Table 4 Stigma domains, key considerations, and question prompts for outbreak responders.

Context

(1) The impact of collective memory on (re)emerging stigma

(2) The stigma associated with not keeping to cultural practices and social norms

(3) Outbreak responses can reduce disease concealability

(4) Religious, political, and historical associations can result in moralisation of particular modes of disease transmission

· Which previous outbreaks or events may affect how the community perceive this outbreak?

· What cultural practices and social norms may be disrupted by outbreak containment efforts? Is there a way to minimise this disruption?

· Can outbreak responses be adjusted to improve confidentiality while still reducing the spread of the disease?

· Have the social practices associated with the mode of transmission previously had moral judgement associated with them?

Thoughts

(5) Those who cannot adhere to prevention measures may unjustly be marked as irresponsible

(6) Hygiene-dominant public health messages can result in beliefs that people who get the disease are ‘dirty’, exacerbating social divides

(7) There is not a linear relationship between knowledge of a disease and amount of stigma

(8) People may use a disease as a reason to further stigmatise high risk groups they morally disagree with (moral-piggybacking)

· Are policies appropriate for all socio-economic levels of society?

· What contextual factors may be contributing to emergent beliefs? Is community listening occurring alongside education?

· What information sources are trusted by the community?

· Are disease prevention messages appropriate for all socio-economic levels of society?

· Are any communities/groups likely to experience compound stigma due to the risk communication messages? Can the messaging be redesigned to reduce this stigma? What can be done to support these groups?

Emotions

(9) Emotional responses (such as fear) can be triggered by automatic negative reactions and therefore difficult to eliminate completely

(10) Appealing to fear for the purpose of enhancing adherence to preventive measures may have undesired consequences

· Is the fear associated with the disease proportionate to risk?

· Is public health messaging purposefully appealing to fear? Could this impair rationality or foster misinformation?

· What additional risk-mitigation actionable steps can be recommended alongside messages that may induce fear?

· Does the disease trigger a ‘disgust’ response? How can this be reframed in messaging?

Manifestations

(11) Stigmatisation in outbreak contexts extends beyond discrimination against infected individuals

(12) Stigma may be enacted directly from contextual factors, without negative beliefs or emotions, due to unconscious bias and social norms

· Which groups may be stigmatised in association with the outbreak? Are families, healthcare workers, and associated communities at risk of stigmatisation too?

· How does stigma typically manifest in the affected community?

· What measures can be introduced to minimise exclusion of recovered persons?

· How might unconscious bias, including language choice, be contributing to stigma?

Impact

(13) Self-stigma may have psychosocial consequences that outlast the disease

(14) Stigma manifestations can have a lasting impact on trust in institutions

(15) Stigma may worsen outbreak control

· Are psychosocial support mechanisms available? Do they directly account for and aim to address stigma for all affected groups in addition to survivors (e.g., family members and response workers)?

· How could the trustworthiness of institutions be enhanced, demonstrated, and maintained?

· Is stigma likely to be reducing healthcare seeking behaviour? Who are the alternative informal carers in the setting and how can they be better equipped?