Constructing feelings of trust in healthcare:
Examining the expectations and experiences of
mothers from the UK and the U.S. who have accessed
maternity care in the Netherlands
1
Zeme Davey Ross
Constructing feelings of trust in healthcare:
Examining the expectations and experiences of mothers from
the UK and the U.S. who have accessed maternity care in the
Netherlands
Master’s thesis
MSc Sociology: Social Problems and Social Policy
Zeme Davey Ross
10711260
First Supervisor: Barbara Da Roit
Second Supervisor: Patrick Brown
Table ofContents
Acknowledgments ...5
Abstract...6
1. Introduction...7
2. Health and maternity care in the U.S., the UK and the Netherlands...11
3. Theoretical framework ...15
3.1 Understandings of trust ...16
3.2 Trust in healthcare: the importance of institutions ...18
Figure 1: Table of research framework to be used to guide empirical analysis ...27
4. Methodology ...29
4.1 Research design ...29
4.2 Data collection ...30
Figure 2: Table of participants from the UK (pseudonyms are used) ...31
Figure 3: Table of participants from the U.S. (pseudonyms are used) ...32
4.3 Data analysis...34
4.4 Ethical considerations...35
4.5 Terminology...37
5. Findings and discussion ...38
5.1 Expectations based on second-hand and mediated knowledge...38
5.2 Expectations of trust in professionals...43
5.3 First-hand experiences of Dutch health and maternity care...47
5.4 Experiences of interpersonal interactions in healthcare ...55
5.5 Conclusion...58
6. Final Conclusion...61
Bibliography ...66
Appendix ...75
Acknowledgments
This thesis has been a journey, and a challenging one at that. There are many people that I would like to thank for supporting me during this time.
Firstly, I would like to thank my supervisors Barbara Da Roit and Patrick Brown for their continued guidance and helpful insights.
I would also like to thank all of the participants who took part in this thesis, who were very open about sharing their thoughts and experiences with me. It was a privilege to meet you all and I am very grateful for your time.
I owe an enormous debt of gratitude to my parents Kirsteen and Richard, my step-mum Gwendolyn and my sister Rosie for being so kind and supportive throughout this, as well as to my niece Sia for cheering me up in the most stressful of moments. I want to show huge appreciation to my network of international friends whom I met in Amsterdam, as well as to my older friends from home and abroad. I really could not have achieved this without all of your enthusiasm, care and also, some of your proofreading skills. I specifically want to thank Celia, Djurre, Jemma and Rachel for their support.
Thank you to Irma and Alan L. for letting me stay with them in Oudebildtzijl during the research period of this thesis. I am grateful for the thoughtfulness you showed me during this time, as well as for facilitating my relocations.
Thank you also to Linda and Alan S. for giving me my new home in London. Your kindness has helped to ease a great deal of pressure.
Finally, I would like to show huge gratitude to the European Union for making it possible for me, a British citizen, to study a Master’s degree in another European country. For this opportunity, I have been very fortunate.
Abstract
This study examines the construction of feelings of trust in healthcare, focusing on how this is shaped by expectations and experiences when crossing cultures and institutions. The aim of this thesis is to examine the cross-cultural, institutional factors that affect trust in the context of healthcare. In order to do so the factors influencing trust between two groups of expats are examined using a comparative design.
By firstly presenting the similarities and differences between health and maternity care in the Netherlands, the UK and the U.S., an assumption about the importance of institutional differences for determining trust is made.
Defining trust links it to other key concepts including confidence and risk, as well as helping to understand how expectations can determine outcomes of trust. Specifically within healthcare, trust is found to prevent feelings of vulnerability and strengthen the relationship between professionals and their patients. Trust is also revealed to be important both at the micro level as well as at the macro level, suggesting that individual experiences of trust have an effect on wider society.
In order to assess the factors that determine feelings of trust in healthcare, this thesis conducted semi-structured interviews with twenty participants, ten ‘expats’ from the UK and ten ‘expats’ from the U.S., who have used healthcare and in particular, maternity care in the Netherlands.
The mediated, public-direct and private-interactive types of knowledge that have been determined by Brown and Calnan (2012) have been used to guide the results of the data analysis (Brown and Calnan, 2012: 49). The results revealed that a number of factors influence trust for those accessing healthcare when crossing cultures and institutions. These factors mainly emphasised the importance of institutional background for determining expectations and experiences of trust in a new healthcare system. Moreover, although mediated experiences are important, it is public-direct and particularly private-interactive experiences that have a more significant impact on outcomes of trust in healthcare.
This thesis has found that research examining the perspective of expat women experiencing maternity care from a range of institutional backgrounds after immigrating to a new country is a neglected area. This thesis hopes to fill this gap, while supplementing future research in this area.
1. Introduction
Trust is ‘essential for the smooth functioning of society’ (van der Schee et al., 2007: 57). It is important to look at trust in the context of healthcare because it ‘vital for quality healthcare outcomes’ (Brown et al., 2011: 280). Furthermore, trust is important for understanding the relationship between medical professionals and their patients (Rowe and Calnan, 2006: 4). A lack of trust in this context may increase feelings of vulnerability, since patients put all of their trust into healthcare professionals based on the assumption that they will always act in their best interest (Gilson, 2003: 1457, Hupcey et al., 2001: 284-285). Vulnerable feelings should be prevented since they create 'stress and anxiety which affects physiological, psychological and social functioning' (Rogers, 1997: 65).
The societal shift to modernity discussed by Giddens (1990), explains that interactions now occur with strangers and not only with people whom we already have social ties (Giddens, 1990: 80). There is now a suggestion that within this, we assume that we can trust professionals (Pilgrim et al., 2011: 15). The interactions that occur with professionals in a healthcare system are hugely important, since they have the ability to impact on the trust of patients. This is because interactions ‘encourage mutual respect’ between patient and doctors, while promoting ‘shared understandings, persuasion and promises’ (Gilson, 2003: 1461). Moreover, trusting outcomes of interactions within a system can reflect the system as a whole rather than just the individuals that represent it (Jalava, 2003: 184).
Expectations and experiences are both important factors for determining feelings of trust. The relationship between trust and expectations is important to consider in the shaping of eventual lived experiences. This is particularly true in healthcare since expectations may impact on future trusting encounters (Howick et al., 2015: 2). Expectations of maternity care may be particularly valuable for determining trust, since the birth of a child is highly anticipated (Martin et al., 2013: 103).
By using these understandings of trust, this thesis has identified the research problem, which it is aiming to investigate. This problem looks at the dynamics that can affect trust in healthcare, and specifically maternity care. In order to explore this, the factors affecting trust between two groups of ‘expats’ living in the Netherlands will be examined.
