Multilevel trust in international marketing of healthcare services: A five-country comparative study

Purpose: This research aims to increase understanding on how multilevel trust is developed as well as how trust levels are interconnected and influence international marketing strategy for healthcare services. Design/Methodology/Approach: A comparative case study approach was applied with Elekta, a Swedish firm, operating in Brazil, the Philippines, China, Russia, and Hong Kong. Findings: The research culminated in a multilevel trust (MLT) model comprised of three levels relating to individuals, company performance, and context. Research implications/limitations: This study offers a context-based multilevel trust model from a process perspective focusing on healthcare. This model can be tested in other service sectors. Practical implications: Managers should consider multilevel trust to boost relationships and achieve local


Introduction
This study deals with multilevel trust in healthcare services and how it affects international marketing strategy in emerging markets. Knowledge on multilevel trust is essential to understand how trust is built to facilitate development of long term relationships (Zaheer & Zaheer, 2006). Trust can be defined as the willingness to rely on an exchange partner one has confidence in (Bianchi & Saleh, 2010). Currall and Inkpen (2006) assert that trust needs to be discussed at different levels-person, group, and firm-to comprehend its role in organizational performance. They further claim that over time interpersonal trust can evolve to intergroup and then to interorganizational trust. Trust is thus dynamic, which makes multilevel trust a major issue in understanding interorganizational relationships.
Considering its importance and limited understanding on multilevel trust, a special issue in Journal of Trust Research was dedicated to this topic (Volume 8:2, 2018). Researchers have studied trust at micro levels (citizenship behavior, Mayer & Gavin, 2005; negotiation success, Lee, Yang, & Graham, 2006), and macro levels (strategic alliances, Fryxell, Dooley, & Vryza, 2002). Mouzas, Henneberg, and Naudé (2007) have discussed trust at personal and organizational levels, differentiating trust between individuals internally and representing different organizations. Lyu and Ferrin (2018) term personal trust as interpersonal trust; Zaheer, McEvily, and Perrone (1998) introduced interorganizational trust, which refers to the collective trust of members of one organization for another. Fregidou-Malama and Hyder (2015) add country-level trust to the other two levels to initiate trust discussion in international marketing.
Through a literature review, Fulmer and Gelfand (2012) have proposed three levels of trust: individual, team, and management, finding the first level to be the dominant one. Multilevel trust has been so far discussed at what level trust occurs and what importance it has to that level. Li (2012), however, observes that trust research has been largely decontextualized, and therefore role of context needs to be stressed. Context deals with opportunities and constraints, which affect organizational behaviors in different situations (Johns, 2006). Context is vital in trust research because factors at one level have impact on behavior and relationships at other level (Fulmer, 2018;Johns, 2006). Contexts are seldom uniform; instead, they are multidimensional and dynamic (Michailova, 2011), particularly in emerging markets (Srivastava et al., 2020;Abraha & Hyder, 2021). Following Johns (2006) and Michailova (2011), we define context as multidimensional and dynamic conditions that can influence organizational behaviors and the process of multilevel trust development by dealing with opportunities and constraints.
The international healthcare context involves complexity, high expenses, and risk of misunderstanding due to intercultural meetings and dealings (Berry & Bendapudi, 2007;Patterson, 2016). In marketing healthcare, Hyder and Fregidou-Malama (2009) found how problematic it is for the service provider to develop trust due to cultural differences as articulated in Hofstede's seminal work (1991). The role and importance of cultural context has been discussed in the international business literature (Cavusgil, Knight, & Riesenberger, 2014;Kahiya, 2020;McLeary & Cruise, 2015). However, we argue that culture is not enough; it is also necessary to consider the impact of country of origin (COO) context in discussing multilevel trust. COO is defined as the country where a product or service is developed (Lee & Lee, 2009) and it affects consumer's trust and the evaluation on the quality of products and services. If the perception of COO is positive to the local people, it will be easier to develop initial trust in marketing high-risk services such as healthcare (Michaelis, Woisetschläger, Backhaus, & Ahlert, 2008). Conversely, we claim that negative COO perception will make trust development difficult at the individual, organizational, and country levels. In this study, we consider organizational context as a combination of national culture and country of origin (COO) which affect trust development in internationalization of healthcare services.
We consider trust development as a process (Boersma, Buckley, & Ghauri, 2003;Langley, Smallman, Tsoukas, & Van De Ven, 2013;Nooteboom & Six, 2003;PytlikZillig & Kimbrough, 2016) and analyze how trust is developed and how service providers advance network relationships with different actors and develop marketing strategies in international contexts, aided by multilevel trust. Vahlne and Johanson (2013) explain business networks as sets of connected business relationships, and Hyder, Rydback, Borg, and Osarenkhoe (2019) and Khakhar and Rammal (2013) link networks with trust development to deal with international marketing of healthcare.
The studied literature shows that little focus is given on how trust at different levels cross-fertilizes (Fulmer & Gelfand, 2012) and what impact context has on the emergence of trust at different levels. Johns (2006) highligts the importance of context and points out the lack of research on how context influences organisational behavior. Further, Srivasta, Singh, and Dhir (2020) observe that most studies on international marketing concentrate on developed economies, and call for qualitative case studies research from emerging market perspective. Thus, we identify three gaps in literature which motivate us to study how trust at different levels develops and affects other levels and how cultural context and country of origin impact levels of trust. We argue that organizational context must be considered in understanding how multilevel trust is built, and there is a relationship between multilevel trust and networks in formulating international marketing strategy for healthcare providers. Missing understanding on context and multilevel trust can make marketing of healthcare complex and difficult. In this research, we fill the above theoretical gaps and facilitate understanding of the process of multilevel trust building. The aim is to analyze the dynamic process of multilevel trust and how it affects International marketing strategy from emerging market perspective. To fulfil this aim, two research questions are addressed: 1 How does context affect the development of multilevel trust in the marketing of international healthcare services? 2 How does multilevel trust influence development of international marketing strategies for healthcare providers?
To conduct the study, we collected empirical data from employees of Elekta (2020), a Swedish multinational engaged in cancer treatment, and employees and customers from Elekta associated firms operating in Brazil, the Philippines, China, Hong Kong, and Russia-five emerging markets from three continents. Sheth (2011 and argues that context matters, and emerging markets with special needs and contexts offer a fruitful environment for exploring new perspectives in marketing and challenging existent theories. We respond to this research need, which justifies our choice of the five cases, to develop new knowledge on multilevel trust development by applying the EM perspective. This study proposes several original contributions: (1) It contributes to theory building by offering an empirically grounded Multilevel Trust (MLT) model to increase understanding on multilevel trust development.
(2) It explains context as a combination of culture and COO by identifying dimensions that influence trust development. (3) It offers knowledge to make strategic choices in international marketing of healthcare from emerging market perspective.

