Coronavirus Disease 2019–Induced Perceived Stigmatization in Physicians Scale

Abstract

The Coronavirus Disease 2019–Induced Perceived Stigmatization in Physicians Scale is a psychometrically validated self-report assessment instrument formulated by Muhammed Fatih Önsüz and colleagues in 2023. Developed amidst the global public health emergency precipitated by the SARS-CoV-2 pandemic, the instrument was engineered to measure the nature, intensity, and multidimensional manifestations of health-related social stigma directed toward medical doctors. Physicians operating on the front lines of pandemic mitigation frequently experienced acute social ostracization, avoidance, prejudice, and discriminatory behaviors stemming from public fears of disease transmission. The instrument addresses a critical diagnostic gap, as pre-existing general stigma inventories failed to capture the idiosyncratic occupational vulnerabilities, professional role conflicts, and dual burdens borne by physicians during infectious disease outbreaks.

The instrument’s development commenced with an initial item pool of 35 items derived from an extensive review of public health, psychiatric, and sociological literature. Content validity was evaluated across iterative panels comprising 4 and 14 medical and behavioral specialists, yielding an 18-item provisional version with a Content Validity Index (CVI) of 0.69. Following a pilot trial, ambiguous and misconstrued items were removed. Successive exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) executed on data collected from practicing physicians established an optimized 10-item, two-factor latent structure comprising Environmental Perceived Stigmatization and Personally Perceived Stigmatization. These two dimensions account for 61.66% of the total variance, with robust standardized factor loadings ranging from 0.66 to 0.85.

The psychometric integrity of the scale is evidenced by high internal consistency, demonstrated by an overall Cronbach’s alpha of 0.88, with subscale alphas of 0.875 for Environmental Perceived Stigmatization and 0.766 for Personally Perceived Stigmatization. Item-total correlation coefficients consistently exceeded 0.30. Test-retest reliability across a two-week interval was exceptional (r = 0.91, p = .125). Criterion validity was verified through a statistically significant positive correlation with the general Stigma Scale (r = 0.345, p < .001). Differential validity testing substantiated that elevated stigma scores were systematically associated with personal COVID-19 diagnosis, infection among close social contacts, and consideration of occupational resignation. The scale provides healthcare administrators, occupational health researchers, and clinical psychologists with a psychometrically sound metric to evaluate pandemic-induced occupational distress and guide institutional mitigation strategies.

Keywords

COVID-19 Stigmatization, Coronavirus Disease 2019, Perceived Stigma, Physicians’ Mental Health, Occupational Stigma, Environmental Perceived Stigmatization, Personally Perceived Stigmatization, Psychometrics, Factor Analysis, Healthcare Worker Burnout, Scale Validation

Authors

The scale was developed and psychometrically validated by an interdisciplinary team of public health scientists, epidemiologists, and clinical psychiatrists affiliated with medical faculties and public health agencies in Turkey:

• Muhammed Fatih Önsüz, MD, PhD — Associate Professor of Public Health, Department of Public Health, Eskisehir Osmangazi University Faculty of Medicine, Eskişehir, Turkey. (Corresponding Author: [email protected])
• Didem Oktar, MD — Public Health Specialist, Department of Public Health, Eskisehir Osmangazi University Faculty of Medicine, Eskişehir, Turkey.
• Sevil Aydoğan Gedik, MD — Public Health Physician, Department of Ministry of Health, Odunpazarı District Health Directorate, Eskişehir, Turkey.
• Sevda Sungur, MD — Public Health Specialist, Department of Public Health, Eskisehir Osmangazi University Faculty of Medicine, Eskişehir, Turkey.
• Selma Metintaş, MD, PhD — Professor of Public Health, Department of Public Health, Eskisehir Osmangazi University Faculty of Medicine, Eskişehir, Turkey.
• Ferdi Köşger, MD — Associate Professor of Psychiatry, Department of Psychiatry, Eskisehir Osmangazi University Faculty of Medicine, Eskişehir, Turkey.
• Ali Ercan Altınöz, MD — Associate Professor of Psychiatry, Department of Psychiatry, Eskisehir Osmangazi University Faculty of Medicine, Eskişehir, Turkey.

