Investigating factors influencing patient trust in a developing Pacific Island Country, Fiji, 2018.

INTRODUCTION: In spite of the current evidence on positive impacts of patient trust on health outcomes, there are limited studies carried out in Pacific Island countries. This qualitative study aimed to explore the factors associated with patient trust in their doctors in Fiji.
MATERIALS AND METHODS: With use of grounded theory research design, twenty participants attending the outpatient department of the health centers in the Suva Sub-division, Fiji were recruited. Audio-recorded in-depth interview was conducted using a semi-structured questionnaire. Transcribed data were analyzed using manual thematic analysis. RESULT: This study showed that interpersonal skills, communication skills, overall attitude and approach (customer care), clinical skills, improving health literacy and patient centred care were some of the factors influencing the level of trust patients had in their doctors. Though, together with communication and explanation, performing physical examination seemed to be bigger influencer of patient trust.
CONCLUSION: It can be concluded that developing policies to improve doctors' communication skills, clinical skills, patients' health literacy and customer care in Fiji can lead to better patient trust in their doctors.

Introduction

In health care systems, trust is applicable to relations among people whereby it is a core factor of the doctor-patient relationship and an intergral element of a satisfying relationship (Lewis and Weigert, 1985; FCMC 2018; Rolfe et al., 2006; Krot and Rudawska 2016). Trust includes both confidence and reliance given that patients are put in a vulnerable situation where they believe that the healthcare-providers will pay attention to their need (Hall et al., 2001). For their own health benefit, patients need to trust the doctors whiles sharing their private information and examining their body as this is essential for proper management (Goold 2002; Hall et al., 2001; Dyer 2001). For some patients, it might be their belief or assumption that the health care provider will behave in a certain way (Pearson and Raeke 2000). Patients might expect their health care provider to be compassionate, empathic, competent, honest, dependable and interested in their good will and look forward for a good outcome of their visit (Pearson and Raeke 2000; Goold 2002).

At the same time, health care providers, in line with medical ethics and code of conduct, have obligations for doing things for the betterment of the patient, being trustworthy; having high levels of clinical and judgement skills, and fulfilling special roles such as the legal obligations. In health care, it is important that patients are able to trust in the discretion of health care providers as it is difficult to separate knowledge and skill competence from moral, in the health care provider's behavior (Rani 2017). Trust is needed at every stage of building a relationship with their doctors. The doctor-patient bonding and relationship that is being formulated can be easily shattered if the doctor is not responsive to the needs of the patient in the early phases of the relationship building process (Bambino 2006). Trust is considered a complex and complicated subject. Some of the factors that determines patient's trust includes the communication behavior of doctor's treatment assurance, patient centered care, shared decision making, respect for the physicians, familiarity with the patients, gender, clinical competency of doctors, age, race, education level, and socioeconomic status and, doctor's communication behaviour (Zhao et al., 2016; Croker et al., 2013; Cooper et al., 2003; Boulware LE et al., 2003; O'Malley et al., 2004; Meyer and Ward 2013; Hall and Roter 2002; Roter DL 2002; Gopichandran and Chetlapalli 2015; Banerjee and Sanyal 2012). Most of these studies has been conducted in developed countries with few in developing countries. Though, most the determinants of trust are similar, the level of influence of these factors on trust seems to differ slightly. For a rural setting, respect for the physician and familiarity with patients influence trust more than the doctor-patient communication or patient centered care as opposed to developed countries (Chandra et al., 2018).

Better patient trust has been shown to have a positive impact on patients' health outcomes, such as better patient's adherence to medication, improved patient satisfaction, and is a better indicator of follow up treatment (Birkhäuer et al., 2017; Goold SD 2002; Goold and Lipkin, 1999; Haskard Zolnierek and DiMatteo 2009; Baker et al., 2003). Lack of trust has resulted in economic burden on the healthcare system in view of poor outcomes such as non-adherence to treatment, persistent symptoms, complications, readmissions and recurrent visits to a health facility (Chipidza et al., 2015; Iuga and McGuire 2014; Viswanathan et al., 2012). Trust and communication failures between doctors and patients has also led to complaints and malpractice suits are lodged against the doctors (Sutcliffe et al., 2004). In resource strained, Pacific Island Country (PIC) like Fiji, issues of non-adherence to treatment plans exits and this has led to readmissions to hospitals and recurrent visits to the health centres; thus, putting the extra economic burden on health systems in managing these complicated cases (Chand, 2012).

