The aim of this study was to investigate the relationship between trust and health in China. Since China has a different culture and measurements of the concepts of trust from Western countries, we paid particular attention to two concepts of trust (namely “out-group” trust and “in-group” trust) and the effects of these concepts at both the individual and societal levels on people’s health in China. The main findings show that higher “out-group” social trust at the societal level (province) is associated with the report of good health; while, higher “in-group” social trust at the societal level is negatively associated with reporting good health. Although Chinese communities are characterized as “low-trust” societies in terms of “out-group” trust, the findings in the 2005 data are consistent with previous studies (i.e. [24]): namely, trust has protective effects for health [17]. Beyond concrete personal connections, Chinese individuals have a “pervasive distrust of strangers” [3] which hinders the cooperation between people, solidarity, spontaneous sociability, a tolerant society, a vibrant social community, and health-related behaviour [4]. Such distrust could reduce the social quality of people’s lives, thus depressing the likelihood of reporting good health in a society with low “out-group” trust; however, from the results in 2010, it was found that societies with higher “in-group” trust do not show better health outcomes.
Such a finding may be due to the Chinese culture and particularly the concept of nepotism. Chinese culture has long been a prototype of a familist and trust-discouraging tradition and it is characterized by a narrow “radius of trust” (from core family members to less familiar persons) ([3, 23], pp.69-95). Higher “in-group” trust societies in China may reflect closer personal connections (networks), where individuals trust their own networks’ members (i.e. family member, relative, friend, colleague and people from the same hometown); conversely, people outside such concrete relationships are hard to be trusted, and the sense of not being considered trustworthy may lead to chronic stress in one’s daily life and may thus increase the risk to one’s health [13]. In addition, moral behaviour in the Chinese culture is closely linked to personal connections [23] and the display of trust is linked more to creating “impressions” towards other individuals rather than making rational judgments [14]. A high “in group” trust society may also reflect a society based on acquaintances which emphasises the “rule of man” rather than the “rule of law”. In this context, the working ethic is primarily based on the degree of closeness of relationships; individuals are more likely to be chosen by core members to achieve their goals if they have a closer and more familiar relationship. Consequently, for those people who are not members of one’s “in-group”, their rights may be violated due to unfair judgments which come as a result of a lack of transparency in rights and responsibilities in terms of public affairs [21]. Therefore, it could be argued that high “in-group” trust societies are not conducive to individuals’ good health. In terms of interpersonal trust, our analyses find that individuals who consider that strangers or most people can be trusted are more likely to report good health than those who consider strangers/most people as untrustworthy.
In addition, some particular groups are more strongly impacted by social trust at the province level than other groups according to the cross-level interaction results. In terms of “out-group” social trust, our findings show that the odds of reporting good health for those with lower levels of educational attainment increase more rapidly than for those with high levels of educational attainment in high “out-group” social trust provinces. Education is stable throughout life and helps people to think logically and rationally, and to analyse problems and solve them; it could also help to solve interpersonal problems in terms of social interaction through shaping people’s communication skills and cognitive flexibility (i.e. negotiating with each other, learning to compromise, respond flexibly and openly to others’ opinions rather resorting to violence) [20]. On the other hand, education has also been regarded as the most effective way of internalizing social norm in traditional Confucianism culture which is prevalent in China, and individuals with higher education are treated as more trustworthy than those with lower education [14].
Three pathways could explain how education can affect trust in China: people’s personality can be shaped by education through embedding honesty into one’s rational behaviour so as to be well received by others in social transactions; higher educational attainment not only can enhance one’s human capital which could improve one’s earnings and social status, but also can enhance trustworthiness; and education could accelerate people’s social participation which conversely facilitates information flow between members of society [14]. Individuals with lower education may not only be less likely to be considered trustworthy, but they may also be more sensitive to such a disadvantage and therefore more prone to assimilate in a social trust environment than well-educated people. Therefore, in higher “out-group” trust societies, lower education attainment may lead to a stronger feeling of being trustworthy which in turn could result in better health. By contrast, in higher “in-group” trust societies, low-educated individuals may find it more difficult to be trustworthy and thus be affected more negatively by a culture of nepotism, which could in turn result in a lower likelihood of reporting good health.
