Trust and the development of health care as a social institution

Health systems are inherently relational and so many of the most critical challenges for health systems are relationship and behaviour problems. Yet the disciplinary perspectives that underlie traditional health policy analysis offer only limited and partial insights into human behaviour and relationships. The health sector, therefore, has much to learn from the wider literature on behaviour and the factors that influence it. A central feature of recent debates, particularly, but not only, in relation to social capital, is trust and its role in facilitating collective action, that is co-operation among people to achieve common goals. The particular significance of trust is that it offers an alternative approach to the economic individualism that has driven public policy analysis in recent decades. This paper considers what the debates on trust have to offer health policy analysis by exploring the meaning, bases and outcomes of trust, and its relevance to health systems. It, first, presents a synthesis of theoretical perspectives on the notion of trust. Second, it argues both that trust underpins the co-operation within health systems that is necessary to health production, and that a trust-based health system can make an important contribution to building value in society. Finally, five conclusions are drawn for an approach to health policy analysis that takes trust seriously.     

Trust but Verify: The Interactive Effects of Trust and Autonomy Preferences on Health Outcomes

Patients’ trust in their physicians improves their health outcomes because of better compliance, more disclosure, stronger placebo effect, and more physicians’ trustworthy behaviors. Patients’ autonomy may also impact on health outcomes and is increasingly being emphasized in health care. However, despite the critical role of trust and autonomy, patients that naïvely trust their physicians may become overly dependent and lack the motivation to participate in medical care. In this article, we argue that increased trust does not necessarily imply decreased autonomy. Furthermore, patients with high levels of trust and autonomy preferences are most likely to have the best health outcomes. We propose a framework for understanding simultaneous trust and autonomy preferences and for recognizing their interactive effects on health outcomes in the dynamic medical encounter. This framework argues that policy makers and health care providers should make efforts to foster not only patients’ trust but also their preferences for autonomy and thus gain the best position for achieving health-related goals.     

Unpacking capacity to utilize research: A tale of the Burkina Faso public health association

One of the most important challenges in addressing global health is for institutions to monitor and use research in policy-making. In low- and middle-income countries (LMICs), civil society organizations such as health professional associations can be key contributors to effective national health systems. However, there is little empirical data on their capacity to use research. This case study was used to gain insight into the factors that affect the knowledge translation performance of health professional associations in LMICs by describing the organizational elements and processes constituting capacity to use research, and examining the potential determinants of this capacity. Case study methodology was chosen for its flexibility to capture the multiple and often tacit processes within organizational routines. The Burkina Faso Public Health Association (ABSP) was studied, using in-depth, semi-structured interviews and key documents review. Five key dimensions that affect the association's capacity to use research to influence health policy emerged: organizational motivation; catalysts; organizational capacity to acquire and organizational capacity to transform research findings; moderating organizational factors. Also examined were the dissemination strategies used by ABSP and its abilities to enhance its capacity through networking, to advocate for more relevant research and to develop its potential role as knowledge broker, as well as limitations due to scarce resources. We conclude that a better understanding of the organizational capacity to use research of health professional associations in LMICs is needed to assess, improve and reinforce such capacity. Increased knowledge translation potential may leverage research resources and promote knowledge-sharing.     

Trust in the context of patient safety problems

PURPOSE: This paper considers some implications of recent developments relating to patient safety for understandings of trust in health care contexts. DESIGN/METHODOLOGY/APPROACH: Conceptual analysis focusing on patients' trust in health care providers and health care providers' trust in patients. FINDINGS: Growing awareness of the scale of the problem of iatrogenic harm has prompted concerns that patients' trust in health care providers may be threatened and/or become inappropriate or dysfunctional. In principle, however, patients' trust may be both well placed and compatible with current understandings of safety problems and efforts to address these. Contemporary understandings of patient safety suggest that, to be deemed trustworthy, health care providers should make vigorous efforts to improve patient safety, be honest about safety issues, enable patients to contribute effectively to their own safety, and provide appropriate care and support after safety incidents. Patients who trust health care providers need not be ignorant of patient safety problems and may be vigilant in the course of their care. Iatrogenic harms do not necessarily reflect breeches of trust (not all such harms are yet preventable), and patients who are harmed might in some circumstances appropriately forgive and resume trusting. Health care providers may feel vulnerable to patients in several respects. From their perspective, trustworthy patients will act competently to optimise the outcomes of their health care efforts and to preserve health care providers' good reputations where those are justified. Providers' trust in patients may strengthen patients' trust in them and facilitate safety improvement work. ORIGINALITY/VALUE: Shows how, in principle, trust can be compatible with current understandings of patient safety issues and may enhance efforts to improve patient safety.     

