Review Article

Trust in Medicine: A Scoping Review of the Instruments Designed to Measure Trust in Medical Care Studies

Introduction

The concept of patient trust has been defined as the idealized acceptance of a vulnerable situation in which the patient entrusts the healthcare professions with the provision of care that aligns with their best interests.¹ Patients need to develop trust in their medical professionals when confronted with an illness, regardless of any prior relationship,²particularly when confronting a serious disease in an emergency, they ought to believe their physicians’ care to save their lives.³

The subject of trust in the patient-physician relationship has been explored in various studies.^4,5 Trust serves as a determining factor in healthcare utilization,⁶ hospital performance,⁷ willingness to treatment adherence,⁸ enhanced treatment experience, improved information exchange, diminished fear, and reduced instances of seeking second opinions⁹ and quality of health care. There is growing information that indicates that trust with an unrevealed mechanism (like a placebo) modifies the interaction between the body and mind and thus changes the effectiveness of almost all care procedures in clinical practice.¹⁰

The topic of trust within the healthcare practice has received significant attention in current policy discussions. This is largely due to assertions that various factors have contributed to a decline in public trust in healthcare institutions and professionals.¹¹ The development of trust is a gradual progression, characterized by its potential to either advance or diminish in potency as a function of time, demonstrating the properties of the concept.⁷ It is not possible to demand trust from others,¹²as it must be acquired through meritorious actions and behavior.

A previous systematic review of the literature study by Ozawa and Sripad resulted in the development of a specialized health systems trust content area framework.¹³ It was observed that several dimensions, including honesty, communication, confidence, and competence were frequently reflected in the framework measures. On the other hand, concepts like fidelity, system trust, confidentiality, and fairness were found to be of lesser significance in the framework.¹³

The domains and determinants of trust in healthcare practice in developing countries are possible to be culturally exclusive. An investigation in India indicated that the concepts of “crowdedness” and capacity to meet financial obligations, as well as emotional dimension have elicited considerable attention in medical trust.¹⁴

Within the current literature, there is a shortage of international comparative investigations using psychometrically sound tools in these concepts. As the caring systems and cultures are diverse in countries, differences between countries regarding trust in healthcare practice are predictable. However, differences in health-service organizations may also provide reasons for differences between patients’ perceptions of care elements¹⁵ such as trust in healthcare professions. The measurement of trust with a valid and reliable instrument is essential,¹⁶ but it is a difficult construct to measure.¹⁷

To the best of our knowledge, most scales developed to measure trust (in healthcare) have emerged from developed countries. Because of its vital importance to medical practice, we need to obtain a thorough understanding of the nature, knowledge gaps, scope of a body of literature, predictors, and consequences of trust between patients and their health providers.¹⁸

Effective assessments of medical trust will be vital resources for evaluating, guiding, and supporting efforts to understand and enhance trust. Also, there is no general agreement about how to best assess trust in medicine. Therefore, characterizing existing measures of medical trust, as well as identifying dimensions to guide future measure creation is needed. This scoping review study was conducted with the aim of identifying dimensions of trust in medicine, trust subjects and correlates among available instruments.

Materials and Methods

Registration and Protocol

This scoping review was prepared in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)¹⁹ and recorded at the Pazhoohan Investigation Information System (registration code: IR.TBZMED.REC.1399.1098).

Data Sources

We searched Medline (via PubMed), Scopus, Embase, Google Scholar, and other information sources of grey literature using the following topic headings and keywords: “Trust” “Medicine,” “Medical,” “Physician,” “Nurses,” “Health Personnel,” “Health Care Professional,” “Healthcare Provider,” “Surveys and Questionnaires,” “Questionnaire,” “Tool,” and their synonyms and related terms. We developed a search strategy in a Supplementary file. In addition, we manually explored the Journal of Trust Research, as well as the bibliographies of all retrieved reports. Also, the International Prospective Register of Systematic Reviews (PROSPERO) was searched to identify ongoing systematic reviews on the same topic. The references of eligible papers were manually explored for additional studies that had not been identified through the electronic search. We ran our initial search strategy in March 2023 and updated it in April 2023 by two researchers, namely ES and HS.

Inclusion and Exclusion Criteria, and Types of Studies

Only psychometric studies with the primary objective of developing or adapting a measurement tool for trust in medical care were considered. Publications were included without time limitations with available titles, abstracts, and full-texts. We considered only English and Persian languages.

