A Qualitative Meta-synthesis Describing the Psychosocial Impacts After Birth Trauma.

PurposePatients’ trust in health care is increasingly recognized as important to quality care, yet questions remain about what types of health care experiences erode trust. The current study assessed the prevalence and impact of institutional betrayal on patients’ trust and engagement in health care.Participants and methodsParticipants who had sought health care in the US in October 2013 were recruited from an online marketplace, Amazon’s Mechanical Turk. Participants (n = 707; 73% Caucasian; 56.8% female; 9.8% lesbian, gay, or bisexual; median age between 18 and 35 years) responded to survey questions about health care use, trust in health care providers and organizations, negative medical experiences, and institutional betrayal.ResultsInstitutional betrayal was reported by two-thirds of the participants and predicted disengagement from health care (r = 0.36, p < 0.001). Mediational models (tested using bootstrapping analyses) indicated a negative, nonzero pathway between institutional betrayal and trust in health care organizations (b = −0.05, 95% confidence interval [CI] = [−0.07, −0.02]), controlling for trust in physicians and hospitalization history. These negative effects were not buffered by trust in one’s own physician, but in fact patients who trusted their physician more reported lower trust in health care organizations following negative medical events (interaction b = −0.02, 95%CI = [−0.03, −0.01]).ConclusionClinical implications are discussed, concluding that institutional betrayal decreases patient trust and engagement in health care.

