International Journal of Audiology 2015; 54: 20–28

Original Article

Perceptions of adults with hearing impairment regarding the promotion of trust in hearing healthcare service delivery Jill E. Preminger*, Maria Oxenbøll†, Margaret B. Barnett*, Lisbeth D. Jensen† & Ariane Laplante-Lévesque†,‡ *Program in Audiology, University of Louisville School of Medicine, Louisville, USA,†Eriksholm Research Centre, Oticon A/S, Snekkersten, Denmark, and ‡Department of Behavioral Sciences and Learning, Linköping University, Linköping, Sweden

Abstract Objective: This paper describes how trust is promoted in adults with hearing impairment within the context of hearing healthcare (HHC) service delivery. Design: Data were analysed from a previously published descriptive qualitative study that explored perspectives of adults with hearing impairment on hearing help-seeking and rehabilitation. Study sample: Interview transcripts from 29 adults from four countries with different levels of hearing impairment and different experience with the HHC system were analysed thematically. Results: Patients enter into the HHC system with service expectations resulting in a preconceived level of trust that can vary from low to high. Relational competence, technical competence, commercialized approach, and clinical environment (relevant to both the clinician and the clinic) influence a patient’s resulting level of trust. Conclusions: Trust is evolving rather than static in HHC: Both clinicians and clinics can promote trust. The characteristics of HHC that engender trust are: practicing good communication, supporting shared decision making, displaying technical competence, offering comprehensive hearing rehabilitation, promoting self-management, avoiding a focus on hearing-aid sales, and offering a professional clinic setting.

Key Words: Trust; hearing healthcare; clinician patient relationship

Trust in a healthcare provider has been defined as the patient’s confidence that the provider will do what is best for the patient (Anderson & Dedrick, 1990). Trust has been studied extensively in the physician literature (e.g. Hillen et al, 2011; McKinstry et al, 2006), yet has received little attention in the audiology and hearing healthcare (HHC) literature. It is important to consider trust, because patients who trust their clinicians typically demonstrate improved satisfaction, treatment adherence, and clinical outcomes in comparison with patients who possess low trust (Farin et al, 2013; Hall et al, 2001; Safran et al, 1998; Thom et al, 2004). Before considering trust in HHC clinicians1 and in the HHC system, it is useful to consider the aspects, or components, of the physician-patient relationship that promote trust. A synthesis of the literature in which patients considered their beliefs regarding trust in their physician and in their healthcare system was performed. Four qualitative studies (Goold & Klipp, 2002; Hillen et al, 2012; Mechanic & Meyer, 2000; Thom &

Campbell, 1997) and three review papers (Hall et al, 2001; Hillen et al, 2011; Thom et al, 2004) are summarized in Table 1. Seven overlapping components of the physician-patient relationship that promote trust were identified from the literature. Patients trust physicians who communicate effectively and those who listen and show concern. Patients trust physicians who have a caring approach, who are willing to invest time in establishing a relationship, and who value patient needs and wellbeing. Patients trust physicians who they believe are competent; however, as it is difficult for patients to judge a physician’s technical competence, patients might assess competence based on education or on recommendations from others (Hillen et al, 2011). Patients trust physicians who are honest and who protect sensitive information about their patients. The final trust component of confidentiality was noted less frequently (Hillen et al, 2012) and may be a characteristic of relevance to healthcare systems more so than healthcare providers (Hall et al, 2001).

Correspondence: Jill E. Preminger: Program in Audiology, MDA Suite 220, University of Louisville School of Medicine, Louisville, KY 40292, USA. E-mail: jill.preminger@ louisville.edu (Received 26 January 2014; accepted 25 June 2014 ) ISSN 1499-2027 print/ISSN 1708-8186 online © 2015 British Society of Audiology, International Society of Audiology, and Nordic Audiological Society DOI: 10.3109/14992027.2014.939776

Trust in hearing healthcare services

Abbreviations AUS dB HL DK HA HHC NHS UK US

Australia Decibel hearing level Denmark Hearing Aid Hearing healthcare National Health Service United Kingdom United States

