What does it mean to trust a health system?

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different features of the trusted health system. The health system and Canadian Medicare are identified sources of trust just as are individual health care ...
Health Policy 91 (2009) 63–70

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Health Policy journal homepage: www.elsevier.com/locate/healthpol

What does it mean to trust a health system? A qualitative study of Canadian health care values Julia Abelson a,∗ , Fiona A. Miller b , Mita Giacomini a a b

Department of Clinical Epidemiology and Biostatistics, Centre for Health Economics and Policy Analysis, McMaster University, Canada Department of Health Policy, Management and Evaluation, University of Toronto, Canada

a r t i c l e

i n f o

a b s t r a c t

Keywords: Trust Health care system Qualitative methods Canada

Objectives: We used a qualitative empirical study of Canadians’ values toward their health system to develop more meaningful conceptualizations of trust and health systems that can inform the pursuit of more trustworthy health systems. Methods: We convened nine focus groups in three Canadian cities in 2002 and 2004 in conjunction with a national public opinion telephone survey of Canadians’ attitudes and values toward their health system. Health system trust emerged as a significant theme in focus group discussions and was investigated using a modified grounded theory approach. Findings: Respondents construct cleavages and alliances to position themselves in relation to different features of the trusted health system. The health system and Canadian Medicare are identified sources of trust just as are individual health care providers. Core to the trust relationship is the experience of vulnerability which provides the impetus for placing trust (in providers, governments and health systems) or seeds distrust, mistrust and resilience in the same. Conclusions: We offer a more robust conceptualization of what it means to trust a health system. Policy maker efforts to intervene to restore lost trust could usefully be informed by these findings. © 2008 Elsevier Ireland Ltd. All rights reserved.

1. Introduction

decline, policy makers take measures to try to restore it. But what does it mean to trust a health system, and how do these meanings guide policy makers seeking to restore lost trust? These are the central questions that are explored in this paper by selectively reviewing the interdisciplinary trust literature to situate the empirical findings from a qualitative study of Canadians’ values toward their health system, which included conceptualizations of public trust in health care. By comparing and contrasting the perspectives of citizen respondents with those derived through theoretical development, we draw more meaningful conceptualizations of trust in the context of health systems to inform the pursuit of more trustworthy health systems.

Philosopher Onora O’Neill describes loss of trust as “a cliché of our times” [1]. Recently, much academic attention has been paid to explaining, predicting and prescribing solutions for this apparent crisis of trust [2–5]. Health systems have been especially scrutinized as they affect the lives of vulnerable patients and are the largest public expenditure program of many industrialized nations. Measures of trust and trustworthiness can be important indicators of support for health systems, and efforts to reform them [6,7]. When public trust appears to be on the

∗ Corresponding author at: Centre for Health Economics and Policy Analysis, Health Sciences Centre, 3H1, McMaster University, 1200 Main Street West, Hamilton, Ontario, Canada L8N 3Z5. Tel.: +1 905 525 9140x22122; fax: +1 905 546 5211. E-mail address: [email protected] (J. Abelson). 0168-8510/$ – see front matter © 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.healthpol.2008.11.006

2. Literature review We conducted a scholarly review of recent Englishlanguage texts on trust and health care systems to situate

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Table 1 Summary of literature search.

ship between the public, health professions and the state in the post-WWII UK NHS [18–20].

Databases (1995–2006)

Keywords (MESH terms)

OVID/MedLine

Trust AND delivery of health care

Applied social sciences index

Trust AND health-care system; Trust AND health system; Trust AND delivery of health care

CSA worldwide political science abstracts

Trust AND delivery of health care; Trust AND health-care system; Trust AND health system

ProQuest [ABI/inform global; dissertation and theses]

Trust AND health-care system; Trust AND health system; Trust AND delivery of health care

ScienceDirect

Trust AND delivery of health care; Trust AND health-care system; Trust AND health system

