Stigma among primary care providers: characterizing attitudes and behaviors in the care of people with chronic hepatitis in the Philippines

Abstract

Background

Stigma is a key barrier to compassionate primary health care delivery and people-centered care (PCC), but is understudied among primary care providers (PCPs). Hepatitis B and C have a significant burden of disease in the Philippines, where there is limited awareness of and access to screening and treatment. Patient-reported stigma has been identified as a significant barrier to hepatitis care in the Philippines, but PCP stigma-related attitudes and behaviors have not been explored in this context.

Methods

In this study, we assessed primary PCP-reported stigma-related attitudes and behaviors toward patients with hepatitis B and C. We surveyed primary PCPs in Tarlac, Philippines working within a network of healthcare facilities that have been part of an initiative to decentralize hepatitis care to the primary care level and prioritize PCC.

Results

We found that PCPs’ self-reported attitudes toward patients with hepatitis B and C reflect a strong sense of responsibility to provide care, and comfort with sensitive history-taking, but also pervasive attitudes of pity and blame. PCPs’ self-reported behaviors showed commitment to providing equal care, but variation in infection control practices suggesting misconceptions about transmission risk.

Conclusions

Our results provide essential insight into PCPs’ stigma-related attitudes and behaviors that will serve as a baseline for future comparison with patient-reported experiences. These findings underscore the critical role of primary care in addressing stigma and improving hepatitis care in the Philippines, highlighting the importance of training, resource allocation, and people-centered care strategies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-025-02915-w.

Background

Primary health care (PHC) has been well-established as a cornerstone approach for achieving universal health coverage (UHC) [1, 2]. People-centered care (PCC) has emerged alongside PHC as a necessary component to ensure access to quality care for all. PCC is a multi-faceted approach that respects the social context – families, communities, populations – in which individuals access care [3–5]. It also orients individuals’ needs, values, and preferences over their life course at the forefront of their care. A key component of this holistic approach includes fostering a compassionate and supportive care environment between care providers and patients that functions in tandem with developing a strong primary care workforce [4, 6]. Ultimately, the goal of PCC is to achieve the right care, at the right time, in the right place, with the right team, in the right way. For this reason, people-centered models of care can support primary health care-oriented health system design and improvement, and the goal of UHC.

With compassion as a driving force of providing primary healthcare the “right way,” its absence in healthcare can lead to discrimination and poor experiences of care as a result of stigma [7]. Compassion has a myriad of positive effects not only on the physical and mental well-being of patients and their providers, but also in driving health services design and delivery that is aligned with community needs [7, 8]. In 2024, the WHO released a report on compassion and PHC, citing that “social, cultural or economic distance from those suffering can lead to misunderstanding, bias and stigmatization” [8]. While this distance, and the resulting stigmatization, are key barriers to compassionate primary healthcare, there is limited literature regarding stigma in the PHC context, especially among primary care providers (PCPs) [9–11].

Here, we use a disease-specific example to study PCPs’ stigma-related attitudes and behaviors in the care of patients with hepatitis B (HBV) and C (HCV) in the Philippines. We define stigma in this context to describe negative stereotypes or social disapproval directed toward individuals based on their hepatitis status. HBV and HCV are endemic to the Philippines and contribute to avoidable mortality [12, 13]. The viruses can be transmitted via blood, sexual contact, unsterile needles from intravenous drug use, tattoo, or piercing practices, accidental needlestick injuries (especially in healthcare settings), unsterile medical or dental procedures, and perinatally. There remain many barriers to accessing and delivering hepatitis screening and treatment in the Philippines, with a recent patient journey mapping study identifying a variety of barriers across the course of patients’ journeys in seeking care, including fear of stigma and discrimination [14].

In this study, we surveyed the attitudes and behaviors of PCPs working at primary care sites under an initiative to decentralize hepatitis care to the primary care level in Tarlac, Philippines. Tarlac has been a focus region of recent governmental efforts to decentralize hepatitis care to the primary care level, aiming to address barriers and provide person-centered care. Our study captured PCPs who care for patients with HBV and HCV, most of whom have undergone training on PCC for people with hepatitis as a part of this initiative [15].

Methods

This study utilized a quantitative 40-question anonymous survey administered online via RedCap. The survey had three parts: (1) attitudes related to hepatitis care provision (9 questions) (2), behaviors related to hepatitis care provision (8 questions), and (3) demographic information (8 questions). Questions in parts 1 and 2 were primarily composed of 5-pt Likert scale (strongly disagree, disagree, uncertain, agree, strongly agree) questions asking respondents to indicate the extent to which they agreed with the listed statements.

