Validation of the group-based medical mistrust scale among urban black men

Who feels safe calling 911: are prior experiences of anti-Black racial discrimination associated with hesitancy seeking emergency medical services in the event of accidental drug overdose? - a study protocol

BACKGROUND

Racial discrimination is associated with health disparities among Black Americans, a group that has experienced an increase in rates of fatal drug overdose. Prior research has found that racial discrimination in the medical setting may be a barrier to addiction treatment. Nevertheless, it is unknown how experiences of racial discrimination might impact engagement with emergency medical services for accidental drug overdose. This study will psychometrically assess a new measure of hesitancy in seeking emergency medical services for accidental drug overdose and examine prior experiences of racial discrimination and group-based medical mistrust as potential corollaries of this hesitancy.

METHOD

Cross-sectional survey of 200 Black adults seeking treatment for substance-use-related medical problems (i.e. substance use disorder, overdose, infectious complications of substance use, etc.). Participants will complete a survey including sociodemographic information, the Discrimination in Medical Settings Scale, Everyday Discrimination Scale, Group-Based Medical Mistrust Scale, and an original questionnaire measuring perceptions of and prior engagement with emergency services for accidental drug overdose. Analyses will include exploratory factor analysis, Cronbach's alpha, and non-parametric partial correlations controlling for age, gender, income, and education.

CONCLUSIONS

This article describes a planned cross-sectional survey of Black patients seeking treatment for substance use related health problems. Currently, there is no validated instrument to measure hesitancy in seeking emergency medical services for accidental drug overdose or how experiences of racial discrimination might relate to such hesitancy. Results of this study may provide actionable insight into medical discrimination and the rising death toll of accidental drug overdose among Black Americans.

Associations Between Religiosity and Medical Mistrust: An Age-Stratified Analysis of Survey Data from Black Adults in Chicago

Medical mistrust is associated with poor health outcomes, ineffective disease management, lower utilization of preventive care, and lack of engagement in research. Mistrust of healthcare systems, providers, and institutions may be driven by previous negative experiences and discrimination, especially among communities of color, but religiosity may also influence the degree to which individuals develop trust with the healthcare system. The Black community has a particularly deep history of strong religious communities, and has been shown to have a stronger relationship with religion than any other racial or ethnic group. In order to address poor health outcomes in communities of color, it is important to understand the drivers of medical mistrust, which may include one's sense of religiosity. The current study used data from a cross-sectional survey of 537 Black individuals living in Chicago to understand the relationship between religiosity and medical mistrust, and how this differs by age group. Descriptive statistics were used to summarize data for our sample. Adjusted stratified linear regressions, including an interaction variable for age group and religiosity, were used to model the association between religiosity and medical mistrust for younger and older people. The results show a statistically significant relationship for younger individuals. Our findings provide evidence for the central role the faith-based community may play in shaping young peoples' perceptions of medical institutions.

Greater Improvements in Vaccination Outcomes Among Black Young Adults With Vaccine-Resistant Attitudes in the United States South Following a Digital Health Intervention: Latent Profile Analysis of a Randomized Control Trial

Background

Negative attitudes toward vaccines and suboptimal vaccination rates among African American and Black (Black) Americans have been well documented, due to a history of medical racism and human rights violations in the United States. However, digital health interventions (DHI) have been shown to address racial disparities in several health outcomes, such as cardiovascular disease, HIV, and maternal health. The Tough Talks COVID (TT-C) study was a randomized controlled trial of a DHI designed to empower Black young adults in the United States South to make informed, autonomous decisions about COVID-19 vaccine uptake by addressing structural barriers and misinformation about vaccines.

Objective

Our objective was to identify subgroups of Black young adults with various vaccine attitudes at baseline and determine the subgroups for which the TT-C DHI was most impactful.

Methods

Black young adults aged 18-29 years in Alabama, Georgia, and North Carolina who were unvaccinated or insufficiently vaccinated against COVID-19 completed three online surveys over three months (N=360). Latent profile analysis was used to identify subgroups based on general vaccine attitudes at baseline, including hesitancy, confidence, knowledge, conspiracy beliefs, and mistrust. Logistic regression was used to examine the associations between latent profiles and vaccine uptake, and linear regression was used to examine changes in vaccine attitudes at three months post-randomization. Modification of the TT-C DHI's effects was assessed by latent profiles.

Results

Three latent profiles emerged: vaccine-receptive (n=124), vaccine-neutral (n=155), and vaccine-resistant (n=81). Political affiliation, income, social support, and recent flu vaccination differed significantly between the three subgroups (P<.05). Vaccine uptake was not significantly different by subgroup, and the TTC-DHI did not have differing effects on uptake across subgroups. However, the DHI had the strongest effect-with statistically significant measures of association (P<.05) and interaction P values (P<.10)-among the baseline vaccine-resistant and vaccine-neutral subgroups compared to the vaccine-receptive subgroups at three months in improving vaccine hesitancy, confidence, and conspiracy beliefs at three months: vaccine-resistant difference: -0.40 (-0.76 to -0.37), 0.39 (0.02 to 0.75), and -0.47 (-0.86 to -0.09); vaccine neutral difference: -0.36 (-0.52 to -0.19), 0.35 (0.18 to 0.51), and -0.24 (-0.44 to -0.03). The DHI had no effects on these outcomes among the vaccine-receptive subgroup.

Conclusions

Our findings revealed subgroups of Black young adults in the United States South with different vaccination attitudes, for which the TT-C intervention had differing effects. Black young adults who are vaccine-resistant or vaccine-neutral may experience larger gains from a digital vaccine intervention. Future work aimed at improving vaccination outcomes could target these populations to maximize resource efficiency and drive the greatest improvements in vaccine outcomes.

Rural and urban differences in HIV pre-exposure prophylaxis (PrEP) awareness and acceptability among Black cisgender women living in the U.S. South

Black cisgender women in the U.S. South experience a significant disparity in HIV infection rates. Pre-exposure Prophylaxis (PrEP) is an effective medication that can reduce HIV risk but is underutilized among Black women. We assessed the association between setting and PrEP awareness and acceptability in Black cisgender women in the U.S. South. A cross-sectional online survey was administered from March to June 2022 to HIV-negative Black cisgender women living in the Southern United States. Participants reported demographic information, PrEP awareness, likelihood of PrEP use, HIV knowledge, risk perception, and healthcare access. Logistic regression models assessed correlates of PrEP awareness and acceptability. Of 491 participants (Mean age = 40.42 [SD = 17.5], 20.0% rural, 80.0% urban/suburban), 44.9% of rural and 38.2% of urban/suburban participants were PrEP aware. 44.9% of rural versus 36.1% of urban/suburban participants were likely to use PrEP. Rural Black women reported higher PrEP acceptability (adjusted odds ratio [aOR] = 1.96, 95% CI 1.20, 3.18, p = 0.01). Having health insurance (aOR = 2.43, 95% CI 1.28, 4.65, p = 0.01) and younger age (aOR = 0.98, 95% CI 0.96, 0.99, p < 0.001) were associated with PrEP acceptability. To improve PrEP awareness, acceptability, and uptake, intervention programs should be tailored to individuals' geographical circumstances and needs.

HIV Testing Barriers Among Black and Latina Women: An Examination of Medical Mistrust, Daily Discrimination, and Current Substance Use

Background: Black and Latina women are disproportionally affected by Human Immunodeficiency Virus (HIV) and medical mistrust may be a testing barrier, especially among women experiencing substance use and discrimination. Objectives: This study examined current substance use, daily discrimination exposure, and medical mistrust factors (medical disparities, medical suspiciousness) on HIV testing. An online survey was completed by 97 Black and/or Latina women. Bayesian generalized linear modeling tested two hypotheses: 1) Current substance use, higher discrimination exposure, and higher medical mistrust would reduce the odds of HIV testing (ever being tested and recent testing within the past year), 2) Substance use and discrimination would moderate associations between medical mistrust and testing. Results: For Hypothesis 1, current substance use (Odds Ratio [OR]=1.42), higher discrimination exposure (OR=1.26), lower medical disparities (OR=0.83), and lower medical suspiciousness (OR=0.70) were associated with higher odds of ever being HIV tested. For Hypothesis 2, current substance use moderated the association between medical disparities with ever being HIV testing, while discrimination exposure moderated the association between medical suspiciousness with ever being tested (ORs<0.66). Current substance use moderated the associations between medical disparities and medical suspiciousness with recent HIV testing, while discrimination exposure also moderated the association between medical suspiciousness with recent testing (ORs>1.11). Conclusions: HIV testing barriers were generally associated with higher odds of testing, suggesting complex relationships may occur within medical settings for high-risk women experiencing discrimination.

