Introduction

The Extended Parallel Process Model (EPPM) is a communication theory; it suggests that the interaction between an external threat, fear and efficacy explains whether a fear appeal will lead to message acceptance or message rejection (Witte 1992). The EPPM suggests that an individual’s evaluation of threat comprises perceived severity (i.e. beliefs about the seriousness of the threat) and perceived susceptibility (i.e. beliefs about how likely it is that the individual will experience the threat). If an individual evaluates an external threat as serious and as posing a risk to them personally, they will likely feel fear. When perceived threat is high, fear is also high, and individuals proceed to evaluate their efficacy to face the threat. Efficacy comprises perceived response efficacy (i.e. beliefs that recommended behaviours protect against the threat) and perceived self-efficacy (i.e. belief in one’s ability to perform the recommended behaviour). If threat and efficacy are both high, individuals respond with a danger control process involving message acceptance and attitude, intention or behaviour change that favours reduced threat and, consequently, reduced fear. When threat is high but efficacy is low, individuals respond with a fear-control process, reject the message and engage in denial or minimisation of the threat to reduce fear. When the sense of threat is low, regardless of efficacy, people are not motivated to further process the message and will do nothing.

Starkly missing from the EPPM is the role of stigma in shaping responses to fear appeals, yet stigma and fear often go together. Stigma exists ‘when elements of labelling, stereotyping, separation, status loss, and discrimination occur together in a power situation that allows them’ (Link and Phelan 2001). Individuals can perceive, anticipate, internalise and act upon stigma—in other words, they try to avoid it and discriminate against others because of it (Kane et al. 2019). Weiss et al. (2006) define health-related stigma as stigma related to a health condition. Health-related stigma can interfere with public health responses by creating barriers to protective behaviours as well as by undermining testing, care-seeking or treatment (Barrett and Brown 2008).

Infectious diseases are fertile breeding grounds for stigma. A biocultural perspective of the evolutionary purpose of stigma suggests it arises when characteristics or actions of a sub-group are perceived to threaten the larger group (Neuberg et al. 2000). Individuals are likely to perceive an incurable, deadly and highly contagious disease such as COVID-19 as highly threatening, resulting in fear and consequently stigma—especially at the beginning of an outbreak. Indeed, reports worldwide suggest individuals perceived to be vectors of COVID-19 transmission experienced stigma and discrimination (Abelhafiz and Alorabi 2020; Bagcchi 2020; Bhanot et al. 2021). Lessons learned from HIV research related to stigma suggest that public health messaging around COVID-19 needs to stay ahead of the stigma by purposefully fostering empathy, diffusing parallel anti-stigma and anti-xenophobia public messaging, training authorities and engaging in sustained efforts to address underlying social inequities that manifest through values, laws and policies (Logie and Turan 2020).

From November through December 2020, Johns Hopkins Center for Communication Programs (CCP), with funding from the US Agency for International Development, led qualitative research to explore stigma related to COVID-19 in Abidjan, the largest city and epicentre of the COVID-19 pandemic in Côte d’Ivoire. The country documented its first case of COVID-19 in March 2020, with cases and deaths remaining low until the first wave during the period June to August 2020, when seven-day averages peaked at approximately 400 new cases per day and two deaths per day (Johns Hopkins Coronavirus Resource Center 2022). CCP conducted the study nine months into the pandemic, three months after the end of the first wave and before the second wave, from January to March 2021. We use data from this qualitative research to illustrate how the response to the COVID-19 pandemic evolved over time and how stigma interacted with perceived threat (fear) and efficacy.

Methods

The Ivorian national research ethics committee (Comité National d’Éthique des Sciences de la Vie et de la Santé) approved the study, as did the Johns Hopkins Bloomberg School of Public Health Institutional Review Board.

Participants were recruited through purposive sampling with support from the Ivorian government agency tasked with tracking COVID-19 cases. Trained community health workers from the National Program for Orphans and Vulnerable Children (PNOEV) used recruitment scripts to identify potential participants at four government-run COVID-19 treatment centres in Abidjan and from surrounding communities. The sample included men and women over the age of 18 years.