A group of ‘expat’ mothers from the UK and a group of ‘expat’ mothers from the U.S. were chosen as the research sample. Within this, the intention has been to research; the significance of a patient’s institutional background for determining their expectations of trust in professionals within a new healthcare system, how expectations of healthcare based on knowledge and autonomy acquired from the media and social networks can help to determine levels of trust when accessing healthcare, and also the influence of interactions with healthcare professionals for shaping feelings of trust and vulnerability in a healthcare system. A research framework has been established to help guide the empirical analysis. This is based on the three types of knowledge identified by Brown and Calnan (2012); mediated,
public-direct and private-interactive experiences that have been found to determine
feelings of trust (Brown and Calnan, 2012: 49).
This thesis has chosen to look at ‘expat’ mothers as a social group. Distinguishing between the identities that are formed from the terms ‘expat’ and ‘immigrant’ is quite problematic. This is because arguably the term ‘expat’ is only applicable to white and middle or upper class individuals (Remarque Koutonin, 2015: 1) who are able to retain ‘the means and the freedom to choose to return to their home country’ (Luu, 2015: 1). Connotations of immigrants are ‘highly racialized and class-based’ (Leinonen, 2012: 213). Since in general, evidence suggests that the term ‘expat’ can be applied only to groups of white individuals living abroad, it is important to note that although this has mostly been found to be true, this research does include a small number of expats who consider themselves to be from an ethnic minority.
The reason that the term ‘expat’ has been chosen in thesis over the term ‘immigrant’ is because many of the participants identify themselves as being part of the expat community in the Netherlands. It was through these networks, that most of the participants became involved in this research and it is because of this that it became an important concept within this research. It is important to point out that despite the problematic connotations of the term, the use of the term ‘expat’ rather than ‘immigrant’ throughout this thesis is not meant to cause any offence.
Expat mothers are an important social group to research because for people living abroad, who are lacking a social support network, feelings of vulnerability can be frequent (Rogers, 1997: 65). Besides this, pregnancy and birth in itself can cause feelings of vulnerability (Spidsberg, 2007: 478). Within these situations, the
importance of trust may become heightened. Moreover, maternity care in the Netherlands is unique due to high rates of midwife-assisted, home births and low rates of pain relief during labour when compared to other developed countries (De Vries, 2004: 7, 9, Klomp et al., 2013: 4-5). As a result, the experiences of using Dutch maternity care institutions offer some very insightful perspectives for this thesis to research.
Empirical research looking at the experience of maternity care is vast. It is often related to the theme of vulnerability. It offers some interesting observations, particularly in relation to those who have suffered from particularly traumatic births (Nilsson et al., 2010: 298), high-risk pregnant women (Kelly et al., 2001: 132, Dudzinski, 2006: W1) and pregnant women from ‘non-Western’ backgrounds (Kabakian-Khasholian et al., 2000: 103, Boerleider, 2015: 3). However, research in this area rarely offers a perspective of women experiencing maternity care from a range of institutional backgrounds. This thesis hopes to fill this gap, while supplementing future research looking at this.
This research is socially relevant because it highlights how the impact of healthcare encounters between healthcare professionals and patients can help the healthy functioning of society. Additionally, this research is relevant to policy since it raises the issue of trust for vulnerable groups within healthcare systems, and suggests ways in which to prevent feelings of vulnerability for these groups in these circumstances.
This thesis initially looks at Health and maternity care in the U.S., the UK and
the Netherlands, contrasting the healthcare systems and maternity care institutions in
the Netherlands, the UK and the U.S. This has been in order to contextualise the expectations and experiences of trust and vulnerability that may have occurred for the participants of this thesis. Following this, a Theoretical Framework has been developed with the aim of defining trust, while also looking at the importance of it in terms of institutions. Following this, a main research question and sub-questions have been specified. Based on these questions, a research framework has been established in order to direct the empirical analysis.
The next chapter focuses on Methodology concentrating on the research design, data collection, data analysis, ethical considerations and terminology. Subsequently, the Findings of this thesis are then discussed, analysing recurring and connecting themes from the interviews that were conducted. These findings have been
arranged into a range of subchapters focusing on; expectations based on second-hand and mediated knowledge, expectations of trust in professionals, first-hand experiences of Dutch health and maternity care and finally, experiences of interpersonal interactions in healthcare. This thesis then concludes in the final chapter.
The United Kingdom has been shortened to the ‘UK’ throughout this thesis and the United States has been shortened to the ‘U.S.’ When referring to the participants, the participants from the United States will be referred to as ‘U.S. participants’, whereas the participants from the UK will be referred to as ‘British participants’. This is because using the term ‘American’ might refer to other parts of the North or South American contents and not only the U.S. (Martinez-Carter, 2013: 1).
2. Health and maternity care in the U.S., the UK and the Netherlands
Examining the differences between maternity care institutions in the UK, the U.S. and the Netherlands will allow for a better understanding of the research design and findings of the thesis. Maternity care institutional differences will also be discussed briefly in relation to the whole healthcare systems in these countries, in order to provide a context for the reader.
Firstly in The Netherlands, the healthcare system is based on the Health Insurance Act, the Zorgverzekeringswet in Dutch, which was implemented in 2006 and which remains embedded in the ideas of ‘Bismarckian’ insurance principles (Schäfer et al., 2010: 13, 21). This has led to a single-tier insurance system in which ‘multiple private health insurers compete for insured persons’ (Schäfer et al., 2010: 13, 19-21). Although this is a private-insurance based system, healthcare in the Netherlands is universal as a result of this act (Mosca, 2012: 8).
Structurally, the UK healthcare system varies in many ways to the Dutch healthcare system. This is mainly due to it being organised through different funding mechanisms. The National Health Service (NHS) in the UK is paid for through taxation and is free at the point of delivery except for certain services such as prescriptions, dental services and eye tests (The King’s Fund, 2016: 1, NHS.uk, 2015: 1), rather than through a private-insurance scheme. But similarly to the Netherlands, the UK has a universal healthcare system (Pilgrim et al., 2011: 105). However, the NHS has been under considerable strain in recent years, where there has been ‘falls in real funding and rising demand’ (Vize, 2011: 1248).
