Is health literacy associated with greater medical care trust?

Is health literacy associated with greater medical care trust? Abstract Objective To examine the relationship between health literacy and trust in physicians and in the healthcare system. Design A cross-sectional survey of a nationally representative sample of adults. Setting Taiwan. Participants Non-institutionalized adults (N = 2199). Main measures Trust in physicians was a composite measure assessing respondents’ general trust in physicians and their perceptions of their physician’s communication, medical skills, beneficence, honesty, confidentiality, respect and fairness. Trust in the healthcare system was a single-item measure. Health literacy was measured by four items. Results Respondents with higher health literacy had, overall, higher levels of trust in physicians (P<0.001) and in the healthcare system (P = 0.04). Health literacy remained significantly and positively associated with trust in physicians (P<0.001) and in the healthcare system (P = 0.001) after adjusting for respondents’ sociodemographic characteristics. Conclusions Our findings demonstrate that health literacy is positively associated with trust. Actionable plans targeting health literacy at the national and local levels to establish a health literate care environment may contribute to enhancing trust in physicians and the healthcare system. trust in physicians, trust in healthcare system, health literacy Introduction Trust in medical care is essential for ensuring the delivery of good healthcare and for achieving desirable health outcomes. Research shows patients who have more trust in medical care are more likely to adhere to treatment and be more satisfied with the quality of care [1, 2]. Trust in medical care also facilitates patient–provider relationships and communication, and increases the willingness of patients to share medical information and participate in medical decision-making [3, 4]. Conversely, lack of trust may reduce access to health services and increase healthcare costs [5, 6]. Patients who have lower trust in physicians, for example, are less willing to disclose their personal and medical information and more likely to seek second medical opinions and obtain care from non-physicians [7]. Such behaviors increase the health burden, as well as healthcare costs, of patients, families and society. Trust in medical care is not monolithic, however. The extant literature differentiates between trust in medical professionals and the healthcare system and suggests that they are equally important in determining healthcare access, quality and outcomes [7, 8]. There is a growing research interest in the relationship between health literacy and trust in medical care [9, 10]. Health literacy means cognitive and social skills that influence the motivation and ability of individuals to gain access to, understand and use health information in ways that promote and maintain good health [11]. Earlier evidence suggested that patient–provider communication and trust have a mutual effect on each other [8, 12]. Inability to adequately understand health information may be a barrier for patients to communicate, and build a trusting relationship, with medical providers. Similarly, poor understanding of health information limits patients’ ability to navigate, and therefore trust, the healthcare system [13]. In turn, trust in medical providers and the healthcare system may motivate patients to acquire, absorb and use health information, which may subsequently improve patients’ health behavior and their ability to maintain good personal health [14]. One recent study found that hospitalized cardiac patients with inadequate health literacy had a higher likelihood of physician distrust [13]. The result was different in a study of Hispanic diabetic patients in the USA, which found that those with lower health literacy had greater trust in their physicians [10]. These two studies, as well as most others in the literature, are focused on hospitalized patients and in clinical settings, and are conducted in the USA. They provide scant evidence regarding the relationship between health literacy and medical care trust in a general population and outside the USA. The purpose of this study was to use a nationally representative sample of Taiwanese adults to examine the association between health literacy and trust in medical care. We followed the literature to differentiate between trust in physicians and trust in the healthcare system. We hypothesized that adults with a higher level of health literacy would have greater trust in physicians and in the healthcare system. Methods Study Design and Sample Data used in this study were extracted from the health module of the Taiwan Social Change Survey (TSCS) [15]. TSCS was a nationwide, population-based survey. The sampling frame was Taiwan’s household registration system. The survey employed a three-stage stratified probability-proportional-to-size random sampling method and selected 4424 non-institutionalized civilians aged 18 years or older to participate in the study. Selected adults were contacted by mail for voluntary participation in the survey. The survey was administered by a group of trained and experienced interviewers who conducted the interviews face-to-face at participants’ homes. A total of 2199 respondents completed the interviews during 2011 and 2012, yielding a response rate of 52.3%. There were not age and gender differences between respondents and non-respondents and the sociodemographic attributes of respondents were similar to those of the national adult population. To ensure effective representation of the population, sample weight was used in the analysis. Measurements Trust in physicians was measured using eight survey items, which assessed the respondents’ general trust in physicians, as well as the respondents’ perception of physician communication, medical skills, beneficence, honesty, confidentiality, respect and fairness. Five of those items were identical to the questions used in the International Social Survey Programme across 29 countries. Those questions were translated into Mandarin via the double-forward-and-backward method. Three additional items were developed in order to assess the respondents’ perception of physicians’ handling of confidentiality and the degree of respect and fairness they received from physicians. All eight items used a five-point Likert scale ranging from strongly disagree [1] to strongly agree [5]. A study was conducted to test the reliability of the 8 items in 243 Taiwanese adults. The Cronbach’s alpha was 0.71, which was acceptable [16]. Factor analysis of the eight items suggested one underlying latent factor. Therefore, we summed the eight items to create a single index, with scores ranging from 8 to 40 and a higher score indicating a higher level of trust in physicians. Trust in the healthcare system was a single-item measure. The respondents indicated their level of trust using a four-point Likert scale. The scores ranged from 1 to 4; a higher score represented greater trust. Health literacy was assessed using four self-reported screening questions. The first two questions were ‘How confident are you in filling out medical forms by yourself (i.e. personal profile, medical history and consent forms)?’ (1 = extremely, 2 = quite a bit, 3 = somewhat, 4 = a little bit or 5 = not at all) and ‘How often do you have problems learning about your health condition because of difficulty understanding medication labels or self-care instructions?’ (1 = all the time, 2 = most of the time, 3 = some of the time, 4 = a little of the time or 5 = none of the time). These two questions have been shown to effectively identify individuals with limited functional health literacy [17]. The other two questions were designed to assess communicative health literacy: ‘How often do you have problems learning about your health condition because of difficulty understanding health providers’ explanations?’ and ‘How often do you have problems learning about your health condition because of difficulty asking health providers questions?’ Answers to these latter two questions were also assessed using a five-point Likert scale. As a set, these four questions assessed, respectively, a respondent’s ability to fill out medical forms, read written health materials, comprehend verbal information and ask questions during a healthcare encounter. Following previous research [17], we coded the response to each question ‘1’ if the respondent indicated having a problem, and ‘2’ if the response was never having a problem. The sum of the four items was then used to measure the overall level of health literacy of the respondent. The demographic variables included as covariates in the analysis were age, gender, educational level, occupation and residential area. Statistical Analysis Descriptive statistics were used to summarize the respondents' sociodemographic characteristics. Pearson correlation, t-test and Analysis of Variance (ANOVA) were used to examine the associations between health literacy, trust in physicians and trust in the healthcare system. We performed the linear regression analysis in a stepwise manner. First, we entered health literacy into the model to see how it was related to trust in physicians and trust in the healthcare system. Second, we added to the model sociodemographic variables to see how those variables changed the association between health literacy and trust. All analyses were conducted using SPSS 20.0. Results Table 1 shows the sociodemographic characteristics and health literacy of respondents. The average age of respondents was 44; male and female respondents were equally distributed; <40% of respondents had college education or above; ~30% had professional or professional associate occupations; the majority resided in cities or economically developed counties; the percentage of respondents able to perform the four health literacy-related tasks ranged from 56% to 78%. Figure 1 shows the level of trust in physicians. The highest level of trust was regarding confidentiality (76.9%) and followed by communication (72.2%). The highest levels of mistrust were in relation to honesty (71.6%), followed by fairness (66.5%) and beneficence (45.5%). Close to 78% of respondents reported that they trusted the healthcare system. Table 1 Subject characteristics of survey participants Characteristics  Mean (SD)  n (%)  Age  44.25 ± 16.63    Gender       Male    1095 (49.8)   Female    1104 (50.2)  Educational