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\begin{document}

\title{A Qualitative Study on Stigmatisation Associated with COVID-19: An
Iranian Experience}



\author[1]{Ahmad  Kalateh Sadati}%
\author[2]{Mohammad Mahdi Parvizi}%
\author[2]{Sedigheh  Forouhari}%
\author[2]{Seyed Ali  Hosseini}%
\author[2]{Mohammad Hossein  Bahmanzadegan Jahromi}%
\author[3]{Mohammad  Jafferany}%
\affil[1]{Yazd University}%
\affil[2]{Shiraz University of Medical Sciences}%
\affil[3]{Central Michigan University}%


\vspace{-1em}



  
  \date{May 24, 2024}


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\selectlanguage{english}
\begin{abstract}
Background: The social stigma associated with a disease represents an
important issue for health policymakers at the local, national, and
international levels. This study aimed to survay and analyze the
experience of stigma among patients with coronavirus disease 2019
(COVID-19) in Iran. Methods and Materials: This qualitative study was
conducted from September to December 2020 in the Fars, Khorasan, and
Yazd provinces of Iran. Sampling was done via the snowball method; based
on data saturation criteria, 24 adults over 18 years of age who had
experienced affliction with COVID-19 were recruited. Semi-structured
telephone interviews were conducted with each patient. Data were
analyzed following the conventional content analysis method described by
Erlingsson and Brysiewicz. Results: The results showed that during their
affliction with COVID-19, the participants experienced difficult,
anxious times, with rejection and alienation from their first-degree
relatives taking them by surprise. The three main themes extracted from
this study were (i) fear and rejection, (ii) discrimination, and (iii)
loneliness. These experiences have changed the attitudes of the
participants toward life and themselves. Conclusion: Based on our
results, it can be said that paying attention to social stigma among
patients during pandemics is an important social necessity and health
policy. It is recommended to have psychological counseling sessions for
those afflicted and to provide education and training to the public
regarding the proper treatment of patients with COVID-19. Quantitative
studies in this field are highly recommended.%
\end{abstract}%



\sloppy


\section*{Introduction}

{\label{introduction}}

A new strain of coronavirus emerged toward the close of 2019 in Wuhan,
China, giving rise to the coronavirus disease 2019 (COVID-19) and
spreading a wave of concern across China (1). This health issue soon
became a pandemic, placing an immense burden on populations all around
the world (2). According to data from the World Health Organization
(WHO), Iran is one of the countries that has been highly affected by
COVID-19 (3). Kalantary H. \emph{et al.} showed that in Iran, up to
one-third of patient deaths due to COVID-19 occurred in individuals aged
over 70 years, while the highest recovery rate was seen in those aged
between 30-39 years (4).

One of the key issues raised from the start of a pandemic is social
stigma (5). The notion of stigma is defined as ``a social process that
results in devaluation and discrediting'' (6). According to Echoing
Goffman, stigma creates a dichotomy between the states of ``being normal
and acceptable'' and the state of ``being tainted and undesirable' or a
dichotomy between ``normal'' and ``undesirable'' states in general. It
is usually associated with an attribute that is deeply discrediting,
reducing an individual ``from a whole and usual person'' to a ``tainted,
discounted one'' (6, 7). In the process of stigmatization, people
involved in the phenomena of the social world are pushed to the margins
of society (8). Stigma may not only affect the mental health (9) and
behavior of those who are stigmatized but also can change and
reconstruct their feelings and beliefs (10, 11). Furthermore, stigma can
cause depression in the short or long term due to the social disrespect
that accompanies it (12).

