Examining Trust in Healthcare: A Multidisciplinary Perspective

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This makes the book fundamental reading for students, academics and professionals across all branches of healthcare, as well as an important resource for those with professional and academic interests in the psychology and sociology of health. Contents Connotations of trust Interpersonal aspects of trust Psycho-social and psycho-ethical aspects of trust Ethics, trust, and healthcare Social aspects of trust Framing trust in healthcare through case study analysis Trust in systems.

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So my references will be to those doctors only, because I trust them and treatment given by them will be perfect treatment, and investigations will be done properly, so I have that trust in them. So I refer to them. This was almost always accompanied by a confidence in their own judgment regarding the competence of these providers. Over time, one becomes sure about getting results from a particular doctor.

We know certain names over the years … know some doctors personally, through the patients we see here. From the treatment given to the patient referred we understand. Allopaths or practitioners of modern medicine both in the public and private sectors unanimously expressed distrust of those ayurvedic and homeopathic practitioners who practise and prescribe modern medicine without a licence or the training to do so. The professional regulator of modern medicine and the health services manager felt the same.

They were, however, accepting of those ayurvedic and homeopathic practitioners who practised what they were trained for, and had congenial relations with them. The allopaths interviewed did not refer their patients to homeopathy or ayurveda practitioners; they did, however, know that some of their fellow allopaths did so. The private ayurveda practitioner and homeopath both exclusively practised their own system of medicine, and reported that their relations with practitioners of modern medicine were congenial and characterised by trust. Asked about their relations with practitioners of modern medicine, including whether they referred patients to these practitioners, the homeopathy practitioner responded:.

Especially in skin disorders, when they find that the patient is not improving or he is getting side reactions from allopathic medicines, then they refer them to homeopathy. Because this they know … there are many things that allopathy does not have medicine for that. So even if they say no … no … we are the best, if the allopathic doctors gets some problem which is not curable with allopathy, he will come to homeopathy himself.

So now that ego factor is going down a lot. The private ayurveda and homeopathy practitioners both acknowledged with some disapproval that many of their peers, particularly in rural areas, prescribed modern medicines even though they were not trained to do so. Some key informants and modern medicine practitioners said that according to their experience, ayurveda and homeopathy were in vogue only among the urban middle classes, and that the rural populace had greater trust in modern medicine.

As a case in point, they mentioned that almost all ayurveda and homeopathy practitioners working in rural areas prescribed modern medicines. The service users we interviewed trusted and used modern medicines more than other types, but also said that they trusted ayurveda in the case of certain kinds of illnesses. They did not have much to say about homeopathy. This preference for allopathy and the fact that the informants trusted it more than the other systems is related to the definite and quick results of allopathic medicines.

As the following interaction in the focus group discussion illustrates, the trust in ayurveda sits comfortably beside the confidence and trust in allopathy. While you were explaining your experience, you mentioned that you later sought ayurvedic treatment — my question to you all is do people trust one pathy more than others?

People trust allopathy more. Indeed slow to act. I mean ayurveda works slowly; in allopathic you get quick relief. So people think like this? And there are no side-effects of ayurvedic medicines. There is benefit, but usually little. But people trust allopathy more. All the private providers felt that the facilities and care in the public sector were poorer than in the private sector. However, they did trust the competence of their peers in the public services. Two or three colleagues of mine are there.. One is a gynaecologist. The service users had an equal amount of confidence in the competence of the doctors working in the public sector.

So you say that if you go to a public facility, you will save money, but does that mean that the doctors there are good? The doctors are good … they are good. Yes, the doctors are good. Why do you say so? Doctors there are good. Now you see … how it is.. What exactly do you mean…. Means more educated … maybe more experienced. They have qualifications, they have experience.

Examining trust in healthcare: a multidisciplinary perspective

The private providers were aware of the operational and managerial constraints under which public providers work. One of them pointed out that this situation made matters worse for those who could not afford private services. The poor class is actually … the poor patients are most worst sufferers in all this system.

One of the private providers felt that public services used to be better and that poor management had led to the deterioration over the last two to three decades. That was how it was with public services then. Now … what has happened.. People in a public hospital do not put their hearts into their work.. The public provider mentioned that working in the public services had its own challenges, including, but not limited to, the fact that people considered these services inferior. They come here, they pay only 10 rupees… and whatever the general medicine we give..

We know they go outside and throw the medicines … They feel that it is such a low level means the medicines must not be good, the doctors must not be good whatever their ideas are…There are some people who absolutely go outside and throw the medicines. Many informants, other than the service users, commented that there had been an erosion in trust, as well as in honesty of intent, at the level of society at large. They felt that relations of trust in the health system must be examined in this context.

So this is an aspect of it. I have seen it with my own eyes — people prostrating in front of doctors my father..

