Unit VIII (Soc Psy)

Stigma on First Responders During COVID-19

Tara Rava Zolnikov National University and California Southern University

Frances Furio California Southern University

During the pandemic, first responders were at an increased risk of being stigmatized because of their direct exposure to COVID-19; stigmatization is an undesirable stereotype that can contribute to a myriad of adverse effects, including, but not limited to, anxiety, depression, devaluing, rejection, stress, health problems, exposure to risks, and limiting protective factors. The objectives of this research were to understand stigma on first responders during the COVID-19 pandemic as well as the consequences of stigma on first responder’s mental health. A qualitative phenomenological study used semistructured interviews to understand the experiences of first responders during the pandemic. This study included a convenience sampling of 31 first responders (e.g., physicians, nurses, paramedics, police officers, firefighters, etc.) located worldwide. First responders reported feelings of isolation, lack of support and understanding by family or friends, decreased or forced removal in immediate social interaction (e.g., within family and friend circles), sentiments of being infected or dirty, increased feelings of sadness and anxiety, and reluctance to ask for help or get treatment (e.g., self-approval of being isolated). By answering these research questions, this information highlighted additional challenges that may be faced by first responders aside from being a frontline worker during a pandemic, which is equally stressful. By understanding the role of stigma, public health practitioners during pandemics or emergency situations can seek to diminish it.

Keywords: COVID-19, coronavirus, first responders, health care workers, stigma

On March 11, 2020, the World Health Organization (2020) characterized the newly emerging respiratory illness, coronavirus 2019 (COVID-19), as a global pandemic. COVID-19 had rapidly spread across the world, creating a surge of cases in countries like Italy, Iran, South Korea, and the United States. Pandemics and disease outbreaks pose significant threats to human health as well as contribute to adverse mental health effects because of drastic life changes along with the inability to predict daily events (Pike, Tomaney, & Dawley, 2010). Anxiety, stress, and fear felt by people during the coronavirus pandemic was real and overwhelm- ing, resulting in strong emotional reactions in adults and children

(Centers for Disease Control and Prevention, 2019). The culmina- tion of these reactions could be directed at first responders, who were at the forefront of treating people affected by the disease and sequentially considered the most exposed population (Adhanom Ghebreyesus, 2020; Ehrlich, McKenney, & Elkbuli, 2020).

During the pandemic, first responders were at an increased risk of being stigmatized (Adhanom Ghebreyesus, 2020; Ehrlich et al., 2020), which is an undesirable stereotype that reduces an accepted person to a tainted one (Goffman, 1963). Stigma has several components, including stereotyping, discrimination, labeling, sta- tus loss, and separation (Link & Phelan, 2001). Stigmatization can negatively impact individuals faced with it, especially if stigma has become internalized (Drapalski et al., 2013). Stigmatization is problematic and can contribute to a myriad of adverse effects, including, but not limited to, anxiety, devaluing, rejection, expo- sure to risks, and limiting protective factors (Link & Phelan, 2006). Stigma has been shown to increase stress among the individuals who experience it (Major & O’Brien, 2005) as well as depression (Benoit, McCarthy, & Jansson, 2015). Stigma can impact an individual’s self-esteem and their overall achievements (Major et al., 2005). Studies have shown that low self-worth and negative health outcomes are both potential outcomes of stigma (Benoit et al., 2015).

During the COVID-19 pandemic, health care workers and first responders described experiencing stigma in their communities. Amid this crisis, a qualitative phenomenological study was con- ducted to understand the experiences of first responders during the pandemic; this is the first study of its kind to review the effects of stigma on first responders in any pandemic. This study used a convenience sampling of first responders (e.g., physicians, nurses,

Editor’s Note. This article received rapid review due to the time-sensitive nature of the content. Our standard high-quality peer review process was upheld throughout.—PWC

This article was published Online First September 17, 2020. X Tara Rava Zolnikov, Department of Community Health, National

University, and Department of Behavioral Sciences, California Southern University; X Frances Furio, Department of Behavioral Sciences, Cali- fornia Southern University.

