Family doctors are widely recognized as essential to primary healthcare and the cornerstone of healthcare systems across the world. They play a crucial role in providing efficient and cost-effective primary care, which can lead to a reduction in avoidable hospitalizations and emergency department visits [1]. Moreover, they offer personalized care that caters to the specific needs of patients, resulting in improved health outcomes and reduced healthcare costs in the long term [2, 3]. Several countries, such as the UK, Canada, and Australia, have established national programs for family doctor services. Meanwhile, China has implemented policies to promote and facilitate the development of family doctor practices [4].
Since its inception in 2009, China has implemented the “health-gatekeeper” system within grassroots health organizations, aiming to strengthen primary care services and improve the accessibility of medical care [5]. Under this system, family doctors are trained to provide comprehensive and integrated services, including preventive care, treatment of common ailments, patient rehabilitation, chronic disease management, and overall health management within primary healthcare organizations. These services are designed to meet the diverse health needs of the population, particularly in rural and underserved areas. A key feature of the Chinese family doctor system is the contractual relationship between patients and family doctors [6]. This relationship is intended to foster continuity of care and establish a stable, trust-based doctor-patient relationship. The family doctor acts as the first point of contact for patients, guiding them through the healthcare system and coordinating their care. The system also emphasizes a two-way referral process, where family doctors manage initial consultations and refer patients to higher-level facilities when necessary, thereby creating a hierarchical framework for diagnosis and treatment.
Despite the progress made, the development of the family doctor system in China faces significant challenges. These include variations in the quality and training of family doctors, inadequate facilities and resources in primary healthcare settings [2, 7], and most notably, a pervasive lack of trust between patients and family doctors [8,9,10]. Trust can be defined as “the optimistic acceptance of a vulnerable situation in which the trustor believes the trustee will care for their interests,” [11, 12]. In the context of China, studies have shown that the issue of trust is a key constraint on the development of the family doctor system [13], with patients exhibiting low levels of trust in their family doctors [10]. Thus, there is a pressing need to adopt a multi-faceted approach to address this trust deficit [7, 14].
The importance of trust in patient-provider relations cannot be overstated, with significant implications for patient satisfaction [5, 6], medication compliance [7, 8], mitigation of health disparities [9], disclosure of sensitive information [10], and overall health outcomes [11]. Given the significance of trust, researchers have long been interested in studies on the definition, measurement, intervention, and mechanism of trust. However, much of research has focused on interpersonal trust [12,13,14], which refers to the trust between healthcare providers and patients.
The complexity and embeddedness intrinsic to relationships have gradually been recognized. The institutional rationalist models, which assume that health systems remain constant and unaffected by contextual circumstances, have been criticized. Gilson [15] and Kittelsen and Keating [16] have proposed that health providers are embedded in health systems and do not act in a social vacuum. Kroegar [17] developed the Facework theory to explain the translation of interpersonal trust into organization or system level trust. Gill and colleagues [13] presented a new conceptual framework of public trust in the health systems, which suggests that public trust is derived from both individual trust in specific healthcare system representatives and more abstract trust in healthcare system organizations and processes. Furthermore, Arakelyan et al. [18] highlighted the embeddedness of health provider and mapped the dynamics between contextual factors, institutional, interpersonal and social trust and health-seeking for non-communicable disease services. However, most of these findings are based on theoretical discussions or analyses of qualitative data, and embeddedness theory needs to be verified in empirical research.
The embeddedness perspective argues that actors’ purposeful actions are embedded in concrete and enduring strategic relationships that impact those actions and their outcomes [19, 20]. It posits that social relations are embedded within broader social structures and institutions. In the context of healthcare system, this theory suggests that trust in family doctor-patient relations is shaped by broader social and institutional factors, including the interpersonal trust between doctors and patients (Interpersonal Trust), institutional trust in the healthcare services institutions which represents community health centers (CHCs) in this study (Institutional Trust), social trust in doctors in general, and the healthcare system as well as broader society (Social Trust). This paper endeavors to establish a theoretical framework encompassing Interpersonal Trust, Institutional Trust, and Social Trust, with the primary objective of investigating the interconnectedness among these three trust dimensions.
