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

Abstract

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.

Keywords

health security system perceptions of medical safety satisfaction with medical care trust in physicians

Introduction

With medical science advancing at an unprecedented rate, bridging the gap between patients and physicians remains a critical issue due to information asymmetry (Blackburn, 2003). Information asymmetry refers to the imbalance of knowledge between patients and physicians, with the physicians possessing specialized medical knowledge that the patients usually lack. This imbalance can lead to suspicion or distrust on the part of patients, who must rely on the physicians to act in their best interests. In China, the world’s most populous country, this challenge has manifested itself in increasing conflict and tension between the general public and healthcare professionals (Tobin, 2018). This friction has escalated into a major social dilemma that requires effective and innovative solutions.

A key factor in mitigating these tensions is to enhance the trust of the general public in their physicians. Trust is an essential element of the doctor-patient relationship and is the basis for effective communication, cooperative decision-making, and mutual respect. However, this trust is gradually disappearing due to the general public misgivings about physicians’ expertise and ethical standards (Calnan and Sanford, 2004; Chawla and Arora, 2013). This distrust not only undermines the delivery of healthcare services, but also discourages potential new entrants into the healthcare industry and exacerbates existing challenges (Hawley, 2015; Xiao et al., 2020).

In this context, the general public’s evaluation of the health security system becomes a potential change factor. In China, health security system refers to the institutional framework that ensures affordable and safe access to healthcare services through mechanisms such as health insurance, financial protection, and regulation (Liu, 2022; Zha, 2021). It includes policies and programs that aim to improve access to healthcare services, control health care costs and improve patient safety (Jakovljevic et al., 2023). China’s health security system is designed to ensure that people can access and afford healthcare services under fair and regulated conditions (Zhao and Chen, 2023). China’s health security system operates primarily under a government-led model, with the government involved in financing and supervision (Zhou et al., 2022). Healthcare is not free, and individuals must pay the full cost of healthcare services unless they have insurance (Wu et al., 2024). The system consists of two main health insurance schemes: Urban Employee Basic Medical Insurance for formal sector workers, and Urban-Rural Resident Basic Medical Insurance for the self-employed, unemployed, and rural population (Liu et al., 2023; Zhang et al., 2023). Although the health security system covers almost the entire population, out-of-pocket expenses remain high, with patients often responsible for a portion of healthcare costs, especially for special care or medications not covered by insurance (Ma, 2021). While China’s public hospitals dominate the healthcare sector, an alternative service is provided by a growing private sector (Zhang et al., 2024). Despite the government’s efforts to improve the health security system, gaps in the quality, affordability and accessibility of healthcare services remain, affecting public’s perceptions of the health security system and trust in doctors. High-quality health security system can significantly impact patient trust by improving the overall patient experience of health care (Li and Khan, 2022). When the general public perceive that health security system comprehensively and effectively meets their healthcare needs, their satisfaction and trust in the health security system may increase. However, there is still a shortage of research in the literature on the relationship between the general public’s evaluation of the health security system and their trust in physicians.

This study aims to fill this research gap by exploring two main questions. (1) How does the general public’s evaluation of the health security system affect their trust in physicians? (2) Do factors such as satisfaction with medical care and perceptions of medical safety mediate the relationship between the general public’s evaluation of the health security system and their trust in physicians?

Concepts and implications for general public’s trust in physicians

The general public’s trust in physicians is an integral part of the therapeutic relationship and is defined as general public’s willingness to disclose personal vulnerabilities to a healthcare provider and relinquish control over medical decisions (Xiao et al., 2020). This trust is not only an emotional state, but also a weighed risk where the general public accept the healthcare provider’s decision without rigorously verifying its veracity (Hu et al., 2020). The dynamics of trust involves a critical balance—it allows providers to act autonomously, leading to effective care, but at the same time exposes patients to the potential risk that provider behavior may not be in their best interest (Nakayachi, 2015; Singh and Ravinetto, 2020). The theoretical framework emphasizes that trust in this context involves both a waiver of personal oversight and an acceptance of the potential risks associated with that waiver.