Recent progress in understanding the lifelong effects of early childhood adversities has clarified the need for an organized strategy to identify and intervene with children, adolescents, and families who may be at risk for maladaptive responses. Trauma-informed care (TIC) in child health care operationalizes the biological evidence of toxic stress with the insights of attachment and resilience to enhance health care delivery to mitigate the effects of trauma. The resulting pediatric health care delivery strategy promotes and restores resilience in children and adolescents, partners with families to support relational health, and reduces secondary trauma among pediatric health care clinicians. This policy statement summarizes what policy makers, legislators, and health care organizations need to consider in terms of infrastructure, resources, and financial support to facilitate the integration of TIC principles into all pediatric points of care. The accompanying clinical report describes the elements of TIC in the direct care of children, adolescents, and families and covers the spectrum from prevention to treatment. The recommendations in this statement and the clinical report build on other American Academy of Pediatrics policies that address the needs of special populations (such as children and adolescents in foster or kinship care, in immigrant and refugee families, or in poor or homeless families) and are congruent with American Academy of Pediatrics policies and technical reports concerning the role of pediatric clinicians in the promotion of lifelong health.Over the past 2 decades, basic science has explained how cumulative adverse childhood experiences in the relative absence of safe, stable, nurturing relationships (SSNRs)1 alter neurohormonal stress responses, gene expression, telomere length, brain development, and immunity, enabling researchers to elucidate how the body biologically embeds childhood trauma. Recent studies of toxic stress support assertions that the origins of lifelong health are in early childhood and that chronic stress in childhood strongly predicts adult health status.2,3 In the context of expanding evidence, pediatricians and others involved in community-based early childhood systems need strategies to mitigate the damaging effects of early childhood trauma and to promote resilience in children and families. Trauma-informed care (TIC) offers an organizing principle for pediatric practice that improves awareness of the spectrum of trauma-related symptoms, promotes an emotionally safe environment of care, and provides specific interventions to mitigate the effects of trauma exposure.4,5 This policy statement presents recommendations for policy makers, legislators, and health care organizations for implementation of TIC into pediatric health systems. The accompanying clinical report6 presents best-practice guidance for TIC in the direct care of children and adolescents.TIC is defined by the National Child Traumatic Stress Network as medical care in which all parties involved assess, recognize, and respond to the effects of traumatic stress on children, caregivers, and health care providers. TIC also includes attention to secondary traumatic stress (STS), the emotional strain that results when an individual, whether a health care worker or parent, hears about or witnesses the traumatic experiences, past or present, of children.Every pediatric encounter presents opportunities to promote family resilience and relational health.7 Informed by research in infant mental health and neurodevelopment, early relational health refers to the establishment of foundational relationships during the first 3 years of life that are central to successful physiologic, emotional, and moral development of the young child.8 Relational health, in a more general sense, is applicable to all age groups, is dyadic, and includes the capacity of both the child and caregiver to enter into a safe, secure, nurturing relationship allowing both to thrive.1,9,10 Strong foundational relationships support resilience and buffer stress in children, so they can be considered primary prevention of stress-related disturbance. Trauma-informed practices also support relational health and family resilience as important protective factors for those who have been exposed to persistent adversity or potentially traumatic events (see Fig 1).Human neuroendocrine–immune networks respond to internal and external sensors that identify danger and safety by activating in dangerous circumstances and deactivating when danger has subsided.11 Toxic stress responses occur with prolonged activation of the neuroendocrine–immune system and dysregulation of homeostasis (or allostasis if multiple systems are involved)12 in the absence of buffering by SSNRs. Toxic stress responses can result in lifelong impairments in physical, mental, and relational health.13The concept of toxic stress adds an important physiologic basis to the study of attachment and our understanding of trauma. Trauma is defined as an event, series of events, or circumstances experienced by a person as physically or emotionally harmful that can have long-lasting adverse effects on the person’s functioning and well-being (emotional, physical, or spiritual).14 Attachment theory describes the deep and enduring relationship between a child and adult caregiver that ideally provides a secure base from which the child can develop and explore the world.15Resilience is the dynamic process of adaptation to or despite significant adversity by using protective factors and learned skills to manage stressful circumstances.16 Resilience may allow a person to experience tolerable rather than toxic stress in response to adversity. Some characteristics of resilient children include strong executive functions (self-control of attention and impulses) and a strong personal identity, often related to a cultural or faith tradition.17 However, most important to both resilience and relational health is the capacity for young children to form at least one stable, caring, and supportive relationship.9,18Almost half of American children, or 34 million younger than 18 years, have faced at least one potentially traumatic early childhood experience.19 More than 1 in 7 adults report exposure during childhood to 4 or more adverse childhood experiences such as abuse, neglect, or other household adversity,20 including intimate partner violence or parental incarceration. Certain populations are at higher risk for trauma exposure, both physical and emotional. In surveys, poverty or financial stress is the most commonly reported childhood adversity, second only to loss of a parent.21,22 Exposure to divorce, child maltreatment, sexual abuse, intimate partner violence, bullying, parental mental illness, parental substance use problems, and community violence are also common.21 Specific populations at high risk for trauma include children and adolescents who identify as LGBTQ, have developmental or behavioral problems,23–25 are in foster or kinship care, are incarcerated, are living in deep poverty, or are immigrants. Potentially traumatic environmental and community-level conditions include economic stress, school or community violence, adverse experiences during and after immigration, natural disasters, pandemics, and mass-casualty events such as shootings or bombings.Racism is a common cross-cutting risk factor. Racial, ethnic, or religious bigotry magnifies the risk inherent to other special populations.26 Experiences ranging from hate crimes, police profiling, bullying, or microaggressions to covert discrimination are traumatic events and may be internalized as trauma by those who are victims, indirectly or directly, of the events.27,28 Historical trauma refers to the collective, transgenerational emotional and psychological injury of specific ethnic, racial, or