After obtaining written informed consent, trained Ivorian qualitative researchers (with advanced social science degrees) conducted in-depth interviews with people who had recovered from COVID-19 (individuals who had COVID-19 and did not die from it), individuals who had lost a family member to COVID-19 and health workers (such as doctors, nurses and pharmacists) to explore individual experiences with stigma related to COVID-19 (Table 13.1). Some of the health workers had also recovered from COVID-19 (not a sampling criteria), and the sample included those who had directly treated COVID-19 patients and those who had not. Qualitative researchers also conducted focus group discussions with members of the general population who knew someone who previously had COVID-19 and members who did not know someone who had been infected with COVID-19 to explore social norms and community perceptions related to COVID-19. The focus groups were of mixed gender, age and educational background. Researchers facilitated interviews and focus group discussions in French and audio-recorded them. Focus group discussions lasted about two hours, and in-depth interviews lasted about 45 minutes.

Table 13.1 Study participants
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FGDs involved three pile-sorting activities around response efficacy, self-efficacy and social norms. Pile-sorting involves grouping items by similarity or category. In this study, interviewers asked participants to sort COVID-19 prevention behaviours, including respecting a quarantine of two weeks after exposure, keeping a distance of 1 metre between people,Footnote 1wearing a mask in public, washing hands frequently, using hand sanitiser frequently, limiting gatherings to fewer than 50 people and limiting non-essential travel into one of three categories. These were ‘very useful’, ‘somewhat useful’ or ‘not at all useful’ for preventing COVID-19 (response efficacy); ‘very easy to do’, ‘somewhat easy to do’ or ‘not at all easy to do’ (self-efficacy); and ‘a lot of pressure’, ‘some pressure’ or ‘no pressure’ to observe the recommended behaviour (social norms). For each pile-sorting activity, the interviewers encouraged discussion and debate.

Interviewers did not conduct the pile-sorting activity in in-depth interviews with those who recovered from COVID-19 or those who had lost family members to COVID-19, but instead explored participants’ COVID-19 journeys from diagnosis and treatment through to recovery and return to their community. The in-depth interview guide for health workers elicited insights on barriers and facilitators to preventive behaviours as well as overall experiences treating COVID-19.

After data collection was complete, the research team transcribed in-depth interviews and FGDs word for word in French. Through a five-day participatory data analysis workshop, 14 stakeholders, including CCP research and programme staff, data collectors and representatives from the Ivorian government, conducted a thematic analysis by reading transcripts and discussing insights in small groups (Braun and Clarke 2006). In plenary sessions, each small group shared insights that were collaboratively synthesised into themes with illustrative quotations and entered into a matrix. These inductive themes—along with deductive themes from the interview guides—comprised the codebook. Following the data analysis workshop, four data collectors coded all transcripts in Atlas.ti using the codebook. They double-coded 19% of transcripts and met to discuss and resolve discrepancies; the other 81% of transcripts were coded by a single coder. The authors exported and analysed transcript excerpts coded with constructs related to the EPPM (response efficacy, self-efficacy, perceived susceptibility, perceived severity), the prevention behaviours, social norms, stigma and other inductive themes that emerged from the participatory data analysis workshop (such as the evolution of the pandemic, COVID-19 denial and comparisons with the West). We report the findings below.

Results

Table 13.2 presents a simplified version of the EPPM. In quadrant I, when threat and efficacy are high, the response is to control the danger by adopting behaviours that reduce the threat. Quadrant I represents the optimal combination of threat and efficacy for an effective response to a pandemic like COVID-19. In quadrant II, threat is high, but efficacy is low. Quadrant III represents low threat and high efficacy. In quadrant IV, both threat and efficacy are low.

Table 13.2 Simplified Extended Parallel Process Model (EPPM)
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We used participants’ narrative accounts of their experiences during the first year of the pandemic to map the evolution of fear, efficacy and stigma over time. Qualitative data from Côte d’Ivoire suggest that the first ten months of the pandemic can be roughly divided into three phases, corresponding to movement through three quadrants of the simplified EPPM diagram. Notably, the response is not static; people move through the quadrants over time as the situation shifts and not necessarily in a linear way. Furthermore, the population may be distributed across all four quadrants at any given time. What follows is meant to illustrate the movement and responses over time and is necessarily a simplification of reality. While these experiences are localised to a particular place and time, this chronology may serve as a blueprint for future pandemics that begin with fear and uncertainty and move through the EPPM quadrants.

