Reducing Stigma and Discrimination Associated with COVID-19: Early Stage Pandemic Rapid Review and Practical Recommendations

"Mitigating the impact of stigma is critical in reducing distress and negative experiences, and strengthening communities' resolve to work together during exceptional circumstances. Ultimately, reducing stigma helps addressing structural inequalities that drive marginalisation and exacerbate both health risks and the impact of stigma."

Health-related stigma can be defined as a personal experience or social process characterised by exclusion, rejection, blame, and devaluation, as a result of anticipating or experiencing negative social judgements due to a person or group being associated with a given health condition. The COVID-19 pandemic has provoked stigmatisation and discriminatory behaviours against people who have, or might have, COVID-19. Stigma is important as it can drive people to deny or hide the illness to avoid discrimination, it can prevent or delay timely healthcare seeking, and it can discourage people from adopting healthy behaviours. Given these negative impacts of stigma, organisations such as the World Health Organization (WHO) have called for interdisciplinary efforts to understand and counter COVID-19 stigmatisation. Thus, the aim of this rapid evidence review was to offer recommendations for strategies and interventions to reduce stigma and discrimination related to COVID-19.

Drawing on the WHO's methodology for developing interim guidelines during health emergencies, the researchers searched PubMed/MEDLINE, PsycINFO, Cochrane Central, and Campbell Collaboration up to mid-April 2020. Searches were supplemented by reference-searching and expert recommendations. The searches identified 4,150 potentially relevant records, from which 12 systematic reviews and 29 additional articles were included. The characteristics of the systematic reviews providing evidence for this review are presented in Table 1 of the paper, with added details in online supplementary materials.

Recommendations on strategies for COVID-19 stigma-reduction were developed using the WHO "Evidence to Decision" framework approach. In brief, they include:

1. Language and words
   • Do not use language and words reflecting stigmatising attitudes when talking about COVID-19 - e.g., do not attach locations or ethnicity to the disease, do not refer to people with COVID-19 as "cases", "victims", or "suspects", and do not use exaggerated language or metaphors (e.g., "plague").
   • Avoid over-emphasising attribution of disease burden, severity, and death to ethnicity, pre-illness behaviour/travel history, age, gender, or underlying medical conditions.
2. Media and journalists
   • Understand language used in the media both as a delivery platform for anti-stigma strategies and as a target for anti-stigma efforts, as media reporting can shape popular perceptions, discourse, communication, and behaviour.
   • Employ mass media to share balanced and accurate information, focused on avoiding COVID-19 stigma, and avoid sensationalist headlines/stories.
   • Provide communication training for those in government and in health/care services, including those providing public briefings.
   • Involve people affected by COVID-19 in shaping media language.
3. Public health interventions
   • Build COVID-19 stigma-reduction initiatives for the general public on knowledge-shaping and attitude-changing strategies.
   • Reduce stigma among the general public by providing treatment programmes for stigmatised conditions within general healthcare settings, particularly in light of the possibility of long-term complications following COVID-19.
   • Craft mass-media-based interventions for the general public to reduce prejudice in the immediate, short, and medium term.
   • Ensure anti-stigma campaigns challenge and correct myths, rumours, stereotypes, and bias, going beyond factual knowledge to strategically address specific public misconceptions, which may vary among different populations and cultural/religious groups.
   • Use artists and art to showcase stories, conditions, and experiences of people who have suffered discrimination in order to cultivate engagement, empathy, acceptance, and social change.
   • Ensure messaging emphasises the joint social responsibility to support efforts to reduce impacts of COVID-19 by focusing on a sense of community and jointly achieved positive outcomes, including public support for frontline workers, rather than fear or shaming.
   • Improve solidarity by framing strategies to reduce and/or slow down transmission as "physical distancing" rather than "social distancing" or "social isolation".
   • Focus on universal public health strategies (e.g., testing; policies like physical distancing, travel bans, and quarantine) vs. targeted strategies that can imply blame on particular individuals/groups.
   • Refrain from excessive policing or criminalising the breaching of COVID-19-related health policies, which risks not only stigma but loss of trust, which may in turn reduce compliance with such measures or lead to protests.
   • Implement public health strategies in the immediate term (e.g., addressing misinformation) complemented by efforts to tackle societal-level issues of social and economic inequalities that facilitate stigma in the long term (e.g., racism, xenophobia, structural-level policies, and laws).
4. Targeted public health interventions for key groups
   • People directly affected by COVID-19: Reduce stigma (anticipated, enacted, internalised) through group-based interventions, psycho-educational interventions, social empowerment strategies, community-based strategies, and self-help interventions.
   • Family members: Build on positive, community-proposed coping strategies, and base interventions on empowerment to mitigate self-stigma.
   • Healthcare and frontline workers: Protect them from discrimination and abuse (e.g., through an information-based approach that includes the involvement of popular opinion leader) and support and provide encouragement/counselling.
   • Vulnerable/high-risk populations: Ensure tailored anti-stigma interventions and protection for disadvantaged and marginalised groups (e.g., homeless people, people with disabilities, people who are incarcerated, migrants and refugees, and racial minorities).
5. Involving communities and key stakeholders
   • Incorporate the voices, stories, recovery, hope narratives, and images of local people who have been affected by COVID-19.
   • Use messaging that is contextualised and targeted, based on local knowledge of the specific beliefs and fears and drive stigma in a given setting, community, or population.
   • Understand context-specific stigma by scoping information from local organisations, community leaders, clinicians, news messages, public health websites, and social media posts.
   • Partner with community leaders, drawing on interpersonal connections to promote reassurance, add legitimacy to general public health efforts, and disseminate information to those who might mistrust official communication channels.

The researchers indicate that these recommendations may be actionable by: policymakers, public health officials, planners, and managers at the local and national levels; researchers; media representatives; national and international non-governmental organisations (NGOs); community-based organisations; people affected by COVID-19; and lay people. They suggest directions for future research, including, for example, qualitative operational research in humanitarian settings, the scalability and sustainability of anti-stigma interventions, and the cost-effectiveness of such interventions. "People who have direct experience of COVID-19 associated stigma should play a key role in the development and implementation of such research."

In conclusion: "Social inclusion, justice and solidarity are key components of health protection, required in the immediate term to manage the current COVID-19 public health emergency, but also in the long term for communities and countries to recover from its impact, and to be better prepared to respond to further waves of the outbreak or to comparable pandemics in the future."