Many informants, including some doctors, were of the view that the widening gulf between doctors and their patients — particularly in terms of money — was an important reason for the erosion of trust and deterioration of the relations between them. Speaking about the matter in the context of the widening economic inequalities, the politician said:. As inequalities increase, it is all about economic inequalities …. It will become difficult for everybody.

The service users, however, seemed to view the situation differently.

THEME: TRUST IN HEALTHCARE

While all of them recognised that there had been a decline in trust in various spheres of public and social life state, judiciary, police and fellow citizens , they did not think that the overall societal situation had a bearing on trust in the healthcare system. Probing this matter did not yield much insight into the effect of the societal situation on the trustworthiness of the health system or the other relations within the system.

This consisted of an examination of the nature of such relations and what influences the shape of these relations. It is problematic to explore the subject of trust relations in Indian society as it is not considered morally or culturally acceptable to say that one does not trust someone. For this reason, our informants were somewhat hesitant to make allegations or moral judgments about others. The only exception was the private providers, who expressed their views on the untrustworthiness of the public regulatory authorities unequivocally.

The Indian people have had a long tradition of expressing anti-establishment views openly. The healthcare providers, private and public alike, were open to talking about their perception of their own trustworthiness and their general experience with relations of trust. However, while they acknowledged that there was growing and widespread distrust, they distanced themselves individually from this state of affairs. A greater and more nuanced insight into this can form the basis for developing interventions.

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The private providers had no doubts about the trustworthiness of colleagues whom they knew or knew of. They expressed frustration both at their own inability to do anything about it and about the fact that not much was being done about it. Similarly, the representative of the professional body expressed a sense of inevitability and helplessness about the situation. While all the providers held that trust had to be earned and be maintained, they were unhappy with the erosion of blind trust in the profession.

The practitioners of modern medicine spoke of stress due to challenges or threats to their professional power, discretion and privilege. They faced stress because of the confusion created perhaps by the challenges to their historically transmitted identity, which was constructed during training and regularly reinforced by society. The confusion was complicated further by the fact that the expectation of a privileged status, hitherto taken for granted, was being simultaneously upheld and challenged by societal actors and institutions. This may also reflect the difference or lack of close fit between the levels and perceptions of trust in the health system as an institution and trust relations at the interpersonal level between practitioner and patient.

Relations between private providers and regulators were characterised by a mutual lack of trust. Regulators seemed to view private providers as driven by money and fair game for extortion. Private providers felt that regulators used the regulations as a pretext to extort money. We must critically examine the lack of faith that both medical professionals and communities have in current regulatory responses to healthcare delivery problems.

If we gain a better understanding of the situation, we can identify opportunities to rebuild trust in these important relationships, and better manage healthcare services. Trust in the relations between private and public providers appeared to be based on the competence of the provider.

While public providers did not trust the intent of the larger body of their peers working in the private sector, they did trust specific providers on the basis of their personal experience and familiarity with them. Amongst doctors who had graduated from public medical colleges, there was an element of distrust about both the financial motives, and to some extent the competence, of doctors graduating from private medical colleges.

These views were justified with the oft repeated, but suppositious arguments that pressures to recoup costs were the likely driver of the alleged money centeredness. Trust relations between providers of different systems of medicine appeared to be based on earned trust, earned through interaction and relations developed on a personal basis, and an individual matter; while the ayurveda and homeopathy providers trusted the competence of the allopathy providers and the system of allopathic medicine to deliver results, this sense was not reciprocated by the allopaths, who were ambivalent about the legitimacy of other systems of medicine.

In addition, patients tended to trust practitioners who used modern medical technology in their practice which may have led to a preference for allopathic medicine. This evidence raises questions about the viability of any policies aimed at integrating different systems of medicine. Further research needs to explore these questions in more detail as the story emerging from this study contained mixed messages about the relationship between allopathic medicine and ayurveda and homeopathy, with a lack of trust emerging at the systems level but harmonious relations apparent at the interpersonal level.

It was expected that caste would be reported as an influence in trust relations. However, all the informants, including the service users, shrugged the question off without much hesitation, though the interviews were conducted by locals and the caste question was asked in a frank and open way. Patients explicitly stated that trustworthiness was related to competence and familiarity. It could be that in the context of healthcare — a major sphere of social life — people no longer repose trust in providers or make care-seeking decisions on the basis of caste.

However, it has been argued that caste has been invisibilised and has escaped scrutiny in Indian society Further research is needed to explore this question and a more sensitive methodology must be developed to get beneath the invisibility of caste and its possible influence on trust in the health system.

This study is perhaps the first to examine trust relations amongst those on the supply side of the health system in India and, more broadly, in low and middle income countries, particularly the situation of private care providers. Given the diversity of actors involved in healthcare provision in India, and the pre-dominant role played by private care providers, this study is pertinent as it exposes key issues vis-a-vis trust relations of private providers; in doing so it also sets the stage for innovative areas of research with potentially important implications for population health outcomes.