Sociological abstracts

Trust AND delivery of health care Trust AND health-care system Trust AND health system

our empirical study in the context of current conceptualizations. We searched seven relevant databases with a pre-defined set of keywords (Table 1). Texts that did not focus on the core theme of trust in health care or health systems or that did not include trust in the article title were excluded. 2.1. Making sense of multiple trust discourses In contrast to the vast interpersonal trust literature [8–10], inquiry into the nature of trust at the health system level is a relatively recent phenomenon [5,11]. It is motivated, on the one hand, by concerns about the transfer of popular mistrust in government and politicians onto health systems, fuelled by uncertainty about the effective, efficient and equitable use of health care funds, widely publicized medical scandals and emphasis on a patient safety culture [12–15]. On the other hand, state-society trust relations may play out in the opposite direction, where mistrust of health care can be transferred to government and models of governance. Because publicly funded health systems comprise such a large degree of state-citizen interaction, mistrust of health systems may contribute to a general mistrust of government. In this way, the health system’s contribution to the construction of broader social values and trust, specifically, flows directly from the interaction between citizens and their health system [5,16]. The health-related trust literature gives particular attention to the central role of trust in patient–provider and provider–state agency relationships [8,14,16,17]. Shifts in citizen–state relations have also garnered attention as the era of paternalistic professional–patient relations has been replaced by the current mode of entrepreneurial customer centered relations. Indeed, consumerism and an erosion of the public service ethos driven by entrepreneurial values in the public sector is widely believed to have undermined the trust in professionalism that underpinned the relation-

2.2. Meanings and levels of trust and trustworthiness Hall et al. [21:615] portray trust as inseparable from vulnerability suggesting “there is no need for trust in the absence of vulnerability”. Indeed, Davies [3] describes trust as an embodiment of expectations that vulnerabilities will be protected rather than exploited. Similarly, dependence, reliance and confidence appear as core dimensions of most trust definitions. Vulnerability and its analogues are typically viewed through the lens of the patient–provider relationship—where vulnerability that is created through illness and the need to seek care as well as the information and other asymmetries that arise from the specialist nature of scientific, medical knowledge [12]. Yet vulnerability, dependence, reliance and confidence could be placed, lost or restored, at either the individual or institutional level and while conceptualizations of these individual–institutional relationships are growing, few empirical investigations have fully explored their dynamics. Evidence to date suggests that interpersonal patient–provider relationships (as compared to the more impersonal relationships with insurance plans) play an important role in shaping views about health plan trust relationships [22] and that measures of system trust contribute to the development of interpersonal trust [23] but precisely how interpersonal trust might affect institutional trust is much less clear [24]. The need to find ways to understand these interdependent relationships is of paramount importance [24,26,27], yet the idea of trust in large-scale institutions or health systems is daunting when the condition of trust—that the ‘truster’ know the ‘trusted’ cannot be fulfilled given the distance of government from its citizens or health plans from its members [25]. Moreover, evidence about how trust can be nurtured, whether it can be viewed as a performance indicator and what makes a health system trustworthy is even scarcer [4,7,20]. Finally, most conceptualizations of trust invoke the related concepts of distrust and mistrust. Political scientists note that democracy itself, paradoxically, institutionalizes distrust, which is considered a positive feature of relations of dependence and authority essential to democratic progress and to the “healthy suspicion of power upon which the vitality of democracy depends” [28: 310]. Distrust provides a form of “insurance for those who would be ready to risk trust, as well as a corrective of actual violations of trust, if they occur” [29:140]. Distrust, then, may comprise healthy skepticism while mistrust comprises a more unhealthy cynicism driven by actual or suspected misdeeds. 3. Methods and data 3.1. Study design Focus groups were convened as part of a study of Canadians’ attitudes and values toward their health system during a period of intense public discussion in the early 2000s. The focus groups were designed to probe the views of a cross-

J. Abelson et al. / Health Policy 91 (2009) 63–70

sectional survey of Canadians, to better understand their attitudes toward options for health system reform. Three sets of three focus groups (N = 9) were held over a 2-year time period in three Canadian cities (Hamilton, Toronto and Montreal). The first set (two English language and one French language) was convened in November 2002, just prior to the release of the final report of a national commission (the Romanow Commission) investigating options for reforming the health system. In November 2004, six additional focus groups were convened in the same three cities. Three of these were ‘new’ focus groups convened with individuals who had participated in a second national cross-sectional survey administered between October and December 2004. The remaining three were ‘reconvened’ focus groups with 2002 participants who had provided their consent to be re-contacted.