Since there are no previously-validated tools to assess hepatitis-related stigma in the Philippine context, parts 1 and 2 questions were developed based on prior studies assessing provider attitudes and behaviors related to hepatitis and HIV care provision from other contexts. Specifically, questions asking about comfort with, and responsibility for, sexual history-taking were adapted from the Healthcare Provider HIV/AIDS Stigma Scale [16]. All other attitude and behavior questions were adapted from Richmond et al. study of health professionals’ attitudes toward patients with hepatitis C [17, 18]. See Supplement for survey questions (S1). To evaluate provider attitudes surrounding feelings of pity, shame or judgment in the care of patients with hepatitis, PCPs were asked to what extent they agree that people who inject drugs deserve to be infected with HBV/HCV, that they feel sorry for people who contracted HBV/HCV, and that they feel judged or shamed by others for providing care and treatment to patients with HBV/HCV. We also assessed provider comfort with taking a patient history about sensitive topics related to hepatitis transmission (substance use, sex) and their sense of responsibility for the care of patients with HBV/HCV. To evaluate provider behaviors, we asked about providing the same standard of care, avoiding transmission of HBV/HCV from their patients to others, and following infection control guidelines.

All questions were reviewed and edited by Filipino researchers familiar with care provision in the Philippines to ensure they were context-appropriate. Part 3 questions asked for standard demographic information, including context of caring for patients with hepatitis, estimated number of patients with hepatitis seen monthly, and whether they have received in-person or telementoring training in the past 12 months.

The study was approved by the Mass General Brigham Institutional Review Board and the University of the Philippines Manila Research Ethics Board. Survey questions were translated from English to Tagalog and respondents were able to select their preferred language in RedCap before completing the survey. All patients consented to the survey by providing an electronic signature at the start of the survey. Survey respondents received 500 PHP (approximately 8.5 USD) via G-Cash (a local Filipino mobile payment platform) for the completion of the survey. The survey was administered during telementoring sessions with providers and was otherwise circulated in informal networks (Messenger, Facebook, WhatsApp) amongst providers working at seven care facilities (TPH Cares, Concepcion Tambayan, Concepcion RHU 1, Concepcion RHU 2, Concepcion RHU 3, Moncada RHU 1, Moncada RHU 2) in Tarlac, Philippines between August-November 2024. Based on estimates of the number of providers involved in hepatitis care decentralization across these facilities, the target number of respondents was 30–40 PCPs. Partial survey responses were not included. “Agree/strongly agree” and “disagree/strongly disagree” Likert responses were combined to represent “Agree” and “Disagree” for the purposes of data analysis.

Results

A total of 30 PCPs completed the entire survey (Table 1). All seven Tarlac healthcare facilities were represented. The majority of respondents were female (83%), nurses (40%), and had received training/telementoring in the past 12 months (80%). The average age of respondents was 42.

Table 1.

Demographic characteristics of respondents

Characteristic
Mean Age	42 (SD = 10.8)
Gender Identity (n, %)
Female/Woman	25 (83)
Male/Man	5 (17)
Occupation (n, %)
Physician	4 (13)
Physician assistant	0 (0)
Pharmacist	0 (0)
Nurse	12 (40)
Medical technician	3 (10)
Nurse assistant	2 (7)
Midwife	6 (20)
Barangay/Community health worker	2 (7)
Other healthcare worker	1 (3)
Average Years in Current Occupation	12.4
Average Years at Current Facility	9.4
Average Number of People Living with Hepatitis Cared for Per Month	9
Received In-Person Training or Telementoring Within Past 12 Months (n, %)	24 (80)

Provider attitudes related to people living with hepatitis B/C

When asked if they feel sorry for individuals who have contracted HBV/HCV, 26% (8/30) indicated they did not (Fig. 1). Almost a third of respondents (30%, 9/30) agreed with the statement that people who inject drugs deserve to be infected with hepatitis B or C (Fig. 1). Similarly, 26% (8/30) did not feel sympathy for individuals who have contracted HBV/HCV (Fig. 1). Judgment or shame from others for providing care and treatment to patients with hepatitis B or C was reported by 23% (7/30) of respondents (Fig. 1). A majority of providers expressed comfort with discussing sensitive topics with their patients. Talking about sexual practices was comfortable for 70% (21/30) of respondents, while 73% (22/30) felt at ease discussing injection drug use practices (Fig. 1).

Fig. 1.

Provider Attitudes Related to Patients with Hepatitis B/C. Providers were asked to the extent to which they agree with statements across domains of feeling pity, shame, or judgment, comfort with sensitive history-taking, feeling responsibility to provide care to patients with hepatitis, and workplace discrimination. Green colors indicate less stigmatizing attitudes while red/orange colors indicate more stigmatizing attitudes

Most providers recognized their role in patient education and treatment. Counseling patients about safe sexual practices was seen as a responsibility by 77% (23/30) of respondents (Fig. 1). Willingness to treat people with HBV/HCV was reported by 93% (28/30), and nearly all providers (97%, 29/30) believed their profession should play a central role in the treatment of hepatitis B and C (Fig. 1). Most respondents (80%, 24/30) also indicated that they would get in trouble at work if they discriminated against a person living with hepatitis B or C (Fig. 1).

