Patient-physician trust among adults of rural Tamil Nadu: A community-based surveyM Baidya1, V Gopichandran2, K Kosalram3
1 MPH Student, School of Public Health, SRM University, Medical College, Kattankulathur, Kancheepuram District, Tamil Nadu, India
2 Doctoral Research Fellow, School of Public Health, SRM University, Medical College, Kattankulathur, Kancheepuram District, Tamil Nadu, India
3 Assistant Professor, School of Public Health, SRM University, Medical College, Kattankulathur, Kancheepuram District, Tamil Nadu, India
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0022-3859.128802
Source of Support: None, Conflict of Interest: None
Background: Trust is the acceptance of a vulnerable situation in which the truster believes that the trustee will act in the truster's best interests. The cornerstone of the patient-physician relationship is "trust". Despite the intensity and importance of trust relationship of patients toward their physician, the phenomenon is rarely studied in developing countries. Objective: Our study aimed to explore the concept of patient-physician trust among adults of rural Tamil Nadu to assess the factors affecting patient-physician trust relationship and patient satisfaction. Materials and Methods: A cross-sectional descriptive household survey was carried out on 112 individuals selected by a multistage random sampling method. Men and women aged above 40 years who have visited a health care service at least once during the last 5 years were included in the study. Thom et al's modification of the Anderson and Dedrick Physician Trust scale was used to measure patient trust in physician. Results: Trust is a one-dimensional construct in the surveyed population as revealed by an exploratory factor analysis which extracted one component explaining 50% of the overall variance. Trust influences patient's self-reported satisfaction (β coefficient of 0.048; P < 0.001) and remains independent of all the other factors assessed in the study such as, age, gender, education, self-reported health status, time spent with the physician, physician's gender, physician's age, and medical specialty that the physician belongs to. Physician's gender, physician's age, self-reported health status, and time spent with the physician were significantly associated with satisfaction with the physician. Conclusion: Trust in physicians seems to not depend on any of the assessed factors and largely seems to be implicit in the physician-patient relationship. Trust in physician is associated with patient satisfaction. Further studies are needed to assess trust in physicians in developing country settings.
Keywords: Physician-patient relationship, patient satisfaction, trust
Interest in patient-physician trust has increased dramatically since 1979, when Russell Caterinicchio published the first study entitled "Testing Plausible Path Models of Interpersonal Trust in Patient-Physician Treatment Relationships". Some theorists consider patient trust to be a set of beliefs or expectations that a physician will behave in a certain way. Others have stressed a more affective nature of trust, identifying patient trust as a reassuring feeling of confidence or reliance in the physician and the physician's intent.  Trust has been defined as the willingness of a party to be vulnerable to the actions of another party based on the expectation that the other will perform a particular action important to the truster, irrespective of the ability to monitor or control that other party.  Trust embodies the notion of expectations: expectations by the public that healthcare providers will demonstrate knowledge, skill, and competence; further expectations too that they will behave as true agents (i.es, in the patients' best interest) and with beneficence, fairness, and integrity. It is these collective expectations that form the basis of trust.  Trust is the acceptance of a vulnerable situation, in which the truster believes that the trustee will act in the truster's best interests. ,, Trust is inseparable from vulnerability. The greater the risk, the greater the potential for either trust or distrust. , Evidence from qualitative studies suggests that patient trust is a "state," not a "trait," and is therefore subject to change. 
Patient trust has been associated with patient-reported satisfaction with their care, ,, intent to retain or switch physicians, willingness to recommend a physician to others, and treatment adherence.  Trust is related to, but distinct from, satisfaction. In contrast with satisfaction, which is an evaluation of previous experiences, trust characterizes a relationship or a cluster of personality and behavioral traits, and it is primarily future oriented ("willingness to be vulnerable"). , Organizational characteristics of health care system have strong influence on patient satisfaction in primary care setting.  Donabedian identified the importance of patient satisfaction. The concept of satisfaction is complicated and is a multidimensional concept that is yet to be well defined. 
The dimensions of trust are entailed for the purpose of measurement of physician attributes identified by patients which are characterized into potentially five overlapping domains: fidelity, competence, honesty, confidentiality, and global trust. 
Trust is often a defining characteristic of patients' relationship with physicians and other care providers.  Patient trust can be considered a collective good, similar to "social capital," that is necessary for an effective health care system. 
