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.

The ABCs of Covid-19 prevention in Malawi: Authority, benefits, and costs of compliance.

A wide array of authorities-from religious leaders to government ministers-call upon citizens to take preventative measures against Covid-19. Which authorities can most effectively gain public compliance, and which measures will the public take up? Moreover, do people comply with authorities out of respect for their legitimacy, due to their expertise, or for fear of sanctioning? Answers to these questions are important for development practitioners, who need to understand how different partnerships might affect health behavior, and for scholars interested in understanding authority, legitimacy, and compliance. We explore these questions using a conjoint experiment embedded in a telephone survey of 641 Malawians. Individuals in our sample are more likely to say that they will comply with precautionary measures when the costs are low and expected benefits are high. Respondents view both traditional authorities and hospital heads as legitimately issuing directives and having the ability to monitor and sanction non-compliance, but appear to comply more with hospital heads and to do so out of respect for their expertise. These results emphasize how who issues directives affects whether individuals comply and provides insights as to why they do so. The findings also reflect individuals' cost-benefit calculations when considering precautionary measures, highlighting the importance of steps that can reduce costs (e.g., food security or income measures) or accurately reflect risks (e.g., information signaling the prevalence of Covid-19). The study not only helps to address the Coronavirus crisis but also has important implications for broader questions of authority and compliance.