COVID‐19‐related stigma and its association with mental health of health‐care workers after quarantine in Vietnam

The coronavirus disease 2019 (COVID‐19) global pandemic is affecting 210 countries and territories around the world. By the end of March 2020, the total number of infected cases had exceeded 3 000 000 with more than 200 000 deaths. ¹ Vietnam is a low‐resource country that has had a good response to the outbreak with only 260 cases and no deaths thanks to the highly restricted infection‐prevention and control policy. ² On 28 March 2020, the government of Hanoi locked down one of largest medical centers in the country, Bach Mai Hospital (BMH), after a large outbreak was detected in staff and linked patients. ³ At the Center for Tropical Diseases where the first two cases were identified, all health‐care workers (HCW) were quarantined for more than 3 weeks. ⁴ The psychological distress of quarantine has been well documented and includes stress, anxiety, confusion, fear, insomnia, and post‐quarantine‐related stigmatization. This distress might impact HCW more severely than the general population. ⁵ We aimed to measure the stigma experienced and its association with mental health problems among HCW after 23 days of quarantine at BMH.

We collected data from HCW between 26 and 29 April 2020. We developed a self‐reported instrument that measures COVID‐19‐related stigma among participants. The questionnaires consisted of 12 questions with response options on a 4‐point Likert scale. Responses were summed to calculate a total score; higher scores indicated a higher level of stigma (Table 1). We referred to Berger's HIV Stigma Scale for the wording of terms and phrasing of measurement items. ⁶ Details of the methods are reported in Appendix S1. The validity assessment followed the COSMIN Risk of Bias Checklist (Appendix S2). ⁷ The study was approved by the Director Board of BMH and all participants provided informed consent.

Table 1.

Factor analysis results of Stigma Scale and the correlation with DAS‐21 Scale scores

Items	Agreed responses (%)†	Domain factors ‡
		Negative Self‐image	Disclosure Concerns and Personalized Stigma	Concerns About Public Attitudes
1. Feel unsafe to be a health worker	18.03	0.86	—	—
2. Feel guilty because of being isolated	34.43	0.80	—	—
3. Feel blamed by relatives or friends	9.84	—	0.67	—
4. Feel ashamed of being isolated	3.28	—	0.81	—
5. Try to hide being quarantined	6.56	—	0.68	—
6. Try to avoid going out	65.57	—	—	0.64
7. Not disclosing to anyone about the feeling	14.75	—	0.76	—
8. Try to avoid work related to COVID‐19	1.64	—	0.85	—
9. People talk behind back	39.34	—	—	0.77
10. People avoid touching and direct contact	34.43	—	—	0.88
11. People feel uncomfortable when around	31.15	—	—	0.84
12. Experienced discrimination actions	6.56	—	—	0.62
Domain scores, median (interquartile range)	—	1 (0.5 to 1.5)	0.6 (0 to 1)	1.2 (0.6 to 1.6)
Floor/ceiling effect (%)	—	1.64/13.11	1.64/19.67	1.64/37.7
Cronbach's alpha score	—	0.75	0.86	0.86
Correlation with DAS‐21 Scale score §
DAS‐21 Scale Depression subscale	—	0.35 (0.10 to 0.55)	0.32 (0.08 to 0.53)	0.33 (0.09 to 0.54)
DAS‐21 Scale Anxiety subscale	—	0.45 (0.23 to 0.63)	0.36 (0.12 to 0.56)	0.39 (0.15 to 0.58)
DAS‐21 Scale Stress subscale	—	0.32 (0.07 to 9.53)	0.16 (−0.1 to 0.40)	0.24 (−0.01 to 0.46)

^† Percent of participants agreeing or strongly agreeing.

^‡ Factor loadings > 0.6.

^§ Spearman's correlation, r‐value (95% confidence interval).

DAS‐21 Scale, 21‐item Depression, Anxiety, and Stress Scale.

A total of 61 participants enrolled in the study; 82.0% were female and the median age was 32 years (interquartile range = 29–36 years). Most of the participants were nurses (73.8%; Table S1). The prevalence rates of depression, anxiety, and stress were 13.11%, 14.75%, and 4.92%, respectively (Fig. S1).

The median of Stigma Scale total score was 11 (interquartile range = 6–15; min.–max. = 0–24). Three dimensions were reconstructed from factor analysis: (i) Negative Self‐image, (ii) Disclosure Concerns and Personalized Stigma, and (iii) Concerns About Public Attitudes. Each domain score was calculated by dividing the total score by the number of items (possible range of 0–3). Cronbach's alpha scores were good to great in all domain factors, ranging from 0.75 to 0.86. Stigma Scale domains showed a moderate correlation with the 21‐item Depression, Anxiety, and Stress Scale subscale scores. ⁸

The success of outbreak containment in Vietnam has been due to the government's early and constantly aggressive approach (including zoning, isolating, and quarantining all infected people and their close contacts ² ) as well as its traditional and modern mass media campaign to improve the awareness of all citizens. ⁹ This may have inadvertently increased the likelihood of stigmatization of people after quarantine regardless of their infection status. In frontline HCW, the negative impacts could be more serious as they are receiving greater attention in the press and mass media.

In our results, higher‐level stigma was found in the domains of Negative Self‐image and Concerns About Public Attitudes, with many participants feeling guilty towards family members and friends, and avoiding contact with neighbors and the community. This finding needs to be further studied as the social‐distancing policy is still in effect and the results only show short‐term effects. Other limitations include: (i) the small sample size; (ii) using an instrument that has not been extensively validated to measure stigma; and (iii) insufficient baseline data. In addition, the sample from BMH did not represent all HCW in Vietnam and the cross‐sectional design might not have been able to establish causal inference.

To our knowledge, this the first study to report COVID‐19‐related stigma among HCW who have experienced a long duration of quarantine. Vietnam has succeeded in preventing widespread outbreaks during the first two phases of the pandemic, with the epicenters in China and the European Union. The third phase will start soon after the initiation of the government's plan to receive thousands of citizens returning from abroad. ¹⁰ As the primary workforce, HCW should receive priority support that minimizes the pressure and burden from non‐work sources; formal psychological support should also be provided, if necessary. In addition, further studies investigating the societal impact of COVID‐19 and related policies should be conducted soon to prepare for the next stage of the outbreak.

Disclosure statement

The authors declare no conflicts of interest.

Supporting information

Appendix S1. Details of Methods.

Appendix S2. COSMIN Risk of Bias checklist.

Figure S1. Classification of 21‐item Depression, Anxiety, and Stress Scale subscales.

Table S1. Demographic characteristics of participants.