Predictors of low trust in national healthcare systems in 30 countries

BACKGROUND: Trust in national healthcare systems is associated with health behaviour and patient outcomes. Individuals with high trust are more likely to participate in preventive services and adhere to medical advice, whereas low trust is linked to poorer health, reduced service use, and lower patient satisfaction. Despite extensive research on interpersonal trust in healthcare professionals, cross-national evidence on public trust in healthcare systems remains limited. This study examines levels of trust in 30 healthcare systems and identifies sociodemographic, attitudinal and experiential predictors associated with low trust. METHODS: The analysis draws on nationally representative data from the 2021 International Social Survey Programme, including 40,392 respondents aged 18 and older across 30 countries. Trust was dichotomised as high versus low trust. Multilevel logistic regression models with random intercepts at the country level were applied to account for data clustering. Individual level predictors included sociodemographic characteristics, health status, political orientation, attitudes toward vaccination and alternative medicine, perceptions of doctors, perceived inequalities in access, personal experiences with access barriers, and satisfaction with the last medical visit. At country level, the Corruption Perceptions Index was used. RESULTS: Trust showed wide variation across countries, peaking in Scandinavian nations and remaining comparatively low in countries such as Poland, Suriname, and Russia. Logistic regression indicates that a high level of trust is associated with low levels of corruption at country level. Younger respondents and women were more likely to report low trust. Poor self-rated health emerged as one of the strongest predictors of low trust. Negative attitudes toward vaccination and voting for extreme political parties were also associated with low trust. Furthermore, both personal experiences of access barriers and perceptions of unequal access were associated with a higher likelihood of low trust. Respondents dissatisfied with their last medical treatment and those with generally negative views of doctors showed markedly lower trust in the healthcare system. CONCLUSION: Trust in national healthcare systems is associated with a broad set of individual and contextual factors. These findings highlight multiple potential leverage points for strengthening trust, ranging from improving doctor-patient interactions to addressing structural inequalities in healthcare access.