Combatting Stigma and Maintaining Good Mental Health During COVID-19

In March 2020, the South African government declared the outbreak of the COVID-19 disease as a national disaster, following in the steps of various countries around the world that have announced strict measures to contain the virus. According to public health officials, the coronavirus is highly contagious and has been spreading across the world at a fast rate. When South Africa announced the measures to curb the spread of the virus, the presidency announced that the country had seen an increase from 1 case to 51 cases in 10 days. Citizens have been advised to minimise social contact and to wash their hands regularly for 20 seconds at a time.

Some of the preventative measures in place announced by the president are:

• Closure of schools from 18 March 2020 until after the Easter holidays
• Suspending visits to correctional services for 30 days
• A ban on gatherings of more than 100 people, and cancelling of large government events
• A travel ban to high-risk destinations
• Mandatory testing and self-isolation or quarantine for South African citizens returning from high-risk countries

While these measures have been reassuring, it also means that the country is now officially in a national state of disaster in terms of the Disaster Management Act, which has caused panic among many citizens. Kumar, Math, Moirangthem & Nirmala (2015) state that developing countries have a high-risk level in terms of proneness to disasters, while also facing challenges related to insufficient resources, poverty, poor infrastructure, illiteracy, corruption, a lack of trained human resources and poor knowledge of managing mental health in disaster situations. The latter is important as disasters have been shown to have a profound effect on both the physical and mental health of the populations that are affected, with the World Health Organisation (WHO) (2020) stating that virtually all people affected by large-scale emergencies will experience psychological distress.

In the face of a global virus pandemic, the fear of contracting COVID-19 is thus now also impacting on the mental well-being of people, and social stigma attached to the coronavirus has started rearing its head (CIFRC, UNICEF & WHO, 2020). Social stigma related to health refers to the negative association between a person or group of people who share characteristics and a specific disease. During a situation such as the COVID-19 outbreak, this could lead to people being stereotyped and discriminated against, treated differently and a loss of status because of the perception of being linked to the illness. This can, in turn, affect those with the illness adversely, along with also impacting on their friends, families, communities and their caregivers. COVID-19 has brought about stigma and discrimination against certain groups of people, based on their ethnicities, along with prejudice against people who have supposedly been in contact with the virus (CIFRC, UNICEF & WHO, 2020).

Social stigma related to COVID-19 is based on three factors – 1) it is a new disease, which still has many unknowns, 2) people are often afraid of the unknown, and 3) fear is easily associated with “others” (CIFRC, UNICEF & WHO, 2020). While public confusion, fear and anxiety is understandable in these times, it is important to recognise that these factors are worsening harmful stereotypes. The reality is that stigma can undermine social cohesion and bring about the isolation of certain groups, leading to situations where the virus is more, not less, likely to spread, leading to more severe health problems and challenges in terms of controlling the disease (CIFRC, UNICEF & WHO, 2020).

Stigma can:

• Push people to hide their illness to avoid facing discrimination
• Prevent people from seeking urgent health care
• Discourage them from adhering to health behaviours

A few useful do’s and don’t’s on how to communicate (CIFRC, UNICEF & WHO, 2020) to help address social stigma:

1. Don’t attach locations or ethnicities to the disease (it is not a “Chinese Virus” or an “Asian Virus”). The correct name was deliberately chosen to avoid stigma: the “co” stands for “Corona”, the “vi” for “virus” and “19” because it emerged in the year 2019. Instead, talk about the “Corona Virus” or “COVID-19”
2. Don’t refer to people with COVID-19 as “COVID-19 cases” or “victims”. Instead, talk about “people who have COVID-19”, “people who are being treated for COVID-19”, “people who are recovering from COVID-19” or “people who died after contracting COVID-19”
3. Don’t talk about “COVID-19 suspects” or “suspected cases”. Instead, talk about “people who may have COVID-19” or “people who are presumptive for COVID-19”  Don’t talk about people “transmitting COVID-19”, “infecting others” or “spreading the virus” as this implies intentional transmission and assigns blame. The use of criminalising or dehumanising terms creates the impression that persons with COVID-19 have done something wrong or are less human than the rest of us. This perpetuates stigma, undermines empathy and has the potential to fuel a reluctance to seek treatment and attend screening, testing and adhering to quarantine. Instead, talk about people “acquiring” or “contracting” COVID-19
4. Don’t share unconfirmed rumours, and avoid hyperbolic terms that perpetuate fear, including “plague” and “apocalypse”. Instead, talk accurately about the risks related to COVID-19, based on scientific data and the latest official health information
5. Don’t dwell on negative issues, messages or threats. We all need to work together to help keep those who are most vulnerable safe. Instead, talk positively and emphasise the effectiveness of prevention and treatment measures because, for most people, this is a disease they will overcome. There are simple steps we can follow to keep ourselves, our families and vulnerable people safe
6. Continue to emphasise the effectiveness of sticking to protective measures to prevent acquiring COVID-19, along with early screening, testing and treatment

