Trust and trust measurement in health care

In recent years, research around the globe has increasingly focused on trust in the context of health care. By doing so, studies have investigated trust in a variety of relationships such as those between patients and doctors, patients and emergency rooms, between different health organisations, and most interestingly, on a larger context between the public and health care systems as a whole. The interest in this research field is fuelled in light of German sociologist Niklas Luhmann’s understanding of trust being fundamental for human life. On the other hand, such investigations have gained popularity due to the belief among many researchers, that general levels of trust in health care settings have decreased, and that suspicion has raised. Shockingly, some have even called it a trust crisis in health care. Such a crisis has important implications in the health setting, since decreased levels of trust often have negative impacts on patients’ health and system functioning. For example low levels of trust undermine patient’s compliance with therapy, or negatively impact medical counselling, due to the patients’ withholding necessary personal information for their doctor. Another alarming example is that of vaccination acceptance. Specifically, due to public’s mistrust in their government which leads to decreased public cooperation, the number of vaccination refusals increase, which in turn can lead to disease outbreaks.

To investigate trust levels, different measurement tools have been developed in recent years, some of the newest examples being from Trinidad and Tobago and India. However, when reviewing measurement tools, it becomes evident, that such measurements build on different understandings of what trust is. Unfortunately, this inconsistency hampers the comparability of outcomes of different studies on a global level. This variety of definitions and understandings of trust, can be explained in many different ways, therefore leading to an important question: What could ‘trust’ mean?

It is probably safe to say that we all have a personal understanding of trust, based on our personal experiences or the chaired experiences of others. We usually encounter first trust experiences through our mother or primary care giver during childhood, and develop our personal understanding of trust when we grow older and start to interact with many other systems outside of our family environment. We learn that generally trust is built between two or more people and that it is future oriented. Specfically, this means that when we trust, we expect or do not expect something to happen in the future. Furthermore, we learn that trusting someone or something can overcome uncertainty and reduce risk, as the person/system we trust in can deal with the risk better than oneself. Also, trust might be associated with vulnerability. For example we trust a surgeon to pursue an operation successfully, or we trust a pilot and technology surrounding us, i.e. the plane, to bring us to our destination. As trust is fragile we also learn that it is easy to destroy and difficult to build up. Last, our perceptions of trust might be influenced by understanding of fairness, values and ethical behaviour. All this leads to the conclusion, as indicated by Ute Frevert (2013), that trust can have many different interpretations, is culturally shaped and that trust is often loaded with different meaning.

Turning from the literature on trust to the scientific articles on trust in health care –   there is an abundance of theories and definitions on trust predominantly developed in the fields of psychology, sociology, philosophy and economics. As mentioned before, there exist a variety of definitions of trust, based on theoretical differences. For instance, according to the German sociologist, Niklas Luhmann (1968), trust can be understood in the abstract manner of being a mechanism to reduce complexity. In contrast, with respect to patient-physician relationships, trust can be viewed as a set of expectations that the physician will behave in a certain way, or as a feeling of confidence in the physician and his/her intentions. From such examples, it becomes very clear that scientific definitions of trust are as diverse as personal understandings of trust, among healthcare systems and the wider public.

Nevertheless, arguably some commonalities can be determined. First, trust is future-oriented; second, trust is linked to vulnerability (risk), in that the question of trust would not arise in a situation where there is a lack of vulnerability; third, trust is based on personal experiences (familiarity) or the experience of others; fourth, trust enables action; and fifth, trust requires communication. As these proposed commonalities are equally abstract, they allow different interpretations in different health care settings.

In conclusion, it is safe to assert that trust is a multidimensional construct, with no single, universal definition. An important implication, therefore is that in any research or measurement tool, it is extremely important to detail the underlying construct/definition of trust. This would not only enable comparability of study outcomes, but also contribute to our overall understanding of trust in general, as well as specifically, in relation to the domain of healthcare.

Felix Gille