Factors influencing stigma among college students with COVID-19 in South Korea: a descriptive study

Article information

Child Health Nurs Res. 2024;30(2):154-163

Publication date (electronic) : 2024 April 30

doi : https://doi.org/10.4094/chnr.2024.013

Sun Nam Park¹, Hyeran An², Jongeun Lee^,3

¹Professor, Department of Nursing, Seoul Women’s College of Nursing, Seoul, Korea

²Assistant Professor, College of Nursing, Daegu Catholic University, Daegu, Korea

³Professor, Department of Nursing Science and Research Institute of Nursing Science, College of Medicine, Chungbuk National University, Cheongju, Korea

Corresponding author: Jongeun Lee Department of Nursing Science and Research Institute of Nursing Science, College of Medicine, Chungbuk National University,1 Chungdae-ro, Seowon-gu, Cheongju 28644, Korea TEL: +82-43-249-1834 FAX: +82-43-266-1710 E-MAIL:agnes38@chungbuk.ac.kr

Received 2024 March 28; Revised 2024 April 15; Accepted 2024 April 25.

Abstract

INTRODUCTION

Coronavirus disease 2019 (COVID-19), first identified in December 2019, was declared a “pandemic” in March 2020. As of a relatively recent report, there have been more than 682 million confirmed cases worldwide [1]. In South Korea, the first case of COVID-19 was reported on January 20, 2020. By January 2022, approximately two years later, the cumulative number of cases had surpassed 750,000. As of August 2023, this number had escalated to more than 34 million, affecting a significant portion of the population [2]. The pandemic has compelled people globally to adapt to numerous changes in their daily routines has been linked to adverse mental health outcomes, including increased levels of stress, depression, and anxiety compared to pre-pandemic times [3].

Stigmatization not only causes public anger, fear, and disgust towards those infected and the diseases themselves, potentially leading to social division and impeding control policies [4], but it is also associated with prolonged stigma. This includes significant mental stress and social disadvantage for the infected individuals and their families even after recovery from the infection [5].

Transitioning into adulthood marks a significant phase between adolescence and full adulthood. During this time, individuals typically experience a noticeable expansion in the scope of their life activities. It is a crucial period for accomplishing developmental tasks such as forming a sense of identity, exploring future possibilities, and beginning to enter the workforce [6]. However, the pandemic has imposed restrictions on most social activities, leading to reports of heightened stress, anxiety, and depression among various age group, including college students [7].

COVID-19 pandemic stress encompasses the stress individuals face due to the ongoing COVID-19 pandemic situation [8]. In this study, we specifically measured COVID-19 pandemic stress, as opposed to general stress, to pinpoint the stress experienced by individuals infected with COVID-19. A report indicating that 50% of patients hospitalized with COVID-19 in South Korea had depression underscored the prevalence of mental health issues during this pandemic [9].

Fear of negative evaluation refers to the fear of being judged negatively by others. This fear frequently co-occurs with depression in people with COVID-19 [10].

The ongoing COVID-19 pandemic places people at a heightened risk of stigmatization, which includes intense anxiety and fear of contracting the virus, as well as sensitivity to judgment from others if diagnosed [11]. Moreover, depression during the COVID-19 pandemic has been linked to stigmatization [12]. Consequently, the fear of social stigmatization not only increases anxiety but also adversely affects quality of life, highlighting the importance of identifying and addressing stigma [13]. During the peak of the COVID-19 pandemic from 2020 to 2021, the fear associated with COVID-19 stigma was found to be more intense than that associated with a COVID-19 diagnosis itself [14]. This study focused on the impact of COVID-19 stigma among college students who tested positive for the virus in 2022, a time when social distancing measures were officially lifted, yet COVID-19 infections continued. Although there is extensive research on social stigma related to COVID-19 [15,16], there is a lack of studies on individuals who have actually received a COVID-19 diagnosis. Therefore, it is important to investigate the stigmatizing factors associated with COVID-19 diagnosis within the Korean cultural context.