Medical Mistrust and Willingness to Use Mental Health Services Among a Cohort of Black Adults

OBJECTIVE

Black adults experience depression that is more severe than that of their White counterparts, yet they are less likely to receive treatment from a mental health professional. This study aimed to examine the relationships between medical mistrust or trust and the willingness to seek mental health care.

METHODS

The authors conducted an online cross-sectional survey of 1,043 Black adults in the United States. The primary variables of interest were medical mistrust (measured via the 12-item Group-Based Medical Mistrust Scale; GBMMS) and a single item, derived from the General Help-Seeking Questionnaire, that assessed willingness to seek mental health care. The authors hypothesized that mistrust would have a negative correlation with willingness to seek help from a mental health professional. To estimate the association between level of mistrust and willingness to seek care, gamma regression models were fitted with a log link, and the analyses were adjusted for age, ethnic identity or origin, education, insurance status, personal income, citizenship status, and length of time in the United States.

RESULTS

At low levels of medical mistrust (GBMMS scores ≤3), an increase in mistrust was significantly associated with an increase in the probability of seeking mental health care (rate ratio [RR]=1.55, p<0.001). At high levels of medical mistrust (GBMMS scores >3), an increase in mistrust was associated with a decrease in care seeking (RR=0.74, p<0.001). Similar patterns were observed for medical trust.

CONCLUSIONS

At low levels of medical mistrust among Black adults, each unit increase in mistrust was counterintuitively associated with an increase in willingness to seek care from a mental health professional.

Medical Mistrust: A Concept Analysis

Background: The term "medical mistrust" has increased in literary usage within the last ten years, but the term has not yet been fully conceptualized. This article analyzes the usage of the term "medical mistrust" in the extant literature in order to articulate its antecedents, attributes, and consequences. The aim of this article is to provide a preliminary conceptual definition and conceptual figure for medical mistrust. Methods: Walker and Avant's method of conceptual analysis was used to extract concept attributes, antecedents, and consequences and define empirical referents. The databases PubMed, CINAHL, Scopus, and PSYCinfo and the Google search engine were used. Results: Medical mistrust is a social determinant of health fueled by a fear of harm and exploitation and is experienced at both the interpersonal, intergenerational, and institutional levels, reinforced by structural racism and systemic inequalities. Medical mistrust is antedated by historical trauma, socioeconomic disparities, medical gaslighting, traumatic medical experiences, maladaptive health beliefs and behaviors, and individual minority identities and is transmitted intergenerationally and culturally. The consequences of medical mistrust include the underutilization of health services, delays in diagnosis and care, poor treatment adherence, poor health outcomes, negative psychological effects, and an increase in the uptake of medical misinformation and maladaptive health behaviors. Conclusions: The findings of this concept analysis have important implications for healthcare providers, healthcare systems, and researchers, as well as healthcare policy makers.

Prevalence and Predictors of Medical Mistrust Among Socioeconomically and Racially Diverse Cancer Patients in Philadelphia

Background/Objectives: Medical mistrust (MM) is associated with adverse health outcomes, but few studies have assessed MM in cancer patients. MM is frequently measured using the Medical Mistrust Inventory (MMI), measuring institutional MM (e.g., government), or the Group-Based Medical Mistrust Scale (GBMMS), measuring race-based MM. We sought to assess the prevalence of MM among cancer patients diverse by age, sex, race/ethnicity, and socioeconomic status (SES), recruited from an urban safety net hospital and a suburban comprehensive cancer center. Methods: Patients completed a one-time survey. The primary outcome was MM as measured by the GBMMS and MMI tools. Covariates included demographics, treatment campus (urban vs. suburban), and psychosocial measures relevant to MM. Results: Purposeful sampling recruitment resulted in 200 participants (survey completion: 74.6%). The median age was 60 years, with 62% female, 45% African-American, 15% Hispanic, 47.5% education ≤ HS diploma, and 51.5% income ≤ USD 50,000/yr. Elevated MMI and GBMMS scores (moderate-to-high) were seen, respectively, in Hispanic (20.7% and 33.4%) and African-American (AA) patients (31.8% and 48.9%), compared with White patients (14.3% and 9.9%). The MMI and GBMMS tools captured complimentary aspects of MM in cancer patients (Spearman's 0.531, p < 0.0001). MMI was associated with lower education (0.034) and race (p = 0.04), while GBMMS was strongly associated with race (p < 0.001), urban campus (p = 0.035), and mistrust of government/health organization information (both p < 0.05). Higher MMI/GBMMS scores were both associated with research mistrust and mistrust of information from physicians. Conclusions: Institutional and race-based MM are prevalent among cancer patients diverse by age, sex, race/ethnicity, and SES. Lower education was associated with institutional MM but not race-based MM.

Medical Mistrust and Healthcare Seeking Among Women of Color with Chronic Vulvovaginal Pain

BACKGROUND

Chronic vulvovaginal pain (CVVP), an umbrella term encompassing several gynecological pain conditions (e.g., vulvodynia, vaginismus), has a prevalence rate of 7-8% in the USA and is characterized by considerable diagnostic delay in patient experience research. Furthermore, current research in this area focuses largely on the experiences of white women, while the experiences of women of color are underrepresented.

METHOD

In the present cross-sectional study (N = 488), we surveyed women of color (i.e., Asian, Black, and/or Hispanic/Latinx women) with CVVP about their perceptions and experiences with medical mistrust, healthcare seeking, and healthcare avoidance.

RESULTS

Using the suspicion subscale of the Group-Based Medical Mistrust Scale, we found significant racial and ethnic differences in medical suspicion scores, with non-Black Hispanic/Latinx women reporting the highest suspicion scores and non-Hispanic/Latinx Black women reporting the lowest scores. Racial differences disappeared, however, after examining medical mistrust and perceived discrimination as predictors for various healthcare outcomes related to the journey to diagnosis and healthcare avoidance behaviors. We found that while suspicion was a reliable predictor of increased diagnostic delay and healthcare avoidance in many contexts, the results for perceived discrimination were more varied, suggesting considerable nuance in the relationship between medical mistrust, perceived discrimination, and healthcare seeking outcomes.

CONCLUSION

These findings point to shared experiences of medical mistrust via suspicion that broadly characterize women of color's experiences in seeking CVVP-related care-future research is needed to examine nuances within racial and ethnic groups regarding their healthcare seeking experiences in the CVVP context.

Understanding and Promoting Preventive Health Service Use Among Black Men: Community-Driven and Informed Insights

Black men experience high rates of adverse health that can be prevented or mitigated by the regular use of preventive health services. Efforts are urgently needed to promote this type of health service use among Black men. The U.S. Preventive Services Task Force and the Institute of Medicine indicate that such efforts must align with Black men's values, perspectives, and preferences. However, little guidance exists on how to align these efforts for Black men. The present qualitative study was developed to understand factors associated with preventive health service use among Black men and community-informed strategies to promote preventive health service use among these men. An approach rooted in community-based participatory research and ecological theory was used. A core leadership team consisting of five Black men from the area guided the project's development, implementation, and evaluation. The core leadership team conducted 22 interviews with Black men from their communities. Four themes emerged from these interviews: (1) holistic well-being challenges faced by Black men: interaction of mental, physical, and societal forces; (2) the interplay of financial, informational, and gendered barriers/facilitators to using preventative health services among Black men; (3) the importance of shared identity in peer health education about preventive health service use; and (4) the need for community-centered initiatives to improve preventive health service use among Black men that prioritize accessibility and information. Findings of the present study can be used to tailor preventive health service use efforts for Black men. Such efforts have the potential to promote health and mitigate health disparities.

Effects of Government Mistrust and Group-Based Medical Mistrust on COVID-19 Vaccine Hesitancy Among a Sample of African Americans

BACKGROUND

Despite the demonstrated efficacy of coronavirus disease (COVID-19) vaccines, higher rates of vaccine hesitancy among African Americans remain concerning. As determinants of vaccine hesitancy, the simultaneous roles of government mistrust and group-based medical mistrust have not been examined via from a cognitive information perspective among African Americans.

PURPOSE

We examined the direct and indirect effects of government mistrust and group-based medical mistrust on COVID-19 vaccine hesitancy in a sample of African Americans.

METHODS

We obtained data from 382 African Americans in South-East Michigan via an online survey. We assessed demographic variables, government mistrust, group-based medical mistrust, COVID risk and COVID worry, and positive and negative beliefs regarding the COVID-19 vaccine (i.e., vaccine pros and cons), and vaccine hesitancy. We examined our hypotheses with path analyses.