level       Junior high and below    377 (17.1)   Senior high/occupational    948 (43.1)   College    453 (20.6)   University    307 (13.9)   Graduate    109 (4.9)   Missing    6 (0.3)  Occupation       Professional    295 (13.3)   Professional associate    352 (16.0)   Clerk    268 (12.2)   Skilled    984 (44.8)   Unskilled/manual    160 (7.3)   Missing    141 (6.4)  Residential area       Metropolitan    482 (21.9)   Industrial city    585 (26.6)   Economically developed county    596 (27.1)   Traditional county    181 (8.2)   Rural county    356 (16.2)  Health literacy       Ability to fill out medical forms    1124 (56.1)   Ability to read written health materials    1555 (77.6)   Ability to comprehend oral information    1426 (71.1)   Ability to ask health questions    1406 (70.1)  Characteristics  Mean (SD)  n (%)  Age  44.25 ± 16.63    Gender       Male    1095 (49.8)   Female    1104 (50.2)  Educational level       Junior high and below    377 (17.1)   Senior high/occupational    948 (43.1)   College    453 (20.6)   University    307 (13.9)   Graduate    109 (4.9)   Missing    6 (0.3)  Occupation       Professional    295 (13.3)   Professional associate    352 (16.0)   Clerk    268 (12.2)   Skilled    984 (44.8)   Unskilled/manual    160 (7.3)   Missing    141 (6.4)  Residential area       Metropolitan    482 (21.9)   Industrial city    585 (26.6)   Economically developed county    596 (27.1)   Traditional county    181 (8.2)   Rural county    356 (16.2)  Health literacy       Ability to fill out medical forms    1124 (56.1)   Ability to read written health materials    1555 (77.6)   Ability to comprehend oral information    1426 (71.1)   Ability to ask health questions    1406 (70.1)  Table 1 Subject characteristics of survey participants Characteristics  Mean (SD)  n (%)  Age  44.25 ± 16.63    Gender       Male    1095 (49.8)   Female    1104 (50.2)  Educational level       Junior high and below    377 (17.1)   Senior high/occupational    948 (43.1)   College    453 (20.6)   University    307 (13.9)   Graduate    109 (4.9)   Missing    6 (0.3)  Occupation       Professional    295 (13.3)   Professional associate    352 (16.0)   Clerk    268 (12.2)   Skilled    984 (44.8)   Unskilled/manual    160 (7.3)   Missing    141 (6.4)  Residential area       Metropolitan    482 (21.9)   Industrial city    585 (26.6)   Economically developed county    596 (27.1)   Traditional county    181 (8.2)   Rural county    356 (16.2)  Health literacy       Ability to fill out medical forms    1124 (56.1)   Ability to read written health materials    1555 (77.6)   Ability to comprehend oral information    1426 (71.1)   Ability to ask health questions    1406 (70.1)  Characteristics  Mean (SD)  n (%)  Age  44.25 ± 16.63    Gender       Male    1095 (49.8)   Female    1104 (50.2)  Educational level       Junior high and below    377 (17.1)   Senior high/occupational    948 (43.1)   College    453 (20.6)   University    307 (13.9)   Graduate    109 (4.9)   Missing    6 (0.3)  Occupation       Professional    295 (13.3)   Professional associate    352 (16.0)   Clerk    268 (12.2)   Skilled    984 (44.8)   Unskilled/manual    160 (7.3)   Missing    141 (6.4)  Residential area       Metropolitan    482 (21.9)   Industrial city    585 (26.6)   Economically developed county    596 (27.1)   Traditional county    181 (8.2)   Rural county    356 (16.2)  Health literacy       Ability to fill out medical forms    1124 (56.1)   Ability to read written health materials    1555 (77.6)   Ability to comprehend oral information    1426 (71.1)   Ability to ask health questions    1406 (70.1)  Figure 1 View largeDownload slide Trust in Physicians. Figure 1 View largeDownload slide Trust in Physicians. As shown in Table 2, older adults had a higher level of trust in physicians (P = 0.003) and in the healthcare system (P<0.001). Individuals with primary school education and below were significantly more likely to report that they trusted physicians (P<0.001) and the healthcare system (P = 0.04), compared to those with more education. Individual without difficulty reading written health materials (P = 0.01), comprehending verbal information (P = 0.004) and asking health questions (P<0.001) were significantly more likely to report trust in physicians. Individual without problems comprehending verbal information (P<0.001) and asking health questions (P<0.001) had a higher level of trust in the healthcare system. Table 2 Associations of medical care trust, sociodemographic characteristics and health literacy Characteristics  Trust in physicians  P-value  Trust in healthcare system  P-value  Mean (SD)  Mean (SD)    Age    0.003a    <0.001a  Gender    0.16    0.65   Male  24.9 (4.3)    2.78 (0.61)     Female  25.2 (4.3)    2.77 (0.54)    Educational level    <0.001    0.04   Primary school and below  26.4 (3.9)    2.86 (0.53)     High school  25.0 (4.4)    2.77 (0.60)     College  24.6 (4.5)    2.75 (0.59)     University  24.6 (4.2)    2.73 (0.59)     Graduate  24.8 (3.8)    2.78 (0.50)    Occupation    0.33    0.68   Professional  25.0 (4.1)    2.79 (0.61)     Professional associate  24.6 (4.4)    2.79 (0.53)     Clerk  25.3 (3.9)    2.76 (0.54)     Skilled  25.1 (4.4)    2.75 (0.61)     Unskilled/manual  25.3 (4.4)    2.80 (0.54)    Residential area    0.04    0.40   Metropolitan  25.0 (4.3)    2.79 (0.58)    Industry city  25.0 (4.2)    2.78 (0.56)     Economically developed county  25.2 (4.6)    2.73 (0.62)     Traditional county  26.2 (4.2)    2.80 (0.63)     Rural county  24.7 (4.1)    2.80 (0.52)    Health literacy           Ability to fill out medical forms    0.26    0.60    Confidence with medical forms  25.0 (4.4)    2.8 (0.58)      Not confidence with medical forms  25.2 (4.2)    2.8 (0.57)     Ability to read written health materials    0.01    0.44    Never having problem  25.2 (4.3)    2.8 (0.58)      Having some problem  24.6 (4.4)    2.8 (0.57)     Ability to comprehending oral information    0.004    <0.001    Never having problem  25.3 (4.2)    2.8 (0.57)      Having some problem  24.6 (4.5)    2.7 (0.60)     Ability to ask health questions    <0.001    <0.001    Never having problem  25.4 (4.2)    2.8 (0.57)      Having some problem  24.5 (4.4)    2.7 (0.59)    Characteristics  Trust in physicians  P-value  Trust in healthcare system  P-value  Mean (SD)  Mean (SD)    Age    0.003a    <0.001a  Gender    0.16    0.65   Male  24.9 (4.3)    2.78 (0.61)     Female  25.2 (4.3)    2.77 (0.54)    Educational level    <0.001    0.04   Primary school and below  26.4 (3.9)    2.86 (0.53)     High school  25.0 (4.4)    2.77 (0.60)     College  24.6 (4.5)    2.75 (0.59)     University  24.6 (4.2)    2.73 (0.59)     Graduate  24.8 (3.8)    2.78 (0.50)    Occupation    0.33    0.68   Professional  25.0 (4.1)    2.79 (0.61)     Professional associate  24.6 (4.4)    2.79 (0.53)     Clerk  25.3 (3.9)    2.76 (0.54)     Skilled  25.1 (4.4)    2.75 (0.61)     Unskilled/manual  25.3 (4.4)    2.80 (0.54)    Residential area    0.04    0.40   Metropolitan  25.0 (4.3)    2.79 (0.58)    Industry city  25.0 (4.2)    2.78 (0.56)     Economically developed county  25.2 (4.6)    2.73 (0.62)     Traditional county  26.2 (4.2)    2.80 (0.63)     Rural county  24.7 (4.1)    2.80 (0.52)    Health literacy           Ability to fill out medical forms    0.26    0.60    Confidence with medical forms  25.0 (4.4)    2.8 (0.58)      Not confidence with medical forms  25.2 (4.2)    2.8 (0.57)     Ability to read written health materials    0.01    0.44    Never having problem  25.2 (4.3)    2.8 (0.58)      Having some problem  24.6 (4.4)    2.8 (0.57)     Ability to comprehending oral information    0.004    <0.001    Never having problem  25.3 (4.2)    2.8 (0.57)      Having some problem  24.6 (4.5)    2.7 (0.60)     Ability to ask health questions    <0.001    <0.001    Never having problem  25.4 (4.2)    2.8 (0.57)      Having some problem  24.5 (4.4)    2.7 (0.59)    aPearson's correlation. Table 2 Associations of medical care trust, sociodemographic characteristics and health literacy Characteristics  Trust in physicians  P-value  Trust in healthcare system  P-value  Mean (SD)  Mean (SD)    Age    0.003a    <0.001a  Gender    0.16    0.65   Male  24.9 (4.3)    2.78 (0.61)     Female  25.2 (4.3)    2.77 (0.54)    Educational level    <0.001    0.04   Primary school and below  26.4 (3.9)    2.86 (0.53)     High school  25.0 (4.4)    2.77 (0.60)     College  24.6 (4.5)    2.75 (0.59)     University  24.6 (4.2)    2.73 (0.59)     Graduate  24.8 (3.8)    2.78 (0.50)    Occupation    0.33    0.68   Professional  25.0 (4.1)    2.79 (0.61)     Professional associate  24.6 (4.4)    2.79 (0.53)     Clerk  25.3 (3.9)    2.76 (0.54)     Skilled  25.1 (4.4)    2.75 (0.61)     Unskilled/manual  25.3 (4.4)    2.80 (0.54)    Residential area    0.04    0.40   Metropolitan  25.0 (4.3)    2.79 (0.58)    Industry city  25.0 (4.2)    2.78 (0.56)     Economically developed county  25.2 (4.6)    2.73 (0.62)     Traditional county  26.2 (4.2)    2.80 (0.63)     Rural county  24.7 (4.1)    2.80 (0.52)    Health literacy           Ability to fill out medical forms    0.26    0.60    Confidence with medical forms  25.0 (4.4)    2.8 (0.58)      Not confidence with medical forms  25.2 (4.2)    2.8 (0.57)     Ability to read written health materials    0.01    0.44    Never having problem  25.2 (4.3)    2.8 (0.58)      Having some problem  24.6 (4.4)    2.8 (0.57)     Ability to comprehending oral information    0.004    <0.001    Never having problem  25.3 (4.2)    2.8 (0.57)      Having some problem  24.6 (4.5)    2.7 (0.60)     Ability to ask health questions    <0.001    <0.001    Never having problem  25.4 (4.2)    2.8 (0.57)      Having some problem  24.5 (4.4)    2.7 (0.59)    Characteristics  Trust in physicians  P-value  Trust in healthcare system  P-value  Mean (SD)  Mean (SD)    Age    0.003a    <0.001a  Gender    0.16    0.65   Male  24.9 (4.3)    2.78 (0.61)     Female  25.2 (4.3)    2.77 (0.54)    Educational level    <0.001    0.04   Primary school and below  26.4 (3.9)    2.86 (0.53)     High school  25.0 (4.4)    2.77 (0.60)     College  24.6 (4.5)    2.75 (0.59)     University  24.6 (4.2)    2.73 (0.59)     Graduate  24.8 (3.8)    2.78 (0.50)    Occupation    0.33    0.68   Professional  25.0 (4.1)    2.79 (0.61)     Professional associate  24.6 (4.4)    2.79 (0.53)     Clerk  25.3 (3.9)    2.76 (0.54)     Skilled  25.1 (4.4)    2.75 (0.61)     Unskilled/manual  25.3 (4.4)    2.80 (0.54)    Residential area    0.04    0.40   Metropolitan  25.0 (4.3)    2.79 (0.58)    Industry city  25.0 (4.2)    2.78 (0.56)     Economically developed county  25.2 (4.6)    2.73 (0.62)     Traditional county  26.2 (4.2)    2.80 (0.63)     Rural county  24.7 (4.1)    2.80 (0.52)    Health literacy           Ability to fill out medical forms    0.26    0.60    Confidence with medical forms  25.0 (4.4)    2.8 (0.58)      Not confidence with medical forms  25.2 (4.2)    2.8 (0.57)     Ability to read written health materials    0.01    0.44    Never having problem  25.2 (4.3)    2.8 (0.58)      Having some problem  24.6 (4.4)    2.8 (0.57)     Ability to comprehending oral information    0.004    <0.001    Never having problem  25.3 (4.2)    2.8 (0.57)      Having some problem  24.6 (4.5)    2.7 (0.60)     Ability to ask health questions    <0.001    <0.001    Never having problem  25.4 (4.2)    2.8 (0.57)      Having some problem  24.5 (4.4)    2.7 (0.59)    aPearson's correlation. The associations between health literacy and the eight items of trust in physicians and trust in the healthcare system are shown in Table 3. Health literacy was positively related to general trust (P<0.001), communication (P = 0.01), medical skills (P = 0.006), beneficence (P = 0.001), confidentiality (P = 0.04) and respect (P = 0.002). However, health literacy was negatively related to honesty (P = 0.005) and not significantly related to fairness (P = 0.37). Table 3 Correlations of health literacy and trust in physicians and healthcare system Item  Pearson's correlation coefficient  Trust in physicians     All things considered, doctors can be trusted (general trust)  0.09*   Doctors discuss all treatment options with their patients (communication)  0.05**   The medical skills of doctors are not as good as they should be (medical skills)  0.06*   Doctors care more about their earnings than about their patients (beneficence)  0.07*   Doctors would tell their patients if they made a mistake during treatment (honesty)  −0.06*   Doctors would maintain privacy of patients’ information (confidentiality)  0.05**   Doctors respect patients’ diverse opinions (respect)  0.07*   Doctors are fairness to take care their patients (fairness)  −0.02  Trust in healthcare system  0.06*  Item  Pearson's correlation coefficient  Trust in physicians     All things considered, doctors can be trusted (general trust)  0.09*   Doctors discuss all treatment options with their patients (communication)  0.05**   The medical skills of doctors are not as good as they should be (medical skills)  0.06*   Doctors care more about their earnings than about their patients (beneficence)  0.07*   Doctors would tell their patients if they made a mistake during treatment (honesty)  −0.06*   Doctors would maintain privacy of patients’ information (confidentiality)  0.05**   Doctors respect patients’ diverse opinions (respect)  0.07*   Doctors are fairness to take care their patients (fairness)  −0.02  Trust in healthcare system  0.06*  *P<0.01 and **P<0.05. Table 3 Correlations of health literacy and trust in physicians and healthcare system Item  Pearson's correlation coefficient  Trust in physicians     All things considered, doctors can be trusted (general trust)  0.09*   Doctors discuss all treatment options with their patients (communication)  0.05**   The medical skills of doctors are not as good as they should be (medical skills)  0.06*   Doctors care more about their earnings than about their patients (beneficence)  0.07*   Doctors would tell their patients if they made a mistake during treatment (honesty)  −0.06*   Doctors would maintain privacy of patients’ information (confidentiality)  0.05**   Doctors respect patients’ diverse opinions (respect)  0.07*   Doctors are fairness to take care their patients (fairness)  −0.02  Trust in healthcare system  0.06*  Item  Pearson's correlation coefficient  Trust in physicians     All things considered, doctors can be trusted (general trust)  0.09*   Doctors discuss all treatment options with their patients (communication)  0.05**   The medical skills of doctors are not as good as they should be (medical skills)  0.06*   Doctors care more about their earnings than about their patients (beneficence)  0.07*   Doctors would tell their patients if they made a mistake during treatment (honesty)  −0.06*   Doctors would maintain privacy of patients’ information (confidentiality)  0.05**   Doctors respect patients’ diverse opinions (respect)  0.07*   Doctors are fairness to take care their patients (fairness)  −0.02  Trust in healthcare system  0.06*  *P<0.01 and **P<0.05. Table 4 presents results of the linear regression analysis. The models show the mean change in trust in physicians and in the healthcare system, per unit increased in health literacy. Health literacy was significantly and positively associated with trust in physicians (P = 0.001) and trust in healthcare system (P = 0.001), and that the association remained statistically significant when adjusted for age, education, gender, occupation and residential location (P< 0.001 for trust in physicians and P = 0.001 for trust in the healthcare system). Table 4 Multivariate liner regression results   Trust in Physicians  Trust in Healthcare System      Model 1  Model 2  Model 1  Model 2    Beta (standardized coefficients)  P-value  Beta (standardized coefficients)  P-value  Beta (standardized coefficients)  P-value  Beta (standardized coefficients)  P-value  Health literacy  0.08  0.001  0.09  <0.001  0.07  0.001  0.08  0.001  Age      0.02  0.42      0.14  <0.001  Gender      0.02  0.52      −0.01  0.76  Education      −0.1  0.002      0.003  0.93  Occupation      −0.02  0.45      −0.02  0.44  Residential area      0.01  0.65      0.01  0.82    Trust in Physicians  Trust in Healthcare System      Model 1  Model 2  Model 1  Model 2    Beta (standardized coefficients)  P-value  Beta (standardized coefficients)  P-value  Beta (standardized coefficients)  P-value  Beta (standardized coefficients)  P-value  Health literacy  0.08  0.001  0.09  <0.001  0.07  0.001  0.08  0.001  Age      0.02  0.42      0.14  <0.001  Gender      0.02  0.52      −0.01  0.76  Education      −0.1  0.002      0.003  0.93  Occupation      −0.02  0.45      −0.02  0.44  Residential area      0.01  0.65      0.01  0.82  Table 4 Multivariate liner regression results   Trust in Physicians  Trust in Healthcare System      Model 1  Model 2  Model 1  Model 2    Beta (standardized coefficients)  P-value  Beta (standardized coefficients)  P-value  Beta (standardized coefficients)  P-value  Beta (standardized coefficients)  P-value  Health literacy  0.08  0.001  0.09  <0.001  0.07  0.001  0.08  0.001  Age      0.02  0.42      0.14  <0.001  Gender      0.02  0.52      −0.01  0.76  Education      −0.1  0.002      0.003  0.93  Occupation      −0.02  0.45      −0.02  0.44  Residential area      0.01  0.65      0.01  0.82    Trust in Physicians  Trust in Healthcare System      Model 1  Model 2  Model 1  Model 2    Beta (standardized coefficients)  P-value  Beta (standardized coefficients)  P-value  Beta (standardized coefficients)  P-value  Beta (standardized coefficients)  P-value  Health literacy  0.08  0.001  0.09  <0.001  0.07  0.001  0.08  0.001  Age      0.02  0.42      0.14  <0.001  Gender      0.02  0.52      −0.01  0.76  Education      −0.1  0.002      0.003  0.93  Occupation      −0.02  0.45      −0.02  0.44  Residential area      0.01  0.65      0.01  0.82  To examine if the results varied based on the level of healthcare experience of the respondents, we classified the respondents in three different ways—(1) those who used outpatient department service or traditional Chinese medicine care in the past 12 months vs. those who did not; (2) those who were hospitalized in the past 12 months vs. those who were not; and (3) those who had chronic disease vs. those who did not—and then performed stratified regression analyses. The findings were consistent between different groups of respondents. Discussion Using a nationally representative sample of Taiwanese adults, the present study provides evidence that health literacy is positively associated with greater trust in physicians and in the healthcare system [14]. The findings corroborate and expand those of previous studies that were conducted in American veterans and hospitalized patients [9, 10, 13]. The delivery of healthcare relies primarily upon the expertize of medical providers. Patients, who usually lack the medical expertize, have traditionally been expected to be dependent on medical providers and the healthcare system for the maintenance of health and treatment of illness. It is conceivable that people with low health literacy may be more dependent on, and therefore have to trust more, medical providers and the healthcare system, for health information, medical advice and personal health decision-making [18]. In contrast to this argument, our study, as well as most prior research, found a positive relationship between health literacy and medical care trust. A plausible explanation is that low health literacy—and the stigma that makes it difficult for individuals with low health literacy to reveal their personal challenges in understanding and use health information—may have adversely affected the communication with medical providers and the ability to navigate the healthcare system [19], resulting in a low level of medical care trust. To the extent this explanation is valid, skills, tools, resources and assistance that medical providers can employ to build a good relationship with patients—particularly those who have low health literacy—during medical encounters would contribute to enhancing medical care trust. A useful tool is the ‘teach-back’ (or ‘show-me’) method, which medical providers can use to confirm a patient’s (or a care taker’s) understanding of what is explained to them [20]. Health policy-makers and organizational leaders in the healthcare system also share the responsibility of designing easy-to-read health information, improving patient and family centeredness in healthcare delivery, and providing necessary assistance and resources to medical providers (e.g. reducing workload, lengthening the clinic time for each medical encounter) to improve healthcare access and enhance medical care trust. It is worth noting that less than one-third of respondents in the study reported trust in physician fairness and honesty and less than half reported trust in physician beneficence. These findings may reflect a tension in the payment system of the National Health Insurance program in Taiwan. Currently, the