Trust in Physicians Among U.S. Chinese Older Adults

Abstract

Background.

Trust in physicians influences the health and well-being of older adults and is an important indicator to assess the quality of medical care. However, Asian aging populations are often underrepresented in studies of patient trust in physicians. This study aims to examine the level of trust in physicians among Chinese older adults in a community-dwelling Chinese aging population.

Methods.

Data were drawn from the Population Study of Chinese Elderly, a population-based survey of U.S. Chinese older adults in the Greater Chicago area. Guided by a community-based participatory research approach, a total of 3,159 Chinese older adults aged 60 and above were surveyed. An 11-item scale was used to measure participants’ trust in physicians.

Results.

On a scale of 11–55, the level of trust in physician among U.S. Chinese older adults was 42.0 (SD = 6.3). Items related to confidence in physicians’ knowledge and skills were most commonly endorsed, including trusting physicians’ judgment on medical care (84.8%), trusting physicians’ advice (84.2%), and trusting physicians’ words that something is so and must be true (81.2%). Younger age, male gender, higher educational level, fewer years of residing in the United States and in the community, poorer self-reported health status, and poorer quality of life were associated with lower level of trust in physicians.

Conclusions.

Trust in physician is commonly endorsed among U.S. Chinese older adults. However, future longitudinal studies are needed to improve our understanding of risk factors and outcomes associated with trust in physicians among U.S. Chinese older adults.

Trust is fundamental in clinical patient–physician relationships (1). Patients’ trust in physicians (TIP) measures the extent to which patients believe that their physicians will act in their best interest to provide medical suggestions, care, and treatment (2). TIP is essential in assessing the quality and effectiveness of medical care because it influences patients’ willingness to seek care, adherence to physicians’ instructions, continuity of care, and overall health outcomes (3). In particular, TIP is critical for older adults due to the high prevalence of multimorbidity and complex medical needs for chronic disease management (4,5).

With the rapidly evolving nature of the health care system, there is a growing need to advance our knowledge on TIP among older adults. Prior studies found that older age is associated with a higher level of TIP (2,5,6). However, these studies were based on the general population and were thus limited in providing detailed information on older adults specifically. Although we have improved knowledge about TIP among older adults in the recent years, most prior studies were based on more selected populations of older adults (7,8) or a single measure of TIP (9).

Furthermore, TIP as a multidimensional construct was measured qualitatively in many studies, and fewer studies explored TIP with quantitative measures (10). In addition, in quantitative studies, TIP was often conceptualized and measured in diverse ways with different subcomponents, which may make meaningful comparisons challenging (10). For instance, although fidelity and competence components are constantly enforced in most scales estimating TIP, Kao’ scale excludes honesty and behavior component, Wake Forest’s scale excludes confidentiality and behavior components, and Anderson et al. Trust in Physician Scale provides a coverage of all six components including fidelity, competence, honesty, confidentiality, global, and behavioral (11).

An increasing body of literature documents racial/ethnic disparities in TIP. Although factors contributing to trust and distrust in physicians may differ across racial/ethnicity groups (12), minority groups were more likely to report greater distrust and lower satisfactory toward their physicians compared with dominant groups. In particular, literature suggests that Asian Americans displayed the lower level of satisfactory and less sharing in patient–physician relationship based on a 100-point self-reported rating (13). A national survey suggests that Asian Americans are more likely than whites to report their physicians as not understanding of their needs and not spending enough time with them (14) based on a dichotomized measure of TIF (14). Despite that Asian Americans are often underrepresented in many studies, they are frequently treated as a homogeneous group in research, limiting our capability to distinguish cultural beliefs and health behaviors in diverse Asian subgroups with respect to TIP.

The Chinese community is the oldest and largest Asian American subgroup in the United States (15). Older adults constitute a large segment of the general Chinese population in the United States, of whom 15.4% are aged 65 or older (15). More than 80% of Chinese older adults were foreign born, and approximately 30% of them immigrated to the United States after the age of 60. Their immigration experiences, degree of acculturation, and previous physician–patient relationships before residing in the United States may contribute to their current levels of TIP in the United States (16). A case study based on a U.S. Chinese immigrant family identified how TIP was influenced by their understanding of different cultures (17). However, the vast intragroup diversity in languages, education levels, socioeconomic status, and degree of acculturation among U.S. Chinese older adults contributes to the dearth of evidence-based research targeting at Chinese older adults (18).

