and institutional factors (trust in medical training, general trust in public institutions, etc.) Certainly, none of the herbalists with whom we worked seriously contemplated taking the KNUST Degree because they didn't need to: patients came to them anyway and, as a signal of competence, an impressive-looking machine was just as effective and much cheaper (in time and money) than a degree certificate. Most work has focussed on doctor-patient relationships in Western settings (e.g. On a large desk sits a Quantum Magnetic Resonance Analyser: an impressive-looking (but not clinically-validated) device that purports to produce vast amounts of clinical information, from cholesterol levels to reproductive function, based on a non-invasive procedure of holding a pulsating electronic probe linked to a computer [Fig. government site. Patient testimonials from unknown callers were particularly compelling for many; one of NS's patients explained: On the radio, he spoke about so many sicknesses he could cure if you come to see him. SH also invests considerable effort in his radio performances, making careful preparations in advance: So when people hear me speak, they respect me because I know what I'm doing. Status Signals: a Sociological Study of Market Competition. Medicines have affective and emotional meanings beyond just their instrumental value (Whyte etal., 2003), and the same has been shown to apply to trust in healthcare practitioners/institutions (Gilson, 2003, Ackatia-Armah etal., 2016, Meyer and Ward, 2013). Brown P.R. This is fine if the practitioner really is trustworthy but, in the highly unregulated informal sector present in many LMICs, this cannot necessarily be assumed. Display of certificates (accreditation, qualification), etc. Some were generally favourably disposed to herbal medicine and came full of hope; others arrived reluctantly as a last resort. The role of trust in healthcare has received significant research attention in recent years. Herbalist interview guides followed a similar format, but focussed more on signal production and perceptions of patient interpretation [Online file B]. However, Signalling Theory has enabled us to go beyond description to formulate theoretically-derived predictions that are amenable potentially to empirical testing. In the early days, when this was a novel forum, it may not have been clear that the chances of being exposed by presenters asking tricky questions or callers complaining about poor treatment would be minimal. As we have suggested above, as long as patients cannot accurately distinguish between some mid- and higher-range signals, it will not make sense (at least in rational choice terms) for herbalists to improve their skills and competence by, for example, embarking on high-quality training programmes. Medicine's inconvenient truth: the placebo and nocebo effect. This collaborative approach will be needed to address the new theoretical complexities that arise when ST is applied to health-related trust problems. 2. Their trust is built on the fact that processed herbal medicines are clean, have dosage and expiry date, and are certified by the Food and Drugs Authority, as one young woman [23y] in SH's clinic put it. Patients will interpret the reliability of signals according to their knowledge/beliefs about their costs (monetary outlays, investment of time, effort, etc.) Operated usually by men, they claim to combine the best of indigenous healing with modern, scientific approaches, positioning themselves strategically within highly-competitive markets. To truly apprehend the parameters of these referred trust games played out at different scales is a major undertaking indeed. Given our sampling strategy, all interviewees believed (or hoped) that some herbalists were well-intentioned and able to give effective treatment. Regulation in Tanzania is, as one Government official put it, way behind Ghana. The recently-established Traditional and Alternative Health Practice Council recently began the mammoth task of registering all traditional healers in the country, while plans to license herbal medicines have yet to be operationalised. Mechanic D., Meyer S. Concepts of trust among patients with serious illness.  Those who have followed correct procedures for packaging medicines are likely to have followed correct procedures for making them. [35y man]. Ozawa S., Walker D.G. money; also perhaps less tangible things like satisfaction), again with varying degrees of certainty. Signalling Theory also enables a basis for comparative work between different empirical contexts that share the underlying condition of uncertainty. Gambetta and Hamill (2005) have noted that, in real life, the situation is usually better represented by continuum of signals that convey varying degrees of imperfect information, operating both singly and in clusters. Meanwhile, improving the rigour of testing and increasing/enforcing penalties for non-compliance could help raise the signal's real costs and reliability. In other words, herbalists have only to invest in signals that are costly enough to convince prospective patients to trust them.