Purpose

The paramount objective of the Coronavirus Disease 2019–Induced Perceived Stigmatization in Physicians Scale is to quantitatively capture and evaluate the subjective experiences of stigmatization, marginalization, and social avoidance encountered by physicians as a direct consequence of their professional duties during the COVID-19 pandemic. Although frontline healthcare professionals were publicly lauded as essential workers during the zenith of global contagion, an inverse societal reaction unfolded simultaneously: fear of contagion transformed medical practitioners into perceived vectors of biological hazard. This paradox placed physicians in a psychologically fraught position where professional dedication was met with interpersonal hostility, neighborhood eviction threats, exclusion from commercial establishments, and estrangement from their own families and social circles.

From an applied clinical and occupational health standpoint, the scale addresses the urgent requirement for standardized diagnostic metrics capable of identifying clinicians at elevated risk for psychological morbidity. Unmitigated perceived stigma among healthcare workers is intrinsically linked to deleterious psychopathological outcomes, including occupational burnout, severe depressive symptomatology, generalized anxiety disorders, acute stress reactions, and post-traumatic stress disorder (PTSD). By pinpointing the specific manifestations of perceived stigmatization—whether experienced within immediate personal spheres or broadly across physical and institutional environments—the instrument enables occupational medicine specialists and hospital administrators to design targeted psychosocial interventions, peer-support networks, and structural protections.

In academic and epidemiological research, this measurement tool provides an empirical apparatus for investigating the downstream organizational consequences of pandemic-induced social rejection. Prior to its publication, researchers relied primarily on generic stigma scales or adapted mental health stigma inventories that lacked contextual sensitivity to airborne pathogen threats, quarantine dynamics, and physician-specific professional ethics. The scale facilitates systematic inquiry into the mechanisms through which social devaluation interacts with physician turnover intention, absenteeism, medical error rates, and diminished empathy in patient care. Furthermore, it serves as a baseline assessment tool for public health agencies to evaluate the efficacy of destigmatization media campaigns and crisis communication frameworks during ongoing and future biological crises.

Psychological Construct

The psychological construct evaluated by the scale is perceived health-related stigma situated within an infectious disease outbreak, conceptualized as a multidimensional phenomenon comprising cognitive, affective, and relational components. Health-related stigma involves social disqualification, negative stereotyping, and status loss directed toward individuals based on their association with a feared medical condition. In the case of frontline physicians during the COVID-19 pandemic, this construct manifested uniquely: the stigmatized status was not merely derived from personal illness, but from occupational proximity to infected patients. The scale operationalizes this construct across two distinct yet interconnected latent dimensions:

1. Environmental Perceived Stigmatization

The Environmental Perceived Stigmatization subscale measures a physician’s perception of devaluing attitudes, institutional barriers, spatial segregation, and generalized exclusionary behaviors occurring within macro- and meso-level environments. This includes experiences within public spaces, residential settings, commercial establishments, and broader community networks. Exemplars of this dimension encompass situations where physicians observe that landlords refuse to renew apartment leases, public transportation passengers physically recoil or demand their egress upon identifying their medical profession, or local businesses decline service under the premise of biohazard mitigation. It also encapsulates vicarious stigma, wherein a physician’s family members, spouses, or children face community ostracism or exclusion from educational facilities simply because of their cohabitation with a practicing physician. This dimension captures the structural and ecological hostility of the external world, producing profound feelings of alienation from the very communities physicians are pledged to treat.

2. Personally Perceived Stigmatization

The Personally Perceived Stigmatization subscale evaluates micro-level interpersonal encounters and the direct relational rupture experienced within close, familiar social networks, including extended families, long-standing friendships, and collegial circles. This facet targets the acute, emotionally devastating experience of being viewed by intimate acquaintances as an active source of contamination. Exemplars include friends declining direct social contact, relatives refusing to attend personal gatherings or prohibiting physicians from attending family milestones, and peers avoiding physical proximity in non-clinical settings. This personal stigmatization generates intense feelings of isolation, rejection, and affective abandonment, systematically dismantling the healthcare provider’s primary interpersonal support systems precisely when psychological resilience is most essential.

Critically, the construct evaluates perceived stigma rather than solely enacted stigma. While enacted stigma refers to overt, demonstrable acts of discrimination, perceived stigma reflects the individual’s subjective appraisal of societal hostility, anticipate prejudice, and the felt awareness of negative social attitudes. Extensive psychometric literature indicates that perceived stigma often exerts an equally or more devastating psychological toll than enacted stigma, as it triggers hypervigilance, social withdrawal, concealment behaviors, and the erosion of self-worth.