Concept of trust
Research on trust links trust to willingness to take risk in a relationship and maintains the effect of context on the characteristics, perceptions, and evaluation of trust (Mayer, Davis, & Schoorman, 1995). These authors emphasize that contextual factors such as power relations or the political climate can affect the outcome of trust. Rousseau, Sitkin, Burt, and Camerer (1998) affirm that trust means an intention to be vulnerable to others if the relationship is linked to positive expectations. Considering the complexity of trust, they highlight the need to study it at different levels. Morgan and Hunt (1994) argue that trust positively relates to sharing values and constitutes a mechanism for coordination. They identify commitment and trust as key variables in developing long-term relationship marketing. MacMillan, Money, Money, and Downing (2005) point out the importance of the individual person, communication between actors, and context in trust building. According to MacDuffie (2011), only individuals can establish trust, not organizations, and Zaheer et al. (1998) find that personal and organizational trust are interrelated. Movement of trust between different levels, particularly in the international context, can therefore be problematic. Blomqvist (1997) finds that trust is situation specific and difficult to conceptualize in international environments. Given the many differences in views among researchers on how to study trust, PytlikZillig and Kimbrough (2016) highlight trust as a process. The classical works of Boersma et al. (2003) and Nooteboom (2003) also highlight the process perspective when looking into trust. We perceive trust as a multiple construct that emerges and changes over time, leading to new organizational arrangements. Dietz, Gillespie, and Chao (2010) observe that it is easier for individuals from the same culture, sharing values, norms, and experiences, to develop trust and relationships. Development of trust is difficult when different cultures meet in doing business. Jiang, Henneberg, and Naudé (2011) find the role of trust important when discussing cross-border intra-and interorganizational trust. They claim that cultural differences at the national level can affect personal trust and international marketing. Fregidou-Malama and Hyder (2015) argue that marketing healthcare across countries with different cultures is a risky project requiring an understanding of how trust is constructed and functions at multiple levels.

Trust development and cultural context
In international business, firms operate in cultural ecosystems characterized by unfamiliar languages and unique value systems, beliefs, behaviors, and norms (Cavusgil et al., 2014;Michailova & Holden, 2019). Hofstede (1991) provided a framework of four cultural dimensions for studying the influence of cultural contexts in international business. The first dimension, Power distance, highlights the role of authority and recognition of inequality in a society. Collectivism refers to how people are integrated and work for collective values and interest. The third dimension, Masculinity/femininity, deals with attitude toward achievement and quality of life and relationships. Finally, uncertainty avoidance indicates how a society perceives and reacts to risk and uncertain situations. Hofstede, Hofstede, and Minkov (2010) argue that cultural dimensions have impact on people's preferences in engaging in relationships and networks. Similarly, researchers like Rodriguez and Wilson (2002) find that cultural dissimilarities may lead to differences in a firm's aims, management, operations, and strategy implementation.
However, Fang (2003) and Minkov (2018) has criticized Hofstede's dimensions as static and not properly addressing the dynamics and complexity of culture. Despite the critiques, Hofstede's work has been found applicable in cultural comparison and has emerged as a norm (Hofstede & Minkov, 2011;McSweeney, Brown, & Iliopoulou, 2016;Soares, Farhangmehr, & Shoham, 2007;Sweeney & Hardaker, 1994) in international marketing studies. Hofstede (1991) further relates culture to organizational behavior and analyzes its consequences from a managerial perspective. Doney, Cannon, and Mullen (1998) and Torelli et al. (2015) discuss the role of culture context with trust building, which Hofstede also addresses. In this study, we apply Hofstede's cultural dimensions to differentiate between case countries and to determine their influence on COO and multilevel trust development. Michaelis et al. (2008) stress COO image and company reputation for creating initial trust when marketing high-risk services like healthcare in different marketing contexts. Absent any earlier experience between the parties, McKnight, Cummings, and Shervany (1998) find the role of initial trust crucial to create trust at other levels. Money, Hillenbrand, Day, and Magnan (2010) argue that a company's reputation is about stakeholder perceptions of a firm's characteristics, and COO's role is to support creating positive perceptions. Usunier (2011) discusses the relevance of the COO perspective in international marketing and its relation to brand origin. She finds that factors such as language can affect identifying the national origin of a brand and customers' willingness and intentions to buy. Magnusson, Westjohn, and Zdravkovic (2011) argue that COO favorably influences the development of a positive image for the producing country and its brand. COO thus contributes to trust development at the company level, which gradually moves to the individual level. Diamantopoulos, Schlegelmilch, and Palihawadana (2011) observe that consumers link COO image to promises and responsibilities to produce quality products and services. Altinay, Brookes, Madanoglu, and Aktas (2014) mean that the competence of a company in brand reputation, business expertise, cultural sensitivity and willingness to share knowledge contribute to development of trust and relationships. On the negative side, Fong, Lee, and Du (2014) discuss how consumers' animosity to a country can be a country-specific disadvantage when entering a new market. Trust and brand familiarity can reduce uncertainty in service encounters in international markets, due to the intangible characteristics of services (Coulter & Coulter, 2002).

