Since the coronavirus disease 2019 (COVID-19) outbreak, the stigma associated with COVID-19 has been of broad interest to the public, researchers of multiple disciplines (e.g., psychologists, sociologists), and policymakers concerning social harmony and public mental health. A series of studies have investigated the public’s COVID-19 stigma from multiple lenses, including the public’s feelings toward people who are stigmatized because of COVID-19 (e.g., Ransing et al., 2020; Ugidos et al., 2020), people being stigmatized during the pandemic (e.g., Baldassarre et al., 2020; Bruns et al., 2020; Earnshaw et al., 2020; He et al., 2020; Muhidin et al., 2020; Jennings et al., 2021), and their thoughts about the harm of COVID-19 stigma to the public’s health and the whole society (Das, 2020). In addition, the public not only held negative attitudes toward COVID-19 related people and groups but also to the innocent people who were unassociated with COVID-19, such as people with a religious belief (i.e., Muslims) (Islam et al., 2021). The stigma stems from an individual’s high sensitivity and fear of disease infection (Ahorsu et al., 2020). And the COVID-19 related people and groups listed above were stigmatized because of being considered as potential virus carriers (Gronholm et al., 2021). It has been well documented that COVID-19 stigma has caused severe consequences on both the individual and society levels (Das, 2020). At the personal level, experiences of being stigmatized aggravated the psychological problems among people who recovered from COVID-19 and those who have been isolated during the pandemic (Bagcchi, 2020; Xin et al., 2020), hampered the social functioning of stigmatized people (Saeed et al., 2020), and triggered interpersonal conflicts, e.g., being evicting from home (Das, 2020). In addition, COVID-19 stigma as a barrier has been found to impact the effectiveness of pandemic prevention and control (Sotgiu and Dobler, 2020). At the same time, studies have found that COVID-19 stigma could hamper the quality of medical services. During the COVID-19 outbreak, health care workers (HCWs) experienced social stigma against them. This psychological distress could lead to serious psychological outcomes like job burnout, which was extremely detrimental to the prevention and control of the epidemic (Patel et al., 2021). Considering the scope and depth of COVID-19 stigma and its consequences, researchers and policymakers urgently need to acquire knowledge about the characteristics and psychological mechanisms of COVID-19 stigma.

Existing literature on COVID-19 stigma has explored the public’s negative emotions (e.g., fear) toward the COVID-19 patients (Ahorsu et al., 2020; Kumar and Nayar, 2020), avoidance of people residing in the COVID-19 affected regions (Ransing et al., 2020; Xin et al., 2020), and negative attitudes toward people who suffered from COVID-19 (Ugidos et al., 2020). However, most of these studies on COVID-19 stigma assessed only one or two dimensions of COVID-19 stigma and investigated it independently without comparing it with other disease stigmas, which couldn’t address the common and different dimensions of COVID-19 stigma other than other stigmas. Toward a more comprehensive understanding, we aimed to assess multiple dimensions of COVID-19 stigma, including emotional, cognitive, motivational, and social dimensions, and compare it with other disease-related stigmas.

People’s affective responses induced by an emerging infectious disease and their discriminative feelings about people with this disease have attracted growing attention in previous research on stigma. According to the pathogen aversion theory (Park et al., 2003; Peng et al., 2010; Oaten et al., 2011) and the behavioral immune system theory (Schaller and Park, 2011; Murray and Mark, 2016), stigma originates from one’s fear of disease, which in turn cause discrimination and social exclusion toward people who are probably carrying the disease virus. Such negative emotion which reflects an automatic and associative (not cognitive and rule-based) component of encoding the potential dangerousness of the disease-related people has been widely seen in a variety of infectious disease stigmas, such as SARS (Person et al., 2004), Ebola (Overholt et al., 2018) as well as COVID-19 stigma (Taylor et al., 2020). The fear associated with the infection or the quarantine might be the common driver that causes such disease stigmas (Ransing et al., 2020). Fear may be one of the core characteristics of the stigmas associated with infectious diseases compared with those related to other non-infectious diseases. As an infectious disease, COVID-19 has caused tens of millions of confirmed cases and the most deaths worldwide since the 21st century (Liu et al., 2020), we speculated that people might have more fear about people associated with COVID-19 than those related to mild infectious diseases (e.g., flu) and other non-infectious diseases, such as mental illness (e.g., depression).