RESULTS

Results indicated significant direct effects of government mistrust on vaccine hesitancy; however, despite a significant correlation, there was no direct effect of group-based medical mistrust on vaccine hesitancy. The effect of group-based medical mistrust was fully mediated by both vaccine pros and cons, whereas the effect of government mistrust was partially mediated by vaccine pros. COVID risk and COVID worry did not mediate the effects of mistrust to vaccine hesitancy.

CONCLUSION

Negative effects of group-based medical mistrust on COVID-19 vaccine hesitancy among African Americans may be amenable to interventions that focus on beliefs about the vaccine rather than beliefs about vulnerability to the virus. However, given its direct effect, it may be necessary to focus directly on government mistrust to diminish its effects on COVID-19 vaccine hesitancy.

Understanding Intentions to Discuss Long-Acting Injectable Pre-Exposure Prophylaxis with Healthcare Providers Among Black and Hispanic Gay and Bisexual Men in Texas

We examined factors influencing the intention of Black and Hispanic gay and bisexual men aged 18-34 years in Texas to discuss starting long-acting injectable pre-exposure prophylaxis (LAI-PrEP) with healthcare providers. Participants were recruited through geosocial apps and community locations, completed online surveys measuring attitudes, subjective norms, perceived behavioral control (Theory of Planned Behavior), internalized homophobia, medical mistrust, HIV risk, and medical mistrust. Among the final sample (N = 190), 63.5% intended to discuss LAI-PrEP. Poisson regression models indicated that higher attitudinal concerns [adjusted prevalence ratio (aPR): 0.80, 95% confidence interval (CI): 0.70, 0.92; P < 0.01) and higher medical mistrust (aPR: 0.98, 95% CI: 0.97, 0.99; P = 0.01) were linked to lower prevalence of intentions. Seeing a doctor in the past 12 months was associated with higher prevalence of discussing LAI-PrEP (aPR: 1.46, 95% CI: 1.00, 2.13; P = 0.05). Addressing concerns and reducing discrimination are crucial for improving LAI-PrEP uptake in this population.

Intersectionality in Health Communication: How Health Communication Influences the Association Between Intersectional Discrimination and Health Information Seeking

With an intersectional orientation, we examine associations between discrimination, health communication, and information-seeking intention about HIV prevention in the context of pre-exposure prophylaxis (PrEP) among cisgender women through an online survey (N = 341). We elaborate on the idea that intersectional discrimination is a social determinant of health by considering the context with differing power relations-day-to-day life and the healthcare field-based on Bourdieu's field theory, and explore moderating roles of health communication in this relationship according to the structural influence model of communication (SIM). The relationships between intersectional discrimination and intention show different patterns by the context in which intersectional experiences are considered, and the relationships are moderated differently by the mode of health communication. We discuss how to conduct intersectionality-informed health communication research without sacrificing intersectionality's foundational foci.

Group-based medical mistrust in genomic medicine: Associations with patient and provider perceptions of a specialty clinical encounter

PURPOSE

Investigating associations between group-based medical mistrust (GBMM) and perceptions of patient-provider encounters can identify one mechanism through which GBMM may influence health outcomes and serve as a barrier to equitable health care. This study investigated associations between GBMM reported by caregivers of children with a possible genetic condition and caregivers' and providers' perceptions of a specialty care appointment discussing diagnostic plans.

METHODS

Caregivers (N = 177) completed the GBMM scale and other measures before their child's initial specialty clinic visit. After the visit, caregivers reported their perceptions of the visit, including patient centeredness and satisfaction with care. Providers (N = 6) reported their perceptions of patient engagement.

RESULTS

Multivariable linear regression showed that higher caregiver GBMM was associated with caregivers' lower satisfaction with care (P < .01) and more negative perceptions of every domain of patient centeredness (P = .001-.04). Multilevel modeling showed that higher caregiver GBMM was associated with more negative provider perceptions of caregivers' preparedness to participate in care (P = .03), likely treatment compliance (P = .03), and relevance of questions asked during visit (P = .04).

CONCLUSION

Our findings extend evidence for detrimental effects of GBMM on patient satisfaction to caregivers of pediatric patients and offer new evidence for associations with health care providers' perceptions of caregivers' engagement with care.

Medical Mistrust Among Black Patients with Serious Illness: A Mixed Methods Study

BACKGROUND

Medical mistrust among Black patients has been used to explain the existence of well-documented racial inequities at the end of life that negatively impact this group. However, there are few studies that describe patient perspectives around the impact of racism and discriminatory experiences on mistrust within the context of serious illness.

OBJECTIVE

To better characterize experiences of racism and discrimination among patients with serious illness and its association with medical mistrust.

PARTICIPANTS

Seventy-two Black participants with serious illness hospitalized at an academic county hospital.

APPROACH

This is a convergent mixed methods study using data from participant-completed surveys and existing semi-structured interviews eliciting participants' perspectives around their experiences with medical racism, communication, and decision-making.

MAIN MEASURES

The experience of medical racism and its association with Group-Based Medical Mistrust (GBMM) scale scores, a validated measure of medical mistrust.

KEY RESULTS

Of the 72 Black participants, 35% participated in interviews. Participants were mostly men who had significant socioeconomic disadvantage, including low levels of wealth, income, and educational attainment. There were reported high levels of race-based mistrust in the overall GBMM scale score (mean [SD], 36.6 [9.9]), as well as high scores within the suspicion (14.2 [5.0]), group disparities in healthcare (9.9 [2.8]), and lack of support (9.1 [2.7]) subscales. Three qualitative themes aligned with the GBMM subscales. Participants expressed skepticism of healthcare workers (HCWs) and modern medicine, recounted personal experiences of discrimination in the medical setting, and were frustrated with poor communication from HCWs.

CONCLUSIONS

This study found high levels of mistrust among Black patients with serious illness. Suspicion of HCWs, disparities in healthcare by race, and a lack of support from HCWs were overarching themes that influenced medical mistrust. Critical, race-conscious approaches are needed to create strategies and frameworks to improve the trustworthiness of healthcare institutions and workers.

Factors predicting primary and booster COVID-19 vaccination in a community sample of African American men and women in the United States Midwest

COVID-19 has disproportionately burdened impoverished minority communities. This study recruited an age- and gender-diverse community sample of 541 Black adults in a United States Midwestern city with large racial health disparities, with the aim of examining factors associated with COVID-19 vaccination. All participants completed measures assessing their COVID-19 vaccination status (unvaccinated, received primary vaccination, or received primary plus booster vaccination) as well as demographic characteristics, socioeconomic factors, health and health system factors, and health behavior theory constructs related to vaccination. In this predominantly low-income sample, 55% of participants had received primary COVID-19 vaccination and 31% of the sample had received a booster dose. Multiple regression analyses established that having primary vaccination was significantly predicted by older age, political identification as Democrat, education beyond high school, barriers to accessing health care, as well as higher trust of vaccine benefits, less preference for natural immunity, stronger social norms favoring vaccination, and perceiving higher levels of collective responsibility. Surprisingly, higher global medical mistrust and difficulty with healthcare access were associated with vaccination. The model explained 76% of the variance in primary COVID-19 vaccination. Having received a COVID-19 booster was predicted by older age, previous COVID-19 infection, higher trust in vaccine benefits, and fewer worries about unforeseen future effects of vaccination. Study findings identified factors associated with COVID-19 vaccine uptake in racial minority communities, and support the benefits of interventions that harness social network supports for vaccination, address community vaccine concerns, and appeal to collective responsibility to promote vaccine uptake.

Validation of a Modified Group-Based Medical Mistrust Scale Among Young Latinx Adults in the United States

Medical mistrust is an important barrier to accessing health care among Latinx populations in the United States (US). However, research on the validity and reliability of medical mistrust scales is limited. We examined the validity and reliability of a modified bilingual version of the Group-Based Medical Mistrust scale (mGBMMS) among a sample of Latinx adults. Participants included 308 Latinx adults (ages 18-25), who responded in Spanish (n = 134) or English (n = 174). Following feedback from bilingual/bicultural staff during the English-Spanish translation process, we made three changes to the original GBMMS. Validation testing of our 12-item mGBMMS scale included: split-half and internal consistency reliability; discriminant, convergent, and predictive validity; and both exploratory and confirmatory factor analyses. The mGBMMS had good internal consistency (overall sample: Cronbach's α = 0.79; Spanish: Cronbach's α = 0.73; English: Cronbach's α = 0.83). The mGBMMS showed good convergent (moderately correlated with the experiences of discrimination scale, r = 0.46, p < 0.001) and discriminant (weakly correlated with the acculturation scale, r = 0.11, p = 0.06) validity. Split-half reliability was 0.71 (p < 0.001). Exploratory and confirmatory factor analyses found a two-factor solution. The mGBMMS was associated with satisfaction with care (OR = 0.60, 95%CI: 0.42-0.87), a sign of good predictive validity. Findings suggest that the mGBMMS is a valid and reliable scale to utilize among bilingual (Spanish/English) populations in the US. Further validation studies should be considered among Latinx respondents of different ages, backgrounds, languages, and US regions.

