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Published in final edited form as: Soc Work Public Health. 2023 Feb 10;38(4):334–343. doi: 10.1080/19371918.2023.2177225

Patient-Provider Communication Quality as a Predictor of Medical Mistrust Among Young Black Women

Vashti Adams a, Jaih Craddock b
PMCID: PMC10120919  NIHMSID: NIHMS1872005  PMID: 36762615

Abstract

The present study explores the association between patient-provider communication quality and medical mistrust in a sample of 174 young Black women, aged 18–24. Data were collected as part of a larger mixed-methods study examining sexual health communication and behaviors. Participants were recruited via non-probabilistic sampling methods between June 2018 and December 2018. Eligible respondents completed a self-administered online study that examined, among other components, healthcare experiences and medical mistrust. Hierarchical linear regression was used to explore the relationship between patient-provider communication quality and medical mistrust. Patient-provider communication quality was a significant predictor of medical mistrust; as communication quality increased, medical mistrust decreased (p < .001). Educational attainment also emerged as a significant predictor. Relative to not completing any college, completing some college was associated with lower medical mistrust (p= .031). Our findings suggest that for providers seeking to address medical mistrust in patients identifying as young Black women, focusing on patient-centered communication may be particularly impactful.

Keywords: medical mistrust, African American women, young adults, healthcare

Introduction

Among Black or African American communities, medical mistrust has been associated with preventative service delays (Hammond, 2010; Powell et al., 2019), low medication adherence (Whetten et al., 2006), and healthcare underutilization (Brenick et al., 2017). Although recent studies have investigated antecedents of medical mistrust among various racial and ethnic minority populations (Alang et al., 2020; Bazargan et al., 2021; Benkert, Peters, et al., 2019; Idan et al., 2020), the experiences of young Black women are scarcely included, particularly for those aged 18 to 24. While some predictors of medical mistrust are likely shared across Black subgroups, the effect of predictors may vary based on other aspects of intersecting social identities, such as age and gender. For instance, because young Black women have often reported having to convince their healthcare providers to provide necessary services (Gomez & Wapman, 2017), patient-provider communication quality may be particularly influential in shaping beliefs about medical systems and providers among members of this population. Thus, the current study seeks to expand the literature on predictors by examining the relationship between patient-provider communication quality and medical mistrust among young Black women.

Existing literature on predictors of medical mistrust among Black populations has identified demographic characteristics (Idan et al., 2020), healthcare interactions (Hammond, 2010), socioenvironmental experiences (Alang et al., 2020), and knowledge of the Tuskegee Syphilis Study (Alsan & Wanamaker, 2018; Gamble, 1997) as explanatory factors. Benkert et al. (2019) identified education level, income, and self-rated health as demographic predictors of medical mistrust in both Black and White Michigan residents, with lower education, income, and self-rated health being associated with higher mistrust. In their study with 216 Black men in California, Idan et al. (2020) confirmed that lower education and income were associated with higher medical mistrust and added that being uninsured was associated with greater mistrust as well. Sutton et al. (2019) found that among Black breast cancer patients identifying as women, insurance type (i.e., public vs private) was also associated with medical mistrust, with publicly insured women having greater medical mistrust than privately insured women.

Moving beyond demographic characteristics, Bazargan et al. (2021) found that among Black, Latinx, and White adults in California, perceived discrimination based on racial or ethnic identity, language, health insurance status, and health insurance type from healthcare providers was associated with greater mistrust. Experiences with discrimination do not have to be healthcare related to be associated with medical mistrust. Negative personal experiences with law enforcement officers (Alang et al., 2020) and mediated experiences with racism via news stories (Williamson, 2021) have been positively associated with medical mistrust as well.

While such studies have contributed to the growing body of knowledge regarding predictors of medical mistrust, the experiences of young Black women are largely missing from the literature. Research regarding racial disparities in health outcomes has identified several areas in which young Black women may be at elevated risk—many of which are related to preventative behaviors negatively associated with medical mistrust. Black women account for 57% of new HIV diagnoses among women in the United States (Centers for Disease Control and Prevention, 2020) and have a higher incidence of breast cancer before age 45 than White women (Yedjou et al., 2019). Young Black women are more likely to have uterine fibroids and a more severe symptom burden compared to young White women (Fuldeore & Soliman, 2017; Stewart et al., 2013) and are also more likely to have hypertension (Hines et al., 2021). Preventive services related to these outcomes, such as pre-exposure prophylaxis (PrEP) uptake for HIV and various risk factor screenings (e.g., cancer, hypertension), may be underutilized due to their association with medical mistrust (Amuta-Jimenez et al., 2020; Sheppard et al., 2013).

