Restoring Trust in Healthcare: Information Impact Case Study in Poland

Restoring Trust in Healthcare: Information Impact Case Study in Poland | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research article Restoring Trust in Healthcare: Information Impact Case Study in Poland Anatoliy Goncharuk, Roman Lewandowski, Giuseppe Cirella This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-195131/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background : This study empirically evaluates the influence of information on trust at the physician level, the medical profession, hospitals, and with the payer. Restoring trust in a medical setting appears to be significantly affected due to the coronavirus pandemic. Trust improves results from medical treatment, raises perception of healthcare performance, and smoothens the overall functionality of healthcare systems. Methods : In order to study trust volatility, participants took part in a three-stage experiment designed via: (1) measured level of trust, (2) randomly dividing participants into two groups—control (i.e., re-examination of level of trust) and experimental (i.e., being exposed to a piece of certain manipulative information), and (3) checking whether observational changes were permanent. Results : Results indicate that in the experimental group the increase of trust was noticed in the payer (27.7%, p < 0.001), hospitals (10.9%, p = 0.011), and physicians (decrease of 9.2%, p = 0.036). Conclusions : The study indicated that in Poland information is likely to influence trust in healthcare while social and interpersonal trust levels may be related to increases of trust in hospitals and in the payer versus decreases in physicians. Health Economics & Outcomes Research Health Policy influence of information physicians hospital medical profession payer pandemic Figures Figure 1 1. Background In many countries, including Poland, a significant number of coronavirus infections occur in medical settings. As a result, a lowering in healthcare trust has been widely reported in terms of other illnesses and diseases not being looked at or treated—especially in a timely manner or at all [ 1 ] [ 2 ] [ 3 ] [ 4 ] [ 5 ]. Trust is crucial for the smooth functioning of complex systems, particularly in healthcare [ 6 ]. It is regarded as an effective tool for evaluating medical performance [ 7 ] [ 8 ] [ 9 ] [ 10 ] as well as of great importance to a well-functioning healthcare system. The study empirically evaluates the influence of information on trust in physicians, the medical profession, hospitals, and the payer—i.e., its main components. Consequently, the notion of restoring trust in healthcare as a result of the coronavirus pandemic or any other relating circumstance is vital to a healthy and viable society. People’s trust with their physician and, generally, with a provider is vital to the care process. It can modify patient attitude and behavior which can result in better levels of treatment [ 11 ] [ 12 ] [ 13 ]. Trust can activate the placebo effect [ 14 ], increase acceptance of medical suggestions and compliance with treatment recommendations [ 15 ], diminish the risk of underusing medications in response to cost pressure [ 16 ] [ 17 ] [ 18 ], and improve motivation to seek help and use preventive care [ 8 ] [ 11 ]. Moreover, trust enhances communication between doctors and patients [ 19 ] [ 20 ] [ 21 ] as well as the perception of efficacy, self-reported health status [ 22 ] [ 23 ], well-being, and quality of life [ 5 ]. Changing attitudes and behaviors associated with patient trust also has a positive impact on healthcare providers. As such, trust in a provider may reduce the number of conflicts between patients and medical staff [ 22 ], diminish the probability of complaining about medical malpractice [ 24 ], lower transaction costs (e.g., expenditures that can decrease patient anxiety via additional diagnostic testing and physician consultation) [ 25 ] [ 22 ], and increase motivation to recommend the healthcare provider to others [ 22 ]. Trust improves the perception of the performance. Studies show that patients with high trust are more likely to perceive a performance positively even if it was objectively mediocre [ 19 ] [ 26 ] [ 21 ]. As a result, low institutional trust may cause inefficiency and undermine the legitimacy of health insurance and eventually decrease solidarity [ 27 ] as well as overall success of health policy [ 28 ]. Thus, an emphasis on the importance of research factors that may affect the level of trust in healthcare become seeming fundamental. Although there is a rich body of knowledge about factors influencing trust in healthcare, a lack of quantitative research on how specific information is delivered—societally—exists. Understanding how information influences trust could have significant consequences, e.g., visiting a physician, the medical profession in general, hospitals, and the payer. Three points of should be considered: (1) can level of trust be influenced or even managed regardless of real healthcare performance; (2) ability to revise the data collected, analyzed, and conclusions drawn from them; and (3) action taken to increase trust as well as criteria of resources allocation in healthcare verified. Trust can be considered both as interpersonal, i.e., trust in a physician, as well as social, i.e., trust in a more abstract sense such as groups of people, institutions, and health systems [ 8 ] [ 29 ] [ 30 ] [ 31 ]. [ 32 ] claimed that interpersonal trust occurs when there is a possibility of repeated testing over time, i.e., to what extent a person is trustworthy. [ 33 ] suggested that a high level of trust in a physician cannot always be explained by evaluation of objective evidence of trustworthiness since it can also arise as a response to psychic distress created by illness. This means that in healthcare trust originates from the fundamental psychological attributes of seeking care in a state of anxiety, rather than from provider characteristics or patient personalities [ 8 ]. This is consistent with other suggestions that asymmetry of information between a patient and physician [ 34 ] in accordance with the logic of professionalism [ 35 ] forces patients to trust their doctor. A meta-analysis of 47 studies showed that the correlation between trust and health outcomes is small to moderate [ 36 ]. Specifically, trust is moderately correlated with self-rated subjective health outcomes, but there is no correlation between trust and objective as well as observer-rated outcomes [ 36 ]. Social trust can be influenced by patient experience and the general public’s view of the system [ 19 ] [ 32 ] [ 37 ]. Institutional trust in such organizations as hospitals, public payers, or insurers may be an indicator of consumer appreciation of the organization [ 27 ] and can be affected by varying degrees of interpersonal and social trust [ 38 ]. In particular, social trust may be influenced by patient experience, general public opinion [ 19 ] [ 32 ] [ 37 ], professional institutions and legal as well as regulatory protections [ 32 ], institutional guarantees, and government regulation of medical education, protection of patient rights, and healthcare quality supervision [ 39 ]. Importantly, these issues need to be conveyed to society as understandable as well as plausibly achievable. This is significant since [ 27 ] pointed out that low levels of trust are due to the fact that people may not fully comprehend how the healthcare system (e.g., health insurance) works and how money influences physicians and provider behavior. Moreover, they predict that political communication and mass media may play a central role in shaping public opinion, as “facts do matter less than the perception of the facts” [ 27 ]. In many countries, a low level of trust is directly correlated with the media, reporting on what goes wrong in healthcare [ 27 ] and why. In short, information is one of the critical factors that influences the level of trust in a healthcare system. [ 27 ] claimed that the central query of “whether better information will indeed translate in higher institutional trust” formulates the foundation of this research. This paper explores these queries in the context of Poland and its institutional trust in its medical profession, hospitals, and payer system as well as interpersonal trust at the physician-based level. A breakdown of the study is structured as follows: Sect. 2 frames the research method, Sect. 3 illustrates the results, and Sect. 4 elucidates a discussion and conclusion on healthcare trust in terms of real performance. 2. Method 2.1. Hypothesis development In trust literature, the most frequently studied elements are a physician (i.e., with whom a patient has the most frequent contact), the medical profession, hospitals, payers, and the overall healthcare system [ 31 ]. Given this study is based in Poland, objects studied in this research are the same except for the healthcare system. This is important since Polish society often confuses the healthcare system with the payer, i.e., the National Health Fund (in Polish Narodowy Fundusz Zdrowia ) (NFZ). In Poland, the NFZ operates as a single centralized payer which is the most visible part of its healthcare system. Confusingly, the media and the public often use the words “system” and “payer” interchangeably, thus blurring the difference between these concepts. Hence, a lack of clear separation between these objects makes it impossible to prepare the appropriate information for the intervention and subsequent interpretation of the results. Therefore, to obtain less ambiguous results from this research, only the payer (i.e., NFZ) was selected as it is a better recognized and defined object. Trust level objects, in particular, may vary since trust in different objects may have diverse levels of susceptibility to the supplied information. In consideration of the existing literature, the degree to which information influences trust level of a particular object, may depend on the frequency people encounter it in a particular healthcare system [ 21 ] as well as the type of trust being considered (i.e., social or interpersonal). The study considers the following three hypotheses. Hypothesis 1 ( H1 ): Trust in the payer, i.e., NFZ, is most vulnerable to delivered information. This hypothesis is based on two foundations. First, trust in an insurer (i.e., in this case the payer) is more amenable to change than in a physician [ 40 ] [ 8 ] [ 41 ], Second, in Poland’s healthcare system patients virtually have no contact with the payer (i.e., NFZ) hence they have no direct experience with it. Hypothesis 2 ( H2 ): Trust in a physician is most resistant to delivered information. According to the literature, the increase of patient trust in a physician may be associated with the improvement in receiving care promptly [ 42 ] as well as perceived physician competence and communication skills [ 8 ]. Interpersonal trust occurs when there is a possibility of repeated testing over time—to determine the extent of a person’s trustworthy [ 32 ]. Additionally, there are significant obstacles in delivering information concerning every individual physician, hence the change of trust in this object, apart from experience, may originate mostly from the interrelationship between social and interpersonal trust claimed by [ 43 ]. Hypothesis 3 ( H3 ): The fluctuation of trust level in the medical profession and hospitals after the delivery of information is within the range of trust in a physician and the payer (i.e., NFZ). Trust in hospitals and the medical profession are related to trust at the physician level [ 19 ]. [ 22 ] claimed that patients who trust their physician may worry less about the hospital due to their reliability from their physician to direct them to a suitable one, monitor their quality of service, and their clinical outcome. [ 38 ] suggested that trust in the medical profession depends to some extent on patients’ previous experiences with their own doctor. Thus, trust in hospitals may be less susceptible than trust in the payer since approximately 15% of Poles have direct (i.e., personal) experiences with hospitals [ 44 ] versus 85% with their doctor. Similarly, trust in the medical profession may be more susceptible to delivered information than trust in a physician since the medical profession is more abstract than an individual physician and trust is not based directly on personal experience. However, trust in the medical profession should be considered less vulnerable than trust in the payer (i.e., NFZ) since trust in the medical profession may be more related to trust of a physician—per se [ 38 ]. 