Social capital, trust in the health-care system and self-rated health: The role of access to health care in a population-based study
Introduction
Health systems are an essential part of society in any country, rather than just a delivery system for health-care interventions (Gilson, 2005). Some societies have effective institutions and healthy citizens while other societies do not (Kawachi, Kennedy, & Glass, 1999). Social capital may be an explanation for such differences.
Social capital is defined as those features of social structures—such as levels of interpersonal trust, norms of reciprocity, and mutual aid—which constitute resources which may facilitate interaction between individuals and groups of individuals to achieve collective action (Coleman, 1990; Putnam, 1993). Social capital may be important for the improvement of government performance and the functioning of democracy as well as the functioning of the economic system (Putnam, 1993), the prevention of crime (Kennedy, Kawachi, Prothrow-Stith, Lochner, & Gupta, 1998), the maintenance of population health (Kawachi, & Kennedy, 1997; Lindström, 2004) and lower mortality rates (Kawachi, Kennedy, Lochner, & Prothrow-Stith, 1997). Social capital promotes health through community-level processes by several different mechanisms. These mechanisms include providing affective support and being a source of self-esteem and mutual respect, increasing access to local services and amenities, promoting the adoption of health-related behaviour norms, social control over deviant health-related behaviours, transmission of health information and preventing violent crime (Kawachi, Kennedy, & Glass, 1999).
Social capital is a complex concept which has been measured at the macro (countries, regions), meso (neighbourhoods), micro (social networks), and individual psychological (trust) levels of analysis (Macinko & Starfield, 2001). While some authors suggest that social capital concerns “ties” and norms which bind individuals together within constituent elements of large organisations or link them across a variety of institutional and formal and informal associational realms (Rueschemeyer & Evans, 1985), other authors regard social capital as a “moral resource” such as trust (Fukuyama, 1999). Social capital has mostly been measured as social participation/social networks or trust (Putnam, 1993). Social participation/social networks is an observable feature of social capital that can be measured either as the density of organisations in a geographical area, or by asking respondents to what extent they are engaged in formal and informal social activities in society (Cattell, 2001). Trust reflects features of social capital that are possible to objectively measure to a lesser extent. Trust includes the expectation that an individual or institution will act competently, fairly, openly, and with concern (Gilson, 2003; Hall, Dugan, Zheng, & Mishra, 2001). Trust is a relational phenomenon which enhances cooperation. The increased propensity for cooperation also enhances trust in a process of mutual dependence, a process which results in an accumulation of social capital (Putnam, 1993). Trust can be divided into vertical trust in the institutions of society (institutional trust), and horizontal trust or generalized trust in other people (Putnam, 1993).
Institutional or vertical trust concerns the trust of the citizens in the institutions, especially the public institutions of society (Veenstra & Lomas, 1999). It has been argued that the levels of trust vary between societies with the level of social connectedness (Thiede, 2005). The health-care system is an institution which often has been discussed in relation to population health. The performance of any health-care system is based on institutional trust. It allows patients to trust providers without any personal knowledge of the health workers which represent the health-care system (Russell, 2005). Trust is central to good interactions between patients and providers because the patient's uncertainty about health conditions, especially serious ones, increases the need to have confidence in a physician's intentions and decisions (Mechanic & Meyer, 2000). Patient trust in health-care providers has been claimed to be associated with the clinical or technical competence of the providers, the interpersonal quality of care (e.g. listening, respect), and the concern for the person, not just the disease (Birungi, 1998; Mechanic, & Meyer, 2000; Straten, Friele, & Groenewegen, 2002). The relationships and emerging trust between patient and provider can be considered at two inter-related levels. Face-to-face encounters with health providers can build or damage personal trust, which is more likely to increase with long-term doctor–patient relationships (Birungi, 1998; Gilson, 2003). There is also faceless institutional trust such as the reliance that health institutional arrangements influencing service delivery will perform in the best interests of the patient (Birungi, 1998; Gilson, 2003). It has been claimed that trust underpins the cooperation within the health-care system that is necessary to health production, facilitates communication (Gilson, 2003), facilitates disclosure of medically relevant information, and is important for patients’ willingness to seek health care (Gilson, 2003; Hall et al., 2001; Russell, 2005). Trust in the health-care system also encourages use of services (Gilson, 2003; Russell, 2005), submission to treatment, and patient compliance (Hall et al., 2001). Moreover, institutional trust is important for economic and political viability of hospitals, insurers, and health-care systems due to the patient support and use of services (Tibandebage & Mackintosh, 2005).
