The application of Signalling Theory to health-related trust problems: The example of herbal clinics in Ghana and Tanzania

Kate Hampshire,Heather Hamill,Simon Mariwah,Joseph Mwanga,Daniel Amoako-Sakyi

doi:10.1016/j.socscimed.2017.07.009

Abstract

In contexts where healthcare regulation is weak and levels of uncertainty high, how do patients decide whom and what to trust? In this paper, we explore the potential for using Signalling Theory (ST, a form of Behavioural Game Theory) to investigate health-related trust problems under conditions of uncertainty, using the empirical example of ‘herbal clinics’ in Ghana and Tanzania. Qualitative, ethnographic fieldwork was conducted over an eight-month period (2015–2016) in eight herbal clinics in Ghana and ten in Tanzania, including semi-structured interviews with herbalists (N = 18) and patients (N = 68), plus detailed ethnographic observations and twenty additional key informant interviews. The data were used to explore four ST-derived predictions, relating to herbalists' strategic communication (‘signalling’) of their trustworthiness to patients, and patients' interpretation of those signals. Signalling Theory is shown to provide a useful analytical framework, allowing us to go beyond the primary trust problem addressed by other researchers – cataloguing observable indicators of trustworthiness – and providing tools for tackling the trickier secondary trust problem, where the trustworthiness of those indicators must be ascertained. Signalling Theory also enables a basis for comparative work between different empirical contexts that share the underlying condition of uncertainty.

Highlights

We propose that Signalling Theory e a variant of Behavioural Game Theory e might provide a valuable tool for enabling a deeper and more theoretically-informed analysis of health-related trust problems
Signalling Theory enables a basis for comparative work between very different empirical contexts that share the underlying conditions of uncertainty, since we can hypothesise that what appear to be very locally-specific practices might share a common underlying logic
Our work suggests that Signalling Theory might usefully be applied to help understand, make predictions about, and perhaps begin to address, trust problems in healthcare, especially in low/middle-income countries (LMICs) where levels of uncertainty are high and formal regulation weak

Summary

Introduction

Patients are faced with the problem of whom and what to trust. Birungi, 1998; Gilson et al, 2005; Russell, 2005; Ozawa and Walker, 2011; Tibandebage and Mackintish, 2005; Ackatia-Armah et al, 2016; Rodriguez, 2016). These studies have identified various inter-personal factors (honesty, sincerity, empathy, evidence of competence, etc.) and institutional factors (trust in medical training, general trust in public institutions, etc.) that interact to promote trust and influence treatment-seeking decisions

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Conclusion