2.2. Study design There is significant difficulty in designing a study that assesses the influence of specific information on societal trust level. Understandably, the possibility of controlling information delivery to individuals and measuring the difference of trust level before and after the delivery is challenging. To overcome this problem, a three-stage experiment in an unchanging group of respondents was applied. The experiment was conducted between September 2015 and March 2016 in two medium-sized Polish enterprises within the context of a multi-staged training program concerning quality systems. The training was conducted in permanent groupings and on all organizational levels, ensuring constant composition of the groups using demographically diverse samples (Table 1 ). At all stages, the level of trust in a physician, the medical profession, hospitals, and the payer were surveyed. Between the first and second stage, the period of at least one month was used to minimize the likelihood that participants could remember their previous responses. In order to determine whether the change was permanent, the third stage was carried out at least two months after the second stage. Table 1 Sample description Demographic factors Stage 1 Stage 2, Control group Stage 2, Experimental group Stage 3, Participants of control group Stage 3, Participants of experimental group Participants N (%) Sample size 248 (100) 125 (100) 123 (100) 118 (100) 119 (100) Gender Female 122 (49) 61 (49) 61 (50) 58 (49) 59 (50) Male 125 (51) 64 (51) 62 (50) 59 (50) 58 (49) No data 1 (0) 1 (1) 2 (1) Age 18–30 years 73 (30) 37 (30) 32 (26) 35 (30) 31 (26) 31–45 years 85 (34) 44 (35) 39 (32) 42 (36) 38 (32) 46–60 years 75 (30) 33 (26) 38 (31) 33 (28) 37 (31) More than 61 years 12 (5) 6 (5) 5 (4) 5 (4) 5 (4) No data 3 (1) 5 (4) 9 (7) 3 (2) 8 (7) Income per family member per month (PPP*) Less than 450 USD 57 (23) 22 (18) 29 (24) 24 (20) 31 (26) 451–850 USD 102 (41) 52 (42) 46 (37) 50 (42) 45 (38) 851–1400 USD 50 (20) 29 (23) 20 (16) 27 (23) 21 (18) More than 1401 USD 21 (9) 8 (6) 11 (9) 8 (7) 11 (9) No data 18 (7) 14 (11) 17 (14) 9 (8) 11 (9) Health status Very well 33 (14) 18 (14) 14 (11) 20 (17) 13 (11) Well 159 (64) 87 (69) 72 (58) 81 (68) 68 (57) Average 45 (18) 17 (14) 29 (24) 14 (12) 30 (25) Bad 3 (1) 1 (1) 2 (2) 1 (1) 2 (2) No data 8 (3) 2 (2) 6 (5) 2 (2) 6 (5) * Purchasing Power Parity – for 2014 from http://stats.oecd.org (Accessed 14.06.2015) 2.2.1. Components of mass media information In the study, the assumption has been adopted that information delivered by mass media is a contribution to the decision-making process, consisting of two components: (1) statisticalobjective and (2) emotional-subjective [ 45 ]. Information (i.e., statistical-objectivity) influences the audience when it is comprehensible for the average user, adequate, knowledgeable, trustworthy [ 46 ], and presented in a structured manner [ 47 ]. As a result, the emotionalnarrative component of information has a more significant impact on the audience than a statistical one [ 48 ] [ 49 ]; however, demonstrating statistical data as a graphical representation can increase its impact on decision-making [ 50 ] [ 51 ]. 2.2.2. Perception of healthcare in Poland Surveys conducted throughout Poland indicate a wide discrepancy between the general public trust in healthcare and individuals using healthcare frequently [ 44 ] [ 52 ]. Responsibility for a lower level of trust from non-users may arise due to a highly correlative link from negative information concerning healthcare disseminated by the media [ 44 ] [ 52 ] — mainly as a side-effect of the system’s rapid change and violent political competition [ 53 ] [ 54 ]. Poland’s healthcare is under constant reform, trying to adjust the post-communistic system to Westernized standards, which leads to conflicts between interest groups struggling to protect their current interests versus efforts to try and obtain better access to public funds. The primary result of this strife is negative media output. 2.2.3. Design of the information package used The information package presented to participants was designed in a manipulative manner by presenting Poland’s healthcare as superior (i.e., in a better light) compared to other countries. All the provided data were drawn from the World Health Organization and Eurostat in which particular indicators were chosen in such a way that Poland was a near top healthcare provider. The information package was not in line with the main “climate” currently being portrayed by Polish mass media. The contrast was designed by comparing the United States as the country with the highest spending rate on healthcare in the world and other wealthy Western European countries as well as with some former communist countries which were on the same economic level before their collapse in 1989. The information package consisted of two types of information. First, it targeted an emotionalnarrative by starting off with the first 30 minutes of the movie “Sicko” directed by Michael Moore, dubbed in Polish [ 55 ]. Second, statistical-objectives were stressed to elucidate data from official international health statistics presenting a number of graphs mostly illustrating country-related expenditure and data concerning medical errors in American hospitals. The information package was prepared in a contradictory manner to the mainstream point of view represented in mass media. It was hypothesized that the movie would have an impact on trust for the payer since it focuses on healthcare insurance and system-specific aspects. It might also affect the medical profession, especially when it portrays a medical doctor making a public confession that she had one primary duty—to use her medical expertise for the financial benefit of the insurer stating “…doctors at health insurance companies actually are responsible for the death of patients”. The data regarding medical errors in the US informed participants about the inevitability of medical risk. As a result, this was supposed to increase the positivity and perception of the performance of Polish hospitals as well as show other countries as less forward-thinking. Moreover, indicators such as standardized death rates for specific cancers or ischemic heart disease illustrated Poland as a comparable alternative to countries spending several times more on healthcare, hypothetically influencing all three objects excluding individual physicians since provided information could not be directly linked to each of the participant’s personal doctor. 2.3. Dependent variables and experimentation Given the lack of scale, measuring for the level of trust and testing for their reliability in terms of societal awareness, Poland inclusive of other central and eastern European countries [ 56 ] scales that were developed and tested in the US were adopted (Table 2 ). Trusting a physician and the medical profession, in general, was measured using five element scales developed by [ 57 ]. To estimate the level of trust in the payer (i.e., NFZ) and hospitals, four and three element scales developed by [ 58 ] were applied. The questionnaires were translated into Polish. To ensure authenticity and accuracy of the translations, they were translated back to English by a secondary translator to check whether the meanings remained the same. For each question, a Likert scale was used, and respondents were asked to choose an answer from the following range: 1—Strongly disagree, 2—Disagree, 3—Neutral, 4—Agree, and 5—Strongly agree. Table 2 Scales used in surveys Indicator Strongly disagree Disagree Neutral Agree Strongly agree Patient trust in a physician 1 * Sometimes Dr. __[ insert name of doctor ]__ cares more about what is convenient for him/her than about your medical needs. Dr. __[ insert name of doctor ]__ is extremely thorough and careful. You completely trust Dr. __[ insert name of doctor ]__’s decisions about which medical treatments are best for you. Dr. __[ insert name of doctor ]__is totally honest in informing you about all of the different treatment options available for your condition. All in all, you have complete trust in Dr. __[ insert name of doctor ]__.6. Patient trust in the medical profession 1 * Sometimes doctors care more about what is convenient for them than about their patients’ medical needs. Doctors are extremely thorough and careful. You completely trust doctors’ decisions about which medical treatments are best. A doctor would never mislead you about anything. All in all, you trust doctors completely.6. Trust in health care payers 2,3 Health care payers are good at what they do. When needed healthcare payers will pay for you to see any specialist. When questioned about what treatments are covered healthcare payers are honest with their answers. Healthcare payers will pay for everything they are supposed to, including treatment that is expensive. Trust in hospitals 2 * Hospitals only care about keeping medical costs down and not what is needed for my health. Hospitals provide the highest quality in medical care. When treating my medical problems, hospitals put my medical needs above all other considerations, including costs. * negatively worded item is reverse coded; [ 57 ] 1 ; 2 [ 58 ]; 3 the Polish translation of the word “payers” was changed into the singular form “ płatnik ”, i.e., NFZ, in every item since there is only one payer in the Polish healthcare system In the first stage of the experiment, for the entirety of the participants, the level of trust in a physician, the medical profession, hospitals, and the payer were measured. In the second stage, participants were randomly divided into experimental and control groups of equal size and characteristics. In the control group, re-examination of the level of trust was surveyed, while in the experimental one (i.e., before the survey) participants were shown the information package. In the third stage, the survey was performed again to observe if any change in trust was observable. The manipulation-based check in this experiment is based on observation as well as whether participants believed the intervention. It was performed by a number of research assistants, who monitored participants and occasionally intervened when they were distracted. The research assistants also asked questions to monitor participant attention and continually verified if all participants, in a similar manner, had understood the information. 3. Results Statistical analysis was performed using Statistica version 13 software with the p-value of 0.05 (i.e., a 95% level of significance). Considering the experiment consisted of three stages in which two of them were performed in two groups, in total, a comparative examination of five tests had to be carried out. To validate the significance of differences in the mean value of the various stages the Tukey post hoc test was applied. This test provides sounder, more conservative results than the comparison of pairs via the use of analysis of variance. Results from the test are illustrated in Fig. 1 . Lack of statistically significant differences in the level of trust between the first stage of the study and the control group in the second stage showed that between the two surveys no factors had influenced the initial level of trust. As a result, changes observed in the experiment were consequential to the information delivered during the study. The results obtained from the Tukey post hoc test indicated substantial increases of trust in the experimental group in the second stage. Comparatively, the control group can be observed by way of the payer (i.e., an increase of 27.7%, p < 0.001) followed by hospitals (i.e., an increase of 10.9%, p = 0.011), and, surprisingly, also in physicians (i.e., a decrease of 9.2%, p = 0.036). It is worth noting that trust in the medical profession and hospitals were presented a very similar level (i.e., p > 0.05) during entirety of the experiment except for the experimental group after the delivery of the information package where trust in hospitals increased (Fig. 1 ). Moreover, in the experimental group, trust in the payer reached a similar level to the medical profession (i.e., p > 0.05) but trust in physicians decreased and converged with the increased level of trust in hospitals. Table 3 Results of Tukey post hoc analysis Healthcare type † Stage of the experiment Stage 2, Ctrl gr. (N = 125) Stage 2, Exp. gr. (N = 123) Stage 3, Part. Ctrl gr. (N = 118) Stage 3, Part. Exp. gr. (N = 119) p-value Physicians Stage 1 (N = 248) 1.000 0.032 0.808 0.277 Stage 2, Ctrl gr. (N = 125) 0.036 0.829 0.298 Stage 2, Exp. gr. (N = 123) 0.416 0.911 Stage 3, Part. Ctrl gr. (N = 118) 0.907 Medical profession Stage 1 (N = 248) 0.735 0.998 0.502 0.975 Stage 2, Ctrl gr. (N = 125) 0.896 0.995 0.975 Stage 2, Exp. gr. (N = 123) 0.701 0.998 Stage 3, Part. Ctrl gr. (N = 118) 0.857 Payer Stage 1 (N = 248) 0.993 0.000 0.957 0.595 Stage 2, Ctrl gr. (N = 125) 0.000 0.999 0.840 Stage 2, Exp. gr. (N = 123) 0.000 0.000 Stage 3, Part. Ctrl gr. (N = 118) 0.946 Hospitals Stage 1 (N = 248) 0.851 0.165 1.000 0.976 Stage 2, Ctrl gr. (N = 125) 0.011 0.774 0.512 Stage 2, Exp. gr. (N = 123) 0.258 0.489 Stage 3, Part. Ctrl gr. (N = 118) 0.994 † Ctrl gr. = control group; Exp. gr. = experimental group; Part. Ctrl gr. = participants of the control group in the second stage of the experiment; Part. Exp. gr. = participants of the experimental group in the second stage of the experiment; N = sample size 4. Discussion And Conclusions The statistical analysis demonstrated that in the third stage, the level of trust of all tested objects returned to initial values. However, in none of the studied objects specific to the second stage, the experimental group showed a significantly different level of trust from the participants of the control group in either the second and third stage. The analyzed experimentation demonstrated that the level of trust in physicians, the payer, and hospitals appeared to be sensitive to submitted information while trust in the medical profession did not. As a result, the research may prove that information, not in line with the mainstream opinion (i.e., projected from the media) could have a significant impact. The study, to some extent, also confirmed H1 and H3 that trust in the payer is more vulnerable than trust in hospitals. Furthermore, attention should focalize on the requirements that decrease the level of trust in a physician, as indicated in Fig. 1 . Compared to hospitals, the change is relatively large and in the opposite direction. Taking a closer look at H2 , this result was not expected since first, there was no particular information aimed at influencing trust in a physician and second, the information package was designed to show Poland’s healthcare in a more favorable light. Hence, the present research has attested that social trust in the payer and hospitals may be strongly related to trust in a physician as many researchers claim [ 43 ] [ 19 ] [ 38 ] but this relationship may also be reversely directed. Due to the unexpected