The authors have nothing to declare in the conception, development, writing, and submission of this research.

The authors acknowledge and thank all the first responders that are sacrificing so much to combat the pandemic.

This research and manuscript did not receive funding. Correspondence concerning this article should be addressed to Tara

Rava Zolnikov, Department of Community Health, National University, 678 Aero Court, San Diego, CA 92123. E-mail: tarazolnikov@gmail.com

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Stigma and Health © 2020 American Psychological Association 2020, Vol. 5, No. 4, 375–379 ISSN: 2376-6972 http://dx.doi.org/10.1037/sah0000270

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paramedics, police officers, firefighters, etc.) who discussed their personal experiences during the pandemic. Highlighted topics of discussion focused on treatment, stigma, feelings, and mental health. The expectation of this research was to upend aspects related to adverse mental health in a vital working population during the pandemic.

Method

A qualitative study was conducted to understand and explore the experiences of health care workers and first responders during the COVID-19 pandemic. This study used a descriptive phenomeno- logical approach, which has been continuously described as a valuable research tool and strategy to understand the lived expe- riences of participants related to a phenomenon (Neubauer, Wit- kop, & Varpio, 2019; Marques & McCall, 2005; Husserl, 1980); the aim of this type of research is to identify the common themes, factors, or components related to a phenomenon to better under- stand the perspectives of those who have experienced it (Marques & McCall, 2005). A phenomenological study looks at both what was experienced and how it was experienced (Neubauer et al., 2019). This method was utilized for this study because first re- sponder experiences offer a unique perspective during the pan- demic, although they are not authorities on pandemic stigma, in general.

Health care workers and first responders were selected as the target population. This selection was due to the fact that these individuals have a unique position within this pandemic because they are likely the population most exposed to COVID-19 during this time. Inclusion criteria for this study was: above the age of 18 years, health care worker or first responder, and worked during the COVID-19 pandemic. Participants were recruited through conve- nience sampling, which used the Facebook platform; participants were then screened, selected, and interviewed via Zoom (per social distancing recommendations by the Centers for Disease Control and Prevention) in a private setting and format, during which questions reviewed challenges faced during the pandemic. After interviews, the data were then analyzed via hand coding, in which themes emerged and presented themselves through repetition. Themes were then made into a codebook, which were used to review all quotes related to the subject matter that directly correlated to answering the research questions. This thematic analysis followed the Moustakas (1994)–modified Van Kaam (1966) method.

All qualitative research must provide measures to ensure valid- ity of the data in the research. In this case, the researchers estab- lished trustworthiness through credibility, multiple participant per- spectives, peer debriefing and review, reflexive journaling, and field notes. Credibility was gained through triangulation of sources and member checking. Multiple participant perspectives were sought when female and males of various ages in different parts of the world working in different occupations were all included to participate in the interviews. Peer debriefing and review occurred before and after developing interview questions and analyzing themes in the data. Reflexive journaling and field notes occurred in a diary, which was used to report on questions related participant reactions and impressions of each interview. That said, limitations in all research exists. Limitations of this study included the pos- sibility of nontransferable results to other first responders in the

world, researcher personal bias (e.g., mental health researcher), and research participant bias.

The study protocol and ethics review were approved by Cali- fornia Southern University. All participants signed informed con- sent prior to the commencement of the interviews and audio recording. Codes were immediately assigned to every participant to ensure deidentified data collection.

Results

Participants’ answers concluded various challenges related to treatment, stigma, feelings, and mental health. Participants de- scribed factors that were associated with stigma, including feelings of isolation, lack of support and understanding by family or friends, decreased or forced removal of immediate social interac- tion (e.g., within family and friend circles), sentiments of being infected or dirty, increased feelings of sadness and anxiety, and reluctance to ask for help or get treatment (e.g., self-approval of being isolated).