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Table 3 Data analysis search terms. Synonyms of trust

Antonyms of trust

Acceptance Accountability Assurance Certainty Certitude Confidence Credence Conviction Dependence Faith Honesty Positiveness Reliance Respect Responsibility Stock

Anxiety Disbelief Distrust Doubt Dubiousness Fear Hidden agenda Incertitude Incredulity Lies Loss of faith Mistrust Non-confidence Skepticism Suspicion Uncertainty

3.2. Focus group participant recruitment Focus group participants were recruited from respondents to a national public opinion telephone survey of a random sample of Canadians conducted by an independent university-based survey research firm. Telephone survey respondents were asked if they would be willing to participate in a 3-h focus group discussion on the same topic. Interested participants consented to release their name, address and telephone number to study researchers to contact them. Recruitment was not linked in any way to survey responses or individual attitudes expressed toward different options for health system reform. 3.3. Focus group participants Participants ranged in age from 18 to 79 with an average participant age of 48 years. Slightly over half of the participants were female and 60% had completed some or all of a university or professional degree program (Table 2). Illustrative quotes have been assigned a code to protect anonymity. Code labels include the city in which the focus group took place and a letter indicating the set of focus groups in which the respondent participated (i.e., 2002 (“A”), 2004 (“B”), 2002 and 2004 (“AB”). Some attrition occurred and 16 of the 27 2002 participants returned to the 2004 focus groups. 3.4. Focus group discussion guide The 2002 focus group guide addressed a number of themes including: (i) what constitutes ‘public values’ toward a health-care system; (ii) what are Canadians’ prevailing values toward their health care system and how

have they changed over time; (iii) what values Canadians hold toward different financing arrangements for health care services; (iv) how values toward health services and their financing arrangements are shaped. A modestly revised version of the focus group guide was used in 2004 to reflect contextual changes to the Canadian health policy landscape. 3.5. Data analysis Focus groups were audio recorded and transcribed verbatim. Formatted transcripts were imported into the qualitative software program QSR NVivo (version 2.0) for analysis. The lead investigator (JA) and one of the co-investigators (FM) read through a subset of the transcripts to generate a set of preliminary themes. During initial research team discussions of the transcript data, health system trust was independently identified by both reviewers as an emerging theme. This theme was then investigated more fully using a modified grounded theory approach, adopting iterative and constant comparative analytic method of grounded theory [30–32] but with a more reflexive, hermeneutic approach to data interpretation that draws on prior theory [32]. The English language transcripts were searched for: the term trust; synonyms of trust and antonyms of trust (Table 3). The text searches informed the development of a preliminary coding scheme which was applied to the full set of 9 transcripts. Discussion among research team members and a review of the conceptual/theoretical and empirical trust literature informed further refinement of the coding scheme. The method of investigator triangulation was used to assure the validity of our findings.

