Trust in Healthcare, Medical Mistrust, and Health Outcomes in Times of Health Crisis: A Narrative Review

Souvatzi, Elisavet; Katsikidou, Magdalini; Arvaniti, Aikaterini; Plakias, Spyridon; Tsiakiri, Anna; Samakouri, Maria

doi:10.3390/soc14120269

Abstract

Background/Objectives: The concepts of trust and distrust in health systems during health crises are significantly related to public adoption of health behaviors and health outcomes. The aim of this review is to examine trust and mistrust during times of health crisis, such as periods of viral pandemics and epidemics, and how these concepts relate to public health behaviors and, by extension, affect health outcomes. Methods: A focused search was conducted in PubMed and Scopus using a Boolean expression to identify relevant articles written in the English language and published between 2003 and 2023. The research methods comprised content analysis, thematic analysis, and a word cloud visualization to identify frequent themes related to trust and mistrust in healthcare systems. Results: The analysis included 57 studies and revealed that trust in healthcare systems, institutions, and professionals plays a significant role in shaping public health behaviors during health crises. The study also highlighted how mistrust leads to negative health outcomes, such as increased belief in conspiracy theories, vaccine hesitancy, and non-compliance with public health measures. Conclusions: The review emphasizes the importance of building and maintaining trust in healthcare systems to ensure better public health outcomes during crises. It calls for further research to better understand the nuances of trust and mistrust, aiming to inform public health strategies and interventions that could lead to more effective crisis management and improved health outcomes.

Keywords:

trust; mistrust; medical distrust; healthcare systems; pandemics

1. Introduction

In modern society, declining public trust in both healthcare and other institutions has been linked to increased questioning of science and experts. People are turning away from so-called expert systems, such as the national health systems. This decline in public trust in health authorities has been widely observed and is associated with significant consequences for public health outcomes, including reduced compliance with health recommendations and lower engagement with healthcare systems [1]. Consequently, individuals seek alternative sources of information and begin to question their trust in public health services [2].

In the literature, the terms ‘mistrust’ and ‘distrust’ are often used interchangeably to describe a lack of trust in the health system, although they have subtle differences in meaning. Distrust refers to an individual’s belief, based on past or present experiences, that the other party will not act in their best interest, often exacerbated by misinformation. For example, a patient who receives contradictory medical advice might distrust the healthcare system [3,4]. Mistrust, on the other hand, is often rooted in historical experiences of marginalization and systemic inequities, expressed through doubt, suspicion, and conspiracy thinking. A central dimension of trust, however, is the expectation of truthfulness [5,6,7,8]. For instance, marginalized communities may mistrust medical institutions due to historical injustices, such as unethical medical experiments conducted without consent. Trust is about believing not only that someone will act in your best interest but also that they will communicate honestly. Truth-telling can, at times, conflict with perceived best interests. For example, a public health authority may withhold certain information to avoid panic, or a clinician might delay delivering bad news to prevent patient distress. Such actions, while intended to protect, can undermine trust if individuals perceive them as dishonest. Understanding trust requires considering both perceived intentions and expectations of honesty [9].

The social sciences divide trust into three categories: i. interpersonal, which refers to interpersonal interactions and experience gained by the individual from others; ii. institutional, which refers to a system or institution such as a hospital; and iii. generalized, which refers to expectations from other people in general and/or strangers, promoting prosocial behavior and cooperation [10,11,12]. When a medical relationship is governed by trust, it is associated with better treatment outcomes, care provision, and adherence to medical guidelines. Conversely, a lack of trust is linked to lower adherence to medical instructions and medication, poor relationships between patients and healthcare providers, and engagement in risky behaviors [13].

This paper addresses the critical problem of declining trust in healthcare, particularly during health crises such as viral pandemics and epidemics. A survey study conducted in the U.S. showed that trust in physicians and hospitals decreased during the COVID-19 pandemic [14]. A study examining the factors contributing to the decline in trust in the health sector in the European Union during the pandemic found that public trust decreased in the majority of countries, with central and western European countries having higher levels of trust than eastern European countries. It also appeared that factors that played a role in trust levels included satisfaction with the measures taken to combat the COVID-19 pandemic, overall life satisfaction, and the socio-economic status of the countries, with countries experiencing economic crisis showing a decline in positive perceptions of health systems [15]. A study conducted in Norway found that trust in public healthcare, in treatment at hospital, and in information at hospital increased after the outbreak of the COVID-19 pandemic. These results can be understood by considering the dynamic relationship between trust in public health, trust in healthcare facilities, generalized trust, and the COVID-19 pandemic, a healthcare crisis situation [11]. Solving this problem is crucial, as doing so can lead to improved health outcomes, better public health responses, and more effective management of health crises. It is important to emphasize that distrust in times of pandemics is associated with a low tendency of individuals to follow and comply with the health measures proposed by health authorities and physicians. In particular, research has shown that low trust in health systems and the information provided by them is associated with high rates of vaccine hesitancy [1]. Despite existing studies on trust and distrust in healthcare, there is a gap in understanding how these concepts evolve during health crises and their specific impact on public health behaviors and outcomes. Therefore, this review aims to fill this gap by analyzing the conditions under which trust and mistrust arise or change during health crises and how these changes affect health outcomes. By addressing this gap, this paper aims to provide insights that can inform future research and public health strategies, ultimately leading to better health outcomes during crises.

2. Materials and Methods

2.1. Data Sources

This article was structured as a narrative literature review. A focused search of international bibliographic sources was conducted using the electronic databases PubMed and Scopus, tailored to the objectives of a narrative review. The aim was to facilitate the analytical integration of studies that highlight and differentiate the concept of trust and mistrust in healthcare systems, while also exploring various perspectives on these concepts during periods of crisis.