Trust development and networks
Networking, relationships, and trust are the core elements in the network perspective (Håkansson & Snehota, 2017). Cova and Salle (2000) observe that logic and dynamics of network relationships can be understood and analyzed by identifying critical actors, activities, and resources. We assume that trust at the individual and company levels is essential to ease the functioning of the network elements. Svensson (2001) identifies trust and mutual trust as contributing factors in developing interpersonal, interorganizational, and intraorganizational relationships, and argues for considering relationships with actors in the firm's context. Dyer and Chu (2000) maintain that stability in human resources helps to develop relationship-based trust, enhancing interorganizational trust. Snehota (2000, 2017) argue that firms are dependent on resources provided by other firms, and this exchange of resources advances knowledge, helping them to develop trust and relationships and gain a position in the market. Freeman and Sandwell (2008) have shown that when entering emerging markets, businesses use personal contacts and previous social relations for market orientation. Currall and Inkpen (2002) argue that trust in international joint ventures changes over time and moves between three levels: person, group, and firm. They state that the cultural and national context of trust affects the development of relationships and trust, suggesting new studies on multilevel trust in different contexts and cultures. Trust at one level can have negative or positive influence at other levels. Thiede (2005) argues that marketing healthcare services in a new country requires good communication between actors and cultural understanding for building trust and networks. He considers trust as the result of social relations developed between people in networks based on shared values. Given the complex nature of healthcare, we think networking is important in different areas for creating multilevel trust. A marketing strategy can only be fruitful when different trust levels are interconnected and mutually reinforced.

Trust development and marketing strategy
Jiménez and San Martín (2014) find that a country's brand reputation impacts trust development and purchase intentions in emerging markets. Helm and Gritsch (2014) find disadvantages to using a one-size-fits-all marketing strategy when entering new markets. Marketing mix is central in planning and developing a strategy for entering both domestic and international markets (Daniels, Radebaugh, & Sullivan, 2013). Whereas Daniels et al. (2013) find marketing mix central, Zeithaml, Bitner, and Gremler (2006) consider marketing mix peripheral and that an in-depth view on service quality and growth of relationships between customers and sellers is needed in developing service marketing strategy. Kotler, Manrai, Lascu, and Manrai (2019) point out that country and company characteristics influence the choice of marketing mix and adaptation, standardization of products and services (Vrontis, Thrassou, & Lamprianou, 2009). In healthcare marketing, we argue that customization and culture closeness are necessary to create trust for customers and surrounding networks to satisfy customer needs. A service marketing strategy needs transparency on how multilevel trust is built, integrated, and communicated with customers.

Theoretical framework
We assume that cultural context and individuals' perception of the COO of brands vary and determine the willingness to develop trust and purchase intentions. We propose a theoretical framework for the process of multilevel trust development (Boersma et al., 2003;Nooteboom & Six, 2003) that rests on four constructs (Fig. 1). It shows how cultural and COO context influence trust development on three different organizational levels (micro-individual, meso-company and macro-country) in relation to network and marketing strategy in international healthcare marketing (Fregidou-Malama & Hyder, 2015;Fulmer, 2018;Hofstede et al., 2010;Michailova & Holden, 2019). Individual-level trust relies on employee values, perceptions, and relationships with actors in the local context (MacDuffie, 2011), company-level trust deals with the reputation and expected competence of the company (Altinay et al., 2014), and country-level trust is based on COO reputation and national culture beliefs and traditions (Johns, 2006;Magnusson et al., 2011;Michaelis et al., 2008). Trust between partners is important for establishing long-term relationships with different actors in the foreign local market (Håkansson & Snehota, 2000;MacMillan et al., 2005MacMillan et al., , 2017. With trust, healthcare service providers can communicate with customers (Gilson, 2006;Patterson, 2016) and choose an appropriate marketing strategy to satisfy their needs (Singh, Kumar, & Baack, 2005).
Local people are involved to make foreign healthcare services visible, trustworthy, local, less unfamiliar, and less uncertain. Similarly, network development encourages resource and information exchange between actors, which helps foreign firms to understand the local culture and maintain credibility in the new context (Cova & Salle, 2000;Mayer et al., 1995). Fig. 1 illustrates the importance of context, its effect on trust levels, and how trust influences business networks and development of marketing strategy, which in turn affects trust development and prevents conflicts.

Methodology
We apply a qualitative research method to provide insights into reallife situations (Yin, 2014). According to Poulis, Poulis, and Plakoyiannaki (2013), qualitative research is suitable to understand the role of actors in different contextual settings and international relations. Doz (2011) observe that international services marketing is complex, and therefore data should be collected from different sources to offer a holistic view of the situation. Considering the complexity of the research issue, we apply the qualitative to develop close and trustful relationships with the respondents of different nationalities. We used a multiple case-study design, where the unit of analysis is the firm Elekta (Fletcher & Plakoyiannaki, 2011;Klein, Dansereau, & Hall, 1994;Levers, 2013) and the level of analysis is the subjective experience and interpretations of independent respondents from the associated firms and the country contexts on how trust has developed. This approach allowed us to collect rich data for developing an empirically grounded multilevel trust model.

