Stigma towards Chronically Ill Patients among Healthcare Workers Caring for COVID-19 Patients during the Outbreak in Jordan

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Introduction
Te COVID-19 pandemic led to signifcant changes in the working environment and job demand of healthcare workers (HCWs) [1][2][3].It resulted in more pressure in the workplace, an unfavorable physical working environment, and made interactions emotionally demanding [2,4,5].As a result, it became very difcult for HCWs to provide care.Some of the themes for HCW that came up include stress, uncertainty, and stigmatization [6][7][8].HCWs often experienced complicated and conficting thoughts and feelings about balancing their roles and as parents [9,10].Tey feel they have a professional responsibility but fear the disease and the guilt of exposing their families if they contract the disease while responding to emergencies such as Ebola and COVID-19 [6,11].Working with chronically ill patients (people who experienced chronic disease such as diabetes mellitus (DM) and hypertension (HTN)) resulted in considerable stigmatization since these people had a very weak immunity system exposed to more threat compared to other type of patients [11].Contagion is associated with diferent forms of attitudes, stigma, stereotypes, prejudices, and beliefs.During these situations, an individual's emotions play an essential role in altering [12] conscious choices or choices made based on facts [5,13].
Te duty of healthcare providers often contradicts their responsibilities to their patients and their attitudes due to the infection [10,14].It can sometimes result in prejudice against people who are considered as "plague spreaders" [15,16].However, the fear of getting infected overrides positive emotions making it difcult to manage contact with infected people or people for their test results [17,18].Te most expressible reaction is fear, which is very important for human survival and self-defense.However, if the fear is expressed at a high level, it will impact the immunity and ability of providing care among people and HCWs.An acceptable level of fear can make HCWs provide substantial care to patients than the quality of care they would have provided in a normal situation [15,19].Healthcare organizations and the government should recognize and acknowledge the impact of working in an infectious environment and potentially infectious patients [6,14].It is necessary to understand the impacts of stigma in relation to HCWs' exposure to the pandemic, job demand, and self-esteem and how they infuence HCWs' outcomes [1,20].
It is, therefore, important to explore whether the variables can result in changes in the quality life of HCWs' professional life and burnout, compassion satisfaction, and compassion fatigue among healthcare workers.Te contribution of contextual variables such as the role, position, type of organization, and years of experience should be hypothesized.Stigma and discrimination tend to exist in the long run after the end of quarantine and containment of the pandemic [6,19].Human resource management (HRM) can provide support to reduce HCW stigma and stress caused by high workloads and performing unfamiliar tasks towards chronically ill patients.Other important tools that can help fght HCW burnout and social stigmas include systematic training, network meetings, and counseling [2,21].Te researchers conducted this study to get more attention to the degree of stigma among HCWs during a pandemic, and this could apply to future pandemics.Tis study aims to examine the stigma among HCWs towards chronically ill patients and to determine the predictors of stigma among HCWs for these patients.

Study Design.
Tis study included 686 HCWs involved in COVID-19 diagnosis and treatment in general hospitals in Jordan that were recruited using social platforms such as Facebook, Twitter, and other types of social media.Tis study used the convenience sampling method.Te study began on May 2021 and ended on July 3, 2021.Te research participants practiced in various internal medicine, infectious wards, and intensive care units (ICUs).Te sample comprised diferent professionals, including nurses, physicians, medical residents, pharmacists, and medical technicians.Some of the research participants were in the frontline, while others were indirectly involved with the care of COVID-19 patients.Te HCWs worked either full-or part-time in the hospital.Te questionnaire was emailed to the respondents online, and they were asked to complete it.
Te respondents volunteered to take part in the study.Te participants were informed by the researchers that they may withdraw from the study at any moment.

Inclusion and Exclusion Criteria.
Te HCWs included in the study were all above the age of 18 years.All participants were involved with the care of COVID-19 patients and not only participants involved in the care of COVID-19 patients but also those dealing with chronic illnesses such as diabetes (DM) and hypertension (HTN) and worked either full time or part time.Besides, the participants were present at the hospital during daily shifts, night shifts, or on rotations and, when willing, entered the research project.

Data Collection.
Demographic information of the participants such as occupation, gender, age, employment status, education level, and type of contact with COVID-19 patients was collected using Google Forms that were distributed online.Data on the perception of stigma among HCWs were collected from a questionnaire that used the COVID-19 Stigma Scale.

