The psychological distress and mental health disorders from COVID-19 stigmatization in Ghana.

The emergence of the COVID-19 global pandemic in Ghana has resulted in various degrees of stigmatization. Previous studies have stressed the need for developing policies to curb the stigma towards COVID-19 survivors and healthcare workers. Some have investigated the knowledge and willingness of people to accept COVID-19 survivors. Others have also explored the experiences of health workers who have been victims of stigma from COVID-19. There is a need for further studies to understand COVID-19 related stigma and related psychological distress. The purpose of this study was to investigate the cases of COVID-19 related stigma and discrimination against healthcare workers, COVID-19 recovered patients, suspected persons of COVID-19, Asians, and persons with travel history from COVID-19 hotspot countries. The study was undertaken using the phenomenology approach to qualitative research. Purposive and snowball sampling techniques were used in recruiting the twenty-eight study participants. Data were garnered using interviews and focus group discussions. Data were analyzed using interpretative phenomenological analysis. The findings revealed that COVID-19 victims have faced various forms of stigma such as stereotyping, social exclusion, mockery, finger-pointing, and insults. The study recommends that the COVID-19 National Response Team in Ghana must put in place a robust psychosocial intervention plan for stigmatized persons to help them cope with the stigma and help in its prevention.

Introduction

Stigmatization is the act of marking a person or an identifiable group of people, place, or country with the stereotype (Lu et al., 2020) or treating them differently in an unfavorable manner because they had or were associated with something people did not want to have or associate with, especially, health conditions (Andoh, 2020). It could take the form of name-calling, branding, and finger-pointing at those suspected to be infected by the virus (Dapaa, 2020). When stigma is as a result of an epidemic, it is labeled as a biosocial phenomenon. This is because though, the stigma is a negative social construct, it results in dire health outcomes (Nylander, 2020). Throughout history, stigmatization always results from the outbreak of any major epidemic or pandemic (Earnshaw, 2020). Epidemics and pandemics in history such as Ebola, Middle East Respiratory Syndrome (MERS), Human Immunodeficiency Virus (HIV), Hansen's disease, and many others have sparked stigma against persons who have tested positive or have been associated with the patients (Morens & Fauci, 2013; World Health Organization, 2020).

The current COVID-19 global pandemic has resulted in an untold degree of stigmatization and discrimination. Xiao (Xiao, 2020) posits that the pandemic did not only increase its mortality rate but has also witnessed a considerable increase in its psychological and mental health disorders. The Ministry of Health and Family Welfare, India (Ministry of Health and Fa, 2020) disclosed that because the COVID-19 is a new disease, its emergence and spread creates tension, confusion, anxiety, and panic among the general public. Also, the misinformation about the COVID-19 (Hu et al., 2020; 2019Shimizu) as well as its association with a particular population or nationality also results in social stigma and discrimination (Centre for Disease Control and Prevention, 2020). Thus, the stigmatization goes beyond only persons who have contracted or are associated with infected persons, such as caregivers, relatives, and frontline health workers, to include persons from a given geographical location and/or country (International Federation, 2020). Stigma and discrimination pose serious health threats (American Psychological As, 2020). It is counterproductive and unfair, derailing all the efforts put in place to fight the disease (Dapaa, 2020). Recovered COVID-19 patients who are stigmatized face rejection by their communities (International Federation, 2020). People who have been stigmatized or discriminated against due to the COVID-19 have to constantly battle with psychological stress and mental health disorders (Bao et al., 2020; Rajkumar, 2020) as a result of excessive anxiety, depression, anger, fear, and post-traumatic stress (World Health Organization, 2020). Stigmatization serves as a negative motivator for people not to disclose their health conditions. It also prevents people from seeking health care during an illness that shows symptoms of COVID19 for fear of being stigmatized (World Health Organization, 2020). This social isolation would make it difficult to control the spread of the COVID-19 pandemic (2020Pomeroy). Also, stigmatization of particular nationalities only results in confrontations and divisions that derail efforts at cross-border collaborations to combat the COVID-19 pandemic (Lu et al., 2020).

After the first two confirmed COVID-19 cases in Ghana on March 12, 2020, there has been several forms of stigma that has been reported against confirmed patients and their relatives, as well as frontline health workers. Ghanaian citizens who have returned from COVID-19 prone countries, and foreign nationals from Asian descent have also experienced several forms of stigma (Dapaa, 2020; Ghana Web, 2020; Joy Online News, 2020). As such, there have been several calls from the Ghana government, mental and psychological health organizations, the mass media, and well-meaning Ghanaians to address all forms of stigma and discrimination against people as a result of the COVID-19 pandemic (Prime News Ghana (April 8, 2020; Andoh, 2020). Social psychologists have called on the government to include specific directives on stigmatization in Ghana's national communication plan of COVID-19 (Joy Online News, 2020). This is crucial in addressing the eventual psychological distress and mental health disorders that will emanate from COVID-19 stigmatization in Ghana. This is as important as the fight for a vaccine for the coronavirus as it would help countries like Ghana to advance efficient measures in preventing and controlling the spread of the pandemic (Banerjee, 2020). Lessons must be learned from past pandemics. Morens and Fauci (Morens & Fauci, 2013) noted that the psychological and mental health issues of countries were not given much attention in various countries during the HIV/AIDS epidemic in the 1980s and the 1990s, the 2002 and 2003 Severe Respiratory Syndrome (SARS), the 2009 H1N1 influenza pandemic, the 2013 Ebola virus outbreak as well as the 2016 Zika virus outbreak. As a result, many countries paid heavily for not putting in place psychological and medical health intervention programs as well as psychosocial support systems to alleviate the anxiety, fear, confusion, and depression from stigmatization from the pandemics.