cultural groups and their descendants who have experienced major events of oppression such as genocide, forced displacement, or slavery.29,30 Originally applied to children of the Holocaust, the concept is now applied to American Indian and Alaskan native people, African American people, Mexican American people, Japanese American people, and other groups of people who have experienced mass trauma.30 Investigators link historical “soul wounding” to current health and behavioral disorders including substance use disorder, domestic violence, and suicide, particularly in Indigenous communities.29,31 Children separated from families during immigration and/or detained in group facilities overseen by the Office of Refugee Resettlement are a recent special population at severe risk for long-term sequelae resulting from forced family separation.32,33In November 2019, the Centers for Disease Control and Prevention reviewed the emerging literature linking early childhood adversity with adult illnesses20,34 and analyzed survey data from 25 states over 2 years.3,35 Researchers concluded that reducing exposure to early childhood trauma and mitigating posttrauma effects would generally and significantly reduce adult morbidity and mortality. Using logistic regression modeling, they estimated potential reductions in incidence from low for obesity (1.7%) to high for heavy drinking, chronic obstructive pulmonary disease, and depression (23.9%, 27.0%, and 44.1%, respectively). Recommendations included creating healthy communities, supporting SSNRs, and developing programs that apply primary (reducing exposure to childhood adversity) and secondary prevention (mitigating the effects of exposure) on the basis of principles of TIC.The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) presents a list of trauma-related disorders ranging from mild (adjustment disorder) to severe (posttraumatic stress disorder [PTSD]).36 Two additional categories, reactive attachment disorder and disinhibited social engagement disorder, are specific to young children (please see the DSM-5 for complete diagnostic criteria). This nosology can be expanded to describe other presentations common in pediatric health care settings: developmental trauma disorder (DTD), pediatric medical traumatic stress (PMTS), and STS, the last being most relevant for health care workers, family members, and caregivers.The diagnosis of PTSD, as outlined in the current DSM-5, does not adequately describe the variable presentations of trauma manifestations in children across developmental stages.37 Children with complex trauma histories often exhibit heterogeneous developmental symptoms as well as difficulties with intimate relationships and with regulation of attention and impulse control.38 DTD is a proposed new diagnostic category that incorporates these differences and attempts to better describe the disturbances that occur in multiple developmental domains.39 The omission of DTD in the DSM-5 has been controversial,40 and the search for a better nosology of trauma, including DTD, is ongoing.41PMTS refers to the distress that patients and family members experience during hospitalization for a perceived life-threatening diagnosis or while living with or caring for individuals with life-altering chronic conditions.42 PMTS is underrecognized and rarely addressed despite its high prevalence.43,44 Up to 80% of ill or injured children and their families may have traumatic stress reactions after a life-threatening illness, injury, or procedure.45 In some surveys, up to 20% of parents of children admitted to a PICU develop PTSD within a few months.45 The suffering of family members and caregivers is often not addressed because of existing structural and reimbursement obstacles for multigenerational care.Although research on PMTS (and on pediatric postintensive care syndrome)46,47 is ongoing, researchers in 1 study found that approximately 10% of children developed PTSD 3 to 5 months after major surgery, and 28% developed posttraumatic stress symptoms (PTSS) resulting in functional disability by parent report.48 PTSS can also occur after a severe injury or diagnosis of an illness such as cancer. In another family study, more than 10% of children had persistent functional impairment from PTSS at 6 weeks and 1 year after a potentially life-threatening injury or diagnosis, and 15% of mothers and 8% of fathers met criteria for PTSD at 1 year.49As described earlier, STS may occur in parents, other family members, and health care workers such as physicians, nurses, other hospital staff, first responders, and therapists. STS may have many of the same long-term effects on health that affect children exposed to trauma.50 Some health care workers may also develop disabling posttrauma symptoms that can interfere with quality of life both at work and home. Health care workers may have their own trauma histories that contribute to their reactions when exposed to the suffering of others. Nonclinical staff may also experience STS triggered by their own trauma histories, especially if the health care facility is located in an area with high adversity and nonclinical staff live in the vicinity.Preliminary evidence exists of a synergistic effect among STS, depression, and burnout in affected health care workers.51 STS in combination with burnout has been associated with a significant increase in the frequency of medical errors.52,53 Depression, anxiety, and suicide are greater risks for physicians than for the general population. In the United States, the rate of suicide among female physicians is 130% higher than among women who are not physicians; the rate for male physicians is 40% higher than for men who are not physicians.51 Burnout includes a spectrum of pathologic conditions that develop in the context of occupational stress and is almost twice as prevalent among physicians. The risk among nurses for burnout, depression, and STS is even higher. More than half of nurses reported suboptimal mental or physical health,54 approximately 35% reported a high degree of emotional exhaustion,55 and 18% reported depression in national surveys. Reports of posttraumatic stress among health care workers related to the coronavirus disease 2019 pandemic prompted worldwide concern for increased awareness and trauma-informed support for the mental health of all involved.56Core principles that can be helpful for policy development, outlined by the National Council on Behavioral Health (2019)57 are outlined in the following sections. Implementation of TIC at a practice level is described in detail in the accompanying clinical report.6The health care organization, workspace, and every encounter should be characterized by compassion, cultural humility, equity, collaboration, and safety for families and employees. An emotionally safe workplace includes acknowledgment of and particular attention to racial and gender discrimination, including implicit bias both in rendering care and workplace human relations. A review of health care settings from the viewpoints of patients, families, and staff can uncover practices, processes, or details in the environment that are potentially traumatizing.Hospital and health system leadership can annually review policies and procedures to ensure a safe work environment and setting to provide TIC, to reduce STS and burnout, and to promote sensitivity to the needs of trauma survivors.58 The alignment of financial and human capital resources to support an optimal health environment in all levels and locations of care is extremely important. Surveys designed to assess system readiness for implementation are available and can be adapted for pediatric health care settings.Surveillance and standardized screening to assess staff and patients for trauma exposure, symptoms, and strengths are important components of trauma-informed