Earning trust and losing it: adolescents' views on trusting physicians

OBJECTIVE: To explore how adolescents with and without chronic illness perceive patient-physician trust and to identify physician behaviors related to these perceptions that might be modified to promote adolescent health care. METHODS: Fifty-four adolescents recruited from the community (healthy subjects) and from hospital-based clinics (subjects with chronic illnesses) participated in 12 focus groups divided by age (11-14 or 15-19 years old), gender, and health status. Major themes related to preferred physician characteristics and trusting one's doctor were derived through a multistep, team-based qualitative analytic process. RESULTS: Adolescents hold varied perspectives of trust in their physicians. They describe elements of patient-physician trust similarly to the comprehensive model developed with adults, including fidelity, confidentiality, competency, honesty, and a global perspective intersecting several of the more specific domains. However, adolescents differ in the relative importance of these dimensions. Younger adolescents express more concern about confidentiality of their health information, and adolescents with chronic illnesses are more interested in involving parents in their care than are adolescents without chronic illnesses. Examples of specific behaviors to improve trust include asking for adolescent's opinion, keeping private information confidential, not withholding information, and engaging in small talk to show concern. CONCLUSION: Understanding the importance of trust and listening to recommendations about behaviors to improve it, in the words of the adolescents, may help physicians build positive relationships with their adolescent patients.     

Optimising the benefits of community health workers’ unique position between communities and the health sector: A comparative analysis of factors shaping relationships in four countries

Community health workers (CHWs) have a unique position between communities and the health sector. The strength of CHWs’ relationships with both sides influences their motivation and performance. This qualitative comparative study aimed at understanding similarities and differences in how relationships between CHWs, communities and the health sector were shaped in different Sub-Saharan African settings. The study demonstrates a complex interplay of influences on trust and CHWs’ relationships with their communities and actors in the health sector. Mechanisms influencing relationships were feelings of (dis)connectedness, (un)familiarity and serving the same goals, and perceptions of received support, respect, competence, honesty, fairness and recognition. Sometimes, constrained relationships between CHWs and the health sector resulted in weaker relationships between CHWs and communities. The broader context (such as the socio-economic situation) and programme context (related to, for example, task-shifting, volunteering and supervision) in which these mechanisms took place were identified. Policy-makers and programme managers should take into account the broader context and could adjust CHW programmes so that they trigger mechanisms that generate trusting relationships between CHWs, communities and other actors in the health system. This can contribute to enabling CHWs to perform well and responding to the opportunities offered by their unique intermediary position.     

The ethics of health systems research in low- and middle-income countries: A call to action

The increasing conduct of health systems research (HSR) in low- and middle-income countries (LMICs) has not been matched by concurrent work to clarify the field's ethical dimensions. To begin to address this gap, a two-day workshop on the ethics of HSR in LMICs was convened at Johns Hopkins University in June 2013. Participants included health systems researchers, philosophers, lawyers, bioethicists and institutional review board members from Botswana, Uganda, the UK, USA and Zambia. Based on discussions from the workshop, the paper affirms that, while HSR in LMICs raises ethical issues in relation to constructs (i.e. consent, risk, equipoise) common to international clinical research, the nature of the issues that arise often differ between the two fields. Three salient features of HSR and the ethical considerations associated with each of them in LMICs are described to demonstrate this point. Recommendations for institutional review boards’ oversight of HSR in LMICs are presented. Finally, a call is made for further action to develop thinking and guidance around the ethics of HSR in resource-poor settings.     

Evaluating the cost-effectiveness of maternal pertussis immunization in low- and middle-income countries: A review of lessons learnt

This issue of Vaccine is devoted to papers from a research project that developed two types of simulation models, static and dynamic transmission, to evaluate the cost-effectiveness of maternal immunization to prevent pertussis in infants in low- and middle-income countries (LMICs). The research was conducted by a multinational team of investigators and funded by the Bill & Melinda Gates Foundation to gain an understanding of when and where maternal immunization might be a good public health investment for LMICs. Here we review the project’s central lessons for vaccine policy and research. Models require a lot of data. As most LMICs lack good data, the models were built using pertussis disease burden data from Brazil, a middle-income country with three long-established, independent information systems (disease surveillance, hospitalization, and mortality), on the hypothesis that the disease process is similar across countries. Values for key parameters, particularly infant mortality, infant vaccine coverage, and costs of vaccination and treatment, were then varied to represent other LMICs. The results show that coverage levels of infant whole cell pertussis (wP) vaccine are key to the cost-effectiveness of maternal pertussis immunization. In settings where infant wP coverage is below the threshold thought necessary to eliminate pertussis in the population, 90–95%, maternal immunization is cost-effective, even cost-saving. By contrast, it is very expensive in countries capable of maintaining infant vaccination in or above the threshold range. The research also suggests that, while static models may serve to explore an intervention’s cost-effectiveness initially, dynamic transmission models are essential for more accurate estimates. These findings can help guide policies toward maternal pertussis immunization, but also show that developing better data on neonatal pertussis mortality burden and infant vaccine coverage in LMICs, and on the duration of immunity of currently available pertussis vaccines, are key priorities to support better vaccine policy.     