Since the commencement of the COVID-19 crisis, infected individuals have
at times been labeled, stereotyped, and discriminated against. Such
stigma can represent a critical issue, threatening both the personal and
social life of healthcare workers, patients, and survivors (5). Ramaci
T. \emph{et al.} showed that the social stigma associated with COVID-19
had a high impact on healthcare workers' psychological and physical
demands, professional quality of life, and self-esteem in Italy (13).
Moreover, several reports have claimed that some people refuse to bury
the corpses of COVID-19 victims in Egypt (14). Gradually, the issue of
COVID-19 associated stigma went beyond personal and social aspects and
turned into an international stigma against races and countries. For
example, anti-Asian stigma was generated by certain groups and even
politicians considering the supposed geographical origin of the disease
(15). Stigma and discrimination~lead to social exclusion, which affects
mental health (16). Stigma does not stop at illness: it marks those who
are ill, their families across generations, institutions that provide
treatment, psychotropic drugs, and mental health workers (17). The
stigma associated with COVID-19 poses a serious threat to the lives of
all those involved directly or indirectly with the disease (5). The
effects of COVID-19-related stigma on the health and social lives of
individuals and societal functioning are enormous (18). The study
conducted by Banks L\emph{. et al} . showed that poverty exacerbation
due to COVID-19 could represent a key social problem among individuals
who reside in low and middle-income countries. The mentioned study
revealed that people with disabilities faced several personal,
economical, and social challenges in the COVID-19 period, with the
researchers concluding that social protection and financial support are
necessary for protecting such individuals from social stigma (19).
Moreover, the study of Gupta J \emph{et al.} revealed that some
protective measures against COVID-19 had negative social effects on
low-income individuals (including those residing in poor areas) due to
inadequate access to health facilities and lack of financial support.
Moreover, the study claimed that some of these social effects may be
stronger than the negative health effects of COVID-19 (20). On the other
hand, frustration and anxiety were reported as the predominant social
theme among the population, particularly among healthcare workers on the
front-lines of COVID-19 management (21, 22).

To the best of our knowledge, few studies are available on COVID-19
associated stigma in Iran, especially ones that are qualitative in
nature. Therefore, this study was conducted to assess COVID-19
associated stigma among the Iranian population through a qualitative
survey.

\textbf{Methods}

\textbf{Study design, participants and samplling}

The present work was a qualitative study that was conducted in January
and February 2021. The study area was the Fars, Yazd, and Khorasan
provinces. Data were obtained through interviews with 24 individuals who
had fully recovered from COVID-19 after treatment. The snowball sampling
method was employed, and sampling was continued until achieving data
saturation. Table 1 shows the characteristics of the participants in the
study (Table 1).

{[}Table 1 here{]}

\textbf{Data collection}

The interview protocol was based on the following questions:

\begin{itemize}
\tightlist
\item
  Can you tell us how did you feel about getting COVID-19 and what you
  did?
\item
  Did people around you andyour relatives change their attitude towards
  you after you tested positive for COVID-19?
\item
  How did people treat you in other environments, such as the workplace
  or hospital?
\item
  Can you describe your perception and understanding of the behaviors of
  those around you?
\end{itemize}

The semi-structured interviews were transcribed after being conducted
via telephone by an expert sociologist. The use of telephone interviews
in qualitative research has proved useful in recent decades (23, 24).
The transcribed data were analyzed via conventional content analysis
(25). For this purpose, the data were read several times by the
researchers to obtain an overview of what the participants were talking
about. Then, condensed meaning units were labeled by formulating codes
that were subsequently grouped into categories. The interviews were
analyzed with the aim of bringing the categories to the highest level of
abstraction, i.e., arriving at specific themes. The reflexive method was
used during this process. Researchers went back and forth several times
between the data and the generated themes in order to arrive at the most
appropriate themes.

\subsection*{Research validity}

{\label{research-validity}}

Given its significance, we attempted to ensure the validity of the work
by following the model of Lincoln and Guba (26). To this end, designing
a suitable qualitative research model, selecting the right participants,
choosing accurate interview questions, and employing appropriate methods
for data analysis were the most important concerns of our research
group. We used member check (27) during the data analysis process as one
way to see if the categories and themes reached were satisfactory.
Assessing the transferability of concepts and themes was also one of our
priorities. Ultimately, our research group aimed to base the concepts
and themes on the actual data rather than relying on individual
preconceptions and assumptions.