2.2. Search Strategy

Boolean operators AND and OR were employed to refine the search. The keywords used in the search were: (“SARS”) OR (“Ebola”) OR (“H1N1”) OR (“COVID-19”) OR (“pandemics”) AND (“trust”) OR (“mistrust”) OR (“distrust”). The specific expression was applied to the title, abstract, and keyword fields. The articles included in the search were published between 2003 and 2023. The search was conducted on 15 July 2023.

2.3. Screening and Selection

The retrieved records were evaluated based on their titles and abstracts. The criteria shown in Table 1 were used for the selection or exclusion of articles.

Table 1. Inclusion–exclusion criteria.

2.4. Inclusion Criteria

Articles focusing on trust or mistrust in the context of SARS, Ebola, H1N1, COVID-19, and pandemics were included.

2.5. Exclusion Criteria

Articles centered specifically on vaccination and immunization policies were excluded, unless they directly addressed broader trust issues during these health crises. This decision was made to focus the analysis on systemic trust dynamics in healthcare during health crises rather than narrowing the scope to vaccination-related trust, which has been extensively covered in separate reviews.

Books and conference papers were excluded to ensure the inclusion of peer-reviewed studies with rigorous methodological standards and to maintain consistency in the quality of evidence considered. However, we acknowledge that these sources may contain valuable insights, and their exclusion represents a limitation of this review. Future studies could explore these sources to provide additional perspectives. In cases where it was necessary, the entire article was read before making the final decision on inclusion or exclusion.

3. Results

3.1. Study Characteristics

A total of 57 studies met the aforementioned criteria and were deemed eligible for inclusion. Table A1 in Appendix A shows the 57 articles that were included. Most studies (twenty-four) were conducted in North America, eighteen in Europe, nine in Asia, three in Africa and Oceania, and none in South America. The map chart in Figure 1 shows the countries where the studies were conducted, with the size and color of the bubbles indicating the number of studies.

Figure 1. Map chart showing the countries where the studies were conducted (the size and color of the bubbles indicates the number of studies).

Most studies were published during the COVID-19 pandemic, with more than half (29 out of 57) published in the 2021–2022 period. The column chart in Figure 2 shows the number of published studies per year.

Figure 2. Publications per year.

3.2. Content Analysis

The fifty-seven papers comprise thirty-seven reviews, thirteen quantitative studies, five opinion papers, one letter to the editor, and one qualitative (observational) study. The thirty-seven reviews include twenty narrative reviews, nine systematic reviews, six scoping reviews, one rapid review, and one critical review. The words ‘vaccine(s)’/‘vaccination’ appear a total of 4817 times within the 57 documents. The words ‘health’ (4202), ‘trust’ (3828), ‘Covid’ (2303), and ‘care’/‘healthcare’ (2198) follow in frequency. In the world cloud of Figure 3, the size of each word is proportional to its frequency of occurrence. The cloud also highlights the most frequently occurring terms in the reviewed literature, providing a visual representation of dominant themes. Words such as ‘vaccine(s)’/‘vaccination’, ‘trust’, ‘health’, and ‘COVID’ appear prominently, reflecting the centrality of these topics in the discourse on trust during health crises. The word cloud is helpful for identifying key areas of emphasis within the reviewed literature. For instance, the high frequency of ‘trust’ and ‘mistrust’ underscores their foundational role in shaping public health outcomes. Additionally, the prominence of terms related to specific pandemics (‘COVID’, ‘SARS’, ‘Ebola’) reflects the targeted scope of the review.

Figure 3. Word cloud resulting from the 57 documents.

3.3. Thematic Analysis

3.3.1. Trust in Health Systems

Trust in the healthcare system encompasses specific structures and individuals, including hospitals, healthcare institutions, medical organizations, pharmaceutical companies, healthcare providers, experts, and employees of these structures [16,17,18,19,20,21].

Sociologists argue that trust is crucial when there is a deficit in knowledge. Both interpersonal experiences and the so-called ‘leap of faith’, i.e., the decision of the individual to trust an institution or system without extensive knowledge about it, contribute to building trust towards public health professionals and institutions. Confidence in the public health system creates expectations of social protection and respect between citizens and the state, and can be shown and proved through behaviors/beliefs such as benevolence, the confidence that another party will act in one’s best interests; honesty; and integrity, the consistency between one’s words and actions, etc. [12,22]. According to the literature, power relations between citizens and health systems can put patients in vulnerable positions. When power is exercised with fairness, empathy, quality of service, and collegiality in the workplace, it can facilitate trust in health relationships. Important factors that contribute to maintaining trust include knowledge sharing, honesty, respect, creation of a professional and emotional bond, supervision (without which positive outcomes for patients cannot be achieved), authentic communication and contact, empathy, competence, support, clear boundaries, positive intentions, and forgiveness (“A patient relies on the nurse’s love and trustworthiness. S/he puts him/herself in the nurse’s hands for help”) [16,22].

3.3.2. Trust in the Doctor–Patient Relationship

The term medical trust incorporates the concept of collaborative trust between patient and physician. It involves common goals, personal contribution to the relationship, mutual respect, and honesty, and focuses on knowledge exchange and emotional and professional development of a lasting relationship, entailing employees’ commitment to communal goals and not simply personal/independent goals, sincere communications, sharing of information, and transparency with respect to one’s actions or plans, etc. [23].

Trust is vital because it allows patients to feel comfortable discussing their health concerns openly and honestly, which can lead to better health outcomes. It is positively related to ensuring adherence to the treatment protocol, maintaining high-quality care, effective communication, and establishing long-term relationships, thereby ensuring optimal clinical outcomes and overall patient satisfaction [24,25].