Apart from confidentiality, the components of trust described in Table 1 are physician characteristics. Thus they can be categorized under the umbrella term interpersonal trust. The umbrella term institutional trust, defined as trust in the healthcare system, may also be considered (Pearson & Raeke, 2000). The demarcation between interpersonal and institutional trust is important, as trust in the system may influence trust in the clinician or vice versa. For example, it has been shown that the method of payment used in a private healthcare system (e.g. fee-for-service versus capitation) has influenced levels of trust in physicians (Kao et al, 1998). Trust has emerged in the literature as an important component of the HHC clinician-patient relationship. For example, adults with hearing impairment have described trust in the HHC clinician as an essential precursor to shared-decision making (Laplante-Lévesque et al, 2010) and as a factor considered prior to hearing-aid adoption (Poost-Foroosh et al, 2011). Additionally, low trust in the HHC clinician has been described as a barrier to the uptake of HHC services (Johnson, 2012). Thus, a greater understanding of trust in a HHC

Table 1. Seven components of the physician-patient relationship that promote trust. Communication ability • Communicating clearly, completely, honestly, and competently1,6,7 • Listening, understanding, showing genuine concern, and compassion1,5,6 • Also referred to as ‘interpersonal competence’3,5,6 Caring • Listening, demonstrating concern, and compassion1,3,5 • Showing sympathy4 Relationship building • Developing a shared history and personal relationship1,7 • Investing time in the relationship4 Fidelity (similar terms also used in the literature: agency, advocacy, dependability) • Demonstrating a commitment to the patient5 • Placing value in the patient and putting the patient’s welfare ahead of other considerations (e.g. cost)5,6 • Acting in the best interest of the patient2,4,5 Competency • Achieving good treatment outcomes and avoiding mistakes2,7 • Displaying efficiency and good technical skills3 • Also referred to as ‘technical competence’3,5,6 Honesty • Telling the truth about the patient’s condition, being stratighforward2,3,4 Confidentiality • Protecting sensitive and private information6 1Goold

& Klipp, 2002; 2Hall et al, 2001; 3Hillen et al, 2011; 4Hillen et al, & Meyer, 2000; 6Thom et al, 2004; 7Thom & Campbell, 2012; 1997. 5Mechanic

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clinician-patient relationship could have a positive influence on hearing help-seeking, treatment uptake, and treatment outcomes. Trust can be seen as a continuum that varies from low to high. It is possible to measure the level of trust within individual components (as shown in Table 1), or globally (Hall et al, 2001). Patients typically enter into a healthcare relationship with a predetermined level of trust and this level of trust is likely modified by the patient’s interaction with both the clinician and the healthcare system (Thorne & Robinson, 1988). If patients enter the relationship with a high level of trust, they may perceive service delivery in a positive manner, which could further build the trust relationship. Patients who enter the relationship with low trust are more likely to perceive service delivery in a negative manner (Hall et al, 2001). Cross-sectional studies have consistently shown that high levels of trust in clinicians are associated with good patient outcomes. High trust levels have been associated with higher patient satisfaction, greater treatment adherence, better health status, and higher quality of life (Farin et al, 2013; Safran et al, 1998; Thom et al, 1999; Trachtenberg et al, 2005). Some studies have attempted to distinguish trust from satisfaction; it has been proposed that satisfaction is related to delivery of service during a specific appointment, whereas trust is based on delivery of service within an ongoing relationship (Chang et al, 2013; Hall et al, 2001). In summary, patients likely develop trust in their physicians based on their beliefs about the physician’s communication ability, caring, relationship building, fidelity, technical competency, honesty, and confidentiality. Patients enter into a relationship with a physician with an initial level of trust: this level may become higher or lower based on the patient’s satisfaction with the services received by the physician and by the healthcare system. Little is known about the components of trust in the patient-HHC clinician relationship. This paper describes how trust is promoted in adults with hearing impairment within the context of HHC service delivery.

Methods Study design Data were examined from a previously published descriptive qualitative study with the aim of exploring the perspectives of adults with hearing impairment on hearing help-seeking and rehabilitation (Laplante-Lévesque et al, 2012). In the original study, the interview transcripts from 34 adults from four countries were analysed using inductive content analysis (Graneheim & Lundman, 2004). Several themes, i.e. common threads across participants’ narratives, emerged from the analysis. Some of these themes have been further analysed and reported in subsequent publications (Knudsen et al, 2013; Preminger & Laplante-Lévesque, 2014). Review of the transcripts revealed that the majority of participants discussed trust in the HHC provider, the HHC system, and HHC services and products.