\subsection*{Study ethics}

{\label{study-ethics}}

The protocol of the study was approved by the Ethics Committee of Shiraz
University of Medical Sciences (Ethics code: IR.SUMS.REC.1399.419).
Informed consent was obtained from all participants. Patients were also
assured that their personal information would remain confidential with
the researchers.

\textbf{Results}

Data analysis revealed that the experience of affliction with COVID-19
was quite difficult for the study participants. This was particularly
prominent in the first two waves of the disease in Iran, where the
participants were under severe psychological pressures. Fear of
transmitting the disease to other family members, fear of illness and
death, rejection by family members, and loneliness comprised the most
common experiences. The three main themes developed were fear and
rejection, discrimination, and loneliness (Table 2).

{[}Table 2 here{]}

\subsection*{Fear and rejection}

{\label{fear-and-rejection}}

Right from the start, affliction with COVID-19 creates a pervasive fear
among patients and more so among those around them. Such fear arises
when the test returns positive, and the patients implicitly or
explicitly start noticing dramatic changes in the behaviors of those
around them as the fear is accompanied by rejection. The most common
experience of the study participants was the behavioral changes that
they witnessed in those around them after declaring positive test for
COVID-19. These changes are shaped by a combination of fear, concern,
suspense, and compassion, though mostly being due to fearing affliction
with the disease. Usually, fear first arises in those around the person,
such as first-degree relatives or colleagues. The behavior that stems
from fear is understandable to the patient. On the one hand, the patient
gives the right to those around him, and on the other hand, witnessing
such extreme fear adds to their concerns. Rejection begins with the
initial distancing from the patient. ''Testing positive'' here means
fear, concern, anxiety, rejection, and seclusion. The person understands
these meanings from the behaviors and attitudes of those around them and
attempts to manage them, where ensuring the well-being of those around
them is the most important solution. The person realizes that those
around them are reluctant to approach them and may be trying to main
their distance. In this situation, everyone is afraid of illness and
death, which are seen to be embodied by the patient. The fear is such
that even patients in the COVID-19 ward were afraid of one another.
Moreover, four participants drew similarities to stigmatized concepts
such as AIDS, leprosy, and \emph{al} 11Mythological demons of childbirth
that interfere with human reproduction., meaning that the atmosphere of
fear is intense to such an extent that it is as if the patient has
contracted such negatively perceived diseases.

See, the disease was so scary that I remember, for instance, when my
test result returned positive, everyone around me became anxious even
though I didn't have a very bad feeling (participant 6). It seems that
you have AIDS or leprosy because a very discomforting feeling touches
you and everyone tries to distance themselves from you (participant 5).

The most important psychosocial issue concerning COVID-19 is that this
fear and rejection may continue even after disease resolution. A miner
still spoke of feeling fear and rejection. He believed that 14 months
after the start of the COVID-19 pandemic, laborers in cities such as
Mashhad, Tehran, and Tabriz who go on leave to their towns and villages
still are avoided by others upon returning.

You know, we're still scared. We are afraid of those who return after
going on leave. We assume that they were gone due to testing positive,
or that they are returning from another area with the virus (participant
1).

The atmosphere of fear and rejection made some prefer to hide the
disease, especially in the first and second waves. The stigmatization of
COVID-19 sufferers and victims represented the main reason for such
concealment. One of the participants, a 34-year-old single man,
described telling a friend to keep it secret after he tested positive.

When I tested positive, I didn't tell anyone. No one in the neighborhood
was aware of my disease. I didn't even tell my family members, except
for my cousin, whom I told so that if my situation worsened, he would be
prepared to take me to the hospital (participant 4).