This study aims to contribute to the existing knowledge base of TIP among U.S. community-dwelling Chinese older adults by examining their level of TIP and the correlations between TIP and sociodemographic, overall health, and quality-of-life characteristics.

Methods

Population and Settings

The Population Study of Chinese Elderly (PINE) is a population-based epidemiological study of U.S. Chinese older adults aged 60 and older in the Greater Chicago area. The purpose of the PINE study is to collect community-level data of U.S. Chinese older adults to examine the key cultural determinants of health and well-being. The project was initiated by a synergistic community-academic collaboration among the Rush Institute for Healthy Aging, Northwestern University, and many Greater Chicago area community-based social services agencies and organizations (19).

In brief, the PINE study implemented culturally/linguistically appropriate community recruitment strategies guided by a community-based participatory research approach (20). Strictly following community-based participatory research approach, we assembled a Community advisory board that consisted of community stakeholders and residents enlisted through more than 20 social groups, community centers, and clinics in the greater Chicago area. Community advisory board played a pivotal role in providing useful perspectives and strategies for aging research conduct and partnership sustainability.

Furthermore, under the guidance of Community advisory board, our targeted community-based recruitment strategy engaged community centers as our main recruitment sites throughout the greater Chicago area, including more than 20 community-based social services agencies, community centers, faith-based organizations, senior apartments, and social clubs. In addition, other outreach channels were also utilized, such as local newspapers advertisements, flyers and posters, community-health educational workshops, word of mouth, participants’ referral, etc. Due to the closely knitted ethnic social network connecting the families of Chinese immigrants, over a third of our study participants learned about the project through family members, neighbors, acquaintance, or friends. All participants were consented and interviewed by trained bicultural research assistants in English or in a Chinese dialect, including Mandarin, Cantonese, Toishanese, and Teochow, according to participants’ preference. Field interviewers were recruited through community partners and were equipped with multilingual abilities. Prior to field interviews, all hired interviewers attended an intensive training that covered from proper data collection techniques, survey questionnaire administration, to in-person communication skills, basic understanding of health sciences research and mock-interview role play. During the field data collection period, booster trainings combined with staff meetings were conducted one to two times a month in order to reinforce specific aspects of in-person training and provide additional training on new issues emerged from the field work. Out of 3,542 eligible participants, 3,159 agreed to participate in the study, yielding a response rate of 91.9%. Based on U.S. Census 2010 and a random block census project, the PINE study is representative of the Chinese aging population in the Greater Chicago area (21). The study was approved by the Institutional Review Board at the Rush University Medical Center.

Measurements

Sociodemographics.

Basic demographic information was collected, including age, sex, education level, annual income, marital status, number of children, and living arrangement. Immigration data relating to participants’ years in the United States and years residing in the current community were also collected. Overall health status was measured by: “In general, how would you rate your health?” on a 4-point scale. Quality of life was assessed by asking participants: “In general, how would you rate your quality of life?” also on a 4-point scale. Health change in last year was measured by the question: “Compared to one year ago, how would you rate your health now?” on a 5-point scale. Health changes were then categorized into three groups (improved, same, or worsened).

Trust in physician.

We used the 11-item Anderson et al. Trust in Physician Scale to assess a patient’s interpersonal trust in his or her physician from three aspects: physician dependability, confidence in physician knowledge and skills, and confidentiality and reliability of information received from the physician (2). Participants were asked how strongly do they agree or disagree on a 5-point Likert scale that they trusted their physician’s judgment on medical care, medical advice, opinions, and words that something is so and that their physicians are experts on medical problems like theirs. Moreover, we asked participants how much they trust their physicians to consider and prioritize their medical needs when treating medical problems, to tell them if a mistake was made in treatment, to keep information private, to care about them as a person, and to do everything they should for patients.

We created a continuous TIP variable by summing scores from the 11 items. Aggregate scores range from 11 to 55, with higher scores indicating greater level of TIP. The reliability of the TIP scale was 0.85 and 0.90 in Anderson’s original work (2).