Shultz, Baingana, and Neria (Shultz et al., 2015) reported how countries lacking well-trained psychiatrists and psychologists witnessed a high rise in psychological distress, resulting in acute forms of psychopathology. Developing countries usually suffer the most as it happened in Sierra Leone and Liberia. The poverty levels of the countries increased dramatically because of the absence of well-planned psychosocial and mental health facilities, intervention plans, and support systems (Shultz & Neria, 2013). The COVID-19 pandemic has also resulted in various forms of stigmatization and discrimination. For instance, in the Indian context, studies such as (Kumar & Nayar, 2020), (Islam et al., 2020), and (Bhattacharya et al., 2020) stressed the need for addressing issues related to COVID-19 stigmatization and discrimination while spreading COVID-19 information as a tool for reducing stigma. Similarly, in the USA context, Bruns et al. (Bruns et al., 2020) also emphasized the need for public health and healthcare providers to prioritize issues of stigma and discrimination while implementing intervention strategies such as social distancing, contact tracing, and quarantine. Sotgiu and Dobler (Sotgiu & Dobler, 2020) mentioned in an Australian study, the effects of social stigma resulting from COVID-19 stigmatization, resulting in delayed diagnosis and under-detection of suspected or affected persons of COVID-19. The stigma associated with caregivers of COVID-19 patients in Italy (Ramaci et al., 2020) and Egypt (Abdelhafiz & Alorabi, 2020; Mostafa et al., 2020) has also been studied. These studies have concluded that stigma against healthcare workers has resulted in high degrees of burnout and fatigue.

Ghana is a developing country that is struggling with the establishment of psychological and mental health systems to handle the high aggregates of psychological distress from the COVID-19 stigmatization. Before the COVID-19 outbreak in Ghana, the country had 650,000 of its citizens suffering from a severe mental disorder (World Health Organization, 2019). Sadly, a nation with a total population estimated at 30 million people can boast of 400 professional psychologists () and 22 psychiatrists (World Health Organization, 2019) as well as 123 mental health facilities, a one-day treatment center, three (3) psychiatric in-patient units, four (4) community residential facilities with one (1) treatment center (Robert et al., 2014) to handle the growing number of psychologically distressed among Ghanaian citizens. With the emergence of the COVID-19 in Ghana, the number of people with psychological distress and mental problems would increase. Evidence on stigma reported in the literature mostly relates to mental illness. For instance, Darko-Gyeke and Asumang (Darko-Gyeke & Asumang, 2013) reported that mentally ill individuals experienced some form of stigma from their friends, families, and community members. Tawiah, Adongo, and Aikins (Tawiah et al., 2015) suggested that economic (e.g., denial of access to food), psychological (e.g., loss of self-esteem), and social (e.g., verbal abuse, ridicule, family blame, and mock) are the forms of stigma mental health patients encounter in the community. The accumulated negative self-stigma of patients negatively impacts their clinical outcomes and their quality of life (Gyamfi et al., 2018). With respect to coping, most mental health patients use religion and hope for healing as strategies for coping (Ae-Ngibise et al., 2015).

Although the enormous negative impact of stigma has been established, the majority of studies (Ae-Ngibise et al., 2015; Arboleda-Florez & Stuart, 2012; Corrigan & Watson, 2002; Ebrahim et al., 2020; Grover et al., 2019) explored stigma among patients with mental illness, and data are often collected from the patients and caregivers. Only few studies have addressed stigmatization related to COVID-19 in the Ghanaian context. Some of the studies have highlighted the essence of healthcare providers devising strategies and policies to reduce or completely curb all forms of stigma from COVID-19 (Agyemang-Duah et al., 2020; Lamptey et al., 2021). One comparative study has attempted to investigate the knowledge and willingness of some Ghanaians and Nigerians to associate with COVID-19 survivors (Lamptey et al., 2021). The study found out that the knowledge and willingness to accept COVID-19 survivors in the two countries were fairly adequate (Lamptey et al., 2021).

Studies shedding light on the psychological distress and mental disorders from COVID-19 related stigma are lacking. This in-depth qualitative study with a heterogenous sampled population is key to providing narratives of the nature of COVID-19 related stigmatization as well as the psychological and mental health implications from them. The findings of the study would greatly benefit health practitioners such as psychologists, mental and public health experts, and regulatory institutions in augmenting efforts towards stigma prevention.

Understanding of pandemic outbreaks and stigma

Human societies have a long history of singling out, disregarding, or keeping away from gatherings of individuals with a particular attribute or characteristic that is seen as bothersome or threatening to others (Fischer et al., 2019). The human race has experienced several forms of stigma, ranging from physical to health. According to Goffman (Goffman, 1963), stigma is an “attribute that is deeply discrediting and has the potency of reducing the bearer from a whole and usual person to a tainted, discounted one” (p. 3). The term stigma is frequently applied when there is a component of naming, stereotyping, separation, status loss, and discrimination, and it is frequently illustrated when a powerful situation unfolds (Deacon, 2006). Health-related stigma is typically characterized by the social disqualification of individuals and populations who are identified with particular health problems that are perceived as threatening to others (Weiss et al., 2006). Both the fear of people who are infected and the fear of contracting the disease can lead to social stigmatization (Goffman, 1963). Occasionally these fears co-occur, resulting in severe stigmatization of strangers with diseases.