pediatric care. Universal screening, when implemented within the larger context of trauma-informed approaches and endorsed and supported by administrative leadership, reduces stigma and allows standardized responses such as time off or referral to an employee assistance program. Families and youth may be queried at the point of care, such as at the time of hospital admission. Formal screening should always be for the benefit of children and adolescents, avoid retraumatization, and identify protective as well as risk factors.59 More specific information about screening is included in the accompanying clinical report.6Involvement of families and youth in the development of TIC policies and practices, particularly regarding cultural, historical, and gender issues, is essential to building an environment of support and mutuality.14 Both formal and informal structures, such as Family Advisory Councils and family-centered rounds,60 create a cultural expectation of collaboration and enable the health care team to understand the strengths and vulnerabilities of individual families and of the populations served. When appropriate, tribal elders, traditional healers, and other faith community leaders can be included in developing individual care plans or institutional quality-improvement efforts. A whole-person, whole-family, whole-community perspective promotes improved awareness of how cultural backgrounds affect the perception of trauma, safety, and privacy.61,62TIC, from a public health perspective, includes primary, secondary, and tertiary prevention strategies. Primary prevention is a comprehensive approach that addresses social determinants of health (such as structural racism, poverty, and violence) that are often root causes of community trauma.63 Promotion of relational health and other resilience factors (such as strong executive function and self-efficacy) may be considered primary prevention.64 Following the fourth edition of Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, promotion of early childhood relational health is a core purpose of both pediatric primary care and early childhood education.65The National Child Traumatic Stress Network includes the promotion of child and family resilience, enhancement of protective factors, awareness of parent or caregiver trauma, and involvement of families in program development and evaluation as secondary prevention.66 Trauma-informed therapies (eg, trauma-focused cognitive behavioral therapy) for symptomatic children and youth are considered tertiary prevention. These therapies are especially important for high-risk populations as identified earlier.67–70 Attachment-based dyadic therapies, such as parent–child interaction therapy, may serve to prevent development of persistent traumatic stress symptoms in high-risk families71 and may be considered both secondary and tertiary prevention.Recruitment and pre-employment practices may help discern the capacity for empathy among prospective employees.72 Training and education of all administrators, clinicians, and staff, both clinical and nonclinical, can promote the appreciation of the lifelong effects of trauma on child and adolescent development and family resilience and the implementation of trauma-aware practices. Continuous quality-improvement programs translate new knowledge and skills about childhood trauma into supervision, training, and patient care.Prevention of STS requires specific training of all staff to raise awareness, promote resilience, and explore the interaction among STS, burnout, depression, substance use, and professional quality of life. Supportive supervision and peer mentoring offer opportunities for all employees to reflect on their own trauma histories and to promote compassion, nonjudgmental attitudes and collaboration.73Trauma-informed health care systems establish and support collaborative, interdisciplinary relationships among community and public health agencies that serve children and adolescents to coordinate care for children, adolescents, and families exposed to trauma. Schools,74 juvenile justice programs,75 mental health professionals,76 home visiting services, child welfare systems,76 and foster care agencies77 are natural partners for pediatric health organizations in promoting community resilience. Many have established TIC programs. Community early intervention programs can help prevent and mitigate adversity and often have the advantage of caring for young children in their natural environment as home visitors.78–80Federal agencies such as the Centers for Disease Control and Prevention can continue and expand research to improve understanding of the developmental effects of trauma and the efficacy of specific interventions for historically resilient populations. Urgently needed are successful strategies to interrupt the intergenerational transfer of family violence. Strategies are also crucial to blunt the impact of historical trauma in communities of color and in American Indian and Alaskan native populations in the United States.30 It is particularly important to identify the origins of and successfully mitigate community violence, including racism, misogyny, and religious, ethnic, and cultural bias.State-level resources can be directed to implementation, dissemination, and evaluation of trauma-informed community programs, such as interagency and multigenerational strategies for opioid dependency. One example of a state interagency, multigenerational treatment program is Ohio START (Sobriety, Treatment and Reducing Trauma).81 States could develop a communication infrastructure to facilitate data sharing, improve interdisciplinary/interagency cooperation, and engage community partners including foundations and academic institutions.Federal guidelines can require that state Medicaid programs ensure comprehensive coverage for all children and adolescents and pregnant mothers without regard for legal or immigration status and mandate that coverage include mental health and substance use disorder services. Financing that increases access to high-quality, comprehensive, coordinated, culturally competent health care for high-risk populations is a high priority. Federal and state regulations can require all insurers, including Medicaid and private health insurers, to include coverage for TIC elements, including surveillance, screening, diagnosis, counseling, case management, follow-up, community collaboration, mental health care, and home visiting.In large health systems, leadership can align its mission and financing with the core elements of trauma-informed systems.82 Supporting TIC includes payment for trauma-informed, integrated mental health services, care coordination, rigorous case management, and seamless referral networks for intensive treatment. Prevention of secondary trauma, including care of affected health care workers, should be built into the mission of the health system.Academic health centers train and educate the next generation of physicians, nurses, and ancillary health personnel and can promote the transformation to TIC in all health settings through education, research, and advocacy. Children’s hospitals and health systems can model mental health integration83 and trauma-informed practices throughout all service lines.84 Because children’s hospitals embrace population health management and community advocacy, they may serve as the anchor institution collaborating with community agencies to address social adversity at the neighborhood level while promoting TIC services.85 Together with community pediatric care systems, academic health centers and children’s hospitals can integrate core elements of education into workforce training for health care workers and community partners such as first responders, child welfare workers, teachers, and juvenile justice personnel.86,87Deborah L. Shropshire, MD, FAAP