results concerning the change of trust in physicians, per se, one week after the last stage of the experiment, a meeting was organized with the experimental group to discuss the results. Some participants suggested (i.e., and some agreed with the suggestion) that after they saw the information, they felt less vulnerable and dependent on their physician then before. Earlier accounts had the majority of them emphasizing their physician was working against the deficiencies of the system. After reflecting on the information package after the results were computed they were more convinced that other elements of “the healthcare chain” work correctly, they felt more secure, and they did not need to trust so much in their physician. The findings from the study are similar to [ 8 ] conclusion in which “the greater the sense of vulnerability the higher the potential for trust” and to some extent to [ 22 ] suggestion that patients who trust their physician may worry less about the performance of other healthcare components. When people perceive healthcare performance as mediocre, they rely more on their physician (i.e., reciprocal with a higher level of trust). But when they realize that other healthcare components work properly, their sense of vulnerability decreases and consequently, they lose trust in physicians who supposedly compensate for the deficiencies of other healthcare components. To some extent, this reasoning might be supported by the fact that under the influence of information, i.e., trust level in a physician, meets trust level in hospitals and approaches trust in the medical profession as well as by the payer. This phenomenon may be interpreted in a way that participants decrease their trust in a physician because they realize their physicians are not bearing exceptional efforts to organize treatment for patients, but operate in an interdependent environment and are equally important as other components of the system. Limitations to this study invites further research to examine intervention level, i.e., it is likely it would not affect all objects in the same manner—distorting the results. Still, as the changes in the payer, physicians, and hospitals reported, these objects were assumed susceptible to delivered information. On the contrary, the lack of change in trust in the medical profession may suggest that the object is vulnerable to delivered information but that the intervention may not have been adequate (i.e., or adequately scaled). Scales used in the study were not tested on the general society Poland-wide, therefore cultural or organizational differences in healthcare between Poland and the US might have affected the outcome. The main conclusions point towards the findings that information can significantly change people’s trust in some components of healthcare regardless of their real performance. This allows for a number of additional inferences to be made. First, trust in healthcare may strongly correlate with the atmosphere in mass media. Second, patient trust in a physician (i.e., at the interpersonal trust level) and social trust in the payer as well as in hospitals may be interrelated also in opposite directions. This means that the increase of trust in hospitals and the payer may correlate with the decrease of trust in a physician. Third, the assessment of healthcare performance [ 59 ] based on trust surveys might be misleading, since any change in trust level may not necessarily translate into an immediate modification (i.e., need) of healthcare functionality. Fourth, delivering designed information is likely to influence the perception of healthcare performance. Fifth, the change in trust level may not be durable. Finally, considering previous studies [ 40 ] [ 39 ], future change in trust is more likely to occur under the influence of information rather than after a genuine change in healthcare performance indicating a long-term conclusiveness even within the bounds of the study’s limitations. In retrospect of the current coronavirus pandemic, these conclusions could be applied to restore trust in healthcare during and after it reaches its end. As such, restoring trust in a medical setting is a contemporary concern that countries alike are and will need to deal with in an ever so changing global health response. Abbreviations NFZ – Polish national payer for medical services (in Polish: Narodowy Fundusz Zdrowia - NFZ) Declarations Ethics approval and consent to participate The Ethical Committee of the Voivodeship Rehabilitation Hospital of Children in Ameryka (Poland) has proved that this study complies with the ethics of scientific research described in the Hospital Charter of Ethics and Ethical Principles of the Declaration of Helsinki and other applicable ethical principles and legislation. Consent for publication Not applicable Availability of data and materials The datasets collected and analysed during the current study are available in the ResearchGate repository (http://dx.doi.org/10.13140/RG.2.2.23077.12004). Conflict of interest statement No conflict of interest has been declared by the authors. Funding Collected data was partially funded from previous research conducted during the COST Action CA15222 “European Network for cost containment and improved quality of care” and National Science Centre, Poland (grant number: 2015/17/B/HS4/02747). Authors Contributions Conceptualization, Data curation, Methodology, Validation, Formal analysis and Writing—Original Draft preparation, A.G.G. and R.L.; Investigation, Resources, Writing—Review and Editing, A.G.G., R.L., and G.T.C.; Project administration, A.G.G. All authors have read and approved the manuscript. Acknowledgments The authors are grateful to the CA15222—European Network for Cost Containment and Improved Quality of Care (CostCares) [ http://costcares.eu ] for supporting this study, support from the National Science Centre, Poland (grant number: 2015/17/B/HS4/02747), as well as the people that agreed to participate in the anonymous survey. References Barach P, Fisher SD, Adams MJ, et al. Disruption of healthcare: Will the COVID pandemic worsen non-COVID outcomes and disease outbreaks? Progress in Pediatric Cardiology. 2020. doi: 10.1016/j.ppedcard.2020.101254 . Bielicki JA, Duval X, Gobat N, et al. Monitoring approaches for health-care workers during the COVID-19 pandemic. Lancet Infect Dis. 2020. doi: 10.1016/S1473-3099(20)30458-8 . Hartley DM, Perencevich EN. Public Health Interventions for COVID-19: Emerging Evidence and Implications for an Evolving Public Health Crisis. JAMA - Journal of the American Medical Association. 2020. doi: 10.1001/jama.2020.5910 . 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Chang C-S, Chen S-Y, Lan Y-T. Service quality, trust, and patient satisfaction in interpersonal-based medical service encounters. BMC Health Services Research. 2013;13(1):22. Safran DG, Taira DA, Rogers WH, Kosinski M, Ware JE, Tarlov AR. Linking primary care performance to outcomes of care. J Fam Pract. 1998;47:213–20. Hall MA. Law, Medicine, and Trust. Stanford Law Review. 2002;55:463–527. Thom DH, Kravitz RL, Bell RA, Krupat E, Azari R. Patient trust in the physician: Relationship to patient requests. Fam Pract. 2002;19(5):476–83. https://doi.org/10.1093/fampra/19.5.476 . Roberts AH, Kewman DG, Mercier L, Hovell M. The power of nonspecific effects in healing: Implications for psychosocial and biological treatments. Clin Psychol Rev. 1993;13(5):375–91. Altice FL, Mostashari F, Friedland GH. Trust and the Acceptance of and Adherence to Antiretroviral Therapy. JAIDS Journal of Acquired Immune Deficiency Syndromes. 2001;28(1):47–58. Thom DH, Hall MA, Pawlson LG. Measuring Patients’ Trust In Physicians When Assessing Quality Of Care. Health Aff. 2004;23(4):124–32. Piette JD, Heisler M, Krein S, Kerr EA. The Role of Patient-Physician Trust in Moderating Medication Nonadherence Due to Cost Pressures. Arch Intern Med. 2005;165(15):1749–55. Johnell K, Lindström M, Sundquist J, Eriksson C, Merlo J. Individual characteristics, area social participation, and primary non-concordance with medication: A multilevel analysis. BMC Public Health. 2006;6(1):52. Mechanic D, Schlesinger M. The Impact of Managed Care on Patients’ Trust in Medical Care and Their Physicians. JAMA: The Journal of the American Medical Association. 1996;275(21):1693. Battaglia TA, Finley E, Liebschutz JM. Survivors of intimate partner violence speak out: Trust in the patient-provider relationship. J Gen Intern Med. 2003;18(8):617–23. Hong H, Oh HJ. (2019). The Effects of Patient-Centered Communication: Exploring the Mediating Role of Trust in Healthcare Providers. Health Communication , 1–10. Zheng B, Hall MA, Dugan E, Kidd KE, Levine D. Development of a Scale to Measure Patients’ Trust in Health Insurers. Health Serv Res. 2002;37(1):185–200. Freburger JK, Callahan LF, Currey SS, Anderson LA. Use of the trust in physician scale in patients with rheumatic disease: Psychometric properties and correlates of trust in the rheumatologist. Arthritis Rheum. 2003;49(1):51–8. Lichtstein DM, Materson BJ, Spicer DW. Reducing the Risk of Malpractice Claims. Hosp Pract. 1999;34(7):69–79. Thom DH. Physician Behaviors that Predict Patient Trust. J Fam Pract. 2001;50:323–8. Caterinicchio RP. Testing plausible path models of interpersonal trust in patient-physician treatment relationships. Social Science Medicine Part A: Medical Psychology Medical Sociology. 1979;13:81–99. Maarse H, Jeurissen P. Low institutional trust in health insurers in Dutch health care. Health Policy. 2019;123(3):288–92. Wilk AS, Platt JE. Measuring physicians’ trust: A scoping review with implications for public policy. Soc Sci Med. 2016;165:75–81. Goold SD, Klipp G. Managed care members talk about trust. Soc Sci Med. 2002;54(6):879–88. Jovell A, Blendon RJ, Navarro MD, Fleischfresser C, Benson JM, DesRoches CM, Weldon KJ. Public trust in the Spanish health-care system. Health Expect. 2007;10(4):350–7. LoCurto J, Berg GM. Trust in healthcare settings: Scale development, methods, and preliminary determinants. SAGE Open Medicine. 2016;4:1–12. Mechanic D. Changing Medical Organization and the Erosion of Trust. The Milbank Quarterly. 1996;74(2):171. Parsons T. (1991). The Social System . Psychology Press. Arrow KJ. Uncertainty and the Welfare Economics of Medical Care. Am Econ Rev. 1963;53(5):941–73. Freidson E. (2001). Professionalism, the third logic: On the practice of knowledge . University of Chicago press. Birkhäuer J, Gaab J, Kossowsky J, Hasler S, Krummenacher P, Werner C, Gerger H. Trust in the health care professional and health outcome: A meta-analysis. PLOS ONE. 2017;12(2):e0170988. Pearson SD, Raeke LH. Patients’ trust in physicians: Many theories, few measures, and little data. J Gen Intern Med. 2000;15(7):509–13. Hall MA, Camacho F, Dugan E, Balkrishnan R. Trust in the Medical Profession: Conceptual and Measurement Issues: Trust in the Medical Profession: Conceptual and Measurement Issues. Health Serv Res. 2002;37(5):1419–39. van der Schee E, Groenewegen PP, Friele RD. Public trust in health care: A performance indicator? Journal of Health Organization Management. 2006;20(5):468–76. Balkrishnan R, Hall MA, Blackwelder S, Bradley D. Trust in Insurers and Access to Physicians: Associated Enrollee Behaviors and Changes over Time: Trust in Insurers and Access to Physicians. Health Serv Res. 2004;39(4p1):813–24. Kao AC, Green DC, Davis NA, Koplan JP, Cleary PD. Patients’ trust in their physicians: Effects of choice, continuity, and payment method. J Gen Intern Med. 1998;13(10):681–6. Mollborn S, Stepanikova I, Cook KS. Delayed Care and Unmet Needs among Health Care System Users: When Does Fiduciary Trust in a Physician Matter? Health Serv Res. 2005;40(6p1):1898–917. Parker SL, Parker GR. Why Do We Trust Our Congressman? The Journal of Politics. 1993;55(2):442–53. Public Opinion Research Centre. (2010). Opinie o opiece zdrowotnej (English: Opinions about healthcare) (No. BS/24/2010). Retrieved from https://www.cbos.pl/SPISKOM.POL/2010/K_024_10.PDF . Hirshleifer J, Riley JG. (1992). The Analytics of Uncertainty and Information . Cambridge University Press. Tio J, LaCaze A, Cottrell WN. Ascertaining consumer perspectives of medication information sources using a modified repertory grid technique. Pharmacy World Science. 2007;29(2):73–80. Brannon LA, Carson KL. Nursing expertise and information structure influence medical decision making. Appl Nurs Res. 2003;16(4):287–90. Fagerlin A, Wang C, Ubel PA. Reducing the Influence of Anecdotal Reasoning on People’s Health Care Decisions: Is a Picture Worth a Thousand Statistics? Med Decis Making. 2005;25(4):398–405. Finucane ML, Alhakami A, Slovic P, Johnson SM. The affect heuristic in judgments of risks and benefits. Journal of Behavioral Decision Making. 2000;13(1):1–17. Feldman-Stewart D, Kocovski N, McConnell BA, Brundage MD, Mackillop WJ. Perception of Quantitative Information for Treatment Decisions. Med Decis Making. 2000;20(2):228–38. Mazur DJ, Merz JF. How the Manner of Presentation of Data Influences Older Patients in Determining Their Treatment Preferences. J Am Geriatr Soc. 1993;41(3):223–8. Public Opinion Research Centre. (2012). Opinie o funkcjonowaniu systemu opieki zdrowotnej (English: Opinions about the functioning of the health care system) (No. BS/34/2012). Retrieved from https://cbos.pl/SPISKOM.POL/2012/K_034_12.PDF . Krakowski K, Morales JS, Sandu D. (2020). Violence Against Politicians, Negative Campaigning, and Public Opinion: Evidence from Poland . Turin. Available at: http://sites.carloalberto.org/morales/vap.pdf . Piotrowska-Marczak K, Kietlińska K. Reforming health and social services in Poland: An overview. Public Management Review. 