Trust in family doctor-patient relations: an embeddedness theory perspective

Abstract

Background

Based on the embeddedness theory, the present study aims to explore the association between patients’ trust in family doctors (Interpersonal Trust), trust in community health centers (Organizational Trust), and trust in society as a whole (Social Trust).

Methods

A cross-sectional survey was conducted in six community health centers in China, using partial least squares structural equation modeling to assess trust scale reliability and validity while testing hypotheses.

Results

The scores of Interpersonal Trust, Organizational Trust, and Social Trust were 3.761, 3.636, and 3.635, respectively. Our findings confirm that Interpersonal Trust is positively associated with Organizational Trust (β = 0.916, p < 0.001), Organizational Trust is positively associated with Social Trust (β = 0.617, p < 0.001) and Interpersonal Trust (β = 0.864, p < 0.001), and Social Trust is positively associated with Organizational Trust (β = 0.784, p < 0.001). However, the relationship between Interpersonal Trust and Social Trust was not demonstrated.

Conclusions

This study enhances our understanding of patient trust in family doctors. Applying embeddedness theory, we reveal positive correlations between Social Trust and Organizational Trust, as well as between Organizational Trust and Interpersonal Trust. Moreover, we have identified Organizational Trust as a crucial mediator in the relationship between Interpersonal Trust and Social Trust.

Introduction

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.

Fig. 1

Conceptual Model

Methods

Study design and sample

The data collection for this study involved the utilization of a CHC-intercept survey, which was conducted between February and April 2022. The survey was administered to patients attending CHCs. A total of six CHCs were selected in Wuhan, encompassing both the central city (Jiangan District and Hanyang District) and the remote city (Caidian District and Donghu New Technology Development Zone) areas. Participants were given the choice to complete the survey either through paper-based questionnaires or online questionnaires on mobile phones/tablets. A total of 240 questionnaires were distributed, out of which 228 valid questionnaires were collected after excluding those with errors, omissions, or logical mistakes, resulting in an effective response rate of 95%. Among the 228 participants, 61.4% were female, the majority were between 19 and 44 years old or 60–74 years old, and 81.1% were local residents. The distribution of residents in the central and remote areas was even. The majority of residents had a high school education or lower (61.4%), and most had an annual income below RMB 24,000 (39.0%). The prevalence of chronic diseases was high, with 76.3% of residents reporting the presence of a chronic illness.

Measurements

All of the measurement scales employed in this study were adapted from previously established studies and underwent extensive pre-testing. Construct refinement was conducted to ensure their applicability to the present context and to establish their validity.

Interpersonal Trust. This study mainly referred to the Wake Forest Physician Trust Scale, which has been translated into Chinese and demonstrated good reliability and validity [29]. After drawing on the research conducted by Egede and Ellis [30] and considering the characteristics of Interpersonal Trust among patients in family doctors, four dimensions, namely loyalty, ability, honesty, and comprehensive trust, were ultimately selected to comprise a total of 10 items.

Institutional Trust. The study also drew on the Multi-Dimensional Trust Scale for Health Care System [30], the European General Practice Assessment Questionnaire (EUROPEP) [31], as well as the measurement dimensions proposed by Zheng [32], Katja [33], Teke [34], Pascoe [35], regarding patient perceived value, satisfaction, and loyalty. A trust scale for Institutional Trust was designed, which includes five dimensions, including loyalty, service quality, reputation, satisfaction, and comprehensive trust, with a total of 10 items.

Social trust. This study referred to the measurement of trust propensity by Sherchan [36], and the Patient General Trust Scale developed by Yang [37] and after modification through discussions with the expert panel, four items were finally determined.

Items of each measurement scales are reported in Supplementary file 1. Participants reported their responses on a five-point Likert scale ranging from “strongly disagree” to “strongly agree”.

Reliability and validity assessment

To test the reliability of the questionnaire, this study employed Cronbach’s α coefficient and Composite Reliability (CR) value. Results showed that the Cronbach’s α coefficient of each scale ranged from 0.872 to 0.981 and the CR value ranged from 0.912 to 0.983 (Supplementary file 1), all exceeding the recommended threshold of 0.7, indicating good reliability of the questionnaire.

To test the validity of the questionnaire, both convergent and discriminant validity were examined. The factor loading coefficients of each item in the questionnaire ranged from 0.798 to 0.947, and the Average Variance Extracted (AVE) values ranged from 0.72 to 0.85 (Supplementary file 1), both exceeding the recommended threshold of 0.5, indicating good convergent validity. Discriminant validity was examined using Structural equation modeling through partial least squares method (PLS-SEM) to calculate the correlation coefficients among the constructs (Supplementary file 2). The square root of the AVE of each construct was greater than the correlation coefficient between the construct and other constructs, and the factor loading of all items of this construct on this variable was greater than the factor loading of all items of this construct on other variables, indicating good discriminant validity of the questionnaire.