Provider behaviors related to people living with hepatitis B/C

The majority of providers (92%, 22/24) indicated that they deliver the same standard of care to patients with HBV/HCV as they do for others (Fig. 2). A substantial portion (69%, 20/29) agreed that identifying patients with hepatitis B or C is necessary to protect the care team from transmission (Fig. 2). While 38% (11/29) believed that patients with hepatitis B or C should be given the last appointment of the day to prevent transmission to others, 62% (18/29) disagreed with this practice (Fig. 2). Concerns about transmission through contact with clothing, bedding, or belongings of affected patients were expressed by 21% (6/29) of respondents (Fig. 2).

Fig. 2.

Provider Behaviors Related to Patients with Hepatitis B/C. Providers were asked to the extent to which they agree with statements across the standard of care provided to patients with HBV/HCV, avoiding transmission, and following infection control guidelines. Green colors indicate less stigmatizing attitudes while red/orange colors indicate more stigmatizing attitudes

A significant proportion (78%, 21/27) agreed that all patients should be tested for HBV/HCV before undergoing invasive procedures (Fig. 2). The preference for using two pairs of gloves when treating a bleeding person with HBV/HCV was reported by 73% (19/26) of providers (Fig. 2). Additionally, 81% (21/26) indicated that they frequently implement extra infection control precautions when treating these patients (Fig. 2). Confidence in infection control guidelines as a protective measure against HBV/HCV transmission at work was shared by 92% (23/25) of respondents (Fig. 2).

Discussion

Attitudes

PCPs indicated strong attitudes of responsibility for hepatitis care. However, responses were notably more mixed around counseling and history-taking for intravenous drug use and sexual practices. Notably, 20% were uncertain about history-taking for injection drug use and 20% were uncomfortable counseling on safe sex. There is a potential underlying training gap needed for PCPs to feel comfortable with these sensitive and highly stigmatized subject areas that are central to preventing transmission of HBV/HCV. While most respondents indicated an absence of directed stigmatizing actions toward patients with hepatitis, a significant minority reported internalized stigmatizing attitudes like pity and blame. These may be linked to prevailing attitudes toward people who use drugs in the Philippines, including that drug addiction is a sign of moral or character weakness or lack of will to stop [19, 20].

Our findings are consistent with the Filipino context and limited studies in the Southeast Asian region. One study found that Vietnamese physicians caring for female sex workers reported less thorough sexual history-taking than physicians in the United States, United Kingdom, and Australia due to patient and physician discomfort with the subject [21]. Additionally, the historical presence of severely punitive drug laws, judicial and extrajudicial killing for drug use in the Philippines may contribute to the stigmatization of intravenous drug use and is likely a forcible contributor to fear and discomfort around discussing the topic in the clinical setting [22, 23]. A Filipino household survey on drug abuse found that health problems were the most cited negative effect of drug use, with over a third of respondents viewing family and police as most helpful to drug users compared to only 19.6% indicating health centers [24]. Given the prevailing pressures around judgment affecting care for hepatitis patients, it will be important to engage PCPs in continuing education about how co-stigmatizing risk factors, like sex and drug use, affect care provision.

Behaviors

Almost all PCPs indicated they provide the same standard of care to patients with and without HBV/HCV, suggesting a reassuring alignment between PCP beliefs and practice. Responses were more mixed when providers were asked about behaviors that effectively “single out” patients with HBV/HCV, including identifying them to protect the care team and giving them the last appointment of the day to prevent transmission to other patients. While intended to prevent transmission, these practices exemplify structural stigma by systematically marginalizing patients through the denial of privacy and reduced accessibility within the healthcare system. In the health setting, structural stigma operates through institutional policies that reinforce exclusion and inequitable healthcare access, shaping not only patient experiences but also provider attitudes and behaviors [25]. Hospital policies and practices like these have historically singled out HBV and HCV (along with HIV), potentially overestimating transmission risks and being driven more by stigma-related fears and anxieties than by evidence-based assessments. This reflects broader societal conditions and institutional norms that constrain opportunities, resources, and the well-being of stigmatized individuals. Similarly, a significant minority of PCPs worried about HBV/HCV transmission through touching patient belongings. Despite most surveyed PCPs having received training on the prevention, and transmission of HBV/HCV, this finding reflects a persistent knowledge and/or practice gap that should be a focus of future training efforts.