Prevalence of Medical Mistrust and Its Impact on Patient Satisfaction in Pediatric Caregivers

Racial minorities report lower perceived quality of care received compared to non-Hispanic White Americans, resulting in racial disparities in patient satisfaction. Medical mistrust, defined as a lack of confidence in the medical establishment and the intentions of medical personnel, is more prevalent among racial minority groups and is associated with poorer health outcomes. This study examines the prevalence and racial differences of patient/caregiver medical mistrust and its relationship to patient satisfaction among the pediatric patient population at a large urban academic medical center. A cross-sectional anonymous survey was conducted for caregivers of pediatric families seen at an urban tertiary care facility, including demographic information, the Patient Satisfaction Questionnaire (PSQ), and the Group-Based Medical Mistrust Scale (GBMMS). Linear regressions and mediation analyses were performed, examining race-based medical mistrust and associations with patient satisfaction. Sixty-seven surveys (67% Black/African American, 24% White) were completed. Black/African American participants reported higher levels of medical mistrust (M = 2.29, SD = 0.88 vs. M = 1.37, SD = 0.50; p < .001), which was associated with lower patient satisfaction (p < .001). In a parallel mediation analysis, disaggregating the GBMMS into three subscales, a significant indirect relationship emerged between race and patient satisfaction via the subscale lack of support from healthcare providers (95% CI [- 1.52, - .02], p < .05). Black/African American participants were more likely to have medical mistrust, and greater medical mistrust was significantly associated with lower patient satisfaction. Black/African American participants were significantly more likely to perceive lower support from healthcare providers which, in turn, was associated with lower patient satisfaction. These findings identify potential areas for intervention to improve Black/African American patients' experience with healthcare.

Group-Based Medical Mistrust in Adolescents With Poorly Controlled Asthma Living in Rural Areas

Black youth and rural adolescents are two groups who experience asthma disparities. Racism and discrimination in health care likely lead to group-based (systems-level) medical mistrust for some adolescents. Group-based medical mistrust, one pathway by which racism drives health inequities, is associated with poorer outcomes for patients with chronic conditions. Despite its potential importance in adolescent asthma, previous research has not considered group-based medical mistrust in this population. To fill this gap, we characterize group-based medical mistrust among rural adolescents with poorly controlled asthma, examining demographic differences. We analyzed baseline data from a school-based clinical trial in which 164 adolescents (mean age = 16.3; 76.2% Black) completed the Group-Based Medical Mistrust Scale (GBMMS). Using linear regression, we tested associations with race, gender, and age, controlling for recent medical visits and insurance status. The total GBMMS mean score was 2.3 (SD = 1.22); subscale scores ranged from 2.3 to 2.4. Black adolescents reported significantly higher total GBMMS scores (β = .45, p = .003) and significantly higher scores on two GBMMS subscales: suspicion of health care providers (β = .56, p = .007) and lack of support from health care providers (β = .36, p = .007). Gender and age were not associated with GBMMS scores. Health care providers need to consider medical mistrust and its role in their clinical care. Together with their institutions, health care providers and researchers should work toward changing systems that perpetuate racism to build trust as a means of reducing asthma disparities among adolescents.

An examination of the independent and intersectional effects of racial and heterosexist medical mistrust on timing of sexual/reproductive health care visits among Black sexual minority women in the USA

Experiences of racism and heterosexism in medical settings are social and systemic barriers to 'on-time' receipt of sexual and reproductive health services among women with both racial and sexual minority identities. Medical mistrust based on experiences related to these dual identities is associated with avoidance and delays in care. However, investigators are just beginning to apply an intersectional lens to quantitatively understanding such barriers. The purpose of this study was to examine the independent and interaction effects of racial and heterosexist medical mistrust on timing of sexual/reproductive health care among Black sexual minority women who have sex with women and men. A total of 320 women participated in an online study of factors affecting sexual health in this population. Ordinal logistic regression was used to assess the independent and interaction effects of racial and heterosexist medical mistrust on self-reported time since last sexual/reproductive health visit. Results indicated an interaction between the two types of medical mistrust. Research on Black women who have sex with women and men's experiences of racism and heterosexism in the US healthcare system can lead to the development of the comprehensive training programmes needed to alleviate medical mistrust among women with racial and sexual minority identities.

Physician Perspectives on Responding to Clinician-Perpetuated Interpersonal Racism Against Black Patients with Serious Illness

BACKGROUND

Racism negatively affects clinical outcomes in Black patients, but uncertainty remains among physicians regarding how to address interpersonal anti-Black racism incidences involving them to facilitate racial healing and promote accountability.

OBJECTIVE

Elicit physician perspectives on addressing concerns from Black patients about interpersonal racism involving them or their team.

PARTICIPANTS

Twenty-one physician subspecialists at an urban academic medical center.

APPROACH

We conducted one-on-one semi-structured interviews to help inform the development of a clinician-facing component of a program to address the distress of racism experienced by Black patients with serious illness. We asked clinicians to describe experiences discussing racism with patients and identify additional resources to support these conversations.

MAIN MEASURES

Physician perspectives, including barriers and facilitators, to promote racial healing and clinician accountability when discussing clinician-perpetuated interpersonal racism with Black patients.

KEY RESULTS

Of the 21 participating physicians, 67% were women with a mean age of 44.2 years and mean of 10.8 years of experience as an attending physician. Four identified as Asian, three identified as Black, and 14 identified as White. Participants largely felt unprepared to discuss racism with their patients, especially if the harm was caused by them or their team. Participants felt patients should be given tools to discuss concerns about racism with their clinicians, but worried about adding additional burdens to Black patients to call out racism. Participants believed programs and processes with both patient- and clinicians-facing components had the potential to empower patients while providing resources and tools for clinicians to engage in these highly sensitive discussions without perpetuating more harm.

CONCLUSIONS

Addressing and improving communication about interpersonal racism in clinical settings are challenging. Dual-facing programs involving patients and clinicians may help provide additional resources to address experiences of interpersonal racism and hold clinicians accountable.

Medical Mistrust on Prostate Cancer Screening: A mixed method study among African Americans, Caribbean immigrants and African immigrants

Objectives

The contribution of medical mistrust to healthcare utilization delays has been gaining increasing attention. However, few studies have examined these associations among subgroups of Black men (African Americans, Caribbean, and African immigrants) in relation to prostate cancer (PCa). This study addresses this gap by assessing how medical mistrust affects PCa screening behavior and to further understand perceptions of medical mistrust among subgroups of Black men.

Methods

This research employs a mixed-methods approach comprising two distinct phases. In Phase 1, a cross-sectional examination was conducted to evaluate the influence of medical mistrust toward healthcare organizations on prostate cancer screening among 498 Black men. In Phase 2, a qualitative investigation was undertaken to delve into the nuances of medical mistrust through six focus groups (n=51) and ten key informant interviews (n=10). Logistic regression and grounded theory methods were employed for data analysis.

Results

Quantitative findings unveiled disparities in mistrust among subgroups, with Caribbean immigrants exhibiting higher levels of medical mistrust. Nevertheless, individuals with a family history of PCa showed elevated likelihoods of undergoing screening, despite mistrust. Qualitative results revealed 1) differences in reasons for medical mistrust among Black subgroups, 2) cultural perceptions which influence medical mistrust and medical care seeking, 3) lack of education in relation to PCa that contributes to medical mistrust, 4) negative past experiences and poor provider communication contribute, and 5) when PCa directly affected one's life, either personally or within the family, there was a recognized importance placed on monitoring one's risk despite mistrust.

Conclusion

While medical mistrust may not significantly deter healthcare utilization among individuals with a family history or diagnosis of PCa, it underscores the variability of medical mistrust and its underlying reasons among different Black subgroups.

