Introduction
Conceptual framework
Considerations in the measurement of trust
Development of the trust in multidimensional healthcare systems scale (TIMHSS)
Methods for development study
Phase 1 methods: systematic review (item generation)
Phase 2 methods: qualitative interviews (item modification)
Measure | Dimensions |
---|---|
Wake Forest Physician Trust Scale [37] | Fidelity Competence Honesty Confidentiality Global trust |
Public Trust in Dutch Healthcare [40] | Patient focus of providers Policies at the macro level will be without consequences for the patient Health care providers’ expertise Quality of care Information supply and communication by care providers Quality of cooperation |
Phase 3 methods: expert validation of items
Results of development study
Phase 1 results: systematic review (item generation)
Phase 2 results: qualitative interview (modification of items)
Phase 3 results: Expert validation of items
Conclusion of the Development Study
Dimension | Items (N = 43) |
---|---|
[Q12] Patient focus of providers (5-point Likert scale) | [a] I trust that doctors put patients’ interests ahead of their own [b] I trust that doctors treat all patients the same [c] I trust that doctors do not judge their patients [d] I trust that doctors are responsive to feedback they receive from their patients [e] I trust that doctors do not take advantage of their patients [f] I trust that patients are taken seriously [g] I trust patients get enough attention [h] I trust that patients are listened to [i] I trust that doctors spend enough time on their patients [j] I trust that doctors will always stick up for their patients [k] I trust that doctors can relate to their patients’ problems [l] I trust that doctors will be consistent in the care they provide [m] I trust that doctors trust me |
[Q13] Policies at the macro level will be without consequences for the patient | [a] I trust that the health system has the staffing and resources needed to provide the care Canadians need [b] I trust that the privatization of health care services does not disadvantage patients [c] I trust that healthcare will be affordable for me [d] I trust that medical help and patient care will not be compromised by waiting lists [e] I trust that patients will not be the victims of the rising costs of health care [f] I trust that waiting times are never too long [g] I trust that doctors have control over the decisions they make about my care |
[Q14] Health care providers’ expertise | [a] I trust that doctors will admit when they have made mistakes [b] I trust that doctors are committed to continuing their education and training [c] I trust that doctors are knowledgeable about a range of diseases [d] I trust that new treatments are put into practice in the healthcare system [e] I trust that the education and training of doctors in this country is one of the world’s best [f] I trust that doctors will continue to respond to new and emerging medical problems |
[Q15] Quality of care | [a] I trust that patients always get the right dose of medicine [b] I trust that patients are referred to specialists in time [c] I trust that patients always get the right type of medicine [d] I trust that doctors will prescribe medicines at the appropriate time (not too early or too late) [e] I trust that patients’ medical information is kept confidential [f] I trust that doctors do enough tests (not too few or too many) [g] I trust that patients will always get the best treatment [h] I trust that doctors will make the right diagnosis |
[Q16] Information supply and communication by care providers | [a] I trust that the information given to patients is clear and understandable [b] I trust that patients get sufficient information about the cause of their problems [c] I trust that doctors discuss things fully with their patients [d] I trust that patients get sufficient information about the various treatment options that are available [e] I trust that patients get sufficient information about the effects of their treatment [f] I trust that doctors make use of the patients’ own understanding and insights |
[Q17] Quality of cooperation | [a] I trust that healthcare providers are good at cooperating with each other [b] I trust that patients are not given conflicting information [c] I trust that high levels of specialisation benefits the healthcare system |
Validation of the trust in multidimensional healthcare systems scale (TIMHSS)
Methods for validation study
