ABSTRACT
The infectious spread of COVID-19 has been accompanied by stigma in both global and local contexts, sparking concern about its negative effect on individuals, communities, and public health responses. The changing epidemiological context of the COVID-19 epidemic and evolving public health responses during the first year of the pandemic (2020) in Vietnam serve as a case study to qualitatively explore the fluidity of stigma. We conducted in-depth interviews with 38 individuals, (13 cases, 9 close contacts, and 16 community members) from areas affected by local outbreaks. Thematic analysis was conducted iteratively. Our analysis indicates that the extent and impacts of COVID-19-related stigma were uneven. Adapting the clinical term 'viral load' as a metaphor, we describe this variation through the wide range of 'stigma load' noted in participants' experiences. Individuals encountering more acute stigma, i.e. the highest 'stigma load', were those associated with COVID-19 at the start of the local outbreaks. These intensively negative social responses were driven by a social meaning-making process that misappropriated an inaccurate understanding of epidemiological logic. Specifically, contact tracing was presumed within the public consciousness to indicate linear blame, with individuals falsely considered to have engaged in 'transgressive mobility', with onward transmission perceived as being intentional. In contrast, as case numbers grew within an outbreak the imagined linearity of the infection chain was disrupted and lower levels of stigma were experienced, with COVID-19 transmission and association reframed as reflecting an environmental rather than behavioural risk. Our findings demonstrate the role of public health policies in unintentionally creating conditions for stigma to flourish. However, this is fluid. The social perceptions of infection risk shifted from being individualised to environmental, suggesting that stigma can be modified and mitigated through attending to the productive social lives of public health approaches and policies.
ABSTRACT
INTRODUCTION: Antimicrobial resistance is a global challenge that threatens our ability to prevent and treat common infectious diseases. Vietnam is affected by high rates of antimicrobial resistant infections, driven by the overuse of antibiotics and the Vietnamese government has recognised antimicrobial resistance as a health security priority. This study aimed to understand how people in Vietnam use antibiotics in community settings, and the factors that impact their practices and decision-making regarding antibiotics. METHODS: We conducted 43 qualitative in-depth interviews with 50 community members in two urban and two rural sites in Vietnam. We conducted iterative, inductive thematic analysis alongside data collection through a process of systematic debriefings based on detailed interview summaries. Through this process, we developed a coding framework that was then applied to transcribed interview data. RESULTS: Frequent and indiscriminate use of antibiotics was driven by the powerful appeal that antibiotics held for many Vietnamese consumers. Consumers were discerning in making decisions in their purchase and use of antibiotics. Consumers' decisions were affected by perceptions of what constitutes high-quality medicine (effective, strong, accessible and affordable); privileging symptom control over diagnosis; social constructions of antibiotics as a trusted remedy with embodied evidence of prior efficacy, which is reinforced by advice from trusted sources in their community; and varied, generally incomplete, understanding of the concept of antibiotic resistance and its implications for individuals and for public health. CONCLUSION: Antibiotic use at the community and primary care level in Vietnam is driven by community members' social and economic response to what constitutes effective healthcare, rather than biomedical logic. Community-based interventions to reduce unnecessary antibiotic use need to engage with the entangled socio-structural factors that 'resist' current public health efforts to ration antibiotic use, alongside biomedical drivers. This study has informed the design of a community-based trial to reduce unnecessary antibiotic use.