global budget in the payment system may have compelled medical providers and organizations to focus on their financial bottom-line at the expense of valuing and promoting the quality of care provided [21]. A public perception may exist that medical providers and organizations are ‘gaming’ the system and that patients do not receive the quantity and quality of care they deserve. This may also explain the finding that individuals with higher health literacy had lower trust in physician honesty and fairness. It is likely that individuals with higher health literacy may have learned more of the exposé in the media and be more critical of the behavior of physicians. Results of the relationships between demographic factors and medical care trust have been inconsistent across studies. While some studies found older patients and less educated patients were more trusting [9, 22], others showed the opposite [13, 23] and yet others did not find a relationship between educational level and trust [24]. In this study, we found a discrepancy between education (and age) and health literacy in relation to medical care trust. Specifically, our analysis indicated that lower education and older age were significantly associated with greater trust and that individuals with higher health literacy had more trust in medical care. Research has consistently shown that older age and lower education are associated with lower health literacy. Taking together, our findings suggest two possibilities. First, persons with lower education and older age may be more likely to have blindly embodied trust, i.e. their medical trust is often based on comfort and emotional assessment [4, 25]. They may have a low interest in collaborative decision-making as their medical knowledge is very scant [3]. If so, providing them complex medical information and actively engaging them in medical decision-making may threaten the trust relationship with healthcare providers. By contrast, younger persons with a higher educational attainment may be more inclined to objectively assess their relationship with medical providers and their perceived trust may tend to be based on their personal involvement; they also may be more likely to question medical advice [26, 27]. If so, the approach that medical providers employ to building medical care trust may need to vary by their patients’ education background and age. Second, research has suggested that health literacy is a better indicator than education in explaining health behaviors and outcomes [28]. It is possible that health literacy, in comparison to education attainment, is a better indicator of individual empowerment, and capability of understanding and appraising health information, effectively communicating with healthcare providers and actively involve participating in shared medical decision-making. These health literacy competences, in turn, may be essential for building trust in medical care. This population-based study provides evidence that links health literacy with medical care trust in a country that has had a comprehensive National Health Insurance system for 20 years. Several study limitations are noteworthy. One is that the measure for health literacy was self-reported, which may be subjective and unreliable. However, research has shown that self-reported assessments are valid and have been commonly used in health literacy studies [29]. Second, trust in the healthcare system was assessed using a single question. A previous study indicated that trust in the healthcare system is single-dimensional and could be measured with one general question [30]. Finally, this study was cross-sectional. Additional research is needed to verify the causal relationships implied in the discussion. These cautions aside, our findings support previous research that health literacy is positively associated with trust in medical care. Actionable plans targeting health literacy at the national and local levels to establish a health literate care environment may contribute to enhancing trust in physicians and the healthcare system. Acknowledgements Data analyzed in this paper were collected in the health module of the research project ‘Taiwan Social Change Survey’ (TSCS Survey 6-2 II). The project was conducted by the Institute of Sociology, Academia Sinica and sponsored by the Ministry of Science and Technology (formerly known as the National Science Council), R.O.C. (NSC 100-2420-H-001002-SS2). The authors appreciate the assistance in providing data by the institutes and individuals aforementioned. The views expressed herein are the authors’ own. Preliminary findings from this study were presented at the 14th International Conference on European Association Communication in Healthcare (EACH). References 1 Brennan N, Barnes R, Calnan M et al.  . Trust in the health-care provider-patient relationship: a systematic mapping review of the evidence base. Int J Qual Health Care  2013; 25: 682– 8. Google Scholar CrossRef Search ADS PubMed  2 Calnan M, Rowe R, Entwistle V. Trust relations in health care: an agenda for future research. J Health Organ Manag  2006; 20: 477– 84. Google Scholar CrossRef Search ADS PubMed  3 Kraetschmer N, Sharpe N, Urowitz S et al.  . How does trust affect patient preferences for participation in decision-making? Health Expect  2004; 7: 317– 26. Google Scholar CrossRef Search ADS PubMed  4 Rowe R, Calnan M. Trust relations in health care—the new agenda Euro. J Public Health  2006; 16: 4– 6. 5 Musa D, Schulz R, Harris R et al.  . Trust in the health care system and the use of preventive health services by older black and white adults. Am J Public Health  2009; 99: 1293– 9. Google Scholar CrossRef Search ADS PubMed  6 Whetten K, Leseran J, Whetten R et al.  . Exploring lack of trust in care providers and the government as a barrier to health service use. Am J Public Health  2006; 96: 716– 21. Google Scholar CrossRef Search ADS PubMed  7 Hall MA, Dugan E, Zheng B et al.  . Trust in physicians and medical institutions: what is it, can it be measured, and does it matter? Milbank Q  2001; 79: 613– 39. Google Scholar CrossRef Search ADS PubMed  8 Hall MA. The importance of trust for ethics, law, and public policy. Camb Q Healthc Ethics  2005; 14: 156– 67. Google Scholar CrossRef Search ADS PubMed  9 Rodríguez V, Andrade AD, García-Retamero R et al.  . Health literacy, numeracy, and graphical literacy among veterans in primary care and their effect on shared decision making and trust in physicians. J Health Commun  2013; 18: 273– 89. Google Scholar CrossRef Search ADS PubMed  10 White RO, Osborn CY, Gebretsadik T et al.  . Health literacy, physician trust, and diabetes-related self-care activities in hispanics with limited resources. J Health Care Poor Underserved  2013; 24: 1756– 68. Google Scholar CrossRef Search ADS PubMed  11 World Health Organization. Health promotion glossary. 1998. 12 Barton JL, Trupin L, Tonner C et al.  . English language proficiency, health literacy, and trust in physician are associated with shared decision making in rheumatoid arthritis. J Rheumatol  2014; 41: 1290– 7. Google Scholar CrossRef Search ADS PubMed  13 Gupta C, Bell SP, Schildcrout JS et al.  . Predictors of health care system and physician distrust in hospitalized cardiac patients. J Health Commun  2014; 19: 44– 60. Google Scholar CrossRef Search ADS PubMed  14 Dawson-Rose C, Cuca YP, Webel AR et al.  . Building trust and relationships between patients and providers: an essential complement to health literacy in HIV care. J Assoc Nurses AIDS Care  2016; 27: 574– 84. Google Scholar CrossRef Search ADS PubMed  15 Chang Y-H, Tu S-H, Liao P-S. Taiwan Social Change Survey 2011, Phase 6, Wave 2 . Taipei: Institute of Sociology, Academic Sinica, 2012. 16 Nunnally JC, Bernstein IH. Psychometric theory . New York: McGraw-Hill, 1994: 264– 5. 17 Chew LD, Griffin JM, Partin MR et al.  . Validation of screening questions for limited health literacy in a large VA outpatient population. J Gen Intern Med  2008; 23: 561– 6. Google Scholar CrossRef Search ADS PubMed  18 Paasche-Orlow MK, Wolf MS. The causal pathways linking health literacy to health outcomes. Am J Health Behav  2007; 31: s19– 26. Google Scholar CrossRef Search ADS PubMed  19 Parikh NS, Parker RM, Nurss JR et al.  . Shame and health literacy: the unspoken connection. Patient Educ Couns  1996; 27: 33– 9. Google Scholar CrossRef Search ADS PubMed  20 Berga AG, Barnard J, Mabachi NM et al.  . AHRQ Health Literacy Universal Precautions Toolkit , 2nd edn. Rockville, M.D.: AHRQ Publication, 2015. 21 Wu T-Y, Majeed A, Kuo NK. An overview of the healthcare system in Taiwan. London J Prim Care  2010; 3: 115– 9. Google Scholar CrossRef Search ADS   22 Gilson L. Trust and health care as a social institution. Soc Sci Med  2003; 56: 1452– 68. Google Scholar CrossRef Search ADS   23 Bonds DE, Foley KL, Dugan E et al.  . An exploration of patients’ trust in physicians in training. J Health Care Poor Underserved  2004; 15: 294– 306. Google Scholar CrossRef Search ADS PubMed  24 Kao A, Green D, Zaslavsky A et al.  . The relationship between method of physician payment and patient trust. JAMA  1998; 280: 1708– 14. Google Scholar CrossRef Search ADS PubMed  25 Meyer S, Ward P, Jiwa M. Does prognosis and socioeconomic status impact on trust in physicians? Interviews with patient with coronary disease in South Australia. BMJ Open  2012; 2: e001389. Google Scholar CrossRef Search ADS PubMed  26 Gopichandran V, Chetlapalli SK. Factors influencing trust in doctors: a community segmentation strategy for quality improvement in healthcare. BMJ Open  2013; 3: e004115. Google Scholar CrossRef Search ADS PubMed  27 McKinstry B. Do patients wish to be involved in decision making in the consultation? A cross sectional survey with video vignettes. BMJ  2000; 321: 867– 71. Google Scholar CrossRef Search ADS PubMed  28 Nielsen-Bohlman L, Panzer AM, Kindig DA. Health Literacy: A prescription to end confusion . Washington, DC: National Academies Press, 2004. 29 Yu ST, Chang HY, Lin MC et al.  . Agreement between self-reported and health insurance claims on utilization of health care: a population study. J Clin Epidemiol  2009; 62: 1316– 22. Google Scholar CrossRef Search ADS PubMed  30 Zheng B, Hall MA, Dugan E et al.  . Development of a scale to measure patients’ trust in heatlh insurers. Health Serv Res  2002; 37: 187–– 202. Google Scholar PubMed  © The Author(s) 2018. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png International Journal for Quality in Health Care Oxford University Press