Several infectious diseases have demonstrated common and distinctive features of stigma throughout history. The outbreaks of infectious diseases like Acquired Immunodeficiency Syndrome (AIDS), Severe Acute Respiratory Syndrome (SARS), and Ebola virus disease recorded some level of stigma (Andoh, 2020; Chang, 2003). The recent outbreak of the Coronavirus pandemic is more likely to record some level of stigmatization considering how dreadful it has been perceived by the public. The public perception of the Coronavirus pandemic could lead to disregard for people who were infected or thought to have been infected. Such an attitude could result from the belief that an individual may be a carrier or simply exposed to those with a serious illness considered to be threatening. Although some authors suggest that fear of people with infectious disease facilitates disease avoidance and adherence to preventive measures (Oaten et al., 2011), it can also be a major barrier to health care and quality of life in illness management. These barriers could potentially contribute to more severe health problems, ongoing transmission, and difficulties in controlling diseases during an infectious disease outbreak.

Materials and methods

Research design

The study aimed at describing the experiences and internal feelings (Abedsaeidi & Amiraliakbari, 2015) of those who have been psychologically disturbed because of stigma from COVID-19, making the qualitative research design the most suitable. Non-numerical, verbal data (Creswell, 2009) from a small sample size (Moriarty, 2011) who have been affected by the COVID-19 or have experiences (Leedy & Ormrod, 2010) on the psychological distress of victims of COVID-19 were garnered. The study was conducted between March 30, 2020, to April 30, 2020, during the lockdown period in the Greater Accra and Greater Kumasi regions of Ghana.

Research method

The study employed the phenomenology approach to qualitative research. This design is used in qualitative research in order to provide detailed accounts and the realities of a phenomenon (Leedy & Ormrod, 2010). Therefore, this approach was selected for this study so that rich data on the stigma and discrimination faced by victims of COVID-19 could be studied (Maypole & Davies, 2001; Welman & Kruger, 1999). The detailed description (Kensit, 2000) of the mental and psychological stress expressed by the victims of the COVID-19 infection was crucial in proposing appropriate interventions to prevent and control the stigma as well as offering psychosocial support on measures to adapt to in coping with the stigma.

Sample selection, size, and design

The researchers purposefully selected only study participants who have personal experiences and/or are knowledgeable (Creswell, 2009; Leedy & Ormrod, 2010) in the psychological distress and mental disorders from stigmatization because of COVID-19 infection. The participants include COVID-19 patients who have tested positive but have recovered, suspected COVID-19 persons quarantined in isolation centers, relatives of COVID 19 patients, Ghanaian returnees, and foreign nationals from COVID-19 hotspot countries, frontline health workers, clinical and social psychologists, and mental health officers.

Owing to the sensitive nature of the study, the members of the target population were not easily accessible (Naderifar et al., 2017) and may not be willing to reveal their identities (Hejazi, 2006), hence the snowball sampling method was adopted in recruiting study participants. In this sampling technique, identified respondents for the study refer the researchers to other people who are knowledgeable in the phenomenon that is being investigated (Hejazi, 2006). Initially, frontline health workers in a health facility were briefed on the study objectives and some volunteered as study participants. These volunteers assisted in reaching out to recovered COVID-19 patients who were willing to share the experiences of the stigma they faced. Table 1 shows the groupings of participants involved in the study.

Table 1

Breakdown of population and sampling size.

Target Population for the Study	Country of Origin	Sample Size
Ghanaian Returnees	U·S.A	2
	U·K	2
	Korea	1
	Switzerland	1
Foreign Nationals	China	3
Recovered COVID-19 Patients	Ghana	2
Relatives of COVID-19 Patients	Ghana	4
Discharged Quarantined Suspected COVID-19 Persons	Ghana	2
Psychologists	Ghana	2
Frontline Health Workers	Ghana	7
Mental Health Officer	Ghana	2
Total		28

Ethical considerations

To ensure that the study followed the accepted ethical procedures for quality research, an approved informed consent form from the Research Ethics Committee of the Kwame Nkrumah University of Science and Technology, Ghana was administered to all the study participants. The informed consent form detailed the purpose of the study, its objectives, its voluntary nature, and the rights of the study participants to withdraw from the study at any time, and the procedures to protect the confidentiality of their narratives and personal identities (Bailey, 1996). The medical officers asked that the COVID-19 patients were masked so as not to reveal their identities, which was accepted by the researchers. They consented to the use of their views in pseudonymous identities. Prospective respondents had two weeks to decide whether or not they wanted to participate. Moreover, all the COVID-19 preventive protocols were followed during each of the sessions of the personal interviews and focus group discussions. Face masks were worn, and hand-cleansing sanitizers and soaps together with water were provided by the researchers.

Data collection tools and procedures

Personal interview and focus group discussions were used in garnering detailed narratives (Fraenkel et al., 2012) of the COVID-19 stigma experiences from the study participants. The relatives of COVID-19 patients, psychologists, and nurses were engaged in separate focus group discussions. All the other study participants were interviewed privately to protect the sensitive views they expressed (Naderifar et al., 2017). A well-developed semi-structured interview guide assisted in the interactions. Each interaction session lasted for close to 2 h, which is a considerable duration of engagement to collect rich data (Creswell, 1998) on the experiences of stigmatization from the study participants. Secondary data on stigma and discrimination against COVID-19 victims were also gathered from news reports and published journal articles (Haris, 2001). The data from the secondary sources were essential in validating the entire data obtained for the study. Upon agreement with the study participants, post telephone interviews (Dolan, 2019) were conducted during the COVID-19 lockdown period in Ghana to validate the transcribed data from the earlier interactions.

Data analysis plan

The data from the study were analyzed using the Interpretative Phenomenological Analysis (IPA). In the first stage of the process, the views of the study participants were carefully transcribed (Smith et al., 2008). This was important to help the researchers in representing the exact voices of the participants through thick quoting of some of the key ideas they expressed (Groenewald, 2004) which were pertinent to answering the research questions for the study. In doing this, great care was taken not to include biases and preconceptions of the researchers (Crabtree & Miller, 1992; Creswell, 1998). Member checking was used in validating the accuracy of the transcribed data (Ebrahim et al., 2020). Telephone interviews were further conducted because of the restrictions on movement as a result of the COVID-19 pandemic lockdown.

