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Graduate Studies Legacy Theses
2000 A matter of trust: Public trust in the Alberta health care system
Kehoe, Susan Marie
Kehoe, S. M. (2000). A matter of trust: Public trust in the Alberta health care system (Unpublished master's thesis). University of Calgary, Calgary, AB. doi:10.11575/PRISM/22216 http://hdl.handle.net/1880/40781 master thesis
University of Calgary graduate students retain copyright ownership and moral rights for their thesis. You may use this material in any way that is permitted by the Copyright Act or through licensing that has been assigned to the document. For uses that are not allowable under copyright legislation or licensing, you are required to seek permission. Downloaded from PRISM: https://prism.ucalgary.ca THE UNIVERSITY OF CALGARY
A Matter of Trust: Public Trust in the Alberta Health Care System
by
Susan Marie Kehoe
A THESIS
SUBMllTED TO THE FACULTY OF GRADUATE STUDlES
IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE
DEGREE OF MASTER OF ARTS
DEPARTMENT OF SOCIOLOGY
CALGARY, ALBERTA
DECEMBER. 2000
@ Susan Marie Kehoe 2000 National Library Bibliothkque nationale 1*1 ofCanada du Canada Acquisitions and Acquisitions et Bibliographic Services services bibliographiques 395 WMmgton Skeet 395. rue Wellington Oltawa ON KlA OW OttawaON KlAON4 Canada Canada
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The author retains ownership of the L'auteur conserve la propriete du copyright in this thesis. Neither the droit d'auteur qui protege cette these. thesis nor substantial extracts fiom it Ni la these ni des extraits substantiels may be printed or otherwise de celle-ci ne doivent Etre imprimes reproduced without the author's ou autrement reproduits sans son permission. autorisation. ABSTRACT
Trust in the Canadian heatth care system, which is a 'source of pride' and a 'symbol of core Canadian values', has declined dramatically in Alberta since the Klein administration began its heatth care reforms in 1993. This research project examines the sociological construct of trust, specifically the nature, distribution, and determinants of the public's trust in the Alberta health care system and in its component parts. The theoretical model proposes that trust is shaped by eight dimensions - sociat demographic characteristics of the respondent, ideologies and orientations of the respondent, the respondent's feelings of efficacy and control, health care experience, perceived effectiveness of the system, media influence, value congruence between the respondent and key decision-makers, and trustworthiness of key sources of information about the health care system.
This study provides a comprehensive profile of various measures of trust, and identifies, through multiple regression analysis, key determinants of that trust. Bernard Barber's three-fold conceptualization of trust - generalized trust. fiduciary trust. and confidence in competence - is also explored.
The data for this study were collected using a mailed, self-administered questionnaire which was distributed to a sample of households in Calgary,
Alberta between November 4 and December 10,1999. Four hundred and ninety three respondents took part in the research project. .-- Ut ACKNOWLEDGEMENTS
I would like to thank my supervisor Or. J. Rick Ponting for his excellent guidance and his tremendous dedication, often above and beyond the call of duty. Thank you for giving me the encouragement to pursue my goals.
I would also like to thank members of my examining committee Dr. Tom Langford and Dr. Roger Gibbins for their insightful comments and advice.
A very special thanks to Marg Maclennan for volunteering her time to help distribute the questionnaire. Thankyou for your hendship and encouragement.
Thanks also to the following individuals: Thomas Huang Dr. Cora Voyageur Dr. Linda Henderson Pamela Weinberger
Thanks to Lana, Margaret, Jordan 8 Diane. I loved walking into the office each day and hearing the latest report on my returns. Thanks for collecting all my mail and all my messages!! Thankyou for your assistance and for your humor.
Many thanks to Lynda Costello who helped make this journey a smoother one.
To my respondents - thankyou for taking the time to share your invaluable insights with me. DEDICATION
To Susan - for encouraging me to pursue my dreams. To my parents, Pat and Maxine Kehoe - who instilled in me a love of learning. To my aunt and uncle, Terry and Dave Markle - your generosrty and support has helped make this journey possible. TABLE OF CONTENTS
Approval Page ...... ii Abstract ...... iii Acknowledgements ...... iv Dedication ...... v Table of Contents ...... vi List of Tables ...... viii List of Figures ...... xi
CHAPTER ONE: INTRODUCTION ...... Importance of the Study of Trust ...... Health Care Context in Alberta ...... Research Question ......
CHAPTER TWO: THEORETICAL FRAMELVORK ...... Social Holism ...... Levels of Trust - Interpersonal and Systemic ...... Theoretical Perspectives on Trust ...... Social Leaming Theory ...... Functionalist Perspectives ...... Trust and Credibility ...... Trust and Contracts ...... Trust and Change ...... Distrust ...... Trust and Confidence ...... Definitions of Trust ......
CHAPTER THREE: LITERATURE REVIEW AND HYPOTHESES...... Measures of Trust in the Literature ...... Literature on Trust in Institutions ...... Determinants of Trust ...... Toward a Theory of Trust ...... Statement of Hypotheses ......
CHAPTER FOUR: METHODOLOGY ...... A Note on Research Design ...... The Sample ...... ,...... Sources of Error ...... Weighting the Sample ...... , ...... The Questionnaire ...... Scale Construction ...... Operationalization of the Dependent Variables ...... Operationalization of the Independent Variables ...... Statistical Procedures ...... ,., ...... vl CHAPTER FIVE: MAPPING THE CONTOURS OF TRUST ...... Confidence Compared to Other Canadian Institutions ...... Confidence in the Quality of Health Care Services ...... Trust in the Health Care Players ...... Trustworthiness of Sources of Information ...... Importance of Sources of Information in Shaping Views ...... Fiduciary Trust in the Policy Community ...... Confidence in the Competence of Health Care Players ...... Credibility of Health Care Players ...... Confidence in the Health Care System - Past vs Present ...... Optimism about the Future Quaiity of the Health Care Services .. Values and Value Congruence...... Who are the trusters? Who are the distrusters? ......
CHAPTER SIX: WHAT SHAPES TRUST? ...... Summary of Hypothesis Testing ...... Deterrninants of Trust ...... Summary of Findings Pertaining to the Model ......
CHAPTER SEVEN: CONCLUSION ...... Contributions to the Study of Trust ...... Conceptualization of Trust ...... Exploratory Component ...... Explanatory. Component...... Policy Implications...... Future Research ......
REFERENCES ......
APPENDIX A: Chronology of News Events in Alberta ......
APPENDIX 0: Operationalkation of Weighting Variables ...... ,..
APPENDIX C: Summated Scafes Summary ...... SPSS Syntax of Credibility and Value Congruence ......
APPE NDlX D: 95% Confidence Intervals for Selected Means ...... List of Variables Used in Multiple Regression Analyses .. Correlation Tables for All Analyses ......
APPENDIX E: Questionnaire and Cover Letters ...... LIST OF TABLES
Table 2.1 Selected Definitions of Trust ...... 30
Table 4.1 Percentage Distribution of the Sample Weighting Variables compared to the Statistics Canada 1996 Census and the 1999 Survey About Health and the Health System ......
Table 5.1 Confidence in Canadian Institutions ...... ,......
Table 5.2 Confidence in Quality of Current Calgary Health Services by Quality of Care Received ......
Table 5.3 Level of Trust in the Health Care Players ......
Table 5.4 Partisanship and Trust in Premier Kiein ......
Table 5.5 Zero-order Correlations, Means and Standard Deviations of Variables Pertaining to Trust in Health Players ......
Table 5.6 Partisanship and Trust in the Administrator of a Regional Health Authority ......
Table 5.7 Partisanship and Trustworthiness of the Alberta Health Minister ......
Table 5.8 Trustworthiness of Sources of information on the State of Health Care in Alberta ...... --.--...--......
Table 5.9 Importance of Sources of Information in Shaping Views ...
Table 5.10 Fiduciary Trust in the Health Policy Community ......
Table 5.1 1 Confidence in the Competence of the AMA and UNA ......
Table 5.12 Credibility of Three Health Care Players ......
Table 5.13 Confidence in the Health Care System - Now Compared to 5 Years Ago ......
Table 5.14 Optimism about the Future Quality of Services by Quality of Care Received ...... Table 5.15 Optimism about the Future Quality of Services by Confidence in the Alberta Medical System......
Table 5.1 6 Importance of five Values in Shaping the Health Care System ......
Table 5.1 7 Value Congruence between Respondents and Selected Health Care Players with Respect to Five Heafth Care Values ......
Table 5.1 8 Characteristics of Trusters and Distrusters ......
Table 6.1 Summary of Hypothesis Testing ......
Table 6.2 Results of Regression of Generalized Trust, Fiduciary Trust and Confidence in Competence on Various t ndependent Van'a bles ......
Table 6.3 Results of Regression of Confidence in the Alberta Medical System and Fiduciary Trust in the Health Policy Community ......
Table 6.4 Results of Regression of Determinants of Trust in Three Health Players ......
Table 6.5 Results of Regression of Determinants of Trust in Premier Klein's Input to Decisions Regarding Changes to the Health Care System ......
Table B.1 Frequency Distribution of Weight Factor Variable ......
Table C.l Summated Scales Summary ......
Table D.1 95% Confidence Intervals for Means of Selected Variables ......
Table 0.2 Zero-urder Correlations. Means, and Standard Deviations for Determinants of Confidence in the Alberta Medical System, Fiduciary Trust in the Health Policy Community and Confidence in the Competence of the United Nurses of Alberta ...... Table 0.3 Zem-order Correlations, Means and Standard Deviations for Determinants of Tnrst in Hospital Nurses, Alternative Health Care Providers, and Premier Klein ...... 214
Table 0.4 Additional Zero-Order Correlations for Hypothesis Testing ...... ~...... 21 5 LIST OF FIGURES
Figure 2.1 Three Facets of Trust ...... 18
Figure 2.2 Continuum of Trust and Distrust ...... 25
Figure 3.1 General Model of Determinants of Trust ...... 47
Figure 7.1 Overlap of Determinants of 3 Facets of Trust ...... 167
Figure 7.2 Overlap of Determinants of 3 Health Players ...... 168 Chapter 1 INTRODUCTION
Trust in social systems is not a zero-sum matter but is the creator of enhanced benefits for all parties in a relationship or social system. (Barber 1983:21)
There is a broad consensus that the Canadian health care system is a collective accomplishment, a source of pride, and a symbol of core Canadian values. (Graves, Beauchamp and Herle 1998:352)
This thesis examines the sociological construct of trust, with particular emphasis on the nature and distribution of the public's trust in the Alberta health care system and its component parts. This project is fuelled by a realization that trust in this system, which is "a source of pride and a symbol of core Canadian values", is on the decline.
This chapter will begin with a brief iilustration of the importance of trust research and, because trust does not operate outside of its social context, with an overview of the health care situation in Alberta. Particular attention is given to significant events which occurred in the months preceding the survey. The final discussion will outline the research questions which guide this survey research project. IMPORTANCE OF THE STUDY OF TRUST
Interest in the concept of 'trust' has a long history dating back to philosophers such as Aristotle and more recently disciplines such as psychology, political science and sociology (Peters, Covello and McCallum 1997). Notwithstanding the fact that discussions on 'trust' can be found in the writing of the early fathers of sociology such as Durkheim and Weber, Lewis and Weigert (1985b:967) suggest that sociologists have only recently begun to treat trust as a sociological topic and that there is, in Niklas Luhmann's (I979:8) words, a 'regrettably sparse literature which has trust as its main theme within sociology". Bernard Barber (1983:170), a key sociological theorist in the area of trust, argues that "we need to discover and continually rediscover how to foster trust and make it more effective". It is the author's hope that this study wit1 contribute to this rediscovery process and to the existing library of empirical research on trust.
Why is the study of trust in a health care system important? Trust in a health care system as an institution carries risks not necessarily present in other institutions. For example, if one loses trust in a religious institution one can leave the church altogether or go to a complementary religion (e.g., Catholic to United) which one trusts. If one distrusts a mechanic, one can choose another mechanic. If one distrusts the current government, one has the ability to effect change through the electoral system, If one loses tmst in the public education system, one can put his/her children in the separate school system or home- school them. If one distrusts the public health care system in Canada, one has few options. There are private. for-profit services available and one can go to the United States for treatment. However, these are very expensive options and out of reach for many Canadians. That is not to say that a system like the U.S. system offers any more options, for most people are tied to their HMO (Health Management Organization) depending on their health insurance, Canadians are essentially reliant on the public health care system for their well-being in case of injury or illness to an extent not found in most other institutions (the criminal 3 justice system is one exception that comes immediately to mind). Institutions such as the public health care system do not provide for the same reciprocal- trust environment of interpersonal relationships or other trust relationships such as market exchange. The truster in this case has little recourse if the trust relationship is broken. In a market exchange situation the truster can withhold payment or go to a competitor or, in an extreme case, go to court.
Health care reform and concern about the health care system is not just an Alberta phenomenon. Health care is a leading issue all across Canada. As a result there has been a great deal of debate and research directed at health care issues and the health care system itself. This thesis contributes to the debate on public health care restructuring and the understanding of the system and the public's attitudes toward the system. It does so by examining an important aspect of the relationship between the public and the health care system and its key players, which has received only limited attention in Alberta; that aspect is trust.
While this research uses Calgary as a case study, the findings have a broader application. They provide a benchmark for comparison with other institutions. Trust is a foundation of legitimacy and legitimacy is a fundamental political resource. Case studies such as the bilingual air traffic controllers conflict in the 1970's and the more recent OkaIKanesatake conflict have demonstrated that establishing trust is crucial in policy-making situations and negotiations (Borins 1983; Campbell and Pal 199 1). The tainted blood scandal is one example where loss of trust became a centrat issue. Recent reconciliations, such as compensation for victims and public apologies, demonstrate attempts to regain that lost trust and re-establish legitimacy. Many other public policy arenas. such as the Constitution, aboriginal affairs, the Canada Pension Ptan, the Young Offender's Act and child welfare, are facing or undergoing fundamental institutional reform. Patterns of trust and distrust engulfing those 4 issue areas, and the politicians overseeing those reforms, will be important influences on the shape taken by institutional reforms in those areas.
THE HEALTH CARE CONTEXT IN ALBERTA
Angus Reid notes that since premier] Ralph Klein's Conservative government took office in June 1993, the public's confidence in the health care system has declined dramatically, falling from 65 per cent who rated the system at above average in January 1993. to fewer than one in three Albertans who gave it passing marks in November 1995. (Elabdi 1996:8).
Over the past few years Albertans have been presented with an increasingly dismal picture of the state of health care in their province. The media is replete with stories of deficiencies in the delivery of health services: long waiting periods for medical, surgical and emergency-room services, cutbacks resulting in layoffs and hospital closures, hospital bed shortages, dire warnings of out-of-control health care spending, and even rumouw and allegations of deaths attributable to these conditions. These conditions are occurring in conjunction with, or as it has been suggested, a result of, the Alberta Government's health care reform initiatives. In 1994, Premier Klein announced funding cuts to health care services which amounted to over $734 million dollars (Crockatt 1994:A14). That same year, Albertans saw the complete restructuring of the Alberta health care system into 17 regional health authorities. Both major cities in Alberta have seen hospital closures. Calgarians, for example, have witnessed the dramatic effects of the restructuring process with the closure of their only inner-city hospitals, which cuiminated in the spectacular demolition of the Calgary landmark Bow Valley Centre of the Calgary General Hospital. 5 How might this largely negative climate have affected Albertans' perceptions of the health care system? Recent public opinion polls indicate health care is the single most important issue facing Albertans today and has been for the past three years (Heffring 1999). It has exceeded concerns over economics, education, deficit reduction, employment and social services. Studies have also indicated that not only is there a decline in satisfaction with health care services, but Albertans are becoming increasingly less confident that publicly-funded health care services will be there when they need them (Kanji and Cooper 1999, PHCA 1998, Walker 1999a).
The situation in 1999 was no different than it had been in past years. For Calgary, the year 1999 was characterized by a number of significant events. The year began with Health Summit '99, Premier Klein's attempt to involve the pubiic and the Alberta health care community in the health care planning process. Throughout the year, Calgarians witnessed numerous reports of a health system in crisis -hospital bed shortages, patients being diverted to other hospitals, long waiting lists. shortages of doctors and nurses, and long wait-times in hospital emergency rooms -followed by promises of increased funding by the provincial government. April saw a major 'planned' shakeup of the Calgary Regional Health Authority, including the appointment of former provincial treasurer Jim Dinning as chair of the CRHA board. In June, Alberta nurses threatened a province-wide strike. Perhaps the most significant event in 1999 occurred just prior to the administration of this survey. At the end of October, Premier Klein announced his intention to introduce Bill 11 -the controversial 'privatization' bill which allows private surgical facilities to perform surgery requiring overnight stays - into the legislature on November 17,1999.
In the interest of providing further background for this study, a chrono(ogy of some of the major news stones since the Klein government began its health care reforms in 1993, and up to November 1999 when this study was conducted, is offered in Appendix A. RESEARCH QUESTION
The Alberta health care system is a multifaceted and complex system, composed of many parts. The intent of this thesis is not only to measure trust in the system itself, but also in the institutions, agencies, and people that comprise the system. Among these 'components' of the Alberta health care system are: nurses, doctors, the Alberta Medical Association, the United Nurses of Alberta, hospital administrators, local and provincial health system administrators. the Government of Alberta and its health department, and the Premier. A few health care players who fall outside of the public health care system have been included because they are, nonetheless, an integral part of the Alberta health care system. Those players include chiropractors, alternative health care providers, medical laboratories, and private hospitals.
The purpose of this thesis research project is to examine the nature, distribution, and determinants of the public's trust in the Alberta health care system. This research project is divided into two components -an exploratory component and an explanatory component.
Exploratory component:
This component is largely descriptive and will map the contours of public trust in the component parts of the Alberta health care system, including among other things, providing a comparison of levels of public confidence in the Alberta medical system vis-a- vis other Canadian institutions, and identrfying levels of trust in fourteen key health care players. Two specific questions guide the analyses: "How trusting are Albertans of the current health care system?" and "Do members of the Alberta public trust different key players in the Alberta public health system to differing degrees ?" Explanatory component:
This component is guided by the specific research question: "What are the determinants of public trust in the Alberta heatth care system and in its component parts?" Multiple regression analysis will be used to identify those factors which shape trust in the various components of the Alberta health care system. It will examine those factors that have the greatest impact on levels of trust and how the profile of factors differs (or is similar) among the dependent variables.
This introductory chapter has provided a brief discussion on the importance of the study of trust, an overview of the health care context in Alberta, and a presentation of the research questions which guide this research project.
Chapter Two of this thesis provides an overview of the theoretical literature on trust and the major theories which shape this thesis project. Chapter Three outlines the empirical literature on trust. with particular emphasis on empirical studies that have identified determinants of trust in institutions. This chapter also presents the model of determinants of trust and the hypotheses tested in Chapter Six.
Chapter Four outlines the methodology used in the design and implementation of this survey research project. Included are discussions of the sampling and weighting procedures, questionnaire construction, scale construction including a discussion of the use of confirmatory factor analysis. operationalization of the dependent and independent variables, and the statistical procedures employed in the analyses in Chapters Five and Six.
Chapter Five presents the findings of the exploratory component of this study. Chapter Six discusses the results of the correlation and multiple regression analyses used in the explanatory component of this study. Included S in the presentation of the results is a summary of the findings of the hypothesis testing.
The final chapter begins with summary statements about the contributions of this project to the study of trust and the conceptualization and operationalization of trust. The findings of both the exploratory and the explanatory analyses are summarized, and implications for policy and future research are considered. Chapter 2
CONCEPTUAL AND THEORETICAL FRAMEWORY
This chapter provides an ovenriew of the theoretical literature on trust and the major theories which shape this thesis project. The theoretical perspectives presented in this chapter come largely from the sociological literature', with particular emphasis on functionalist approaches to the problem of social order. As no single theory encompasses all aspects of trust in an institution the size or complexity of a health care system. a number of complementary theories have been incorporated.
SOCIAL HOLISM
7mst is a relationship, not only an individual trait. " (Lewis and Weigert 1985a:467)
David Lewis and Andrew Weigert (1985a:455) distinguish between two approaches to the study of trust - 'social atomism' and 'social holism'. Social atomists view trust as residing in the individual, a state of the individual. Individuals are seen as autonomous and negotiations or 'social contracts' are sought to advance the individual's private interests (Lewis and Weigert 1985a:455). It is this approach that is most often seen in the social psychological and exchange theory literature on trust.
Lewis and Weigert (1985b) would argue that atomism ignores the 'social' aspect of trust, in that trust does not exist in absence of a social relationship, as
' Sociological theory represents just one approach to the study of bust. Some other approaches include risk theory, games theory. and experimental approaches such as the 'Prisoner's Dilemma'. Also, there is a large literature on interpersonal trust in the fields of psychology and organizational behaviour. This study has not been designed to address those parts of the literature. there would be no need for it. They instead advocate a 'holistic' approach to the study of trust, one that takes into account the social conditions in which trust relationships are produced and maintained (Lewis and Weigert 1985a).
Other contemporary theon'sts share Lewis and Weigert's belief that this holistic 'sociological' approach to the study of trust is necessary for the understanding of trust. Niklas Luhmann (1979) advocates an integration of the macro- and micro-level aspects of trust. Luhmann (1979:6) states that "trust occurs within a framework of interaction which is influenced by both personality and social system, and cannot be exclusively associated with either". Bernard Barber (1983) argues that the expectational components of trust operate on both the individual level and the system level. Trust can exist between individuals and between individuals and systems (Barber 1983:18). Social holism demands that one look not only at the individual for an understanding of 'trust', but afso at the social context in which trust relationships are created and maintained. Using this 'holistic' approach, this thesis will examine how contextual factors such as the perceived workload of nurses and doctors shape trust in the health care system.
LEVELS OF TRUST - INTERPERSONAL AND SYSTEMIC
Theorists make a distinction between two realms of trust - interpersonal and systemic (or impersonal) trust. lnterpersonal trust is that trust which exists between individuals. Its foundation rests on an emotional bond between those individuals (Lewis and Weigert 1985a:463). It is often seen as a function of individual personality traits (Barber 19835). lnterpersonal trust involves an expectation of fairness that is in keeping with the individual's personalrty (Luhmann 1979; Westacott and Williams 1976). Interpersonal trust has been studied extensively in the psychological and social-psychological literature, as well as the intra-organizational literature on employeelemployer relations, job satisfaction and organizational productivity (Thomas 1993:37). Systemic trust refers to that trust which exists between individuals and institutions or between institutions themselves2. Systemic trust is roughly defined as confidence in the traditional institutions of society such as government and the professions (Lewis and Weigert 1985a; 1985b). It is a trust in the competence of the agents of these institutions (such as doctors, politicians and policymakers) and the institutions themselves (such as the regional health authorities or the Provincial Department of Health). Systemic trust ostensibly lacks the element of emotional bonding found in interpersonal bust relationships. While systemic trust may share some of the same determinants as interpersonal trust, systemic trust does not require mutual confidence among the participants in the trust relationship.
When assessing how much emphasis to put on the interpersonal level of trust for an analysis of trust in a health care system, a point made by Oliver Williamson is worth taking into consideration. Williamson argues that 'exchanges based on interpersonal trust are relatively rare outside of the familym and that when exchanges are based on 'calculative' behavior, rather than 'tnrst- based' behavior, they "are themselves backed up by various social and legal institutions embedded in trust" (Williamson 1991 as cited in Thomas 1993:43). This argument is in keeping with the ideas of both Luhmann and Barber who view trust as primarily a social structural and cultural phenomenon (Barber 19835). While systemic trust is the primary focus of this thesis, it could be argued that some aspect of interpersonal trust exists in all tmst relationships, even when the person being trusted may be an employee of an institution or organization. and a complete stranger. When we go to the hospital we are trusting in individuals, an organization, and the health care system simuftaneously. An illustrative example occurs when questions are asked about tmst toward specfic heatth care practitioners. That is, when asked about one's trust in hospital nurses, one may be thinking of nurses as a professional group of
Inter-organizational trust will not be discussed here. health care practitioners or one may be thinking of one's own personal experience as a patient. It may be difficult to distinguish between systemic and interpersonal trust in these situations. Therefore, in keeping with the 'holistic' approach both levels of trust must be acknowledged.
THEORETICAL PERSPECTIVES ON TRUST
A review of the theoretical literature on trust supports Niklas Luhmann's (1988:94) contention that trust has not received consistent attention in mainstream sociology over the years. The earliest socioIogical writings about trust appear in the works of three classical theorists of the late 1800's and early 1900's - Emiie Durkheim, Max Weber and Georg Simmel. Neither Durkheim nor Weber offers a true theory of trust. Trust is discussed as part of a larger concept. For Durkheim, trust was necessary for the long-term sustainability of market exchange and the division of labour (Rueschemeyer 1994:66). Trust is incorporated into Weber's theory of legitimate authority. For example, in the case of 'charismatic' authority, trust is invested in a leader by virtue of his or her 'charismatic' personality or revelation (Weber 1968). Simmel's theory on trust is discussed later in this section.
Major sociological theory on trust does not appear again until the fate 1960's. with Talwtt Parsons' treatises on doctorlpatient trust, influence, and the linkage between values and trust. The late 1970's and early 1980's constitute a third wave of sociological interest in trust, with the influential works of Niklas Luhrnann and Bernard Barber. Much of the subsequent sociological literature on trust is being influenced by the theories of these three major trust theorists.
Sociological interest in trust remained throughout the 1980's and the 1990's (see, for example, Coulson 1998; Gambetta 1988; Giddens 1990; Hardin 1993; Lewis and Weigert 1985; Sellerberg 1982; S hapiro 1987; Thomas 1993, and Zussman 1997); and theories were developed which build upon those of Parsons, Luhmann and Barber. The latter part of the twentieth century may signal the beginning of a resurgence of interest in trust, particularly as it relates to crises in health care and health care delivery. For example, David Mechanic (1998:171-172) reports that trust in health care leaders in the United States has dropped from 73 percent in 1965 to 22 percent in 1993, and he attributes much of the current decline in trust in health care to the trend toward a for-proft, managed care system in the form of HMOs (health management organizations).
There are a number of different perspectives from which trust can be studied. In the sociological literature, functionalism has been the prominent theoretical perspective from which trust has been studied (Lewis and Weigert 1985a). The majority of trust theorists mentioned thus far write from this functionalist perspective. One other theoretical perspective that contributes to the study of 'trust' is the social leaming perspective of such theorists as Julian Rotter. While Rottets theory comes from a psychological tradition, one could argue that his theory is in keeping with Lewis and Weigert's 'holistic' approach, in that it involves a type of learning that can not be separated from its social context. The discussion which follows looks at trust in terms of the social leaming theory of Julian Rotter, functionalist perspectives and three other contemporary theories which are felt to be relevant to the study of institutions, and the Alberta health care situation in particular.
Social Learning Theory
Social leaming theory posits that behaviour is based on an expectancy that a particular behaviour in a particular situation will lead to a particular outcome. Social leaming theorists focus on interpersonal trust. Rotter (1967:651) defines interpersonal trust as "an expectancy held by an individual or a group that the word, promise, verbal or written statement of another individual or group can be relied upon". Social learning theorists also suggest that these 'generalized expectancies' or generalized attitudes can be learned through the direct behavior of others and through verbal and written communications such as newspapers and television. Based on this proposition, Rotter (1967:653) suggests that individuals can come to distrust others "without personal experience" by learning that distrust from those whom they trust. This point has important implications for this thesis for two reasons. First, friends and family may be important sources of information about experiences with the health system. Secondly, the media is a big player in the current Alberta health care debate and a major source of information for the public.3
Functionalist Perspectives
Theorists writing from a functionalist perspective all agree that trust is necessary for the proper functioning of society. Durkheim asserts that "generalized trust is a necessary condition of sociality" (Lewis and Weigert 1985a:460). Simmel states that without faithfulness (trust), society would not exist (Lewis and Weigert 1985a). Parsons stresses that confidence, trust and faith are necessary for the ongoing functioning of the social order (Mayhew 1982:55). Luhmann (1979) contends that trust is a means for reducing complexity in the social world. Barber (1983:21) suggests that "trust is an integrative mechanism that creates and sustains solidarity in social relationships and systems". Lewis and Weigert (1985a) view trust as a necessary functional component of society. Giddens (1990:120) suggests that "with the development of abstract systems pn modem society], trust in impersonal principles, as well as in anonymous others, becomes indispensible to social existence".
3 A recent study indicates that the media in Alberta receives a level of trustworthiness that exceeds that of various health administrators (Elabdi 1996). Georg Sirnmel
In contrast to Durkheim and Weber, Simmel does offer a definition of trust. He states that without "faithfulness" society could not exist (Simmel 1950:379). Simmel distinguishes between two types of trust. Metaphysical trust (vertrauen), or 'faithfulness' is a generalized, universal type of trust based on "social connectednessn(Simmel 1964318n as cited in Lewis and Weigert 1985a:458). Metaphysical trust acts in the same way as Durkheim's notion of trust, in that social contracts would not be possible without it. In this thesis 'metaphysical' trust is operationalized as global trust and hypothesized, as a general life orientation, to have a positive effect on trust in institutions. Existential trust is a more specific type of trust. It is "specific, dynamic and situational" and is based on "perceived trustworthy qualities of the other" (Simmel 1964318 as cited in Lewis and Weigert 1985a:458). Trustworthiness of a health care player as a source of information about the health care system is one example.
Simmel recognizes the importance of 'knowledge' in his notion of trust. Existential trust lies somewhere between total knowledge and total ignorance. If one has total knowledge of another then there is no need for trust. Conversely, if one has absolutely no knowledge of the other it is unlikely that there would be a high degree of existential trust placed on the other (Simmel 1950:318). Trust serves to reduce the complexity of life by allowing one to trust others without requiring full knowledge of the other. Another function of trust relates to 'specialized' knowledge, that is, the knowledge held by 'experts'. Trust has a 'protective' function. in that it 'allows us to act effectively and confidentlywin areas where the 'specialized' knowledge of the experts exceeds our own knowledge (Simmel 1964:333-334 as cited in Lewis and Weigert 1985a:459). While this is certainly true in most doctor-patient relationships, it may be particulary relevant in the case of alternative health care where, for most people, the knowledge held by an alternative health care provider far exceeds that of the patient with regards to treatment.
Talcott Parsons
An important aspect of Parsons' theory is the notion that shared norms and values are necessary components of the trust relationship (Parsons 1970: 126). In order for a trust relationship to exist, four conditions must be satisfied to some general degree. Both actors must share common values. They must also agree that the actions that result from these shared values are directed toward a shared common goal. Both parties must be collectively invotved and "there must be some adequate "symbolization" of both competence and integrity" (Parsons 1970:128). Values, once internalized, 'operate as empirical factors in social process and constitute structural components of social systems" (Parsons 1968:136). The five principles of the Canada Health Act may be seen to operate in this way. Shared values make agreement on common goals easier and 'confidence in competence 'makes commitment to mutual involvement in such goals easier" (Parsons 1970:128). Furthermore. when people are seen to share one's values, they "come to be thought of as 'trustworthy" (Parsons 1970:128). Value congruence between the respondent and administrators of the health care system is hypothesized to be a major determinant of trust in the system in this thesis.
Commenting on Parsons' theory, Alexander (1991:125-126) suggests that individuals might come to *trust in the integrity and sincerity of the officeholder without demanding proof of sincerity or immediate beneficial resultsn if the power that the officeholder holds is regulated by a code or set of values that is shared by the individual. The Canada Health Act attempts to regulate the provision of health care through the intrenchment of its five principal values of universality, portability, accessibility, public administration and comprehensiveness. Further to this notion is the concept Parsons calls 'symbolic media', the acceptance of society's symbolic structures, such as the monetary system, the legal system and political institutions (Parsons 1967). Trust in the reliability, effectiveness and legitimacy of these 'symbolic media' is essential for their continuance (Parsons 1968:155; Lewis and Weigert 1985b). In Canada, 'medicare', and by extension the medical system itself, is an important symbolic structure. It is a symbol of our collective identity and of personal security.
Niklas Luhmann
Niklas Luhmann (1979:4) defines trust in general terms as a "sense of confidence in one's expectations*. He shares with Simmel the idea that there is a basic, universal form of trust whereby individuals put their trust in the *self- evident matter-of-fact 'nature' of the world and of human nature every day" (Luhmann 1979:4). This allows individuals to deal with the uncertainty and complexity of the social world and it operates in this way on both the individual and the system level (Lewis and Weigert 1985a:462). For Luhmann, knowledge forms the basis of trust as "trust begins where knowledge ends" (Lewis and Weigert 1985a:462). Having this trust based in knowledge of the past, one is able to make predictions of the future. While this study does not include questions about people's knowledge about the Calgary health care system, it does ask about usage of health care services. The relationship between health care service usage and trust in the health care system is examined in this thesis. Luhmann (1979) argues that affirmative experiences allow individuals to trust that the system is functioning as it should. With experience comes knowledge, and with knowledge comes familiarity. One is more likely to trust the familiar before the unfamiiiar (Luhmann 1979:33).
As stated previously, Luhrnann distinguishes between interpersonal trust and system trust System trust is similar to Simmel's metaphysical trust (Lewis IS and Weigert 1985a). System trust provides a framework in which interpersonal trust can operate. Therefore, interpersonal trust, or the tnrst between individuals, becomes more risky when there is a low level of system trust (Lewis and Weigert 1985a:463). Luhmann's ideas on trust and change are discussed later in this chapter.
Bernard Barber
In his work, The I ogic and Limits of Trust (1983) Bemard Barber highlights what he considers an inadequacy of past research on trust and that is the lack of a concise working definition of trust useful in empirical research on trust. Barber begins his theory of trust with a general definition of trust that is very similar to Simrnel's 'metaphysical' trust. This highly generalized form of 'trust', that he defines as an "expectation of the persistence and fulfillment of the natural and the moral social orders", is oriented toward the social and cultural system (Alexander 1991, Barber 1983:9). This is the general form of trust that allows for social interaction.
Figure 2.1 THREE FACETS OF TRUST
Generalized Trust
Fiduciary Trust Trust in Competence
In addition, there are two more specific types of trust. The first involves the "expectation of technically competent role performance from those involved with us in social relationships and systems" (Barber 198319). Technical competence may involve "expert knowledge, technical facility, or everyday routine performance" (Barber 1983:14). This type of tnrst is observed in the physician-patient relationship where the patient must trust that the physician has the necessary skills to perform the appropriate medical procedure, or in the patient-hospital administrator relationship where the patient wants to trust (versus must trust) that the administrator has professionally organized the hospital division of labour. The second type of trust involves the "expectation that partners in interaction will carry out their fiduciary obligations and responsibilifes, that is, their duties in certain situations to place others' interests before their ownn (Barber 1983:9). Fiduciary trust might come into play in the case of a govemment minister of health. The public wants to trust that this political representative will put the public's health ahead of his or her own political ambitions. Fiduciary trust necessarily implies a moral dimension to trust (Barber 1983).
Both forms of trust can operate on the individual, as well as the system level. In a review of Barbets theory, Jeffrey Alexander (1991:127) observes that "one can have faith in the "system" (be it a society, a form of govemment, a way of life. or an organization) without having faith in the institutions or subsystems that compose it: or one may trust in the role (in its fiduciary mandate, for example) but not in the person performing it - in his or her fiduciary commitments or technical competencen. While it may be true that one can have 'faith' in a group of actors in general (such as physicians), but pehaps not in a single actor (such as one's family doctor)', the sustainability of such equivocal trust over time is questionnable. In this thesis we shall examine whether or not tnrst in the heaith care system requires trust in the institutions, subsystems and people that compose it.
A situation such as this may arise if one's family doctor has misdiagnosed a medical problem causing the patient further discornfon Lewis and Weigert
Lewis and Weigert (1985a; 1985b) buiid upon the sociological theories of trust by introducing three dimensions of trust - cognitive, affective or emotional, and behavioral -which illuminate not only the different types of trust but also the different bases of trust. First, the cognifive dimension involves trust that is "built upon knowledge of the personal and institutional attributes of trusted individuals" (Lewis and Weigert 1985a:464). Secondly, on the affective dimension, trust involves an emotional bond and emotional investment in the trust relationship between actors (Lewis and Weigert 1985b). The final, behavioral dimension of trust is the "undertaking of a risky course of action on the confident expectation that all persons involved in the action will act competently and dutifully" (Lewis and Weigert 1985b: 971). Violations of these behavioral expectations result in negative consequences for all.
As do the previous theorists, Lewis and Weigert see trust as a necessary functional component of society. They state 'society is only possible through tmst in its members, institutions, and forms (Lewis and Weigert 1985a: 455). Referring to the various objects of trust such as individuals, media, agencies and institutions, Lewis and Weigert (1985a:462) suggest that "it is necessary to distinguish these objects of trust in order to analyze the dynamics of creating, sustaining, or restoring trust in the different objects, or the relationships between trust in one class of objects and trust in anothef. This advice is followed in this thesis, for measures of respondents' trust in numerous actors are taken.
Anthony Giddens
Giddens does not differ from the other theorists discussed in this chapter in regards to a belief in the functionality of trust. Like Simmel, Giddens (1990:35) argues that trust has a 'protective' function, in that it 'serves to reduce or minimise the dangers to which particular types of activity are subje&. Giddens (1990:33), like Simmel, believes that trust derives form a ''faith in the reliability of a person or system. Giddens (1990:34) defines trust as a "confidence in the reliability of a person or system, regarding a given set of outcomes or events, where that confidence expresses a faith in the probity or love of another, or in the correctness of abstract principles (technical knowledge)". Giddens definition addresses two important points. First, trust occurs in the absence of full information or knowledge of an 'expert' system (Giddens 1990:33). This point is shared with Luhmann (1979) and Rotter (1967)- Trust is also bound up with contingency. Giddens (1990:33) states that "trust always carries the connotation of reliability in face of contingent outcomes, whether these concern the actions of individuals or the operation of systems". Reliability and contingency, while not addressed in this thesis, are important issues for future research.
Giddens understanding of trust in expert systems is somewhat contradictory to Barber's theory on trust. Both theorists agree that trust rests upon the belief in the technical competence of the trusted. However, Giddens (1990:34) argues that trust in expert systems does not rest upon "faith in the "moral uprightness" (good intentions) of others". This contradicts Barber's theory that there is a 'fiduciary' aspect to trust relationships, be they interpersonal or impersonal.