The therapeutic alliance also depends on the personal bond between doctor and patient [24]. When a more person-centered approach is applied to patient care, wherein medical services pay attention to both treatment and outcomes, as well as patients’ living conditions, psychological needs, feelings, and thoughts, better outcomes are achieved and there is a stronger relationship [26]. Patients who actively participate in their choice of treatment receive information from their physicians more effectively, recover more quickly, achieve better health outcomes, and show greater levels of satisfaction [24,25].

The factors that can affect a patient’s trust in their physician are the communication skills, competence, and empathy of the doctor, as well as transparency and responsible prescribing (“I feel like sometimes the doctors do not listen to what you are saying … a lack of knowledge or feelings”) [27]. Trust can also be influenced by external factors such as the healthcare system, media, and cultural beliefs. Patients may have lower levels of trust in physicians if they have had negative experiences with the healthcare system, experienced discrimination, been exposed to negative media portrayals, been withheld information, or been given inaccurate information by the medical provider (“I probably suffer more than I should because I do not have the money to pay for medication”; “You are treated different when you do not have insurance”; “Sometimes I think you are treated different based on your color, on your race”) [28].

Overall, trust in doctors is essential for effective medical care and patient satisfaction. Regarding the trust that doctors have towards their patients, the literature shows that doctors have medium or low levels of trust in their patients and may distrust them. Physicians should strive to build and maintain trust with their patients, taking into account the above factors that influence trust building in healthcare systems in general [25,27,29,30].

3.3.3. Mistrust and Conspiracy Theories

Modern democratic societies have several powerful institutions, such as governments and the legal system, designed to organize society and facilitate collective cooperation. According to studies, however, institutional trust worldwide has declined over the past twenty years. Institutional mistrust and conspiracy beliefs converge in the rejection of social instructions. During the COVID-19 pandemic, conspiracy theories emerged, reducing individuals’ interest in volunteering and collaboration, and leading to the rejection of social norms [31].

This contemporary reality is characterized by a tendency of alienation and mistrust in social relations, with changed perceptions of social norms, and reduced trust in institutions and traditional values. Belief in conspiracy theories is associated with a general tendency toward suspicion, paranoid thinking, and antisocial behavior (e.g., “Research is part of a conspiracy to harm minority groups”; “The health care system experiments on patients without them knowing”; “Patients have sometimes been deceived or misled at hospitals”) [32].

Conspiracy theories are distinguished by four common characteristics: (a) the world or an event is considered not to be as it seems, (b) the belief that there is a cover-up by powerful people, (c) the theory is accepted only by a minority, and (d) this theory is not supported by facts and evidence. Conspiracy beliefs are rooted in the psychology of mistrust and are attempts to explain world events that are threatening or inconsistent with personal expectations. Conspiracy theories are much more likely to be adopted by individuals who have higher levels of mistrust and who feel threatened by social change, feel uncertain, lack sociopolitical control, and have lower social status, less analytical thinking, and lower levels of education and income [33].

3.3.4. Medical Mistrust and Health Outcomes

Medical mistrust has been identified as a social determinant of health, a barrier to health improvement, and a factor linked to healthcare inequalities primarily in terms of ethnic and racial groups and other minorities [3,5,9,34,35]. Medical mistrust is associated with fears that the individual will be harmed by medical treatment, doubts about the accuracy or value of medical information, and questioning the integrity or motivations of the healthcare system [5,36], especially in individuals who feel discriminated against [34]. Medical mistrust differentiates itself from interpersonal distrust; it does not mean a complete lack of trust in a particular doctor, but suggests that a person’s negative beliefs lead them to think that the health provider will work against their best interest [10,13,22]. For example, a person may trust a particular clinician but have a suspicious attitude towards the wider healthcare system to which that clinician belongs.

The most common health issues associated with medical mistrust include cancer, general health, organ and blood donation, HIV, and vaccine-related concerns. Medical mistrust is often directed at public health authorities, pharmaceutical companies, and medical researchers, particularly in the context of vaccines and medication safety. For instance, suspicions about vaccine development, drug efficacy, and the motives of public health institutions have been widely documented. In these situations, higher levels of mistrust are linked to reluctance to accept diagnoses, limited engagement with healthcare providers, lower adherence to treatment protocols, reduced uptake of preventive measures, and poorer overall physical and mental health outcomes [7,9,36,37,38].

3.3.5. Medical Mistrust in Times of Health Crisis

Trust is a crucial factor in determining compliance with public health policies during health crises [11,39,40,41]. High levels of trust in society can enhance citizens’ acceptance of public health measures and positively influence health outcomes [32,33,42].

The role of public trust in managing health crises was notably evident during the COVID-19 pandemic. Research has found that high levels of citizens’ trust in government institutions were associated with effective crisis management and control efforts [11]. Additionally, societies with pre-existing high trust in medical staff, public healthcare, and hospitals experienced lower mortality rates during the pandemic [10,16,17,43].

In studies focusing on the Ebola, H1N1, SARS 2003, and COVID-19 pandemics, it is found that there are some common characteristics both in the issue of crisis management and that of trust. A common feature of all health crises has been the implementation of preventive measures to limit the spread of the virus, such as house arrest and curfew, avoidance of social contacts, contact tracing, quarantine, and closure of public facilities, often accompanied by increasing unemployment and food shortages [10,39,41,44,45,46,47]. However, these measures often led to a significant decline in public confidence, particularly during the early stages and peak of the crisis [10,48,49].