The units of meaning from each of the interviews conducted were outlined. All statements that were crucial in answering the research questions of the study were deemed relevant and as such were extracted (Holloway, 1997; Hycner et al. Burgess). Significance was judged by the number of times a unit of meaning appeared in the transcribed data (Smith et al., 2008). However, unique views that gave richer interpretation on the main theme of COVID-19 stigma and its psychological implications were also considered as significant in the units of meaning or interpretation. The overarching themes were discussed under the research questions. Finally, the various themes were rigorously discussed using the theories in the existing literature to produce an intellectually captivating and scholarly study.

Results and discussion

Demographic characteristics of participants

The participants included twenty-one males and seven females with a range of educational qualifications (Table 2 ). The majority of the participants were within the age range of 50–59 and endorse Christianity as their faith. All of the participants had some form of education with five participants being university graduates. The participants represented five ethnic groups, with the majority being Akan which is the dominating ethnic group in Ghana. Besides, among the range of occupations, most of the participants were traders.

Table 2

Demographic data of Participants.

Demographic Variables	Frequency	Demographic Variables	Frequency
Sex		Age range
Male	21	20–29	3
Female	7	30–39	4
		40–49	9
		50–59	12
Education		Occupation
Graduate	5	Medical Doctor	2
HND	7	Nurse	5
NVTI	8	Trader	12
SSCE	3	Psychologist	2
JHS	5	Mental Health Officer Unemployed	2
Religion		Ethnic Society
Islam	7	Dagbani	4
Christianity	17	Akan	12
Buddhism	4	Ewe	4
		Ga	5
		Han Chinese	3

The psychological stress faced as a result of the COVID-19 global pandemic

Pandemics in human history have always resulted in psychological problems such as fear, anger, confusion, stigma, discrimination, prejudice, and marginalization toward the disease and all kinds of people ranging from healthy people, patients, and health care providers (Mak et al., 2009). This section presents findings and discussion of both primary and secondary data on the psychological stress as a result of stigmatization faced by patients in quarantine and their relatives, frontline health workers, people from Asian countries, and Ghanaian travelers from COVID-19 hotspot countries.

Stigmatization and discrimination against suspected COVID-19 patients

Suspected COVID-19 patients are put in quarantine and isolation centers as a preventive measure against the spread of the disease (Denis et al., 2020). However, many of the suspected victims of the coronavirus have been objects of stigma and discrimination in Ghana. A recovered Ghanaian COVID-19 patient mentioned that he felt stigmatized by terrified medical officers because he was the first COVID-19 patient. He felt lonely and had various forms of anxiety about the certainty of his survival from the disease. In a personal interview, he said:

‘The medical officers did not want to come close to me. I was given a device to check and send my daily body temperature every morning and evening to the medical officers via telephone. They left my food deliveries at the entrance and had to pick on my own. I had no company and I felt depressed. I lost my appetite for food’ (A recovered Ghanaian COVID-19 patient, Male, 44 Years).

Foreigners and Ghanaian citizens who are returnees from COVID-19 hotspot countries have been quarantined at hotels so that they could be tested for coronavirus disease. Some of them have complained about the poor treatment given to them by hotel attendants. Some do mention that their meals were placed at the doors of their room on bare floors while others have mentioned that their room has not been cleaned for days (TV3 Joy Online News, 2020). The hotel attendants had a fear of contracting the coronavirus from these suspected persons under quarantine. Because of the social stigma, suspected persons are anxious, confused, and angered by the condition they find themselves in (Rana et al., 2020). They have to deal with various degrees of psychological distress from the stigma from the hotel attendants and medical officers. They are restless, knowing that they have to be socially isolated from their friends and family for close to 28 days. Brooks et al. (Brooks et al., 2020) agree that stressors such as a long quarantine period, fear of contracting the disease, inadequate supplies, stigma, and boredom from social isolation from quarantine can have serious psychological impacts on such suspected COVID-19 persons.

Upon returning from isolation centers and testing negative to the COVID-19, such persons are often stigmatized by their community and even by their friends. A quarantined person who tested negative to COVID-19 told the researchers that his friends and his community members despised him and run away from him upon returning from the isolation center. The stigma continues for a long period for quarantine returnees who are not at risk of spreading the virus (Korte et al., 2020). This could result in psychological stress or even worse, moderate to mild mental health disorders (Cummins, 2020).

Stigma against Ghanaian Returnees and foreigners from COVID-19 hotspot countries

There have been several calls from the Ghana Health Service and the Ghana Psychology Council to address all forms of stigmatization against Ghanaian returnees and foreigners from COVID-19 hotspot countries (Dapaa, 2020), where there have been many reported cases. A large section of the Ghanaian populace holds the notion that the disease is for the white-skinned and their associates. Therefore, Ghanaian returnees from foreign countries, referred to as Bogas (Well-to-do financially) and foreigners with white skin, especially those of Asian descent, are stigmatized and discriminated against by some section of the Ghanaian populace. The researchers interviewed a Ghanaian returnee from Bronx, New York, the U.S.A. who resides in a community in Kumasi, Ghana. He alleged that he has been stigmatized upon returning home by some relatives, friends, and neighbours though he has tested negative to the COVID-19. He lamented:

‘When I came from the U.S. A, my relatives and friends who usually come to visit anytime they hear that I have returned did not come to visit this time around. Sadly, efforts to visit them myself have proved futile as they have not opened their doors for me. They fear that I may infect them with COVID-19’ (A Ghanaian Returnee from the U.S.A, Male, 41 Years).

