The Role of Knowledge and Personal Experience in Shaping Stigma Associated With COVID-19 and Mental Illness
Article information
Abstract
Objective
Stigma influences perceptions of mental illness and novel diseases like coronavirus disease-2019 (COVID-19), often impeding healthcare access despite advancements in medical treatment. This study compares the stigma associated with COVID-19 and mental illness to identify factors that could help reduce stigma.
Methods
An online survey was conducted in May 2023 among 1,500 participants aged 19 to 65 in South Korea, using a panel from Embrain, an online survey service. The survey assessed stigma and distress related to COVID-19 and mental illness using a validated questionnaire. It collected demographic and clinical data, evaluated COVID-19-related stigma, fear, and knowledge, and measured prejudice and attitudes toward psychiatric treatment. Personality traits were assessed using the Big Five Inventory (BFI)-10. Factors significantly associated with stigma scores were entered into linear regression analysis.
Results
COVID-19-related stigma scores were significantly negatively correlated with knowledge of COVID-19 and positively correlated with fear of infection and age. Individuals with a history of COVID-19 infection had significantly lower scores on COVID-19-related stigma. Similarly, mental illness stigma was negatively correlated with knowledge of psychiatric treatment and positively correlated with age, as well as conscientiousness and neuroticism in the BFI. Personal experience with individuals with mental illness was associated with significantly lower stigma scores.
Conclusion
This study suggests that the mechanism-making stigma was similar in cases of traditional mental illness and a novel infectious disease. Both cognitive and experiential factors influence stigma. Educating the public about the disease and enabling interactions with affected individuals emerge as effective strategies for stigma reduction.
INTRODUCTION
The concept of stigma has its roots in ancient Greek culture, where it denoted marking or tattooing something perceived as abnormal or undesirable, carrying connotations of negativity [1]. Evolutionarily, it can be seen as an adaptive strategy for protecting oneself from crises, such as infectious diseases, conflicting values, and unforeseen risks [2-4]. Regrettably, during medieval Europe, individuals with mental illness were commonly perceived as embodiments of the devil’s influence or as recipients of divine punishment for moral transgressions [5]. Despite significant advancements in treatment technologies over time, the stigma surrounding mental illness has persisted throughout this historical progression. For individuals with mental illness, stigma has a profound impact on their lives, often being referred to as a “second illness” due to its considerable influence [6]. Such stigma can lead to social isolation, resulting in individuals with mental illness reducing their use of mental health services [7]. In addition, patients with higher perceived stigma were more likely to have depressive symptoms [8].
Stigma can arise in response to the emergence of new diseases with limited knowledge, as well as in the cases of mental illness. The emergence of the novel coronavirus disease-2019 (COVID-19) has been a global issue since late 2019, affecting societies worldwide and leading to devastating consequences [9]. Diverse policies have been attempted internationally to prevent and treat the spread of COVID-19. However, like the case of mental illness, misinformation, fear, and social attitudes towards COVID-19 perpetuated stigma. The stigma surrounding COVID-19 can be understood as a social mechanism to exclude individuals perceived as potential sources of infection, thereby threatening the effective functioning of social life [10]. Social stigma to COVID-19 infection in the early pandemic might contribute to higher stress and depressive symptoms [11]. Like the case of mental illness, stigma leads individuals with infection to conceal their illness and delay diagnosis and treatment to avoid discrimination [10]. Despite the World Health Organization’s declaration of the conclusion of the emergency phase of COVID-19 in May 2023 [12], addressing stigma remains pivotal in disease management for the present and future.
Stigma stems from ignorance and fosters prejudice, leading to discriminatory behavior, which can result in social confusion [13]. It is well known that when individuals recognize public stigma, they tend to withdraw and distance themselves from the public rather than fight against prejudice [14]. This phenomenon presents challenges to effective intervention and resolution of the issues. To our understanding, a few researches on the stigma associated with COVID-19 exist [10,11,15,16], but there is a scarcity of studies examining factors that could influence it. In this study, we aim to identify the key factors contributing to the occurrence of stigma in the context of COVID-19 and mental illness and to assess their respective impact. We hypothesize that the mechanism underlying the development of stigma is similar in the cases of COVID-19 and mental illness. Specifically, personal experience with the illness may be the critical factor associated with stigma.
