Health Belief Model is actually at the end of the Introduction, prior to the Methods. We have added a brief description of the model to the Introduction. We now have brief descriptions of the model in the Introduction, the Methods and the Discussion, and believe that readers who are not familiar with the Health Belief Model will understand the basic premise that greater threat of the disease will lead to greater motivation towards stigmatizing and imposing behavioral restrictions on persons associated with the disease. We have added the rationale for the questions on perceived stigmatization related to COVID-19 and to race/ethnicity to the Methods section. We would note here that we did not observe any relationships between the perceived stigmatization questions and stigmatizing of persons associated with COVID-19.

Author Response: This is an interesting hypothesis, and we have now included wording on experiencing vaccination side effects as another possible source for stigmatizing in the Discussion. We would note a variation of this hypothesis in which persons who suffered side effects from vaccination might be resentful of public health authorities who convinced them to get vaccinated and quite willing to stigmatize the Chinese for allowing the virus to spread throughout the world. Unfortunately, our survey did not obtain sufficient data on vaccination side effects to test such hypotheses.

On language and formatting: please don’t underline words or sentences, and please refrain from using terms such as ‘extreme’ in ‘extremely useful’

Author response: We have removed underlined phrasing in the updated draft and have modified language to remove extreme statements in the updated draft.

Again, we would like to thank the reviewer for their careful reading of the revision and believe that the manuscript has been improved as a result of these comments.

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PLoS One. doi: 10.1371/journal.pone.0283467.r007

Decision Letter 3

Ismail Ayoade Odetokun

9 Mar 2023

COVID-19 Stigmatization after the Development of Effective Vaccines: Vaccination Behavior, Attitudes, and News Sources

PONE-D-22-15278R3

Dear Dr. Des Jarlais,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Ismail Ayoade Odetokun, DVM, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #1: Yes

Reviewer #2: No

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Reviewer #1: Revisions are spot on. I still don't like the stigma item saying people who spread COVID should be executed.

Reviewer #2: (No Response)

**********

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PLoS One. doi: 10.1371/journal.pone.0283467.r008

Acceptance letter

Ismail Ayoade Odetokun

19 Apr 2023

PONE-D-22-15278R3

COVID-19 Stigmatization after the Development of Effective Vaccines: Vaccination Behavior, Attitudes, and News Sources

Dear Dr. Des Jarlais:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

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Thank you for submitting your work to PLOS ONE and supporting open access.

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on behalf of

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Associated Data

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Supplementary Materials

S1 Checklist. Clinical studies checklist.

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S2 Checklist. Strobe checklist for cohort observational studies.

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Data Availability Statement

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PERMALINK

COVID-19 stigmatization after the development of effective vaccines: Vaccination behavior, attitudes, and news sources

Don C Des Jarlais

Sarah Lieff

Margaux Grivel

Gabriella Meltzer

Jasmin Choi

Chenziheng Allen Weng

Jonathan P Feelemyer

Virginia W Chang

Lawrence Yang

Roles

Abstract

Objective

Methods

Results

Conclusions

Introduction

Methods

Data collection

Study variables

Table 1. List of different COVID-19 related questions and variables and recoding schemes for analysis.

Primary outcome

Contact with persons with or associated with COVID-19 and with Chinese persons

Experiences of discrimination related to COVID-19 and race/ethnicity

Other COVID-19 related questions

Preferred news source

Lack of hypotheses

Statistical analysis

Results

Table 2. Sample characteristics for Waves 1 (N = 517) and 2 (N = 812).

Table 3. Endorsements of the five SABR items for Waves 1 (N = 517) and 2 (N = 812).

Table 4. COVID-19 related experiences and vulnerabilities for Waves 1 (N = 517) and 2 (N = 812).

Factors associated with endorsing SABRs in August 2020 and May 2021 surveys

Table 5. Logistic regression results for associations with COVID-19 stigma for Waves 1 (N = 517) and 2 (N = 812).

Table 6. SABRs by vaccine intentions for Wave 2, N = 812.

Table 7. Selected COVID-19 experiences and vulnerabilities by vaccine intentions, Wave 2, N = 812.

Discussion

Reduction in stigmatization

Continuity in factors associated with endorsing stigmatizing attitudes

The Health Belief Model and the SABR scale

Vaccination behaviors and intentions

News sources

Potential causal pathways

The SABR scale

Future research

Limitations

Conclusions

Supporting information

Acknowledgments

Data Availability

Funding Statement

References

Decision Letter 0

Maria Elisabeth Johanna Zalm

Roles

Author response to Decision Letter 0

Decision Letter 1

Pieter-Paul Verhaeghe

Roles

Author response to Decision Letter 1

Decision Letter 2

Ismail Ayoade Odetokun

Roles

Author response to Decision Letter 2

Decision Letter 3

Ismail Ayoade Odetokun

Roles

Acceptance letter

Ismail Ayoade Odetokun

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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