Scaling-up community self-reporting rate for COVID-19: Implication for assessing the perceived stigmatization of COVID-19 survivors among residents of Agege local government, Lagos, Nigeria

Objective: Coronavirus disease 2019 (COVID-19) is an emerging public health problem with over forty-four million conrmed infections globally. Previous studies showed that stigma impedes response activities. Therefore, this study was conducted to assess the perceived stigmatization of COVID-19 survivors among residents of Agege local government, Lagos State, Nigeria. We conducted a cross-sectional survey among 333 consenting residents recruited from Agege local government using a multi-stage sampling technique. An interviewer-administered questionnaire was used to collect data on perceived stigmatization. Bivariate and multivariate analyses were done using Chi-square and logistic regression respectively. Results: The mean age of the respondents was 35.7 ± 13.6 years. The proportion of respondents with poor knowledge was 50.5% and awareness for COVID-19 was 95.2%. Television and radio were the two major sources of awareness for COVID-19. A higher likelihood of perceived stigmatization was found among those aged 25 – 49 years (aOR= 3.1, 95% CI = 1.4 – 6.7), ≥ 50 years (aOR= 2.1, 95% CI = 1.1 – 3.9) and married respondents (aOR= 1.8, 95% CI = 1.1 – 2.9). To reduce the effect of stigmatization, we recommend a holistic response plan designed with basic facts about COVID-19 using programmes targeting married respondents as well as the adults.


Introduction
Many infectious diseases are associated with stigma and this has been found to impede the response activities in the control of the outbreak of such diseases. These diseases include Tuberculosis, Human Immunode ciency Virus (HIV) and leprosy [1][2][3]. Also, there is a stigma attributed to Stigma comes in multiple forms such as perceived, internalized, or experienced (discrimination). During the epidemics, people can be discriminated against because of their perceived association with the individuals thought to have come in contact with the virus. Thus, people with such diseases may avoid seeking health care, making it much harder to control the disease.
In Nigeria, after the report of the rst case of COVID-19, there was a surge in the number of positive cases, with disturbing evidence of community transmission. For example, the number of cases recorded on the 16th April 2020, 16th May 2020 and 16th June 2020 were 442, 5,621 and 17, 148 respectively [5]. The Nigeria Center for Disease Control (NCDC) reported that this surge was aided by social stigma against people perceived to have contracted the virus [6][7][8].
Surprisingly, inspite of the effects of stigmatization on the community self-reporting rate [6,8,9], a lot efforts have been geared towards the cure for COVID-19 among other non-pharmacologic preventive measures without corresponding measures to dissipate stigmatization in the community. Hence, this study was designed to assess the perceived stigmatization of COVD-19 survivors among residents of Lagos State.

Study location
The study was carried out in Ilobu community, Oko-Oba, Agege local government area (LGA) of Lagos State. Agege LGA has a projected 2019 population of 692,686 using a growth rate of 3.4% and 2006 population gure as the baseline [10] . The LGA is majorly populated by Yoruba ethnic group. Inhabitants were mostly artisans

Study design and population
This was a descriptive cross-sectional survey carried out in Oko-Oba area of Agege local government area (LGA) of Lagos State between May and June 2020. The study population included all consenting males and females of 18 years and above who were resident in Ilobu community in Oko-Oba at the time of the study.
Sample size and sampling technique A prevalence of 63.0% [11] of a similar study was used with the margin of error set at 5%. Factoring non-response rate of 10%, a minimum sample size of 394 was arrived at. A multi-stage sampling technique was used. Stage one: Oko-Oba was selected from the list of the catchment areas in Agege LGA using ballot technique. Stage two: Ilobu community was selected from the list of communities in Oko-Oba area using ballot technique. Stage three: A systematic sampling technique was used to select the eligible respondents from the list of the households retrieved from the o ce of the National Programme on Immunization (NPI) in Agege LGA. The rst household was selected by simple random sampling through a ballot and all the eligible respondents interviewed. Subsequently, every 4th house was selected until the desired sample size was met.

Research instrument and data collection methods
The COVID-19 related stigma was measured by an interviewer-administered questionnaire adapted from the previous studies [12][13][14]. We engaged eleven of the 20 people trained by WHO for active case search (ACS). They were trained for two days, 2 hours daily by the principal investigator on data capturing tools and the techniques for questionnaire administration.

Measurement of main outcome variables
Knowledge score was assessed using questions adapted from the previous studies [15,16]. Each correct response was scored one point while each wrong response was scored zero. The total obtainable score was 7 which agrees with a Chinese study [17]. Perceived stigmatization was assessed using an adapted HIV-Stigma Index [12]. The stigmatization scale used consists of negative attitude, perceived discrimination and equity (Additional le 3:S3). The mean stigmatization score was 68.8. The respondents who scored up to or above the mean were categorized as those with perceived stigmatization. The Cronbach's alpha coe cient of the perceived stigmatization questionnaire was 0.84 in our sample, indicating acceptable internal consistency.