Beyond India, this study is also one of the few empirical investigations on trust relations as experienced by healthcare providers The study has its limitations. Providers working as employees in private corporate hospitals were not interviewed, nor were their managers.

Given the growing corporatisation of healthcare delivery, they need to be understood better. The private providers interviewed were all established practitioners, and all general practitioners; their views on the state of trust relations within the health system might be different from those of private providers who are younger, or have a referral-based or specialist practice.

All service user informants were women, and it is possible that men have different views and experiences and that trust relation is a gendered phenomenon. Similarly, all service user informants were from the middle to lower middle class, and urban; rural, poorer citizens may have different points of view. The study was conducted in one part of India, and some of the findings may not apply nationally and across regions. Informants, particularly the non-medical professionals, referred to different levels of care when expressing their views; one can expect the nature of trust relations to vary across primary care services, higher levels of services, and diagnostic services; this study was unable to disentangle this post facto, and its scope was in any case insufficient to cover these possible differences.

However, this was beyond the scope of our work. In conclusion, this exploratory study exposes potentially important issues around the state of trust relations in the supply side of the health system, particularly in the stewardship of the healthcare system in India; these deserve further and more extensive examination.

Online submission is not open so please mail submissions to: Toggle navigation Indian Journal of Medical Ethics. How to cite item. Introduction The latest report on the global burden of disease shows that India accounts for around Trust and its importance in the health system Trust is recognised as significant for providing effective healthcare across national systems and provider contexts 13 , 14 , Trust relations in healthcare in India — An exploratory study.

Findings The first part of this section consists of a discussion of themes related to the changing context of healthcare in India. Changing nature of healthcare: Marketisation of healthcare According to our informants, market forces are aligned in such a way today that the family doctor-based care model is becoming increasingly unsustainable in major urban settings.

Marketisation of medical education: Importance of personal manner in the building of trust The importance of building and cultivating trust and reputations — with patients and within communities — emerged as a major theme.

Breakdown of trust between regulators and providers Private providers disapproved of the regulatory interventions that they were now subject to. Asked about their relations with practitioners of modern medicine, including whether they referred patients to these practitioners, the homeopathy practitioner responded: Relationship between public and private providers All the private providers felt that the facilities and care in the public sector were poorer than in the private sector.

Private provider 3 The service users had an equal amount of confidence in the competence of the doctors working in the public sector. Overall decline in trust in society at large? Speaking about the matter in the context of the widening economic inequalities, the politician said: Strengths and limitations of the study This study is perhaps the first to examine trust relations amongst those on the supply side of the health system in India and, more broadly, in low and middle income countries, particularly the situation of private care providers.

Global Burden of Disease. Institute for Health Metrics and Evaluation; IDS Working Paper Barua N, Pandav CS. The allure of the private practitioner: Indian J Public Health. Health care and equity in India. Horton R, Das P. Does healthcare need healing? Trouble at the Medical Council of India. How free healthcare became mired in corruption and murder in a key Indian state. Violence against doctors in India. Indian J Med Ethics. How should hamsters run?

Some observations about sufficient patient time in primary care. Dibben RM, Lean M. Achieving compliance in chronic illness management: Health, Risk and Society.

Examining Trust in Healthcare

Public Trust in health care: Rowe R, Calnan M. Trust relations in health care: Eur J Pub Health. An investigation of maternal deaths following public protests in a tribal district of Madhya Pradesh, central India. Trust matters in health care. Reason, routine and reflexivity. Trusting on the Edge. Trust in the health-care provider—patient relationship: Trust as a process: Trust and the development of health care as a social institution. Trust and health worker performance: Calnan M, Rowe R. Researching trust relations in health care: J Health Organ Manag. Connell NA, Mannion R. Conceptualisations of trust in the organisational literature: Some indicators from a complementary perspective.

Examining trust in health care: Gopichandran V, Chetlapalli SK. Dimensions and determinants of trust in health care in resource poor settings—a qualitative exploration. Factors influencing trust in doctors: Using the framework method for the analysis of qualitative data in multi-disciplinary health research. Bauman G, Gingrich A, eds. Patient-physician trust among adults of rural Tamil Nadu: Our watchdog sleeps, and will not be awakened. Why I returned to the UK. Professional codes, dual loyalties and the spotlight on corruption. The health of India: Gerald Gartlehner et al.

Why we resigned , September 15, A moral governance crisis: The growing lack of democratic collaboration and scientific pluralism in Cochrane. Doctors seek changes to sex test rules. Why does the UGC still use them? The Wire, April 18, The elephant at the workplace, Indiatoday. Over 24, clinical trial deaths and SAEs in India in ten years.

The Sunday Guardian, New Delhi: Indian Medical Association asks that doctors be excused from participating in execution of convicts. Chennai Medical students unlikely to be altruistic doctors: Times of India, Chennai edition: Hiding vaccine-related deaths with semantic sleight-of-hand.

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