Theoretical background
Trust is an expectation of responsibility and obligation fulfillment towards others in social interactions. Initially, interpersonal trust was established based on familiarity and emotional ties between individuals, relying on kinship or geographic ties [21, 22]. However, with the advent of modern society, social interactions have transcended traditional forms, and trust has shifted towards individuals without any intimate relationship [21]. The detachment of social interaction space and social relationships from specific fields and familiar boundaries has made the generation of trust increasingly complex. Consequently, there is a critical need to expand the scope of trust among residents and family doctors to encompass the dimensions of Institutional Trust and Social Trust, while simultaneously exploring the interrelationships among these three domains.
Embeddedness Theory is a fundamental concept in the field of new economic sociology. This theory suggests that individual behavior is not solely based on “rational calculation,” as individuals are embedded within complex social networks at the micro-level, and are influenced by other elements within the network. From a macro perspective, cultural, political, and customary factors all influence individual behavior [19, 23]. This theory places multiple influencing factors within a unified framework, providing a logical structure for problem analysis. Among existing research, Granovetter’s theory of “structural embeddedness” is one of the most frequently cited frameworks. It emphasizes the overall structure and function of the social network among participating subjects, while also focusing on the position of each subject within the social network [20]. In this study, “embeddedness” refers to the family doctor’s integration into CHCs, and the integration of CHCs into the broader social environment.
Conceptual model
Interpersonal Trust. Interpersonal trust refers to the trust that exists between two individuals in a specific relationship; in this study, it refers to the trust that patients have in their family doctors. In the context of healthcare, the trust patients place in their personal family doctors can have a consequential impact on their overall trust in the affiliated CHCs and the perceived quality of healthcare provided by their doctors [24, 25]. This trust can subsequently extend to encompass their trust in the broader healthcare system and even society as a whole.
Institutional Trust. Institutional Trust encompasses the trust patients place in the CHCs where their family doctors practice. The service quality, medical technology and equipment conditions, and medical environment of CHCs exert a direct influence on patients’ inclination to seek medical treatment. Notably, Institutional Trust can exert a halo effect, potentially influencing patients’ Interpersonal Trust, particularly in nascent relationships [26]. As family doctors operate within the CHCs, patients’ initial perceptions of their family doctors are heavily shaped by their prior positive experiences during previous visits to the CHCs. Given their central role in China’s healthcare service delivery system, CHCs are integral to establishing patient trust in the broader healthcare system and even society as a whole. Therefore, the extent to which CHCs can offer safe, convenient, and reasonably-priced healthcare services profoundly impacts patients’ trust in the overall health system.
Social Trust. Social trust encompasses an individual’s inclination to trust doctors in general, the healthcare system, and society as a whole. It serves as an internal factor that influences individual trust and reflects their willingness to place trust in others, characterized by either blind trust or general trust. Given that CHCs are embedded within the broader social environment, patients’ perceptions of the healthcare system and all doctors contribute to their initial impressions of CHCs. Moreover, patients with a higher trust tendency are more likely to trust their family doctors.
Hypotheses. Given the interplay between these dimensions of trust, we hypothesize that Interpersonal Trust, Institutional Trust, and Social Trust are strongly interconnected. Specifically, we propose that higher levels of Interpersonal Trust in family doctors will enhance Institutional Trust in CHCs, which, in turn, will strengthen Social Trust in the broader healthcare system and society. Similarly, a positive perception of Institutional Trust is expected to reinforce both Interpersonal Trust and Social Trust, suggesting a robust and mutually reinforcing dynamic between these forms of trust.
Framework for Exploring Influencing and Resulting Factors of Interpersonal Trust. To further explore the relationships between Interpersonal Trust, Institutional Trust, and Social Trust, this study categorizes these relationships into two distinct types: influencing factors and resulting factors of Interpersonal Trust. According to Embeddedness Theory, Interpersonal Trust is influenced by Institutional Trust and Social Trust [18, 27]. Furthermore, Pavlou’s Trust Transfer Theory [28] suggests that trust in one party can be transferred to another party through mutual relations between the parties. In this context, Institutional Trust plays a mediating role in the relationship between Interpersonal Trust and Social Trust (Fig. 1. Model a). Conversely, Interpersonal Trust impacts both Institutional Trust and Social Trust, with Institutional Trust serving as a mediator between the two (Fig. 1. Model b). Subsequent subsections will delve into a more detailed discussion of the primary factors and research hypotheses.
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