2010;3(2):281–93. Moore M. Sicko (pl. Chorować w USA). Studio: Weinstein Company; 2007. Ozawa S, Sripad P. How do you measure trust in the health system? A systematic review of the literature. Soc Sci Med. 2013;91:10–4. Dugan E, Trachtenberg F, Hall MA. Development of abbreviated measures to assess patient trust in a physician, a health insurer, and the medical profession. BMC Health Services Research. 2005;5(1):64. Egede LE, Ellis C. Development and Testing of the Multidimensional Trust in Health Care Systems Scale. J Gen Intern Med. 2008;23(6):808–15. Lo Storto C, Goncharuk AG. Efficiency vs effectiveness: a benchmarking study on European healthcare systems. Economics Sociology. 2017;10(3):102–15. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Major revision 07 Mar, 2021 Review # 2 received at journal 01 Mar, 2021 Reviewer # 2 agreed at journal 28 Feb, 2021 Review # 1 received at journal 05 Feb, 2021 Reviewers invited by journal 04 Feb, 2021 Reviewer # 1 agreed at journal 04 Feb, 2021 Editor assigned by journal 30 Jan, 2021 Submission checks completed at journal 30 Jan, 2021 Editor invited by journal 30 Jan, 2021 First submitted to journal 16 Dec, 2020 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-195131","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":9831991,"identity":"7546e29e-9ec0-4614-9d64-efcce5713314","order_by":0,"name":"Anatoliy Goncharuk","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAiElEQVRIiWNgGAWjYHACxgdAgp8kLcwGQEKygRQtbBKkaeHvX36tmqeGQUKXaD0SN96U3eY5xiBhdoBoa26cSbvNw8ZQR7wWeaCWYp5/pNhicL79GDNvGylaDG/wMEvO7ZMgQYvc+eMPP7z5ZkOK9yVyQDEpQbR6IOA//oAU5aNgFIyCUTASAQDBaCUo1OP0EgAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0001-9870-4679","institution":"International Humanitarian University","correspondingAuthor":true,"prefix":"","firstName":"Anatoliy","middleName":"","lastName":"Goncharuk","suffix":""},{"id":9831992,"identity":"07edee19-1939-43ef-af68-7f55b8826353","order_by":1,"name":"Roman Lewandowski","email":"","orcid":"","institution":"University of Social Sciences","correspondingAuthor":false,"prefix":"","firstName":"Roman","middleName":"","lastName":"Lewandowski","suffix":""},{"id":9831993,"identity":"997e45dc-92b4-4611-864a-8776bd5befb9","order_by":2,"name":"Giuseppe Cirella","email":"","orcid":"","institution":"Gdansk University: Uniwersytet Gdanski","correspondingAuthor":false,"prefix":"","firstName":"Giuseppe","middleName":"","lastName":"Cirella","suffix":""}],"badges":[],"createdAt":"2021-01-31 19:48:38","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-195131/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-195131/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":5787814,"identity":"efb9add8-aee1-40ba-adad-ae906e34b7fb","added_by":"auto","created_at":"2021-02-09 17:10:14","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":41497,"visible":true,"origin":"","legend":"Mean value of the level of trust and confidence interval (i.e., 95%). Ctrl gr. = control group; Exp. gr. = experimental group; Part. Ctrl gr. = participants of the control group in the second stage of experiment; Part. Exp. gr. = participants of the experimental group in the second stage of experiment; N = sample size ","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-195131/v1/25370891ab7a24df41a95ccc.png"},{"id":13657395,"identity":"a5e115be-6e85-4187-8a54-4bedc5c15cfd","added_by":"auto","created_at":"2021-09-17 10:10:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":591589,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-195131/v1/b13c51bd-70b7-45f3-aa95-9db1c31db148.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eRestoring Trust in Healthcare: Information Impact Case Study in Poland\u003c/p\u003e","fulltext":[{"header":"1. Background","content":" \u003cp\u003eIn many countries, including Poland, a significant number of coronavirus infections occur in medical settings. As a result, a lowering in healthcare trust has been widely reported in terms of other illnesses and diseases not being looked at or treated\u0026mdash;especially in a timely manner or at all [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Trust is crucial for the smooth functioning of complex systems, particularly in healthcare [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. It is regarded as an effective tool for evaluating medical performance [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] as well as of great importance to a well-functioning healthcare system. The study empirically evaluates the influence of information on trust in physicians, the medical profession, hospitals, and the payer\u0026mdash;i.e., its main components. Consequently, the notion of restoring trust in healthcare as a result of the coronavirus pandemic or any other relating circumstance is vital to a healthy and viable society.\u003c/p\u003e \u003cp\u003ePeople\u0026rsquo;s trust with their physician and, generally, with a provider is vital to the care process. It can modify patient attitude and behavior which can result in better levels of treatment [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Trust can activate the placebo effect [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], increase acceptance of medical suggestions and compliance with treatment recommendations [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], diminish the risk of underusing medications in response to cost pressure [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], and improve motivation to seek help and use preventive care [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Moreover, trust enhances communication between doctors and patients [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] as well as the perception of efficacy, self-reported health status [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], well-being, and quality of life [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Changing attitudes and behaviors associated with patient trust also has a positive impact on healthcare providers. As such, trust in a provider may reduce the number of conflicts between patients and medical staff [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], diminish the probability of complaining about medical malpractice [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], lower transaction costs (e.g., expenditures that can decrease patient anxiety via additional diagnostic testing and physician consultation) [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], and increase motivation to recommend the healthcare provider to others [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Trust improves the perception of the performance. Studies show that patients with high trust are more likely to perceive a performance positively even if it was objectively mediocre [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. As a result, low institutional trust may cause inefficiency and undermine the legitimacy of health insurance and eventually decrease solidarity [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] as well as overall success of health policy [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Thus, an emphasis on the importance of research factors that may affect the level of trust in healthcare become seeming fundamental.\u003c/p\u003e \u003cp\u003eAlthough there is a rich body of knowledge about factors influencing trust in healthcare, a lack of quantitative research on how specific information is delivered\u0026mdash;societally\u0026mdash;exists. Understanding how information influences trust could have significant consequences, e.g., visiting a physician, the medical profession in general, hospitals, and the payer. Three points of should be considered: (1) can level of trust be influenced or even managed regardless of real healthcare performance; (2) ability to revise the data collected, analyzed, and conclusions drawn from them; and (3) action taken to increase trust as well as criteria of resources allocation in healthcare verified. Trust can be considered both as interpersonal, i.e., trust in a physician, as well as social, i.e., trust in a more abstract sense such as groups of people, institutions, and health systems [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] claimed that interpersonal trust occurs when there is a possibility of repeated testing over time, i.e., to what extent a person is trustworthy. [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] suggested that a high level of trust in a physician cannot always be explained by evaluation of objective evidence of trustworthiness since it can also arise as a response to psychic distress created by illness. This means that in healthcare trust originates from the fundamental psychological attributes of seeking care in a state of anxiety, rather than from provider characteristics or patient personalities [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. This is consistent with other suggestions that asymmetry of information between a patient and physician [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] in accordance with the logic of professionalism [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] forces patients to trust their doctor. A meta-analysis of 47 studies showed that the correlation between trust and health outcomes is small to moderate [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Specifically, trust is moderately correlated with self-rated subjective health outcomes, but there is no correlation between trust and objective as well as observer-rated outcomes [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSocial trust can be influenced by patient experience and the general public\u0026rsquo;s view of the system [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Institutional trust in such organizations as hospitals, public payers, or insurers may be an indicator of consumer appreciation of the organization [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] and can be affected by varying degrees of interpersonal and social trust [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. In particular, social trust may be influenced by patient experience, general public opinion [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], professional institutions and legal as well as regulatory protections [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], institutional guarantees, and government regulation of medical education, protection of patient rights, and healthcare quality supervision [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Importantly, these issues need to be conveyed to society as understandable as well as plausibly achievable. This is significant since [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] pointed out that low levels of trust are due to the fact that people may not fully comprehend how the healthcare system (e.g., health insurance) works and how money influences physicians and provider behavior. Moreover, they predict that political communication and mass media may play a central role in shaping public opinion, as \u0026ldquo;facts do matter less than the perception of the facts\u0026rdquo; [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In many countries, a low level of trust is directly correlated with the media, reporting on what goes wrong in healthcare [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] and why. In short, information is one of the critical factors that influences the level of trust in a healthcare system. [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] claimed that the central query of \u0026ldquo;whether better information will indeed translate in higher institutional trust\u0026rdquo; formulates the foundation of this research. This paper explores these queries in the context of Poland and its institutional trust in its medical profession, hospitals, and payer system as well as interpersonal trust at the physician-based level. A breakdown of the study is structured as follows: Sect.\u0026nbsp;\u003cspan refid=\"Sec2\" class=\"InternalRef\"\u003e2\u003c/span\u003e frames the research method, Sect.\u0026nbsp;\u003cspan refid=\"Sec9\" class=\"InternalRef\"\u003e3\u003c/span\u003e illustrates the results, and Sect.\u0026nbsp;\u003cspan refid=\"Sec10\" class=\"InternalRef\"\u003e4\u003c/span\u003e elucidates a discussion and conclusion on healthcare trust in terms of real performance.\u003c/p\u003e "},{"header":"2. Method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch2\u003e2.1. Hypothesis development\u003c/h2\u003e\n\u003cp\u003eIn trust literature, the most frequently studied elements are a physician (i.e., with whom a patient has the most frequent contact), the medical profession, hospitals, payers, and the overall healthcare system [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e]. Given this study is based in Poland, objects studied in this research are the same except for the healthcare system. This is important since Polish society often confuses the healthcare system with the payer, i.e., the National Health Fund (in Polish \u003cem\u003eNarodowy Fundusz Zdrowia\u003c/em\u003e) (NFZ). In Poland, the NFZ operates as a single centralized payer which is the most visible part of its healthcare system. Confusingly, the media and the public often use the words \u0026ldquo;system\u0026rdquo; and \u0026ldquo;payer\u0026rdquo; interchangeably, thus blurring the difference between these concepts. Hence, a lack of clear separation between these objects makes it impossible to prepare the appropriate information for the intervention and subsequent interpretation of the results. Therefore, to obtain less ambiguous results from this research, only the payer (i.e., NFZ) was selected as it is a better recognized and defined object. Trust level objects, in particular, may vary since trust in different objects may have diverse levels of susceptibility to the supplied information. In consideration of the existing literature, the degree to which information influences trust level of a particular object, may depend on the frequency people encounter it in a particular healthcare system [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e] as well as the type of trust being considered (i.e., social or interpersonal). The study considers the following three hypotheses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHypothesis 1\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(\u003cem\u003eH1\u003c/em\u003e): Trust in the payer, i.e., NFZ, is most vulnerable to delivered information.