Discrimination and Medical Mistrust in a Racially and Ethnically Diverse Sample of California Adults

Mohsen Bazargan, PhD; Sharon Cobb, PhD, MPH, MSN, RN; Shervin Assari, MD, MPH

Disclosures

Ann Fam Med. 2021;19(1):4-15. 

In This Article

Abstract and Introduction

Abstract

Purpose: Although we know that racial and ethnic minorities are more likely to have mistrust in the health care system, very limited knowledge exists on correlates of such medical mistrust among this population. In this study, we explored correlates of medical mistrust in a representative sample of adults.

Methods: We analyzed cross-sectional study data from the Survey of California Adults on Serious Illness and End-of-Life 2019. We ascertained race/ethnicity, health status, perceived discrimination, demographics, socioeconomic factors, and medical mistrust. For data analysis, we used multinomial logistic regression models.

Results: Analyses were based on 704 non-Hispanic Black adults, 711 Hispanic adults, and 913 non-Hispanic White adults. Racial/ethnic background was significantly associated with the level of medical mistrust. Adjusting for all covariates, odds of reporting medical mistrust were 73% higher (adjusted odds ratio [aOR] = 1.73; 95% CI, 1.15–2.61, P <.01) and 49% higher (aOR = 1.49; 95% CI, 1.02–2.17, P <.05) for non-Hispanic Black and Hispanic adults when compared with non-Hispanic White adults, respectively. Perceived discrimination was also associated with higher odds of medical mistrust. Indicating perceived discrimination due to income and insurance was associated with 98% higher odds of medical mistrust (aOR = 1.98; 95% CI, 1.71–2.29, P <.001). Similarly, the experience of discrimination due to racial/ethnic background and language was associated with a 25% increase in the odds of medical mistrust (aOR = 1.25; 95% CI, 1.10–1.43; P <.001).

Conclusions: Perceived discrimination is correlated with medical mistrust. If this association is causal, that is, if perceived discrimination causes medical mistrust, then decreasing such discrimination may improve trust in medical clinicians and reduce disparities in health outcomes. Addressing discrimination in health care settings is appropriate for many reasons related to social justice. More longitudinal research is needed to understand how complex societal, economic, psychological, and historical factors contribute to medical mistrust. This type of research may in turn inform the design of multilevel community- and theory-based training models to increase the structural competency of health care clinicians so as to reduce medical mistrust.

Introduction

Medical mistrust is a major barrier to a strong patient-clinician relationship.[1–3] Patient mistrust in health care clinicians and in the health care system generally, negatively influences patient behavior and health outcomes.[1–3] Medical mistrust can greatly influence the communication of sensitive medical history and information between patients and health care clinicians.[4] It has also been shown to reduce patient commitment to their treatment plan prescribed by their health care clinician.[4]

Previous research has proposed several theoretical frameworks and models describing how mistrust influences health outcomes. For example, Lee and Lin[5] proposed that patient mistrust influences health outcomes via patient disclosure, the placebo effect, compliance, and the physician's caring behaviors. Several empirical studies have shown that mistrust is associated with a variety of adverse health outcomes including, but not limited to, nonadherence.[6–9] A recent meta-analysis of 47 studies documented the effect of patient mistrust on health outcomes.[10] Although it found only a small to moderate overall effect, the meta-analysis revealed that, from a clinical perspective, medical mistrust is linked to lower adherence to recommended healthier lifestyles, more adverse symptoms, less satisfaction with medical care, and poorer quality of life. Moreover, the same study showed a significant correlation between mistrust and self-reported subjective outcomes, which can greatly affect patient satisfaction and treatment outcomes.

For racial/ethnic minorities, medical mistrust may be rooted in patients' past experience of discrimination.[11–15] An extensive review of the literature revealed that among minority groups, patient mistrust is linked to a lack of commitment to treatment plans, negative health behaviors, and undesired health outcomes.[6,12,15,16] Insufficient comparative studies have been conducted to explore the impact of various types of discrimination by the health care system on patient mistrust. Additionally, the issue of medical mistrust is still relatively unexplored among the Hispanic population. Careful examination of this association within and between racial/ethnic groups may shed light on this complex phenomenon. Understanding the mechanisms of these racial differences may lead to better optimization of therapeutic effectiveness and decreased patient mistrust.[17]

The main objective of this comparative analysis was to examine correlates of medical mistrust among a large sample of non-Hispanic Black, Hispanic, and non-Hispanic White adults. Specifically, 2 distinct types of perceived discrimination by the health care system were examined, namely, discrimination based on race/ethnicity and language, and discrimination based on income and type of or lack of insurance.

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