Investigation of Trust in the Context of a Community-Based Health Insurance

Scheme in Cambodia

Sachiko Ozawa, MHS, PhD CandidateJohns Hopkins Bloomberg School of Public Health

October 9, 2008

Managed by Cambodian NGO Enrollment: 20-25% out of 22,000 families 20,000 insureds – largest scheme in Cambodia Insured families can access 10 Health Centers,

Thmar Pouk & Mongkol Borei Hospitals for free Enrollment by family; Premium is $2.00 per person

per year, up to maximum of $12.00 per family

Community-Based Health Insurance

*CAAFW: Cambodian Association for Assistance to Families and Widows

Scheme operated by CAAFW* in Thmar Pouk, Banteay Meanchey Province since Feb ‘05

Trust in CBHI Trust is hypothesized to be one of the

factors affecting enrollment in CBHI schemesTrust may be critical in CBHI where:

Enrollment is voluntary Health care spending entails an element of risk Health care arrangements are relational

Research Question:

Is CBHI enrollment associated with trust?

Trust CBHI Enrollment

Research Design: Mixed Methods Qualitative Research

Focus Groups Explore the meaning and role of trust Culturally-adapt existing survey instruments

Quantitative Research Cluster-Randomized Household Survey

Develop scales to measure trust levels Examine the relationship of trust with other variables Is CBHI enrollment associated with trust?

Analytical methods Qualitative Research

Grounded Theory Develop theory grounded in field data Inductive & Deductive approach Systematic Coding, Reflexivity Adaptation of existing survey instruments

Quantitative Research Factor Analysis

Development of Trust scales

Multiple Regression Analysis Examine associations: trust & enrollment

Strengths of the Research Design Scientific rigor in methodology Follows established method to study trust

Uses complementary qualitative & quantitative approaches

Comparable with other trust measures

Lessons are transferable Meanings of trust in CBHI Scales to measure trust in CBHI

Goudge J, Gilson L. How can trust be investigated? Drawing lessons from past experience. Social Science and Medicine 2005;61(7):1439-51.

Hall MA, Camacho F, Dugan E, Balkrishnan R. Trust in the medical profession: conceptual and measurement issues. Health Services Research 2002;37(5):1419-39.

Limitations of the Research Design Only CAAFW’s scheme in Banteay Meanchey Only community member’s trust Cross-sectional data Differences in quality of care Endogeneity between trust and enrollment Difficult to earn interviewees’ trust Illiteracy compounds difficulty of questions Difficult to integrate qualitative & quantitative results

Other Research Design Options Qualitative Only

Key Informant Interviews Observational Research Ethnographic Research

Quantitative Only Randomized Control Trial Cohort study Panel study Game Theory

With Comparator

Needs of researchers vs. policy makers Researchers

Scientific rigor first

Definitions, Hypothesis Conceptual framework Literature review Objectivity Generalizability Uncertainty Minimize bias Research ethics Dissemination

Policy makers Need insight to guide policy

Balance political interests Applied research with

actionable results

Timely results Relevance to policy agenda Results put in context e.g.

comparisons, costs etc. Awareness of results

Questions for Reflection

How can researchers better design studies with policy implementation in mind?

How can policy makers objectively give feedback to researchers’ study designs?