Giddens addresses the issue of trustworthiness. Trustworthiness can be divided into two types: (1) t~st~orthinessbetween individuals, and (2) trustworthiness between an individual and an 'abstract system' (such as a health care system). Trustworthiness can occur in interpersonal relationships where both parties are well know to each other, In this case, the 'othet is seen as reliable and credible (Giddens 1990:83). Trustworthiness in relationships involving individuals and 'abstract systems', while still based on reliability and credibility, does 'not presuppose any encounters at all with the individuals or groups who are in some way 'responsible" for them" (Giddens 1990:83). The idea that the trust (or distrust) does not require actual personal contact is a key point shared with Julian Rotter, and will be explored in this thesis, particularly as it relates to health care experience and media communications.
Giddens ideas on trust in abstract systems deserve further attention here. Giddens (199033) refers to those individuals or groups who work for these abstract systems as "access points". Most encounters with abstract systems are periodic or transitory and involve contact with these "access points". It is for this reason that the criteria for trustworthiness differ. Whereas, in regular encounters (such as with your family doctor) trust is built on familiarity and friendship, the transitory nature of contact with the "access pointsnof abstract systems precludes this type of relationship. Further, Giddens (1990:85) contends that in these individual to 'abstract' system encounters, the "real repository of trust is the abstract system, rather than the individuals who in specific contexts 'represent itr." Trust toward 'abstract' systems (such as a health care system) can be "strongly inff uenced by experiences at access pointsn (Giddens 1990:91). Bad experiences at access points may lead to a sort of 'resigned cynicism [and, perhaps distrust] or, where this is possible, to disengagement from the system altogether" (Giddens 1990:91), Disengagement in a public health care system may take the form of increased use of alternative health care providers or private medical facilities. As previously stated, the impact of experience as a patient in the health care system on trust in the health care system is explored in this thesis.
Trust and Credibility
Jon EIster (1989) comments on the relationship between credibility and trust in his study of social order entitIed The Cement of Society. Elster (1989:272-3) asserts that "the ability to make credible communications about what one will do under future circumstances" is an important condition for predictive behaviour and it enables people to co-operate. Trust and trustworthiness are related to that ability to make and keep credible promises. While others (Dasgupta 1988) have treated trust and credibility as synonymous, Elster (1989:275) argues that trust goes beyond credibility "to include a belief that the other party will act honourably even under unforeseen circumstances not covered by contract or promises".
Trust and Contracts
One school of thought on tmst conceptualizes trust as an alternative to contracts (Coulson 1998; Thomas 1993). Contracts are designed to specify the details of a relationship in an enforceable manner. In those situations where contracts are left vague, either deliberately or because they are unable to cover all conceivable situations, trust takes over (Bryan 1995; Coulson 1998; Thomas 1993). Durkheim reminds us that trust "can neither be supplied by contractual agreement among individuals nor be imposed by the state, unless they [trust, regulations and institutional guarantees] have a basis in the structure and normative culture of moral communitiesn (Rueschemeyer 1994:66)
This discussion has important implications for the Canadian health care system, in that the Canada Health Act can be seen as a contract between the Government of Canada Health department and its provincial counterparts, and the people of Canada to provide quality health services in keeping with the 'five principles of medicare'. However, as stated above, contracts are often vague (as is the Canada Health Act), open to interpretation and vulnerable to failure, in that they cannot anticipate all situations. Therefore, in spite of the existence of a government statute dictating the conditions under which health care is to be administered, trust remains essential. This thesis will examine the role played by some of the values enshrined in Ute Canada Health Act in shaping trust and distrust.
Trust and Change
"Trust increases the 'tolerance of uncertainty'" (Luhmann 1979:15)
As the Alberta health care system has undergone major restructuring, a special note on trust and change is warranted. Luhmann (1979:13) contends that as complexity increases, the "need for assurances, such as trust" increases. Luhmann does not expect scientific and technological advances to reduce the need for trust. On the contrary, "one should expect trust to be increasingly in demand as a means of enduring the complexity of the future which technology will generate" (Luhmann 1979:16).
Thomas (199358) suggests that 'reorganizations may be more likely to produce distrust than trust. ' Reorganization involves the implementation of changes which may "not conform with existing expectationsw,thereby creating unease and decreasing trust (Thomas 1993:58). An example of this in the Alberta health care system is the provincial government's emphasis on the use of privately-provided health services as a reform strategy. Privatization may be seen as contrary to the principfes of the Canada Health Act and may arouse fears about the future availability of affordable, quatity health care.
Distrust
Thus far, the discussion has focussed primarily on trust. Distrust, however, is an equally important and necessary functional component of the social system. As with trust, distrust senres to reduce the complexity of daily life 25 encounters and promote social control (Barber 1983; Luhmann 1979). Distrust is commonly defined as a lack of trust or confidence. Luhmann (1979:71)argues that distrust is "not just the opposite of trusr, but is also a "functional equivalent for trustn. When trust is not possible or a preexisting trust relationship has been broken, distrust provides an alternative strategy.'
Distrust, though, does not completely negate trust, for some degree of trust is present in all situations (Luhmann 1: 979;Thomas 1993). Diego Gambetta (1 988:218) suggests that there is a continuum of trust ranging from "extremes of blind trustn on one end to a "complete absence of trust" on the other, with "uncertainty" being the mid-point (Thomas 1993:44). Luhmann may agree with Gambetta, but he would aiso caution that it is not possible to live in a complete state of either extreme (Luhmann 1979:72).~
FIGURE 2.2 CONTINUUM OF TRUST AND DISTRUST
Discrepancies, disappointments and violations of expectations of trust do not necessarily result in distrust (Garnbetta 1988; Luhmann 1979;Thomas 1993). According to Luhmann (1979:73)the existence of thresholds restrains the shift
Distrust is not the only alternative to trust, *Informal social controls" such as ridicule and ostracism can also be used "to bring an untrustworthy actor into line" (Barber 1983:22). a Hardin (1993:519) disagrees with Luhmann's contention that neither trust nor distrust is feasible as a universal attitude, particularly in the case of trust He argues that "trust as a univeral attitude could pay off for someone in a very benign world in which the level of trustworthiness is quite high" (Hardin 1993:s 19). from trust to dist~st.~Trust gives way to distrust only after a set of boundariss that define the threshold has been crossed. Thresholds are not predetermined; they develop and \ary subjectively, as a result of individual predispositions (one's inclination to take risks or degree of tolerance of potential disappointment)" and "in accordance with objective circumstancesn(Gambetta 1988:222).
Barber, as with Luhmann, incorporates 'distrust' into his theory of social action. He suggests that both 'types' of trust are necessary and occur in varying degrees depending on the situation in which they occur. Contrary to orthodox functionalism, Baker views distrust as necessary and normative (Alexander 1991). He distinguishes between two types of distrust - rational and irrational.'
Barber (1983:166) sees 'rational' distrustg, which he defines as based expectations that technically competent performance andlor fiduciary obligation and responsibility will not be forthcomingn,as functional and necessary to keep those with power accountable for their actions. Rational distrust judiciously applied serves to equalize power by monitoring the actions of others for competence and fiduciary responsibility (Stebbins 1988). A certain amount of 'rational' distnrst is, therefore, beneficial. It ensures the effective functioning of society by helping maintain social order and control (Barber 1983; Luhmann 1979; Shapiro 1987).
On the other hand, 'irrational' distrust, which can arise from alienation and negativism, is dysfunctional (Barber 1983:93). Distrust becomes 'irrational' and
7 The shift from distrust to trust is much rarer (Luhmann 1979:73) a Barber (1983:167) does not specifically label this second type of distrust as 'irrational' distrust, but he does refer to a "paranoid and irrational" type of distrust. 9 This concept was originally posited by Vivien Hart in her 1978 treatise 'Distrust and Democracy". '' By 'rational*he means that distrust is 'based on knowledge. experience and values" (Barber 1983367). dysfunctional when it has the power to "dissolve or paralyze relationships" particularly fiduciary relationships (Tiryakian 1984:90). The question arises, "at what point does distrust move from being rational and functional to irrational and destructive"? Lewis and Weigert (1985b:981) use the run of investors and debtors on financial institutions as an example. However, when they ask the same question about a "breaking point" as it relates to citizens and the state, they unfortunately have to conclude that no answers are available" (Lewis and Weigert 1985b:981). Perhaps there is a threshold effect in the switch from rational to irrational forms of distrust as Luhmann (1979) suggests there is in the switch from trust to distrust. While this question can not be answered within the scope of this thesis, an interesting future inquiry may be threshold effects as they relate to types of distrust.
The importance of this discussion of distrust for institutions and organizations is that they need to be aware of the destructive nature of irrational distrust. While a cemin level of distrust is not only expected, but is also functional, institutions need to learn to identify those boundaries that define the thresholds between functional trust and destructive distrust.
TRUST AND CONFIDENCE
The use of the terms 'trust' and 'confidence' has been a topic of debate wRhin the trust literature. Some (Luhmann 1988; Seligman 1998; Tway 1994) argue that these two terms are conceptually distinct. yet these two terms are often used interchangeably in the literature. This tatter point is evident in the Oxford dictionary definitions of these two terms where each term is contained within the definition of the other. Oxford defines 'confidence' as 'a firm trusr or *a feeling of reliance or certainty" (Thompson 1995279) and 'trust' as "la. a firm belief in the reliability or truth or strength etc. of a person or thing, 1b. the state of
7 t I am not aware of any furVler research into this question. being relied on, 2. a confident expectation ... 5. reliance on the truth of a statement etc. without examination" (Thompson 1995:1498).
Theorists, such as Luhmann and Seligman, argue for making a distinction between the two terms. While Luhmann (1988:87) concedes that trust and confidence both involve 'expectations', he suggests the distinction between confidence and trust is one's ability to distinguish between dangers and risks. Trust presupposes risk, while confidence does not. Luhmann (I988:98) states "trust is only required if a bad outcome would make you regret your action". Luhmann (1988). in fact, calls for empirical research to test these assertions. Seligman (1998:391) argues that 'confidence is what you have when you know what to expect in a situation; trust is what you need to maintain interaction if you do not".I2
In contrast, for Giddens, confidence and trust are conceptually similar. Giddens (1990:32) argues, somewhat against Luhmann, that trust is "a particular type of confidence rather than something distinct from itn. As with Giddens. Barber (1983) does not necessarily see confidence and trust as two different concepts. His major argument against the use of the term 'confidence' is that it has been poorly conceptualized in empirical research, that the meanings are vague and that they do not make a distinction between aspects of competence and fiduciary responsibility (Barber 1983:86-87). In the present study certain trust questions have been specifically designed to address the issues of competence and fiduciary responsibility.
Yet, while there may be some valid theoretical and linguistic (see Tway 1994) reasons for distinguishing between confidence and trust, one could argue that the majority of respondents in survey research do not make that distinction
'2 For a detailed discussion of distinction between trust and confidence see Seligman (1998). (Wrightsman 1991:374).13 Trust and confidence will be treated as conceptually similar concepts in this thesis.
DEFINITIONS OF TRUST
What is most evident from a review of the literature on trust is that there is no consensus on the definition of this important concept. Trust is a multiiacetted concept and any definition of trust must take that into account. The multifacetted nature of trust and the fact that a 'single' definition of trust is not appropriate for all situations may explain the multifarious definitions found in the theoretical and empirical work on trust. Table 2.1 ouffines some of the definitions of trust found in the trust literature.I4
While doing the background research for this study of trust in a health care system, I concluded that neither a single theory nor a single definition of trust is sufficient to explain a system of this size and complexity. For that reason, this thesis will draw primarily upon Barber's conceptualization of trust. Barber (1983), as previously outlined. proposes three types of trust - generalized trust, fiduciary trust, and confidence in competence. Using Barber's three definitions. trust can be operationalized so as to differentiate between trust in a generalized sense (such as trust in a health care system) and contextual trust (such as fiduciary trust in the health policy community or confidence in the competence of a health care player). In addition, this thesis will probe Barbets conceptualization of trust so as to determine empirically whether these facets of trust are, in fact, distinct.
'' A study reported by Citrin and Muste (I 999472) found that 'almost 35% chose trust as the meaning of confidence, and the dosely related terms having faith or believing in an institution's leaders were mentioned by another 22%"when asked to evaluate their level of confidence in ovemment institutions. 94 Only some of these sources are discussed in this thesis. Table 2.1 Selected Definitions of Trust AUMOR 1 DEFINITION OF TRUST Barber (1983) [ Three facets of trust (1) Generalized trust ='expectation of the persistence and fulfillment of the naturaf and the moral socia1 orders". 1 (2) Fiduciary trust = 'expectation that partners in interaction will carry out their fiduciary obligations and responsibilities". 1 (3) Confidence in cornpeten- = -expectation of technically competent mle pehnanse from those involved with us in social relationships and I systems'. Fukuyama (199526) 'The expectation that arises within a community of regular, honesf and cooperative behavbr, based on commonly shared norms, on the part of other members of that community'. Garfinkel (as cited in Thomas ' The belief that others will comply with the expectancies -or rules - of 1993:46) I daily life.. Giddens (199034) ( 'Confidence in the reliability of a person or system, regarding a given 1 set of outcomes or events, where mat confidence expresses a faith in 1 the probity or love of another, or in the correctness of abstract principles i (technica~knowledger. Lewis and Weigert (1985a; I Three dimensions: (I)Cognitive = "built upon knowledge of the personal and institutional attributes of trusted individuals'. (2) Affective = invokes an emotional bond and emotional investment in the trust relationship between actors. (3) Behavioral = 'undertaking of a risky course of action on the
confident expectation that afl oersons involved the action will act- - / competentiy'and dutifullf. ' Luhmann (1979) I General bust = 'a sense of confidence in one's expectations". Personal bust = 'the generalized expectation that the other will handle his freedom, his disturbing potential for diverse action, in keeping with his personality - or. rather. in keeping with the personality which he has presented and made socially visible*. Systemic trust = trust in social systems and institutions. lllishra 1996 (as cited in Coulson Trust in one party's wiIIingness to be vulnerable to another party based 1998:14) / 00 the belief that the latter .party - is competent. ooen. concerned and I reliable*. Moorman, Zaltrnan and *A willingness to rely on an exchange partner in whom one has Deshpande (in Bryan 1995:Yl / confidencem. Rotter (1967:651) i *An expectancy hefd by an individual or a group that the word, promise. I verbal or wntten statement of anather individual or group can be relied : upon". Oxford Dictionary (1995:1498) 1 'A firm belief in the reliabiBty or truth or strength etc. [sic] of a person or 1 thing; the state of being relied on: a confident expectation? Simmel 1964 (as cited in Lewis Trust as 'faithfulness". Metaphysical trust is based on 'social and Weigert- 1985a) / connectedness"and erj.nerIial trust is based on *oerceived trustworfhv I quaities of the othef. Tway (1994:8) ] The state of readiness for unguarded interaction with someone or . - - .- .- - .- . . Zussman (1997:253) ! *A firm belief in the honesty. truthfulness. iustice or wwer of a oerson 1 or a thing, the obligation o;&ponsibility ikposed on a personainwhom 1 confidence or authority is placed, a confident expectation or hope'. This chapter has outlined the main sociological perspectives and theories on trust which inform this thesis research project. As previously stated, this thesis will take a 'holistic' approach to the study of trust, one that takes into account not only the individual characteristics of trusters and distrusters, but also the social contexts in which trust relationships operate. We now turn to an examination of the empircal literature on trust and presentation of the model of tmst in the health care system to be tested in this thesis. That model was developed using the combined input of the theoretical and empirical literatures on trust. Chapter 3 LITFRATURE REVIEW AND HYPOTHESES
Chapter Two outlined the main theories on trust which shape this thesis research project. Chapter Three will now outline the empirical literature on trust, with particular emphasis on empirical studies that have identified determinants of trust in institutions. The literature review was by no means restricted to the sociological literature. Literature was reviewed in many different disciplines including business administration, communications, medicine, organizational behaviour, political science, behavioural and social psychology, and sociology. The literature review was, also, not restricted to North America. Insights from research conducted in Australia, Peru, South Afn'ca, many European countries, and some post-communist societies were incorporated into the discussion which follows. This chapter is divided into the following five sections;
w measures of trust in the titerature literature on trust in institutions literature on determinants of trust toward a theory of trust statement of hypotheses
MEASURES OF TRUST IN THE LITERATURE
In Chapter Two, many theories and definitions of trust found in the literature were presented. How then has trust been operationalized in the empirical literature on trust in institutions? One might expect, based on the plethora of definitions of trust, a similar profusion of trust measures. While some measures focused on the fiduciary aspect of trust (Pescosolido, Boyer and Tsui 1985), others focused on a specific aspect or object of trust such as a hospital, a health insurance company, a doctor or nurse (AlbertaRN 1998; Elabdi 1996; National Coalition on Health Care 1997; Pfau, Multen and Garrow 1995; Walker 1999a). However, most of the empirical literature on trust in institutions, reviewed for this thesis, used variations of the following two questions:
1. "As far as the people running gnstitution] are concerned, would you say you have a great deal of confidence, only some confidence or hardly any confidence at all in them" (Brehm and Rahn 1997; Citrin and Muste 1999; Hoffman 1998)'
2. "1 am going to read you a list of institutions in American society. Would you tell me how much confidence you, yourself, have in each one?" (Canadian Gallup Poll 1989; Citrin and Muste 1999; Listhaug 1984; McAneny 1996; Mishler and Rose 1997; Papadakis 1999).
Response options were typically three or four point Likert-type scales (e.g., 1. a great deal, 2. only some, 3. hardly any, or 1. a great deal, 2. quite a lot, 3. some, 4. very little). The list of organizations varied from study to study, but could include education, the military, organized religion, major companies, Congress (US. only), the Supreme Court, the press, organized labour and medicine.
LITERATURE ON TRUST IN INSTITUTIONS
The literature on trust in institutions is dominated by an interest in political and governmental institutions (Brehm and Rahn 1997; Lipset and Schneider 1983; Listhaug 1984; Mishler and Rose 1997; Papadakis 1999). Only a handful of research-related articles addressed trust in health care players and medical institutions; most of them simply reported levels of trust (AlbertaRN 1998; Elabdi 1996; McAneny 1996; National Coalition on Health Care 1997; ffau, Mullen and
This question has been used extensively in me General Social Surveys and Hams Polls in the United States (Citrin and Muste 1999). Garrow 1995; Snow 1997; Zussman 1997). An extensive search of the available literature databases2 failed to find any empirical studies that examine determinants of trust in a health care system in the manner proposed in this the~is.~
Despite the lack of empirical studies on the determinants of trust in medical institutions, the reviewed literature provides valuable insights into the dynamics of trust and factors influencing trust in institutions. The next section discusses those insights which are instrumental in the development of a model of trust in a health care system
DETERMINANTS OF TRUST
This section is divided into six broad areas - social demographic characteristics, ideologies and orientations, efficacy and controt, health care experience, media influence, and values and value congruence - which represent most4 of the major factors hypothesized to be determinants in the model of trust in the Alberta health care system.
Social Demographics
Five social demographic variables - gender, age, income. education and
These include. but are not limtted to, Articles First, Canadian News Disc, Canadian Research Index. CINAHL. Dissertation Abstracts. Healthstar, International Political Science Abstracts, Medtine, PAIS. PapersFirst, Psyclnfo, Saskatchewan News Index, Social Science Abstracts, Sociological Abstracts. and U of C ThesidDissertation Database. There is a large literature on trust in physicians and nurses. However. that literature focuses on interpersonal trust in the doctor-patient or nurse-patient relationship. '' For example. credibility was not discussed in this review of the literature because it has already been discussed in the preceding chapter on trust theory. self-rated health status5 -were considered for inclusion in the model of systemic trust. The majority of studies which included a variable for gender found either no relationship (Lagace and Gassenheimer 1989; Papadakis 1999; Rotenberg 1990). or a very weak relationship (Hoffman 1998; Listhaug 1995; Mishler and Rose 1997) between gender and trust, regardless of whether they were testing trust in people or institutions. Citrin and Muste (1999474) found males were slightly more trusting in medicine and government than females.
There are conflicting findings on the effect of age on trust in institutions. Some studies have concluded that younger people are more trusting than older people (Citrin and Muste 1999; Nevitte 1996; Papadakis 1999). Hoffman (1998:333) found younger people have greater confidence thar, older people in medicine. In a study of trust among the elderfy, Rotenberg (1990) found there was a cunrilinear relationship whereby trust decreased from young-old (aged 60- 69) to middle-old (aged 70-79) and increased to old-old (aged 80-89). Still other studies found that younger people had less confidence in institutions than older people (Listhaug 1984; Listhaug 1985).
Cohort effects may account for some of the conflicting findings on the relationship between age and trust. Gary Orren (1997:84) found that 'since 1964 the oldest cohort of citizens has been the least trusting [of government], and the youngest cohort the mostn. Interestingly, the older cohorts (those born before 1945) are the most trusting of "their fellow citizens" (global trust) (Oren 1997:85). Brehm and Rahn (1997:102) found a negative relationship between the Baby Boomer and Generation X cohorts and interpersonal trust. Note that the findings discussed here use U.S. cohort categories and that Canadian cohort categories
5 Some may not consider 'self-rated health status' a 'true' demographic variable. However, for this present study, variables measuring characteristics of individuds are grouped into three dimensions - social demographics, ideologies and orientations, and efficacy and control. As self- rated health status does not conceptually fit with either of the latter dimensions it is being discussed under the heading of social demographics, do differ. The baby boom in Canada, for example, began in 1947, a year later than the U.S. baby boom (Foot and Stoffman 19961." Canadian 'front-end' boomers are those born between 1947 and 1959, and Generation Xers are those born between 7960 and 1966. Foot and Stoffman (1996:20) comment that these two 'boomer' cohorts do not "share much in the way of cultural attitudes or life experiences". In fact, the cohort which follows the Gen-Xers. the Baby Busters (1967-1979), have more in common with the Front-end Boomers than the Gen- Xers (Foot and Stoffman 1996). Foot and Stoffman (199622) suggest that the particular life experiences of the Gen-Xer cohort have made them the least trusting of "any sort of large institution, whether in the public or private sectof. These hypotheses will be explored in this thesis.
The effects of education on trust, particularly trust in institutions, is somewhat more consistent than the effects of age in the trust literature. The majority of studies found that as education level increased, trust in institutions decreased, although in many cases that effect was weak (Nevitte 1996; Papadakis 1999; Pesmsolido, Boyer and Tsui 198s7). In two studies looking at interpersonal trust, education was positively related to trust (Brehm and Rahn 1997; Uslaner 1998). Mishler and Rose (1997) found education level was not a significant source of generalized trust in social and political institutions.
Few studies included income or measures of socio-economic status (SES). Westacott and Williams (1976:118) report on two studies that found a positive correlation between SES and trust. In the study by Brehm and Rahn (1997:1012) income was positively, but weakly related to both confidence in government and interpersonal trust,
- - - Foot and Stoffman (1 996) suggest that the impact of the 'Baby Boom' generation was more sign~ficantin Canada than in the United States. 7 Note that this study did not address trust directly, but looked instead at how education affected evaluations of government performance in medical care. Brehm and Rahn (1997:1012) found that 'general life satisfaction' had a positive effect on interpersonal trust and confidence in government. As health status could be seen as a measure of 'satisfaction' with one's health, the relationship between self-rated health status and trust in the health care system should be a positive one. In fact, Rotenberg (1990) found that among the elderly, health status was positively correlated with trust.
Ideologies and Orientations
The ideologies considered for inclusion in the model of trust in a health care system refer to individuals' dispositions toward life and the world arcund them. These ideologies (and orientations) include optimism, global trust, cynicism and political affiliation or partisanship.
Optimism has been found to have a significantly strong, positive effect on trust. Uslaner (7998) concluded that his measure of optimism had the strongest effect on interpersonal trust of all measures in his model. Westacott and Williams (1976:126) found that "individuals who felt that things were getting worse for man tended to be highly distrustful of others". The reader will recall, from the previous chapter, that Thomas (1993) contends that organizations in a state of reorganization are more likely to produce distrust than trust. Studies have found that communities in transition express lower or low optimism (Hams 1997; Mishler and Rose 1997). This point may be significant when it comes to measuring object-specific optimism such as optimism in a health care system (as opposed to general optimism) as the Alberta health care system has been in a state of transition for a number of years now.
Global trust is a generalized trust in other people. Ingtehart (1997:231) reminds us that Yhe decline in confidence in established institutions and of trust in government does not represent a broad withdrawal of trust concerning people in general". According to the results of the World Values Surveys, Canada ranks fifth behind Sweden, Norway, Finland and the Netherlands in global trust (Ingiehart 1997:231). All of the studies reviewed found a positive. albeit sometimes modest, relationship between trust in other people (global trust) and trust in institutions (Orren 1997; Papadakis 1999; Westacott and Williams 1976; Wrightsman 1991).
The findings on the effects of cynicism on trust are unequivocal. As cynicism increases, trust decreases (Capella and Jamieson 1996: Citn'n and Muste 1999'). Cappelta and Jamieson (1996:72) contend that "cynicism saps the public confidence in politics and govemment, and encourages the assumption that what we see is not what it seemsw. Papadakis (1999) shares this view of the negative effect of cynicism on trust. In regards to role of the media, Cappella and Jamieson (1996:80) found that reading print news articles which focused on "problems facing the country's health care system and their solutions" activated cynical responses. This is a significant observation considering the nature of news st~riesabout the health care system in Alberta, and especially in the Calgary Herald, over the past few years.
Unfortunately, all of the studies that included measures of political affiliation involved politicaI party systems that are not directly comparable to Canada's political paw system. What is evident is that there is a relationship, although weak in most cases, between partisanship or political ideologies and trust (Brehm and Rahn 1997; Hoffman i998; Listhaug 1984; Papadakis 1999; Pescosolido. Boyer and Tsui 1985). Of particular interest is the finding that voting for the incumbent party increases, and is the strongest predictor of, trust in institutions of govemment (Papadakis 1999:84). Trust in this case may have more to do with affiliation with an incumbent party than support for a particular political ideology.
a Citrin and Muste (1999) report the findings of a number of studies of cyniasm and trust Efficacy and Control
Internal control (or self-efficacy) refers to the belief that one can "control life's outcomes and the world is not capriciousn (Westacott and Williams 1976:123). External control, on the other hand, is the belief that luck, fate, or powerful others (such as physicians) have control (Spector 1992:17). Internal control (or self-efficacy) has a strong, positive effect on trust (Westacott and Williams 1976). Westacott and Williams (1976:125) found that those who relied on luck to take care of them were more distrustfil than those who were less fatalistic.
Political efficacy is a particular kind of efficacy related to people's "estimation of their own personal capacity to comprehend and influence political events" (Lipset and Schneider 1983b:383). While most studies involving political efficacy and trust used both measures as indicators of a third variable, those studies which examined the effect of political efficacy found that the more politically efficacious a person feels, the greater hislher trust in institutions such as government (Brehm and Rahn 1997; Chan 1997; Westacott and Williams 1976; Wrightsman 1997 ).
Health Care Experience
A number of social theorists (Luhmann 1979; Lewis and Weigert 1985; Rotter 1967; Zucker 1986) point to the experiential aspect of trust: that is, trust is built on knowledge acquired through experience. Zucker (1986:50) argues that trust is "produced thmugh repeated exchanges". Luhrnann (1979) suggests that affirmative experiences allow individuals to trust that the system is functioning as it should. Therefore, cumulative experience as a patient in the health care system, if it is functioning well, should result in greater trust of that system. A study by Crandall and Duncan (1981) suggests that 'repeated exchanges' do not necessarily produce trust. They found that "low-income people who reported a high frequency of medical care encounters also reported a low level of trust in physicians" (Crandall and Duncan 1981:72). Unfortunately, it is not known whether those medical encounters were positive or negative, which may help explain the negative findings. The fact that these findings were predominantly among lower income people in the United States suggests that 'ability to pay', which can be problematic in this type of managed-care system, may be a factor infiuencing trust.
While the review of the literature did not reveal any studies directly addressing the impact of satisfaction with the quality of health care received and trust in the health care system, three studies did find a positive relationship between satisfaction and trust in institutions. As stated previously, Brehm and Rahn (1997:1012) found that 'general life satisfaction' had a positive effect on both interpersonal trust and confidence in government Listhaug (19841 13) found a weak, positive relationship between various satisfaction measures and confidence in institutions. A study by Papadakis (1999) also found a positive relationship between general life satisfaction and confidence in institutions. However, that confidence was limited to the police and the legal system. This thesis will explore the relationship between self-rated quality of health care received and various aspects of trust in a health care system.
Media Influence
The view that the media -television and newspapers - have a significant impact on attitudes (including trust) was expressed in many of the articles reviewed for this thesis. While some may not agree entirely with the statement made by Lipset and Schnieder (1983a:403) that the media [news and public affairs programming] are "themajor source of information concerning the condition of the country", many agree that the media do have an effect on the way we view our society and its institutions (Becker, Sobowaie and Casey 1979; Chan 1997; Capella and Jamieson 1996: Lipset and Schnieder 1983b; McLeod and McDonald 1985; Mechanic 1996; Mechanic 1998; Pfau, Mullen and Garrow 1995).
Most of the studies reviewed were testing to some degree the 'mean worid thesis', whether stated explicitly or not. The 'mean world thesis' holds that negative impressions of the world portrayed on television and in the print media make people pessimistic (Uslaner 1998). Television portrayals are more negative than newspaper portrayals as television focuses on images, whereas newspapers focus on *substantivedata" that has been "artificially balanced to present both sides" (Becker, Sobowate and Casey 1979:465). Further, media effects vaned depending on the type of media -television versus newspapers - and how media influence was measured -exposure versus attention or dependency. Brehm and Rahn (1997:1009) found that newspaper readingghad a weak positive, but statistically significant effect on interpersonal trust. Television viewing, however, was not statistically significant (Brehm and Rahn 1997). UsIaner (1998:447) found that the effect of frequency of television viewing on trust became non-significant when optimism was introduced into the model. Sophia Chan (1997:292) found a negative relationship between 'attention' to campaign news and political trust, but that effect was limited to television and not newspapers. A study by Becker, Sobowale and Casey (1979) found a link between knowledge, dependency on type of media, and trust. Those dependent on newspapers were more knowledgeable than television dependent persons, and subsequently, more trusting in crty officials (8ecker. Sobowale and Casey 1979:473). There was also an association fbund between dependency on the newspaper for local news and trust in officials for those greater than 28 years
9 Newspaper reading was measured by asking respondents how many days each week they read the newspaper (Brehm and Rahn 1997:1019). of age and with a high school education or greater (Becker, Sobowale and Casey 1979:470). Several other studies have reported findings which varied depending on the education level of the respondent (Chan 1997; Chafee and Schleuder 1986; McLeod and McDonald 1985). Chan (1997:291) reported that the effect of attention to campaign news on levels of political trust (distrust of government) was not significant among the more educated for either medium -television or newspapers. Among the less educated, attention to television campaign news was strongly and significantly related to distrust of government (Chan 1997:290). Chan (1997) suggests that the less educated usually obtain political news from television and not newspapers.
A study by ffau, Mullen and Garrow (1995) sheds some light on the effects of television portrayals of physicians and tmst. They argue that *past prime-time television depictions of physicians were consistently positivenwhich contributed to positive attitudes toward the medical profession and trust. Current depictions may not always be as positive because they often take issues of the "political economy of modem medicine" such as for-profit medical systems (Pfau, Mullen and Garrow 1995:441). Social learning theorists suggest that knowledge about other people and institutions is often the result of "a unique combination of direct and mediated experiences" (Pfau, Mullen and Garrow 1995:442; Rotter 1967). Television medical dramas serve this role because they allow access to the 'backstage' of medicine that is not often seen through direct experience. The 'front' region is that public region to which one is exposed every time one visits a family doctor. The 'back' region, or 'backstage', is the nonpublic domain. This region is where 'professionals may act inconsistently with their frontstage performance"; access to these backstage behaviours may undermine trust in medical professionals (Pfau, Mullen and Garrow 1995:444; Giddens 1990). The results of the study by ffau, Mullen and Gamw (1995:454) indicate that television medical dramas inffuence public perceptions of physicians and rentatively suggest the possibility of negative influencesn. Both the effect of attention to health care issues in the news media and the effect of television medical programmes on trust in the health care system will be explored in this thesis.
Values and Value Congruence
When one thinks of values and health care in Canada, one often thinks of the five principles of the Canada Health Act :lo
Universality - all Canadians wilt be provided with equal health care coverage. Portability - no barriers to coverage between provinces. Accessibility - all Canadians will have equal and reasonable access to the same quality of health care. Public Administration - the health care insurance plan must be operated on a non-profit basis and administered by the provincial government. Comprehensiveness - all Canadians shall have access to basic health services.
These values are central to the way Canadians think about and administer the health care system in this country and these values are often "held in contradistinction to perceptions of the American [health care] system" (Graves, Beauchamp and Herle 1998:352). Conversely, the Calgary Regional Health Authority in its submission to Health Summit '99 held in Calgary, Alberta stated that the three 'pillars' of the health system are global competitiveness, quality health services and social norms and values (CRHA 1999:8). The 'Rethinking Government' survey (Graves, Beauchamp and Herle 1998:383)found that
'O For more detailed information see CRHA 1996 and Health Canada 1998. Canadians rated all the values" as important, while giving priority to the values of "efficiency, performance, and equality of access" by Canadian public. Although 'efficiency' is not one of the core values of the Canada Health Act, it is a "major principle driving the restructuring of health care" (Burke 1998:2).12
Parsons' (1970) theory that value congruence, or shared norms and values, is a key component of trust relationships has received some empirical support.13 The 1996 Why Don't Americans Trust the Government study found that among the stated reasons for lack of trust was "policies don't reflect own beliefs 8 values"; approximately 80% stated that as a minor or major reason, while only 20% stated it was not a reason at all (Zussman 1997:245). Listhaug's (1984:121) conclusion based on the Norwegian Values Study was that "attitudes and values which are in opposition to the dominant values of the society may lead to a loss of confidencen in institutions. Deutsch's contention that similarities in main values are conducive to greater trust between people is supported in Nevitte's (1996:137) analysis of economic ties between Canada and the United States. Nevitte (1996:143) found that convergence on "main [economic] values" led to mutual trust, which in turn led to support for closer economic ties and support for political integration. Sources from the organizational behaviour literature, while not referring diredy to issues of trust, found that value congruence with a 'leader' of an organization was associated with greater satisfaction with that leader (Ashkanasy and O'Connor 1997; Meglino, Ravlin and Adkins 1991). This thesis will further examine the relationship between value congruence and trust; it hypothesizes a positive relationship between the two.
11 The 'Rethinking Government' survey listed values that are not part of the five principles of the Canada Health Act. Those additional values included efficiency, performance of results, prevention. freedom of choice. compassion and flexibility (Graves. Beauchamp and Herle 1 998:384). '' Burke (1998) raises a concern that the emphasis on 'efficiency' may be overwhelming and marginalizing the five criteria of the Canada HeJth Act. l3 The literature review for this thesis found very few articles reporting empirical findings on the relationship of value congruence and trust in institutions. TOWARD A THEORY OF TRUST IN A HEALTH CARE SYSTEM
A major aim of this project is to develop a model of trust in a health care system. While the model presented here (Figure 3.1), in its current design, is specific to the Alberta health care context, probably only minor modifications, if any, would be necessary to apply it to other health systems in Canada.
Before proceeding with a presentation of the model of determinants of trust in the Alberta health care system and the hypotheses imbedded in that model, it is important that we review the research questions which guide this project. The main research question which guides the explanatory component (Chapter 6) is: What are the determinants of public trust in the Alberta health care system and in its component parts?" In the exploratory component (Chapter 5) the questions which guide the analyses are: "How trusting are Albertans of the current health care system?" and *Do members of the Alberta public trust different key p/ayers in the Alberta public health system to differing degrees?"
The Alberta health care system is multifaceted and complex. While being a distinct entity itself, it also comprises a number of institutions, agencies, administrative bodies and people. It is not enough to simply look at trust in the 'health care system'. One must also Iook at trust in its component parts to get a true, nuanced picture of trust in such a complex system. Given the large number of variables measuring trust l4 and the volume of hypotheses generated by this research project, a limited selection of hypotheses will be used for analysis. In addition, the following six dependent trust variables have been selected for analysis in Chapter Six:
'' The questionnaire contains thirty variables measuring different aspects of bust in the health care system and in its component parts. confidence in the Alberta medical system. fiduciary trust in the health poiicy community. confidence in the competence of the United Nurses of Alberta. trust in a hospital nurse's input to decisions regarding changes to the health system. trust in an alternative health care player's input to decisions regarding changes to the health system. r trust in Premier Klein's input to decisions regarding changes to the health care system.
Note that elements of Barber's (1983) theory regarding the three facets of trust - generalized trust, fiduciary trust and confidence in competence - have been incorporated into this analysis as indicated by the first three variables listed above.
Other measures of trust, used in the exploratory analysis to map the contours of trust in the Alberta health care system (Chapter Five), but not used as 'dependent' variables in the analyses in Chapter Six. are:
confidence in the competence of the Alberta Medical Association. confidence in the quality of current health care services in Calgary. trust in the input of fourteen health care players' (including hospital nurses', alternative health care providers' and Premier Klein's, as listed above) input to decisions regarding changes to the health care system. trustworthiness of sources of information about the health care system. confidence in the present health care system compared to five years ago.
What shapes trust in a health care system? The theoretical model (Figure 3.1) being tested in this thesis proposes that trust is shaped by the following eight dimensions:
social demographic characteristics of the respondent. ideologies and orientations of the respondent. the respondent's feelings of efficacy and control. health care experience. media influence. perceived effectiveness of the system. value congruence between the respondent and key decision-makers. trustworthiness of key sources of information about the health care system.
These eight dimensions represent quite different 'orders' of phenomena - namely, characteristics of the respondent, the social experience of the respondent within the health care system, perceived characteristics of the system and its component parts, societal influences (specifically the media), values of the respondent, and perceived values of two major health care players.
Next we outline those hypotheses selected for use in the analyses which follow this chapter.
STATEMENT OF HYPOTHESES
For the sake of simplicity, and unless otherwise stated, the phraseology 'the health care system' used in the hypotheses below refers to all measures of trust tested in this thesis, whether they be measures of systemic trust, per se, or of interpersonal trust. When the hypothesis refers to the health care system specifically (irrespective of its component parts), the phraseology will be 'the Alberta medical system'.