Participants

A total of 31 health care workers and first responders were interviewed for this study. The mean age was 36.129 years, with a range between 23 and 57 years. In relation to gender, 18 partici- pants identified as female, and 13 participants identified as male. Participants were located worldwide, including the United States (28), Kenya (one), Ireland (one), and Canada (one). Ethnicities included African/Kenyan, Arab/Palestinian, Caucasian, Cauca- sian/Russian, Caucasian/Iranian, and Caucasian/Irish. Of these, 18 of the participants were married, and 13 of the participants were single. Sixteen of the participants had children, with an average of 2.25 children per subject, a median of 2.5 children, and a range of one to four children.

The education levels of participants included high school (one), some college (four), associate degrees (six), bachelor degrees (13), graduate degrees (three), and medical school educations (four). All participants worked within roles as health care workers or first responders during the COVID-19 pandemic; there were physi- cians/doctors (three), nurses (14), a nurse tech, a behavioral ther- apist, an orthodontist, a dialysis technician, a technician in medical surgery, a data specialist, a paramedic, firefighters and paramedics (three), a firefighter and emergency medical technician, and police officers (three).

Experiencing Stigma

In the cohort of interviewees, many participants discussed as- pects of stigma, although never directly associated themselves with stigma or being stigmatized. “I haven’t had any [stigma]. . . . I [did] stay at the abandoned other house that we have . . . for about 2 weeks and, you know, tried not to come home” (P4.5). Partici- pants used various negative words to describe how they felt during the pandemic, “like I was infected, . . . like I was dirty” (P3.3) or “contaminated” (P9.2) and how they were regarded: “They treat me like I had the plague” (P4.1). These feelings were hard to dismiss,

[I feel] “dirty.” My clothes are “dirty”, my hair is “dirty”, my shoes are “dirty,” . . . everything with me has been “stained” with COVID

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376 ZOLNIKOV AND FURIO

19 . . . including my body. I know that the “dirtiness” of it all isn’t me personally, but it is hard to turn away and not take it personal and feel helpless. . . . I guess I just do not want to feel dirty anymore; it’s draining. (P7.3)

Participants believed that being isolated was justified, “Well, I mean, . . . it’s understandable. People were just scared, I think” (P95). This negatively affected participants: “Well, initially I was quite sad to [be treated differently] because it was all of a sudden. But then . . . it becomes the norm” (P1.2).

Isolation and directed fear came from different layers of people, including the general public, friends, and family. The public had an interesting response to first responders. This reaction ranged and included arm’s-length support. “[I received] cards, like kindness cards, words written to us. Loved ones sending food to us. . . . And just encouragement from the community” (P1.1). Alternatively, the response also included aggressive behavior: “. . . She pulled down her mask and coughed at us” (P10.3). These situations contributed to first responders not wanting to declare their occu- pations and place of work.

If people would ask me what I did for work, I was kind of proud to say, you know, I work at the hospital. . . . [Now] I don’t make a habit of telling anybody I work at the hospital, just because most people get kind of freaked out. (P4.1)

In addition to the public, first responders most often experienced stigma from the people closest to them—friends and family mem- bers. “Usually people start to become very cognizant and aware exactly where you’re standing so they don’t touch those things. Yeah, I’m not allowed at my parent’s house. [Friends] call me, but nobody wants me over [and] of course, nobody’s coming over” (P1.2). And friends created a physical separation between first responders and themselves:

. . . It’s like everyone would jump back 10 feet. Even my mom would stay away from me. When I did come home, . . . I’d be carrying on a conversation with [my mom], and if I took a step forward to like pick something up, she would take a step back, kind of like reflexively, like jumping back [and keep] this imaginary bubble. And in my house, I wasn’t [even] allowed in the kitchen area. (P4.1)

Alienation frequently occurred because first responders found it difficult to find safe places to go and often found comfort in solitude:

I don’t enjoy people as much anymore; . . . like even my family will get together and I sit there but then I’m really annoyed with all of them. . . . I don’t want to engage. And I don’t want to have conver- sations and I sometimes just want to go home and be like—where’s the one place that nobody will be that I can go? I want to grab my wine and be alone. I don’t want to talk to anybody. . . . On my ride home, which is like a 40-min ride, no radio, no, it was just silent. (P3.2)

Others were convinced or coerced into quarantine or separation from immediate family:

Nobody wanted to be around you. . . . When you have [a] hard day or, you know, there’s a lot going on, you have a lot of stress, and then you come home and then you’re treated like you’re, you know, a leper; . . . it doesn’t make you feel very good; . . . there’s nobody to share [anything] with. (P7.1)

Common words to describe emotions and feelings as a result of being stigmatized, included “sadness” (P1.1), feeling “blue” (P7.1), and “extremely stress[ed]” (P3.3) while living in a situation that “is so demoralizing” (P9.4). These effects could be translated to adverse mental health effects that are commonly associated with stigma, such as depression, anxiety, and stress. Reactions to these feelings included alcohol use. “I feel very isolated, lonely, de- pressed even. I found my alcohol intake increased” (P11.1).

Participants described several solutions related to the stigma that was faced during the COVID-19 pandemic. Participants mentioned how communication was an important component to consider. This included communication among colleagues: “Talk to your colleagues or talk to somebody that you trust about what you’re going through mentally, emotionally” (P1.1). This also included communication among those in supervisor or managerial roles: “I think there needs to be a lot more communication and honesty” (P4.2). Participants also described the importance of health care workers and first responders maintaining a connection with those outside their professional roles, including other members of the general population and those in their communities: “Just keep in touch with these people, like they’re not diseased, . . . continue to call them and keep talking with them; . . . people should make an effort to continue to speak to these people” (P1.2).

Many participants described improvements related to education and dissemination of science-based information related to the COVID-19 pandemic as an important potential solution. “More real education and less completely false news would be great” (P3.3). “I think education could definitely help next time” (P6.2). Participants stated that “more facts” would be helpful (P3.4). “The biggest thing is misinformation” (P6.2). “Public awareness cam- paigns and things like that could do a lot of good” (P7.2). “Public health education, educating the public on the modes of transmis- sion of some conditions like this one” (P9.4). “I don’t think there really is anything you can do aside from educating the public” (P10.4).

Even when discussing potential solutions, participants still ac- knowledged the challenges and difficulties that came to stigma faced by health care workers and first responders. “How do you simultaneously convey the message that this is something that needs to be taken seriously as well as then downplay the effect of people who are most exposed?” (P4.4). The messages conveyed how difficult it would be tackling stigma in first responders: “You’re always gonna have people that are gonna be rude; . . . there’s always gonna be the people that think that you’re icky and infected, and I don’t think we’ll ever get away from that” (P5.1).

Discussion

First responders have a unique position as first-line response to COVID-19 patients, which results in an increased likelihood for exposure to the virus. Because of this position, mental health problems, such as anxiety, depression, insomnia, and stress, have been revealed in this population (Liu et al., 2020). A 2-fold mental health problem occurs when adding stigma as well; the first layer of adverse mental health occurs because of direct exposure to the disease within a work setting, and the second layer occurs with stigmatization faced outside the work setting. Poor mental health for the most important line of defense against the pandemic is important to address because it is responsible for long-term work

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377STIGMA ON FIRST RESPONDERS DURING COVID-19

absence, which makes it difficult to tackle and curb the results of the pandemic (Blank, Peters, Pickvance, Wilford, & Macdonald, 2008).

In addition to the negative effects experienced, major issues described in this study were lack of support and isolation, which have been linked to anxiety, restlessness, emptiness, marginality, decreased sleep, decreased immunity and inflammatory control, and higher morbidity rates (Cacioppo, Hawkley, Norman, & Bern- tson, 2011; Weiss, 1973). Finally, stigma can upend self-esteem and sense of meaningful existence or belonging and can result in social pain and distress (Almutairi, Adlan, Balkhy, Oraynab, & Clark, 2018).