Table 2 Demographic characteristics of focus group respondents. Focus group location

Participants (N)

Female (N)

Mean age (range)

Education level (N) High School

Hamilton Toronto Montreal

21 26 20

10 15 11

48(19–79) 46(18–72) 50(23–76)

Total

67

36

48

Tech/college

University/professional

6 2 6

8 3 2

7 21 12

14

13

40

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4. Findings In discussing the health system and their relationship with it, our respondents pose three interrelated questions: Where should we place our trust? What makes a health system trustworthy? And, What is the role of trust? In asking, “Where we should place our trust?” respondents attempt to locate themselves in relation to the thing to be trusted. This effort involves positionings that specify cleavages between “us” and “them,” and by extension, identify alliances that define who is “us” – the truster – and who or what is “them” – the health system to be trusted. In asking “What makes ‘them’ trustworthy?” respondents consider the role of institutions as guarantors of the trustworthy behaviour of those working according to their rules. Finally, in asking, “What role does trust play?” respondents contemplate the relationships between trust, distrust and mistrust, illuminating the important role of distrust for those vulnerable to the harms of health systems, and the risk of mistrust where vulnerabilities and trust are betrayed. 4.1. Thematic findings I: where should we place our trust? Locating trust in health systems Focus group participants vividly portray efforts to locate themselves with respect to people or things to be trusted. A range of trust cleavages – cleavages that separate “us” from “them” are revealed through these depictions. Simultaneously, these cleavages construct alliances – between individuals and different actors in the health system (e.g., providers, governments, industry and the media). Participants characterize these alliances according to their beliefs about which players in the health system share vulnerable individuals’ interests and fulfill a fiduciary duty to protect them. Symmetrically, cleavages are drawn where participants perceive conflicts of interest or lack of overriding commitment to care and protection. A first location is that of the “outsider” – where the individual positions him/her-self “outside” the system as a whole, including its agents. For some “outsiders,” this positioning arises from a sense of profound vulnerability. For example, a vulnerable older person of limited financial means is concerned that the system, depicted as an alliance of government and doctors, might not value or care for him. . . . I find as I get older, the ability of the health care system on any level becomes more and more important. . . .I have to try to trust that my doctor knows. . . . I think it’s mostly getting older that I want to develop more confidence in my doctor in the health care system and so on and I’ve got to admit that I’m feeling a little neglected on a social level . . . And I’m just concerned; it is a value thing that I’m going to become even more meaningless in the next 10 years than I feel now . . .. [Hamilton AB] A second “outsider” positioning – and trust cleavage – is found in respondents who position themselves as allies with their health care provider against the system (specifically, government forces). Health care providers are portrayed as trusted patient allies working in their patients’ best interests despite a government that is working against these interests. Perceptions of government

waste and inefficiency simultaneously bolster the alliance between patient and provider – where trust resides – and deepen the cleavage with government – where trust is correspondingly diminished. My family doctor is an awesome doctor; I know he takes a number of patients that he’s not supposed to be taking but this is because he speaks the language and he can help those people. But the government has given him so much trouble. He takes 100 patients a day and the government only wants to pay him for 25 and every time he takes more patients, the government cuts more money that he’s getting. And this guy’s not working for the money, he’s working to help people and I really think that it should change. [Hamilton B] A third trust cleavage expands the “us” beyond the classic “patient and provider” dyad to include a nebulous sense of the larger “system”. For some respondents, the system includes government as a partner. Part of the idea of a good health care system, does it foster a belief that in broad terms it’s going to be able to take care of the people who need to tap into that resource. Largely we depend on Government to make certain decisions that hopefully positively effect health care for me. I believe they are doing what they can to help. [Hamilton A] More typically, governments, and the politicians who run them, are located “outside” the system. In these conceptualizations, the system remains larger than the simple doctor–patient (or health professional) dyad: it is the “supplier”, providing “services.” Respondents have faith in the system: “it’s a good system.” Yet they fear the hidden agendas of governments and politicians as described below. Part of me sort of believes in kind of a conspiracy theory that governments do sort of starve the system for a while just to sway people in the direction that they want and then make people lose hope and lose patience and then sort of use that as justification for changing the system. So I think I agree, we have to fix what we have and show, I believe it’s a good system and I think we can make it better by efficiency and accountability if you want to use those key words. [Toronto AB] Government and public institutions are not the only targets of harsh criticism. Industry – corporate interests and pharmaceutical companies in particular – is viewed as a complicit collaborator in the design of government’s or politicians’ hidden agendas and is the object of some of the most vehement expressions of mistrust. I think that our governments, doesn’t matter which one it is, are run by big business and the corporations and pharmaceutical companies. . . . it’s the corporations who are running the world and . . . they’re sort of inundating people with this message, “we can’t afford this health care system.” Why can’t we afford it? We have a surplus; our GNP is higher than it’s ever been. We can afford it; we can afford to look after our people. [Hamilton AB] Media are similarly portrayed, though their partners are not always the same. Sometimes media are viewed as

