Stigma and Health

© 2020 American Psychological Association 2020, Vol. 5, No. 4, 375–379

ISSN: 2376-6972 http://dx.doi.org/10.1037/sah0000270

Stigma on First Responders During COVID-19

Tara Rava Zolnikov Frances Furio

National University and California Southern University California Southern University

During the pandemic, first responders were at an increased risk of being stigmatized because of their
direct exposure to COVID-19; stigmatization is an undesirable stereotype that can contribute to a myriad
of adverse effects, including, but not limited to, anxiety, depression, devaluing, rejection, stress, health
problems, exposure to risks, and limiting protective factors. The objectives of this research were to
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understand stigma on first responders during the COVID-19 pandemic as well as the consequences of
This document is copyrighted by the American Psychological Association or one of its allied publishers.

stigma on first responder’s mental health. A qualitative phenomenological study used semistructured
interviews to understand the experiences of first responders during the pandemic. This study included a
convenience sampling of 31 first responders (e.g., physicians, nurses, paramedics, police officers,
firefighters, etc.) located worldwide. First responders reported feelings of isolation, lack of support and
understanding by family or friends, decreased or forced removal in immediate social interaction (e.g.,
within family and friend circles), sentiments of being infected or dirty, increased feelings of sadness and
anxiety, and reluctance to ask for help or get treatment (e.g., self-approval of being isolated). By
answering these research questions, this information highlighted additional challenges that may be faced
by first responders aside from being a frontline worker during a pandemic, which is equally stressful. By
understanding the role of stigma, public health practitioners during pandemics or emergency situations
can seek to diminish it.

Keywords: COVID-19, coronavirus, first responders, health care workers, stigma

On March 11, 2020, the World Health Organization (2020)
characterized the newly emerging respiratory illness, coronavirus
2019 (COVID-19), as a global pandemic. COVID-19 had rapidly
spread across the world, creating a surge of cases in countries like
Italy, Iran, South Korea, and the United States. Pandemics and
disease outbreaks pose significant threats to human health as well
as contribute to adverse mental health effects because of drastic
life changes along with the inability to predict daily events (Pike,
Tomaney, & Dawley, 2010). Anxiety, stress, and fear felt by
people during the coronavirus pandemic was real and overwhelm-
ing, resulting in strong emotional reactions in adults and children
Editor’s Note. This article received rapid review due to the time-sensitive
nature of the content. Our standard high-quality peer review process was
upheld throughout.—PWC
This article was published Online First September 17, 2020.
X Tara Rava Zolnikov, Department of Community Health, National
University, and Department of Behavioral Sciences, California Southern
University; X Frances Furio, Department of Behavioral Sciences, Cali-
fornia Southern University.
The authors have nothing to declare in the conception, development,
writing, and submission of this research.
The authors acknowledge and thank all the first responders that are
sacrificing so much to combat the pandemic.
This research and manuscript did not receive funding.
Correspondence concerning this article should be addressed to Tara
Rava Zolnikov, Department of Community Health, National University,
678 Aero Court, San Diego, CA 92123. E-mail: tarazolnikov@gmail.com
(Centers for Disease Control and Prevention, 2019). The culmina-
tion of these reactions could be directed at first responders, who
were at the forefront of treating people affected by the disease and
sequentially considered the most exposed population (Adhanom
Ghebreyesus, 2020; Ehrlich, McKenney, & Elkbuli, 2020).
During the pandemic, first responders were at an increased risk
of being stigmatized (Adhanom Ghebreyesus, 2020; Ehrlich et al.,
2020), which is an undesirable stereotype that reduces an accepted
person to a tainted one (Goffman, 1963). Stigma has several
components, including stereotyping, discrimination, labeling, sta-
tus loss, and separation (Link & Phelan, 2001). Stigmatization can
negatively impact individuals faced with it, especially if stigma has
become internalized (Drapalski et al., 2013). Stigmatization is
problematic and can contribute to a myriad of adverse effects,
including, but not limited to, anxiety, devaluing, rejection, expo-
sure to risks, and limiting protective factors (Link & Phelan, 2006).
Stigma has been shown to increase stress among the individuals
who experience it (Major & O’Brien, 2005) as well as depression
(Benoit, McCarthy, & Jansson, 2015). Stigma can impact an
individual’s self-esteem and their overall achievements (Major et
al., 2005). Studies have shown that low self-worth and negative
health outcomes are both potential outcomes of stigma (Benoit et
al., 2015).
During the COVID-19 pandemic, health care workers and first
responders described experiencing stigma in their communities.
Amid this crisis, a qualitative phenomenological study was con-
ducted to understand the experiences of first responders during the
pandemic; this is the first study of its kind to review the effects of
stigma on first responders in any pandemic. This study used a
convenience sampling of first responders (e.g., physicians, nurses,