Minority and non-minority patients in the United States have different levels of trust in health care; however, few studies have examined how determinants of trust and distrust in health care vary across diverse groups. To explore how trust in health care institutions varies across diverse populations. We conducted 17 focus groups with 117 participants in Chicago: 9 with African American, 5 with Hispanic, and 3 with white participants. Discussions were audiotaped, transcribed verbatim and coded using grounded theory analysis to identify dominant themes. We found a core set of factors that contribute to trust and distrust across racial/ethnic groups. In addition, there were unique factors that contributed to distrust among African Americans and Hispanics. Both of these groups discussed expectations of discrimination in the health care setting and African Americans discussed expectations of being experimented on as determinants of distrust. Based on these findings, we developed a hypothetical model of how different factors influence trust and distrust in health care across these different racial/ethnic groups. Contributors to trust and distrust in health care institutions are not always uniform across racial/ethnic groups. These differences should be addressed in future research and efforts to enhance trust in health care institutions.

BackgroundPeople's trust in health care and health care professionals is essential for the effectiveness of health care, especially for chronically ill people, since chronic diseases are by definition (partly) incurable. Therefore, it may be understandable that chronically ill people turn to complementary and alternative medicine (CAM), often in addition to regular care. Chronically ill people use CAM two to five times more often than non-chronically ill people. The trust of chronically ill people in health care and health care professionals and the relationship of this with CAM use have not been reported until now. In this study, we examine the influence of chronically ill people's trust in health care and health care professionals on CAM use.MethodsThe present sample comprises respondents of the 'Panel of Patients with Chronic Diseases' (PPCD). Patients (≥25 years) were selected by GPs. A total of 1,625 chronically ill people were included. Trust and CAM use was measured by a written questionnaire. Statistical analyses were t tests for independent samples, Chi-square and one-way analysis of variance, and logistic regression analysis.ResultsChronically ill people have a relatively low level of trust in future health care. They trust certified alternative practitioners less than regular health care professionals, and non-certified alternative practitioners less still. The less trust patients have in future health care, the more they will be inclined to use CAM, when controlling for socio-demographic and disease characteristics.ConclusionTrust in future health care is a significant predictor of CAM use. Chronically ill people's use of CAM may increase in the near future. Health policy makers should, therefore, be alert to the quality of practising alternative practitioners, for example by insisting on professional certification. Equally, good quality may increase people's trust in public health care.