Therefore, this study was conducted to examine the factors contributing to stigma among college students with COVID-19, with the goal of providing foundational data to assist college students in better adapting. To achieve this, the following objectives were formulated: (1) examining differences in stigma according to the general characteristics of college students; (2) identifying the levels of COVID-19 pandemic stress, depression, fear of negative evaluation, and stigma in college students; (3) calculating the correlations among major variables; and (4) determining the factors influencing stigma in college students.

METHODS

RESULTS

1. Participants’ General Characteristics

The average age of the study participants was 21.80±2.57 years. The group comprised 85.1% females and 14.9% males, with seniors making up the largest subgroup at 34.3%, followed by juniors at 24.0%, freshmen at 21.1%, and sophomores at 20.6%. A majority of the students, 79.4% were enrolled in health-related major, while 20.6% pursued non-health-related majors. Geographically, 44.6% of participants resided in Gyeongsang province, 36.0% in Seoul, and 19.4% in Chungcheong province. Regarding living arrangements, 56.6% lived with their family, 24.6% lived alone, and 18.9% lived with friends. In terms of perceived economic status, 72.6% identified as “middle class,” 14.3% as “poor,” and 13.1% as “rich.” Religiously, 73.7% of respondents had no affiliation, followed by Christians at 12.6%, Catholics at 10.9%, and Buddhists at 2.9%. Satisfaction level varied across different aspects of university life: 66.9% of students were satisfied with their major, 28.0% were neutral, and 5.1% were unsatisfied. Satisfaction with academic achievement showed 45.7% neutral, 39.4% satisfied, and 14.9% unsatisfied. Satisfaction with university life overall was reported as 53.7% satisfied, 34.9% neutral, and 11.4% unsatisfied. In terms of interpersonal relationships, 75.4% were satisfied, 18.9% neutral, and 5.7% unsatisfied. The majority (82.3%) of study participants were diagnosed with COVID-19 between January and March 2022, whereas 17.7% were diagnosed between April and May 2022. Treatment predominantly occurred at home (97.1%), with living treatment centers accounting for 1.7% and hospitalization for 1.1%. The severity of COVID-19 symptoms was classified as moderate in 49.1% of cases, mild in 30.9%, and severe in 20.0%. Before contacting COVID-19, 67.4% of participants considered themselves "healthy," 28.0% "fair," and 4.6% "unhealthy." Post-infection, these perceptions changed to 44.0% feeling "healthy," 39.4% "fair," and 16.6% "unhealthy” (Table 1).

Table 1.

General Characteristics of the Participants Related to Stigma (N=175)

Complications were reported by 65.1% of the cases, with the most common being cough (20.0%), sputum (7.6%), fatigue (6.4%), shortness of breath (6.0%), sore throat (4.8%), decreased or loss of smell (3.6%), weakness (2.8%), chest pain (2.4%), decreased or loss of taste (2.4%), and runny nose (2.0%) (Table 2).

Table 2.

Types of Post-COVID Conditions (N=175)^a)

3. COVID-19 Pandemic Stress, Depression, Fear of Negative Evaluation, and Stigma Levels

The participants’ mean scores was 1.81±0.89 out of 5 for COVID-19 pandemic stress, 1.16±0.36 out of 3 for depression, 3.21±0.82 out of 5 fear of negative evaluation, and 0.63±0.51 out of 3 for mean stigma (Table 3).

Table 3.

Score of COVID-19 Pandemic Stress, Depression, Fear of Negative Evaluation, and Stigma (N=175)

4. Correlations among COVID-19 Pandemic Stress, Depression, Fear of Negative Evaluation, and Stigma

Stigma showed significant positive correlations with the COVID-19 pandemic stress (r=.50, p<.001) and depression (r=.41, p<.001). COVID-19 pandemic stress showed a significant positive correlation with the depression (r=.32, p<.001), and fear of negative evaluation (r=.17, p=.023). Depression exhibited a significant positive correlation with fear of negative evaluation (r=.35, p<.001) (Table 4).

Table 4.