\u003c/p\u003e\n\u003cp\u003eThis hypothesis is based on two foundations. First, trust in an insurer (i.e., in this case the payer) is more amenable to change than in a physician [\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e] [\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e] [\u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e], Second, in Poland\u0026rsquo;s healthcare system patients virtually have no contact with the payer (i.e., NFZ) hence they have no direct experience with it.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHypothesis 2\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(\u003cem\u003eH2\u003c/em\u003e): Trust in a physician is most resistant to delivered information.\u003c/p\u003e\n\u003cp\u003eAccording to the literature, the increase of patient trust in a physician may be associated with the improvement in receiving care promptly [\u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e] as well as perceived physician competence and communication skills [\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e]. Interpersonal trust occurs when there is a possibility of repeated testing over time\u0026mdash;to determine the extent of a person\u0026rsquo;s trustworthy [\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e]. Additionally, there are significant obstacles in delivering information concerning every individual physician, hence the change of trust in this object, apart from experience, may originate mostly from the interrelationship between social and interpersonal trust claimed by [\u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHypothesis 3\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(\u003cem\u003eH3\u003c/em\u003e): The fluctuation of trust level in the medical profession and hospitals after the delivery of information is within the range of trust in a physician and the payer (i.e., NFZ).\u003c/p\u003e\n\u003cp\u003eTrust in hospitals and the medical profession are related to trust at the physician level [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e]. [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e] claimed that patients who trust their physician may worry less about the hospital due to their reliability from their physician to direct them to a suitable one, monitor their quality of service, and their clinical outcome. [\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e] suggested that trust in the medical profession depends to some extent on patients\u0026rsquo; previous experiences with their own doctor. Thus, trust in hospitals may be less susceptible than trust in the payer since approximately 15% of Poles have direct (i.e., personal) experiences with hospitals [\u003cspan class=\"CitationRef\"\u003e44\u003c/span\u003e] versus 85% with their doctor. Similarly, trust in the medical profession may be more susceptible to delivered information than trust in a physician since the medical profession is more abstract than an individual physician and trust is not based directly on personal experience. However, trust in the medical profession should be considered less vulnerable than trust in the payer (i.e., NFZ) since trust in the medical profession may be more related to trust of a physician\u0026mdash;per se [\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n\u003ch2\u003e2.2. Study design\u003c/h2\u003e\n\u003cp\u003eThere is significant difficulty in designing a study that assesses the influence of specific information on societal trust level. Understandably, the possibility of controlling information delivery to individuals and measuring the difference of trust level before and after the delivery is challenging. To overcome this problem, a three-stage experiment in an unchanging group of respondents was applied. The experiment was conducted between September 2015 and March 2016 in two medium-sized Polish enterprises within the context of a multi-staged training program concerning quality systems. The training was conducted in permanent groupings and on all organizational levels, ensuring constant composition of the groups using demographically diverse samples (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). At all stages, the level of trust in a physician, the medical profession, hospitals, and the payer were surveyed. Between the first and second stage, the period of at least one month was used to minimize the likelihood that participants could remember their previous responses. In order to determine whether the change was permanent, the third stage was carried out at least two months after the second stage.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eSample description\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eDemographic factors\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eStage 1\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eStage 2, Control group\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eStage 2, Experimental group\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eStage 3, Participants of control group\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eStage 3, Participants of experimental group\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd colspan=\"5\" align=\"left\"\u003e\n\u003cp\u003eParticipants N (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSample size\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e248 (100)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e125 (100)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e123 (100)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e118 (100)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e119 (100)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGender\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFemale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e122 (49)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e61 (49)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e61 (50)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e58 (49)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e59 (50)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e125 (51)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e64 (51)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e62 (50)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e59 (50)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e58 (49)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo data\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAge\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18\u0026ndash;30\u0026nbsp;years\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e73 (30)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e37 (30)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e32 (26)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e35 (30)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e31 (26)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e31\u0026ndash;45\u0026nbsp;years\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e85 (34)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e44 (35)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e39 (32)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e42 (36)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e38 (32)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e46\u0026ndash;60\u0026nbsp;years\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e75 (30)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e33 (26)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e38 (31)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e33 (28)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e37 (31)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMore than 61\u0026nbsp;years\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12 (5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6 (5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo data\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9 (7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8 (7)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eIncome per family member per month (PPP*)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLess than 450 USD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e57 (23)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22 (18)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e29 (24)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e24 (20)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e31 (26)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e451\u0026ndash;850 USD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e102 (41)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e52 (42)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e46 (37)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e50 (42)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e45 (38)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e851\u0026ndash;1400 USD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e50 (20)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e29 (23)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e20 (16)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e27 (23)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e21 (18)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMore than 1401 USD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e21 (9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8 (6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11 (9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8 (7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11 (9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo data\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18 (7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14 (11)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e17 (14)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9 (8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11 (9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHealth status\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eVery well\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e33 (14)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18 (14)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14 (11)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e20 (17)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13 (11)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWell\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e159 (64)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e87 (69)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e72 (58)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e81 (68)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e68 (57)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAverage\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e45 (18)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e17 (14)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e29 (24)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14 (12)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30 (25)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBad\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo data\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8 (3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6 (5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6 (5)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"6\"\u003e* Purchasing Power Parity \u0026ndash; for 2014 from \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://stats.oecd.org\u003c/span\u003e\u003c/span\u003e (Accessed 14.06.2015)\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cdiv id=\"Sec5\" class=\"Section3\"\u003e\n\u003ch2\u003e2.2.1. Components of mass media information\u003c/h2\u003e\n\u003cp\u003eIn the study, the assumption has been adopted that information delivered by mass media is a contribution to the decision-making process, consisting of two components: (1) statisticalobjective and (2) emotional-subjective [\u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e]. Information (i.e., statistical-objectivity) influences the audience when it is comprehensible for the average user, adequate, knowledgeable, trustworthy [\u003cspan class=\"CitationRef\"\u003e46\u003c/span\u003e], and presented in a structured manner [\u003cspan class=\"CitationRef\"\u003e47\u003c/span\u003e]. As a result, the emotionalnarrative component of information has a more significant impact on the audience than a statistical one [\u003cspan class=\"CitationRef\"\u003e48\u003c/span\u003e] [\u003cspan class=\"CitationRef\"\u003e49\u003c/span\u003e]; however, demonstrating statistical data as a graphical representation can increase its impact on decision-making [\u003cspan class=\"CitationRef\"\u003e50\u003c/span\u003e] [\u003cspan class=\"CitationRef\"\u003e51\u003c/span\u003e].