COVID 19 Related Social Stigma among Women of Reproductive Age in Jos, Plateau State, Nigeria

The novel coronavirus, SARS-CoV-2, which was detected in Wuhan China in 2019 has infected millions of people around the world with many mortalities, regardless of race or ethnicity [1]. Generally, the most common symptoms of COVID-19 are fever, dry cough, and tiredness. Other symptoms that are less common and may affect some patients include aches and pains, nasal congestion, headache, conjunctivitis, sore throat, diarrhoea, loss of taste or smell, a rash on skin or the discoloration of fingers or toes. These symptoms are usually mild and begin gradually. Some people become infected but only have very mild symptoms [2, 3].Most people (about 80%) recover from the disease without requiring hospital treatment. One in five people who are infected with COVID-19 become seriously ill and develop breathing difficulty. Older people and those with underlying medical problems like high blood pressure, heart and lung problems, diabetes or cancer have a higher risk of developing serious illness. However, anyone can be infected with COVID-19 and become seriously ill [2].

Globally, the number of infected persons is increasing with the highest infection rate currently in America, while the Western Pacific has the lowest number of confirmed cases.Africa region and Nigeria are gradually recording steady increase in number of confirmed cases [4, 5]. There are various understanding and perception of COVID 19 depending on profession and countries, however, the success or failure of preventive measures depends largely on the general public and the level of stigma attached to the disease [6]. Stigma can be considered mark of disgrace which keeps a person apart from others, it could be stigma against self (self-stigmatisation) or stigma against others (public stigmatisation),[7] Social stigma in the context of health is the negative association between a person or group of people who share certain characteristics and a specific disease [7]. For infectious diseases that could culminate into an outbreak, people can be labelled, stereotyped, discriminated against, treated separately, and/or experience loss of status because of a perceived connection to the disease. These kinds of treatment can negatively affect those with the disease, as well as their caregivers, family, friends and communities [8]. Stigmatisation can substantially increase the suffering of those with the disease; even those at risk of contracting the infection may avoid seeking health care, making it much harder for public health authorities to control the disease. Furthermore, professionals and volunteers working in the field may also become stigmatised, leading to reduced performance of the health workforce [9, 10]. It has been found that familiarity or knowing persons with a disease can be an important factor in mitigating social stigma against people with the same disease [11]. This may also be the case for COVID-19. The COVID-19 outbreak has provoked social stigma and discriminatory behaviours against persons who have or have had the disease as well as anyone perceived to have been in contact with such persons [12]. This experience of stigmatization, whether by self or others, may cause people to take all precautionary measures to avoid contracting the infection, especially when they perceive they are at risk of the disease. Therefore, this study was conducted to assess the risk perception, infection prevention practice of COVID-19 and social stigmatisation (self and public) among women of reproductive age in Jos, Plateau State, Nigeria.

Study design 

It was a descriptive, cross sectional study design conducted among women of reproductive age in the selected units where they attend clinic activities.

Setting 

This study was carried out in Plateau state, North Central Nigeria with an estimated land area of approximately 26,890sq.km lying between latitude 80^o 22’ and 100^o 20’North and longitude 80^o 32’ and 100^o 38’East and its capital is Jos. It has seventeen local government areas and shares boundaries with Kaduna State (North West), Bauchi State (North East), Nasarawa State (South West) and Taraba State (South East). The state has a projected population of 4,131,870 (2,060,436 males and 2,071,434 females) [13]. The study was carried out in the Family Health Clinic (FHC) and Antenatal Clinic (ANC) of the Jos University Teaching Hospital (JUTH) and the Plateau State Epidemiological Unit (Immunisation unit). The FHC and the Epidemiological unit are clinics where immunisation activities are conducted especially for children under the age of five years but also other members of the family are attended to for their health needs. The ANC in a clinic for the routine care of pregnant women.

Study population and sampling strategy 

The study population consisted of women of reproductive age (aged 15-49 years) who gave consent and excluded those women of reproductive age group who themselves or their children were very sick at the time of data collection.Sample size was determined using the Cochrane formula for sample size determination for cross sectional studies. A minimum sample size of 400 was obtained after adjusting for 10% non-response. A proportion to size allocation was done to determine the number of women to be selected in each of the clinics based on the estimated number of women in the register who are being attended to in those clinics on a monthly basis, these formed the sampling frame. A systematic sampling technique was thereafter employed after calculating the sampling interval to select study participants. Simple random sampling, by balloting was carried out to select the first woman in each clinic and subsequently, every 2^nd, 3^rd and 3^rd woman in the FHC, ANC clinic and Epidemiologic unit respectively were selected. If there was any client that didn’t meet the inclusion criteria the next eligible woman was picked, however the sampling interval was maintained. This was done until the sample size was met.