Case selection
Considering theory building (Eisenhardt, 1989;Martin & Eisenhardt, 2010;Miles, Huberman, & Saldana, 2014) and the need to explain the process of multilevel trust construction, we selected five Elekta cases that would allow us exposure to different geographical locations (Johns, 2006;Langley et al., 2013) and cultural contexts (Hofstede et al., 2010). The selected countries differ from Sweden in two of Hofstede's cultural dimensions indicating large power distance and collectivsm (1991). We considered different forms of business operations like Elekta subsidiaries in Brazil, Hong Kong, and China; a private company in the Philippines; and distributors in Russia, to obtain robust data from different contexts and permit comparison between the cases. The aim was to contribute new insights focusing on professional experience within heterogeneous settings. The selected firms, which had been established and operated for more than five years, represent different sizes. We obtained understanding of the case environments from different perspectives by using interviewers who spoke local languages including Swedish, English, Filipino, Mandarin, and Russian in combination with English. The interviews were transcribed into English to allow comparison of the informants' answers. By selecting multiple cases in different contexts, we responded to previous researchers' call to developing marketing theories based on empirical facts and comparison across cases (Miles et al., 2014;Zeithaml et al., 2020).

Data collection
Observations, documents, and semi-structured interviews were employed to increase our understanding of multilevel trust development. Thirty-six interviews lasting 30-210 min were conducted during 2010 and 2016 at Elekta's head office and Karolinska University Hospital in Sweden, as well as at the case companies and their customers. According to Johns (2006), one of the contextual dimensions affecting organizational behavior is time. We have therefore carefully examined whether the time period of the cases and for the interviews had impact on trust development themes. We found that the time perspective helped us to develop concise concepts and formulate a theory on multilevel trust founded on five different context realities, with different chronological times and language use of the respondents (Langley et al., 2013;Michailova & Holden, 2019).
We applied purposive sampling, allowing variation in sources and replication of the information for triangulation (Patton, 1990). Using a snowball technique (Bryman & Bell, 2015), we approached key knowledgeable professional experts in medical and business issues involved in the process of healthcare services marketing (Table 1). Thus, our data from diverse participants reached saturation level (Glaser & Strauss, 1967), confirming that further data could not add additional value for categorization (Bowen, 2008).
Considering cultural sensitivity, and to increase credibility, we made contextual observations while visiting customers in two hospitals and two private clinics specialized in the treatment, the headquarters in Stockholm, and two of the firms' offices, and used annual reports. We were able, for example, to monitor quality, meet engineers and medical experts in the hospitals or clinics, observe and discuss the treatments or the interaction between customers and employees, and read about how the parent company Elekta shares responsibilities with their associated companies. A research protocol covering the study topic, ethical issues (Richards & Schwartz, 2002), and areas including background of the respondents and the firms was applied. The repondents were asked to share what challenges they met and how they dealt with them in marketing of Elekta products and services in the new locations. Annonimity of the repondents was maintainted while presenting the data to encourage the repondents talking freely. The multiple sources of evidence and the contextual knowledge the participants offered us enhance the credibility and the construct validity of our research (Yin, 2014).

Data analysis
The two authors together inductively coded the data manually in collaboration with the interviewers to avoid misinterpretation. We performed within-case and cross-case analysis, considering each firm as a case to identify and create themes for developing theory (Martin & Eisenhardt, 2010;Tasavori, Zaefarian, & Ghauri, 2015;Yin, 1981). To conceptualize our thinking on the individual responses, we analyzed the interviews in order to write memos and develop codes (Glaser & Strauss, 1967; Miles et al., 2014), considering explanations, relationships, and challenges the respondents met (Table 2).
With open coding (Corbin & Strauss, 1990), we scrutinized each company's data to ascertain whether we had obtained accurate empirical evidence to proceed with thematic analysis (Braun & Clarke, 2006). We prepared case histories on Elekta's operations in each of the five countries by synthesizing all interview responses (section 4). We developed extracts considering similarities and differences by constant comparison of research data to identify four central concepts linked to trust: culture, COO, networks, and market. We linked the concepts to four initial themes conceptualized as (1) Trust and culture, (2) Trust and COO, (3) Trust and networks, and (4) Trust and market (Table 3). Under each theme, we grouped data that emerged by within-case analysis, comparing similar phenomena in the cases to understand how multilevel trust was developed.
The next step of the analysis was to group similar phenomena by cross-case comparison of the coded evidence (Corbin & Strauss, 1990) to identify characteristics of trust at three levels-individual,-company and -country-theorized as individual, company and national-level trust (Table 4). Following Patton's (2002) dual criteria for judging categories, we checked the internal homogeneity and external heterogeneity of the data, confirming that trust characteristics fit together meaningfully and that distinctions within trust levels existed. We critically examined and refined the research data and linked trust levels with the relevant theories. Fig. 2 presents our empirically grounded emerging theory on multilevel trust, along with the characteristics of the three levels of trust and the dynamic relationship between them.
According to Eisenhardt (1989), 4-10 cases can be suitable when the aim of a study is theory development. The confirmation between earlier theories and the developed theory of multilevel trust establishes internal validity and allows generalisation of the results.

Empirical evidence
Responses from informants related to each country case are presented here. The cases are developed by following the intial themes. Quotations have been used when the respondents like to highlight some important issues.