Demographics
While the majority of studies found no differences between males and females in their levels of trust in institutions, I suspect that we may find gender differences when it comes to trust in specific health care actors. Women are probably more likely than men to seek treatment from alternative health care providers because of specific women's health problems, such as endometriosis, for which conventional medical treatments have not always been satisfactory. It could also be argued that women enter into trust relationships with their physicians and attending nurses more regularfy than men for reasons related to childbirth and childcare. Based on the above argument, one would expect that women will be more trusting of health care practitioners than men. Citrin and Muste (1999) suggest that when it comes to political institutions, men are more trusting than women, and this may extend to political actors as well. Therefore, it is hypothesized that;
HI.I Females will express higher levels of trust in health care practitioners, and lower levels of trust in the health policy wrnmunty and political health care actors than males.
With the exception of the cohort born between 1960 and 1966 (the Generation X cohort), age appears to be inversely related to trust in institutions, particularly government institutions. The opposite is expected when it comes to the relationship between age and trust in traditional health care practitioners. As the older generation grew up in an era where doctors commanded a great deal of trust and their authority was rarely questionned, it is expected that the otder people will express higher levels of trust in traditional health care providers. Hence,
H1.2 As age increases, trust in the Alberta medical system, the health policy community, and poiitical and administrative actors decreases. HI-3 As age increases, trust in traditional health care practitioners (doctors and nurses) increases. HI-4 As age increases, trust in non-traditional health care practitioners (chiropractors and other alternative health care providers) decreases. H1.5 The Generation X (1960-1 966) cohort will be the least trusting of all
Education is an important variable for a number of reasons. Studies suggest education has a negative effect on trust in institutions. Education also serves as an important variable in the understanding of the relationship between media influences and trust.
H1.6 As education increases, trust in the health care system decreases.
As mentioned in the literature review. income has been included in only a few empirical studies on trust. This may be due to the strong correlation between education and income. In many cases, in order to examine the effects of income one needs to control for the effects of education on income first. One of the biggest debates surrounding health care reform in Alberta is privatization. Many critics of the provincial government's reform strategy express great fear that by allowing private for-profit health care services to operate in Alberta we shall be creating a two-tiered health system. A two-tiered health system, as seen in the
l5 This cohort argument ignores immigrant respondents who may be included in the sample. Due to the small sample size, a question asking respondent's immigrant status was not included. United States, disadvantages lower income people. Income, or ability to pay for needed services, becomes a very salient issue. It is, therefore, hypothesized that;
H1.7 Lower income people will have less trust in the health policy community, political and administrative actors, and the Alberta medical system, and more trust in traditional health care providers.
Given the findings that general life satisfaction is positively related to trust, it is reasonable to extend that idea to self-reported health status. That is, as health status decreases, trust in the health care system and its administrators decreases. When it comes to the effect of health status on trust in health care providers, one would expect that as health status decreased, the need to trust a health care provider would increase. A second measure of health status is included here. Chronic illness plays a dual role. Depending on the nature and severity of a chronic illness, one's life may be affected more negatively as a result of that illness. In addition, having a chronic illness often results in increased use of health care services which is hypothesized to have a negative effect on trust.
HI.8 Respondents' health status is positively related to trust in the Alberta medical system, the health policy community and Premier Klein, and negatively related to trust in health care providers. HI-9 Respondents with a chronic health problem that requires regular health services will report tower levels of trust in the Alberta medical system. the health policy community and Premier Klein, and higher levels of trust in health care providers than those without a chronic health problem. Ideologies and Orientations
Global trust differs from trust in an institution or a specific actor. Global trust is a general life orientation. Global trust is a way of viewing the world and the people around us. If one is trusting in one area of life, it stands to reason that one would be tmsting in other areas as well. Therefore, it is hypothesized that;
H2.1 As generalized trust in other people (global trust) increases, trust in the health care system increases.
People with optimistic outlooks generally evaluate the world around them more positively. Studies support the hypothesis that optimism increases trust, whereas pessimism decreases trust. Two measures of optimism are included in this study - a generalized optimism and optimism specific to the future quality of health care in Calgary. Given the current state of health care in Alberta, we may find that people are less optimistic about the future of health care in Alberta than they are about life in general. However, both measures of optimism are hypothesized to have the same effect on levels of trust.
H2.2 As optimism increases, trust in the health care system increases.
Cynicism, like global trust, can be seen as a life orientation, a way of viewing the world around us. Political cynicism is distinguished from general cynicism in this study. Cynicism, particularly political cynicism, should figure prominently in this study given the highly-charged political nature of the debate surrounding health care reform in Alberta. As stated in the literature review. the findings on the effects of cynicism on trust are unequivocal; cynicism, whether general or politically-oriented, breeds distrust. H2.3 As political cynicism increases, trust in the health policy community, Premier Klein, and the Alberta medical system decreases. H2.4 As general cynicism increases, trust in the health care system decreases.
As the debate surrounding health care is highly politicized, the exclusion of a measure of political affiliation would be negligent. The inclusion of a measure of political affiliation is largely based on the suggestion by Papadakis (1999) that there is a link between affiliation with the incumbent party and confidence in governmental institutions. The Alberta health care system is a government-run institution; in fact, the provincial Premier is the major spokesperson for health care reform in the province. Therefore, affiliation with the incumbent, Progressive Conservative, party should increase trust in the health care system. In spite of this argument, it is expected that partisanship will not be a factor in all cases. While partisanship may be an important factor in determining trust in the 'political' health care actors, it should not be a factor in determining trust in 'non-political' health care actors. The following three hypotheses are offered:
H2.5 Progressive Conservative party supporters have higher levels of trust in the health policy community, Premier Klein, and the Alberta medical system than Liberal and New Democratic party supporters.
Efficacy and Control
A review of the literature indicates that internal control is positively related to trust, whereas external control is negatively related to trust. Three health locus of control measures are used in this study. Internal health locus of control refers to the degree of control one has over one's own health. Those who have a high degree of self-reliance may be more willing to extend trust to others because they feel confident in their ability to control uncertain situations. Those who believe that their health and well-being is controlled by powerful others or fate may be more likely to invoke rational distrust as a means of coping with uncertain situations. Three hypotheses are:
H3.1 As internal health locus of control increases, trust in the health care system increases. H3.2 As a belief in external control (powerful others externality) increases, trust in the health care system decreases. H3.3 As a belief in chance (chance health locus of control) increases, trust in the health care system decreases.
Studies indicate that political efficacy is positively related to trust. Politically efficacious people may be invoking the same sorts of mechanisms and rationales as those who have a high degree of internal control. Control leads to a willingness to trust.
H3.4 Political efficacy is positively related to trust in the health policy community, Premier Klein and the Alberta medical system.
Health Care Experience
There is an interesting contradiction between the theoretical literature and empirical findings with regards to effect of experience on trust. The theoretical literature suggests that experience increases knowledge which in turn increases trust (Luhmann 1979; Zucker 1986). The finding by Crandall and Duncan (1981 ) sheds some doubt on that conclusion. They find that increased use of physician services decreases trust There are two possible explanations for this contradictory finding. Increased use of health care services may be the result of poor health status, which as previously hypothesized, decreases trust.16 In addition, as the use of health care services increases the possibility for negative experiences increases, resulting in decreased trust. Therefore, it is hypothesized that:
H4.1 As the breadth of experience as a patient in the health care system increases, trust in the health care system decreases. H4.2 As the frequency of experience as a patient in the health care system increases, trust in the health care system decreases.
Satisfaction with the quality of health care services received and satisfaction with waiting times for health care services are both salient issues in the minds of Albertans, and perhaps, all Canadians facing the health care crisis. The literature on satisfaction and trust suggests a positive relationship. Therefore, it is hypothesized that ;
H4.3 Quality of health care services received is positively related to trust in the health care system.
Media Influence
The effect of media influence on trust is not as straightforward as one might expect, as evidenced by the literature reviewed. Trust varies according to the type of media and whether influence is measured as exposure or attention. Trust in particular health care providers may also be affected by the message presented by those media. (See the discussion of media messages and trustworthiness of sources of information about the health care later in this
'' A path analysis, proposed for future research, may shed some light on the indirect effect of experience an trust chapter.) The effect of media influence is somewhat confounded by education level. Several studies found that the influence of media on trust differed among those with different education levels. Typically, those with lower levels of education rely on television for health care information and those with higher levels of education rely on newspapers. Hence,
H5.1 The higher the attention paid to health care issues in the news (television and newspapers), the lower the trust in the Alberta medical system, the health policy community and Premier Klein, and the higher the trust in health care providers, controlling for education. H5.2 Those who pay greater attention to health care issues in newspapers will report higher levels of trust in the Alberta medical system and the health policy community than those who pay greater attention to health care issues in the news on television.
The study by Pfau, Mullen and Garrow (1995) suggests that current portrayals of physicians on television medical dramas are more negative than they have been in the past and the effect is decreased trust in physicians. They explained that this effect relates to access to the nonpublic domain (the 'backstage') of medicine. In the conclusion to their article, Pfau, Mullen and Garrow (1995:455) recommend that future research include the 'new genre of fast paced medical shows (e-g., ER, Chicago Hope, etc.)". The 'political economy' of health care is often central in these 'new' medical dramas. It is, therefore, hypothesized that;
H5.3 Exposure to television medical dramas is negatively related to trust in the health care system. Over the past few years television viewers have been increasingly exposed to a new trend - real-life medical programmes. Programmes, such as The Operation and Trauma -Life in the ER,depict real-life surgical procedures and medical emergencies. These medical programmes do not depict medical professionals in the same way that fictional medical dramas do; nor do they focus on the 'political economy' of health care. Instead, medical professionals are shown fulfilling their fiduciary responsibilities to patients. Real-life medical programmes are hypothesized to have the opposite effect on trust from medical dramas.
H5.4 Exposure to real-life medical programmes is positively related to trust in the health care system.
Effectiveness of the System
With reports of long waiting times for health care services and shortages of doctors and nurses, the effectiveness of Alberta's health care system has been put into question. As the perceived effectiveness of the system decreases, one would expect that trust in the system would also be negatively affected. The following exploratory hypothesis is offered;
H6.1 The greater the perceived workload of nurses and doctors, the lower the trust in the health policy community and the Alberta medical system.
Values and Value Congruence
Both theoretical and empirical sources suggest that value congruence - shared norms and values - has a positive effect on trust regardless of the object of that trust. The five values included in this model are Accessibility ('that all Albertans have equal access to quality health caren), Efficiency ("that the health care system is run efficiently"), Public.Administration ("that the health care system is publicly funded"), Speedy Access (mat Albertans have speedy access to health servicesn) and Privatization ("that privately provided health care services be available to Albertans"). It is hypothesized that:
H7.1 The greater the congruence between the respondent and the Calgary Regional Health Authority with respect to each of the five values - accessibility, efficiency, public administration, speedy access, and privatization - the higher the respondent's trust in the health policy community and the Alberta medical system.
H7.2 The greater the congruence between the respondent and Premier Klein with respect to each of the five values - accessibility, efficiency, public administration, speedy access, and privatization - the higher the respondent's trust in the health policy community, Premier Klein and the Alberta medical system.
As the value of privatization is contrary to the Canada Health Act, it is a hotly debated subject in Alberta. Despite objections from the Alberta health minister and the Premier, critics have argued that the current provincial administration supports privatization of the Alberta health care system. These criticisms were further fuelled by the Premier's announcement, at the Tories' annual policy convention the last weekend of October 1999, of his intention to "push ahead with legislation [Bill 11 - The Health Care Protection Act] to allow private interests to perform operations requiring an overnight stay" (Martin 1999). As support for privatization may be seen as support for the provincial government health reform initiatives, it is hypothesized that; H7.3: The greater the support for privatization of health care services, the greater the trust in the provincial health care administration and the health policy community.
Trustworthiness of Sources of Information
A measure of trustworthiness for three main sources of information abut the heafth care system - medical professional sources (such as doctors and hospital nurses), government and administrative sources (such as the Calgary Regional Health Authority, the Alberta government health minister, and Premier Klein), and media sources (such as local newspapers) -was created for this study. It is expected that the level of trustworthiness will vary among the various heath care system players. Political health care players may be seen to have a vested interest in portraying the health care system in a positive light, and as a result be seen as fess trustworthy sources of information than health care professionals such as doctors and nurses. Hence,
H8.1 Medical professionals such as doctors and nurses will be seen as more trustworthy sources of information about the health care system than political actors and agencies such as the Calgary Regional Health Authority and Alberta health.
The effect of trustworthiness of an information source on trust in the Alberta health care system depends on the message being presented by that source. If the position taken by that source is critical of the current health care system, and that source is perceived as tnrstworthy, then trust in the health care system may be diminished. Conversely, if the position taken by that source is positive and supportive of the current health care system, and that source is perceived as trustworthy, then trust in the heaIth care system will increase. As the medical profession has been very critical of the current health care system by higblighting deficiencies in the system (AlbertaRN 1998; AMA 1999a. 1999b. Kenny 1999; UNA 1999; Walker 1999c,19994,1999f), seeing medical professionals (doctors and nurses) as trustworthy sources of information about the system will likely cause trust in the health care system to decrease. Therefore, it is hypothesized that:
H8.2 As trustworthiness of medical professional (doctors and nurses) sources of information about the health care system increases, confidence in the Alberta medical system decreases.
On the other hand, govemment sources of information (the Alberta govemment minister of health, the Calgary Regional Health ~uthority'~,and Premier Klein) present a much more positive image of the current state of Alberta's health care system, often highlighting govemment initiatives designed to improve the system'8 (Government of Alberta 1999a;1999b; Henton 1999; Walker 1999e,1 999g,1999i). Therefore, it is hypothesized that:
H8.3 As trustworthiness of govemment sources of information about the health care system increases, confidence in the Alberta medical system increases.
A measure of trustworthiness of newspapers has also been included as much of the debate over health care reform in Alberta has been played out in the
" Kevin Taft (2000:l)suggests that the Calgary Regional Health Autharity (CRHA) 'is peppered with allies of the Premier" and 7n the public eye the CRHA seems so closely tied to Mr. IUein that it has become a barometer of trust for his government and for him". '' This was probably best illustrated in Premier Klein's November 16, 1999 teievision address aRer his announcement of Bill 11 (Government of Alberta 1999~). print media. A re vie^'^ of media stories in a local newspaper suggests that the health care system is being portrayed as a system in crisis. Hence,
H8.4 As trustworthiness of newspapers as sources of information about the health care system increases. confidence in the Alberta medical system will decrease.
The hypotheses outlined in this chapter will be examined in the analyses presented in Chapters Five (Mapping the Contours of Trust) and Six (What Shapes Trust in a Health Care System?). A summary of the findings with respect to these hypotheses is found at the end of Chapter Six.
'' Articles about the health care system, in a major local Calgary newspaper, were collected on a daily basis for approximately nine months prior to the administration of the survey. Although a proper content analysis has not yet been conducted, the general tone of the artides for that penod suggests that the media is more critical of 'political' health care actors. Chapter 4
This chapter will outline the methodology used in the design and implementation of this survey research project. Included in this chapter are discussions on the sampling and weighting procedures, questionnaire construction, scale construction and operationalization of the dependent and independent variables, and the statistical procedures used to test the hypotheses outlined in the previous chapter.
A NOTE ON RESEARCH DESIGN
Response rates have always been an issue when employing any type of survey research methodology. Melevin, Dillman, Baxter and Lamiman (199959) report that mail surveys of the general public now often produce response rates corn parable to telephone surveys. Nonetheless, the reduction of nonresponse still plays a major role in research design. Nonresponse can affect the interpretability and generalizability of survey results. As this project utilized a mailed, self-administered questionnaire to survey the general public, every effort was made to reduce non-response.
Nonresponse is of particular concern in surveys of the general public. ' Don Dillman (1991 :234)reports that general public surveys utilizing his Total Design Method should and typically do attain response rates between 50 and 70 percent. Levy and Lemeshow (1991:303) are less optimistic; they suggest that even some large-scale surveys must take considerable measures to achieve even a 50 percent response rate.
' Response rates are generally higher for more homogenous groups (Baumgartner and Heberlein 1984; Dillman 1991 ). A great deal of research2 has been devoted to increasing response rates and many of the recommendations have been incorporated into the research design for this thesis project (Babbie 1995; Bailey 1982; Baumgartner and Heberlein 1984: Church 1993; de Vaus 1990; Dillman 1991, Dillman, Dillman and Makela 1984; Erdos 1983; Fox, Crask and Kim 1988; Melevin, Dillman, Baxter and Lamiman 1999: Sudman and Bradbum 1984). The recommendations of the above authors and those of the oft-cited Dillman Total Design Method, which was recently renamed the 'Tailored Design ~ethod'~,(Ditlman 2000) cover all aspects of research design. from questionnaire construction to return envelopes. Below is a list of the main factors affecting response rates:
1. Salience of the subject matter 2. Number, nature and timing of follow-ups to the first mailing 3. Financial incentives 4. Pre-notification 5. Sponsorship 6. Stamped return envelope versus business reply 7. Length of the questionnaire (typically shorter is better) 8. Cover (etters 9. Questionnaire format (letter sized or booklets are preferable to legaI size) 10. Questionnaire colour (green versus white) 11. Questionnaire layout (simple and easy to read with clear instructions) 12. Personalization of correspondence
Baumgartner and Heberlein (198467) found that number of contacts [initial mailing and follow-ups) and salience of the topic explained roughly 50% of the variance in the final response rate (42% and 7.3%. respectively). They also
' The sources cited for this thesis are only a very small pmpartion of the available literature an this subject Dillman (7997226) comments that a bibliography compiled for the dted artide contained aver 400 entries, all published since 1970. found that including a questionnaire with the second follow-up was more cost effective and produced a better rate of return than including one with the first follow-up (Baumgartner and Heberlein 1984:68). In an examination of 10 surveys, the most important factors influencing response rates were follow-ups, financial incentives, stamped return envelopes, followed by salience of the topic, prior notification, special postage and sponsorship (Dillman 199j 239). Questionnaire length (generally shorter is better), a cover letter and personalization had varied influence depending on the study. Fox, Crask and Kim (1988:483) found that university sponsorship increased response rates by almost 9%, pre-notification by fetter increased response rates by roughly 8% and choosing a stamped return envelope over a business reply envelope increased response rates by over 6%. Postcard follow-ups, first dass versus other outgoing postage and green versus white questionnaires had small but statistically significant effects on response rate. Stamped versus metered outgoing postage, notification of a cut-off date and personalized postscripts asking for cooperation had no statistically significant effect on response rates (Fox, Crask and Kim 1988:484).
Those recommendations, which have been incorporated into the research design for this study, are briefly outlined here. The topic of trust in health care system may be considered a salient topic in Alberta in light of the health care system reform initiatives over the past few years. Financial incentives could not be offered due to budgetary constraints. However, respondents could request a summary of the findings. For budgetary reasons it was necessary to print the questionnaire on white legal-size paper instead of the recommended letter-size or booklet format. The following techniques, as recommended, were employed to increase the response rate:
-- 3 me 'Tailored Design Method' addresses the 'onemethad-fits-all limitation" of the original Total Design Method proposed in 1978 (Diilman 1991237; Dillman 2000) i. Two follow-up letters; the second included a replacement questionnaire. ii. Pre-notification by letter (handdeiivered) iii. Sponsorship by a university (the university logo and departmental affiliation used on all correspondence, the envelopes and the questionnaire) iv. Self-addressed, stamped return envelopes v. A five page questionnaire (3 legal sheets) vi. A cover letter explaining the project accompanied the first mailing4 vii. All letters (initial and follow-up) were personally signed by the researcher.
THE SAMPLE
This survey was conducted in the city of Calgary, Alberta. Calgary covers a geographical area of 721.42 square kilometers, and its population in 1999 was approximately 842,000 (City of Calgary 1999). An area sample was used, whereby a map of the city was divided into a grid pattern. The details of the sampling procedure are outIined in this section.
A number of factors influenced the decision as to how large the sample should be - the predicted response rate (between 25 and 30%)'~the need for a sample size sufficient for proper statistical analysis, the available labour, and financial resources. After considering all of the above factors, I determined that an initial sample of 1000 participants would yield a final sample that would be large enough (at least 200-300 cases) for meaningful statistical analysis.
Respondents were advised that the questionnaire should take approximately 25 minutes to complete (based on the pre-test). Haurngamer and Heberlein (1984:70) found that indicating a time cue around 20 minutes produced a better response rate (41-5%) than either a longer time cue of 45 minutes (25.575) or a control group with no time cue (31.5%). This estimate is considerably lower than the response rates reported by Oillman (1991 ) for three reasons. Firstiy, the pre-test response rate for this study was roughly 33%. Secondly, personal conversations with other social researchers reveal typical response rates of around 25 to 30%. Thirdly, this survey follows some, but not all of the recommendations of Dillman and others, as outlined at the beginning of this chapter, so the same high level of response was not expected. The sampling frame was constructed using four levels of sampling. The sampling methods used, which involved random, cluster and systematic techniques, were chosen for a variety of reasons including the reduction of noncoverage and sampling error, feasibility and economy (Babbie 1995; Fowler 1988; Levy and Lemeshow 1991). The first level involved the random selection of cells on a map within the city of Calgary municipal boundaries. The area for study was initially determined using a map of the city of Calgary which was divided into 1 kilometer by 1 kilometer cells (MapArt 1999). Of the 596 cells that were within city limits, 418 contained residential areas and were determined suitable for sampling. Of those 418 cells, 167 were randomly selected for use in the study using a computer-generated random number selection process. The decision to select 167 cells was based on the desire to ensure maximum coverage (spread throughout the city16, and the desire for an initial sample of approximately 1000. This decision was also influenced by the physical limitations imposed by the manual method of constructing the sampling frame.
Each of the 167 cells represented a cluster within which 6 households7 were systematically selected to receive a pre-notification letter (Fox, Crask and Kim 1988) advising them of their selection as potential participants in the study and the upcoming delivery of the questionnaire0 Further sampling was done within each household by requesting that the person 18 years of age or older with the next birthday after October 20,1999 complete the questionnaire.
3 Non-coverage error can be problematic in studies using area sampling techniques (Dillman 1991). ' tt was decided that six is the minimum acceptable number of households per cell. a Within each cell, households were sampled as follows: sampling began on the street closest to the SE corner of the cell. The first drop off was the 'second' residential dwelling from the indicated start position. A pre-notification was then dropped off to every 'third' residential dwelling until the quota of six had been reached. If the first street selected contained fewer than six eligible residences. the deliverer was instructed to continue by moving to a second pre- determined location (next closest street to the SE comer of the cell) until all six residences had been sampled. For more information on the sampling strategy used in this survey please contact the researcher. The Sampling and Data Collection Process
Between October 15 and 20,1999, with the help of two volunteers, pre- notification letters were handdelivered to 1004 households? At the same time, the sampling frame was constructed as per specific instructions for systematic sampling within each cell. As each address was recorded, a pre-notification letter was de~ivered.'~(See Appendix E for a copy of pre-notification letter.) Of the 1004 households visited, 9 were recorded as refusals (without replacement) due to the posting of a "no unsolicited mail" sign'' on their mailbox and were not given a pre-notification letter.
On November 4,1999 survey packages were mailed to the 995 households in the sampling frame (initial 9 refusals excluded). These packages included a questionnaire, an addressed, stamped, return envelope and a cover letter stating the purpose of the study, providing instructions to the selected respondent, and informing the respondent of his or her voluntary participation and confidentiality as per the University of Calgary Ethics Board guidelines. (See Appendix E.) Returns were recorded daily and carefully tracked to ensure that the first reminder letter was sent at an optimal time when the return rates were starting to diminish (Bailey 1982; Erdos 1983). Roughly 50 percent (N = 254) of the completed questionnaires had been returned by November 18, 1999 without reminder.
A reminder letter was sent on November 22,1999 to all those who had not returned a completed questionnaire by that date. By December 8, 1999 almost three-quarters of all completed questionnaires (N = 360) had been returned and returns continued to be tracked on a daily basis.
- - 9 The grand N is 1004 instead of 1002 (167 cells x 6 households per cell = 1002) due to minor over-sampling error in three cells and under-sampling mrin one cell. One hundred and seventeen prenotification letters were mailed. '' Residences displaying 'no soliciting', 'no flyers', and 'no junk mail' were not treated as refusals. A second and final reminder letter with another copy of the questionnaire was sent on December 10,1999. The total number of completed and usable questionnaires returned was 493, which resulted in a response rate of 49.1016.'~ Ninety-five percent of all completed questionnaires had been returned by December 30,1999. The final 5% were returned between January 4 and April 4, 2000. With a final sample size of 493, this survey is considered to be accurate to within t 5 percentage points, at the 95% confidence level (de Vaus 1990:72).13
The response rate was calculated using the following formula:
Response rate = # of completed question na ires IN=493) # of questionnaires mailed (N=995) plus # of initial refusals (N=9)
SOURCES OF ERROR
There are four potential sources of error which may result in the over- or under-representation of some subgroups within the sample. One source of error occurs when certain members of the population within the sampling frame are deliberately excluded (Dillman 1991; Fowler 1988). Below are the criteria by which households (or members within a household) were included or excluded from the sampling frarne14:
" Both Babbie (1995:262) and Gdos (f 983:144) suggest a response rate of at least 50 percent is adequate for analysis and reporting. However, both add that a higher response rate does not automatically mean a more representative sample. This estimate is based on a 50150 distribution of responses. A more skewed (ie: 20180) distribution would result in a confidence interval that was accurate r 4%. 19 times out of 20 (de Vaus 1990:72), 14 Exclusions occurred on two levels. tfie dwelling itself and within the household. due to the layers of sampling methods used. Exdusion differs from refusal in that exclusions are not considered part of the sampling frame and refusals are calculated into the final response rate. Inclusion Criteria: 1. Age >= 18. 2. English-speaking. 3. All residents of dweilings within Calgary city limits except those listed below.
Exclusion Criteria:
1. Residents with supermailboxes (where mailing address not available). 2. Residents of dwellings where access to the mailboxes and mailing addresses not available (such as high security a artrnent buildings, nursing homes, and other institutional housing)I? . 3. Residents of unconventional dwellings (such as industrial buildings) or those without a permanent residence (such as the homeless).
Noncoverage error involves those members of the population covered by the sampling frame (Dillman, 1991). Due to the large geographical area encompassed by this study and some practical limitations, some areas were excluded from the sampling frame.16 These areas included cells containing large expanses of undeveloped or park land and highdensity industrial areas where the sparseness of residential dwelfings made sampling physically impractical or the location of residential dwellings could not be ascertained.
As discussed at the beginning of this chapter, a person's refusal to participate in the study or failure to return a completed questionnaire can result in nonresponse error and this type of error is considered a major weakness of mailed surveys (Bailey 1982; de Vaus 1990; Dillman 1991). Nonresponse reduces the overall sample size and bias may result from the over- or under- sampling of certain subgroups within the population (Norusis 1990; StataCorp 1999b). As discussed in the previous section on research design, nonresponse
15 Three apartment buildings and one single-family dwelling were excluded for this reason (a fifth dwelling was excluded because of a threatening message attached to the mailbox). This researcher does not believe these exclusions bias the results. '' Every effort was made to reduce noncoverage error. Area suitability was partially confirmed using postal-walk information from Canada Post (Canada Post 1999). this researcher's own knowledge of the city and physically driving to specific areas. issues were addressed through careful design of the questionnaire and the questions, and through the sampling procedure.
The fourth type of error, which can result in the introduction of bias due to the unequal representation of certain segments of the population within the sample, is measurement error. Measurement error can occur when the respondent is either unable to answer a particular question on the questionnaire or, for whatever reason, provides an incorrect or false answer or refuses to answer that particular question (Dillman 1991). Measurement error can be controlled, to some extent. in the wording of a question or the order in which questions appear on the questionnaire (Babbie 1995; Bailey 1982; Dillman 1991; Fowler 1995; and Strack 1992). In an effort to reduce measurement error resulting from questionnaire design, a pre-test was conducted approximately two weeks prior to the start of the project. Pre-test results are discussed in the section on questionnaire construction later in this chapter.
WEIGHTING THE SAMPLE
As discussed in the preceding section, errors in sampling and survey design can introduce bias which results in a sample that is different from the population from which it was taken. Applying sampling weights in the data analysis can reduce this bias and allow for estimators that are approximately unbiased and representative of the population under study (Babbie 1995:193; Norusis 1990; StataCorp 1999b:323).
As shown in the Table 4.1, the unweighted sample data (referred to as the '1999 Trust Survey' in Table 4.1) differ slightly on some characteristics and significantly on others from the population data. In order to allow for generalizations from the sample to the population under study, sampling weights were used. Weight factors were calculated by comparing the sample to the 1996 Census of Canada for the Calgary Census Metropolitan Area (CMA)" on three demographic variables - sex, age and education (Statistics Canada 1996a),18 This was done by creating crosstabulations using SPSS for each dataset on all three variables, then calculating a weight factor value in each cell where there was complete data on all three variables. In the case where the sample frequency was zero'' for a particular cell or there was incomplete information for one or more variables." the weight factor was set to 1.000.~' The resulting weighted sample, as shown in Table 4.1, closely approximates the population on all three weighting variables - sex, age and education. Generally one could say that the weighted sample is representative of the population. For a frequency distribution of the weight factor variable and operationalization of the three Statistics Canada weighting variables refer to Appendix 6.
In addition, the weighted 1999 Trust Survey closely approximates the figures for the 1999 Survey about Health and the Health System (Alberta ~ealth1999)~for both ~algar-$~and the province as a whole on 'self-rated
I7 The Calgary CMA includes the outlying communities of Airdrie, Beiseker, Chestermere, Cochrane, Crossfield. Irricana. Rockyview Municipal District #44 and Sarcee Reserve #f 45. Although the census data covers a geographical area greater than Calgary city limits (the 1999 Trust Survey covers only those areas within the city limits), the population outside the Calgary city limits comprised only about 6.5% of the total CMA population in 1996. 1 do not feel this has changed significantly since that date nor does it introduce any serious bias into the sample. '' The 1996 Census data was used as there were no other data sources available which included information on all three weighting variables - sex. age (1 8 years and over) and education -for the city of Calgary. Neither the 1996 nor the 1999 City of Calgary Civic Census include information on education (City of Calgary 1999). Anomalies occurred as zem ceI! frequencies because of Me distribution in a small sample. For example, there were no males between the ages of 25 and 34 years with less than high school graduation. '' Setting the weight factor to 1.Q00 for these cases allows them to remain in Me initial analysis. This study was conducted by the Population Research Laboratory, University of Alberta between May 1 and June 17.1999. The dab for the Calgary health region were received via email correspondence with Michael Harvey of Alberta Health, April 7, 2000. Table 4.1 Percentage Distribution of the Sample compared to the Statistics Canada 1996 census and the 1999 survey- bout Health and the Health System Unweighted Weighted Statistics lggg Survey about 1999 1999 Canada Health and the Trust Trust 1996 Survey Survey Census Health System Calgary Calgary Calgary CMA Calgary Alberta Sex Female 60 54 5 1 5 1 50 Male 40 46 49 49 50
N 460 460 606384 Education c High school 7 20 23 Completed high school 13 12 12 Some post-secondary 24 15 12 Completed non-university 23 33 33 COm~leteduniversity 33 21 20 N 485 48s 606384 Chronic Illness Yes No N 45 1 450 665 3996 Self-rated Health Status Poor Fair Good Very good Excellent N 488 488 664 3990 Quality of Service Receiveda A BAB Poor 4 434 5 5 Fair 12 13 15 f6 18 17 Highly variable in quality 11 nla 11 nia n/a nla Good 47 53 46 52 50 51 Excellent 27 30 25 28 28 28 N 445 395 445 395 502 3032 a. Subcolumn 'B for the 1999 Trust SWey has kenmodified lo bettwapproximate the category structure at lbe 1999 Survey Ahaut Heallh and the Health System. That is. the middle mtegacy 'highly variable in quality' has been omitted and the percentages recalculated. health status'24and reported 'quality of service received'. As shown in Table 4.1, the 1999 Trust Survey had a slightly higher percentage of those reporting having a 'chronic illness' than the 1999 provincial survey about health.
THE QUESTIONNAIRE
Pre-testing the Questionnaire
Between September 26 and October 6,1999 questionnaires (with a cover letter and stamped, addressed, return envelope) were distributed to a non- random sample of 78 persons including friends, colleagues and the general public.25 A total of 26 completed questionnaires was returned (33.3% response rate). Analysis of the frequencies and comments revealed no major problems and only minor changes were required for the final questionnaire.
Some Considerations in Questionnaire Construction
The construction of the questionnaire could be divided into two main areas of consideration. The first area of consideration involved those issues related to reducing non-response, such as the length of the questionnaire itself, the layout and the simplicity and readability of the questions and instructions (Converse and Presser 1986; Fowler 1995; Neuman 1997).1~The length of the questionnaire,
'* The 1999 Health Survey question on self-reported health status read, 'In general, campared with other people your age. would you say your health is ..." (Alberta Heaith t 999%). This differs only slightly from the question used in the 1999 Tnrst Survey (see the 'Operationalization of the Independent' section in this chapter). The wording of the other two items, 'chronic illness' and 'qual~tyof services received' does not differ between the two surveys. On October 6, t 999, five questionnaires with an accompanying cover Ietter and stamped, addressed return envelope were handdelivered to three non-random areas within each of the four quadrants for a total of 60 pretest questionnaires. The mree areas within ead quadrant represented an estimation of lower, middle, and upper income districts based on this researcher's knowledge of the city. The remaining 18 questionnaires were distributed to friends and colleagues between September 26 and October 6,1999. zs Many of the references cited in the section at the beginning of this chapter entitled 'A Note on Research Design', were consulted for this stage of the project and will not be listed again here. as already stated, was limited by financial resourcesz7. There were many issues to consider in designing the layout of the questionnaire. 'Order effect', that is, the effect that a preceding question can have on questions that follow, is one example (Converse and Presser 1986; Strack 1992). One of the main dependent variables, 'confidence in the Alberta health care system', was deliberately placed near the beginning of the questionnaire so that answers to that question would not be influenced by other questions in the questionnaire. In tfie construction of the questions on 'values related to health care and health care detivery' the item asking the respondent's view ('... to you?") was placed before the items asking the views of the other two health care players2' in an attempt to reduce the 'false-consensus effect', that is, the "tendency for people to overestimate the proportion of others who share their points of viewmon an issue when "respondents are asked first about others' attitudes and subsequently about their own" (Krosnick and Abelson 1992). As the response formats used were standard LikeR-type scales, the most common format in survey research, instructions could be kept to a minimum.
The second consideration involves a number of aspects related to question construction such as open versus closed formats, Likert-type scales versus other formats, the number and type of response categories to use, offering a middle (neutral) category, and offering 'don't know' optionsa (Alwin and Krosnick 1991; Camaghan 1996; Converse and Presser 1986; de Vaus 1990; Fowler 1995; Krosnick and Abelson 1992; Peterson 1985; Smith 1994). Two examples of the decisions based on the above considerations include the offering of a 'don't know' category and the use of the qualifier 'completely' instead of 'strongly' for the five-point Likert-type scales which measure level of
This project was funded by a thesis research gwnt provided by the Office of the Vice-President (Research). University of Calgary and by the generous donation of a member of the Calgary comrnunlty. See the 'Operationalization of the Independent Variables' section in this chapter. This is by no means a complete list, but is representative of the main considerations. agreement. The literature suggests that 'don't know' categories should be offered when asking questions about people's opinions or perceptions (Converse and Presser 1986; Fowler 1995: 165). This provides respondents with an option when: they lack the knowledge to answer the question, they wish to keep their opinion to themselves, they have no firm attitude about the issue, or the issue is simply not important to them (Camaghan 1996:361; Converse and Presser 1986:35; Fowler 1995164).=' The most common measurement dimension for Likert-type response scales is the 'strongly agree - strongly disagree' format. Converse and Presser (1986:38) and Fowler (I9951 63) argue against the use of the qualifier 'strongly'. Based on Fowler's (1995:163) suggestion the use of the qualifier 'completely' is used for all agreement response scales in the questionnaire.
The construction and operationalization of the dependent and independent variables used in the mapping of the contours of public trust in the Alberta health care system and the analyses of determinants of trust are discussed next.
SCALE CONSTRUCTION
A number of concepts in this study are measured using summated rating scales. Some of those scales (for example, the health locus of control measures) are condensed versions of standardized scales found in the literature, some (such as the optimism scale) have been created using items from more than one scale in the literature, and a few (for example, the fiduciary trust in the health policy community) have been constructed specifically for this study. In some cases, where standardized scales from the literature have been used, not all questions from that scale have been included. Scale items from the literature
Alwin and Krosnick (1991:167) found that the inclusion of a 'don't know' option did not increase reliability. were excluded on the basis of face validity3', because they were too lengthy to administeP2, or because of space limitations on the questionnaire itself.
All scales were constructed in the same way. Items were first recoded for consistency of directionality. The respondents' scores for each question in each scale were then totaled and that sum was divided by the number of valid33 responses. The resulting scales ranged from 1 to 5 with divisions between the upper and lower ranges. "
A good summated rating scale must be both reliable and valid. While test- retest reliability3' cannot be assessed for those scales specially created for this study, one can be more confident in the test-retest reliabiltty of those scales created from standardized scales found in the literature. Validity and intemal- consistency reliabi!ity are discussed next.
All scales had to satisfy the following criteria before being included in this study. First, the scaie must have face and construct validity. All of the items included in the scale must make sense logically and they must all load on the same factor in factor analysis. Secondly, the inter-item correlations must be at least rn~derate'~(r > -20)and they must be statistically significant at the .05 level.
31 For an example of this refer to the discussion of the 'Optimism' scale in the Operationalization of the Independent Variables section that follows. * For example, the original Multidimensional Health Locus of Control Scale consisted of three, six-item subscales comprising a total of 18 items (Lefcourt 1991). A shorter version of the original scale was created for use in this questionnaire by choosing 3 items from each subscale. 'Valid responses* refers to the number of questions that must be answered before that case is included. For example, for a 5item scale the respondent must have answered at least 3 of the 5 questions. W For the Fiduciary Trust scale the response categories range from 1 to 4. " Test-retest reliabiliw is a measure of how stable or reliable that measurement is over time. 36 For this study Pearson correlation coefficients of < .20 are considered weak. Correlations between .20 and .40 are moderate and correlations -40or higher are strong. Internal-consistency refiability, the degree to which the items in the scale intercorrelate with one another, was determined using procedure 'Reliability' in SPSS.~~Cronbach's alpha was calculated for all scales and those scales with an alpha reliability level of .50 or greater were retained. Although the generally accepted rule of thumb for demonstrating internal consistency is an alpha level of .70 or greater (Spector 1992:32), the use of a lower alpha for these scales is justified in this case due to the low number of items in some scales (range is 2 to 5 items). Cronbach's alpha is sensitive to the magnitude of intercorrelations among the items and, particularly to the number of items in the scale (Spector 1992:31). Typically, higher levels of each produce higher alpha coefficient levels. In fact, even in the presence of low intercorrelations, alpha can be increased simply by increasing the number of items in the scale (Spector 1992:31).