Accumulating evidence has demonstrated that perceivers, or called stigmatizers, may activate both affective and cognitive processes when they meet and interact with people and groups that are socially stigmatized (Schmidt and Weiner, 1988; Weiner, 1995; Kurzban and Leary, 2001; Pryor et al., 2004; Krendl et al., 2006). For instance, Krendl et al. (2006) using fMRI found that increased activation in the brain areas related to aversive emotions (amygdala and insula) as well as the regions associated with cognitive control (anterior cingulate and lateral prefrontal cortex) were observed when participants were evaluating people from well-established stigmatized groups (e.g., obesity, transsexuality) relative to the controls. Previous research has demonstrated that cognitive attribution (i.e., perceived controllability of disease) could modulate the affective responses of disease stigmas, which help combat the disease and avoid fueling fear (Schmidt and Weiner, 1988; Weiner, 1996). However, little is known about whether the differences between COVID-19 stigma and other stigmas are reflected in the cognitive processes, e.g., cognitive attribution. Previous research has shown that individuals were less likely to attribute the cause of the epidemic disease (i.e., SARS) to the patients than what they did to people with other diseases (i.e., AIDS) (Mak et al., 2006). Accordingly, it is possible that people may endorse less perceived controllability of disease for people and groups related to COVID-19 than those associated with other diseases (e.g., AIDS and mental illness).

From a social psychological perspective, one function of stigmatization is disease avoidance, which hinders social interactions of the stigmatized people (e.g., withdrawing from social situations during COVID-19, Zhang et al., 2020). What’s more, during the COVID-19 outbreak, a wide range of groups, such as healthcare workers, COVID-19 survivors, Asians, were avoided, shunned, or ostracized because they were perceived as the sources of infection (Gronholm et al., 2021). Given the severity and contagion of COVID-19 stigma, it is highly likely that the public would show less approach but more avoidance tendencies for the COVID-19 related group than other disease-related groups during the COVID-19 pandemic.

Another function of public stigma is social norm enforcement (e.g., deviant identity or behavior) (Phelan et al., 2008). The public’s discrimination is viewed as a threat to deviants to conform to the mainstream norms. The stigmatization of deviants protected against infectious diseases, which in turn facilitates survival under pandemic threats (Kurzban and Leary, 2001; Phelan et al., 2008). Considering the public’s intention of norm enforcement during the pandemic, we expected that the public would endorse more deviating from social norms for people and groups related to COVID-19 (i.e., the COVID-19 patients) relative to other mild infectious and common diseases like flu.

While one line of research has been focusing on the explicit processes of stigmatization (i.e., attitudinal, evaluation processing) (Brunstein and Schmitt, 2004), another mainstream of previous research has illuminated the implicit discrimination against the stigmatized groups (i.e., the automatic response based on unconscious processing) (Rydell and McConnell, 2006). People’s implicit attitude is typically assessed by the implicit association test (IAT) – a classical paradigm to measure individual implicit attitudes (Greenwald et al., 2003). Using the IAT, a set of studies have revealed the implicit processing of various disease-related stigmas, such as mental illness (Wang et al., 2012; González-Sanguino et al., 2019) and eating disorders (Elran-Barak et al., 2020) using the IAT paradigm. To be noted, the implicit and explicit components of stigma have proven to be independent (Wang et al., 2012; González-Sanguino et al., 2019). Researchers have demonstrated that people’s implicit attitudes toward others are processed automatically rather than reflectingly in real-time interpersonal communication (Pryora et al., 2013) and could have a greater impact on their actual behavior than explicit attitudes (Kurdi et al., 2019). Sometimes stigmatization could only be observed at the implicit level instead of the explicit level (e.g., González-Sanguino et al., 2019). So far, the implicit processing of COVID-19 stigma was largely neglected, though the public’s explicit attitudes toward people associated with COVID-19 have widely been investigated using a subjective reporting approach. Considering that the importance of the implicit aspect of stigma, we are curious about whether COVID-19 stigma could be detected at the implicit level and whether such stigma may differ from other similar stigma induced by a previous pandemic (i.e., SARS) in terms of its implicit processing.

