Association of stigma with mental health and quality of life among Indonesian COVID-19 survivors

Abstract

Background and objective

Coronavirus disease 2019 (COVID-19) survivors face societal stigma. The study aims to analyze the association of this stigma with the mental health and quality of life of COVID-19 survivors.

Methods

In this cross-sectional study, we observed 547 adults who were previously documented as severe acute respiratory syndrome coronavirus (SARS-CoV-2) positive by a polymerase chain reaction (PCR) test, treated in a hospital or an emergency hospital and proven to be SARS-CoV-2 negative by their latest PCR test. We adopted the Berger HIV Stigma Scale to measure stigma; the World Health Organization Quality of Life Brief Form to measure quality of life; and the Mental Health Inventory-38 to measure mental health. The chi-square and binary logistic regression tests were used to find the correlation between the variables.

Results

The multivariate analysis revealed that medium stigma was more likely related to quality of life and mental health than low stigma. Females were less likely to experience stigma related to mental health than men, and respondents who worked as laborers and entrepreneurs were less likely to experience stigma related to mental health than those who worked as civil workers/army personnel/teachers/lecturers. COVID-19 survivors experienced medium stigma in society and lower quality of life and mental health status. We found that quality of life and mental health were affected by stigma, sex, and occupation.

Conclusion

COVID-19 survivors are a vulnerable group that is most at risk when they return to their communities. Creating a safe environment and providing respectful care, including addressing complex stigma factors, is vital for developing appropriate interventions.

About the Authors:

Joni Wahyuhadi

Roles Data curation, Writing – original draft, Writing – review & editing

Affiliation: Department of Neurosurgery, Soetomo General Hospital, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia

Ferry Efendi

Roles Conceptualization, Data curation, Formal analysis, Software, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation: Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia

ORCID logo https://orcid.org/0000-0001-7988-9196

Makhyan Jibril Al Farabi

Roles Conceptualization, Formal analysis, Software, Writing – original draft, Writing – review & editing

Affiliation: Department of Cardiology and Vascular Medicine, Universitas Airlangga, Surabaya Indonesia

Iman Harymawan

Roles Data curation, Writing – original draft, Writing – review & editing

Affiliation: Faculty of Economy and Business, Universitas Airlangga, Surabaya, Indonesia

Atika Dian Ariana

Roles Conceptualization, Formal analysis, Software, Writing – original draft, Writing – review & editing

Affiliation: Faculty of Psychology, Universitas Airlangga, Surabaya, Indonesia

Hidayat Arifin

Roles Conceptualization, Formal analysis, Software, Writing – original draft, Writing – review & editing

Affiliation: Department of Medical-Surgical, Critical, Emergency, and Disaster Nursing, Faculty of Nursing, Universitas Padjadjaran, Bandung, Indonesia

Qorinah Estiningtyas Sakilah Adnani

Roles Data curation, Writing – original draft, Writing – review & editing

Affiliation: Department of Public Health, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia

Inbar Levkovich

Roles Data curation, Writing – original draft, Writing – review & editing

Affiliation: Faculty of Graduate Studies, Oranim Academic College of Education, Kiryat Tiyon, Israel

Introduction

The coronavirus disease 2019 (COVID-19) pandemic has affected the worldwide population, thus creating a burden of disease and mortality and an unprecedented impact on social life [1, 2]. According to the World Health Organization (WHO), on February 18, 2021, more than 109 million cases had been confirmed and approximately two million deaths had occurred across 223 countries [3]. Insufficient knowledge and contradictory information about the severity of and protection against severe acute respiratory syndrome coronavirus (SARS-CoV-2) has increased anxiety among the population [1]. This uncertainty and anxiety have led people to easily believe vague and biased information from the media, social media, and self-proclaimed experts [4]. At the same time, this rapidly spreading and unpredictable pandemic has led to the imposition of social stigma and discrimination against COVID-19 survivors [5, 6]. According to the WHO, “all efforts must be taken to scientifically destigmatize COVID-19 instead of statutory sermons by lawmakers” [7]. Usually, stigma develops when people are afraid and believe that COVID-19 survivors are still contagious.