An illustration of whole systems thinking.

The complexity of policy-making in the NHS is such that systemic, holistic thinking is needed if the current government's plans are to be realized. This paper describes systems thinking and illustrates its value in understanding the complexity of the diabetes National Service Framework (NSF); its role in identifying problems and barriers previously not predicted; and in reaching conclusions as to how it should be implemented. The approach adopted makes use of soft systems methodology (SSM) devised by Peter Checkland. This analysis reveals issues relating to human communication, information provision and resource allocation needing to be addressed. From this, desirable and feasible changes are explored as means of achieving a more effective NSF, examining possible changes from technical, organizational, economic and cultural perspectives. As well as testing current health policies and plans, SSM can be used to test the feasibility of new health policies. This is achieved by providing a greater understanding and appreciation of what is happening in the real world and how people work. Soft systems thinking is the best approach, given the complexity of health care. It is a flexible, cost-effective solution, which should be a prerequisite before any new health policy is launched.     

中低收入国家药品定价和采购的政策选择

药品支出上涨是全球问题。为应对这一压力,多数高收入国家制定并实施了一系列的药品定价和采购政策。然而,尽管中低收入国家希望能够有效控制药品支出预算,但其药品市场不规范,并缺乏可行的药品定价或采购政策。高收入国家药品支出通常由国家或社会医疗保险机构支付,而中低收入国家大多是个人自付,这会给政策执行造成阻力。由于对药品定价和采购政策是否高效缺乏严谨的调查研究,因而一定程度上阻碍了中低收入国家政策方案的实施。本文对已发表的有关药品定价和采购政策的文章进行综述发现,许多有效的政策也伴随着各种风险。全球尚没有一种最佳的政策选择,各国应根据具体国情,多种政策结合使用。中低收入国家的实证研究尚不足,由于缺乏完善的法律体系以及未建立专门的药品采购机构,任何一种政策选择所伴随的风险在这些国家都会引起更大的争议,然而这或许是帮助其改善药品定价和采购体系的关键因素。     

关于健康社会决定因素研究的博士及博士后人才培养案例

全球特别是中低收入国家的健康及健康不公平问题日益严峻,这些国家缺乏健康社会决定因素研究能力,无法有效地参与国家和国际卫生政策的改革,实现健康公平。面对这一问题和挑战,中低收入国家亟需进行医学教育的创新和改革,培养一批从事健康社会决定因素研究的人才。在此背景下,“加强亚洲地区健康社会决定因素研究能力（Asian Regional Capacity Development for Research on Social Determinants of Health,ARCADE-RS-DH）暠应运而生。该项目通过国际化强强合作,应用混合教学模式,培养一批在健康社会决定因素研究领域学有所长的博士和博士后人才,以提高中低收入国家在健康社会决定因素领域的研究能力,力图解决当前的健康不公平问题。对该项目的研究背景、定位和实施、教学创新等方面作了简要概述。     

Cultural barriers to health care for Aboriginal and Torres Strait Islanders in Mount Isa

Objective: Access barriers to health care for minority populations has been a feature of medical, health and social science literature for over a decade. Considerations of cultural barriers have featured in this literature, but definitions of what constitutes a cultural barrier have varied. In this paper, data from recent interviews with Aboriginal and Torres Strait Islander people, Aboriginal Health Workers and other non‐Indigenous health professionals in north‐west Queensland assist to refine the meaning of this term and uncovered other issues disguised as ‘cultural’ difference. Design: Semistructured interviews with community and health professionals. Setting: Mount Isa, Queensland, Australia. Participants: Aboriginal and Torres Strait Islanders, Aboriginal Health Workers and other health professionals in Mount Isa between 2007 and 2009. Results: Cultural barriers were considered differently by Aboriginal patients and health practitioners. While Aboriginal patients focused heavily on social relationships and issues of respect and trust, most practitioners seemed more focused on making Aboriginal people feel comfortable with changes to physical environments and systems, with less emphasis on creating strong interpersonal relationships. Conclusions: For Aboriginal patients the focus on interpersonal relationships between themselves and health practitioners is paramount. Creating comforting physical environments and systems that are easier to navigate do assist in overcoming cultural barriers, but are often seen as little more than token gestures if trusting interpersonal relationships are not formed between patient and practitioner.     