Content validity was assessed by a group of bilingual and bicultural study researchers with expertise in Chinese cultural issues, health, and aging. The original English versions of the instruments were first translated into Chinese by a bilingual research team. Due to the vast linguistic diversity of our study population, the Chinese version was then back translated by bilingual and bicultural investigators fluent in dialects including Mandarin and Cantonese to confirm consistency in the meaning of the Chinese version with the original English version. Both written scripts (traditional and simplified Chinese characters) were subsequently examined. More than 20 Community advisory board members subsequently examined the Chinese versions to ascertain that the meanings of the items in Chinese conveyed the meanings to Chinese older adults from diverse linguistic backgrounds.

Data Analysis

Descriptive univariate statistics were used to summarize the sociodemographic, family composition, and health-related characteristics of the sample population. We examined the psychometric properties of the TIP scale to test their adequacy and expanded use to U.S. Chinese older adults. Internal consistency reliability was assessed by determining the coefficient alpha and inter-item correlation coefficients. Means and standard deviations were used to describe TIP. The analysis of variance F test was used to examine whether level of trust differed significantly by age, gender, income, education, health status, years of residence in the United States, or years of residence in the community. Pearson correlation coefficients were used to examine the correlations between different variables and TIP. Statistical analyses were conducted using SAS, Version 9.2 (SAS Institute Inc., Cary, NC).

Results

Sample Characteristics

Of the 3,159 participants enrolled in the study, 58.9% were women, 71.3% were married, and 85.1% had an annual income below $10,000. The mean age of our participants was 72.8 (SD = 8.3) and the average years of education completed was 8.7 (SD = 5.1). The majority (92.7%) of our participants were born in mainland China and 53.9% preferred to complete the interview in Cantonese. More than half (57.3%) of the participants have lived in the United States for less than 20 years. Overall, 39.0% of participants perceived their health status as good or very good, and 50.4% perceived their quality of life as very good or good.

Scale Reliability

The alpha coefficient for the Chinese version of the TIP scale was .84 (Table 1). All correlations were significant at the .001 level. The inter-item correlations ranged from .05 to .69, demonstrating that the constructs were not too closely correlated to indicate unidimensionality. Item 3 (trust following physician’s advice), Item 4 (physician tells me something is so, then it must be true), and Item 6 (trust physician’s judgment) showed some of the highest inter-item correlation coefficients, ranging from .65 to .69.

Table 1.

Endorsement of Trust in Physicians Scale Items

Items of Trust in Physicians Scale	Strongly Disagree, N (%)	Disagree, N (%)	Neutral, N (%)	Agree, N (%)	Strongly Agree, N (%)
1. I doubt that my physician really cares about me as a person	620 (20.0)	1,564 (50.4)	478 (15.4)	305 (9.8)	135 (4.4)
2. My physician is usually considerate of my needs and puts them first	38 (1.2)	244 (7.9)	635 (20.6)	1,547 (50.2)	617 (20.0)
3. I trust my physician so much that I always try to follow his/her advice	18 (0.6)	139 (4.5)	335 (10.8)	1,538 (49.4)	1,082 (34.8)
4. If my physician tells me something is so, then it must be true	14 (0.5)	163 (5.3)	407 (13.1)	1,567 (50.4)	956 (30.8)
5. I sometimes distrust my physician’s opinion and would like a second one	661 (21.3)	1,637 (52.7)	341 (11.0)	40 (12.9)	68 (2.2)
6. I trust my physician’s judgment about my medical care	15 (0.5)	138 (4.4)	320 (10.3)	1,715 (55.2)	920 (29.6)
7. I feel my physician does not do everything he/she should for my medical care	419 (13.6)	1,470 (47.7)	477 (15.5)	495 (16.1)	218 (7.1)
8. I trust my physician to put my medical needs above all other considerations when treating my medical problems	28 (0.9)	189 (6.2)	582 (18.9)	1,683 (54.8)	592 (19.3)
9. My physician is a real expert in taking care of medical problems like mine	41 (1.3)	396 (12.9)	704 (23.0)	1,439 (47.0)	483 (15.8)
10. I trust my physician to tell me if a mistake was made about my treatment	110 (3.8)	525 (18.2)	926 (32.0)	1,009 (34.8)	327 (11.3)
11. I sometimes worry that my physician may not keep the information we discuss totally private	865 (28.4)	1,685 (55.3)	342 (11.2)	133 (4.4)	21 (0.7)