In spite of knowing the consequences of lack of trust and proper communication in a doctor-patient relationship and its impact on health outcomes, there are few studies conducted in PICs in general and specifically none in Fiji. Fiji is a multicultural island nation compromising majorly of indeginious Fijians, Indo-Fijians and other ethnic groups with cultural traditions of Oceanic, European, South Asian, and East Asian origins (Solomoni and Walker, 2001). Together with the culture and diversity, Fiji is also known for the friendly people and the bula smile (World Wide Fund for Nature 2018).

Therefore, this study was conducted with the intention to explore some of the factors associated with patient trust and whether these factors are similar to those in developed countries. The results of this study would help in confirming the factors influencing patient trust in Fiji and help the health services managers to come up with strategies to promote better patient trust and overall to improve compliance and better health outcomes.

Materials and methods

Study design and sample

This was a qualitative study employing the grounded theory research design. Study was conducted in the outpatient setting of three randomly selected health centers located in Suva, Fiji, 2018. Suva is the capital of Fiji on the main Island, Vitilevu. Fiji is a multiracial country with 2 major ethnicity, i-Taukei and Indo-Fijian anad some minoe ethnic group. In view of 2 major ethnic group in Fiji, convenient purposeful sampling was used to recruit the participants to explore if there was any difference in these two groups.

Participants’ recruitment

Prior to the study period (July to August, 2018), flyers were put up at the health centers for invitation to take part in the study. Those who were over 18 years, self-identified Fijian, either i-Taukei or Indo-Fijian, any gender and attending outpatient services in the Suva sub-divisional health centers, Fiji, 2018 were selected. Those who were not willing to take part were excluded. During the study period those who were waiting to be seen by the doctors were approached by the main researcher and those who showed interest and met the inclusion and exclusion criteria were provided with the information sheet and explained about the purpose of the study. After their consultation, the selected participants who were willing to take part were given the consent form and once the consent was obtained, interviews were conducted over the study period, with an average of 3 interviews per week.

Interview procedure

Participants were advised that the interview would be audio-recorded. These participants were guided to a quiet room assigned by the medical officer in-charge of the health center, where face-to-face in-depth interview was conducted. Inductive thematic saturation was used to get the sample size where by data saturation was noted with 20 interviews as there was repeatation of themes noted in the later interview (Saunders et al., 2018). Audio recorded interview guided by a standardized open-ended semi-structured questionnaire was conducted with each interview being 30–40 min long. The questionnaire included 10 open-ended questions (Table 1) which focused on participants’ trust in their doctors, factors affecting their trust and reasoning for coming to that particular health center. All the participants were coded as P1, P2, P3 and so on (participant 1, participant 2…).

Table 1

Statement used in the questionnaire to guide the interview.

	Statements in the questionnaire
1	How was the experience with the doctor? Please elaborate
2	How was the doctor's behavior towards you? Can you please tell me in detail?
3	Did you feel scared, relaxed, comfortable or safe while with the doctor? Please explain why.
4	Do you think the doctor provided you with a good management and care? Please explain
5	Do you trust your doctor? Please explain what made you trust the doctor and in what sense.
6	Do you feel obliged to trust doctors out of respect for them? Please explain.
7	Were you able to understand what all the doctor advised you? Please explain
8	How do you think we can improve the consultation? Is there anything that doctors need to improve on or change?
9	Were you satisfied with the services provided? Please elaborate
10	Would you recommend the doctor or this health center to other people and please tell me why?

Data analysis

Two consequential layers of analysis was performed: open coding and focused coding (Khan 2014; Larossa 2005). Data were principally coded by Author 1, but also cross-coded by author 2 to increase analytical rigour. The open coding provided a description of the themes arising from the data, from the perspective of the participants. This was carried out throughout the data collection process, and our initial open coding illuminated the content of subsequent interviews. Individual interview was transcribed directly (after translation) after the interview for easier comparison of data collected and analysed. Participants either spoke in English or Hindi during the interview and no one spoke in Fijian language. The information in Hindi language was directly translated word by word in English. The audio recording was heard over and over to ensure the transcribed data was exactly as in the audio. The action of open coding followed the following known stages: breaking down, examining, comparing, conceptualising and categorising data (Mehmetoglu and Altinay 2006). When performing open coding, the actual content from the transcribed data was used for coding words or sections of text (Nvivo codes), or by grouping similar words conceptually.