A confirmatory factor analysis using principal components analysis was conducted to further test the validity of some scales38;that is, to confirm empirically that all scale items are part of the same hypothesized factor structure. Factor analysis was not conducted in the case of bivariate scales as such an analysis would not contribute any further information than what is already available from the inter-item correlations and the reliability analysis (Kim and Mueller 1978b:46). In all cases, where applicable, the varimax-rotated solution is reported. Kim and Mueller (1978a:50) caution that "no method of rotation improves the degree off& between the data and the factor structure", but rotation can simplify the factors and make them more interpretable.
As per the requirement of confirmatory factor analysis, the number of factors to be extracted was hypothesized prior to conducting the test (Kim and Mueller 1978b:55). An illustrative example is the construction of the two cynicism
- - -~ '' Version 10.0, SPSS Inc. 1999. 38 Paul Spector (1992) lists 'confirmatory factor analysis' as an appropriate validation strategy for scales. Principal components analysis is one method of conducting a confirmatory factor analysis. scales; each measured by three items. In order to confirm that 'political' cynicism and 'general' cynicism were empirically distinct concepts, a principal components analysis was done. All six items were put into the analysis and the extraction of two components was requested. Each set of items loaded on a different factor.
This appears to disconfirm Citrin and Muste's (1999:476) suspicion that "the standard measures of political cynicism appear to tap a more generalized suspiciousness and pessimism rooted in social circumstances of disadvantaged strata rather than a critical evaluation of current politics" and canfirm that these two measures of cynicism are empirically distinct. These two scales are discussed in further detail in the 'Operationalization of the Independent Variables' section in this chapter. Summary statistics for all scales discussed in the sections on operationalization can be found in Appendix C.
OPERATIONALIZATION OF THE DEPENDENT VARIABLES
This section outlines the operationalization of the main dependent variables, all of which measure trust in the Alberta health care system and its component parts. These variables include generalized confidence in the Alberta health care system as a whole, fiduciary trust in the policy community, three measures of confidence in the competence of health care players, and trust in the health care players (14 single items and 6 scales).
Confidence in the Alberta Health Care System
Confidence in the Alberta health care system ('conmed') was measured using the question: 'In general, how much confidence do you have in the following Canadian institutions" (Q2.1).3gNote that the Alberta medical system was just one of seven institutions listed. Others included the police, Canadian banks ('conbanks'), Alberta public schools ('conschls'), the Supreme Court of Canada ('concourt'), large corporations ('concorp'), and labour unions ('conunion'). Respondents were asked to indicate their level of confidence on a five-point Likert-type scale - (1) None at all, (2) Very little, (3) Some confidence, (4) A great deal, (5) Complete confidence.
Two objectives of this study are mapping the contours of trust in the Alberta health care system and identifying the determinants of that trust. This measure of confidence in the Alberta health care system ('conmed') serves both purposes. As a measure of confidence in Canadian institutions it allows for the comparison of the level of confidence in the Alberta medical system with the six other institutions listed. Confidence in the Alberta medical system ('conmed') also serves as a 'generalized trust' measure. It measures the respondent's level of confidence in the system as a whole. It does not specify a particular health care player, nor does it differentiate between fiduciary trust and confidence in c~mpetence.~"
Fiduciary Trust in the Health Policy Community
The fiduciary trust in the health policy community scale ('fidtrust') measures the degree to which respondents trust that the health policy community will take their well-being into account when making health policy decisions. The definition of fiduciary trust used here is Barber's (1983:9);that is, the *expectation that partners in interaction will carry out their fiduciary obligations and
f9 For all references to questions in the questionnaire, the interpretation is as follows. For example, '(22.1' refers to question number 1 in section 2 of the questionnaire. The questionnaire is found in Appendix E. Ju It is recognized that with a general question such as this, one can never be certain what frame of reference the respondent is using when answering the question. responsibilities". While the three players comprising the health policy community for this scale -the Calgary Regional Health Authority ('mncrha'), the Government of Alberta ('conabgav') and the Alberta Medical ~ssociation~' ('conama') -do not constitute the entire health policy community in Alberta, they include the major players. Respondents were asked to indicate on a four-point Likert-type scale how much confidence they have that each of the three organizations listed will take the well-being of people like them into consideration when making decisions regarding changes to the health care system ((24.2):'
This fiduciary trust scale ('fidtrust') was constructed as outlined in the previous section on scale construction. The scores for each of the items ('concrha', 'conabgov', and 'conama') in the scale were summed, then the sum was divided by the number of valid responses. In this case, the respondent must have responded to all three items for that case to be included in the scale. The principal components analysis confirmed a valid scale with factor loadings of ,735 to .860and an eigenvalue of 1.939. The average inter-item correlation was .47 and the internal-consistency reliability was confirmed with a Cronbach's alpha of
Confidence in Competence of Health Players
Bernard Barber (I983) identifies an important facet of trust as being the degree to which we expect those involved with us in a trust relationship to be technically competent. Technical competence means that actors or organizations are capable of carrying out their duties and responsibilities in an effective manner through the possession of the necessary skit Is, knowledge or
11 The Alberta Medical Association was chosen over the College of Physician and Surgeons for this survey as it was felt that respondents were more likely to recognize the AIberta Medical Association as a professional association for physicians than the College of Physicians and Surgeons. It was felt that some respondents might misinterpret 'college' to mean an educational institute. 12 See Table 5.1 0 in Chapter Fwe for frequency distributions and summary statistics. resources. Technical competence in the members of a health organization and an organization itself differ only slightly in content A surgeon, for example, must possess a specialized knowledge of human pathology and the requisite surgical skills to be deemed technically competent to perform surgical operations. An organization, on the other hand, must possess the necessary resources (such as adequate staff and finances) to be able to operate in a competent and effective manner.
This study measures the degree of 'confidence in the competence' of three different health care players - members of the Alberta Medical Association ('amacomp'), the United Nurses of Alberta ('unacomp'), and the Calgary Regional Health Authority ('conre~').~Confidence in the competence of physician members of the Alberta Medical Association ('amacomp') was measured using respondents' level of agreement on a five-point Likert-type scale, where the 1 is 'completely disagree' and 5 is 'completely agree', to a statement which reads: "Although the Alberta Medical Association members are highly skilled doctors they are not qualified to reorganize the Alberta health care systemn (Q4.6m). Confidence in the competence of members of the United Nurses of Alberta ('unacomp') is measured using the same disagree-agree scale. Respondents were asked how much they agree to the statement: 'I believe that the United Nurses of Alberta union knows what is needed in the health care system of the futuren (Q4.6j).
Confidence in the competence of the Calgary Regional Health Authority ('conres') was operationalized using the question: "How much confidence do you have that the Calgary Regional Health Authority has the resources necessary to deliver quality health care services?" ((24.5). The response options were (1)
U The Alberta Medical Association is the professional 'union' organization for physicians in Alberta. The United Nurses of Alberta is the professional union organization for registered nurses in Alberta. The Calgary Regional Health Authority is the non-elected administrative body responsible for the delivery of health sewices in the Calgary area. none at ail, (2)very little confidence, (3) some confidence, and (4) a great deal of confidence. No summative scale of these three variables was constructed.
Trust in the Health Care Players
Trust in the health care players is operationalized as the degree to which respondents trust each player when it comes to that player's input to decisions on changing the health care system ((24.1). Fourteen health care players were listed and respondents were given response options ranging from 1 'distrust a lot' to 5 'trust a lot'. The fourteen health care players listed44 were:
i. Your family doctor (or, if none, a family doctor from whom you have received services in the last 12 months) ('tfamdoc'). ii. Other doctors in general ('tgendoc'). iii. A hospital nurse ('tnurse'). iv. A chiropractor ('tchiro'). v. An alternative health care provider such as an acupuncturist ('tacupun'). vi. A senior administrator at a hospital ('thspadmn'). vii. A senior administrator of a regional health authority ('trha'). viii. The provincial government health department ('tgovhlth'). ix. Premier Ralph Klein ('tklein'). x. A citizen chosen at random ('tciti~en').~~ xi. Private hospitals ('tprvhosp'). xii. Medical laboratories ('tmedlabl).* xiii. The Alberta Medical Association, the group that lobbies on behalf of physicians ('tama'). xiv. The United Nurses of Alberta, the group that lobbies on behalf of nurses ('tuna').
11 The order of presentation of the items in the scale was not rotated in the questionnaires. The inclusion of this item reff ects both a 'neutral' reference point and the Alberta government's incorporation of public 'consultations' in their reform strategy. This item came about particularly as a result of the inclusion of approximately 100 participants 'chosen at random' fram the general public in the Health Summit hosted by Alberta Health in Calgary in February of 1999 (Health Summit '99 1999). 46 The primary provider of laboratory services in Calgary is Calgary Laboratory Services. Calgary Laboratory Services is both a private and a public health care providerwith a *publidprivate 50150" partnership between the Laboratory subsidiary of the Calgary Regional heal^ Authority and MDS Kasper Medical Laboratories (CLS 1998). Next we turn to a discussion of the operationalization of the independent variables used in the analyses in this thesis.
OPERATlONALlZATtON OF THE INDEPENDENT VARlABLES
The independent variables are organized according to the eight dimensions outlined in the model of trust in the health care system in Chapter three - demographics, ideologies and orientations, efficacy and control, health care experience, media influences, effectiveness of the system, values and value congruence, and trustworthiness of sources of information about the health care system.
Demographic Variables
The following are the demographic variables used in the descriptive and explanatory analyses in Chapters Five (Mapping the Contours of Trust) and Six (What Shapes Trust in a Health Care System?).
Age ('age') was calculated by asking the respondents to indicate their year of birth (Q1.2), then subtracting that year from 1999. Ages ranged from 18 to 85 years. Age was further collapsed into the following seven age groups - 18 to 24 years, 25 to 34 years, 35 to 44 years, 45 to 54 years, 55 to 64 years, 65 to 74 years, and 75 years and older.
Cohort
Cohort ('cohort') categories were constructed using Foot and Stoffman's (1996) classification of Canadian cohorts. Those cohort categories are: 1. World War 1 (1914 - 1919) 2. Roaring Twenties (1 920 - 1929) 3. Depression (1930 - 1939) 4. World War I1 (1 940 - 1946) 5. Early Baby Boom (1947 - 1959) 6. Generation X (1960 - 1966) 7. Baby Bust (1967 - 1981y7
Education
Education ('edlevel') was measured by asking respondents their highest level of education completed (Q7.2). Education was collapsed into five categories as shown below.
1. Less than High School 2. Completed High School 3. Some post-secondarj 4. Completed non-university 5. Completed university
Income
Income ('income') was measured by asking respondents to indicate the 'total combined annual income of all persons' in the household for 1998 before taxes and deductions ((27.4). The nine response categories were: 'less than $20,000', '$20,000 to $39.999'. '$40,000 to $59,999', '$60,000 to $79,999'. '$80,000 to $99,999', '$100,000 to $1 19,0001, '$120,000 to $139,999'. '$140,000 and over', and 'don't know'.
" Technically the 'Baby Bust ends in 1979. However, there were too few cases in the birthyears 1980 and 1981 to warrant a Separate Mtegorj. Chronic lllness
Chronic illness ('chronic') is a dichotomous variable (0 'no', 1 'yes') and asks respondents to indicate if they have a chronic health problem that requires regular health services (Q3.3). fhis question was used in the Survey about Health and the Health System in Alberta for the years 1998, 1999 and 2000 (Alberta Health 1998, 1999,2000).
Self-rated Health Status
Respondents were asked: "In general, for a person your age, is your health ... " (3.8). Response options were on a fivepoint scale - 1 'poor', 2 'fair', 3 'good', 4 'very good', and 5 'excellent'. A similarly worded question was asked on all three Alberta Health surveys mentioned above.
Ideologies and Orientations
Measures of ideologies and orientations include global trust, optimism, political cynicism, general cynicism and political affiliation.
Global Trust
The Global Trust Scale ('glotrust') measures one's general level of confidence in the trustworthiness, honesty and goodness of other people (Wrightsman 1991:404). The Global Trust Scale ('glotnrst') used in this thesis is a modification of the Survey Research Center's (Wrightsman 1991:406) 'Trust in People' scale. The original 'Trust in People' scale contained three dichotomous forced-choice items (Wrightsman 1991:408) which could be problematic as there may be some who disagree (or agree) with both choices (ffau, Muilen and Gamw 1995:447). In the revised Global Trust Scale ('glotnrst') each of the six items was asked separate~y~~and the respondents were asked to indicate their agreement on a five-point Liked-type scale where 1 was 'completely disagree' and 5 was 'completely agree'. The final scale items were:Jg
Q2.2a - Most people can be trusted ('trusted') Q2.2~- People try to be helpful most of the time ('helpful') Q2.2d - People are mostly just looking out for themselves* ('look2') Q2.2e - Most people would try to take advantage of you if they got the chance* ('take2') Q2.2f - Most people try to be fair ('befait) * reverse-coded for use in the scale.
Optimism
The Oxford and Memarn-Webster dictionaries define optimism as "an inclination to hopefulness and confidence" and "an inclination to anticipate the best possible outcome of actions or events" (Thompson 1995:957; Woolf 1974:492). This thesis utilizes two measures of optimism, a two-item General Optimism Scale ('optimism') and a health care system specific measure ('expfive'). The two items comprising the General Optimism ~cale"are:
.la Items were asked in the same order in which they appear in the original, paired. forced-choice format 59 One item (Q2.2b) was not included in the final scale as the correlation coefficients with the other items were low (-059 to .268) and in two cases were not statistically significant. The principal components analysis indicated that item (b) was loading on a separate factor and the reliability analysis suggested that the alpha level could be increased from .7724 to .8107 by dropping that item. 50 The original scale from which these items were taken was a four-item scale (see Uslaner 1998). However, the two other items were rejected by this researcher on the basis of questionable face validity. Q2.3b - It is hardly fair to bring a child into the world with the way things look for the future ('fairchl2') Q2.3f - The lot of the average person is getting worse ('1otwors2')~'
Respondents were asked to indicate their level of agreement on a five- point Likert-type scale where 1 was 'completely disagree' and 5 was 'completely agree'. Disagreement with the statement indicated an optimistic response. Both items were reverse-coded in the construction of the optimism scale so that a high score on the optimism scale indicates high optimism.52
The second measure of optimism ('expfive') is specific to the health care situation in Alberta. Respondents were asked: "Five years from now do you expect the quality of publicly funded health care sewices in Calgary to be (1) better, (2) worse or (3) about the same?" ((23.6).
Political Cynicism
A cynic is defined as 'a person who has little faith in human sincerity and integrity" (Thompson 1995335). Political cynicism reflects cynical attitudes toward politics and politicians. The first two itemss3in the Political Cynicism Scale ('policyn'), shown below, are from Citrin's and Elkins' 1975 Political Cynicism Scale (Citrin and Muste 1999:503) and the third item is from Uslaner's
5 1 The anginal item read 'average man'. 'Man' has been replaced with 'person' to maintain gender neutrality. While a three-item scale is always preferable to a two-item safe, I felt that these two items combined provided a better measure of general optimism Ban either of the single items on its own. The correlation between the two items was -29 and the Cronbach's alpha was -45. 3 A third item from the Citrin and Ukins scale was originally considered ("Despite what some people say, most politicians try to keep their campaign promises") but was dropped in favour of the Uslaner item. I felt that the Uslaner item was a better measure of cynicism and captured a fiduciary aspect of politics. 'optimism' scales4mentioned previously (Usianer 1998:448).
The response categories for this three item Political Cynicism ('policyn') scale ranged from 1 'completely disagree' to 5 'completely agree'. One item (Q2.3a) was reverse-coded before construction of the Political Cynicism Scale ('policyn'). A high score on the scale indicates high cynicism. The constituent items of the scale ('policyn') are:
Q2.3a - Most government officials try to serve the public interest even if it goes against their own personal interests' ('servpub2'). Q2.3h - Most politicians will do a lot of talking but they do little to solve the really important issues facing the country ('politalk'). Q2.3j - Most public officials are not really interested in the problems of the average citizen ('notinter'). reverse-coded for use in the scale.
General Cynicism
Three items from Lawrence S. Wrig htsman's "Revised Philosophies of Human Nature scalens were chosen for this General Cynicism Scale ('gencyn') based on the impression of their face validrty and applicability to the health care situation in Alberta (Wrightsman, 1991:393). Only 3 items were selected because of space limitations on the questionnaire.
Respondents were asked to indicate their level of agreement with the three statements listed below on a scale of 1 to 5 where 1 was 'completely
54 Although Uslaner uses his item as a measure of optimism, I contend that it is actually a measure of cynicism - people who agree with this statement would be expressing in public officials sincerity in dealing with "the problems of the average citizen" (Note: Uslanets original item read 'average man'.) 55 Wrightsman's original 20 item scale contains 10 trust items and 10 cynicism items. disagree' and 5 was 'completely agree'. A high score on this scale indicates a high level of general cynicism.
Q 2.3~- People pretend to care more about one another than they really do ('pretmre'). Q2.3c - Most people would tell a lie if they could gain by it ('mostlie'). Q2.3e - People claim to have ethical standards regarding honesty and morality, but few people stick to them when the chips are down ('honesty'),
Politica1 A filiation (Partisanship)
Herbert Weisberg (1999:681) states that partisanship is a central concept because "political conflict in modem democracies is usually organized around political parties". Respondents were asked: "If a provincial election were held today, how would you vote?" The response options were (1) Liberal, (2) New Democrat, (3) Progressive Conservative, and (4) other? ~ummyvariables ('dpc', 'dnd' and 'doth') were created for use in the multiple regression analyses. Liberal was not dummy coded and is used as the reference category.
Efficacy and Control
Political Efficacy
Political efficacy is ?he feeling that political and social change is possible, and that the individual citizen can play a part in bringing about this change" (Campbell, Gurin and Miller 1954:188). This Political Efficacy Scale ('poleff) was constructed with items from two scales. Two items (Q2.3g and Q2.3d) are from sa The 'other' category was an open-ended question. Some of the responses included 'Reform'. 'undecided'. and 'don't vote'. Campbell, Gurin and Miller's 1954 Political Efficacy Scale (Reef and Knoke 1999:427). A third item (Q2.3k) is a modification of an item from Paulhaus' 1983 Sociopolitical Control Scale (Lefcourt 1991:430).~~
Respondents were asked for their level of agreement to the three statements on a five-point Likert-type scale where 1 was 'completely disagree' and 5 was 'completely agree'. One statement (Q2.39) was dropped from the scale because it had very weak correlations (r = .186 and .090)with the other two items. The remaining items, listed below, were reversecoded for use in the scale, so a high score on the Political Efficacy Scale ('poleff') indicates high efficacy.
Q 2.3d - Sometimes politics and government seem so complicated that a person like me can't really understand what's going on. ('policom2') Q2.3k - This province is run by a few people in power and there is not much that people like me can do about it ('fewpowet).
Health Locus of Control - 3 Scales
These three health locus of control scales measure respondents' beliefs about their 'personal control, the effectiveness of powerful others, and the role of chance in determining one's health status" (Lefcourt 1991:475). Internal Health Locus of Control ('ihlc') refers to the degree of control people feel they possess over their own health situation. Powerful Others ExternalS ('phlc') refers to the degree to which people rely on others for their health and well-being. Chance Health Locus of Control ('chlc') refers to the degree to which people rely on chance or luck when it comes to control over their health status.
57 The original item read "This world is run by the few people in power and there is not much the little guy can do about it". Three items were chosen from each of the three subscales of Wallston, Wallston and DeVellis' 1978 Multidimensional Health Locus of Control Scale (Lefcourt 1991:477)." Respondents were asked to indicate their level of agreement for each of the 9 items on a five-point Likert-type scale where 1 is 'completely disagree' and 5 is 'completely agree'. The nine items comprising the three health locus of control scales are:
Internal Health Locus of Control ('ihlc')
Q4.6a - I am in control of my health. ('icontml') Q4.6i - If I take care of myself. I can avoid illness. ('iavoid') Q4.6n - If I become sick, I have the power to make myself well again. ('ipower')
Powerful Others Externality ('phlc')
Q4.6~- Having regular contact with my physician is the best way for me to avoid health problems. ('bestway') (24.61 - I can only maintain my health by consulting with health professionals. ('maintain') Q4.6d - The type of care I receive from other people is what is responsible for how well I recover from an illness ('othrcare')
Chance Health Locus of Control ('chlc')
Q4.6f - Luck plays a big part in determining how soon I will recover from an illness. ('luck') (24.69 - Often I feel that there is really nothing I can do to prevent getting sick. ('prevent') 59 Q4.6k - My good health is largely a matter of good fortune. ('fortune')
The alpha reliability coefficients for each of the three-item scales (.52, -60 and -62) were consistent with the alpha levels reported for the three original six-
53 Some of the items were chosen from schedule A and some from schedule B in the original WalIston and DeVellis scaie. As the correlations between the two schedules was found to be relatively high (.38 to .77), the combining of items from the two scales is not considered roblematic. 'This item is a combination of the wording of the first item on each of schedule A and B in Wallston and DeVallis' original scaie (Lefcourt 1991). item scales (Lefcourt 1991:476). Refer to Appendix C for complete summary statistics.
Credibility
Credibility was measured using responses to a question which asked respondents to indicate which of three health care players they would 'believe most' ('blvmost') and 'believe least' ('blvleast') when it came to a dispute between the Alberta government Department of Health (Alberta Health), the Calgary Regional Health Authorrty and Calgary doctors over the proper use of health care funds in Calgary, when all three are saying they know what is best for Calgarians. A measure of credibility was created for each of the three health care players - Alberta Health ('credabh'), the Calgary Regional Health Authority ('credcrha'), and Calgary doctors ('creddrs') using a series of logical statements in SPSS. First, a 'believe middle' ('blvmid') variable was created. An example of one of the logical statements (see Appendix C for full syntax) used to create that variable is as follows:
if (blvmost = 1 and blvleast = 2) blvmid = 3.
Therefore, if 'believe most' ('blvmost') equals Alberta Health (I),and 'believe least' ('blvleast') equals the Calgary Regional Health Authority (2),then 'believe middle' ('blvmid') equals Caiga~ydoctors (3). The second step, the creation of the credibility variables, involved another set of logical statements using the three 'believe' variables ('blvmost', 'bivmid', and 'blvleast'). An example of the creation of the credibility in Alberta Health ('credabh') variable (see Appendix C for full syntax) is as follows:
if (blvmost = 1 and blvmid =2 and blvleast = 3) credabh =3. Therefore, if 'believe most' ('blvmost') equals Alberta Health (1 ), and 'believe middle' ('blvmid') equals the Calgary Regional Health Authority (2), and 'believe least' ('blvleast') equals Calgary doctors (3).then credibility in Alberta Health ('credabh') is high (3). Categories for the three-point scale are: 1 'low credibility', 2 'moderate credibility', and 3 'high credibility'.
Health Care Experience
Utilization of Heaff h Care Senices
To measure utilization of health care sewices, respondents were asked: *Thinking back over approximately the last 12 months, how many times have you used each of the following health sewices (Q3.2). A list of the fourteen health sewices used in this question is found on page 3 of the questionnaire in Appendix E. Two 'utilization of health care services' measures were created.
The first measure is a proxy for the total number of visits to health care providers over the past 12 months ('visits'). This measure was created through a simple summation of responses for each case. For instance, if a respondent saw hidher family doctor four times over the last twelve months and had lab work done once, but used none of the other services on the list (s)he would have a score of (3 + 1 = 4) 4 on this scale. The second measure indicates how many different health care providers a respondent has used in the past 12 months. This measure was created by using a simple 'count' command in SPSS.
The accuracy of recall is an important consideration when asking respondents to estimate the total number of visits to health care providers over a period of time, such as "the past 12 month^".^ Two problems could occur. Forgetting of actual visits is largely responsible for underreporting6', whereas 'fonvard telescoping' can result in overreporting. Foward telescoping is a "memory distortion in which events that occurred prior to the beginning of the reference period are telescoped fonrvard into the reference periodn (Loftus, Smith, Klinger and Fiedler 1992: 120). Telescoping of earlier visits can actually compensate for the forgetting of actual visits and produce an estimate that is "closer to realityn(Loftus, Smith, Klinger and Fiedler 1992:121). Loftus, Smith, Klinger and Fiedler (1992:114) conclude that while people may not be able to recall each specific incident, people do 'have a good idea about how many times certain events happened in their livesn.
Quality of Health Care Services Received
Quality of health care services received ('qualeare') was measured using the question: "Overall, how would you rate the quality of health care you received in Alberta during approximately the last 12 months?" ((23.4). Response options were (1) poor, (2) fair. (3) highly variable in quality, (4) good, and (5) excellent. This is a subjective measure of the respondent's perception of quality.
Effectiveness of the System
Two questions asking the respondent's perception of the workload of health care professionals such as doctors and nurses were used as proxies for
W Loftus, Smith, Klinger and Fiedler (1992:113) found differences in recall were not affected by age, education level. or subjective health ratings. However, women had a higher percentage (59% versus 46%) accurately recalled visits than men (Loftus, Smith, Klinger and Fiedler 1992: 1 13) '' Social desirability may also come into play as the respondent may view the reporting of a large number of visits as an admission of poor health and. therefore, be inclined to underreport (Loftus, Smith, Klinger and Fiedler 7992:134) the respondent's perception of the effectiveness of health care system. Respondents were asked to indicate their level of agreement, on a five-point Likert-type scale where 1 is 'completely disagree' and 5 is 'completely agree', with the statements:
(24.60 - Nurses in the Calgary region are overworked. ('nurswork') Q4.6p - Doctors in the Calgary region are overworked. ('docwork')
Media Influence
Attention to Health Care issues in the News Media
Media effects are typically measured using 'exposure' or 'time spent' questions such as how often one reads a newspaper or watches the local news. However, no standardized metric exists for comparing 'time spent' between those two media (Chafee and Schleuder j986:90). A review of some of the relevant literature on media effects suggested that 'attention to media' is an appropriate alternative, given the objectives of this thesiss2(Becker, Sobowale and Casey 1979; Chafee and Schleuder 1986; Chan 1997; McLeod and McDonald 1985).
Attention to health care issues in the two news media - television ('atttv' and newspapers ('attpapet) - was measured subjectively using the question: "How much attention do you pay to news about health care issues in (a) your local newspaper and (b) on television?" (Q6.1). For each of the two media respondents were asked to indicate (1 ) none, (2) very little, (3) some, (4) a fair amount, or (5) a great deal.
62 A comparison of how much time people spend reading orwatching the two media is not an objective of this thesis project. Exposure to Medical Programs on Television
There are two types of medical programs currentiy available on television - medical dramas such as ER and Chicago Hope and real-life medical programmes such as Trauma - Life in the ER and The Operation.
Exposure to medical television dramas ('meddrama') is measured using the question: "How often do you watch television medical dramas such as ER or Chicago Hope?" ((26.3). Exposure to real-life medical programmes ('reallife') is measured using the question: mereare some N programs that take a camera into an actual, real-life emergency room. How often do you watch this type of programme?" ((26.4). Response categories for both questions included: (1) never, (2) rarely, (3) sometimes, (4) often, and (5) very often.
Values and Value Congruence
Respondents were asked to rate on a five-point Likert-type scale, where 1 is 'not at all important' and 5 is 'very important', how important five values related to health care and health care delivery are to them, to the Calgary Regional Health Authority (CRHA) and to Premier Ralph Klein (Q5.1).63 The five values include Accessibility ("that all Albertans have equal access to quality health care"), Efficiency ("that the health care system is mn efficiently), Public Administration ('that the health care system is publicly fundedn), Speedy Access (What Albertans have speedy access to health senricesn) and Privatization ("that privately provided health care services be available to Albertans"). See Table 5.1 6 in Chapter Five for frequencies and summary statistics on these five items for each of the three actors.
e3 This question was modelled after a similar question used in the 1996 Rethinking Government survey (Graves,Beauchamp and Hale 1998:384). For any one of the five values listed above, value congruence is defined as the degree to which the respondent feels a particular health care actor (the CRHA or Premier Klein) shares that particular value with the respondent. Two measures of value congruence were created for each of the five values. One measures value congruence with the CRHA and one measures value congruence with Premier Klein. The creation of the 'accessibility value congruence with the CRHA' variable (hereafter referred to as EQUALI), shown below, serves as an illustrative example.
EQUAL1 was created using responses to the item which asked respondents how important it is to them (eqyou) and to the CRHA (eqcrha) "that all Albertans have equal access to quality health care". Congruency level measures the distance or difference in value scores between the actors and was calculated by subtracting the score for the CRHA (eqcrha) from the respondent's score (eqyou). A difference of zero was coded as 4 'high congruence', a difference of one was coded 3 'moderate congruence', a difference of two was coded 2 'tow congruence' and a difference of more than two was coded as 1 'very low congruence'. An excerpt from the SPSS variable creation syntax (see Appendix C for full syntax) is shown below.
compute equall = 0. if (eqyou - eqcrha = 0) equall = 4. if (eqyou - eqcrha = 1) equall = 3. if (eqyou - eqcrha = 2) equal1 = 2. if (eqyou - eqcrha > 2) equall = 1.
Therefore, using the first SPSS logical statement (if eqyou - eqcrha = 0) equall = 4)as an example, if the difference between the respondent's score on the importance of the value of accessibility ('eqyou') and the respondent's perception of the importance of that value for the Calgary Regional Health Authority ('eqcrha') is zero, value congruence with the Calgary Regional Health Authority ('equall') is high. Note that what this measure does not tell us is whether or not the shared feeling relates to this value being important (or not important) when shaping the health care system.
Support for the privatization of health care services was measured by asking respondents to indicate their levei of agreement, on a five-point Likert- type scale were 1 is 'completely disagree' and 5 is 'completely agree', with the statement: "People shoutd be allowed to pay to get quicker access to health care services" (Q4.6e).
Importance of Sources of information on Shaping Views about the Health Care System
Respondents were asked to indicate how important each of the seven sourcesw listed below have been when it comes to shaping respondent's views on the overall quality of health care Albertans now receive ((24.3). Response options ranged from 1 'not at all important' to 5 'very important'.
Items were:
Your family doctor (or, if none, a family doctor from whom you have received services in the last t2 months). Other medical doctors. Experience of family or fnends who are heaIth care workers. (d) Experience of family or friends who are not health care workers. (e) Your own direct experience, other than any of the above. (f) A local daily newspaper. (g) A local TV news program.
a The eigh~item ('Other - Please Specify') did not receive a sufficient number of responses and was, therefore, excluded fmm analysis. Trustworthiness of Sources of Information
Trustworthiness is defined as "the extent to which people are seen as moral, honest, and reliablen(Wrightsman 199 1:385). Respondents were asked to rate the trustworthiness of the sources listed below when it comes to their giving accurate inforrnation about the state of health care in Alberta (Q6.5). Response options ranged from 1 'not at ail trustworthy' to 5 'very t~stworthy'.
Items were:
(a) Your family doctor (or, if none, a family doctor from whom you have received services in the last 12 months) (b) Doctors in general (c) Hospital nurses (d) The Calgary Regional Health Authority (e) The Alberta government health minister (f) Premier Ralph Klein (g) Your local newspaper
Two three-item scales were created for use in multiple regression analysis. A summated scale of 'trustworthiness of medical professional sources of inforrnation about the state of health care in Alberta' (MEDINFO) was created using items (a) through (c) above. A summated scale of 'trustworthiness of government sources of information about the state of health care in Alberta' (GOVINFO) was created using items (d) through (f) above. Principal components analysis and reliability analysis were used to confirm the scales. Summary statistics for both scales can be found in Appendix C.
STATISTICAL PROCEDURES
As the analyses which follow in Chapters Fve and Six examine trust in the Alberta health care system on two levels - exploratory and explanatory - a number of different descriptive and inferential sbtistial procedures are employed. This section briefly outlines those procedures.
Descriptive Statistics and Diagnostics
Data from all questionnaires were entered into a data editor program (StataCorp 1999a) then transferred to SPSS for data analysis. Univariate frequency distributions and basic descriptive statistics such as means and standard deviations were calculated for all variables in the analyses. SPSS (I999) procedure ANOVA is used to test for statistically significant differences in the means of selected independent variables on generalized trust (see Chapter Five).
All the data were carefully screened prior to use, according to the recommendations of John Fox (1991 :75). Errors in data entry and coding, as well as high skew, extreme non-linearity and outliers were checked using the univariate frequencies, procedure 'Explore' in SPSS and bivariate plots (independent variable by dependent trust variable) combined with means analysis. As most of the variables are ordinal-level, an examination of the bivariate plots was not always informative. The 'deviation from linearity' test in procedure 'Means' was used to identify bivariate combinations which were non- linear (SPSS 1999: 100). Those bivariate combinations where non-linearity was suspected were further examined by plotting the means for each category of the independent variable on the original bivariate plots.
Additional diagnostics were conducted using SPSS procedure 'Regression'. Tolerances were calculated to test all variables used in the multiple regression analyses for multicollinearity. Tolerances, which range from 0 to 1, measure the extent to which a particular independent variable occupies unique territory. A tolerance close to 1 indicates very IittIe overlap between the independent variables and multicollinearity is not a problem. Low tolerances (Tol < .200)indicate that the 'correlations among the independent variables in the estimation sample are too large to allow for precise estimates of the unique effects of independent variables" (Berry 1993:27). Partial-regression plots were produced to test for leverage and influential cases (SPSS 1999:201) and finally. plots of studentized residuals against adjusted predicted values were produced to test for heteroscedasticity (Pedhazur 1982:33). Fox (1991:76) points out that heteroscedasticity or nonconstant error variance, that is, the "tendency of the error variance to change with the level of y", is problematic .
Measures of Association for Contingency Tables
For tables where at least one of the variables is measured at the nominal level, a chi-square test for independence will first be undertaken and two measures of association - Cramer's V and Lambda -will be calculated. The chi- square test for independence tests the null hypothesis that two variables are independent, that is, statistically unrelated. While rejecting the null hypothesis of independence tells us the two variables are statistically related, it does not tell us the strength of that relationship (Elifson, Runyon and Haber 1998:39f ). Cramer's V and lambda both provide measures of the strength of association ranging from 0 (not related) to 1 (perfectly related).
While Cramer's V and lambda are both appropriate measures of association for contingency tables with nominal-level variables, each has limitations which makes the reporting of both preferable. Cramer's V, like all chi- square based measures is sensitive to sample size, difficult to interpret and only provides a symmetrical^ measure of the association (Elifson, Runyon and Haber 1998; Norusis 1990:133). Lambda. on the other hand, is not sensitive to sample
* *Symmetrical measures of association make no distinction between the independent and dependent variables" (Eliion. Rznyan and Haber 1998:162) size, provides both a symmetrical and an asymmetrical measure of association and a clear proportional reduction in error (PRE) interpretation. " One significant limitation of lambda is that when the "withincategory modes of the independent variable occur in the row containing the modal category of the dependent variable" lambda equals 0 (Elifson, Runyon and Haber 1998:168). However, when lambda equals zero one can not necessarily conclude statistical independence between the two variables. In this case one must rely on Cramer's V.
While Somer' s d is based on gamma and gamma is the most frequentty used measure of association for contingency tables containing ordinal-level variables, Somer's d has been chosen for this analysis because it offers some improvements over gamma. Somer's d ranges from - 1 (perfect negative relationship) to + 1 (perfect positive relationship), can provide both a symmetrical and asymmetrical measure of association, and is a more conservative measure. A significant improvement over gamma is that Somer's d does not ignore tied pairs; a limitation which resulted in the tendency of gamma to overstate the actual relationship (Elifson, Runyon and Haber 1998:175).
Multiple Regression Analysis
Multiple regression analysis is used to examine the relationship between a dependent variable and two or more independent variables (Pedhazur 1982). The identification of determinants of various types of trust in the Alberta health care system is of particular interest in the thesis project. For that reason, the standardized regression coefficient (Beta or P) will be used to compare the strength and direction of the effects of all independent variables on the dependent variable (Pedhazur 1982). In the case of dummycoded variables, the
- -- The lambda statistic tells you 'how much better you can predict the values of a dependent variable when you know the values of an independent variable" (Norusis 1998:354). unstandardized regression coefficient (b) will be reported. For a detailed example of the interpretation of the standardized and unstandardized regression coefficients see Chapter Six. Two goodness of fit statistics are reported for each analysis. The coefficient of multiple determination (p)indicates the proportion of total variation in a dependent variable that is explained jointly by the independent variables and ranges from 0 to 1 (Elifson, Runyon and Haber 1998:253). Adjusted F?, which is adjusted for sample size, more closely reflects the "goodness of fit of the model in the populationn(Norusis 1990:251). The 'constant' is reported for all regression analyses and is defined as the value of the dependent variable when all independent variables equal zero (Pedhazur 1982:15; SPSS 1999:190). Chapter 5 MAPPING THE CONTOURS OF TRUST
This chapter provides a fairly comprehensive picture of trust in the Alberta health care system and pinpoints those areas where trust is greatest and where trust is lacking. Two general questions which guide the following analyses are: "How trusting are Albertans of the current health care system?" and "Do members of the Alberta public trust different key players in the Alberta public health system to differing degrees?" These questions will be answered by looking at various aspects of trust in the Alberta health care system, such as confidence compared to other Canadian institutions, confidence in the quality of health care services, trust in health care players, trustworthiness of sources of information about the system, fiduciary trust, confidence in the competence of certain health care players and finally, the identification of the characteristics of trusters and distrusters. While the intent of this section is to focus on variables measuring trust and confidence in the health care system, there are three independent variables which deserve special attention here as they have been identified as important components of trust in the trust literature and they provide valuable contextual information. They are measures of the credibility of health care players, optimism about the future quality of health care services, and values related to health care and health care delivery.
CONFIDENCE COMPARED TO OTHER CANADIAN INSTITUTIONS
As noted in the review of the literature, confidence is one component of trust. The analysis begins by looking at the level of public confidence in the Alberta health care system as compared to other Canadian institutions. As shown by the mean confidence scores in Table 5.1, among the seven institutions listed, the Alberta medical system ranks third behind police and Canadian banks and about on par with the Supreme Court of Canada. The majority of respondents (81%) indicate some level of confidence, as opposed to 'none at all' or 'very little', in the Alberta medical system, but only about four in ten indicate 'a great deal' or 'complete' confidence. Significantly, confidence in Alberta's medical system is well above another provincially funded institution - Alberta public schools - and leagues above large corporations and labour unions.