Lack of trust in government and health systems has been closely linked to public reluctance to comply with health measures [39,50,51,52,53]. This was particularly evident during the early years of the COVID-19 pandemic, with significant vaccine hesitancy contributing to the risk of virus spread [16,54,55,56,57,58,59,60,61,62,63]. Concerns over the motives of governments and pharmaceutical companies, along with issues related to rapid vaccine development, mandates, and side effects, further fueled mistrust [6,17,18,19,20,21,53,59,60,61,64,65]. This mistrust was associated with increased virus spread, reluctance to adhere to protective measures [62,63], strained relationships between communities, authorities, and health workers, and the proliferation of conspiracy theories [48,54,58,59,64].

4. Discussion

The purpose of this review was to examine the concepts of trust and mistrust in times of health crisis, such as periods of viral pandemics and epidemics, and their impact on public health behaviors. The findings indicate that during the COVID-19 period, these concepts were of greater concern to authors than during any other period, with particular emphasis on vaccines and vaccination (Figure 2 and Figure 3).

An important challenge noted was the inconsistent use of the terms ‘mistrust’ and ‘distrust’ in the literature, where ‘distrust’ is often used as a synonym for ‘mistrust’. ‘Mistrust’ is typically associated with ‘medical mistrust’, referring to skepticism towards medical treatments and healthcare providers, while ‘distrust’ often describes a lack of trust in health systems, government, and other institutions. This inconsistency complicates the clear definition and distinction of these terms, leading to confusion in their use.

The thematic analysis revealed that public trust and mistrust (or distrust) during health crises are critical determinants of public health outcomes. These concepts influence beliefs and behaviors towards health systems and their providers, and towards governing authorities. Identifying the factors that foster trust and help diminish mistrust is crucial for effective health crisis management [65]. Key indicators of mistrust include increasing complaints against doctors, legal disputes between patients and doctors, low provider communication skills, and the use of alternative therapies without disclosure to treating physicians [23].

Factors influencing the building of trust during pandemics include effective communication methods followed by the government, citizen involvement in decision-making, and active participation.

Building trust involves efforts at multiple levels, including individual, community, and institutional interactions. For individuals, healthcare providers can build trust with their patients by demonstrating empathy, cultural competence, and consistent, clear communication. For example, creating a person-centered approach that takes into account the patient’s personal experiences and preferences fosters a sense of reliability and trustworthiness. At the institutional level, clinics and hospitals serving local populations can cultivate trust by establishing a strong presence within the community, engaging in outreach programs, and maintaining transparency in their operations. Trust-building initiatives such as regular community feedback sessions, partnerships with local organizations, and the employment of diverse staff representative of the local population can help bridge gaps in trust [66,67].

Regarding government efforts, fostering trust goes beyond simply providing information through reliable people and valid sources. It requires addressing the perception of reliability itself. Populations are more likely to perceive a source as valid when it aligns with their values and demonstrates consistency, transparency, and fairness. For instance, ensuring that spokespeople have a proven track record of honesty and expertise, engaging respected community leaders to act as intermediaries, and openly acknowledging past mistakes while detailing corrective actions can enhance credibility. Tailoring interventions to the cultural, social, and environmental contexts of each community, rather than imposing external solutions, is also essential in fostering trust [68]. Flexibility and the design of differentiated interventions according to the needs of each community appear to contribute significantly to enhancing public trust and compliance [69,70].

This review has some limitations. The decision to conduct a narrative review, rather than a systematic review, represents a limitation, particularly in terms of the systematic search process and the precision of included articles. However, this methodology allows us to draw attention to key issues described in the literature, providing valuable insights aimed at fostering a deeper understanding of the subject matter. Studies related to mistrust in the context of cancer, HIV, organ and blood donation, general examinations, immunization and vaccination issues, and research participants were excluded. In addition, book or conference papers and documents in languages other than English were not included. Because of these exclusions, valuable insights that could enrich our understanding of trust and mistrust in health crises may have been omitted.

Despite these limitations, our findings provide useful information and highlight the importance of exploring the relationship between trust and health services. The existing literature demonstrates the need for further clarification of the definitions of medical mistrust and distrust, and a deeper understanding of these phenomena [71]. While we know that medical mistrust has a negative impact on health, we do not know enough about its contribution in the long run. Future research should focus on the mediating factors between mistrust, public behavioral responses, and health outcomes in order to develop interventions that will positively reshape the health system.

A challenging question for future research is how to support healthcare stakeholders—providers, patients, and managers—in promoting positive expectations and building trusting relationships. The concept of trust is multidimensional and includes not only interactions in the healthcare system, but also institutional trust in government authorities and cooperation with the community. It would be useful to devise proposals and stage interventions that will help build trust and better manage crises, e.g., improving the communication skills of government representatives or creating informational material to answer questions regarding important health decisions for the public such as vaccination. Therefore, further studies on building public trust in government and its proposed measures, beyond health systems, are needed. Such research can lead to interventions that build trust, eliminate mistrust, and improve crisis management by government and health authorities.

5. Conclusions

This review highlights the critical role of trust and mistrust in shaping public health behaviors and outcomes during health crises, such as pandemics and epidemics. The findings indicate that the concepts of trust and mistrust were particularly prominent during the COVID-19 pandemic, with a strong focus on vaccines and vaccinations dominating scientific discussions. Trust in healthcare systems and providers is associated with positive health outcomes, adherence to treatment protocols, and effective management of health crises, whereas mistrust leads to negative health behaviors, poor health outcomes, and increased belief in conspiracy theories.

It is therefore important to study further the building of public trust in government and the measures it entails overall, beyond health systems. It is important to study further the factors that mediate between distrust, behavioral responses of the public, and health outcomes in order to institute possible interventions to reverse negative results and reshape the health system to promote and not undermine trust within the relationships that govern it. The question of how we can support healthcare actors—providers, patients, and governing authorities—in creating positive expectations for each other, creating fertile ground for trusting relationships, remains unclear and creates appropriate ground for future research. We consider it important to encourage the conducting of further research, and studies on the issue of trust in health systems during pandemics with even more systematic and accurate methods.