Endorsement of TIP Scale Items

Descriptive data for the 11-item TIP scale are highlighted in Table 2. A high percentage of older adults trusted their physician’s judgment on medical care (84.8%), medical advice (84.2%), and words that something is so and must be true (81.2%). Moreover, most participants trusted their physicians to consider their needs (70.2%) and prioritize their medical needs when treating medical problems (74.1%). However, only 62.8% of participants agreed that their physicians were experts on medical problems like theirs and 46.1% participants trusted their physician to tell them if a mistake was made in their treatment. With regard to items worded in a negative direction, the majority of participants disagreed or strongly disagreed about: worrying that physicians may not keep information private (83.7%), distrusting physician’s opinion and wanting a second opinion (74.0%), doubting that physicians really cared about them as a person (70.4%), and feeling that physicians did not do everything they should have for their medical care (61.3%).

Table 2.

Trust in Physicians Scale and Item—Total Correlation and Correlation Coefficients

Items	Alpha If Item Removed	1	2	3	4	5	6	7	8	9	10	11
1.	.83	1.0
2.	.82	0.38	1.0
3.	.82	0.33	0.50	1.0
4.	.82	0.31	0.48	0.69	1.0
5.	.83	0.32	0.33	0.44	0.48	1.0
6.	.82	0.31	0.48	0.65	0.68	0.48	1.0
7.	.85	0.39	0.26	0.23	0.22	0.27	0.22	1.0
8.	.82	0.31	0.65	0.51	0.52	0.36	0.55	0.22	1.0
9.	.84	0.14	0.34	0.32	0.34	0.22	0.34	0.05	0.37	1.0
10.	.84	0.25	0.35	0.33	0.37	0.22	0.32	0.25	0.35	0.19	1.0
11.	.84	0.28	0.26	0.28	0.27	0.33	0.30	0.22	0.26	0.15	0.14	1.0

TIP Level

TIP levels differed by age (p < .001), gender (p < .001), education (p < .001), and income (p < .001; Table 3). Participants aged 80 and older were more likely to report a higher TIP score (M = 43.3, SD = 6.2) than younger participants. Men showed a lower TIP level (M = 41.3, SD = 6.3) in comparison with women (M = 42.4, SD = 6.3). The TIP level was higher among participants with 0–6 years of education (M = 43.1, SD = 5.9) compared with participants with higher educational attainment. Participants with annual income of more than $20,000 had lower TIP (M = 39.8, SD = 7.0) compared with lower income participants.

Table 3.

Endorsement of Trust in Physicians by Sociodemographics and Health Measures

Age										F Value	p Value
60–64 (N = 661)		65–69 (N = 635)		70–74 (N = 597)		75–79 (N = 546)		80+ (N = 666)
Mean	SD	Mean	SD	Mean	SD	Mean	SD	Mean	SD
40.5	6.2	41.3	6.6	42.1	6.3	42.8	6.0	43.3	6.2	20.7	<.001
Sex
Men (N = 1,301)		Women (N = 1,804)
Mean	SD	Mean	SD
41.3	6.3	42.4	6.3							25.6	<.001
Education
0–6 (N = 1,349)		7–12 (N = 1,086)		13+ (N = 651)
Mean	SD	Mean	SD	Mean	SD
43.1	5.9	41.3	6.5	40.7	6.6					40.8	<.001
Income
$0–$4,999 (N = 1,017		$5,000–$9,999 (N = 1,597)		$10,000–$14,999 (N = 304)		$15,000–$19,999 (N = 68)		>$20,000 (N = 86)
Mean	SD	Mean	SD	Mean	SD	Mean	SD	Mean	SD
41.3	6.5	42.7	6.2	40.9	6.0	41.3	6.0	39.8	7.0	14.3	<.001
Overall Health Status
Very Good (N = 135)		Good (N = 1,073)		Fair (N = 1,303)		Poor (N = 594)
Mean	SD	Mean	SD	Mean	SD	Mean	SD
42.6	7.1	42.3	6.1	42.0	6.0	41.1	7.1			5.1	.002
Quality of Life
Very Good (N = 213)		Good (N = 1,352)		Fair (N = 1,441)		Poor (N = 98)
Mean	SD	Mean	SD	Mean	SD	Mean	SD
44.6	7.8	42.2	6.2	41.6	6.1	38.4	5.9			26.0	<.001
Health Change Over Past Year
Improved (N = 269)		Same (N = 1,502)		Worsened (N = 1,332)
Mean	SD	Mean	SD	Mean	SD
41.8	6.2	42.2	5.8	41.8	7.0					1.4	.24
Years in the United States
0–10 (N = 813)		11–20 (N = 958)		21–30 (N = 759)		31+ (N = 561)
Mean	SD	Mean	SD	Mean	SD	Mean	SD
41.3	6.4	42.1	6.2	42.2	6.5	42.2	6.1			4.02	.007
Country of Origin
Mainland China (N = 2,878)		Hong Kong/Macau (N = 104)		Taiwan (N = 42)		Others (N = 81)
Mean	SD	Mean	SD	Mean	SD	Mean	SD
42.0	6.3	40.3	6.4	40.9	8.0	42.3	5.5			2.9	.04
Preferred Language
Cantonese (N = 1,656)		Toishanese (N = 729)		Mandarin (N = 687)		English (N = 33)
Mean	SD	Mean	SD	Mean	SD	Mean	SD
42.0	6.2	43.0	6.1	40.9	6.8	40.6	5.6			14.0	<.001