Factors affecting general public’s trust in physicians are categorized into macro-environmental and micro-individual influences. Macro-environmental factors include a wide range of social factors such as economic conditions (Tumlison and Song, 2019), social climate (Lerch et al., 2024; Song and Yoo, 2020), healthcare system structure (Jao et al., 2015), cultural traditions (Jao et al., 2015), and media images (Mechanic, 1996; Mohammadi et al., 2020). These factors, due to their generalizability, usually have a consistent impact across regions, leading to relatively consistent trust within these regions (Toll, 2019). In contrast, individual micro-factors, such as personal characteristics (Olagoke et al., 2020), psychological perceptions (Ahnquist et al., 2010), personal resource availability (Bruskotter et al., 2011), and family dynamics (Melovic et al., 2020) bring about significant differences in trust at the individual level. Theoretical explorations of these micro-factors have revealed their profound impact on the formation and maintenance of trust, emphasizing the importance of individual differences in shaping the healthcare experience (Taylor et al., 2012).

Relationship between the general public’s evaluation of the health security system and their trust in physicians

Theoretically, health security system plays a crucial role in shaping patient trust in physicians. The health security system provides a regulatory framework that can influence healthcare interactions by establishing standards and norms of practice (McGraw, 2013). High-quality health security system increases patient trust by creating a structured environment that reduces the likelihood of unethical behavior by healthcare providers. The framework theoretically reduces the risks associated with waiver of control because it introduces oversight and accountability measures that align provider behavior with patient interests (Vilpert et al., 2020). In addition, the availability and adequacy of resources provided by health security system may help patients to manage trust-related risks more broadly, thereby affecting their overall trust in healthcare providers (Vilpert et al., 2020).

Mechanisms of influence: Satisfaction with medical care and perceptions of medical safety

The theoretical link between the general public’s evaluation of the health security system and their trust in physicians is further explored through the concept of satisfaction with medical care. High-quality health security system is expected to increase patient satisfaction by improving access and affordability of care. Theoretically, such improvements could address patients’ concerns about the healthcare process and overall experience (Alimena and Air, 2016; Tang, 2011). Theoretically, increased satisfaction with medical care can reduce patients’ skepticism of healthcare providers, leading to a more trusting relationship (Tang, 2011). This mechanism emphasizes the role of satisfaction as a key factor in the impact of the general public’s evaluation of the health security system on trust in physicians.

Another important theoretical mechanism is the effect of health security system on patients’ perceptions of medical safety. Theoretically, a high-quality health security system can enhance oversight and accountability, thereby increasing patients’ perceptions of medical safety during healthcare interactions (Bernal-Delgado et al., 2012). By standardizing care processes and increasing transparency, high-quality health security system can theoretically reduce patients’ concerns and increase their trust in healthcare providers (Pugh et al., 2020). This increased perception of medical safety is an important part of the overall trust-building process, illustrating the important role of regulatory quality in shaping the patient experience.

The present study

Existing research has extensively explored macro- and micro-level factors that influence public trust in doctors. However, there is a notable gap in the literature regarding how institutional trust, in particular the general public’s evaluation of the health security system, influences interpersonal trust in physicians. While health security system plays a crucial role in shaping patient experiences, there has been little empirical research on the extent to which confidence in the health security system translates into trust in healthcare providers. Furthermore, the mechanisms underlying this relationship remain unclear. Specifically, it is not yet clear whether and how satisfaction with medical care and perceptions of medical safety mediate the relationship between the general public’s evaluation of the health security system and their trust in physicians. By addressing these questions, this paper aims to provide valuable insights for improving the doctor-patient relationship and optimizing the effectiveness of China’s health security system. Based on prior research, the following hypotheses are proposed:

H1: The general public’s evaluation of the health security system will be significantly and positively associated with trust in physicians.

H2: Satisfaction with medical care will partially mediate the relationship between health security system evaluation and trust in physicians, with higher satisfaction leading to greater trust.

H3: Perceptions of medical safety will also mediate this relationship, reinforcing the impact of health security system evaluation on trust in physicians.

Methods

Participants & Procedure

The study utilizes data from the China Social Survey (CSS), a comprehensive social survey program conducted by the Chinese Academy of Social Sciences (CASS). The survey uses probability sampling and covers a large amount of data from all provinces in China. The 2017 CSS and 2019 CSS came from 151 county-level districts and a total of 604 villages/habitat committees across the country. Participants were aged 18–70, and 17,054 questionnaires were returned.