Table 5.1 Confidence in Canadian ((22.1 )' In general, how much confidence do ypy have in the following Canadian institutions? A B C D E F G
Police Canadian Alberta Supreme Alberta Large Labour Level of banks medical Court public corporations unions Confidence system schools None at all 0 2 2 4 3 6 24 ------Very little 3 12 17 18 19 24 34 Some -30 41 -----43 42 53 53 3 1 A great deal 54 733 26 21 15 10 Complete 13 8 5 10 5 3 1 ~ota~'~'- 100 - 99 100 - 100 101 101 100
Mean' 3.76 3.36 3.24 3.1 9 3.05 2.83 2.29 Std. Dev. .72 .89 .a5 .98 .84 .84 .97 N 481 483 487 46s 460 459 436 (a) Cells are Denentaaes. excent where noted. ibj Columns do not qial 100 ¢ due to rounding.
CONFIDENCE IN THE QUALITY OF HEALTH CARE SERVICES
Respondents were asked how confident they are that publicly funded health care services currently available in Calgary are generally of good quality. In fact, 42% say they are 'very' confident and 54% say they are 'somewhat'
' For all references to questions in the questionnaire. the interpretation is as follows. For example. '(22.1' refers to question number 1 in section 2 of the questionnaire. The questionnaire may be found in Appendix E. ' See Appendix D for 95% confidence intervals for means. confident that publicly funded health care services in Calgary are of good quality. Only 5 percent indicate no confidence at all.
In order to explore the degree to which the reported high levels of confidence in the quality of health care services are a product of positive personal health care experiences, a crosstabuiation of the measure for confidence in the quality of health care services (Q3.5) and the measure for respondent's rating of quality of health care services received in the past 12 months ((23.4) was done. The results are reported in Table 5.2. Only a very small percentage (4%) of those who rate the quality of care they received as 'poor' or 'fair' state that they are very confident in the quality of health care
Table 5.2 Confidence in Quality of Current Calgary Health Services, by Quality of Care ~eceived(~)@) Quality of Care Received I Highly 1 Goodl PwrlFair j var;r;;in Excellent 6 1 / ~otat all conlent l7 / of Services 44 / Somewhat confident 1 82 I I I I 55 Very confident / I i I 1 I Total Percentage 100 1 100 loo1 I
Somer's d = -497- (with Confidence in Quality of Sewices dependent) I - p r .001 (a) Quality of Care Received has been collapsed hum a 5-pnlnt to J-pant scale to s~mplifypresentation in this table. (b)Cells are percentages.
available in Calgary. Of those who rate the quality of health care services they have received in the past 12 months as 'good' or 'excellent', only a slight majority (55%) describes itself as 'very confident' in the quality of health care currently available in Calgary. One additional finding of note (not shown in Table 5.2) is that 16% indicating they are 'not at all' confident in the quality of health care services available in Calgary have personally experienced a level of service which they rate as 'good' or 'excellent1.' A poll conducted in May of 1999 for the Calgary Regional Health Authority found similar discrepancies between levels of confidence in the system and reported quality of health care received (Walker 1999h). The relationship between quality of health care services received and confidence in the quality of health care services is a moderately strong, positive one (Somer's d = .497) when quality of health care services received serves as the independent variable, and the relationship is statistically significant @ I.001).
TRUST IN THE HEALTH CARE PLAYERS
An important part of mapping the contours of trust in the Alberta health care system is ascertaining which actors the public trusts and to what degree. Respondents were asked (Q4.1) how much they would trust each of the fourteen players listed in Table 5.3 when it comes to these actors' input to decisions on changing the health care system. As explained earlier, these fourteen players only comprise some of the possible contributors to health care reform. All fourteen players are ranked in Table 5.3 in descending order of mean level of trust, 'A citizen chosen at random' appears in this table for the purpose of providing a benchmark for trust.
Overall, the public apportions the greatest amount of trust to the health care professionals, specifically doctors and nurses and their unions. However, only three actors command majority trust. Almost three quarters (72%) state they tmst their family doctor, about two thirds (66%) state they trust hospital nurses, and 56 percent state they tn~st'other doctors in general' when it comes
3 Due to the small number of cases in the 'not at all' category, any conclusions based on these findings are suggestive, at best. to input to decisions on changing the health care system. There is widespread ambivalence about many of the actors. Medical laboratories, which share with the Alberta Medical Association similar levels of trust and distrust, have the highest level of ambivalence with 45 percent stating they neither trust nor distrust this actor's input to decisions regarding changes to the health care system. If we use the percentage falling in the neutral category as a measure of ambivalence. respondents appear to be the least ambivalent about their level of trust in their 'family doctor' and Premier Klein.
Table 5.3 Level of Trust in the Health Care Players Re: Input to System changeda' I Distrust I Neither / Trust I I 1 Std. Health Care Players (percentage) "' N / ~ean'" 1 Der. R's family doctor 6.8 I 21.5 1 71.6 466 I 4.03 i 1.02 ' Hospital nurses 8.8 / 25.3 7 65.8 456 I 3.76 1 1.03 Other doctors 9.3 1 34.3 1 56.4 432 t 3.58 1 .90 United Nurses Assoc. 22.1 j 32.5 ] 45.3 4461 3.251 1.10 Medical labs 22.5 1 45.0 1 32.5 4321 3.151 1.03 Alberta Medical Assoc. 25.1 1 39.6 1 35.3 4501 3.131 1.06
Chiropractors 35.9 1 35.9 1 28.2 356j 2.841 1.16 Hospital administrator 37.8 j 32.4 1 29.7 412 1 2.84 1 1.15 RHA administrator 40.5 ! 34.0 1 25.5 4161 2.761 1.13 A citiren 37.4 1 41.8 1 20.8 430 2.72 1.08 Alt. health providers 42.1 1 41.3 ( 16.6 35 1 2.63 1.05 Premier Klein 50.8 1 22.2 27.0 46 1 2.62 1.31 Alberta Health 47.8 ) 33.2 19.0 450 1 2.57 1.08 Private hospitals 56.3 1 28.6 15.1 397 1 2.32 1.09 (a) Response cateqones ham been dlapsed from Wntto JOoint to sirndify. -. oresenfaam in this table. (b)Means and standard devlafiw are &ed an the 5gant Se. (c) Rows totals do nat equl t OO percent due b rounding.
For many of the health care players the percentage of respondents who distrust that player is higher than the percentage who trust that player. For example, between 25 and 30 percent of the respondents say they trust local hospital and regional health authority administrators while roughly 40 percent say they distrust these local administrators. In fact, for 8 of the 14 players distmst is higher than trust. This is reflected both in the percentages and in the mean (mean c 3.0) levels of trust for those players. Their distributions are skewed to the left or 'distrust' side of the scale.
All but four health care players attain higher levels of trust than the benchmark 'a citizen chosen at random'. Those attaining lower mean levels of trust than the benchmark include alternative health care providers, Premier Klein, Alberta Health and private hospitals. While 27% say they trust Premier Klein's input to decisions on changing the health care system, almost twice as many say they do not. This is not an enviable position from which the Premier launched his Bill 1? privatization initiative.
Alberta Health commands a similar level of distrust, as 48% say that when it comes to input on changing the health care system, they distrust this, the very department charged with the primary responsibility of overseeing that system. Significantly, private hospitals, Alberta Health's partial answer to the problems of the Alberta health care system, receive the lowest level of trust (15%) and the highest level of distrust (56%) of any of the players. These views are highly correlated as the Pearson's correlation coefficient (Table 5.5) for trust in Premier Klein with trust in Alberta Health is -67, for trust in Premier Klein with trust in private hospitals is .41, and for trust in private hospitals with trust in Alberta Health is .42.'
The finding of widespread distrust of Premier Klein on issues pertaining to changing the health care system warrants further attention due to its political significance. Hence, it is examined in Table 5.4 in terms of the provincial political partisanship of the respondents. Here we observe that although distrust of
' All correlation coefficients are significant at the -001 level (1-tailed). Premier Klein is, as expected, most pronounced among non-Tories, even among Tories there is a significant amount of distrust (28%). and the Premier fails to command the trust of even a majority of Tories (48% 'trust'). The relationship between partisanship and trust in Klein is only moderate (Lambda = .241) and is statistically significant at the -001 level.
Table 5.4 Partisanship and Trust in Premier ~lein'') 1 Provincial Voting Intention (Q7.3) '" Trust in - Premier Klein 1 PC ~otal' (Q4.li) i LIBERAL ND Yo I ! Distrust 28 74 1 92 46 Neutral 25 ! 17 14 2 1 Trust I 48 9 i 4 33 Total % j 100 100 I 100 100 N of Cases I 200 I 89 1 26 315 Cramer's V = .364- I Lambda = .241°** (with Trust in Premier Klein dependent) 1 -p5 001 (a)Cells are percentages. except where noted (b) T31svanable was collapsed lnb 3 political categories far this analysts. The ongnal fourth category 'omef was not retevant to ths analysis and was coded 'system rnlssng'.
The zero-order correlations reported in Table 5.5 indicate some distinct groupings of health care players. There is a high correlation between local health care administrators. For example, trust in a senior hospital administrator ('hspadmn') is highly correlated (r = .8l) with trust in a senior regional health authority administrator ('trha'). There is also as strong correlation (r = .72) between trust levels of non-traditional health care players such as chiropractors ('tchiro') and alternative health care providers ('tacupun'). Trust in hospital nurses is not as highly correlated with tntst in doctors as one might expect. The Pearson's correlation coefficient for trust in a hospital nurse ('tnurse') with trust in a family doctor ('tfamdoc') is -34, and for trust in other doctors in general ('tgendoc') is -41. The high correlation (r = -69)between trust in a regional health
5 Total percentages for Trust in Premier Klein ('tklein') differ from Table 5.3 due to the exclusion in Table 5.4 of those who cited 'Othef or did not state a party preference. Table 5.5 Zero-order Correlations, Means, and Standard Deviations for TRUST IN HEALTH PLAYERS Variables
1. TFAMDOC 2. TGENDOC 3. TNURSE 4. TCHIRO 5. TACUPUN 6. THSPADMN 7. TRHA 8. TGOVHLTH 9. TKLElN 10. TCiTIZEN 11. TPRVHOSP 12. TMEDLAB 13. TAMA 14. TUNA
Means 4.03 3.58 3,76 2.84 2.63 2.84 2.76 2.57 2.62 2.72 2.32 3.15 3.13 3.25 N 466 432 456 356 351 412 416 450 461 430 397 432 450 446 * p e .05; ** p < .Ol (1-lalled) NOTE: Standard devlallons on dlagonal.
TFAMDOC 'Your' family doctor TRHA A senior RHA administrator TAMA The Alberta Medical Associallon TGENDOC Other doctors in general TGOVHLTH Provincial gov, dept. of health TUNA The United Nurses of Alberta TNURSE A hospital nurse TKLEIN Premier Ralph Kleln TCHIRO A chiropractor TCITIZEN A citizen chosen at random TACUPUN An allernative health provider TPRVHOSP Private haspitals THSPADMN A senior hospital admlnistralor TMEDLAB Medical laboratories authority ('trha') and trust in the provincial government department of health ('tgovhlth') is perhaps not surprising in light of the appointment of former Alberta government treasurer Jim Dinning, as chair of the Calgary Regional Health Authority in early 1999.
Partisanshi@and Trust
Given the findings reported in Table 5.4, and the politically-charged atmosphere surrounding health care in Alberta, further examination of the relationship between partisanship and trust is warranted. Crosstabulations (not shown) of 26 measures6of trust reported in this study by the measure for partisanship used in the analysis of partisanship and trust in Premier Klein (Table 5.4) reveal some interesting patterns:
Without exception, respondents indicating New Democratic party support exhibit lower levels of trust (and, where applicable, higher levels of distrust) than either Liberal or Progressive Conservative party supporters. Compare to Liberal and New Democratic party supporters, Progressive Conservative party supporters exhibit higher levels of trust (and, where applicable, lower levels of distrust when all three parties are exhibiting distrust) in health policy actors such as the Alberta Medical ~ssociation', the Calgary Regional Health Authority, Alberta Health and the health minister, the Government of Alberta, and Premier Klein.
6 Those measures of trust include: generalized trust in the Alberta medical system, fiduciary trust in three health policy community actors, trust in various health care players. and trustworthiness of various sources of information about the health care system. 7 This refers to fiduciary trust in the Alberta Medical Association only (Yidama'). Progressive Conservatives and Liberals are almost identical in their level of fiduciary trust in this actor. Liberal party supporters exhibit higher levels of trust in traditional health care practitioners -doctors and nurses - and their 'unions' than Progressive Conservative or New Democratic party supporters.
r New Democratic party supporters and Liberal party supporters exhibit similar levels of distmst in political health care actors such as the Government of Alberta, Albeda Health and Premier Klein. r Liberal party supporters and Progressive Conservative party supporters exhibit similar levels of trust (or distrust when all three parties are exhibiting distrust) on 11 of the 26 trust variables. Those variabIes included trust in alternative health care providers, doctors, the Alberta Medical Association, hospital administrators, the Calgary Regional Health Authority, and trustworthiness of doctors and nurses as sources of information about the health care system.
One additional finding of note, which mirrorsBthe finding in Table 5.4, is that Progressive Conservative party supporters still exhibit a significant amount
Table 5.6 Partisanship and Trust in the Administrator of a Regional Health Authority "' Trust in RHA Provincial Voting Intention ((27.3) '" I Administrator I - - (Q4.lg) I PC \ LIBERAL ] ND 1 Total % I Distrust I 35 ! 45 1 96 I 43 Neutral I 35 i 33 1 4 32
Trust I 30 I 22 i 0 25
- 5:.. i, 100 q 100 1 100 I 100 NofCases i 178 1 82 I 23 283 Crarnets V = 234- Lambda = not applicableP "ps.001 (a) Cdk are pemtages. exeept where noW. (b)This variable was coltapsed into 3 mitical camforthis analysis. The onqinal fourth category 'orher' was not relevant to this analysis and was coded 'system missing'.
%is findings excfudes the three measures of fiduciary trust in the health policy community actors (Table 5.10) 9 Lambda equals zero when the all modes fall on the same row. of distrust (22% to 35%), even when they exhibit the highest level of trust (or the lowest level of distrust when all three parties are exhibiting distrust) in political health care actors. Tables 5.6 and 5.7 serve as examples illustrating this point.
Table 5.7 Partisanship and Trustworthiness of the Alberta Health Minister as a Source of Information about the Health Care System "' Provincial Voting Intention (Q7.3) "' of A6 Health I Minister (Q6.5e) Total Distrust 1 27 50 1 89 1 43 Neutral 1 44 42 1 12 32 Trust 1 30 , 8 1 0 25 Total % i 100 I 100 100 100 8N of Cases 1186 , 300 Crarner's V = .292" I Lambda = .151m (with Trustworthiness of AB Health Minister dependent) I "~s.001:~~s.Ol (a).Cells are percentages, except where noted. (b) This variable was collapsed into 3 political categories forthis analysis. The original ~WIUI ategory 'other' was not relevant to this adysis and was coded 'system missing'.
TRUSTWORTHINESS OF SOURCES OF INFORMATION
Another perspective of the trustworthiness of the Premier and the health policy community can be derived from questions on the trustworthiness of sources of information about the state of health care in Alberta ((26.5). Here again we find extremely low levels of trust in the Premier in the slightly different list of actors provided to respondents and shown in Table 5.8. Actors are listed in descending order of mean level of trustworthiness. It is significant that the two Table 5.8 Trustworthiness of Sources of Information on the State of Health Care in ~lberta'~) ~rustworthiness'~ i Sources of Not at 3 Information all Very N Mean I Dev.Std. R's family doctor 0 3 27 36 34 425 4.00 -87 Hospital nurses 4 5 26 46 19 445 3.70 .96 Other doctors 0 7 35 45 13 445 3.62 -80 Local newspapers 6 15 45 31 3 451 3.09 -90 CRHA 9 20 45 24 2 417 2.90 .94 Alberta Health minister 18 26 36 16 3 429 2.59 1.05 Premier KIein 23 25 30 16 6 433 2.56 1.17 (a) Cells are percentages. except where noted. principal spokespersons for this government-run health care system - the Alberta government health minister and Premier Ralph Klein - are seen as the least trustworthy sources of information about that system and rank 6' and 7' (means = 2.59 and 2.56, respectively) out of the field of 7 actors. The Calgary Regional Health Authority (CRHA) does not fare much better in terms of respondents' perceptions of trustworthiness (mean = 2.90) and, like the Alberta Health minister and the Premier, ranks lower in mean level of trustworthiness than local newspapers (mean = 3.09). The health care professionals, doctors and nurses, are again perceived as the most trustworthy of the actors included in this study. The mean levels of trustworthiness for each of the three health care professionals listed are greater than 3.60.
IMPORTANCE OF SOURCES OF INFORMATION IN SHAPING VIEWS ABOUT THE HEALTH CARE SYSTEM
Social learning theorists suggest that individuab can come to trust (or distrust) others "without direct experience". Trust (and distrust) can be learned
'' As shown in Q6.5 in the questionnaire (Appendii E), the actual format of the question was a five-point scale of trustworthiness on which only the two extreme positions ('not at all' and Lerj') were labeled. through the communication of the experiences of tmsted others such as friends and family. Table 5.9 explores how important respondents feel various sources
Table 5.9 Importance of Sources of Information on the State of Health Care in Alberta in Shaping Respondent's Views of the I lmportanca"
Sources of Not at 3 Std. Information all Very N Mean Dev. Own direct experience 3 7 19 25 47 448 4.06 1.08 R's family doctor 9 9 27 25 30 456 3.58 11.25 Friendslfamily who are 14 8 23 34 21 375 3.41 1.29 health care workers Fnendslfamily who are 9 12 30 26 23 437 3.41 1.22 not health care workers ------Other medical doctors 17 14 31 23 15 411 3.04 i 1.28 Local TV news 18 18 35 22 7 4701 2.82 ! 1.17 Local newspapers 17 19 35 23 6 465i 2.80 11.14 (a) Cells are percentages. except where noted. have been in shaping their own views on the overall quality of health care Albertans now receive (Q4.3).
Clearly, and not surprisingly, respondents perceive their 'own direct experience' (mean = 4.06) to be more important in shaping their views on the current quality of health care in Alberta than the experiences of others and communications from the media. While this question taps only the respondent's perception of the influence of the above sources in shaping herlhis views, it does lend some support to the above theory proposed by social learning theorists. Specifically, communications from health care sources - family doctors and friends and family who are health care workers - are considered by a majority of the respondents (55% and 55%, respectively) to be 'important' shapers of their
tl As shown in Q4.3 in the questionnaire (Appendix E). the actual format of the question was a five-point scale of importance on which only the two extreme positions ('not at all' and 'very') were labeled. views on the current overall quality of health care in Alberta. The importance given to family doctors is somewhat expected given the high degree of trust accorded these health care actors. What is more compelling is the high level of importance given to friends and family, be they health care workers or not (55% and 49%, respectively), in influencing respondent's attitudes toward the health care system.
FIDUCIARY TRUST IN 1HE POLICY COMMUNITY
As discussed in the review of the theoretical literature, Bernard Barber (1983) and others posit that an important facet of trust is the trust that partners in interaction will carry out their fiduciary responsibilities. In order to examine 'fiduciary' trust, respondents were asked: "How much confidence do you have that the following organizations will take the welt-being of people like you into consideration when making decisions regarding changes to the health care system?" ((24.2). The three organizations constituting the 'health policy
Table~~ 5.1 0- Fiduciary Trust in the Health Policy r I 1 1 1 AMA CRHA Alberta Gov. Level of Confidence None at all 5 10 14 Very little 15 19 34 Some 60 62 44 A great deal 20 10 8 Total "' 100 101 100 ! MeantL' 2.94 2.71 2.47 Std. Dev. -74 .n .83 N 459 468 479 (a) Cells are percentages. except where noted. (b) Column totals do not equal 100 parrent due b rwnding. (c) Mean on the 4-pomt scale (1 'not at alP and 4 'a great deal') community"* for this analysis, and shown in Table 5.10, are the Alberta Medical Association (AMA), the Calgary Regional Health Authority (CRHA) and the Government of Alberta.
To the extent that the percentage of those reporting 'a great deal' of confidence is less than 100 percent, it could be argued that respondents are skeptical that these three policy actors will fulfill their fiduciary responsibilities to Albertans when making health care reform decisions. When it comes to 'fiduciary' trust in the AMA, a very small percentage (20%) report 'a great deal' of confidence. A substantially lower percentage of respondents (10% and 8%. respectively) report 'a great dealt of confidence that the CRHA and the Government of Alberta will fulfill their fiduciary responsibilities to Albertans when making decisions regarding changes to the health care system. The lower level of trust in the Government of Alberta compared to other health care players is consistent with the findings in earlier tables regarding trust in the Premier, the provincial health minister, and Alberta Health*
CONFIDENCE IN THE COMPETENCE OF HEALTH CARE PLAYERS
Another important facet of trust is the expectation that those being trusted are technically competent to perform their duties and responsibilities. In order to examine the level of confidence in the 'competence' of health care players, three actors were chosen -the Alberta Medical Association (AMA), the United Nurses of Alberta (UNA) and the Calgary Regional Health Authority (CRHA).
To assess the public's confidence in the competence of the members of the Alberta Medical Association (AMA) and the United Nurses of Alberta (UNA),
'* These three organizations do not constitute the entire health policy community. but include the major players. respondents were asked how qualified AMA members are in terms of reorganizing the A1 berta health care system (Q4.6m) and how knowledgeable UNA is in assessing future needs of the health care system (Q4.6j). As shown in Table 5.1 1 respondents express almost identical levels of confidence in the competence of the AMA and UNA (means = 3.04 and 3.02, respectively) when it comes to these actors' knowledge and ability to make good decisions regarding changes to the health care system, The level of confidence in this aspect of the competence of these two actors is not overwhelmingly high. In both cases, roughly one in three respondents (32% and 31% respectively) report
Table 5.11 Confidence in the Competence of the AMA and UNA''' Alberb Medial Assoc. Level of Confidenca United Nurses of Alberta Low 10 9 2 17 19 3 42 42 4 23 23 High 9 8 Total "' 100 100
L Mean 3.04 3.02 Std. Dev. 1.07 1.03 N 420 434 (a) Cells are percentages, except where noted. (b) Cdurnn totals do not equal 100 percent due to rounding. moderately high to high confidence (coded 4 and 5 on the 5-point scale). The percentage of respondents reporting low or moderately low confidence (coded 1 and 2 on the 5-point scale) in the competence of the AMA and UNA is slightly greater than one-quarter (27% and 28% respectively). In both cases a large proportion of the public with holds judgement on this matter, which might be surprising to doctors and nurses. As discussed earlier in the methodology chapter, 'competence' can be measured a number of ways. Competence in individual members of an organization such as the physician members of the AMA and the nurses of UNA can be measured in terms of their possession of special qualifications and insights, as seen in the above analysis. Competence in an organization itself, without particular reference to its constituent members, can be measured by looking at what that organization possesses that allows it to carry out its duties and fulfill its responsibilities effectively.
To assess the levet of confidence in the competence of the Calgary Regional Health Authority (CRHA), respondents were asked, on a four-point scale, how much confidence they have that the CRHA has the resources necessary to deliver quality health care services (~4.5)'~.Respondents do not express the high levels of confidence one might expect given the Alberta government's promise of increased health care funding (Henton 1999). While half of all respondents (54%) report 'some' confidence in the competence of the CRHA, only 15% state they have 'a great deal' of confidence in the competence of the CRHA in terms of possessing the necessary resources to carry out their duties and responsibilities effectively. Thirty percent state they have 'very little' (24%) or 'no confidence at all' (6%).
CREDlBlLiN OF HEALTH CARE PLAYERS
Jon Elster (1989) suggests that credibility is a basis of trust and is linked
'' This is a four-point scale with response categories being 'none at all'. 'very littie', 'some'. and 'a great deal'. to perceptions of trustworthiness. Table 5.12'' shows the perceived credibility of each of the three players listed when it comes to a hypothetical dispute over the proper use of health care funds in Calgary and all three are saying they know what is best for Calgarians ((24.4). Looking at the cells in Table 5.12 with the largest percentages, it is very clear whom respondents perceive as most credible and whom they perceive as least credible. Calgary doctors are seen as the most credible (67Oh 'high credibility'), while Alberta Health is seen as the least credible (57% 'low credibility').
Table 5.12 Credibility of Three Health Care Players Re: Proper Use of Health ~unds'~) Calgary . CRHA Alberta Level of Credibility doctors Health Low 17 24 57 Moderate 1 16 50 28 High 67 26 15 Total [ 100 100 100
Mean 2.50 2.0 1 1.57 Std. Dev. .76 -70 .73 N 384 375 369 (a) Cells are percentages. except where noted.
CONFIDENCE IN THE HEALTH CARE SYSTEM - PAST VERSUS PRESENT
Respondents were asked to indicate their level of agreement to a statement which read: "Compared to five years ago, I am now more confident that the health care system will take good care of me when I need it" (Q4.6b). The purpose of this question is to gauge respondents' perceptions of how much
14 Table 5.1 2 is reporting the scares on the 'credibility' scales created from question 4.4aBb. The questionnaire asked which of the three players (Alberta government department of health, the Calgary Regional Health Authority and Calgary doctors) respondents would believe most and least in their daim that they know what is best for Calgarians. their confidence in the health are system has changed since the present provincial administration began its health are reform program.l5
As shown in Table 5.13, only a small percentage (18%) feel that their confidence that the health care system will take good care of them when they need it has increased over the past five years. Over half of the respondents
Table 5.1 3 Confidence in the Health Care System Now compared to 5 Years Ago "Campared to 5 years ago I am now more confident that the health care system will take good care of me when I need it" Percent Comptetely disagree 19 Disagree somewhat I 33 Neither agree nor disagree 30 Agree somewhat I 14 Completely agree I 4 I 100 Mean i 2.52 Std. Oev. 1 1.08 N 1 470 either 'completely disagree' (19%) or 'disagree somewhat' (33%) with the statement in Table 5.1 3. That suggests that these respondents' level of confidence has either decreased or stayed the same over the past five years. Space limitations on the questionnaire precluded any further specification.
OPTIMISM ABOUT THE FUTURE QUAUN OF HEALTH CARE SERViCES
In addition to asking respondents how their confidence has changed over the past five years, respondents were also asked how optimistic they are about
I' While there can be serious validity problems with the use of retrospective questions such as this, the interest here is the respondenrs 'perception' of the change, not the actual change. the future of health care services. Specifically, they were asked: "Five years from now, do you expect the quality of publicly funded health care in Calgary to be 'better', 'worse' or 'about the same'?" ((23.6). Almost half of the respondents (48%) state they expect that five years from now the quality of publicly funded health care in Calgary will be 'worse'. Only 15 percent expect it will be 'better' and 37% expect it will be 'about the same'. These findings suggest that the Calgary Regional Health Authority is facing a serious crisis of confidence.
In order to examine the degree to which optimism about quality of health care services in the future ((23.6)is related to the quality of care received in tne past year (Q3.4) and to get a better idea of what respondents may mean when they say they expect the quality five years from now will be 'about the same', a
Table 5.14 Optimism about the Future Quality of Health Care Services, by Quality of Care Received in the Past 12 ~onths"' 1 I Quality of Care Received I Highly PoorIFair variable in Uce,,enlGood/ i quality Optimism about the 1 i Worse 62 70 41 Future Quality of : 1 1 Health ~a& I I Services I Same I 17 i 43 i Better ! 16 1 13 / 16 I
I Total Percentage I 100 1 100 iI 100 I -- --. I N of cases I 69 I 47 I 279
Somer's d = .186" (with Optimism about Future Quality dependent) -p 5 .ool (a) Cells are percentages, except where noted.
crosstabulation of these two variables was undertaken. Table 5.14 shows the results. Not surprisingly, almost two-thirds (62%) of those who rate the quality of care received in the past years as 'poor' or 'fair' also state that they expect the quality of health care five years from now will be 'worse'. The vast majority (70%) who found the quality of care received to be 'highly variable in quality' expect the quality of health care five years from now will be 'worse'. Interestingly, only 16% of those who rate the quality of health care received in the past year as 'good' or 'excellent' indicate they expect the quality of health care five years from now will be 'better', and fully four in ten of those who received 'good' or 'excellent' care expect a deterioration over the next five years. Given this pessimism, government and Regional Health Authority publicists face a significant challenge.
The relationship between the quatrty of care received and optimism about the future quality of health care services is a positive, albeit relatively weak, one (Somer's d = -186). but statistically significant at the .001 level. Despite the finding of a statistically significant positive relationship between these two variables, one should use caution when concluding that the receipt of 'good quality' health care will result in an optimistic view of the future quality of health care services. The results of this analysis do not support that kind of conclusion in a large minority (41%) of cases.
Table 5.15 offers a preliminary took at the relationship between trust in the Alberta health care system (Q2.1f) and optimism about the future quality of health care services (Q3.6). This analysis differs from analyses presented in Chapter 6 in terms of the treatment of the measure of optimism. The reader will recall from the methodology chapter that there are two measures of optimism - a generalized optimism scale and optimism specific to the Alberta health care system ((23.6). In Chapter 6, the 'generalized optimism' scale is treated as the independent variable. In this case, because the measure of optimism being used is very specific to the health care system, it could be argued that it makes more sense causaIly to treat it as the dependent variable in this analysis. That is, confidence in the current system influences feeling of optimism about health care in the future.
As shown in Table 5.1 5, among respondents who express 'a lot' of confidence in the Alberta health care system, one finds that a surprisingly large percentage (36%) expect the quality of health care services five years from now will be 'worse'. In addition, only 22% who indicate 'a lot' of confidence in the current Alberta health care system expect the future quality of health care services to be 'better'. The relationship between optimism about the future
Table 5.15 Optimism about the Future Quality of Health Services, by Confidence in the Alberta Health Care I I iI Confidence in the Alberta Health Care ~ystern''' I i Very little I Same 1 A lot 1 Optimism about the : Worse I 46 36 Future Quality of i 1 I Health Services I 1 Same I 18 4 1 1 42 I I I I ~etter I 4 14 22 1 I I I Total ~ercentage'~' i 100 100 I 100 i / ; I N of cases i n 1 190 1 163
I Somer's d = .24SH' (with Optimism about the Future Quality of Health Services dependent) 1 - p s .w1 (a) Wkare perwntages. except where noted. (b)Response categanes have been cdlapsed from a Ipolnt to a Wntde to simplify pmtafion in this ale. (c)Column mtals do not equal 100 percent due to munding,
quality of health care services and confidence in the Alberta health care system is positive, of moderate strength (Somer's d = .245), and statisticalIy significant at the .001 level. Caution should be exercised when concluding that high levels of confidence in the current health care system will result in high levels of optimism about the future quality of that system, as the results of this analysis do not support that conclusion for 36% of the cases.
VALUES AND VALUE CONGRUENCE
As proposed by social theorists such as Talcott ~arsons'' and corroborated by social researchers such as Listhaug (1984) and Zussman (1997), shared norms and values are critical components of any trust relationship, including Wst in public institutions such as government and health care. Respondents were asked how important five specific values are to them, to the Calgary Regional Health Authority (CRHA) and to Premier Klein (Q5.1).17 As the reader will recall from the methodology chapter, those five values include Accessibility ("that all Albertans have equal access to quality health caren), Efficiency ("tat the health care system is run efficiently), Public Administration ("that the health care system is publicly fundedn), Speedy Access (What Albertans have speedy access to health servicesn)and Privatization (?hat privately provided health care services be available to Albertansn). Table 5.16 shows how the respondents rate importance of the five values listed for themselves, for the CRHA and for Premier Klein.
A substantial majority of respondents (83% and 61 %, respectively) rate the two Canada Health Act values listed - acces~ibility'~and public administration - as 'very' imporbnt in shaping the health care system. Similarly, 86% rate speedy access and 79% rate efficiency as 'very' important in shaping the health care system. However, even though a plurality (42%) favour privatization. 39%
l6 See Parsons (19683 970), Lewis and Weigert (1985a. 1985b) and Thomas (1993). 17 This measures tfie respondent's 'perception' of how important these five values are to the CRHA and the Premier. oppose it. Privatization clearly stands apart as outside the consensus on values surrounding health care in Alberta.
As shown by the frequencies and the mean scores for each actor on each value, respondents rate four of the five values (accessibility, efficiency, public administration and speedy access) as substantially more important to themselves
Table 5.1 6 How important are the following values to ... (a)'b) Not at all 2 3 4 Very Mean N
Accessibility YOU 1 2 3 It 83 4.74 485 CRHA 4 8 26 30 34 3.83 417 KLElN 15 20 17 20 1 29 3.27 419
Efficiency YOU 0 1 6 14 1 79 4.72 1 477 CRHA 3 4 21 28 1 44 4.051 421 KLElN 7 10 16 20 f 47 3.89 ! 423 -- -
Public YOU 2 2 12 23 1 61 4.38 453 administration CRHA 5 5 20 33 1 37 3.92 371 KLEIN - 14 19 17 17 134 3.39 377
Speedy YOU 0 1 2 12 186 4.82- 482 access CRHA 5 7 18 28 1 41 3-93 415 KLElN 11 15 23 17 1 34 3.50 472
Privatization YOU 28 11 19 17 25 3.00 1 443 CRHA 19 15 30 17 19 3.071 358 KLElN 12 7 22 22 37 3.63 1 360 (a}Cab are percentages. Rows totals may not equal 100 percent due to rounding. (b}As shown In Q5.1 in the queso'onnaire (Appendix E). the aca.ral format of the queslon w;rs a fiua-polnt scale of ~mportancean which only the tvvo extreme pos~tians('not at alr and very') were labeled.
than to either the CRHA or Premier Klein. In the case of 'privatization', the mean scores for the respondent (3.00) and the CRHA (3.01) are almost identical and hover around the mid-point of the importance scale. The mean score for Premier
'' This finding. and the finding for the value of efficiency is consistent with the finding of the 1996 'Rethinking Government' study (Graves, Beauchamp and Herfe 1998:384). Klein is substantially higher (3.63),which indicates a much higher level of importance on this value for this actor.
The importance of perceptions of shared norms and values can not be understated here. The finding of a 1996 US. study reported by Zussman (1997) bears repeating. Among the major reasons cited for not trusting the U.S. government was that "policies don't reflect own [respondent's] beliefs and values" (Zussman 1997:245).
The degree to which respondents feel the CRHA and the Premier share with them the five values listed above is investigated using the value congruence scales reported in Table 5.1 7 (see Chapter Four for a discussion of the operationalization of value congruence). Value congruence is not particulariy high (between 34 and 50 percent 'high' congruence) between respondents and
Table 5.17 Value Congruence Between Respondents and Selected Health Care Players with respect to Health Care Very tow Low Moderate High Mean N 1 Accessibility 10 21 31 38 296 417 32 16 18 34 2.54 419
Efficiency CRHA I 6 1 16 I 28 I 50 1 3.27 1 420 KLEIN 14 15 22 48 3.04 420 ; I 1 1
Public CRHA 1 8 I 17 I 29 1 47 1 3.14 1 367 administration KLEIN I 26 16 17 41 1 274 1 375
Speedy CRHA I 12 1 15 1 30 I 44 1 3.05 1 414 access KLElN I 23 23 16 38 I 268 1 412
Privatization 14 1 23 I 22 I 41 1 297 1 355 25 16 20 39 1 273 1 356 (a)Cells are percentages. except where noted. the selected health care players on any of the five val~es.'~In all cases, looking at the 'high' congruence category and the mean scores on each value, respondents indicate greater shared values with the CRHA than with the Premier.
Where the greatest contrast occurs is in the 'very low' value congruence or value dissonance category. In all cases, except for the value of efficiency, a large minority of respondents (41 to 48%) report feeling that Premier Klein does not share with them the same values regarding two of the principles of the Canada Health Act - accessibility and public administration - as well as efficiency, speedy access to health sewices and privatization. In the case of the CRHA, those figures range between 25 and 37 percent [excluding efficiency].
In light of these findings, we can conclude that the malaise affecting the health care system is not rooted in just a disagreement on means for achieving consensually-held goals, but rather in a perceived difference on the very values according to which the health system should be shaped. Further analysis of the importance of value congruence for shaping trust in the health care system is presented in Chapter Six.
Who are the TRUSTERS? Who are the DISTRUSTERS?
What differentiates tnrsters from distrusters? Using the indicator (~2.lf)'' of generalized trust in the Alberta health care system ('conmed'), the analysis in Table 5.1821below reveals that the answer to this question is: cohort, income,
:s The reader is reminded that the value congruence measures only indicate the degree to which two parb'es are perceived to share a value; it does not give any indication as to the importance of that value for either party. See also Column C in Table 5.1. '' Note that in Table 5.18 the mean of GeneraIized Trust ('conmed') is based on a five-point scale where 1 is 'low trust' and 5 is 'high trust'. health status, political affiliation, political cynicism, optimism about the future quality of health care, breadth of health care experience, quality of health care received, value congruence with Premier Klein, and a belief in public administration of the health care system as opposed to privatization.
Let us consider a specimen entry in Table 5.1 8. There we observe that those who report receiving good quality health care services have a mean (3.47) that indicates a high level of trust, while those who report receiving poor quality health care services fall on the other side of the mid-point on the five-point trust scale with a mean of 2.56. Among those reporting good quality health care services received, trusters outnumber distrusters by a ratio of five to one (50%: 10%), whereas among those reporting poor or fair quality health sewices received, trusters are outnumbered by distrusters by nine to one, as 43% fall among the distrusters and 5% fall among the trusters, for a ratio of 0.1:1 in the 'Ratio' column of the table.
Trusters are disproportionately represented among Baby Busters (1967- I981), those in the lower-middle and the highest income brackets, those reporting very good or excellent health, Progressive Conservative party supporters, those with low levels of cynicism, optimisl, those with a narrow breadth of experience as a patient in the Alberta health care system, those who have received good to excellent health care services, those who eschew the Canada Health Act's emphasis on services being publidy funded, those who believe they share with the ~rernie? the same level of importance with regards to the value of public administration, and those who support privatization of
22 Findings were similar on other Wue congruence' variables. For example. on the same value (Public Administration) for the CRHA, the ratio of trusters to distrusters for the terjlow' congruence category was 0.6:1 and far the 'high' congruence category was 431. Table 5.18 Characteristics of Trusters and Distrusters 132 health care services. Conversely, distrusters are over-represented among New Democratic party supporters and those who have received poor quality health care services.