In terms of the differences between rural and urban residents, the traditional beliefs and social structures in rural areas involve less radical ideological transformations than in urban areas; the social networks in rural areas are more traditional and “tighter knit” than those in urban areas, and interaction with strangers is much more restricted for rural residents in China [23]. Therefore, higher “out-group” trust societies could result in rural residents having stronger feelings of being trustworthy than urban residents which could accelerate better health for rural residents compared to their urban counterparts. Apart from the reduced likelihood of being able to afford health care consumption and medical expenditures, individuals on lower incomes are often marginalized and the social distance between them and those who are “well-off” is extended in an unequal society [18]. Additionally, the sense of not being trustworthy, as well as the feeling of shame and exclusion, may lead to chronic stress in one’s daily life thus increasing the risk of poor health [13]. This could be the reason why the gaps between individuals on lower and higher income are smaller in high “out-group” social trust areas than in low “out-group” social trust areas.
In terms of “in-group” social trust at the province level, the explanation for the different levels of income groups in social trust is similar as previously stated. The feeling of exclusion from networks of well-off people or being isolated from other individuals’ personal connections may be more harmful for the health of those on lower incomes in high “in-group” social trust areas. For the cross-level interaction between “in-group” interpersonal trust (individual level) and “in-group” social trust (societal level), the odds of reporting good health dramatically decrease between provinces with low “in-group” social trust and provinces with high “in-group” social trust for individuals who think that most people can be trusted (high trust). Trust is a two-way process, therefore if high trust individuals know that they are not trustworthy or they are not able to be ones’ “in-group” members and be trusted by others in their personal networks, they may feel disappointment and shame, thus increasing the risk to their health. By contrast, individuals who think that most people cannot be trusted or “as many can be trusted as distrusted”, are already less likely to trust others, and it seems that they have lower expectations of being trustworthy [6], therefore, whether they live in high or low “in-group” social trust areas, the effect of distrust on health remains the same for them.
Three limitations in this study were recognized. The CGSS does not provide a consistent questionnaire on “out-group” trust and “in-group” trust between 2005 and 2010. In addition to shedding light on this relationship in a non-western society, this study also fills gaps in contemporary knowledge of “in-group” / “out-group” trust and health in the context of China. The second limitation of the study is its repeated cross-sectional nature, which does not allow us to draw conclusions on the causal direction of the relationship between trust and health status. Although the examination of such relationship with longitudinal data would be beneficial, nevertheless from our knowledge, there is currently no available longitudinal survey which has such consistent information about trust and health in China. The third limitation could the geography layer. Measurement of social trust in the province level may not appropriate; however, the changed survey methods of CGSS from county level in 2005 to community level in 2010 could result in inconsistent measure scale of social trust. On the other hand, the population weight the CGSS provided is based on province level, the weighted social trust in province level could reflect the real social trust environment in China. Despite these limitations, the findings in this paper fill the gap in our knowledge of trust and health in the context of China and provide additional insight into the effects of “in-group” trust and “out-group” trust on health in China.
Confucian social ethics have been the dominant traditional culture in China, and such ethics are also emphasized by the Chinese government [23]. Although there is a Confucian emphasis on ritual and civility in concrete personal relationships, this lack of “rules for impersonal dealings beyond the face-to-face level” also means that there is a lack of trust that extends beyond the realm of concrete relationships [23]. Other research has noted that trust in China is based more upon “impression” rather than rational judgment [14]. A key challenge to policy implementation is how to improve the “out group” social trust thereby improving the population health. First, Torpe and Lolle [27] found that high educational attainment was positively associated with high social trust (“out group”) in western countries; therefore, governments could invest more on educational attainment across the population. Higher levels of educational attainment not only could improve social trust, but also could protect people’s health even in a society with low “out-group” trust. Education could also help to improve people’s rational judgments in daily life which could improve interpersonal communication. Second, income inequality between the top and bottom levels of society might be an obstacle for the development social trust. Effective social security (i.e. health care, health insurance, unemployment insurance), may help to reduce the inequalities and thus improve the social trust and health outcomes. Finally, the establishment of rules for impersonal dealings beyond the face-to-face levels, which can improve personal connections with strangers beyond individuals’ personal networks, could also encourage individuals to develop more trust within society.