Another Ghanaian returnee from Korea who even came to Ghana before the lockdown was stigmatized by those living in his community. He said in an interview that the situation has even affected the economic activity of his aged parents who sell water from their dug-well in their house for a living. Because their house is labeled as a COVID-19 infectious house, no community resident wants to fetch water from their house (A Ghanaian returnee from Korea, Male, 37 Years).

In another interview, a Ghanaian returnee from the U.K. likewise told the researchers that he and his family also faced stigmatization from members of their community. He disclosed in a personal interview that her sister has closed down her Hair Do Shop (a business establishment for plaiting hair) because of no patronage from community members (A Ghanaian returnee from the U.K, Male, 44 Years). These findings corroborate the view of Earnshaw (Earnshaw, 2020) that travelers from COVID-19 prone countries face stigmatization and discrimination from their community members upon returning home.

Likewise, some foreign nationals, especially those from Asian countries have been unjustly stigmatized (2019Shimizu). This is because of the misinformation and tagging of the COVID-19 to residents from Asian countries (Earnshaw, 2020). The three Chinese nationals who were interviewed mentioned how they were discriminated against and stigmatized. They mentioned in an interview that no passenger wanted to sit in public transport they boarded prompting them to board a private taxi at a higher cost. They also said the drivers hooted them and insulted them as being carriers of coronavirus. They added that they have also closed down a restaurant they own in Kumasi because of no patronage and also for fear that the angry community members who label them as coronavirus carriers may burn down their establishment (Three Chinese nationals: 1. Male, 34 Years; 2. Male, 39 Years; 3. Female, 30 Years).

The lead investigator of this study also observed how people run away from two Chinese nationals who were buying items in a popular market square. Market women drove them away from the market, refusing to sell their items to them. The wrong stereotyping of people of Asian descent with the coronavirus (Goh et al., 2020) has been the main reason for such discrimination and stigmatization. The CNN (CNN, 2020) news report that Chinese nationals have faced various forms of stigmatization has been substantiated by the findings of our study. As Lu et al. (Lu et al., 2020) noted in their study, Chinese nationals who are stigmatized and stereotyped as carriers of the coronavirus are deeply hurt and psychologically traumatized. UNICEF (The social stigma, 2020) has lashed out on individuals, governments, and media outlets who wrongly label all Chinese nationals and those of Asian descent as carriers of the coronavirus. This action by UNICEF is laudable and commendable. Divisiveness among global communities would only make our efforts in the common fight against the coronavirus pandemic futile (World Health Organization, 2020).

Stigma against COVID-19 patients, caregivers, frontline health workers, and their respective families

Caregivers, frontline health workers, and COVID-19 patients are possible targets for stigmatization and discrimination (International Federation, 2020; Rajkumar, 2020). The Upper West Regional Minister of Ghana, Dr. Hafiz Bin Salih has warned against the stigmatization of COVID-19 patients, their relatives, communities that have recorded cases of the disease, caregivers, and frontline health workers, claiming that such actions by some members of the general public would draw back the efforts that the country is putting in place to prevent and control the spread of the virus (Ghana News Agency, 2020). The findings of our study revealed that more has to be done to educate the general public on the need to expunge all forms of stigmatization against COVID-19 patients, caregivers, and frontline health workers. A Ghanaian COVID-19 recovered patient in an interview told us that he and his family have had to deal with stigmatization from members of their community. He said:

‘Some members in my community have labeled my house as a COVID-19 infected house. Owners of retail shops in my vicinity do not want to sell items to me or my family members. They claim our monies have been infected with COVID-19. But I have recovered and tested negative for the coronavirus and so are my family members. We feel disappointed and very sad that our neighbours and friends have turned their backs on us when we need them most’ (A recovered Ghanaian COVID-19 patient, Male, 38 Years).

Similarly, the family of a young boy who died of COVID-19 is facing stigma from community members who call them names and despise them even though none of the family members is a carrier of the coronavirus. They mentioned that they are depressed and are grieved greatly as a result of the stigma. Two market women in the family who have also tested negative to the COVID-19 mentioned the stigma and discrimination that has been meted against them by their fellow market women. They said:

‘We have been refused entry into the market to sell our products. Everyone thinks we are infected with the COVID-19. We are deeply sad and disturbed psychologically’ (Family members of a COVID-19 deceased person, 1. Female, 46 Years; 2. Female, 34 Years).

Such actions could result in serious psychological distress or even mental health disorders for the members of the family who are emotionally broken as a result of the death of their loved one. At these times, such family members need support from friends and the community to be able to cope with the difficult times. Fresh grief from the loss of a relative to the COVID-19 could be very daring. Sadly, when such people are ignored and made to mourn their dead alone, they would likely experience untold anxiety, depression, and complicated grief (Cummins, 2020). Social isolation from relatives and friends of deceased victims can result in long-lasting grief and worse mental and physical health (Briunsma et al., 2015). Thus, it is improper to stigmatize such a grieving family.

The family of a COVID-19 suspected man also faced stigma from their community members. In an interview, the man said that their society members do not want to have anything to do with him and his family. He continued that members of his community finger-point and mock his family (COVID-19 Suspected Infected Person, Male, 48 Years). An advisor to the COVID-19 National Response Team-Ghana, Dr. Ama Edwin warned against the stigmatization against relatives of COVID-19 suspected patients. She said that such stigmatized persons have been unjustly robbed of their social status in society and mocked, which could result in serious psychological distress (Andoh, 2020). Stigmatization also has a negative social impact. Because society members do not want to experience the pain of social isolation, they are less likely to get tested or seek treatment if they experienced symptoms (Earnshaw, 2020).