Elekta in Brazil
Elekta entered Brazil in 1998 via a representative and started a wholly owned company in Sao Paulo in 2007. This change was made due to the absence of trust of the representative: he sold used equipment and customers thought Elekta offered only old technology, which the competitors used against the company damaging Elekta's reputation.
The respondents explained that they tried to change this conception by asking doctors what they needed so they could provide the right facilities. They invited customers/doctors to visit the cancer center to show and discuss the offerings with them, to create trust of and loyalty to Elekta. To provide the customers the best solution, Elekta representatives offer knowledge and information on how to use the technology.
The informants stated that the Swedish approach is well accepted in Brazil and people appreciate the Swedish way of doing research and taking care of their customers. People think Swedes are careful and consider Sweden a serious and successful country, and they feel the same for Swedish brands. Swedish diplomacy, humanitarian efforts in the world, and the culture are well known, which opens doors.
The company offers solutions for oncology clinics, develops training systems, and offers high-tech equipment and qualified service support to users. Elekta introduced training for employees and end users and certified the education to ensure customers receive the same highquality service. The service technicians and salespeople receive expert help from Sweden to formulate contracts, adapting them to local rules. Elekta succeeded in hiring a local person with unique expertise to do business in Latin America. This executive, who also became the head of the Brazilian subsidiary, was respected in the market for his close contact with the customers and the government. One respondent explained: We hired a person who used to work with neurosurgeons in the operation room. This person knew about Gamma Knife, making a good start for us. This approach helped us to sell eight Gamma Knife facilities in three years.
The company recruits people who know the healthcare market, and the doctors are well known in the local community. One informant remarked: The goal is to have local management and local services show commitment to the local market. Radiosurgery is a small market and people know each other, and trust and confidentiality are keys to success.
The Brazilian government has asked Elekta to assist in cancer treatment planning due to a lack of local experts. The executive vice president describes a risk of a brain drain of healthcare experts from emerging markets. Therefore, Elekta must assist in developing education and research possibilities, establish reference centers, and adapt to the country conditions. Elekta develops relationships with governmental officials and experts in cancer treatment, and cooperates with the National Cancer Institute in Sao Paulo, universities, hospitals, and clinics. The company also offers a network for knowledge exchange as part of the Leksell Gamma Knife Society. The company offers customized aftersales maintenance and customer support, with a team of engineers both in hospitals and remotely. They tailor the technology to the customer's needs, offer total solutions, upgrade the offerings, and have the right person to treat the right need.

Gamma knife in the Philippines
In 1997, a few doctors established the Philippine Gamma Knife Centre Inc. (PGKC), located at the Cardinal Santos Medical Centre, to facilitate bringing in patients from the hospital to the clinic and developing networks. To spread knowledge about the service offerings, the company introduced free Gamma Knife treatment for military personnel and their families. Informal relationships with medical schools and hospitals provided positive information about the service.
The doctors were trained in Sweden and Germany to become licensed medical physicists to handle the Leksell Gamma Knife and bring new technology and the same quality of treatment as in Sweden to the Philippines. To deal with old traditions and resistance from other doctors, the company introduced the Gamma Knife treatment through lectures and newspaper and journal articles. One repondent explained their commitment on the treatment:

Gamma Knife is one of the rare developments in the field of neurosurgery that actually makes a difference in the treatment of neurosurgical problems. Gamma Knife is a new technology with a new mentality of treatment replacing the traditional way of thinking.
To recruit employees, they use personal relations. When treating people, they meet patients together with their family members and introduce them to experts involved in the treatment. To live up to the promised standard of quality, the doctors practice time management and professionalism. The doctors consider advertising healthcare unethical and rely on word-of-mouth recommendations by satisfied patients for treatment of more patients.
The firm offers internships to medical students. It also uses the equipment for diseases like Parkinson's and dystonia. PGKC is a member of the Leksell Gamma Knife Society and the Asian Leksell Gamma Knife Society and shares information, experiences, clinical techniques, and advances in scientific research. Through informal networking and social activities, they develop knowledge for curing diseases. The doctors adapt prices considering the economic situation of patients and treat some patients for free.

Elekta in China
China is Elekta's second-largest market after the USA. The company is situated in Shanghai and was established in 2000. In 2006, a second joint venture was started in Beijing. Elekta's mission is to improve radiation therapy, emphasizing research and development by recruiting highly skilled local engineers. By accepting the firm's promotional activity, Chinese authorities show confidence in Elekta and the Swedish state-of-the-art solution.
Elekta offers hospitals access to publications and networks and encourages sharing ideas and knowledge. Communication of the benefits of the solutions, service quality, and relationships in the local market persuades customers to trust Elekta's offerings. They find Sweden's reputation advances the corporate reputation and benefits the company. Word of mouth is also important in initiating, developing, and maintaining trust locally. Elekta recruits local employees familiar with the market and culture and fluent in the language.
One informant states: Emphasize the need to meet individual users and other customers to get the opportunity to talk with them about the services.

Trust and market
The company's culture should be based on the local culture to understand what the customer says. Chinese also learn from the Swedish values of responsibility and service orientation to patients.
The respondents emphasize it is essential for Elekta to establish contacts with the local government and customers and develop guanxi. Guanxi facilitates permission to enter the market and creates the trust needed for getting licenses. Respondents believe guanxi can only be established by developing personal relationships with authorities and customers. Trust must be developed before selling a service, and guanxi must be cultivated with authorities and customers even after selling equipment. One respondent explains: In marketing of healthcare, you must provide today high quality of services, offer better prices and build trust to compete in the Chinese market. Our engineers work day and night to solve the customers' problem. We cannot let customers stop providing a service, it does not matter how much it costs for us.
Elekta standardizes the training system and sets the pricing to maintain service quality. The company offers education and training and sends updates to the customers. Elekta considers it important to establish treatment centres in rural areas with qualified specialists and engineers to train customers/users and provide good service.