The U.S. healthcare system is different in many ways to the Netherlands, but is especially different to the UK. Since 2010, the Patient Protection and the Affordable Care Act (U.S. Department of Health & Human Services, 2015: 1), also known colloquially as ObamaCare (Zezima, 2014: 1) has been in place. The intention of this has been to make healthcare more affordable and more accessible in the U.S. (U.S. Department of Health & Human Services, 2015: 1). Overall, there has been a drop in the rate of those who are uninsured, which can be linked to the implementation of the Affordable Care Act (Smith and Madalia, 2015: 18-21). However, most people are still insured through private insurance companies and others do not have insurance at all (Smith and Medalia, 2015: 1). Unlike the Netherlands, the U.S. has a two-tier system (Schäfer et al., 2010: 13, Pilgrim et al,
2011: 30). The U.S. also does not have universal healthcare (Davis et al., 2014: 1), unlike the Netherlands and the UK. Instead it has a ‘market-based system’ (Barton, 2010: 3). The lack of universal healthcare in the U.S. might be understood within the individualism that is ‘highly favoured’ in the U.S. and the fact that solidarity is ‘distrusted much more than in Northern Europe’ (Pilgrim et al., 2011: 100).
The Netherlands’ unique approach to maternity care has helped to focus this thesis specifically around maternity care expectations and experiences. As De Vries author of Pleasing Birth: Midwives and Maternity Care in the Netherlands (2004) explains: ‘birth in the Netherlands is accomplished much differently than it is elsewhere' (De Vries, 2004: 9). Much of this relates to the high rates of midwife-assisted, home births in the Netherlands and how this greatly differs from other developed countries where medical intervention during birth has increased with the rise of technology (Johanson et al., 2002: 892). Home birth policies are also greatly supported by the Dutch government in the Netherlands, which De Vries argues is unusual for developed countries (De Vries, 2004: 7). As well as home births, it is fairly common to not receive pain relief during labour (Klomp et al., 2013: 4-5). Klomp et al.’s (2013) study shows that in 2011, 85.5 percent of the women in their study were preparing to give birth without any type of pain relief, while the eventual findings showed that only 9.8 percent eventually had an epidural (Klomp et al., 2013: 4).
Furthermore, a particularly exceptional feature of Dutch maternity care is the postnatal service that is offered to new parents for up to 8-10 days in the Netherlands (Boztas, 2013: 1). After a woman has delivered her baby, she is given the opportunity to have a maternity nurse, a kraamverzorgster in Dutch, come to her home to assist her with a number of needs. These needs are not only related to caring for the baby but include many other helpful tasks including; cleaning, cooking, shopping, assistance with breastfeeding and looking after the other children if there are any (Kraamzorg Homecare, unknown date: 1). This postnatal service is well supported by policymakers and the government in the Netherlands, who see it as a ‘pillar’ of maternity care (De Vries, 2004: 74). This service also further enables women to give birth at home or to have short-stay hospital births, which may especially be beneficial to women who lack a network of friends and family in the Netherlands (De Vries, 2004: 76).
In relation to this, expat websites guiding new residents of the Netherlands, emphasise the differences to expect in the Dutch maternity care when moving to the Netherlands. They focus on home births; midwife-led care and postnatal services, contrasting this with other developed countries’ approaches to birth (Expatica.com, 2012: 1 and Walsh, 2015: 3).
There are some similarities between maternity care in the UK and in the Netherlands. In the UK, midwives also provide the primary care for expectant mothers (National Childbirth Trust, unknown date: 1, Valk, 2011: 12). A recent survey of senior midwives in the UK revealed that they were overworked and understaffed due to ‘maternity unit closures, budget and training cuts’ (The Royal College of Midwives, 2015: 1). While many midwives in the UK were found to be working unpaid overtime and missing out on breaks (The Royal College of Midwives, 2015: 1).
In terms of pain relief, the use of epidurals and spinal anaesthetic in the UK in 2009 had risen to 36.5 percent (Campbell, 2009: 1) and is therefore somewhat higher than in the Netherlands, suggesting that birth is fairly medicalised in the UK.
Postnatal care in the UK does exist but is minimal. A survey conducted by The Royal College of Midwives has found that postnatal care is not prioritised in the UK, where current visits are considered to be too short (The Royal College of Midwives, 2014: 11). They also argue that individualised and regular postnatal care, organised preferably during the antenatal period, helps women’s long-term health as well as post-birth (The Royal College of Midwives, 2014: 5).
In the U.S., maternity care is highly medicalised (Bak, 2003: 1) especially when compared to in the Netherlands. It is rarely midwife-led and is more likely to be delivered by an obstetrician (De Vries, 2004: Figure 2-3 43 and Rochman, 2012: 1). Furthermore, caesarean sections are common, especially when compared to the Netherlands (De Vries, 2004: Figure 2-5 45). In fact the high rate of Caesarean sections, 32.9 percent of all births in the U.S. in 2009, has led to criticism by the World Health Organisation (WHO) who advise that the Caesarean rate should not exceed 15 percent (Hendrickson, 2012: 1). Moreover, in 2003 it was found that up to 61 percent of women have had an epidural or spinal anaesthesia during labour (Osterman and Martin, 2011: 1). Cheng et al. (2006) argues that finding information about postnatal care in the U.S. is difficult but they did find that the current routine
typically happens 6 weeks after birth and is ‘limited to vaginal examinations and contraceptive educations’ (Cheng et al., 2006: 37-38).
This research aims to use these understandings of different healthcare systems in the Netherlands, the UK and the U.S. This is to reveal the different ways in which pre-determined ideas of healthcare influence the experiences of trust and vulnerability in maternity care in the Netherlands.
3. Theoretical framework
This chapter examines the vast amount of research that is available investigating both trust as a concept, and as a part of experiencing healthcare. Trust in healthcare is important to research, since as Shore (2007) explains trust is 'the very foundation' of healthcare and prevents feelings of uncertainty for patients (Shore, 2007: 4). Furthermore as Brown (2009) finds, trust facilitates ‘positive patient experiences’ (Brown, 2009: 391). Both Brown and Pilgrim et al. (2011) find that a lack of trust can lead to vulnerability (Brown, 2009: 391, Pilgrim et al., 2011: 11), which can undermine an individual or group’s ontological security. Rogers (1997) supplements this, arguing that vulnerability leads to 'stress and anxiety, which affects physiological, psychological and social functioning' (Rogers, 1997: 65). Additionally, Brown et al. (2011) view trust as being imperative both at the micro and macro levels (Brown et al., 2011: 281), suggesting that the effect of trust is not only important for individual experience but also for wider society.
In terms of related literature, research looking at trust in healthcare institutions has thus far been neglected (Rowe and Calnan, 2006: 5). According to Rowe and Calnan (2006), literature in this area can be expanded through studies focusing on ‘inter-country comparisons to identify whether such trust varies by health system’ (Rowe and Calnan, 2006: 5). There is some research on changing trust patterns within national health systems but much less is known about trust across different health systems. This is also an important area to examine, due to increasing mobility worldwide, where as Giddens (1990) argues, the local and the global ‘have become inextricably intertwined’ (Giddens, 1990: 108). This has resulted in health systems becoming more open. These are areas that this thesis hopes to add to.
