BACKGROUND: Enacted healthcare stigma has a complex and severe impact on physical and mental health of men who have sex with men (MSM). However, most studies measured enacted healthcare stigma using self-reported measures that may have been limited by social desirability bias. This study applies standard patient (SP) approach to covertly observe provider behaviors to assess the impact of stigma against MSM in terms of HIV, sexual or its intersection on the quality of syphilis care in healthcare settings in China.
METHODS: Trained SPs conducted unannounced visits with consenting providers. We randomly varied the HIV status and sexual orientation of each presented case to quantify stigma as differences in care across case scenarios. Care quality was assessed in 4 domains including adherence to clinical guidelines, diagnostic testing, patient-centred care, and visit duration. Item response theory models were used to calculate weighted indices for continuous care scores. Fixed effect linear and logistic regressions were used to assess differences in care quality across scenarios.
RESULTS: SPs conducted 123 clinic visits with 41 providers across 17 clinics. Scores for clinical guideline adherence were lower in all stigmatized scenarios as compared to the referent condition of an HIV negative straight man, though only the estimate for HIV- MSM was statistically significant (ß, - 0.61, 95% CI, -1.18, -0.04). Appropriate diagnostic testing was less likely when SPs presented as HIV positive irrespective of sexual orientation (HIV+ straight: OR, 0.35, 95% CI 0.00-3.35; HIV+ MSM: OR 0.08, 95%CI 0.01- 0.77)). We did not observe differences in patient-centred care scores. No adverse events or overtly hostile provider behaviours were reported.
CONCLUSIONS: Our novel incognito patient approach documented notable declines in healthcare quality among cases presenting as HIV positive, MSM, or both. SPs presenting with stigmatized identities experienced less thorough clinical assessments or diagnostic testing, suggesting that stigma most often manifests in the form of less attentive or even neglectful care. Our findings provide key insights to understand how stigma in marginalized populations can impair health even in the absence of grossly negligent. Results also informed the design of a pilot stigma reduction for providers, results of which are forthcoming.