Examining the Relationship between Anti-Black Racism, Community and Police Violence, and COVID-19 Vaccination

In 2020, the COVID-19 pandemic emerged against a backdrop of long-standing racial inequities that contributed to significant disparities in COVID-19 mortality, morbidity, and eventually, vaccination rates. COVID-19 also converged with two social crises: anti-Black racism and community and police violence. The goal of this study was to examine the associations between community violence, police violence, anti-Black racism, and COVID-19 vaccination. Survey data were collected from a sample of 538 Black residents of Chicago between September 2021 and March 2022. Structural equation modeling was used to test associations between neighborhood violence, police violence, racism, medical mistrust, trust in COVID-related information, depressive symptoms, and having received a COVID-19 vaccination. In line with predictions, neighborhood violence had a significant indirect effect on vaccination via trust in COVID-related information from a personal doctor. Additionally, racism had a significant indirect effect on vaccination via trust in COVID-related information from a personal doctor, as well as via medical mistrust and trust in COVID-related information from a personal doctor. These findings add to the growing body of literature demonstrating the importance of medical mistrust when examining COVID-19 vaccination disparities. Furthermore, this study highlights the importance of considering how social and structural factors such as violence and racism can influence medical mistrust.

Family cascade screening for equitable identification of familial hypercholesterolemia: study protocol for a hybrid effectiveness-implementation type III randomized controlled trial

BACKGROUND

Familial hypercholesterolemia (FH) is a heritable disorder affecting 1.3 million individuals in the USA. Eighty percent of people with FH are undiagnosed, particularly minoritized populations including Black or African American people, Asian or Asian American people, and women across racial groups. Family cascade screening is an evidence-based practice that can increase diagnosis and improve health outcomes but is rarely implemented in routine practice, representing an important care gap. In pilot work, we leveraged best practices from behavioral economics and implementation science-including mixed-methods contextual inquiry with clinicians, patients, and health system constituents-to co-design two patient-facing implementation strategies to address this care gap: (a) an automated health system-mediated strategy and (b) a nonprofit foundation-mediated strategy with contact from a foundation-employed care navigator. This trial will test the comparative effectiveness of these strategies on completion of cascade screening for relatives of individuals with FH, centering equitable reach.

METHODS

We will conduct a hybrid effectiveness-implementation type III randomized controlled trial testing the comparative effectiveness of two strategies for implementing cascade screening with 220 individuals with FH (i.e., probands) per arm identified from a large northeastern health system. The primary implementation outcome is reach, or the proportion of probands with at least one first-degree biological relative (parent, sibling, child) in the USA who is screened for FH through the study. Our secondary implementation outcomes include the number of relatives screened and the number of relatives meeting the American Heart Association criteria for FH. Our secondary clinical effectiveness outcome is post-trial proband cholesterol level. We will also use mixed methods to identify implementation strategy mechanisms for implementation strategy effectiveness while centering equity.

DISCUSSION

We will test two patient-facing implementation strategies harnessing insights from behavioral economics that were developed collaboratively with constituents. This trial will improve our understanding of how to implement evidence-based cascade screening for FH, which implementation strategies work, for whom, and why. Learnings from this trial can be used to equitably scale cascade screening programs for FH nationally and inform cascade screening implementation efforts for other genetic disorders.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05750667. Registered 15 February 2023-retrospectively registered, https://clinicaltrials.gov/study/NCT05750667 .

Project CHARIOT: study protocol for a hybrid type 1 effectiveness-implementation study of comprehensive tele-harm reduction for engagement of people who inject drugs in HIV prevention services

BACKGROUND

People who inject drugs (PWID) remain a high priority population under the federal Ending the HIV Epidemic initiative with 11% of new HIV infections attributable to injection drug use. There is a critical need for innovative, efficacious, scalable, and community-driven models of healthcare in non-stigmatizing settings for PWID. We seek to test a Comprehensive-TeleHarm Reduction (C-THR) intervention for HIV prevention services delivered via a syringe services program (SSP).

METHODS

The CHARIOT trial is a hybrid type I effectiveness-implementation study using a parallel two-arm randomized controlled trial design. Participants (i.e., PWID; n = 350) will be recruited from a syringe services program (SSP) in Miami, Florida. Participants will be randomized to receive either C-THR or non-SSP clinic referral and patient navigation. The objectives are: (1) to determine if the C-THR intervention increases engagement in HIV prevention (i.e., HIV pre-exposure prophylaxis; PrEP or medications for opioid use disorder; MOUD) compared to non-SSP clinic referral and patient navigation, (2) to examine the long-term effectiveness and cost-effectiveness of the C-THR intervention, and (3) to assess the barriers and facilitators to implementation and sustainment of the C-THR intervention. The co-primary outcomes are PrEP or MOUD engagement across follow-up at 3, 6, 9 and 12 months. For PrEP, engagement is confirmed by tenofovir on dried blood spot or cabotegravir injection within the previous 8 weeks. For MOUD, engagement is defined as screening positive for norbuprenorphine or methadone on urine drug screen; or naltrexone or buprenorphine injection within the previous 4 weeks. Secondary outcomes include PrEP adherence, engagement in HCV treatment and sustained virologic response, and treatment of sexually transmitted infections. The short and long term cost-effectiveness analyses and mixed-methods implementation evaluation will provide compelling data on the sustainability and possible impact of C-THR on comprehensive HIV prevention delivered via SSPs.

DISCUSSION

The CHARIOT trial will be the first to our knowledge to test the efficacy of an innovative, peer-led telehealth intervention with PWID at risk for HIV delivered via an SSP. This innovative healthcare model seeks to transform the way PWID access care by bypassing the traditional healthcare system, reducing multi-level barriers to care, and meeting PWID where they are.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05897099. Trial registry name: Comprehensive HIV and Harm Prevention Via Telehealth (CHARIOT). Registration date: 06/12/2023.

Factors Associated with Planned Future Use of PrEP in the Next 3 Months and Likelihood to Use PrEP Among Black Cisgender HIV-negative Women in Texas

Identifying and then addressing barriers and leveraging facilitators is important to help increase pre-exposure prophylaxis (PrEP) use among Black women vulnerable to HIV acquisition. The present cross-sectional study examined what factors were associated with future plans to use PrEP, and general likelihood to use it among a convenience sample of 152 adult, Black cisgender women from three metropolitan areas in Texas. The final multivariable logistic regression model revealed that relationship status (aOR = 0.20, 95% CI: 0.05-0.73, p < 0.05), PrEP anticipated stigma (aOR = 0.29, 95% CI: 0.10-0.78, p < 0.05), perceived discrimination (aOR = 0.40, 95% CI: 0.21-0.78, p < 0.01) and interest in learning more about PrEP (aOR = 5.32, 95% CI: 2.60-10.9, p < 0.001) were associated with future plans to use PrEP. The final multivariable linear regression model with maximum likelihood estimation identified that perceived discrimination (β=-0.24, SE: -0.38 - -0.10, p < 0.01), perceived HIV risk (β = 0.33, SE: 0.18-0.49, p < 0.001), willingness to use PrEP with condoms (β = 1.26, SE: 0.94-1.60, p < 0.001), and comfort communicating about PrEP with a provider (β = 0.23, SE: 0.06-0.41, p < 0.01) were associated with general likelihood to use PrEP. Findings reveal key factors that warrant further attention and examination toward improving PrEP use within this population.

Geometric approach to measuring intersectional stigma among black sexual minority men: reliability and validity in an HIV prevention context

BACKGROUND

Stigma and discrimination experiences attributable to multiple intersecting facets of the self (e.g. intersectional stigma) pose substantial challenges to accessing health services, including HIV prevention. While there have been theoretical advances in understanding multiple co-occurring stigmas, there are few psychometric instruments available to assess intersectional stigma. We have developed an approach to assessing intersectional stigma that conceptualises an intersection in geometric terms, defined as the line that connects points on two (or more) stigma dimensions and calculates scores derived from the geometric definition of intersecting lines.

METHODS

Following pilot studies to derive items and response formats, we administered newly developed enacted stigma (24-items) and anticipated stigma (17-items) scales with attributions to race and sexual minority status for stigma experiences to a sample of 422 Black sexual minority men at risk for HIV recruited through social media platforms.

RESULTS

The enacted and anticipated intersectional stigma scales, including subscales representing discrimination, interpersonal and felt stigma demonstrated evidence for reliability and construct validity. The enacted stigma scales were associated with medical mistrust, whereas the anticipated stigma scales predicted perceived barriers to using pre-exposure prophylaxis for HIV prevention.

CONCLUSIONS

The intersectional stigma scales offer greater specificity in measuring stigma experiences attributed to race, sexual minority status and the intersection of racial-sexual minority status.