Indonesia is one of the countries that has suffered remarkably in terms of the number of COVID-19 cases. With approximately 270 million inhabitants of over 300 ethnicities scattered across 34 provinces, morbidity and mortality associated with COVID-19 in Indonesia are among the highest the world wide, and together with India and Sri Lanka, Indonesia continues to report the highest number of new cases and new deaths in Southeast Asia, thus contributing to the global burden of COVID-19 cases [8]. Global statistics on February 17, 2021 revealed that Indonesia reported a large number of new cases (9687) and 192 new deaths, which marked more than a million confirmed cases and 33788 deaths since the first case was reported in March 2020 [9].

Although the Indonesian government has implemented certain interventions, including quarantine, travel restrictions, social distancing, and health education (e.g., encouraging wearing masks and hand washing), the virus continues to spread through community transmission [10]. The fundamental strategy for hospitals and health workers has been for essential core health services to be intensified to deal with COVID-19 cases; however, the country has struggled to prevent community transmission. The high number of health worker deaths due to COVID-19 invited speculation on health workers’ job insecurity, insufficient health supplies, and inadequate health facilities and resources (10). Thus, the trend of a high number of newly confirmed cases and new deaths due to COVID-19 is still tracking nationally [11].

As Indonesia continues its effects to reduce the number of new confirmed cases and new deaths, the incidence of stigma toward COVID-19 survivors in social media has become a serious concern [11]. People who have recovered from SARS-CoV-2 infection may experience multiple types of stigma, such as anticipated stigma, i.e., fear of being tested for SARS-CoV-2, perceived stigma, i.e., feeling judged by others, and internalized stigma, i.e., experiencing shame and self-rejection [1]. Many COVID-19 survivors have even reported discrimination, stereotyping, and job loss as a result of people associating them with a deadly disease [6, 12]. Social stigma has also negatively affected social justice for COVID-19 survivors because a stigmatized person cannot actively participate in society [13]. Some COVID-19 survivors have suffered severe mental distress even after discharge and rehabilitation [14, 15]. All of these phenomena can reduce the quality of life and mental health of COVID-19 survivors [16, 17]

The Quality of Life (QoL) scale is an important measurement of the impact of COVID-19 infection on the physical, mental, and social domains of COVID-19 survivors. Assessing QoL helps health care providers identify key factors affecting QoL and recognize the aspects of COVID-19 management that can be improved to enhance the QoL of COVID-19 survivors [18]. A total of more than one million confirmed recovered COVID-19 cases out of more than six million tested in Indonesia raises the question of the needs of COVID-19 survivors when discharged from the hospital [19]. An understanding of COVID-19 survivors’ stigma associated with mental health and QoL is critical and will enable policy-makers to better understand the patterns of the pandemic and design more targeted programs for this group. To date, few studies have used primary data to evaluate this stigma and its impact on COVID-19 survivors, and none have focused on Indonesia. Therefore, the present study aimed to expand upon and quantify stigma and its impact on the QoL and mental health status of the general community of COVID-19 survivors.

Materials and methods

Design and participants

We conducted a cross-sectional study of adult COVID-19 survivors in East Java Province, one of Indonesia’s 34 provinces. According to statistics, East Java has one of the highest numbers of confirmed COVID-19 cases, deaths, and recoveries [7, 9]. Adults aged 20 or older who recovered from COVID-19 in Indonesia were recruited from a COVID-19 Survivors Community registry. The study was conducted over two months from October 1 to December 1, 2020. The number of required samples was calculated using a 95% confidence level, and an assumed 50% distribution of results [19], with a minimum sample size of 334 required. Participants in the study were COVID-19 survivors who were previously diagnosed as SARS-CoV-2 positive from a PCR test, treated in hospital, and proven to be SARS-CoV-2 negative by their latest PCR test. The COVID-19 survivors enrolled in our study were defined as older than 20 years of age and of either gender by convenience sampling. COVID-19 survivors were eligible for the study if they were willing and able to participate and provided online informed consent. All participants provided digitally signed informed consent. A total of 547 COVID-19 survivors agreed and consented to participate in the study. This study was approved by the Health Ethics Committee, Faculty of Nursing, Airlangga University, under reference number 2105-KEPK. The Strengthening the Reporting of Observational studies in Epidemiology (STROBE) statement was used as the standard for writing this study, and all of the methods used were performed in accordance with the relevant guidelines and regulations [20].