This study seeks to examine the factors contributing to the stigma surrounding COVID-19 via survey analysis and juxtapose them with those influencing stigma towards mental illness. Therefore, the objective is to provide foundational data for identifying factors contributing to stigma and develop effective strategies to mitigate stigma that interferes with disease management. In this context, analyzing the factors influencing stigma related to COVID-19 and mental illness may be particularly meaningful.
METHODS
Study design and participants
The present study was a part of serial mental health surveys on the psychosocial effects of COVID-19 in the Korean general population since 2020 [17-21]. We conducted an online survey of the general population with participants aged 19 to 65 in South Korea. The survey utilized a panel of online survey services (Embrain) [17]. This study utilized data from a survey conducted in May 2023. Participants provided consent for using their personal information, and the study received approval from the Institutional Review Board of Chonnam National University Hospital (CNUH-2021-297).
Outcome measures
Demographic variables included sex, age, and education level. Clinical information included a history of COVID-19 infection and an experience meeting patients with mental illness. Personality traits were assessed using the Big Five Inventory (BFI)-10, a short-form version of the BFI that measures five dimensions of personality, including extraversion, agreeableness, conscientiousness, neuroticism, and openness to experience [22,23].
A previously developed and validated questionnaire by the authors was utilized to measure the COVID-19 stigma, fear of infection, and knowledge about COVID-19.17 The stigma of COVID-19 was assessed using these items, evaluating societal harm caused by infected individuals, viewing them as abhorrent, and the belief that they carry a fatal virus [17]. The internal consistency of this questionnaire was acceptable (Cronbach’s α=0.777). Fear of COVID-19 infection was assessed using seven items. Fear of COVID-19 was assessed using seven items, including concerns about personal and family infection, the potential for death, asymptomatic carriers, the impact of quarantine, and causing harm to others if infected [17]. The item regarding fear of quarantine after contact with an infected person was replaced with an item assessing fear of health deterioration due to limited hospital access in response to changes in COVID-19 policy. This questionnaire’s internal consistency was good (Cronbach’s α=0.886). All items were rated on a 5-point Likert scale, from “Not at all” (1 point) to “Very much” (5 points), with score ranges of 3 to 15 and 7 to 21, respectively. Higher scores indicated greater levels of stigma and fear of infection. Knowledge of COVID-19 was assessed using seven items, including six from our previous studies [24,25] and one new item addressing the increased risk of death for individuals with underlying health conditions following new clinical evidence. Correct answers were awarded one point, with a total score range of 0 to 7. A higher score indicated a higher level of knowledge. The internal consistency of this questionnaire was moderate (Cronbach’s α=0.635), probably due to the reverse scoring of three incorrect items.
Prejudice and discriminative behavior were measured using seven items from the 2008 “Survey on Discrimination and Prejudice against Mental Health Patients” by the Korea National Human Rights Commission [26]. The questionnaire included items addressing avoidance of personal and official relationships and discriminatory behavior toward individuals with mental illness. Participants responded using a 5-point Likert scale, with a score range of 7 to 35, and higher scores indicated greater stigma. The internal consistency of this questionnaire was excellent (Cronbach’s α=0.901). A six-item questionnaire was used to assess knowledge and attitude toward psychiatric treatment. Five incorrect knowledge items were adapted from our previous studies [27], and one correct item on the benefits of early mental health intervention was newly added. Participants indicated whether each item was correct, with scores ranging from 0 to 6. The internal consistency of this questionnaire was acceptable (Cronbach’s α=0.705). A higher score indicated a higher level of knowledge.
Statistical analysis
The dependent variables in this study were the stigma associated with COVID-19 and mental illness, as measured by a questionnaire. Their associations with sociodemographic and clinical characteristics were analyzed using Pearson’s correlations for continuous variables and independent t-tests for categorical variables. Fear of infection and knowledge of COVID-19 were included as variables in the Pearson correlation analysis for stigma against COVID-19. Knowledge of psychiatric treatment was used as a variable in the Pearson correlation analysis for stigma against mental illness. Factors significantly associated with stigma scores in the univariate analyses were entered into a multivariate linear regression analysis to control for confounding effects. All statistical tests were twotailed; p<0.05 was taken to indicate statistical significance. The statistical analysis was performed using SPSS software (version 25.0; IBM Corp., Armonk, NY, United States).