Correlations among COVID-19 Pandemic Stress, Depression, Fear of Negative Evaluation, and Stigma (N=175)

5. Determinants of Stigma

Factors affecting stigma among college students were analyzed using stepwise multiple regression analysis. Variables that influenced stigma scores, including participants' general characteristics, COVID-19 pandemic stress, and depression, were identified and set as independent variables. Categorical variables were treated as dummy variables, with reference groups defined as “25 years old or older” for age, “satisfied” major satisfaction and interpersonal satisfaction, January to March 2022 for the time of COVID-19 diagnosis, “home treatment” as the treatment type, and “healthy” for recent subjective health status as reference variables. To identify multicollinearity among the independent variables, the tolerance before the regression analysis was conducted was .76 to .98, which was greater than 0.1 and less than 10, and the variance inflation factor ranged from 1.02 to 1.32, lower than 10, with all variables determined to have no problem with multicollinearity. Analysis of the residuals confirmed the normality of error terms, homogeneity of variances, and the linearity of the model. In the autocorrelation test, the Durbin-Watson statistic stood at 1.95, indicating the absence of autocorrelation. Consequently, the regression model was found to be statistically significant (F=18.46, p<.001), with its explanatory power calculated at 37.6%. The most important factor influencing stigma was COVID-19 pandemic stress (β=.36, p<0.001), followed by depression (β=.26, p<0.001), date of COVID-19 confirmation (January–March 2022) (β=.18, p=.003), treatment modality (hospitalization) (β=.13, p=.034), recent subjective health condition (fair) (β=.13, p=.038) and satisfaction with major (unsatisfied) (β=.12, p=.042) (Table 5).

Table 5.

Factors Influencing Stigma among College Students with COVID-19 (N=175)

DISCUSSION

As COVID-19 was an unprecedented global pandemic that has significantly impacted the economy, society, and psychosocial functioning of nations, it is crucial to address the stress it has caused and the subsequent mental health issues. This study investigates the levels of COVID-19 pandemic stress, depression, fear of negative evaluation, and stigmatization among college students diagnosed with the COVID-19 virus in the first half of 2022. During this period, students were still grappling with the ongoing pandemic but had more resources to manage the infection. The study also explores the key factors influencing their perceptions of stigma. Importantly, this research focuses on individuals who have personally experienced a COVID-19 diagnosis, rather than those who are merely observers of the situation. A discussion of the study's key findings is presented below.

First, when examining differences in stigma levels based on the general characteristics of the participants, it was observed that older age group perceived more stigma. Participants who were less satisfied with their major and those with lower interpersonal satisfaction also exhibited higher levels of stigmatization. Although there are no previous studies confirming the difference in stigma according to major satisfaction and interpersonal satisfaction, it is believed that major satisfaction and interpersonal relationships are related to depression, and depression is correlated with stigma. In the future, we propose a study to confirm the effect of major satisfaction and interpersonal satisfaction on stigma using depression as a parameter. Using April 2022, when social distancing measures were officially lifted, as a reference point, college students diagnosed with COVID-19 prior to this date reported higher levels of stigmatization compared to those diagnosed between April and May 2022. Additionally, those who underwent inpatient treatment experienced more stigma than those treated at living treatment centers or at home. Lastly, individuals who perceived their health as having deteriorated post-COVID-19 diagnosis reported higher stigma levels, a finding supported by Park et al. [11], who noted that an increase fear of social stigma correlates with more negative perceptions of life changes.

While most people can resume normal activities after recovering from a COVID-19 infection, some may experience symptoms that persist for weeks or even months. Symptoms that continue for more than 12 weeks post-diagnosis and cannot be attributed to other conditions are known as post-COVID conditions (also referred to as long-term COVID, long COVID, or chronic COVID), though there is no globally accepted definition [23]. This study found that college students in early adulthood primarily reported persistent respiratory symptoms such as cough, sputum production, sore throat, and runny nose. They also experienced systemic symptoms like fatigue and weakness. Common cardiovascular symptoms included dyspnea and chest pain, along with disturbance in smell and taste.