The available research focusing on maternity care is limited in respect of trust. Boerleider’s (2015) study is closest in resemblance to this one, since it analyses the experience of maternity care for women living abroad in the Netherlands (Boerleider, 2015: 3). Her study focuses on the prenatal period for ‘non-western women’, their midwives and maternity care assistants (Boerleider, 2015: 17). Boerleider found that the inadequate experiences of prenatal care for these women were related to a number of factors including: cultural differences, socio-economic status, social networks, and communication factors such as language barriers (Boerleider, 2015: 171-2). This gives an idea about what themes could be present within the findings of this study,
despite the differences in background between Boerleider’s participants and the participants of this thesis.
The aim of this thesis is to examine dynamics that can affect trust in healthcare, and specifically maternity care. In order to do so the factors affecting trust between two groups of expats living in a third country will be examined. This theoretical framework focuses on: theoretical understandings of trust, the importance of institutions for trust in healthcare, what factors have been found to influence trust in healthcare and how institutions interact with these factors. After this, a research framework is established in order to guide the empirical analysis. Within the following areas, key concepts are considered in order to establish a research question and related sub-questions. These concepts are also expected to be present within the empirical findings.
3.1 Understandings of trust
Firstly, to understand trust, it is important to acknowledge how it links with
confidence. As Luhmann (1990) argues, the concepts of trust and confidence often
become combined in meaning (Luhmann, 1990: 96-99). Giddens responds to Luhmann, arguing that trust is actually a part of confidence, rather than a completely separate notion (Giddens, 1990: 32). Giddens views trust as being part of society’s shift to modernity (Giddens, 1990: 87) and defines trust as the: ‘confidence in the reliability of a person or system, regarding a given set of outcomes or events, where that confidence expresses a faith in the probity or love of another, or in the correctness of abstract principles’ (Giddens, 1990: 34). Also in response to Luhmann, Jalava (2003) argues that confidence is more easily attainable than trust since trust is spread by familiarity (Jalava, 2003: 175, 178).
Luhmann continues by arguing that the similarity between trust and confidence can be understood by considering that they both offer an expectation that may convert into feelings of disappointment (Luhmann, 1990: 97). This link between trust and expectations in Luhmann’s explanation links closely to this thesis’ argument that expectations have the ability to shape feelings of trust in healthcare institutions.
In relation to this, Gilson (2003) argues that the patient and provider relationship is ‘rooted in specific expectations’ which vary in degree depending on the
perceived risk, patient discretion and access to information (Gilson, 2003: 1459). Howick et al. (2015) add that both positive and negative expectations are thought to have an impact on an eventual trusting encounter (Howick et al., 2015: 2). A negative expectation, may lead to a loss of trust in a health institution and a withdrawal of similar interactions, while a positive expectation may have the opposite effect.
In terms of the themes of this thesis, expectations of maternity care institutions may be particularly valuable in determining trust, since as Martin et al. (2013) argues, there is often increased anticipation surrounding the birth of a child (Martin et al., 2013: 103). Furthermore, individuals may have culturally specific expectations of how a doctor should behave with their patients, which could possibly lead to disappointment or confusion, and also to a loss of trust. Bussey-Jones and Genao (2003) found this to be true and they argue that respect of cultural diversity will lead to positive healthcare outcomes (Bussey-Jones and Genao, 2003: 733). This includes incorporating patterns of communication that permit language differences (Bussey-Jones and Genao, 2003: 733).
To further understand the meaning of trust, it is necessary to relate trust to
risk. Luhmann views trust as providing a solution for problems of risk and the
outcome of possible trust depending on our capability to discriminate between risks that are either ‘remote or a matter of immediate concern’ (Luhmann, 1990: 95, 98). In situations of encountered risk such as when accessing healthcare, the probability of trust is likely only where damage is more likely than advantages (Luhmann, 1990: 98). In terms of this thesis, this may apply to women who are more at risk of a complicated birth, who may feel an enhanced need to trust their midwife or doctor, especially if they lack a strong social network.
In the same way as Luhmann, Lewis and Weigart’s (1985) theory of trust argues that there is always the potential for risk in trusting encounters (Lewis and Weigert, 1985: 968). They view trust as a ‘collective attribute’ among social groups rather than an individually experienced psychological state (Lewis and Weigert, 1985: 968). Lewis and Weigart offer two relevant explanations of trust that are expected to help in understanding the experience of trust in healthcare institutions in this thesis. Firstly trust can be understood as a cognitive process, where we actively choose who is trustworthy and who is not (Lewis and Weigert, 1985: 970). Hupcey et al. (2001) support this theory arguing that if a risk is seen as being too great; individuals consciously decide not to trust (Hupcey et al., 2001: 285).
Secondly for Lewis and Weigart, trust can be understood emotionally, where we devote ourselves emotionally to particular social situations, leading to the possibility of distrust (Lewis and Weigert, 1985: 971). Similarly, Pilgrim et al. view trust as ‘both negative and positive, calculative and non-calculative, rational and emotional’ (Pilgrim et al., 2011: 11). These theories of different types of trust particularly emphasise the social and psychological implications of trust that may be present in the findings of this thesis.
The aspects of trust that have been discussed: confidence, expectations, risk, and cognitive and emotional elements, are anticipated to be present within the empirical findings. They are also likely to be shaped by the institutional context in which they are embedded, and as a result institutions are likely to have an important role in shaping trust. Considering this, this thesis will now continue by looking at the importance of institutions for trust in healthcare.
3.2 Trust in healthcare: the importance of institutions
According to Schwei et al. (2014), trust in healthcare institutions covers a wide variety of areas, they define it as: 'patient's trust in the medial profession, hospitals, insurers, healthcare organizations and systems' (Schwei et al., 2014: 333). Rowe and Calnan explain that traditionally trust in institutions has been high, which they believe is linked to ‘patients’ high level of interpersonal trust in their doctor’, ‘clinician’s professional status’ and ‘recent provision of health care as a state guaranteed right’ (Rowe and Calnan, 2006: 4). However, more recently they have found that structural and organisational changes within healthcare, including the rise of patient autonomy, as well as public portrayals of healthcare have impacted on trust in institutions (Rowe and Calnan, 2006: 4-5).