Data collection The original data were collected at four different sites: University of Queensland in Australia (AUS), Eriksholm Research Centre in Denmark (DK), Hull York Medical School in the United Kingdom (UK), and University of Louisville in the United States (US). Sites obtained ethical clearance from their relevant ethical review committees. At each site, one researcher conducted personal interviews at a location convenient for each participant. Participants were recruited via flyers, electronic message boards in community locations such as libraries and community centers, and word of mouth. Semi-structured interviews followed a topic guide (Supplementary Appendix 1

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to be found online at http://informahealthcare.com/doi/abs/10.3109/ 14992027.2014.939776) which focused on the participants’ actions, thoughts, and feelings in relation to their hearing help-seeking and rehabilitation. Trust was not a topic included in the interview topic guide, however most participants brought up this topic without direct prompting. Interviewers may have asked for elaboration on this topic as this is the nature of the semi-structured interview technique (Smith & Osborn, 2008). Interviews lasted approximately one hour in duration. All interviews were audio-recorded and transcribed verbatim, and the Danish interviews were translated into English. The accuracy of each transcription was verified by the researcher who performed the interview.

Participants In total, 34 participants took part in the original interview study. Each participant believed that he/she had a hearing impairment and this was verified with pure-tone audiometry such that each participant had at least one threshold greater than 25 dB HL in the octave audiometric range between 500 and 4000 Hz. Participants who had a history of ear surgery, had a medical history suggesting cognitive impairment, or who used hearing aids that were older than five years old were excluded. Participants were purposefully recruited and sampled, via questionnaire, according to five levels of experience with hearing help-seeking and rehabilitation: (1) never sought hearing help; (2) sought hearing help but did not obtain hearing aids; (3) obtained hearing aids but had not used them for at least three months; (4) used hearing aids regularly but did not report satisfaction with them (reported satisfaction as very dissatisfied, dissatisfied, or neutral); and (5) used hearing aids regularly and did report satisfaction with them (reported satisfaction as satisfied or very satisfied). The sample includes participants with both preconceived perceptions/ expectations about HHC service delivery (which were not based on personal experience) as well as perceptions based on different levels of experience.

Data analysis Interpretative phenomenological analysis (IPA) was used to identify, organize, and describe relevant data pertaining to trust in HHC clinicians and the HHC system (Braun & Clarke, 2006; Knudsen et al, 2012; Smith & Osborn, 2008). The transcripts were reviewed using a double hermeneutic approach in which the authors interpreted the transcript excerpts with the knowledge that the transcript excerpts were examples of the participants making sense of their personal experience (Smith & Osborn, 2008) As there is no standard definition of trust used in the healthcare literature, a working definition of trust was created: confidence in the ability and the integrity of the HHC clinician and the HHC system. As a first step, a Doctor of Audiology student (Sara Labhart) and author JEP read all interview transcripts and identified excerpts in which the participant expressed trust or confidence in: (1) the HHC clinicians’ knowledge and abilities; (2) the services provided by the HHC clinician; and/or (3) the services and technologies recommended by the HHC clinician. With this approach the investigators selected 106 excerpts or ‘meaning units’; a meaning unit is a group of words or statements that relate to the same central meaning (Graneheim & Lundman, 2004). As a second step, the meaning units were labelled with codes by authors JEP and MBB: a code emphasizes the core content of each meaning unit. Next, all five authors reviewed the codes and determined that all but six could be categorized under the topics: ‘Trust’, ‘Satisfaction with Service’, or ‘Trust and Satisfaction with

Service’. (The six uncategorized meaning units were eliminated from the data set). The authors attempted to differentiate trust and satisfaction and to determine whether data relating only to satisfaction with services should remain in the dataset. A review of the healthcare delivery literature revealed that other authors have attempted to unravel trust from satisfaction; for example it has been posited that satisfaction develops based on services received and trust develops over repeated visits (Thom & Campbell, 1997), satisfaction is determined by service delivery whereas trust is based on the patient-clinician relationship (Hall et al, 2001), and satisfaction is based on past experience whereas trust implies an expectation about what will happen in the future (Thom et al, 2004). The current authors concluded that trust and satisfaction are interdependent and decided to include data which referred to satisfaction, only when it was related to service delivery, with the premise that satisfaction with service promotes trust (English & Kasewurm, 2012). One hundred meaning units related to trust and satisfaction with service remained. As a third step, these data were re-coded by authors JEP and MBB; to capture all concepts expressed by participants, meaning units conveying more than one concept were coded by as many different codes as required. Each meaning unit was coded to remain as close to the actual content as possible. These codes were reviewed and adjusted by authors LDJ and MO. As a fourth step, patterns and relationships across the codes were examined and codes were organized into a hierarchy of meaning (i.e. superordinate themes, themes, and subthemes). All authors reviewed the thematic structure and made suggestions for revision. When adjustments were made, authors JEP and MBB reread the interview transcripts to ensure the identified themes accurately represented the meaning and context of the participants’ narratives. During this phase, the authors generated a thematic map to visualize the themes and their relationships. Subthemes were refined and rearranged and new superordinate themes were created as required to express the various concepts in the data. This iterative process involved all authors; the ongoing discussion of the thematic structure across multiple researchers improves the transferability of the findings (Guba, 1981). The qualitative research software NVivo 9 (www.qsrinternational.com) served as a platform for coding and sorting codes into themes.