In Phase 1, from March through May 2020, the Ivorian participants largely situated themselves and others in quadrant I: high threat, high efficacy and appropriate danger control response. In Phase 2, from June to August 2020, participants described moving into quadrant II: a space of high threat, but low efficacy, and adopting a fear control response. In Phase 3, from September to December 2020, by the time we collected data, many participants had moved into quadrant IV: a low-threat, low-efficacy space with dropped prevention behaviours.

Some focus group participants, the members of the group who know someone who had COVID-19 (noted throughout the chapter as FGPs*), explained the evolution over time: ‘In the beginning the disease provoked fear,’ said one. ‘Everyone was afraid because we didn’t know what would happen to us, especially given the information that we had about China, Europe.’ Then, as a second participant added:

There was an evolution. At the beginning it was fear … [Then] at one point there was anger, when people came to contaminate our population … Some people were treated differently. The children of soccer players, the wives of ministers refused to respect the quarantine. These people mixed with the population and in the days that followed, we discovered a lot of cases of the illness.

This FGP* added public officials’ attitudes created additional challenges: ‘When the president said, “We don’t care about corona,” people said, “It’s over. There’s no more corona.” So, we fell into indifference.’

Phase 1, Quadrant I: High Threat, High Efficacy (March to May 2020)

Fear

At the beginning of the pandemic, televised images of COVID-19’s death toll in China and Europe struck fear in the hearts of Ivorians. One health worker said, ‘[People] say to me … if COVID killed in Africa like it kills in Europe, it would decimate all of Africa. So, people are afraid of COVID.’ The lack of information around COVID-19 also generated fear. A participant who had recovered from COVID-19 said, ‘With all the publicity on TV, it was scary. People say, when you have corona, you’ll die within minutes. That’s it! No one was informed.’ Furthermore, COVID-19 is highly contagious, as another FGP* said: ‘It’s a serious disease that has wreaked a lot of havoc; it kills easily, and contamination is very, very, very, very easy compared to other diseases.’

Efficacy

When the first cases of COVID-19 appeared in Côte d’Ivoire in March 2020, the government shut down the country. Fear was high, stigma was yet to develop and efficacy was strong. The government closed bars, restaurants, clubs and movie theatres, put resources into awareness campaigns and mobilisation efforts and enforced prevention measures such as mask-wearing and limiting the number of public transport riders and people at gatherings, which bolstered perceptions of response efficacy and self-efficacy. People responded with an appropriate danger control response to reduce the threat and felt empowered by the government’s lead. One of the focus group participants who was part of the group that did not know anyone who had previously had COVID-19 (noted throughout this chapter as FGP~) shared, ‘At the beginning of COVID, the neighbourhood youth installed a handwashing station … When you passed, you were obligated to stop. If you didn’t wash your hands, you couldn’t pass.’

As another FGP~ expressed it, the norms established by the government created an enabling environment for the adoption of barrier measures: ‘The pressure was there at the beginning [of the pandemic]. For example, when you went out, at the intersections, health workers checked vehicles and police officers sometimes revoked drivers’ licenses if people weren’t wearing masks.’

Because the perceived threat was so high, people deemed the government’s response appropriate. An FGP* said:

At the beginning, people responded well to the barrier measures [the government] took because, frankly, at the beginning when they showed images of death from China, people were aware that it was serious and they respected all the barrier measures, the curfews.

Stigma

As the number of cases and deaths reported on Ivorian media grew, the fear that incited adherence to the barrier measures also generated stigma. As one FGP* explained:

You know, when someone is living with a disease, like right now with this pandemic … she is ashamed to say, ‘I have COVID,’ in the neighbourhood … You’re seen like in the old days when someone had HIV. Automatically you become everyone’s target.