375
 376 ZOLNIKOV AND FURIO
paramedics, police officers, firefighters, etc.) who discussed their
personal experiences during the pandemic. Highlighted topics of
discussion focused on treatment, stigma, feelings, and mental
health. The expectation of this research was to upend aspects
related to adverse mental health in a vital working population
during the pandemic.
Method
A qualitative study was conducted to understand and explore the
experiences of health care workers and first responders during the
COVID-19 pandemic. This study used a descriptive phenomeno-
logical approach, which has been continuously described as a
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valuable research tool and strategy to understand the lived expe-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
riences of participants related to a phenomenon (Neubauer, Wit-
kop, & Varpio, 2019; Marques & McCall, 2005; Husserl, 1980);
the aim of this type of research is to identify the common themes,
factors, or components related to a phenomenon to better under-
stand the perspectives of those who have experienced it (Marques
& McCall, 2005). A phenomenological study looks at both what
was experienced and how it was experienced (Neubauer et al.,
2019). This method was utilized for this study because first re-
sponder experiences offer a unique perspective during the pan-
demic, although they are not authorities on pandemic stigma, in
general.
Health care workers and first responders were selected as the
target population. This selection was due to the fact that these
individuals have a unique position within this pandemic because
they are likely the population most exposed to COVID-19 during
this time. Inclusion criteria for this study was: above the age of 18
years, health care worker or first responder, and worked during the
COVID-19 pandemic. Participants were recruited through conve-
nience sampling, which used the Facebook platform; participants
were then screened, selected, and interviewed via Zoom (per social
distancing recommendations by the Centers for Disease Control
and Prevention) in a private setting and format, during which
questions reviewed challenges faced during the pandemic. After
interviews, the data were then analyzed via hand coding, in which
themes emerged and presented themselves through repetition.
Themes were then made into a codebook, which were used to
review all quotes related to the subject matter that directly
correlated to answering the research questions. This thematic
analysis followed the Moustakas (1994)–modified Van Kaam
(1966) method.
All qualitative research must provide measures to ensure valid-
ity of the data in the research. In this case, the researchers estab-
lished trustworthiness through credibility, multiple participant per-
spectives, peer debriefing and review, reflexive journaling, and
field notes. Credibility was gained through triangulation of sources
and member checking. Multiple participant perspectives were
sought when female and males of various ages in different parts of
the world working in different occupations were all included to
participate in the interviews. Peer debriefing and review occurred
before and after developing interview questions and analyzing
themes in the data. Reflexive journaling and field notes occurred in
a diary, which was used to report on questions related participant
reactions and impressions of each interview. That said, limitations
in all research exists. Limitations of this study included the pos-
sibility of nontransferable results to other first responders in the
world, researcher personal bias (e.g., mental health researcher),
and research participant bias.
The study protocol and ethics review were approved by Cali-
fornia Southern University. All participants signed informed con-
sent prior to the commencement of the interviews and audio
recording. Codes were immediately assigned to every participant
to ensure deidentified data collection.
Results
Participants’ answers concluded various challenges related to
treatment, stigma, feelings, and mental health. Participants de-
scribed factors that were associated with stigma, including feelings
of isolation, lack of support and understanding by family or
friends, decreased or forced removal of immediate social interac-
tion (e.g., within family and friend circles), sentiments of being
infected or dirty, increased feelings of sadness and anxiety, and
reluctance to ask for help or get treatment (e.g., self-approval of
being isolated).
Participants
A total of 31 health care workers and first responders were
interviewed for this study. The mean age was 36.129 years, with a
range between 23 and 57 years. In relation to gender, 18 partici-
pants identified as female, and 13 participants identified as male.
Participants were located worldwide, including the United States