Several studies have been performed in the past which have assessed trust in health care in resource poor settings. In Sri Lanka, despite the strong public health system, poor quality of interpersonal relationships prevents even the poor from accessing the system. Thus, deteriorating interpersonal relationships between the doctors and patients could act as potential threats to universal health access even in robust public health systems.  In rural Cambodia public health care providers were trusted for their skills, abilities, and effective referral system. Thus, skills and ability are reported as important determinants of trust. 
Psychosocial aspect is an essential dimension of an individual's health. Trust in physician can significantly influence self-healing and lead to placebo effect among the patients. , Despite the importance of trust in physicians, it is scarcely studied. There are very few studies on the dimensions and determinants of trust from developing country settings. Trust in health care as measured and understood in the Western context is likely to be very different from that in developing settings. The managed care health system, nearly universal health access, large coverage of health insurance, and high quality health system functioning lead to different dimensions of trust in the developed countries. With structural readjustment programs and introduction of private players in health care system, health care cost is sky rocketing in several developing countries. Increasing commercialization of medical practice is eroding the faith and trust of common man in the medical profession. 
There is a need to understand the dimensions and factors influencing trust in this background. Trust is often implicitly or explicitly used in marketing hospitals, health plans, and physician groups. However, if the patient trust is not measured, it is unlikely to be valued sufficiently to balance the economic forces believed to reduce the strength and quality of medical relationships.  Different physicians from different background evaluate and treat clinically similar patient in very different ways.  A person who trusts a provider is more likely to seek care, to comply with treatment recommendations, and to return for follow-up care than a person who has little trust in a specific provider or health care system at least when the cost of medications are financially feasible. , Understanding trust can give vision of how health law and medical markets should function, but compelling laws can have paradoxical effect on trust by suppressing people's intrinsic motives. 
This study aimed to explore the concept of patient-physician trust among adults of rural Tamil Nadu, and to assess the factors affecting patient-physician trust relationship and patient satisfaction.
This cross-sectional household survey included men and women above 40 years of age who may or may not be suffering from any illness during the time of study but have visited a physician at least once during the past 5 years. Since healthy people, who are not in a state of vulnerability in terms of health, are more likely to be capable of thinking about trust in a conscious, calculative fashion they were chosen for the study.  Assuming 50% prevalence of Patient-physician trust in rural Tamil Nadu with 10% allowable error, the sample size of 120 was calculated but only 112 samples responded giving a response rate of 93.3%. A multistage random sampling method was used. Tamil Nadu, a state in the southern part of India, is divided into 32 districts. Kancheepuram is a district in the northeastern part. The Kancheepuram district is divided into 13 rural development blocks. Thirukalukundram, one of the blocks, was selected by simple random sampling from the list of blocks. From the list of villages in that block, eight villages were selected by simple random sampling. From the selected villages, 14 samples each selected conveniently based on eligibility criteria. The Physician Trust Scale,  which was further modified by Thom et al. in 1999, was used for measurement of patient-physician trust in this study. The scale has total 11 items which were given scores according to the response on a Likert-type scale with a maximum of 5 and minimum of 1 corresponding to "strongly agree" and "strongly disagree", respectively. The scale covered questions pertaining to the domains of physician dependability, reliability of the information provided by the physician, and confidentiality and competence of the physician. The scores for each respondent were totaled to give a maximum possible score of 55 and a minimum of 11. The median score was taken and all those with scores above the median were classified as those with high trust and those with scores below the median as those with low trust. This was carried out only for convenience of analysis. The "high trust" and "low trust" do not reflect the levels of trust in the community. Sociodemographic variables such as age, gender, education (no formal education vs. any education), self-reported health status, basis of choice of physician (having a choice vs. not having a choice), time spent with physician (<10 min vs. more than 10 min), physician characteristics such as age, gender, and type of practice (Allopathy vs. complementary medicine) which are likely to be associated with trust in physician and satisfaction with care were analyzed using the Fisher exact test. Simple linear regression analysis was done to assess the relationship between patient satisfaction and physician-patient trust. Exploratory factor analysis was performed to assess the domains of trust in physician as perceived by the sample of respondents.