Selection Process and Data Extraction

Two assessors screened all titles and abstracts of retrieved papers separately. Additionally, full-texts of related papers were screened for eligibility by two reviewers and the reasons for exclusion were recorded for the excluded full-texts and disagreements were discussed and resolved. The following data was extracted from the papers: the first author, publishing year, country, study design, sample size (SS), language, administration, sampling method, response rate, pilot study SS, target population, subject in medical trust, initial/conceptual dimension, number and name of final dimension, number of items, variance of factors, eigenvalue for factors, reliability, validity including (content, face, structural, constructive, predictive, convergent), scoring range, and correlates or associates of trust in medicine. In order to synthesize the included studies the qualitative data approach of content analysis for variables of interest was used. The risk of bias was not evaluated in the included studies. This is usually how scoping studies are typically done.^20,21

Results

Study Characteristics

Eligible Studies

A total of 3641 publications were identified. Out of 3641 studies, 741 of them were duplicates. 400 were selected for further scrutiny on the basis of screening the titles. Following a review of the abstracts, the full text of 140 publications was retrieved, and assessed on their fulfillment of the selection criteria. Finally, 52 publications were synthesized in the current evaluation (Figure 1), of existing evidence between 1990 to 2023 (Table 1).

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Figure 1.

Flow diagram of this study

Figure 1.

Flow diagram of this study

Distribution in Countries and Languages

Trust in medical care was the subject of studies in a wide range of countries. Of 52 studies, 19 were done in the United States,^{8,23,25,40,44,45,48-50,55,56,58,60,61,63-67} seven in Iran,^{10,22,24,28,29,37,38} six in the Netherlands,^{18,36,41,47,52,62} two in Italy,^26,27 two in Poland,^30,31 two in India.^17,32 Also, other studies were two in China,^35,39 two in the UK,^54,57 and the rest (one) in Australia,³³ Greece,³⁴ Finland,¹⁶ Nigeria,⁴ Liberia,⁴² Turkey,⁴³ Germany,⁴⁶ Singapore,⁵¹ Thailand,⁵³ Georgia.⁵⁹

From 52 studies, 27 of the tools developed on the subject of trust in medicine were in English language, seven in Persian, five in Dutch, three in Greek, two in Italian, two in Polish, two in Tamil, two in Chinese, two in German, and the rest (one) in Finnish, Swedish, Kpelle, Mano, Turkish, Thai.

Study Design, Administration of Tools, Sampling Methods, Response Rate, and Target Population in İnstruments Designed for Trust in Medicine Studies up to 2023

Cross-sectional studies were the most frequent 80 % (n = 42) type of study. Regarding administration of tools, 61 % (n = 32) were self-reported. As to the types of sampling methods, twenty were nonprobability, seventeen were random, three were in a cluster, three in multistage, two were in stratified, and five did not report the sampling methods. In sum, 37228 cases were included in these studies with a minimum sample size of 36 and a maximum of 3442 cases. The mean response rate was 64 ( ± 22.8). Sixty-seven percent (n = 35) of the studies have used pilot study. The majority of the participants 67 % (n = 24 943) were adults ( ≥ 18). Also, 47 % (n = 24) included diverse patients like cancer, internal medicine, general surgery, obstetrics gynecology, diabetes, chronic health conditions, rehabilitation, rheumatoid arthritis, osteoarthritis, fibromyalgia, psychiatric disorders, HIV, emergency patients, family practice, traumatic patient (see Table 2).

Trust in Medical Scales’ Research Subjects in Studies up to 2023

In terms of trust scales subjects (52 studies), about 71 % (n = 37) of the scales were measuring trust in the medical profession (among them physician (n = 17), nurses (n = 6), care providers (n = 4), oncologist (n = 4), midwifery or maternal healthcare workers (n = 3), pharmacists (n = 2), dentists (n = 1)). Also, health care systems14 % (n = 7), emergency department (n = 1), trauma care department (n = 1), and health care team (n = 1) were trust in medicine scales subjects. The rest involved public health authorities, health insurers, COVID-19 control and prevention policies, telemedicine care or telehealth, medical technology, physician trust in the patient, performance, and general trust.

The current study found that different dimensions for measuring trust have been expressed in different studies which may be classified into one,^{16,18,23,26,33,35,37,40,41,44,45,47,50,52,58,60,61,64,67} two,^{4,2,25,28,34,39,42,48,59,63} three,^{17,29,43,49,51,53-56} four,^32,46 five,^17,36,57 six,^10,38,62 seven,²⁴ and nine⁶⁶ dimensions.

Initial Dimensions of Trust in Medical Care Questioners Designed for Trust Studies

About 57 % (n = 30) of trust in medical care questioners designed for trust studies have reported initial or conceptual dimensions, although all the references used in the studies are mentioned in the item generation sources section (Table 2).