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working with government to coerce the public; in other instances, media are viewed as voices for corporations trying to influence change. In these portrayals, the system and government are almost viewed as trusted partners working against powerful media that are skewing their messages. I am very critical when it comes to the behaviour of the media. I think that they have proven to be very irresponsible in the last few years. I believe that the media has a great deal of responsibility where the public is concerned, especially when dealing with a gullible public. And I believe that if we could set the public’s perception of medical treatments or of the Canadian health care system straight, we could then, maybe, have a good health care system. . . .I believe that the media and the governments have a huge responsibility where we’re concerned. [Montreal A] 4.2. Thematic findings II: what makes health systems trustworthy? Sources and determinants of trustworthiness To some of our respondents, the health system and its institutional features evoke powerful expressions of trustworthiness. Expressions of “comfort” and “security” derive from a system that they were “brought up with” {Hamilton A] with its core attributes of access to care based on need rather than income. . . . one sense I get from the Canadian health care system the way it is now, is a sense of security and I think that everyone here has been touching on that too, saying that they know they’re secure in terms of their illnesses getting taken care of and I feel the same way. [Hamilton B] These powerful images of what constitutes a trusted health system also evoke strong views about how the “system” must be structured to ensure that it remains trustworthy. Dealing with abuses of the system through accountability structures like the one proposed here is one way of ensuring this. He was charging for people that hadn’t even been to see him. . . . let’s suppose that I go and get a minor surgery done. Two weeks later, I should receive a statement of charges in the mail which tells me “Mr. JL, you had a minor surgery and it cost the public so much.” Ha! That would be the way to do it. [. . ..] So that’s also something that’s a problem. It’s that we don’t see the costs. We imagine what they could be but we don’t see them. There were salaries of over twenty thousand a month and they were working something like sixteen hours per month. You do the math. It’s awful. I mean to say, there’s something that must be done there, . . . frankly I find that it constitutes abuse. [Montreal A] Concerns about the profit motive and business models in health care are also seen as threats to trustworthiness. Respondents highlight their vulnerability to inferior quality care, and to the reduced commitment to, and scrutiny of, patient care perceived to be associated with these models. In so doing, they suggest that the system is made trustworthy by structuring the individuals working within it to behave appropriately.

