Trust: A vital factor in health care-seeking behavior

When it comes to health care in the United States, patients are expected to place their trust in their providers — and also in other key players including pharmaceutical companies, regulators, and insurers. Breakdowns in trust at any point have the potential to cause “a cascading erosion of confidence in the entire health care system,” note Johns Hopkins University Carey Business School researchers Michael Darden and Mario Macis. 

“Yet,” they add, “studies in economics analyzing how varying levels of trust can directly influence care-seeking behaviors are scarce.” 

The two set out to fill that gap with a recent study that analyzes the relationship between trust and care-seeking behavior. “This was a first strike at trying to measure trust in an economic sense and it was very eye-opening,” says Darden, an associate professor and a faculty research fellow at the National Bureau of Economic Research, or NBER. “In the context of health care disparities, there’s been a lot of research on education and income levels. We found variations in trust to be just as predictive.”

An important predictor

In their working paper, “Trust and Health Care-Seeking Behavior,” which is part of a series published by NBER, Darden, and Macis tap into data from a survey of 1,235 respondents from across the United States conducted by Social Science Research Solutions. Participants were selected to be representative with respect to age, gender, race and ethnicity, education, Census region, political party registration, and language.

To explore the role of trust in patient behavior, the researchers asked questions related to preventive, non-emergency health care behaviors: getting a flu shot, an annual physical examination, a prescription, and the COVID-19 vaccine. The survey also included trust questions specific to different sectors of the health care system.

“We found that health care providers, such as doctors and nurses, are highly trusted. In contrast, health insurance companies and pharmaceutical companies are among the least trusted,” notes Macis, a professor of economics and a member of the core faculty of the Hopkins Business of Health Initiative.

The researchers also found overall levels of trust in the health care system to be an important factor in patients’ decision to seek care, such as getting a flu shot or an annual physical: Just 35.5% of respondents in the lowest quartile for trust received a flu shot, while 68.4% in the highest trust quartile got the shot. Similarly, 64.8% in the lowest trust quartile had a physical exam, compared to 78.7% in the highest trust quartile.

With COVID-19 vaccine status, “the data again show a pronounced difference based on trust levels,” the researchers write. Darden and Macis found that only 19.6% in the lowest trust quartile are fully vaccinated compared to 66.4% in the highest trust quartile.

 “These patterns suggest a positive association between trust and health care utilization similar in magnitude to the association between income and utilization,” they write in their paper.

The need for measurement

Interestingly, their study found no differences in the relationship between trust and care-seeking behavior between Black and white respondents, “but we do find important differences by age and political beliefs,” Darden notes. For example, low-trust registered Republicans are 21 percentage points more likely to be unvaccinated against COVID-19 relative to low-trust Democrats.

Overall, Macis and Darden say their analysis shows that trust in the U.S. health care system tends to increase with age, education, and retirement status and decrease with lack of insurance, unexpected medical bills, and subjective assessments of personal health.

The researchers note the limitations of their study. Since it is not a randomized trial, they can show an association but not a causal relationship between trust and care-seeking. Nonetheless, their findings hold important implications for health care policy, they say.

“We have been able to document the importance of trust, so the main policy implication is that we need to measure it,” says Darden. “So much of health care policy is about encouraging people to adopt preventive care, and in every government survey we measure income and education levels. If we’re missing trust as a measurement, we are missing an important predictor.”

In their next project, Darden says he and Macis aim to examine “where trust comes from.” Insights could have major implications for health care policy, says Darden, “because well-informed policies could presumably change the trajectory of how trust is formed” — resulting in broader uptake of preventive health care services.