COVID-19 Vaccine Hesitancy in Cameroon: The Role of Medical Mistrust and Social Media Use

Most African countries report low COVID-19 vaccination rates (Msellati et al., 2022; WHO Africa; 2020). This study focuses on factors associated with vaccine hesitancy specifically in the country of Cameroon. Social media use and medical mistrust have been suggested as key variables that may increase vaccine hesitancy. Adopting the information-related perspective guided by the risk information seeking and processing model, the current research explored how social media use and medical mistrust are related to vaccine hesitancy among Cameroonians. Survey results from a sample of 1,000 Cameroonians fielded in early 2022 showed that social media use and medical mistrust were positively associated with belief in misinformation related to the COVID-19 vaccine. Belief in misinformation about the COVID-19 vaccine was negatively associated with perceived information insufficiency. A positive relationship between perceived information insufficiency and information seeking, as well as a negative relationship between information seeking and vaccine hesitancy were also found. Theoretical and practical implications are discussed.

Novel Latent Profile Analysis of a Test of Concept, Stigma Intervention to Increase PrEP Uptake Among Black Sexual Minority Men

BACKGROUND

Pre-exposure prophylaxis (PrEP) has demonstrated efficacy for HIV prevention, yet uptake of PrEP among populations in urgent need of prevention tools (eg, Black sexual minority men) is limited, and stigma and medical mistrust remain strong barriers to accessing PrEP.

PURPOSE

To evaluate a test of concept brief intervention to address stigma and medical mistrust as barriers to PrEP uptake using novel latent profile analysis.

METHODS

Participants (N = 177) residing in the southeastern US were randomized to 1 of 4 arms to establish the potential impact of a brief, stigma focused counseling intervention (referred to as Jumpstart ) to increase PrEP uptake. We estimated intervention effect size (Cramer's V) for PrEP uptake and then explored differential intervention effects across latent profiles of psychosocial barriers to PrEP use.

RESULTS

The intervention resulted in small, but meaningful effect size, with self-reported PrEP uptake increasing across Jumpstart conditions with the control condition reporting 24% uptake and Jumpstart plus text/phone calls (the most intensive intervention arm) reporting 37% uptake, and a similar pattern emerging for biologically confirmed PrEP use. Among participants 30 and older, Jumpstart participants were more likely to move to a postintervention profile with fewer barriers than control participants and reported the highest uptake of PrEP.

CONCLUSIONS

Addressing social/emotional barriers to PrEP uptake is an essential component of bridging the gap between advances being made in biomedical forms of HIV prevention, and establishing and supporting access to those advances.

Medical Mistrust Among a Racially and Ethnically Diverse Sample of Sexual Minority Men

Purpose: Medical mistrust is a barrier to health care utilization and is associated with suboptimal health outcomes. Research on mistrust among sexual minority men (SMM) is limited and largely focuses on Black SMM and HIV, with few studies assessing mistrust among SMM of other race/ethnicities. The purpose of this study was to examine differences in medical mistrust among SMM by race. Methods: From February 2018 to February 2019, a mixed-methods study examined the health-related beliefs and experiences of young SMM in New York City. The Group-Based Medical Mistrust Scale (GBMMS) was used to measure medical mistrust related to race, and a modified version of the scale assessed mistrust related to one's "sexual/gender minority" status (Group-Based Medical Mistrust Scale-Sexual/Gender Minority [GBMMS-SGM]). With an analytic sample of 183 cisgender SMM, a one-way multivariate analysis of variance was used to examine differences in GBMMS and GBMMS-SGM scores by race/ethnicity [Black, Latinx, White, "Another Racial Group(s)"]. Results: There were significantly different GBMMS scores by race, with participants of color reporting higher levels of race-based medical mistrust than White participants. This finding is supported by effect sizes ranging from moderate to large. Differences in GBMMS-SGM scores by race were borderline; however, the effect size for Black and White participants' GBMMS-SGM scores was moderate, indicating that higher GBMMS-SGM scores among Black participants is meaningful. Conclusion: Multilevel strategies should be used to earn the trust of minoritized populations, such as addressing both historical and ongoing discrimination, moving beyond implicit bias trainings, and strengthening the recruitment and retention of minoritized health care professionals.

Marcotte A, M. Kaufman E, Moscovici Z, R. Adams O, Lovins S, R. Garcia J, N. Gesselman A. American Singles' Attitudes Toward Future Romantic/Sexual Partners' COVID-19 Vaccination Status: Evidence for both Vigilance and Indifference in a National Sample

Around 142 million American adults are currently single; at least half of these singles want to pursue a romantic partner. Romantic dating can involve exposure to numerous people. Thus, dating can significantly impact pathogen exposure risk. In a demographically-representative cross-sectional survey conducted in 2021 (N = 5,000), we examined U.S. American singles' COVID-19 vaccination status, assessed their preferences around a potential partner's COVID-19 vaccination status, and identified demographic subgroups of singles particularly opposed to or indifferent to a partner being vaccinated against COVID-19. Our results showed 65% of participants were fully vaccinated, 10% were partially vaccinated, and 26% were unvaccinated against COVID-19. With regards to partner preferences, half wanted a vaccinated partner; 18.9% wanted a vaccinated partner but would make exceptions; 6.1% wanted an unvaccinated partner; and 25% reported that they did not care about their dating partner's vaccination status. Partner preferences were largely aligned with participants' own vaccination status, such that vaccinated participants preferred vaccinated partners. However, those preferring unvaccinated partners-or those willing to make exceptions for a partner-were most likely to identify as men, younger in age, a political affiliation outside of the two-party political system, a gender or sexual minority, or as a racial minority (i.e., Black/African-American or South Asian). Additionally, participants who were employed (vs. unemployed) were more likely to make exceptions for or prefer an unvaccinated partner. These results suggest that singles prefer homophily in COVID-19 vaccine status, and that minoritized subgroups of singles are more likely to maintain a social network including unvaccinated close others.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12119-023-10097-9.

Understanding medical mistrust and HPV vaccine hesitancy among multiethnic parents in Los Angeles

Determinants of parental HPV vaccine hesitancy, including medical mistrust and exposure to negative vaccine information, are understudied in racial/ethnic minority communities where vaccine uptake is low. We conducted a cross-sectional survey (March 2021) among parents of adolescents, ages 9-17 years, from an academic enrichment program serving low-income, first-generation, underrepresented minority families in Los Angeles to understand determinants of parental HPV vaccine hesitancy. Parents completed self-administered surveys, including a 9-item HPV vaccine hesitancy scale, in either English, Spanish, or Chinese. Logistic regression was used to identify individual and interpersonal factors associated with parental hesitancy and adolescent HPV vaccination. One-fifth of parents (n = 357) reported high HPV vaccine hesitancy and > 50% reported concerns about safety or side effects. High medical mistrust was associated with high parental HPV vaccine hesitancy (adjusted-OR 1.69, 95% CI: 1.13, 2.37). Community-tailored and multilevel strategies to increase vaccine confidence are needed to improve HPV and other adolescent vaccinations.

Racial and Ethnic Disparities in Barriers to Care in Patients with Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is a leading cause of death in patients with cirrhosis and has a rising mortality rate in the United States.1 Racial and ethnic minorities experience a disproportionate burden of HCC, including higher incidence rates, more late-stage diagnoses, and worse survival.2,3 These disparities are complex in nature and can be attributed to many proximal, intermediate, and distal determinants, such as health literacy and behaviors, social support, social needs, social determinants of health, and access to health care.4 Prior studies have identified racial and ethnic differences in clinical factors, including receipt of HCC surveillance and tumor stage5; however, few studies have examined differences in patient-reported barriers that may partly explain observed disparities. Understanding these data is essential to inform interventions to address and mitigate disparities. Therefore, we described patient-reported barriers to medical care and examined differences in barriers by race and ethnicity in a large, diverse population of patients newly diagnosed with HCC.

Racial Disparities in Barriers to Care for Patients With Diabetic Retinopathy in a Nationwide Cohort

Purpose

To ascertain specific barriers of care among patients with diabetic retinopathy (DR) from different racial/ethnic groups.

Methods

In this cross-sectional study, we included adult participants in the National Institutes of Health All of Us Research Program with DR who answered questions in the Healthcare Access & Utilization survey and Social Determinants of Health (SDoH) survey. Logistic regression was used to study the association between barriers to care and race/ethnicity.

Results

Our cohort included 885 DR patients who answered the Healthcare Access & Utilization survey and 385 DR patients who responded to the SDoH survey. After adjusting for confounders, Hispanic individuals were more likely than non-Hispanic White individuals to report delaying getting medical care due to not being able to get child care (odds ratio [OR] = 6.57 [95% confidence interval {CI}, 1.67-27.8]). Furthermore, compared to non-Hispanic White individuals, non-Hispanic Black individuals were significantly more likely to report being treated with less respect (OR = 2.62 [95% CI, 1.15-5.80]), treated with less courtesy (OR = 2.51 [95% CI, 1.01-5.92]), and receive poorer service than other people (OR = 2.85 [95% CI, 1.25-6.34]) when they go to a doctor's office or other healthcare provider.