If public trust in health care is to be used as a performance indicator for health care systems, its measurement has to be sensitive to changes in the health care system. For this purpose, this study has monitored public trust in health care in The Netherlands over an eight-year period, from 1997 to 2004. The study expected to find a decrease in public trust, with a low point in 2002. Since 1997, public trust in health care was measured through postal questionnaires to the "health care consumer panel". This panel consists of approximately 1500 households and forms a representative sample of the Dutch population. Trust in health care and trust in hospitals did not show any significant trend. Trust in medical specialists displayed an upward trend. Trust in future health care, trust in five out of six dimensions of health care and trust in general practitioners actually did show a decrease. However, only for trust in macro level policies and trust in professional expertise this trend continued. For the remaining trust objects, after 1999 or 2000, an upward trend set in. No support was found for our overall assumption. Explanations for the fact that trust did increase after 1999 or 2000 are difficult to find. On the basis of these findings the study questions whether the measure of public trust is sensitive enough to provide information on the performance of the health care system. The aim of this research is to study public trust in health care on its abilities to be used as a performance indicator for health care systems.

Does corruption undermine trust in health care? Results from public opinion polls in Croatia

Health care delivery, and therefore medical education, is an inherently risky business. Although control mechanisms, suchas external audit and accreditation, are designed to manage risk in clinical settings, another approach is 'trust'. The use of entrustable professional activities (EPAs) represents a deliberate way in which this is operationalised as a workplace-based assessment. Once engaged with the concept, clinical teachers and medical educators may have further questions about trust. This narrative overview of the trust literature explores how risk, trust and control intersect with current thinking in medical education, and makes suggestions for potential directions of enquiry. Beyond EPAs, the importance of trust in health care and medical education is reviewed, followed by a brief history of trust research in the wider literature. Interpersonal and organisational levels of trust and a model of trust from the management literature are used to provide the framework with which to decipher trust decisions in health care and medical education, in which risk and vulnerability are inherent. In workplace learning and assessment, the language of 'trust' may offer a more authentic and practical vocabulary than that of 'competency' because clinical and professional risks are explicitly considered. There are many other trust relationships in health care and medical education. At the most basic level, it is helpful to clearly delineate who is the trustor, the trustee, and for what task. Each relationship has interpersonal and organisational elements. Understanding and considered utilisation of trust and control mechanisms in health care and medical education may lead to systems that maturely manage risk while actively encouraging trust and empowerment.