The value of the present study is great both for the specialized scientific community and for the broader public. For the specialized scientific community, this review underscores the need for further research to better understand the nuances of trust and mistrust in healthcare, especially during health crises. Identifying the factors that influence trust can help in designing interventions that promote trust and mitigate mistrust. For the broader public, the practical applications of these findings are profound. Enhancing public trust in healthcare systems can lead to better compliance with public health measures, improved health outcomes, and more effective management of future health crises. Policymakers and healthcare providers must consider these factors to build and maintain trust, ensuring better health outcomes and stronger public health responses.

Author Contributions

Conceptualization, E.S. and M.K.; methodology, M.K. and A.A.; software, E.S. and S.P.; validation, M.K., M.S. and S.P.; investigation, E.S. and M.K.; resources, A.A. and A.T.; data curation, S.P.; writing—original draft preparation, E.S., M.K. and A.A.; writing—review and editing, S.P. and M.S.; visualization, A.T. and S.P.; supervision, M.K. and M.S.; project administration, A.A.; funding acquisition, A.T. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

As a review article, no new data have been generated. The data for the review are the articles in Table A1.

Conflicts of Interest

The authors declare no conflicts of interest.

Appendix A

Table A1. The 57 articles included in the review.

Author (Reference)	Aim of the Study	Methodology	Outcome
Adhikari, et al. [60]	Exploring whether trust is the key denominator for the acceptance of the COVID-19 vaccine	Literature review of 68 documents, sourced from the MEDLINE, Scopus, and Web of Science databases	The impact of trust on the willingness to accept a vaccine was confirmed, but the study did not provide details about what trust is, how it affects willingness, or why this effect occurs.
Ahmad, et al. [18]	Studying the factors influencing vaccination hesitancy among nurses and doctors	Systematic review and qualitative meta-synthesis of 22 qualitative and mixed-method studies	Vaccine hesitancy among nurses and doctors stemmed from distrust towards healthcare authorities and their employers, the effectiveness and safety of vaccines, and the motives of pharmaceutical companies.
Allen, et al. [34]	Investigating the relationships between COVID-19 vaccine uptake, medical distrust, and experiences of discrimination	Cross-sectional online research in a sample of adults in the United States aged 18 and above	An increase in the medical distrust index was associated with a 16% decrease in the likelihood of vaccination. However, experiences of discrimination did not correlate with vaccination intent.
Arthur, et al. [51]	Assessing trust in the national government and iNGOs (international non-governmental organizations) over time in locations with varying levels of Ebola incidence	Cross-sectional research in households in Liberia	Public trust was higher in non-governmental organizations (NGOs) than in the government during all phases of the epidemic, and it significantly decreased from the beginning to the peak of the epidemic.
Bangerter, et al. [53]	Studying the evolution of public trust in institutions, during and after the 2009 pandemic in Switzerland	A two-phase (in 2009 and in 2010) longitudinal study involving 2400 members of the Swiss public, with 602 participants responding in both phases	Participants reported moderate to high levels of trust in medical organizations, the WHO, the government, the pharmaceutical industry, and the European Union. Trust was low in the media, institutions, vaccines, and the government’s handling of the epidemic.
Benkert, et al. [5]	Examining how medical distrust has been measured as a step toward informing relevant health promotion efforts	Systematic review following PRISMA-P guidelines of 36 qualitative and 88 quantitative studies, sourced from the PubMed, CINAHL, PsycINFO, and EMBASE databases	A correlation between medical distrust and health behaviors was identified.
Bhatnagar, et al. [41]	Summarizing available data regarding the “Ebola Virus Disease” (EVD) epidemic	Scoping review conducted using PubMed and Google Scholar and databases	Factors exacerbating the pandemic included weak healthcare systems, adverse cultural practices, poverty, illiteracy, distrust in government, extensive cross-border movement, slow response from international organizations, and a lack of proven treatment and prevention strategies. Implementing simple measures like universal prevention, isolation, contact tracing, supportive care, and appropriate burial practices proved challenging.
Biswas, et al. [58]	Investigating key factors contributing to global COVID-19 vaccine hesitancy	A scoping review following PRISMA-ScR guidelines, sourced from the Embase, PubMed, and Google Scholar databases	Factors influencing vaccination intent include the effectiveness and side effects of the vaccine, distrust in healthcare, religious beliefs, and trust in information sources. Additionally, vaccination intentions are affected by demographic factors such as age, gender, education, and region.
Blair, et al. [39]	Assessing the relationship between trust in the government and compliance with Ebola virus control interventions	Survey conducted during the Ebola Virus Disease (EVD) epidemic in 2014–2015 in Monrovia, Liberia	Respondents who expressed low trust in the government were significantly less likely to take precautions against the Ebola virus or adhere to social distancing measures and control policies, such as “safe burial” practices for infected bodies.
Blasi, et al. [64]	Analyzing the reasons for the low acceptance rate of H1N1 vaccination in the general population and among healthcare workers	Narrative review	The main reasons cited by the public for not accepting the H1N1 vaccine included concerns about potential risks associated with the influenza A (H1N1) virus strain, vaccine distrust, and safety concerns regarding vaccines. Concerns about vaccine safety and distrust in healthcare authorities are the most common reasons for low vaccine compliance among healthcare workers.
Charura, et al. [54]	Exploring the factors contributing to hesitancy towards COVID-19 vaccination and the intent to get vaccinated within ethnically diverse communities, with a focus on medical distrust	An online survey of 161 unvaccinated adults from various ethnic backgrounds in the UK	Medical distrust was associated with hesitancy towards COVID-19 vaccination and reduced likelihood of getting vaccinated.
