Lower Minority Screening Rates Tied to Mistrust


Mistrust of the health care system was linked to lower use of breast cancer screening among black, Hispanic, and Arab American women, in a prospective study of 341 patients from these ethnic groups.

Using the previously validated seven-item Medical Mistrust Index, community health workers found that more than 40% of the women in these three racial-ethnic groups agreed or strongly agreed with all of the mistrust statements in the index.

For example, 49% of surveyed women agreed with the statement that “Patients have sometimes been deceived or misled by health care organizations.”

Black, Hispanic, and Arab American women with higher levels of mistrust were less likely to adhere to appropriately timed breast cancer screening, Dr. Karen Patricia Williams and her associates reported at the American Association for Cancer Research conference on the science of cancer health disparities.

Overall, 44% of these women who had never had a clinical breast exam agreed with the statement that “Health care organizations have sometimes done harmful experiments on patients without their knowledge,” compared with 38% of women who had ever received a clinical breast exam. The difference between groups was significant.

Significantly more women who had not received a clinical breast exam in the previous 12 months (49%) also agreed with this same statement, compared with women who had had a breast exam in the previous 12 months (33%), the investigators reported.

In addition, 64% of women who had no history of an exam in the previous 12 months agreed with the statement “Sometimes I wonder if health care organizations really know what they are doing,” compared with 47% of those who had received an exam in the past year—a significant difference.

“Typically, what we have done is intellectualize the problem; that the problem is that blacks have a memory of the Tuskegee Experiment,” Dr. Williams said in an interview. “But this shows that medical mistrust goes beyond Tuskegee to where we are today in 2009,” and that it's not just blacks, but also Arabs and Hispanics.

“That says something about the system and that we need to work on the system itself,” she said.

Black women were found to have the highest level of medical mistrust.

More than one-third (39%) of black women strongly agreed with the statement that “Health care organizations don't always keep your information totally private,” compared with 15% of Hispanic women and 9% of Arab American.

Hispanic and Arab American women may have demonstrated less distrust because many were newly immigrated and may have had limited experience with the health care system, according to Dr. Williams of the departments of obstetrics, gynecology, and reproductive biology at Michigan State University, East Lansing.

The Medical Mistrust Index was orally administered by community health workers in English, Spanish, or Arabic to 116 black women, 113 Hispanic women, and 112 Arab American women.

Their median age was 44 years (range 21–87 years). Annual income was $40,000 or more for 14% of black women and 8% of Hispanic and Arab women.

Insurance was in place for 94% of blacks, 45% of Hispanics, and 43% of Arabs.

During a press conference at the meeting, Dr. Williams acknowledged that insurance coverage plays a large role in the use of cancer screenings but said that the role of medical mistrust cannot be ignored.

She urged health care organizations to tailor prevention interventions to individual ethnic groups, rather than adopting a “one size fits all” approach.

All of the women in the study were marginalized, she said, citing racial discrimination for blacks, immigration concerns for Hispanics, and anger toward Arabs over Sept. 11.

When asked specifically how this played out in the patient-physician interaction, Dr. Williams said they had only anecdotal information and it was directed at the health care system as a whole.

She also noted that women in the study used various health care systems in southeast Michigan, suggesting that mistrust is not with one problematic clinic, but rather is systemwide.

“Our medical systems in general have some work to do to build trust with racial [minorities] and ethnic women,” she said.

It is unclear how the level of medical mistrust observed in these three ethnic groups compares with mistrust among whites, Dr. Williams said.

The next step is to study the issue in a larger, national population as it relates to the use of breast and cervical screening and other medical services.

The study was funded by Susan G. Komen for the Cure.

The investigators reported no conflicts of interest.

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