To uncover the implicit and explicit processes underlying COVID-19 stigma, the present research compared participants’ explicit and implicit attitudes toward people associated with COVID-19, we conducted three studies on 1,493 Chinese participants from the outbreak to the recovery period of the COVID-19 pandemic. To test whether and to what extend COVID-19 stigma might be different from a preexisting disease stigma during the COVID-19 outbreak, Study 1 was set out to compare participants’ negative attitudes toward the COVID-19 related group with their attitudes toward the SARS related group and the control group. We selected the SARS-related people as the main control group because the two diseases had similar medical characteristics (e.g., symptoms, the way of transmission) (Saeed et al., 2020). Additionally, Chinese participants have experienced the two infectious diseases. Given that COVID-19 is more severe than SARS in terms of its scope and infectivity, we hypothesized that participants would report more negative attitudes for the COVID-19 related group than the SARS related group and other control groups (i.e., the SARS related people, people from the participants’ permanent residence). To test whether the discrepancy between COVID-19 stigma and SARS stigma remains and which dimensions (e.g., emotional, cognitive) may play a role in differentiating the COVID-19 stigma and other disease stigmas during the recovery stage of COVID-19 when the pandemic has been controlled in China, Study 2 extended single evaluation on negativity to multidimensional measures (i.e., emotional reactions, cognitive processing, withdrawal/approach motivations, social dimensions, and overall evaluations). Additionally, toward a better understanding of the common and distinct aspects underlying COVID-19 stigma, we included various control groups in Study 2, including SARS which is similar to COVID-19, severe infectious diseases (i.e., Ebola and AIDS), the mild and common infectious disease (i.e., cold), non-infectious diseases (e.g., depression and schizophrenia). Based on previous research on disease stigmas (Goffman, 1969; Madru, 2003; Mak et al., 2006; Krendl et al., 2013; Shamblaw et al., 2015; Krendl, 2016; Botha et al., 2017; Das, 2020; Saeed et al., 2020; Taylor et al., 2020; Stevens and Taber, 2021), we hypothesized that participants would report more negative emotions (such as fear), less perceived responsibility of the disease, more avoidance motivation (such as avoidance), and more negative social evaluation (such as social harmfulness) for the COVID-19 related group (vs. other groups we measured). Last but not the least, we were interested in whether the public negative attitudes toward the COVID-19 related people could be internalized and reflected at the implicit level. To address this, by using a revised IAT (Greenwald et al., 2003), Study 3 compared participants’ implicit attitudes (i.e., IAT scores) in the COVID-19 condition relative to those in the preexisting pandemic disease condition (i.e., SARS). If the pandemic-related stigmas shared a common mechanism which is an automatic process (Pryor et al., 2004; Oaten et al., 2011), i.e., instinctive fear of disease, we may expect that there would be no differences in the implicit processing between the two conditions.

COVID-19 stigma poses a severe threat to the mental health and social function of a wide range of people (i.e., people who have recovered from COVID-19) and groups (i.e., Asian, Chinese) (Bavel et al., 2020; Zhao et al., 2021). Many efforts have been made to understand and deal with such stigma. For example, WHO (World Health Organization) suggested that social media needed to carefully use words when describing this disease to prevent and reduce stigmatization at the beginning of the COVID-19 outbreak (World Health Organization [WHO], 2020). In addition, psychologists have attempted to uncover the psychological mechanisms underlying the disease-related stigmas and search for the possible way of individual and group intervention (Pappas et al., 2009; Morris, 2012; White Hughto et al., 2015; Fischer et al., 2019; Stangl et al., 2019). Along this line of research, the first study collected 1,094 Chinese participants from January to February 2020 online and revealed that the public endorsed more negative attitudes toward the COVID-19 related people (i.e., the COVID-19 patients, people who have recovered from COVID-19, and people from the high pandemic risk areas) than the SARS related people (i.e., the SARS patients, and people who have recovered from SARS) and the control group (i.e., people from the participants’ permanent residence) at the early stage of the COVID-19 pandemic. The second study further revealed that COVID-19 stigma remained at the late stage of COVID-19 and was more severe than other preexisting stigmas in multiple aspects, including the higher possibility of attributing the cause of the disease to the person, more keeping avoidance of, less willingness of becoming neighbors, higher levels of social harmfulness, and more deviating from social norms. Furthermore, using the IAT tasks, the third study further demonstrated that the implicit COVID-19 stigma existed at the late stage of COVID-19 and no significant difference was shown in the implicit processing between COVID-19 and SARS stigma. Taken together, the current research provided the first empirical evidence for the explicit and implicit aspects of COVID-19 stigma and its common and unique processes with other stigmas.

