What causes patients to trust medical professionals? Insights from mothers in Juba
Trust in medical professionals is an important aspect of demand for health care in South Sudan, without which many patients may never attempt to access clinics and hospitals. This qualitative research study used in-depth biographical interviews to explore family health histories according to the experiences of South Sudanese mothers in Juba. The resulting data demonstrates that trust in medical professionals is conditional on patients’ particular experiences. Participants acknowledged the resource constraints that medical professionals work under, and called on decision-makers to prioritise health services as an indicator of peace. Nevertheless, health care workers can take practical steps to build trust through their day-to-day interactions with patients. In addition to medical competence, participants valued a respectful, attentive and supportive quality of care, and working practices that ensured accountability in the way this care was delivered.
Key Words trust, quality, care, accountability, qualitative
“Arguably, there are few relationships where concerns about trust loom larger than in the relationship between patients and their physicians.” 
Developing health care systems in South Sudan is a long-term task. The Ministry of Health and its development partners take a strategic lead in this, while dedicated health-care workers on the ground also play an important role in constantly improving standards of care. One important issue is the supply of health care, through the provision of accessible, equipped health facilities , along with the trained staff to operate them . Another, less recognised problem is the demand for medical care, which is also beginning from a very low level in South Sudan . This study examined the trust in medical professionals as an important factor that influences patients’ decision to access medical care.
The perspectives of mothers are vital in understanding the health needs of families in South Sudan due to their primary care-giving role. Further, the indirect consequences of war, in particular poor health, have a disproportionate impact on women and children . The experiences of South Sudanese mothers therefore have the potential to provide important messages for health care workers about how to provide the best possible care for patients, even where resources are limited. These messages could hardly be more relevant given the severe challenges to health care provision at present .
Using a qualitative approach, I conducted 13 in-depth biographical interviews with mothers in Juba during July-August 2012. The participants were all South Sudanese, current carers of at least one child aged 14 years or younger, with a range of educational levels, from P1 to master’s degree. Some mothers had experienced raising their children in the context of the second civil war (1983-2005), including in the bush and/or refugee camps and in the context of attacks, while mothers of young children had given birth and raised their children in peace time. Where necessary I worked with an interpreter.
During the interviews I asked each mother to tell me the story of her life, particularly focusing on her own and her family’s health. In order to enable participants to engage more actively in telling their stories and to introduce a visual medium into the data, I used a participative technique based on the timeline. Participants chose beads, shown in figure 1, which they threaded on a piece of cord during the interview forming a bracelet which represented their lives and experiences . The experiences that they retold included treatment by doctors, medical officers, nurses and midwives, as well as traditional healers, family members and self-help.
Figure 1. Materials used and example timeline bracelet
The interviews were audio-recorded, then I transcribed them and undertook thematic analysis. The names of participants have been changed to ensure their anonymity. Although this study included methodological and theoretical findings, in this article I focus particularly on substantive aspects of care by medical professionals that may lead to greater trust among patients.
Trust – a theoretical framework
Although most people believe trust is important for social relations to function effectively, it is not easily defined . In this study I treat trust as a process that enables a person to take action in situations where they are vulnerable, where there is uncertainty about what the outcome will be, and where they depend on others [9, 8].
The process of trusting has four main stages: interpretation, suspension, favourable expectation, and evaluation [10, 11]. Interpretation involves an evaluation of the ‘good reasons’ that someone might have to act in a way that makes them vulnerable to another person. This may involve both rational and emotional elements and is deeply affected by the limited range of choices available to a person. Interpretation does not take place in social isolation but involves advice and guidance within the community; in some cases a trusted third party will become a repository of trust that intervenes where reasons to trust are insufficient. Suspension involves the “leap of faith” where a person puts aside uncertainty and vulnerability without eliminating them. This enables them to enter a state of favourable expectation, where they can act based on interpretative knowledge, treating it as if it were momentarily certain [10, 11].
Trust is a dynamic process: it changes over time based on experience. The outcome of an instance where trust was exercised informs the process of interpretation on future occasions through the stage of evaluation . Qualitative, biographical interviews with mothers therefore provide an excellent tool for in-depth exploration of trust in health care contexts as they enable reflection on critical past experiences that inform present decisions on accessing health care.
Mothers expressed respect for medical professionals in general, but this did not automatically translate to trust: for the majority of participants, trust was conditional on their experience of individual practitioners:
“Some people trust … medical professionals, some do not trust. Why? Because if you get a good doctor who is able to give attention to you, then you trust that doctor. If you find a doctor that does not give attention to you then you don’t trust them. The reason is some people really have the interest of serving their patients, but some medical professionals do not have that interest.” (Rose, 07/08/12)
The interview data clearly reveals the nuanced understanding mothers had of the institutional environment and constraints that medical professionals were working within; as one mother who had suffered an avoidable miscarriage reflected, “You can just blame the whole situation” (Mama Emma, 25/07/12). Participants identified the lack of medicines and facilities, as well as limitations to training opportunities, which can leave medical professionals powerless to intervene, particularly in remote clinics where supplies are cut off through conflict: “these doctors have nothing else but to resort to praying to God because there’s nothing else they can do” (Sandia 08/08/12). They also acknowledged that medical professionals are “overloaded with the work” (Mama Emma 25/07/12) and often receive insufficient payment to provide for their families (Sue-Ann, 07/08/12).