\subsection*{Discrimination}

{\label{discrimination}}

Another key experience among the participants was discrimination, which
they saw either in themselves or in their relatives. Fear and exclusion
lead to the construction of an atmosphere of discrimination. Several
participants described their experiences with occupational
discrimination. At the beginning of the pandemic, when intense fear
prevailed throughout society, occupational discrimination became
prominent. In the workplace, anyone who coughed or sneezed was labeled
as infected or suspicious, leading to their rejection by others.
Notably, people who became infected continued to experience a sense of
discrimination even after returning to work. The discrimination seems to
be involuntary; it may be a social compulsion influenced by the
atmosphere of fear, where the pandemic appears to have led to such
discrimination against COVID-19 patients.

My father was hospitalized and died in a COVID-19 ward for unknown
reasons. You can't imagine the calamity that we went through. There was
no one to participate in the funeral, and I was deprived of seeing my
father for a final farewell, which is something that will forever hurt
me (participant 22). I went to a company for a job interview. The
employer asked me to pull my mask down. I said that I am suspicious
{[}for COVID-19{]}. He asked what I was doing there, and told me to
leave immediately and to come back later. In my current workplace, my
co-workers told the employer to prevent me from coming to work
(participant 17).

Another form of discrimination was familial discrimination, where the
atmosphere of fear and rejection would prevent family members from
paying appropriate attention to a person with or suspected of COVID-19.
The family is not interested in communicating with or caring for the
individual, treating him or her in such a way that they come to the
conclusion that they must minimize their expectations from the family.

\emph{I saw my family behaving in such a way as if I no longer had a
place in the house \ldots{} they would treat me differently than other
family members. That's why I moved out; I found living apart to be
better. I've lived apart from them ever since (participant} 8).

Social discrimination also occurs in social interactions between healthy
individuals and suspects or sufferers, their families, and families who
have lost members due to COVID-19. In these situations, minimal contact
is made with these individuals, and even condolences are sparingly
given. These people are also kept away from social spaces when others
know them. Perhaps the reason for all this social discrimination is that
people are afraid that as soon as they enter into a conversation with
these people, they may be infected or will be forced to visit the
affected person or family.

In our neighborhood, I remember that no one would even reply to the
greeting of the first person who became infected; people would pass by
him swiftly as if he had all sorts of faults. An old man fell victim to
COVID-19. When he died, even the way that people offered their
condolences to the family differed from the usual (participant 4).
Someone had willed for their body to be taken to the family village
after their death. However, the villagers blocked the ambulance from
entering the village. Ultimately, the person was buried in a desert
nearby the village (participant 23).

\subsection*{Loneliness}

{\label{loneliness}}

One of the prominent themes among those with the experience of
affliction with COVID-19 was the intense feeling of loneliness. The
first issue associated with loneliness is the loss of social and
psychological support from loved ones, which was experienced by over
one-third of the participants. In fact, families were in a state of fear
and rejection. In these situations, family members usually inadvertently
change their behavior toward the sufferers. Furthermore, some
participants described that the family members would specifically expose
the sufferer to severe social pressure in demanding that they follow the
protocols during isolation. Many participants who stayed home in
self-quarantine and sent their family members elsewhere experienced
extreme loneliness. The absence of the closest loved ones such as the
spouse, children, or parents on the one hand and the fear and concern of
illness and death on the other created an overwhelming situation. In a
house with multiple family members, the patient was typically imprisoned
within a room and given food and medicine. Our participants described
that the infected or suspected person was constantly warned by those
around them. While some had sent their family members to live apart from
them, others were made to feel abandoned as their family members
themselves had made such a move. It seems that the most difficult
experiences were described by those who had to suddenly live alone.

As soon as I got sick, my parents left me alone and went to the village.
I became very sad. My sister would visit every day and put the food
behind the door; she wouldn't even stop a moment to talk to me
(participant 11). My older sister kept calling and saying that if mom
and dad got sick, it would be my fault (participant 17).

Another category of loneliness is a sort of biological-physical
experience related to the first theme, i.e., fear and rejection. In this
situation, the sufferer is dominated by the components of fear, worry,
uncertainty, feeling dirty, and feeling like they have a terrible
illness, giving rise to an unpleasant feeling of disgust toward the
individual's own body. Any physical symptom reinforces this feeling of
self-disgust, also strengthening the fear of getting worse and dying.