Theoretical Framework

The conceptual architecture of the Coronavirus Disease 2019–Induced Perceived Stigmatization in Physicians Scale is anchored in seminal sociological and socio-cognitive theories of stigma, synthesized with contemporary evolutionary and public health models:

Goffman’s Social Stigma Paradigm

The foundational bedrock of the instrument traces to Erving Goffman’s (1963) landmark theoretical formulation of stigma as an “attribute that is deeply discrediting,” which reduces the bearer from a whole and usual person to a tainted, discounted one. Goffman categorized stigma into three distinct typologies: abominations of the body (physical deformities), blemishes of individual character (perceived moral failures), and tribal stigma of race, nation, and religion. In the context of infectious outbreaks, physicians experience a dynamic transformation where their high-status professional identity undergoes a temporary, catastrophic degradation into a biological blemish—a physical peril to society. Furthermore, Goffman’s conceptualization of courtesy stigma (stigma by association) directly underpins the scale’s environmental dimension, explaining how physicians’ families absorb secondary discrimination due to their relational proximity to the frontline healthcare environment.

Link and Phelan’s Modified Labeling Theory

The scale heavily integrates the socio-structural framework articulated by Bruce Link and Jo Phelan (2001), who conceptualize stigma as the convergence of five interrelated components occurring within unequal power situations: (1) distinguishing and labeling human differences; (2) linking labeled persons to undesirable characteristics or negative stereotypes; (3) separating “us” (the non-infected general public) from “them” (the potentially infectious clinicians); (4) status loss and discrimination leading to unequal outcomes; and (5) the exercise of power. In pandemic circumstances, societal labeling instantly categorized physicians as high-risk reservoirs of viral transmission. The scale measures the psychological manifestations of this separation and status loss, evaluating how physicians navigate the cognitive dissonance of being celebrated rhetorically while concurrently subjected to interpersonal and structural subjugation.

The Behavioral Immune System and Evolutionary Disease Avoidance

Complementing sociological perspectives, the instrument is grounded in the evolutionary psychological framework of the Behavioral Immune System (BIS), pioneered by Mark Schaller and colleagues. The BIS represents a suite of proactive psychological mechanisms designed to detect potential disease-carrying entities in the immediate sensory environment and trigger rapid cognitive, affective, and behavioral avoidance responses (e.g., disgust, spatial withdrawal). In normal circumstances, medical clothing and clinical environments symbolize safety and healing; during uncontrolled epidemics, these same cues act as potent disease primes that trigger involuntary avoidance reactions in the general populace. The scale directly captures the interpersonal fallout generated by hyperactivated behavioral immune responses among the public, documenting the lived psychological impact on the targets of this evolutionary avoidance machinery.

Validity

The validation protocol for the Coronavirus Disease 2019–Induced Perceived Stigmatization in Physicians Scale adhered strictly to international standards established by the American Educational Research Association (AERA), the American Psychological Association (APA), and the National Council on Measurement in Education (NCME). Multiple empirical validation modalities were executed to confirm the instrument’s psychometric fidelity.

Content Validity

The initial content domain was established through a systematic literature search focusing on infectious disease outbreaks (including SARS-CoV-1, MERS-CoV, and Ebola), yielding an initial pool of 35 items. Content validation was executed across two distinct specialist committees. Initially, four public health and mental health specialists screened the items for linguistic clarity, cultural relevance, and theoretical alignment. Subsequently, an expanded multidisciplinary panel of 14 specialists (encompassing public health physicians, psychiatrists, clinical psychologists, and epidemiologists) evaluated each item using standardized relevance scoring. The aggregate Content Validity Index (CVI) calculated for the revised 18-item intermediate instrument was 0.69. Following a subsequent pilot study comprising practicing medical doctors, items exhibiting interpretive ambiguity or low item-total correlations were eliminated, successfully refining the scale to its robust 10-item final formulation.

Criterion-Related Validity

Criterion validity was established by assessing concurrent associations with an established, psychometrically validated general stigma instrument: the Stigma Scale developed by Yaman and Güngör (2013). Non-parametric correlation analyses revealed a statistically significant, moderate positive correlation between the overall score of the Coronavirus Disease 2019–Induced Perceived Stigmatization in Physicians Scale and the general Stigma Scale (Spearman’s rho = 0.345, p < .001). This moderate correlation coefficient confirms convergent validity while demonstrating that the physician-specific pandemic scale captures a unique domain of occupational infection stigma distinct from generalized social devaluation.

