Impact of public evaluation of the health security system on the trust in physicians: Mediating roles of satisfaction with medical care and perceptions of medical safety
Restricted accessResearch articleFirst published online May, 2026
Impact of public evaluation of the health security system on the trust in physicians: Mediating roles of satisfaction with medical care and perceptions of medical safety
This empirical study investigates how evaluations of the health security system (independent variable) affect trust in physicians (dependent variable), focusing on the mediating role of medical satisfaction and perceptions of medical safety (mediators). Using 2017 and 2019 China Social Survey (CSS) data (N = 17,054, aged 18–70, Mean = 47.33, 55.13% female), findings reveal a significant positive relationship between evaluations of the health security system and trust in physicians. The relationship is partially mediated by satisfaction with medical care and perception of medical safety, and the satisfaction with medical care shows a stronger mediating effect. This research highlights the crucial role of institutional trust in shaping public trust in physicians, an often-overlooked factor in healthcare trust studies. By identifying satisfaction with medical care and perceptions of medical safety as key mediators, the study provides actionable insights for policymakers aiming to strengthen doctor-patient relationships through systemic healthcare improvements.
AhnquistJWamalaSPLindstromM (2010) What has trust in the health-care system got to do with psychological distress? Analyses from the National Swedish Survey of Public Health. International Journal for Quality in Health Care22(4): 250–258.
2.
AlimenaSAirME (2016) Trust, Satisfaction, and confidence in health care providers among student and professional dancers in France. Medical Problems of Performing Artists31(3): 166–173.
3.
AllenMSIliescuDGreiffS (2022) Single-Item Measures in Psychological Science. Newburyport: Hogrefe Publishing.
4.
ArkedisJCreightonJDixitA, et al. (2021) Can transparency and accountability programs improve health? Experimental evidence from Indonesia and Tanzania. World Development142: 105369.
5.
BellerJSchäfersJHaierJ, et al. (2023) Trust in healthcare during COVID-19 in Europe: Vulnerable groups trust the least. Journal of Public Health31(9): 1–1504.
6.
BergkvistLRossiterJR (2007) The predictive validity of multiple-item versus single-item measures of the same constructs. Journal of Marketing Research44(2): 175–184.
7.
Bernal-DelgadoEGarcía-ArmestoSMartínez-LizagaN, et al. (2012) Should policy-makers and managers trust PSI? An empirical validation study of five patient safety indicators in a National Health Service. BMC Medical Research Methodology12: 19.
8.
BlackburnGL (2003) Questions & answers: How might my doctor confirm his suspicion that I have gallbladder disease?Health News9(12): 16.
9.
BruskotterJTEnzlerSATrevesA (2011) Science and law: Rescuing wolves from politics: Wildlife as a public trust resource. Science333(6051): 1828–1829.
10.
CalnanMSanfordE (2004) Public trust in health care: The system or the doctor?BMJ Quality & Safety13(2): 92–97.
11.
CastroMSBahliBFerreiraJJ, et al. (2023) Comparing single-item and multi-item trust scales: Insights for assessing trust in project leaders. Behavioral Sciences13(9): 786.
12.
ChakrVCBG (2021) Building up trust in the doctor-patient relationship. Andes Pediatrica92(3): 480–482.
13.
ChawlaNAroraNK (2013) Why do some patients prefer to leave decisions up to the doctor: Lack of self-efficacy or a matter of trust?Journal of Cancer Survivorship7(4): 592–601.
14.
CipollinaRSanchezDT (2023) Racial identity safety cues and healthcare provider expectations. Stigma and Health8(2): 159–169.
15.
CourbageCNicolasC (2021) Trust in insurance: The importance of experiences. Journal of Risk and Insurance88(2): 263–291.
16.
ElkefiSAsanO (2023) The impact of patient-centered care on cancer patients’ QOC, self-efficacy, and trust towards doctors: Analysis of a national survey. Journal of Patient Experience10: 23743735231151533.
17.
FareedNJonnalagaddaPSwobodaCM, et al. (2021) Socioeconomic factors influence health information seeking and trust over time: Evidence from a cross-sectional, pooled analyses of HINTS data. American Journal of Health Promotion35(8): 1084–1094.
18.
FuchsCDiamantopoulosA (2009) Using single-item measures for construct measurement in management research: Conceptual issues and application guidelines. Die Betriebswirtschaft69(2): 195.
19.
FülöpFBőtheBGálÉ, et al. (2020) A two-study validation of a single-item measure of relationship satisfaction: RAS-1. Current Psychology41: 2109–2113.
20.
GuttmanOTLazzaraEHKeeblerJR, et al. (2021) Dissecting communication barriers in healthcare: A path to enhancing communication resiliency, reliability, and patient safety. Journal of Patient Safety17: e1465–e1471.
21.
HanYLieRKLiZ, et al. (2022) Trust in the doctor–patient relationship in Chinese public hospitals: Evidence for hope. Patient Preference and Adherence16: 647–657.
22.
