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 Table of Contents  
Year : 2022  |  Volume : 22  |  Issue : 2  |  Page : 51-55

Effect of stigma on COVID-19 cases management at the treatment unit of the Yaounde Central Hospital, Cameroon

1 Faculty of Medicine and Pharmaceutical Sciences, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang; Division for Operational Health Research, MSP; Yaounde Central Hospital, Cameroon
2 Faculty of Medicine and Pharmaceutical Sciences, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Bafoussam; Division for Operational Health Research, MSP, Cameroon
3 National AIDS Control Committee, Cameroon
4 Yaounde Central Hospital, Cameroon
5 Integrated Project for the Promotion of Self-Development; Yaounde Central Hospital, Cameroon
6 Faculty of Medicine and Pharmaceutical Sciences, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang; Integrated Project for the Promotion of Self-Development, Cameroon
7 Yaounde Central Hospital; Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Cameroon
8 Faculty of Medicine and Pharmaceutical Sciences, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon

Date of Submission04-Apr-2022
Date of Acceptance23-Apr-2022
Date of Web Publication21-Mar-2023

Correspondence Address:
Dr. C Kouanfack
Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njhs.njhs_12_22

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Background: The coronavirus pandemic coronavirus disease-19 (COVID-19) has affected the whole world, causing the lives of many victims. Africa has recorded more than a million cases and Cameroon around 18,600 cases (August 2020) since the first case was notified. The rapid spread of this disease (among other factors) could have contributed to creating a situation of fear and stigma among affected populations. It is, therefore, necessary to identify the characteristics of this stigma and its effect on the case management of this disease.
Materials and Methods: We carried out a cross-sectional study with positive COVID-19 people at the Central Hospital of Yaoundé, Cameroon, from May 2020 to June 2020. A questionnaire adapted from the stigma index of persons living with human immunodeficiency virus and from the SAPHORA-MCO 2009 guide was administered to participants.
Results: Among 138 patients with confirmed COVID-19 infection during the study, 134 (97%) accepted the study, 115 (85.8%) reported auto-stigmatisation, 29 (22%) indicated having been stigmatised by the community and 20 (15%) by medical personnel. Auto-stigmatisation increased the risk of seeking care late (odds ratio [OR] = 3.4 with a confidence interval [CI] of 0.99–11.5; P = 0.049), unlike stigma by the community, which tended to result in early care seeking, but not significantly (OR = 0.6 with a CI of 0.26–1.66; P = 0.479).
Conclusion: Stigma is highly prevalent among patients affected by COVID-19. Action should be taken to address stigma to increase the overall adherence to disease control strategies.

Keywords: Coronavirus disease-19, stigma, Yaoundé Central Hospital

How to cite this article:
Kouanfack C, Kuathe K, Zemsi A, Zemsi S, Edingue A, Youm E, Nangmo A, Sanou M, Sobngwi E, Fouda J P, Ateudjieu J. Effect of stigma on COVID-19 cases management at the treatment unit of the Yaounde Central Hospital, Cameroon. Niger J Health Sci 2022;22:51-5

How to cite this URL:
Kouanfack C, Kuathe K, Zemsi A, Zemsi S, Edingue A, Youm E, Nangmo A, Sanou M, Sobngwi E, Fouda J P, Ateudjieu J. Effect of stigma on COVID-19 cases management at the treatment unit of the Yaounde Central Hospital, Cameroon. Niger J Health Sci [serial online] 2022 [cited 2023 Jun 10];22:51-5. Available from: http://www.https://chs-journal.com//text.asp?2022/22/2/51/372259

  Introduction Top

Coronavirus disease 2019 or (COVID-19) is an emerging infectious disease caused by the strain of severe acute respiratory syndrome coronavirus.[1],[2] The first reported case is a 55-year-old patient who fell ill on 17 November 2019 in China.[3] On 15 December, the number of cases was 27, and on 20 December, 60, who were hospitalised in Wuhan hospital, Hubei region, with pneumonia.[4],[5],[6],[7] On 9 January 2020, the Chinese Center for Disease Control and Prevention announced that the pneumonia cases that had increased since December in the city of Wuhan were due to a novel coronavirus.[8] The statement preceded the death of the first patient in China on 11 January by days, followed by the detection of the first case outside China, in Thailand, on 13 January.[9] It was then not until 23 January that the Chinese authorities placed Wuhan in quarantine, before gradually extending it to neighbouring towns, as part of the largest operation to set up a cordon sanitaire ever.[10] On 30 January 2020, the World Health Organization declared the outbreak of a new coronavirus disease, COVID-19, a public health emergency of international concern. The organisation mentioned that there was a high risk of the COVID-19 disease spreading to other countries around the world and declared in March 2020 that COVID-19 could be characterised as a pandemic.[11],[12]

Since its appearance in China on 17 November 2019, the 2019 coronavirus disease has continued to spread around the world, causing many deaths. Figures as of August 2020 reported nearly 21 million confirmed cases, and more than 775,000 deaths worldwide.[13] Cameroon, which is one of the most affected countries on the African continent, had a total of 33,749 confirmed cases to date.[14] The COVID-19 pandemic has contributed to create a climate of social stigma. It resulted in labelling people with the illness, contributing to fear.[15] It also resulted in the disease being associated with a population or certain locations.[16] With COVID-19, people of Asian origin and those coming from countries strongly affected by the pandemic were associated with the disease and therefore very stigmatised as well as people suspected of being infected.[17] This virus had even been nicknamed by certain 'Chinese viruses',[18] thus creating social stigma linked to COVID-19.[19] COVID-19 was a recent disease with many unknowns such as the virus spread, the origin of the virus, the treatment.