Procedures

Recruitment of participants was conducted through an online platform, the COVID-19 Survivors Community registry. Potential respondents were identified from this registry, and an invitation via a one-to-one private WhatsApp message was sent to each survivor. Their responses were obtained by data collectors (aged > 20 years) trained in research methods, and they were neither students nor trainees. Once the data collectors received feedback from the COVID-19 survivors, they were assessed for eligibility against certain criteria. The respondents who met the criteria were provided with brief information about the study, and those who agreed to participate were enrolled and invited to participate via questionnaires, which were circulated through an online platform. Those who were interested in joining the survey were asked to voluntarily fill out the online form.

In this study, we measured three aspects of post-COVID-19 life: stigma, QoL, and mental health. All the questionnaires were translated into Bahasa Indonesia and pilot tested prior to the study. Validation was conducted before using this measurement tool. Stigma among COVID-19 survivors was measured using the Berger HIV Stigma Scale questionnaire, which was adapted for COVID-19 stigma [21]. Cronbach’s alpha was used to measure the internal consistency of the scale, and factorial analysis was used to adapt the questionnaire. Then, the questionnaire responses were divided using the mean score into three categories: low, medium, and high.

The second questionnaire utilized was the WHO Quality of Life Brief Form (WHOQOL-BREF), which originally contained 26 items. The current study used the WHOQOL-BREF Indonesian version [22], which has proven to be reliable and valid across many different populations [23]. A five-point Likert scale was used for the WHOQOL-BREF. Each item was scored from 1 (the worst condition) to 5 (the best condition), with higher scores representing a better QoL; moreover, questions 3, 4, and 26 had a negative value. In addition, the WHOQOL-BREF includes four domains: physical (questions 3, 4, 10, 15, 16, 17, and 18), psychological (questions 5, 6, 7, 11, 19, and 26), social (20, 21, and 22), and environmental (8, 9, 12, 13, 14, 23, 24, and 25) [24]. Questions 1 and 2 ask the participants to assess their overall QoL and health in general. We categorized the total questionnaire responses into lower (< mean) and higher (> mean) QoL based on a previous study [25].

The Mental Health Inventory-38 was used to assess the mental health state of COVID-19 survivors [26]. The questionnaire consists of two dimensions: psychological well-being and psychological distress. These scales encompass various subscales: positive affect and emotional ties and anxiety, depression, and loss of behavioral/emotional control. Most items have a six-point Likert scale, while two have a 5-point scale. Each point was associated with the frequency or intensity level of the behaviors, feelings, or thoughts the person experienced. Higher scores indicated a higher level of overall mental health and its specific dimensions. Then, we categorized the total questionnaire answers into lower (< mean) and higher (> mean) mental health. Moreover, we only used the total scores and did not include the subscales, as indicated in previous studies [26, 27].

Statistical analysis

Distributions of the characteristics of respondents were represented using descriptive statistics. The chi-square test was used to determine the association of stigma with mental health and quality of life faced by COVID-19 survivors. Binary logistic regression tests were performed by adjusting all variables with a p value < 0.05. The associations among variables were measured as odds ratios and 95% confidence intervals (CIs). The regression model met the requirements of both the omnibus (p value < 0.05) and the Hosmer & Lemeshow tests for goodness of fit (p value > 0.05). All statistical analyses were performed using SPSS version 20 (IBM, Chicago).

