What factors shape doctors’ trustworthiness? Patients’ perspectives in the context of hypertension care in rural Tanzania

Introduction:  There is increasing evidence that improving patient trust in doctors can improve patients’ use of healthcare services, compliance and continuing engagement with care –particularly for chronic diseases. Consequently, much of the current literature on trust in therapeutic relationships focuses on factors shaping doctors’ trustworthiness. However, few studies on this issue have been conducted among rural populations in low-income Africa, where health service delivery, cultural norms and patient expectations differ from those in high-income countries. This study examined patients’ perspectives of factors that shape doctors’ Rural and Remote Health rrh.org.au James Cook University ISSN 1445-6354


Introduction
Evidence suggests that improving trust in doctors could assist in addressing challenges associated with patient healthcare service uptake, compliance and continuing engagement with care, particularly among those with non-communicable diseases. A high level of patient trust in doctors is reported to improve biomedical healthcare seeking and use , reduce risky behaviours and increase medication adherence , continuity with care and disease control . Therefore, much of the current literature concerning trust in therapeutic relationships has focused on factors that shape patients' trust in doctors in primary healthcare settings . Existing research has facilitated the design and testing of trust improvement interventions and generated a number of measures of patient trust in high-income countries . However, most studies on factors shaping patent trust in doctors, especially those related to doctors' trustworthiness, have been conducted in urban settings in high-income countries. Although the health service delivery, cultural norms and patient expectations in typical rural low-income Africa differ from those in high-income countries, factors shaping doctors' trustworthiness have not been examined in this context. This study draws on the perspectives of patients in rural Tanzania to examine the factors that shape doctors' trustworthiness in the context of hypertension care. This will provide much-needed information for designing and testing trust improvement interventions in rural low-income Africa.

Methods
The methods used in this study have been reported elsewhere . In summary, this article is based on a qualitative study that sought to examine the meaning, benefit and factors shaping patient trust in doctors in rural Tanzania . Tanzania was selected as it is a unique rural low-income Africa setting . Tanzania also has a rapidly growing burden of non-communicable diseases characterised by poor patient healthcare seeking, non-adherence, poor continuity with care and poor disease control . Hypertension was chosen as the exemplar because of the lengthy patient-doctor interactions required during hypertension management. The study from which the present data were drawn was conducted in 12 health facilities in two predominantly rural districts of Shinyanga region, Tanzania, between October 2015 and March 2016.
Participants were purposively sampled and recruited via verbal advertisements during health education sessions and institutional meetings, and through peer referrals. Purposive sampling was used because statistical representation was not the primary goal .
During participant recruitment, no strict inclusion criteria were applied other than the inclusion of patients who were seeking hypertension care at the time this study was conducted. Interviews with participants were conducted in quiet, isolated rooms that were disconnected from regular clinics in the participating health facilities. The interviews were audio-taped with participants' consent. Data were gathered using a flexible interview guide that covered the perceived meaning and benefits of trust, and factors shaping patient trust in doctors. A consultative process involving experts in both Tanzania  was generated from the interviews. Codes were then sorted into potential subthemes and themes, followed by collation of all relevant coded data extracts into identified themes. Throughout this process of coding and refinement, the research team held frequent discussions to reflect on the themes generated. This peer consultation also aimed to address potential bias that might have resulted from KI's interpretation of the data, as that author is a medical doctor in the country where the research was conducted.
Patients' accounts of provider factors that shaped their trustworthiness were used for this analysis.

Ethics approval
This study received ethics approval from the Human Research Ethics Committee at the University of New South Wales, Australia (HC15535) and the National Institute for Medical Research, Tanzania (NIMR/HQ/R.8a/Vol. IX/2024). Authorisation was also obtained from local health authorities.