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Who is going to watch dog the non-unionized worker? The nurse who maybe didn’t quite cut it for the hospital, but this person who’s hired them for a for-profit centre and isn’t quite up to snuff and she’s done something wrong, or a doctor for that matter. Is there a watch dog over them or a right to sue there? [Toronto A] 4.3. Thematic findings III: what is the role of trust? Vulnerability and “healthy skepticism” Respondents’ efforts to locate trust, and to figure out who is “on our side,” together with discussions of what make a health system “trustworthy,” are saturated with expressions of vulnerability. Vulnerability and trust are twinned: where respondents are vulnerable to the effects of a health system (or health care professional), they articulate a desire or demand for trust. Yet trust is not simply an automatic response to vulnerability, it is an active stance. People place their trust in some objects and not others; they deem some institutional arrangements to be more or less trustworthy. They also – as we discuss here – use trust as a “test” of the health system, through expressions of distrust or “healthy skepticism”. Active efforts to place trust in a system to which they are vulnerable (through distrust or healthy skepticism) can lead some to withdraw from the situation of vulnerability. I think as we get older our values change and I like the idea of looking at this in a sharing, compassion community and I think of all warm fuzzy words that are great and everybody feels really good about them, until you are in a position where it actually starts applying to you. And I know with my own circumstances, one of the things I found most difficult in dealing with the health care system is the complete and absolute sense of futility. [. . ..] As I get older and go through some personal things myself I start thinking you know, if the option is there that I can pay for this and look after myself, great! I love the idea of a universal health care system but you know as I think I’m going to get older and start needing it; I’m going to look at different options. [Toronto B] For other respondents for whom independence is not an option, vulnerability to the system fosters healthy skepticism to ensure that powerful players are “doing what they can to help”. . . . I think right now the health care system is being challenged. . . . I guess part of the idea of a good health care system, does it foster a belief that in broad terms it’s going to be able to take care of the people who need to tap into that resource . . .. Largely we depend on Government to make certain decisions that hopefully positively affect health care. I believe they are doing what they can to help. [Hamilton A] Distrust of the system to which one is vulnerable is illustrated by perpetual scrutiny of the system’s actions. This scrutiny may be comparative. In the quote below, one provincial government’s health system (Quebec) is perceived to be failing in its obligations, leading to mistrust, while another system (Ontario’s) is seen to be meeting its obligations, leading to at least a modest expression of trust.

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At the end of the day, hope, along with fear and vulnerability, is expressed that agendas are, at least, above board. . . .what concerns me from a trust standpoint, do you folks remember a story a couple of months ago or whatever that there was an extremely aggressive strain of a disease in hospitals in Quebec that had killed, like what was it 100 or 1000 people? I can’t remember and they kept it under wraps for months [yeah]. That’s the kind of thing that scares the crap out of me. I remember when we had SARS, yes it had a terrible economic effect but you know we were advised what to do. And that’s what you want, your health care system to spring into effect when something like that goes on. I guess where I’m going is if everybody has an agenda, there’s a lot of mistrust with the government, wait a second what’s the government agenda? They are concerned about impressing us! And I’m not sure that’s entirely great, but in the grand scheme of things that’s got to be at least one notch lower, that is to say better than some sort of hidden agenda. [Toronto B] In the passage below, a veiled plea for government transparency is issued to assuage the fear (and vulnerability) associated with expected hidden agendas. So I think, and the government doesn’t seem to be, that’s kind of like the third rail. They’re not willing to address that and say look, we can’t afford to do everything for everyone that we can do, that is possible to do because we would bankrupt ourselves overnight if we tried to do that. So we have to ration services but not admit it [. . ..] we’re going to all work around it and try to make all these adjustments to the health care system but not ever come out and say that when you get into a two tiered system, you say okay look we can only provide basic care for people under the universal health care system and if you want more than that well then hey, you’ve got to have deep pockets, you’ve got to pay for it yourself. [Hamilton AB] In the following quote, we see how healthy distrust (here referred to as disrespect) actually mutates into mistrust. So that was a question of political leadership at a time when people, I have recollections, you read about it that a lot of people thought the NDP were idiots for thinking there should be nationalized health care, but that was when people had respect or serious disrespect based on honest human judgments. Now I think people see all politicians as crooks to be distrusted, so why should we let them do anything with our health care? Now people are more acrimonious. They question everything that goes on. Whereas once politicians had all the answers, good or bad. Now people aren’t willing to take that risk or to even try what some of the suggestions are. [Toronto A] 5. Discussion Our respondents’ depictions of trust in their expressions of hope, fear, worry, comfort and security resonate with those documented in previous health system trust studies [22]. Portrayals of mistrust through references to hidden agendas are also consistent with theoretical definitions of mistrust [28,29]. Our analysis offers new insights into how