The CSS is divided into basic, topical, and iterative data. The basic data is fixed in content and includes basic demographic information, employment status, family structure and economic status. The topical data is re-surveyed at regular intervals on topics such as social mobility, social security, consumption patterns and social values. The iterative data is adjusted according to the latest trends in social development and covers thematic research such as livelihood issues, urbanization, and the interests of social groups.

In terms of data quality control, the CSS adopts multi-level measures to ensure scientific rigor. Sampling design draws on district and county-level data from the fifth and sixth national population censuses of China, and a map-address sampling method is used to increase coverage of the floating population.

Informed consent was not required for this study, as it utilized a publicly available secondary dataset containing de-identified information. Ethical clearance was obtained from China Social Survey (CSS) at http://css.cssn.cn/css_sy/zlysj/.

About 44.87% of the respondents were male, the mean age was 47.33 years (SD = 13.95, range 18–70), 76.56% lived in rural areas, the majority (89.92%) were married, the average number of years of education is 8.87, 64.24% of the respondents were employed, 65.08% of the respondents considered themselves to be in a low social status, and the average family size is 4.43 persons (SD = 1.93, range 1–13).

Measures

Most of the survey content in CSS is assessed using single-item measurement methods, which is consistent with many large-scale social surveys, as the main consideration is the efficiency of large-scale social surveys and the burden on respondents. Some studies have found that the most obvious benefits of single-item measures are that they are more time-efficient to administer in large-scale social surveys, and can increase people’s willingness to spend time completing and returning questionnaires, as well as reducing data processing costs (Bergkvist and Rossiter, 2007; Wanous et al., 1997). The key variables in this study were also assessed using single-item measures.

The dependent variable is the trust in physicians, which was assessed by answering the question “Do you trust the physicians?” Responses were categorized as follows: “very much trust” and “relatively trust” were assigned a value of 1 (trust), while “relatively distrust” and “very much distrust” were assigned a value of 0 (distrust).

The independent variable is the general public’s evaluation of the health security system. This is based on the question “How do you feel about the health security system provided by the Chinese government?” Responses of “very good” and “good” were assigned a value of 1 (good evaluation), while responses of “bad” and “very bad” assigned a value of 0 (bad evaluation).

Mediating variables included satisfaction with medical care and perception of medical safety. Satisfaction with medical care was measured by asking “Are you satisfied with current medical care?” Respondents rated their satisfaction on a scale of 1–10, with higher scores indicating greater satisfaction. Perception of medical safety was assessed by asking “What do you think about current medical safety?” Responses of “very safe” and “relatively safe” were assigned a value of 1 (safe), while responses of “unsafe” and “very unsafe” were assigned a value of 0 (unsafe).

In order to distinguish the impact of the evaluation of the health insurance system on trust in doctors, the study controlled for several demographic and socioeconomic factors. Control variables included age, gender, place of residence, marriage, education, whether working, income, self-assessed social status, and the household size. These variables were chosen because previous studies have shown that they affect access to healthcare, patient experience, and trust in physicians (Li and Khan, 2022; Fareed et al., 2021; Katz et al., 2024; Prasad et al., 2021). Controlling for these factors helps ensure that observed relationships are not confounded by individual demographic differences or social determinants that may independently influence trust in physicians.

Analytic strategy

All analyses were conducted using Stata 16.0, and the significance level was set to conventional thresholds (p < 0.05, p < 0.01, p < 0.001) to ensure statistical robustness. Descriptive statistics was used to summarize the distributions of independent variables, dependent variables, control variables, and mediating variables.

Probit regression was used to examine the relationship between health security system evaluation and trust in physicians (Hypothesis H1). In this study, the potential endogeneity problem mean that the public’s evaluation of the health security system not only affects trust in physicians, but may also be partially affected by trust in physicians or other unobserved factors that also affect trust. This endogeneity problem may lead to bias or inconsistency in the relationship between health security system evaluation and trust in physicians. IV-Probit regression was used to address the potential endogeneity problem. This method helps ensure that the observed relationship is not biased by omitted variables or reverse causality.