Low levels of interpersonal (horizontal) trust are related to low levels of trust and confidence in public institutions and government (Brehm & Rahn, 1997; Putnam, 1993), low levels of political participation (Kennedy et al., 1998; Putnam, 1993), and reduced efficacy of government institutions (Putnam, 1993). Mistrust and poor relationships with public providers can increase the financial cost burdens related to illness and can hinder discouraged people from seeking health care (Tibandebage & Mackintosh, 2005). Without trust patients may well not gain access to health-care services (Rowe & Calnan, 2006; Russell, 2005; Tibandebage & Mackintosh, 2005), and may not disclose all important medical information (Rowe & Calnan, 2006). It should be noted that such plausible barriers to health care and, in the next step in the chain of causality, health are in accordance with the health belief model (Rosenstock, Strecker, & Becker, 1988), in which the dimension “perceived barriers” has been shown to be among the strongest dimensions (Janz & Becker, 1984).
An important factor related to care-seeking behaviour is trust in the health-care system. Trust provides a context, in which patients and providers can work effectively to establish and achieve care objectives (Mechanic & Meyer, 2000; Perry et al., 1999). Several studies have found that system trust could help the development of interpersonal trust, but it is not known how interpersonal (generalized/horizontal) trust affects institutional trust (Gilson, 2003; Hall, Camacho, Dugan, & Balkrishnan, 2003).
Low trust has been shown to be associated with poor self-rated health (Kawachi et al., 1997). In Sweden self-rated health has been claimed to be associated with features of social capital such as generalised trust in other people and social participation (Kawachi & Kennedy, 1997; Lindström, Moghaddassi, & Merlo, 2004). Self-rated health—recommended by the WHO for monitoring in health surveys—is a multifaceted measure of overall health. Self-rated health assessment is used increasingly to measure population health and has been shown to be a significant predictor of morbidity and mortality (Franks, Gold, & Fiscella, 2003; Kaplan et al., 1996). Besides the impact of specific diseases, self-rated health could be affected by socio-demographic and socio-economic factors (Franks et al., 2003), as well as social capital (Kawachi et al., 1999; Lindström, 2004; Lindström et al., 2004). Such measures allow clinicians and the health-care system to identify individuals and groups at risk for poor health outcomes.
One recent study in the USA found that lack of trust in the health-care system was significantly associated with self-rated health (Armstrong et al., 2006). To our knowledge there are no other studies concerning this topic. To our knowledge there is no investigation on the effects of care-seeking behaviour on self-rated health. In this study we aim to investigate the association between self-rated health and institutional (vertical) trust in the health-care system with respect to the role of access to health-care services.
Section snippets
Objective
To investigate the effects of institutional trust in the health-care system and care-seeking behaviour on self-rated health in the population of Scania, southern Sweden during the autumn (September–December) of 2004.
Study population
Data from the 2004 public health survey in Scania in southern Sweden were used. A postal questionnaire was sent out to a random sample of 47,621 persons aged 18–80 years during the autumn (September–December) of 2004. Two letters of reminder were sent to the respondents and a subsequent phone call was made to the remaining non-respondents. A total of 27,963 respondents returned complete answers (right persons in the household according to age and sex answered the questionnaire). The response
Results
The demographic characteristics of the sample population are summarized in Table 1. The distribution of self-rated health, socio-economic, horizontal and vertical trust variables was almost similar between men and women. A 28.7% proportion of the men and 33.0% of the women rated their health as poor. Almost 12% of the respondents were born in other countries than Sweden. The prevalence of high education was 32.5% among men and 38.9% among women. The proportion with 9 years of education or less
Discussion
This study is one of the first to study the relationship between institutional trust in the health-care system, care-seeking behaviour, and self-rated health. The results of this study indicate that individuals with low institutional trust in the health-care system to a significantly higher extent have poor self-perceived health. The interpretation could be that the level of institutional (vertical) trust affects (self-rated) health. This association may be partly mediated by care-seeking
Conclusion
Low trust in the health-care system is associated with poor self-rated health. This association may be partly mediated by not seeking health care when needed. However, this is a cross-sectional exploratory study and the causality may go in both directions.
Acknowledgements
This study was supported by grants from the ALF Government Grant dnr M:B 39 921/2006, Sweden.
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