COVID-19 Social Stigma Scale

1. Abstract

The COVID-19 Social Stigma Scale is an empirical psychometric instrument developed by Neti Juniarti and colleagues (2023) to operationalize, measure, and evaluate social stigma associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Initially formulated as an extensive 123-item pool generated from a comprehensive literature review and scrutinized by an expert panel for content validity, the instrument underwent rigorous item-reduction protocols via modern psychometric frameworks. Utilizing Item Response Theory (IRT), specifically dichotomous and polytomous Rasch model parameterizations, the scale was distilled to an optimized, parsimonious 11-item self-report inventory. The instrument captures seven interrelated dimensions of infectious disease-related social stigma: (1) social distancing, (2) traditional prejudice, (3) exclusionary sentiments, (4) negative affect, (5) treatment carryover, (6) disclosure carryover, and (7) perceptions of dangerousness.

Administered using a 5-point Likert response format (ranging from 1 = “strongly disagree” to 5 = “strongly agree”, with a midpoint of “unsure” or “don’t know”), the instrument was calibrated on a representative adult cohort in Indonesia. Psychometric evaluations confirm exceptional measurement properties. Rasch calibration metrics demonstrated outstanding item fit, with mean infit mean square (INFIT MNSQ) and outfit mean square (OUTFIT MNSQ) values converging at 0.99 (ideal benchmark = 1.00), alongside infit and outfit standardized z-scores (ZSTD) of 0.99 and 0.88, respectively. The instrument demonstrated remarkable internal consistency and person/item separation, evidenced by a Cronbach’s alpha of +0.96, an IRT person reliability coefficient of +0.94, and an item reliability coefficient of +0.94. This brief yet theoretically robust diagnostic tool provides public health authorities, community health nurses, epidemiological researchers, and clinical psychologists with a validated mechanism for identifying structural and perceived stigma, enabling the formulation of targeted anti-stigma interventions during infectious disease outbreaks.

2. Keywords

COVID-19 Social Stigma Scale, social stigma, Rasch analysis, item response theory, infectious disease stigma, public health, health-related stigma, psychometrics, Indonesia, social distancing, traditional prejudice

3. Authors

The scale was developed and psychometrically evaluated by a multidisciplinary team of community health nursing and public health researchers at the Faculty of Nursing, Universitas Padjadjaran, Bandung, Indonesia:

• Neti Juniarti, PhD, MN, BSc – Department of Community Health Nursing, Faculty of Nursing, Universitas Padjadjaran, Indonesia. Corresponding Author: [email protected]
• Raini Diah Susanti, MN – Department of Community Health Nursing, Faculty of Nursing, Universitas Padjadjaran, Indonesia.
• Desy Indra Yani, PhD – Department of Community Health Nursing, Faculty of Nursing, Universitas Padjadjaran, Indonesia.
• Nurani Nurhasanah, MN – Department of Community Health Nursing, Faculty of Nursing, Universitas Padjadjaran, Indonesia.

4. Purpose

The primary purpose of the COVID-19 Social Stigma Scale is to provide a reliable, valid, and culturally sensitive psychometric metric to quantify perceived, enacted, and anticipated social stigma in the context of pandemic respiratory pathogens. Pathogen outbreaks do not merely present biological and immunological challenges; they elicit profound psychosocial disruptions characterized by xenophobia, ostracization, blame, and pervasive discrimination. Stigmatization during the COVID-19 pandemic severely compromised non-pharmaceutical interventions, diagnostic screening, contact tracing, and adherence to medical management, particularly in collectivist cultural ecosystems such as Indonesia.

The theoretical rationale for the instrument’s development stemmed from the acute necessity to understand how societal fear precipitates exclusionary behaviors and psychological trauma among patients, survivors, and suspected carriers of the virus. When individuals fear that being identified as infected will lead to social repudiation, economic termination, or public humiliation, they frequently underreport symptoms, conceal positive diagnoses, evade polymerase chain reaction (PCR) or rapid antigen testing, and refuse to cooperate with epidemiological surveillance. Consequently, untreated transmission chains perpetuate community spread. By capturing the underlying dimensions of stigma, this instrument aims to diagnose specific barriers to healthcare compliance and guide healthcare systems in decoupling public health compliance from social devaluation.