Frontline health workers who are putting their lives on the line of duty have been socially shunned and stigmatized because of their contact with COVID-19 patients or suspected persons (IASC, 2020; Fraser, 2020). These frontline health workers, including nurses, doctors, ambulance drivers, case identifiers (Contact tracers) are all targets of discrimination. Some nurses who were interviewed told the researchers that when the COVID-19 emerged in Ghana, they were at high risk of stigmatization by the general public. They told the researchers in a focus group discussion as follows:

‘Anytime we boarded public transport, people do not want to sit beside us for fear that they might contract the COVID-19 virus. The members of the general public claim we work closely with all patients and some of them might be carriers of the COVID-19' (5 Females Nurses of the age range of 20–35 years).

Aside facing stigma from members of the general public, some frontline workers have to stand verbal stigma from relatives and friends. The medical doctors interviewed remarked that some of their friends and relatives deliberately shunned their company. This finding corroborates the views of the IFRC (International Federation, 2020) that frontline health workers are likely to face ostracization from members of their family and their friends. Aside having to deal with the stigmatization from friends, family, and the community, frontline health workers have to cope with their fears and anxiety of contracting the virus (Maunder et al., 2003). Lai et al. (Lai et al., 2020) noted that healthcare workers on the frontline and are directly involved in the diagnosis, treatment, and care of COVID-19 patients are likely to develop psychological distress and other mental health symptoms. The ever-soaring number of confirmed and suspected cases, having to work for long hours, widespread media coverage of the COVID-19 pandemic are likely to result in some mental distress for many frontline health workers (Lee et al., 2020). Saddled with stressful work schedules and stigmatization, many of these frontline health workers may not have the pleasure of going to work or would wish to quit their jobs (Bai et al., 2004) as a result of the anxiety, insomnia, depression, and distress they experience. Therefore, instead of increasing their psychological distress by stigmatizing and discriminating against them, society must offer their kind support to these hardworking frontline health workers (Andoh, 2020).

Psychosocial strategies for dealing with psychological distress and mental health disorders from COVID-19 global pandemic

In this section, we present results and discussions of time-tested strategies that can be implemented by all persons who have faced stigmatization or discrimination as a result of the COVID-19. Some of the practical suggestions are those from recovered COVID-19 patients, discharged quarantined persons, mental health officers, and psychologists.

Acknowledge your emotions

In the wake of infectious disease, people may feel anxious about their health status and the health status of others they believe may have been exposed to the disease (Substance Abuse and Mental Health Services Administration, 2014). The feeling of sadness, stress, confusion, and anger is normal during a crisis. What is worth knowing in periods of crisis is how our bodies can be reinforced against anxiety. Keeping connected and maintaining social networks can help maintain a sense of normalcy and provide valuable outlets for sharing feelings and relieving stress (Wilson, 2020). Sharing thoughts and having practical communication with friends and relatives or health professionals can reduce adverse psychological responses and increase behavioral adherence. Granted, in periods of quarantine and isolations as a result of the COVID-19, physical contact may not be possible. In these times, the frequent use of internet-based video communication such as Zoom, Google Duo, Skype and telephone communications with loved ones can reduce the possible stressors that might have resulted in either psychological distress or mental disorders (Cummins, 2020). A discharged quarantined COVID-19 person told the researchers:

‘I always keep in touch with my aged mother and two sisters as well as my girlfriends. I mostly use zoom to have a video chat with them. When the network is poor, I give them telephone calls. The upbuilding and refreshing conversations I have with them keep my hopes alive and revert my loss of appetite’ (Discharged quarantined person, Male, 52 Years).

Keep things in perspectives

It is a frightening time and you must stay informed, so you adhere to safety precautions and do your part to slow the spread of the virus (Smith & Robinson, 2020). But there is a lot of misinformation and myths that only feeds into fear (Mostafa et al., 2020; 2019Shimizu). It is important to be discerning about what you read and watch. Opening up to all sorts of information can make you obsessive hence stick to trustworthy sources for information on the COVID-19 such as the CDC, the World Health Organization, and local public health authorities. Limit worry and agitation by lessening the time you spend watching or listening to upsetting media coverage (Wilson, 2020). Get yourself informed by relying on credible sources. In moments of anxiety, take a break from watching the news and focus on things that are positive in your life and things you have control over (Wilson, 2020). These are exactly the things that one of the recovered COVID-19 patients told the researchers:

‘I regularly visit the website of the Ghana Health Service for live updates of the COVID-19 situation in Ghana. I read reliable facts about the coronavirus from the WHO website.’ (Recovered COVID-19 Patient-2, Female, 51 Years).

A discharged suspected COVID-19 person who was quarantined told us that he always watched movies and listened to music to take off his anxiety and worries of the COVID-19. Another discharged suspected person disclosed to us that he always gets himself busy by cleaning his hotel room, washing his few clothes, and exercise. These activities helped in taking their minds off their uncertain health conditions.

Practice mindfulness and acceptance

The outbreak of the Coronavirus pandemic has heightened uncertainty among us. However, as human beings, we wish to have a sense of security and have a feeling of control over our lives. Fear and uncertainty may lead to stress and anxiety (Smith & Robinson, 2020). They can keep you worrying about what tomorrow may bring. According to Wilson (Wilson, 2020), asking the question “what now” rather than “why” will help. Instead of constantly blaming yourself about why you got infected or have been quarantined, contemplate what you must do to help you treasure positive thoughts. One of the recovered COVID-19 patients interviewed by the researcher said:

‘When I am depressed and uncertain of my health condition, I resort to prayers because anytime I tell God what I feel, I regain my strength. Also, I contemplate the happy moments I have had with my family in the past and why I am striving hard to get well to unite with my family and bring joy to their faces. These positive thoughts and actions lessened my distress and anxiety’ (A recovered Ghanaian COVID-19 patient, Male, 46 Years).