Due to the way my colleagues would treat me, I would be left feeling
dirty. It was a very, very bad feeling (participant 17). It was as if I
had leprosy; it was a very unique situation (participant 5). When you
test positive, it's like you have al\ldots{} it's not a good feeling
(participant 1).

The final category of the loneliness theme reflects the most important
phenomenon that patients experience in the COVID-19 era, which is being
distant from friends, family, and society. In addition to the
difficulties embedded in the disease process, the absence of
first-degree relatives from around the patient creates a psychologically
challenging condition. Constantly thinking about loneliness, continuous
worrying, fear of disease progression and death, and the absence of a
first-degree relative cause a kind of loneliness that is extremely
troubling for the individual. The sufferer feels a deep sense of
loneliness -- as if it's the end of the world and there is no one left
to come to their aid.

I realized something during this period: it is because of this
loneliness that people get sicker and lose their spirit, or even pass
away. Living alone is not part of human nature, and this phenomenon
itself can hurt people a lot (participant 21). Psychologically, I felt
completely torn apart for a while. Everyone avoided me and whoever had
contracted the disease after seeing me even a long time beforehand would
blame me. They would even call me up to condemn me (participant 20).

\section*{Discussion}

{\label{discussion}}

The present study revealed that stigma in patients with COVID-19 is not
an individual or minor problem, but rather comprises a very serious
social issue. According to our analysis, three major themes were found:
(1) fear and exclusion (2) discrimination, and (3) loneliness. It is
understandable that there is confusion, anxiety, and fear about this
unknown and rapidly transmitted disease among the public. However, this
does not justify the deprivation of COVID-19 patients and even their
families from their human and social rights (28, 29).

In the current pandemic, there has been a lot of social stigma and
discrimination against individuals perceived to have been in contact
with the potentially deadly viral agent (5, 13) responsible for
COVID-19. This is not a new issue, as Davtyan et al. found that there
were forms of stigma in the Ebola outbreak that were similar to those
reported in HIV/AIDS studies (30). Also, Karamouzian and Hategekimana
pointed to the fear and stigma of Ebola as a barrier to preventing the
disease from spreading (31). A study by Faraq et al. also reflected
stigmatization during the Middle East respiratory syndrome (MERS)
pandemic in Qatar (32). However, we believe that stigmatization in this
pandemic has been much more severe.

In line with our findings, other studies have shown that social
exclusion has created barriers between COVID-19 patients and society,
influencing the physical and mental health and overall well-being of
those who become afflicted (33, 34). The study of Ernel et al. (2020)
showed that negative social stigma is mostly due to rejection and fear
of acquiring COVID-19. Some researchers have referred to a solid sense
of anxiety endured by the population (35-37). Other researchers (38)
have theorized the relationship between the disease and the prevalence
of anxiety. This is while some have addressed the exceptional state of
social lockdown, self-isolation orders, and strict quarantine measures,
emphasizing the importance of the potentially neglected mental health
outcomes of the pandemic (39). Not only does the situation alter the
attitudes of individuals but also it transforms and reassembles their
emotions, beliefs, and values (13). In addition, living habits and daily
behaviors are affected strongly by the COVID-19 outbreak (40).

Stigma may influence the actions of those who are stigmatized. Many of
the participants in the present study described their social experiences
with the central concept of discrimination. Discrimination is in fact a
state of differentiation and stereotyping at the community level where
an individual is made to feel that he or she does not belong to a
certain class. In other words, in the process of social discrimination,
a symbolic social order assigns an individual to a class that they do
not belong to according to the individual's own criteria and according
to those of society in its normal state. The individual experiences
verbal indifference, even from relatives and loved ones. Such
discrimination also gives rise to a sense of injustice, which has been
reflected in many studies in the field of COVID-19 associated stigma.
Repetitive reports, across the globe, admit consensually the fact that
fear and anxiety about the virus has led to social stigma and
discrimination (15). Addressing fear, loneliness, and discrimination
toward COVID-19 patients should be a priority for public health
professionals (41, 42). Cooperation between all sections of society in
dealing with negative social stigma is essential but represents a
serious challenge (43).