Signalling Theory, whose origins lie in economics (Akerlof, 1970, Spence, 1973: Podolny, 2005) and evolutionary biology (Zahavi and Zahavi, 1997), has more recently been used by biological anthropologists (Bliege Bird and Smith, 2005, Sosis and Alcorta, 2003) and sociologists (Bacharach and Gambetta, 2003, Gambetta and Hamill, 2005, Gambetta, 2009, Hamill, 2011) to understand how communication works under conditions of uncertainty. While there were some differences between Ghana and Tanzania in the nature and degree of regulation, and in some of the strategies adopted by herbalists (for example, the use of radio broadcasts in Ghana), there was a remarkable degree of similarity observed between the two countries. Recent in-vivo and in-vitro studies in Ghana (e.g. Genuine healers, it was argued, were not out to make big money, so many of the fake herbalists are those who demand a lot of money, as one Tanzanian patient [25y woman] claimed. The primary trust problem is to ascertain an individual's trustworthiness by looking for observable indicators of that property. Second, because our 2015-16 study involved all herbal clinics identified in each city, this includes the three previously studied in Cape Coast; the sites where predictions were made and further investigated are therefore not fully independent. Nonetheless, herbal clinics share some common features which form the basis of our working definition: a fixed premises; operated by a practitioner claiming expertise in traditional herbal medicine; producing and selling manufactured, plant-derived capsules, powders, ointments and/or bottled medicines. Gilson L. Trust and development of health care as a social institution. Patients range from highly-educated professionals, well aware of the difference between a KNUST Degree and an unaccredited online course, to those for whom any certificate looks impressive: Fig. We argue that much can be gained from combining the rigorous theoretical models offered by Game Theory with the nuance and contextual detail enabled by ethnographic enquiry. In a recent edited volume, Broch-Due and Ystanes (2016) have argued persuasively that the ethnocentric assumptions of Western scholars have resulted in the privileging of individualistic, calculative models of trust, obscuring other modalities. This is the first research study that explores the correlation between presidential signalling and market volatility. One patient explained, It would be difficult you cannot just talk about something you don't know. FOIA KW's patients are indeed convinced by this display of knowledge: When I heard him on the radio, and how he was explaining things and the assurance he gave out, I was convinced that he would be able to solve my problems, said one [45y woman], while another was persuaded by KW's empathic manner: The doctor was patient and explained things clearly, so I thought he would be patient and have time to listen [33y woman]. The answers inform people about what you are doing, how you do it and it will ultimately attract them. McMillen H. The adapting healer: pioneering through shifting epidemiological and sociocultural landscapes. You may be able to access this content by logging in via your Emerald profile. Gilson L., Palmer N., Schneider H. Trust & health worker performance: exploring a conceptual framework using South African evidence. Trusting and its Tribulations: Interdisciplinary Engagements with Intimacy, Sociality and Trust. Even less is known about possible harmful effects of herbal medicines, especially chronic toxicity. Although, understandably, some patients were anxious not to be delayed for too long, most people were eager to share their experiences, generating a rich dataset. Arnold M.H., Finniss D.G., Kerridge I. The Hoods: Crime and Punishment in Belfast. They demand little time investment, no third-party validation, with little/no sanction for dishonest signalling. In addition to these practical challenges, bringing together different kinds of data into a single analytical framework presents epistemological challenges, which will require ethnographers and formal Game Theorists to develop new collaborative ways of approaching problems. For example, EL, a Ghanaian herbalist, deliberately used expensive embossed packaging for his medicines, which could only be purchased in bulk (50,000 packages at a time, costing GHS 50,000 [$12,500]), reasoning that, Those that copy cannot afford to do this they make cheap ones without embossment. Others spoke in similar ways about major infrastructural investment. The study used two separate data sources, the S&P 500 and 51,500 pages of the public papers between 1981 and 1999, nearly 20years of data. Many people therefore preferred to consult a local practitioner, whose reputation could more easily be assessed. Notably, despite some contextual differences, the signals displayed are remarkably similar in both countries. In-vivo efficacy of top five surveyed Ghanaian herbal anti-malarial products. Signs and signals used by herbalists and clinics to convey properties of trustworthiness: competence and integrity. Moreover, many conditions resolve themselves regardless of (or despite) medical intervention, and the widespread practice of polypharmacy (attempting several treatments simultaneously) makes it difficult to distinguish the effect of each, while widespread beliefs that divine intervention plays a strong part in healing further complicate the business of ascertaining which herbalists and therefore what kinds of signals were in fact trustworthy. A similar logic was used by some to reason that only genuine healers, confident in their abilities, would offer medicines on credit (usually in the form of a small up-front fee with the balance paid on results). This latter is behind SH's strategic display of an Ontario Council for Herbal Medicine membership certificate, acquired on an extended visit to Canada. The patients we interviewed were diverse with regard to gender, age and socio-economic/educational background, although women and younger adults were in the majority: Table1. Some relevant data could be obtained relatively straightforwardly: for example, average daily clinic takings or the official costs of registering a medicine (although not necessarily the unofficial costs). Careers. will also be available for a limited time. Nondo etal., 2016) have detected varying levels of antimicrobial activity and efficacy in commonly-marketed herbal medicines. Herbalists operating clinics will use a range of signals to communicate their trustworthiness to patients. and, sometimes, the observable indicators of those qualities (making eye contact, smiling, listening, etc.). At the back of the room, behind a curtain, is an examination couch. A good radio broadcast can now be achieved by both competent, empathetic herbalists and by confident, quick-thinking charlatans, while patients struggle to distinguish between the two. In this paper, we propose that Signalling Theory a variant of Behavioural Game Theory might provide a valuable tool for enabling a deeper and more theoretically-informed analysis of health-related trust problems. Langwick S. From non-aligned medicines to market-based herbals: China's relationship to the shifting politics of traditional medicine in Tanzania. Signalling theory, strategic interaction, and symbolic capital. General reputation within and beyond local community. Many interviewees described long, arduous and often expensive therapeutic quests, finally coming to a herbal clinic desperate for relief, ready to try anything that might help.