In agreement with Rowe and Calnan, Robb and Greenhalgh (2006) relate trust to global changes such as: ‘economic growth, stable and efficient democratic government, the equitable provisions of public goods such as education and health care, and social integration’ (Robb and Greenhalgh, 2006: 435). These changes can be understood within Giddens’ theory of modernity, in which he argues that society has seen large transformations with a ‘worldwide’ influence since the seventeenth century (Giddens, 1990: 1, 96)
Modernity has resulted in a society of disorientation ‘caught up in a universe of events we do not fully understand’ (Giddens, 1990: 2), in which we have very little control (Giddens, 1990: 2-3). This relates to trust in institutions because within this historical shift to modernity, interactions now occur with strangers and not simply with people whom we already know (Giddens, 1990: 80). This includes interactions, what Giddens refers to as ‘facework commitments’, that occur during ‘access points’ with professionals representing abstract systems, providing a dependence on trust (Giddens, 1990: 26, 85).
Professionalism, perceived goals and means of healthcare
Firstly, certain expectations about professionalism within healthcare institutions are relevant to trust. Brown and Calnan (2012) argue that professionals are only a small part of institutional care but they are perceived to be most important because they make a diagnosis (Brown and Calnan, 2012: 33-34).Pilgrim et al. add that the general assumption is that healthcare professionals are ‘trustworthy’ based on the competence, honesty and integrity that patients expect of them (Pilgrim et al., 2011: 15). Shore agrees, explaining that expectations of healthcare professionals’ competency can influence feelings of trust (Shore, 2007: 4), given their training in a particular medical field.
This links to a hypothesis provided by Plomp and Balast (2010), arguing that in a time of vulnerability; for example when experiencing maternity care living in a new country, trust in healthcare professionals will actually be enhanced because there is a greater need for support (Plomp and Balast, 2010: 262). Based on these understandings, one might hypothesise that the participants of this research will have a similar level of trust in professionals across cultures, considering that there is a general expectation about their abilities and ethics as professionals.
However, the organisational and funding means of healthcare, and the views that patients have of these, might also impact on the level of public trust in certain institutions. According to Shore, medical practitioners are meant to have the patients’ ‘best interests at heart’ rather than a financial incentive (Shore, 2007: 4). Gilson expands on this by arguing that the funding mechanisms of healthcare have the ability to enhance or undermine the trusting relationship between patient and provider
(Gilson, 2003: 1459). Gilson finds that the NHS in the UK has been perceived as fair and trustworthy based on its honest financial incentives (Gilson, 2003: 1459).
Further evidence provided by van der Schee et al. (2007) adds to this argument, discovering that trust in healthcare providers was high in both the UK and the Netherlands (van der Schee et al., 2007: 59). For Gilson, this seems especially true when compared to privately funded systems such as the U.S. healthcare system, who ‘generate distrust’ since it is seen as working towards a financial incentive instead of the patients’ best interest (Gilson, 2003: 1459). Shore develops this, stating that trust in healthcare institutions in the U.S. is at 'an all-time low' (Shore, 2007: 3), which he feels 'seriously compromises medical outcomes' (Shore, 2007: 3). This implies that public trust in privately funded healthcare institutions is currently low since they are viewed as working for profit, while healthcare institutions that that are funded through public means are deemed as being trustworthy by the public.
However, later evidence provided by Pilgrim et al. argues that there is currently a ‘crisis of trust’ in the NHS in the UK (Pilgrim et al., 2011: 151). Straten et al. (2002) also argue that public trust in Dutch healthcare institutions is eroding (Straten et al., 2002: 228). Shore argues that the main reason for a general decline in trust in healthcare is attributable to a change in the way that healthcare is delivered (Shore, 2007: 7).
For Shore, eroding trust is as a result of ‘society-wide trends’ including decreasing trust in institutions and science since the 1960s (Shore, 2007: 7). These changes have seen an increase of ‘profit obsessed corporations, overstressed doctors, and large impersonal institutions’ (Shore, 2007: 13). He adds that there are now more ‘gatekeepers’ within healthcare, which has lead to an increase in perceived ‘profit making’ in this sector (Shore, 2007: 7-8). This suggests that trust in the organisation of healthcare institutions is generally lowered, and that there are not many differences across cultures.
Changing professional-patient relations, autonomy and knowledge
Further expectations that have been found to affect trust in healthcare relate to the changing professional-patient relationship resulting from patient’s increasing autonomy within healthcare, as well as their access to both ‘mediated’ (Brown and Calnan, 2012: 49) and second-hand knowledge.
Within what Rowe and Calnan describe as the ‘changing nature of trust’ that has occurred between clinicians and patients, patient’s have had an increase in knowledge and a more ‘active stance’ within their own healthcare (Rowe and Calnan, 2006: 5). Shore agrees that increasing autonomy has given patients the capability to ‘manage their own health’ in many cases (Shore, 2007: 9).
This may refer to the patients managing and being active in their own maternity experience and therefore having less trust in professionals within institutions for administering their care. This can be linked to the choices that patients make about using pain relief during birth and where they choose to give birth, which connects with expectations of maternity institutions for women living abroad. Considering that the Netherlands takes a more natural approach to birth than other developed countries (De Vries, 2004: 9, Johanson et al., 2002: 892), women may feel that they have autonomy in their choices during birth and therefore may be more distrustful of professionals or institutions. These expectations will be based on the knowledge of maternity institutions in their country of origin where for example, birth may be more likely to take place in a hospital, or where epidurals could be common.
Patients also have increasing access to information on healthcare. Knowledge accumulated from media sources is believed to affect trust in healthcare institutions, often in a negative way, affecting public expectations of healthcare. According to Pilgrim et al., there is often a concentration on dramatic stories of broken trust in healthcare within the media (Pilgrim et al., 2011: 145), which Shore argues has put healthcare under scrutiny (Shore, 2007: 10-11). Shore views the media as creating or at least adding to feelings of distrust (Shore, 2007: 10-11) by focusing on patient safety and medical errors (Shore, 2007: 7). Brown and Calnan add that the use of personal narratives helps to make opinions about institutions feel more ‘immediate’ for the public, affecting their system-based trust if the perception is negative (Brown and Calnan, 2012: 34, 38). In addition to this, Brown and Calnan find that stigmatising labels can be a direct consequence of negative media portrayal (Brown and Calnan, 2012: 34), and this might affect first-hand experiences of healthcare for individuals.