COVID-19 patients must practice patience with themselves and others. They should allow things to unfold and assume others are trying to do the right thing. They must remain optimistic about what tomorrow may bring.

Be mindful of your assumption about others

In the event of an infectious disease outbreak, many people become over-anxious and skeptical. The fear of contracting the disease could alter people's attitudes (Robert et al., 2014). Our perception toward each other and the worry of getting into close contact with people showing symptoms similitude to the pandemic make people rush to making uncertain conclusions (Wilson, 2020). For example, someone who has a fever does not necessarily have coronavirus. Though self-awareness is important in the wake of a crisis, it should not lead to stigmatizing others in our community, one of the psychologists interviewed said (Psychologist-2, Female, 49 Years).

Utilise your thoughts to effectively manage worry

It is natural to be concerned about what may happen next when events are out of our control (Smith & Robinson, 2020). For example, people worry about their children now that they have to stay home from school (International Federation, 2020). Thinking about these uncertainties may lead to worry or anxiety. When irrational fears and worries take hold, it can be hard to think logically and accurately. In the event of such imbalance, Wilson (Wilson, 2020) suggests the use of thought control skills like the “Worry Container”. According to Wilson (Wilson, 2020), the “Worry Container” activity involves picturing in detail a container or a box with a lid that closes. Visualize things that keep you anxious. Imagine moving them from your mind and placing them into the container. The container will hold whatever you place in it. Close the container firmly and move it to one side to allow you to focus on other things that you can control. One of the psychologists stressed:

‘Engaging in mindful activities during isolations due to the COVID-19 could help in improving the physical health of patients and suspected persons of the coronavirus by reducing stress, lowering blood pressure and improving sleeping habits’ (Psychologist-1, Female, 53 Years).

Seeking counselling and psychotherapy services

Persons who are psychologically disturbed because of stigmatization must seek counsel on how to cope with the stress before it aggravates into serious mental health disorders. It is appropriate to admit that you are sick and that you must seek professional advice and assistance to cope with the increasing anxiety, distress, and pain from COVID-19 stigma from appropriate psychological and mental health support systems (Rana et al., 2020). Counselling and psychotherapeutic services must be sought by COVID-19 patients, their relatives, frontline health workers, and all who have been affected by the COVID-19 pandemic. The national response team for COVID-19 must have a psychosocial support system available to offer the needed assistance for persons who have psychological distress from stigmatization. Free toll hotlines for these services must be readily available.

Also, in the planning of interventions to reinforce COVID-19 stigmatized persons, frontline health workers must be targeted as they have to deal with even higher forms of psychological distress (Lai et al., 2020). The relatives of suspected COVID-19 patients interviewed mentioned how they benefitted from the services provided by the psychologists in the national COVID-19 response team. They told the researchers how they offered the needful counsel that calmed them down to cope with the stigma they faced from their communities. The children of a man who was put in an isolation treatment center told the researchers that:

‘We were highly depressed by the health condition of [his children] our father, fearing that he might die from the COVID-19. Our community members run away from us anytime they cited us. We were emotionally restless. However, the psychologists who came to us frequently in our house counselled us all the time. They advise and suggest what we needed to do to cope with the stigma (Children of a Recovered COVID-19 Patient, Female child, 22 Years; Male child, 20 Years).

The way forward in public health education against stigmatization against COVID-19 victims

Public health authorities have used a variety of methods in an attempt to reduce the stigma associated with infectious diseases. In the wake of the Coronavirus pandemic, we suggest the following practical strategies, many of whom were shared by psychology and mental health experts, some of whom were interviewed for the study.

Stigma must be envisioned during an outbreak

The perception that an individual may be a carrier or simply exposed to those with infectious diseases is common during an outbreak. Stigma is common and mostly unfolds when a disease is perceived as dreadful. Infectious diseases like Ebola, HIV, and SARS have a record of sigma during its outbreak (Chang & Cataldo, 2014; Lin et al., 2010). The population most often stigmatized include individuals from affected countries, international travelers, citizens in hotspot zones, and health care workers from affected facilities, and it may extend to family members of healthcare workers (Mostafa et al., 2020). Public health officers and psychologists must always envision stigma during an outbreak of disease that may empower public health authorities in their planning. Doing this would assist them in coordinating efforts to address the stigma and along these lines possibly balance its negative impact. The view expressed by one of the mental health officers interviewed emphasized this:

‘Plans and interventions on how to deal with stigma must always be part of the robust national preventive machinery for the outbreak of any pandemic such as the COVID-19. This is important as the canker of stigma is evident in the eve of every pandemic’ (Mental Health Officer-2, Female, 52 Years).

The underlying causes of stigma must be understood through a rigorous assessment of public knowledge on the COVID-19 global pandemic

Assessing public knowledge about the pandemic could help in identifying the myths and misinformation people have about the disease. Misinformation and myths are key contributors to stigma (Mostafa et al., 2020). It is, therefore, vital to assess people's views, beliefs, and what they are hearing and saying about the pandemic. One effective way of gathering public views about the pandemic is to have a platform for the public around the world to discuss their issues and opinions (Akram & Kumar, 2017). Analyzing social media posts and messages could be a rich source of obtaining misinformation and myths about the pandemic. This approach may call for significant expertise and time. The services of social media experts could help. These approaches would provide information about where people might lack knowledge, which, in turn, could help determine where stigma might arise. The method or approach used in gathering information should be valid and reliable. Public surveys and polls via scientific procedures for data collection were suggested by one of the psychologists interviewed as one of the effective means of gathering public knowledge about the pandemic.