Validity and reliability

The qualitative data can be considered trustworthy. Prior studies conducted on similar topic including both quantitative and qualitative studies was reviewed, and comparison was made with this study findings. In-depth description of the methodology used in the qualitative design is provided. Focused coding was followed by open coding whereby the open codes were grouped into larger categories. Focused coding is more directed and selective than open coding, as it explains larger bodies of text by using significant and/or frequent codes (Rogers 2018). This process involved an iterative process of placing each of the initial open codes into larger categories. This was based on their ‘semantic fit’ or themes linking similar ideas or issues. The initial focused codes were large and was further reduced over a number of analytical readings of the codes in order to permit sensible interpretation.

The whole process from proposal, data collection, analysis and results were reviewed and criticized by the co-author and his peer, Professor Paul Ward.

Research ethics approval

Ethics approval was obtained from the Fiji National University College Health Research Ethics Committee (CHREC) and from the Fiji National Research Ethics Review Committee (FNRERC). All the selected participants who were willing to take part were given the consent form before collecting data.

Results

The mean age of the participants was 42 years (SD = ± 12) with age ranging between 23 years to 66 years. From the total of 20 participants, 10 were male and female each, 10 were i-Taukei and Indo-Fijian each, 14 participants were less than 50years and 6 participants were 50 years and more. Table 2 summarizes the characteristic of the participants.

Table 2

Characteristics of the participants (n = 20).

	N
Gender
Male	10
Female	10
Race
i-Taukei	10
Indo-Fijan	10
Age
<50years	14
≥50 years	6

Themes identified from this data included ‘Doctor's approach to patient’, ‘Health literacy and Patient-centred care’, ‘Examination and Clinical outcome’ and Trust in ‘Doctors’ and doctor preference’ and ‘Patient's reaction after consultation’ as shown in Table 3.

Table 3

Analysis of the data with identified themes, subthemes and categories.

Themes	Sub-themes Categories
Doctors' approach to patient	Doctor's communication behaviour	Attitude
		Tone
		Polite
		Welcoming
	Proper Communication	Obtaining proper history
		Two-way communication
Health literacy and Patient centred care	Providing explanations	Telling the diagnosis
		Informing the management
		Stating the prognosis
	Patient centred care	Patients encouraged to question
		Considering patient requests
		Consensus with treatment plan
Examination and clinical outcomes	Expectations not met	Appropriate examination
		Appropriate questioning
	Health outcomes	Recovery status
		Recurrent visitation
		Seeking Second opinion
Trust in doctors and doctor preference	Reasoning for trust	Doctors communication behaviour
		Title of a doctor
		Blind trust
	Doctor preference	Gender based
		Ethnicity based
Patients reaction after consultation	Positive impression	Trust and satisfaction
		Compliance with treatment plan
	Negative impression	Doubt in treatment plans
		Seeking second opinion

Doctor's approach to patient

Participants highlighted that the doctors’ general approach and attitude towards the patient was something that caught their attention. Some of the factors that they liked was the soft tone of the doctors, their politeness and them not sounding harsh, and being welcomed by the doctors when they entered the consultation room. These factors made the patients feel comfortable like a friend.

A 49-year-old i-Taukei male stated, “The doctor was friendly and polite”. A 23-year-old Indo-Fijian male stated, “The ways doctors' approach me…uhm and the way they talk and their tone.” while another 42-year-old i-Taukei female stated, “Their first expression… the way they look and greet…it felt nice”.

When it came to trust in their doctors, patients mentioned mostly similar factors as above. The way their doctor treated and communicated with them, helped in building the trust. When patients felt comfortable, they were also able to ask questions or clear their doubts and this strengthened the level of trust the patients have in their doctors

A 46-year-old i-Taukei female said, “I trust the doctors because of how they have treated me…. Doctor says morning to me. The face was welcoming, and I feel free to talk to the doctor.”

Another 48-year-old Indo-Fijian male said, “It was a good experience with doctors…I trust the doctor… the way they talk is good, I could ask them, the doctors and nurses are asking things and cared about my need and explained.”

Also, considering that the long waiting time can be frustrating and anxiety-inducing, patients felt ease and relaxed when doctor greet them well as they enter the room and if their consultation was good.

A 31-year-old Indo-Fijian male said, “In the beginning, I am frustrated and at the same time bit scared but when I enter the room and the way the doctor greets me, I can understand that I can be comfortable with this doctor.”