Results
In total, 34  before, during and after a therapeutic encounter). suggested that a patient's own behaviours and institutional resources may also play a significant role in shaping trust in therapeutic relationships. However, this aspect was beyond the focus of the present article.  Therefore, this research was designed to investigate trust by considering its complexity and multifaceted nature in a specific context, as suggested by some social theories. This strategy allowed a contextualised account of patient trust in doctors in rural Tanzania to emerge throughout data collection and analysis, without viewing trust through an existing theoretical framework.
However, the authors understand that investigating trust this way positioned the research within the constructivist paradigm . This means that the research relied on participants' descriptions to examine how patient trust in doctors was constructed in a specific context (rural Tanzania) as a construct shaped by different factors, rather than assuming it to be a positivist concept with a universal definition. The authors recommend that further studies on this topic consider using a theory-driven inquiry in a similar context. In an attempt to contextualise trust, the present findings draw on accounts of two distinct groups of participants: healthcare workers as patients (nurses, clinicians and attendants) and non-healthcare workers (farmers, teachers, homemakers, small business owners and retired government officials).
Patients' judgements of doctors' trustworthiness started with an initial level of trust before the therapeutic encounter, which was shaped by access to information about a doctor's reputation from social networks (family, friends and neighbours) and other patients. The finding that a doctor's reputation in society shaped initial trust appeared to be novel and has not been reported in previous empirical research. However, a similar concept can be seen in some theoretical literature . Some trust literature has proposed that a patient's own behaviour and biography may influence a doctor's reciprocity during therapeutic encounters . This implies that efforts to promote doctors' trustworthiness also need to encompass those seeking to construct trustworthy behaviours among patients.
It is also important to acknowledge that doctors' trustworthiness may be shaped by the trustworthiness of the institutions in which they work. Some studies have indicated the availability of resources (eg sufficient doctors, medicines and medical equipment) as essential in creating an environment where trust can be established and sustained . The need for physical examinations and medical investigations as described by participants in the present study may not be fulfilled in the absence of functional medical equipment and medical supplies.
Although these issues are beyond the scope of this article, a doctor's ability to negotiate for alternatives to institutional barriers remains an important skill that may shape patients' judgement of their trustworthiness. These issues also suggest that trust improvement interventions in rural low-income Africa need to extend beyond patient-doctor relationships to consider health system barriers that contribute to patient distrust in doctors in Western practice. However, given the limited research on patient trust in doctors in rural low-income Africa, further research is needed to generate evidence on how institutional resources and a patient's own history impact their trust judgements of doctors in this setting. In addition, more research is needed on how trust changes over time during and after therapeutic encounters and its measures in the study setting, given the long-term therapeutic nature of hypertension/non-communicable disease care.

Limitations
This article did not explore all features pertaining to doctors that shape patients' perception of their trustworthiness, such as factors that are beyond the doctors' behaviour, demeanour and perceived technical competence (eg age, tribe and gender). Most participants identified as being of the Sukuma tribe, and the interviews were conducted in Swahili. These patients were selected from characteristically rural districts (over 95% rural occupancy) characterised by public monopoly in health services , centralised hypertension care, prolonged waiting times, low use of health services and medical pluralism . Similarly, the accounts of women participants (n=28) used in this manuscript exceeded those of male participants (n=6). As noted elsewhere , possible explanations for this include that 9 out of 12 enrolment assistants were female, making it more likely to enrol women; the study was conducted during a farming season, meaning men may have prioritised farming activities over study participation; and hypertension is more prevalent among females than males in Tanzania, possibly making women more likely to frequently seek hypertension care compared with men. Therefore, the present findings cannot be applied to patients and doctors from both sexes, and those from culturally, linguistically and structurally diverse backgrounds. Only considering patients' accounts in this article may be taking the path of previous studies that have restricted the examination of factors shaping trust to patients' perceptions. However, the present study included healthcare workers (eg nurses, medical attendants and clinicians) who participated as patients, and these participants often drew on their experiences as agents of healthcare institutions. This facilitated bringing providers' voices to this inquiry. Additionally, all interviews were conducted by one author (KI) who has a medical background and has previously worked as healthcare service advocate in Tanzania. This might have impacted the interview process, choice of themes, related subthemes and codes that were considered most appropriate. It might also have affected the interpretations of participants' accounts and the conclusions in seeking to answer the research questions. However, peer consultation within the research team was used throughout this study to help address these issues.
Finally, the unit of analysis employed in this study was a medical consultation rather than the longitudinal patient-doctor relationship. The authors' choice to analyse the patient-doctor relationship in the context of a consultation was dictated by what defines the relationship itself -a physical encounter during medical consultation -particularly in low-income rural settings where non-physical patient-doctor relationships are largely unavailable. In addition, factors shaping patient-provider relationships beyond the experiences surrounding a medical consultation were examined. For example, developing initial trust without an individual patient's experience of medical consultation, and trust based on treatment outcomes where the ability of a doctor's treatment to bring relief and cure, emerged as shaping trust. As this was the first study to be conducted in this rural context, further studies may look at the patient-doctor relationship from different perspectives. Improved patient trust in doctors is documented to impact patients' service uptake, adherence and continuity with care . The practical implications of the study findings include three major premises. First, the findings provide a gateway for trust improvement interventions by identifying specific factors shaping doctors' trustworthiness or untrustworthiness that need to be promoted (or discouraged) to improve patient uptake, adherence and continuity of primary healthcare services. Participants' accounts of the factors that shaped doctors' trustworthiness in rural Tanzania indicate a need to engage both patients and doctors as partners in health care, as well as addressing structural barriers at the institutional level to maximise the success of trust improvement interventions. Second, the findings of this study provide doctors with evidence of aspects that can be used to selfaudit their current practices versus those desired by their patients to improve trust. Third, this study generated a list of doctors' behaviours, demeanours and technical skills that may be useful in improving medical training curricula to foster a culture of trustworthiness among medical graduates in rural low-income Africa settings.