Extensive public education on the COVID-19 stigma and its negative implications

Education is a powerful tool to deconstruct stigma and the harmful stereotypes against particular nationalities such as Asian Americans (Earnshaw, 2020). Public education is most effective when respected community group leaders and celebrities serve as a conduit to disseminate information to individuals and groups who might mistrust the government or other sources. Therefore, in the outbreak of a disease, government organizations should partner with respected community groups and leaders to spread information on the need to expunge stigma. Using public figures could help spread valuable information about stigmatization to the public. Besides, the education of the public should be done through community campaigns aimed at fighting stigma. According to Fischer, Mansergh, Lynch, and Santibanez (Mostafa et al., 2020), when public message directly counters stigmatization of groups or individuals, it helps in addressing disease-related stigma. Disease responders can develop and disseminate messages through public outreach and social marketing campaigns with trusted community leaders and subject matter experts. Working with community leaders or peer role models for messaging can be helpful. Engaging community leaders or peer role models could help to channel health messages and interventions for specific populations because the experience of disease-related stigma can vary across groups (Malavé et al., 2014).

One of the psychologists also suggested the engagement of recovered COVID-19 patients to give positive experiences of the coronavirus disease and the need not to stigmatize and discriminate against people because they have contracted COVID-19. Also, online and electronic media should be used in creating local websites for delivering medical advice (Zheng, 2020) on the dangers of stigmatization of persons who have been associated with the COVID-19 infection. One of the mental health officers interviewed commended the Government of Ghana for giving a regular situational update on the COVID-19 via the Ghana Health Organization website and via press releases and media encounters by the Ministry of Information and the Ministry of Health to speak and discuss openly the COVID-19 and its associated stigma (Mental Health Officer-2, Female, 52 Years).

In Ghana, there have been several public concerns that most of the information on the COVID-19 is delivered in English. To prevent this situation, the Ghana government must engage the services of the National Commission for Civic Education (NCCE) to translate all COVID-19 related information into the local languages for the entire population especially the older adults in the majority of the rural communities in Ghana who are not competent in English to be able to understand the information.

Implement practical intervention programs to reduce stigma

Interventions may focus on providing support for affected persons, changing behavior among people who stigmatize in the general population, and eliminating or controlling the stigmatized condition. Interventions that could help reduce stigma include intensive education. For example, as more information about the Coronavirus pandemic becomes available and easily accessible to the public over time, individual fears that lead to stigma may be reduced. Target populations for intervention may include community leaders, religious leaders, peer role models and people with infection could be used. Creating opportunities for affected groups to interact with unaffected groups is a promising approach to reduce stigma, particularly when combined with information-based interventions (Brown et al., 2003). A legal intervention like invoking laws or policies prohibiting stigmatization and discrimination could also help reduce stigma. Also, contact-based intervention may include counselling, engaging in one-on-one conversation, or listening to a testimonial from an affected individual (Mburu et al., 2014).

Rana et al. (Rana et al., 2020) advise the development of a Psychological Crisis Intervention Model (PCIM) which is deployed through internet technology. This PCIM should consist of a team of experts such as physicians, psychiatrists, psychologists, and mental health officers as well as social workers to deliver the early psychological intervention to patients, families, and medical staff. In developing countries where there are challenges with internet infrastructure, nationwide psychological assistance telephone hotlines must be made available (Lai et al., 2020). Interventions designed to reduce stigma should be evaluated regularly. Evaluation in this context involves making a judgment about how successful the interventions were (Coleman, 2001). Thus, evaluation calls for undertaking a process to provide information to be used as a basis for judging a situation. Such useful information is obtained through assessment (Overton, 2012). The assessment of interventions should be carried out by members of the evaluation team and should have a clear understanding of the program or intervention's goals and objectives. Assessment tools like surveys, interviews, and reports can be used in the evaluation process to obtain feedback from those who delivered and from those who received the interventions to assess not only whether the interventions worked, but also whether they reached the target groups (Mostafa et al., 2020; Overton, 2012). The evaluation process can help in monitoring public reaction to information which will serve as a basis for improvement.

Conclusion

The study has investigated the psychological distress and mental health disorders faced by COVID-19 victims as a result of stigmatization. The key findings of the study have shown that community members showed apathy towards the COVID-19 victims and demonstrated social rejection. The views expressed by the COVID-19 victims indicate that they are psychologically distressed and might lead to mild to severe forms of mental health. This often leads to loss of self-esteem, self-dignity, and social isolation due to stigma. For the patients who have tested positive for the COVID-19, stigma can make the recovery process very difficult as some may not eat healthily, take their medications, and refuse to observe safety protocols because of loss of hope. Many of these COVID-19 victims could resort to suicide, quitting of job, development of hatred, and other forms of negative actions that could put their lives in great peril or culminate into untimely death. The study has suggested various psychosocial intervention strategies for all persons affected by the COVID-19. These include acknowledging their emotions, keeping things in perspective, engaging in mindful activities, being mindful of their assumptions about others, effectively using their thoughts in such a way to manage worries, and seeking counselling and psychotherapy assistance. Also, the study has discussed the actions that should be taken by the appropriate bodies in preventing COVID-19 related stigma and the coping mechanisms they should employ in helping victims of COVID-19 related stigma. It suggests that regulatory agencies like the Ghana Psychology Council, the Psychiatry and Mental Health Association, the Ghana Health Service, and other allied institutions should envision stigma during pandemic outbreaks and make the needful arrangement towards it. Also, the study urges these bodies to conduct an extensive assessment of the public knowledge about the COVID-19 pandemic to know the underlying causes of the stigma. Finally, embarking on an intensive public education on the COVID-19 stigmatization and its negative implications, and implementing a well-developed intervention program for stigma would assist in rooting out all forms of stigma against COVID-19 among the Ghanaian general public.

Conflict of interest form

The authors declare that there is NO conflict of interest.

Credit author statement

All the authors contributed equally to the manuscript preparation.