Final Dimensions of Trust in Medicine in Scales Designed for Trust Studies (up to 2023).

Figure 2 provides the final dimensions of trust in medical care in instruments developed for trust studies up to 2023.

Out of 100 % (113) reported domains, trust in professions was reported in 21 % (n = 24) of these studies. Communication (respectful interpersonal connection) was described in 11 % (n = 12) of these studies, participation (coordination) was disclosed in 8 % (n = 9) of studies, and competency and providers’ expertise (professional skill) were noted in 5 % (n = 6) of these studies. System (institutions) trust was announced in five studies, and effective treatment, care policies at the macro level, and patient-centered (focus) have been expressed 4 times each in studies.

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Figure 2.

Frequency of final dimensions of trust in medicine in instruments designed for trust studies up to 2023

Figure 2.

Frequency of final dimensions of trust in medicine in instruments designed for trust studies up to 2023

Quality of care, benevolence, information supply, and organizational resources were revealed three times each in studies. Also, general trust, honesty, reliability or confidentiality, emotional support, team or labor trust, trust in technology, and trust in payers were each recorded twice in these articles as a domain. Beneficence, fairness, behavior, patient evaluation, prevention, education, understanding experience, specific or optimal tasks, trust in telemedicine, discrimination, and skepticism were narrated as a domain in these studies. Four of these studies reported factors or domains without a specific name.

Trust in Medicine Correlates (Associates) in Developed Tools for Trust Studies in the Literature

Trust correlates are considered in ten categories including care, patient behavior, healthcare-patient, care provider professional, healthcare organization, personal health status, social, demographic, insurer, and other characteristics.

Healthcare-related characteristics included patient satisfaction, continuity, quality of care, public health behavior, accessibility, interpersonal treatment, comprehensiveness, service use/acceptance, patient-centeredness, and parent experience (Table 3).

Patient behavior covers features such as adherence, number of physician visits, choice, seeking a second opinion, returning for care, independent decision-making, routine health exams or health-seeking, and membership in managed care.

Care-patient features include unwillingness to switch, recommendation, previous experience, and pain manageability.

Care provider include elements like length of relationship, disputation, behavior, trust, type of service provider, expertise, interaction, trusting information from provider, the number of physicians in practice, educational grade of care provider, and graduated place.

Healthcare organization characteristics included institutional trust, integration, and health plan. Health status comprised general health, mental health, physical health, health locus of control, depression, fibromyalgia, osteoarthritis, and schizophrenic.

Social categories include general trust, minority, racism especially in health care, interpersonal trust, racism especially in health care, the federal government, ethnic identity, social desirability, social support, partner’s support, and macro-level policy. Demographics include characteristics such as age, education, income, nationality, sex/gender, marital status, and job.

Insurer categories included methods of payment and incentives for opportunistic behavior. Other characteristics included friend referral and skepticism.

Items Numbers, Variances for Domains, Eigenvalue, Reliability, and Scoring of Trust in Medicine Developed Tools in the Literature

On average, 18 final items were obtained in each tool with a maximum and minimum of 80 and 4 cases, respectively. On average, 3 dimensions have been obtained in each tool, single dimension is the most frequent with 35 %, and the maximum dimension was reported in seven domains. Most of the studies reported variances of 54 % (n = 28), with a minimum of (3.3 %), and with a maximum of (82 %). Thirty-eight percent (n = 20) reported eigenvalue (λ) in the developed tools. The average reliability of the studies was 86.44( ± 7.26) with max = 0.98, and min = 0.68. Most of the studies used a 5-point Likert-type scale (82 %). Two of the studies used a 4-point Likert-type scale (Table 2).

Validity Status in Developed Scales in Medical Care (n = 52)

Exploratory factor analysis was used in 46 % (n = 24) of studies. Confirmatory factor analysis was used in 38 % (n = 20) of the studies. Convergent validity was used in 17 % (n = 9) of the studies. Criterion validity was applied in two of the studies. External validity was used in two of the studies. Regarding content validity clarity, wording, relevancy, semantic equivalence, item position, and grammatical/linguistic were the most common properties, respectively (Table 2).

Discussion

This is the first study to undertake a scoping review of all available evidence of instruments designed for measuring trust in medical care in the world up to 2023. This study was conducted to identify dimensions of trust in medical care, common trust subjects, and correlates, comprehensively.

Trust in professions, communication, participation or coordination, competency, expertise, system trust, effectiveness, care policies, patient-centeredness, quality of care, benevolence, informed care, resources, general trust, honesty, reliability, fidelity, and support were the most prevalent dimension of trust in medicine, respectively. Furthermore, beneficence, fairness, behavior, patient evaluation, prevention, education, understanding experience, specific task, trust in telemedicine, no discrimination, skepticism each were seen once as dimension of trust in medicine in literature studies.