Conclusions

We found that Hispanic and non-Hispanic Black individuals with DR reported greater delays/barriers to care compared to non-Hispanic White individuals even after controlling for individualized socioeconomic factors.

Translational Relevance

This study highlights the importance of taking steps to promote health equity, such as increasing access to child care resources and reducing implicit bias among eye care providers, to increase access to care and prevent vision loss from DR.

Fifty Years of Trust Research in Health Care: A Synthetic Review

Policy Points First, policymakers can create conditions that will facilitate public trust in health care organizations by making creating and enforcing health policies that make exploitative behavior costly. Second, policymakers can bolster the trustworthiness of health care markets and organizations by using their regulatory authority to address and mitigate harm from conflicts-of-interest and regulatory capture. Third, policymakers and government agencies can further safeguard the public's trust by being transparent and effective about their role in the provision of health services to the public.

CONTEXT

Trust plays a critical role in facilitating health care delivery and calls for rebuilding trust in health care are increasingly commonplace. This article serves as a primer on the trust literature for health policymakers, organizational leaders, clinicians, and researchers based on the long history of engagement with the topic among health policy and services researchers.

METHODS

We conducted a synthetic review of the health services and health policy literatures on trust since 1970. We organize our findings by trustor-trustee dyads, highlighting areas of convergence, tensions and contradictions, and methodological considerations. We close by commenting on the challenges facing the study of trust in health care, the potential value in borrowing from other disciplines, and imperatives for the future.

FINDINGS

We identified 725 articles for review. Most focused on patients' trust in clinicians (n = 499), but others explored clinicians' trust in patients (n = 11), clinicians' trust in clinicians (n = 69), and clinician/patient trust in organizations (n = 19) and systems (n = 127).  Across these five subliteratures, there was lack of consensus about definitions, dimensions, and key attributes of trust. Researchers leaned heavily on cross-sectional survey designs, with limited methodological attention to the relational or contextual realities of trust. Trust has most commonly been treated as an independent variable related to attitudinal and behavioral outcomes. We suggest two challenges have limited progress for the field: (1) conceptual murkiness in terms and theories, and (2) limited observability of the phenomena. Insights from philosophy, sociology, economics, and psychology offer insights for how to advance both the theoretical and empirical study of health-related trust.

CONCLUSION

Conceptual clarity and methodological creativity are critical to advancing health-related trust research. Although rigorous research in this area is challenging, the essential role of trust in population health necessitates continued grappling with the topic.

High Psychosocial Burden Relates to Poorer Antiretroviral Treatment Adherence Among Black/African American People with HIV

Black/African American communities continue to be disproportionately impacted by HIV with Black people with HIV (PWH) exhibiting poorer outcomes along the HIV treatment cascade. Psychosocial burden may, in part, explain these health disparities among PWH. We implemented a culturally adapted intervention [individualized Texting for Adherence Building (iTAB)] to improve ART adherence among 89 Black PWH in San Diego, CA. We aimed to (1) characterize psychosocial risk factors (depression, negative life events, discrimination, medical mistrust) hypothesized to be barriers to HIV outcomes among Black PWH and (2) determine if these factors influence intervention engagement, HIV outcomes, and self-reported physical and mental health. We identified three levels of psychosocial burden (low, moderate, high) through hierarchical cluster analysis. Participants in the high burden cluster (n = 25) experienced the highest levels of depression, negative life events, and discrimination, in addition to the poorest intervention outcomes, HIV outcomes, and physical and mental health compared to low and moderate burden clusters. Participants in the low (n = 29) burden cluster had less medical mistrust than the moderate (n = 34) and high burden clusters, but low and moderate clusters did not differ on any outcomes. Overall, self-reported ART adherence was 83%, which is above estimates of ART adherence in the Western region of the United States. The iTAB intervention shows promise in improving HIV-related outcomes among Black PWH with low to moderate psychosocial burden; however, additional supports may need to be identified for those with high psychosocial burden.

Differences in psychosocial factors of mental health in an ethnically diverse Black adult population

We conducted a cross-sectional analysis in a convenient sample of Black adults in the United States (n = 269, ages 18-65) from diverse ethnic backgrounds (African-Americans, African immigrants, Afro-Caribbean immigrants). We examined mean differences in self-reported medical mistrust, use of mental health services, depression symptom severity, mental health knowledge and stigma behavior (or a desire for separation away from people living with a mental illness) according to ethnicity, citizenship status, age group, and gender. African Americans with moderate to severe depression symptoms had greater stigma behavior (mean = 12.2, SD = 3.2) than African Americans who screened in the minimal to mild depression range (mean = 13.1, SD = 3.5). Across the spectrum of depression, immigrants showed greater stigma than African Americans (p = 0.037). This is a pilot study that explores heterogeneity in the Black population in depression symptom severity and psychosocial factors related to mental health. Understanding these differences may contribute to how we approach needs and health system practices and policies at the individual, systemic, and structural level of mental health care.

The Interplay of Trust and Subjective Norms in Telemedicine Adoption by a Minority Community at Einstein Medical Center Philadelphia

Telemedicine is not released into a social vacuum. In some communities - such as the underserved, low income, mostly minority community served by Einstein Medical Center Philadelphia (EMCP) - the social context presents the medical center with unique challenges centered on a strong community sense of historical discrimination. That context is manifested in people being less inclined to trust symbols of external authority and in their strong reliance on subjective norms. Analyzing 540 survey responses by EMCP emergency department (ED) patients shows that trust in the EMCP portal was the strongest predictor of its acceptance. Being an African American had no effect on portal acceptance compared to others in the community. Importantly, there was a negative interaction effect of subjective norms and trust on portal acceptance - meaning that increasing this trust can reduce the importance of subjective norms or, alternatively, that lower subjective norms may increase the importance of trust in determining acceptance. This moderation may have very practical implications for EMCP because, while it might be challenging for EMCP to change long established subjective norms, it is within their power to increase trust in the portal. Theoretical and practical implications are discussed.

Treatment Seeking for Anxiety and Depression Among Black Adults: A Multilevel and Empirically Informed Psycho-Sociocultural Model

Black adults with anxiety and/or depressive disorders underutilize outpatient psychotherapy and pharmacological treatment compared to White adults. Notably, anxiety and depressive disorders tend to be chronic and Black individuals with these disorders experience greater functional impairment than White individuals. Documented racial disparities in mental health treatment initiation indicate a need for research that addresses culture-specific barriers to treatment. This review paper critically evaluates existing theoretical models of treatment seeking among Black adults to inform a novel integrated, culturally contextualized model. This model extends previous ones by incorporating factors relevant to treatment seeking among Black adults (e.g., racial identity, perceived discrimination, medical mistrust) and critically examines how these factors intersect with key factors at three levels of influence of the treatment seeking process: the individual level, the community level, and the societal level. We posit interactions among factors at the three levels of influence and how these may impact treatment seeking decisions among Black adults. This model informs suggestions for enhancing interventions designed to support outpatient service use among Black adults.

Beyond Personal Experiences: Examining Mediated Vicarious Experiences as an Antecedent of Medical Mistrust

African Americans consistently report higher levels of medical mistrust than their White counterparts. As a result, medical mistrust is considered to be a contributor to racial health disparities. Despite calls to address medical mistrust, few studies have explicitly examined it as a phenomenon of interest; those that have, tended to focus on personal experiences while neglecting vicarious experiences. The current study a) explicitly tests the effects of two types of news story content on reported levels of medical mistrust within an African American adult sample and b) examines two widely used medical mistrust measures. Participants (N = 410) were randomly assigned to view a news story based on a 2 (health care, non-health care) x 2 (racial discrimination, nonracial discrimination) experimental design. Results indicated that individually, both health care content and racial discrimination content increased race-based medical mistrust, but had no effect on general medical mistrust. However, when all four conditions were examined, exposure to health-related racial discrimination stories resulted in higher levels of race-based and general medical mistrust than non-health, nonracial discrimination stories. Findings are discussed in terms of the theoretical and practical implications for health communication scholars.

Medical Mistrust, COVID-19 Stress, and Intent to Vaccinate in Racial-Ethnic Minorities

Members of the Black, Asian, and Latinx community have been particularly vulnerable to the COVID-19 pandemic but may be hesitant to vaccinate. In a December 2020 study in Black, Asian, and Latinx adults in the U.S. (n = 779), only 50% of Black respondents endorsed intending to vaccinate against COVID-19, followed by 65% and 75% of Latinx and Asian participants, respectively. Medical mistrust, fears about COVID-19 contamination, and a proclivity for compulsive checking behaviors related to COVID-19 were significant predictors of intent to vaccinate in Black respondents. Similarly, Asian respondents' intent to vaccinate was predicted by medical mistrust, fears of the dangerous nature of the virus, and xenophobic concerns about viral spread. In Latinx participants, medical mistrust and compulsive checking for COVID-19-related information were significant predictors of intent to vaccinate. Our findings identify specific behaviors, attitudes, and beliefs we can target to inform community-wide outreach and increase the uptake of COVID-19 vaccines.