\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section3\"\u003e\n\u003ch2\u003e2.2.2. Perception of healthcare in Poland\u003c/h2\u003e\n\u003cp\u003eSurveys conducted throughout Poland indicate a wide discrepancy between the general public trust in healthcare and individuals using healthcare frequently [\u003cspan class=\"CitationRef\"\u003e44\u003c/span\u003e] [\u003cspan class=\"CitationRef\"\u003e52\u003c/span\u003e]. Responsibility for a lower level of trust from non-users may arise due to a highly correlative link from negative information concerning healthcare disseminated by the media [\u003cspan class=\"CitationRef\"\u003e44\u003c/span\u003e] [\u003cspan class=\"CitationRef\"\u003e52\u003c/span\u003e] \u0026mdash; mainly as a side-effect of the system\u0026rsquo;s rapid change and violent political competition [\u003cspan class=\"CitationRef\"\u003e53\u003c/span\u003e] [\u003cspan class=\"CitationRef\"\u003e54\u003c/span\u003e]. Poland\u0026rsquo;s healthcare is under constant reform, trying to adjust the post-communistic system to Westernized standards, which leads to conflicts between interest groups struggling to protect their current interests versus efforts to try and obtain better access to public funds. The primary result of this strife is negative media output.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section3\"\u003e\n\u003ch2\u003e2.2.3. Design of the information package used\u003c/h2\u003e\n\u003cp\u003eThe information package presented to participants was designed in a manipulative manner by presenting Poland\u0026rsquo;s healthcare as superior (i.e., in a better light) compared to other countries. All the provided data were drawn from the World Health Organization and Eurostat in which particular indicators were chosen in such a way that Poland was a near top healthcare provider. The information package was not in line with the main \u0026ldquo;climate\u0026rdquo; currently being portrayed by Polish mass media. The contrast was designed by comparing the United States as the country with the highest spending rate on healthcare in the world and other wealthy Western European countries as well as with some former communist countries which were on the same economic level before their collapse in 1989. The information package consisted of two types of information. First, it targeted an emotionalnarrative by starting off with the first 30 minutes of the movie \u0026ldquo;Sicko\u0026rdquo; directed by Michael Moore, dubbed in Polish [\u003cspan class=\"CitationRef\"\u003e55\u003c/span\u003e]. Second, statistical-objectives were stressed to elucidate data from official international health statistics presenting a number of graphs mostly illustrating country-related expenditure and data concerning medical errors in American hospitals. The information package was prepared in a contradictory manner to the mainstream point of view represented in mass media.\u003c/p\u003e\n\u003cp\u003eIt was hypothesized that the movie would have an impact on trust for the payer since it focuses on healthcare insurance and system-specific aspects. It might also affect the medical profession, especially when it portrays a medical doctor making a public confession that she had one primary duty\u0026mdash;to use her medical expertise for the financial benefit of the insurer stating \u0026ldquo;\u0026hellip;doctors at health insurance companies actually are responsible for the death of patients\u0026rdquo;. The data regarding medical errors in the US informed participants about the inevitability of medical risk. As a result, this was supposed to increase the positivity and perception of the performance of Polish hospitals as well as show other countries as less forward-thinking. Moreover, indicators such as standardized death rates for specific cancers or ischemic heart disease illustrated Poland as a comparable alternative to countries spending several times more on healthcare, hypothetically influencing all three objects excluding individual physicians since provided information could not be directly linked to each of the participant\u0026rsquo;s personal doctor.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n\u003ch2\u003e2.3. Dependent variables and experimentation\u003c/h2\u003e\n\u003cp\u003eGiven the lack of scale, measuring for the level of trust and testing for their reliability in terms of societal awareness, Poland inclusive of other central and eastern European countries [\u003cspan class=\"CitationRef\"\u003e56\u003c/span\u003e] scales that were developed and tested in the US were adopted (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Trusting a physician and the medical profession, in general, was measured using five element scales developed by [\u003cspan class=\"CitationRef\"\u003e57\u003c/span\u003e]. To estimate the level of trust in the payer (i.e., NFZ) and hospitals, four and three element scales developed by [\u003cspan class=\"CitationRef\"\u003e58\u003c/span\u003e] were applied. The questionnaires were translated into Polish. To ensure authenticity and accuracy of the translations, they were translated back to English by a secondary translator to check whether the meanings remained the same. For each question, a Likert scale was used, and respondents were asked to choose an answer from the following range: 1\u0026mdash;Strongly disagree, 2\u0026mdash;Disagree, 3\u0026mdash;Neutral, 4\u0026mdash;Agree, and 5\u0026mdash;Strongly agree.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eScales used in surveys\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eIndicator\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eStrongly disagree\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eDisagree\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eNeutral\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eAgree\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eStrongly agree\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"6\" align=\"left\"\u003e\n\u003cp\u003ePatient trust in a physician\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e*\u003c/sup\u003eSometimes Dr. __[\u003cem\u003einsert name of doctor\u003c/em\u003e]__ cares more about what is convenient for him/her than about your medical needs.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Dr. __[\u003cem\u003einsert name of doctor\u003c/em\u003e]__ is extremely thorough and careful.\u003c/p\u003e\n\u003cp\u003eYou completely trust Dr. __[\u003cem\u003einsert name of doctor\u003c/em\u003e]__\u0026rsquo;s decisions about which medical treatments are best for you.\u003c/p\u003e\n\u003cp\u003eDr. __[\u003cem\u003einsert name of doctor\u003c/em\u003e]__is totally honest in informing you about all of the different treatment options available for your condition.\u003c/p\u003e\n\u003cp\u003eAll in all, you have complete trust in Dr. __[\u003cem\u003einsert name of doctor\u003c/em\u003e]__.6.\u003c/p\u003e\n\u003cp\u003ePatient trust in the medical profession\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e*\u003c/sup\u003eSometimes doctors care more about what is convenient for them than about their patients\u0026rsquo; medical needs.\u003c/p\u003e\n\u003cp\u003eDoctors are extremely thorough and careful.\u003c/p\u003e\n\u003cp\u003eYou completely trust doctors\u0026rsquo; decisions about which medical treatments are best.\u003c/p\u003e\n\u003cp\u003eA doctor would never mislead you about anything.\u003c/p\u003e\n\u003cp\u003eAll in all, you trust doctors completely.6.\u003c/p\u003e\n\u003cp\u003eTrust in health care payers\u003csup\u003e2,3\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eHealth care payers are good at what they do.\u003c/p\u003e\n\u003cp\u003eWhen needed healthcare payers will pay for you to see any specialist.\u003c/p\u003e\n\u003cp\u003eWhen questioned about what treatments are covered healthcare payers are honest with their answers.\u003c/p\u003e\n\u003cp\u003eHealthcare payers will pay for everything they are supposed to, including treatment that is expensive.\u003c/p\u003e\n\u003cp\u003eTrust in hospitals\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e*\u003c/sup\u003eHospitals only care about keeping medical costs down and not what is needed for my health.\u003c/p\u003e\n\u003cp\u003eHospitals provide the highest quality in medical care.\u003c/p\u003e\n\u003cp\u003eWhen treating my medical problems, hospitals put my medical needs above all other considerations, including costs.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"6\"\u003e\u003csup\u003e*\u003c/sup\u003e negatively worded item is reverse coded; [\u003cspan class=\"CitationRef\"\u003e57\u003c/span\u003e] \u003csup\u003e1\u003c/sup\u003e; \u003csup\u003e2\u003c/sup\u003e [\u003cspan class=\"CitationRef\"\u003e58\u003c/span\u003e]; \u003csup\u003e3\u003c/sup\u003e the Polish translation of the word \u0026ldquo;payers\u0026rdquo; was changed into the singular form \u0026ldquo;\u003cem\u003epłatnik\u003c/em\u003e\u0026rdquo;, i.e., NFZ, in every item since there is only one payer in the Polish healthcare system\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eIn the first stage of the experiment, for the entirety of the participants, the level of trust in a physician, the medical profession, hospitals, and the payer were measured. In the second stage, participants were randomly divided into experimental and control groups of equal size and characteristics. In the control group, re-examination of the level of trust was surveyed, while in the experimental one (i.e., before the survey) participants were shown the information package. In the third stage, the survey was performed again to observe if any change in trust was observable. The manipulation-based check in this experiment is based on observation as well as whether participants believed the intervention. It was performed by a number of research assistants, who monitored participants and occasionally intervened when they were distracted. The research assistants also asked questions to monitor participant attention and continually verified if all participants, in a similar manner, had understood the information.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eStatistical analysis was performed using Statistica version 13 software with the p-value of 0.05 (i.e., a 95% level of significance). Considering the experiment consisted of three stages in which two of them were performed in two groups, in total, a comparative examination of five tests had to be carried out. To validate the significance of differences in the mean value of the various stages the Tukey post hoc test was applied. This test provides sounder, more conservative results than the comparison of pairs via the use of analysis of variance. Results from the test are illustrated in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLack of statistically significant differences in the level of trust between the first stage of the study and the control group in the second stage showed that between the two surveys no factors had influenced the initial level of trust. As a result, changes observed in the experiment were consequential to the information delivered during the study. The results obtained from the Tukey post hoc test indicated substantial increases of trust in the experimental group in the second stage. Comparatively, the control group can be observed by way of the payer (i.e., an increase of 27.7%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) followed by hospitals (i.e., an increase of 10.9%, p\u0026thinsp;=\u0026thinsp;0.011), and, surprisingly, also in physicians (i.e., a decrease of 9.2%, p\u0026thinsp;=\u0026thinsp;0.036). It is worth noting that trust in the medical profession and hospitals were presented a very similar level (i.e., p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) during entirety of the experiment except for the experimental group after the delivery of the information package where trust in hospitals increased (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). Moreover, in the experimental group, trust in the payer reached a similar level to the medical profession (i.e., p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) but trust in physicians decreased and converged with the increased level of trust in hospitals.