Rowe and Calnan, also discuss the impact of public health reports, which mention ‘waiting times, patient satisfaction, and clinical outcomes’ (Rowe and Calnan, 2006: 5). They argue that on the surface, these appear to build public trust since it allows patients ‘to make an informed choice about where to seek treatment’
(Rowe and Calnan, 2006: 5). Despite this, the achieved outcome actually ‘further undermines trust’ (Rowe and Calnan, 2006: 5). This is because patients are ‘sceptical’, perceiving managers as playing with the system ‘to meet targets’ (Rowe and Calnan, 2006: 5).
In light of this, negative media coverage, is perceived as being a more honest representation of healthcare systems than publically released reports. This appears to have helped in the creation of the crisis of trust in healthcare. For the participants of this thesis, the kind of media exposition they view of Dutch health care system will influence how they trust in healthcare. In addition, considering the concentration on dramatic stories within the media of healthcare, this thesis plans to focus on how everyday experiences of maternity care are important for influencing trust.
Second-hand knowledge, gained through the first-hand experiences of friends and family is a particularly significant factor for affecting trust in healthcare institutions. Brown and Calnan argue that there is not enough emphasis on the importance of second-hand knowledge within research on trust relations (Brown and Calnan, 2012: 38). They find that social networks are more important for determining trust than media sources since they are closer ‘geographically and emotionally’ rather being at the national or global level (Brown and Calnan, 2012: 38). Similar evidence provided by Calnan and Rowe (2008) show that overall patients’ both direct and indirect experience of friends and family had the potential to build trust (Calnan and Rowe, 2008: 138). An example they found within their study was that individuals focused on how hygienic their friends and family had found a particular hospital and what the quality of food was like (Calnan and Rowe, 2008: 138).
This research implies that the healthcare experiences of friends and family of will have a major impact on how mothers expect to experience healthcare within maternity institutions. It is implied that this will be the case more so than the media. This thesis assumes that the participants will be friends with other expats, which will increase the influence of institutions in determining their trust, since they are lacking a wider social network.
First-hand experiences and interactions
Despite the importance of expectations, it is the actual lived experiences that found to be the most important area for determining trust. A particularly significant factor with
the potential for influencing feelings of trust in healthcare institutions is the impact of interactions between professionals and patients. Brown and Calnan find that experiences and specifically interactions are found to be the ‘least generalisable and measurable’ within research and their significance is often ‘overlooked’ (Brown and Calnan, 2012: 39). Furthermore, although other forms of knowledge are important, they argue that it is these ‘private-interactive’ (Brown and Calnan, 2012: 49) experiences that ‘generate more concrete forms of knowledge’ (Brown and Calnan, 2012: 38) and are most important in relation to trust (Brown and Calnan, 2012: 39).
Giddens argues that ‘facework commitments’ (Giddens, 1990: 85) between doctor and patient can be crucial for the enhancement of trust in healthcare since the outcome of this interaction can be ‘psychologically consequential’ (Giddens, 1990: 33). In order for trust to be enhanced, a demonstration of ‘warmth and openness’ (Giddens, 1990: 121) is necessary. In agreement with Giddens, Gilson argues that interactions ‘encourage mutual respect’ between patient and practitioner, while positive interactions help to ‘reinforce our trust in the expert system of medical knowledge’ (Gilson, 2003: 1458) while also providing a ‘therapeutic effect’ (Gilson, 2003: 1459).
Additionally, Gjengedal et al.’s (2013) study shows that patients feel more comfortable around healthcare professionals who are sensitive and mitigating to their vulnerability (Gjengedal et al., 2013: 136). Specifically within maternity care for women living abroad in the Netherlands, Boerleider has found that cultural sensitivity is particularly important during maternity care (Boerleider, 2015: 159-160). Both feelings of vulnerability and cultural differences are expected to be important themes in the findings of this thesis since the participants will have experienced healthcare while exposed to a new and unfamiliar culture. This may particularly be the case for the U.S. participants, since because of geographical closeness and being part of the same continent, the Netherlands may be more similar in culture to the UK, and this may enhance the British participants trust more than for the U.S. participants.
Gjendegal et al. also point out ways in which interactions can have a negative effect. Their study shows that professionals, who become self-centred and direct their attention towards their own problems during healthcare interactions, fail to be sensitive to the vulnerability of their patient (Gjengedal et al., 2013: 136). Trusting outcomes of interactions within an institution reflect the system as a whole rather than individuals within it (Jalava, 2003: 184), for example: assuming that any good or bad
outcome is in regards to an entire institution and not simply one professional. For the participants of this thesis, this may have caused hindered trust in all healthcare institutions rather than in the professional whom they have interacted with.
In relation to interactions, transparency of information between doctor and patient in healthcare institutions is hugely important for building a trusting relationship. Larson and Heymann (2010) define this as being clear about ‘what is unknown and what is known’ and concerning ‘the basis for decision making’ (Larson and Heymann, 2010: 272). Larson and Heymann acknowledge that enhancing and maintaining trust has become increasingly demanding in the age of the Internet where patients face ‘contradictory information’ online and often distrust institutions, as was pointed out in the previous subchapter (Larson and Heymann, 2010: 272). Within their theory of transparency in healthcare, they argue for ‘knowledge and expertise; openness and honesty; and concern and care’ (Larson and Heymann, 2010: 272). Taking these elements into consideration may help to increase public trust in healthcare systems and may increase the influence of institutions, especially when considering the current crisis of trust.
This theoretical framework has revealed that a number of factors can influence trust and shape feelings of vulnerability in healthcare institutions. It also has shown that institutions are likely to have a great impact on how these factors work. It is important to look at cross-country experiences of healthcare because trust relations in healthcare vary depending on ‘the model of health care delivery’ (Rowe and Calnan, 2006: 5), which differ between countries. This has an influence on perceptions, knowledge, meaning and experiences. Thus, this thesis has chosen to examine the perspectives of people from varying institutional backgrounds. The decision to specifically look at the experience of expats was made because they have encountered different healthcare institutions prior to moving to the Netherlands and therefore are able to offer a comparative understanding of their experience. A comparative design such as this helps to understand their experiences in more depth since it is exploring the perspective of two groups (Bryman, 2015: 64-65). In order to analyse the research data and guide the empirical chapter, a research framework will now be determined.
This research framework will be used to determine how the theoretical investigation can guide the empirical chapter of this thesis. The empirical chapter will use systematic analysis to examine the themes that emerged from the data analysis. In order to conduct this analysis, this thesis has chosen to use the theoretical structure established by Brown and Calnan (2012) that has been briefly referenced thus far.