TIP levels also differed by years in the United States (p < .01), country of origin (p < .05), and preferred language (p < .001; Table 3). Participants who lived in the United States for less than 10 years presented a lower level of TIP (M = 41.3, SD = 6.4). Older adults who were born in Hong Kong/Macau (M = 40.3, SD = 6.4) and Taiwan (M = 40.9, SD = 8.0) had relatively lower level of TIP compared with those born in Mainland China (M = 42.0, SD = 6.3). Participants who preferred to be interviewed in Cantonese (M = 42.0, SD = 6.2) and Toishanese (M = 43.0, SD = 6.1) presented a higher level of TIP than those who were interviewed in Mandarin or in English.

In addition, the level of TIP differed by overall health status (p < .01) and quality of life (p < .001). Lower levels of TIP were present among participants who reported poor health status (M = 41.1, SD = 7.1) and poor quality of life (M = 38.4, SD = 5.9).

Correlations

Higher TIP was significantly correlated with older age, female gender, lower educational level, being unmarried, having more children, having lived longer in the United States, having lived longer in the community, China as the country of origin, living with fewer persons, better overall health status, and better quality of life (Table 4). Income and health change over the last year were not significantly correlated with TIP.

Table 4.

Correlations Between Endorsement of Trust in Physicians and Sociodemographic Variables

	Age	Sex	Edu	Income	MS	Living	Children	Yrs in U.S.	Yrs in Com	Origin	LP-CT	OHS	QOL	HC	TP
Age	1.0
Sex	0.01	1.0
Edu	−0.12***	−0.21***	1.0
Income	0.05**	0.00	0.01	1.0
MS	−0.33***	−0.32***	0.22	−0.03	1.0
Living	−0.35***	−0.07***	0.02	0.16***	0.24***	1.0
Children	0.32***	0.09***	−0.38***	0.00	−0.13***	−0.07***	1.0
Yrs in U.S.	0.35***	0.03	−0.10***	0.35***	−0.2***	−0.31***	0.15***	1.0
Yrs in Com	0.23***	0.02	−0.11***	0.24***	−0.13***	−0.18***	0.10***	0.66***	1.0
Origin	0.04*	−0.01	−0.08***	−0.20	0.05**	0.05**	0.04*	−0.2***	−0.15***	1.0
LP-CT	−0.02	−0.01	−0.56 ***	−0.03	−0.06***	0.06***	0.27***	0.18***	0.20***	0.06**	1.0
OHS	−0.08***	−0.06**	0.06***	0.12***	0.05**	−0.00	−0.00	−0.01	0.05*	−0.03	−0.01	1.0
QOL	0.06***	0.05**	0.09***	0.08***	0.03	−0.01	0.04*	0.00	−0.02	−0.04*	0.12***	0.32***	1.0
HC	−0.11***	−0.03	0.02	0.05**	0.07***	0.01	−0.02	−0.04*	0.03	−0.00	−0.03	0.15***	0.15***	1.0
TP	0.16***	0.09***	−0.16***	0.02	−0.09***	−0.12***	0.15***	0.08***	0.04*	0.04*	0.10***	0.06**	0.13***	0.02	1.0

Notes: Children = number of children; Edu = education; HC = health changes over last year; Living = living arrangement; LP-CT = language preference of Cantonese and Toishanese; MS = marital status; OHS = overall health status; Origin = country of origin; QOL = quality of life; TIP = trust in physician; Yrs in com = years in the community; Yrs in U.S. = years in the United States.

