Trust, the core of the harmonious doctor-patient relationship, is related to the process and the final results of medical diagnosis and treatment.1 A majority of the existing empirical and theoretical research in this area has shown that the patient who trusts the doctor has more satisfaction at the treatment, more beneficial health behaviors and higher intention to comply.2-4 In contrast, due to mistrust, the patient suspects the doctor’s motivation and even treats the therapeutic staff aggressively.5 During the process, necessary self-protection measures by the doctor lead to conservative medical treatment and difficulty of communication.6 Therefore, a good patient’s trust is not only the basis of effective treatment but also a vital link to build a harmonious doctor-patient relationship.
Patient’s trust
Patient’s trust is the willingness of the patient to be vulnerable to the actions of the doctor based on the expectation that the doctor will perform a particular action important to the patient, irrespective of the ability to monitor or control that the doctor.7,8 Due to the painful injury of the disease and the asymmetry of information in the medical process, the patient trust their doctor who can bring them recovery.9-12
With regard to the types of the patient’s trust, Hall classified it into two categories: technical competence trust, which is qualified practice skills to make correct decisions and avoid mistakes, and benevolence trust, which is interpersonal and communication skills to care the patient’s interests and tell the truth.8 Besides, some researchers have proposed that patient’s trust consists of affective trust and cognitive trust.13,14 Sun and Wang conceptualized patient’s trust as three-dimensional: interpersonal trust, intergroup trust and institutional trust.15-17 We adopted the Hall’s classification in this study which was used by the most researchers.2,8
There are a variety of the patient’s trust scales, especially in the developed countries. In 1990, Anderson explored the first English-language scale for the systematic assessment of patient trust which has good reliability and established a standard for such measurement tools in the future.18 Since then, many researchers have begun systematic studies on patient’s trust scales, such as the Safran Primary Care Scale,19 the Kao Patient Trust Scale, 20 and the Wake Forest Physician Trust Scale (WFPTS).8 However, the study of the patients’ trust scale in China is still in the initial stage, because most researchers used the Chinese adaptation of the WFPTS to assess the patients’ trust in China, rather than designing questionnaires based on the actual state of China.2, 21-23
Patient’s trust in China
At present, the status of the patient’s trust in the world is still unknown. The global comparisons of trust attitudes around the world suggested that the share of people reporting to trust others in China is much higher than that in most developed countries.24 However, in the past decade, doctor-patient conflicts occurred frequently and the negative reports about the relationship between doctors and patients have been overwhelming in China, which led to the original harmonious doctor-patient relationship has been becoming tense.12
Before 2009, the patient’s trust in China was high.25 However, the results of several studies in recent years have shown that the patient’s trust was at a low level.26-30 Meanwhile, after comparing the level of interpersonal patient’s trust between China in 2011 and 2016, it was found that the trust in 2016 was significantly lower than that in 2011.23 These findings have prompted calls for increased attention to the patient’s trust in China.
In 2002, Chinese researchers started exploring doctor-patient trust from the perspective of ethics. There is quite more theoretical research on the concept, model construction, evolution process and evaluation system, while few empirical studies focus on improving patient’s trust.31 As far as the research content is concerned, the current empirical research of patient’s trust has been lagging behind the investigation of the characteristics and overall situation of both doctors and patients, which lacks in-depth medical research with the dynamic and systematic construction. With regard to the measurement tools, we lack a universal scale that is fully applicable to the Chinese patient’s trust research. These studies in China, which should have supported the government in improving patient’s trust, are still in their infancy. Therefore, it is urgent for Chinese organizations and researchers to take better measures to improve the patient’s trust.
Factors influencing patient’s trust in China
In order to improve the patient’s trust, we need to explore the main influencing factors of the trust in China. Some researchers summarize the antecedents of the patient’s trust, including social environment, treatment situations and individual characteristics.12 At present, few research studies in China focus on treatment situations and doctors' characteristics. Therefore, we summarized the influencing factors of the patient’s trust from two aspects: patients’ characteristics and social environment.
Patients’ characteristics
A majority of the existing empirical researches in this area have begun to focus on the influence of patients’ characteristics.12,22,32 From the perspective of patient demographic variables which were studied most, some research pointed out that female patients and the patient with the same gender as the doctor trust doctors more;33,34 some studies found that patient age is negatively related to patient’s trust,33 but some evidence show the opposite result.1,22,34 Additionally, a positive correlation between patients with different educational background and the patient’s trust was also demonstrated.35However, the relationship among patient gender, age, education and trust are controversial, since some studies found no clear correlation between them, 36-38 and some research investigated that patient gender, age, education may influence the patient’s trust.32-34 Additionally, little evidence showed that these factors such as occupation, social class, economic status, and family background seem to affect patient’s trust.12,39-41 Inpatients, rural patients and the patient with the serious illness also have a high level of trust.25,42,43
Social environment
The formation of patient’s trust depends not only on patients’ characteristics, but also on social factors such as government, organizations and media. Among them, the changes of China's medical policy and the growing number of doctor-patient conflicts have the greatest impact on the patient’s trust.44-46
In 1949-1977, the doctor-patient relationship was good. People enjoyed free medical services and high public welfare. However, a market-oriented operation adopted in the healthcare industry led to the fragile doctor-patient relationship in 1978-2002. Since 2003, in order to better realize the transition from market-oriented operations to public welfare-oriented operations for the medical industry, the State Council of China launched a new round of medical reform programs in 2009, which aimed to establish and develop the basic coverage system for urban and rural residents. Especially, with the incessant deepening of the healthcare industry reform between 2013 and 2017, a package of measures has been established, including the hierarchical medical system, lowering drug prices, medical insurance fee system, promoting the reform of public hospitals, and equalization of basic public health service.44 The farmer-friendly policy which involved in the interests of a majority of the people may promote the trust level of the public.24,45
However, in recent years, China's doctor-patient conflicts occurred frequently. Statistics from the National Health and Family Planning Commission of China (2001-2016) showed that the number of vicious incidents caused by doctor-patient conflicts was 4,914 in 2001, increasing to over 8,000 in 2004, and nearly 10,000 in 2006. In 2016, the number of conflicts between doctors and patients was 20,833.46-49 Violence against the medical personnel has become a terrible wound in Chinese society.50 These conflicts exacerbated the mistrust between doctors and patients,51 which is also the main reason for the deterioration of the doctor-patient relationship.52
Although we summarized these important factors on patient’s trust, evidence about the role of these influencing factors in the patient’s trust is still unknown. Therefore, it is essential for China to understand the changing trend of patient’s trust in these years, explore the effect of the influencing factors of the changes and determine the relationship between some patient characteristics and patient’s trust. To date, to our knowledge, there is no studies comprehensively examining the status of patient’s trust, including the status, influencing factors, existing problems and future research directions of Chinese patient’s trust. To address this research gap, we conducted a systematic review and a cross-temporal meta-analysis to explore whether patients' trust to doctors has changed over the years.53-55 We also investigated whether the policy stage, the type of patients, and the scales differentially influence the trust. Especially, about the patient type, most studies used t test and F test to analyze the relationship between some patient characteristics (gender, age and education) and patient’s trust, rather than separately exploring the trust value of different gender, age and education. In order to clarify the influence of these patient characteristics on patient’s trust, we conducted a related meta-analysis to examine the association between patient demographic variables (gender, age, and education) and patient’s trust.