Psychological distress and trust in healthcare: individual perceptions and national contexts - a multilevel analysis

Abstract Aim This study examines the association between trust in doctors, income-based perceived fairness, income-based access inequality in healthcare, and self-reported psychological distress, considering individual perceptions and country level socioeconomic context. Methods ISSP 2021 Health and Health Care data were analyzed ( N = 26 023; 21 countries). A multilevel logistic regression model was estimated. Country level indicators included income inequality (Gini coefficient), Human development index (HDI) and average confidence in the healthcare system. Results Compared with neutral trust, trusting doctors was associated with lower odds of distress (OR = 0.78, 95% CI 0.72–0.84), while distrust was associated with higher odds (OR = 1.14, 95% CI 1.01–1.30). Strong perceptions of healthcare injustice were associated with elevated distress, reflected in higher odds among those rating the system as very unfair (OR = 1.26 95% CI 1.16–1.37) and those perceiving access as harder for the poor (OR = 1.30 95% CI 1.20–1.41). At the country level, higher income inequality (OR = 1.26, 95% CI 1.10–1.44) was associated with higher distress, whereas HDI and average confidence in the healthcare system was not significantly related to distress. Discussion Overall, the findings highlight that psychological distress is closely linked to both individual-level institutional perceptions and broader societal inequalities, with trust in doctors emerging as a particularly strong psychosocial resource.