Lack of understanding or insufficient access to information can cause fear or panic within communities, leading to irrational assumptions and the need to blame others. It is necessary to study, on the one hand, the effect of stigma on care seeking by patients confirmed with COVID-19 and, on the other hand, the level of patient satisfaction after being in the management unit.

  Materials and Methods Top

We conducted an analytical cross-sectional study in people positive for the reverse transcription-polymerase chain reaction of COVID-19 and managed at the treatment unit of the Yaoundé Central Hospital from May 2020 to June 2020. During this period of study, the Yaoundé Central Hospital was the only diagnostic and treatment unit for COVID-19 in the country.

We conducted a consecutive and exhaustive sampling, with the inclusion of all patients with a positive COVID result for at least 2 days who were asymptomatic or mildly symptomatic. We excluded patients who presented in critical condition (need for oxygen therapy or treatment charge in an intensive care unit). Data were collected through the administration of a questionnaire during a face-to-face interview. Socio-demographic characteristics (sex, age, marital status), history of the disease (duration of knowledge of the diagnosis, symptomatology), perception of the disease by the patient (auto-stigmatisation), perception by members of the community (perception of stigma by the community), the attitude of the nursing staff (perception of stigmatisation by the medical staff) and the satisfaction of the patients after the treatment were captured.

We considered as auto-stigmatised, stigmatised by the community or by the medical staff any patient answering in the affirmative to at least one of the series of questions of the corresponding section, and as late arrival, any patient taking more than 5 days to seek care after the onset of symptoms.

We evaluated associations between categorical variables using the Chi-squared test or the Fisher's exact test as relevant. Associations between continuous variables and categorical variables were evaluated using Student's t-test after checking the assumptions of normality and equality of variance.

The association between the presence of stigma and delay in seeking care was investigated in the subgroup of participants who presented symptoms at the time of diagnosis. The satisfaction rate was calculated as the proportion of patients who chose the positive response modality (very satisfactory and satisfactory) among the five proposed modalities.

We performed our analyses using SPSS version 20 software.International Business Machine, (USA).

  Results Top

Of the 138 eligible participants during the study, 134 agreed to participate in the study, for a response rate of 97.1%. The median age was 43 years (interquartile range: 37–50 years), and 58.2% of participants were female and all participants resided in the city of Yaoundé which is an urban area of Cameroon. The educational levels of the participants were secondary for 43.3% of them and higher education for 54% and a total of 85% of the participants were married.

At the time of diagnosis, 72.4% (97/134) of participants were already symptomatic and 53.6% (52/97) had taken more than 5 days after the onset of symptoms before seeking treatment. The rate of disclosure of positive results by participants to members of the same household was 94.74% (126/134). Stigma experienced by people positive for COVID-19.

Auto-stigmatisation and fear at the onset of symptoms

A total of 85.8% (115/134) of the participants had experienced at least one of the feelings of auto-stigmatisation. The main manifestations of auto-stigmatisation in the study participants were feeling such as being a burden on others (73.9%), feeling worthless (73.1%), guilt (67, 9%), fear of rejection (63.4%), self-censorship (34.3%) and feelings of shame (23.1%).

The presence of auto-stigmatisation was not associated with gender (P = 0.35), marital status (P = 0.19) or presence of symptoms (P = 1).

Stigmatisation by members of the community

A proportion of 23.1% reported having had at least once an experience of stigmatisation from the members of their community. This community stigma presented in the form of abandonment of the person with COVID-19 by his/her friends reported by 18.7% (25/134) of participants, of abandonment by family members reported by 4.5% (6/134) participants, insults from the community reported by 2% (3/134) of participants and loss of employment and housing reported by one participant (0.75%).

Stigma by community members was not associated with gender (P = 0.29), marital status (P = 0.38) and presence of symptoms (P = 0.27).

Stigmatisation on the part of medical personnel

At the hospital level, 20 respondents (15% of the study population) believed that they had been the victim of at least one act of stigmatisation from the medical staff. This stigma was manifested primarily by the feeling of being neglected as reported by 10.45% (14/134) of participants, feeling that staff was uncomfortable in the presence of the patient in 6% (8/134) and feeling of lack of respect for the patient-reported by about 2% (3/134). A participant reported that she/he was refused care. The presence of stigma by medical personnel was not associated with gender (P = 0.93), marital status (P = 0.45), presence of symptoms (P = 0.58) [Table 1].
Table I: Participants' characteristics

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Factors associated with delay in care-seeking

Among symptomatic participants, the female sex significantly increases the risk of delay in care seeking by almost 3.3 times (Confidence Interval [CI]: 1.4–8.3).