Historically, large-scale pandemics have led to significant emotional difficulties, including severe stress, depression, and anxiety [24]. Recent research indicates a notable rise in anxiety and depression during the current pandemic [25], with a specific study from Korean highlighting that college students in early adulthood are particularly affected [7]. The term “COVID-19 Pandemic Stress” encapsulates the stress experienced due to the ongoing pandemic, impacting various aspects of life and presenting a more pervasive form of daily stress as it affects family, economic, educational, and work domains. Recent findings suggest that about 25% of the surveyed population is experiencing high stress levels due to COVID-19, leading to negative emotions such as anxiety, depression, and frustration [25]. In this study, the COVID-19 pandemic stress level among participants was 36.2%, significantly lower than the 47.8% reported in a similar study among nursing students in a different region at a comparable time [26]. The lower stress scores in this study may be attributed to the inclusion of a broader demographic of general university students, as opposed to nursing students who faced additional pressures due to their clinical responsibilities during the pandemic. Conversely, depression scores were higher among general students, with a total score of 23.2 compared to 17.2 among nursing students [26]. This discrepancy suggests that general university students may be frustrated by the lack of realistic experience of college life due to the transition of all classes to face-to-face compared to nursing majors, who have mandatory provisions such as meeting practicum hours in terms of class participation [27], and may also be more susceptible to misinformation via social media and other media outlets during outbreaks of new infectious diseases like COVID-19, which may lead to feelings of helplessness. Therefore, it is crucial to provide these students with education on managing emerging infectious diseases, which is expected to enhance their sense of personal control over the disease through accurate information on quarantine and personal hygiene management.

Stigma was positively associated with COVID-19 pandemic stress and depression, with fear of negative evaluation being linked to higher levels of both COVID-19 pandemic stress and depression. Since fear of a negative evaluation can increase depression levels among individuals, enhancing psychological health to better cope with such fear is considered necessary. Higher levels of COVID-19 pandemic stress were associated with increased depression levels, consistent with findings from a study involving healthy college students [27].

Finally, stress related to the COVID-19 pandemic was identified as the strongest predictor of stigma, followed by depressive variables. A later diagnosis of COVID-19 was associated with lower levels of stigmatization. Other influential factors included hospitalization, feeling fairly healthy recently, and reduced satisfaction with one’s major, collectively explaining 37.6% of the variance. In particular, in South Korea, adults have reported high levels of fear regarding social stigma [28]. This is attributed to the rapid increase in confirmed cases in specific regions and among certain religious groups, as well as widespread social condemnation. As information about individuals quarantined or infected with COVID-19 is shared on social media and their identities become public, the social stigmatization may increase not only for those infected but also for the general public observing the situation. In Korean society, there is a prevalent belief that contracting COVID-19 is due to personal failings, leading people to search for causes within individual’s life or lifestyle [29]. This perception intensifies the fear of infection and psychological decline. Social stigmatization can thus worsen individual distress, complicate resolution efforts, and contribute to emotional issues such as depression.

Fear of negative evaluation was not identified as a cause of stigma in this study. Although fear of negative evaluation is an underlying emotion that leads to mistrust, suspicion, and a sense of victimization of others [30], it may not have been a direct cause of stigma in this study. This could be because the public perceived the pandemic as a part of everyday life to which they had successfully adapted after April 2022, when COVID-19 transitioned into pandemic phase 2 [31].

Based on our findings, the limitations and suggestions for future research are as following. Firstly, the participants in this study were early adult in good health, which does not reflect the typical demographics of health, medical, and service occupations, where there is a higher fear of actual infection. Secondly, the data collection occurred after the peak of the COVID-19 outbreak, which may affect the generalizability of the results. Thirdly, mental health experts identify the three years following a pandemic as the most critical period for psychiatric sequelae. Therefore, ongoing research is essential to monitor this potentially serious social issue. Consequently, our study recommends the development of programs that proactively educate individuals about the factors influencing social stigma and aim to alleviate psychological distress while enhancing mental health management skills among college students who have encountered COVID-19.

CONCLUSION

This study is significant as it explores the emotional changes associated with pandemic stress, depression, fear of negative evaluation, and stigma among college students who have been diagnosed with COVID-19. In practical terms, it is essential to provide accurate information about the disease and to support those who are quarantined or infected without bias, especially in the context of an infectious disease like COVID-19, for which no definitive treatment has yet been established. Consequently, the findings of this study advocate for the creation of programs designed to educate individuals about the effects of social stigma on mental health. These programs aim to alleviate psychological difficulties and enhance the mental health management skills of college students who have contracted COVID-19.

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