PHC is a health delivery approach for optimizing equity in providing health services to the whole of community. The results of the present study showed that PHC trust was in an average level however, it was not acceptable. Age, gender, being married, type of health insurance, SES level, and living in the province capital were the affecting variables of PHC trust level. PHC focuses on population requirements and preferences, both individually and as a community, and systematically address health social determinants by providing proper services for health promotion [33]. PHC is the most comprehensive and primary level of health services delivery in Iran with the focus on deprived population [29, 34]. According to the literature, a trusted health team could provide patients with more emotional care and information and help them in shared decision making on their health (cognitive care) [33, 35, 36]. On the other side, low level of public trust in PHC will affect efficiency of health services and patients’ comply with healthy behaviors suggested by PHC providers [15, 37]. Kelley et al. (2014), in a systematic review of 13 randomized clinical trials, concluded that trust have a small but significant effect on health outcomes [17].
Tabrizi et al reported the mean of public trust in health system as 53.91±13.7 (out of 100) in Tabriz in the year 2014. Using a visual scoring method, people’s trust in urban health centers and public hospitals were calculated as 54.15 and 61 (out of 100), respectively [5]. Van der Schee et al (2007) reported a mean public trust of 70 in the Netherlands [9], higher than our results. In a Chinese study , researchers revealed that the public trust in physicians experienced a significant decrease from 2011 to 2016 and they asked policy-makers for taking relevant actions [38]. PHC system needs to be more trustful than other sectors of health system. Because it provides preventive health services with the focus on population health requirements and interventions which support achieving Sustainable Development Goals (SDGs) and also address the social determinants of health such as healthy childhood. Identifying PHC trust determinants and employing proper policies to increase its level, must be a priority policy-making system.
Women, younger people, married people, people who have insurance, households with higher level of SES, and also participants from cities other than Tabriz (the province capital) showed higher level of trust with a significant difference (p<0.05) when compared to corresponding variables. In contrast with our results, Zhao et al (2017) resulted that younger people in China had lower level of trust in health system [39]. It was reported, in previous studies, that age had a positive and significant association with the level of trust saying that people with higher age have higher level of trust in health system or health providers [38, 40]. In fact, PHC system in Iran does not efficiently provide health services needed for middle-aged and elderly[34]. However, beside clinical services, individuals in these age groups mostly need routine care, education, and empowerment. Population aging is a real challenge in Iran and other countries. It makes PHC systems to consider the changing face of the health needs and adopt more responsibility and accountability. This could help to bring more trust on PHC system.
Results revealed that people with chronic disorders have less level of the PHC trust than others. This was consistent with Ronny et al (2016) which stated that people with fewer chronic disorders had higher trust level on physicians [41]. This may be due to the prolonged treatment of these individuals and experiencing system deficiencies during their treatment. PHC system mostly provides care services and suggests lifestyle interventions for chronic patients which has long-term outcome. This is not a pleasant achievement for patients and they are seeking for short-term positive outcomes. This issue probably affects their trust level in PHC services.
It was revealed that demographic variables had a small but significant relation with PHC trust level (R2= 0.14383). In a study by Jodyn E. Platt et al (2017), demographics only described 18% of the trust in health system level [42]. Zhao et al (2019) in study of trust in physicians trend in China in 2011-2016, revealed that demographic variables have a small share in predicting trust level [38]. Trust is a multifaceted concept which is affected by different social, economic, personal and behavioral variables. Trust in health system, as a complex system, is associated with institutional and individual factors and also the context and picture of health system in the society. Literature reported that interpersonal relation between providers and patients, health provider skills, patients' experiences on the delivery and outcomes of health services, the quality of services provided by health facilities, and social image of health system made by social media affect public trust in health system [9, 43]. It was also reported that patients’ participation in PHC services delivery and shared decision making will lead to improved trust and public sphere of the health system [44, 45]. Policy-makers should adopt reforms on PHC system according to social context in order to create positive experiences. For countries, public trust in PHC is a vital prerequisite for increasing health level and also achieving Universal Health Coverage (UHC) goals. As a first level of health services delivery, PHC should be trustful to encourage people to employ healthy lifestyle and also to adopt healthy behaviors.
It should be in mind that PHC organization and services delivery model in Iran might influence the results. Moreover, use of cross-sectional design and self-reported questionnaire which did not provide casualty relations and may have been over or under-estimated can be other limitation. Notwithstanding, to the best of our knowledge, this is one of the first studies empirically explored PHC trust in a population and emphasized its importance in PHC policy development in the world.