HawleyK (2015) Trust and distrust between patient and doctor. Journal of Evaluation in Clinical Practice21(5): 798–801.
23.
HuLLiuRZhangW, et al. (2020) The effects of epistemic trust and social trust on public acceptance of genetically modified food: An empirical study from China. International Journal of Environmental Research and Public Health17(20): 7700.
24.
JabeenGGoliGKafila (2024) Building trust: The foundations of reliability in Healthcare. In: KumarPSinghPDiwakarMet al. (eds) Healthcare Industry Assessment: Analyzing Risks, Security, and Reliability. Cham: Springer, pp.43–65.
25.
JakovljevicMChangHPanJ, et al. (2023) Successes and challenges of China’s health care reform: A four-decade perspective spanning 1985—2023. Cost Effectiveness and Resource Allocation21(1): 59.
26.
JaoIKombeFMwalukoreS, et al. (2015) Research stakeholders’ views on benefits and challenges for public health research data sharing in Kenya: The importance of trust and social relations. PLoS One10(9): e0135545.
27.
JiangSWuZZhangX, et al. (2024) How does patient-centered communication influence patient trust?: The roles of patient participation and patient preference. Patient Education and Counseling122: 108161.
28.
KalajaR (2023) Determinants of patient satisfaction with health care: A literature review. European Journal of Natural Sciences and Medicine6(1): 43–54.
29.
KatzEEdelsteinBTurianoNA (2024) Age as a moderator of health outcomes and trust in physicians. Journal of Aging and Health36(5-6): 308–319.
30.
KleibergenFPaapR (2006) Generalized reduced rank tests using the singular value decomposition. Journal of Econometrics133(1): 97–126.
31.
KrukMEKapoorNRLewisTP, et al. (2024) Population confidence in the health system in 15 countries: Results from the first round of the people’s voice survey. Lancet Global Health12(1): e100–e111.
32.
LeeJIDirksKTCampagnaRL (2023) At the heart of trust: Understanding the integral relationship between emotion and trust. Group & Organization Management48(2): 546–580.
33.
LerchSPHänggiRBussmannY, et al. (2024) A model of contributors to a trusting patient-physician relationship: A critical review using a systematic search strategy. BMC Primary Care25(1): 194.
34.
LiCKhanMM (2022) Public trust in physicians: Empirical analysis of patient-related factors affecting trust in physicians in China. BMC Primary Care23(1): 217.
35.
LiuJ (2022) Health security and public health emergency management in China. In: Chi Z (eds) Human Security in China: A Post-Pandemic State. Singapore: Palgrave Macmillan, pp.175–198.
36.
LiuKLiuWHeAJ (2023) Evaluating health policies with subnational disparities: A text-mining analysis of the Urban Employee Basic Medical Insurance Scheme in China. Health Policy and Planning38(1): 83–96.
37.
LiuPLZhangLMaX, et al. (2024) Communication matters: The role of patient-centered communication in improving old adults’ health competence and health outcomes. Health Communication39(2): 363–375.
38.
LuCZhangZLanX (2019) Impact of China’s referral reform on the equity and spatial accessibility of healthcare resources: A case study of Beijing. Social Science & Medicine235: 112386.
39.
LyndonADavisDASharmaAE, et al. (2023) Emotional Safety is Patient Safety. London: BMJ Publishing Group Ltd, pp.369–372.
40.
MaX (2021) Medical Insurance and Out-of-Pocket Expenses on Medical Care. Public Medical Insurance Reforms in China. Cham: Springer, pp.161–192.
41.
McGrawD (2013) Building public trust in uses of health insurance portability and accountability act de-identified data. Journal of the American Medical Informatics Association20(1): 29–34.
42.
MechanicD (1996) Changing medical organization and the erosion of trust. Milbank Quarterly74: 171–189.
43.
MelovicBStojanovicAJVulicTB, et al. (2020) Perceptions and attitudes of parents toward vaccination of children in Western Balkan countries: Trust in function of improving public health. Balkan Medical Journal38: 59–60. DOI: 10.4274/balkanmedj.galenos.2020.2020.7.110.
44.
MiJDuXAiliY, et al. (2024) Unveiling patient trust in physicians across China: Insights from a nationwide cross-sectional study. Risk Management and Healthcare Policy17: 1039–1052.
45.
MohammadiMRZarafshanHKhayam BashiS, et al. (2020) The role of public trust and media in the psychological and behavioral responses to the COVID-19 pandemic. Iranian Journal of Psychiatry15(3): 189–204.
46.
NakayachiK (2015) Examining public trust in risk-managing organizations after a major disaster. Risk Analysis35(1): 57–67.
47.
Newman-TokerDENasseryNSchafferAC, et al. (2024) Burden of serious harms from diagnostic error in the USA. BMJ Quality & Safety33(2): 109–120.
48.
OlagokeAAOlagokeOOHughesAM (2020) Psychological pathways linking public trust during the coronavirus pandemic to mental and physical well-being. Frontiers in Psychology11: 570216.
49.