To help counter the stigma associated with COVID-19, people can 1) spread the facts through using simple terminology, not clinical terms, 2) engage social influencers to help amplify messages about curbing stigma, 3) promote the stories of people who have experienced COVID-19 and have recovered, 4) promote diversity and respect for different ethnicities by showing how all people are working together during this time, 5) encourage and engage in ethical journalism by reporting positively and not stigmatising people, and 6) linking up to existing anti-stigma efforts and promoting/creating an ethical environment based on care and empathy (CIFRC, UNICEF & WHO, 2020).

But why focus on stigma? And what (if any) is the link to mental health?

The SA Federation for Mental Health is particularly concerned about stigma and would like to highlight its impact on mental health and well-being. Stigma, as a major cause of discrimination and exclusion, affects people’s self-esteem, disrupts relationships and limits people’s ability to socialise and access housing and employment (WHO, 2020). It also obstructs the prevention of mental health problems, the promotion of mental well-being and the provision of effective modes of care and treatment. Stigma also contributes directly to human rights abuses. Recognising the need for mental well-being during this period of mass panic, WHO (2020) has developed guidelines for mental and psychological well-being of adults and children during the COVID-10 outbreak. Because the disease is likely to affect people from all walks of life, these considerations aim to assist people to cope, from ordinary members of the public to health care workers, as well as children and elderly persons In order to reduce anxiety.

In addition to what was listed earlier in terms of combatting stigma and discrimination, here is what members of the public can do to ensure their mental well-being and of people around them (WHO, 2020):

Do’s

1. Protect yourself and be supportive to others. Assisting others in their time of need can benefit the person receiving support, as well as the helper.
2. Seek information updates at specific times during the day, once or twice. The sudden and near-constant stream of news reports about an outbreak can cause anyone to feel worried. Get the facts! Gather information at regular intervals, from the WHO website and local health authorities, in order to help you distinguish facts from rumours.
3. Honour caretakers and health care workers supporting people affected by the disease in your community. Acknowledge the role they play to save lives and keep your loved ones safe.

Don’ts

1. Avoid watching, reading or listening to news that cause you to feel anxious or distressed; seek information mainly to take practical steps to prepare your plans and protect yourself and loved ones.

Support for health professionals

According to a new study (Cheung et al, 2020) mental health care for patients and health professionals directly affected by the global COVID-19 epidemic has been under-addressed. Using data from mental health problems and interventions observed during the 2003 SARS outbreak as reference, the researchers state that health care workers in hospitals caring for people with confirmed or who may have COVID-19 are vulnerable to both high risk of infection and mental health problems. On Thursday the 19th of March 2020, the confirmed cases of COVID-19 in South Africa stood at 150 (News24, 2020), and locally health care workers may thus also be experiencing fear of contagion and transmitting the virus to their families, friends, or colleagues. It is also important to note that many NGOs will continue their work in caring for children, mental health care users and the elderly by managing residential and day care facilities. Social services caring for these groups can also benefit from WHO guidelines on caring for one’s mental health during this period.

For health workers, the WHO (2020) says feeling stressed is a normal experience that most will likely go through. Here are some considerations for those tasked with ensuring the well-being of people who are being treated for COVID-19:

Do’s

1. Managing your stress and psychosocial well-being during this time is as important as managing your physical health.
2. Take care of your basic needs and employ helpful coping strategies. Make sure you rest and get respite during work or between shifts, eat sufficient and healthy food, engage in physical activity, and stay in contact with family and friends.
3. Some health care workers may, unfortunately, experience being avoided by their family or community due to stigma or fear. This can make an already challenging situation even more difficult. If possible, stay connected with your loved ones including through digital methods as a way to maintain contact.
4. Turn to your colleagues, your manager or other trusted persons for social support – your colleagues may be having similar experiences to you. 5. Use understandable ways to share messages with people with intellectual, cognitive and psychosocial disabilities.

Don’ts:

1. Avoid using unhelpful coping strategies such as tobacco, alcohol or other drugs to cope. In the long term, these can worsen your mental and physical well-being.