In contrast, those who experience with the doctor was not good, the waiting time was also an issue for them. Also, few patients voiced disappointment when their doctors did not talk to them well or explained things to them. Providing explanation was important for almost all the patients. Either it being their medical condition, diet advice or medicine, patients were appreciating it and that they got to understand things better and vice-versa when they were not.

A 25-year-old Indo-Fijian male said, “I waited so long to see the doctor and the doctor didn't examine her and just ignored…I don't trust the doctors from here”.

Another 38-year-old Indo-Fijian female said, “…the doctor was rude, just saw, wrote the prescription… just sitting and didn't ask” and a 66-year-old Indo-Fijian male said, “…doctor tells things but at times might not be all the information that I needed. Sometimes the doctors don't explain well, depends on the doctors…”.

The words ‘depends on the doctors’, highlights that most of the patients have been through different doctors and encountered different experience, indicating individuality of doctors during consultation; reflecting their interpersonal skill.

Health literacy and patient-centred care

Doctors making an effort to explain the patients about their sickness was appreciated by the patients. For patients to understand about their sickness helps to reduce their anxiety or fears. For majority of the participants, when they were provided with an explanation concerning their sickness, what it is or might be and the reasoning for further investigation, it had an impact on building trust as well.

A 59-year-old i-Taukei male said, “My experience with doctor is 100%. The 100% is how they perform when you explain the sickness to them, the right medication and what it can do and the side-effects”. While another 42-year-old Indo-Fijian male said, “…. the way they saw me and explained me and of course they are doctors, I trust that person. I get more trust due to the interaction with the doctor…”.

It was also seen that when doctors involved patients while making the management plan, provided them with options and welcomed their say, the patients appreciated their involvement in the discussion and for the doctors listening and respecting their opinion.

A 51-year-old i-Taukei female said, “They respect your opinion… they gave me time to ask the questions and I asked them more questions and was happy with the answers.”

Allowing patients to ask questions or clear their doubts or have a say in their management, were some of the positive feedback from the patients.

“Here they listen to my opinion” was stated by a 44-year-old Indo-Fijian male, while another 39 years, Indo-Fijian female stated, “The doctors talk very nicely, they let me ask questions and when they explain I understand…I trust my doctor”.

In contrast, those patients who were not provided with explanation or had little contribution during the consultation or their requests were not considered by their doctors, voiced disappointed and lack of trust in their doctor.

A 30-year-old i-Taukei male said, “I am not sure if I trust the doctor because they never explain all the things about high blood pressure.” Similarly when one of the patients view was not considered, he lost in that doctor; the 48-year-old Indo-Fijian male said, “I asked them to give me the medicine from another IV site, but they didn't listen at XXX (name of HC deleted) …my hand got swollen...I will not go back to the doctor.”

Examination and Clinical outcome

For those participants who mentioned that they don't completely trust their doctors, performing physical examination was mentioned as a reasoning for not trusting the doctors by all of them.

A 49-year-old i-Taukei male stated that “…like I would prefer if she (the doctor) could examine me but she didn't… she just asked questions and I responded to her questions and she gave me the medication to collect from pharmacy.” While another 39-year-old, Indo-Fijian female stated, “My experience was not good. When I came here, my daughter was coughing, doctor, Indian doctor told not to give cold things and gave amoxicillin quickly, neither asked anything or did examination.”

Patients expected their doctors to consult them in a certain manner; either ask questions, examine them or explain things to them.

A 43-year-old i-Taukei male said “…. well I was expecting for her to give me a medical check like I would prefer if she (the doctor) could examine me but she didn't.”

For some patients, it was their clinical outcome after their visit which was linked to their trust in that doctor. If they improved and got better, then they trust that doctor.

A 66-year-old Indo-Fijian male said, “I trust them… main thing for me is that I should get better, does not matter who saw me.”

In contrast, when the patients did not improve and had to sort for second opinion, they trust in the first doctors gets distorted. There were few patients whose trust got distorted due to them not improving or getting better despite recurrent visits for the same condition.

A 39-year-old Indo-Fijian female stated, “I got better only when I went to the private doctors. I was dehydrated and the doctors from here didn't treat me. I was coming here for 3 weeks…I don't trust… prefer to get seen somewhere else” while another 42-year-old i-Taukei male said, “The doctors I visit, they could not provide the treatment that the doctors of this health facility have provided me. They took my blood test and they advised me on diet which helped me a lot”.

