Dec 17, 2019

The Most Overlooked Social Determinant of Health?

Healthcare as an industry is heavily focused on social determinants of health (SDOH) these days, but there’s one barrier to member engagement and treatment compliance that is mentioned less often than housing, food and transportation. That ingredient is trust. Confidence in the medical establishment has been on the decline for decades, despite Americans having some of the most advanced health technologies and treatments in the world. When people don’t trust the system, they don’t engage with it. This is a challenge for every health plan and provider.

More than 75 percent of people had great confidence in doctors in 1966, but that share has dwindled to just 34 percent over the years. So, what’s up with that? Americans are less confident overall in institutions than in the past, but some developments have worsened trust in the healthcare system. Among these are highly publicized medical errors and data breaches, escalating costs, and advertising tactics for home remedies on this theme: “What doctors don’t want you to know.” The availability of online information – some credible, some not – has patients second-guessing professional advice.

Reasons for low trust play out differently in various communities. For example, elderly people feel less safe welcoming a healthcare provider or social worker into their homes. Lower-income people are more likely to rely on pharmacists, or friends and relatives with some medical training for information. This population is keenly sensitive to being looked down upon on the basis of income, insurance status and race. They scour online reviews to gauge how they will be treated, looking for friendly faces and positive reviews from people similar to themselves. This sense of stigma is a widespread and significant barrier to their accessing care.

Why Patients Don’t Share

Research shows most people withhold clinically relevant information from their providers. In virtually all populations, people do not want to be lectured about their unhealthy behaviors, so they don’t share certain facts or they downplay them, especially if the information will end up “in the computer,” perhaps to their disadvantage later on. Lower-income parents withhold even benign SDOH information for fear their children might be taken from them. Research also indicates patients fail to speak up when they disagree with a provider’s instructions or don’t understand them. Whatever the cause, low trust works against care planning and increases the risk of adverse medical events.

Trust as a factor in good care is being studied, but the answers will not be simple or fast. Most obviously, anyone in contact with health plan members or patients needs to treat them with respect. Research shows that one-on-one relationships may override distrust of the system; conversely, a positive experience with a hospital can outweigh interactions with a doctor or care team. Pharmacists and nurses are highly trusted and can help foster engagement. For example, patients are more likely to admit to a nurse than a doctor that they are skimping on medications because of cost.

Life Events Can Be Entry Points

There are opportune moments to create trust. Research reveals that engaging with parents around the birth of a baby is one such opportunity. A child will be seen by a provider as many as 11 times during their first two years of life, and that is a chance to strengthen relationships with parents. Adverse medical events increase the odds patients will pay attention to clinical advice, but everyone in healthcare is scrambling to get ahead of these!

Health plans and providers are smart to acknowledge trust as a social determinant of health and seek creative ways to enhance relationships, respect and communication. Understanding their populations, and identifying opportune moments could help. Engaging with members and communities outside of the care relationship might build a positive image for providers and payers that serves as a foundation for later interactions. 

Recognizing that trust is declining in the healthcare system led the Robert Wood Johnson Foundation to issue a 2017 call for proposals to study building trust with patients and fostering respect across the healthcare system. It won’t change overnight, but trust can open doors to better health.