Framing of sensitive topics in surveys measuring corruption in healthcare

Corruption is a costly, consequential and complex phenomenon facing healthcare systems globally. Measuring the prevalence of petty corruption, such as bribery and informal payments, is challenging due to the hidden and sensitive nature of these exchanges. This paper explores how question framing influences estimates of informal payment prevalence in doctor-patient relationships in two steps. We analyze the responses from the Eurobarometer survey and then conduct a novel survey experiment in Bulgaria and the UK, comparing the effect of 'neutral' (avoiding corruption-related terms) versus 'loaded' (using corruption-related terms) question wording on individuals' reports of experiences with informal payments. Data from the Special Eurobarometer 397 survey (N = 16,051) fielded in 2013 reveals a notable framing effect: respondents report higher prevalence of informal payments when questions are neutrally framed, as opposed to using corruption-related language. This result is confirmed by a survey experiment we ran between November 2023 and February 2024 in with participants in Bulgaria (N = 428) and the UK (N = 424). Respondents exposed to neutral framing were significantly more likely to admit making informal payments compared to those in the loaded treatment group. The difference in response rates between countries suggests that cultural and normative specificities play a role in willingness to report healthcare corruption. Our results underscore the trade-off between using culturally contextualized terminology to elicit responses on sensitive topics and adopting a universal approach that facilitates cross-country comparisons. We further discuss the behavioral and normative implications of using neutral versus corruption-related language when investigating informal practices in healthcare settings.