This statement also highlights how interpersonal trust in his doctors have led him to have institutional trust in the health facility overall.

Trust in ‘doctors’ and doctor preference

As mentioned earlier from the statement of the 42-year-old Indo-Fijian male said, “…. the way they saw me and explained me and of course they are doctors, I trust that person….”, the title of a doctor also influenced their level of trust. These patients have faith and believe or just blindly trust their doctors because they are professionals, qualified enough to be sitting in the doctor's chair.

A 30-year-old Indo-Fijian male said, “For me, if the doctor is there, what I know, and belief is that he is qualified, and I trust them.”

Some patients believe that whatever the doctor will do or give is the right thing. For them, it is like something that was passed from the generation that doctors will make you better, they are the life-savers.

A 48-year-old Indo-Fijian female stated, “I trust they give me the right things, for my wellness. I trust the doctors would be doing the better thing”. Another, 52-year-old i-Taukei female said, “I trust all the doctors, our lives are in their hand… because maybe from our younger days, that the doctor will treat you and you will be well, the trust is there…I think it is their belief”. Linked to the profession of doctors, is the respect for them as well.

The majority of patients did not voice any preference for a particular doctor. They were comfortable with any doctor seeing them, as they had trust in the fact that a person was a ‘doctor’ – a sense of institutional trust in medicine. Though, majority patients believed that all doctors are the same and they should provide you with a good treatment, few patients preferred to be seen by a doctor of same ethnicity as they would be able to understand better if things were explained in their first language, thus have better understanding about their sickness and management.

A 66-year-old Indo-Fijian male said“…But I prefer Indian doctor because I can't speak English well, but anyone would be ok” while another 30-year-old i-Taukei male said, “Yes, I Prefer i-Taukei, if Fijian doctor then they explain nicely”

For few participants, they preferred to be seen by a doctor with same gender as theirs as they will feel secured and can disclose their information easily. Especially when it comes to problems or issues with reproductive health, few patients preferred to see doctor of the same gender but with any other issues, they can see any doctor.

A 23-year-old Indo-Fijian male said, “No, can see any doctor…though, I would prefer male doctor then more comfortable if issues with genitals.”

Patients reaction after consultation

As highlighted earlier, once patients came out of the consultation room, few patients had negative impression, and some had positive impression and attitude towards their health. It was noted that trust and satisfaction with the consultation were the common driving factors behind their actions. Those who had trust and were satisfied with the consultation stated they would follow the treatment given by the doctors.

A 30-year-old Indo-Fijian male said that “Yes, I always follow the advice, the way they saw me and explained me and of course they doctor…I trust that person.”

For those, who had bad encounter with the doctors or were not satisfied with the services, they were less like to adhere to the treatment plan and those who doubted their doctor, they mostly ended up getting a second opinion from another doctor.

A 60-year-old Indo-Fijian female said, “… and I sometimes don't trust that the doctor is giving the right medicine. I didn't take my medicine”. While another 43-year-old i-Taukei male said “… but, I don't doubt what they give, but I prefer something different…. I think I will go and look for one cough mixture from pharmacy….”

Discussion

This study assessed the factors affecting patients level of trust in their doctors in the Pacific Island Country, Fiji. This study revealed a number of factors which can be affecting the level of patient trust. Firstly, this study revealed that doctor’ communication behaviour and interpersonal skill was linked to patient trust. How the doctors presented themselves to the patients; their attitude, tone, expressions and their approach when patients come in matters when it comes to building patient trust. Secondly, examination of the patients also seemed to be an important factor in terms of building trust. Patients tend to better trust the treatment provided by the doctors if they were given a proper examination rather than just history taking and giving the treatment. Thirdly, in addition to communication skills, improving health literacy of the patients by providing explanation, giving advice, and discussing the prognosis was also linked with patient trust. Lastly, patient-centered care was linked with patient trust as well.

Most of these factors related to trust are consistent with other studies done previously including developed countries (Zhao et al., 2016; Croker et al., 2013; Jalil et al., 2017; Kee et al., 2018; Gupta et al., 2014; Cheng et al., 2003; Fiscella et al., 2004). Findings of a study done by Jalil et al. (2017) showed that several aspects of doctor-patient interaction, such including approachability and communication, were associated with patient experiences of vulnerability. Similarly, Kee et al. (2018) in their study which was conducted in Singapore, identified that most of the complaints lodged concerning health care were communication issues, including specific nonverbal and verbal communication errors, content errors, as well as poor attitudes during doctor-patient interaction. As for health literacy, study conducted on hospitalized cardiac patients showed that patients with inadequate health literacy were more likely to distrust their treating physician (Gupta et al., 2014).