Results Transcript excerpts related to trust were identified in 29 out of the 34 (85%) participant interviews. Trust was discussed by 7 out of 8 participants from AUS, 8 out of 9 from DK, 7 out of 8 from the UK, and 7 out of 9 from the US. From this point forward only the 29 individuals who discussed trust during their interviews will be considered; an overview of the sample is shown in Table 2. A total of 100 meaning units were identified and these were described with 193 codes. Data analysis revealed that each code could be categorized into one of four superordinate themes which will now be referred to as the four dimensions of trust, encompassing the (1) Components of trust, (2) Assignment of trust, (3) Level of trust, and (4) Time course of trust. The four dimensions of trust are expanded in Table 3, visualized in Figure 1, and described here. First, the four components of trust are shown in the center circle of Figure 1. These components were further categorized into subcomponents which are listed in Table 3. Second, each meaning unit could be classified according to the assignment of trust, shown around the circle perimeter (Figure 1). Codes classified under Interpersonal Trust relate specifically to

Trust in hearing healthcare services the HHC clinician, and codes classified under Institutional Trust relate specifically to the HHC office, the HHC system, or the HHC profession. The majority of codes in Relational Competence and Technical Competence were organized under Interpersonal Trust, whereas the majority of codes in Clinical Environment and Commercialized Approach were organized under Institutional Trust. Thus, the four components of trust overlay both Interpersonal Trust and Institutional Trust. The third dimension of trust is the level of trust which can vary from low to high. The level of trust may be considered for each of the four components of trust or for trust as a global concept. Finally, the fourth dimension is the time course of trust, which is shown with the arrows in Figure 1. Prior to entering the HHC system, most patients have Service Expectations, a preconceived level of trust that can vary from low to high. These expectations are typically formed by information gathered from other healthcare professionals, friends, family, the internet, advertisements, etc. Once patients receive services their levels of trust may increase or decrease based on their own experiences (Service Experienced), which then becomes their level of trust prior to their next HHC encounter. The following transcript excerpt2 was expressed by a participant who had worn hearing aids for approximately 40 years and who had experience with both the National Health Service (NHS, the public healthcare system in the UK) as well as private hearing-aid providers. I never thought for a minute that National Health would be as good. I thought they’d be just basic hearing aids. That’s what I thought. Where did you get that idea from? Well I don’t know. I suppose one almost assumes that if you pay for things… [Female, 85, UK, satisfied HA user] Table 2. Summary of participant characteristics (n  29). Characteristics Experience with hearing healthcare help-seeking Never sought hearing help Sought hearing help but did not obtain hearing aids Obtained hearing aids but have not used within past three months Dissatisfied hearing-aid user Satisfied hearing-aid user Country Australia Denmark United Kingdom United States of America Age Mean, (years  SD) Range (years) Gender Male Female Hearing impairment (n  58 ears) Minimal ( 25 dB HL) Mild ( 25 and  40 dB HL) Moderate ( 40 and  60 dB HL) Severe ( 60 and  80 dB HL)

Percent (number)

10% (3) 14% (4) 21% (6) 17% (5) 38% (11) 24% 28% 24% 24%

(7) (8) (7) (7)

65.1  15.56 35–96 41% (12) 59% (17) 9% (5) 41% (24) 41% (24) 9% (5)

Note. Percent and number of subjects per category are shown in column 2 except for Age, where the mean, standard deviation, and range are shown in years.