RESULTS
Among 1,500 general population individuals, 944 (62.9%) reported a history of infection by COVID-19, and 752 (50.1%) reported experiences meeting a patient with a mental disorder. Table 1 shows Pearson correlation coefficients between stigma associated with COVID-19 or mental illness and clinical characteristics. Scores on stigma against COVID-19 were significantly negatively correlated with educational level, knowledge of COVID-19, and the agreeableness dimension of the BFI. They were significantly positively correlated with fear of infection, age, and the neuroticism dimension of the BFI. People who had a history of COVID-19 infection had significantly lower scores on stigma against COVID-19 (Table 2). Multivariate linear regression analysis revealed that age, fear of infection, knowledge of COVID-19, and history of COVID-19 infection were significantly associated with scores on stigma against COVID-19 (Table 3).

Pearson correlation coefficients between stigma associated with COVID-19 or mental illness and clinical characteristics

Comparison of scores on stigma against COVID-19 or mental illness according to sex and personal history
Scores on stigma against mental illness were significantly negatively correlated with knowledge of psychiatric treatment and positively correlated with age, as well as consciousness and neuroticism subscale scores on the BFI (Table 1). People who had an experience meeting patients with mental illness had significantly lower scores on stigma against mental illness (Table 2). Multivariate linear regression analysis revealed that all factors, including an experience meeting patients with mental illness, were significantly associated with scores on stigma against mental illness (Table 4).
DISCUSSION
The findings from our study suggest that the stigma associated with both COVID-19 and mental illness is socially constructed through similar mechanisms, primarily driven by ignorance and misinformation rather than the illness’s inherent characteristics. Both stigmas were significantly related to personal experiences and knowledge of the disease, with individuals who had experienced COVID-19 or interacted with those with mental illness reporting lower levels of stigma. This highlights how societal narratives shape stigma, which can be mitigated through direct experience and education. In both cases, misinformation and fear lead to the perception of individuals as threats to public safety—COVID-19 as an infectious danger and mental illness as a disruption to societal norms—resulting in discrimination and social exclusion.
For stigma related to COVID-19, negative correlations were observed with knowledge of COVID-19 and history of COVID-19 infection. The knowledge of COVID-19 is crucial for implementing appropriate precautions such as hand washing and mask-wearing to mitigate the spread of COVID-19. Possessing this relevant knowledge fosters confidence in one’s ability to protect against the disease. Research has been found to improve the management of COVID-19 among those who received accurate information [28], suggesting that such understanding can reduce the fear of infection. Prior studies have demonstrated that the fear of COVID-19 infection contributes to stigmatizing groups perceived as potential virus transmitters [10]. Interestingly, our study also found a positive correlation between fear of infection and COVID-19-related stigma. It can be implied that accurate knowledge leads to reduced fear of disease, which explains our findings that stigma is negatively correlated with knowledge.
Regarding stigma for mental illness, negative correlations were also found with the knowledge regarding psychiatric treatment and an experience meeting patients with mental illness. Given that the stigma originates from ignorance [13], our study found that inaccurate information, common in novel infectious viruses and mental illnesses, exacerbates stigma. Thus, addressing prejudice by disseminating accurate information is essential, thereby preventing prejudice and discrimination.
Another point to note in this study is that individuals infected with COVID-19 exhibited lower levels of stigma associated with the disease. Similarly, individuals who had an experience meeting people suffering from mental illness or were acquainted with someone experiencing mental illness exhibited lower levels of stigma toward mental illness. Like the impact of knowledge, experience also appears to influence stigma reduction in both diseases. Prior research has demonstrated that individuals who undergo experience-led learning processes exhibit fewer negative stereotypes towards people with mental illness compared to those who do not engage in such experiences [29]. Also, social contact with people with mental illness was the most effective intervention for the short-term improvement of stigma-related knowledge and attitudes [30]. Direct interaction with individuals experiencing mental illness was found to have the most beneficial impact in reducing stigma, compared to educational programs about mental illness and advocating against negative attitudes towards them [31]. Experience may more strongly influence attitude toward an illness than intellectual knowledge [32]. Empirical factors seem to be critical in reducing stigma. Upon reviewing the findings of these studies, it becomes apparent that the stigma is influenced by both cognitive factors, such as knowledge, and experiential factors.