The government’s COVID-19 response and the deadly, invisible, and highly contagious nature of the virus fuelled fear and stigma. A participant who recovered from COVID-19 described the arrival of the mobile testing unit at his house and the stigma that ensued:

It was like a movie, because the COVID agents arrived [at the house] in gear like on television; they arrived like Martians, and it attracted a lot of attention, and everyone was afraid because what we saw on TV among the whites was death and desolation. So it provoked … curiosity and fear. And, for the first time, I, a sociable person, was someone whom others fled.

Community members perceived everyone as a potential threat—especially unfamiliar others. An FGP* said, ‘It paralysed the population. They couldn’t go to work; even visiting a neighbour was impossible. Everyone stayed in their own corner.’ Other participants drew a distinction between close others, perceived as safe, and distant others, perceived as potential vectors of the virus, as stated by one FGP*: ‘People think that keeping [1 metre] distance is only for people who aren’t family or aren’t from the neighbourhood.’

Participants described anticipated and enacted stigma and discrimination surrounding testing sites and treatment centres, service providers and people (and their families) known or suspected to have COVID-19. A COVID-19 testing centre was burned, and people with COVID-19 were kicked out of their homes and lost their jobs. A participant who had recovered from COVID-19 recounted: ‘The owner of the compound [where we live] called my husband and said, “Sir, people say your wife has coronavirus. You need to take your wife and leave the house by this evening.”’

Another participant who had recovered from COVID-19 said, ‘They chased me away [from my workplace] like an animal, “Go! Go! Go! Go!” As if they didn’t know me. But I’m telling you, before I was the company’s go-to man.’ Health workers were stigmatised due to their perceived proximity to people infected with COVID-19: ‘Because he treats people, they will think he has the disease too’ (FGP*).

Furthermore, participants described that COVID-19 stigma and discrimination were not limited to the period of illness or infection. A teacher who had recovered from COVID-19 said, ‘The label, it sticks to your skin—you had COVID.’ She described the stigma she faced and how sad she felt that COVID-19 had become like a ‘second name’ for her and that people now ‘viewed her differently’. Scientific uncertainty around the period of infectiousness for COVID-19 rendered the participants in our study suspicious that those who had recovered from COVID-19 were still disease incubators. As an FGP* said, ‘We now see him as the devil because he has the disease … It’s now like a venom that can catch you from afar.’

Response

At the beginning of the pandemic, Ivorians stayed home, isolated as best they could and tried to adopt other recommended prevention behaviours such as wearing masks, washing hands/using hand sanitiser and avoiding physical greetings such as shaking hands and hugging. As a FGP* said:

At the beginning, we protected ourselves. Parents bought masks so as not to contaminate one’s brothers and sisters at home and, when we went out, before re-entering the courtyard there was a bucket and soap, you had to wash your hands and dry them well before entering the house. We protected ourselves. Even among friends in the neighbourhood, we sat one metre apart, and we didn’t shake hands anymore.

However, people avoided COVID-19 testing sites and testing because of fear of stigma. A healthcare worker who conducted mobile COVID-19 testing explained:

At the beginning, when we went to take samples at homes, people immediately labelled those people. So, when people have these symptoms, they don’t even want to come to the hospital because they think they’ll be stigmatised if people say that they have COVID-19.

An FGP* confirmed this: ‘They ask themselves, if they take the test and it’s positive, how are others going to treat them?’ Rumours circulated, suggesting that COVID-19 tests were being used to infect people with the virus, that positive test results were fabricated and that people with positive test results would be forced to quarantine against their will. Furthermore, people avoided hospitals at all costs, even for routine services. One health worker said:

In the months of March and April, people rarely came. People didn’t even come to the hospital anymore, they feared even coughing: ‘I’d better not cough, people will say that I have COVID.’ So, at the beginning, they were afraid of the stigma.

Some patients who did seek services for symptoms refused to be tested for COVID-19 or hid from health workers for fear of being tested.