Results

Characteristics of the respondents

Table 1 depicts the characteristics of the respondents. Between October 1 and December 1, 2020, we collected responses from 580 COVID-19 survivors who voluntarily agreed to join this study. Of these, 33 individuals were excluded because they were under 20 years old; thus, the final number was 547 respondents. The baseline demographic characteristics showed a balance of male and female genders. The younger age group (52.65%) dominated over older age groups. In our study, we found that most of the respondents (287, 52.47%) did not know from whom they had contracted COVID-19 and that a majority of them isolated in the hospital (368, 67.28%). Our findings also revealed that most of the participants recovered in less than a month (452, 82.63%) and did not show any symptoms (485, 88.67%). The prevalence of medium stigma due to COVID-19 was 70.02%; the prevalence of lower QoL was 45.52%; and the prevalence of lower mental health was 49.54%. Further information about the respondents’ characteristics is available in Table 1.

[Figure omitted. See PDF.]

Table 1. Characteristics of respondents (n = 547).

https://doi.org/10.1371/journal.pone.0264218.t001

Bivariate analysis

Table 2 provides detailed results for the bivariate analysis and shows the variables related to QoL and mental health status. We found that the stigma faced by COVID-19 survivors (p<0.001) had a significant correlation with QoL and mental health. The sex (p = 0.002) and occupation (p = 0.038) of the COVID-19 survivors had a significant correlation with mental health.

[Figure omitted. See PDF.]

Table 2. Bivariate analysis of quality of life and mental health among COVID-19 survivors in Indonesia.

https://doi.org/10.1371/journal.pone.0264218.t002

Multivariate analysis

Table 3 presents the detailed results of the multivariate analysis. We omitted salary, pregnancy status, and symptoms because those factors failed to meet the threshold for significance. The results were adjusted for other potential confounders, as shown in Table 2. A high level of stigma was positively correlated with lower QoL and lower mental health status [p = 0.038; CI = 1.032–2.946; AOR = 1.744 and p = 0.038; CI = 1.032–2.946; AOR = 1.744, respectively]. Females were less likely to experience stigma related to mental health [p = 0.003; CI = 0.393–0.830; AOR = 0.571] than men. We also discovered that laborers [p = 0.047; CI = 0.351–0.992; AOR = 0.590] and entrepreneurs [p = 0.030; CI = 0.266–0.934; AOR = 0.498] were less likely to experience stigma related to mental health than respondents who worked in the civil/army/teaching/lecturing fields. More detailed results can be found in Table 3.

[Figure omitted. See PDF.]

Table 3. Multivariate analysis of quality of life and mental health among COVID-19 survivors in Indonesia.

https://doi.org/10.1371/journal.pone.0264218.t003

Discussion

In the Indonesian setting, confirmed COVID-19 cases and deaths as well as recovered cases continue to be reported; however, research on issues related to stigma, QoL and mental health status among COVID-19 survivors is currently limited. COVID-19 survivors seem to be vulnerable in the community, putting them at the greatest risk in the general population. We found that a high level of stigma was positively correlated with lower QoL and mental health status among Indonesian COVID-19 survivors. Our findings point toward stigmatization among COVID-19 survivors and reveal the need to develop specific programs for targeted groups.

Pandemics may increase stigmatization, as previously observed during the severe acute respiratory syndrome (SARS) epidemic and the bubonic plague [28, 29]. The stigma and fear that has developed alongside COVID-19 is likely due to the uncertain characteristics and course of the disease as well as how it is treated. This is especially true when there are limited approved treatments with unpredictable outcomes, which may generate negative psychological responses. Thus, COVID-19 survivors are likely to be labeled and discriminated against because of the perceived connotations of and links to the disease [30]. In addition, most countries were not prepared for the pandemic, thus exacerbating chronic inequities and increasing the mortality rate [31–33]. A similar study from Hong Kong found that COVID-19 survivors experienced a high level of externalized stigmatization compared to those with HIV/AIDS and tuberculosis. The stigma that occurs in the community is due to the fear that survivors can still transmit COVID-19, which is due to a lack of accurate knowledge and information [34, 35] The stigma experienced by survivors can increase their suffering and cause them to hide symptoms to avoid discrimination. In addition, they may hide their medical history and information about disease transmission, which can facilitate transmission in the community and impact how the pandemic is controlled [30]. Thus, such an environment can fuel harmful stereotypes and undermine social cohesion. Moreover, stigma can lead people to physical violence and hate crimes [31]. Creating a safe environment and providing respectful care may result in better treatment for COVID-19 survivors when they return to their communities. In addition, governments should focus on programs for disseminating the facts about COVID-19 across sectors by community leaders, mass media, artists or social influencers [36]. The subsequent increase in knowledge can lessen the anxiety associated with the COVID-19 pandemic.