The diversity in different dimensions of trust tools in the medical field can be caused by the sample size, disease-specific, study design, subject of trust, level of measurement, department or institution, time of study, time saving, and uniqueness of a language, type of specialties, data collection method, and location under investigation. Future research should, therefore, concentrate on the investigation of trust in medicine dimensions. “Trust will not be the same at all times and in all places”.¹²¹

Considering that there is a priority for one-dimensional scale, it may be conceivable to measure patients’ trust through a shorter form. Such a shortened form would be of specific intrigue for investigations including time-saving.¹⁸ A brief scale would reduce the patient and investigator burden, especially in investigations in which trust is not the essential focus.¹⁸ Due to the subjective nature of patient trust and its crucial importance in the physician-patient relationship, it is imperative to employ specialized instruments which are tailored to particular patient populations in the quantitative assessment of patient trust.³⁹

Tool development studies in the field of trust in medicine have identified many correlates of trust in medicine which fall into nine general categories. These characteristics are related to healthcare (such as quality of care, patient-centeredness, acceptance, patient satisfaction …), patient behavior, healthcare-patient, care provider professional, healthcare system, individual health status, social factors, demographics, insurer, and other characteristics.

The results of this study showed that trust in medicine is closely related to all factors affecting the survival of the health organization, including the customer (patient), service provider, organization, and social systems. Trust acts as the glue that holds the system together.¹²² The decreasing trust is a sign of the quality of care decline of the systems that need attention to improve the family of trust to continually quality improvement. The existence of trust is the factor of people’s cooperation and their participation in public spheres and normal behaviors. The coronavirus pandemic showed that lack of trust leads to people’s non-cooperation which in turn brings about poor consequences.^123-126 It is suggested that trust building should be seriously included in the main program of management and leadership of health organizations.

Based on the findings of the present study, the following themes are suggested for future research towards building confidence in medicine scales: It is advised that the association of these factors is investigated in future studies. In developing tools, we need to pay attention to the most common dimensions of trust. Measurements of trust in medicine have implications for clinical practice by influencing therapeutic patient-provider relationships, patient engagement, adherence to treatment plans, perception of quality of care, satisfaction, and ultimately, patient outcomes. Trust in medical care and public health is crucial for the well-being of individuals and society as a whole.

The emergency department is one of the important and busy departments^127,128of the clinical settings that may have a significant impact on the satisfaction of the patients^129,130 which should be given more attention in measuring the trust and satisfaction of the patients.

Although this scoping review research extends our knowledge of measuring trust in medicine, it has some restrictions. The biggest drawback of this study was that it only looked at literature in English and Persian, even if there may be worthwhile studies in other languages that were left out of the current synthesis. Another drawback of this study is the subjective interpretation of the results. Also, we did not evaluate the quality of each of the included studies.

Further investigation and experimentation into measuring trust in medical care is strongly recommended. It is recommended that further research in the development of tools related to the measurement of trust in medicine should pay attention to the most frequent dimensions and correlates of family of trust.

Conclusion

This study provides a comprehensive view of the discussion of creating and developing tools in the field of medical care trust. However, existence of trust is an important factor, especially in the provision of medical and health practice. Trust in professions, communication, participation, competency, expertise, system trust, effectiveness, policies, patient-centeredness, quality of care, benevolence, informed care, resources, general trust, honesty, reliability, fidelity, and support were the most widespread dimensions of trust in medicine. The findings from this study make several contributions to the current literature. First, researchers in the field of trust are recommended to pay more attention to the most commonly known domains in preparing tools. Second, medical care providers and authorities need to consider the most common dimensions for the improvement of trusted care as an important index of healthcare quality improvement for future practice.

Acknowledgements

This study is part of a larger study and extracted from a doctoral dissertation. Authors appreciate road traffic injury research center of Tabriz university of medical sciences (Number: 66846). The authors would like to appreciate the cooperation of the Clinical Research Development Unit, Imam Reza General Hospital, Tabriz, Iran, in conducting this study.

COI-Statement

The authors declare that they have no conflicts of interest.

Data Availability Statement

All data generated or analyzed during this study are included in this published article.

Ethical Approval

This research was approved by the Research Ethics Committee of Tabriz University of Medical Sciences, Iran with No. IR.TBZMED.REC.1399.1098. All methods were performed following the relevant guidelines and regulations of the Declaration of Helsinki (DoH).

Research Highlights

Supplementary File

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