Parents’ Trust in Their Child’s Physician: Usingan Adapted Trust in Physician Scale

Kathryn L. Moseley, MD; Sarah J. Clark, MPH;Achamyeleh Gebremariam, MS; Michelle J. Sternthal, BA;

Alex R. Kemper, MD, MPH, MS

Objectives.–To assess the performance of the Pediatric Trust inPhysician Scale (Pedi-TiPS) that refers to a child’s physician andis a modified version of the Trust in Physician Scale (TiPS), andto explore the association of trust to demographic variables.Methods.–We performed a cross-sectional survey of parents inpediatric specialty and primary care sites. Parents completed ananonymous questionnaire that included the Pedi-TiPS. Our mainoutcome variable was total Pedi-TiPS score (higher scores �higher trust). Reliability was determined by Cronbach’s alpha.Bivariate comparisons and linear regression modeling exploredpotential associations between demographic variables and totalscore.Results.–Five hundred twenty-six parents completed surveys

Received for publication October 8, 2004; accepted August 3, 2005.

AMBULATORY PEDIATRICSCopyright © 2006 by Ambulatory Pediatric Association 58

good internal consistency (� � .84). In bivariate analysis, lowerscores were associated with being a father (P � 0.03), olderparent age (P � 0.02), private insurance status (P � 0.01), parenteducation greater than high school (P � 0.04), and not having achild age �3 years (P � 0.03). In a regression model adjusted forother factors, parents who were either African American (P �0.05), or “other” race (P � 0.01), parents with private insurance(P � 0.02), and parents who had no children �3 years of age (P� 0.04) had lower trust.Conclusions.–The Pedi-TiPS has properties similar to the orig-inal instrument. We found associations between trust and demo-graphic factors that should be confirmed with further studies.KEY WORDS: doctor-patient relationship; parents; race; trust

(73% response rate). The mean total score was 45.4 (SD 6), with Ambulatory Pediatrics 2006;6:58–61

Trust is an essential component of the physician/patient relationship. In adult patients, higher levelsof trust are associated with greater continuity of

care, receipt of preventive care, adherence, and satisfac-tion.1–8 Some studies, though not all, have found thatminority populations, particularly African Americans,have lower levels of trust in their physician than non-Hispanic White patients.4,9–11 Patients younger than 65years7,8 and patients with public insurance9 have also beenfound to have lower trust.

To our knowledge, no previous study has measuredparents’ trust in their child’s physician in the outpatientsetting in a previously unselected population. Given theassociation of physician trust with health-promoting be-haviors and beliefs in adult patients, this is a significantgap in our knowledge.

The objectives of our study were 1) to determine thereliability of an existing measure of physician trustadapted for parents of pediatric patients and 2) to explorethe association of parents’ trust in their child’s physician,with demographic variables identified as significant inadult patient populations (parental age, race, and insurancestatus).

From the Child Health Evaluation and Research Unit, Division ofGeneral Pediatrics, University of Michigan Health System, Ann Arbor,Mich.

Address correspondence to Kathryn L. Moseley, MD, 300 N Ingalls,6C13, Division of General Pediatrics, University of Michigan Health Sys-tem, Ann Arbor, MI 48109-0456 (e-mail: klmosele@med.umich.edu).

METHODS

DesignWe performed a cross-sectional survey of a conve-

nience sample of parents whose children were patients atseveral university-affiliated, outpatient pediatric clinics insoutheast Michigan. The study sites consisted of 2 com-munity-based general pediatric clinics, 1 community-based pediatric/family practice clinic, and 2 hospital-basedpediatric subspecialty clinics (pediatric cardiology and amultispecialty clinic, not including hematology/oncology).The study was approved by the Institutional Review Boardof the University of Michigan Medical School.

Pediatric Trust in Physician ScaleThe Trust in Physician Scale (TiPS) is one of several of

instruments that have been used to measure adult patienttrust in a specific physician.4,7,10,12–16 This validated 11-item scale has a scoring range of 11–55, assessing severalcomponents of trust in a specific physician, includingcompetence, dependability, and confidentiality. Answersare on a 5-point Likert scale from “strongly disagree” to“strongly agree.” The scale has good internal consistency(� � 0.85–0.90).13 Scores on the TiPS are positivelycorrelated with patient satisfaction, desire for physiciancontrol of decision-making, and personal knowledge of thephysician.13,14 In adult patients, mean scores range from41.9–51.3.7,10,13,14 We based the Pediatric Trust in Phy-sician Scale (Pedi-TiPS) on the TiPS as originally writ-ten,13 modifying it only by substituting the phrases “my

child’s doctor” for “my doctor,” and “my child,” for “me”

Volume 6, Number 1January–February 2006

AMBULATORY PEDIATRICS Parents’ Trust in Their Child’s Physician: Using an Adapted Trust in Physician Scale 59

(Table 1). Question 9, originally written as, “My doctor isa real expert in taking care of medical problems likemine,” was changed to, “My child’s doctor is a real expertin taking care of children like mine.” Participants areinstructed to answer the questions about their child’s reg-ular doctor or the doctor their child sees most.