It is important to delve into the depth of stigma. Individuals perceiving stigma from community versus internalizing stigma can contribute to various mental health outcomes. In this study, public stigma occurred in various places with participants (e.g., grocery stores, gas stations, driving, etc.). This is important to discuss because it became internalized by participants, who described feeling dirty or infected and believed social outcasting was war- ranted. Internalized stigma is a self-agreement with negative ste- reotypes and often results in personal rejection and distress (Quinn et al., 2014). Adverse mental health outcomes that can arise from internalizing stigma include depression, avoidant coping, social avoidance, decreased hope and self-esteem, psychiatric symptoms, and decreased mental health support (Drapalski et al., 2013). Moreover, internalized stigma can mediate the relationship be- tween public stigma and mental health treatment (Brown et al., 2010). As a result, suggesting internalized stigma occurred in first responders during the pandemic is of utmost concern because this can contribute to the development of negative attitudes and lack of mental health treatment in an at-risk population.

In regard to reducing stigma, many participants described improvements needed related to the lack of accurate informa- tion being shared with the media. Interviews with health care workers and first responders demonstrated the need for im- provements related to education and dissemination of science- based information related to the COVID-19 pandemic as an important potential solution. Literature has described the pro- liferation of misinformation related to the COVID-19 pandemic (Pennycook, McPhetres, Zhang, Lu, & Rand, 2020). Many individuals receive information related to important global is- sues from social media outlets, including, but not limited to, YouTube, Twitter, and Instagram (Cinelli et al., 2020). Litera- ture has described the panic related to the COVID-19 pandemic as spreading faster among media outlets than it has as a virus in the community (Depoux et al., 2020).

Reporting in the media is said to have a significant impact on the public (Depoux et al., 2020). When faced with inaccurate infor- mation, individuals can be more likely to overreact, underreact, or turn to infective solutions and remedies (Pennycook et al., 2020). Literature has shown that increases in media exposure related to COVID-19 content is correlated with increases in stress and anx- iety among individuals, in general (Garfin, Silver, & Holman, 2020). This is a likely scenario that contributes to the stigma of first responders during the pandemic.

Solutions to this problem could include real-time and urgent information being conveyed to the public while being mindful of untoward exposure to the media (Garfin et al., 2020). The goal is to reduce hysteria and mitigate the transmission of

misinformation (Depoux et al., 2020; Garfin et al., 2020). Detecting inaccurate rumors, attitudes, and perceptions related to COVID-19 will be required to effectively respond (Depoux et al., 2020). Turning to health care providers, specifically, for critical information related to the topic at hand could also be helpful (Garfin et al., 2020). The acknowledgment of inaccurate information and dissemination of science-based information related to COVID-19 could potentially improve communication and reduce the stigmatization that health care workers and first responders have described in this study.

Conclusion

Facing stigma is often invisible, in that the effects are not often recognized; despite the inability to see it, experiencing stigma can be dangerous to health while also diminishing the value of a person through discrimination and loss of status by being devalued, re- jected, and excluded (Link et al., 2006). The compounding adverse mental health effects in an essential population used to fight the pandemic turns an already challenging situation dire. By under- standing how stigma affects first responders, blurred lines can start to become visible, and public health practitioners now and in future pandemics or emergency situations can seek to diminish it. Future research could focus on understanding stigma, both within individuals and perceived stigma through the community. This research can highlight areas for interventions to modify and de- crease negative attitudes that may exist (Rost, Smith, & Taylor, 1993). Other areas of interest can focus on understanding the relationships between internalized stigma, coping strategies, and mental health services used. For example, another qualitative study could be implemented to reveal a baseline of information describ- ing coping strategies and accessed mental health treatment in first responders. Ultimately, this type of information could then be used to support mental health needs in first responders during the pandemic.

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Accepted July 24, 2020 �

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379STIGMA ON FIRST RESPONDERS DURING COVID-19