(28), Kenya (one), Ireland (one), and Canada (one). Ethnicities
included African/Kenyan, Arab/Palestinian, Caucasian, Cauca-
sian/Russian, Caucasian/Iranian, and Caucasian/Irish. Of these, 18
of the participants were married, and 13 of the participants were
single. Sixteen of the participants had children, with an average of
2.25 children per subject, a median of 2.5 children, and a range of
one to four children.
The education levels of participants included high school (one),
some college (four), associate degrees (six), bachelor degrees (13),
graduate degrees (three), and medical school educations (four). All
participants worked within roles as health care workers or first
responders during the COVID-19 pandemic; there were physi-
cians/doctors (three), nurses (14), a nurse tech, a behavioral ther-
apist, an orthodontist, a dialysis technician, a technician in medical
surgery, a data specialist, a paramedic, firefighters and paramedics
(three), a firefighter and emergency medical technician, and police
officers (three).
Experiencing Stigma
In the cohort of interviewees, many participants discussed as-
pects of stigma, although never directly associated themselves with
stigma or being stigmatized. “I haven’t had any [stigma]. . . . I
[did] stay at the abandoned other house that we have . . . for about
2 weeks and, you know, tried not to come home” (P4.5). Partici-
pants used various negative words to describe how they felt during
the pandemic, “like I was infected, . . . like I was dirty” (P3.3) or
“contaminated” (P9.2) and how they were regarded: “They treat
me like I had the plague” (P4.1). These feelings were hard to
dismiss,
[I feel] “dirty.” My clothes are “dirty”, my hair is “dirty”, my shoes
are “dirty,” . . . everything with me has been “stained” with COVID
 STIGMA ON FIRST RESPONDERS DURING COVID-19
19 . . . including my body. I know that the “dirtiness” of it all isn’t me
personally, but it is hard to turn away and not take it personal and feel
helpless. . . . I guess I just do not want to feel dirty anymore; it’s
draining. (P7.3)
Participants believed that being isolated was justified, “Well, I
mean, . . . it’s understandable. People were just scared, I think”
(P95). This negatively affected participants: “Well, initially I was
quite sad to [be treated differently] because it was all of a sudden.
But then . . . it becomes the norm” (P1.2).
Isolation and directed fear came from different layers of people,
including the general public, friends, and family. The public had an
interesting response to first responders. This reaction ranged and
included arm’s-length support. “[I received] cards, like kindness
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cards, words written to us. Loved ones sending food to us. . . . And
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just encouragement from the community” (P1.1). Alternatively,
the response also included aggressive behavior: “. . . She pulled
down her mask and coughed at us” (P10.3). These situations
contributed to first responders not wanting to declare their occu-
pations and place of work.
If people would ask me what I did for work, I was kind of proud to
say, you know, I work at the hospital. . . . [Now] I don’t make a habit
of telling anybody I work at the hospital, just because most people get
kind of freaked out. (P4.1)
In addition to the public, first responders most often experienced
stigma from the people closest to them—friends and family mem-
bers. “Usually people start to become very cognizant and aware
exactly where you’re standing so they don’t touch those things.
Yeah, I’m not allowed at my parent’s house. [Friends] call me, but
nobody wants me over [and] of course, nobody’s coming over”
(P1.2). And friends created a physical separation between first
responders and themselves:
. . . It’s like everyone would jump back 10 feet. Even my mom would
stay away from me. When I did come home, . . . I’d be carrying on a
conversation with [my mom], and if I took a step forward to like pick
something up, she would take a step back, kind of like reflexively, like
jumping back [and keep] this imaginary bubble. And in my house, I
wasn’t [even] allowed in the kitchen area. (P4.1)
Alienation frequently occurred because first responders found it
difficult to find safe places to go and often found comfort in
solitude:
I don’t enjoy people as much anymore; . . . like even my family will
get together and I sit there but then I’m really annoyed with all of
them. . . . I don’t want to engage. And I don’t want to have conver-
sations and I sometimes just want to go home and be like—where’s
the one place that nobody will be that I can go? I want to grab my
wine and be alone. I don’t want to talk to anybody. . . . On my ride
home, which is like a 40-min ride, no radio, no, it was just silent.
(P3.2)
Others were convinced or coerced into quarantine or separation
