Introduction

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), ^{Reference Harapan, Itoh and Yufika1} was declared as a pandemic by the World Health Organization (WHO) on 11 March 2020 due to its alarming level of spread and severity. ² The emergence and spread of COVID-19 has caused confusion, anxiety and fear, and led to stigma on certain populations for being the reason for this outbreak. ^{3,Reference Ren, Gao and Chen4} In the era of social media as it is today, myths and fake news around COVID-19 also spread rapidly, creating fear and stigma among the society. ^{Reference Roy, Tripathy, Kar, Sharma, Verma and Kaushal5} There was frequent use of terms like “Chinese virus” or “China virus” instead of COVID-19 on Twitter, indicating that stigma may be perpetuated on social media. ^{Reference Budhwani and Sun6} A rise of stigma against people from China was also observed in Indonesia at the early phase of the pandemic, where the disease was referred to as “Chinese virus,” or as a punishment for Chinese suppression of Uighur Muslims. ^{Reference Jemadu7}

Stigma against particular ethnic groups was also reported in previous outbreaks. ^{Reference Person, Sy, Holton, Govert and Liang8–Reference Qarawi, Ng and Gad11} Fear, stigmatization, and discrimination towards Russian Jewish immigrants was reported in New York City during the typhoid and cholera outbreak in 1892. ^{Reference Craddock and Markel10} The Chinese-American community in San Francisco faced extreme discrimination during an outbreak of bubonic plaque in 1900, attributed to rats transported from Hong Kong. ^{Reference Person, Sy, Holton, Govert and Liang8} An outbreak of hantavirus in the United States in 1993 led to fear, stigmatization, and discrimination towards native Americans due to reports that referred the infection as a Navajo disease. ^{Reference Childs, Kaufmann, Peters and Ehrenberg9} During the severe acute respiratory syndrome (SARS) outbreak, stigma towards people who look Asian in the United States was reported, although the country was not severely affected. ^{Reference Person, Sy, Holton, Govert and Liang8} Stigma against health care workers (HCWs) also often occurs during outbreaks, due to their close contact with patients. ^{Reference Person, Sy, Holton, Govert and Liang8,Reference Qarawi, Ng and Gad11}

Studies suggest that stigma is associated with negative health outcomes. ^{Reference Budhwani and De12–Reference Pachankis, Hatzenbuehler and Wang14} Stigma and discrimination negatively affect public health efforts in diseases such as mental illness, epilepsy, tuberculosis, leprosy, and HIV/AIDS. ^{Reference Person, Sy, Holton, Govert and Liang8,Reference Budhwani and De12,Reference Turan, Budhwani and Fazeli13} Stigma caused people with HIV to hide their disease, avoid voluntary testing and counseling, and not seek for treatment, which pushed the epidemic underground. Fear of being stigmatized during an outbreak may cause people to deny clinical symptoms and not seek medical care. ^{Reference Roy, Tripathy, Kar, Sharma, Verma and Kaushal5,Reference Person, Sy, Holton, Govert and Liang8} Furthermore, stigma may lead people to distrust the government, health professionals, and the health care system. ^{Reference Budhwani and Sun6,Reference Budhwani and De12,Reference Turan, Budhwani and Fazeli13} In the context of the COVID-19 pandemic, public health measurements taken to contain the outbreak such as mask use, quarantine, and isolation fueled stigma towards the disease. ^{Reference Logie and Turan15} It is therefore imperative that people trust their government and health care systems, so that they will be cooperative. ^{Reference Budhwani and Sun6}

Stigma associated with a particular disease is very dangerous, in particular if it comes from HCWs, as it may lead to poor health care service provision, and even denial of treatment to patients. ^{Reference Zarei, Joulaei, Darabi and Fararouei16} According to previous studies, factors associated with stigma among HCWs include inadequate knowledge of the disease, irrational fear, working at an educational or public hospital, low level of education, and being male. ^{Reference Zarei, Joulaei, Darabi and Fararouei16–Reference Harapan, Khalilullah and Anwar21} Inadequate knowledge of transmission routes may lead to irrational fear and overestimated risk, which can be followed by stigma. ^{Reference Zarei, Joulaei, Darabi and Fararouei16,Reference Harapan, Khalilullah and Anwar19} As a newly emerging disease, knowledge about COVID-19 is still limited, thus people rely more on social media, where misconception and myths that create stigma often occur. ^{Reference Budhwani and Sun6,Reference Bhagavathula, Aldhaleei, Rahmani, Mahabadi and Bandari22} With regard to gender, men showed more stigmatizing attitudes compared to women. ^{Reference Zarei, Joulaei, Darabi and Fararouei16} Studies also showed that HCWs had higher perception of risk in others, as they feared getting infected with COVID-19, ^{Reference Zhang, Zhou and Tang23} which may also lead to stigma.

The authors are aware of some studies exploring the stigma experienced by HCWs during the COVID-19 pandemic. ^{Reference Ren, Gao and Chen4,Reference Qarawi, Ng and Gad11} There has however been no study exploring the views of HCWs themselves towards the disease. Stigma and other negative attitudes associated with the disease may harm public health measurements during pandemic like this. Therefore, this study was undertaken to assess the stigma associated with COVID-19 among HCWs in Indonesia.