In our study, stigma among COVID-19 survivors remained a salient issue that was significantly associated with QoL. A high level of stigma was positively associated with lower QoL. These findings are consistent with those of studies conducted among health care workers in Italy and Egypt [37, 38]. Considering that stigma among COVID-19 survivors is a pressing issue for individuals, the community, and health care workers, there is still a lack of research into the relationship between stigma and QoL among COVID-19 survivors in the community. More data are needed to scrutinize the impact of stigma on individual QoL. The only study explaining the mechanism of stigma on QoL was conducted with regard to HIV [39]. In addition, our findings that COVID-19-related stigma has a significant correlation with survivors’ mental health are consistent with a previous study detailing how stigmatization is related to a high possibility of having poor mental health [40]. COVID-19 survivors may experience excess stress from stigma and discrimination, which may ultimately lead to mental disturbances. The stigmatization process occurs as a result of fear and being held responsible for contracting COVID-19 in the community. When this happens, individuals begin to gossip, become too interested in their COVID-19 experiences, and become wary of interacting with survivors. Such behavior leads to dread in disclosing a positive COVID-19 status as well as an unwillingness to meet new individuals, particularly those from high-risk groups [41]. Finally, negative effects on social interactions are associated with a reduction in the overall quality of life and mental health of the individual.

In this study, we found that females were less likely to experience stigma related to mental health than males; however, females present significantly higher levels of stress and anxiety and poorer mental health statuses [42]. Males also face problems associated with work, income, family, and life transition factors that have an impact on stress and mental disorders. Additionally, the lack of counseling facilities for men associated with stereotypes of masculinity needs further attention [43, 44]. During the COVID-19 pandemic, male survivors also experienced impacts on work, income, and self-actualization, which promote the development of mental disorders [45, 46]. COVID-19 survivors have struggled to lead a meaningful life and have been burdened with mental health issues [47, 48]. The significant correlation between men and mental health leading to worse outcomes in COVID-19 has been supported by other studies in China [49]. However, understanding and providing a psychological consultation room can help reduce the psychological burden experienced by males.

We also discovered that laborers and entrepreneurs were less likely to experience stigma related to mental health. Testing positive for COVID-19 while working as a laborer may cause insecurity due to lost work productivity. However, a good and conducive work environment can provide material, psychological and social support. Previous research has stated that a good work environment can provide support for COVID-19 survivors to recover quickly and promote enthusiasm during quarantine [50, 51]. Such support can be in the form of food, money, and daily necessities. The WHO stated that the effects of stigma on mental health among health care workers, patients, and survivors could be avoidable through adequate education through the media [6]. Understanding the primary drivers of misinformation is critical to preventing misjudgment in the community and increasing the sense of brotherhood among individuals.

In our research, the respondents were asked specific questions about several elements of their QoL and mental health. Standardized surveys measuring QoL and mental health status can reduce information bias [26], which we believe is a strength of our study. To our knowledge, this was the first analysis of stigma against Indonesian COVID-19 survivors associated with mental health indicators and QoL. The results call for urgent action to develop programs to destigmatize COVID-19 at every level, ranging from personal to policy. The main limitation of this study is its cross-sectional design, which cannot explain causality. Additionally, the study was conducted only in East Java Province; thus, the results of this study have limited generalizability because the respondents are representatives of the Indonesian population.