The majority of respondents agreed with testing for HBV/HCV before invasive procedures, double-gloving when handling blood, and using additional infection control precautions. WHO recommendations for preventing HBV/HCV infection include hand hygiene, safe handling of waste/sharps, equipment cleaning, testing donated blood, improving access to safe blood, and health personnel training, but do not indicate specific protocols for these guidelines [26]. Basic infection prevention and control guidelines are set by the Department of Health in the Philippines, serving as a foundation for hospital-specific protocols [27]. PCPs can decide the extent of personal protective equipment and practices they use, introducing variation in practice that may not be evidence-based. Current evidence is insufficient to suggest double gloving significantly prevents transmission of blood-borne viruses [28]. Extra prevention efforts may reflect an effort by PCPs to protect themselves, suggesting a fear of HBV/HCV that may consciously or subconsciously drive stigmatizing practices. Future studies will be needed to elucidate the motivations behind these personal protective choices.

Stigma as a systems-level barrier to PCC

Stigma has commonly been studied from a disease-specific lens but can, and should, be studied as a systems-level barrier of compassionate care [29, 30]. PCPs care for patients across multiple communicable (HIV, hepatitis, respiratory viral illness etc.) and non-communicable (obesity, diabetes, smoking-related lung diseases, etc.) disease processes that may be afflicted by stigmatizing attitudes and behaviors leading to negative health outcomes [11, 30]. Additionally, PCPs face multiple pressures including increased provider workload, inadequate provider compensation, and worker shortages, potentially contributing to job stress and burnout which is common among PCPs in LMICs [31, 32]. The effect of these burdens on worsening stigmatizing attitudes and behaviors should be further investigated. Future studies will be necessary to explore how programs can build supportive environments and clinical mentorship that mitigate added job stress from care delivery interventions.

Limitations

Our study has several limitations. First, the study is likely subject to interviewer and conformity bias as survey administration occurred during or directly following PCC training sessions with the research team. This led to our survey primarily capturing trained PCPs and may have led them to answer more favorably. Second, our sample of PCPs is small and though capturing healthcare facilities across Tarlac, likely limited in generalizability to other providers across the Philippines. Our sample of surveyed PCPs is also mostly concordant with data on the composition of the primary care workforce in the Philippines and internationally. Of note, female nurses were most represented in our sample, and BHWs were underrepresented compared to national estimates [33]. We are also capturing a small sample of providers who haven’t received PCC training. This untrained population of PCPs may be an important future comparator group to evaluate stigma. Additionally, this study adapted survey questions validated in other contexts. There remains a need for validated context-appropriate tools to study hepatitis-related stigma in the Philippines and the broader Southeast Asian region where the prevalence of chronic viral hepatitis is high. Future development of these tools should prioritize the lens of primary care providers, who remain the foundation of hepatitis care delivery in the Philippines.

Conclusions

This survey of Filipino PCPs is the first, to our knowledge, to survey their attitudes and behaviors toward patients with HBV/HCV. PCP attitudes reflect a strong commitment to equal, non-discriminatory care for patients. However, a significant minority hold stigmatizing attitudes that may reflect the history of criminalization of drug use in the Philippines. Though these laws have since changed, they leave a legacy that warrants future study, especially in the primary care context. PCPs in the Philippines also practice infection control behaviors that may single out HBV/HCV patients, reflecting structural stigma and resulting in non-evidence-based choices around personal protection in the healthcare setting. This variation in practice may reflect a need for further standardization of infection control practices across institutions and especially for stigmatized diseases like hepatitis. Overall, our study provides initial insight into stigma at the PHC level in the Philippines. Promoting compassionate PHC by addressing stigma at a systemic level is essential for achieving UHC, ensuring that all patients– regardless of their condition– receive equitable, evidence-based, and non-discriminatory care.

Abbreviations

BHWs

Barangay health workers

HBV

Hepatitis B virus

HCV

Hepatitis C virus

PCPs

Primary care providers

LMICs

Low- and middle-income countries

Authors’ contributions

NHK analyzed the survey data with review from MG, JM, and BH. NHK wrote the initial draft of the manuscript, which was read, edited and approved by JM, MG, MF, TM, JA, JB, DRS, JPO, TMP, DBD, and BH.

Funding

This work is part of a project funded by Gilead Sciences, Inc. Gilead Sciences and its representatives had no input or role in the study design, data collection, data analysis or interpretation, writing, or decision to publish.

Data availability

The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The study was approved by the Mass General Brigham Institutional Review Board (Protocol Number 2023P003011) and the University of the Philippines Manila Research Ethics Board (UPMREB 2023-0751-0). Informed consent was obtained and documented from all study participants. This research was conducted in accordance with the ethical principles of the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.