How can trust be investigated? Drawing lessons from past experience
Introduction
The concept of trust has become popular in public debate and academic analysis. In high income countries this interest is associated with concern for the decline of trust in governments and professionals, and in developing countries has been prompted by debates around the notion of social capital. For the health sector, trust has long been recognised as crucial to the patient/provider relationship (Parsons, 1951). Recent work has also begun to highlight its potential value in understanding the performance of health care organisations (Goold, 2001) and health systems (Gilson, 2003).
Yet the notion of trust is often regarded as ambiguous—difficult to define and to investigate. Trust has only recently begun to be measured and analysed systematically in the health sector, and almost no empirical investigation of this kind has so far been conducted in developing countries. Gilson (2003) presented a synthesis of theoretical perspectives, looking at the meaning, bases and outcomes of trust and its relevance to the health system. This companion paper reviews the methods applied in investigating trust, drawing on literature from different contexts and disciplinary perspectives. Seeking to encourage rigorous empirical investigation of the role of trust in a range of health system relationships and across countries, this paper describes methodological approaches that have been used in such studies, drawing out guidance about how to conduct future work on trust.
Two search strategies were used to identify English-language papers that provided a reasonable level of detail about their methods. First, two data bases covering the health and broader social science fields (Medline and the Bath Information and Data Services Bibliography of the Social Sciences) were searched using a wide range of terms. No period was specified but this search primarily identified papers from 1993-2002. Abstracts were reviewed and those papers discussing their methods in adequate detail were selected. Second, additional references were identified either through the initial searches or as a result of discussions with knowledgeable people. All the selected publications were then reviewed and a core sample of papers that provided sufficient detail about different types of methodological approaches in different contexts, or about important conceptual issues, were chosen for review. Where papers used the same overall methodological approach, only those illustrating key differences were included in this core sample. More health papers were selected than those from other fields. This paper, therefore, presents an illustrative but comprehensive review of the major methodological approaches that have so far been used in investigating trust across contexts.
The remainder of the paper has three sections. Section 2 summarises the settings in which trust has been investigated and highlights some of the key similarities and differences in how trust is defined. Section 3 then examines the main methodological approaches used in investigating trust. Finally, Section 4 summarises the key lessons drawn from this review.
Section snippets
Does the context matter in investigating trust?
Table 1 outlines the six settings from which the papers identified for review were drawn, giving examples of the types of research questions investigated in each setting and the outcomes found to be associated with trust.
The table shows that questions and outcomes differ quite substantially within settings. However, trust is often found to support co-operation, with this co-operation enabling the achievement of a range of outcomes. In health care, trusting provider-patient relationships may
How are different types of research questions investigated?
Only a small number of papers aim primarily to explore the meaning of trust in a particular setting or for a particular group of respondents; these primarily use qualitative data collection and analysis approaches. Instead, most articles measure trust or trustworthiness using structured survey tools and then either consider the statistical correlation between trust and an outcome variable, or examine how the level of trust or trustworthiness differs across contexts. Some papers place emphasis
Conclusion
This paper provides an overview of the range of approaches that have been used in investigating trust in different settings. Few detailed investigations of trust have so far been undertaken in the health sector, and most in the USA. Further investigation in other country contexts will be important in allowing wider understanding of the relevance and role of trust in health settings. A gap of current inquiry is the limited investigation of the dynamics of trust in health sector relationships,
Acknowledgements
Thanks to Annabel Bowden for her initial work on this review, to Gavin Mooney and three reviewers for comments. Lucy Gilson is a part-time member of the Health Economics and Financing Programme of the London School of Hygiene and Tropical Medicine, UK, which is funded by the UK Department for International Development (DFID). The views and opinions expressed here are those of the authors alone.
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