Articipants provided consent and subsequently transcribed; otherwise, notes recorded during the interviews were used for the analysis.Ethics statementStudy procedures were approved by the Institutional Review Board at the University of North Carolina Chapel Hill and the Guangdong Provincial Dermatology Hospital. Participants provided written informed consent to participate in the study.PLOS ONE | DOI:10.1371/journal.pone.PXD101 web 0123255 May 12,4 /African Migrant Patients’ Trust in Chinese PhysiciansTheoryPatient-physician trust includes both interpersonal trust–trust in an individual physician– and impersonal trust–trust in physicians in general [1,2]. These types of trust are inter-related. Impersonal or institutional trust enables a patient to trust a new physician, and trust relations built through interpersonal interactions with physicians help to sustain impersonal trust in physicians in general and the institutions they represent [1,35?7]. We focused on interpersonal patient-physician trust because the importance of this type of trust for patient care outcomes has been demonstrated [4?]. Drawing from Hall et al. [19] and Russell [37], we define trust as the optimistic acceptance of a vulnerable situation in which the truster believes the trustee will care for the truster’s interests and has the competency to do so. Given the inter-related nature of interpersonal, impersonal, and institutional trust in the health care system, we sought to identify not only factors at the patient-physician level that may influence African patients’ trust in Chinese physicians, but also structural and socio-cultural factors. As Wuthnow argues, “trust does not depend only on judgments one person makes about another, but also on assumptions that emerge from the context in which relationships take place, on ZM241385 site expectations derived from previous relationships, and on criteria for making judgments that are deemed legitimate by the actors involved” [38]. We used a modified version of the social ecological model [39,40] as a framework for organizing the themes that emerged from the interviews (Fig 1). The social ecological model has been widely used in the field of public health to analyze factors affecting health behavior and health promotion interventions. This model recognizes that behavior is affected by not only individual factors but also multiple spheres of influence in an individual’s social environment. InFig 1. Social ecological framework for African migrant patients’ trust of Chinese physicians. doi:10.1371/journal.pone.0123255.gPLOS ONE | DOI:10.1371/journal.pone.0123255 May 12,5 /African Migrant Patients’ Trust in Chinese Physiciansthe modified social ecological model we used for this analysis, we included the following levels: interpersonal, social network, health system, and socio-cultural.AnalysisTwo researchers reviewed the transcripts and inductively developed a preliminary list of codes representing the main themes. These codes were categorized into one of four levels of a modified social ecological framework. Using the initial code structure, three individuals independently coded transcripts and cross-checked coding until a consensus was reached about the code structure. The data were analyzed using Atlas.ti version 7 (Scientific Software Development GmbH, Berlin, Germany).ResultsAmong the 40 African migrant participants, 29 were traders, 9 were students, one was a restaurant worker, and one was a housewife (supporting information, S1 Table. Dem.Articipants provided consent and subsequently transcribed; otherwise, notes recorded during the interviews were used for the analysis.Ethics statementStudy procedures were approved by the Institutional Review Board at the University of North Carolina Chapel Hill and the Guangdong Provincial Dermatology Hospital. Participants provided written informed consent to participate in the study.PLOS ONE | DOI:10.1371/journal.pone.0123255 May 12,4 /African Migrant Patients’ Trust in Chinese PhysiciansTheoryPatient-physician trust includes both interpersonal trust–trust in an individual physician– and impersonal trust–trust in physicians in general [1,2]. These types of trust are inter-related. Impersonal or institutional trust enables a patient to trust a new physician, and trust relations built through interpersonal interactions with physicians help to sustain impersonal trust in physicians in general and the institutions they represent [1,35?7]. We focused on interpersonal patient-physician trust because the importance of this type of trust for patient care outcomes has been demonstrated [4?]. Drawing from Hall et al. [19] and Russell [37], we define trust as the optimistic acceptance of a vulnerable situation in which the truster believes the trustee will care for the truster’s interests and has the competency to do so. Given the inter-related nature of interpersonal, impersonal, and institutional trust in the health care system, we sought to identify not only factors at the patient-physician level that may influence African patients’ trust in Chinese physicians, but also structural and socio-cultural factors. As Wuthnow argues, “trust does not depend only on judgments one person makes about another, but also on assumptions that emerge from the context in which relationships take place, on expectations derived from previous relationships, and on criteria for making judgments that are deemed legitimate by the actors involved” [38]. We used a modified version of the social ecological model [39,40] as a framework for organizing the themes that emerged from the interviews (Fig 1). The social ecological model has been widely used in the field of public health to analyze factors affecting health behavior and health promotion interventions. This model recognizes that behavior is affected by not only individual factors but also multiple spheres of influence in an individual’s social environment. InFig 1. Social ecological framework for African migrant patients’ trust of Chinese physicians. doi:10.1371/journal.pone.0123255.gPLOS ONE | DOI:10.1371/journal.pone.0123255 May 12,5 /African Migrant Patients’ Trust in Chinese Physiciansthe modified social ecological model we used for this analysis, we included the following levels: interpersonal, social network, health system, and socio-cultural.AnalysisTwo researchers reviewed the transcripts and inductively developed a preliminary list of codes representing the main themes. These codes were categorized into one of four levels of a modified social ecological framework. Using the initial code structure, three individuals independently coded transcripts and cross-checked coding until a consensus was reached about the code structure. The data were analyzed using Atlas.ti version 7 (Scientific Software Development GmbH, Berlin, Germany).ResultsAmong the 40 African migrant participants, 29 were traders, 9 were students, one was a restaurant worker, and one was a housewife (supporting information, S1 Table. Dem.