Phase 2, Quadrant II: High Threat, Low Efficacy (June to August 2020)

Fear

In Phase 2, when COVID-19 cases and deaths did not explode in Côte d’Ivoire as they had elsewhere and stigma around COVID-19 was in full bloom, fear of the disease was partially replaced by fear of stigma related to the disease. Seeing is believing, and Ivorians did not see the bodies piling up. A participant who had recovered from COVID-19 said, ‘We don’t see cadavers, and we don’t see sick people; [so we assume] everything is happening among the whites.’

But stigma was still a primary source of fear. As an FGP~ explained, ‘The fear is not in the test itself; it is in the results.’ A woman whose husband had died of COVID-19 explained her reluctance to get tested in public for fear of what people would think and say: ‘We’re so well known. If we were to go stand in line, what would people think of us? People would think we are sick. That’s why [we didn’t go].’

Participants expressed hiding their COVID-19 diagnosis from others for fear of stigma.

Efficacy

Over time, the real and perceived efficacy of the shut-down and other barrier measures deteriorated for economic, socio-cultural and political reasons. A health worker pointed out, ‘These measures are only feasible for a limited period.’ The health worker refers here to the notion that some behaviours become unviable if they must be sustained for a long period of time. An FGP~ added:

In the first and second month, we didn’t go out, but when you stay home and the little things you stocked at home, everything is finished, you are obligated to go out. So, after two, three months, everyone started to go out.

In Côte d’Ivoire, physical isolation was not sustainable except among the most privileged of Ivorians. Most Ivorians live hand-to-mouth so, forced to venture out to support themselves and their families, people turned to fear-control strategies including stigmatising, trivialising, and buying into conspiracy theories and misinformation. As one FGP* explained:

Some people trivialise [COVID-19] … In Africa and especially here, people live day to day. So, for someone who must go out and get his food every day, he knows, he’s aware that it’s a danger, but he doesn’t have a choice.

Faced with the choice between feeding their families and potentially exposing themselves to COVID-19, Ivorians understandably chose the former. ‘They fear hunger more than they fear COVID,’ observed one health worker.

The shutdown also severely impacted jobs and businesses. A health worker praised the government for its COVID-19 communication efforts, but lamented the lack of economic support:

Where are the [economic] support measures? We are in Africa where 80 per cent are in the informal sector. If you block the activity of a small trader, it prevents them from meeting their needs and they will not respect the government’s regulations.

Although the government promised economic aid, participants expressed frustration at the lack of transparency in the distribution: ‘Some people have had COVID grants, but others have not. And those who didn’t get COVID grants, who have had their businesses closed, but have not been subsidised, are frustrated’ (FGP~).

Furthermore, the barrier measures recommended to prevent the spread of COVID-19 went against the grain of the Ivorian culture and threatened social cohesion, lowering efficacy because of social norms. While moderate use of hand sanitiser was acceptable, wearing masks when not required by an external authority, handwashing, maintaining 1 metre distance from others, limiting gatherings to 50 people, limiting non-essential trips and quarantining were all perceived as anti-social and stigmatising of others (Tibbels et al. 2022a).

On the political front, after the death of Prime Minister Amadou Gon Coulibaly on 8 July 2020, bans on travel and public gatherings were flouted for funeral rites. An FGP* recounted his impressions:

The State doesn’t think it is important [to limit social gatherings]. At the funeral of our Minister Gon in Korhogo and Félicia, there were a lot of people … even more than 40,000 people and the head of State was there. So, if they don’t respect [COVID-19 safety regulations], we can’t respect [them].

Another FGP* added, ‘If you tell me not to do something and then you go ahead and do it yourself, it means that it isn’t very important, so I will do it too.’

The apparent disorganisation of the medical system, the absence of effective treatments and insufficient quarantine sites—on top of the lack of transparency in the distribution of monetary aid—broke down trust in the government. One participant who had recovered from COVID-19 described a series of frustrations, including failing to receive her test results, self-medication with ulcer medication for chest pain likely caused by COVID-19, receiving a positive COVID-19 test result, then waiting hours in line in a room full of people who were not physically distancing only to be given medication without further examination and sent to quarantine at home. She said, ‘I eventually started to doubt [in the government], because, on TV, they said that when you’re sick, you must be quarantined, that you will be taken care of, [but I received] nothing!’