Statistical analysis

Statistical procedure. To ascertain the reliability and validity of the measurement tool, PLS-SEM was utilized. Descriptive statistics such as means and proportions were employed to present the demographic characteristics of the study population. Additionally, Pearson’s correlation analysis was conducted to explore the relationship between Interpersonal Trust, Institutional Trust and Social Trust. The significance of the path coefficients was estimated using the PLS-SEM with bootstrapping methods, testing the research hypotheses and strengthen the validity of the findings. All of this analysis was performed using SPSS 25.0 and SmartPLS 3.0.

PLS-SEM. The PLS method was chosen for this study due to its minimal sample size requirements and its flexibility in terms of residual distribution assumptions, as highlighted by Chin [38]. The adoption of the PLS technique eliminates the necessity for conventional goodness-of-fit (GoF) measures, as emphasized by Hulland [39]. Instead, model predictability is assessed through the examination of R² values for the dependent latent variables. To further enhance the robustness of the model, control variables were included, specifically gender, age, place of residence, educational level, economic status, and the presence of chronic diseases. The examination of the explained variance of the endogenous constructs is pivotal in assessing the predictive power of the model. In line with existing literature, it is suggested that R² values of 0.67, 0.33 and 0.19 represent substantial, moderate, and weak explanatory power, respectively [40]. In this study, R² values were employed to assess the fit of the model, enabling a comprehensive evaluation of its predictive capabilities.

Results

The Interpersonal Trust score assigned by patients to their family doctors was found to be 3.761, with a standard deviation (SD) of 0.963. In comparison, the patients’ Institutional Trust score towards CHCs was slightly lower at 3.636 (SD = 0.888), while the Social Trust score was 3.635 (SD = 0.752).

Through Pearson correlation analysis, it was found that there was a significant correlation between patients’ Interpersonal Trust in family doctors, Institutional Trust in CHCs, and Social Trust, as shown in Table 1. The strongest correlation is between Interpersonal Trust and Institutional Trust, followed by the correlation between Institutional Trust and Social Trust.

Table 1 Pearson correlation analysis

PLS-SEM analysis was employed to assess the predictability of the proposed research model. The explained variance (R²) for each of the endogenous constructs is summarized in Fig. 2. Based on the Chin and Marcoulides’ criteria [40], all of the R² values for each latent construct were satisfactory.

Fig. 2

Results of PLS-SEM

To assess the significance of the path coefficients and validate the robustness of the findings, bootstrapping was conducted alongside the PLS technique. The study outcomes substantiated hypotheses H1 (β = 0.916 ***), H3 (β = 0.617***), H4 (β = 0.864***) and H6 (β = 0.784***). However, hypotheses H2 (β = 0.179) and H5 (β = 0.072) did not receive support (Table 2).

Table 2 Confirmation of hypothesis

Discussion

Our study reveals that the trust model of patients in family doctors is a chain model, which is inconsistent with the initial hypothesis of two “circular” models, and contradicts the viewpoint proposed by some scholars that “social trust influences initial trust” [41]. This finding may be influenced by China’s unique differential mode of association, which considers China’s social structure as being centered around blood, kinship, and territorial ties [22]. Consequently, it is plausible that Social Trust has limited influence on Interpersonal Trust. Additionally, according to the “stratified pattern” theory, the nature of the trust relationship in China can be likened to throwing a stone into a pool and producing circles of ripples that push outwards, with each person being the center of the circles pushed out by their social influence [42]. At this point, trust relies more on the emotional connection between the parties involved, and trust generated by individual family doctors may not directly influence patients’ social trust. Therefore, the mutual influence of interpersonal trust and social trust among patients has limited effects, and cannot be directly transmitted.

This study revealed that the Interpersonal Trust score (3.761) was slightly higher than the scores for Institutional Trust (3.636) and Social Trust (3.635), which aligns with findings from previous studies [43]. One possible explanation for this could be that Institutional Trust is a more complex and comprehensive construct compared to Interpersonal Trust, making it hardly to be improved over time [26]. Moreover, previous studies have indicated a strong correlation between patients’ individual trust in a physician and the physician’s institution. However, the direction of influence between the two remains unclear [25, 43]. In contrast, the findings of this study revealed that the strength of the relationship from Institutional Trust to Interpersonal Trust was 0.864, which was lower than the strength of the relationship from Interpersonal Trust to Institutional Trust (0.916). The establishment of a positive relationship between Interpersonal Trust and Institutional Trust relies on certain prerequisites, such as adequate infrastructure, a favorable environment, and high-quality healthcare services provided by healthcare institutions. Notably, this positive relationship may not be feasible in contexts like South Africa due to structural poverty, community vulnerability, and limited support from the health system [44].