Data collection 

Data was collected using a structured, interviewer-administered questionnaire which was adapted from previous studies that have already been validated [7, 12, 14]. The assessment instrument had four distinct sections. The first section- sought for information on socio-demographic characteristics of the women, section two asked questions on perception, the third section covered issues regarding stigma (self and public), while section four assessed the respondent’s safety practices in theprevention of COVID-19 infection. The perception, social stigma and practice of prevention sections were measured on a five-point Likert scale (where 5 = strongly agree, 4 = agree, 3 = neutral, 2 = disagree and 1 = strongly disagree). Negative questions were reverse-scored to ensure the direction was consistent for all items and higher scores represented a more positive score.Personal protective Equipment (PPE) such as facemask and hand sanitisers was used by all the respondents and the research assistants.

Statistical analysis 

After collection, the responses were appropriately coded, entered into a spreadsheet i.e. Microsoft excel software and cleaned; thereafter, the data was exported to IBM Statistical Package for the Social Sciences (SPSS) version 23 for analysis.The background characteristics of the women was assessed and reported using simple frequency table and the proportion of perception, social stigmatisation and practice of prevention of COVID-19 was assessed by scoring of more appropriate responses on Likert scale with higher scores (A Likert type item is on an ordinal scale). Scores of ≥80% = High risk perception/No stigma/Good practice; ≥60% to <80% = Moderate risk perception/Low stigma/Fair practice; <60% = Low risk perception/High stigma/Poor practice). Chi-square test was then used to test for associations. A p-value of ≤0.05 was considered statistically significant.

Ethical consideration 

Ethical clearance was obtained from the Jos University Teaching Hospital (JUTH), Human and Research Ethics Committee with permission number and permission obtained from the Plateau State ministry of health. The objective of the study was also explained to the respondents, and informed consent was obtained before the administration of the questionnaire. Confidentiality and anonymity were ensured and maintained.

A total of 400 respondents completed and returned the study questionnaire giving a response rate of 100%.Out of the 400 respondents who participated in the study, majority (83.2 %) were in the age group < 35 years whilst the remaining (16.8%) are in the age group > 36 years with a mean age of 28.8+ 6.9 years and age range of 15-49 years. More than half (57.2%) had tertiary education. Sixty one percent (61%) are employed while 39% are unemployed (Table 1). 

Table 1: Socio-demographics 

In this study, 66.8% of respondents had high risk perception. About Forty three percent had high self-stigma about covid-19 while 36.3% had high public stigma. Majority (61.3%) had good COVID-19 prevention practice (Table 2). 

Table 2: Risk perception, stigmatization (self and public) and practice on COVID-19 prevention

Religion (p=0.008) and level of education (p=0.001) had a statistically significant relationship with respondents’ risk perception to covid-19.There was no statistically significant association with other socio-demographic variables (Table 3). 

Table 3: Relationship between sociodemographic characteristics of the respondents and Risk perception to COVID-19 

Also as shown in (Table 4), there was no statistically significant association (p=0.216) between self-stigmatization and risk perception to covid-19 among respondents whereas, there is a statistically significant association between public stigmatization (towards others) and practice of covid-19 prevention (p= 0.018 and < 0.001 respectively) to risk perception to covid-19 amongst respondents (Table 4). 

Table 4: Relationship between characteristics of the respondents and level of self-stigmatization 

Only age had a statistically significant relationship with the respondents’ level of self-stigmatization whereas, religion (p=0.714) and other sociodemographic had no statistically significant relationship (Table 5). 

Table 5: Relationship between characteristics of the respondents and level of public-stigmatization 

It was observed that age (p=0.025) and level of education (p= 0.002) had a statistically significant association with respondents’ level of public-stigmatization whilst, marital status (p= 0.636) and other socio-demographics had no statistically significant relationship (Table 6). 

 Table 6: Relationship between characteristics of the respondents and practice of COVID-19 prevention.

Findings in this study depicts that only religion and level of education (p= < 0.001 and 0.033 respectively) had a significant relationship with respondents’ practice of covid-19 prevention whereas, residence (p= 0.456) and other socio-demographics showed no statistically signification relationship. (Table 7). 

Table 7: Relationship between stigma and practice of COVID-19 prevention among respondents and Risk perception to COVID-19 

Finally, Table 8 showed that respondents’ self-stigma and risk perception had a statistically significant association (p= < 0.001 and 0.048 respectively) to practice of covid-19 prevention while public stigmatization (towards others) had no statistically significant association (p=0.066) (Table 8). 

Table 8: Relationship between stigma and risk perception among respondents and practice of COVID-19 prevention.