from immediate family:
Nobody wanted to be around you. . . . When you have [a] hard day or,
you know, there’s a lot going on, you have a lot of stress, and then you
come home and then you’re treated like you’re, you know, a leper; . . .
it doesn’t make you feel very good; . . . there’s nobody to share
[anything] with. (P7.1)
377
Common words to describe emotions and feelings as a result of
being stigmatized, included “sadness” (P1.1), feeling “blue”
(P7.1), and “extremely stress[ed]” (P3.3) while living in a situation
that “is so demoralizing” (P9.4). These effects could be translated
to adverse mental health effects that are commonly associated with
stigma, such as depression, anxiety, and stress. Reactions to these
feelings included alcohol use. “I feel very isolated, lonely, de-
pressed even. I found my alcohol intake increased” (P11.1).
Participants described several solutions related to the stigma that
was faced during the COVID-19 pandemic. Participants mentioned
how communication was an important component to consider.
This included communication among colleagues: “Talk to your
colleagues or talk to somebody that you trust about what you’re
going through mentally, emotionally” (P1.1). This also included
communication among those in supervisor or managerial roles: “I
think there needs to be a lot more communication and honesty”
(P4.2). Participants also described the importance of health care
workers and first responders maintaining a connection with those
outside their professional roles, including other members of the
general population and those in their communities: “Just keep in
touch with these people, like they’re not diseased, . . . continue to
call them and keep talking with them; . . . people should make an
effort to continue to speak to these people” (P1.2).
Many participants described improvements related to education
and dissemination of science-based information related to the
COVID-19 pandemic as an important potential solution. “More
real education and less completely false news would be great”
(P3.3). “I think education could definitely help next time” (P6.2).
Participants stated that “more facts” would be helpful (P3.4). “The
biggest thing is misinformation” (P6.2). “Public awareness cam-
paigns and things like that could do a lot of good” (P7.2). “Public
health education, educating the public on the modes of transmis-
sion of some conditions like this one” (P9.4). “I don’t think there
really is anything you can do aside from educating the public”
(P10.4).
Even when discussing potential solutions, participants still ac-
knowledged the challenges and difficulties that came to stigma
faced by health care workers and first responders. “How do you
simultaneously convey the message that this is something that
needs to be taken seriously as well as then downplay the effect of
people who are most exposed?” (P4.4). The messages conveyed
how difficult it would be tackling stigma in first responders:
“You’re always gonna have people that are gonna be rude; . . .
there’s always gonna be the people that think that you’re icky and
infected, and I don’t think we’ll ever get away from that” (P5.1).
Discussion
First responders have a unique position as first-line response to
COVID-19 patients, which results in an increased likelihood for
exposure to the virus. Because of this position, mental health
problems, such as anxiety, depression, insomnia, and stress, have
been revealed in this population (Liu et al., 2020). A 2-fold mental
health problem occurs when adding stigma as well; the first layer
of adverse mental health occurs because of direct exposure to the
disease within a work setting, and the second layer occurs with
stigmatization faced outside the work setting. Poor mental health
for the most important line of defense against the pandemic is
important to address because it is responsible for long-term work
 378 ZOLNIKOV AND FURIO
absence, which makes it difficult to tackle and curb the results of
the pandemic (Blank, Peters, Pickvance, Wilford, & Macdonald,
2008).
In addition to the negative effects experienced, major issues
described in this study were lack of support and isolation, which
have been linked to anxiety, restlessness, emptiness, marginality,
decreased sleep, decreased immunity and inflammatory control,
and higher morbidity rates (Cacioppo, Hawkley, Norman, & Bern-
tson, 2011; Weiss, 1973). Finally, stigma can upend self-esteem
and sense of meaningful existence or belonging and can result in
social pain and distress (Almutairi, Adlan, Balkhy, Oraynab, &
Clark, 2018).
It is important to delve into the depth of stigma. Individuals
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perceiving stigma from community versus internalizing stigma can
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contribute to various mental health outcomes. In this study, public