Structural Equation Modeling (SEM) was used to examine the mediating effects of satisfaction with medical care and perceptions of medical safety on the relationship between the general public’s evaluation of the health security system and their trust in physicians (Hypothesis H2 and H3). This method can simultaneously estimate direct and indirect effects, providing a comprehensive assessment of the proposed mediation pathways.

Results

Table 1 presents the main descriptive statistical information of the sample. Most of the respondents (81.99%) expressed trust in physicians. A significant proportion of the respondents (74.89%) gave a good evaluation of health security system. The mean score of satisfaction with medical care was 6.64 (SD = 2.43, range 1–10), and most respondents (80.39%) reported perceived medical safety.

Table 1.

Characteristics of variables.

Variables	Name	N	Range	Mean	Percentage
				(SD)
Dependent variable	The general public’s trust in physicians	17,054	0–1	0.82
	Distrust				18.01
	Trust				81.99
Independent variable	The general public’s evaluation of the health security system	17,054	0–1	0.75
	Bad evaluation				25.11
	Good evaluation				74.89
Mediating variables	Satisfaction with medical care	17,054	1–10	6.64
				(2.43)
	Perceptions of medical safety	17,054	0–1	0.80
	Unsafe				19.61
	Safe				80.39
Control variables	Gender	17,054	0–1	0.45
	Female				55.13
	Male				44.87
	Age	17,054	18–70	47.33
				(13.95)
	Residence	17,054	0–1	0.23
	Rural				76.56
	Urban				23.44
	Marriage	17,054	0–1	0.90
	Unmarried				10.08
	Married				89.92
	Years of education	17,054	0–19	8.87
				(4.44)
	Whether work or not	17,054	0–1	0.64
	Not work				35.76
	Work				64.24
	Income	17,054	0-13.82	7.93
				(3.77)
	Self-assessed social status	17,054	0–1	0.35
	Low				65.08
	High				34.92
	Household size	17,054	1–13	4.43
				(1.93)

Impact of health security system evaluation on trust in physicians

Table 2 demonstrates the impact of the general public’s evaluation of the health security system on their trust in physicians using Probit regression. Males were less likely to trust physicians (β = −0.180, p < 0.001). Conversely, increasing age (β = 0.005, p = 0.005) and higher self-assessed social status (β = 0.151, p < 0.001) were associated with higher odds of trusting physicians. Urban residents showed lower trust in physicians (β = −0.190, p < 0.001). Compared to unmarried individuals, married individuals were less likely to trust physicians (β = −0.288, p < 0.001). The higher the number of years of education, the lower the trust in physicians (β = −0.015, p = 0.012). Employed individuals had a higher level of trust in physicians compared to non-employed individuals (β = 0.112, p = 0.017). There was no significant relationship between income and trust in physicians (β = −0.009, p = 0.133). Household size had no significant effect on trust in physicians (β = 0.017, p = 0.102). Most importantly, the general public’s evaluation of the health security system was significantly and positively associated with trust in physicians (β = 0.640, p < 0.001). Thus, hypothesis H1 is confirmed.

Table 2.

Impact of the general public’s evaluation of the health security system on their trust in physicians (N = 17,054).

Variables	β	SE	z	p	95% CI
The general public’s evaluation of the health security system	0.640	0.041	15.69	<0.001	0.560	0.720
Gender	−0.180	0.045	−4.03	<0.001	−0.267	−0.092
Age	0.005	0.002	2.81	0.005	0.002	0.009
Residence	−0.190	0.051	−3.75	<0.001	−0.289	−0.091
Marriage	−0.288	0.079	−3.65	<0.001	−0.443	−0.134
Years of education	−0.015	0.006	−2.52	0.012	−0.027	−0.003
Whether work or not	0.112	0.047	2.39	0.017	0.020	0.204
Income	−0.009	0.006	−1.50	0.133	−0.021	0.003
Self-assessed social status	0.151	0.042	3.61	<0.001	0.069	0.233
Household size	0.017	0.011	1.63	0.102	−0.003	0.038

Addressing endogeneity using instrumental variables

The IV-Probit regression method was employed to address the potential endogeneity. Two indicators from the CSS survey were selected as instrumental variables: “fairness of public health insurance (Fair = 1, Unfair = 0)” and “burden of medical expenses (Heavy = 1, Not heavy = 0).” These variables were chosen because they influenced the general public’s evaluation of the health security system, but were not related to the general public’s trust in physicians.