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Table 3. The four dimensions of trust that emerged from the data. Dimension 1. Components (and subcomponents) of Trust • Relational Competence ◦ Communication style ◦ Empathy ◦ Instruction for self-management ◦ Promotion of shared decision making • Technical Competence ◦ Based on services received ◦ Based on reputation or education • Commercialized Approach ◦ Solicitation ◦ Focus on service versus focus on sales ◦ Cost of hearing aid ◦ Public versus private healthcare system • Clinical Environment ◦ Clinic setting ◦ Clinical services ◦ Public versus private hearing healthcare Dimension 2. Assignment of Trust • Interpersonal trust • Institutional trust Dimension 3. Level of Trust • Varies from low to high Dimension 4. Time Course of Trust • The level of trust prior to receiving hearing healthcare services • The level of trust after receiving hearing healthcare services

This meaning unit was coded as ‘Did not expect NHS would have hearing aids as good as private HHC clinician’’ and categorized under Commercialized Approach in the subcomponent Public versus Private Healthcare System, and it was also categorized under Institutional Trust. The same meaning unit was also coded as ‘Expected a better hearing aid from private vs. NHS due to cost’ under Commercialized Approach in the subcomponent Cost of Hearing Aid (see Table 3). The participant’s preconceived trust level for services received from the public HHC system was interpreted as low (as she intimated that ‘you get what you pay for’), and it was interpreted as increasing when she did not discover a difference in the hearing aids received between the public and the private HHC systems. The following section focuses on the four components of trust (in the center of Figure 1) and the subcomponents.

Components of trust

RELATIONAL COMPETENCE Of the four trust components, Relational Competence was discussed most frequently by the participants during the interviews. Relational Competence includes four subcomponents listed in Table 3. In regards to Communication Style participants described both positive (e.g. laughs at my jokes, answers my questions) and negative (e.g. talked down to me, would not explain) communication styles. Here is an example of a participant who trusted a HHC clinician because she was capable of varying her communication style as needed: What makes you trust3 somebody or what makes you not trust somebody, when they’re trying to provide you with hearing care or healthcare? If I use (current HHC clinician) as an example, she talks serious business but she also jokes. [Male, 78 years old, US, dissatisfied HA user]

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Trust

Low/high

Service Expected

Trust

Low/high

Service Experienced

Trust

Low/high

Figure 1. A visual representation of the four dimensions of trust: The four components of trust, the type of trust (Interpersonal versus Institutional), the level of trust, and the time course of trust.

Participants discussed Empathy across two areas: (1) the HHC clinician was (or was not) caring and listened to my needs, and (2) the HHC clinician was (or was not) direct and truthful and made recommendations based on my hearing needs. Caring and listening were described: It’s the very presence (that HHC clinicians) show their clients, that care and presence. Of course there is also empathy, that they are there simply with the aim, with the primary aim to help me. They don’t have some medical approach as to how severe or how mild (the hearing loss) is. They’re there simply to find precisely the best and most optimal solution to the problem being presented to them. [Female, 55, DK, dissatisfied HA user] Please note that the preceding meaning unit does not explicitly relate to trust, but it does relate to satisfaction with service. As discussed previously, it was decided to include data which referred to satisfaction with service delivery, with the premise that satisfaction with service promotes trust (English & Kasewurm, 2012), thus this meaning unit was included in the analysis. Whereas we named a subcomponent Instruction for SelfManagement, participants did not use this particular term; instead they described the information they required from their HHC clinician to manage their hearing impairment. Participants trusted clinicians who provided comprehensive and understandable information about hearing impairment, treatment options, and hearing aid maintenance: Well, the only thing I have against it really, the service, was that I don’t think there was enough explanation given on how to care for the hearing aids and things. [Female, 69, AUS, satisfied HA user] The following excerpt shows a positive experience related to the Promotion of Shared Decision Making, whereas other participants described negative experiences such as clinicians who ‘decided everything’ without their input: They realize that I have spent my whole life with this hearing loss. That I probably know better than them what I need from my

hearing and I know better than them if there is something wrong. Whereas for them all they know is the technology behind it. They know how to test the hearing, they can do it very well, but they realize there’s a compromise that you have to make between the hearing-impaired person and the audiologist. You cannot just tell the hearing-impaired person: ‘This is what you need.’ You have to agree with the hearing-impaired person and say: Yes you’re right, that’s probably better for you than another product. [Female, 46, AUS, dissatisfied HA user]

TECHNICAL COMPETENCE This component included two subcomponents, the first being Based on Services Received. Participants trusted clinicians whose test results matched their own interpretation of their hearing impairment, who knew how to use the testing equipment, and who appeared able to fine-tune hearing aids. Participants had low trust in clinicians who rushed through an appointment or who appeared incompetent in their actions, for example when performing an assessment in a sound-proof booth: She didn’t close the door completely. And also I could see her reflection on the glass so I knew when she was pushing buttons [Female, 58, AUS, hearing evaluation but no HA experience] Participants also trusted providers Based on Reputation or Education: What was their job (the HHC clinicians)? Audi something … I suppose they’re like opticians, they haven’t got a proper medical degree or anything like that. But they are experts in their field, yes. [Male, 61, UK, satisfied HA user]

