Elsevier

Social Science & Medicine

Volume 57, Issue 7, October 2003, Pages 1195-1203
Social Science & Medicine

Social capital and trust in providers

https://doi.org/10.1016/S0277-9536(02)00494-XGet rights and content

Abstract

Trust in providers has been in decline in recent decades. This study attempts to identify sources of trust in characteristics of health care systems and the wider community. The design is cross-sectional. Data are from (1) the 1996 Household Survey of the Community Tracking Study, drawn from 24 Metropolitan Statistical Areas; (2) a 1996 multi-city broadcast media marketing database including key social capital indicators; (3) Interstudy; (4) the American Hospital Association; and (5) the American Medical Association. Independent variables include individual socio-demographic variables, HMO enrollment, community-level health sector variables, and social capital. The dependent variable is self-reported trust in physicians. Data are merged from the various sources and analyzed using SUDAAN. Subjects include adults in the Household Survey who responded to the items on trust in physicians (N=17,653). Trust in physicians is independently predicted by community social capital (p<0.001). Trust is also negatively related to HMO enrollment and to many individual characteristics. The effect of HMOs is not uniform across all communities. Social capital plays a role in how health care is perceived by citizens, and how health care is delivered by providers. Efforts to build trust and collaboration in a community may improve trust in physicians, health care quality, access, and preserve local health care control.

Introduction

This paper examines variations in physician trust across communities in the United States. Reasons for community variation in levels of physician trust may include the extent of community-level managed care penetration, other characteristics of the health sector such as physician supply; and community social capital. Social capital refers to the networks of community relationships that facilitate trust and motivate purposeful action (Coleman, 1990) and is characterized by levels of trust, civic engagement and norms of reciprocity (Putnam, 1993; Lochner, Kawachi, & Kennedy, 1999). Social capital is evidenced by relationships among people in a community, shared norms, and shared activities that advance shared norms (Mechanic, 2000). There is growing interest in the effects of social capital on health and health care, including recent studies of the relationship between social capital and health care access, mental health outcomes, mortality, violent crime, health status, and alcohol abuse in young adults (Hendryx & Ahern, 2001; Hendryx, Ahern, Lovrich & McCurdy, 2002; Rosenheck et al., 2001; Weitzman & Kawachi, 2000; Kawachi, Kennedy, Lochner, & Prothrow-Stith, 1997; Kawachi, Kennedy, & Glass, 1999; Kennedy, Kawachi, Prothrow-Stith, Lochner, & Gupta 1998).

Trust in medical care focuses on two questions: (1) Is the physician able to make an accurate diagnosis and provide appropriate treatment; and (2) Is the physician acting in the best interest of the patient (Newcomer, 1997). These two questions address the competence of the physician in care delivery as well as their objectivity despite pressures from managers, insurers or their own financial self-interest. Because patients must depend on physicians for the information needed to answer those questions, patients are vulnerable. Physicians maintain that professionalism safeguards patients, reducing their vulnerability.

However, the effectiveness of professionalism is under challenge from patients and health care purchasers, with managed care representing one form of this challenge. Trust in the fiduciary ethic of physicians, it has been argued, has been declining, and was declining even before the rise of managed care (Inlander, Levin, & Weiner, 1988; Gray, 1997). Many trust-reducing trends began under fee-for-service medicine, which was prevalent from 1965 into the early 1990s. Among these trends are rapidly growing health care costs, malpractice crises, growing fraud and abuse, unexplainable variations in patterns of care and high levels of inappropriate services, and growing medical commercialism and conflicts of interest (Gray, 1997). All of these trends have reduced both patients’ and payers’ trust in both the competence and financial ethics of providers.

A further erosion of trust may result from the way managed care has been conducted. Managed care has been associated with loss of patient trust due to perceived conflicts of interest associated with compensation methods, division of physicians’ loyalties away from their patients, and rules limiting alternatives that doctors can offer patients (Macklin, 1993; Mechanic & Schlesinger, 1996; Woolhandler & Himmelstein, 1995).