In clinical and community health applications, the scale functions as an assessment instrument across multiple structural domains:

• Epidemiological Surveillance and Disease Control: Identifying geographic communities or demographic strata where elevated stigma threatens diagnostic reporting and contact-tracing veracity.
• Intervention Design and Evaluation: Providing pre- and post-intervention outcome metrics for community-based educational programs, anti-stigma public service campaigns, and psychosocial support mechanisms.
• Occupational Health Assessment: Evaluating workplace reintegration barriers for individuals returning to professional duties following acute SARS-CoV-2 illness or quarantine.
• Psychological Triage: Screening infected individuals and their families for elevated levels of anticipated or internalized discrimination, facilitating targeted mental health counseling to mitigate depressive, anxious, and trauma-related symptom cascades.

5. Psychological Construct

The COVID-19 Social Stigma Scale conceptualizes stigma not as a monolithic affective response, but as a multidimensional socio-cognitive construct rooted in threat appraisal, social identity preservation, and fear-induced behavioral avoidance. The operational architecture of the 11-item model comprises seven distinct theoretical dimensions:

1. Social Distancing

Within this scale, social distancing departs from the benign public health prescription of physical separation and reflects defensive social self-isolation driven by fear of interpersonal blame. The individual closes themselves off socially, not purely out of civic duty, but as a protective mechanism against severe moralizing, accusation, and societal culpability. This construct captures the internalized anticipation that social interaction inevitably invites reproach, hostility, and severe societal censure.

2. Traditional Prejudice

Traditional prejudice embodies classical stigmatizing attitudes characterized by deep embarrassment, acute shame, and fear regarding the exposure of one’s disease status. It reflects the perception that contracting COVID-19 implies personal carelessness, moral deviance, or biological contamination. Patients fear that their diagnostic identity will be publicized, triggering deep-seated social dishonor and familial disgrace within their immediate cultural and neighborhood network.

3. Exclusionary Sentiments

This subscale captures structural and interpersonal ostracization, specifically the anticipation or enactment of societal expulsion and economic disenfranchisement. Driven by institutional and communal intolerance, individuals intentionally fail to report viral exposure because they anticipate being shunned by their peers or arbitrarily terminated from their employment. It assesses the high tangible stakes tied to diagnosis disclosure, where biological infection translates directly into socio-economic jeopardy.

4. Negative Affect

Negative affect encapsulates the profound emotional and moral distress elicited by the disease, centering on notions of public disgrace (aib), contamination, and self-directed indignity. It operates both at the perceived societal level and the personal level, causing symptomatic individuals (such as those experiencing telltale hallmark symptoms like anosmia or dysgeusia) to actively suppress medical help-seeking or refuse diagnostic testing to avoid societal humiliation and perceived loss of dignity.

5. Treatment Carryover

Treatment carryover measures how the consequences of undergoing formal healthcare interventions persist as stigmatizing attributes even after therapeutic protocols or medical monitoring conclude. It reflects the persistent concealment of one’s exposure or clinical history due to the fear that past medical intervention or documented contact with quarantine facilities will lead to permanent workplace termination, professional demotion, or continuous interpersonal suspicion.

6. Disclosure Carryover

This dimension operationalizes the psychological aversion and maladaptive behaviors associated with diagnostic confirmation and public revelation. Individuals exhibit extreme reluctance to undergo diagnostic rapid testing out of fear that a positive test result will expose them to public scrutiny. Furthermore, this construct identifies pseudo-compliant health behaviors, such as declaring self-isolation without adhering to quarantine protocols, which serves as a facade to avoid formal diagnostic verification while evading the societal consequences of a confirmed infection.

7. Perception of Dangerousness

Perceptions of dangerousness evaluate the interpersonal threat level that individuals project onto the infection and its epidemiological sequelae. It assesses the fear of social alienation that obstructs epidemiological mitigation; specifically, it manifests as the refusal to disclose the names of close contacts during public health tracing efforts due to acute fear of permanently destroying social bonds, friendships, and community solidarity.

6. Theoretical Framework

The structural underpinnings of the COVID-19 Social Stigma Scale integrate established sociological, evolutionary, and socio-cognitive theories of deviance, disease avoidance, and social devaluation.