This study focuses on how to achieve trust within psychosis services (Brown and Calnan, 2012: 33), and is therefore centred on a different area of healthcare. Despite the differences to this thesis, the framework of this study has been chosen due to its closeness in methodology, conceptual themes and its similar findings. Brown and Calnan focus their research on three forms of knowledge that they found to be important in their study; ‘mediated’, ‘public-direct’ and ‘private-interactive’ (Brown and Calnan, 2012: 49). These three forms of knowledge are part of what Brown and Calnan refer to as the ‘trialectic’, because all three can be linked to one another (Brown and Calnan, 2012: 40-41).
As already mentioned, mediated information refers to media coverage and publicly released reports. Within this, Brown and Calnan argue that there is ‘selective framing’ using ‘personal stories’ to make it both more real and more urgent to the public (Brown and Calnan, 2012: 38). As previously stated, these reports are often negative which is anticipated to shape both individual and societal expectations of healthcare systems. Mediated information can be linked to the expectations of mediated knowledge that this thesis is examining within its findings and discussion.
The understanding of public-direct experiences are based on a Schutzian perspective arguing that ‘first-hand observations’, those of an individual or a friend or relative, are more important for determining feelings of trust than mediated knowledge (Brown and Calnan, 2012: 38). This is when systems become ‘less abstract’ and ‘more concrete’ to the public (Brown and Calnan, 2012: 38-39). Therefore the second-hand knowledge of the experience of friends and family is ultimately more important for determining feelings of trust than more distant, mediated experiences (Brown and Calnan, 2012: 38). These public-direct forms of knowledge can be linked to a number of the areas that this thesis is also examining. These are; expectations based on second-hand knowledge, expectations of trust in professionals within healthcare and the first-hand experiences of a healthcare system.
Finally, private-interactive experiences are even more important for determining trust than both mediated and public-direct experiences (Brown and
Calnan, 2012: 39). This type of knowledge specifically refers to interpersonal interactions, and links to Giddens’ ‘facework commitments’ that were referred to earlier (Brown and Calnan, 2012: 39, Giddens, 1990: 85). Private-interactive experiences concern the importance of being able to interact with professionals (Brown and Calnan, 2012: 39). Within this, being able to view their body language for feelings of trust to occur for patients is also important (Brown and Calnan, 2012: 39). Private-interactive experiences link to the first-hand experiences and healthcare interactions that this thesis is focusing on.
This thesis will use these three types of knowledge; mediated, public-direct and private-interactive, to determine what influences trust when crossing cultures and institutions for two groups of expats living in a third country. The empirical chapter will also make use of the other theoretical literature that has been presented thus far in the theoretical framework, in order to clarify the link between them.
This theoretical and research framework has helped to establish the following research questions:
Main research question: How do expectations and experiences when crossing
cultures and institutions influence trust in maternity care among British and U.S. expats living in the Netherlands?
Sub-questions:
a) How do expectations of healthcare based on knowledge acquired from social networks and the media help to determine feelings of trust when accessing healthcare?
b) What is the significance of a patient’s institutional background for determining their expectations of trust in professionals within a new healthcare system?
c) In what ways do first-hand experiences of healthcare in a new culture influence feelings of trust?
d) Within first hand experiences of healthcare, how influential are interactions for shaping feelings of trust and vulnerability?
The following table outlines these research questions in relation to which type of knowledge determined by Brown and Calnan they link with, as well as which step identified during the research collection and the interview questions that were asked in relation to them that they also link with.
Figure 1: Table of research framework to be used to guide empirical analysis
Research question Type of knowledge (Brown
and Calnan, 2012) Step Questions considered during the interviews
How do expectations of healthcare based on knowledge acquired from social networks and the media help to determine feelings of trust when accessing healthcare?
Mediated and public-direct To identify expectations of Dutch health and maternity care
To establish what has influenced these expectations
1. What impressions of Dutch healthcare do expats have from the media? 2. In what ways does second-hand knowledge shape expectations? 3. What expectations of Dutch maternity care came from social networks? 4. Which type of knowledge is more important for determining expectations? What is the significance of a
patient’s institutional background for determining their expectations of trust in professionals within a new healthcare system?
Public-direct To determine how varying institutional backgrounds can shape trust in professionals
5. What expectations do those from British and U.S. healthcare backgrounds have in professionals in the Netherlands?
6. Were their expectations of professionals culturally specific or generalised? 7. What were their expectations based on? 8. How did this affect their trust?
In what ways, do first-hand experiences of healthcare in a new culture influence feelings of trust?
Public-direct and private-interactive
To examine how first hand experiences of maternity care can determine trust To look closely at their experience of maternity care in a new culture
9. What have been expats’ experiences of maternity care in the Netherlands? 10. Do they have experience of maternity care in their home country?
11. Which experiences met their expectations? 12. How was this influential for their trust?
of healthcare, how influential are interactions for shaping feelings of trust and vulnerability?
interactions during maternity care for determining feelings of trust and also vulnerability
feelings of trust within interactions for those accessing healthcare in a new country?
14. What specific healthcare interactions do expats focus on?
15. How did their interactions affect their overall experience of maternity care?
4. Methodology
This thesis chose to collect qualitative data since it aimed to look at the social world from the perspective of the participants involved. Through the collection of qualitative data, the intention was to gain thick description, exploring ‘rich accounts of the details of a culture’ (Bryman, 2015: 384).
Through the interviews, this thesis has been able to work out how trust and vulnerability have been constructed through experiences and expectations. A constructionist position such as this, assumes that ‘social phenomena and their meanings are continually being accomplished by social actors’ (Bryman, 2015: 29). Furthermore, it suggests that ‘the categories that people employ in helping them to understand the world around them are in fact social products’ (Bryman, 2015: 30). Despite this, it is important to consider that culture obviously also has a reality that pre-dates a particular group of people (Bryman, 2015: 30).
The research has used a combination of deduction and induction. It has been deductive in its approach since concepts were derived from theory, which has guided the research question formulation and data collection. But the data has also been treated inductively, given the expectation that concepts and ideas would also emerge from the empirical evidence collected.
In what follows, the details of the research design, the data collection, the data analysis, ethical considerations and terminology used throughout this thesis are illustrated.
4.1 Research design
A comparative design was used, evaluating the experiences and expectations of two groups: 10 women from the UK and 10 women from the U.S. aged between 30 and 50 who; are mothers, consider themselves to be part of the expat community, are living in the Netherlands and have experienced healthcare in the Netherlands. Although it was beneficial to the research if they had experienced maternity care in the Netherlands, this was not initially the focus and it was therefore not in the original inclusion criteria. This specification is explained in the following subchapter.
Purposely, interviewees with similar socio-economic backgrounds were chosen, allowing for a straightforward comparison. The assumption was made that
they were all middle-class based on the their occupation or their partner’s occupation. It is important to acknowledge that this may have had some influence over how they experienced or expected maternity care to be in the Netherlands. If this thesis had been looking at the maternity care experiences and expectations of working-class women or refugee women, the results could have been different.