Is health literacy associated with greater medical care trust?

Loading next page...
 
/lp/ou_press/is-health-literacy-associated-with-greater-medical-care-trust-vT0gOXU0nz
Publisher
Oxford University Press
Copyright
© The Author(s) 2018. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
ISSN
1353-4505
eISSN
1464-3677
D.O.I.
10.1093/intqhc/mzy043
Publisher site
See Article on Publisher Site

Abstract

Abstract Objective To examine the relationship between health literacy and trust in physicians and in the healthcare system. Design A cross-sectional survey of a nationally representative sample of adults. Setting Taiwan. Participants Non-institutionalized adults (N = 2199). Main measures Trust in physicians was a composite measure assessing respondents’ general trust in physicians and their perceptions of their physician’s communication, medical skills, beneficence, honesty, confidentiality, respect and fairness. Trust in the healthcare system was a single-item measure. Health literacy was measured by four items. Results Respondents with higher health literacy had, overall, higher levels of trust in physicians (P<0.001) and in the healthcare system (P = 0.04). Health literacy remained significantly and positively associated with trust in physicians (P<0.001) and in the healthcare system (P = 0.001) after adjusting for respondents’ sociodemographic characteristics. Conclusions Our findings demonstrate that health literacy is positively associated with trust. Actionable plans targeting health literacy at the national and local levels to establish a health literate care environment may contribute to enhancing trust in physicians and the healthcare system. trust in physicians, trust in healthcare system, health literacy Introduction Trust in medical care is essential for ensuring the delivery of good healthcare and for achieving desirable health outcomes. Research shows patients who have more trust in medical care are more likely to adhere to treatment and be more satisfied with the quality of care [1, 2]. Trust in medical care also facilitates patient–provider relationships and communication, and increases the willingness of patients to share medical information and participate in medical decision-making [3, 4]. Conversely, lack of trust may reduce access to health services and increase healthcare costs [5, 6]. Patients who have lower trust in physicians, for example, are less willing to disclose their personal and medical information and more likely to seek second medical opinions and obtain care from non-physicians [7]. Such behaviors increase the health burden, as well as healthcare costs, of patients, families and society. Trust in medical care is not monolithic, however. The extant literature differentiates between trust in medical professionals and the healthcare system and suggests that they are equally important in determining healthcare access, quality and outcomes [7, 8]. There is a growing research interest in the relationship between health literacy and trust in medical care [9, 10]. Health literacy means cognitive and social skills that influence the motivation and ability of individuals to gain access to, understand and use health information in ways that promote and maintain good health [11]. Earlier evidence suggested that patient–provider communication and trust have a mutual effect on each other [8, 12]. Inability to adequately understand health information may be a barrier for patients to communicate, and build a trusting relationship, with medical providers. Similarly, poor understanding of health information limits patients’ ability to navigate, and therefore trust, the healthcare system [13]. In turn, trust in medical providers and the healthcare system may motivate patients to acquire, absorb and use health information, which may subsequently improve patients’ health behavior and their ability to maintain good personal health [14]. One recent study found that hospitalized cardiac patients with inadequate health literacy had a higher likelihood of physician distrust [13]. The result was different in a study of Hispanic diabetic patients in the USA, which found that those with lower health literacy had greater trust in their physicians [10]. These two studies, as well as most others in the literature, are focused on hospitalized patients and in clinical settings, and are conducted in the USA. They provide scant evidence regarding the relationship between health literacy and medical care trust in a general population and outside the USA. The purpose of this study was to use a nationally representative sample of Taiwanese adults to examine the association between health literacy and trust in medical care. We followed the literature to differentiate between trust in physicians and trust in the healthcare system. We hypothesized that adults with a higher level of health literacy would have greater trust in physicians and in the healthcare system. Methods Study Design and Sample Data used in this study were extracted from the health module of the Taiwan Social Change Survey (TSCS) [15]. TSCS was a nationwide, population-based survey. The sampling frame was Taiwan’s household registration system. The survey employed a three-stage stratified probability-proportional-to-size random sampling method and selected 4424 non-institutionalized civilians aged 18 years or older to participate in the study. Selected adults were contacted by mail for voluntary participation in the survey. The survey was administered by a group of trained and experienced interviewers who conducted the interviews face-to-face at participants’ homes. A total of 2199 respondents completed the interviews during 2011 and 2012, yielding a response rate of 52.3%. There were not age and gender differences between respondents and non-respondents and the sociodemographic attributes of respondents were similar to those of the national adult population. To ensure effective representation of the population, sample weight was used in the analysis. Measurements Trust in physicians was measured using eight survey items, which assessed the respondents’ general trust in physicians, as well as the respondents’ perception of physician communication, medical skills, beneficence, honesty, confidentiality, respect and fairness. Five of those items were identical to the questions used in the International Social Survey Programme across 29 countries. Those questions were translated into Mandarin via the double-forward-and-backward method. Three additional items were developed in order to assess the respondents’ perception of physicians’ handling of confidentiality and the degree of respect and fairness they received from physicians. All eight items used a five-point Likert scale ranging from strongly disagree [1] to strongly agree [5]. A study was conducted to test the reliability of the 8 items in 243 Taiwanese adults. The Cronbach’s alpha was 0.71, which was acceptable [16]. Factor analysis of the eight items suggested one underlying latent factor. Therefore, we summed the eight items to create a single index, with scores ranging from 8 to 40 and a higher score indicating a higher level of trust in physicians. Trust in the healthcare system was a single-item measure. The respondents indicated their level of trust using a four-point Likert scale. The scores ranged from 1 to 4; a higher score represented greater trust. Health literacy was assessed using four self-reported screening questions. The first two questions were ‘How confident are you in filling out medical forms by yourself (i.e. personal profile, medical history and consent forms)?’ (1 = extremely, 2 = quite a bit, 3 = somewhat, 4 = a little bit or 5 = not at all) and ‘How often do you have problems learning about your health condition because of difficulty understanding medication labels or self-care instructions?’ (1 = all the time, 2 = most of the time, 3 = some of the time, 4 = a little of the time or 5 = none of the time). These two questions have been shown to effectively identify individuals with limited functional health literacy [17]. The other two questions were designed to assess communicative health literacy: ‘How often do you have problems learning about your health condition because of difficulty understanding health providers’ explanations?’ and ‘How often do you have problems learning about your health condition because of difficulty asking health providers questions?’ Answers to these latter two questions were also assessed using a five-point Likert scale. As a set, these four questions assessed, respectively, a respondent’s ability to fill out medical forms, read written health materials, comprehend verbal information and ask questions during a healthcare encounter. Following previous research [17], we coded the response to each question ‘1’ if the respondent indicated having a problem, and ‘2’ if the response was never having a problem. The sum of the four items was then used to measure the overall level of health literacy of the respondent. The demographic variables included as covariates in the analysis were age, gender, educational level, occupation and residential area. Statistical Analysis Descriptive statistics were used to summarize the respondents' sociodemographic characteristics. Pearson correlation, t-test and Analysis of Variance (ANOVA) were used to examine the associations between health literacy, trust in physicians and trust in the healthcare system. We performed the linear regression analysis in a stepwise manner. First, we entered health literacy into the model to see how it was related to trust in physicians and trust in the healthcare system. Second, we added to the model sociodemographic variables to see how those variables changed the association between health literacy and trust. All analyses were conducted using SPSS 20.0. Results Table 1 shows the sociodemographic characteristics and health literacy of respondents. The average age of respondents was 44; male and female respondents were equally distributed; <40% of respondents had college education or above; ~30% had professional or professional associate occupations; the majority resided in cities or economically developed counties; the percentage of respondents able to perform the four health literacy-related tasks ranged from 56% to 78%. Figure 1 shows the level of trust in physicians. The highest level of trust was regarding confidentiality (76.9%) and followed by communication (72.2%). The highest levels of mistrust were in relation to honesty (71.6%), followed by fairness (66.5%) and beneficence (45.5%). Close to 78% of respondents reported that they trusted the healthcare system. Table 1 Subject characteristics of survey participants Characteristics  Mean (SD)  n (%)  Age  44.25 ± 16.63    Gender       Male    1095 (49.8)   Female    1104 (50.2)  Educational level       Junior high and below    377 (17.1)   Senior high/occupational    948 (43.1)   College    453 (20.6)   