Table 5.18 reports only those independent variables where the differences in mean level of trust among the categories of the independent variable were statistically significant (p1.05) in an analysis of variance.= Thus, for instance, there is no significant difference between men and women or among different levels of education; therefore, neither the sex variable nor the education variable was reported.
Two findings regarding values are of particular note because they are unequivocal. That is, among those who feel the Premier shares with them the same level of importance regarding public administration of the health care system, trusters outnumber distrusters by a ratio of five to one. In addition, among those who report that a publicly funded health care system is of little or no importance to them, trusters in the health care system outnumber distrusters by a ratio of 15 to 1, as 75% fall among the t~stersand only 5% fall among the distrusters.
Chapter Five has provided a profile of trust in the Alberta health care system and its component parts. It has pinpointed those areas where trust is greatest (among traditional health care providers such as doctors and nurses) and where trust is lacking (among health policy players and political actors such as the Calgary Regional Health Authority, the Alberta Government, the Alberta department of health and its minister, and Premier Klein). In addition, this chapter highlighted several important issues (such as quality of care received,
23 Note that Table 5.18 tells us nothing about the relative weight of the variables in determining whether a person will be a truster or distruster. (For that we lurn later to a multiple regression analysis.) The present table merely identifies for us some important dimensions on which trusters and distrusten differ. 133 credibility of health care players, optimism about the future quality of health care, and values and value congruence), examined the relationship between partisanship and trust, and provided a profile of some of the characteristics of trusters and distrusters. We now turn to Chapter Six, where we will examine the question: What shapes trust in a health care system?" Chapter 6 WHAT SHAPES TRI IST IN A HEALTH CARE SYSTEM?
Before proceeding with a discussion of the results of the analyses of determinants of trust in the health care system, we should remind ourselves of the research question which guides this research project. The general research question is: "What are the determinants of public trust in the Alberta health care system and in its component parts?" The reader is referred to Chapter Three for a summary of hypotheses being tested.
As the reader will recall from Chapter Three (Figure 3.1). the general model being tested includes eight dimensions - demographic characteristics of the respondent, ideologies and orientations, efficacy and control, health care experience, media influence, effectiveness of the system, value congruence and trustworthiness of sources of information. Given the large number of potential dependent trust variables, six have been strategically selected for analysis in this chapter. The general model will be modified where necessary, as some of the dimensions are not applicable to all dependent variables.
This chapter is divided into the following three sections:
Summary of Hypothesis Testing Determinants of Trust Summary of Findings Pertaining to the Model SUMMARY OF HYPOTHESIS TESTING'
Table 6.1 provides a summary of all hypotheses tested using zero-order correlation analysis. Cells in the table indicate whether each hypothesized relationship between an independent and a dependent variable was supported at a statistically significant level ('supported'), supported in direction only ('dir only'), or not supported ('not supp'). In addition, the hypothesized direction of the relationship is indicated in brackets in each cell. For example, in the cell summarizing the result of the zero-order correlation analysis of the relationship between age ('age') and confidence in the Alberta medical system ('conmed'), we find that the hypothesis (HI .2: As age increases, confidence in the Alberta medical system decreases) was supported in direction only. That is, the correIation coefficient was negative, but not statistically significant at the .05 level.
The majority (70%) of the 143 hypothesis tests summarized in Table 6.1 received either full support (47%) or partial support (direction only) (23%). However, for three of the dependent variables ('unacomp', 'tnurse', and 'tklein'), the percentage of hypotheses receiving full support is low (less than 50%). For example, only 15 percent (3 of 20) of the hypothesized relationships between the selected independent variables and confidence in the competence of the United Nurses of Alberta ('unacomp') were supported and statistically significant at the -05 level. In some cases the hypothesized relationship between an independent variable and the dependent variables received support on all, or at least a majority, of dependent variables tested. Those independent variables indude measures of global trust, optimism, cynicism, chance health locus of control, political efficacy, quality of care received, perceived workload of nurses, and
Correlation tables are found in Appendix D Not supported = not supported
Brackets (+) Indicate hypotheslzed direction
[a) lHLC = inlernal health locus of control; PHLC = powerful oU~ersexlernalily; CHLC =cha~~h~dlhlocusof conlrol [b) Results lor 'allpaper' and 'alltv' are based on parlial correlalion analyses, conlrollina for level of educalion
C W OI 137 value congruencez.
There are four unexpected, or contradictory findings that desewe mention here. Of note is the paucity of support for the hypotheses involving the demographic variables - gender, age, education, income, health status and chronic illness. For the most part, there does not appear to be a direct correlation between these variables and trust. Perhaps there are intervening variables, not modeled by these hypotheses, or not included in this study, which better explain the relationship between demographic characteristics of a respondent and trust in a health care system.
It was surprising to find that the hypotheses (H4.1 and H4.2) for the measures of health care system utilization ('difpmv' and 'visits') were only supported for one of the six dependent variables ('fidtrust'). In fact, the finding of positive correlations (only two were statistically significant) for both independent variables on three of the dependent variables ('unacomp', 'tnurse', and 'tacupun') contradicts the hypothesized relationship between health system utilization and trust.
The hypothesized relationship between the media and trust in the health care system and in its component parts is called into question given the general lack of support for hypotheses involving the media variables ('attpaper', 'attiv', 'meddrama', and 'reallife'). None of the hypothesized positive relationships (H5.4) between exposure to real-life medical television programmes ('reallife') and the six dependent variables was supported. Interestingly, all of the correlation coefficients were negative, and two were statistically significant
- - "ypotheses were supported and statistically significant (p c .05) for all measures of value congruence (accessibility, efficiencj, public administration, speedy access. and privatization) on all dependent variables tested ('conrned', Kdhst', and 'tklein'). 138 (p < -05) but weak. The results for the hypotheses involving attention to health care issues in the media ('attpaper' and 'atttv') are based on partial correlation analyses which controlled for the effects of level of education. These results differ significantly from the zero-order correlation analyses in only one case. While the hypothesis (H5.1) for the relationship between attention to health care issues on television ('atttv') and confidence in the Alberta medical system ('conmed') at the zero-order level was supported in direction only, it was fully supported and statistically significant (p < -05)when controls for level of education were introduced.
Table 6.1 only reports those hypotheses tested using correlation analysis. Four hypotheses were tested using other statistical methods. The results in Table 5.18 in Chapter Five indicate that based on the mean level of trust, and disregarding the tiny Worfd War I cohort (N=6), the Generation X cohort (mean = 2.02) is the least trusting cohort. This supports hypothesis 1.5. Hypothesis 2.5 states that Progressive Conservative party supporters will have higher levels of trust in the health policy community, Premier Klein, and the Alberta medical system3 than Liberal and New Democratic party supporters, and is supported by the crosstabulation analysis reported in Chapter Five. The hypothesis (H5.2) that those who pay greater attention to health care issues in newspapers will report higher levels of trust in the Alberta medical system and the health policy community than those who pay greater attention to health care issues in the news on television was not supported by either crosstabulation or means analysis. Hypothesis 8.1, that medical professionals would be seen as more trustworthy sources of information about the health care system than political actors and agencies, is supported by Table 5.8 in Chapter Five.
Results of the cmsstabulation analysis (not reported in Chapter Five) of partisanship and confidence in the Alberta medical system (Iconmed') revealed that Progressive Conservative party supporters were more busting in the system than Libera1 and New Democratic party supporters. 139 DETERMINANTS OF TRUST
The discussion of determinants of trust in the Alberta health care system will begin with an examination of the relationship between three facets of trust. As the reader will recall, Bernard Barber (1983) posits that there are three facets to trust - an overarching generalized trust and two more specific types, trust or confidence in the competence of the actor (or agency) and fiduciary trust. Multiple regression analysis4 is used to answer the question: 'Are these measures of the three facets of trust being shaped by the same factors?" If the dependent variables representing the three facets are explained by a rather different set of variables, or if the same set of variables explains markedly different amounts of variance in the dependent variables, Barber's conceptualization is more compelling. To explore these issues, a basic model (see variable list in Table 6.2) is applied to all three trust measure^.^
Confidence in the Alberta medical system ('conmed') is used as a measure of generalized trust in institutions as it simply asks for the respondent's level of confidence in the system without specifying a particular health care player or the fiduciary or competence aspects of that Fiduciary trust was measured using the fiduciary trust in the health policy community scale ('fidtrust'), which asked: "How much confidence do you have that the following organizations [the Calgary Regional Health Authority ('concrha'), the Government of Alberta ('conabgov') and the Alberta Medical Association ('wnama')] will take the well- being of people like you into consideration when making decisions regarding changes to the health care system?". Trust in competence was measured using
' Pairwise deletion of missing cases was used. as listwise deletion of missing cases greatly diminished the number of cases remaining in the analysis. Pairwise deletion was preferred over the more conservative 'mean-substitution' method, although the results of the two options were :ot significantly dient. Variables were entered into the regressian analysis by the researcher using SPSS method 'Enter'. which is to say all the variables were entered at the same time. 6 The variable global trust ('glotrust') could be used to test 'generalized trust'. However, it is not specific to health care and, therefore, not appropriate for this anaIysis. L 40 the variable which tapped confidence in the competence of the United Nurses of Alberta ('unacomp') 7.
In accordance with Barber's three-fold conceptual distinction, Table 6.2 shows that each of the three measures of trust is, for the most part, being shaped by a different set of factors. There are, however, some noteworthy similarities which are identified here before the differences are discussed:
Both confidence in the Alberta medical system ('conrned') and fiduciary trust in the health policy community ('fidtrust') are being shaped. to a statistically significant degree, by education ('edlevel'), specific optimism ('expfive'), political cynicism ('policyn'), and quality of care ('qualcare'), although the magnitude of the effects differs between the two.
Both fiduciary trust in the health policy community ('fidtrust') and confidence in the competence of the United Nurses of Alberta ('unacomp') are being shaped by political affiliation, specifically New Democratic party affiliation ('dnd'). In these cases, affiliation with the New Democratic party has a negative effect on trust.
Fiduciary trust in the health policy community ('fidtrust') and confidence in the competence of the United Nurses of Alberta ('unacomp') are also being shaped by respondent's reported health status ('hlthstat'), Yet, it is important to note that health status ('hlthstat') exhibits a negative effect on fiduciary tnrst ('fidtrusf) and a positive effect on confidence in the competence of the United Nurses of Alberta ('unacomp').
7 The measure for confidence in the competence of the Alberta Medical Association ('amacomp') was excluded from the analysis as the magnitude of R~ (.041) was too small to be meaningful and was not statistically significant (F=.739. sig. = -786) (Pedhazur 1982:449). 0 Media influences are significant factors shaping confidence in the Alberta medical system ('conmed') and fiduciary trust in the health policy community ('fidtrust'), although the type of media and direction of the influence differs.
We will now turn to illustrations of the interpretation of cell entries in Table 6.2. Table 6.2 reports only those unstandardized (b) and standardized regression coefficients (B) that are statistically significant at the -05level or better @ < .05 or .Ol or -001). For example, in the equation for determinants of fiduciary trust ('fidtmst'), the standardized regression coefficient (B ) for optimism about the future quality of health care in Calgary ('expfive') is .270. This means that, holding all other variables in the table constant, for one standard deviation increase in optimism about the future quality of health care in Calgary ('expfive'), there is an expected .270 standard deviation increase in the respondent's score on the scale of fiduciary trust in the health policy communrty ('fidtmst'). The fiduciary trust ('fidtrust') scale ranges from 1 to 5 and has a standard deviation of .629. In the case of dummy-coded variables (three political affiliation variables and chronic illness8)only the unstandardied regression coefficients (b) are interpretable (Pedhazur 1982:64). For example, the unstandardized regression coefficient (b) for New Democratic party affiliation ('dnd') as a determinant of fiduciary trust ('fidtrust') is -598. Therefore, compared to Liberals (the reference category), and holding all other variables in the table constant, it is expected that, on average, New Democratic party supporters ('dnd') will exhibit a score .698 units lower on the scale of fiduciarj trust in the health policy community ('fidtrust' ).
B In the case of dichotomous dummycoded variables (such as chronic illness 'chronic') it is acceptable to discuss the relative strength of the effect of the standardized regression coefficient (B ) on the dependent variable in comparison to the effects on the dependent variable of other standardized regression coefficients in the table. However. the standardized regression coefficient itself is not interpretable. 142 Table 6.2 Results of Regression of Generalized Trust, Fiduciary Trust and Confidence in Competence on Various Independent Variables
Confidence in FidUciaFl Cmptenc. of Medical Trust in UNA System the Policy Community (CONMED) (FIDTRUST) (UNACOMP)
Indenendentr Variable I Demograahi~s Varlabel I b a I b R
Constant 1.833 2782 1-474 If 384 -435 -173 Adjusted d: 345 .399 .I27 N 493 493 493 NO= Unsfandardized regressIan axffidents are in parentheses and are significant at the .05 level (one-tailed) (a) IHLC = tntemaI heath iocra of mnml: PHLC = powerful others externality; CHLC = chance health locus of control
Identification of the three variables with the strongest, statistically significant effects for each measure of trust illustrates the point that these measures of the three facets of trust are being shaped by different factors. In shaping confidence in the Alberta medical system ('conmed') the independent variables with the greatest impact are the respondent's rating of quality of care received ('qualcare') (P = .347), general optimism ('optimism') (B = .I91 ), and optimism about the future quality of the health care system ('expfive') (J = -172). For fiduciary trust in the health policy community ('fidtrust'), the strongest effects are exhibited by optimism about the future quality of the health care system ('expfive') = -270)'political cynicism ('policyn') = -.172), and the respondent's rating of quality of care received ('qualcare') (P = .146). The strongest effects shaping confidence in the competence of the United Nurses of Alberta ('unacomp') are global trust ('glotrust') (P = .156), political efficacy ('poleff') (/? = -. 145). and health status ('hlthstat') (4 = .I43). While there is some overlap in these lists of the strongest determinants of the three respective dependent variables, that overlap is very limited (2 variables) and is confined to two of the three dependent variables. Furthermore, there are some variables (e.g., internal health locus of control) that exert statistically significant effects upon only one or two dependent variables and not upon the other two or one dependent variables.
Examining the dependent variables in pairs, we observe that as between 'conmed' and 'fidtrust' there are only four factors operating to shape both these dependent variables ('edlevel', 'expfive', 'policyn' and 'qualcare'), but another ten which operate on only one of these two dependent variables. Finally, 'fidtrust' and 'unacomp' have only two causal determinants in common ('hlthstat' and 'dnd'), but fourteen unshared causal determinants.
Thus, the multiple regression analysis buttresses Barber's three-fold distinction among generalized trust, fiduciary trust, and a competence dimension of trust, Apart from any consideration of the validity of Barber's three-fold conceptualization of trust, the model is of some considerable value in explaining observed levels of tnrst. More specifically, it does a better job of explaining levels of trust in the overall health care system (a faceless bureaucracy), than it does in the front-line service providers (nurses as represented by the United Nurses of Alberta) with whom Calgarians come into contact. While the model does a reasonable job of explaining the variation in levels of confidence in the Alberta medical system ('conmed') (adjusted = 345) and in fiduciary trust in the health policy community ('fidtrust') (adjusted R~ = -399)'it lacks explanatory power for confidence in the competence of members of Alberta's nurses union - the United Nurses of Alberta ('unacomp') (adjusted = .I21).
The basic model used in this analysis has identified some of the main determinants of these measures of the three facets of trust presented. However, the model was simplified so that it could be applied to all three measures of trust. As a result, some factors (namely perceived effectiveness of the system, perceived value congruence, and perceived trustworthiness of sources of information about the health care system), that have been hypothesized to be important determinants of only certain forms of trust, have been left out. Next we examine the impact of these three perceptual factors on two of the measures of trust - confidence in the Alberta medical system ('conmed') and fiduciary trust in the health policy community ('fidtrust') - by adding the perceptual variables to the basic model to form what can be called an 'expanded model'.
Expanded Model of Determinants of Generalized and Fiduciary Trust
Table 6.3 reports the findings of two multiple regression analyses. While the results for both 'expanded models' - confidence in the Alberta medical system ('conmed') and fiduciary trust in the health policy community ('fidtrust') - are shown in the table, each model will be discussed separately. The analysis is presented, not as a comparison of determinants across trust measures, but as a means of identifying important determinants of each measure of trust. The addition of variables measuring perceptions of effectiveness of the system, value congruence, and trustworthiness of sources of information about the health care system to the basic model utilized in the previous analysis permitted the testing of the full model of determinants in the Alberta health care system as presented in Figure 3.1 in Chapter Three.
The reader will note that measures of trustworthiness of sources of information about the health care system were not entered into the equation testing the model of determinants of fiduciary trust in the health policy community ('fidtrust'). These variables were excluded because no reasonable hypotheses were found or formulated to justify their inclusion. The variable measuring the respondent's perception of the workload of doctors was included as a proxy for perceptions of the 'effectiveness' of the system.' Due to the problem of multicollinearity, only two sets" of value congruence measures are used. They are: (1) congruence with the values of the Calgary Regional Health Authority ('equall') and of Premier Klein ('equal2') on the value of accessibility; and (2) congruence with the values of the Calgary Regional Health Authority ('effl') and Premier Klein ('em')on the value of efficiency.
Determinants of Confidence in the Alberta Medical System ('conmed')
Comparing the adjusted @values for this model (Table 6.3) and the basic model, we find that this model explains much more of the variance in confidence in the Alberta medical system ('conmed') than the basic model presented in the
9 fhe measure for 'workload of nurses' ('nuwork') was not included as the inclusion of that variable resulted in a drop in the adjusted @, and the 'nurswork' variable was not statistically significant. 'O These two sets of variables were chosen based on explanatory power and statistical significance for both models. Table 6.3 Regression Analysis of Confidence in the Alberta Medical System and Fiduciary Trust in the Health Policy Community
Confidence Fiduciary in Medical Trust System (CONMED) (FIDTRUST) Indenendent Variables
I Ideoloaies L Orientations I I I
'am* ..-..ma,L , ...... -.. - %,
. %.
Effectiveness of System
Value Congruence Accassibfty-CRHA :- Accessibility - Premier Fein EffXency-CRHA -' .: ~f~iciency- premier ieim' ;
Constant t253 2136 R' -481 -480 Adjusted @ A31 -438 N 493 443 NO- Unstandatuii regression coeffiaents are in parentheses and are signifignt at me .05 level (one&iled) (a) IHLC = internal health locus of conbd: PHLC = pOwerful others externality; CHLC =chance health lacus of mbol previous analysis. The adjusted R~ in this model is -431 as compared to .345 in the basic model.
The overall profile of determinants in the expanded model differs from the basic model. As shown in Table 6.3, age ('age'), optimism about the future of health care ('expfive'), political cynicism ('policyn'), powerful others health locus of control ('phlc) and medical television dramas ('meddrama') are no longer statistically significant determinants of confidence in the Alberta medical system
('conmed'). "
Of the new variables added to this expanded model, five are statistically significant determinants of confidence in the Alberta medical system. Those five are: perceived workload of doctors ('docwork') (B = -.133), value congruence with Premier Klein on the value of accessibility ('equal2') (P = .277), value congruence with the Calgary Regional Health Authority on the value of efficiency ('effl ') (p = .113), value congruence with Premier Klein on the value of efficiency ('em') w = -.164), and trustworthiness of government sources of information about the health care system ('govinfo') (P = .197). It is interesting to note that value congruence with the Premier on the value of efficiency ('em') has a negative impact on confidence in the Alberta medical system. The strongest impact on confidence in the Aiberta medical system is exerted by value congruence with Premier Klein on the value of accessibility ('equal2) (B = -277). quality of care received ('qualcare') (P = -274). and trustworthiness of sources of information about the health care system ('govinfo') (P = .197).
11 When using SPSS method 'enter' to enter the variables into the regression analysis, all variables in the model are taken into consideration. Therefore. the strength and statistical significance of each variable can vary when additional variables are entered into the model. Note: the entering (or removal) of variables using this method is investigator controlled and not determined by the statistical program. Determinants of Fiduciary Trust in the HeaRh Policy Community (Yidtmst')
The addition of the measures of effectiveness of the system and value congruence increases slightly the explanatory power of this model for fiduciary trust in the health poIicy community ('fidtrust'). The adjusted R~in this model is .438 as compared to .399 in the basic model.
While the addition of variables increases the explanatory power of the model of determinants of fiduciary trust in the health policy community ('fidtrust'), the overall profile of determinants does not differ in a major way from the basic model. In the expanded model, health status ('hlthstat') is no longer statistically significant. Political efficacy ('poleff'), which was not statistically significant in the basic model, is significant in the expanded model. Only one of the additional variables - value congruence with Premier Klein on the value of accessibility ('equal2') - has a statistically significant impact on fiduciary trust in the policy community ('fidtnrst'). Three variables with the greatest impact on fiduciary trust ('fidtrust') are optimism about the future quality of health care ('expfive') (p = ,229)' political efficacy ('poleff') (,d = .139), and attention to news about health issues in the newspaper ('attpaper') (P = -.I29). Political cynicism (p = -.126) runs a close fourth.
Comparison of Determinants of Trust in Three Health Care Players' Input to Decisions on Changing the Health Care System
Out of the more than one dozen actors on which we have measures of trust, three measures -a hospital nurse ('tnurse'), an alternative health care provider ('tacupun'), and Premier Klein ('tklein') - have been selected to illustrate another way in which the data from the survey can be used to examine trust in the system. Trust, in this case, is trust in a health care actor's input to decisions on changing the health care system ((24.1). The actors chosen are 149 representative of three different areas of health care -traditional health care. non-traditional health care, and health care system administration. Non- traditional health care providers, such as acupuncturists and naturopaths, are not officially part of the 'public' health care system. However, one could argue that they are nonetheless an integral part of Alberta's overall health care system.12 The analyses which follow utilize a modified version of the basic model presented earlier in this chapter. The 'politics-related' variables which were included in the basic model were appropriate as determinants for only some of the health players in this selection, so were excluded from this analysis. They are: political cynicism ('policyn'), political efficacy ('poleff'), and the three political affiliation dummy-coded variables ('dpc', 'dnd', 'doth').
While the determinants with the greatest impact on each measure of trust vary, we note from Table 6.4 there are some similarities of particular note:
r All three measures of trust in the input of health care players are being shaped by health status ('hlthstat'), global trust ('glotrust') and general optimism ('optimism').
Trust in hospital nurses' input ('tnurse') and alternative health care providers' input ('tacupun') are being shaped by internal health locus of control ('ihlc').
Trust in hospital nurse's input ('tnurse') and trust in Premier Klein's input ('tklein') are being shaped by chance health locus of control ('chic') and quality of care received ('qualcare').
'' Non-traditional health services, such as acupuncture. are being offered in some sport medicine and physiotherapy (traditional health care services) clinics in Calgary. Canadian Sport Rehab, a member of the Calgary Sport Physiotherapy Gmup of Clinics, is one such example. I50 It is important to note that the magnitude and direction of those effects which are held in common by all three heaith players - health status ('hlthstat'), global trust ('glotrust') and general optimism ('optimism') - vary between players on each independent variable. For example, health status ('hlthstat') has a positive effect on trust in hospital nurses ('tnurse') (B= .101), while having a negative effect on both trust in Premier Klein ('tklein') (B = -.162) and trust in alternative health care providers ('tacupun') (/I= -.I16).
Table 6.4 Regression Analysis of Determinants of T rust in Three Health Players
Hospital Premier Alternative Nurses Klein Health Provider (TNURS E) (TKLEIN) (TACUPUN) Independent Variables Demographics B e 4 e Var hbel
~i,,Ej&hst I.<-; . , ,.-,:IL:? . -7::- ,; ..:.. .oPtiniisin(sen&a~) ->.. ~enemt~iusm_.:- .F> Efficacy & Control
-- I Health Care Dperience I I I
gns- Adjusted Rf
N- - 1 NOTE Unslandardi regression coaffidmts are in parenmases and ara significant at the .05 level (onetaded). (a) IHLC = inbema1 heath toeus of aintrd: PHLC = pme& others exbtwl~CHLC =chance health loaJs of con@d 151 Looking at the three variables with the strongest, statistically significant effects for each measure of trust in health players' input, we find that trust in these three players, while being shaped overall by similar factors, is being influenced most strongly by different factors. In shaping trust in hospital nurses' input to decisions on changing the health care system ('tnurse'), the independent variables with the greatest impact are global trust ('glotrust') (P = .263), powerful others health locus of control ('phlc') (J = .185), and chance health locus of control ('chlc') (P = -.172). For trust in Premier Klein ('tklein'), the strongest effects are quality of care received ('qualcare') @'= .269), self-rated health status ('hlthstat') w = -.162), and chance health locus of control ('chlc') (p= -.149). The strongest effects shaping trust in an alternative health care provider's input are global trust ('glotrust') (P = .236), internal health locus of control ('ihlc'), and age ('age') @ = -.194).
This model (Table 6.4) explains more of the variance in trust in alternative health care providers (a@/?'= -192) than trust in hospital nurses (adj~~= .173) or trust in Premier Klein (a@@= .I01 ). These adjusted l? values are relatively low, which indicates that there are other factors, not covered in this model or not even captured in this study, which better explain trust in a health care player's input to decisions on changing the health care system. The exclusion of the 'politics- related' variables from the model may explain the low adjusted @ (.101) for trust in Premier Klein's input to decisions regarding changes to the health care system.
An expanded model presented in Table 6.5 illustrates the impact of seven additional variables on trust in Premier Klein's input to decisions on changing the health care system. These include five 'politics-related' variables - political efficacy ('poleft'), political cynicism ('policyn'), and three measures of political affiliation ('dpc', 'dnd', 'doth') - and two value congruence variables - value congruence with Premier Klein on the value of accessibility ('equal2'), and value 152 Table 6.5 Regression Analysis of Determinants of Trust in Premier Klein's Input tobecisions ~egardingChanges to the Health Care System ('tkldn') I I I Model 1 Model 2 Model 3 Independent Variables Demographics 4 B Var label 4 B 4 B
Efficacv & Control
I Health Care moerience I I I 1 umber of visits' Quality of care - - - . IMedia Influence
Political Cynicism PoIiticaEef@aq - I Value Canmence
PC (PC=l ) - not entered * not entered c638) 243 ND (ND=l) ' 1 , I not aite~d notHIW~CL 1(-(11) --.On- - I Other political (OTH=I) doth- ,-- notentered =-- not entered . - Constant 2090 -1.022 -.780 If -140 -462 .504 Adjusted 2 -100 .43 1 .470 @change - .323 -041 N 493 493 493 NOTE: UnstandarQired regression coeffiaents are in parentheses and are significant at the .05 tevel (onetaild). (a) IHLC = internal health locus of mal: PHLC = powerful others externality; CHLC =chance health loars of control
congruence with Premier Klein on the value of efficiency ('em'). Model I represents the revised basic model as presented previously in Table 6.4. Model 153 2 adds" the measures for political cynicism ('policyn') and political efficacy ('poleff), and the two value congruence variables - value congruence with Premier Klein on the value of accessibitity ('equaB') and value congruence with Premier Klein on the value of efficiency ('em'). Adding these variables to the revised basic model increases the explanatory power of the model considerably14. They increase adjusted Pfrom .I00 in Model 1 to -431 in Model 2.
The three dummy-coded variables for political affiliation ('dpc', 'dnd', and 'doth') were added last (Model 3), in order to assess their unique contribution to the overall explanatory power of the model. As expected, Progressive Conservative party affiliation ('dpc') (b =.638) has a positive effect on trust in Premier Klein's input to decisions on changing the health care system. That is, compared to Liberals, and holding all other variables in the table constant, it is expected that Progressive Conservative party supporters ('dpc') on average will exhibit a score -638 units higher in trust in Premier Klein's input to decisions on changing the health care system. Conversely, and not surprisingly, New Democratic party affiliation ('dnd') (b = -.417) has a negative impact on trust in Premier Klein's input. What is surprising, is the negligible contribution (R' change = .041) made by these three political affiliation variables ('dpc', 'dnd'. and 'doth') to overall explanatory power of the model. With the addition of the three political affiliation variables adjusted @ increased from -431 in Model 2 to .470 in Model 3.
It is important to note that in this final model (Model 3) health status ('hlthstat') and quality of care received ('qualcare'), and political affiliation ('dpc' and 'dnd') remain significant determinants of trust in Premier Klein. Furthermore,
l3 Variables were added to Model 1 in blocks using SPSS procedure 'enter'. 14 The contribution of political efficacy ('paler) and political cynicism ('policyn') to is minimal (pchange = .023). 154 age ('age'), political efficacy ('poleff), and the two media influence variables - attention to news about health care issues in the local newspaper ('attpapet) and attention to news about health care issues on television ('attb') - become statistically significant determinants of trust in Premier Klein's input with the addition of all seven variables to the model.
In shaping trust in Premier Klein's input to decisions regarding changes to the health care system ('tklein'), the strongest effects are exhibited by the two value congruence measures ('equal2' P = .358 and 'em' a = .154), political efficacy ('poleff) (P = .148), attention to news about health care issues in local newspapers ('attpapet) (P = -.137), and quality of care received ('qualcare') (p = .135).
SUMMARY OF FINDINGS PERTAINING TO THE MODEL
Below is a summary of the findings of the regression analyses reported in Tables 6.2 through 6.5. The reader is reminded that the dependent variables under consideration are:
Confidence in the Alberta medical system ('conmed') Fiduciary trust in the health policy community ('fidtrust') Confidence in the competence of the United Nurses of Alberta ('unacomp') Trust in hospital nurses' input to decisions regarding changes to the health care system ('tnurse') Trust in alternative health care providers' input to decisions regarding changes to the health care system ('tacupun') Trust in Premier Klein's input to decisions regarding changes to the health care system ('tklein') With the exception of the measure of value congruence with the Calgary Regional Health Authority with respect to the value of accessibility ('equall'), all independent variables tested demonstrated statistical significance on at least one measure of trust. The profile of determinants of trust was different for each of the six measures of trust. The results in Table 6.2 indicate that confidence in the competence of the United Nurses of Alberta ('unacomp') is being shaped largely by characteristics and orientations (ideologies and efficacy) of the respondent. In Table 6.3 we find that confidence in the Alberta medical system ('conmed') is being shaped largely by value congruence with the Calgary Regional Health Authority ('effl') and the Premier ('equal2' and 'eff2'). In contrast, fiduciary trust in the health policy community ('fidtrust') is being shaped (Table 6.3) largely by orientations of optimism ('expfive'), political efficacy ('poleff), attention to news about the health care system in newspapers ('attpaper'), and cynicism ('policyn'). Political partisanship, particularly New Democratic party support ('dnd'), exhibits a negative effect on fiduciary trust.
Table 6.4 profiles the determinants of trust in the input to decisions regarding changes to the health care system for three health care players - hospital nurses ('tnurse'), alternative health care providers ('tacupun'), and Premier Klein ('tklein'). The analysis reveals that trust in these three health care players is being influenced by different factors. Trust in the input of alternative health care providers ('tacupun') is affected largely by characteristics of the respondent, in particular globaI trust ('glotrusf), internal health locus of control ('ihlc'), and age ('age'). Trust in the input of hospital nurses ('tnurse') is being shaped by a more diverse set of factors. In fact. at least one variable from each of the five dimensions - demographics, ideologies and orientations, efficacy and control, health care experience and media influence - is found to be statistically significant. Referring to the expanded model for trust in Premier Klein's input to decisions regarding changes to the health care system (Table 6.5). we find that trust is being shaped by value congruence with the Premier ('equal2' and 'eff2'), political efficacy ('poleff'), attention to news about health care issues in local newspapers ('attpaper'), reported quality of health care received ('qualcare') and, not surprisingly, political partisanship ('dpc' and 'dnd').
Despite these differences in the profiles of determinants of trust, there are some similarities in determinants among these six measures of trust. Optimism (general or specific) shapes five of the six dependent trust variables. Quality of care received, health status, the health locus of control measure^'^ and the media variables are all prominent in the profiles of the majority of dependent trust variables. In some cases the effects vary in direction. For example, self- reported health status has a negative effect on fiduciary trust in the health policy community (Table 6.3), on trust in Premier KIein's input to decisions on changing the health care system (Table 6.5), and on trust in the input of alternative health care providers (Table 6.4). Self-reported health status, conversely, has a positive effect on confidence in the competence of the United Nurses of Alberta (Table 6.2) and trust in hospital nurses' input to decisions on changing the health care system (Table 6.4).
As reported above, some variables, such as self-reported health status ('hlthstat'), optimism ('optimism'), and powerful others health locus of control ('phlc'), exhibited an effect in the opposite direction to that which was expected on some of the dependent variables. Possible explanations for some of these findings will be discussed in the concluding chapter which follows.
In some eases the independent variables exhibited either a very weak
15 The effect of health locus of control varies by type of locus of control measure. For example. internal health lows of control ('ihlc') and chance health locus of control ('chlc') are both significant for confidence in the competence of the United Nunes of Alberta, whereas only chance health locus of control ('chlc') is significant for confidence in the Alberta medical system. 157 effect on trust, or were not statistically significant. This may suggest that these variables are better modeled as indirect causes of trust, rather than direct causes.
The explanatory power of the models of determinants of trust vaned depending on the type of measure of trust being tested. The general model of trust presented in this analysis, in its appropriately revised forms. did a better job of explaining variation in fiduciary trust in the health care policy community ('fidtrust'), trust in Premier Klein's input to decisions on changing the health care system ('tklein'), and the system in general ('conmed'), than it did of explaining variation in trust of health care workers (such as nurses, their union and alternative health care providers). The adjusted I? values for confidence in the Albem medical system ('conmed'), fiduciary trust in the health policy community ('fidtrust') and trust in Premier Klein's input to decisions on changing the health care system ('tklein') were all greater than .400. The adjusted l? values for confidence in the competence of the United Nurses of Alberta ('unacornp'), trust in the input of hospital nurses ('tnurse') and trust in the input of alternative health care providers ('tacupun') were between .I00 and .200.
This chapter has provided a detailed summary of the results of the hypothesis testing, and the multiple regression analyses used to answer the question: *What shapes trust in a health care system?". or more specifically "What are the determinants of public trust in the Alberta health care system and in its component parts?". In the concluding chapter, implications of these findings for policy and for future research are addressed. Chapter 7 CONCLUSION
We need to discover and continually rediscover how to foster trust and make it more effective. (Barber 1983:170)
The purpose of this thesis research project was to examine the sociological construct of trust, specifically the nature, distribution, and determinants of the public's trust in the Alberta health care system. This project was divided into two components -an exploratory component (Chapter Five) and an explanatory component (Chapter Six). The data for this study were collected using a mailed, self-administered questionnaire which was distributed (as outlined in Chapter Three) to a sample of individuals in Calgary, Albeita between November 4 and December 10,1999.
This chapter will begin by outlining some of the important contributions this study has made to the understanding of trust in systems, and will proceed to discussion of the conceptualization and operationalization of trust. Following that is a summary of the main findings of both the exploratory and explanatory components of the research. Implications for policy and recommendations for future research will round out the chapter.
CONTRIBUTIONS TO THE STUDY OF TRUST
As stated in the introduction to this thesis, and in reference to the above quotation, the author's hope was that this research project would contribute to that rediscovery process. I believe the findings of this research project do contribute to our understanding of trust, particularly our understanding of trust in institutions, and I believe that by furthering our understanding of trust we may learn 'how to foster trust and make it more effective". This study contributes to the understanding of trust in three important ways. First, it simultaneously brings to bear a broad array of independent variables shaping trust, and assesses their independent causal impact net of each other. Secondly, this study sets the stage for path analysis and the examination of interaction effects. Thirdly, it shows the causal determinants for a variety of different types and facets of trust. The identification of key determinants of trust in a system not only contributes to our understanding of systemic trust; it also provides a valuable resource for policy makers.
CONCEPTUALIZATION OF TRUST
This study presented the opportunity to probe Bemard Barber's (1983) conceptualization of trust In his treatise, The Logic and Limits of Trust, Barber (1 983) posited that there are three facets to trust - an overarching generalized trust and two more specific types, confidence in the competence of the actor (or agency) and fiduciary trust. He was concerned that the empirical study of trust was based on conceptually vague definitions of trust and that important aspects of trust (namely competence and fiduciary obligations) were being ignored. Barber (19835) offers his three definitions of trust so that the "empirically based and theoretically sound study of trust [will have] a finer foundation".
By way of review, the regression analysis in Chapter Six began with an examination of Bernard Barber's (1983) three-fold conceptualization of trust. The regression analysis found that, while there was some overlap, all three facets of trust were essentially being explained by a different set of variables. This lends support to Barber's three-fold conceptualization of trust and suggests the importance of the operationalization of tnrst in empirical research. How one operationalizes trust can affect the outcome of the results. Trust in competence and trust in the fulfillment of fiduciary obligations are conceptually two different aspects of trust. Furthermore, to measure 'generalized' trust. or 'faith', using a measure containing aspects of fiduciary obligation or competence wouid confuse the interpretation of results. The 'trust' being measured would no longer be 'generalized faith'; it would now be focused on a 'specific aspectt of trust. Later in this chapter I discuss the implications of the operationalization of trust for future research.
EXPLORATORY COMPONENT
In Chapter Five we asked the research questions: "How fmsting are Albertans of the cumnt health care system?"and "Domembers of the Alberta public trust different key players in the Alberta public health system to differing degrees?" In Table 5.1 the results of a comparison of confidence in seven Canadian institutions were reported. We saw that the Alberta medical system ranked higher on mean level of trust than the Supreme Court of Canada, Afberta public schoo~s,large corporations, and labour unions, but slightly lower on mean level of trust than police and Canadian banks. While this may indicate that people are generally confident in the Alberta medical system, they are not overwhelmingly so. Only 38 percent reported 'a great deal' or 'complete' confidence in the Alberta medical system as opposed to the 67 percent who exhibited that level of confidence in police.
The large percentage (43%) of people reporting 'some' (the middle category of the five-point scale) confidence in the Alberta medical system (Table 5.1 ) is somewhat troubling. Does this indicate apathy, ambivalence or doubt? Apathy implies indifference. Given the fact that studies indicate the number one issue on the minds of Canadians is health care, it is doubtful that apathy is the explanation. Doubt is certainly a possibility given the uncertain future of the public health care system in the face of increased privatization. Ambivalence is another reasonable explanation. It is possible that feelings of both trust and distrust exist within the minds of people when they think about the heaith care system as a whole.
The issue of conflicting feelings of tnrst and distrust in a system was raised by Jeffrey Alexander (1991). From Chapter Three, the reader will recall Jeffrey Alexander's (1991 :127) observation that:
"One can have faith in the 'system" (be it a society, a form of government, a way of life, or an organization) without having faith in the institutions or subsystems that compose it; or one may trust in the role (in its fiduciary mandate, for example) but not in the person performing it - in his or her fiduciary commitments or technical competence".