Stigma

Othering is a common manifestation of stigma, whereby individuals create distance between themselves and those who are afflicted. Participants in our study referred to COVID-19 as a disease of others, not themselves. COVID-19 in Côte d’Ivoire was conceptualised as a disease of the wealthy, those who ‘live in Cocody’ (a wealthy neighbourhood) and who travel abroad. A health worker recounted people saying that COVID-19 ‘Is a disease of the Boss. They are the ones who travel; we’ve never gone [abroad]. They are the ones who went and brought it here.’ Ivorians regarded COVID-19 as a disease of foreigners who may be considered ‘weak’ in contrast to ‘strong’ Africans perceived to be immune to COVID-19.

Adding elements of moral judgement, blame and responsibility, some participants even described COVID-19 as a well-deserved scourge of God against the wealthy and against white people. An FGP~ said, ‘It is the white skin; I don’t know what they did to God, but God is fair to everyone.’ Collective imagery depicted Africans as spared by the virus because of their moral and physical constitution and the climate.

Response

To manage the fear of having to face daily exposure to an invisible, highly contagious and deadly virus, Ivorians trivialised the disease. Denial and humour were coping mechanisms for people who did not have the luxury to stay home, away from harm. This fear-control strategy involved referring to the virus with mocking nicknames, claiming that local alcohol or herbal remedies protected against COVID-19 and questioning the existence of the virus in Côte d’Ivoire. People used a variety of names to refer to COVID-19 and thus minimise the perceived threat: ‘People call it “connerina virus” [bullshit virus] and “betisavirus” [stupid virus] … so as to not take the disease seriously’ (FGP*).

Participants in the study felt bolstered by their belief that home remedies were an effective cure for COVID-19. An FGP~ noted, ‘People say that by drinking Koutoukou [local alcohol], they will be cured of Corona. And others … say that the leaves of the Neem tree will heal them, to the point where they don’t take the disease seriously.’

People started to doubt the existence of COVID-19 in Côte d’Ivoire and to replace it with a narrative that the government had invented cases of COVID-19 to make money. An FGP~ repeated a common rumour: ‘Maybe we must reach a certain number of sick people, to get a bigger grant [from international agencies].’

Ivorians met words and actions that challenged the narrative that Africans are immune to COVID-19 with a fierce backlash. A health worker recounted, ‘When you talk about curfew or isolation it makes people angry because they say that COVID doesn’t exist here.’ A participant who had recovered from COVID-19 added, ‘When you tell [someone] to wear a mask, they insult you: “You’re pissing people off with your Corona business; Corona is finished!”’

Phase 3, Quadrant IV: Low Threat, Low Efficacy (September to December 2020)

Fear

When data collection took place in November and December 2020, fear of COVID-19 had been widely replaced among participants by a narrative that the virus was gone (among scepticism that it had ever truly been there in the first place) and that Africans were immune. An FGP~ explained:

In the beginning it was a threat because it was new. But with time, we’ve come to realise that it is just another type of malaria that they’ve sent. When the bodies of Ivorians get used to it, it will no longer be a threat. Right now, that’s where we are because people are no longer afraid of it.

The overall sentiment largely mirrored that of Ivorian president Alassane Ouattara when, at a political rally at an Abidjan stadium in front of more than 50,000 spectators on 22 August 2020, he said, ‘On s’en fout de Corona!’ (‘We don’t care about Corona!’). Several participants referenced this statement, either by echoing it or by reflecting on the far-reaching consequences. For example, an FGP~ said:

We don’t care … In the beginning, we believed in this disease. We saw on TV what was happening … But then we realised that it’s a scam … We see that the leader of the people himself says that we don’t care about Corona.

A health worker lamented:

When someone very influential goes on television and says, ‘We don’t care about Corona’, nothing you say as a health worker matters. There has been a complete reversal since that phrase was uttered. It has buffeted the whole of Côte d’Ivoire and undone everything we have done in terms of raising awareness.