Goffman’s Theory of Stigma

The foundational bedrock of this measurement tool traces to Erving Goffman’s (1963) seminal formulation of stigma as an attribute that deeply discredits an individual, reducing them from a whole and usual person to a tainted, discounted one. Goffman delineated three distinct topologies of stigma: (a) abominations of the body (physical deformities), (b) blemishes of individual character (perceived moral failures, mental disorders, dishonesty), and (c) tribal stigma of race, nation, and religion. Within the context of the COVID-19 scale, infectious status represents a hybrid manifestation: biological infection acts as an acute bodily threat, yet it is instantly conflated with character blemishes (e.g., irresponsibility, failure to maintain sanitary standards, moral transgression). The scale effectively operationalizes Goffman’s constructs of discredited identities (where the condition is visible or known) and discreditable identities (where individuals exhaust cognitive and behavioral resources in managing secret information to avert exposure).

The Health Stigma and Discrimination Framework

The instrument aligns with the Health Stigma and Discrimination Framework articulated by Stangl et al. (2019). This global conceptual model traces stigma across a continuum comprising:

1. Drivers (e.g., fear of contagion, moral judgment, economic precarity);
2. Facilitators (e.g., cultural norms regarding honor and shame, legal and institutional guidelines);
3. Stigma Manifestations (experienced, internalized, and anticipated stigma, alongside discriminatory practices); and
4. Outcomes (diminished healthcare access, delayed diagnosis, adverse psychological morbidity).

The seven dimensions identified by Juniarti et al. represent direct operational manifestations of these stages. For example, traditional prejudice and negative affect function as primary affective and cognitive drivers, while disclosure carryover and exclusionary sentiments embody profound behavioral manifestations that dictate health-seeking decisions.

The Behavioral Immune System (BIS)

From an evolutionary perspective, the scale draws upon the Behavioral Immune System (BIS) paradigm formulated by Schaller and Park (2011). The BIS posits that human beings evolved a suite of psychological mechanisms designed to detect sensory cues indicating the presence of infectious pathogens in others, activating disgust, negative affect, and proactive behavioral avoidance. In pandemics characterized by asymptomatic transmission, the BIS exhibits a hyper-vigilant “smoke detector” principle, where benign or unverified interpersonal interactions are treated as lethal threats. This evolutionary avoidance drives societal ostracization, justifying exclusionary sentiments and excessive social distancing beyond epidemiological recommendations, converting biological prophylaxis into punitive social alienation.

7. Validity

The empirical validation of the COVID-19 Social Stigma Scale was conducted using a rigorous psychometric pipeline spanning classical qualitative vetting and advanced probabilistic item modeling.

Content and Face Validity

The instrument began as an initial reservoir of 123 prospective items, generated via systematic reviews of infectious disease literature (including historical psychometrics associated with HIV/AIDS, SARS, and tuberculosis). To establish absolute content validity, this item pool was submitted to a panel of expert judges comprising doctoral-level nursing scientists, community healthcare specialists, clinical psychologists, and epidemiologists. The panel systematically assessed each statement for item clarity, semantic relevance, theoretical congruency, and cultural appropriateness within the targeted social setting. Items exhibiting conceptual redundancy, ambiguous syntax, or weak alignment with the theoretical facets of social stigma were discarded or rewritten, solidifying high face and content validity.

Construct Validity via Rasch Latent Modeling

Construct validity was formally evaluated using modern Item Response Theory (IRT) principles via Rasch calibration. Unlike classical test theory (CTT), which assumes linear raw-score intervals, Rasch modeling transforms ordinal Likert ratings into genuine linear log-odds units (logits), calibrating person ability (the respondent’s latent endorsement of stigma) against item difficulty (the threshold severity of the stigmatizing statement). The Rasch calibration proved that the reduced 11-item set mapped effectively onto the underlying latent continuum of COVID-19 social stigma without measurement redundancy or construct underrepresentation.