Conclusions

A considerable proportion of the COVID-19 survivors in this cross-sectional study experienced COVID-19-related stigmatization at a medium level. Stigma among COVID-19 survivors has a close relationship with their QoL and mental health. These findings highlight the need for specific research and targeted interventions to address these issues for COVID-19 survivors. Given that Indonesia has suffered a high number of confirmed COVID-19 cases and deaths, the stigma experienced by COVID-19 survivors should be more broadly studied. COVID-19 survivors are a vulnerable group, and it is essential to identify new strategies to promote the well-being of this group as soon as possible. Our findings can inform policymakers to ensure the availability of a safe environment supported by respectful care. Urgent action is required to destigmatize COVID-19 at every level, ranging from personal to policy.

Citation: Wahyuhadi J, Efendi F, Al Farabi MJ, Harymawan I, Ariana AD, Arifin H, et al. (2022) Association of stigma with mental health and quality of life among Indonesian COVID-19 survivors. PLoS ONE 17(2): e0264218. https://doi.org/10.1371/journal.pone.0264218

References

1. Sotgiu G, Dobler CC. Social stigma in the time of coronavirus disease 2019. Eur Respir J. 2020 Aug;56(2):2002461. pmid:32631833

2. Donthu N, Gustafsson A. Effects of COVID-19 on business and research. J Bus Res. 2020/06/09. 2020 Sep;117:284–9. pmid:32536736

3. World Health Organization. Coronavirus disease (COVID-19) [Internet]. [cited 2021 Feb 23]. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019?gclid=Cj0KCQjwhIP6BRCMARIsALu9Lfnbx3ahXR8sSvIS65OyGIzjUfvucEyuf6mqVIHlN4tY9itTDGwlOxIaAgkgEALw_wcB

4. Malecki KMC, Keating JA, Safdar N. Crisis Communication and Public Perception of COVID-19 Risk in the Era of Social Media. Clin Infect Dis. 2020 Jun;

5. World Health Organization. Social stigma associated with Covid-19. WHO. Geneva, Switzerland: WHO; 2021.

6. Bagcchi S. Stigma during the COVID-19 pandemic. Lancet Infect Dis. 2020 Jul;20(7):782. pmid:32592670

7. World Health Organization. Indonesia WHO Coronavirus disease. Geneva, Switzerland: WHO; 2021.

8. World Health Organization. Weekly epidemiological update [Internet]. 2021 [cited 2021 Feb 23]. Available from: https://www.who.int/publications/m/item/weekly-epidemiological-update—16-february-2021

9. World Health Organization. Coronavirus Disease 2019 (COVID-19) Situation Report 43 [Internet]. 2021 [cited 2021 Feb 23]. Available from: https://cdn.who.int/media/docs/default-source/searo/indonesia/covid19/external-situation-report-43_17-february.pdf?sfvrsn=1889cdf9_5

10. Djalante R, Lassa J, Setiamarga D, Sudjatma A, Indrawan M, Haryanto B, et al. Review and analysis of current responses to COVID-19 in Indonesia: Period of January to March 2020. Prog Disaster Sci. 2020 Apr;6:100091. pmid:34171011

11. KawalCovid19. Informasi terkini Covid-19 di Indonesia. KawalCovid19. 2021.

12. Mahmud A, Islam MR. Social Stigma as a Barrier to Covid-19 Responses to Community Well-Being in Bangladesh. Int J Community Well-Being. 2020 Aug; pmid:34723103

13. Bailey TC, Merritt MW, Tediosi F. Investing in justice: ethics, evidence, and the eradication investment cases for lymphatic filariasis and onchocerciasis. Am J Public Health. 2015 Apr;105(4):629–36. pmid:25713967

14. Chwaszcz J, Palacz-Chrisidis A, Wiechetek M, Bartczuk R, Niewiadomska I, Wośko P, et al. Quality of life and its factors in the COVID19 pandemic situation. Results of Stage 1 studies during the pandemic growth period. 2020;