Data Analysis
Data were analyzed using IBM SPSS version 25. Categorical variables were reported as frequencies and proportions/percentages. Associations between the stigmatization and other categorical variables were assessed using Chi-square. Logistic regression was used identify the predictors of the perceived stigmatization of COVID-19 survivors. The level of statistical signi cance was set at p < 0.05.

Socio-demographic characteristics of the respondents
The mean age of the respondents was 35.7 ± 13.6. The proportion of respondents in the 25-49 years age category was 59.8% with a higher proportion (56.8%) of male respondents. Married respondents were 51.7%, 56.0% were Christians and 53% belonged to the Yoruba ethnic group.

Discussion
The overall awareness of COVID-19 outbreaks among the respondents was 95.2% with male predominance and this could be attributed to higher educational attainment by the male respondents. This high prevalence could result from the effectiveness of the strategies deployed to disseminate COVID-19 information by the Government of Nigeria. Mass media, particularly television (43.5%) and radio (36.9%) were found as the major sources of information about COVID-19 and this corroborated ndings from the previous studies [18][19][20][21][22]. However, it negated the report of Abdelha z et al in Egypt where the social media and internet were the major sources of information during this COVID-19 outbreak [13].
In view of this, the mass media should be intensively used to further propagate awareness, most especially on non-pharmacologic prevention.
The study revealed poor knowledge of COVID-19 among the study subjects and could result from the low tertiary educational status and 'unstable' epidemiologic pattern of the virus. This agreed with what was documented in some Nigerian and Bangladesh studies [23][24][25][26] but opposed to what was reported in Egyptian and Chinese studies where a higher prevalence of good knowledge of COVID-19 was documented [17,19]. The higher prevalence recorded in these two studies could be due to the recruitment of seemingly educated online study populations.
On the mode of transmission of COVID-19, the majority of the respondents reported cough, sneezing and contacts as the major routes of transmission. This testi es to the dissemination of correct information about the way the virus spreads. However, efforts should be geared towards scaling-up information dissemination so as to catch-up with the handful proportion of those with incorrect knowledge of the mode of transmission of the virus.
The prevalence of perceived stigmatization was 47.7% and many studies on similar infectious diseases such as Severe Acute Respiratory Syndrome (SARS), tuberculosis and Ebola corroborated our result by demonstrating the negative effects of stigmatization on the preventive and control efforts [1,22,27]. Stigma against the survivors poses signi cant bar riers and makes access to treatment a herculean task. Incidentally, this may cause unnecessary delay in seeking care and this could aggravate the suffering of the survivors [28][29][30].
The respondents in the age of 25 years and above were potentially more likely to stigmatize against COVID-19 survivors compared with those who belonged to the age group of less than 25 years. This was not surprising because youths are known for their explorations and knowledgeseeking behaviours compared with the adults. Their penchants for knowledge could have afforded them the opportunity of understanding the epidemiology of COVID-19, hence, their low predisposition to perceived stigmatization in this study. This is consistent with the reports of Des Jarlais et al. and Usifoh et al. in the U.S.A and Nigeria respectively [31,32].
Married respondents were more likely to stigmatize the survivors of COVID-19 compared with other forms of marital statuses because they are more involved in cultural issues and often listen to advice from their families where stigma was found to be emanating from [33,34]. In order to stem this ugly tide, efforts should be geared towards community engagement and raising public awareness on the myths and facts relating to COVID-19 pandemic.

Conclusion
Adults and married women displayed a high level of perceived stigmatization and this could be attributable to poor knowledge. To scale-up selfreporting for COVID-19, we recommend a holistic emergency response plan, packaged with accurate knowledge targeting married respondents as well as the adults.

Study limitation
Social desirability bias was envisaged and this was reduced by avoiding the leading questions and use of interval questions. We might not be able to generalize our ndings to the whole country. However, the ndings of our study could be extrapolated to the Southern part of Nigeria because of the similarities in the socio-economic and cultural characteristics. This is the rst psychosocial survey to assess stigmatization in the control of community transmission of COVID-19 in Nigeria.

List Of Abbreviations
LGAs Availability of data and materials The respondents used to generate this data have not been reported in any other submission by the authors or anyone else. However, upon request, we can offer on-site access to external researchers to the data analyzed at the Oriire Local Government Health Authority, Ikoyi-Ile, Oyo State, Nigeria. To do so, Dr. Olaniyan Akintunde Babatunde should be communicated.