University    307 (13.9)   Graduate    109 (4.9)   Missing    6 (0.3)  Occupation       Professional    295 (13.3)   Professional associate    352 (16.0)   Clerk    268 (12.2)   Skilled    984 (44.8)   Unskilled/manual    160 (7.3)   Missing    141 (6.4)  Residential area       Metropolitan    482 (21.9)   Industrial city    585 (26.6)   Economically developed county    596 (27.1)   Traditional county    181 (8.2)   Rural county    356 (16.2)  Health literacy       Ability to fill out medical forms    1124 (56.1)   Ability to read written health materials    1555 (77.6)   Ability to comprehend oral information    1426 (71.1)   Ability to ask health questions    1406 (70.1)  Characteristics  Mean (SD)  n (%)  Age  44.25 ± 16.63    Gender       Male    1095 (49.8)   Female    1104 (50.2)  Educational level       Junior high and below    377 (17.1)   Senior high/occupational    948 (43.1)   College    453 (20.6)   University    307 (13.9)   Graduate    109 (4.9)   Missing    6 (0.3)  Occupation       Professional    295 (13.3)   Professional associate    352 (16.0)   Clerk    268 (12.2)   Skilled    984 (44.8)   Unskilled/manual    160 (7.3)   Missing    141 (6.4)  Residential area       Metropolitan    482 (21.9)   Industrial city    585 (26.6)   Economically developed county    596 (27.1)   Traditional county    181 (8.2)   Rural county    356 (16.2)  Health literacy       Ability to fill out medical forms    1124 (56.1)   Ability to read written health materials    1555 (77.6)   Ability to comprehend oral information    1426 (71.1)   Ability to ask health questions    1406 (70.1)  Table 1 Subject characteristics of survey participants Characteristics  Mean (SD)  n (%)  Age  44.25 ± 16.63    Gender       Male    1095 (49.8)   Female    1104 (50.2)  Educational level       Junior high and below    377 (17.1)   Senior high/occupational    948 (43.1)   College    453 (20.6)   University    307 (13.9)   Graduate    109 (4.9)   Missing    6 (0.3)  Occupation       Professional    295 (13.3)   Professional associate    352 (16.0)   Clerk    268 (12.2)   Skilled    984 (44.8)   Unskilled/manual    160 (7.3)   Missing    141 (6.4)  Residential area       Metropolitan    482 (21.9)   Industrial city    585 (26.6)   Economically developed county    596 (27.1)   Traditional county    181 (8.2)   Rural county    356 (16.2)  Health literacy       Ability to fill out medical forms    1124 (56.1)   Ability to read written health materials    1555 (77.6)   Ability to comprehend oral information    1426 (71.1)   Ability to ask health questions    1406 (70.1)  Characteristics  Mean (SD)  n (%)  Age  44.25 ± 16.63    Gender       Male    1095 (49.8)   Female    1104 (50.2)  Educational level       Junior high and below    377 (17.1)   Senior high/occupational    948 (43.1)   College    453 (20.6)   University    307 (13.9)   Graduate    109 (4.9)   Missing    6 (0.3)  Occupation       Professional    295 (13.3)   Professional associate    352 (16.0)   Clerk    268 (12.2)   Skilled    984 (44.8)   Unskilled/manual    160 (7.3)   Missing    141 (6.4)  Residential area       Metropolitan    482 (21.9)   Industrial city    585 (26.6)   Economically developed county    596 (27.1)   Traditional county    181 (8.2)   Rural county    356 (16.2)  Health literacy       Ability to fill out medical forms    1124 (56.1)   Ability to read written health materials    1555 (77.6)   Ability to comprehend oral information    1426 (71.1)   Ability to ask health questions    1406 (70.1)  Figure 1 View largeDownload slide Trust in Physicians. Figure 1 View largeDownload slide Trust in Physicians. As shown in Table 2, older adults had a higher level of trust in physicians (P = 0.003) and in the healthcare system (P<0.001). Individuals with primary school education and below were significantly more likely to report that they trusted physicians (P<0.001) and the healthcare system (P = 0.04), compared to those with more education. Individual without difficulty reading written health materials (P = 0.01), comprehending verbal information (P = 0.004) and asking health questions (P<0.001) were significantly more likely to report trust in physicians. Individual without problems comprehending verbal information (P<0.001) and asking health questions (P<0.001) had a higher level of trust in the healthcare system. Table 2 Associations of medical care trust, sociodemographic characteristics and health literacy Characteristics  Trust in physicians  P-value  Trust in healthcare system  P-value  Mean (SD)  Mean (SD)    Age    0.003a    <0.001a  Gender    0.16    0.65   Male  24.9 (4.3)    2.78 (0.61)     Female  25.2 (4.3)    2.77 (0.54)    Educational level    <0.001    0.04   Primary school and below  26.4 (3.9)    2.86 (0.53)     High school  25.0 (4.4)    2.77 (0.60)     College  24.6 (4.5)    2.75 (0.59)     University  24.6 (4.2)    2.73 (0.59)     Graduate  24.8 (3.8)    2.78 (0.50)    Occupation    0.33    0.68   Professional  25.0 (4.1)    2.79 (0.61)     Professional associate  24.6 (4.4)    2.79 (0.53)     Clerk  25.3 (3.9)    2.76 (0.54)     Skilled  25.1 (4.4)    2.75 (0.61)     Unskilled/manual  25.3 (4.4)    2.80 (0.54)    Residential area    0.04    0.40   Metropolitan  25.0 (4.3)    2.79 (0.58)    Industry city  25.0 (4.2)    2.78 (0.56)     Economically developed county  25.2 (4.6)    2.73 (0.62)     Traditional county  26.2 (4.2)    2.80 (0.63)     Rural county  24.7 (4.1)    2.80 (0.52)    Health literacy           Ability to fill out medical forms    0.26    0.60    Confidence with medical forms  25.0 (4.4)    2.8 (0.58)      Not confidence with medical forms  25.2 (4.2)    2.8 (0.57)     Ability to read written health materials    0.01    0.44    Never having problem  25.2 (4.3)    2.8 (0.58)      Having some problem  24.6 (4.4)    2.8 (0.57)     Ability to comprehending oral information    0.004    <0.001    Never having problem  25.3 (4.2)    2.8 (0.57)      Having some problem  24.6 (4.5)    2.7 (0.60)     Ability to ask health questions    <0.001    <0.001    Never having problem  25.4 (4.2)    2.8 (0.57)      Having some problem  24.5 (4.4)    2.7 (0.59)    Characteristics  Trust in physicians  P-value  Trust in healthcare system  P-value  Mean (SD)  Mean (SD)    Age    0.003a    <0.001a  Gender    0.16    0.65   Male  24.9 (4.3)    2.78 (0.61)     Female  25.2 (4.3)    2.77 (0.54)    Educational level    <0.001    0.04   Primary school and below  26.4 (3.9)    2.86 (0.53)     High school  25.0 (4.4)    2.77 (0.60)     College  24.6 (4.5)    2.75 (0.59)     University  24.6 (4.2)    2.73 (0.59)     Graduate  24.8 (3.8)    2.78 (0.50)    Occupation    0.33    0.68   Professional  25.0 (4.1)    2.79 (0.61)     Professional associate  24.6 (4.4)    2.79 (0.53)     Clerk  25.3 (3.9)    2.76 (0.54)     Skilled  25.1 (4.4)    2.75 (0.61)     Unskilled/manual  25.3 (4.4)    2.80 (0.54)    Residential area    0.04    0.40   Metropolitan  25.0 (4.3)    2.79 (0.58)    Industry city  25.0 (4.2)    2.78 (0.56)     Economically developed county  25.2 (4.6)    2.73 (0.62)     Traditional county  26.2 (4.2)    2.80 (0.63)     Rural county  24.7 (4.1)    2.80 (0.52)    Health literacy           Ability to fill out medical forms    0.26    0.60    Confidence with medical forms  25.0 (4.4)    2.8 (0.58)      Not confidence with medical forms  25.2 (4.2)    2.8 (0.57)     Ability to read written health materials    0.01    0.44    Never having problem  25.2 (4.3)    2.8 (0.58)      Having some problem  24.6 (4.4)    2.8 (0.57)     Ability to comprehending oral information    0.004    <0.001    Never having problem  25.3 (4.2)    2.8 (0.57)      Having some problem  24.6 (4.5)    2.7 (0.60)     Ability to ask health questions    <0.001    <0.001    Never having problem  25.4 (4.2)    2.8 (0.57)      Having some problem  24.5 (4.4)    2.7 (0.59)    aPearson's correlation. Table 2 Associations of medical care trust, sociodemographic characteristics and health literacy Characteristics  Trust in physicians  P-value  Trust in healthcare system  P-value  Mean (SD)  Mean (SD)    Age    0.003a    <0.001a  Gender    0.16    0.65   Male  24.9 (4.3)    2.78 (0.61)     Female  25.2 (4.3)    2.77 (0.54)    Educational level    <0.001    0.04   Primary school and below  26.4 (3.9)    2.86 (0.53)     High school  25.0 (4.4)    2.77 (0.60)     College  24.6 (4.5)    2.75 (0.59)     University  24.6 (4.2)    2.73 (0.59)     Graduate  24.8 (3.8)    2.78 (0.50)    Occupation    0.33    0.68   Professional  25.0 (4.1)    2.79 (0.61)     Professional associate  24.6 (4.4)    2.79 (0.53)     Clerk  25.3 (3.9)    2.76 (0.54)     Skilled  25.1 (4.4)    2.75 (0.61)     Unskilled/manual  25.3 (4.4)    2.80 (0.54)    Residential area    0.04    0.40   Metropolitan  25.0 (4.3)    2.79 (0.58)    Industry city  25.0 (4.2)    2.78 (0.56)     Economically developed county  25.2 (4.6)    2.73 (0.62)     Traditional county  26.2 (4.2)    2.80 (0.63)     Rural county  24.7 (4.1)    2.80 (0.52)    Health literacy           Ability to fill out medical forms    0.26    0.60    Confidence with medical forms  25.0 (4.4)    2.8 (0.58)      Not confidence with medical forms  25.2 (4.2)    2.8 (0.57)     Ability to read written health materials    0.01    0.44    Never having problem  25.2 (4.3)    2.8 (0.58)      Having some problem  24.6 (4.4)    2.8 (0.57)     Ability to comprehending oral information    0.004    <0.001    Never having problem  25.3 (4.2)    2.8 (0.57)      Having some problem  24.6 (4.5)    2.7 (0.60)     Ability to ask health questions    <0.001    <0.001    Never having problem  25.4 (4.2)    2.8 (0.57)      Having some problem  24.5 (4.4)    2.7 (0.59)    Characteristics  Trust in physicians  P-value  Trust in healthcare system  P-value  Mean (SD)  Mean (SD)    Age    0.003a    <0.001a  Gender    0.16    0.65   Male  24.9 (4.3)    2.78 (0.61)     Female  25.2 (4.3)    2.77 (0.54)    Educational level    <0.001    0.04   Primary school and below  26.4 (3.9)    2.86 (0.53)     High school  25.0 (4.4)    2.77 (0.60)     College  24.6 (4.5)    2.75 (0.59)     University  24.6 (4.2)    2.73 (0.59)     Graduate  24.8 (3.8)    2.78 (0.50)    Occupation    0.33    0.68   Professional  25.0 (4.1)    2.79 (0.61)     Professional associate  24.6 (4.4)    2.79 (0.53)     Clerk  25.3 (3.9)    2.76 (0.54)     Skilled  25.1 (4.4)    2.75 (0.61)     Unskilled/manual  25.3 (4.4)    2.80 (0.54)    Residential area    0.04    0.40   Metropolitan  25.0 (4.3)    2.79 (0.58)    Industry city  25.0 (4.2)    2.78 (0.56)     Economically developed county  25.2 (4.6)    2.73 (0.62)     Traditional county  26.2 (4.2)    2.80 (0.63)     Rural county  24.7 (4.1)    2.80 (0.52)    Health literacy           Ability to fill out medical forms    0.26    0.60    Confidence with medical forms  25.0 (4.4)    2.8 (0.58)      Not confidence with medical forms  25.2 (4.2)    2.8 (0.57)     Ability to read written health materials    0.01    0.44    Never having problem  25.2 (4.3)    2.8 (0.58)      