Approach to convergent, discriminant and criterion validity
Question | Contribution to validation (citation of measure, where applicable) |
---|---|
[Q19] I never question the medical advice I am given by my doctor. (agree/disagree) | Discriminant validity – Dependence |
[Q20] I have no choice but to follow the recommendations provided by my doctor. (agree/disagree) | Discriminant validity – Dependence |
[Q21] I always follow doctors’ recommendations. (agree/disagree) | Criterion validity - Acceptance of medication or treatment plan |
[Q22] I would be willing to accept a new vaccine if my doctor recommended it. (agree/disagree) | Criterion validity - Uptake of new vaccines |
[Q23] During the past 12 months, was there any time when you didn’t get the medical care you needed (yes/no) | Criterion validity – Delay in access to care |
[Q24] I always tell my doctor the truth when they ask for information relevant to my healthcare. (yes/no) | Criterion validity – Disclosure of medically relevant information [63] |
[Q25] Have you changed physicians in the past or sought a second opinion due to concerns about care? (yes/no) | Criterion validity – Request for second opinion [37] |
[Q26] I am perfectly satisfied with the health care I have been receiving. (strongly agree to strongly disagree) | Convergent validity – Satisfaction [64] |
[Q27] There are some things about the health care I have been receiving that could be better. (strongly agree to strongly disagree) | Convergent validity – Satisfaction |
Study sample
Statistical analysis
Validity tests
Outcome variable | Reference group | Slope estimate | Standard error | z-value | p-value |
---|---|---|---|---|---|
Always follow doctors’ recommendations | Disagree | 0.49 | 0.05 | 9.15 | < 0.0001 |
Would be willing to accept a new vaccine if my doctor recommended it | Disagree | 0.41 | 0.06 | 7.30 | < 0.0001 |
In last 12 months, chose not to get needed medical care | No | − 0.33 | 0.05 | -5.98 | < 0.0001 |
Always tell the doctor the truth about health information | No | 0.21 | 0.09 | 2.47 | 0.01 |
Previously changed physicians or asked for second opinion due to concerns about care | No | − 0.30 | 0.05 | -5.99 | < 0.0001 |
Measurement of invariance
Results of validation study
Sociodemographic characteristics
Variable | Response option | Wave 1 (N = 694) % of sample (n) | Wave 2 (N = 740) % of sample (n) |
---|---|---|---|
Gender identity | Man | 42.5 (299) | 45.7 (338) |
Woman | 56.0 (389) | 52.7 (390) | |
Agender | 0.1 (1) | 0.1 (1) | |
Bigender | 0.3 (2) | 0.3 (2) | |
Genderqueer / Gender non-conforming / Gender non-binary | 1.0 (7) | 0.9 (7) | |
Intersex | 0.0 (0) | 0.0 (0) | |
Pangender | 0.0 (0) | 0.1 (1) | |
Trans | 0.4 (3) | 0.7 (5) | |
Two-spirit | 0.6 (4) | 0.1 (1) | |
Queer | 0.4 (3) | 1.8 (13) | |
Another gender identity not listed | 0.1 (1) | 0.3 (2) | |
Sexual orientation | Heterosexual | 78.2 (543) | 76.5 (566) |
Gay man | 6.0 (42) | 4.2 (31) | |
Lesbian | 1.7 (12) | 2.0 (15) | |
Bisexual / Pansexual | 9.2 (64) | 11.1 (82) | |
Asexual / Aromantic | 1.4 (10) | 2.2 (16) | |
Questioning | 1.0 (7) | 1.3 (10) | |
Another sexual orientation not listed | 1.1 (8) | 1.6 (12) | |
Ethnicity | Caucasian | 55.6 (386) | 68.6 (508) |
Asian | 10.9 (76) | 9.2 (68) | |
First Nation, Inuit, Metis | 13.3 (92) | 8.4 (62) | |
Black / African Canadian | 17.1 (119) | 9.7 (72) | |
South / Central American | 0.6 (4) | 0.3 (2) | |
Arab | 0.4 (3) | 0.8 (6) | |
Another ethnicity not listed | 2.0 (14) | 3.0 (22) | |
Age group | 18–24 | 14.3 (99) | 14.7 (109) |
25–34 | 23.5 (163) | 18.1 (134) | |
35–44 | 18.6 (129) | 15.7 (116) | |
45–54 | 21.8 (151) | 15.8 (117) | |
55–64 | 12.1 (84) | 15.4 (114) | |
65–74 | 7.2 (50) | 15.5 (115) | |
75–84 | 2.3 (16) | 4.6 (34) | |
85+ | 0.2 (2) | 0.1 (1) | |
Gross household income | <$19,999 | 6.8 (47) | 13.2 (98) |
$20,000 - $39,999 | 16.1 (112) | 17.3 (128) | |
$40,000 - $59,999 | 17.3 (120) | 13.6 (101) | |
$60,000 - $79,999 | 15.0 (104) | 10.8 (80) | |
$80,000 - $99,999 | 12.4 (86) | 13.0 (96) | |
$100,000 - $119,999 | 8.5 (59) | 9.6 (71) | |
$120,000 - $139,999 | 4.2 (29) | 5.0 (37) | |
$140,000 - $159,999 | 3.6 (25) | 4.3 (32) | |
>$160,000 | 8.8 (61) | 5.9 (44) | |
Prefer not to answer | 7.3 (51) | 7.2 (53) |
Item descriptive statistics
Sampling adequacy
EFA models
Survey question | System | Policy | Doctor | Uniqueness |
---|---|---|---|---|
Q12a-I trust that doctors put patients’ interests ahead of their own | 0.59 | 0.50 | ||
Q12b-I trust that doctors treat all patients the same | 0.89 | 0.33 | ||