Strategies for overcoming new forms of social stigma against emerging illnesses may mirror those employed for mental illness and COVID-19. Public health initiatives should focus on providing accurate information and addressing misinformation through mass media and other channels to correct misconceptions about diseases [20,24,33,34]. Additionally, involving individuals with lived experience of both conditions as educators or advocates could effectively dismantle stigma within communities and healthcare settings [35]. Anti-stigma programs that offer opportunities for direct interaction between individuals with diseases and the public could significantly reduce social stigma and prejudice. Such interventions would improve social attitudes and encourage those affected to seek timely diagnosis and treatment, ultimately improving public health outcomes.
Positive correlations between stigma and neuroticism dimension of personality were observed. Neuroticism is characterized by traits such as anxiety, sadness, and emotional instability [36,37]. Neurotic individuals are more likely to have increased anxiety and feelings of insecurity, particularly in the face of unfamiliar mental illness. This provides a potential explanation for our findings that there is a positive correlation between stigma and neuroticism. Furthermore, previous research has indicated that individuals with high levels of neuroticism tend to prefer greater social distance [38].
The correlation between mental illness stigma and conscientiousness aligns with prior research [36,39,40]. Conscientiousness pertains to individuals characterized by their attention to detail, effectiveness, and capacity for self-regulation [41,42]. Previous studies indicate a positive association between conscientiousness and right-wing authoritarianism [43]. Furthermore, elevated levels of right-wing authoritarianism demonstrate a robust correlation with prejudicial attitudes and negativity toward individuals with mental disorders [43].
There was a negative correlation between age and stigma in COVID-19 and mental illness. This outcome aligns with the conclusion drawn from numerous previous studies regarding the relationship between old age and stigma about mental illness [44,45]. It has been suggested that aging may be associated with increased prejudice among older adults due to a diminished capacity to suppress automatically activated biased associations [46]. Given that older adults are less likely to seek professional mental health services when needed [47], stigma may play a significant role in deterring them from seeking assistance. Anti-stigma intervention targeting the elderly may be necessary for effective disease management.
This study had some limitations. First, it was an online survey, which may have introduced selection bias. Second, it relied on self-reported data without objective assessments. Finally, while this study suggests that the pathways leading to stigma against mental illness and COVID-19 may be similar, the scales used to measure stigma for these two conditions were not identical. However, both scales addressed components related to prejudice and negative perceptions about the illness. Despite these limitations, the study suggests that the mechanisms underlying the formation of stigma are similar for traditional mental illness and novel infectious diseases. Furthermore, strategies for overcoming new forms of social stigma against emerging illnesses could mirror those already employed to address the stigma surrounding mental illness and COVID-19.
In conclusion, despite COVID-19 being acknowledged as a prevalent infectious disease, the potential emergence of unfamiliar diseases persists, and apprehension regarding these unknown illnesses may exacerbate stigma. Stigma poses a significant obstacle to disease treatment and contributes to societal disarray. Our research underscores the importance of knowledge and experience as pivotal factors in addressing stigma. Educating the public about the disease and enabling interactions with affected individuals emerge as effective strategies for stigma reduction.
Notes
Availability of Data and Material
The datasets generated or analyzed during the study are available from the corresponding author on reasonable request.
Conflicts of Interest
Sung-Wan Kim, a contributing editor of the Psychiatry Investigation, was not involved in the editorial evaluation or decision to publish this article. All remaining authors have declared no conflicts of interest.
Author Contributions
Conceptualization: Sung-Wan Kim. Data curation: Seunghyong Ryu, Sung-Wan Kim. Formal analysis: Sung-Wan Kim. Funding acquisition: Sung-Wan Kim. Investigation: all authors. Methodology: Ji-Min Yoo, Sung-Wan Kim. Supervision: Ju-Wan Kim, Seon-Young Kim, Ju-Yeon Lee, Sook-In Jung, Jae-Min Kim. Validation: all authors. Writing—original draft: Ji-Min Yoo, Sung-Wan Kim. Writing—review & editing: all authors.
Funding Statement
This research was supported by a grant of the Korean Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI) (grant number: HI22C0219), funded by the Ministry of Health & Welfare, Republic of Korea.
Acknowledgements
We thank Anna Jo and Min-Ju Oh for contributing to the research and collecting data.