*p < .05, **p < .01, ***p < .001.

Discussion

As the first population-based study that examined interpersonal TIP among U.S. Chinese older adults, we found that TIP was commonly endorsed, especially items related to confidence in physician knowledge and skills. However, a lower level of TIP was present among participants who were younger, male, or had higher educational level, lived fewer years in the United States and in the community, or had poorer self-reported health status and quality of life.

Items related to confidence in physician knowledge and skills were most commonly endorsed, such as trusting physician’s judgment on medical care (84.8%), following physicians’ advice (84.2%), and trusting physicians’ words that something is so and must be true (81.2%). These aspects of high interpersonal TIP should be interpreted within a Chinese cultural context. In traditional Chinese culture, physicians are socially respected and admired due to the humanitarian nature of the career and the asymmetry of medical knowledge between physicians and patients (18). Traditional ethics emphasize high moral standards for health practitioners, and patients are also expected to be open to physicians and willing to share their information (22), which may explain our finding that 83.7% of respondents trusted their physicians to keep their medical information private.

Mean TIP score was 42.0 (SD = 6.3) among our sample of U.S. Chinese older adults on a scale of 11–55, the greater score representing higher levels of TIP Although there are many theoretical frameworks and measures of TIP, a dearth of available studies utilizing the same scale precludes our ability to make valid comparisons. One prior study demonstrated that level of TIP among domestic population was 45.1 in the United States and 45.7 in the United Kingdom, with Asians represented less than 2% of the study sample (6). Another study applying Anderson et al.’s Tip Scale estimated 76.25 as the level of TIP on a scale of 0–100 among patients with rheumatic disease (23).

A study of Chinese community in Canada reported that comparing to Caucasian counterparts, Chinese participants reported a lower level of TIP and less likelihood to follow medical advice (24). The mean of TIP level identified in our study may appear to be lower compared with the mean identified in studies of Mainous and coworkers (6) and Freburger and coworkers (23). However, our study is based on a sample of community-dwelling older adults; the other two studies are based on clinical setting and not specifically targeted at aging population. Thus, the level of TIP estimated in our research enriched the current knowledge of TIP among the community-dwelling U.S. Chinese older adults. We call for future in-depth analyses of TIP among aging population in different community settings.

Consistent with previous studies on domestic older adults (2,5,6,25), our findings indicate that older age is associated with a higher level of TIP. The increased level of TIP with age could be attributed to the value and ideological gap between the young–old and the old–old—the old-olds generally were more likely to show higher respect to authorities and be more obedient to the physicians’ instructions and suggestions or could also be attributed to more frequent contact with physicians as one ages. Moreover, our study indicates that female Chinese older adults tended to show a higher level of TIP compared with males, which is inconsistent with prior studies that have reported nonsignificant gender differences (26,27). The expected role of Chinese women to be dependent and obedient in Chinese traditional culture may have contributed to the relatively higher level of TIP among women found in our research.

In consistent with most previous research (26,27), our study indicated that participants with a higher education had a lower level of TIP. However, this finding is consistent with the work of Anderson and Dedrick (2), in which patients’ trust was negatively correlated with patients’ desire for personal control and positively correlated with patients’ desire for control from clinicians. One explanation may be that participants with higher educational level may experience a higher level of desire and capacity to control their lives (28); this control may transfer to lower reliance of and TIP. Consistent with prior studies (6,27), we found that income was not significantly correlated with trust. However, our data revealed a lowered TIP level (39.8) among participants with income of $20,000 or more compared with other income groups (40.9–42.7).

Older adults who have resided more years in the United States or more years in the community showed higher level of TIP. Increased years of residence in the United States may indicate a higher level of acculturation, a better understanding of the U.S. health care system, and more experiences navigating through the health care system. Moreover, since 1978, China has taken steps to reform its centrally planned health system to a market-based system. The failure of Chinese health reform has resulted in a decline of TIP in China (29). Earlier immigrants to the United States may have been less exposed to the trust crisis in China and may thus have retained a higher level of TIP in the United States.