Having some problem  24.6 (4.4)    2.8 (0.57)     Ability to comprehending oral information    0.004    <0.001    Never having problem  25.3 (4.2)    2.8 (0.57)      Having some problem  24.6 (4.5)    2.7 (0.60)     Ability to ask health questions    <0.001    <0.001    Never having problem  25.4 (4.2)    2.8 (0.57)      Having some problem  24.5 (4.4)    2.7 (0.59)    aPearson's correlation. The associations between health literacy and the eight items of trust in physicians and trust in the healthcare system are shown in Table 3. Health literacy was positively related to general trust (P<0.001), communication (P = 0.01), medical skills (P = 0.006), beneficence (P = 0.001), confidentiality (P = 0.04) and respect (P = 0.002). However, health literacy was negatively related to honesty (P = 0.005) and not significantly related to fairness (P = 0.37). Table 3 Correlations of health literacy and trust in physicians and healthcare system Item  Pearson's correlation coefficient  Trust in physicians     All things considered, doctors can be trusted (general trust)  0.09*   Doctors discuss all treatment options with their patients (communication)  0.05**   The medical skills of doctors are not as good as they should be (medical skills)  0.06*   Doctors care more about their earnings than about their patients (beneficence)  0.07*   Doctors would tell their patients if they made a mistake during treatment (honesty)  −0.06*   Doctors would maintain privacy of patients’ information (confidentiality)  0.05**   Doctors respect patients’ diverse opinions (respect)  0.07*   Doctors are fairness to take care their patients (fairness)  −0.02  Trust in healthcare system  0.06*  Item  Pearson's correlation coefficient  Trust in physicians     All things considered, doctors can be trusted (general trust)  0.09*   Doctors discuss all treatment options with their patients (communication)  0.05**   The medical skills of doctors are not as good as they should be (medical skills)  0.06*   Doctors care more about their earnings than about their patients (beneficence)  0.07*   Doctors would tell their patients if they made a mistake during treatment (honesty)  −0.06*   Doctors would maintain privacy of patients’ information (confidentiality)  0.05**   Doctors respect patients’ diverse opinions (respect)  0.07*   Doctors are fairness to take care their patients (fairness)  −0.02  Trust in healthcare system  0.06*  *P<0.01 and **P<0.05. Table 3 Correlations of health literacy and trust in physicians and healthcare system Item  Pearson's correlation coefficient  Trust in physicians     All things considered, doctors can be trusted (general trust)  0.09*   Doctors discuss all treatment options with their patients (communication)  0.05**   The medical skills of doctors are not as good as they should be (medical skills)  0.06*   Doctors care more about their earnings than about their patients (beneficence)  0.07*   Doctors would tell their patients if they made a mistake during treatment (honesty)  −0.06*   Doctors would maintain privacy of patients’ information (confidentiality)  0.05**   Doctors respect patients’ diverse opinions (respect)  0.07*   Doctors are fairness to take care their patients (fairness)  −0.02  Trust in healthcare system  0.06*  Item  Pearson's correlation coefficient  Trust in physicians     All things considered, doctors can be trusted (general trust)  0.09*   Doctors discuss all treatment options with their patients (communication)  0.05**   The medical skills of doctors are not as good as they should be (medical skills)  0.06*   Doctors care more about their earnings than about their patients (beneficence)  0.07*   Doctors would tell their patients if they made a mistake during treatment (honesty)  −0.06*   Doctors would maintain privacy of patients’ information (confidentiality)  0.05**   Doctors respect patients’ diverse opinions (respect)  0.07*   Doctors are fairness to take care their patients (fairness)  −0.02  Trust in healthcare system  0.06*  *P<0.01 and **P<0.05. Table 4 presents results of the linear regression analysis. The models show the mean change in trust in physicians and in the healthcare system, per unit increased in health literacy. Health literacy was significantly and positively associated with trust in physicians (P = 0.001) and trust in healthcare system (P = 0.001), and that the association remained statistically significant when adjusted for age, education, gender, occupation and residential location (P< 0.001 for trust in physicians and P = 0.001 for trust in the healthcare system). Table 4 Multivariate liner regression results   Trust in Physicians  Trust in Healthcare System      Model 1  Model 2  Model 1  Model 2    Beta (standardized coefficients)  P-value  Beta (standardized coefficients)  P-value  Beta (standardized coefficients)  P-value  Beta (standardized coefficients)  P-value  Health literacy  0.08  0.001  0.09  <0.001  0.07  0.001  0.08  0.001  Age      0.02  0.42      0.14  <0.001  Gender      0.02  0.52      −0.01  0.76  Education      −0.1  0.002      0.003  0.93  Occupation      −0.02  0.45      −0.02  0.44  Residential area      0.01  0.65      0.01  0.82    Trust in Physicians  Trust in Healthcare System      Model 1  Model 2  Model 1  Model 2    Beta (standardized coefficients)  P-value  Beta (standardized coefficients)  P-value  Beta (standardized coefficients)  P-value  Beta (standardized coefficients)  P-value  Health literacy  0.08  0.001  0.09  <0.001  0.07  0.001  0.08  0.001  Age      0.02  0.42      0.14  <0.001  Gender      0.02  0.52      −0.01  0.76  Education      −0.1  0.002      0.003  0.93  Occupation      −0.02  0.45      −0.02  0.44  Residential area      0.01  0.65      0.01  0.82  Table 4 Multivariate liner regression results   Trust in Physicians  Trust in Healthcare System      Model 1  Model 2  Model 1  Model 2    Beta (standardized coefficients)  P-value  Beta (standardized coefficients)  P-value  Beta (standardized coefficients)  P-value  Beta (standardized coefficients)  P-value  Health literacy  0.08  0.001  0.09  <0.001  0.07  0.001  0.08  0.001  Age      0.02  0.42      0.14  <0.001  Gender      0.02  0.52      −0.01  0.76  Education      −0.1  0.002      0.003  0.93  Occupation      −0.02  0.45      −0.02  0.44  Residential area      0.01  0.65      0.01  0.82    Trust in Physicians  Trust in Healthcare System      Model 1  Model 2  Model 1  Model 2    Beta (standardized coefficients)  P-value  Beta (standardized coefficients)  P-value  Beta (standardized coefficients)  P-value  Beta (standardized coefficients)  P-value  Health literacy  0.08  0.001  0.09  <0.001  0.07  0.001  0.08  0.001  Age      0.02  0.42      0.14  <0.001  Gender      0.02  0.52      −0.01  0.76  Education      −0.1  0.002      0.003  0.93  Occupation      −0.02  0.45      −0.02  0.44  Residential area      0.01  0.65      0.01  0.82  To examine if the results varied based on the level of healthcare experience of the respondents, we classified the respondents in three different ways—(1) those who used outpatient department service or traditional Chinese medicine care in the past 12 months vs. those who did not; (2) those who were hospitalized in the past 12 months vs. those who were not; and (3) those who had chronic disease vs. those who did not—and then performed stratified regression analyses. The findings were consistent between different groups of respondents. Discussion Using a nationally representative sample of Taiwanese adults, the present study provides evidence that health literacy is positively associated with greater trust in physicians and in the healthcare system [14]. The findings corroborate and expand those of previous studies that were conducted in American veterans and hospitalized patients [9, 10, 13]. The delivery of healthcare relies primarily upon the expertize of medical providers. Patients, who usually lack the medical expertize, have traditionally been expected to be dependent on medical providers and the healthcare system for the maintenance of health and treatment of illness. It is conceivable that people with low health literacy may be more dependent on, and therefore have to trust more, medical providers and the healthcare system, for health information, medical advice and personal health decision-making [18]. In contrast to this argument, our study, as well as most prior research, found a positive relationship between health literacy and medical care trust. A plausible explanation is that low health literacy—and the stigma that makes it difficult for individuals with low health literacy to reveal their personal challenges in understanding and use health information—may have adversely affected the communication with medical providers and the ability to navigate the healthcare system [19], resulting in a low level of medical care trust. To the extent this explanation is valid, skills, tools, resources and assistance that medical providers can employ to build a good relationship with patients—particularly those who have low health literacy—during medical encounters would contribute to enhancing medical care trust. A useful tool is the ‘teach-back’ (or ‘show-me’) method, which medical providers can use to confirm a patient’s (or a care taker’s) understanding of what is explained to them [20]. Health policy-makers and organizational leaders in the healthcare system also share the responsibility of designing easy-to-read health information, improving patient and family centeredness in healthcare delivery, and providing necessary assistance and resources to medical providers (e.g. reducing workload, lengthening the clinic time for each medical encounter) to improve healthcare access and enhance medical care trust. It is worth noting that less than one-third of respondents in the study reported trust in physician fairness and honesty and less than half reported trust in physician beneficence. These findings may reflect a tension in the payment system of the National Health Insurance program in Taiwan. Currently, the global budget in the payment system may have compelled medical providers and organizations to focus on their financial bottom-line at the expense of valuing and promoting the quality of care provided [21]. A public perception may exist that medical providers and organizations are ‘gaming’ the system and that patients do not receive the quantity and quality of care they deserve. This may also explain the finding that individuals with higher health literacy had lower trust in physician honesty and fairness. It is likely that individuals with higher health literacy may have learned more of the exposé in the media and be more critical of the behavior of physicians. Results of the relationships between demographic factors and medical care trust have been inconsistent across studies. While some studies found older patients and less educated patients were more trusting [9, 22], others showed the opposite [13, 23] and yet others