Disrupting a cycle of mistrust: A constructivist grounded theory study on patient-provider trust in TB care.

Despite the importance of patient-provider trust identified in earlier research on tuberculosis (TB) care, there has been no in-depth exploration of its determinants and how it affects TB patient experiences. We conducted a constructivist grounded theory study to explore the process of patient-provider trust in the context of TB care. This study took place in Cape Town, South Africa, an urban setting with a high prevalence of TB, and where treatment for TB is provided free-of-charge. We used theoretical sampling to select participants (TB patients and providers) from four public primary care clinics and one public TB hospital between Dec. 2015 to May 2017. We conducted in-depth, semi-structured interviews with 33 adult TB patients and 26 TB providers (including doctors, nurses, counsellors and community health workers). Interviews were transcribed and analyzed using a constant comparative approach. Our resultant theory, entitled "Disrupting a cycle of mistrust", describes a cycle of mistrust between TB patients and their providers that is grounded in health system norms and guidelines, and in subsequent provider and patient actions. This cycle is disrupted when providers develop and demonstrate trust towards their patients, which in turn builds patient trust in them and promotes positive treatment experiences. This theoretical model demonstrates the connection between structure (health system, local norms) and agency (individual practices and behaviours), and shows how the rigidity of current global TB treatment practices undermines opportunities to establish patient-provider trust. The model should guide future research on measuring and building patient-provider trust in TB care, and motivate for a new TB treatment paradigm that focuses more on patient-provider trust, and less on patient supervision and mistrust.