Our research suggests that a higher level of TIP was present among participants living with fewer persons or who were unmarried. Living with fewer persons and not being married may indicate a weaker social network and social support system (30). It is possible that participants with weakened social support may be more likely to develop trust in their physicians, who could be their major source of professional health care advice and support.

With respect to language and country of origin, a higher level of TIP was presented among participants from mainland China and those preferred to complete our study interview in Cantonese or Toishanese. We postulate that the score difference by dialects may be a result of older adults’ differing home region where they migrated from, which is highly intertwined with U.S. Chinese immigration trajectory (19). Earlier immigrants to Chicago are more likely to be Cantonese- and Toishanese-speaking Chinese. The majority of them came to United States due to the fact of chain migration and family reunions; most of them arrived with lower educational level, limited English proficiency, and less capital (31). These earlier immigrants often chose to reside around Chinatown area and represent the low socioeconomic class. After the passage of the 1965 Immigration Act, a new wave of Chinese immigrants settled in the greater Chicago area, and many of whom are from Taiwan and Mainland China and mandarin speaking (32). In contrast, most of the mandarin-speaking Chinese older adults are more affluent and well educated. After 1989, Chicago has witnessed another influx of Chinese families who came to the United States for political asylum (31); many of them were scholars and high-skilled professionals who settled in United States to advert from culture revolution in mainland China, as well as parents and relatives who came to United States to reunion with their well-educated children who resided in United States for promising careers. The interaction of sociodemographic characteristics, previous medical experiences in their country of origin, and their immigration acculturation experiences may all contribute to the variations in TIP among Chinese older adults who speak different languages.

Consistent with a prior study (3), our study indicates that better health status and quality of life were associated with higher level of TIP. It is possible that older adults with better health status may have had more positive encounters with their physicians and thus may have placed more trust toward their physicians. Nonetheless, our findings call for special attention on the sick and the urgent needs of these older adults.

This study is subject to several limitations. First, although this study was representative of Chinese older adults in the Greater Chicago area, our findings may not be generalizable to other Chinese populations in the United States or in Asia. Future studies are needed to explore the TIP among diverse Chinese populations. Second, our study collected data from older patients’ perspectives and we were unable to elucidate their physician’s sociodemographic characteristics, behaviors, languages, and communication styles. We also did not collect participants’ insurance information, length of contact with physicians, and number of physician visits, which may likely affect their perceptions toward physicians as well. Third, the cross-sectional design of our study can only assess participants’ trust in current physicians but is limited in providing an understanding on of their previous patient–physician relationships. Fourth, the cross-sectional design and correlation analysis cannot establish causality between sociodemographic variables and TIP level. Future studies applying mixed methods and longitudinal designs are needed to better understand TIP and its impact on health outcomes among Chinese older adults.

Despite these limitations, our study has potential implications for research and practice. First, this study points to the need for further investigations on TIP among Chinese older adults. Future research on TIP should include assessing physician’s sociodemographic characteristics, personality characteristics, and language and ethnic concordance. Second, it is important to raise health practitioners’ awareness and knowledge of culturally appropriate medical practices and communications. Health care practitioners should be trained with appropriate culture and communication competency to deliver medical care services to minority older adults (30,33). Our study also revealed the importance of maintaining the high endorsement of TIP among Chinese older adults. Third, at the policy and institutional level, guidelines and policies should be established to enforce physicians’ responsibilities of fostering and sustaining trust in their relationships with their patients.

Conclusion

In sum, this study indicates that TIP is commonly endorsed among the U.S. Chinese older adults. However, several subgroups of Chinese older adults tended to have lower level of trust toward their physicians, including the young–old, males, and older adults with higher education and poorer health status. Future longitudinal studies are needed to improve our understanding of risk factors and outcomes associated with TIP among U.S. Chinese older adults.

Funding

X.D. and M.A.S. were supported by National Institute on Aging grant (R01 AG042318, R01 MD006173, R01 CA163830, R34MH100443, R34MH100393, P20CA165588, R24MD001650, and RC4 AG039085), Paul B. Beeson Award in Aging, The Starr Foundation, American Federation for Aging Research, John A. Hartford Foundation, and The Atlantic Philanthropies.