Elsevier

Social Science & Medicine

Volume 57, Issue 6, September 2003, Pages 1065-1075
Social Science & Medicine

Value importance and value congruence as determinants of trust in health policy actors

https://doi.org/10.1016/S0277-9536(02)00485-9Get rights and content

Abstract

The paper examines levels and determinants of trust in a health care system and in key actors in the health policy community. Talcott Parsons theorizes that the sharing of common values is a necessary condition for interpersonal trust to exist; this paper tests that notion at the level of systemic (institutional) trust. The paper reports findings of a 1999 survey of 493 randomly selected residents of Calgary, Alberta, Canada. It uses multiple regression analysis to identify the determinants of three different types of trust—generalized systemic trust, fiduciary trust, and generalized trust in particular actors’ input to health system changes. Among the numerous independent variables, special attention is devoted to the degree of congruence or incongruence between the importance which respondents attach to one of the values enunciated in the Canada Health Act—namely, ‘accessibility’ (equal access to quality health care)—and the importance which respondents believe is attached to that value by the Regional Health Authority and by the Premier of the province. Both value importance and value congruence on equal accessibility are found to be important factors explaining variation in all three types of trust. In explaining levels of trust in the Premier on the issue of health care system reform, congruence on equal accessibility proved to be even more important than such factors as political partisanship, political cynicism, and personal experience as a patient in the health care system. Findings also suggest that there is an emotional component to systemic trust.

Introduction

The Canadian health care and health insurance system has come under scrutiny by other countries, especially the United States, as a potential model for reform in their systems. Within Canada, the province of Alberta has taken the lead in launching major reforms involving hospital closures, privatization, regionalization, and much more. Insights into the way in which major structural reform in Alberta has been received by Albertans, and factors shaping that reception, are potentially very useful to policy planners and political strategists who are considering major reforms in other jurisdictions. One important aspect of the public reception of reform is trust.

Trust has emerged as a major issue in a variety of institutional spheres in contemporary society (Fukuyama, 1995), including the health care system and its reform. Examples of egregious violation of trust relationships by individuals and institutions abound around the world and have transformed the landscape in terms of how some individuals relate to institutions in which such violations have occurred. Exit from, or hyper-vigilance toward, those institutions has been a common response to violations of trust. Yet, as Hirschman points out, there are some situations, including certain public services such as medical services, in which opting out in the face of a generalized loss of confidence in the traditional system either is not likely to be an adequate safeguard of the consumer's interests or is otherwise ‘dysfunctional’ (or too costly) to the system (Hirschman, 1980, pp. 436–438, 451). In such situations it is incumbent upon the architects of system reform and managers of the system not to lose the trust and confidence of their clientele.

The present paper has two main purposes. One is to identify the determinants of three different types of trust. Special attention is given to the role played by one of the values embodied in Canada's national health legislation, the Canada Health Act (Revised Statutes of Canada, 1985, cC-6, Sections 7–12), in determining the level of trust that individuals have in their health care system and in key actors in the health policy community. More specifically, we focus on the importance that the individual attaches to ‘equal accessibility’ (equal access to quality health care) and on the degree of congruence between the importance which the individual attaches to ‘equal accessibility’ and the importance that s/he perceives the provincial Premier and the Regional Health Authority (CRHA) attach to that value. Our interest in ‘equal accessibility’ is prompted by the findings of the National Forum on Health (1997), which found that “equality of access is one of the most important values consistently advocated” by Canadians. Our second purpose is to assess the contribution of value importance and value congruence relative to other variables identified in the trust literature.

Our data are from a 1999 survey of residents of Calgary, Alberta (a city of about 875,000 residents at the time of the study). The core of the paper consists of regression analyses in which the dependent variables are six measures of trust representing three different types of trust.

Section snippets

Review of the literature on trust and values

The literature on trust in institutions is dominated by an interest in political and governmental institutions. Articles addressing trust in health care players and medical institutions report merely levels of trust (Alberta RN, 1998; Elabdi, 1996; National Coalition on Health Care, 1997; Snow, 1997; Zussman, 1997), rather than determinants of trust. The exception is the extensive literature on interpersonal trust in the context of the doctor–patient or nurse-patient relationship.

Graves,

Data

After pre-testing, a five-page questionnaire containing 150 variables in the form of 30 questions was mailed to 995 randomly selected households in Calgary, Alberta, Canada on November 4, 1999. (This was less than 1 month after the provincial Premier first announced the provincial government's intention to introduce Alberta's controversial Health Care Protection Act—Bill 11—which allows for the expansion of private, for-profit surgical facilities in the province.) Eligibility to participate in

Dependent variables

The six dependent variables chosen for this analysis represent three different aspects of trust—generalized systemic trust in the health care system (one variable), fiduciary trust in health policy actors (two variables), and generalized trust in particular actors’ input to health system changes (three variables). Response categories were either on a 4-point or a 5-point Likert-type scale where higher scores indicate greater trust.

Question phraseology for the dependent variables is shown below,

Results

Multiple regression analysis offers the very attractive advantage of enabling us to ascertain the impact of any given independent variable on the dependent variable, holding constant the effect of all other variables in the analysis. The regression analysis for any given dependent variable was conducted with the independent variables being entered en bloc. In addition, blank cells in the tables below denote coefficients that were not statistically significant at the 0.05 level. Diagnostic tests

Discussion and conclusions

Our research (tables not shown) found moderate levels of trust in the Alberta medical system and surprisingly low levels of trust in key actors in the health policy field—namely, the provincial Premier, the provincial health department, and a ‘senior administrator in a regional health authority’. The Calgary Regional Health Authority and the Government of Alberta (not further specified) fared better, in terms of fiduciary trust invested in them by Calgarians. Levels of trust in these six

Acknowledgements

The research reported here was partially funded by grants from University of Calgary and from an individual who wishes to remain anonymous but who had no vested interest in the results. The authors express their sincere appreciation to the following persons for their valuable assistance: Dr. Tom Langford, Dr. Richard Wanner, Pam Weinberger, Susan Jenkins, Margaret MacLennan, and the anonymous reviewers.

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