Understanding Trauma-Informed Care in the PALTC Setting

In April 2003 the Alberta government integrated specialized mental health services, formerly organized independently, with the health regions, which are responsible for general health services. The objective of this article is to determine whether the transfer was associated with an increase or decrease in the share of resources in the region allocated to mental health care relative to total spending for health care. The measure of the share for mental health care is the total costs for mental health care resources as a percentage of total health care spending. Resources and spending examined were those that were actually or potentially under the regions' control. Annual costs for mental health services in the province were obtained for a seven-year period (fiscal year [FY] 2000 through FY 2006) from provincial utilization records for all residents in the province. Unit costs were assigned to each visit. The trend in the share measure was plotted for each year. The share for mental health care increased overall from FY 2000 (7.6%) to FY 2003 (8.2%), but returned to pre-FY 2003 levels in the three years after the transfer (7.6%). Despite concerns expressed before the transfer by federal and provincial reports over the level of expenditures devoted to mental health care, the integration of mental health services with other health services did not result in an increase of the share for mental health care.

Background Trust in the functioning of health care (HC) is crucial for the legitimacy of the public health care system. A decline in trust may lead to a reduced willingness among taxpayers to finance the system. This study examines the trends and correlates of trust in HC among the Finnish population. Methods Data from the Healthy Finland survey (2024, n = 26,628, aged 20+) were used, along with earlier surveys (2020, 2018,2022) to assess trends. Complex samples logistic regression was applied to analyze associations between independent variables (sociodemographics, self-rated health (SRH), mental health, HC use, and access barriers) and trust in HC. Results Trust in HC was reported by 79.8% (95% CI: 78.2-80.3) in 2018, 75.8% (CI: 75.0-76.5) in 2020, and 65.9% (CI: 65.5-66.3) in 2022 and 54.4% (CI: 53.5-55-4) in 2024. In the fully adjusted model (2024 data), higher trust was observed among frequent HC users (vs. no users OR = 1.62, CI: 1.43-1.83). Lower trust was reported by rural residents (vs. urban residents OR = 1.28, CI: 1.15-1.43)those with poor SRH (OR = 0.70, CI: 0.63-0.77), poor mental health (OR = 0.57, CI: 0.50-0.66), those experiencing poor service integration (OR = 0.66, CI: 0.60-0.74), long waiting times (OR = 0.63, CI: 0.56-0.70), high user fees (OR = 0.77, CI: 0.70-0.86), and long-distance access barriers (OR = 0.77, CI: 0.69-0.86). Initially, higher income was linked to stronger trust, but not in the fully adjusted model. Conclusions The results indicate a declining trend in trust in the functioning of HC services. Poor health status and difficulties in accessing services are linked to reduced trust. Measures to improve access to HC services are essential to strengthen the legitimacy of the system. Key messages • Trust in HC is declining. Poor health and access difficulties are linked to lower trust. • Improving access is vital to strengthening system legitimacy.

Objectives: To examine how the public assess trust in health care in England and Wales. Design: Postal structured questionnaire in cross sectional survey. Setting: Random sample of people on the...

