Beyond diagnosis in primary health care social punishment and treatment exclusion among people living with stigmatized conditions and survivors of sexual violence in fragile health systems
1
Public Health, Modibbo Adama University, Yola, Yola, Nigeria
2
Sociology and Anthropology, Adamawa State University, Mubi, Mubi, Nigeria
Popul. Med. 2026;8(Supplement Supplement 1):
ABSTRACT
INTRODUCTION:
In fragile health systems shaped by conflict, poverty, and weak governance, access to care does not end at diagnosis. For people living with stigmatized diseases and survivors of sexual violence, social punishment manifested through blame, exclusion, and moral judgement frequently undermines treatment initiation, follow-up, and disclosure within primary health care settings. Despite widespread recognition of stigma, its operational effects inside frontline health facilities remain poorly documented. This study examined how social punishment influences treatment access and continuity of care in fragile primary health care systems.
METHODS:
A mixed-methods study was conducted between february and october 2025 across 30 primary health care centers in conflict-affected and post-conflict regions in Adamawa State, Nigeria. Quantitative data were extracted from 912 patient records involving stigmatized conditions and sexual violence presentations. Qualitative data were collected through in-depth interviews with 56 patients and 48 frontline health workers. Key variables included treatment delay, referral completion, follow-up attendance, and provider attitudes. Quantitative data were analysed using descriptive statistics and multivariable logistic regression, while qualitative data were analysed thematically.
RESULTS:
Treatment delays exceeding 72 hours were observed in 46.8% of cases, largely driven by fear of social exposure and judgement. Loss to follow-up within 30 days occurred in 39.5% of patients. Negative provider attitudes were reported by 33.2% of respondents and were significantly associated with treatment discontinuation (adjusted odds ratio 2.18). Qualitative findings revealed social punishment through gossip, moral labeling, and breaches of confidentiality, reinforcing silence, avoidance of care, and disengagement despite clinical need.
CONCLUSIONS:
Social punishment within primary health care settings represents a critical but underrecognized barrier to equitable treatment in fragile health systems. Addressing this challenge requires stigma-responsive service design, provider accountability mechanisms, survivor-centered protocols, and integration of social protection approaches to advance inclusive, sustainable, and rights-based access to care beyond diagnosis.
In fragile health systems shaped by conflict, poverty, and weak governance, access to care does not end at diagnosis. For people living with stigmatized diseases and survivors of sexual violence, social punishment manifested through blame, exclusion, and moral judgement frequently undermines treatment initiation, follow-up, and disclosure within primary health care settings. Despite widespread recognition of stigma, its operational effects inside frontline health facilities remain poorly documented. This study examined how social punishment influences treatment access and continuity of care in fragile primary health care systems.
METHODS:
A mixed-methods study was conducted between february and october 2025 across 30 primary health care centers in conflict-affected and post-conflict regions in Adamawa State, Nigeria. Quantitative data were extracted from 912 patient records involving stigmatized conditions and sexual violence presentations. Qualitative data were collected through in-depth interviews with 56 patients and 48 frontline health workers. Key variables included treatment delay, referral completion, follow-up attendance, and provider attitudes. Quantitative data were analysed using descriptive statistics and multivariable logistic regression, while qualitative data were analysed thematically.
RESULTS:
Treatment delays exceeding 72 hours were observed in 46.8% of cases, largely driven by fear of social exposure and judgement. Loss to follow-up within 30 days occurred in 39.5% of patients. Negative provider attitudes were reported by 33.2% of respondents and were significantly associated with treatment discontinuation (adjusted odds ratio 2.18). Qualitative findings revealed social punishment through gossip, moral labeling, and breaches of confidentiality, reinforcing silence, avoidance of care, and disengagement despite clinical need.
CONCLUSIONS:
Social punishment within primary health care settings represents a critical but underrecognized barrier to equitable treatment in fragile health systems. Addressing this challenge requires stigma-responsive service design, provider accountability mechanisms, survivor-centered protocols, and integration of social protection approaches to advance inclusive, sustainable, and rights-based access to care beyond diagnosis.
| eISSN: | 2654-1459 |
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