Social factors associated with trust in healthcare in northern Sweden: a cross-sectional study | BMC Public Health
About two thirds of the participants (68.5%) had high confidence in the health system. Younger participants, women, those born outside Sweden, living in smaller municipalities, having lower education, experiencing financial stress or having lower social capital were associated with lower confidence in healthcare. But lower income was associated with higher confidence.
The study showed a moderately high level of confidence in healthcare in northern Sweden. This can be compared with the national average of 61% reported in 2019 and with the 73.3% reported in southern Sweden in 2007 [4, 21]. An international comparison of 31 countries that used the same question to assess confidence in the health system was made between 2011 and 2013 and showed that Belgium had the highest level with 72% reporting high confidence, followed by Spain and the Scandinavian countries, with percentages ranging from 56 to 59%. Large differences between the countries were reported: Germany (42%), France and the United Kingdom (about 30%) and the United States (19%). [19]. However, comparing countries is a challenge due to the differences in health systems and cultures and the lack of a standard method of measuring trust [22].
The relationship between age and trust is in line with previous research, which has shown that older populations tend to have more confidence in the health system [12, 23, 24]. This can be explained by the modernization theory, which postulates that the economic, political and cultural changes in the post-industrial societies result in the rejection of traditional social institutions. Younger generations are assumed to have greater changes in cultural values, which in turn can lead to greater distrust of the institutions; that is, these structural changes make it more difficult for young people to pursue the same things that previous generations had aspired to. [25].
This study observed lower confidence among women compared to men. Although these differences were small, this finding was surprising as a previous study in 2009 from northern Sweden showed an opposite relationship [12]and the literature often shows lower confidence among men [9]. Women are usually more exposed to health care through their own experiences or by accompanying their spouse or children. This higher exposure to services together with the constant threat to close down healthcare, including maternity wards, in rural northern Sweden [26]may have led to different experiences and perceptions of health care among women, and consequently to reduced confidence in the health system [27].
According to our results, lower education and experiencing financial stress were also associated with lower confidence, while lower income was associated with higher confidence. The literature points in different directions when it comes to the relationship between trust and income and education. Some studies have shown a link between low income and lower confidence in caregivers and health information [9, 10]while other studies have observed that higher education and income were associated with lower confidence in the health system [19, 23, 24]. The different direction of the relationship between economic stress and annual disposable individual income and confidence in this study suggests that these two variables capture distinct aspects of socioeconomic status that need to be further explored.
Participants born outside Sweden reported lower confidence in healthcare compared with those born in Sweden. Previous research in Sweden showed similarly low confidence in Swedish healthcare among refugees and immigrants [13, 14]. These differences can be explained by the perceived discrimination of the system against participants born outside Sweden [11]. The different health system’s expectations of immigrants could further lead to worse experiences and thus reduce confidence in the health system [13, 14].
According to our results, participants living in smaller rural municipalities had lower confidence in the health system compared to those living in larger urban areas. However, a multinational study with 31 countries showed opposite results; people living in urban areas showed lower confidence in the health system [19]. Results have been observed in China similar to the case in northern Sweden, while no differences between urban and rural areas were reported in the UK [23, 28]. Our results are probably context-specific for northern Sweden where there are smaller rural municipalities without hospitals and relatively long distances from care facilities, and where rural citizens experience a policy to abandon by central authorities. For example, the closure of certain services in rural areas led to mistrust of institutions in general and healthcare in particular. [17].
Finally, our study showed that those with better social capital had more confidence in the health system. A complex and two-way relationship between horizontal trust and social or public trust in the health system has been discussed in the literature [29]. Studies have shown that social capital can improve trust in, quality of and access to the health system by changing users’ perceptions of healthcare [9]. This reinforces the theory of social capital, indicating that social experience and involvement in social activities play an important role in building social and horizontal trust, which in turn helps to build reliable organizations. [9].
Strengths and limitations
The HET survey offers a unique set of data that contains several sociodemographic variables, the variable confidence in the health system and a representative large sample of the region. Complementing HET with register-based socio-demographic data also reduced reporting bias, especially for sensitive information such as income and place of birth.
However, several issues should be considered when interpreting the results. First, while the response rate of 48% is comparable to other national surveys, we can not rule out sample bias because the population composition in the included regions, for example, indicates a higher proportion of people born outside Sweden (9.1% compared to 6.4% who responded on this survey). The extent and direction of such bias could not be assessed. Second, given the study design, a reverse causality can not be ruled out. For example, horizontal trust has been associated with high confidence in the health system, while trust in authorities and social institutions can strengthen horizontal confidence. [30]. Third, certain relevant factors such as healthcare needs, experience in healthcare, behaviors of healthcare professionals, continuity of care and availability of services could not be measured in this study. Because these factors are important for understanding trust, their inclusion may have changed some of our results. In addition, since ethnicity was not measured in the survey, we could not assess the Sami indigenous population’s confidence in the health system. Finally, our results are time and place limited. It is unclear whether our findings can be generalized to other environments in or outside Sweden. Although the current Covid-19 pandemic may have affected the level of trust in health care in northern Sweden, we expect the pattern of trust among people over the various social characteristics to remain similar.