did not find a relationship between educational level and trust [24]. In this study, we found a discrepancy between education (and age) and health literacy in relation to medical care trust. Specifically, our analysis indicated that lower education and older age were significantly associated with greater trust and that individuals with higher health literacy had more trust in medical care. Research has consistently shown that older age and lower education are associated with lower health literacy. Taking together, our findings suggest two possibilities. First, persons with lower education and older age may be more likely to have blindly embodied trust, i.e. their medical trust is often based on comfort and emotional assessment [4, 25]. They may have a low interest in collaborative decision-making as their medical knowledge is very scant [3]. If so, providing them complex medical information and actively engaging them in medical decision-making may threaten the trust relationship with healthcare providers. By contrast, younger persons with a higher educational attainment may be more inclined to objectively assess their relationship with medical providers and their perceived trust may tend to be based on their personal involvement; they also may be more likely to question medical advice [26, 27]. If so, the approach that medical providers employ to building medical care trust may need to vary by their patients’ education background and age. Second, research has suggested that health literacy is a better indicator than education in explaining health behaviors and outcomes [28]. It is possible that health literacy, in comparison to education attainment, is a better indicator of individual empowerment, and capability of understanding and appraising health information, effectively communicating with healthcare providers and actively involve participating in shared medical decision-making. These health literacy competences, in turn, may be essential for building trust in medical care. This population-based study provides evidence that links health literacy with medical care trust in a country that has had a comprehensive National Health Insurance system for 20 years. Several study limitations are noteworthy. One is that the measure for health literacy was self-reported, which may be subjective and unreliable. However, research has shown that self-reported assessments are valid and have been commonly used in health literacy studies [29]. Second, trust in the healthcare system was assessed using a single question. A previous study indicated that trust in the healthcare system is single-dimensional and could be measured with one general question [30]. Finally, this study was cross-sectional. Additional research is needed to verify the causal relationships implied in the discussion. These cautions aside, our findings support previous research that health literacy is positively associated with trust in medical care. Actionable plans targeting health literacy at the national and local levels to establish a health literate care environment may contribute to enhancing trust in physicians and the healthcare system. Acknowledgements Data analyzed in this paper were collected in the health module of the research project ‘Taiwan Social Change Survey’ (TSCS Survey 6-2 II). The project was conducted by the Institute of Sociology, Academia Sinica and sponsored by the Ministry of Science and Technology (formerly known as the National Science Council), R.O.C. (NSC 100-2420-H-001002-SS2). The authors appreciate the assistance in providing data by the institutes and individuals aforementioned. The views expressed herein are the authors’ own. Preliminary findings from this study were presented at the 14th International Conference on European Association Communication in Healthcare (EACH). References 1 Brennan N, Barnes R, Calnan M et al.  . Trust in the health-care provider-patient relationship: a systematic mapping review of the evidence base. Int J Qual Health Care  2013; 25: 682– 8. Google Scholar CrossRef Search ADS PubMed  2 Calnan M, Rowe R, Entwistle V. Trust relations in health care: an agenda for future research. J Health Organ Manag  2006; 20: 477– 84. Google Scholar CrossRef Search ADS PubMed  3 Kraetschmer N, Sharpe N, Urowitz S et al.  . How does trust affect patient preferences for participation in decision-making? Health Expect  2004; 7: 317– 26. Google Scholar CrossRef Search ADS PubMed  4 Rowe R, Calnan M. Trust relations in health care—the new agenda Euro. J Public Health  2006; 16: 4– 6. 5 Musa D, Schulz R, Harris R et al.  . Trust in the health care system and the use of preventive health services by older black and white adults. Am J Public Health  2009; 99: 1293– 9. Google Scholar CrossRef Search ADS PubMed  6 Whetten K, Leseran J, Whetten R et al.  . Exploring lack of trust in care providers and the government as a barrier to health service use. Am J Public Health  2006; 96: 716– 21. Google Scholar CrossRef Search ADS PubMed  7 Hall MA, Dugan E, Zheng B et al.  . Trust in physicians and medical institutions: what is it, can it be measured, and does it matter? Milbank Q  2001; 79: 613– 39. Google Scholar CrossRef Search ADS PubMed  8 Hall MA. The importance of trust for ethics, law, and public policy. Camb Q Healthc Ethics  2005; 14: 156– 67. Google Scholar CrossRef Search ADS PubMed  9 Rodríguez V, Andrade AD, García-Retamero R et al.  . Health literacy, numeracy, and graphical literacy among veterans in primary care and their effect on shared decision making and trust in physicians. J Health Commun  2013; 18: 273– 89. Google Scholar CrossRef Search ADS PubMed  10 White RO, Osborn CY, Gebretsadik T et al.  . Health literacy, physician trust, and diabetes-related self-care activities in hispanics with limited resources. J Health Care Poor Underserved  2013; 24: 1756– 68. Google Scholar CrossRef Search ADS PubMed  11 World Health Organization. Health promotion glossary. 1998. 12 Barton JL, Trupin L, Tonner C et al.  . English language proficiency, health literacy, and trust in physician are associated with shared decision making in rheumatoid arthritis. J Rheumatol  2014; 41: 1290– 7. Google Scholar CrossRef Search ADS PubMed  13 Gupta C, Bell SP, Schildcrout JS et al.  . Predictors of health care system and physician distrust in hospitalized cardiac patients. J Health Commun  2014; 19: 44– 60. Google Scholar CrossRef Search ADS PubMed  14 Dawson-Rose C, Cuca YP, Webel AR et al.  . Building trust and relationships between patients and providers: an essential complement to health literacy in HIV care. J Assoc Nurses AIDS Care  2016; 27: 574– 84. Google Scholar CrossRef Search ADS PubMed  15 Chang Y-H, Tu S-H, Liao P-S. Taiwan Social Change Survey 2011, Phase 6, Wave 2 . Taipei: Institute of Sociology, Academic Sinica, 2012. 16 Nunnally JC, Bernstein IH. Psychometric theory . New York: McGraw-Hill, 1994: 264– 5. 17 Chew LD, Griffin JM, Partin MR et al.  . Validation of screening questions for limited health literacy in a large VA outpatient population. J Gen Intern Med  2008; 23: 561– 6. Google Scholar CrossRef Search ADS PubMed  18 Paasche-Orlow MK, Wolf MS. The causal pathways linking health literacy to health outcomes. Am J Health Behav  2007; 31: s19– 26. Google Scholar CrossRef Search ADS PubMed  19 Parikh NS, Parker RM, Nurss JR et al.  . Shame and health literacy: the unspoken connection. Patient Educ Couns  1996; 27: 33– 9. Google Scholar CrossRef Search ADS PubMed  20 Berga AG, Barnard J, Mabachi NM et al.  . AHRQ Health Literacy Universal Precautions Toolkit , 2nd edn. Rockville, M.D.: AHRQ Publication, 2015. 21 Wu T-Y, Majeed A, Kuo NK. An overview of the healthcare system in Taiwan. London J Prim Care  2010; 3: 115– 9. Google Scholar CrossRef Search ADS   22 Gilson L. Trust and health care as a social institution. Soc Sci Med  2003; 56: 1452– 68. Google Scholar CrossRef Search ADS   23 Bonds DE, Foley KL, Dugan E et al.  . An exploration of patients’ trust in physicians in training. J Health Care Poor Underserved  2004; 15: 294– 306. Google Scholar CrossRef Search ADS PubMed  24 Kao A, Green D, Zaslavsky A et al.  . The relationship between method of physician payment and patient trust. JAMA  1998; 280: 1708– 14. Google Scholar CrossRef Search ADS PubMed  25 Meyer S, Ward P, Jiwa M. Does prognosis and socioeconomic status impact on trust in physicians? Interviews with patient with coronary disease in South Australia. BMJ Open  2012; 2: e001389. Google Scholar CrossRef Search ADS PubMed  26 Gopichandran V, Chetlapalli SK. Factors influencing trust in doctors: a community segmentation strategy for quality improvement in healthcare. BMJ Open  2013; 3: e004115. Google Scholar CrossRef Search ADS PubMed  27 McKinstry B. Do patients wish to be involved in decision making in the consultation? A cross sectional survey with video vignettes. BMJ  2000; 321: 867– 71. Google Scholar CrossRef Search ADS PubMed  28 Nielsen-Bohlman L, Panzer AM, Kindig DA. Health Literacy: A prescription to end confusion . Washington, DC: National Academies Press, 2004. 29 Yu ST, Chang HY, Lin MC et al.  . Agreement between self-reported and health insurance claims on utilization of health care: a population study. J Clin Epidemiol  2009; 62: 1316– 22. Google Scholar CrossRef Search ADS PubMed  30 Zheng B, Hall MA, Dugan E et al.  . Development of a scale to measure patients’ trust in heatlh insurers. Health Serv Res  2002; 37: 187–– 202. Google Scholar PubMed  © The Author(s) 2018. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Journal

International Journal for Quality in Health CareOxford University Press

Published: Mar 28, 2018

There are no references for this article.

You’re reading a free preview. Subscribe to read the entire article.


DeepDyve is your
personal research library

It’s your single place to instantly
discover and read the research
that matters to you.

Enjoy affordable access to
over 18 million articles from more than
15,000 peer-reviewed journals.

All for just $49/month

Explore the DeepDyve Library

Search

Query the DeepDyve database, plus search all of PubMed and Google Scholar seamlessly

Organize

Save any article or search result from DeepDyve, PubMed, and Google Scholar... all in one place.

Access

Get unlimited, online access to over 18 million full-text articles from more than 15,000 scientific journals.

Your journals are on DeepDyve

Read from thousands of the leading scholarly journals from SpringerNature, Elsevier, Wiley-Blackwell, Oxford University Press and more.

All the latest content is available, no embargo periods.

See the journals in your area

DeepDyve

Freelancer

DeepDyve

Pro

Price

FREE

$49/month
$360/year

Save searches from
Google Scholar,
PubMed

Create lists to
organize your research

Export lists, citations

Read DeepDyve articles

Abstract access only

Unlimited access to over
18 million full-text articles

Print

20 pages / month

PDF Discount

20% off