It seems that stigma and its psychosocial complications have been
substantially embedded within the context of COVID-19 disease. Patients
have found the atmosphere of being rejected by those around them to be
quite disturbing. The absence of others from the scene has added
psychological and social strains to their health problems. Our
interviewees described literally or figuratively the unique feeling of
being made to realize that you have to distance yourself from others.
This unique feeling brings about a sense of rejection that increases the
suffering of the patient. Feeling rejected may extend over time, with
the individual feeling the stigma even after being assured by their
doctor that they are no longer infectious (\emph{continuation of
rejection} ).

Fear and rejection intervene and intersect with the meaning units of the
third theme. A child's conceptual network may be disturbed in its mirror
stage, as described in Lacan's psychoanalytic theories under the
influence of Freud. Normally, in the epistemological network of the
individual, there is an overall conceptual framework that lacks any deep
gaps (44, 45). Here, when a person acquires COVID-19 and is faced with
rejection from those around them, their conceptual framework is
disrupted. The loneliness that comes with rejection is considered as a
harm in the patient's cognitive network as they expect the company of
loved ones but instead become the subject of stigma and are avoided,
similar to that which occurs in the mirror stage in a child's mental
system. Phenomenologically, this experience is rather unique, with a
reflection of it being available from the personal accounts and
reflections of those afflicted during the pandemic (46, 47). The social
stigma of disease and stereotyping seen in the current pandemic should
trigger radical changes to help patients in terms of their social and
psychological wellbeing.

In their 2020 study, Grover et al. demonstrated an urgent need to
understand and address the mental health issues of patients with
COVID-19 during hospitalization or quarantine. Uncertainty about the
illness, limited support from family, and fear of death of oneself or
loved ones give rise to severe psychological stress, making mental
health assessments and the provision of mental health support crucial
(48). Brans et al. (2020) showed that from the start of the COVID-19
pandemic, feelings of fear have encompassed patients. There are concerns
that fear and stigma may be more severe during the current pandemic
relative to other infectious disease outbreaks.

In line with the literature, the findings of the present study revealed
that the stigma caused by COVID-19 at the individual level may lead to
delay or refusal of care, non-compliance with containment measures and
treatment, and physical and psychological stress. In addition, Ren et
al. (2020) showed that stigma is associated with problems in diagnosing
and controlling the disease, feelings of rejection and loneliness, and
increased mortality and complications, consequently exerting negative
effects on public health (49). Persistent discrimination and false
beliefs associated with the disease may become major barriers to
effective public health interventions such as vaccinations. Many studies
have rightly pointed out that for an infectious disease prevention
program to be effective, the stigma associated with it must be actively
addressed. Therefore, addressing the fears, loneliness, and
discrimination felt by those afflicted with COVID-19 should be a
priority for public health professionals (41, 42).

Combating COVID-19 associated stigma requires evidence-based cultural
strategies. Lessons learned from successful experiences of dealing with
past epidemics as well as WHO guidelines for dealing with such social
stigma can help inform public health campaigns in fighting this issue.
While emphasizing the importance of words, the WHO recommends that
people afflicted with the disease should not be addressed as ''COVID-19
cases'' or ``COVID-19 victims''. Furthermore, the patients' families
should not be addressed using terms like ''COVID-19 suspects'' or
''suspicious cases'', and conversations about the patients should not
include the use of phrases such as ''carriers and transmitters of the
disease'' or ''contaminants of others''. These recommendations are
because such words implicitly indicate intentional transmission and put
blame on the patient, reinforcing attitudes of stigmatization and
labeling (50, 51).