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eResults of Tukey post hoc analysis\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth rowspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eHealthcare type\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eStage of the experiment\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eStage 2, Ctrl gr. (N\u0026thinsp;=\u0026thinsp;125)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eStage 2,\u003c/p\u003e\n\u003cp\u003eExp. gr. (N\u0026thinsp;=\u0026thinsp;123)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eStage 3, Part. Ctrl gr. (N\u0026thinsp;=\u0026thinsp;118)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eStage 3, Part. Exp. gr. (N\u0026thinsp;=\u0026thinsp;119)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ep-value\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePhysicians\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eStage 1 (N\u0026thinsp;=\u0026thinsp;248)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.000\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.032\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.808\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.277\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eStage 2, Ctrl gr. (N\u0026thinsp;=\u0026thinsp;125)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.036\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.829\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.298\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eStage 2, Exp. gr. (N\u0026thinsp;=\u0026thinsp;123)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.416\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.911\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eStage 3, Part. Ctrl gr. (N\u0026thinsp;=\u0026thinsp;118)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.907\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedical profession\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eStage 1 (N\u0026thinsp;=\u0026thinsp;248)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.735\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.998\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.502\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.975\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eStage 2, Ctrl gr. (N\u0026thinsp;=\u0026thinsp;125)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.896\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.995\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.975\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eStage 2, Exp. gr. (N\u0026thinsp;=\u0026thinsp;123)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.701\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.998\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eStage 3, Part. Ctrl gr. (N\u0026thinsp;=\u0026thinsp;118)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.857\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePayer\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eStage 1 (N\u0026thinsp;=\u0026thinsp;248)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.993\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.000\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.957\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.595\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eStage 2, Ctrl gr. (N\u0026thinsp;=\u0026thinsp;125)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.000\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.999\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.840\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eStage 2, Exp. gr. (N\u0026thinsp;=\u0026thinsp;123)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.000\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.000\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eStage 3, Part. Ctrl gr. (N\u0026thinsp;=\u0026thinsp;118)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.946\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHospitals\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eStage 1 (N\u0026thinsp;=\u0026thinsp;248)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.851\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.165\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.000\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.976\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eStage 2, Ctrl gr. (N\u0026thinsp;=\u0026thinsp;125)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.011\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.774\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.512\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eStage 2, Exp. gr. (N\u0026thinsp;=\u0026thinsp;123)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.258\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.489\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eStage 3, Part. Ctrl gr. (N\u0026thinsp;=\u0026thinsp;118)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.994\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\"\u003e\u003csup\u003e\u0026dagger;\u003c/sup\u003e Ctrl gr. = control group; Exp. gr. = experimental group; Part. Ctrl gr. = participants of the control group in the second stage of the experiment; Part. Exp. gr. = participants of the experimental group in the second stage of the experiment; N\u0026thinsp;=\u0026thinsp;sample size\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e"},{"header":"4. Discussion And Conclusions","content":" \u003cp\u003eThe statistical analysis demonstrated that in the third stage, the level of trust of all tested objects returned to initial values. However, in none of the studied objects specific to the second stage, the experimental group showed a significantly different level of trust from the participants of the control group in either the second and third stage. The analyzed experimentation demonstrated that the level of trust in physicians, the payer, and hospitals appeared to be sensitive to submitted information while trust in the medical profession did not. As a result, the research may prove that information, not in line with the mainstream opinion (i.e., projected from the media) could have a significant impact. The study, to some extent, also confirmed \u003cem\u003eH1\u003c/em\u003e and \u003cem\u003eH3\u003c/em\u003e that trust in the payer is more vulnerable than trust in hospitals. Furthermore, attention should focalize on the requirements that decrease the level of trust in a physician, as indicated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Compared to hospitals, the change is relatively large and in the opposite direction. Taking a closer look at \u003cem\u003eH2\u003c/em\u003e, this result was not expected since first, there was no particular information aimed at influencing trust in a physician and second, the information package was designed to show Poland\u0026rsquo;s healthcare in a more favorable light. Hence, the present research has attested that social trust in the payer and hospitals may be strongly related to trust in a physician as many researchers claim [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e] [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] but this relationship may also be reversely directed.\u003c/p\u003e \u003cp\u003eDue to the unexpected results concerning the change of trust in physicians, per se, one week after the last stage of the experiment, a meeting was organized with the experimental group to discuss the results. Some participants suggested (i.e., and some agreed with the suggestion) that after they saw the information, they felt less vulnerable and dependent on their physician then before. Earlier accounts had the majority of them emphasizing their physician was working against the deficiencies of the system. After reflecting on the information package after the results were computed they were more convinced that other elements of \u0026ldquo;the healthcare chain\u0026rdquo; work correctly, they felt more secure, and they did not need to trust so much in their physician.\u003c/p\u003e \u003cp\u003eThe findings from the study are similar to [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] conclusion in which \u0026ldquo;the greater the sense of vulnerability the higher the potential for trust\u0026rdquo; and to some extent to [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] suggestion that patients who trust their physician may worry less about the performance of other healthcare components. When people perceive healthcare performance as mediocre, they rely more on their physician (i.e., reciprocal with a higher level of trust). But when they realize that other healthcare components work properly, their sense of vulnerability decreases and consequently, they lose trust in physicians who supposedly compensate for the deficiencies of other healthcare components. To some extent, this reasoning might be supported by the fact that under the influence of information, i.e., trust level in a physician, meets trust level in hospitals and approaches trust in the medical profession as well as by the payer. This phenomenon may be interpreted in a way that participants decrease their trust in a physician because they realize their physicians are not bearing exceptional efforts to organize treatment for patients, but operate in an interdependent environment and are equally important as other components of the system.\u003c/p\u003e \u003cp\u003eLimitations to this study invites further research to examine intervention level, i.e., it is likely it would not affect all objects in the same manner\u0026mdash;distorting the results. Still, as the changes in the payer, physicians, and hospitals reported, these objects were assumed susceptible to delivered information. On the contrary, the lack of change in trust in the medical profession may suggest that the object is vulnerable to delivered information but that the intervention may not have been adequate (i.e., or adequately scaled). Scales used in the study were not tested on the general society Poland-wide, therefore cultural or organizational differences in healthcare between Poland and the US might have affected the outcome.\u003c/p\u003e \u003cp\u003eThe main conclusions point towards the findings that information can significantly change people\u0026rsquo;s trust in some components of healthcare regardless of their real performance. This allows for a number of additional inferences to be made. First, trust in healthcare may strongly correlate with the atmosphere in mass media. Second, patient trust in a physician (i.e., at the interpersonal trust level) and social trust in the payer as well as in hospitals may be interrelated also in opposite directions. This means that the increase of trust in hospitals and the payer may correlate with the decrease of trust in a physician. Third, the assessment of healthcare performance [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e] based on trust surveys might be misleading, since any change in trust level may not necessarily translate into an immediate modification (i.e., need) of healthcare functionality. Fourth, delivering designed information is likely to influence the perception of healthcare performance. Fifth, the change in trust level may not be durable. Finally, considering previous studies [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e] [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e], future change in trust is more likely to occur under the influence of information rather than after a genuine change in healthcare performance indicating a long-term conclusiveness even within the bounds of the study\u0026rsquo;s limitations. In retrospect of the current coronavirus pandemic, these conclusions could be applied to restore trust in healthcare during and after it reaches its end. As such, restoring trust in a medical setting is a contemporary concern that countries alike are and will need to deal with in an ever so changing global health response.\u003c/p\u003e "},{"header":"Abbreviations","content":"\u003cp\u003eNFZ \u0026ndash; Polish national payer for medical services (in Polish: Narodowy Fundusz Zdrowia - NFZ)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Ethical Committee of the Voivodeship Rehabilitation Hospital of Children in Ameryka (Poland) has proved that this study complies with the ethics of scientific research described in the Hospital Charter of Ethics and Ethical Principles of the Declaration of Helsinki and other applicable ethical principles and legislation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets collected and analysed during the current study are available in the ResearchGate repository (http://dx.doi.org/10.13140/RG.2.2.23077.12004).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo conflict of interest has been declared by the authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCollected data was partially funded from previous research conducted during the COST Action CA15222 \u0026ldquo;European Network for cost containment and improved quality of care\u0026rdquo; and National Science Centre, Poland (grant number: 2015/17/B/HS4/02747).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization, Data curation, Methodology, Validation, Formal analysis and Writing\u0026mdash;Original Draft preparation, A.G.G. and R.L.; Investigation, Resources, Writing\u0026mdash;Review and Editing, A.G.G., R.L., and G.T.C.; Project administration, A.G.G. All authors have read and approved the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors are grateful to the CA15222\u0026mdash;European Network for Cost Containment and Improved Quality of Care (CostCares) [\u003ca href=\"http://costcares.eu\"\u003ehttp://costcares.eu\u003c/a\u003e] for supporting this study, support from the National Science Centre, Poland (grant number: 2015/17/B/HS4/02747), as well as the people that agreed to participate in the anonymous survey.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBarach P, Fisher SD, Adams MJ, et al. Disruption of healthcare: Will the COVID pandemic worsen non-COVID outcomes and disease outbreaks? 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How do you measure trust in the health system? A systematic review of the literature. Soc Sci Med. 2013;91:10\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDugan E, Trachtenberg F, Hall MA. Development of abbreviated measures to assess patient trust in a physician, a health insurer, and the medical profession. BMC Health Services Research. 2005;5(1):64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEgede LE, Ellis C. Development and Testing of the Multidimensional Trust in Health Care Systems Scale. J Gen Intern Med. 2008;23(6):808\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLo Storto C, Goncharuk AG. Efficiency vs effectiveness: a benchmarking study on European healthcare systems. Economics Sociology. 2017;10(3):102\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"influence of information; physicians; hospital; medical profession; payer; pandemic","lastPublishedDoi":"10.21203/rs.3.rs-195131/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-195131/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: This study empirically evaluates the influence of information on trust at the physician level, the medical profession, hospitals, and with the payer. Restoring trust in a medical setting appears to be significantly affected due to the coronavirus pandemic. Trust improves results from medical treatment, raises perception of healthcare performance, and smoothens the overall functionality of healthcare systems.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: In order to study trust volatility, participants took part in a three-stage experiment designed via: (1) measured level of trust, (2) randomly dividing participants into two groups—control (i.e., re-examination of level of trust) and experimental (i.e., being exposed to a piece of certain manipulative information), and (3) checking whether observational changes were permanent.