Our questionnaire also included demographic questions,including parental age, sex, race, and number and ages ofchildren 18 years of age or younger. Parents identifiedtheir race/ethnicity and that of their children using the UScensus categories.17

SampleBetween February and June of 2004, 1 of 3 research

assistants (2 non-Hispanic White, 1 African American)recruited potential subjects in the clinic reception areaimmediately after check-in. No attempt was made to ra-cially match research assistants and participants. Researchassociates did not approach parents whose children, in theresearch assistant’s judgment, required the parent’s undi-vided attention due to illness and/or behavior. All parentsover age 18 years who were accompanying their child toan appointment were eligible to participate. We excludedparents who had no children under the age of 19 years,those who were nonparental guardians, those with diffi-culty speaking or reading English, and those who werecalled to the examination room before consent could beobtained.

VariablesThe outcome variable was total Pedi-TiPS score. Inde-

pendent variables were parent/child race, parent education,parent age, parent gender, site of care, child’s insurancestatus and being the parent of a child �3 years of age.

For race, parent/child pairs were categorized into 5groups: 1) non-Hispanic White: parents who chose thesingle racial category of non-Hispanic White for them-selves and their children; 2) African American: parentswho chose the single racial category of African Americanfor themselves and their children; 3) other: parents who

Table 1. Descriptive and Psychometric Properties of the Pedi-TiPS (N

Item

1. I doubt that my child’s doctor really cares about my child as a pers2. My child’s doctor is usually considerate of my child’s needs and pu3. I trust my child’s doctor so much that I always try to follow his/her4. If my child’s doctor tells me something is so, then it must be true.5. I sometimes distrust my child’s doctor’s opinion and would like a s6. I trust my child’s doctor’s judgment about my child’s medical care.7. I feel my child’s doctor does not do everything he/she should for m8. I trust my child’s doctor to put my child’s medical needs above all

treating his/her medical problems.9. My child’s doctor is a real expert in taking care of children like mi

10. I trust my child’s doctor to tell me if a mistake was made about my11. I sometimes worry that my child’s doctor may not keep the informa

†Cronbach’s alpha 0.84.*Reverse-coded items.

chose a single racial category that was neither African

American nor non-Hispanic White and chose the sameracial category for their children; 4) multi: parents whochose multiple racial categories for themselves or theirchildren, or who chose a racial identity different from thatof their children; and 5) unknown: parents who did notdesignate a race for themselves or their children. Parenteducation was dichotomized into high school graduate orless, and any education past high school including trade orvocational school. Parental age was categorized as �30years, 31–40 years, and �40 years. Practice sites weredichotomized as primary or specialty care. We classifiedchild insurance status as any public, only private, or none.Because young children generally have a large number ofphysician visits which may influence parental trust in thephysician, we created the variable “any child �3 years ofage,” to compare parents with and without young children.

Data Analysis

Parents who responded to all 11 Pedi-TiPS items (N �526) were included for the calculation of descriptive sta-tistics, bivariate analyses, Cronbach’s alpha, correcteditem-to-scale correlations, range, mean, and medianscores. In the multivariate analysis, responses with miss-ing independent variables were excluded, reducing thenumber included in the final model to 485.

Linear regression modeling was used for both the initialbivariate and multivariate analyses after assessing forskewness. All variables with a P value of 0.2 or less inbivariate analysis were included in the multivariate regres-sion model to mitigate any potential confounding thatcould occur if the independent variables were not trulyindependent of each other.18 Because greater proportionsof African American parents had public insurance andwere younger than the other parents, we also tested themultivariate model with interaction terms for race andinsurance as well as for race and age. The results of thismodel are presented in Table 2. All analyses were per-formed using Stata 8.1 (Stata Corporation, College Sta-

6)

Mean SD

CorrectedItem-Scale

Correlation†

4.4 1.0 .26m first. 4.4 0.8 .58ce 4.2 0.8 .63

3.5 0.9 .47one.* 3.7 1.0 .49

4.3 0.7 .63ld’s medical care.* 4.3 0.9 .52considerations when 4.2 0.8 .59

4.2 0.8 .65’s treatment. 3.9 0.9 .59e discuss totally private.* 4.3 0.8 .41

� 52

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AMBULATORY PEDIATRICS60 Moseley et al

RESULTSOf 878 parents approached for participation, 161 were

ineligible. From the remaining 717 participants, we re-ceived 526 completed surveys (73% response rate).

The mean total score was 45.4 (SD 6.0) and the medianwas 46 (range 24–55). The scale was internally consistent(� � .84), and all items had a corrected item-total corre-lation �0.4, with the exception of the first item (Table 1).

Demographic characteristics and scores of parents withcompleted Pedi-TiPS surveys are shown in Table 2. Theracial composition and insurance mix of study participantswere similar to the usual patient population of the study-site clinics.19

In bivariate analysis, lower scores were associated withbeing a father (P � 0.03), older parent age (P � 0.02),private insurance status (P � 0.01), parent educationgreater than high school (P � 0.04), and not having a childage �3 years (P � 0.03). However, in the multivariatelinear regression model, parents who were either AfricanAmerican or “other” race, parents with private insurance,and parents who had no children �3 years of age hadsignificantly lower trust than their reference groups (Table2). The interaction terms for race and insurance, as well asrace and age, were not significant.