Item Fit and Measurement Invariance

The 11 items demonstrated exceptional fit statistics, indicating that the empirically observed response patterns aligned with theoretical Rasch probabilistic expectations:

• Infit Mean Square (INFIT MNSQ): The average person infit MNSQ was 0.99 (ideal benchmark = 1.00), demonstrating that items were sensitive to targeted latent traits without unexpected in-system distortion.
• Outfit Mean Square (OUTFIT MNSQ): The average person outfit MNSQ was 0.99 (ideal benchmark = 1.00), confirming that the instrument was free from erratic or outlying responses at the extreme poles of the latent continuum.
• Standardized Fit (ZSTD): Person infit ZSTD averaged 0.99, and outfit ZSTD averaged 0.88, closely approximating the ideal expected value of 0.0 and falling within the acceptable psychometric window of -2.0 to +2.0.

Differential Item Functioning (DIF) analyses were applied to verify measurement invariance across key demographic subgroups, including gender and age categories. The 11 items exhibited no significant DIF bias, ensuring that individuals possessing identical levels of latent stigma endorsement had an equal probability of selecting corresponding response categories, regardless of their sociological demographics.

8. Reliability

The COVID-19 Social Stigma Scale demonstrates exceptional reliability parameters across both classical internal consistency metrics and probabilistic Rasch separation metrics.

Classical Internal Consistency

The internal consistency reliability of the instrument is remarkably high:

• Cronbach’s Alpha: The overall scale achieved an empirical Cronbach’s alpha coefficient of α = +0.96. In classical psychometric theory, values exceeding 0.90 indicate extraordinary internal consistency, confirming that the individual survey items share substantial common variance and measure a cohesive latent phenomenon. Corrected item-total correlations across the 11 items remained strong, with no individual item attenuation reducing scale homogeneity.

Rasch Separation and Person/Item Reliability

Classical alpha coefficients can often be artificially inflated by sample size or high item redundancy. Consequently, the authors substantiated scale stability using Rasch-based separation indices, which provide an unbiased, distribution-independent estimate of measurement replicability:

• Person Reliability: The Rasch person reliability coefficient was established at +0.94. This high value confirms that the instrument reliably differentiates respondents across multiple distinct strata of latent stigma endorsement (stigma sensitivity strata ≥ 3), demonstrating that the instrument possesses high diagnostic precision for individual-level clinical and epidemiological screening.
• Item Reliability: The Rasch item reliability coefficient was established at +0.94. This confirms that the empirical sample was sufficiently large and diverse to reliably verify the hierarchical difficulty order of the items across the continuum, ensuring that the calibrated item difficulty calibrations will remain stable and reproducible when administered to external populations.

9. Factor Analysis

The architectural configuration of the COVID-19 Social Stigma Scale relies on an established seven-dimensional structure distilled from an expansive initial pool through modern psychometric pruning.

Dimensional Reduction Protocol

The preliminary development phase yielded 123 items across seven theoretically postulated domains:

• Social Distancing: 32 original items
• Traditional Prejudice: 15 original items
• Exclusionary Sentiments: 14 original items
• Negative Affect: 11 original items
• Treatment Carryover: 4 original items
• Disclosure Carryover: 16 original items
• Perceptions of Dangerousness: 31 original items

To eliminate psychometric noise, construct overlap, and participant burden, the authors applied Rasch dimensional analytics. Rasch principal components analysis of residuals (PCAR) was employed to verify whether secondary variance components breached the assumption of local item independence and unidimensionality within subscale structures.

Item Parameter Calibration and Retention

Items were iteratively eliminated if they exhibited infit/outfit mean square values outside the acceptable psychometric boundary (0.60 to 1.40 for rating scales), exhibited excessive multi-collinearity, or displayed significant DIF. This rigorous calibration winnowed the initial 123 items down to an optimized 11-item set that preserves the full breadth of all seven theoretical dimensions:

Dimension	Initial Items	Final Items	Primary Latent Focus
1. Social Distancing	32	Item 1	Defensive isolation driven by fear of blame
2. Traditional Prejudice	15	Items 2, 3	Identity exposure, diagnostic shame
3. Exclusionary Sentiments	14	Items 4, 5	Interpersonal shunning, fear of job loss
4. Negative Affect	11	Items 6, 7	Internalized disgrace, symptomatic denial
5. Treatment Carryover	4	Item 8	Sustained status concealment post-exposure
6. Disclosure Carryover	16	Items 9, 10	Aversion to rapid tests, non-compliant quarantine
7. Perception of Dangerousness	31	Item 11	Contact tracing concealment, relationship preservation

Residual variance explained by the primary Rasch dimension satisfied unidimensional construct requirements, indicating that the combined 11 items act cohesively to represent the overarching latent continuum of COVID-19 Social Stigma, while their categorical distribution honors the specific thematic facets identified by the expert panel.