Nevertheless, mothers expressed significant pride in their ability to protect their children despite considerable suffering, and bright hopes for their futures. This was expressed by Praise (08/08/2012) through her choice of a silver-coloured bead for her timeline (see figure 2):
“This one I took it I want to talk about the future, yeah. I felt after all these sufferings and I was able to cover with all these children of mine … I wanted God to give them a bright future, so they became children who are also to help build this country of ours.” (Praise, 08/08/12)
Figure 2: Beads selected by Praise
The combination of mothers’ appreciation of resource constraints and aspirations for their children and their country translated to a clear message for South Sudan’s leaders. For the mothers interviewed, the state of health care provision is a primary indicator of how successfully peace has been achieved:
“The big people up there should consider the situation of Southern Sudanese women, to improve the situation in the hospitals so that there can be some peace in Sudan” (Sandia 08/08/12).
While structural improvements are essential, and participants hold decision-makers rather than medical professionals responsible at that level, there are nevertheless important factors within the direct control of individual health care workers that affect the extent to which mothers trust them to care for their families.
The degree of competence that medical professionals exhibit is a key factor affecting trust. Many participants related a story involving a health care worker who they perceived to act rudely (including verbal abuse), negligently, or to be lazy. However, they also identified key professional practices that convinced them of medical professionals’ competence and therefore contributed to greater trust, including:
- Carrying out appropriate tests to confirm diagnosis prior to treatment;
- Consistent diagnoses between colleagues;
- Calling a senior colleague in a timely manner when the case requires it;
- Ability to identify a serious case through triage and prioritise treatment accordingly;
- Consistent follow-up of patients to check progress.
Participants attributed the degree of competence directly to the training that medical professionals received. This included both the quality of initial training and participation in continued professional development, such as reading journals and mentoring/supervision by colleagues as well as formal training courses. Those medical professionals who were trusted the most diligently maintained the professional standards they had been trained in when working under adverse conditions.
Studies in Europe have indicated that patients’ trust in health professionals is earned by their experience of care and the nature of their relationship to the clinician, including concern and empathy . In other words, medical professionals are expected to care, as well as to cure . In this study, the quality of the care provided to mothers was a powerful factor in determining their trust in medical professionals. This caring capacity was described as a particular gift or talent:
“God creates people in different ways, some their heart was created to do so, some their heart was not created to do good things.” (Betty, 31/07/12)
“The talent varies … that is what they have to do and what they have really determined to do in their life, to help others.” (Yomina, 31/07/12)
“I was so impressed … he trusted the life first, he valued that life, he didn’t value his money … you know you need not to force yourself, it should be a call from your heart that I want to serve people.” (Peninah, 24/07/12)
South Sudanese mothers described the qualities of this caring approach to patients in a way that directly reflected their description of the care a mother has for her child. This has several characteristics. A trusted medical professional has a respectful relationship with their patients, where “they talk to you, they ask you questions, they are concerned about you” (Nyidor, 06/08/12). They are available to the patient, including being “attentive” (Sandia, 08/08/12), maintaining a continual presence, “the doctors are there all the time, attending, and all the nurses are there to attend to you, and it was really very good” (Mama Emma, 25/07/12), and they follow-up the patient, “[she] always goes to check her, look for her every day” (Igbowalya, 03/08/12). They “talk politely” to patients (Mama Emma, 25/07/12), and are supportive to them, “they are just trying to comfort you and give you some courage” (Sue-Ann, 07/08/12). Finally, the patient is a priority and they will “rush to help you” (Igbowalya 03/08/12), as Nyidor (06/08/12) explained:
“This good one normally if she had something she’d leave that something, she’s not go for the breakfast until she treats you and she checks you up and after that she’d go over for breakfast.”
In order to build trust among medical professionals, competence alone is not enough: this quality of care is a decisive factor affecting trust in medical professionals to whom South Sudanese mothers entrust their families.
The data indicated a general preference for private health clinics over state provision; however this was based on participants’ perception that there is greater accountability in private health contexts. As Yomina (31/07/12) summarised,
“Whoever works there you have to do your duty because you have been hired to do that. Then if you fail to do your work, which means you will be sent away.”
This accountability included a number of facets. Firstly, participants were confident that an appropriately skilled person would be available at all times. Secondly, participants expect transparency in the role and level of training of the person they are dealing with (e.g. nurse, medical officer, junior doctor, consultant), which should be clear through uniform and through the introductions at a consultation. Thirdly, where medical professionals are part of a team with clear supervision arrangements between colleagues, patients are assured that practice is monitored and high standards maintained. Finally, safeguards such as complaints procedures ensure that patients’ right to good care is demonstrably upheld without the need for payment to act as a guarantee. While there is a particular duty for those who undertake day-to-day management of hospitals and clinics to formally put procedures in place, all medical professionals can adopt practices that embed these aspects of accountability in routine practice.
Even in the absence of sufficient resources to provide optimal care, there are a number of steps that all medical professionals can take to increase their patients’ trust. In every patient interaction, health care workers have the opportunity to build trust in themselves as a particular practitioner, and in health professionals in general. They can do this by being diligent in applying the professional standards they have been trained in and seeking out professional development opportunities; by providing a respectful, attentive and supportive quality of care akin to the care a mother provides to her child; and by conducting themselves in a way that upholds accountability in the health care context they work in.
Building trust among mothers is a critically important task, as it impacts on whether patients attempt to access health care in formal settings at all. The simple measures to increase competence, caring and accountability that participants have outlined therefore have the potential to make a significant tangible difference to health outcomes.
All figures are by Rachel Ayrton
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