Procedure.
Several hospitals in Jordan included in this study are all covered by the Ministry of Health.Te province in which the study was conducted is a province with the highest number of people in Jordan.Te researchers evaluated HCWs working in ICUs, infectious wards, and internal medicine wards.

Participant Selection.
Tousands of surveys were sent to HCWs.Te response rate was 68.6%, and the total number of questionnaires evaluated was 686.Te participants entered the study voluntarily as the researchers used a convenience sampling method.Diferent items had several missing data related to incomplete answers provided by the participants.

Te Perception of Stigma.
Te questionnaire adopted from the COVID-19 Stigma Scale [20] focused on determining the experiences and feelings of HCWs during the COVID-19 outbreak.Tis instrument was used to measure stigma among HCWs towards HIV patients.Tis instrument was validated by the authors of this study to measure stigma towards chronically ill patients from HCWs.Some studies used the theoretical domains to evaluate the status of the perceptions of stigma among the participants.Other factors that are often considered include shame, social isolation, discrimination, and status.However, questionnaires related to the perception of stigma associated with another disease can also be used.Te study used a 12-item modifed stigma-related questionnaire for COVID-19 patients.Tis tool consists of the following three aspects: discrimination, acceptance of COVID-19 previously infected, and fear [20].Te questionnaire adopted the 4-point Likert scale.Te internal consistency of the frst two subscales of discrimination and acceptance of COVID-19 risk people was good with Cronbach's alpha of 0.82 and 0.81, while the third subscale was 0.68, which is acceptable.

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Nursing Forum Te questionnaire was translated into Arabic language, which was further evaluated for validity and reliability after the translation that was conducted by fve experts in the area.Te instrument was translated to facilitate the participants' understanding of the survey.All items had a Cronbach's coefcient of 0.75.Te participants answered the questionnaire by choosing one of the available four options which include "strongly disagree," "disagree," "agree," and "strongly agree."2.7.Ethical Consideration.Tis study was approved by the Institutional Ethics Committee at Jordan University of Science and Technology IRB (810-2020).Te researchers assured the participants that participation is voluntary and no risks will be there from participating in the study.To protect the anonymity of the participants, no information regarding ID of the participants was included.Te participants signed electronic consent online.

Data Analysis. Te Statistical Package for the Social
Sciences version 25 was used for all statistical analyses (IBM, Armonk, NY, USA).Te results of the descriptive and bivariate analyses were deemed signifcant based on an alpha level of less than 0.05.Te Kolmogorov-Smirnov test was used to test for the normality of all continuous variables.Any discrepant variables were transformed into more distributed scores.Te subjects' responses were evaluated for each variable (measure).If each variable had 40% or more missing data, then the participants' responses for that measure were deleted listwise.Te multiple regression test was used to determine the predictors of HCWs stigma towards patients with chronic illnesses.Tis test was done after careful determination of the variant infation factor (VIF) to determine the multicollinearity among variables.

Demographic Variables.
Te number of females was 424 (61.8%), and the number of males was 262 (38.2%).Te majority were nonsmokers (74.8%), and a quarter were medical doctors (25.7%).About two-thirds of participants had working experience of less than 5 years (63%).Other characteristics are listed in Table 1.

Description of Stigma towards Chronic Patients.
Te data showed that HCWs showed some type of stigma against patients.Te prevalence of stigma (who agree or strongly agree) among HCWs towards chronic patients was 20%.Tis presents agree and strongly agree with HCWs.Te range of stigma among HCWs was 12-44.Te following statements showed high levels of stigma by HCWs.You are not against patient care, but it is better for you not to approach them (51.3%), the best way to prevent COVID-19 infection is to avoid any contact with sick people (33.6%), and if you can choose, you do not want to deal with any patient (24.2%) (see Table 2).

Comparison on Stigma between Participants From Different Specialties.
Te results showed no signifcant diference in stigma between people from diferent specialties (F � 1.9 and P � 0.073), which means that nurses are not diferent from people from diferent specialties.