Our study explored the correlation between Interpersonal Trust, Institutional Trust, and Social Trust in the context of the patient-family doctor relationship. Our findings are consistent with those of Arakelyan et al.‘s [18] research and provide empirical evidence to support the multidimensional nature of trust. However, given the complexity of the trust concept, researchers have yet to establish a consensus definition that captures all its dimensions. In our study, we defined Institutional Trust as trust towards organizations that represent (CHCs), while others defined it as trust in health systems [18]. Pearson and Raeke [45] did not distinguish between institutional trust and social trust, defining the latter as trust in collective institutions influenced broadly by the media and by general social confidence in particular institutions. Therefore, further research is needed to refine and standardize the conceptualization and measurement of trust in healthcare.

Firstly, it is important to note that while this study does include several control variables, such as education level, economic condition, and gender, the inclusion of control variables is not comprehensive. Specifically, important variables such as social capital were not included, which may limit the depth of the analysis regarding potential mediators and moderators. Secondly, trust among patients is a dynamic construct that develops gradually through interpersonal interactions. However, this study only examines the cross-sectional trust and does not investigate the relationship between Interpersonal Trust and Institutional Trust at different stages of trust development. Future research should conduct a more comprehensive and longitudinal examination of the dynamic process of patients’ trust evolution over time. Thirdly, our study reveals the complexity of the conceptual framework of trust, suggesting that existing measures may not capture all relevant dimensions of trust adequately. This finding aligns with the investigation conducted by Richmond et al. [46]. While Richmond and colleagues introduced three trust measures (Trust in My Doctor, Trust in Doctors in General, and Trust in the Health Care Team scales), there is still a need to develop high-quality measures for Interpersonal Trust, Institutional Trust, and Social Trust.

Conclusion

This study contributes to a more comprehensive understanding of the relationship between family doctors and patient trust. By adopting the lens of embeddedness theory, we have explored the interconnectedness of Interpersonal Trust, Institutional Trust, and Social Trust, particularly within the specific contextual setting of China. Our findings support the “stratified pattern” viewpoint and reveal positive correlations between Social Trust and Institutional Trust, as well as between Institutional Trust and Interpersonal Trust. Moreover, we have identified Institutional Trust as a crucial mediating factor between Interpersonal Trust and Social Trust. However, to further enhance the validity and applicability of our findings, future research should consider incorporating additional variables to strengthen the model, conduct longitudinal studies to examine trust development over time, and develop more comprehensive measures to capture the multidimensional nature of trust accurately. These proposed improvements will contribute to a deeper understanding of trust dynamics within healthcare settings and inform the development of effective strategies to promote trust between family doctors and patients.

Practice implications

The results of this study reveal that the levels of Interpersonal Trust, Institutional Trust, and Social Trust among patients were not particularly high, with scores of 3.761, 3.636, and 3.635, respectively. These findings indicate the need for improvements in trust levels among patients. Moreover, the study emphasizes the significance of patients’ trust in family doctors within the specific institutional and contextual setting of China. Strengthening trust in family doctors has the potential to enhance Institutional Trust, which, in turn, contributes to the development of Social Trust.

The interplay between trust in family doctors, Institutional Trust, and Social Trust highlights the significance of fostering trust in healthcare providers to positively impact broader societal trust dynamics. To achieve this, it is crucial to improve family doctors’ loyalty, honesty, and their ability to provide healthcare services. Offering patients high-quality, personalized, and satisfying contracted services that meet their health needs can greatly enhance interpersonal trust. Additionally, in line with McAllister’s affect- and cognition-based trust theory [47], efforts should be made to enhance patients’ cognition and awareness of their family doctors through information disclosure, social media, or health education. Moreover, building familiarity between patients and family doctors is important to establish affect-based trust. Through ongoing communication and attentive care provision, Interpersonal Trust between patients and family doctors can be strengthened, fostering a harmonious and trusting doctor-patient relationship.

From the Institutional Trust perspective, CHCs should optimize their disease prevention and treatment functions to deliver efficient, high-quality, and convenient medical services to patients, thereby bolstering trust in these institutions. Furthermore, it is imperative to enhance the healthcare service delivery capabilities of family doctors and improve the incentive mechanisms to foster their motivation for effective health care gatekeeping [48, 49]. Establishing a conducive environment for the sustainable operation of the family doctor system requires the implementation of scientific and effective compensation systems, performance evaluation and distribution mechanisms, as well as compensation mechanisms. Although enhancing Interpersonal Trust presents challenges [26], it is plausible that with improved satisfaction levels at CHCs and other contributing factors, this type of trust can gradually be strengthened over time. Ultimately, this may lead to a continuous enhancement of patients’ social trust in medical staff and the medical and health system, fostering a positive social atmosphere for the long-term development of family doctor contracted services.