This specific inclusion criterion was mostly related to the accessibility of this particular group. English was the first language for both groups of participants, and this meant that there might be less restriction in terms of communicating with them since it is also my first language.
The aim was to collect in-depth data of their expectations and experiences of healthcare institutions since living in the Netherlands. Taking the perspectives of two groups into consideration within a research design has allowed for a thorough comparison (Bryman, 2015: 64-65).
4.2 Data collection
A combination of purposive and snowball sampling was used. At times, the sampling strategy was purposive since participants were not picked at random but rather for being part of a specific social group linked to the research question. As well as purposive sampling, a snowball sample was also used, since a number of individuals acted as gatekeepers to the participants, including some of the participants themselves.
Initially, it was assumed that getting access to this group would be difficult since there had been no prior involvement with the expat community. Furthermore, the difficulty of discussing healthcare experiences, which is a sensitive subject, was expected to be a deterrent for some people. However this was not generally found to be the case, a post was shared on Amsterdam Business Mamas explaining the aim of this research and the specific sample of people it hoped to use. This attracted a large number of the participants who became involved with this research. Towards the end of the research collection, more than the required twenty people were willing to take part.
A sample using the above inclusion criteria was found, although the eventual age of the participants was between 33 and 50. Twelve of the participants lived in
Amsterdam while the other eight lived in other parts of the Netherlands. The variation in location offered a broader perspective on their expectations and experiences. Moreover, there does not appear to be much research within the area of women experiencing maternity care abroad. It is important to note that some of the participants mentioned that they felt under-researched both as mothers and as expats. Furthermore, before it became clearer that this thesis would focus closely on maternity and postnatal aspects of healthcare experiences in the Netherlands, one participant who was interviewed, Audrey, U.S., had no experience of maternity or postnatal services in the Netherlands as she had both of her children in the U.S. before she emigrated to the Netherlands. Despite this, she was able to offer some interesting perspectives in more general areas related to healthcare and therefore she is quoted on occasion.
The participants from this thesis are outlined in the following tables using pseudonyms, divided into two groups, one group from the UK and the other group from the U.S.
Figure 2: Table of participants from the UK (pseudonyms are used)
Name Age Ethnicity Occupation Number
of Children Where they reside in the Netherlands Interview setting Date of interview Amanda 38 White British
Cook 3 Amsterdam Skype 06.08.15
Caroline 46 White
European
Cleaner 1 Amsterdam Her home 30.06.15
Jade 41 White
European
HR Manager 2 Amsterdam Skype 25.08.15
Jaz 40 White British Stay at home Mum 2 (Was pregnant with her third child at the time of interview)
Amsterdam Her home 26.08.15
Jeanne 40 White British Marketing Manager 2 Woerden Café 30.06.15 Laura 33 White British Editor and Writer 1 Amsterdam Café 29.06.15 Matilda 44 White British Stay at home Mum 2 Amsterdam Café 26.06.15
Nicole 42 White British Self employed 2 Breda Skype 14.07.15 Sandra 43 White British Stay at home Mum 3 Amsterdam Phone 17.08.15 Steph 40 White British Senior Lecturer 2 Utrecht Skype 12.08.15
Figure 3: Table of participants from the U.S. (pseudonyms are used)
Name Age Ethnicity Occupation Number of
Children Where they reside in the Netherlands Interview setting Date of interview Audrey 42 African American Communicati ons Manager 2 Amsterdam Café 20.08.15 Billie 42 White American
Life Coach 1 Vleuten Skype 22.07.15
Edith 48 White
American
Housewife 1 Leeuwarden Café 19.08.15
Elsa 38 White American English Teacher 2 Drachten Facetime 18.08.15 Gina 45 White American Freelance Digital Advertiser 1 Amsterdam Facetime 25.08.15 Jessie 50 Mixed American Student and Volunteer 1 Amsterdam Café 24.06.15 Maggie 40 White American Stay at home Mum 7 Gouda Skype 28.08.15 Maxine 48 Mixed American Business owner 1 Amsterdam Café 19.06.15 Sasha 42 Asian American Events Contractor 1 Amsterdam Café 14.07.15 Sylvie 41 White American Research Officer 1 Amersfoort Café 24.07.15
The data from this research was collected from June to August 2015 using semi-structured interviews as the main research method. Semi-semi-structured interviews allow the researcher to keep an open mind about ‘the shape of what he or she needs to know about, so that concepts and theories can emerge out of the data’ (Bryman, 2015: 10). This relates directly to the focus of maternity care in this thesis, rather than what was originally planned, to look at healthcare as a whole. The choice to specifically look at maternity care emerged during the interview process.
An interview guide was used during the interviews. The interview guide was based around the theoretical framework and the original research question from the thesis proposal, looking at what this original question aimed to find out. Research questions are important since they help to keep the research focused (Bryman, 2015: 8). The original research question was focused more broadly on healthcare and the current one is more specified around maternity care. As a result, the questions in the interview guide were related to healthcare experiences and expectations in a general way. However, the interview guide also suggests to: specifically mention maternity
and gynaecological care. Over time, there was less emphasis on gynaecological care
since many of the participants had very little experience of this since living in the Netherlands. This resulted in maternity becoming even more of a focus. None of the questions in the interview guide specifically mentioned the word ‘trust’ and this is because the concept of trust is both nuanced and at times vague. Therefore, it made sense for the participants to bring the term into the interview themselves, or for an assumption to be made about when they were referring to feelings of trust.
Within the interview guide, the questions were direct and open which stimulated a conversation with the participants, whilst encouraging them to talk expansively. The questions also flowed and were linked to one another. Although the questions asked throughout the interviews were generally based on the interview guide, like in many semi-structured interviews, there was space for other questions to be asked if it was relevant to the research (Bryman, 2015: 468). If the participants ever went off topic, they were brought back to the theme of trust and healthcare when it was suitable. The participants did not need to be probed often since the questions were formulated to relate generally to all of them and the tone was often conversational. The interview guide is attached in the appendix.
Before referring to the interview guide, each interview began with some general questions about the participants, these asked about their; name, age, ethnicity, occupation, number of children, where they are from and where they reside in the Netherlands. This was followed by a question asking about what prompted the participants to move to the Netherlands.
Each interview varied in length, the shortest one lasted for 30 minutes and the longest one lasted for 2 hours. The variation in length was expected since the questions were open and each participant had varying accounts of their experiences and expectations. This was also because some participants had particularly traumatic