15. Pierce M, Hope H, Ford T, Hatch S, Hotopf M, John A, et al. Mental health before and during the COVID-19 pandemic: a longitudinal probability sample survey of the UK population. The Lancet Psychiatry. 2020;7(10):883–92. pmid:32707037

16. Bargon C, Batenburg M, van Stam L, van der Molen DM, van Dam I, van der Leij F, et al. The impact of the COVID-19 pandemic on quality of life, physical and psychosocial wellbeing in breast cancer patients–a prospective, multicenter cohort study. Eur J Cancer. 2020;138:S17–S17.

17. Batawi S, Alraddadi B, Tarazn N, Al-Raddadi R, Sindi A, Uyeki T. Quality of Life Among Survivors of Middle East Respiratory Syndrome Corona Virus. Open Forum Infect Dis. 2016 Dec;3(suppl_1).

18. Testa MA, Simonson DC. Assessment of Quality-of-Life Outcomes. N Engl J Med. 1996 Mar;334(13):835–40. pmid:8596551

19. Price JH, Daek JA, Murnan J, Dimmig J, Akpanudo S. Power analysis in survey research: Importance and use for health educators. Am J Heal Educ. 2005;36(4):202–9.

20. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. PLoS Med. 2007 Oct;4(10):e296–e296. pmid:17941714

21. Berger BE, Ferrans CE, Lashley FR. Measuring stigma in people with HIV: Psychometric assessment of the HIV stigma scale¶. Res Nurs Health. 2001;24(6):518–29. pmid:11746080

22. World Health Organization. WHOQOL-BREF versi Indonesia. World Heal Organ Qual Life (WHOQOL-BREF). 2004;1–5.

23. Anwar SA, Arsyad DS, Dwinata I, Ansar J, Rachmat M. Quality life of PROLANIS participants using WHOQOL BREF Indonesian version: A community in primary health care. Enfermería Clínica. 2020 Mar;30:213–7.

24. World Health Organization. Introduction, Administration, Scoring, and Generic Version of The Assessment. 1996;(December).

25. Silva PAB, Soares SM, Santos JFG, Silva LB. Cut-off point for WHOQOL-bref as a measure of quality of life of older adults. Rev Saude Publica. 2014 Jun;48(3):390–7. pmid:25119934

26. Veit CT, Ware JE. The structure of psychological distress and well-being in general populations. J Consult Clin Psychol [Internet]. 1983 [cited 2021 Feb 23];51(5):730–42. Available from: https://pubmed.ncbi.nlm.nih.gov/6630688/ pmid:6630688

27. Al Mutair A, Alhajji M, Shamsan A. Emotional Wellbeing in Saudi Arabia During the COVID-19 Pandemic: A National Survey. Risk Manag Healthc Policy. 2021 Mar;Volume 14:1065–72. pmid:33737847

28. Washer P. Representations of SARS in the British newspapers. Soc Sci Med. 2004;59(12):2561–71. pmid:15474209

29. Murray DR, Jones DN, Schaller M. Perceived threat of infectious disease and its implications for sexual attitudes. Pers Individ Dif. 2013;54(1):103–8.

30. Dar SA, Khurshid SQ, Wani ZA, Khanam A, Haq I, Shah NN, et al. Stigma in coronavirus disease-19 survivors in Kashmir, India: A cross-sectional exploratory study. PLoS One. 2020 Nov;15(11):e0240152. pmid:33253177

31. Eddleston M, Chowdhury FR, Mccready C. UK COVID-19 public inquiry needed to learn lessons and save lives. 2020;6736(20):177–80.