Panel A of Table 3 presents the first-stage estimation of the IV-Probit. The instrumental variables had significant correlation with the evaluation of the health security system, which confirmed that the instrumental variables met the condition for instrumental variable validity. In addition, the Wald test was conducted to ensure that instrumental variables were not weak. According to the empirical methodology, the p-value of the Wald test should be less than 0.05 if there is no weak instrument problem (Kleibergen and Paap, 2006). The p-values of both Wald statistics in Panel A are much less than 0.05, indicating that there is no problem of weak instrumental variables in the estimation.

Table 3.

IV-Probit estimation (N = 17,054).

Variables	A		B
	First-stage:		Second-stage:
	The general public’s evaluation of the health security system		The general public’s trust in physicians
Fairness of public health insurance	0.290***
	(0.013)
Burden of medical expenses		−0.087***
Burden of medical expenses		(0.012)
The general public’s evaluation of the health security system			3.169***	2.974***
			(0.188)	(0.574)
Wald test	283.31***
	[0.000]
		26.86***
		[0.000]

Panel A and Panel B both control the demographic characteristics of respondents including age, gender, place of residence, marriage, education, whether working, income, self-assessed social status, and the household size. Standard errors of coefficients are reported in round brackets and p-values in square brackets. *p < 0.05. **p < 0.01. ***p < 0.001.

Panel B of Table 3 presents the second-stage estimation. The study found that the evaluation of the health security system was significantly associated with trust in physicians, with coefficients of (β = 3.169, p < 0.001) and (β = 2.974, p < 0.001) in separate models. After the endogenous problem is solved, hypothesis H1 is once again confirmed.

Analysis of mediating effect

The SEM was used to test and quantify the mediating effects of the general public’s evaluation of the health security system on their trust in physicians. Figure 1 shows that the evaluation of the health security system significantly increased the satisfaction with medical care (β = 1.364, p < 0.001) and perceptions of medical safety (β = 0.210, p < 0.001). Both satisfaction with medical care (β = 0.044, p < 0.001) and perceptions of medical safety (β = 0.159, p < 0.001) had a positive effect on the general public’s trust in physicians. Thus, hypothesis H2 and H3 are confirmed.

Figure 1.

Impact path.

Table 4 quantifies the indirect effect. Specifically, the indirect effect through satisfaction with medical care was 0.060 (1.364 × 0.044), representing 57.69% of the total effect, while the indirect effect through perceptions of medical safety was 0.033 (0.210 × 0.159), representing 17.19% of the total effect. These findings emphasize the key role of satisfaction with medical care and perceptions of medical safety as mediators, with satisfaction with medical care showing a more important mediating effect.

Table 4.

Decomposition of the effects of the general public’s evaluation of the health security system on their trust in physicians.

Variables	Direct effects	Indirect effects	Total effects	Percentage of indirect effects
Satisfaction with medical care	0.044	0.060	0.104	57.69
Perceptions of medical safety	0.159	0.033	0.192	17.19
The general public’s trust in physicians	0.085	0.093	0.178	52.25

The total effect was 0.178 (0.085 + 0.060 + 0.033). The combined mediating effect of satisfaction with medical care and perceptions of medical safety was 0.093 (0.060 + 0.033), accounting for 52.25% of the total effect. These results suggest that the proposed mediation pathway effectively elucidates the effect of the general public’s evaluation of the health security system on their trust in physicians.

Discussion

This study aimed to investigate the relationship between the general public’s evaluation of the health security system and their trust in physicians, as well as the mediating role of satisfaction with medical care and perceptions of medical safety. The results provide clear answers to these questions. First, the results found that evaluation of the health security system was significantly and positively associated with trust in physicians, confirming hypothesis H1. Second, this relationship was partially mediated by the satisfaction with medical care and perceptions of medical safety, confirming hypothesis H2 and H3. The results of this study provide new insights into the relationship between the general public’s evaluation of the health security system and their trust in physicians, filling a gap in this area in previous studies. The results show that the general public’s positive evaluations of the health security system significantly enhance trust in physicians, and that trust is largely determined by satisfaction with medical care and perceptions of medical safety, with the satisfaction with medical care showing a stronger mediating effect. This study goes beyond the existing literature by not only revealing the existence of this relationship, but also the mechanism by which institutional trust is transformed into interpersonal trust.