stigma occurred in various places with participants (e.g., grocery
stores, gas stations, driving, etc.). This is important to discuss
because it became internalized by participants, who described
feeling dirty or infected and believed social outcasting was war-
ranted. Internalized stigma is a self-agreement with negative ste-
reotypes and often results in personal rejection and distress (Quinn
et al., 2014). Adverse mental health outcomes that can arise from
internalizing stigma include depression, avoidant coping, social
avoidance, decreased hope and self-esteem, psychiatric symptoms,
and decreased mental health support (Drapalski et al., 2013).
Moreover, internalized stigma can mediate the relationship be-
tween public stigma and mental health treatment (Brown et al.,
2010). As a result, suggesting internalized stigma occurred in first
responders during the pandemic is of utmost concern because this
can contribute to the development of negative attitudes and lack of
mental health treatment in an at-risk population.
In regard to reducing stigma, many participants described
improvements needed related to the lack of accurate informa-
tion being shared with the media. Interviews with health care
workers and first responders demonstrated the need for im-
provements related to education and dissemination of science-
based information related to the COVID-19 pandemic as an
important potential solution. Literature has described the pro-
liferation of misinformation related to the COVID-19 pandemic
(Pennycook, McPhetres, Zhang, Lu, & Rand, 2020). Many
individuals receive information related to important global is-
sues from social media outlets, including, but not limited to,
YouTube, Twitter, and Instagram (Cinelli et al., 2020). Litera-
ture has described the panic related to the COVID-19 pandemic
as spreading faster among media outlets than it has as a virus in
the community (Depoux et al., 2020).
Reporting in the media is said to have a significant impact on the
public (Depoux et al., 2020). When faced with inaccurate infor-
mation, individuals can be more likely to overreact, underreact, or
turn to infective solutions and remedies (Pennycook et al., 2020).
Literature has shown that increases in media exposure related to
COVID-19 content is correlated with increases in stress and anx-
iety among individuals, in general (Garfin, Silver, & Holman,
2020). This is a likely scenario that contributes to the stigma of
first responders during the pandemic.
Solutions to this problem could include real-time and urgent
information being conveyed to the public while being mindful
of untoward exposure to the media (Garfin et al., 2020). The
goal is to reduce hysteria and mitigate the transmission of
misinformation (Depoux et al., 2020; Garfin et al., 2020).
Detecting inaccurate rumors, attitudes, and perceptions related
to COVID-19 will be required to effectively respond (Depoux
et al., 2020). Turning to health care providers, specifically, for
critical information related to the topic at hand could also be
helpful (Garfin et al., 2020). The acknowledgment of inaccurate
information and dissemination of science-based information
related to COVID-19 could potentially improve communication
and reduce the stigmatization that health care workers and first
responders have described in this study.
Conclusion
Facing stigma is often invisible, in that the effects are not often
recognized; despite the inability to see it, experiencing stigma can
be dangerous to health while also diminishing the value of a person
through discrimination and loss of status by being devalued, re-
jected, and excluded (Link et al., 2006). The compounding adverse
mental health effects in an essential population used to fight the
pandemic turns an already challenging situation dire. By under-
standing how stigma affects first responders, blurred lines can start
to become visible, and public health practitioners now and in
future pandemics or emergency situations can seek to diminish it.
Future research could focus on understanding stigma, both within
individuals and perceived stigma through the community. This
research can highlight areas for interventions to modify and de-
crease negative attitudes that may exist (Rost, Smith, & Taylor,
1993). Other areas of interest can focus on understanding the
relationships between internalized stigma, coping strategies, and
mental health services used. For example, another qualitative study
could be implemented to reveal a baseline of information describ-
ing coping strategies and accessed mental health treatment in first
responders. Ultimately, this type of information could then be used
to support mental health needs in first responders during the
pandemic.
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Received July 6, 2020
Revision received July 22, 2020
Accepted July 24, 2020 䡲