A novel psychometric approach to assessing intersectional hiv stigma: the geometric intersectional stigma scales

Recent advances in stigma theories have emphasized intersectionality, but there are currently few approaches to measuring intersectional HIV stigma. Here we present a novel approach to assessing intersectional HIV stigma. Black/African American sexual minority men living with HIV (N = 437) completed newly developed measures of enacted and anticipated stigma along with a battery of instruments to examine construct validity. For each endorsed stigma item, participants rated three personal attributes ascribed to the stigma experiences, specifically race, same-sex sexual behavior, and HIV status. Based on the notion that intersecting orthogonal dimensions such as attributions for experiencing stigma can be conceptualized geometrically, we used the Pythagorean Theorem to calculate intersectional stigma scores. Results showed that the enacted and anticipated stigma scales and the assessment of intersectional stigma attributes demonstrated acceptable response rates, internal consistency and a pattern of associations with correlates that suggests construct validity. In separate tests of construct validity, regression models predicting medication adherence indicated varied results among stigma measures, demonstrating clear advantages to separating the assessment of stigma experiences from the attributes to which stigma experiences are ascribed. Findings from this geometric approach to assessing intersectional HIV stigma were promising and warrant further investigation.

Diagnosing PrEP Communication Self-Efficacy in a Community-Based Peer Leader Intervention for Black Sexual Minority Men

HIV prevention interventions that leverage endogenous peer leaders to communicate about Pre-Exposure Prophylaxis (PrEP) and other HIV prevention tools in their social networks offer a way to reach greater portions of communities most impacted by HIV like Black/African American gay, bisexual, same gender-loving, and other sexual minority men (BSMM). However, the success of these interventions hinge on the communication self-efficacy of its peer leaders. In this exploratory study, we present a multi-theoretical framework that situates the PrEP communication self-efficacy (PCSE) of a cohort of young BSMM peer leaders (n = 303) in the context of personal, behavioral, social, and structural factors. Using censored regression models, our analysis shows that PCSE is influenced by evaluations of PrEP itself (its relative advantage, complexity, and compatibility), network embeddedness (degree centrality) among other BSMM, social media network exposure to HIV information, and medical mistrust. We conclude with a discussion of the practical implications of our findings for intervention design and implementation.

Group-based medical mistrust and care expectations among black patients seeking addiction treatment

Background

Black patients seeking addiction care experience poorer treatment access, retention, and outcomes when compared to White counterparts. Black patients may have elevated group-based medical mistrust, which has been associated with poorer health outcomes and increased experiences of racism across multiple healthcare contexts. The relationship between group-based medical mistrust and expectations for addiction treatment among Black individuals remains untested.

Methods

A total of 143 Black participants were recruited from two addiction treatment centers in Columbus, Ohio. Participants completed the Group Based Medical Mistrust Scale (GBMMS) and answered questions related to expectations of addiction treatment. Descriptive analysis and Spearman's rho correlations were performed to assess for relationships between group-based medical mistrust and expectations of care.

Results

Group-based medical mistrust in Black patients was associated with self-reported delay in accessing addiction treatment, anticipation of racism during addiction treatment, non-adherence and discrimination-precipitated relapse. However, non-adherence to treatment was least strongly correlated with group-based medical mistrust demonstrating an opportunity for engagement.

Conclusion

Group-based medical mistrust is associated with Black patients' care expectations when seeking addiction treatment. Use of the GBMMS within addiction medicine to address themes of mistrust in patients, and potential biases in providers, may improve treatment access and outcomes.

Validating the Group-Based Medical Mistrust Scale with English and Spanish Speaking Latino Parents of Adolescents

BACKGROUND

Medical mistrust can be a barrier to health care utilization. While the Group-Based Medical Mistrust Scale (GBMMS) has been validated among diverse populations, we know little about its psychometric performance among English-Speaking (ES) and Spanish-Speaking (SS) Latinos. We aim to examine the factor structure of GBMMS among Latino parents and explore whether scale latent factor structures would be different across preferred languages.

METHODS

Parents of adolescents participating in an urban academic enrichment program for low-income students completed an online survey as part of a cross-sectional study about Human Papillomavirus (HPV) prevention. We tested the validity of the GBMMS in ES and SS respondents and performed exploratory factor analysis to identify latent factors. We examined scale scores, item means, item endorsement, and residual variance across language groups.

RESULTS

2-factor latent structure was identified for both ES and SS groups; factors were labeled as 'Suspicion' and 'System-wide discrimination.' Scale validity was better among SS (α = 0.76). Medical mistrust scores did not vary across language groups, but variation emerged in item endorsement by language.

DISCUSSION

Our results suggest that the factor structures of the medical mistrust construct, measured by the GBMMS, are similar across ES and SS Latinos and that the GBMMS is valid for both populations. High factor pattern loading reflects a shared mistrust of how health care systems view and treat people of their racial/ethnic background, independent of their preferred languages. Measurement of medical mistrust and identifying its underlying causes are needed within diverse populations to fully address structural- and community-level influences on health inequities.

Assessing medical mistrust in organ donation across countries using item response theory

Although medical mistrust (MM) may be an impediment to public health interventions, no MM scale has been validated across countries and the assessment of MM has not been explored using item response theory, which allows generalisation beyond the sampled data. We aimed to determine the dimensionality of a brief MM measure across four countries through Mokken analysis and Graded Response Modelling. Analysis of 1468 participants from UK (n = 1179), Ireland (n = 191), India (n = 49) and Malaysia (n = 49) demonstrated that MM items formed a hierarchical, unidimensional measure, which is very informative about high levels of MM. Possible item reduction and scoring changes were also demonstrated. This study demonstrates that this brief MM measure is suitable for international studies as it is unidimensional across countries, cross cultural, and shows that minor adjustments will not impact on the assessment of MM when using these items.

Medical Mistrust and Adherence to Care Among a Heterogeneous Cohort of Women Living with HIV, Followed in a Large, U.S. Safety Net Clinic

Purpose: To explore the relationship between medical mistrust, as measured by the Group-Based Medical Mistrust (GBMM) scale, and HIV care adherence among a cohort of minority women receiving care in a U.S. safety net clinic.

Methods: English-, Spanish-, and Haitian Creole (Creole)-speaking patients with a recent history of nonadherence to care were surveyed.

Results: English speakers endorsed the highest level of mistrust, followed by Spanish speakers and Creole speakers. Creole speakers endorsed lower mistrust, lower suspicion of providers, and lower levels of “perceived health care disparities.” Higher mistrust was associated significantly with lower medication adherence, and lower rates of viral suppression (nonsignificant).

Conclusion: Understanding perceptions of medical care and the relationship to HIV care adherence is an important step to addressing negative health outcomes for ethnic minority women with HIV.

Clinical Trial Registration Number: NCT03738410.

Examining the association between religiosity and medical mistrust among churchgoing Latinos in Long Beach, CA

Medical mistrust among racial/ethnic minorities has been associated with decreases in health care utilization, whereas religiosity has been separately linked with increases in this behavior. However, very few studies have examined the relationship between religiosity and medical mistrust among Latinos, a group with strong religious connections and potentially high mistrust. In-person, self-administered surveys were collected among 767 adult Latinos attending three Latino churches (one Catholic and two Pentecostal) in Long Beach, CA. Measures included a previously validated 12-item medical mistrust scale, religiosity (religious denomination, length and frequency of attendance, and number of groups or ministries involved in), health care access, and sociodemographic factors. Medical mistrust score was 2.47 (standard deviation [SD] = 0.77; range 1-5). Almost two-thirds of participants (62%) attended religious services frequently (once a week or more), and the majority attended a Catholic church (80%). About half of the participants had attended their church for ≥5 years (50%) and participated in one to two church groups or ministries (53%). Multivariable analyses show that Pentecostal church congregation and those identifying as Mexican/Chicano were negatively associated with medical mistrust. On the contrary, participating in church groups or ministries and having an immigrant parent were positively associated with medical mistrust. Our findings suggest that church-based health initiatives should consider church denomination, length of attendance, participation in groups or ministries, and ethnic differences to address medical mistrust issues among Latino congregants.