Barriers and opportunities for developing sustainable relationships for health improvement: The case of public health and primary care in the UK

The British National Health Service has enjoined public health and primary care via a series of policy initiatives. Inter-organizational relationships provide the foundation for managing the system changes required to deliver policy, but are often taken for granted. This article reports on a study that sought to answer three key questions. First, which relationships are important for improving health? Second, what are the key areas in these relationships that might impact on delivery of improved public health? Third, what issues should be addressed in developing emerging relationships? Following a questionnaire to a sample of primary care organizations and a series of intensive workshops with key informants, findings indicate that there is an extensive network of relationships in which public health staff may participate. However, active participation is problematic in terms of identifying the most relevant relationships and ensuring protected time to develop these. Key relationship dimensions impacting on improved public health included different organizational perceptions of relationships and limited mutual understanding. However, despite a lack of a shared view of public health, the diversity of skills and backgrounds was viewed as an asset to joint working. Emerging relationships were generally perceived to be quite effective and expected to significantly improve though capacity issues and the frequency of organizational change appeared to make relationships more difficult to sustain. These issues needed to be recognized in developing and implementing policy, with further clarity needed as to which relationships are key for public health development and the costs and dividends of supporting these.     

The market shaping of charges, trust and abuse: health care transactions in Tanzania

Effective health care is a relational activity, that is, it requires social relationships of trust and mutual understanding between providers and those needing and seeking care. The breakdown of these relationships is therefore impoverishing, cutting people off from a basic human capability, that of accessing of decent health care in time of need. In Tanzania as in much of Africa, health care relationships are generally also market transactions requiring out-of-pocket payment. This paper analyses the active constitution and destruction of trust within Tanzanian health care transactions, demonstrating systematic patterns both of exclusion and abuse and also of inclusion and merited trust. We triangulate evidence on charges paid and payment methods with perceptions of the trustworthiness of providers and with the socio-economic status of patients and household interviewees, distinguishing calculative, value based and personalised forms of trust. We draw on this interpretative analysis to argue that policy can support the construction of decent inclusive health care by constraining perverse market incentives that users understand to be a source of merited distrust; by assisting reputation-building and enlarging professional, managerial and public scrutiny; and by reinforcing value-based sources of trust.     

Private obstetric practice in a public hospital: mythical trust in obstetric care

There is evidence to suggest the decline of trusting relationships in modern healthcare systems. The primary aim of this study was to investigate the role of trust in medical transactions in Thailand, using obstetric care as a tracer service. The paper proposes an explanatory framework of trust for further investigation in other healthcare settings. The study site was a 1300-bed tertiary public hospital in Bangkok which it provides two forms of obstetric care: regular obstetric practice (RP) and private obstetric practice (PP). Forty pregnant women were selected and interviewed using a set of guiding questions. A thematic analysis of the interviews was undertaken to generate understanding and develop an explanatory framework. It was found that patients' trust in obstetric services was influenced by their perceptions of risk and uncertainty in pregnancy and childbirth, and that these perceptions were linked to their social class. Social class also influenced the accessibility and affordability of care to patients. Middle class pregnant women with relatively high-level concerns about risk and uncertainty preferred using PP service as a means to achieve interpersonal trust. These women thought that an informal payment would provide the basis for interpersonal trust between themselves and the chosen obstetricians. In practice, however, obstetricians involved in PP rarely acknowledged this reciprocal relationship and hardly expressed the additional courtesy expected by patients. As a result, PP service only created an expensive impersonal trust that was mistaken as interpersonal trust by patients. Negative outcomes from PP often caused disappointment that could eventually lead to medical litigation. The study suggests that there are some negative impacts of PP within the health system. Negative experiences among PP users may undermine trust not only in the specific doctor but also trust in health professionals and hospitals more generally. Steps need to be undertaken to protect and strengthen existing impersonal trust, which combine institutional trust based on good governance and service quality with trust in the professional standard of practice. The explanatory framework developed through this study provides a foundation for further studies of trust in different specialties and care settings.     