Q12c-I trust that doctors do not judge their patients | 0.78 | 0.36 | ||
Q12d-I trust that doctors are responsive to feedback they receive from their patients | 0.81 | 0.35 | ||
Q12e-I trust that doctors do not take advantage of their patients | 0.65 | 0.43 | ||
Q12f-I trust that patients are taken seriously | 0.79 | 0.28 | ||
Q12g-I trust patients get enough attention | 0.82 | 0.28 | ||
Q12h-I trust that patients are listened to | 0.83 | 0.26 | ||
Q12i-I trust that doctors spend enough time on their patients | 0.78 | 0.34 | ||
Q12j-I trust that doctors will always stick up for their patients | 0.77 | 0.27 | ||
Q12k-I trust that doctors can relate to their patients’ problems | 0.69 | 0.40 | ||
Q12l-I trust that doctors will be consistent in the care they provide | 0.73 | 0.28 | ||
Q12m-I trust that doctors trust me | 0.70 | 0.34 | ||
Q13a-I trust that the health system has the staffing and resources needed to provide the care Canadians need | 0.62 | 0.50 | ||
Q13d-I trust that medical help and patient care will not be compromised by waiting lists | 0.83 | 0.24 | ||
Q13e-I trust that patients will not be the victims of the rising costs of health care | 0.70 | 0.37 | ||
Q13f-I trust that waiting times are never too long | 0.78 | 0.33 | ||
Q14b-I trust that doctors are committed to continuing their education and training | 0.64 | 0.49 | ||
Q14c-I trust that doctors are knowledgeable about a range of diseases | 0.77 | 0.44 | ||
Q14d-I trust that new treatments are put into practice in the healthcare system | 0.70 | 0.46 | ||
Q14e-I trust that the education and training of doctors in this country is one of the world’s best | 0.83 | 0.46 | ||
Q14f-I trust that doctors will continue to respond to new and emerging medical problems | 0.84 | 0.40 | ||
Q15a-I trust that patients always get the right dose of medicine | 0.61 | 0.41 | ||
Q15c-I trust that patients always get the right type of medicine | 0.65 | 0.37 | ||
Q15d-I trust that doctors will prescribe medicines at the appropriate time (not too early or too late) | 0.61 | 0.37 | ||
Q15e-I trust that patients’ medical information is kept confidential | 0.77 | 0.49 | ||
Q15f-I trust that doctors do enough tests (not too few or too many) | 0.56 | 0.41 | ||
Q15g-I trust that patients will always get the best treatment | 0.56 | 0.29 | ||
Q15h-I trust that doctors will make the right diagnosis | 0.63 | 0.34 | ||
Q16a-I trust that the information given to patients is clear and understandable | 0.67 | 0.41 | ||
Q16b-I trust that patients get sufficient information about the cause of their problems | 0.59 | 0.40 | ||
Q16c-I trust that doctors discuss things fully with their patients | 0.51 | 0.37 | ||
Q16d-I trust that patients get sufficient information about the various treatment options that are available | 0.62 | 0.35 | ||
Q16e-I trust that patients get sufficient information about the effects of their treatment | 0.70 | 0.36 | ||
Q16f-I trust that doctors make use of the patients’ own understanding and insights | 0.55 | 0.36 | ||
Q17a-I trust that healthcare providers are good at cooperating with each other | 0.58 | 0.54 | ||
Q17b-I trust that patients are not given conflicting information | 0.53 | 0.46 | ||
Q17c-I trust that high levels of specialisation benefits the healthcare system | 0.75 | 0.54 |
CFA models
Structural equation modelling
Validity tests
Item distributions for equity-deserving populations
Measurement invariance across demographic subgroups
Model | DF | Chi-square | RMSEA | CFI | SRMR | AIC |
---|---|---|---|---|---|---|
Three-factor | 1,288 | 3,294.3 | 0.055 | 0.937 | 0.047 | 62,265.19 |
Full metric invariance | 1,323 | 3,361.9*** | 0.055 | 0.935 | 0.057 | 62,262.72 |
Full scalar invariance | 1,358 | 3,436.4*** | 0.055 | 0.933 | 0.058 | 62,267.24 |
Full residual invariance | 1,396 | 3,506.0 | 0.054 | 0.932 | 0.058 | 62,260.85 |
Partial metric invariance | 1,318 | 3,336.9 | 0.054 | 0.936 | 0.053 | 62,247.71 |
Partial scalar invariance | 1,344 | 3,366.7 | 0.054 | 0.936 | 0.054 | 62,225.55 |
Model | DF | Chi-square | RMSEA | CFI | SRMR | AIC |
---|---|---|---|---|---|---|
Three-factor | 1,288 | 2,722.6 | 0.065 | 0.913 | 0.058 | 28,449.73 |
Full metric invariance | 1,323 | 2,751.3 | 0.064 | 0.913 | 0.065 | 28,408.43 |
Full scalar invariance | 1,358 | 2,789.9* | 0.064 | 0.912 | 0.066 | 28,377.06 |
Full residual invariance | 1,396 | 2,877.6* | 0.064 | 0.910 | 0.068 | 28,388.67 |
Partial scalar invariance | 1,355 | 2,782.6 | 0.063 | 0.913 | 0.066 | 28,375.66 |