Efficacy

Any remaining response efficacy and self-efficacy to implement prevention behaviours was damaged by the government’s stance on COVID-19. An FGP~ said:

When a parent gives orders to a child, he needs to model them. In the beginning, when [the government] talked about Corona, the population applied the barrier measures. But since the month of October and the election, frankly we’ve remarked that it is no longer important because the people who talked to us about Corona, they aren’t good examples, they don’t respect the barrier measures.

Without the government establishing favourable norms and expectations around prevention behaviours and enforcing safety regulations, fatalism set in. Another FGP~ observed, ‘If the people at the top are gathering in large numbers, we cannot do anything at our level and so we go on with our lives.’ Trust in the government was broken: ‘Today it is as if the state has abandoned the population’ (FGP*).

Stigma

Fear of stigma and trauma from lived rejection lingered, but as fear of the disease diminished so did the stigma. An FGP* explained, ‘In the beginning, there was automatically stigma that developed given the dangerousness of the disease as depicted by the media. But, today, no one cares about corona.’

As the disease became less stigmatised, barrier measures became more stigmatised. Trivialisation and mockery of COVID-19 led to mockery of people who practised barrier measures in places and spaces where they were not required. For example, wearing masks, physical distancing, washing hands or using hand sanitiser may have been required to access shared transportation, supermarkets, pharmacies, health centres and banks, and in these spaces, people obliged. However, community members saw people who diligently practised prevention measures as either having COVID-19 or as excessively gullible, fearful or antisocial. One FGP~ said, ‘It’s because you have Corona that you wear [a mask],’ and other FGPs* said, ‘[Someone who follows barrier measures] thinks he is better than us. He thinks his Corona is so important, so he wears his mask even to speak with his brother, and he says, “My sister, 1 metre.”’

Response

In late 2020, participants reported that life in Côte d’Ivoire was largely back to normal except for masks and handwashing still being required in some places. The government stopped enforcing prevention measures and the public followed suit. A health worker said, ‘When it was the law, everyone towed the line, but the moment that the restrictions were lifted, people stopped respecting [the barrier measures].’

People were no longer making much effort to practise the prevention behaviours they had adopted in phases 1 and 2. An FGP~ said, ‘In public places like supermarkets, people are required to wash their hands. At the beginning, there was pressure [to wash hands] at home too. … But now it’s finished, we no longer require anyone to wash hands [at home].’ People started seeking routine health services again. A health worker said, ‘People weren’t coming to the hospital for treatment, but thank God, it’s over, they’re coming now.’

The COVID-19 vaccine was viewed as unnecessary by many and dangerous by some. Careless words by French researchers who, in April 2020, suggested testing vaccines in Africa reverberated among participants, as did rumours about the nefarious motives behind the vaccine, including suggestions that it would infect Africans with COVID-19, decimate the population and sterilise Africans (‘Coronavirus: France racism row’ 2020). A health worker said, ‘They say, if there is a vaccine, they should test it in Europe first before bringing it to Africa.’ An FGP~ said, ‘We refuse to be the white people’s experiment.’ Another participant in the same FGD added, ‘We’ll refuse to get it because we’ll tell ourselves that maybe they are coming to give us COVID-19.’ Distrust in the vaccine was reflected in participant responses, and in general, people adopted a ‘wait-and-see’ attitude towards the vaccine (Tibbels et al. 2022b).

Post-study Update

Public attitudes towards the end of 2020, when the study took place, paired with holiday travel, set the stage for a second wave of COVID-19 in Côte d’Ivoire from January to March 2021, with higher daily case numbers and death counts than those during the first wave in the period from June to August 2020. Seven-day averages peaked at 450 new cases and three deaths in one day (Johns Hopkins Coronavirus Resource Center 2022). Two more waves then occurred (July to September 2021 and December to January 2022). Vaccines against COVID-19 became available in Côte d’Ivoire and since then risk communication efforts have focused on increasing vaccine uptake.

