Discrimination in healthcare: A field experiment with Pakistan’s Transgender community

Last registered on August 30, 2021

Pre-Trial

Trial Information

General Information

Title
Discrimination in healthcare: A field experiment with Pakistan’s Transgender community
RCT ID
AEARCTR-0008158
Initial registration date
August 27, 2021
Last updated
August 30, 2021, 5:19 PM EDT

Locations

Region

Primary Investigator

Affiliation
University of East Anglia

Other Primary Investigator(s)

PI Affiliation
Sewanee: The University of the South
PI Affiliation
University of East Anglia

Additional Trial Information

Status
Completed
Start date
2017-06-01
End date
2019-01-01
Secondary IDs
Prior work
This trial is based on or builds upon one or more prior RCTs.
Abstract
Transgender individuals face high levels of discrimination including in healthcare. Lack of adequate legal protections can exacerbate the problem in developing countries. At the same time, low-cost private clinics can mitigate discriminatory practices due to the costs of discrimination. We conduct an audit study with male and transgender standardized patients visiting private health care clinics in Pakistan and find evidence of discrimination in non-obvious domains. Physicians differentiate between patients in culturally sensitive areas: they substitute in procedures that require less physical contact; are less likely to engage in verbal examination (i.e. avoid uncomfortable questions); and are subsequently more likely to recommend placebo or insufficient treatments for transgender patients, relative to the male benchmark. This ultimately yields lower quality of care for transgender patients.
External Link(s)

Registration Citation

Citation
Ahmad, Husnain, Sheheryar Banuri and Farasat Bokhari. 2021. "Discrimination in healthcare: A field experiment with Pakistan’s Transgender community." AEA RCT Registry. August 30. https://doi.org/10.1257/rct.8158-1.0
Experimental Details

Interventions

Intervention(s)
We conduct an audit study, using professional actors hired through a local acting troupe. We selected 4 actors for the study: 2 male and 2 transgender actors. Our actors were given a consistent background, symptoms and opening script, adapted from Das et al. (2016). Our standardized patients reported symptoms that were consistent with asthma. Each of the private health clinics were visited twice, at least two weeks apart, once by a male actor and once by a transgender actor (order randomly determined). We kept the day and time across each wave constant for every clinic to maximize the probability of facing the same healthcare provider. We randomized the gender of the patient visiting each clinic in the first wave. The minimum two-week gap was implemented to ensure there was limited contamination across the two visits.

* Note that this study is being registered post-completion. The study was completed in 2018.
Intervention Start Date
2018-02-01
Intervention End Date
2018-08-31

Primary Outcomes

Primary Outcomes (end points)
We utilise the British guidelines on the management of asthma (SIGN 2019) to pre-specify our diagnostic variables of interest:

Patient History
1. Previous breathing problems
2. History of asthma (family)
3. Chest tightness
4. Episodic nature of cough
5. Exposure to allergens
6. Previous medication

Physical Examination
7. Recorded observation of wheezing
8. Pulse
9. Temperature check
10. Blood pressure

Miscellaneous
11. Ask for follow-up visits
12. Inquire about past visits to other doctors for same ailment
13. Recommend advanced tests
14. Throat Examination (to rule out other ailments)
15. Prescribe medicines
Primary Outcomes (explanation)

Secondary Outcomes

Secondary Outcomes (end points)
In addition, we also measured the patient’s subjective evaluation of the clinic environment, the time taken at each stage of the process, fees paid, as well as any treatment recommendations (including injections offered, medicines dispensed, and tests prescribed).
Secondary Outcomes (explanation)

Experimental Design

Experimental Design
we conducted a census of private clinics in two low-income neighbourhoods of Pakistan’s second largest city, Lahore: Walton and Dharmapura. Listing was done in two phases: (1) clinics were identified, photographed, and geo-located by local informants. Our research team confirmed these locations, and collected other preliminary information, such as fees and specialties. This process generated a set of 52 clinics, with consultancy fees ranging from PKR 50 to 1,000 (about USD 0.42 to 8.40 at the time of the study), which were then refined to a universe of 36 feasible clinics, after excluding irrelevant clinics (i.e., clinics for mental health, pediatrics, and gynecology). A vast majority of clinics were single provider clinics and while our unit of analysis is the clinic, the study was designed such that all visits were at the same time and day for each clinic, to maximize the likelihood of meeting the same healthcare provider.

We conduct an audit study, using professional actors hired through a local acting troupe. we selected 4 actors for the study: 2 male and 2 transgender actors. Our actors were given a consistent background, symptoms and opening script, adapted from Das et al. (2016). Our standardized patients reported symptoms that were consistent with asthma.

Each of our 36 clinics were visited twice, at least two weeks apart, once by a male actor and once by a transgender actor (order randomly determined). We kept the day and time across each wave constant for every clinic to maximize the probability of facing the same healthcare provider. We randomized the gender of the patient visiting each clinic in the first wave. The minimum two-week gap was implemented to ensure there was limited contamination across the two visits. Recall that patient load at these clinics is large, and given this and the gap in time, we do not anticipate healthcare providers noticing any similarities across visits and found no evidence that they did.

Before each visit, actor health was checked to ensure they did not carry any contaminating physical symptoms. Across all visits, actors were accompanied by a research assistant who would remain outside the clinic. The research assistant formed part of our safety protocol, in addition to collecting data immediately after a completed visit.

Upon completion of all visits, medicines dispensed (typically unmarked) or prescribed were identified and categorised by a team of three pharmacists. Overall, the study took a year to run, with background work, such as focus groups with our panel of doctors, and identifying an appropriate acting troupe beginning in the summer of 2017 and continuing into the fall. Preparations for the visits (auditions, training, piloting and two rounds of listing) took place in the Winter of 2017, with our rounds of data collection taking place in February and March 2018. Finally, medication categorization and data cleaning were completed over the summer of 2018.
Experimental Design Details
Randomization Method
Done in office via computer.
Randomization Unit
Visits
Was the treatment clustered?
Yes

Experiment Characteristics

Sample size: planned number of clusters
36 clinics
Sample size: planned number of observations
72 visits
Sample size (or number of clusters) by treatment arms
36 male visits, 36 transgender visits
Minimum detectable effect size for main outcomes (accounting for sample design and clustering)
NA
IRB

Institutional Review Boards (IRBs)

IRB Name
Lahore University of Management Sciences IRB
IRB Approval Date
2017-05-23
IRB Approval Number
2017-05-23

Post-Trial

Post Trial Information

Study Withdrawal

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Intervention

Is the intervention completed?
No
Data Collection Complete
Data Publication

Data Publication

Is public data available?
No

Program Files

Program Files
Reports, Papers & Other Materials

Relevant Paper(s)

Reports & Other Materials