The mean age of respondents was 53 years, where 51% of them were male. About 35% were illiterate and only about 30% had high school education. When asked about place for last health checkup, 49.11% reported "Government Hospital" as the place for last health checkup, where convenience (60.71%) of the location of the health care facility was reported as the main factor for choice of the facility. Roughly, 52% of the respondents were in good self-reported health status at the time of study. About 72% of them were seeing allopathic physicians for their health checkup, whereas 17.86% of respondents were unaware about the practice background of their physicians. When asked about exclusive time spent with physician, 50.89% of respondents reported that they spend 5-10 min exclusively with physicians. The majority of respondents (70.54%) reported that they were satisfied with their last health checkup. These characteristics of the study respondents are shown in [Table 1]. The characteristics of the last physician seen by the respondents were reported. This revealed that 81% were male physicians, and about 64% were perceived to be between 25 and 40 years of age and more than 60% were in hospital/institutional practice. This information is depicted in [Table 2].
The mean trust score from 112 respondents was 39.05 with standard deviation of 7.67. The minimum trust score obtained in the study was 15, whereas the highest score was 54. The median trust score was 39. As shown in [Table 3] respondents gender, education level of respondents, occupation, place of last health checkup, basis of physician's choice, present health status of respondent, physician's practice background, physician's gender, physician's age, physician's practice type, and exclusive time spent with physician did not have an influence on the trust.
Simple linear regression of satisfaction as a dependent variable and trust score as the independent variable revealed that there was a statistically significant association (P < 0.001) and the regression showed that every unit increase in trust led to a 0.048-unit increase in the satisfaction level with a constant of 2.094. Exploratory factor analysis was done to study the construct of trust in this sample. The Physician Trust Scale was originally a three-dimensional scale, and factor analysis was performed to see if the same pattern of factor extraction happened in this sample. The sample size for factor analysis was sufficient (KMO measure of sampling adequacy = 0.902). The factor model was a good fit (Bartlett's test of sphericity, P < 0.001). Of the 11 trust variables in the questionnaire, only nine items were included for the factor analysis by the principal component method of extraction because of the complex structure shown by the two items from the scale as indicated by high communality, which would hamper the interpretation of the analysis. The nine-item components together explained 50.12% of the variance. The factor structure is shown in [Table 4]. Only one component was extracted supporting that all those nine components were measuring one dimension. The data had high internal consistency with a Cronbach's a of 0.87.
Trust in physicians is a scarcely studied construct, especially in the setting of developing countries. Even in developed western world, there is barren dichotomy between the significance of trust in medical relationships and lack of attention to trust in existing legal analyses. Bloche alludes to anecdotes where characterization of the stark dichotomy of legal medical care system against trust issues of the general patient.  This study looked at trust in physician in a rural community based setting in India. In this study, we have chosen to present the various factors associated with trust, association between trust and satisfaction and the dimensional properties of the trust scale rather than categorizing the respondents as having high or low trust. The definition of high or low trust has been artificially introduced for the sake of convenience of analysis and therefore it cannot be presented as prevalence. The important finding was that trust in physician is a one-dimensional construct. All the components of the questionnaire were perceived as pertaining to trust in the physician by the respondents. None of the demographic characteristics of the patient or the physician or self-rated health status were associated with trust. Nevertheless significant association was found between trust and patient satisfaction, higher the trust, higher being the level of satisfaction. Even though the sample included healthy people living in the community, about 50% of them reported poor health status. The study found that the respondents had a high level of satisfaction out of their last clinical encounter during the past 5 years. Satisfaction with care is usually high in those who are healthy,  which can be the reason for high level of satisfaction among the majority of respondents due to the absence of any form of overt illness requiring active treatment.