Thus, one could have trust in the health system itself, but lack confidence in some of the elements that comprise it.' However, the findings in this study suggest that lack of confidence in various component parts of a system may undermine confidence in the system itself. As previously stated, only 38 percent expressed 'a great deal' or 'cornpiete' confidence in the Alberta medical system. Roughly 20 percent expressed a lack of confidence. Without counting those middle category ('some') respondents, one would have to conclude that Calgarians do not have a high level of confidence in their health care system. An
------A secondary analysis (not reported) revealed that the percentage of those who distrust a health player, but have confidence in the Alberta medical system is between 20 and 40 percent examination of the levels of trust in the component parts of the health care system may help explain why. Of the fourteen health care players (Table 5.1) for whom respondents were asked to indicate their level of trust, eight had higher levels of distrust than trust. Among those receiving the highest IeveIs of distmst are key members of the health policy community. Those players include 'a senior hospital administrator', 'a senior administrator of a regional health authority', Alberta Health, and Premier Klein. While Liberals and New Democratic party supporters were, as expected, the least trusting of Premier Klein's input to decisions on changing the health care system, a full 28% of the Progressive Conservative party supporters expressed distrust in the Premier. In addition, almost one half (48%) of all respondents expressed low levels ('very little' or 'none at all') of confidence that the Government of Alberta would fulfill its fiduciary responsibilities to Albertans when making health care reform decisions. While partisanship does play a role in influencing trust (and distrust) in the Alberta health care system, and the people and agencies that make up that system, reported affiliation with the incumbent Progressive Conservative party does not guarantee a trusting orientation toward political and health policy actors or agencies, nor does it guarantee trust in the system itself. As previously suggested, this pervasive distrust of the health policy community on the fiduciary dimension may explain the diminished levels of trust in this the system that figures so prominently in Canadian identity. Indeed, because medicare figures so prominently in the Canadian identity, the fiduciary obligation of the government is perhaps heightened in the mind of members of the mass public.
As stated in Chapter Five, these findings would suggest that Alberta Health and the Calgary Regional Health Authority are facing a serious crisis in confidence. In response to a question designed to tap respondents' perceptions of how their confidence in the health care system has changed over the past five years, a majonty (52%) indicated that they are not now more confident that the health care system will take care of them when they need it. This does not necessarily indicate that their confidence has dropped, but does indicate that their confidence has not increased. How optimistic are Calgarians about the future quality of publicly funded health care senrices in Alberta? The answer is 'not very'. Only 15 percent expect that the quality of health care services will get better. Almost half (48%) state they expect the quality of health care to be worse!
Contested Terrain ?
The preceding discussion highlights the fact that different groups of health care players are accorded different amounts of trust. Health care professionals such as doctors and nurses are bestowed the largest share of trust. Alternately, there is an obvious withdrawal of trust from the political and administrative health care players. The question arises: Is trust in a system (such as the Alberta health care system) a zero-sum game? A zero-sum game model would postulate that trust in a system is confined within a boundary. Within the confines of this boundary there is only so much trust to go around. The investment of trust in one area (such as doctors and nurses) means the withdrawal of trust in another area (such as political and administrative health care players). Trust then becomes a contest. Competition for this limited resource ensues. One wonders what effect the December 2000 job action (withdrawal of services) taken by physicians in Alberta will have on fiduciary trust in that group of health actors. What would the effect of an outright strike be on trust? Assuming the zero-sum game model, a withdrawal of trust in physicians would mean an increased share of trust for other another group or groups (such as non-traditional health care providers). In the present study there are only two bases by which to test the applicability of this zero-sum model for the Alberta health care system. By examining correlation tables for two trust in health care players measures we can determine if there are any statistically significant negative correlations that would indicate that as trust in one actor increases, trust in another actor decreases. Trust in nurses and trust in their union appears to be negatively correlated with trust in Premier Klein, trust in private hospitals, and trust in Alberta Health. However, with the exception of the correlation between trust in the United Nurses of Alberta's input and trust in Premier Klein (r = -.09), all of the correlations are very weak and none are statistically significant. An examination of the correlations for trustworthiness of sources of information about the health care system revealed no statistically significant, negative correlations. In fact, there were no negative correlations between any of the actors. Although these findings are by no means conclusive, they do indicate that trust in the Alberta health care system is not a zero-sum game. Perhaps it is a more dynamic phenomenon which allows these boundaries to grow as trust increases, or even recede in the case of a serious betrayal of trust (the 'tainted blood' and the Walkerton (Ontario) water contamination scandals come to mind).
EXPLANATORY COMPONENT
In Chapter Six two types of analysis were used to answer the general research question: 'What shapes trust in a health care system?". Zero-order correlation analysis2was used to test the hypotheses outlined in Chapter Three. Multiple regression analysis was used to test the model proposed in Chapter Three and identify important determinants of trust in a health care system and in its component parts. As summaries of the findings of both analyses can be found in Chapter Six, this section will provide an overview of the main findings and highlight a selection of unexpected or contradictory findings.
2 Four hypotheses were tested using other statistical procedures such as crosstabulation and means analysis. The theoretical model (Figure 3.1) presented in Chapter Three proposed that trust is shaped by eight dimensions - social demographic characteristics of the respondent, ideologies and orientations of the respondent, the respondent's feelings of efficacy and control, health care experience, perceived effectiveness of the system, media influence, value congruence between the respondent and key decision-makers, and trustworthiness of key sources of information about the health care system. Reviewing the hypothesis tests summarized in Table 6.1, one finds that there was generally good support for hypotheses related to ideologies and orientations of the respondent, the respondent's feelings of efficacy and control, perceived effectiveness of the system, and value congruence between the respondent and two key decision-makers - the Calgary Regional Heaith Authority and Premier Klein. In fact, all hypotheses related to value congruence, for all measures of value congruence and for all dependent variables tested, received and statistically significant support at the -05level.
Hypotheses related to dimensions such as demographic characteristics of the respondent, health care experience, and media influence received little support. The lack of support for the hypotheses involving demographic and media influence variables may suggest that the relationship between these variables and trust is better explained using a path analytic model. Although the exploration of the relationship between exposure to real-life medical television programmes and trust in a health care system did not produce the hypothesized results, it is perhaps premature to conclude that real-life medical television programmes have no effect on levels of trust in health care players and in a health care system. Real-life medical programmes represent a new genre of television programming and warrant further attention.
Multiple regression analyses were used to answer the research question: "What are fhe determinants of public tmst in the Alberta health care system and in its component parts?". Six dependent trust variables were chosen for testing: confidence in the Alberta medical system ('conmed'), fiduciary trust in the health policy community ('fidtrust'), confidence in the competence of the United Nurses of Alberta ('unacomp'), trust in hospital nurses' input to decisions on changing the health care system ('tnurse'), trust in alternative health care players' input to decisions on changing the health care system ('tacupun'), and trust in Premier Klein's input to decisions on changing the health care system ('tklein').
What shapes trust in the Alberta health care system? Figures 7.1 and 7.2 illustrate the degree to which there is overlap in determinants for two groups of dependent trust variables -the three facets of trust and trust in health players, Figure 7.1 illustrates those variables which are shared by the three facets of trust and those variables that are unique causal determinants of each measure. Here we find that although confidence in the Alberta medical system ('conmed') and fiduciary trust in the health policy community ('fidtrust') are being shaped similarly by four variables, confidence in the Alberta medical system ('conmed') is being shaped by five variables not shared with fiduciary trust ('fidtrust'). In addition, fiduciary trust ('fidtrust') has six of its own causal determinants not shared with confidence in the Alberta medical system ('conmed'). Findings are similar for the three health players (Figure 7.2). The relative importance of these determinants in terms of the strength of their effect on the dependent trust variables was profiled in Chapter Six and will not be repeated here.
Overall, by social science standards, the models (general model and revised/expanded versions) tested in this thesis did a good job of explaining variation in levels of trust in the Alberta medical system, fiduciary trust in the health policy community, and trust in Premier Klein. Where the models lacked explanatory power was in the explanation of variance in levels of trust in hospital Figure 7.1 Overlap in Determinants of Confidence in the Alberta Medical System, Fiduciary Trust in the Health Policy Community, and Confidence in the Competence of the United Nurses of AIberta
LEGEND
General optimism Education level Quality of care received Value congruence with Premier Klein on value of accessibility Progressive Conservative party affiliation New Democratic party affiliation Chance health locus of control Workload of doctors Value congruence with the CRHA on value of efficiency Value congruence with Premier Klein on value of efficiency Trustworthiness of government sources of information Optimism about quality of health services in future Total number of visits to health care providers Attention to health care issues in local newspapers Attention to health care issues on television Self-reported health status Global trust in others Internal health Iocus of control Powerful others externality health Iocus of control 168 Figure 7.2 Overlap of Determinants of Trust in Hospibl Nurses' Input, Trust in Attemative Health Care Providers' Input, and Trust in Premier Klein's Input to Decisions on Changes to the Health Care System
LEGEND
Self-reported health status Internal health locus of control Global trust in others General optimism Quatity of care received Attention to heaith care issues an television Powerful others health locus of control Chance health locus of control Age of respondent Presence of chronic health problem General cynicism Exposure to real-life television medical programmes Attention to health care issues in local newspapers Exposure to television medical dramas Progressive Conservative party affiliation New Democrative party affiliation nurses' input, in alternative health care providers' input, and in confidence in the competence of the United Nurses of Alberta.
There were some unexpected findings which contradicted the hypotheses outlined in Chapter Three. One very surprising finding is that optimism, a key determinant of trust in five of the six dependent variables, has a negative effect on trust in hospital nurses' input to decisions regarding changes to the health care system, trust in alternative health care providers' input to decisions regarding changes to the health care system, and confidence in the competence of the United Nurses of Alberta. The literature suggests, and it was hypothesized, that the greater the optimism, the greater the trust. One possible explanation for this very interesting finding is that the more optimistic one is, the less one feels @)heneeds to be dependent on the services of these health care providers. therefore the less need there is to trust that health player. Perhaps we are seeing Simmel's 'protective functian' of trust in reverse? In these specific circumstances, and relating to these particular types of actors, it may not be necessary to invoke the 'protective function' of trust as optimism prepares one for uncertainties in some situations.
For two of the dependent variables (fiduciary trust in the health policy community and trust in Premier Klein), as hypothesized, attention to newspapers had a negative effect on trust That is not surprising, given such things as the tone of newspaper articles and editorials on the state of health care in Alberta over the months preceding the survey, Premier Klein's public admission that he had no plan in mind when his government cut $734 million from the health care budget, and Premier Klein's announcement of his intention to bring fonvard legislation extending services to private health care providers just days before
Simmel suggests that trust has a 'protective function', in that it "allows us to act effectively and confidently" in areas where the 'specialized' knowledge of the experts exceeds our own knowledge (Simmel1964:333-334 as cited in Lewis and Weigert 1985a:459). the first wave of questionnaires went out to respondents. While it was hypothesized that attention to news about health care issues on television would exhibit a negative effect, the opposite was found for fiduciary trust in the health policy community and for trust in Premier Klein. One possible explanation is that television news coverage of health policy actors in Alberta is not as negative as Calgary newspaper coverage.' One other possible explanation is that Premier KIein's public address on November 16, 1999 in regards to Bill 11 may have actually had an initial positive effect on respondents' views of the system.
Another unexpected finding is that, for three of the dependent variables, self-reported health status was found to have an effect opposite to that which was hypothesized. Health status was found to have a positive effect on trust in hospital nurses' input to decisions on changing the health care system and confidence in the competence of the United Nurses of Alberta, While there is no clear answer, one could suggest that those reporting good health may be more willing to trust others including health caregivers such as nurses. In addition, health status exhibited a negative effect on trust in Premier Klein. While one might expect that those with compromised health would be less trusting of someone who is perceived to be supportive of the privatization of health services and its resultant 'a bility-to-pay' issues, this does not appear to be the case for Premier Klein. f erhaps those with compromised health are more hopeful that Klein's initiatives will improve the health care delivery and subsequenffy alleviate some of the problems (e.g., long waiting lists) encountered by those using the system.
The general lack of support for the hypotheses related to two specific dependent variables - confidence in the competence of the United Nurses of Alberta and trust in hospital nurses' input to decisions on changing the health
- -~ Relentless cntidsm of the Alberta health care system is very evident in the Calgary Herald. care system -, and the lack of explanatory power of the regression models for these two dependent variables, suggests that there may be other factors which better explain levels of trust in these two health care players.
The lack of support for the hypothesized relationship between the breadth and frequency of a respondent's health care experience was unexpected given the compelling arguments raised by Giddens (1990) and Luhmann (1979) over the importance of experience in developing trust. Perhaps, as suggested by Giddens (1990), it is not simply the frequency of contact (which according to Luhmann would create 'familiarity'), but the nature of the encounter that influences levels of trust. Repeated bad experiences may diminish trust, whereas repeated positive experiences may increase trust. Future research may want to address this issue by including a measure of whether the encounter was positive or negative.
One final comment with regards to the explanatory analysis reiates to an argument made at the beginning of Chapter Two that "trust occurs within a framework of interaction which is influenced by both personality and social system, and cannot be exclusively associated with either" (Luhmann 1979:6). Note that the determinants listed above are not limited to characteristics of the respondent, Trust is shaped just as much by social and experiential factors. such as quality of care received and media messages, as it is by orientations and characteristics of the respondent, such as optimism and health status.
POLICY IMPLICATIONS
A note on the importance of public opinion research for policy is warranted. The survey conducted for this study of trust in the Alberta health care system utilized a sample of the general public. One objective of this study was to examine people's perceptions of trust in the health care system. For that reason, this study relies to a large extent on the subjective opinions of respondents. Because public opinion research tends to be subjective, some view it as unreliable. However, public opinion can be very valuable in policy formation. As Pescosolido, Boyer and Tsui (1985277) note, research involving public opinion "allows us (1) to understand the climate in which programs operate, (2) to ascertain the support programs receive from various segments of the population, and (3) to see how reactions relate to general support for political and medical systemsn.
Before proceeding with a discussion of the implications of this study for policy, it is important to remind the reader of the general theoretical orientation underlying this study. As evidenced by the theoretical discussion in Chapter Two, this study is influenced largely by theorists writing from a functionalist perspective. That is, trust is seen as a necessary functional component of society. Building and maintaining trust in a health care system is seen as indispensable for the continued existence of that institution, and for ongoing effective social relationships with the public that use the health care system. An equally valid and compelling argument is put fonvard by political economy theorists. Political economists are more interested in what role trust plays in social relationships, than in trust building. The December 2000 job action by physicians in Alberta serves as one example of how political economists might view trust in the health care system. In this case, politicai economists might argue that because doctors command a high level of trust from the public, they are using that trust as a weapon to further their own interests. This situation necessarily demands that the Alberta government (and its agencies involved in negotiations with Alberta physicians) attempt to undermine trust in physicians in order to level the playing field. Trust, in this case, is seen as a resource. Further examples of insights from the political economy perspective will be introduced in this section where appropriate.
What are the implications of this study for policy? Earlier in this chapter we discussed the relatively low levels of trust in the health care system and some of its key players. That finding is interesting in light of the fact that roughly 70 percent (frequency table not reported) of respondents rate the quality of health care services they received in the last year as 'good' or 'excellent'! Perhaps this gap between personal experience in the health care system and the negative assessment of its future is due to govemment having broken an emotional bond between Canadians and their health system, such as by blowing up hospitals! That is, maybe there is a symbolic, emotional bonding component to systemic trust (especially in Canada where Medicare is a symbol of our national identity) that the literature has overlooked. Parsons (1968:155) suggests that trust in the reliability, effectiveness, and legitimacy of 'symbolic structures' (such as a health care system) is essential for their continuance. The present research suggests that efforts to restore confidence in the health care system should include a focus on re-building that symbolic, emotional bond.
The importance of the public's perception of value congruence with key policy-makers cannot be ignored. A study conducted in the United States indicated that one of the reasons for lack of trust in govemment was that government policies did not reflect the respondent's own views (Zussman 1997). Given the importance of the five principles of the Canada Health Act to Canadians and Canadian identity, policy makers and stakeholders like the Alberta Medical Association and the United Nurses of Alberta should use extreme caution when formulating policy that may challenge those values. The 7996 Rethinking Government study found that Canadians Want health care reform to reflect the values they believe in and to be undertaken with an eye not of dismantling what exists, but toward improving and preserving what they consider to be important about it" (Graves. Beauchamp and Herle 1998:393). It has been demonstrated, in this study and others (such as Graves, Beauchamp and Herie 1998), that Canadians place a high level of importance on those values entrenched in the Canada Health Act; namely, the five principles of universality, portability, accessibility, public administration, and comprehensiveness. Further violence to that emotional bond that Canadians have with the Medicare system may result in greater distrust of the health care system and the health policy makers. Mishler and Rose (1997:418) remind us that trust enables government to "make decisions and commit resources without having to resort to coercion or obtain the specific approval of citizens for every decision". If health policy makers want to build trust, then conducting meaningful consultations with the public before making major system changes may help to re-establish some of the lost trust. If, however, those consultations are seen as 'tokenistic', tmst may be undermined.
Why is low trust in the health care system seen as dysfunctional? A serious consequence of low trust in the health care system is that people might disengage themselves from the system. Some may choose to seek treatment from health care services outside of the public system. Others may choose to go elsewhere (such as the United States) for treatment. More importantly, others may not seek treatment when they need it. If one is not confident that one wiil receive prompt and effective treatment from a hospital emergency department, for example, one may hesitate or fail to go when one has a serious illness or injury.
The legitimacy of the health care system and its administrators is undermined by low trust Political economists might argue that the Alberta government is deliberately trying to undermine the legitimacy of the public health care system in order to allow for a private system. A serious consequence of a loss of legitimacy in the health care system is that it may cause a generalization of distrust to other public institutions. It would be an unfortunate legacy for any administration to leave in an atmosphere of distrust, and there may be a political price to pay for politicians who significantly undermine legitimacy in favoured public institutions like the health care system.
lfthe health care administration is truly interested in shoring up the legitimacy of the health care system as key communicators they may want to rely more on doctors and nurses and less on distrusted sources (such as the Alberta Government and the Catgary Regional Health Authority). As evidenced by the tables presented in Chapter Five, messages from the Alberta health minister and Premier Klein may be seen as 'tainted'. While it is unrealistic to suggest that these key government officials not act as spokespersons for the Alberta health care system, messages should be buttressed by more trusted messengers such as those identified in Chapter Five.
FUTURE RESEARCH
This final section identifies some questions which deserve attention in future research, and addresses some of the limitations of this study that could be overcome in future studies.
A gap exists between people's experience with the health care system and their assessments of it. This gap was evidenced in this study and in a number of studies conducted for the Calgary Regional Health Authority. The preceding discussion offered one possible explanation, but more research is needed before we can understand this interesting paradox. Future research should examine further both the idea that the government has broken an emotional bond between Canadians and their health system and the notion of trust as a fluid or dynamic commodrty. Under what conditions is it withdrawn and under what conditions is it bestowed. My research provides a point of departure for such a line of inquiry, but my research does not tap the full potential of conceptualizing trust as fluid. Furthermore, the aforementioned "under what conditions" questions pertain to societal (institutional)-level developments, whereas my research focused on characteristics of individuals (within the societal context).
Outcomes are another aspect of trust that could be investigated in future studies. This study has examined those factors which lead to or cause trust and distrust, but we can only speculate on the effect of trust and distrust on behavioural outcomes. Do people with low levels of tmst act differently toward the health care system? Does distrust cause one to disengage oneself from that system? If so, how and with what effect on the individual's health?
One limitation of self-administered questionnaire survey research is that it does not allow one to probe why someone has indicated a trusting or distrusting answer. Future studies should employ interview or focus group techniques. Questions from the current study could be used with the addition of probes asking why respondents answered the way they did or asking for examples which support their answer.
Another limitation of the present analysis of the determinants of trust in the Alberta health care system is that only 'direct' effects of independent variables on the dependent variables have been examined. The fact that some of the hypothesized relationships for some of the variables are found not to be significant may signal that their effect on the dependent variables is actually an indirect one. Future research is proposed which will employ a path analytic technique in order to explore both the 'directt and 'indirect' effects of independent variables on trust.
This study was limited to English-speaking people (only an English version of the questionnaire was administered). It would be useful to replicate this study (using translators) in ethnic communities among those who do not speak English so as to examine the multicultural aspects of trust in health care.
Finally, a key recommendation regarding the operationalization of trust, whether it be trust in a health system or trust some other institution, relates to the use of Barber's three-fold conceptualization of trust. The development and testing of conceptually concise and empirically sound measures of trust based on Barber's conceptualization would further the understanding of the dynamics of trust. Because the present study went beyond simply testing Barber's three-fold conceptualization of trust, the variables used to measure the three facets involved different actors or objects. Despite that, the findings in the multiple regression analysis make Barber's conceptualization of trust more compelling. A 'purer' test of Barber's threefold distinction would use measures with the same object, for example, the Calgary Regional Health Authority. The Calgary Regional Health Authority is, itself. a system comprising many parts. An examination of generalized trust, fiduciary trust, and confidence in competence as it relates to the Calgary Regional Health Authonty would not only contribute to the understanding of trust. but it would also have some important policy implications. Findings on different facets of tmst may affect policy differently. If, for example, it were found that confidence in the competence of the Calgary Regional Health Authority is low, that might signal a lack of resources, staff and facilities, or problems with accessibility, availability and convenience of health services. If it were found that fiduciary trust is low, then the Calgary Regional Health Authonty may need to work on communications strategies. If generalized trust in the Calgary Regional Health Authority is found to be low, then the Calgary Regional Health Authority may need to investigate other factors affecting trust.
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CHRONOLOGY OF NEWS EVENTS IN ALBERTA Chronoloav of Some Maior Events and News Stories out the Health Care Svstem in Alberta from 1993 to 1999 "All cited articles appeared in the Calgary Herald.
February 1993 'Alberta's health care crisis: can we afford the bill? Deeper in the hole" (Robert Walker 1993 Feb 21 :81) January 1994 Premier Klein announces health care budget being cut by 17.6 percent. "Hospital cuts are 'impossible': essential medical services will be lost, administrators say" (Robert Walker 1994 Jan 21 :51) April 1994 "Private care trend rapped: federal health minister 'deeply concerned' with Alberta's 'two-tiet look" (Sheldon Alberts 1994 Apr 14:Al) June 1994 Alberta health care system divided into f 7 regional health authorities. July 1994 Closing of the Grace and Holy Cross hospitals announced. "Closing of holy cross ranks with the bizarre" (Don Braid 1994 July16:Bl) "Dark clouds swirl over Fort Foothills" (William Gold 1994 July 21:A5) August 1994 "Hospital brass face scalpel" (Robert Walker 1994 Aug 6:Al) September 1994 "Transplant trip was a nightmare" (Robert Walker 1994 Sept 8:Al) "Edmonton protest: hospital cutbacks slammedn (Rick Pedersen 1994 Sept 9:A2) "Klein blames hospital workers for health care risksn(Joan Crockatt 1994 Sept 16:A14) Cuts to health care amount to $734 million. October 1994 'Wary unions jeer health care plan" (Robert Walker 1994 Oct 7:Al) 'Risking our health: why the big rush to close city hospitals - editorial" (1994 Oct 9:A4) 'Tax on rural patients decried: surcharge idea could spur health wars, doctor warns" (Robert Walker 1994 Oct 13A1) "Hospital staff 'devastated' by call for pay cutsn (Dave Palmer 1994 Oct 19:63) November 1994 'Health board worriedn (Robert Walker 1994 Nov 1:Bl) December 1994 "Downs syndrome: doctors angry as test axed" (Robert Walker 1994 Dec 31:Al) March 1995 "Chinook closes hospitals, cuts acute care beds" (Robert Walker 1995 Mar 11:B16) "Health chief suddenly quits post" (Robert Walker 1995 Mar 29:Al) April 1995 "Health chairman backs doctors" (Robert Walker 1995 Apr 18:Al) May 1995 "Plan fuels quality concerns" (Robert Walker 1995 May 20:Bl) 'AMA survey: doctors leaving Alberta" (Tom Arnold 1995 May 25:A14) June 1995 "Authorities' autonomy in question" (Bob Bergen 1995 June?1 :A1 ) "Calgary Regional Health Authority: building cooperation out of near chaos" (Bob Bergen 1995 June 11 :A8) Closing dates for the Bow Valley Hospital announced *Health bosses seek new uses for hospitals" (Robert Walker 1995 Junel2:Al) July 1995 "Physios face funding crunch: latest cuts could force some clinics to close their doorsn (Wendy Dudley 1995 July 14:Bl) August 1995 "Health cuts: widow alleges poor care; premier and province sued - Alberta's health budget trimming blamed in death of Winnipeg man" (Gordon Jaremko 1995 Aug 9:Bl) "Doctor exodus not a problem" (Don Braid 1995 Aug 17:Bl) November 1995 "Alberta cuts 'are the deepest'" (Robert Walker 1995 Nov 9:A4) "Shock treatment: Alberta's three-year financial plan to save health care is in danger of killing it" (editorial 1995 Nov 17A14) "Health care: doctors warn cuts must stop - elderly, chronically ill patients are being hurt by health reform" (Robert Walker 1995 Nov 17:Al) March 1996 "Health care dangerously compromised: union members deserve to be paid a fair wage for increased workloads" (Elisabeth Ballertnann 1996 Mar 13:A14) May 1996 "Alberta Health Care: McClellan failing ailing ministry" (Don Martin 1996 May 2:A16) June 1996 "Calgary needs General Hospital: Keeping it open also makes economic sense" (Main E. Matheson 1996 June 25A12) July 1996 "Edmonton doctors protest shortage of beds: MD says patients having heart attacks while waiting for surgeryn(Ed Struzik 1996 July 25:A4) "Below an acceptable level: MD 'blows lid" off Edmonton hospital caren (Tom Arnold 1996 July 26:A5) August 1996 "Health Care: Public needs the factsw(Jim Cunningham 1996 Aug 3:Al) September 1996 "Doctors issue warning but Klein denies Alberta becoming a "wasteland" (Robert Walker 1996 Sept 22:AI ) + "Klein can make health-care peace: Premier should block decision to close the General Hospital" (Robert Bragg 1996 Sept 22:A6) November 1996 + "More than half of three year's cuts restoredn(Robert Walker 1996 Nov 26:A6) December 1996 + "Albertans mistrustful of reforms, poll shows" (Robert Walker 1996 Dec 19:BlO) April 1997 + "Easy does it: The General Hospital shouldn't be hastily demolished" (Editorial 1997 Apr 11 :A1 8) May 1997 r "Electioneering figures into policy on health caren (Don Martin 1997 May 17:J5) "Health group denies links to US. chainw(Robert Walker 1997 May 22:B3) June 1997 QJ 'Doctor will work both systems [public and private]" (Canadian Press 1997 June 5:A6) QJ "Hundreds travel here [to Calgary From Edmonton] to use MRI machines" (Lisa Dempster 1997 June 21:Bl) ."Private facility faces strict limits on servicesn(Tom Arnold 1997 June 24:A2) cc "Regional elections [RHA's] could be good for your healthn(Don Martin 1997 June 24:A19) July I997 cc "Doctors campaign for health pay hikem(Don Martin 1997 July 8:All) August 1997 .'Doctors on the move leave small~ownsin the lurchn(Don Martin 1997 Aug 23:J5) October 1997 "Klein sets priorities: Education, health and infrastructure" (Steve Chase 1997 Od 1:Al) "Klein strangely balky about elected boards [RHA'sl" (Don Martin 1997 Oct 31:A19) January 1998 "Province takes on power to approve private hospitals" (Sean Gordon 1998 Jan 1:62) February 1998 "Hospitals could have been put to good use" (Dr. L.O. Bradley 1998 Feb 25:A17) March f 998 "CRHA dips into emergency fund" (Mark Lowey 1998 Mar 13:Al) "Health districts plead for $138M" (Robert Walker 1998 Mar 22:Al) "NDs, government spar over private hospitalsw(Raquel Exner 1998 Mar 30:B5) April 1998 "Health bill only appears innocent" (Don Martin 1998 Apr 21 :A1 7) May 1998 "MD protest may mean more caesarean birthsn(Robert Walker 1998 May 7161) June 1998 "Hospital bed cuts 'deepest in Canada' (Mark Lowey 1998 June 8:Al) JuIy f 998 "Nursing shortage curtails ER surgeryn (Rick Pedersen 1998 July 10:A4) "Medical waits too long, survey says" (Robert Walker and Mark Lowey 1998 July 29:Al) "Poll gives high marks to health carew(Robert Walker 1998 July 30:A3) August 1998 "Health system still needs work - report" (Robert Walker 1998 Aug 28:Al) October 1998 "Demolition set; doubts linger" (Mark Lowey and Robert Walker 1998 Oct 4:A9) Calgary General Hospital imploded at 9 a.m. on October 4. "Collapse of General Hospital leaves questions in Ward 4: Health care, redevelopment among concerns" (Juliet Williams 1998 Oct 8232) January 1999 "Wave of patients swamps hospitals" (Jim Cunningham and Darcy Henton 1999 Jan 20:Al) "Crisis in hospitals is for real, Ralph" (John Gradon 1999 Jan 29:Bl) February 1999 "Klein shifts focus to education, healthw(Darcy Henton and Helen Dolik 1999 Feb 5:Al) "$23M boost for health" (Robert Walker 1999 Feb 16:Al) "Rockyview patients diverted" (Mario Toneguzzi 1999 Feb 18) "Albertans fear for future of health care" (Robert Walker 1999 Feb 27:A4) "Health Summit '99: Finding a health balance" (Mebs Kanji and Barry Cooper 1999 Feb 20:H6) w Health Summit '99 held in Calgary between February 25 to 27. w "Delegates refuse to rank essential health servicesn (Darcy Henton 1999 Feb 27:A4) March 1999 a "Health regions desperate for cash as deficits pile up" (Robert Walker 1999 Mar 7:Al) w "Alberta health gets $1 B boost" (Monte Stewart 1999 Mar 9:Al) a "Calgary health leaders warn $77M not enoughn (Robert Walker 1999 Mar 12:A8). w "Consultants blast CRHA management stylen (Robert Walker 1999 Mar 31:Bl) April 1999 a Former provincial treasurer Jim Dinning appointed chair of CRHA as part of a planned 'shakeup' of the CRHA board and hospital administration a "Nurses... and Workloads: An important message from Alberta's Health Authoritiesn (Alberta Health Authorities 1999 April 8:83) a "City health chief replaced todayn (Don Martin 1999 Apr 13:Al) "Dinning vows to fix CRHA problemsn(Robert Watker and Darcy Henton 1999 April 14:Al) "2,000 new RNs needed. union tells health boards" (Kathleen Engman 1999 Apr 14:B 1) "CRHA to investigate confidential files found in back yardn (Tara Hamilton 1999 Apr 14:88) "Doctors may hand out waiting list warningn (Robert Walker 1999 Apr 28331 ) May 1999 + "Alberta's nursing shortage growing" (Robert Walker 1999 May 11:A5) "Residents 'cynical' about plans for General Hospital site" (Colette Denrvoriz 1999 May 13:84) + 'Dinning to hire 240 more nurses* (Robert Walker 1999 May 21:Bl) "Doctor shortage growing in Calgary" (Robert Walker 1999 May 31:Al) June 1999 + Provincial nurses threaten strike action. I "CRHA can't shake crisis stigman (Robert Walker 1999 June 15:Al-2) + "Health, education get $160Mm(Darcy Henton 1999 June 25:Al-2) July 1999 + "CRHA promises shorter waitsn (Robert Walker 1999 July 3:B7) r "Premier's advisor lands top health job: CRHA post puts Davis on other side of the fence" (Robert Walker 1999 July 28:Al) August 1999 "Albertans slam health-care waits in survey" (Robert Walker 1999 Aug 25:A18) September f 999 "Hospital bursting at seams, say MDs" (Frank King 1999 Sept 14:Bl) "CRHA deficit surges to $52mn (Don Martin 1999 Sept 22:A1] "Top doctor leaves in CRHA revamp" (Robert Walker 1999 Sept 2531) October 1999 "Prognosis for private hospitals very dim" (Don Martin 1999 Oct 3:A18) "Poor planning cited for severe bed shoage: Auditor general says $600M neededn(Larry Johnsrude and Helen Dolik 1999 Oct 6:A5). Oct 30 - Premier Klein announces intention to introduce Bill 11 at annual Tory convention. November 1999 'Klein pledges to abolish two-tier healm system" (Don Martin 1999 Nov 5:Al) Nov 16 - Premier Klein makes public television address announcing his intention to introduce Bill 11 into the Alberta legislature Nov 17. "Health plans sparks uproar" (Derek McNaughton and Raquel Exner 1999 Nov 18:Al) "Klein must not betray people's trustw(Editorial 1999 Nov 22A15) APPENDIX B
OPERATIONALIZATION OF WEIGHTING VARIABLES OPERATIONALIZATION OF WEIGHTING VARIABLES
The variables from the Statistics Canada 1996 (3% sample) Census for the Calgary Census Metropolitan Area (CMA) were recoded for use in the weighting procedure. The variable SEXP (SEX) was recoded 1 'female' and 0 'male'. Age and education were recoded as follows.
New Variable
AGEP AGE (actual age in years) 18 to 24 years minimum 0 25 to 34 years maximum 85 35 to 44 years 45 to 54 years 55 to 64 years 65 to 74 years 75 years and over
HLOSP (highest level of schooling) EDUCZ (education level) c than Grade 5 1 < than High School 1 (1-3) Grade 5-8 2 Completed High School 2 (4) Grade 9-1 3 3 Some post-secondary 3 (6.9) High School Grad 4 Completed non-university 4 (5,7,8,10) Trades CeNDiploma 5 Completed university 5 (11-14) 0th nonu: No 0th Cert. 6 0th nonu: with Trade 7 EDUCI (education level) ' 0th nonu: with 0th Cert. 8 < than High School 1 (1-3) Univ: No CeNDipl. 9 Completed High School 2 (4) Univ: With CeNDipl. 10 Some post-secondary 3 (6,9) Univ: BA or Prof Deg 11 Completed non-university 4 (5,7,8) Univ: BA + CeNDipl. 12 Completed university 5 (10-1 4) Univ: MA 13 Univ: PhD 14
"Note: This alternative collapsing scheme was initially considered but later abandoned in favor of EDUC2 as EDUC2 better approximates the figures published on the Statistics Canada Census 96 website for the same educational categories (Statistics Canada 1999b). FREQUENCY DlSTRlBUTtON OF WEIGHT FACTOR VARIABLE
Table 6.1 Weight Factor Variable - Unweighted
Weight Factor Frequency Percentage
< .499 166 34 .SO0 - .999 109 22 1.ooo - 1.499 t4a 30 1.SO0 - 1.999 35 7 2.000 - 2.499 10 2 2.500 - 2.999 8 2 3.000 - 3.499 4 1 3.500 - 3.999 4 1 4.000 - 4.499 0 0 4.500 - 4.999 3 1 5.000 - 5499 0 0 5.500 - 5.999 0 0 6.000 - 6.499 1 0 6.500 - 6.999 1 0 7.000 - 7.499 0 0 7.500 - 7.999 1 0 8.000 - 8.499 2 1 8.500 - 8.999 1 0
TOTAL 493 100 Mean -99949 * APPENDIX C
SUMMATED SCALES SUMMARY SPSS SYNTAX OF CREDIBILITY AND VALUE CONGRUENCE VARIABLES Table C.l SUMMATED SCALES SUMMARY
AVG Number of CONCEPTS & FACTOR POSSIB. STAND ALPHA INTER-ITEM EIGEN Items VALID VAR4 NAME COMPONENTS LOADING MEAN RANGE DEVW RELIAB. CORREL.N CASES Mln. Max.
DEPENDENT VARIABLE FIDTRUST Fiduciary Trust Q4.2a concha Q4.2b conabgov Q4.2~consma
INDEPENDENT VARIABLES GLOTRUST Global Trust Q2.2a trusted 02.242 helpful 02.2d look2 02.20 lake2 Q2.2f befalr
OPTIMISM General Opllmlsrn Q2.3b falrchl2 02.3 lotwors2
POLICYN Pollllcal Cynicism Q23a servpub2 (323-1polhalk (32.3) nolinter
GfNCYN General Cynlclsm Q2.3~pretcare Q2.3e mostlie Q2.31 honesty Table C.l cont. SUMMATED SCALES SUMMARY
AVG Number of CONCEPTS 8 FACTOR PoSSIB. STAND ALPHA INTER-ITEM VALUEElGEN llems VALID NAME COMPONENTS LOADING MEAN RANGE DEV'N RELIAB. CORREL.N CASES Min. Max.