Elekta in Russia
The first medical center was established in Moscow in 2005 for stereotactic radiosurgery and a second in St. Petersburg in 2008 to operate on patients with brain tumors.
Russians believe Swedish people are open, direct, and honest. The interviewers observed a positive response from the Russian doctors to participate in the research, as soon they understood that it concerned a Swedish research project. The doctors say that the image of Sweden positively influences quality perceptions.
Elekta creates loyal customers by developing long-term relationships and providing quality products and services. The corporate image of the company affects the establishment of trust between doctors. One informant states: Especially those who are involved in the medical area, they usually know Karolinska Institute and its research, which benefits the Swedish equipment and increases trust and awareness.
The purchasing procedure varies depending on the customer. For private clinics, interaction takes place directly with Elekta. In public healthcare, relationships with Elekta are often indirect and go through local distributors. Regardless of how the equipment is acquired, a  customer must have a license to offer medical services and must follow the legal requirements in the Russian market. In turn, Elekta must follow local standards to qualify as a medical equipment supplier and gain tax exemption. Elekta participates in congresses and fairs, performs peer-to-peer activities, and develops contacts with policy makers. They train and educate users and communicate with medical centers to ensure they deliver the best treatment. The most important contacts are with research institutions, for exchange of information and experience. Elekta translates the software into Russian and organizes events with Russianspeaking doctors to facilitate knowledge transfer and sharing of experience. Elekta operates in Russia through prescreened distributors, who sign a code of conduct promising they will not engage in corruption. The distributors help Elekta understand the Russian market and discuss local issues with authorities.

Elekta in Hong Kong
Elekta's entry into Hong Kong began in 1992 through distributors; a regional office was established in 1996, which is the base for Elekta Far East. The staff is a mix of expatriates and local staff, but they prefer locals for cultural and language skills.
An important group for Elekta to develop trust with is the neurosurgeons, who learn about the invention of the Leksell Gamma Knife during their studies. They consider Sweden to be a producer of hightech, high-quality, reliable products. One repondent comments: We try to show ourselves as honest Swedes and an honest Swedish company that is possible to rely on, maybe this is a strategy we use. We try to make our values visible.
Elekta markets their offerings to public hospitals and is asked to present creative ways of financing and sharing risk with customers, invest in the hospitals' operation, and locate staff in medical centers. During consultations, doctors prefer patients to have family members present, because patients can get upset and have trouble remembering what was discussed. Price is set by the market; customers are aware of prices and good at negotiating. Elekta must convince local staff of the applicability of the treatment; otherwise, they refuse to learn new systems.
Elekta sends experts to meetings of the Gamma Knife Societies. An additional network through professional organizations lets them exchange employees between the hospitals. Personal relationships are important in the healthcare industry. Long-term relationships are significant between salespeople and customers, but the status difference between doctors and salespeople must be maintained. Elekta cooperates with public hospitals, which can send patients to private clinics; they also attend conferences and customer meetings to create confidence, and they use a local third party to establish trust.

Results and discussion
This section presents four initial themes. We reflect on similarities and differences in the answers of the respondents under each theme and link to the theories. An empirically based multilevel trust (MLT) model is then presented.

Construction of the initial themes
After the case descriptions, we summarize here the coded evidence in four initial themes (Table 3).

Trust and culture
In the cases, cultural context largely consists of factors such as family presence (the Philippines and Hong Kong), significance of local language (Brazil, Hong Kong, Russia), collaboration (Hong Kong), respect for tradition (all cases), and the role of authority (China, Brazil, and Russia). These concepts can be related to collectivism, power distance, and femininity (Jiang et al., 2011). The large power distance and collectivism of the investigated countries and femininity of Sweden necessitates relationship development with individuals, local organizations, and groups. Building formal relationships, which is a requirement in Sweden, a small-power-distance country, requires respect for local traditions and collectivistic values, as suggested by Hofstede et al. (2010). Failure to understand cultural differences and the local language complicates the development of relationships between stakeholders (Friman, Gärling, Millett, Mattsson, & Johnston, 2002). Local understanding (Michailova & Holden, 2019) and response to local cues, as Dietz et al. (2010) argue, were found to minimize cultural difference and

Trust and COO
Trust development emphasizes the role and effect of Swedish highquality medical treatment (all cases), country and company reputation (Brazil, Russia, and the Philippines), personal contacts (all cases), socializing and interacting with actors (Hong Kong), providing technical support (Brazil and China), and service quality (all cases). These findings are in line with MacMillan et al. (2005) and MacDuffie (2011), who emphasize the importance of personal communication and context in trust building. Michaelis et al. (2008) and Diamantopoulos et al. (2011) affirm the impact of COO and people's perception of brand quality as part of marketing strategy in developing trust which our cases also highlight. The cases stress the importance and effect of COO on individuals' positive attitudes toward the healthcare brand of Elekta, which elevates the trust development process.

Trust and networks
This study indicates networks can take different forms, such as longterm relationships (Russia and Hong Kong), guanxi development (China), exchange of views (the Philippines and Russia), contact with policy makers and authorities (Brazil, Russia, and China) and networking among individual employees, customers, international professionals, and organizations (all cases). Thus, network development can vary in different cultural and COO contexts and can involve a long process to develop trust through exchange of knowledge and experience between individuals, as observed by Håkansson and Snehota (2017). The cases highlight the need to establish relationships with local actors for knowledge development and trust creation to ease formulation of marketing strategy and delivery of healthcare services (Svensson, 2001).