COMMERCIALIZED APPROACH In regards to Solicitation, participants were generally distrustful of clinicians or clinics that appeared to be advertising their services, for example those who offered free hearing tests: I’m a little bit leery of the actual hearing-aid places that advertise the free hearing things. I’d rather hear it from a doctor. [Female, 77, US, no HHC experience]

Trust in hearing healthcare services Within the subcomponent Focus on Service versus Focus on Sales, participants were wary of clinicians (or clinics) that appeared to focus on hearing-aid sales rather than providing comprehensive diagnostic and rehabilitative services: I feel like I’m buying storm windows or a used car. That’s just the feeling that I get. They didn’t explain what they do or how they work... they were just more interested in giving me hearing aids. [Female, 80, US, dissatisfied HA user] The Cost of Hearing Aid was also a subcomponent influencing trust. Some participants had higher trust in providers who did not systematically recommend the most expensive hearing aids: I trusted his advice (about which HA to purchase), because he said: ‘No need to go for the gold or whatever it is. Just go for the middle of the road.’ [Male, 61, UK, satisfied HA user] Public versus Private Healthcare System is a subcomponent which occurred under two of the components; an example meaning unit for the component Commercialized Approach is shown in the third paragraph of the Results section. In order to determine if this subcomponent was representative of the perceptions from all subjects, the public versus private healthcare experience was investigated for all participants (Table 4). Whereas at least one individual from each country had HHC experience with a public system, only three individuals from Denmark and three from the United Kingdom had experienced both public and private systems. Thus all of the meaning units for the subcomponent Public versus Private Healthcare System are from individuals from those two countries. Within the context of Commercialized Approach, some participants discussed preconceived notions about these systems, specifically that the public system would provide lower quality hearing aids and that clinicians in the private system were primarily interested in selling expensive hearing aids rather than providing comprehensive rehabilitation services.

CLINICAL ENVIRONMENT

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professional. Clinical Services were considered in terms of Interpersonal Trust and Institutional Trust; participants described policies of the HHC system or clinic, as well as direct service by individual clinicians. Participants had high trust in systems and clinicians who offered good follow-up care, who offered comprehensive services, and who took a team approach in patient care: Some (HHC providers), not all, are interested in selling hearing aids and not the maintenance of hearing aids. Because those first hearing aids, they didn’t tell me anything about coming to get them adjusted, about having them cleaned, anything about that. [Female, 73, US, satisfied HA user] In considering the Clinical Environment, the participants once again considered the Public versus Private Healthcare System. Participants actively compared the two types of HHC systems and compared the benefits and limitations of each. Participants had low trust in the public or the private system when they felt that they had been treated dismissively: Do you regret not having gone earlier to the NHS? Well it would have saved me quite a lot of money. Are there any other advantages about going privately? You can get an earlier appointment perhaps. I don’t know. Up to now I’ve been quite happy with the service I get from the National Health. I’ve been told to go back ‘If there’s any problem do ring us and come back’. [Female, 85, UK, satisfied HA user] In summary, Relational Competence and Technical Competence were typically described in terms of Interpersonal Trust, whereas Commercialized Approach and Clinical Environment were typically discussed in terms of both Interpersonal Trust and Institutional Trust. Participants’ descriptions of the level of each trust component varied from low to high and in some instances the Level of Trust changed following clinical service.

Discussion

The fourth trust component includes participants’ descriptions of the Clinic Setting. They appeared to have high trust when the clinician and the office staff spent time with them and had low trust when they had difficulty getting an appointment and when they felt rushed or dismissed: They all behaved as if they had oceans of time and were very nice and helpful. So I thought it was a very good experience. It was not like: ‘Come here, and pay now!’ (laughs) [Female, 60, DK, satisfied HA user] Participants also considered the visual presentation of both the office and the clinician and deemed whether or not both appeared

From this analysis of 29 participants with hearing impairment, it appears that the most important characteristics of HHC clinicians, and systems, that engender trust are: (1) Relational Competence, i.e. practicing good communication, providing and promoting shared decision making and self-management; (2) Technical Competence, as assessed by patients based on services received, reputation, or education; (3) the absence of a Commercialized Approach, focusing on a comprehensive hearing rehabilitation approach rather than on hearing-aid sales, and; (4) a professional Clinical Environment, where staff listen to and respond to patient needs and inquiries. Some participants entered into an initial HHC appointment with low trust. For example, assumptions were made that services offered