Choy and Ismail [23]	Identifying the issues leading to medical distrust and potential indicators for future prediction in healthcare	Narrative review conducted using MEDLINE, Google Scholar, and Google search	Possible indicators of distrust include an increase in medical disputes and complaints against doctors, a lack of interpersonal communication skills among healthcare providers, and patients’ use and non-disclosure of alternative therapies.
Crawshaw, et al. [21]	Examining the key behavioral determinants of COVID-19 vaccination among healthcare workers	Rapid review conducted using MEDLINE and Cochrane databases and grey literature to identify contemporary, qualitative, and cohort studies	The most common barriers to COVID-19 vaccination were concerns about the safety, effectiveness, and speed of vaccine development, as well as distrust in the government and/or public health response to COVID-19. Key factors contributing to COVID-19 vaccination among healthcare workers included systematic vaccination for seasonal flu, concerns about COVID-19 infection, and direct work with COVID-19 patients.
Deurenberg-Yap, et al. [43]	Assessing knowledge of Singapore residents regarding SARS and infection control measures	Telephone survey conducted in 2003 in Singapore among adults	The study found low overall knowledge about the SARS virus and the control measures taken. However, 93% of adults were satisfied with the government’s response. Generally, residents of Singapore exhibited a high level of trust, including satisfaction with the government, confidence in institutions, and faith in the adequacy of the measures implemented.
Dobson [6]	Exploring internal dynamics of science, the nature of doubt and distrust, and identifying potential solutions	Narrative review	A correlation between distrust in science and vaccine hesitancy was identified.
Fong and Chang [48]	Analysing the collective response to the outbreak of the epidemic based on trust and reciprocity	Telephone survey of a representative sample of the population in Taiwan in 2003	Trust and reciprocity were found to be unrelated to the community’s collective action during an epidemic outbreak.
Freeman, et al. [33]	Evaluating the prevalence of conspiracy theories during the pandemic period	Online survey of 2501 adults in England	The highest levels of conspiracy thinking about the coronavirus were associated with less adherence to all government guidelines and less willingness to undergo diagnostic tests, antibody tests, and vaccination.
Freimuth, et al. [49]	Describing public trust in government recommendations during the early stages of the H1N1 pandemic and identifying factors responsible for trust levels	Online survey of 1543 respondents in the United States	Trust in the government was generally low and varied across demographic groups. Black and Hispanic individuals reported higher trust in the government compared to White individuals. Healthcare professionals had high trust in the government, whereas religious leaders had lower trust. Significant predictors of trust included monitoring news about the flu virus, knowledge about H1N1, and prior experiences of discrimination.
Gilson [30]	Creating a discussion on the critical theoretical perspectives shaping the work on trust and healthcare	General review, drawing both on conceptual literature and relevant empirical research	The relationships surrounding the concepts of trust and its construction, the risks of trust, and understanding the nature of healthcare systems were discussed.
Hall and Heath [7]	Investigating non-compliance with medication adherence in the African American patient community	A review of 58 articles sourced from the Web of Science, Derwent Innovations Index, BIOSIS, PsycINFO, and MEDLINE databases	Preventive factors for medication non-adherence include distrust in diagnosis, pharmaceutical treatment, doctors, and the healthcare system, as well as a belief in alternative medicine, cultural norms, and limited access to healthcare. Medical mistrust was identified as one of the most significant factors. Preventive factors for medication non-adherence include distrust in diagnosis, pharmaceutical treatment, doctors, and the healthcare system, belief in alternative medicine, cultural norms, and access to healthcare. One of the most significant factors was medical mistrust.
Harbishettar, et al. [25]	Examining the impact of the 2017 Mental Healthcare Act (MHCA) on the doctor–patient relationship	Narrative review	Trust in the doctor-patient relationship is an integral part of patient care and leads to therapeutic benefits.
Henry [28]	Describing the doctor–patient relationship in terms of uncertainty, responsibility, and its evolution	Letter to the editor	Uncertainty in information sharing between doctors and patients leads to an increase in mistrust.
Ho, et al. [36]	Combining knowledge on medical distrust and health among marginalized women	Scoping review of 62 articles sourced from the CINAHL, MEDLINE, PsycARTICLES, PsycBOOKS, and PsychINFO databases	Medical mistrust has been shown to have a detrimental impact on health-related behaviors and health outcomes.
Hudson and Montelpare [62]	Summarizing current research on factors leading to COVID-19 vaccine hesitancy	Review of the literature, including PsycInfo, PubMed, and Google Scholar databases	The demographic determinants for vaccine hesitancy are age, income, educational level, health literacy, living in rural areas, and parental/family status.
Hussain, et al. [56]	Identifying factors associated with concerns about the COVID-19 vaccine among ethnic minorities in the United Kingdom	Systematic review of 24 studies following PRISMA model sourced from AMED, CINAHL, Embase, Ovid Medline, and PsycInfo	Vaccine hesitancy, which is more common in certain ethnic minority groups, appeared to be attributed to misinformation, distrust, concerns about safety and effectiveness, and systemic inequalities.
Jaiswal and Halkitis [3]	Summarizing articles related to medical distrust	Opinion paper	Social inequality causes distrust, leading to negative health outcomes such as reduced use of healthcare services and poor health management.
Jakovljevic, et al. [16]	Promoting a culture of trust and compassion in the context of public and global mental health	Literature review of public trust during the COVID-19 pandemic	Distrust and conspiracy theories can have negative effects at an individual level, but also at the group and community levels. Trust, both among people and between people and their institutions, is crucial for addressing the COVID-19 pandemic.
Kalenga, et al. [45]	Examining key approaches and ongoing challenges in the operational response to the Ebola epidemic in the Democratic Republic of Congo	Special report on the government’s response to the Ebola outbreak of 2018–2019	There was distrust of the government and the healthcare system in their response to the demands of the pandemic.