Parallel to communication was receiving patient centered care. Fiscella et al. (2004) in their study showed that patient-centred care and friendly behaviour of doctors increase the trust significantly. One of the interesting factors brought up in this study was the importance of getting a physical examination done. Those patients who were disappointed with their consultation and had distrust in the doctors and management provided, mentioned doctors not performing a physical examination as a common factor. This factor seemed more important to the patients then the communication and attitude of the doctors. There does not seem to be any previous research done to evaluate this aspect of the consultation though it can be associated to the competency of the doctors. Thom in his study showed that technical competency was one of the doctors’ behavior which was strongly associated with patient trust (Thom 2001).

In addition, public might have a preconceived idea that without examination, making a diagnosis and treating patients is not possible, so the doctor is not a competent doctor. Also, the outcome of the patient's visit was also picked up as one of the factors linked to patient trust. Some of the patients who have visited the health center previously, mentioned that they got better, they tend to trust those doctors more, whereas those who didn't get better and had to consult another doctor lost the trust in the first doctor. This finding was consistent with findings of a study done by Cheng et al., in Taiwan. It showed that health status of the patient was an important predictor of trust and patient's overall satisfaction (Cheng et al., 2003).

This study also pointed out some of the known negative effects of lack of trust in the doctors. Those who didn't trust their doctors, experienced a lack of communication or were disappointed, voiced that they would probably seek a second opinion. Disappointment as a reason for seeking second opinion was similar to the findings from a study conducted by Van-Dalen et al. (2001). Their study found that the reasons for seeking second opinion included disappointment concerning their original treatment, or because they wanted more information about their condition and/or its treatment.

In contrast to studies (Cooper et al., 2003; Tarn et al., 2005; Epstein and Street 2007; Nwankwo 2015) that showed better trust in physicians when there is patient-doctor ethnic match, this study didn't show ethnicity to be linked with patient trust. The majority of patients did not voice any preference for a particular doctor; either the same ethnic background or gender. They were comfortable with any doctor seeing them, as they had trust in the fact that a person was a ‘doctor’ – a sense of institutional trust in medicine. A study done by Meyer and Ward (2014) showed that in the public hospital system, there was a ‘trust'in the medical system and therefore in all people called ‘doctors’ – patients can't choose which doctor to see, so they need to trust that all doctors are appropriately trained and thus trustworthy. It can be also explained by the fact the Fijians generally put doctors as people of higher status and trust them out of respect and for their profession.

Strengths and limitations

In-depth description of the methodology was provided, and an audit trail was developed. The whole process from proposal, data collection, analysis and results were reviewed and criticized by co-author. The purposeful sampling ensured homogenity of the participants as there were equal number of participants each ethnic group, gender and age group. Though, this study also has its limitation as well. There are other minor ethnic groups who utilize the services but were not included in this study. Other factors which also can affect patient trust such as patient's medical diagnosis and prognosis, doctors gender and ethnic background has not been included in the study. Also, this study was conducted only in the urban and peri-urban situated health centers.

Conclusion

This study showed that factors influencing trust in a developing Pacific Island country like Fiji is mostly the same as those in other developed countries. This study showed that a doctors’ interpersonal skills, communication skills, overall attitude and approach, clinical skills, improving health literacy and patient centered care was influencing the level of trust patients had in their doctors. Together with communication and explanation, performing physical examination seemed to be bigger influencer of patient trust. Also for Fiji, the respect for the doctors and their profession seems to be influencing the patient trust. With this baseline information, it would be advised for Suva sub-divisional doctors to further strengthen their interpersonal and communication skills, clinical competency and provide more patient centered care. It would be also be recommended for further studies to be done to explore the strength of association between these factors and trust.

Declarations

Author contribution statement

M. Mohammadnezhad: Conceived and designed the experiments; Performed the experiments; Analyzed and interpreted the data; Contributed reagents, materials, analysis tools or data; Wrote the paper.

S. Chandra: Conceived and designed the experiments; Analyzed and interpreted the data; Wrote the paper.

Funding statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability statement

Data will be made available on request.

Declaration of interests statement

The authors declare no conflict of interest.

Additional information

No additional information is available for this paper.