In the wake of COVID-19 being declared a public health emergency of international concern and a pandemic, it is important to examine the response of people towards the disease. Understanding the perception of the population about their susceptibility is important in the control. It is impressive that a high proportion of the respondents in this study had high risk perception about COVID-19. This is comparable to an online cross-sectional survey carried out to assess the knowledge, risk perception and preparedness towards COVID-19 among Ghanaians where a high proportion of the study population had high risk perception towards COVID-19, Ghana and Nigeria share so many similarities in culture and way of life and so it is not surprising [15]. Similarly, the study conducted in Egypt on the knowledge perceptions and attitudes of respondents to COVID-19 revealed that 86.9% of the study’s respondents were concerned about the risks of infection [16]. Outside the African continent, the findings are not much different, a study conducted among college students in China on risk perception to the disease, reported a very high risk perception, believing that healthy persons in the general population were susceptible to the disease. This may be the reason for the ease in observing preventive measures and the success recorded in the control against the disease. The study noted that females had a higher risk perception as compared to their male counterparts and this relationship between risk perception and gender was significant [17]. This is not unanticipated as females have been known and observed to demonstrate a high risk perception to diseases and other phenomena in addition to the wide public awareness about the novel virus [18, 19]. The fear of the morbidity and mortality associated with the COVID 19 has been associated with stigma which is an important concern. Some evidence exists to indicate that stigma associated with COVID-19 may cause those who are sick to hide and defer seeking for treatment. A good proportion of the study population here demonstrated high level of self-stigmatisation i.e. internalised sigma if diagnosed with COVID-19 while others would stigmatize those diagnosed with COVID 19. Patients with COVID-19 have been known to experience all types of stigma including internalised stigma which is exhibited as shame and self-rejection [20]. Stigma towards persons with COVID-19 has been experienced in many parts of the world. In a study carried out among residents in a locality in Lagos Nigeria to assess perceived stigmatization of survivors of COVID-19, almost half of the respondents admitted to stigmatizing survivors [21]. A qualitative study carried out in Ghana to assess the psychological distress and mental health disorders associated with COVID-19, revealed that many survivors and those suspectedto be infected had experienced stigma from family, health workers and others due to COVID-19 [22]. In Egypt, respondents in a opined that the disease is associated with stigma. The reason for stigma is predictable in the case of COVID-19 as the disease is novel and has been portrayed to be very infectious though not because of any moral transgressions like the case of HIV. This picture of stigmatization is however different in societies where stigma is entrenched in culture and as such more cases of stigma associated with the disease is being experienced there [23]. 

Concerning practice of precautionary measures towards COVID-19, quite a number of the respondents demonstrated good preventive practice, this may be due to the fear of the morbidity and mortality of the disease in this early phase, it is hoped that the preventive practices are sustained in other to win the fight against COVID 19. In a similar study conducted among pregnant women in the south eastern region of the country, most of the respondents had poor practice of precautionary measures despite the fact that a high proportion of the respondents demonstrated good knowledge of precautionary measures [24]. The disparity in the results obtained could be due to the time the study was conducted: it was conducted at the beginning of the pandemic in the country and as such it is probable that individuals threat of susceptibility to the disease was low as compared to the present time where the population of those who have been infected has increased exponentially in the country. The study further demonstrates a significant relationship between practice of precautionary measures with religion and educational status. This is corroborated by a study in Turkey which showed a correlation between the practice of preventive measures with a higher level of education, high perception of vulnerability and the female gender among other factors. Since education plays an important role in knowledge and subsequent practice, it is expected that those with lower education may not fully comprehend what is globally going with the COVID-19 pandemic especially as it is novel [25]. The same results were seen in the relationship between practice of precautionary measures and stigmatization of others. Though, not many studies have elucidated this, it is plausible: fear has been demonstrated to have a significant relationship with the practice of precautionary measures and also known to be a driver of stigma towards COVID-19 [25, 26]. It may well be concluded that issues of stigmatisation should be given the utmost consideration even as the spread of the disease is being managed to prevent possible long and short-term poor mental health consequences of this pandemic.

The cross-sectional nature of this study may not allow to a broader applicability and to demonstrate causality. Furthermore, the fact that the study was conducted in a limited area of Plateau State may not allow for internal validity and generalizability.

An expansion of the method of data collection that would include qualitative studies and a larger population may make for a better representativeness of the general population.

The Authors are appreciative of the respondents who gave their time for the data to put together. Special thanks also go to the management and staff of the Jos University Teaching Hospital (JUTH) and the Plateau State Ministry of Health (SMoH) for the understanding and support given to the research team even when they had to hurriedly see their clients at the service points while data collection was still ongoing in this period of COVID-19 pandemic.

The authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article.

Conceptualization, methodology, validation, formal analysis, investigation, data curation, writing—original draft preparation, writing review and editing, visualization was done by all authors. All authors have read and agreed to the publishing of this version of the manuscript.

This research received no external funding.

The data that support the findings of this study are available from the corresponding author, [EEA], upon reasonable request.

 Views expressed in the submitted article are authors’ own and not an official position of any institution or funder.