<b>Objectives:</b> To examine how the public assess trust in health care in England and Wales. <b>Design:</b> Postal structured questionnaire in cross sectional survey. <b>Setting:</b> Random sample of people on the electoral register in England and Wales. <b>Subjects:</b> People aged 18 and over. <b>Main outcome measures:</b> General levels of trust and confidence in health care. <b>Results:</b> The response rate was 48% (n = 1187). The mean level of confidence (trust) in the healthcare system was 6.0 out of a score of 10. Levels of distrust appeared relatively high with at least 356 (30%) respondents reporting little or very little trust for 28 of 32 specific aspects of health care. The highest levels of distrust were found in relation to how the health service was run and financed, particularly waiting times and the implication of cost cutting for patients. Statistical analysis by univariable linear regression of the specific determinants of generic assessments of public trust (confidence) suggested that the key aspects were patient centred care and levels of professional expertise. Being covered by private health insurance was also a key determinant of levels of public trust. <b>Conclusion:</b> Public assessment of trust tends to address the views of care at the micro level. Policy makers concerned with the erosion of public trust need to target aspects associated with patient centred care and professional expertise.

Trauma and childbirth-related posttraumatic stress disorder (c-PTSD) are underrecognized possible consequences of birth and obstetric care that may affect maternal well-being, parent-infant bonding, and future reproductive decisions. Despite a growing body of research, gaps remain in the implementation of robust screening, timely diagnosis, and trauma-informed practices to prevent and address c-PTSD. Review our current understanding of psychological birth trauma and c-PTSD, emphasizing provider roles in prevention, identification, and management. PubMed and Google Scholar literature search from 2000 to 2024. Birth trauma is a subjective experience, often driven by factors such as poor communication, lack of informed consent, and perceived loss of control. Only a subset of individuals with traumatic births develops c-PTSD. Prior trauma, mental health conditions, obstetric complications, and inadequate support exacerbate risk. c-PTSD affects approximately 3% to 6% of low-risk, postpartum individuals and up to 18% of postpartum individuals in high-risk populations. Diagnosis requires assessment of associated symptoms with validated tools. Interventions range from psychosocial support, medications, and trauma-focused therapies. Preventive strategies include maternal mental health collaborative models and trauma-informed care that emphasizes respectful communication, autonomy, and continuity of care. Obstetric providers are key actors in shaping a positive childbirth experience through respectful communication and shared decision-making. Early follow-up, mental health screening, and collaborative, trauma-informed care may help mitigate long-term psychological sequelae of birth trauma and c-PTSD to improve outcomes for birthing individuals and families.

Advancing Vaccine Uptake in People With HIV: A Call for Research on Trust and Intellectual Humility in Health Care.

BackgroundPublic trust is often advantageous for health authorities during crises such as the COVID-19 pandemic. Norwegian health authorities used the public´s high trust to control the pandemic, resulting in relatively few casualties.MethodsWe wanted to describe and compare the Norwegian public trust in GPs, public healthcare, information and treatment in hospitals before and during the early phases of the COVID-19 pandemic. Further, we wanted to investigate the relationship between somatic or mental illness, and trust in GPs and public health information, and to develop a theoretical understanding of the relationship between trust in healthcare institutions, generalised trust and the societal situation caused by the COVID-19 pandemic. We performed two surveys, the first in December 2019; the second in May 2020, thus providing two snapshots of the Norwegian public’s trust in healthcare and healthcare actors before and during the COVID-19 pandemic.ResultsThere was statistically significant increased trust in public healthcare, in treatment at hospital and in information at hospital after the outbreak of the COVID-19 pandemic. There was a non-significant rise in trust in GPs. We found that trust in public health information was not related to mental health nor having a chronic, somatic disease.ConclusionThe findings confirm that the Norwegian public’s trust in healthcare and healthcare actors is high. The trust levels are also relatively stable, and even show an increase during the early phases of the pandemic. We suggest that there is a dynamic relationship between trust in public health information, healthcare institutions, generalised trust and a societal crisis situation such as the COVID-19 pandemic. However, the GP-patient trust seems less affected by a crisis situation, than the public´s trust in healthcare institutions. This difference may be explained by the relative stability caused by mandates of trust obtained from the patient.