Discussion

This qualitative exploration of stigma related to COVID-19 in Côte d’Ivoire suggests that stigma should be considered alongside fear and efficacy in the EPPM. Stigma develops in response to fear and, in turn, generates fear, leading to a twofold threat: the disease threat and the threat of stigma (Holmes 2008). In its current form, the EPPM considers only the disease threat. The EPPM suggests that a high (disease) threat and high efficacy lead to an appropriate danger control response, which was observed in our data. Participants described that fear and efficacy were high in the beginning of the pandemic, and people tried to follow the barrier measures recommended to prevent the spread of COVID-19. However, the EPPM does not consider how the threat of stigma interacts with disease threat and efficacy. Our data suggest that stigma may be linked to increased fear and decreased efficacy. Both among participants who had previously had COVID-19 and those who had not described how anticipated stigma, or the fear of being stigmatised, prevented them from seeking testing/treatment and adopting prevention measures. Participants who had recovered from COVID-19 were ostracised at home and at work (enacted stigma). Participants who had recovered from COVID-19, health workers and people who had lost a family member to COVID-19 were also marginalised by the prevailing narrative that COVID-19 did not exist in Côte d’Ivoire.

This study provides unique insight into how EPPM constructs such as fear and efficacy may evolve over time in response to an emergent and global pandemic like COVID-19. Over the course of the first year of the pandemic, participants described moving from a space of high threat, high efficacy (quadrant I) to high threat/low efficacy (quadrant II) to low threat/low efficacy (quadrant IV). The data suggest that the factors that may contribute to shifts in perceived threat include communication about the disease, the trajectory of the disease, the government’s response and stigma.

Participants described that, initially, mass media highlighting the caseload and death counts abroad contributed to high perceived disease threat but that, over time, the perceived threat of COVID-19 decreased given that cases and deaths did not skyrocket in Côte d’Ivoire as they did elsewhere. The initial shutdown imposed by the government appears to have heightened perceived disease threat; however, as the government relaxed enforcement of barrier measures, perceptions of disease threat diminished along with trust in the government, giving way to narratives denying or minimising the threat of COVID-19 for mainstream Ivorians.

The pattern observed here reflects that described by Joffe (2011) with respect to public response to emerging and re-emerging infectious diseases: distancing, blame and stigmatisation. The data suggest that, in Côte d’Ivoire, people viewed COVID-19 as a disease of the West. Within Côte d’Ivoire, blame for COVID-19 was directed upwards at the wealthy and powerful—those who travelled abroad and who flouted public health safety measures—not the average person. Stigma was directed at those who had had COVID-19 or were suspected of having COVID-19, including those who had long since recovered. Participants described that the threat of stigma related to COVID-19 increased over time and lingered well after perceptions of the disease threat waned.

The data suggest that factors that may contribute to shifts in efficacy include the government response, the sustainability of the recommended behaviours, cultural and social norms, and stigma. The government sets the tone for the response to a disease threat and can negatively affect prevention efforts by not modelling the appropriate prevention behaviours. Furthermore, prevention behaviours that are feasible for a short period of time can quickly become unfeasible over a longer period. This appears to be particularly salient with respect to behaviours that have an economic impact, either because they interfere with an individual’s ability to earn a living (limiting travel, limiting gatherings and maintaining a distance of 1 metre from others) or because they cost money (masks and hand sanitiser). Cultural and social norms also play a role in the sustainability of prevention behaviours; behaviours that are culturally appropriate may be sustained for longer and more easily than behaviours that are not. Non-normative behaviours are also easier to stigmatise, and we noted a certain derision towards behaviours that were considered anti-social, such as distancing, masking, limiting gatherings and handwashing (Tibbels et al. 2022a).

These findings have implications for risk communicators and for future research. Risk communicators should anticipate how perceived threat and efficacy may change over time by considering the characteristics of communication around the disease, the disease trajectory and prevention behaviours. For example, how sustainable are the behaviours in both the short and long term? What is the economic impact of the behaviours? Are the behaviours culturally and socially acceptable? Risk communicators should also anticipate stigma, strive to minimise stigma in the response and prevention efforts and identify strategies to proactively diffuse stigma.

Future research should explore whether there is a predictable pattern of movement through the EPPM during a pandemic. In addition, it should explore, through quantitative methods, exactly how threat, stigma and efficacy interact at different points in time throughout the response to a pandemic.