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Results indicate that in the experimental group the increase of trust was noticed in the payer (27.7%, p \u0026lt; 0.001), hospitals (10.9%, p = 0.011), and physicians (decrease of 9.2%, p = 0.036).\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: The study indicated that in Poland information is likely to influence trust in healthcare while social and interpersonal trust levels may be related to increases of trust in hospitals and in the payer versus decreases in physicians.\u003c/p\u003e\u003cp\u003e\u003cbr\u003e\u003c/p\u003e","manuscriptTitle":"Restoring Trust in Healthcare: Information Impact Case Study in Poland","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-02-09 17:10:12","doi":"10.21203/rs.3.rs-195131/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2021-03-08T00:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-03-02T00:00:00+00:00","index":2,"fulltext":"Recommendation: Major revisions required\nForm responses:\n---\n\nComments to Author:\n---\nThank you for the opportunity to review this paper on the impact of information on trust in various aspects of health services. The authors undertook a randomised controlled experiment to test their hypotheses. This topic is interesting and particularly relevant in the COVID-19 pandemic which has been accompanied by an 'infodemic'. However, the clarity of the reporting of the methods and findings needs improvement before publication.\n\nThe authors should ensure that they are reporting against all aspects of the CONSORT statement (http://www.consort-statement.org/). This sentence from section 2.3 was particularly concerning 'In the second stage, participants were randomly divided into experimental and control groups of equal size and characteristics.' The benefit of randomisation is that it ensures that any differences between the intervention and control group are due to chance. There is no guarantee that the groups will be matched on characteristics, therefore the authors statement left me wondering if some form of stratification was applied to the randomisation to match the characteristics?\n\nIt would also greatly help the reader to understand the intervention if it was reported according to the TIDieR guide (https://doi.org/10.1136/bmj.g1687).\n\nFigure 1 is confusing, while I appreciate the desire to combine the results into one plot, reporting findings from experimental and control groups on connected lines is misleading. For each of the four groups (Physicians, Medical profession, Payer and Hospital), there should be separate lines for the experimental and control groups. Although you have reported that prior to randomisation the baseline data were collected on a single group, I think for clarity the group should, if possible, be split into the experimental and control groups from baseline. The apparent jittering of the groups is also confusing, as the x-axis somewhat presents the passage of time.\n\nMinor points\n* I think it would be useful to provide more of an introduction to the Polish health system. There are useful comments about this throughout the paper, but if these could be consolidated and the concept of the payer explained earlier, the paper will make more sense from the outset.\n* Currently, whenever the authors want to cite someone by name, only the citation number is visible, please use the appropriate format for citations using the authors name in a sentence.\n* Background, 3rd paragraph link number 10 - I think you mean psychological rather than psychic distress.\n* A couple of times in the paper you talk about interpersonal trust occurring when testing is repeated over time. It was not clear to me whether you meant that it was only possible to assess interpersonal trust with repeated measurement. Or by using the term interpersonal trust did you mean the trust that might develop between a patient and another healthcare professional (like a physiotherapist or a nurse running regular blood tests) over time, who they are seeing for repeated testing or treatment?\n* In section 2.2 you talk about the experiment taking place in two medium-sized enterprises. Hopefully as part of fulfilling the CONSORT statement you will explain a little more about this setting. Where they employees, what area of business were the enterprises in?\n* Section 4, 1st paragraph line 5 - focus would be better than focalize.\n* The language is occasionally a little unusual (e.g. my 3rd and 6th minor points), I suspect as a result of not writing in Polish. Any additional help with translation would improve the paper.* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons after the final decision on the manuscript has been made. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **No**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **No**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"reviewerAgreed","content":"","date":"2021-03-01T00:00:00+00:00","index":2,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-02-06T00:00:00+00:00","index":1,"fulltext":"Recommendation: Reject\nForm responses:\n---\n\nComments to Author:\n---\nReview of: Restoring trust in healthcare: Information impact case study in Poland (BHSR-D-20-02977)\n\nGeneral comment:\n\nDear Authors,\nThank you for submitting your manuscript and providing me the opportunity to read your work. Your work is interesting and can be an important contribution to the field of trust research.\n\nHowever, the manuscript as it is presented here is not suitable for publication despite its potential. I strongly encourage you to revise your manuscript before submitting it elsewhere. It took me some time to go through it, but I hope my comments below are useful for you. Here are some general comments:\n* Trust theory: you build your work on empirical trust research. I strongly suggest to include at least a paragraph on trust theory to justify your take on trust. You could draw on Piotr Sztompka, Giddens or Luhmann. There are many to choose from. This will help you to better explain why you choose to research institutional, social or individual trust.\n* Information and communication theory: Same as for trust theory, you provide hardly any information about how communication and information influences trust. Please introduce the importance of information to the reader.\n* Please streamline your Background and Methods section. Also, please reconsider what actually belongs into which section. E.g. you present methods in the results section, you provide background information in the methods section etc.\n* As you will see from my comments, in many occasions you are either superficial, vague, or assume that the reader knows what you refer to.\n* Wording, some of your word choices are not precise enough, e.g. elements.\n* Please re structure your discussion to follow your results.\n\n\nBest wishes,\nYour reviewer\n\nPage Comment\nTitle Please specify the trust relationship. Restoring trust of whom? I assume you refer to the Polish public or Polish patients. Also, what kind of information do you refer to? Medical information?\nAbstract You write:\n''Background: This study empirically evaluates the influence of information on trust at the physician level, the medical profession, hospitals, and with the payer. Restoring trust in a medical setting appears to be significantly affected due to the coronavirus pandemic.''\n\nPlease specify who is trusting in these trust relationships. Do you refer to patient trust in e.g. physicians, or do you describe trust between physicians? Which trust needs to be restored? The trust of the Polish public? \nAbstract You write:\n''Methods: In order to study trust volatility, participants took part in a three-stage experiment designed via: (1) measured level of trust, (2) randomly dividing participants into two groups—control (i.e., re-examination of level of trust) and experimental (i.e., being exposed to a piece of certain manipulative information), and (3) checking whether observational changes were permanent.''\n\nPlease specify 'participants', this might be clear if you address the previous comment.\nAbstract You write:\n'' Conclusions: The study indicated that in Poland information is likely to influence trust in healthcare while social and interpersonal trust levels may be related to increases of trust in hospitals and in the payer versus decreases in physicians.''\n\nWhat kind of information do you refer to?\np.2, l.4 Please add the trusting party to the running title, e.g. Restoring patient trust in healthcare.\np.3, l.27 Who reports the decline of trust, the media, research community? Please specify.\np.3, l.32 Which study to you refer to? Your own?\np.3, 1st paragraph The last two sentences of the first paragraph read like a concluding remark yet you continue to describe the importance of trust for healthcare activities in the 2nd paragraph. I suggest to merge the two paragraphs and cut the two sentences.\np.4, l.0 Please correct: Three points of should be considered:\np.4, l.1 Please explain how you came up with the three points. What is their basis?\nBackground You conclude that your study focuses on ''institutional trust in its medical\nprofession, hospitals, and payer system as well as interpersonal trust''. I suggest that you streamline your background section and focus it much more on these two forms of trust. At present, I feel that your background section provides a list of important information about trust, but there is not enough focus on these two forms of trust - It is confusing.\n\nFurther, information plays a vital role in your paper, yet there is little introduction to the type of information you refer to as well as how the information is communicated. Please unpack. This is necessary to understand your hypotheses in the Methods section.\np.4, l.48 Do you refer to medical literature? Please specify.\np.4, l. 50 Please rephrase: institutional trust in its medical profession, hospitals, and payer system as well as interpersonal trust\np. 5, l. 6 Delivered by whom?\np.5, l.47 You write:\n\n'' The experiment was conducted between September 2015 and March 2016 in two medium-sized Polish enterprises within the context of a multi-staged training program concerning quality systems.''\n\nPlease specify ''enterprise'' and ''quality systems''? Do you write about universities or hospitals and their health quality training programs? \np. 5 Study design I find this section confusing. You may want to explain better your motivation to choose the specific setting, given your explanation of to be expected difficulties. You may also want to consider to discuss these difficulties in the background to set the stage accordingly and to be able to rebut the difficulties.\np.6 , l.0 Certainly too late in the text to introduce that you actually talk about mass media information. You mention the media before, but please make this explicit in the introduction.\np.6, 2.2.1. Components of mass media information I suggest to move the information you provide here to the introduction and please rephrase and unpack. This section is difficult to follow, especially for those who have not a background in trust and information research.\np.6, 2.2.2. Perception of healthcare in Poland I suggest to move the information you provide here to the introduction and please rephrase and unpack.\np.6, l.33 Please explain what the content of the first 30 minutes of Sicko are. Readers of your article will not necessarily know this movie. Also, how do you justify your choice.\np.6, l.41 Please justify your hypothesis and explain who hypothesized this hypothesis, who is 'It'?\np.6, l.57 Please rephrase this sentence, I am puzzled.\np.6, l.60 What do you refer to when using the word 'element'? Do you write about items? Questions? Same for the following reference to 'element'.\np.6/7 Figure 2 and scales You combine a range of scales. Please explain why those scales as opposed to other scales. Also, when comparing the questions for 'Patient trust in a physician' and 'Patient trust in the medical profession', I doubt that they actually measure different relationships. They are extremely similar. Please explain your rational for choosing and combining these questions.\np.8, l.15 Move the experimental groups up to the Methods section.\n\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons after the final decision on the manuscript has been made. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **No**\n* Declaration of competing interests: **None**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **No**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **No**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"reviewersInvited","content":"","date":"2021-02-05T00:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2021-02-05T00:00:00+00:00","index":1,"fulltext":""},{"type":"editorAssigned","content":"","date":"2021-01-31T00:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2021-01-30T23:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2021-01-30T23:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"","date":"2020-12-17T00:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"564073ad-a74e-4008-a3d5-7a6edb98e07c","owner":[],"postedDate":"February 9th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":2198924,"name":"Health Economics \u0026 Outcomes Research"},{"id":2198925,"name":"Health Policy"}],"tags":[],"updatedAt":"2021-02-09T17:10:12+00:00","versionOfRecord":[],"versionCreatedAt":"2021-02-09 17:10:12","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-195131","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-195131","identity":"rs-195131","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}