Previous research has typically focused on macro-level contextual or individual factors that influence trust in doctors (Chakr, 2021; Jabeen et al., 2024; Kleibergen and Paap, 2006; Platt et al., 2018; Rowe and Calnan, 2006). This study goes beyond these approaches by highlighting an understudied institutional factor: the role of the health security system. The study finds that a well-functioning health security system significantly increases public trust in healthcare providers, highlighting the importance of systemic reforms in addressing interpersonal trust. This link is crucial in healthcare systems, as the complex interplay between institutional and interpersonal trust is often overlooked.

The study further distinguished between macro- and micro-level influences on trust in physicians. While individual-level variables such as age, employment and education were found to have a significant impact on trust, the quality of the health security system was the most important factor. This suggests that system-level improvements may offer a more effective route to improving doctor-patient relationships than focusing solely on patient or doctor characteristics.

One of the most striking findings is the mediating role of satisfaction with medical care and perceptions of medical safety. These results suggest that satisfaction with medical care and perceptions of medical safety are key pathways through which the impact of the general public’s evaluation of the health security system influences their trust in physicians. This finding not only highlights the importance of improving health care services, but also the importance of managing patient perceptions. A high-quality health security system can promote medical supervision, accountability, and standardization, thereby alleviating patients’ concerns about safety and fairness and thus establishing a more trusting relationship with health care providers.

Existing literature suggests that patient satisfaction and feelings of safety are key to building trust in physicians (Beller et al., 2023; Cipollina and Sanchez, 2023; Kalaja, 2023; Lyndon et al., 2023; Mechanic, 1996). However, this study provides empirical evidence supporting these views, while also demonstrating the key role that health security systems play in shaping these perceptions. This suggests that efforts to improve general public’s trust in physicians cannot be separated from broader reforms in the health security system including improvements in the safety, accessibility, affordability, insurance coverage and regulatory oversight of healthcare services. Greater transparency, safety protocols, and accessibility of healthcare services are key features of a robust health security system that are essential to building and maintaining trust.

The results of the study have important implications for health policy, not only in China but also in other countries facing similar healthcare challenges. As the results show, the higher the general public’s evaluation of the health security system, the higher the public’s trust in physicians. This is of great significance for policymakers seeking to alleviate the tense doctor-patient relationship. While previous approaches have focused primarily on improving physician behavior, training, and patient communication strategies (Lee et al., 2023; Taylor et al., 2023; Wang et al., 2023), this study suggests that systemic reforms can yield equally or more effective results. For China’s rapidly evolving healthcare environment, the study highlights the importance of addressing issues related to healthcare safety and patient satisfaction within broader reforms in the health security system. Policymakers must ensure that health security systems not only provide access to care, but also deliver high-quality, transparent, and safe healthcare services to improve public perceptions. Such an approach could reduce the likelihood of conflict between patients and healthcare providers and improve the overall healthcare experience.

In addition to the role of the health security system, this study proposes a broader model for understanding how institutional trust affects interpersonal trust in healthcare settings. The findings challenge traditional models of healthcare trust, which emphasize individual-level factors such as doctor-patient communication or personal relationships as the main drivers of trust. Instead, this study argues that broader institutional frameworks play a foundational role in shaping these relationships. This study introduces a new dimension to trust research that emphasizes the interconnection between institutional design and interpersonal trust. Public trust in physicians can be seen as a by-product of their trust in the institutions that regulate and oversee medical practice. Therefore, any effort to improve trust must consider the structural and regulatory environment in which healthcare is delivered.