Predictors of Stigma towards Chronic Patients from
HCWs.Te multiple regression model was signifcant (F � 1.75 and P � 0.04).Tis means that many factors were able to predict stigma towards patients from HCWs.Tese factors were years of experience (B � −0.157 and P � 0.017) and number of children for HCWs (B � 0.149 and P � 0.016).As the years of experience increases, the stigma level decreases.Also, HCWs with more children show more stigma towards chronic illness patients (see Table 3).

Discussion
Te fndings of the study showed some stigma of HCWs who work with COVID-19 patients towards chronically ill patients in Jordan.Our study also revealed that the stigma is closely linked to low job experience.Other studies also revealed that low job experience, prior COVID-19 interactions, and exposure to pandemic-related educational materials could cause some patients to experience stigma from HCWs towards them [4,5].Similarly, our study found that stigmatizing was widespread towards chronic patients by low experience HCWs.Te fndings of this research are like the results of previous studies during the pandemic [22,23].Moreover, in African countries, these individuals have lower educational level and revealed that the stigma is closely linked to low job experience levels compared to other healthcare professionals.Besides, this group does not need to pass COVID-19 educational courses [24].Various studies have shown that higher COVID-19 knowledge leads to less fear and hence lower stigma.For instance, individuals who are less knowledgeable and less educated have been found to have more stigmatizing attitudes related to COVID-19 [25,26].
Our study did not fnd any diference in the sociodemographic variables.It should be mentioned that HCWs play a crucial role in putting awareness practices into place because they can predict the negative efects of stigmatization and lessen them through institutional and social media interventions [20].In earlier research [27,28], it was also found that dental professionals and laboratory staf for infected persons during the pandemic experienced substantial COVID-19-related stigma [4,22].
According to the literature, the high stigma prevalence may be because of frequent contact with blood and other contagious bodily fuids.Te study also indicated that HCWs experienced stigmatizing attitudes when referring a patient to a dental clinic or department [22].A study conducted in Nigeria found that the high prevalence of stigma among laboratory personnel and dentists were due to the diference in work culture and environment [11].Despite this, the fndings of both studies highlight the signifcance of targeting healthcare providers through training programs.Many HCWs in our study stated "the best way to prevent COVID-19 infection is to avoid any contact with sick people" and "they are not against patient care, but it is better for you not to approach them."Tis fnding is consistent with results of a previous study in Jordan that suggested that the cause of stigmatizing attitude is the fear of contracting the virus [6].Interventions such as training and basic knowledge on the virus have been proven to be efective in dealing with stigma and can be implemented to enhance the quality of care.Te study also found that educational courses on COVID-19 and other infectious disease can reduce the prevalence of stigma and stigmatizing attitudes [3,8].Besides, there are positive associations between knowledge on how COVID-19 can be transmitted and low COVID-19-related stigma.According to these fndings, healthcare providers can utilize programs to confrm their fears, contagion, and negative social judgment, which can help reduce COVID-19-related stigma.

Limitations.
Although this study highlights signifcant observations, it has limitations.First, the study was carried out in one large city, limiting the fndings' generalizability to other parts of the country.However, due to the cultural context of Jordan, the fndings are informative when applied to other provinces.Like other studies conducted in the area, our fndings rely on self-reported responses made by the healthcare providers.Terefore, the responses are subject to social desirability and reporting biases.Nursing Forum hospital settings [1].Tese actions include (i) educating people to lessen their fear of contracting the virus; (ii) using peer groups; (iii) interactive modular training of healthcare providers on stigma related to COVID-19 and medical ethics; and (iv) dissemination of policy guidelines, training, and workshops for the healthcare providers.Tese measures could improve the standard of treatment provided to COVID-19 patients in Jordan.

Conclusion
In conclusion, this study's fndings revealed some stigma towards patients with chronic diseases even if they did not indicate high levels of stigmatization of healthcare workers during the COVID-19 epidemic.Te prevalence of stigma among HCWs towards chronic patients was 20%.Notably, it is crucial to put awareness practices into place for HCWs because they can anticipate the negative efects of stigmatization and lessen them through institutional and social media interventions.

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Implication.All healthcare professionals should be trained in the care of COVID-19 patients and in COVID-19related topics.In general, prior research recommends fve measures to lessen stigma associated with COVID-19 in

Table 1 :
Demographic and work characteristics of the study participants (N � 686).
Dependent variable: stigma of HCWs towards patients with chronic diseases.