32. Horton R. Offline: Europe and COVID-19—struggling with tragedy. Lancet [Internet]. 2021;396(10264):1713. Available from: http://dx.doi.org/10.1016/S0140-6736(20)32530-7

33. Lal A, Erondu NA, Heymann DL, Gitahi G, Yates R. Health Policy Fragmented health systems in COVID-19: rectifying the misalignment between global health security and universal health coverage. Lancet [Internet]. 2021;397(10268):61–7. Available from: pmid:33275906

34. Abdelhafiz AS, Alorabi M. Social Stigma: The Hidden Threat of COVID-19. Front Public Heal. 2020 Aug;8. pmid:32984238

35. National Center for Chronic Disease Prevention. Reducing Stigma. CDC. 2021.

36. WHO SEARO. Stigma Sosial terkait dengan COVID-19. WHO. 2020.

37. Ramaci T, Barattucci M, Ledda C. Social Stigma during COVID-19 and its Impact on HCWs Outcomes. 2020;1–13.

38. Mostafa A, Sabry W, Id NSM. COVID-19-related stigmatization among a sample of Egyptian healthcare workers. 2020;1–15. Available from: http://dx.doi.org/10.1371/journal.pone.0244172

39. Zarei N, Joulaei H. The Impact of perceived stigma, quality of life, and spiritual beliefs on suicidal ideations among HIV-positive patients. AIDS Res Treat. 2018;2018. pmid:30356375

40. Yi S, Chhoun P, Suong S, Thin K, Brody C, Tuot S. AIDS-related stigma and mental disorders among people living with HIV: a cross-sectional study in Cambodia. PLoS One [Internet]. 2015 Mar 25;10(3):e0121461–e0121461. Available from: https://pubmed.ncbi.nlm.nih.gov/25806534 pmid:25806534

41. Lohiniva A-L, Dub T, Hagberg L, Nohynek H. Learning about COVID-19-related stigma, quarantine and isolation experiences in Finland. Yourkavitch J, editor. PLoS One. 2021 Apr;16(4):e0247962. pmid:33852581

42. Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, et al. Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China. Int J Environ Res Public Health. 2020;17(5). pmid:32155789

43. Chatmon BN. Males and Mental Health Stigma. Am J Mens Health. 2020 Jul;14(4):155798832094932. pmid:32812501

44. Affleck W, Carmichael V, Whitley R. Men’s Mental Health: Social Determinants and Implications for Services. Can J Psychiatry. 2018 Sep;63(9):581–9. pmid:29673270

45. Al Dhaheri AS, Bataineh MF, Mohamad MN, Ajab A, Al Marzouqi A, Jarrar AH, et al. Impact of COVID-19 on mental health and quality of life: Is there any effect? A cross-sectional study of the MENA region. Mahapatra B, editor. PLoS One. 2021 Mar;16(3):e0249107. pmid:33765015

46. International Labour Organization. The impact of the COVID-19 pandemic on jobs and incomes in G20 economies. Saudi Arabia: International Labour Organization; 2020.

47. Hosey MM, Needham DM. Survivorship after COVID-19 ICU stay [Internet]. Vol. 6, Nature Reviews Disease Primers. Nature Research; 2020 [cited 2021 Feb 23]. p. 1–2. Available from: www.nature.com/nrdp https://doi.org/10.1038/s41572-019-0135-7 pmid:31907359

48. Wu C, Hu X, Song J, Yang D, Xu J, Cheng K, et al. Mental health status and related influencing factors of COVID‐19 survivors in Wuhan, China. Clin Transl Med [Internet]. 2020 Jun 5 [cited 2021 Feb 23];10(2):e52. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1002/ctm2.52 pmid:32508037

49. Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020;395(10223):507–13. pmid:32007143

50. Taylor H, Collinson S, Saavedra-Campos M, Douglas R, Humphreys C, Roberts DJ, et al. Lessons learnt from an outbreak of COVID-19 in a workplace providing an essential service, Thames Valley, England 2020: Implications for investigation and control. Public Heal Pract. 2021 Nov;2:100217.

51. Schnettler B, Orellana L, Miranda-Zapata E, Saracostti M, Poblete H, Lobos G, et al. Diet quality during the COVID-19 pandemic: Effects of workplace support for families and work-to-family enrichment in dual-earner parents with adolescent children. Appetite. 2021 Nov;105823. pmid:34822922