Differential (Known-Groups) Validity

The scale exhibited exceptional differential validity, demonstrating statistically significant score variations across known sub-populations of physicians experiencing varying degrees of pandemic stress:

• COVID-19 Diagnosis History: Physicians who had tested positive for COVID-19 exhibited statistically significantly higher perceived stigmatization scores compared to their uninfected colleagues, reflecting compounded personal and occupational stigma.
• Infection Among Close Contacts: Physicians who had family members or close friends diagnosed with COVID-19 demonstrated markedly elevated perceived stigma scores relative to those whose networks remained unaffected.
• Turnover Intentions: Physicians who reported actively contemplating resignation or retirement from medical practice during the pandemic recorded significantly higher scores on both the environmental and personal subscales, confirming the scale’s sensitivity to occupational attrition risks.
• General Stigma Concordance: Physicians who scored above the clinical threshold (55 points and above) on the Yaman & Güngör Stigma Scale similarly scored significantly higher on the COVID-19-Induced Perceived Stigmatization in Physicians Scale, underscoring strong discriminatory accuracy across differentiated psychological strata.

Reliability

The scale demonstrates exemplary psychometric reliability across assessments of internal consistency, item homogeneity, and temporal stability:

Internal Consistency

For the aggregate 10-item instrument, the global Cronbach’s alpha reliability coefficient was determined to be 0.88, denoting high internal consistency without reaching levels indicative of item redundancy (> 0.90). Reliability analyses of the discrete subscales revealed strong internal consistency across both latent factors:

• Factor 1 (Environmental Perceived Stigmatization): Cronbach’s alpha = 0.875
• Factor 2 (Personally Perceived Stigmatization): Cronbach’s alpha = 0.766

All individual corrected item-total correlation coefficients substantially exceeded the conventional psychometric threshold of 0.30, spanning from 0.42 to 0.74. This indicates that every retained item contributes meaningfully and coherently to the overall measurement of the target construct.

Temporal Stability (Test-Retest Reliability)

To evaluate the invariance of the instrument over time in the absence of acute environmental shifts, a sub-sample of physicians completed a retest administration following a two-week interval. The test-retest correlation coefficient was r = 0.91, demonstrating exceptional temporal stability. Furthermore, paired-sample statistical evaluations revealed no significant difference between the initial baseline scores and the repeat assessment (p = .125), confirming that the instrument exhibits high reproducibility and minimal measurement error across longitudinal intervals.

Factor Analysis

The latent structural validity of the scale was established through a sequential psychometric evaluation involving both Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA).

Exploratory Factor Analysis (EFA)

Prior to factor extraction, the adequacy of the correlation matrices was established through the Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy and Bartlett’s Test of Sphericity, both confirming data suitability for structural reduction. Item reduction proceeded iteratively:

• Items displaying factor loadings below 0.30 were eliminated.
• An initial EFA run led to the removal of one cross-loading item that demonstrated ambiguous saturation across multiple components.
• A subsequent iteration on the remaining 12 items identified two items that failed to load cleanly onto theoretically coherent dimensions; these were systematically excised.
• The terminal EFA model executed on the optimized 10 items yielded a distinct, clean two-factor solution without structural complexity or problematic cross-loadings.

The two latent factors accounted for a robust 61.66% of the total cumulative variance. Standardized factor loadings across all 10 items ranged from 0.66 to 0.85, reflecting exceptional item-to-factor saturation.

Confirmatory Factor Analysis (CFA)

To confirm the empirical replicability of the two-factor model, a Confirmatory Factor Analysis was conducted utilizing maximum likelihood estimation. The hypothesized two-factor latent structure exhibited strong goodness-of-fit across standard structural equation modeling indices:

• Chi-Square / Degrees of Freedom: χ² = 152.30, df = 34, χ²/df = 4.47 (p < .00001)
• Comparative Fit Index (CFI): 0.96 (reflects excellent fit against the baseline independent model; threshold ≥ 0.95)
• Incremental Fit Index (IFI): 0.96 (confirms superior incremental structural explanatory power)
• Normed Fit Index (NFI): 0.95
• Non-Normed Fit Index (NNFI / TLI): 0.95
• Relative Fit Index (RFI): 0.93
• Goodness of Fit Index (GFI): 0.91
• Adjusted Goodness of Fit Index (AGFI): 0.85
• Parsimony Normed Fit Index (PNFI): 0.72
• Parsimony Goodness of Fit Index (PGFI): 0.56
• Standardized Root Mean Square Residual (SRMR): 0.051 (denotes low residual covariance; threshold ≤ 0.08)
• Root Mean Square Residual (RMR): 0.068
• Root Mean Square Error of Approximation (RMSEA): 0.107 (acceptable given model parsimony and pandemic contextual variance)

Collectively, these fit indices substantiate that the empirical data aligns closely with the hypothesized two-dimensional model of pandemic-induced perceived stigmatization.

Instrument / Measurement Tool

The structural characteristics, administration parameters, and scoring framework of the measurement tool are delineated below:

• Official Title: Coronavirus Disease 2019–Induced Perceived Stigmatization in Physicians Scale (COVID-19-Induced Perceived Stigmatization in Physicians Scale).
• Test Classification: Psychometric Self-Report Rating Scale / Occupational Health Inventory.
• Primary Target Population: Practicing medical doctors (physicians) across all clinical specialties, hospital tiers, primary care centers, and intensive care units.
• Age Demographics: Adults aged 18 years and older (including early-career residents [18–29 yrs], mid-career physicians [30–39 yrs and 40–64 yrs], and senior medical practitioners [≥ 65 yrs]).
• Administration Mode: Paper-and-pencil questionnaire or secured digital/web-based survey platform.
• Completion Time: Approximately 3 to 5 minutes.
• Total Item Count: 10 items.
• Subscale Structural Division:
  • Environmental Perceived Stigmatization: Evaluates community, structural, public, and institutional devaluing encounters.
  • Personally Perceived Stigmatization: Evaluates interpersonal rejections, relational strain, and avoidance within immediate social and familiar circles.
• Response Format: 5-point Likert-type scaling ranging from 1 to 5:
  • 1 = Strongly Disagree
  • 2 = Disagree
  • 3 = No Idea (Neutral)
  • 4 = Agree
  • 5 = Strongly Agree
• Scoring Mechanism: Scale scores are calculated by summing item responses across the aggregate instrument (total score range: 10 to 50) and within each subscale. Higher cumulative and dimensional scores correspond directly to elevated levels of perceived stigmatization.
• Original Language: Turkish (with cross-cultural psychometric adaptation frameworks applicable for international translations).

Permissions & Fee and Test Year

The Coronavirus Disease 2019–Induced Perceived Stigmatization in Physicians Scale was formally published in 2023 in the peer-reviewed international psychiatric journal Alpha Psychiatry.

• Licensing and Research Use: The scale is available for non-commercial academic research, institutional evaluation, and clinical inquiry without financial charge. Users are not required to pay licensing fees for academic use.
• Permissions Protocol: Researchers and healthcare organizations wishing to administer, reproduce, adapt, or translate the instrument are required to obtain formal written permission from the corresponding author, Assoc. Prof. Muhammed Fatih Önsüz, MD, PhD ([email protected]), and properly cite the primary validation paper in all resulting scientific communications.

References

• Goffman, E. (1963). Stigma: Notes on the management of spoiled identity. Prentice-Hall.
• Link, B. G., & Phelan, J. C. (2001). Conceptualizing stigma. Annual Review of Sociology, 27(1), 363–385. https://doi.org/10.1146/annurev.soc.27.1.363
• Önsüz, M. F., Oktar, D., Gedik, S. A., Sungur, S., Metintaş, S., Köşger, F., & Altınöz, A. E. (2023). Development and validation of Coronavirus disease 2019-Induced Perceived Stigmatization in Physicians Scale. Alpha Psychiatry, 24(4), 138–145. https://doi.org/10.1055/a-2005-7269
• Schaller, M., & Park, J. H. (2011). The behavioral immune system (and why it matters) for public health, clinical psychology, and society. Perspectives on Psychological Science, 6(1), 99–103. https://doi.org/10.1177/1745691610393524
• Yaman, E., & Güngör, H. (2013). The development of the Stigma Scale: A study of validity and reliability. Journal of Psychiatric Nursing, 4(1), 21–28.

Items of the Scale