 Rhawer, mae gennym ni yn rhoi i gael eich ffordd i gael chi fel y gwaith yn gyntaf fydd yn ymwyaf. Rwy'n rhaid i'n du yn ymdifus ymdill o ddydd, mae'n ddiddorol i ddod o ddod o ddod o ddod o ddod o ddod o ddod o ddod o ddod o ddod o ddod o ddod o ddod, a meddwl yw'r meddwl yw'n ymwyaf ar hyn o ffyrdd, ac mae yw'n ddorol o ddod o ddod o meddwl yma yn bwysig, a llwyddoedd ychydig i Ganna a Tantania, a, yn ffwrdd, y dyfodol, y gallwn y gynhyrchu'r cyffredinol yn ei wneud, yn cyd-200 ymdweud ac yn ymdweud o'r oesaf o'r cyffredinol, yn cyd-9 o'r cyffredinol yn Ganna. Yn ymgyrch oedd, nid yw ymddiwch yn cael ei ffyrdd yma, sy'n ddyn nhw'n ddweud o'r ffyrdd yma, ond ond ymddiwch yn cael ei ffyrdd yn ymddiwch that will someone will perform an action that is beneficial or at least not detrimental to us, and that probability is high enough for us to consider engaging in some form of cooperation with them. Now it's generally accepted across the kind of broad social scientific literature that trust is granted to those who we find trustworthy, i.e. those who demonstrate enough competence and integrity for us to place our trust in them, and this formulation has underpinned the vast majority of the research on trust in health care that is focused a lot on doctor-patient relationships in western or global north settings and on surveys of generalized trust in North America and Europe, and in this work trust and trustworthiness are understood in the context of robust regulatory institutions and meaningful choice, but more recent work that has been focusing around resource per contexts where inadequate service provision and financial barriers may severely constrain choice has highlighted the importance of social relationships and mutual understanding between health care providers and those seeking care, and in these settings where the risks and uncertainties can be extraordinarily high, researchers have increasingly been questioning the premise that trustworthiness underpins trust, and they've highlighted the importance of living with uncertainty rather than seeking to eliminate it, and sometimes the need to actually trust the on trustworthy. In this work we can characterise the medicine buyer's dilemma as a trust problem because you cannot look at a medicine and ascertain its trustworthiness as my colleagues had previously been discussing, so people are not necessarily putting their trust in the product, but they may be putting their trust in the sellers of medicines, and buying medicines like buying anything we can characterise as an economic transaction and an asymmetrical economic transaction where the buyer has more power than the seller, and I think that that power differentiation is particularly strong in the case of buying medicines in resource per contexts because although a seller may not know what the quality of the medicine is, they tend to know more about the medicine than the buyer does, at least they know where they procured the medicine from. The consequences of getting it wrong in terms of having a poor quality medicine are typically much greater for the buyer than for the seller, especially in contexts where regulation is weak and the likelihood of anything actually happening to the buyer for selling a poor quality medicine is pretty low, and pharmaceutical medicines are typically bought whenever someone is unwell, and this sense of urgency can impair decision making, putting the customer in a position of structural disadvantage vis-à-vis the seller. So private sector medicine transactions in situations of relatively low regulatory capacity and enforcement occur within a context of uncertainty, information asymmetry and buyer vulnerability, and these information asymmetries on certain days and lack of vulnerabilities can also provide transactions at every stage in the supply chain. As retailers make decisions about procurement, which is what Kate has just been talking about, with less information on a medicine's quality and provenance than their suppliers. So one of the big questions that we're asking in this research is how do buyers of pharmaceutical medicines in these contexts manage this on a certain day? What this case does is highlights the limits of rational cognitive-based assessments of trustworthyness that really perviad the global north focused literature on trust, because there are no observable signs of proxy or observable signs or proxies that we can actually use to determine medicine quality. And in poorly resourced countries and communities buyers have very limited ability to act on this information about quality anyway. And even taking the medicine, so even ingesting the medicine, does not necessarily close the information gap about quality because people take lots of different medicines at the same time, so it can often be very difficult to tell which is working or not working. And of course there's a well-recognised placebo effect and also people often naturally just recover from illness. There's also an interesting belief around the idea that medicines are personal in some way, so that a particular medicine might work for me, but it might not work for you. And that also can blur or make it difficult to make a therapeutic link between ingesting the medicine and the therapeutic outcome. So one of the things you might say to me is hang on a minute, you know, whenever I go in to buy into a pharmacy or into a shop to buy a medicine, I just do it really quickly. And or whenever I observe people buying medicines, I don't actually see them spending a lot of time carefully checking the packaging, looking at the box, asking the pharmacist or the seller about what's in the medicine. People just go in, they buy their medicine and they move on. It happens very quickly with very little scrutiny. And in the observations that we carried out, this was true. A lot of buyers just simply went in bought medicine and left. And these buyers appeared to be no less vulnerable than the people who spent more time actually scrutinising the medicine and asking questions about it. And one thing that might be happening is that with acute illness, there are very strong practical and economic