10. Instrument / Measurement Tool

The structured technical characteristics of the measurement tool are summarized below:

• Instrument Name: COVID-19 Social Stigma Scale
• Authors: Neti Juniarti, Raini Diah Susanti, Desy Indra Yani, and Nurani Nurhasanah (2023)
• Target Population: General community adults (aged 17–18 years and older), including patients, close contacts, and community members
• Test Type: Original psychometric self-report questionnaire
• Administration Format: Paper-and-pencil, computer-assisted personal interview (CAPI), or secure online survey platforms
• Item Count: 11 items across 7 distinct dimensions
• Response Scale: 5-point Likert scale formatted with the following response selections:
  • 1 = Strongly disagree
  • 2 = Disagree
  • 3 = Don’t know / Unsure
  • 4 = Agree
  • 5 = Strongly agree
• Scoring Rules:
  • All 11 items are framed in a direct, positively keyed direction reflecting the presence of social stigma, blame, diagnostic fear, or concealment behaviors. No reverse scoring is necessary.
  • Raw Composite Score: Summation of all 11 items, yielding a possible score range between 11 and 55. Higher composite scores represent elevated levels of perceived, anticipated, or enacted social stigma.
  • Dimension Sub-scores: Dimension scores can be calculated by summing the items corresponding to each of the 7 subscales to isolate specific intervention targets (e.g., Exclusionary Sentiments vs. Disclosure Carryover).
  • Rasch Calibrated Logit Measure: In advanced clinical or epidemiological applications, raw ordinal scores may be transformed into linear logit measures using the published Rasch difficulty parameters to perform parametric statistical evaluations.
• Estimated Completion Time: Approximately 3 to 5 minutes, ensuring minimal participant burden in rapid epidemiological screening contexts.

11. Permissions & Fee and Test Year

• Test Publication Year: 2023
• Original Copyright Holders: Neti Juniarti, Raini Diah Susanti, Desy Indra Yani, and Nurani Nurhasanah.
• Licensing and Usage: The scale was published under an open-access format governed by the Creative Commons Attribution 4.0 International License (CC BY 4.0).
• Fee: Free of charge ($0.00). No licensing or administration fees are required for academic, public health, educational, or clinical research usage.
• Permissions Requirement: Researchers, psychologists, and healthcare organizations are permitted to copy, distribute, adapt, and build upon this material for non-commercial and commercial research or teaching purposes, provided appropriate academic attribution is credited to the original authors and the source publication in PLoS ONE.
• Author Correspondence: Requests regarding adaptations, translations, or technical Rasch parameter tables should be directed to Dr. Neti Juniarti, Faculty of Nursing, Universitas Padjadjaran ([email protected]).

12. References

• Goffman, E. (1963). Stigma: Notes on the management of spoiled identity. Prentice-Hall.
• Juniarti, N., Susanti, R. D., Yani, D. I., & Nurhasanah, N. (2023). Psychometric development and evaluation of a COVID-19 social stigma scale in Indonesia. PLoS ONE, 18(4), Article e0283870. https://doi.org/10.1371/journal.pone.0283870
• Schaller, M., & Park, J. H. (2011). The behavioral immune system (and why it matters for global health). Journal of Social Issues, 67(1), 99–117. https://doi.org/10.1111/j.1540-4560.2010.01688.x
• Stangl, A. L., Earnshaw, V. A., Logie, C. H., van Brakel, W., C-S Simbayi, L., Barré, I., & Dovidio, J. F. (2019). The Health Stigma and Discrimination Framework: A global, crosscutting framework to inform research, intervention development, and policy on health-related stigmas. BMC Medicine, 17(1), Article 31. https://doi.org/10.1186/s12916-019-1271-3
• World Health Organization. (2020). Social stigma associated with COVID-19: A guide to preventing and addressing social stigma. World Health Organization, UNICEF, & IFRC.

13. Items of the Scale