From the practical and policy perspective, health administrators and policymakers should also prioritize patient-centered strategies to improve the individual healthcare experience and broader institutional trust. This requires not only addressing coverage gaps and reducing financial burdens through strategic reforms to the health security system, but also creating an environment that recognizes patients’ diverse needs, promotes open communication, and continuously improves the quality of healthcare services (Jiang et al., 2024; Lerch et al., 2024; Liu et al., 2024; Mi et al., 2024). Ultimately, the goal of the health security system is to create a healthcare environment where patients have more trust in their doctors by making sure that systemic policies don’t just work behind the scenes, but are translated into the daily benefits of patients (Elkefi and Asan, 2023; Han et al., 2022). On the one hand, addressing financial concerns remains the cornerstone of patient-centered healthcare. High out-of-pocket expenses, complex insurance processes, and unpredictable coverage decisions often undermine public confidence in healthcare services and ultimately tarnish their view of the healthcare profession itself (Courbage and Nicolas, 2021; Kruk et al., 2024; Roder-DeWan et al., 2020). Policymakers can implement targeted reforms to minimize financial stress on patients. These measures can enhance a sense of security and alleviate the stress and anxiety often associated with healthcare visits (Pandrangi et al., 2022; Yu et al., 2021). Moreover, policymakers need to address geographic disparities and unequal distribution of healthcare resources, which often create mistrust in certain regions or among specific socioeconomic groups (Lu et al., 2019; Yuan et al., 2023). On the other hand, addressing patient safety remains an important pillar for trust. While data generally show that serious medical errors are relatively rare, public fears of misdiagnosis or malpractice often outweigh their actual frequency (Guttman et al., 2021; Newman-Toker et al., 2024). To combat these fears, the health security system should enhance transparency and accountability in healthcare services. Providing clear recourse routes, legal support or compensation mechanisms for patients affected by medical errors can further convey the message that the health security system values accountability and fairness over self-preservation (Arkedis et al., 2021). At a broader policy level, these efforts benefit from public education campaigns that highlight ongoing health security system reforms and encourage patients to proactively engage (Panjaitan et al., 2023; Siddique et al., 2024).

While this study revealed an important relationship between the general public’s evaluation of the health security system and their trust in physicians, future research could explore other factors that may further moderate this relationship. For example, exploring how media coverage of the health security system and physician behavior influences public perceptions could provide further insight into how trust is built or destroyed. Moreover, as health security systems evolve globally, particularly with the integration of technology and telehealth, future research could explore the impact of digital healthcare services and innovative care delivery methods on satisfaction and trust. The role of trust in these emerging healthcare environments may be very different from traditional models of care, requiring new frameworks and approaches to patient-provider interactions.

There are some limitations of this study that should be considered. First, the use of single-item measures for key variables limits the ability to assess internal consistency and reliability. However, the use of single-item measures limits the ability to assess internal consistency and construct validity. Despite this limitation, a large body of research suggests that single-item measures can be valid proxies when assessing the construct of simple indicators such as general trust and satisfaction (Allen et al., 2022; Castro et al., 2023; Fuchs and Diamantopoulos, 2009; Fülöp et al., 2020). While single-item scales are commonly used in large-scale social surveys to increase efficiency, future research should use multi-item validated scales to ensure robust measurement of evaluation, trust, and satisfaction. Second, the conceptual distinction between “health security system” and “healthcare services” needs to be further explored. In China, the policies and institutional structures that ensure that healthcare services are accessible, safe, affordable, and regulated are referred to as the health security system. This term may be referred to differently in other countries. Future research should distinguish between institutional trust in the health security system and trust in the experience of healthcare services in order to better understand their respective impacts on trust in physicians. In addition, the specific context of this study, which was conducted in the Chinese health security system, may limit the generalizability of the findings.

Conclusion

In conclusion, this study emphasizes the important role of the general public’s evaluation of the health security system in shaping trust in physicians. The mediating role of satisfaction with medical care and perceptions of medical safety is critical to understanding this relationship. The findings emphasize the importance of system quality improvement and provide practical insights for enhancing trust in health care providers. By addressing endogeneity and utilizing a rigorous analytical approach, this study contributes to the theoretical and practical understanding of trust in health care and provides a basis for future research and policy development. Furthermore, the study provides a novel model for understanding trust in healthcare, suggesting that institutional trust forms the basis of interpersonal trust in healthcare settings. This perspective has important policy implications, as it points to the importance of strengthening health security systems as a means of rebuilding public trust in healthcare professionals.

Footnotes

Data sharing statement

The data generated during and/or analysed during the current study are publicly available at .

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by grants from the Minzu University of China (2024QNYL15).

Ethics approval

Ethical approval was obtained from the Minzu University of China.

Informed consent

Informed consent was not required for this study, as it utilized a publicly available secondary dataset containing de-identified information.

ORCID iD

Jinghua Gao

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