Stigma, Trust, and procedural integrity: Covid-19 testing in Malawi

An emerging consensus in public health views testing for Covid-19 as key to managing the pandemic. It is often assumed that citizens have a strong desire to know their Covid-19 status, and will therefore take advantage of testing opportunities. This may not be the case in all contexts, however, especially those where citizens perceive stigma associated with the Covid-19, have low trust in health institutions, and doubt the procedural integrity of the testing process. This article explores willingness to receive a free Covid-19 test via a vignette experiment (conjoint design) embedded in a phone survey conducted in Malawi in May 2020. The experiment varied test provider (public clinic versus international health organization), proximity to illness, and reassurance of confidentiality. We find that Malawians expect higher uptake of testing in their community when the international health organization offered the test rather than a public clinic, an effect we attribute to higher trust in the organization and/or perceptions of greater capacity to ensure procedural integrity. The confidentiality reassurance did not substantially alter beliefs about the privacy of results, but did increase doubts about the willingness of community members to get tested in a public health clinic. Our findings suggest the importance of considering the demand side of testing in addition to well-known challenges of supply.