Prior studies on the pandemic stigmas have uncovered the public’s discriminatory attitudes toward disease-related people and groups (Ahorsu et al., 2020; Kumar and Nayar, 2020; Ransing et al., 2020; Ugidos et al., 2020; Xin et al., 2020; Nguyen et al., 2021). Among previous studies, a few attempts have been made to compare the newly emerging pandemic disease-related stigma with other stigmas. For example, Des Jarlais et al. (2006) found no difference between United States participants’ attitudes toward AIDS and SARS. The combined fear of the disease and the sufferers led to similar patterns of the two stigmas, such as social exclusion (Des Jarlais et al., 2006). Similarly, Li M. et al. (2021) compared COVID-19 stigma with AIDS stigma during the outbreak of COVID-19 and found that Chinese participants had a higher level of avoidance for the COVID-19 patients relative to the AIDS patients. Though these studies compared the COVID-19 stigma with the existing disease stigma, namely AIDS, they may have some limitations. For instance, AIDS differs from the two pandemic diseases (i.e., SARS and COVID-19) in many aspects, such as symptoms, curability, and the way of transmission (Li M. et al., 2021). Some researchers have pointed out that the stigma associated with different pandemics may have different characteristics and that such differences may be caused by differences in the disease (e.g., the way of transmission) (Saeed et al., 2020). Considering the similarity between COVID-19 and SARS in terms of pathogenesis and clinical features (Caldaria et al., 2020), Study 1 using the common control and SARS group as controls first demonstrated that participants of different ages and genders consistently reported more negative attitudes toward the COVID-19 group (vs. the SARS group) at the outbreak and recovery period of COVID-19. Specifically, this difference was mainly reflected in the participants’ negative evaluation of patients with the disease rather than those who recovered from the disease. One possible account could be that the public may perceive more risks of COVID-19 than SARS due to the fact that the former is more severe and threatens their present life but the latter has receded for nearly 20 years. In addition, our data showed that the difference between the public’s negative attitudes toward the COVID-19 patients and those for the SARS patients difference tended to narrow as the COVID-19 pandemic entered into the recovery stage. Similarly, Li Q. et al. (2021) found that when a pandemic disease broke out, the perception of uncertainty about the pandemic environment may increase the severity of stigma. Consistent with the previous work, our results suggest that when facing with a new pandemic disease, effective pandemic prevention and control can not only effectively protect people’s physical health (Kang et al., 2020; Gelfand et al., 2021) but also reduce the pandemic disease-related stigma to promote interpersonal collaboration.

To be noted, our study is the first to compare COVID-19 stigma with other disease-related stigmas at multiple dimensions, including emotional responses, cognitive processes, motivational, and social evaluations. On the one hand, our results suggest that there might be a common mechanism among disease-related stigmas. Specifically, the common drive is highly likely to be reflected in the emotional dimension, i.e., fear. Such negative emotion has been widely discussed in previous research (Ransing et al., 2020). Previous studies have shown that fear occurs in the early stages of disease-related stigma processing, which may involve an automated process (Pryor et al., 2004; Oaten et al., 2011). In the process of further cognitive processing, motivation tendency, and social evaluation, we found that participants reported more withdrawal tendencies for, and less willingness of being neighbors with the COVID-19 patients relative to the other disease patients (i.e., SARS, Ebola, AIDS, and flu). Future research may explore at which stage of the stigma processing the more significant stigma of the newly generated pandemic disease occurs and explore the psychological processes involved in this process.