meanings of trust in health systems are derived through different constructs of the “health system”. To assess trust in health systems, or to restore apparently lost trust, we need to understand how people think about health systems and their relationships to them. Core to this relationship is the experience of vulnerability which manifests itself in different ways. Our findings support earlier conceptualizations of vulnerability as the primary reason for trust being placed in providers; it commands trust in the form of protection from exploitation, and in its absence, trust is not required [3,9,21]. Occasionally, this vulnerability is extended to governments as major health system actors and, consequently, as locations of trust. These same vulnerabilities also seed distrust (through healthy skepticism), mistrust (through failed trust), resilience and independence (through efforts to reduce or eliminate vulnerability). 5.1. Trust “cleavages” and “alliances” Key to the trust construct is who the vulnerable party (“us”) is, and who the health system (“them”) is. Individuals construct these alliances and cleavages in importantly different ways and trust is sometimes undermined by uncertainty about who is on which side. Individuals tend to portray themselves (the vulnerable party) either as outsiders or even victims of the health system – including their own providers – or alternatively, as partners in collaboration with their providers against the government and private interests. Notably, among these “us” vs. “them” constructs, our respondents rarely include government on the vulnerable “us” side of the equation raising broader issues of how well governments are trusted to advocate on the side of citizens against private interests. Respondents express the view that the system is part of “us” and should be controlled by “us” (i.e., the public) yet clear boundaries between government as “us” and government as “them” are not evident. Moreover, governments and policy makers are objects of palpable mistrust and are sometimes viewed as manipulated by industry and corporations with profit-making interests. The media, when mentioned, are also seen as untrustworthy instruments of governments or powerful commercial interests. 5.2. Determinants of trustworthiness Our study findings challenge the assertion that trust in large-scale institutions cannot be fulfilled due to the distance of government from citizens. The powerful imagery of confidence, comfort and security in the institution of Canadian Medicare used by our respondents suggests that trust relationships can indeed be built through institutions. At the same time, respondents’ reliance on individual experiences and anecdotes to form and convey generalizations about health system trust confirms the central role played by interpersonal trust in understanding how citizens build or lose trust in health systems and their supporting institutions.

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Our findings deepen and extend our understanding of what constitutes a trusted health system, how people come to trust their health systems and the role of the health system in structuring the behaviour of individuals working within it. The importance of accountability structures for dealing with abuses are emphasized but these are overshadowed by concerns about the inferior quality of care that would result from for-profit systems where individual providers lack the regulatory oversight associated with publicly administered systems. These findings support prior work on trustworthiness and health care. First, ownership seems to matter; forprofit ownership evokes expressions of mistrust in our focus groups as they have in US surveys on the subject [4]. Second, concerns about deceit, false promises and hidden agendas portrayed in our findings suggest non-deceptive practices [4] may indeed be worth pursuing though the practical challenges of doing so are considerable. 5.3. Vulnerability and healthy skepticism The mistrust in government that was so powerfully articulated in our findings also reflects its essential role: government needs to be with the people and part of the system. This mistrust can also be interpreted as evidence of distrust – that citizens are carefully scrutinizing their government to make sure it’s doing its job – and that if and when breaches of trust occur, this distrust is more easily and quickly transformed into high levels of mistrust. Mistrust of private institutions and the foothold they are perceived to have in the health system is as disconcerting to our study participants as is their mistrust of government. Yet, distrust appears to be reserved for government and is not evident in depictions of trust relationships with other parts of the health system, suggesting again that governments might be worthy of trust. These inextricable and shifting government-health system trust relationships suggest that re-storing or strengthening trust in health systems will only succeed if it is conceived within a broader political and institutional context. 6. Conclusions Through this qualitative analysis of Canadians’ expressions of values toward their health system, we offer a more robust conceptualization of what it means to trust a health system. This conceptualization features a series of trust cleavages and alliances between individuals and health system actors. It provides deeper insights into the centrality of vulnerability to trust relationships and suggests an alternative depiction of interpersonal–institutional relationships in the context of health system trust relationships. Finally, it offers a more complete picture of the pathways leading to and between trust, distrust and mistrust. We encourage others to examine, apply and strengthen this revised conceptualization to improve our understanding of these all important relationships and to

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