INDEPENDENT VARIABLES POLEFF Polllical Efficacy Q2.3d policom2 Q2.3k fewpow2
IHLC Internal Heallh Locusol Control 3.356 1 lo 5 .751 .52 .26 1.607 3 3 457 Q4.6a Icontrol ,668 Q4.61 iavold ,659 Q4.6n ipower ,756
PHLC Powerful Olhers Externalily 2.865 1 to 5 .891 .60 .34 1.676 3 3 4 26 Q4.0~bestway ,795 Q4.61 maintain 579 Q4.8d olhrcara ,765
CHLC Chance Heallh Locus of Control 2.099 1 lo 5 .853 .62 .36 1.737 3 3 467 Q4.6f Luck .736 Q4.6~prevenl .816 Q4.6k fortune .773
MEDINFO Ttuslworthlness Medlcal Sources 3.795 1 to 5 .729 .79 .57 2.219 3 3 305 Q6.5a lnlofdoc .876 Q6.5b bnfogdoc .900 Q6.5c infonurs .770
GOVJNFO Trusiworthlness Governmonl Sources 2.66 1105 .923 .85 .66 2.324 3 3 400 Q6.5d intocrha ,792 Q6.5~lnfohllh .946 (36.51 inlokln .806 SPSS SYNTAX FOR CREDIBILITY compute blvmid = 0. if (blvmost = 1 and blvleast = 2) blvmid = 3. if (blvmost = 1 and blvleast = 3) blvmid = 2. if (blvmost = 2 and blvleast = 1) blvmid = 3. if (blvmost = 2 and blvleast = 3) blvmid = 1. if (blvrnost = 3 and blvleast = 1) blvmid = 2. if (blvmost = 3 and blvleast = 2) blvmid = 1. recode blvmid (sysmis=O). recode blvmost (sysmis=O). recode blvleast (sysmis=O). compute credabh = 0. compute credcrha = 0. compute creddrs = 0. if (btvmost = 1 and blvmid = 2 and blvleast = 3) credabh = 3. if (blvmost = 1 and blvmid = 2 and blvleast = 3) credcrha = 2. if (blvmost = 1 and blvmid = 2 and blvleast = 3) creddrs = 1. if (blvmost = 1 and blvmid = 3 and blvleast = 2) credabh = 3. if (blvmost = 1 and blvmid = 3 and blvleast = 2) credcrha = 1. if (blvmost = 1 and blvmid = 3 and blvleast = 2) creddrs = 2. if (blvmost = 2 and blvmid = 1 and blvleast = 3) credabh = 2. if (blvmost = 2 and blvmid = 1 and blvleast = 3) credcrha = 3. if (blvmost = 2 and blvmid = 1 and blvleast = 3) creddrs = 1. if (blvmost = 2 and blvmid = 3 and blvleast = 1) credabh = 1. if (blvmost = 2 and blvmid = 3 and blvleast = 1) credcrha = 3. if (blvmost = 2 and blvmid = 3 and blvleast = 1) creddrs = 2. if (blvmost = 3 and blvmid = 1 and blvleast = 2) credabh = 2. if (blvmost = 3 and blvmid = 1 and blvleast = 2) credcrha = 1. if (blvmost = 3 and blvmid = 1 and blvleast = 2) creddrs = 3. if (blvmost = 3 and blvmid = 2 and blvleast = 1) credabh = 1. if (blvmost = 3 and blvmid = 2 and blvleast = 1) credcrha = 2. if (blvmost = 3 and blvmid = 2 and blvleast = 1) creddrs = 3. if (blvmost = 1 and blvmid = 0 and blvleast = 0) credabh = 3. if (blvmost = 2 and blvmid = 0 and blvleast = 0) credcrha = 3. if (blvmost = 3 and blvmid = 0 and blvleast = 0) creddrs = 3. if (blvmost = 0 and blvmid = 0 and blvleast = 1) credabh = 1. if (blvmost = 0 and blvmid = 0 and blvleast = 2) credcrha = 1. if (blvmost = 0 and blvmid = 0 and blvleast = 3) creddrs = 1. recode credabh (0 = sysmis). recode credcrha (0 = sysmis). recode creddrs (0 = sysmis). recode blvmost (0 = sysmis). recode blvmid (0 = sysmis). recode blvleast (0 = sysmis). execute. SPSS SYNTAX FOR ACCESSIBILITY VALUE CONGRUENCE - CRHA compute equall = 0. if (eqyou - eqcrha = 0) equal1 = 4. if (eqyou - eqcrha = I)equal1 = 3. if (eqyou - eqcrha = 2) equal1 = 2. if (eqyou - eqcrha > 2) equall = 1. if (eqyou = 4 and eqcrha = 5)equall = 3. if (eqyou = 3 and eqcrha = 5) equall = 2. if (eqyou = 3 and eqcrha = 4) equall = 3. if (eqyou = 2 and eqcrha = 5) equal 1 = 1. if (eqyou = 2 and eqcrha = 4) equall = 2. if (eqyou = 2 and eqcrha = 3) equal1 = 3. if (eqyou = 1 and eqcrha = 5)equall = 1. if (eqyou = 1 and eqcrha = 4) equall = 1. if (eqyou = 1 and eqcrha = 3) equall = 2. if (eqyou = 1 and eqcrha = 2) equall = 3. recode equal 1 (O=s ysmis) (else=co py ). execute. APPENDIX D
DATA ANALYSIS TABLES Table 0.1 95% Confidence Intervals for Means of Selected Variables 95% Confidence Table Variable Variable Label Mean 1 I I Interval Police conpolic 3.76 3.69 - 3.82 5.1 Cdn banks conbanks 3.36 ' 3.28 - 3.44 Confidence in ... ' AB medical system canrned 324 3.16 - 3.31 Supreme Court i concourt 3.19 3.10 - 3.28 ' A8 public schools conschls 3.05 2.97 - 3.1 3 Large corporations concorp , 2.83 2.75 - 2.91 Labour unions canunion 1 2.29 2.20 - 2.38
R's family doctor 1 tfamdbc I 4.03 3.93 - 4.12 5.3 Hospital nurses ! tnurse 3.76 3.66 - 3.85 Trust in input ... Other doctors I tgendoc 3.58 3.50 - 3.67 United Nurses Assoc. ) tuna 3.25 3.15 - 3.35 Medical labs j bnedlab 3.15 3.05 - 3.24 Alberta Medical Assoc. I tama 1 3.13 3.03 - 3.23 Chiropractors 1 tchiro 2.84 2.72 - 2.96 / Hospital administrator 1 thspadmn 2.84 1 2.73 - 2.95 I RHA administrator I trha 2.76 ) 2.65 -2.86 ! A citizen j tcitizen 2.72 2.62 - 2.83 j Alt. health provider 1 tacupun 1 2.63 2.52 - 2.74 I Premier Klein i tklein i 2.62 1 2.50 - 2.74 / Alberta Health i tgovhlth 2.57 1 2.47 - 2.68 I Private hospitals ] tprvhosp 2.32 2.21 - 2.42
/ Own direct experience 1 sownexp 4.06 3.96-4.16 5.9 / R's family doctor 1 sfamdoc --3.58 3.46 - 3.69 Importance of / Frienddfamily who are sfamhlth 3.41 Source of Info 1 health care workers 3.28 - 3.9 about the Health 1 Fnenddfamily who are I SfilmnOt 3.41 3.30 - 3.53 Care System .-• not health care wo~kwsI Other medical doctors sgendoc 3.04 2.92 - 3.15 Local TV news shews j 2.82 1 2.71 -2.92 / Local newspapers snewspap 2.80 1 2.70 -2.91
5.1 0 1 AB Medical Assoc. conama 1 2.94 2.88 -3.01 Fiduciary trust 1 CRHA concrha 2.71 1 2.64 - 2.78 in ... j Alberta Gov. conabgav f 2.47 1 2.40 -2.55
5.1 1 ] amacomp 3.04 2.94 - 3.14 Confidence in competence ... / unsmmp 3.02 2.93 -3.12 Table D.l cont 95% Confidence Intervals for Means of Selected Variables Table Variable Variable Label I Mean 95% Confidence I I lntenfal i Calgary doctors I ueddrs 2.50 2.43 2.58 5.12 - I CRHA / aedcrha 2.01 1.95 2.09 Credibility of ... I AlbeM - . I 1 credabh I 1.57 1 1.50-1.65
5.1 6 How important 4 i &&a i 3.83 i 3-72 -3.93 are the I Klein ( eqklein 1 3.27 1 3.13 - 3.40 following 1 Efficiencv-. - - . . - I I ! values to ... You i effyou 1 4.72 1 4.66 -4.77 1 I CRHA ) effcrha / 4.05 1 3.95-4.15 Klein ( effklein 1 3.89 1 3.76 - 4.01 ! Public Admin. I I , YOU I pubyou 1 4.38 ( 4.29 - 4.46 I CRHA / pubcrha 1 3.92 / 3.81 -4.04 I Klein \ pubklein 1 3.39 3.24 - 3.54 I Speedy Access I I I I YOU I,.. SO~VOU ! 4.82 1 4.77 - 4.86 I CRHA ! sodcrha I 3.93 i 3.02 - 4.04 1 Klein 1 spdklein 1 3.50 / 3.36 - 3.63 / Privatization I I I YOU I PWOU 3.00 2.86 - 3.15 1 CRHA I prvcrha 3.01 2.87 - 3.4 5 I Klein I orvklein I 3.63 i 3.49 - 3.77
: Accessibility i 5.1 7 CRHA i equal1 2.96 2.87 - 3.06 Value I Klein I equal2 2.54 2.43 - 2.67 congruence / €fficiency I i 1 CRHA 1 effl 3.21 3.12 - 3.30 I ! Klein i eff2 3.04 2.94 - 3.1 5 I Public Admin. 1 T CRHA public1 3.14 3.05 -3.24 I I 1 Klein I wblic2 1 2.74 1 2.62 - 2.87 I Speedy Access 1 I i I ! CRHA I speedy1 3.05 2.96 - 3.1 6 I Klein 1 soeedv2 2.68 1 2.57 - 2.80 j Privatization i ! CRHA / private1 2.91 1 2.80 -3.03 I Klein 1 ohate2 2.73 1 2.60 -2.86 2 10
LIST OF VARIABLES USED IN MULTIPLE REGRESSION ANALYSES
DEPENDENT VARIABLES
Q2.lf CONMED Confidence in the Alberta medical system. (24.2' FIDTRUST Fiduciary trust in the heaith policly community [scale]. Q4.6j UNACOMP Confidence in the competence of United Nurses of Alberta. Q4.1 c TNURSE Trust in a hospital nurse's input to decisions on changing the health care system, Q4.le TACUPUN Trust in an akemative health care providets input to decisions on changing the health care system. (24.1 i TKLEIN Trust in Premier Ktein's input to decisions on changing the health care system.
INDEPENDENT VARIABLES
Q1.2 AGE Age of respondent in years. (27.2 EDLEVEL Highest level of education completed. (23.3 CHRONIC Chronic health problem (Yes=l , No=O). (23.8 HLTHSTAT Respondent's self-rated health status. Q2.2"GLOTRUST Global trust (generalized trust in others) [scale]. Q2.3"OPTIMISM Optimism [scale]. (23.6 EXPFIVE Optimism (specific to future quality of health services). Q2.3"POLICYN Political cynicism [scale]. Q2.3"GENCYN General cynicism [scale]. (27.3 DPC Progressive Conservative affiliation - dummycoded (0,l). Q7.3 DNDP New Democratic party affiliation - dummy-coded (0,l). (27.3 DOTH Other political category - dummy-coded (0,l). Q2.3"POLEFF Political efficacy [scale]. Q4.6"IHLC Internal health locus of control [scale]. Q4.6"PHLC Powerful others externality [scale]. Q4.6"CHLC Chance health locus of control [scale]. Q3.2"VIS ITS Total number of visits to health care providers [scale/. (23.4 QUALCARE Quality of health care received over past 12 months. Q6.1 AUPAPER Attention to health care issues in the local newspaper. Q6.2 AlTV Attention to health care issues on television. (26.3 MEDDRAMA Exposure to medical television dramas. Q6.4 REALLIFE Exposure to real-life medical television programmes. Q4.6p DOCWORK Perceived wotkfoad of Calgary doctors. Q5.la EQUAL17* Value congruence with CRHA on value of accessibility. Q5.la EQUAL2" Value congruence with KIein on value of accessibility. Q5.1b EFF1" Value congruence with CRHA on value of efficiency. Q5.l b EFFT7 Value congnlence with KIein on value of efficiency. Q6.5"MEDINFO Trustworthiness of medical sources of information about the health care system [scale]. Q6.S7GOV1NF0 Trustworthiness of government sources of information about the health care system [scale]. Q6.5g INFONEWS Trustworthiness of newspaper sources of information about the health care system.
see 'Operationalization of the Dependent Variables' section for scale items. " see 'Operationalization of the Independent Variables' section for scale items. Table D.2 Zero-order Correlations, Means, and Standard Deviations for Determlnants of Confidence in the Alberta Medical System, Fiduciary Trust in the Health Policy Community and Confidence in the Competence of the United Nurses of Alberta
14 1. CONMED - 2. AGE 3. EDLEVEL 4. CHRONIC 5. HLTHSTAT 6. GLOTRLIST 7. OPTIMISM 8. EXPFIVE 0. POLICYN 10. GENCYN 11. DPC 12. DNDP 13. WTH 14. POLEFF 1.o 15. IHLC ill 16. PHLC -p 17. CHLC -,ae 18. VISITS -jlA 19. OUALCARE 20. ATTPAPER if! 21. Am .05 22. MEDDRAMA -'I7 23. REALLIFE -/in 24. WCWORK .03 25. EQUALl .07 26. EQUAL2 .07 27. EFFI .07 28. EFF2 ;I4 20. MEDlNFO .oo 30. GOVJNFO 90 31. INFONEWS -.01 32. FIDTRUST \w 33. UNACOMP -;?a Mlnlmwn 11810111111000111111111 1 Maulmum 585515553551 115555555555 MEAN 3.2 43 3.2 .32 36 3.3 33 1.7 3.7 3.0 .48 -06 -24 2.8 3.4 2.9 2.1 6.7 3.7 3.4 3.5 2.6 2.8 N 487 460 485 450 488 488 420 433 453 449 431 439 431 483 457 426 467 486 445 484 483 488 488 Note: Standard deviations on Ihe diagonal. Shaded coefficients are stalislically slgnllicant a! Iha .05 leval (one-lailod). Table D.2 cont. Zero-order Correlations, Means, and Standard Deviations for Determinants of Confidence In the Alberta Medical System, Fiduciary Trust in the Health Policy Community and Confidence in the Competence of the United Nurses of Alberta
24 25 26 27 28 29 30 31 32 33 24. DOCWORK 1.2 25. EQUAL1 28. EQUAL2 27. EFF1 28. EFF2 29. MEOINFO 30. GOVINFO 31, INFQNEWS 32. FIDTRUST 33. UNACOMP
Mlnlmum 111011111 1 Maximum 5551555355 MEAN 3.6 2.1) 2.5 3.2 3.0 3.8 2.7 3.1 2.7 3.2 N 405 417 418 420 420 395 400 451 452 434 Nota: Standard deviations on the diagonal. Shaded coefficients ara slatislically significanl at Ute .05 level (one-tailed). Table 0.3 Zerosrder Correlations, Means and Standard Deviations of Determinants of Trust in Nurses, Altemative Health Care Providers, and Premier Klein ~ Tmst in Hospital Trust in Alternative Trust in Premier Nurses' Input Health Providers' Klein's Input lnput Variable TNURSE TACUPUN TKLEIN AGE .051 -.I 86- .050 EDLEVEL .085' -071 .057 CHRONIC .069 -.085 -004 HLTHSTAT .I55 .075 -.023 GLOTRUST -311 " .274" -025 OPTIMISM .090° -.054 .159" GENCYN -.185* .006 -.072 IHLC .155- .305" .068 PHLC .124" -.096' .034 CHLC -224" -.203" -.175" VISITS -089' .082' -.030 QUALCARE .222- ,076 .245- ATTPAPER .018 -.030 ,032 ATm/ -.Illw -.025 .039 MEDDRAMA -.020 -.ON -.122" REALLIFE --029 -.081 -.079* POLEFF - - ,243" POLICYN - - -.1W DPC - - ,518" DNDP - - -.264- DOTH - - -.179" EQUAL2 - - .572" EFF2 - - -516-
Mean 3.76 2.63 2.62 Standard Deviation 1.03 1.05 1.31 N 456 351 46 1 ' p c .05;" p c .Ol (one-tailed). Table 0.4 Addiiional Zero41 ler Correlations for Hypothesis Testing (Table 6.1) Confidence in Flduclary Trust Competence Hospltal Alternative Premier Independent Medlcal System In the Policy of UNA Nurse's Provider's Kleln's Variables Community Input input Input Var Labels (CONMED) (FIDTRUST) (UNACOMP) (TNURSE) (TACUPUN) I (TKCEIN) 1 Gender dfemale ---.019 --- .011 .139" 150" -.105' income .067 - .027 -.004 - -.034 ------.097' -- difprov - -.033 -.107' .073 .057 -.030 -.047 Workload of nurses nurswork -.119"
- Public admin - CRHA -- public1 ,233" - Public admin - Klein public2 .255** -speedy access - CRHA - 2eedy .349" Speedy access - Klein speedy2 ,422" Prlvatlzalion - CRHA private1 .log' Privallzatton - Klein private2 .255'" Privatlzat~on allowpay ' p < .05; ** p c .0l (one-lailec ). APPENDIX E
QUESTIONNAIRE AND COVER LETTERS Department of Sociology
Telephone: (403)220-6501 Fax: (103)282-9298
October 1 5, 1999
YOUR NOTIFICATION OF THE UPCOMING UNIVERSITY OF CALGARY HEALTH CARE SYSTEM SURVEY
Dear Health Care Survey Participant,
Your household is one of 1000 households in Calgary that have been randomly selected to participate in an important survey that focuses on Calgarians' confidence In Alberta's health care system and on Calgarians' opinions about that system.
In a few days you will receive the questionnaire in the mail. I would be most grateful if the person in your household who is over age 18 years and has the next birthdav after October 20, would take the time to fill it out. Hisjher participation will help ensure the success of this survey.
I thank you in advance for your assistance with this, my MA. thesis research project.
Sincerely,
Susan Kehoe Graduate Student (403) 220-6501
2500 University Drive N.W., Calgary, Alberta, Canada T2N 1N4 a www,ucalgary.ca ITY OF ARY I IS FACULTY OF SOCIAL SCIENCES Department of Sociology
Telephone: (103) 220-6501 Fax: (403) 282-9298 November I. 1999 Dear Health Care System Survey PartIapant,
The Alberta health care system is undergoing many significant changes and these changes affect all of us. Ifeel that it is important that we listen to what Calgarians have to say about that system. This survey givs your household the opportunity to have your voice heard. Iwould be grateful if the appropriate p-son (identified Mow) from your household would be so krnd as to share those views with me.
This research is part of my Master of Arts thesis which focuses on Calgarians' confidence in Alberta's health care system and op~nionsabout that system. My expectation for this study IS that the lnformabon gathered here will help researchers, health policy makers and health care professionals to understand better Calgarians' views of the health care system.
As mentioned in my prevlous let&, your household is one of 1000 households in Calgary that has been randomly sdwed to partiapate in thls study. Parbcipation in this study IS voluntary. Among the adult members of your household who are age 18 years or over, thls quesbonna~reshould be completed by the person who has lfie next biiffida~.Thls quemonnaire should take appm~imately25 minutes to complete and most quesbons can be answered with check marks or by arcling the appropriate response. You are lnvlted to add any comments on the last page.
Th~sproject has been approved by the appropr~ateUniversity of Calgary ethics review comm~ttee. The number on the last page of your questionnaire serves only to prweit sending a second qumonna~reto persons who complete and return the first one. Your lndivldual answers will be kept confidential and used only in combination witfi the answers of other partrapants. By compl&ng and return~ngthis questionnaire, you are ~ndicabngyour consent to partiapate in this study.
Please return the completed questtonnaire at your earliest convenience in the addressed, stamped, return envelope provided. IF you are interested in receiving a summary of the findings of this research, please indicate that on the last page of the queshonnaire. If you have any questrons about partidpation in this study you may ather contact me or the Chair of the Ethics Committee, Department of Soaology at 220- 6501. Thank you in advance for your partiapation,
Sincerely yours,
Susan Kshoe Graduate student (403) 220-6501
2500 University Drive N.W., Calgary, Alberta, Canada T2N 1 N4 www.ucalgary.ca FACULTY OF SOCIAL SCtENCES Department of Sociology
Telephone: c403) 120-6501 Fax: (1031 282-9298
Dear Health Care System Survey Participant,
About two weeks ago a questionnaire asking for your views about Alberta's health care system was mailed to you.
If you have completed the questionnaire already please accept my sincere thanks. In doing so you, along with other partiupants in this survey, are making a significant contribution to the understanding of Calgarians' confidence in Alberta's health care system.
If you have not yet had a chance to complete the questionnaire, Iwould be most grateful if you would do so now. As Isent out only a limited number of quesbonnaires, your answers are very important to the accuracy of this survey.
If by some chance you did not receive the questionnaire or have mislaid it, please call 220-6501 and Ill send you another questionnaire today. Please note this is an independent thesis research project and is being funded by myself, by a research grant from the University of Calgary and by the generous donation of a fellow social scientist.
SincereIy yours,
Susan Kehoe Graduate student (403) 220-6501
P.S. Even if you have not been a frequent user of health services lately, you still have perceptions about the health care system that are important to this study. If you could complete the questionnaire and return it to me at your earliest convenience, Iwould be most grateful.
2500 University Drive N.W., Calgary, Alberta, Canada T2N IN4 www.ucalgary.ca 220
FACULTY OF SOCIAL SCIENCES Department of Sociology
Telephone: (403) 220-6501 Fax: (403)282-9298
December 9. 1999 Dear Health Care System Survey Participant,
A few weeks ago I wrote to you seeking your views about Alberta's health care system, To date a number of Calgarians have been kind enough to help me with this important project. Participants in this study will be making a significant contribution to the understanding of Calgarians' confidence in Alberta's health care system and views about that system. If you have already completed the questionna~replease accept my heartfelt "thanks".
In case you were away or too busy to complete the questionnaire, Iwould be most grateful if you would do so now. As 1 sent out only a limited number of questionnaires, your answers are very important to the accuracy of this survey. Even if you have not been a frequent user of health services lately, you still have views about the health care system that are valuable to this study. Your completed and returned questionnaire is important.
Please note this is an independent thesis research project and is being funded by myself, by a research grant From the University of Calgary and by the generous donation of a feilow social scientist. If you have any questions about participation in this study you may either contact me or the Chair of the Ethics Committee, Department of Sociology at 220-6501. Many thanks for your participation in this study which I am doing for my M.A. degree thesis.
Sincerely yours,
Susan Kehoe Graduate student (403) 220-650 1
P.S. Ifyou feel that some questions do not apply to you, please answer only those which do, I need your questionnaire even if not completely filled out. Ifyou could complete the endosed questionnaire and return it to me at your earliest convenience, Iwould be most grateful.
2500 University Drive N.W., Calgary, Alberta, Canada T2N 1 N4 m www.ucalgary.ca $p;..w '6&$3 UNIVERSITY OF CALGARY HEALTH CARE SYSTEM SURVEY
--- THESE FOUR QUmONS ARE NECESSARY IN HELPING DETERMINE THAT I HAVE A GOOD CROSS-SECTION OF PEOPLE FROM YOUR HEALTH REG..CN.
2. How long have you lived in Alberta?
Less than 1year [ 11 6 to 10 years [ 13 16 to 20 years [ 15 1 to 5 years [ 12 11 to 15 years [ 14 More than 20 years [ 16 2. In what YEAR were you born? (e.g., m)
3, Are you,,,? Male [ lo Female []I
4. What is today's date? (manth/day/year)
1. In general, how much confidence do have in the following Canadian institutions.
None Very Some A great Complete Don't at all little confidence deal confidence know a. The police ...... [I1 112 [I3 [I4 [Is [ 18 b. Canadian banks ...... [I1 [I2 [I3 114 [Is [ la c. Alberta public schools ...... [I1 [I2 [I3 [I4 [Is [ 18 d. The Supreme Court of Canada ...... 111 [I2 [I3 114 [I5 [ 18 e. Large corporations ...... [I1 [I2 [I3 [I4 [Is [ 18 f. The Alberta medical system ...... [I1 [I2 [I3 [I4 [Is [ 18 g. Labour unions ...... [I1 [I2 [I3 [I4 115 [ 18
2. Please use the following 5-point scale to indicate how much you AGREE or DISAGREE with the following general statements. The higher the number the more you AGREE. Completely Completely Don't disagree agree know 12345 a.Mostpeopleanbetrusted ...... [I [I [I [I [I [] b. You can't be too careful in dealing with people ...... [I [I [I [I [I [I c. People try to be helpful most of the time ...... [I [I [I [I [I [I d. People are mostiy just looking out for themselves ...... [I [I [I [I [I [I e. Most people would tF/ to take advantage of you if they got the chance ...... 11 [I [I [I [I [I f. Most people tty to be fair ...... [I [I [I [I [I [I 3. How much do you AGREE or DISAGREE witti the following statements. The higher the number the more you AGREE. Completely Completely Don't disagree agree know a. Mostsd-senenthffiaaaa6 by 6-me 6&-pU--e-m-erd~It s12345 4:;4,.i:- - - %-y.&*,-. against their*owliperionat integ&.':r: *r-i-:.~5-~,-~-~L"t"t-=-:-[3..[~~E J- LK f ] [ 1 b. It is hardly fair to bring a child into the world with the way things look for the future. [I [I-[] [I [I [I c- People pretend.to ca& more abbut one anotkwthe&al~ do. [ 1 [ ] [ 1 d. Sometimes politics and government seem so complicated that a prsan like me can't really underand what's going on. *. -? - - C1 [I El [I [I [I e. ~ostpeaplewou~ tell i Ii&-itr_~&uklgairc'&k ,. ._:;. :: - . [ ] [ ] f. The lot of the average person is getting worse. [I [I [I [I [I [I g. voting is the oniy way thatpeoplelike rni~~6~iGSa~ahut. - - . r. ---, ,- i' howthegovemmentmns.~ingr.'~~:-,';_ -*7 -A .'-TEELU[] L] [I h. Most politiaans will do a lot of talking but they do little to solve the really important issues facing the country. [I [I [I [I [I [I i. People daim that they have ethiiisfiidards regrang hen*, but few people stick to them when the chipi are down, - UCIC1tiCI 11 j. Most public offiaals are not really interested in the problems of the average atizen. [I [I [I [I [I [I k This province is run by a few people in power and there b not much that people like me can about itc . Ll El [I I1L1 [ 1
1. Is there a family doctor that you go to mularly when you have medical problems? Yes [ 11 (IF YES, GO TO 2a) No [ 30 (IF NO, GO TO 2b) 2. Here is a list of some health care services people might use. Thinking back over aunroximatelv the last 12 months how many times have YO1J used each of the following health services? Please CIRCLE your response for item.
* -- . . - - - . -c-"NONE ,- - - ONE- TWO 3 or MORE ' " *. I-. . a. your family do&.- :-- rL 2%" 2- L -L L :------>---2!!k: & 1 2 >:z--- - L.3 b. Walk-in clinic where you were seen by a doctor. 0 1 2 3 c -~~ihe&aido&~r&ch as, a nG5bgi&di&ijirst; + -
.. psuttr'aw Otdiolt&~t ~~~phthafm~@Jist,~1 -:" >-'O!._ -1- -a- 2 * rA3 d. An eye exam by an optometrist 0 I 2 3 a -~~aftydinesuch as, diaet~n&r-OF *fat&-- .I"' z-@+l-:l-A:-- 2 - --I> f, Lab work, blood tests, X-rays_- (NOT-+- dental). 2 3 . -** -- 0 1 - - -, -- :=-- g. Physiotherapy. -. .- &-A. - --. t - I - 0 --- -1 -.z----;3 A chiropractor. 0 1 2 3 Art alternative health care providerCsu& akiaKSpunctu-& * * ,*- .&=- -:---2 ,. . pr a naturopath- --_ - - +-- - - :A ,-..- &A -- :L-:.0 --- 1.- -2 :--3 Hospital care where you were admitted to stay overnight. 0 1 2 3 Hospital emergency room treatment. vhthot&.. ovenifght admtision. - ._ . O 1 2 .- 3 I. Other hospital out-patient care. 0 1 2 3 m. Care by a nurse outside of a hospi€at, dinic or doctor's office. 0 ' 1 & - _ 3 n. Other medical or nursing home care services. 0 1 2 3
IFYOU HAVE ANSWERED 'NONE'TO &OF THE ABOVE ITEMS PLEASE GO TO QUEsnON 5. OTHERWISE, CONTINUE WrlW QUESnON 3.
3. Do you have a chronic health problem that requires regular health services? Yes []I No[]o
4. Overall, how would you rate the gualiw of health care received in Albem during approximately the last 12 months? Excellent [ IS Highly variable in quality [ 13 Poor []I ~aad [14 Fair [ 12 Does not apply to me [ ]a
5. How confident are you that publidy funded health can services cumntlv available in Calgav are generally of aood aualityl
Not at all [ ]L Somewhat [I2 Very [I3 Don't know [ 18
6, Five vears from now, do you ex- the auali& of publidy funded health care services in Calgary to be BElTER, WORSE, or ABOUT THE SAME?
Better [ 13 About the same [ 12 Worse [ 11 Don't know [ Je 7. Overall, how satisfied are you with the lenrrtkof- vou had to wait for each of the following services in the past 12 months. Check ONE response per ikm. Very Somewhat Neither Somewhat Very Does not dissatisfied dissaMed satisfied nor satisfied satisfied apply dissaMed to me a. An appointment to see a family doctor [ 11 [ 12 13 [Is (15 [ 18 6. An appointment to see a medical specialist [11 [ 12 [ P [ I4 [1s [ 18 c. An elective surgical procedure [ 11 I 12 [ 13 [ 14 [1s I 18 d. Hospital emergency room care [ ]I [ 12 l 13 [ 34 [ 15 [ 18 e. Tests at a walk-in medical taboratov [ 11 [ 12 [ P [ 14 [ 1s C 18
8. In general, for a person your age, is your health: Excellent [ 1s Fair [ 12 DonZ know [ 18 very C 14 Poor I 11 Good [ 13
1. How much would you trust each of the following when it comes to fheir in~utto decisions on chanaino the health care svstem? Use the following 5-point scale where the higher number shows greater trust,
DSiS Trust Don't a lot a bt know a. your family-dxkr (or, if none, df&~@&&rfmm;-tuhom 12345 youEwvereceiwdserviaesinthetastllmonths~.- - _l:F7Tlc [E'[Icfi [I [] b. Other doctors in general. ------7- - 7.- [IJI _[I -[I CI [I CA haspitat nu= _ - - A-m.. 2- - - 1 1:-1 1 [I d. A chiropractor. [I [I [I [I 11 [I e. hahativehea~~-pdck&-as aii aiqmhikr- pGEI'Cl ELCLEI [I f. A senior administrator at a hospital. ------.-- [I [I [I_ 11-11 [I g. A senior adminisbat&bf 6-qign&~~mth@yL~F~:ii-5~fJ-''[I:[ 1 3 f* :C] [ ] h. The provinaal government.- -- health department. - '------,LT---.--r -. ..-* 1 . .. CI [I-[I [I-I1 [I i. Premier Ralph Kleirt,-" -. %-- __ . - . - -3.[ [ ] j. A citizen chosen at mndom. I--@$ - 7 - --"..--r--- - ?-$:%%<: r- - tF- [IJI [I +[I-[I [I -*: , k-wk2 11 ._- t,- -::EL[I I. Medical laboratories. CI [I [I [I I1 [I rn.TheAberta'M&i~~& 3. How important has each of the following been in bha~inavour views on the overall aualitv of health ca~Albertans now receive? Not at all Very Don't important important know a. Your family doctor (or, if none, a Family doctor from whom 1 2 3 4 5 8 you have received services in the last 12 months)...... [ 11 [ 12 [13 [ 14 [ 1s [ 10 b. Other medical doctors...... [ 11 [ 12 [ 13 [ 14 [ 1s [ 1s c. Experience of family or friends who are health care workers.. [ 11 [ 12 [ 13 [ 14 [ 1s [ 18 d. Experience of family or friends who are not health care workers ...... 111 [I2 [I3 [I4 [Is [Is e. Your own direct experience, other than any of the above ...... [ ]I [ 12 [ 13 [ 14 [ 1s [ ]a f. A local daily newspaper...... [IL112 [P [14 [IS 118 g. A lccal TV news program...... [11 112 [13 [B [IS 118 h. Other (PLEASE SPECIFY) 4a. LeYr pretend that there is a dispute between the Alberta government's Department of Health, the Calgary Regional Health Authority (CRHA), and Calgary doctors over the proper use of health care funds in Calgary. All three are saying know what is best for Calaarians. Which of the three would you say you are most likely to believe? Choose ONE. Alberta Health [ It the CRHA [I2 Calgary doctors [ 13 Don't know [ Is 4b. Which of the three would you say you are least likely to believe? Choose ONE. Alberta Health [ 11 the CRHA [ 12 Calgary dodors [ 13 Don't know []a 5. How much confidence do you have that the Calgary Regional Health Authority the resources n-ru to del'ier aualihr health care sewi-3 None at Very liie Some A great deal Don't all confidence confidence confidence know [ 11 [ 12 [ 13 I14 118 6. Please use the following 5-point scale to indicate how mu& you AGREE or DISAGREE with the following general statements. Campletely Completely Don't disagree agree know I.--..-" * r. -. - w. - . - -- 12345 a. f am in-1 of my health-- - 2 :-;-.2; .-" :- ;-.-;-s :.,, -- ,- ,: - WEE EkLH1 b. Compared to S years ago I am now more confident that the Hm*nghealth care systemcok&-& will take* goodphg-&r&riw care of me when Ineed foE,-& it [I [I [111[1 - -.- * L. .-- --:*& - " :-., $k%3 avoid health problems, .- - - - -:. kLuA,- --;-y;S:i~-3--- =-~-"$b~$'~f[3't;i d. -The type of care I receive from other people is what is responsible for haw well Irecover from an illness. 11 [I [1[111 e. PeophshouldkaII&edbpaybgetqui:ckera=tiifi&mi , - - - . 5 .:s - -# -.c--% GUe&CeS. - -': - * - - , ,--. .-?= .---. - - '?EF~~,-L~L~~l F. Luck plays a big part in determining how soon Iwill recover from an illness. [I [I [lCI[l g, Often 1feet that there is really nothing E on do: :to p&it -- . --.I-_ gem-ng sick. - . - .- -- --XL -.- - - -I CJ-c-fEllIfl h. Although the Albetta Medical Association is responsible for looking out for the needs of physicians, Ibelieve they put the needs of patients first. [I [I []I][] i. If I take care of niyself, 1can avoid iliness. CT El IlhlEI j. Ibelieve that the United Nurses of Alberta unionlknows what is needed in the health care system of the future. ------. -- [I [I [lCI[l k. ~~~aodhealthbtargelyainatter*ofg~fbrtu*_- -'-2 -_:CL[:I LICILI 1. Ican only maintain my health by consulting health professionals. [ ] [ ] [ ] [ ] [ ] m, Althgh the Alberta MedkalAscn5atblt memmembeiSbeiSa~hrghfy'$dired doctors they are not qualii'tareorganize:tFieAlbertaF heal^ care -. "- -' a''' -0 - - --,- ,,:LTLL€TE1LI n. If 1 become sid, Ihave the power to make myseif- -- well again.- - [I [I [][I[] o. Nurses in the Calgary are wenkrked. - r -,: region '- - - .---rm CILXI p. Doctors in the Calgary region are overworked. [I [I [][Ill MIS SECITON IS ABOUT VALUES THAT SOME PEOPLE HAVE REGARDING MEHEALTH CARE SY!TEM. 1. There are a number of values that can define our health care system. Please rate how imoortant each of the following should be in bhanina the health ramm. Not at all Very Don't important important know L 2345 8 a. That all Albertans have equal access to quality health ore. HOW IMPORTANT IS m...... to you? r I1 I12 [ I3 E I4 115 [ 18 ... to the CRHA? C 11 [ 12 [ 13 114 [ 15 [ 18 ... to Premier Ralph Klein? 111 [Mb 114 115 [I8 b. That the health care system is run efficiently. ... to you? [ 11 [ 12 1 13 [ 14 [ 15 18 ... to the CRHA? []I [I2 [ 13 [I4 [Is [ 18 ... to Premier Ralph Klein? [I: [P[P [I4 [Is [Is c. That the health care system is publidy funded. ... to you? [11 [I~[P~14 [IS 110 ... to the CRHA? [ll [32[~[14[1s 118 ... to Premier Ralph KIein? [11 [12 [13 [ 14 CIS 118 d. That Albertans have speedy access to health services. ... to you? [ 11 [ 12 [ I3 [ 14 [ Is [ I8 ... to the CRHA? [ 11 E 12 [ 13 [ 14 [ 15 [ 18 ... to Premier Ralph Klein? CI~[12[13[14[15 [IS e. That privately provided health care services be available to Albertans. ... to YOU? C 11 C 12 [ I3 [ I4 I Is [ 18 .. . lo the CRHA? [ 11 I12 [ 13 [ 14 [ 15 I 18 ... to Premier RaIph Klein? []I [I2[13 [I4 (15 El8 SYSTEM. 1. How much attention do you pay b news about health care issue ... None Very little Some A fair amount A great deal a. in your local newspaper? [ 11 112 [ 13 [ 14 [ 15 b. on television? c 11 [ 12 113 [ 14 [ Is 2. When reading your local newsuaner how much attention do you pay to article about national oolitics and aovernment? None Very little Some A fair amount A great deal [I1 [I2 [I3 [ 14 [ 15 3. How often do you watch teleuision medical dramas such as ER or Chicago Horn Never Rarely Sometimes Often Very often r 11 C I2 [ P r 14 [ Is 4. There are some TV programs that take a camera into an actual, real-life emergency mom. How often do you watch this type of programme? Never Rarely Sometimes Often Very often [ 11 [ 12 t 13 [ 14 [ Is 5. How ftustworthy are the following source when it comes to aivina vou aauratp information about the state of health care in Alberta? Not at all very Don? trustworthy trusWorthy know a. Your family doctor (or, if none, a family doctor 1 2 3 4 5 from whom you have received services in the last 12 months). [I [I [I [I [I [I b. Doctors in general. [I [I [I [I [I [I c. Hospital nurses. [I [I [I [I [I [I d. The Calgary Regional Health Authority. [I [I [I [I [I [I e. The Alberta government health minister. [I [I [I 11 [I [I f. Premier Ralph Klein. [I [I [I [I [I [I g. Your local newspaper. [I [I [I [I [I [I MESE FOUR ANAL QUEmONS WILL HELP IN UNDERSTANDING THE DIFFERENT POINTS OF VIEW OF THOSE WHO TOOK PART INTHIS STUDY. 1. Including yourself, how many people NORMALLY live in your household? a. Total number of persons age 18 or over b. Total number of children under 18 years of age 2. What is the highest level of education you have completed? Choose ONE. Less than high school [ 11 Completed college or technical training [ 1s Some high school [ 12 Some university 116 Completed high school [ 13 Completed university [ 17 Some college or technical training [ 14 Other (PLEASE SPECIFY) 3. If a pmvindal election were held today, how would you vote? Liberal [ ]I Progressive Conservative [ 13 NDP []z Other (SPECIFY)4 4. What was the total combined annual income of all persons in your household in 1998 before taxes and deductions? Less than $20,000 [ ]r $80,000 to $99,999 [Is Don't know [ 19 $20,000 to $39,999 [ 32 $loo,ooo to $119,999 [ 16 $40,000 to $59,999 [ 13 $120,000to $139,999 [ 17 $60,000 to $79,999 [ 14 $140,000 or over 118 YOU HAVE REACHED MEEND OF THIS QUESIIONNAIRE. I THANK YOU FOR TAKING THE TIME 10 COMPLETE IT. I PLEASE WRITE ANY COMMENTS ON BACK PAGE, IF DESIRED Health Can Synem Survey (Calgary) November 1999