The presence of auto-stigmatisation in symptomatic patients also increases the risk of delayed care seeking after symptom onset with an Odds ratio (OR) = 3.4 (CI: 0.9–11.5), although this increase is not significant. Likewise, the feeling of stigmatisation by the medical staff was mainly reported in patients who sought treatment late (23.5% vs. 8.9% in patients who arrived early), but the difference was not significant. On the other hand, though not significant, stigmatisation by the members of the community could favour reduce the risk of with an OR = 0.6 (0.2–1.7) but this in an insignificant way (P = 0.2) [Table 2].
Table II: Factors associated with late seeking of care among symptomatic patients (n=97)

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Patient satisfaction rate according to the different aspects of the patients' management explored

The overall satisfaction score (very satisfactory and satisfactory) of the patients managed at the COVID-19 treatment unit was 21.4%. There were very low levels of satisfaction about patient reception (4.48%) and waiting times before treatment received (5.22%) [Table 3].
Table III: Rates of patient's satisfaction

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  Discussion Top

Stigma has been studied for certain pathological conditions such as obesity and schizophrenia[20],[21] and certain infectious pathologies with high epidemic potential, such as Ebola virus infection or human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), but its presence and effects in the context of the COVID-19 infection remain to be determined in the Cameroonian context.

Our study highlighted the presence of three aspects of stigma in these cases of COVID-19, namely auto-stigmatisation, community stigmatisation and stigmatisation by medical staff.

These three aspects were also highlighted in other studies carried out on COVID-19,[22],[23] on HIV/AIDS, and in a study conducted on the Ebola virus infection in Senegal in 2014.[24] The lessons learned in the context of these studies could modulate our approach to the stigma caused by COVID-19.[25]Davtyan et al.[24] found in their multinational study on HIV stigma and accompanying discrimination that the factors contributing to HIV-related stigma were: 'fear of transmission, fear of suffering and death and the burden of care', which can also be found in the context of COVID-19.

Hospital quarantine of COVID-19 patients was applied as the primary method of limiting the spread of infection early in the epidemic. Furthermore, media psychosis, associated with the prospect of death as in the case of Ebola virus infection[26] may have contributed to creating moral suffering, which may explain these fairly high rates of stigma in COVID-19 cases. This stigma is also associated with the time taken by the COVID-19 patient to seek medical care after the onset of symptoms. A tendency was observed between being auto-stigmatised (P = 0.049), stigmatised by medical staff (P = 0.098) and late seeking health care. The presence of auto-stigmatisation increased the risk of late seeking treatment in the care centre and the feeling of being stigmatised by the medical staff tended to increase the risk of seeking treatment late by 2.9 times, and this is because of the prior fear of stigmatisation might have prevented the patient to seek for care. This effect of stigma on the delay to seek healthcare assistance was also recorded in a similar study in Tunisia, where many of the patients infected by tuberculosis arrived late in healthcare facilities due to stigmatization by the medical personnel.[27] This was also observed by Sébastien Tasset in his study on the impact of stigma where he specifies that, at the individual level, stigma leads to delayed consultation or an absence of care seeking.[28]

Female sex was associated with delay in seeking care, with women having three times higher risk (CI [1.4; 8.3]) to seek care late. This result is consistent with the observations of Haddad et al. on inequalities in access to health services and their determinants in Burkina Faso, who found that women use health services much less often and later.[29] There may be various reasons for this delay, including delay in awareness of the danger, delay in decision-making, delay in seeking alternative care, attribution of symptoms to a cultural cause or the delay of transport to services due to lack of means of transport as described in a study on severe diseases among women of childbearing age in Congo.[30] However, the wide confidence interval suggests that a study with more patients is needed to assess the true risk based on sex.

In addition to the aspects of stigmatisation experienced by patients, the degree of satisfaction of the latter with the various services was also reported. Overall, only about 21.4% of participants were satisfied, and many expressed dissatisfaction with the quality of reception of the patient and his family. This result in terms of the level of satisfaction could reflect the impact of the stigma created by this pandemic on the compliance of health-care workers.[31] Particular attention should be paid to these aspects to considerably improve the level of satisfaction of each patient.

Study limitations

Our main limitation is the small sample size but also the fact that we restricted our study to patients from a single COVID-19 case management site. Furthermore, information bias could have arisen as a result of certain questions answered with uncertainty or of the personal feelings of certain patients. The subjectivity of the feeling of stigmatisation constitutes a real obstacle to its estimation.

  Conclusion Top

This study shows that people who test positive for COVID-19 are victims of stigmatisation in various forms, in particular, self-stigmatisation, which is the most represented from here, followed by stigmatisation by members of the community and stigmatisation by the medical staff who are represented at a very low rate. The effect of these on the delay in seeking hospital care by these patients is considerable and deserves special attention. Furthermore, there is a need to improve service quality so that the patients' low levels of satisfaction could be addressed. The quality of hospital PEC also comes up against many difficulties.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2], [Table 3]


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