On the other hand, our study suggested that COVID-19 stigma and other disease stigmas differ in multiple dimensions. For example, participants’ negative attitudes toward the COVID-19 patients were more significant than their negative attitudes toward the SARS patients but less than their negative attitudes toward the AIDS and Ebola patients. Similarly, in the social evaluation and cognitive processing dimensions, participants stigmatized the COVID-19 patients (e.g., social deviant, social harmfulness, and attribution) more than the SARS patients and the patients with mild infectious diseases (i.e., the common flu), but less than the severe infectious diseases (i.e., AIDS and Ebola) and the psychiatric disorders (i.e., schizophrenia and depression). The above results collectively indicate that the public’s COVID-19 stigma is more severe than the stigmas related to most of the existing infectious diseases but less than those associated with severe infectious diseases and mental illnesses in the cognitive processing and social evaluations (Supplementary Figure 3). In the motivation dimension, participants reported the highest avoidance for the COVID-19 patients (vs. the patients with all other diseases we measured). In the negative emotional dimension, COVID-19 stigma, as a category of infectious disease-related stigma, had no significant difference in the emotion dimension (i.e., fear) compared with other infectious disease stigmas. However, compared with non-communicable diseases (e.g., mental illness), participants had a higher degree of fear of the COVID-19-related group. This may indicate that the emotion help distinguish infectious disease stigma from non-communicable disease stigma. However, in the positive emotional dimension (i.e., sympathy), we found that participants reported the highest possibility of feeling sympathy for the COVID-19 patients (vs. the patients with all other diseases we measured). Although studies have documented a negative association between compassion and stigma (Batson et al., 1997; Galinsky and Moskowitz, 2000; Stark et al., 2013; Boag and Carnelley, 2016; Álvarez-Castillo et al., 2018; van Bommel et al., 2021). The public’s sympathy for people associated with the pandemic disease might be crucial to the development of stigmatization interventions in future research. In sum, our research, using a horizontal comparison among the newly emerging pandemic stigma and other stigmas, is conducive to precisely characterizing and differentiating the pandemic-related stigma (vs. the other disease stigma).

The IAT results demonstrated that the implicit COVID-19 stigma existed and further revealed the separation of explicit and implicit stigma toward COVID-19-related people. Our findings contribute to this field by providing first evidence on a common implicit basis for processing pandemic stigmas. Additionally, we found no differences in the public’s implicit attitudes toward the newly emerging pandemic disease (i.e., COVID-19) and the existing pandemic disease (i.e., SARS). Implicit stigma reflects the connection between the target people and negative characteristics in the early stage of individual cognitive processing (Greenwald et al., 2003), which is linked with emotional processing (Pryor et al., 2004; Oaten et al., 2011). This is consistent with the results of our research that the public has the same degree of fear for the COVID-19 group and the SARS group. This suggests that there may be consistent activities in the neural processing of pandemic disease-related stigma, such as the activities of the amygdala and insula (Harris and Fiske, 2006; Krendl et al., 2006, 2013; Krendl and Cassidy, 2017; Finnell, 2018). Combined with our multidimensional exploration of the stigma of different diseases, future research needs to explore how the public stigma of different diseases is differentiated from the same processing, what neural or psychological activities are involved in this process, and how it is affected by the social environment.

The current results shed new light on the newly emerging pandemic stigma which involves in common (implicit level) but distinct (explicit level) psychological processes. The present findings enrich the existing literature on the mechanism underlying pandemic-related stigma. Future research is encouraged to step further on the neural mechanisms underlying such stigma. For policymakers, developing effective disease prevention and control policies and reducing infection risks in the environment are key to promoting stable social functioning. At the same time, because the public’s stigma toward the COVID-19 patients is mainly manifested in their avoiding motivation, policymakers and health workers should strive to ensure that reasonable social distancing can be maintained in public places to eliminate the uncertain risk of the disease and thereby reduce the stigma.

De-identified data and code of the present study are available upon request to the corresponding author.

The studies involving human participants were reviewed and approved by the Ethics Committee of the Institute of Psychology, Chinese Academy of Sciences. The participants provided their written informed consent to participate in this study.

YM conceived the project. YM and JZ designed the project and wrote the manuscript. JZ and LY implemented the experiment and collected the data. JZ pre-processed the data and performed the analyses. All authors discussed the results.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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