PandrangiVCMaceJCDetwillerKY, et al. (2022) Financial hardship impacts depression and anxiety among US patients with sinusitis. American Journal of Rhinology and Allergy36(4): 491–502.
50.
PanjaitanNSihombingSPalenK, et al. (2023) Enhancing government communication strategies for effective health in-formation and public health education. Law and Economics17(2): 151–169.
51.
PlattJEJacobsonPDKardiaSLR (2018) Public trust in health information sharing: A measure of system trust. Health Services Research53(2): 824–845.
52.
PrasadTButaEClearyPD (2021) Is patient–physician gender concordance related to the quality of patient care experiences?Journal of General Internal Medicine36: 3058–3066.
53.
PughMJrPerrinPBRybarczykB, et al. (2020) Racism, mental health, healthcare provider trust, and medication adherence among black patients in safety-net primary care. Journal of Clinical Psychology in Medical Settings28: 181–190.
54.
Roder-DeWanSGageAHirschhornLR, et al. (2020) Level of confidence in and endorsement of the health system among internet users in 12 low-income and middle-income countries. BMJ Global Health5(8): e002205.
55.
RoweRCalnanM (2006) Trust relations in health care—the New Agenda. European Journal of Public Health16(1): 4–6.
56.
SiddiqueARahmanTPakrashiD, et al. (2024) Raising health awareness in rural communities: A randomized experiment in Bangladesh and India. Review of Economics and Statistics106(3): 638–654.
57.
SinghJARavinettoR (2020) COVID-19 therapeutics: How to sow confusion and break public trust during International Public Health Emergencies. Journal of Pharmaceutical Policy and Practice13: 47.
58.
SongEYooHJ (2020) Impact of social support and social trust on public viral risk response: A COVID-19 survey study. International Journal of Environmental Research and Public Health17(18): 6589.
59.
TangL (2011) The influences of patient’s trust in medical service and attitude towards health policy on patient’s overall satisfaction with medical service and sub-satisfaction in China. BMC Public Health11: 472.
60.
TaylorAWChittleboroughCGillTK, et al. (2012) Relationship of social factors including trust, control over life decisions, problems with transport and safety, to psychological distress in the community. Social Psychiatry and Psychiatric Epidemiology47(3): 465–473.
61.
TaylorLANongPPlattJ (2023) Fifty years of trust research in health care: A synthetic review. Milbank Quarterly101(1): 126–178.
62.
TobinMJ (2018) Conflicts of interest and the patient-doctor covenant. Intensive Care Medicine44(10): 1760–1761.
63.
TollJ (2019) Expertise, integrity, public trust, and professionalism in environmental risk assessment. Integrated Environmental Assessment and Management15(5): 672–673.
64.
TumlisonCSongG (2019) Cultural values, trust, and benefit-risk perceptions of hydraulic fracturing: A comparative analysis of policy elites and the general public. Risk Analysis: An International Journal39(3): 511–534.
65.
VilpertSBorrat-BessonCDomenico BorasioG, et al. (2020) Correction: Associations of end-of-life preferences and trust in institutions with public support for assisted suicide: Evidence from nationally representative survey data of older adults in Switzerland. PLoS One15(6): e0234954.
66.
WangYLiuCWangP (2023) Patient satisfaction impact indicators from a psychosocial perspective. Frontiers in Public Health11: 1103819.
67.
WanousJPReichersAEHudyMJ (1997) Overall job satisfaction: How good are single-item measures?Journal of Applied Psychology82(2): 247–252.
68.
WuJYangYSunT, et al. (2024) Inequalities in unmet health care needs under universal health insurance coverage in China. Health Economics Review14(1): 2.
69.
XiaoSWangLEdelmanEJ, et al. (2020) Interpersonal factors contributing to tension in the Chinese doctor-patient-family relationship: A qualitative study in Hunan Province. BMJ Open10(12): e040743.
70.
YuanLCaoJWangD, et al. (2023) Regional disparities and influencing factors of high quality medical resources distribution in China. International Journal for Equity in Health22(1): 8.
71.
YuQZhuCFengS, et al. (2021) Economic burden and health care access for patients with inflammatory bowel diseases in China: Web-based survey study. Journal of Medical Internet Research23(1): e20629.
72.
ZhaD (2021) China and the global search for health security: History, vaccines, and governance. China International Strategy Review3(1): 137–153.
73.
ZhangLChenRFangY (2023) Effects of urban and rural resident basic medical insurance on healthcare utilization inequality in China. International Journal of Public Health68: 1605521.
74.
ZhangXZimmermanAZhangY, et al. (2024) Rapid growth of private hospitals in China: Emerging challenges and opportunities to health sector management. The Lancet Regional Health–Western Pacific44: 100991.
75.
ZhaoNChenK (2023) Equity and efficiency of medical and health service system in China. BMC Health Services Research23(1): 33.
76.
ZhouYLiCWangM, et al. (2022) Universal health coverage in China: A serial national cross-sectional study of surveys from 2003 to 2018. Lancet Public Health7(12): e1051–e1063.