Lieneck, et al. [38]	Exploring the underlying issues contributing to mental distress experienced by the U.S. population during the COVID-19 pandemic	Systematic review conducted using the Academic Search Complete, Complementary Index, and MEDLINE Complete databases	Demographic factors, self-care, and economic concerns were identified as protective factors potentially reducing the frequency of mental distress during the pandemic. Aggravating factors included health status, social status, and distrust towards the government.
MacKay, et al. [40]	Reviewing trust in communication methods during health crises	Systematic review conducted using the Ovid MEDLINE, CAB Direct, PsycINFO, and Web of Science databases and synthesis of the qualitative literature through GRADE-CERQual assessment	The public’s trust in crisis communication during health emergencies is influenced by factors such as the consistency, repetition, and timeliness of the information shared, as well as transparency and the handling of uncertainty. Public health communication is more reliable when the presenter is a healthcare official, the information is current, and it is not perceived as politicized.
Magarini, et al. [42]	Analyzing the scientific literature related to misinformation and conspiracy theories associated with COVID-19	Scoping review conducted using the PubMed, Scopus, PsycINFO, Web of Science, and CINAHL databases	Specific socio-environmental conditions, psychological processes, and behaviors, along with factors such as high levels of perceived self-risk and anxiety, appear to support adherence to conspiracy theories, resulting in significant health impacts.
Majid, et al. [17]	Identifying the reasons contributing to increasing distrust towards authorities and experts responsible for public health recommendations	Systematic review conducted using the MEDLINE, Embase, PsychINFO, and Global Health databases	In many countries, there was inconsistency in public trust towards the government and the media, while trust in healthcare providers was generally reported to be high. Outcomes of public distrust included non-compliance with recommended health measures, seeking information from alternative sources, and vaccine hesitancy.
Mao, et al. [26]	Assessing factors related to the therapeutic relationship in Chinese hospitals	Systematic review conducted using the PubMed, EMBASE, and Web of Science databases	Trust plays a crucial role in improving the therapeutic relationship.
McFadden, et al. [63]	Reviewing literature regarding vaccine hesitancy, acceptance, and intention to vaccinate during the early development of COVID-19 vaccines among Black and Hispanic communities and other immigrants	Literature review conducted using the PubMed and Google Scholar databases	The general population of the United States appeared hesitant about vaccination during the early release of the vaccine due to factors related to the speed of vaccine development, trust in the government’s ability to participate in vaccine development, and general distrust in the government. Among Black and Hispanic Americans, hesitancy was expressed as mistrust in the medical system related to previous and current medical mistreatment they had experienced.
Minaya, et al. [55]	Investigating psychological factors and attitudes (medical mistrust) as factors of hesitation towards vaccination among African Americans, Asians/Americans, and Hispanic/Latino individuals	Online survey of 779 African Americans, Asians/Americans, and Hispanic/Latino individuals	Medical mistrust, fears of COVID-19 infection, and COVID-19-related control behaviors were significant predictors of vaccination intention.
Obilade [46]	Identifying social characteristics responsible for stigma and its impact on controlling Ebola virus spread	Literature review conducted using the PubMed and Google Scholar databases	Distrust of government contributes to the increase of fear and stigma.
Østergaard [22]	Examining how healthcare professionals perceive and experience trust in their interpersonal relationships within healthcare systems	Narrative review conducted using the Web of Science, SCOPUS, Medline, FRANCIS, Anthropology Plus, and Google Scholar databases	The conscious use of power by healthcare workers, empathy towards patients, the quality of medical care, and collective solidarity in the workplace contribute significantly to building trust relationships within healthcare systems.
Ozawa and Sripad [4]	Determining populations reluctant to accept and participate in vaccination	Systematic review conducted using the PubMed, Embase, Web-of-Science, Scopus, and Google Scholar databases	Populations more hesitant to get vaccinated include those who although they have access, face difficulty due to mistrust, religious beliefs, lack of awareness of vaccine benefits, poverty, or low socioeconomic status. Additionally, those who do not have time available to access vaccination services or have experienced discriminatory behaviors based on gender may also be hesitant to get vaccinated.
Pavlovic, et al. [19]	Developing future strategies for improving trust and acceptance of vaccines among healthcare professionals and the public	Review of the literature as part of a broader study conducted in 15 countries examining healthcare workers’ trust	Factors influencing healthcare employees’ intention to get vaccinated included concerns about both short-term and long-term side effects of the vaccine, distrust in health authorities, and skepticism toward the pharmaceutical industry.
Pertwee, et al. [52]	Providing arguments regarding the fact that the COVID-19 pandemic has magnified social concerns and issues of trust, leading to vaccine hesitancy	Opinion paper	Trust is crucial for overcoming vaccine hesitancy, especially in a context of social uncertainty prevalent during a pandemic. Effective strategies for building trust in vaccines are highlighted.
Peters [57]	Providing information about the importance of vaccination among healthcare workers and the interventions to address vaccine hesitancy	Narrative review	Factors contributing to vaccination hesitancy include ease of access, clarity of information, individual assessments of risk versus benefit, trust or distrust in authority and healthcare, personal beliefs, customs, and group ideologies. Interventions focused on dialogue and communication are effective in addressing vaccine hesitancy/resistance.
Pummerer [32]	Supporting the view that non-standard behavior of people who believe in conspiracy theories is a consequence of a different social reality	Narrative review	The non-standard behavior of individuals who believe in conspiracy theories is a natural consequence of their distinct social reality. This reality is marked by a tendency toward discrimination, distrust in social relationships, different perceptions or questioning of norms, reduced trust in institutions and traditional principles, and the adoption of alternative rules.