Trust and market
Market strategy derives from involving highly skilled local people (Brazil and Russia), focusing on service quality (Brazil, the Philippines, and Russia), using the reputation and image of Sweden as COO (China and Hong Kong), contacts with family during consultation and treatment (Hong Kong), offering expert help (Russia and Brazil), and using word of mouth (China and the Philippines). Singh et al. (2005) connect marketing strategy with trust and network development by emphasizing service quality and the role of context. Wong andMerrilees (2009) andJiménez andSan Martín (2014) point out the need for local adaptation in developing a trustworthy marketing strategy in new contexts, which our cases also highlight. We agree with Zeithaml et al. (2006) who maintain that marketing mix is less relevant and therefore focus is required on individual customer needs and perceptions in different eco-systems.
To summarize, importance of service effectiveness and Swedish branding are evident in all cases and can be linked to cultural context and COO of the healthcare service. Service quality is maintained differently in each case. In the Philippines, service quality relates to supporting teamwork and allowing relatives for consultations and taking joint decisions. In Brazil, it is expressed in terms of knowledge generation and technical support. Following local rules and prioritizing local people represents service quality in China. Using local distributors, respect and exchange of experience are highly appreciated in Russian marketing of healthcare services. Hong Kong is close to the Philippines in valuing teamwork, while close to Russia in knowledge exchange. In contextualizing its service concept, Elekta has maintained a standardized quality of service offering but adapted to local values and conditions for marketing. This mixed marketing strategy, influenced by cultural values and COO image, has contributed to service quality, trust development, and finally the MLT model.

MLT model and interaction between trust levels
Considering Table 3 and the similarities and dissimilarities across cases, we can categorize trust into three levels: individual, company, and national (Table 4) in constructing an MLT model (Fig. 2). We connect our finding and MLT model with Currall and Inkpen (2006);Fregidou-Malama and Hyder (2015); Fulmer (2018); Jiménez and San Martín (2014); Lyu and Ferrin (2018); Mouzas et al. (2007);Nooteboom (2003) and PytlikZillig and Kimbrough (2016), who identified different trust levels. National-level trust at the macro-level relies on image of the healthcare brands, reputation and image of people and the healthcare service quality of COO. Company-level trust at the meso-level is based on word of mouth communication of service quality, customization of services, corporate support and parent company's cultural sensitivity. Individual-level trust at the micro-level depends on professionals' local expertise, relationships, and communication of skills. Although national level trust offers initial trust and eases information sharing, all the trust levels in the MLT model are interconnected, reinforce each other, and can be simultaneously effective.

Individual-level trust
Elekta has developed trust at the individual level by recruiting local employees, distributors, experts, and developing long-term relationship in all countries. Word of mouth is stressed in the Philippines and China while family presence is highlighted in the Philippines and Hong Kong and peer to peer activites are appreciated in Russia. Jiang et al. (2011) and Patterson (2016) point out the importance of cultural context and communication between individuals for trust development. After-sales maintenance, word of mouth, teamwork, and respect for local rules, language, and traditions (Michailova & Holden, 2019;Usunier, 2011) further confer individual-level trust. Collectivism in the investigated countries and femininity in Sweden create personal relationships and networks. In addition, power distance relies on formal and informal relationships, showing the importance of people for trust development at the micro level in all cases and adaptation to local context as part of international marketing strategy, which our cases demonstrate (Hofstede et al., 2010;Fregidou-Malama & Hyder, 2015;Wong & Merrilees, 2009).

Company-level trust
Individual-level trust enhances the development of networks via word of mouth from satisfied doctors and other users, as found in the Philippines and China. Allowing the presence of family members in Philippines and Hong Kong, and the use of local expertise in all cases, increases trust at the company level (Zaheer et al., 1998). Thus, perceived service quality at the individual level is communicated through word of mouth and networking for enhancing the reputation of the firms and company-level trust. Elekta contributes to trust development at the company level by involving their customers in networks such as the Gamma Knife society, transferring know-how and team-building in the Philippines, introducing a training package in Brazil, bringing consistent service quality in all cases, sharing knowledge in China, team building and educating users in Russia, and offering financial solutions in Hong Kong. Elekta adjusts to local context requirements and adapts its marketing strategy to legitimize the companies and develop trust on the company level by employing individual-level trust.

National-level trust
Our research shows that positive COO perceptions, reputation of people and country and company image results in customers' and other stakeholders' willingness to learn about the company brand, which was expressed in this research as "reputation and image of Sweden" in Brazil, "Swedish treatment," in the Philippines, "Swedish state-of-the-art solution" in China, "Swedish openness and honesty" in Russia or "made in Sweden" in Hong Kong. This indicates that awareness of a brand's COO stimulates interest in the brand, informing the quality of the offering. COO has been found to influence trust and helps trust building on the country level, which we conceptualize as national-level trust in international healthcare services marketing (Diamantopoulos et al., 2011;Kotler et al., 2019;Michaelis et al., 2008). We argue that congruence of collectivistic and feminine values, and respect and belief in relationships among the studied countries, as well as the positive expectations and reputation of Sweden as COO of the healthcare service lead to the development of national-level trust (Table 4).
Networking helps to underline and communicate the importance of standard and high quality of healthcare offerings, as suggested by Zeithaml et al. (2006). Mayer et al. (1995) and Altinay et al. (2014) argue that belief in an organization's competence develops its credibility, and Jiménez and San Martín (2014) state that brand reputation enhances company trust, which our research also shows. National-level trust eases communication between individuals by positively affecting their expectations and confidence in Elekta at the company level. Singh et al. (2005) emphasize the relationship between trust, networks, marketing strategy, and service quality. Our empirical findings support a similar relationship, showing that multilevel trust is embedded in a contextualized complex interaction of individuals' cultural values and beliefs and COO perceptions in the international ecosystem.