Caring for children

The national state of disaster has also resulted in the prolonging school holidays. During periods such as these WHO (2020) notes that children feel relieved if they can express and communicate their feelings in a safe and supportive environment. Here is how to assist children:

Do’s

1. Help children find positive ways to express disturbing feelings such as fear and sadness. Every child has their own way of expressing emotions. Sometimes engaging in a creative activity, such as playing and drawing, can facilitate this process.
2. Keep children close to their parents and family, if considered safe for the child. If a child needs to be separated from their primary caregiver, ensure that appropriate alternative care is available and that a social worker or equivalent will regularly follow up on the child’s situation.
3. In the event of separation, ensure that, during periods of separation, regular contact with parents and caregivers is maintained, such as twice-daily scheduled phone or video calls or other age-appropriate communication.
4. Maintain familiar routines in daily life as much as possible, especially if children are confined to home. Provide engaging, age-appropriate activities for children. As far as possible, encourage children to continue to play and socialise with others, even if only within the family, when advised to restrict social contract.
5. Discuss the COVID-19 with your children in an honest way and with age-appropriate information. If your children have concerns, addressing those together may ease their anxiety. Children will observe adults’ behaviours and emotions for cues on how to manage their own emotions during difficult times.

Don’ts

1. Avoid separating children and their caregivers as much as possible.

Elderly persons, especially in isolation and those with cognitive decline or dementia, may become more anxious, angry, stressed, agitated, and withdrawn during the outbreak or while in quarantine. Those who are caring for elderly persons should note the following:

1. Provide practical and emotional support through informal networks (families) and health professionals.
2. Share simple facts about what is going on and give clear information about how to reduce the risk of infection in words that they can understand. Repeat the information whenever necessary.
3. Instructions need to be communicated in a clear, concise, respectful and patient way. It may also be helpful for information to be displayed in writing or in pictures. Engage their family and other support networks in providing information and helping them practice prevention measures e.g. handwashing.
4. Encourage older adults with expertise, experiences and strengths to volunteer in community efforts to respond to the COVID-19 outbreak. For example, the healthy, retired, older population can provide peer support, neighbour checking, and childcare for medical personnel restricted in hospitals fighting against COVID-19.

In March 2020, South Africa (and much of the world) finds itself headfirst in frightening and uncertain territory. But while COVID-19 is placing pressure on and testing the resilience of individuals, communities, entire nations and continents, and ultimately that of the whole human race, it is also giving us the opportunity to show that, despite our perceived differences in terms of ethnicity, culture, class, social standings, income and educational levels, we are able to collectively stand together to fight the virus. Over the past few days we’ve seen unprecedented scenes of cross-political party cooperation and a sense of local and global unity in the face of COVID-19, with nations uniting, all in the name of survival.

But while so much of the focus is currently on washing our hands, coughing into our elbows and maintaining adequate social distance, the SA Federation for Mental Health would also like to remind people to be kind to their minds during this time and to take care of and support the mental and emotional needs of those around us.

Someone once said “If it were not for hopes, the heart would break”. Let us maintain hope, positivity and a fighting spirit during this time. So that we may prosper not only physically, but also mentally.

References:

Cheung, T., H Ng, C., Li, W., Xiang, Y, T., Yang, Y., Zhang L., & Zhang Q. (2020). Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed. The Lancet (7), 228-229.

CIFRC, UNICEF & World Health Organisation (2020). Social stigma associated with COVID-19. Retrieved from https://www.epi-win.com/sites/epiwin/files/content/attachments/2020-02-24/COVID19%20Stigma%20Guide%2024022020_1.pdf

Kumar, N. C., Math, S. B., Moirangthem, S., & Nirmala, M. C. (2015). Disaster management: Mental health perspective. Indian Journal of Psychological Medicine, 37 (3), 261-271.

News24 (2020). Coronavirus: There is no negotiation, says Cele and cases jump to 150. Accessed at https://www.news24.com/SouthAfrica/News/coronavirus-all-the-latest-news-about-covid-19-in-south-africa-and-the-world-20200312

The Presidency (2020). The Statement by President Cyril Ramaphosa on measures to combat COVID-19 epidemic. Accessed at http://www.thepresidency.gov.za/press-statements/statement-president-cyril-ramaphosa- measures-combat-covid-19-epidemic

World Health Organisation (2020). Mental health and psychosocial considerations during COVID-19 outbreak.Retrieved from https://www.who.int/docs/default-source/coronaviruse/mental-health-considerations.pdf

World Health Organisation (2020). Mental health in emergencies. Accessed at https://www.who.int/news-room/fact-sheets/detail/mental-health-in-emergencies

World Health Organisation (2020). Stigma and discrimination. Accessed at http://www.euro.who.int/en/health-topics/noncommunicable-diseases/mental-health/priority-areas/stigma-and-discrimination

For enquiries:
Masutane Modjadji
Project Leader – Info & Awareness
Email: masutane@safmh.org
Tel: 011 781 1852

Please note that, until further notice, SAFMH will only be available for phone interviews and email enquiries.