DISCUSSIONIn this study of parents’ trust of their child’s physician

in the outpatient setting, we found the mean score andinternal consistency of our modified instrument to besimilar to those reported in adult patients. The correcteditem-to-total scale correlations were comparable to previ-

Table 2. Descriptive Characteristics of Respondents, Total Pedi-TiPS SDemographic Variables with Pedi-TiPS Score (N � 526)

Entire Sample Respondents %T

Parent/Child RaceNon-Hispanic 63WhiteAfrican American 18Other 7Multi 11

Parent GenderMale 15Female 84

Parent Age (y)�30 3231–40 43�40 24

Child’s InsurancePublic 33Private 61None 1

Parent Education�HS graduate 21�HS graduate 74

Any Child Age �3 yearsNo 65Yes 35

*CI indicates confidence interval; HS, high school; SD, standard dev

ous studies with the marked exception of the first question,

which asks whether the physician “really cares about mychild as a person” (r �.26). This question may not beappropriately worded to assess physician dependabilityand concern for patient best interests for this population.

We found significant differences in parental trust oftheir child’s physician. Child health insurance status andhaving a child �3 years of age were significant both inbivariate and multivariate analyses, whereas parental racewas significant only in the multivariate model.

Unlike adult patient populations, parents of childrenenrolled in Medicaid had higher trust than those withprivate insurance. It may be that parents with privateinsurance are better-informed consumers of health care.Having done their own research, they may expect to bemore active participants in the child’s health care.20,21 Inbivariate analysis, parents with more than a high schooleducation had lower trust, potentially corroborating thisfinding. More research needs to be done to explore therelationship of parental education, insurance, and parentaltrust.

Parents without children younger than 3 years of agewere significantly less trusting than parents with youngchildren, though the difference was small. This findingmay be related to the frequent physician visits made byyoung children for recommended preventive care as wellas for illness.

We also found lower mean scores in the African-Amer-ican and other-race parents as compared with non-His-panic White parents in the multivariate model. ThoughAfrican American parents were also more likely to havepublic insurance and to be younger than non-Hispanic

and Results of Multivariate Linear Regression Model of Associations of

Score (SD)*.4 (6.0) Coefficient (95% CI)† P

.7 (6.0) Reference

.7 (5.9) �1.52 (�3.01, �0.03) 0.05

.4 (4.7) �2.80 (�4.80, �0.80) �0.01

.5 (6.2) �1.06 (�2.76, 0.64) . . .

.1 (6.9) Reference

.6 (5.7) 1.01 (�0.39, 2.58) . . .

.1 (6.3) Reference

.6 (5.5) 0.41 (�0.92, 1.73) . . .

.1 (6.1) �1.04 (�2.68, 0.60) . . .

.5 (5.4) Reference

.8 (6.1) �1.48 (�2.68, �0.27) 0.02

.8 (3.7) �3.67 (�8.84, 1.49) . . .

.4 (6.0) Reference

.1 (6.0) �0.82 (�2.14, 0.50) . . .

.0 (6.0) Reference

.2 (5.8) 1.29 (0.08, 2.50) 0.04

.

core,

otal45

45

444345

4445

464544

464443

4645

4546

White parents, there was no significant interaction be-

AMBULATORY PEDIATRICS Parents’ Trust in Their Child’s Physician: Using an Adapted Trust in Physician Scale 61

tween these variables. It is likely that some other unmea-sured variable may be confounding the association of trustand race in the bivariate analysis. Patient reports of per-ceived discrimination in health care22–24 and perceptionsof physician behavior and style vary by race for adultpatients.4,25,26 The finding of racial differences in percep-tions of physician behavior and style has also been con-firmed in parents of pediatric patients27 It is probable thatthese perceptions may also influence trust and may explainour findings.

Parents were assured of anonymity and so were notasked to identify their child’s regular physician or toreveal the length of their relationship with that physician.This may have limited our findings. Other variables we didnot measure included the health status of the children andthe existence of racial concordance between the physician,parent, or child. Though the number of African-Americanphysicians at any of the various practice locations wassmall, it is possible that African-American parents prefer-entially selected the minority providers, potentially affect-ing our findings of race and trust.

Scores on the Pedi-TiPS are similar to adult patientscores on the TiPS. However, the differences in scoresbetween groups of parents are small but statistically sig-nificant. Other variables affect parental trust in addition tothose measured in this study. Future studies should explorethe relationship of trust with other variables and examinewhether clinical outcomes are related to differences inparents’ trust in their child’s physician.

Our study has important implications for directing fu-ture research in child health. Adult patients’ trust in theirphysician has been shown to be strongly associated withpositive health behaviors and beliefs, such as adherenceand satisfaction. Pediatric researchers can use this reliableinstrument to measure parents’ trust in their child’s phy-sician and its association to important child health out-comes.

ACKNOWLEDGMENTThis study was supported by a grant from the Life Science, Values, and

Society Program of the University of Michigan U011038 P1: Kathryn L.Moseley, MD.

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