The strength of this study is that it is, to our best knowledge, the first study to explore trust in physician in the community setting in rural India. This is also probably one of the two studies which have made use of the Trust in the Physician Scale in India. One previous study by Banerjee and Sanyal conducted in Pune, India, has explored trust in physicians using the same scale. However, that institution-based study did not assess the dimensional structure of trust and did not look into trust-related factors other than concordance with the physician.  The validity of using this scale, which has been developed and validated in a Western setting, in India is a point to be discussed. The items of the questionnaire have face validity. They seem to cover the important domains of physician trust, which are likely to be similar across the world irrespective of the type of health system. The scale does not have items which pertain to financial aspects or payment methods, which are drastically different between the Western and Indian settings. Thus, the questionnaire has high face and content validity for the Indian setting. The factor structure was one-dimensional, but the factor model could explain only about 50% of the total variance. There could be several reasons for the unidimensional structure of the questionnaire apart from the low percentage of variance explained. One of the important reasons could be that the respondents perceived each item to directly relate to trust in physician or some other latent variable which related to trust. Respondents were unable to slot their trust appraisal of their physicians and simply lumped all trust dimensions together, suggesting that patients have one residual type of trust assessment of their physician.  The lump of trust dimensions can be due to inability of patients to judge physician's knowledge or skill, but they judge their health care on the basis of other dimensions that relate to areas that they personally know and value.  People in the sample do not appear to distinguish trust in medical profession among the previously defined trust dimensions. , In such a setting where trust is implicit and not objectively assessed, there is a need for higher responsibility on the part of the physician to practice ethical medicine to safeguard the interest of the patients. The high level of trust despite the vulnerability is all the more reason for avoiding exploitation.
Socially desirable response bias could be another reason for strong one-dimensionality of the questionnaire. The proper dynamics of trust in physician in the rural Indian context can be fully understood only after thorough qualitative explorations and development of a scale unique to the Indian setting. If the same domains are obtained, after qualitative studies, and the scale found suitable, the findings of this study could be validated.
Several previous studies have also shown that the physician trust has an extrinsic value because of its link with patient satisfaction,  and the patient trust has been associated with patient-reported satisfaction with care. ,, Trust often corresponds with satisfaction, but the two are different concepts. Currently, patient satisfaction is widely used as a measure of quality of patient care. It is important to note that trust might be a better indicator as it has a strong emotional component, takes time and effort to build and reflect a long-standing benchmark of physician-patient relationship. Theoretically, patient trust should serve to reinforce the functioning of clinical relationship thereby increasing probability of patient satisfaction. 
The major limitation of the study was that it could not capture the interpersonal and behavioral factors of physicians as the prime focus was given toward the factors affecting the trust relationship. Small sample size due to a high level of expected error (10%) only capturing scenario of adult population in the rural settings was also a limitation of the study. The study is largely exploratory of the concept of trust in a typical resource poor setting such as rural India. It does not address the clinical implications and applications of trust in health care. The above-mentioned limitations of the sample size and the restricted scope of domains assessed the limit of these analyses. Nevertheless, it gives a very important perspective of the need to explore the aspect of patient-physician trust in the Indian setting. The fact that the study was conducted in the community setting among healthy individuals is both strength and a weakness of the trust assessment. It is strength because, as noted before, healthy individuals are at a better position to make objective assessments of their trust in physician. It is a weakness because there could be a significant recall bias of the nature of trust that existed at the point of contact with the physician, especially given that trust is a state and not a trait. The aspects of trust captured by the institution-based study and the community-based study are likely to be different. While the institution-based study assesses the immediate trust state that the patient has in the physician in the context of the illness, the community-based assessment gives a picture of the overall trust in health care, with particular reference to the physician. Further a qualitative study focusing on interpersonal skills of physicians could better clarify the relationship between dimensions of satisfaction and trust.
Research on trust is important in the developing country setting. There is increasing realization that health is a basic human right. Therefore, many developing countries are working on universal health access. This health for all will be a reality only if trusting patient-physician relationships are fostered. Therefore, there is a need to research trust and understand the dynamics of trust in physicians.
Trust in physician is a one-dimensional construct in the rural Indian community setting when measured using a tool developed in a Western context. It seems to not depend on any of the assessed factors such as gender, education level of respondents, occupation, place of last health checkup, basis of physician's choice, present health status of respondent, physician's practice background, physician's gender, physician's age, physician's practice type, and exclusive time spent with physician and largely seems to be implicit in the physician-patient relationship. Further studies are needed to assess trust in physicians in developing country settings. The scale used in this context seems to capture trust as a unidimensional construct. The validity of this needs to be explored in greater depth. Qualitative studies to explore the dimensions of trust in physician will help in developing a unique tool in the resource poor settings.
The authors acknowledge the intellectual contributions of Prof. Chetlapalli Satish Kumar toward the design of the study and help in interpretation of the results. VG is supported by the INSPIRE Fellowship of the Department of Science and Technology, Government of India.
[Table 1], [Table 2], [Table 3], [Table 4]