ReferenceSocial Science and Medicine 2002; 54: 879–888
Authors and institutionSusan Dorr Goold, Department of Internal Medicine; Glenn Klipp, General Medicine Division, University of Michigan Medical Center, US
BackgroundThe study began as ‘an investigation into members' “consent” to health insurance decision making, focusing on what information they valued or used, what important features led them to choose a health plan, and whether their experiences fitted their expectations.’
SettingEnrollees in managed healthcare plans in south-east Michigan, US
AimsTo explore consumer expectations and experiences in managed health plans. The report however ‘focuses on the role of trust in members' perceptions and experiences of managed care, a topic that participants spontaneously raised during the study’
Research designSemi-structured, open-ended interviews (31 interviews with 40 participants)
SamplingInterviewees were selectively sampled through area employers (11), community-based organisations (14), personal contacts (11), and upon referral by other interviewees (3). For four interviewees in two interviews they were unsure of the sampling source. They sought to include people of diverse ethnicity, educational labels, and health status. In order to focus on the lay perspective, health professionals were excluded. Participant characteristics: mean age 41 years (range 25–71 years); 65% were male; 50% white, 30% African-American, 7.5% Hispanic, the remainder being Indian, Arab or of mixed race; self-reported health status varied from excellent to poor; annual family income varied from <US$15 000 to >US$60 000. Illnesses reported during interviews included chronic medical, mental illness and acute conditions
Data collectionParticipants were asked about health insurance choices, experiences, and expectations. If health experiences were limited, interviewees were asked to consider a hypothetical scenario. After ‘early analysis revealed the importance interviewees attached to relationships in health care’, later interviewees were asked ‘to comment generally about their relationships with their primary doctor(s) …’ Interviews were audiotaped and transcribed verbatim
ReflexivityNot discussed
Ethical issuesNot discussed
Data analysisFormatted transcripts were imported to QSR NUD*IST for analysis. Goold coded the first 11 transcripts to develop a typology of themes. This schema was then reviewed by Klipp and Goold who finalised themes and their definitions. Interpretive analysis of the transcripts resulted in 141 individual themes organised in a hierarchical or tree structure, including eight categories with varying numbers of subthemes. Analysis focused first on themes that emerged spontaneously in interviewee discourse, including that of trust. Patterns and relationships between codes were examined in order to learn about the context in which trust discourse occurred. Trustworthiness of data interpretation was assessed by: having both investigators code a random sample of 10% of interviews and measuring agreement; asking a third party, unfamiliar with the coding scheme, to read 486 randomly selected text units (1 %) of data and to independently describe these units; presentations to others knowledgeable in the area; and coherence with existing theories and studies about interpersonal and institutional trust.