Providing health care to low-income women: a matter of trust

BACKGROUND: Trust is an important indicator of quality in patient-provider relationships and predicts adherence to certain protective health behaviours. It has been relatively unexplored among low-income or minority women. OBJECTIVES: We explored health care experiences that influence patient trust among low-income women in the USA with respect to professionals and lay health workers (LHWs). METHODS: Focus groups were conducted with 33 prenatal and postpartum women, aged 18-45 years, recruited from community-based public prenatal care programmes. Focus groups were audio-recorded, transcribed, and independently coded by readers. A model of factors associated with trust was developed based on the major thematic categories. RESULTS: Most women were Black (67%) and had completed high school (85%). Factors related to greater trust specific to patient-provider relationships were: continuity of the patient-provider relationship, effective communication, demonstration of caring and perceived competence. Women with less trust in their physicians reported an unwillingness to follow his/her advice. Most women reported having more trusting relationships with LHWs and nurses than with physicians, probably due to greater contact with these staff. Several women with a low level of trust reported experiences of discrimination due to lack of insurance. CONCLUSIONS: Prenatal care presents a unique opportunity for providers to contribute to the elimination of health disparities among low-income women. Improving continuity with public health prenatal care providers and building strong relationships with LHWs may enhance quality of care and contribute to achieving this goal. Better patient-provider communication is also a practical area of focus towards improving patient trust.     

Researching trust relations in health care: conceptual and methodological challenges--introduction

PURPOSE: The aim of this paper is to provide a rationale for examining trust in health care. DESIGN/METHODOLOGY/APPROACH: Conducts a review of the literature of trust relations in health care that highlighted that most empirical research has addressed threats to patient-provider relationships and trust in health care systems from the patient's perspective, but studies in the organisational literature suggests that trust relations in the workforce, between providers and between providers and managers, may also influence patient-provider relationships and levels of trust. FINDINGS: Suggests that trust is not primarily dispositional or an individual attribute or psychological state, but is constructed from a set of inter-personal behaviors or from a shared identity. These behaviors are underpinned by sets of institutional rules, laws and customs. RESEARCH LIMITATIONS/IMPLICATIONS: This introductory paper has presented some evidence from an international, comparative study but there is the need for further, more detailed investigation into why trust relations may vary in different health care systems. ORIGINALITY/VALUE: This introductory paper provides a rationale for examining trust in health care and a context for the different elements of trust.     

Trust relations in health care: an agenda for future research

PURPOSE: The aim of this paper is to draw together suggestions for future research from the papers and from the discussion that took place at the workshop. DESIGN/METHODOLOGY/APPROACH: The suggestions are summarised under four broad themes. FINDINGS: At an international workshop on trust organised by the U.K. MRC Health Services Research Collaboration there was broad agreement that trust was still a salient issue in diverse health care contexts. The workshop proceedings identified a number of important questions for empirical research and several key conceptual, theoretical and methodological questions relating to trust that need to be addressed in support of or alongside this. The collection of papers in this volume starts to address some of these questions. ORIGINALITY/VALUE: Considers trust relations in health care from patient, clinical, organisational and policy perspectives.     

A working relationship model that reduces homelessness among people with mental illness

We applied grounded theory methodology to generate a working relationship model that influences motivation for stable housing among homeless people with serious mental illness, to understand the role of a working relationship in critical service transitions. We focused on practitioners' perspectives and practices in Critical Time Intervention (CTI), a community intervention aimed to reduce homelessness through providing support during the transition from institutional to community living. We found a working relationship that highlighted "nonauthoritative" and "humanistic" features. Workers respected client autonomy and maintained flexibility in the format of client contact and service activities. They used practice strategies including following client leads and informal relating approaches to facilitate the development of client trust. The trusting relationship enhanced client interest in obtaining housing and the commitment to the transformation crucial for retaining housing. We discuss the significance of the relationship and ethical considerations of relationship-building activities in community mental health practices.     

The power of ethics: a case study from Sweden on the social life of moral concerns in policy processes

In this paper I report on an ethnographic study of an ethics policy developed by a start‐up genomics company at the time it gained all commercial rights to a population‐based biobank in the town of Umeå in northern Sweden. Tracing the interdependencies between power and morality, my research compares moral reflections and stances among 1) policymakers, 2) health professionals and 3) donors, in relation to the issues identified in the policy. These people seem to agree that trust and fairness are important issues and that ‘something’ needs protection in the face of commercial genetic research. However, their perceptions of trust, fairness and what it is that needs protection differ significantly. I conclude by considering the implications of variances in moral perspectives for the social study of ethics.