Conclusions
The purpose of this research was to advance multilevel trust theory in relation to the international marketing of healthcare services. Our empirically developed MLT model reveals that trust is built at three interrelated levels: micro-individual, meso-company, and macronational (Fig. 2), each of which can affect the other. The newly conceptualized national-level trust and construction of the MLT model add value to the extant trust literature. The analysis identifies that company context sets the stage for the three levels of trust based on cultural values of collectivism, femininity and power distance, COO perceptions of reputation and image, and expectations of service quality and openness of the parent company. The study reveals that individuallevel trust is enhanced by company representatives' experience and market know-how in dealing with local customers. Company-level trust is augmented by responding and adapting to local context requirements for knowledge transfer, offering high-quality healthcare service and customer support. Company-level trust contributes to national-level trust by boosting country and people reputation of COO. Nationallevel trust initiates and revolves the trust development process by highlighting the technological and quality status of the healthcare service of the COO and by encouraging employees and the company to develop solid networks and a locally adapted marketing strategy to facilitate relationship development.
The study suggests that multilevel trust is a dynamic construct that generates understanding between service providers and local customers. These trust-based relationships generate ties with public authorities and institutions to gain acceptability for the healthcare services. We argue that understanding the cultural context and ability to network are linked to trust development in formulating an effective marketing strategy. Our research reveals that the cultural dimensions of power distance, collectivism, and femininity influence the trust development process by developing relationships, enhancing interaction, and networking to make services reliable and visible. What unites the layers of multilevel trust is the perceived competence of individual actors, the competence of the companies, and the country of origin reputation, which highlights the dimension of credibility in the process of trust building (Altinay et al., 2014). The cultural and COO environment involve the emotional congruence between individual, company, and country values to support the MLT building process.

Theoretical and practical implications
This study makes several theoretical and practical contributions. First, we complement and advance trust theory with the empirically grounded MLT model for international marketing of healthcare services. We conceptualize trust at three levels to demonstrate their dynamic interrelatedness in the trust development process. Second, we contribute to services literature by introducing the role of context in the process of multilevel trust development, utilizing characteristics of reputation, image, culture, and COO perceptions. We consider multilevel trust starts at individual level to proceed in parallel with company-level trust. National-level trust enhances corporate reputation at the company level, while the influence of word of mouth and local relationships support cultural integration and individual level trust. Third, this five-country comparative study is original and unique for jointly studying cultural context with COO to conceptualize multilevel trust as a new phenomenon. Previous trust studies have considered trust levels separately (Lyu & Ferrin, 2018;Zaheer et al., 1998). The MLT model instead takes up major components of the trust levels and shows how the three levels interact and reinforce each other in the trust development process for services marketing. Fourth, in this research we provide empirical results on how trust develops in five emerging markets, thus we respond to calls for research of Sheth (2020) and Zeithaml et al. (2020) on the need of just in time research in specific context. We present an empirically grounded model in a specific ecosystem. Fifth, we identify the role of language in developing interaction and multilevel trust in international marketing which also Michailova and Holden (2019) and Usunier (2011) highlight. Finally, our study implies that although the two cultural dimensions "collectivism" and "femininity" (Hofstede et al., 2010) are different, they have same impact on relationship and trust development. These dimensions help to bridge cultural value differences and facilitate networking and the process of multilevel trust.
As practical implications, the introduction of this MLT model provides insights into how managers can improve relationships and generate trust to market services internationally. Developing individual trust depends on how employees can interact and communicate with customers and other stakeholders through word of mouth and relationships. We recommend managers work in conformity with local practices primarily by recruiting local people to enhance individual trust, contextualizing local values, beliefs, and knowledge. Once individual trust is developed, we suggest managers work with companylevel trust by ensuring service quality and knowledge transfer and developing networks with the business community, public institutions, and other stakeholders. Networking is important for company credibility, which can be enhanced by the use of local language to sustaining a marketing strategy.
We advise managers to boost the positive characteristics of COO, share knowledge, offer expert assistance, and respond to local cultural value codes for enhancing national-level trust. In case of a negative COO reputation, we recommend managers focus on the company's strengths and create local contacts and networks for positive impact on trust development. Local recruitment is a way to value local expertise and practices when communicating with customers. Adapting to context contributes to locally relevant knowledge and viable cancer treatment alternatives, thus making a societal contribution in helping people around the globe to avoid suffering. We suggest managers to treat individual recruitment and company establishment simultaneously to facilitate multilevel trust development in the international marketing of services.

Limitations and future research
Our limitation to the healthcare sector and the selected countries opens new paths for further research. By careful selection of countries, firms, and respondents, the conceptual model of multilevel trust can be replicated in other contexts and services for generalization. In this research, we have compared individual respondents' answers from a country perspective. Comparing data between categories of respondents (nurses, managers, and doctors) would benefit research because different professions may affect trust development differently (Hofstede et al., 2010). A longitudinal study could be conducted to capture the dynamic nature of the multilevel trust in different times. This research is limited by applying a qualitative method. A quantitative or mixed method study combining cultural context and COO could complement trust theory building in the service literature. Furthermore, we explored the effect of the four original cultural dimensions of Hofstede (1991). Future studies could consider the other two incorporated cultural dimensions (Hofstede et al., 2010), "Long versus short time orientation" and "Indulgence versus constraint" to extend the current research. In this study we analyzed multilevel trust development from a country perspective to construct the MLT model. It could be valueable to explore if there is any other level of trust when dealing with geographical regions or clusters of country collaborations such as the European Union. This study does not consider the effects of digitalization and the challenges of the pandemic in multilevel trust development. We can see a new avenue of research to examine the role of digitalization and pandemic in international marketing, which Ghauri, Strange, and Cooke (2021) also highlight.