Fifty Years of Trust Research in Health Care: What Does It Mean for Policymakers?

Emerging Leaders Program Milbank Fellows Program State Health Policy Leadership Health Equity

The literature on trust in health care services is vast and vexing. In a new Milbank Quarterly article, we review 50 years (1970–2020) of this research to inform the health policy and health services research communities about themes, key findings, and methodological gaps. Despite the significant challenges for empirical investigations, efforts to understand trust’s role in health care are of paramount importance.

What are the implications for state and federal health policymakers? First, policy has a direct role in providing guardrails that influence the trustworthiness of health care organizations. Second, public perceptions of the trustworthiness of policymakers affect public trust in the industries that they regulate, indicating a need to strengthen anti-corruption efforts. Finally, policymakers who are in direct communication with the public play a critical role in safeguarding the public’s trust in science and health care.

What do we mean by trust?

Definitions of key terms, including both trust and trustworthiness, vary widely in health services research, making it difficult to integrate findings across papers and generating methodological challenges.

Researchers and scholars have used the term trust is used in at least two ways. Some researchers talk about trust as an attitude, or affect. These researchers consider questions such as “How much do you trust…?” and look for answers that are on a scale between none and a lot. Others talk about trust as a behavior and consequently think about its presence or absence. Trustworthiness is often casually defined as “the quality of being trusted,” but is more precisely the quality of being deserving of trust.

Clarifying trust and trustworthiness may seem a semantic debate – but in fact, allows for important conceptual clarity. For starters, it allows us to recognize the following social reality: some people or institutions are trustworthy but not trusted. Alternatively, people or institutions sometimes enjoy a great deal of trust without being trustworthy. We can only recognize these scenarios as problems deserving of policy and managerial attention by being precise with our language.

The flood of trust measures available to researchers is indicative of the challenges researchers have had capturing these complex topics in survey form. We suggest that drawing on disciplines like sociology or economics may inform the way forward on trust research. In our Milbank Quarterly article, we propose a roadmap for the field, with study approaches and examples. This research agenda includes, for example, studying trust as an outcome and not just an input to the delivery of care, and expanding trust research to address health inequity by examining the impact of racism and other forms of discrimination on the way the health care system treats patients and people’s trust.

Implications for policymakers

Policymakers have potential to create conditions that will facilitate trust in health care. First, policymakers have some control over what health care organizations do (and don’t do) – and can influence the degree to which health care organizations behave in ways deserving of the public’s trust. Our review found evidence for at least three major threats to trust in health care: 1) adverse events/medical errors, 2) racial and gender discrimination, and 3) profit/ financial conflicts of interest. Policymakers can directly advance policy that address these three issues, or at least assess policy options with these concerns in mind (See Table).

Major Threat to Trust in Health CarePolicy Levers Available to Facilitate Public Trust in Health Care
Adverse events/medical errorsQuality reporting and incentives; require evidence-based practices for limiting errors
Racial and gender discriminationCollect data on health outcomes by race/gender and the composition of the health care workforce by race/gender; potentially require some portion of certificate of need programs or community benefit spending to prioritize groups that have been historically discriminated against

Profit motive/financial conflicts of interestPlace limits and set rules about the pursuit of medical debt; limit amount of cash reserves for insurance companies; revisit standards for board-level disclosures to ensure independence (See e.g.,Sachin Jain, 2022)

Second, policymakers – by virtue of being regulators – impart a certain trustworthiness to health care markets and organizations. If policymakers are perceived to be untrustworthy (corrupt), the spaces that they regulate are likely to be deemed less trustworthy as well. In light of this, policymakers may want to see anti-corruption efforts as trust maintenance or building efforts. With regard to health care, these might include limits on the revolving door between government and health care organizations and sensitivities to regulatory capture by hospitals and health systems.

Finally, policymakers and government administrators have a role to play in safeguarding the public’s trust in science by virtue of the role government plays in directly communicating and providing services to the public. COVID-19 highlighted this role for government, as mayors, governors, public health department chiefs and many other policymakers were thrust into inescapable and high-profile health communicator roles. Just as clinicians have to consider how they can become trusted purveyors of information, so too do policymakers. Notably on this point, policymakers that trusted the public with the complex realities of the emerging COVID-19 pandemic were better positioned to earn the public’s trust and willingness to adopt preventive measures.

As we conclude in our Quarterly article, to ensure patients are able to receive care and clinicians are in a position to provide care, organizations need to be sensitive to the human needs of their patients and professionals. Trust, and its meaning and measurement, should therefore remain a priority for researchers, health systems, and policymakers.