Health Facility Staff: Observed Enacted Stigma (Tier 1 for High HIV Prevalence and Tier 2 for Low HIV or Concentrated Prevalence Settings)

Export Indicator

Percent of health facility staff who have observed unjust treatment of patients living with HIV in their facility.
What it measures

It measures health facility staff’s observation of enacted stigma towards a patient living with HIV in a healthcare setting.


In addition to measuring programmatically actionable drivers of stigma and discrimination (Indicators 1.1, 1.2 and 1.3), it is important to capture the manifestations of HIV stigma and discrimination from the health facility staff’s perspectives. Measuring enacted stigma by directly asking health facility staff if they themselves have engaged in a specific stigmatizing behavior does not work well because most staff know that this type of behavior is generally not socially acceptable and are therefore likely to provide the socially desirable response, whether or not they have engaged in the behavior. However, asking facility staff about what they have observed provides a more accurate measure, because staff are more comfortable reporting what they see happening (including what they themselves may have done).

Observed stigma is also an important measure because individuals are often influenced by what they see is happening around them. For example, observing stigma in a health facility may lead health facility staff to avoid HIV testing themselves (or if found positive, to seek treatment), for fear that their colleagues will treat them the same way they observe their colleagues behaving towards HIV positive patients. For example, further analysis of the data collected in the field-tests demonstrated that 65% of health facility staff observed stigma towards HIV-positive patients in their health facility in the past 12 months. Those who observed stigma were 1.93(CI: 1.54-2.41) times more likely to report hesitancy among staff to get tested for HIV themselves. Perceptions of stigma can also influence discriminatory behaviors because if staff perceive a stigmatizing health facility environment is acceptable or the norm, this shapes the way they themselves interact with and offer services to HIV positive patients.


Among health facility who reported observing a patient living in their facility within the past 12 months, number of health facility staff who reported yes to either question.


Number of all health facility staff who reported observing a patient living in their facility within the past 12 months


Numerator / Denominator

Method of measurement

Any type of facility-based surveys, e.g. Service Provision Assessment or Quality Assurance Surveys

This indicator is constructed from the responses to the following set of prompted questions:

  • In the past 12 months, have you observed the following in your healthcare facility?

1. Healthcare workers unwilling to care for a patient living with or thought to be living with HIV

2. Healthcare workers providing poorer quality of care to a patient living with or thought to be living with HIV

Measurement frequency
  • Biennial
  • Every 3-5 years
Strengths and weaknesses

The question measures quality of care provided in a healthcare facility, as observed by health facility staff. Observations effect perceptions, which in turn can affect individual attitudes and lead to stigmatizing behaviors. The second question asks health facility staff for their perceptions of care offered to HIV positive patients compared to care offered HIV negative patients, and such perceptions may include unauthorized HIV status disclosure, making a patient wait longer than others to be seen, making care conditional, gossip about a patient’s status, inappropriate transfer or referral of a patient living with HIV, or speaking badly to a patient living with HIV, among other behaviors. The definition of differential quality of care is respondent-driven. What is important here is not the exact definition of quality of care, but that the respondent perceives that different levels of care (lower levels of care) are being offered to a patient living with HIV over a patient who is not living with HIV.

There is an important distinction to note when analyzing the results of this indicator in low HIV prevalence settings compared to high prevalence settings. In low prevalence settings the “opportunity” to observe stigmatizing behavior may be low because there are few patients living with HIV in healthcare settings, making this a less reliable indicator of enacted stigma in low prevalence settings. Therefore it is classified as a Tier 2 indicator in low prevalence and concentrated epidemic settings. In high prevalence settings, this indicator is important to ask because it provides a measure of stigmatizing behaviors occurring in a healthcare setting, and is recommended as a Tier 1 indicator.

However, because this is a measure of what the respondent observes happening around them, this question may lead to an underestimate of the prevalence of enacted stigma because not all health facility staff may have the opportunity to observe the actions of their peers. The measure may also be subject to social desirability if respondents are hesitant to report observations of stigmatizing behaviors in their facilities.

Further information

For further information on the methodology and survey instruments, visit

Jain, A., and L. Nyblade. 2012. “Scaling Up Policies, Interventions, and Measurement for Stigma-Free HIV Prevention, Care, and Treatment Services.” Working Paper #3. Washington, DC: Futures Group, Health Policy Project.

Nyblade, L., Stangl, A., Weiss, E., & Ashburn, K. (2009). Combating HIV stigma in health care settings: what works?. Journal of the International AIDS Society,12(1), 15.

Nyblade, L. Jain, A. et al. Journal of the International AIDS Society 2013, 16(Suppl 2):18718 |