Saleska and Choi [61]	Examining the factors influencing the public‘s decision to receive or not a future COVID-19 vaccine in the context of frequent side effects and pre-existing distrust	Commentary/position paper	Three common cognitive biases have been shown to influence vaccination decision-making: confirmation bias, negativity bias, and optimism bias.
Shears and Garavan [47]	Investigating the Ebola epidemic in 2018/19	Narrative review accessing the following sources of information: (a) PUBMed, (b) Google Scholar, (c) Pro Med mail updates, (d) WHO, (e) Comité Multisectoriel de la Riposte à la Maladie à Virus Ebola, (f) communication with, and direct reporting from, health staff working during the outbreak in DRC	The response to the Ebola virus health crisis at the time led to increased distrust and decreased community participation in the virus containment program.
Skirbekk, et al. [11]	Describing Norwegian public trust in general practitioners, public healthcare, information, and hospital treatment before and during the early phases of the COVID-19 pandemic	A two-phase online survey (in the years 2019 and 2020) in the Norwegian population	Trust in public healthcare, hospital treatment, and hospital information increased after the outbreak of the COVID-19 pandemic.
Suite, et al. [35]	Investigating the role of long-term experiences in maintaining distrust among people of color	Narrative review	The failure of doctors to acknowledge the historically significant experiences of people of color contributes to distrust in medical and mental health communities and perpetuates ongoing healthcare inequalities.
Thoresen, et al. [10]	Assessing public trust during the COVID-19 pandemic	Cross-sectional web survey of 1041 subjects in the general population of Norway	Individuals who had a personal experience, tested positive, lost someone to the disease, or were admitted to the hospital were found to have higher trust. Concerns related to the pandemic and high perceived health threat were linked to lower levels of general trust.
Tofan, et al. [24]	Reviewing and further exploring the doctor–patient relationship	Literature review of 58 articles	Trust and distrust in the doctor–patient relationship have been studied in the literature in two streams of research including trust and ethical supervision, as well as patient information, and their relationship to decision-making.
Van der Weerd, et al. [44]	Describing changes and factors related to public intentions during the H1N1 pandemic in 2009 in the Netherlands	A cross-sectional study involving 16 telephone surveys conducted in the Netherlands in 2009	Trust in the government started high but declined over time. Early in the pandemic, trust, perceived vulnerability, and risk perception influenced protective measures. Later, vaccination intent was tied to government trust, fear, and vulnerability, while seeking information became key to taking protective actions.
Van Prooijen, et al. [31]	Supporting the perspective suggesting that low-quality social institutions worsen the quality of social relationships	A literature review on the effects of suspicion towards institutions on people’s social relationships	Suspicion of institutions reduces trust within social groups, intensifies prejudices, fuels intra-group conflicts, and increases division and extreme ideologies.
Ward [12]	Supporting the view that public health professionals and policymakers should prioritize “public trust” to improve public health and relationships between the public and health systems	A literature review of the theory of trust in sociology	Public health professionals were seen as important in building and maintaining trusting relationships with patients, because individuals who do not trust public health services are less likely to use them, less likely to follow advice or recommendations, and more likely to have worse health outcomes.
Wilk and Platt [29]	Evaluating how trust is framed in studies of physician trust	Scoping review conducted using the Ovid/Medline, Pubmed, Proquest, Scopus, Elsevier, and Web of Science databases	Few studies in the literature focus on studying physician trust, measuring it accurately, and examining the factors that shape it.
Willems, et al. [20]	Providing information on healthcare workers’ intentions and attitudes towards COVID-19 vaccination	Scoping review of 26 studies sourced from CINAHL, APA PsycArticles, APA PsycInfo, Web of Science, Semantic Scholar, Prospero, Outbreak Science, Cochrane, and Scopus databases	Concerns about the vaccine’s safety, its effectiveness, and its short-term side effects were the factors that most strongly influenced the vaccination intentions of healthcare workers.
Williamson and Bigman [9]	Investigating how medical distrust can impact health promotion efforts	Systematic Review conducted using the PubMed, PsycINFO, ERIC, and Communication and Mass Media Complete databases	Among the validated medical mistrust scales, the “Group-Based Medical Mistrust Scale”, the “Medical Mistrust Index”, and the “Health Care System Distrust Scale” are commonly used.
Woskie and Fallah [50]	Understanding the role and consequences of distrust in healthcare systems	Qualitative research (observation)	Distrust in the healthcare system can reduce individuals’ willingness to use healthcare services. This mistrust is often rooted in the historical operations of the system itself. Therefore, countries need to focus on building trust to improve patient decision-making.
Yaqub, et al. [59]	Reviewing public and healthcare professionals’ attitudes toward vaccination in Europe	Literature review conducted using the PubMed, Embase, Cochrane, and Web of Science databases	The need for health professionals to build trusting relationships with patients was recognized. Reasons for vaccine hesitancy were related to a lack of awareness or misinformation and distrust.
Yetman, et al. [37]	Examining how virtual medications play a role and contribute to negative health-related outcomes associated with health disparities	Narrative review	Poor communication between doctors and patients, medical distrust, and perceived discrimination can all affect virtual medication adherence and impact later stages of treatment.

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Articles published in peer-reviewed journals	Articles published in other sources (e.g., books, conferences)
English language	Other languages
Articles published between 2003 and 2023	Articles published in other time periods
Articles focusing on trust or mistrust in the context of SARS, Ebola, COVID-19, and pandemics	Articles focusing on trust or mistrust in the context of cancer, HIV, HPV, vaccination intentions for children, immunizations, clinical trial participation, and other diseases or medical issues