Importantly, research shows that the effectiveness of professionalism has been challenged in many other areas in our society in the past three or so decades. In other words, there has also been a general loss of trust in our society. Trust is a key by-product of social capital (Fukuyama, 1999). When people keep commitments, engage in cooperative reciprocity, and avoid opportunistic behavior, groups of individuals will more easily form and achieve shared goals.

According to Fukuyama and other researchers, trust has been in decline during recent decades, reaching historic lows during the 1990s (Fukuyama, 1999; Nye, 1997). For example, in 1958, 73% of Americans said they trusted the federal government to do what is right either “most of the time” or “just about always”; by 1994, this figure was only 15% (Bowman & Ladd, 1998, Tables 5–20). Further, the medical profession, corporations, organized labor, banks, organized religion, the military, education, television, and the press all showed declines in the proportion of people who trusted them (American Enterprise, 1993). Loss of social capital may be traced to multiple factors, including cultural and racial conflict; population growth, dispersion and transience; economic demands placed on households; economic disparity; television; weak community leadership; historical and political events; and social heterogeneity.

Thus, the question we address in this paper is the following: Are levels of trust in physicians related to factors specific to the health care system, or is there a broader relationship with levels of community social capital? A direct interpretation of how trust in physicians results from social capital may be found in the nature of social capital itself. Two of the key theoretical ingredients of social capital are general community trust and generalized reciprocity (Putnam, 1993). Reciprocity refers to norms of cooperative behavior whereby people are inclined to support and help one another. To the extent that physicians and patients feel that they are participating in a non-reciprocal environment (for example, one with weak health leadership and few shared values), they are less likely to communicate effectively and to preserve their implicit contract to comply with care instructions (in the case of the patient), and to deliver appropriate and effective care (in the case of the physician). It is reasonable to hypothesize that communities higher in general trust and cooperation will also evidence higher trust in the physician–patient relationship.

In this paper, we use individual and community measures to foster a greater understanding of the factors that contribute to variation in trust of physicians. We focus on managed care, other characteristics of the health sector, and community social capital, while controlling for individual characteristics.

In particular, we present the following research hypotheses: (1) there is significant variation in physician trust across communities; (2) variations in physician trust are correlated with variations in social capital across communities; (3) variations in trust due to HMO enrollment vary across communities, due to mediating community factors including social capital; (4) social capital across communities is significantly associated with physician trust, after controlling for health sector influences, including HMO coverage, HMO market penetration, and HMO competition.

Section snippets

Sources of data

The data for this study are from three sources: the Community Tracking Study (CTS) Household Survey, the National Institute of Health Care Management (NIHCM), and the Stowell National 1996 Media Marketing Database. The CTS is an initiative of the Robert Wood Johnson Foundation including 60 randomly selected Metropolitan Statistical Areas (MSAs) nationwide (Kemper et al., 1996).

The 60 sites were randomly selected with probability in proportion to population to insure representation of the US

Descriptive findings

A summary of the variables used in subsequent models is provided in Table 1. The sample size for this study is limited to adults in the 24 cities who responded to the items on trust in physicians (N=17,653). The individual trust in physicians variable unweighted mean score was 4.14 (range 1–5, S.D.=0.85). We conducted a number of transformations and found essentially the same model results, so we report results for the original variable. The social capital measure ranged from 38.9 to 57.5

Discussion and conclusions

Evidence from this study suggests that there are significant variations in trust in physicians across communities, and that these variations are partly explained by community levels of social capital. Further, evidence suggests that although the impact of HMO coverage on trust is often negative and significant, this impact is not consistent across all communities. Social capital seems to mediate or reflect how health care is perceived and delivered in various communities. Another way to phrase

Acknowledgements

Supported by a grant to the authors from the Robert Wood Johnson Foundation, Changes in Health Care Financing and Organization Program.

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