and emotional pressures to act. And so there may be an acceptance of a lower threshold of trustworthiness. There may be little point in worrying about trustworthiness of a product. Because even if it is poor quality, what are you going to do about it? There may also be little point in worrying about the trustworthiness of the seller, because it might be that the guy down the street is worse. And this quotation from Diego Gambetta, slightly encapsulate this whenever he says that we may have to trust blindly, not because we do not or do not want to know high on trust where the others are, but simply because the alternatives are worse. And so when choice is so constrained, it may be pointless to scrutinise and probe. And so how are people dealing with this dilemma? Well, over half of the interviews were over half of the interviewees were making a repeat visit to an outlet selling medicines. And some have been visiting the same outlet for many, many years. And their purchases had become socially embedded. They were interpersonal exchanges based on economic and social ties that had been reinforced over time. And there was a clear attempt to alleviate vulnerability by invoking what we call in the literature an effective basis of trust. So trust based on emotional bonds and obligations that have been generated through repeated interaction and through an attempt to generate empathy. And these social connections often preceded the economic relationship through kinship or through third party connections with church based relationships being particularly strong. And importantly, once a relationship had been established between a buyer and a seller, the impetus to address issues of uncertainty and informational asymmetry around quality diminishes a lot. So when trust is socially embedded, oh sorry, when trust is socially embedded, it reinforces the relationship and intensifies a moral obligation to be trustworthy if you like it almost forces people to be more trustworthy. But we find that in this situation people were more likely to give others the benefit of the doubt, even when presented with evidence to the contrary. And they were very wary of damaging long standing relationships. And this means that regulatory systems around improving and innovating reporting and monitoring systems may struggle to actually get any real purchase on this issue and therefore may be underused if trust is based on these kinds of social times. There's also no guarantee that you can do better elsewhere, as I said. So the guy down the street selling medicine might be just as bad or even worse than the person you built up a relationship with. So there are strong incentives to maintain less than optimal economic relationships. And it may be really counterproductive to take precautions. So when uncertainty is so great and you have very limited choice, it's much easier just to engage in wishful thinking or to not think about it than to manage the kind of cognitive dissonance of purchasing an evidently useless product. And also suspicious behaviour or behaviour that implies that you are suspicious of the other, you're suspicious of the seller by checking the packaging carefully, asking probing questions may actually undermine the relationship. And it's often the relationship with the person you're dealing with, which is ultimately more important to you because they may be the only person selling medicine within a 50 mile radius of you and you want to ensure that you can maintain that supply over time into the future. And these dilemmas are encapsulated in this quotation, which we was taken from an interview done with someone living in a village in Ghana, where he's talking about the only medicine shop in his village and he's talking about his relationship with the seller. And he's saying that the truth is that the man is basically good, but he drinks and when he drinks his mid swings, but that's not really the really interesting part of this quotation, is whenever he says, I am not just his customer, we also attend the same church. If I don't buy from him, he will tell our pastor. Moreover, as a fellow church member, I have to buy from him so that his business will boom. I don't have any other option to buy from him. So in this context, there's very little point in this man asking any significant questions about the quality of the product that he's buying. So some conclusions are that the sort of rational and cognitive based calculations of trustworthyness, where we look for signs and signals of trustworthyness, we probe, we scrutinise, we ask questions, can be very limited in situations of extreme poverty, constraint or desperation, where the choice might be to take whatever is available or do nothing at all. And that actually the relational and effective based trust can be undermined by these cognitive approaches of scrutiny and information seeking. However, effective based relationships cannot solve the problem. They cannot eliminate uncertainty. They cannot solve the trust problem, but they can make it more manageable. They can make it something that we can live with. Also importantly and interestingly, individual level decisions, which are made with good intentions in the moment where everyone is trying to do the best they can, actually can have a very negative overall effect at the systems level. So all of these individual micro level decisions, which are made under sub optimal conditions, but are made with the best of intentions, if you aggregate them all up at a systems level, you can see how that can have a very bad effect, a very negative effect on medicine quality overall. It's also important to note that the distinction between cognitive and effective based trust is not just a simple straightforward binary one. Decisions are often based on a fragile balance of the two, and we need to understand that balance better and the implications of it for understanding the behaviour that we can observe, but also for thinking carefully about the impact of future interventions on this issue around medicine quality. So thank you very much for some acknowledgments and look forward to any questions that you might have.