title: A qualitative study of the role of workplace and interpersonal trust in shaping service quality and responsiveness in Zambian primary health centres.
abstract: BACKGROUND
  Human decisions, actions and relationships that invoke trust are at the core of functional and productive health systems. Although widely studied in high-income settings, comparatively few studies have explored the influence of trust on health system performance in low- and middle-income countries. This study examines how workplace and inter-personal trust impact service quality and responsiveness in primary health services in Zambia.
  
  
  METHODS
  This multi-case study included four health centres selected for urban, peri-urban and rural characteristics. Case data included provider interviews (60); patient interviews (180); direct observation of facility operations (two weeks/centre) and key informant interviews (14) that were recorded and transcribed verbatim. Case-based thematic analysis incorporated inductive and deductive coding.
  
  
  RESULTS
  Findings demonstrated that providers had weak workplace trust influenced by a combination of poor working conditions, perceptions of low pay and experiences of inequitable or inefficient health centre management. Weak trust in health centre managers' organizational capacity and fairness contributed to resentment amongst many providers and promoted a culture of blame-shifting and one-upmanship that undermined teamwork and enabled disrespectful treatment of patients. Although patients expressed a high degree of trust in health workers' clinical capacity, repeated experiences of disrespectful or unresponsive care undermined patients' trust in health workers' service values and professionalism. Lack of patient-provider trust prompted some patients to circumvent clinic systems in an attempt to secure better or more timely care.
  
  
  CONCLUSIONS
  Lack of resourcing and poor leadership were key factors leading to providers' weak workplace trust and contributed to often-poor quality services, driving a perverse cycle of negative patient-provider relations across the four sites. Findings highlight the importance of investing in both structural factors and organizational management to strengthen providers' trust in their employer(s) and colleagues, as an entry-point for developing both the capacity and a work culture oriented towards respectful and patient-centred care.
authors.affiliation: Schools of Public Health and Medicine, University of Alabama, Birmingham, USA, Centre for Infectious Disease Research in Zambia, PO Box 30338, Lusaka, Zambia, Nossal Institute for Global Health, University of Melbourne, Level 4, 161 Barry Street, Alan Gilbert Building, Carlton 3010, VIC, Australia and globalstopp@gmail.com.
authors.forename: Stephanie M
authors.initials: SM
authors.lastname: Topp
authors.affiliation: University of Lusaka, Plot No 37413, Mass Media, Lusaka 101010, Zambia.
authors.forename: Julien M
authors.initials: JM
authors.lastname: Chipukuma
mesh_terms: D001291:Attitude of Health Personnel; D003695:Delivery of Health Care; D006801:Humans; D007400:Interprofessional Relations; D019982:Organizational Case Studies; D011320:Primary Health Care / Q000458:organization & administration; D011369:Professional-Patient Relations; D036301:Qualitative Research; D011787:Quality of Health Care; D035502:Trust; D017132:Workplace / Q000523:psychology*; D015024:Zambia
keywords: Health systems; primary health care; service delivery; trust