This study included a number of limitations, mostly revolving around the
telephone-based nature of the interviews. Firstly, telephone interviews
may possibly result in shorter conversations with the interviewee
compared to face-to-face interviews. Secondly, the physical and spatial
conditions of the interviewees may have varied at the time of the
interview, possibly affecting the findings. Finally, it seemed to be
more difficult to gain a patient's trust in a telephone interview
relative to a face-to-face interview. Nonetheless, telephone-based
interviews seemed to be more appropriate considering the urgent health
situation caused by the current pandemic.

\section*{Conclusion}

{\label{conclusion}}

The findings of the present study reveal that fear, rejection, and
loneliness are serious issues affecting the lives of those afflicted
with COVID-19 in Iran. Familial, social, and occupational
discrimination, embarrassment, social isolation, and disruption of
social support systems and relationships affect the mental health of
COVID-19 patients. These factors may negatively affect recovery from the
disease, making it more difficult for health officials to curb the
pandemic. We recommend that attention is directed toward the
psychological needs of stigmatized patients and their families.
Furthermore, efforts should be made to minimize stigmatization and its
associated pressures through different cultural and educational
programs. Finally, to appreciate the5. long-term mental health
consequences of this devastating pandemic, prospective and/or
retrospective multicenter studies with larger sample sizes should be
conducted.

\textbf{Aknowlegement:}

This study was supported by the Vice-Chancellor of Research, Shiraz
University of Medical Sciences, Shiraz, Iran (Grant No: 20183).
Moreover, The authors thank every participants who helped in this study.

\textbf{Conflicts of interest:}

Nothing to declare.

\textbf{Ethics approval}

The protocol of the study was approved by the Ethics Committee of Shiraz
University of Medical Sciences (Ethics code: IR.SUMS.REC.1399.419).

\textbf{Authors contribution:}

conceptualisation: AKS, MMP, SF, MJ; data curation: MMP, AKS, formal
analysis: AKS, MMP, MHBJ, SAH funding acquisition: MMP, investigation:
AKS, MMP, MJ, SF MHBJ, methodology: AKS,MMP, SF, MJ, MHBJ, project
administration: MMP, AKS, resources: AKS,MMP, software, supervision:
AKS, MMP, SF, , validation: AKS, MMP, SAH, , visualisation: AKS, MMP,
MJ, MHBJ, original draft: AKS, MMP, MHBJ, SF, SAH, and writing review \&
editing: SAH, MJ, MMP.