Table 4. Summary of participant experience with public and private hearing healthcare delivery systems across country (n  29). Experience with Hearing Healthcare Systems

No experience with HHC system Experience with private HHC system Experience with public HHC system Experience with both public and private HHC systems

Australia (7)

Denmark (8)

United Kingdom (7)

United States (7)

Total (29)

14% (1) 57% (4) 29% (2) 0% (0)

0% (0) 13% (1) 50% (4) 37% (3)

14% (1) 14% (1) 29% (2) 43% (3)

14% (1) 72% (5) 14% (1) 0% (0)

10% (3) 38% (11) 31% (9) 21% (6)

Note. Percents are shown with participant numbers in parentheses.

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by HHC clinicians and staff in the public system would be rushed and incomplete, whereas others were concerned that private HHC clinicians would focus on selling a particular brand of hearing aids at a high price. Alternatively, some participants entered into the HHC system with high trust; this often occurred based on the (inferred) training of the clinician or when referred by a physician. Trust levels often appeared to change following an appointment. Participants gained trust when the HHC clinician displayed Relational and Technical Competence. Participants lost trust when these components were not evident. The first two components of trust, Relational and Technical Competence, are similar to many of the components of trust found in the physician literature (Table 1). Thom and Campbell (1997) included a component of trust which they called ‘structural/staffing factors’ and the description of this component is similar to Clinical Environment in the present study (structural/staffing factors did not appear in Table 1 as it focused on the physician-patient relationship). It is not surprising that some of the results found here are similar to those found in the physician literature. At least two reasons for these could exist. Firstly, both the physician literature and the present study focused on the delivery of healthcare services. Secondly, in the double hermeneutic approach for data analysis used here, the conceptions of the researchers, which includes the knowledge of the previously published literature, may influence the data organization and structure (Smith & Osborn, 2008). Commercialized Approach was infrequently described in the physician literature and this difference is discussed in the next section.

Approach may be linked to the unique cost and payment issues associated with hearing-aid dispensing. In some countries individuals can choose between no-cost (or low-cost) hearing aids supplied by a public health system versus high-cost hearing aids from a private HHC clinician. In fact, in the US the purchase of a hearing aid can be the third most expensive item purchased by individuals after a home and a car (Donahue et al, 2010). Additionally, in most countries individuals have the option to purchase a hearing aid (or personal sound amplification product) through the mail or over the internet with little or no involvement from a HHC clinician. This potential focus on the device and its cost without appropriate consideration of the importance of HHC rehabilitation services may lead individuals to view the HHC system in a commercialized manner. The interview excerpts show that a Commercialized Approach typically results in low trust, but what is not clear is whether a Commercialized Approach creates ‘distrust’. Some authors differentiate low trust from distrust (Lewicki et al, 1998; Sitkin & Roth, 1993); for example, low trust may be considered the absence of trustworthy behaviors, whereas distrust may be considered wariness and suspicion, or the expectation of unacceptable or harmful actions (Hall et al, 2001; Hillen et al, 2011; Sitkin & Roth, 1993). If distrust is considered as distinct from trust then it is possible for a patient to have high trust as well as high distrust in a healthcare provider (Lewicki et al, 1998). This did appear to be the case for some participants who trusted their HHC clinician due to their Interpersonal Trust and Technical Competence while at the same time they had distrust in their clinician due to the HHC system favoring a Commercialized Approach.

Distrust and the commercialized approach It is interesting to consider whether trust in HHC providers is inherently different than trust in other healthcare providers. There is evidence to believe that patients have different expectations of trust in different healthcare providers. For example, when asked to describe trust in nurses, patients considered caring, whereas when asked to consider trust in physicians, the same patients considered competence, communication, and fidelity (Hupcey & Miller, 2006). From the present analysis it appears that when patients consider trust in HHC clinicians, they do consider caring and competence, but also consider the cost of services and devices. It should be noted that this likely applies to HHC clinicians who dispense hearing aids as most of the HHC experience by the participants reported here included hearing-aid dispensing (76% of participants, see Table 2). It is interesting that patients do not consider cost when considering trust in physicians, when in fact physicians can be thought of as ‘selling’ clinical services (Williams, 1984). The traditional physician-patient relationship has been one in which the physician designed a treatment plan that the patient was expected to follow (Roter, 2000). Current financial considerations challenge this relationship. Patients have become ‘consumers’; doctors have become ‘providers’, healthcare has become a commodity, and ‘third parties’, including insurance companies and social service agencies, have become part of the equation (Dyer, 1985). Some physicians dispense devices along with their services (e.g. artificial hips or cochlear implants). However, when third parties (e.g. public or private insurance) pay the medical device cost, patients do not consider this a selling act. Perhaps the difference in attitudes regarding the Commercialized Approach for HHC clinicians versus physicians is whether or not the medical device is covered by a third party versus a direct payment by the patient. Alternatively, the perceptions of the participants regarding the Commercialized