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\textbf{Table 1:} Demographic characteristics of participants in the
study of social stigma among patients afflicted with COVID-19.\selectlanguage{english}
\begin{longtable}[]{@{}llllllllll@{}}
\toprule
Participant No. & Gender & City & Age (year) & Occupation & Participant
No. & Gender & City & Age & Occupation\tabularnewline
\midrule
\endhead
1 & Man & Yazd & 43 & Miner & \textbf{2} & Woman & Shiraz & 39 &
Nurse\tabularnewline
3 & Woman & Yazd & 34 & Tailor & \textbf{4} & Man & Shiraz & 34 &
Lawyer\tabularnewline
5 & Woman & Shiraz & 43 & Housewife & \textbf{6} & Man & Shiraz & 58 &
Freelance\tabularnewline
7 & Man & Shiraz & 43 & Sport coach & \textbf{8} & Man & Yazd & 23 &
Student\tabularnewline
9 & Woman & Yazd & 18 & Student & \textbf{10} & Woman & Yazd & 38 &
Housewife\tabularnewline
11 & Woman & Yazd & 22 & Student & \textbf{12} & Woman & Yazd & 26 &
Hospital social worker\tabularnewline
13 & Man & Yazd & 34 & Faculty member & \textbf{14} & Man & Yazd & 34 &
Freelance\tabularnewline
15 & Woman & Yazd & 17 & Housewife & \textbf{16} & Woman & Yazd & 39 &
Nurse\tabularnewline
17 & Woman & Yazd & 34 & Housewife & \textbf{18} & Woman & Yazd & 20 &
Medical student\tabularnewline
19 & Woman & Yazd & 38 & Housewife & \textbf{20} & Woman & Yazd & 43 &
Housewife\tabularnewline
21 & Woman & Yazd & 23 & Housewife & \textbf{22} & Woman & Yazd & 48 &
Housewife\tabularnewline
23 & Man & Khorasan Rzavi & 42 & Executive manager & \textbf{24} & Man &
Khorasan Rzavi & 77 & Retired\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 2.} Concepts, categories, and themes developed in patients
afflicted with COVID-19.\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
Theme\strut
\end{minipage} & \begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
Category\strut
\end{minipage} & \begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
Meaning units\strut
\end{minipage} & \begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
Sample statements\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Fear and rejection\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Fear and distance The unpleasant feeling of rejection The continuation
of rejection\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Extreme fear Distancing of strangers Distancing of colleagues Distancing
of hospital personnel Feeling distant from family members Feeling
rejected by colleagues Fear and hope of those around you Rejection of
rural laborers Continuation of fear and distancing among colleagues
Continuation of fear among friends\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
In the first wave, people had extreme fear and stress about COVID-19 and
assumed that whoever acquired it would die. Everyone distanced
themselves from me as soon as my test returned positive. I told a woman
on the bus that I might be afflicted, and she immediately pulled herself
away from me. I saw my colleagues moving away from me in the dressing
room as if I was dirty. I went to a general hospital and as soon as I
said that I might be afflicted, the nurses ordered me to leave and visit
a COVID-19 hospital. You feel like you have to leave since your family
is afraid of you. It's a unique feeling; you realize you have to
distance yourself. You feel like they are afraid of you yet they also
want to help you. Their view was that rural workers who commute from
their homes should not enter the factory. I returned to the hospital
after 21 days, but everyone was still moving away from me. Even now that
a year has passed, I jokingly or seriously tell any of my colleagues who
go on trips across cities that I wish they had not returned immediately
to work; we are still really scared. I returned to work after two weeks,
but I saw that my colleagues would become scared when they came near to
me, and this was not pleasant.\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Discrimination\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Occupational Familial Social\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Loss of employment; forced leave; fear of getting fired. Neglection of
the patient, indifference, and/or discrimination by the family, Verbal
indifference, social distance, and physical distance,\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
I went for a job interview. The employer asked me to pull my mask down.
I said that I am suspicious {[}for COVID-19{]}. He asked what I was
doing there! The employer would immediately send those who were
suspicious on leave. The workers were afraid even to cough. Nobody paid
attention to me; I took care of myself. The family did not say anything
but I felt they were paying more attention to other members. When I got
sick, my family left me and went to their village, but they called me
and said that I should not leave the room at all. Even my mother would
not let me out of the room, and I was coughing very badly and was short
of breath. I was constantly in tears because of their behavior. In the
factory, people who have passed the disease course are ignored. The
expectation is that we should never come back to the workplace. We are
ignored and others distance themselves from us. On the bus, I told a
lady to keep her distance because I was suspicious. After my affliction,
I saw our neighbors pass by us very quickly while ignoring us.\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Loneliness\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Loss of psychosocial support Self-disgust Loneliness\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Feeling forgotten Distancing of the closest relatives Feeling bad
Feeling danger from the disease Feeling dirty Lack of establishing
communications Feeling lonely Experiencing the reality of
loneliness\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
I felt that everything about love and affection was lies and I felt
severely left out. Not even my brother came to visit me. It's an
unpleasant feeling -- as if you have HIV or plague. I said: ``do I have
leprosy?!'' Among the workers, if someone tested positive it was like
they had al11Mythological demons of childbirth that interfere with
reproduction.. I felt dirty; it gave me a very bad feeling You see that
you cannot have a relationship with anyone We were quarantined and felt
introverted and lonely My sister called and told me not to leave my room
It was very difficult to be alone and away from my wife and children.
During the quarantine, you are completely lonely and all you have is
your thoughts and imagination.\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\selectlanguage{english}
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