Strengths and limitations The qualitative method used here to explore the concepts of trust in HHC service delivery has both strengths and limitations. Possible methods of data collection in qualitative research include interviews, for example as used here, and research observations, for example of clinical appointments (Knudsen et al, 2012). Whereas research observations have the advantage of providing information on the phenomenon without a potential recall bias, the interpretation of observations is often left to the researcher. Therefore an investigation of trust using observations would require a significant amount of researcher interpretation. Semi-structured interviews, such as those used in the present study, allow for the researcher to collect and clarify the participants’ perspectives on the phenomenon of interest, although some recall bias from the part of the participant can occur when describing past events. Interviews and observations can be done in a direct or indirect way. In this study, trust was investigated in an indirect way: the participant was not made aware that their perspectives on trust were going to later become a focus of study. Actually, this was also unknown to the researchers at the time of the interviews, as the theme of trust emerged during the initial data analysis reported in Laplante-Lévesque et al (2012). The fact that the research question used to collect the data is not the same as the question posed in the current study (i.e. that trust was investigated in an indirect way) is both a strength and a limitation. The concept of trust was not in the interview topic guide, yet participants frequently discussed trust. This is a strength as it demonstrates that the majority of participants discussed trust spontaneously, without being explicitly prompted to do so. This same finding occurred in one of the studies used to synthesize the data presented in Table 1 (Goold & Klipp, 2002): ‘Results are presented for the theme of trust (and distrust), which emerged spontaneously

Trust in hearing healthcare services in discussions about healthcare and health insurance’ (p. 879). The benefit of the spontaneous generation of the data is that it freed participants from formulating their preconceived perceptions they directly associate with the concept of trust. The fact that the participants were not asked specifically about trust, however, limits this report to a first attempt at describing trust in HHC, rather than a more comprehensive and nuanced description of trust in HHC. Additionally, participant sampling was done in accordance with the initial research question rather than with the concept of trust. A study focusing on trust would potentially benefit from sampling participants from every type of healthcare system within each country. Sampling of a wider variety of participants is needed before definitive conclusions regarding trust in private and public healthcare systems can be generated. Finally, it would be useful to employ both qualitative and quantitative approaches, utilizing a variety of methodology, in the examination of trust.

Conclusions The present results show that patients from different countries and with different levels of experience with hearing help-seeking and rehabilitation consider trust in the HHC clinician and the HHC system as important. Trust is evolving rather than static in HHC and both clinicians and clinics can promote trust. The characteristics of HHC clinicians that engender trust are: practicing good communication, providing empathy, promoting shared decision making, displaying technical competence, offering comprehensive hearing rehabilitation, promoting self-management, and avoiding a focus on hearing-aid sales. The characteristics of a HHC clinic that engender trust are similar to the characteristics of the clinician and include providing comprehensive services that focus on service rather than sales and offering a professional clinic setting. This paper is a first attempt at conceptualizing trust in HHC. Future research is necessary to determine whether the dimensions and components of trust described here transfer to new samples of HHC patients. Once trust is well understood, future research can determine whether higher trust in the HHC clinician and system leads to improved treatment adherence, satisfaction, and outcomes.

Notes 1. We use the term hearing healthcare (HHC) clinician rather than audiologist throughout the paper. We do so because participants were often unable to distinguish services provided by audiologists from services provided by other HHC providers. 2. Each meaning unit is followed by information about the participant: gender, age (in years), country, and experience with the HHC system. Excerpts in bold italics were spoken by the interviewer. Comments in parentheses provide contextual information or replace proper nouns. HA  Hearing Aid 3. Whereas the topic of trust was not in the interview guide, interviewers sometimes did ask about trust as a follow-up to statements made by the participant.

Acknowledgements The authors sincerely thank the Oticon Foundation for making this work possible and Sara Labhart for assistance with the data analysis. The authors also thank Louise Hickson, Lesley Jones, Line

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Vestergaard Knudsen, Sophia Kramer, Thomas Lunner, Graham Naylor, Claus Nielsen, and Marie Öberg for their valuable contributions to the original study. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

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