Importantly, some studies examining the association between medical mistrust and preventative behaviors in young Black women have produced contradictory findings. For instance, Bynum et al. (2012) found that among Black college students identifying as women, medical mistrust was not associated with human papillomavirus (HPV) vaccine acceptability. However, the number of significant associations warrants further examination of predictors of medical mistrust among young Black women.

Patient-provider communication quality, which has been identified as a predictor of medical mistrust in Black men (Hammond, 2010), may be a particularly salient predictor of medical mistrust in young Black women as well. Young Black women may be aware, either through cultural transmission or educational experiences, of the reproductive abuses Black women have historically faced (Prather et al., 2018). As a result, providers’ lack of attention to patient input or failure to clearly explain procedures may contribute to mistrust (Cuevas et al., 2016; Prather et al., 2018; Randolph et al., 2020). Young Black women often describe not being listened to or not having their input respected when seeking family planning services and provide examples of being encouraged to continue with oral contraceptives despite difficulty adhering to the daily schedule or being given incomplete information about the risks associated with long-acting reversible contraceptives (Logan et al., 2021). Young Black women also report engaging with healthcare providers who downplayed the severity of their uterine fibroids or suggested more invasive treatments and surgeries rather than less invasive alternative therapies (VanNoy et al., 2021). These experiences are not limited to gynecological care. Black women across age ranges describe being given unsolicited weight loss advice (Ferrante et al., 2016) and are frequently denied sufficient pain medication (Hoffman et al., 2016; Rice et al., 2020).

Given that many of the healthcare needs of this population require provider-buy-in to access appropriate referrals and services (Gomez & Wapman, 2017), patient-provider communication quality may be particularly impactful in influencing patients’ attitudes towards healthcare systems and providers as well as decisions to initiate or continue healthcare service usage. The association between patient-provider communication quality and healthcare usage has been previously explored. Poor quality communication has been consistently associated with reduced healthcare utilization among Black women of varying age ranges and with diverse healthcare needs (e.g., pregnancy, sexually transmitted infections, autoimmune disease) (Cazeau-Bandoo & Ho, 2022; Leung et al., 2021; Mazul et al., 2017). Delay or avoidance of medical care, in turn, is a known contributor to racial disparities in health outcomes (Noonan et al., 2016).

Less is known, however, about the association between patient-provider communication quality and medical mistrust. To address this gap, the current study examined the relationship between patient-provider communication quality and medical mistrust in a sample of young Black women, aged 18 to 24. Controlling for demographic covariates, lower quality patient-provider communication quality was hypothesized to predict greater medical mistrust.

Methods

Participants

Data for the present study derive from a larger mixed methods study examining sexual health communication amongst young Black women (Craddock, 2020). Participants were recruited using a combination of online and in-person outreach methods (e.g., Facebook and Twitter posts, advertising in community events, and peer referrals) from June 2018-December 2018 (see (Craddock, 2020) for additional recruitment details). To be eligible for the parent study, participants had to (1) be between 18–24 years old, (2) identify as a Black or African American woman, and (3) have ever been sexually active. To be included in the present study, participants also had to report being seen by a healthcare provider in the last 12 months. Of the 200 respondents who participated in the parent study, 174 (87%) were also eligible for the current study. Participants electronically provided informed consent and were compensated $15 for their time. All study procedures and materials were approved by the Institutional Review Board at the University of Maryland Baltimore.

Measures

Medical mistrust

Medical mistrust was assessed using the 12-item Group Based Medical Mistrust Scale (GBMMS) (Thompson et al., 2004). The GBMMS measures perceived mistreatment due to ethnicity (e.g., “People of my ethnic group cannot trust doctors and healthcare workers”, “Doctors and healthcare workers sometimes hide information from patients who belong to my ethnic group”). Items were scored on a five-point scale ranging from 1 (strongly disagree) to 5 (strongly agree). Four reverse worded items were recoded for consistency in scoring. Scores were averaged for a possible range of 1–5, with higher scores indicating greater mistrust. Cronbach’s alpha for the current sample was .85.

Patient-provider communication quality

Patient-provider communication quality was assessed using the four-item Doctors Who Communicate Well composite from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) health plan survey (Hargraves et al., 2003). The CAHPS health plan survey is a widely used and validated measure for assessing various components of patient-centered care. The communication composite assesses four aspects of patient-centered communication (i.e., “How often in the past 12 months did your doctor or healthcare providers listen carefully? Explain things clearly? Show respect for what you had to say? Spend enough time with you?”). Items were scored on a four-point scale ranging from 1 (never) to 4 (always). Scores were averaged for a possible range of 1–4, with higher scores indicating better quality communication. Cronbach’s alpha for the current sample was .88.

Covariates

Participants reported the highest level of education completed (high school, some college, college degree or higher), health insurance status (uninsured, insured), self-rated health (fair or worse, good, excellent), and time since last healthcare visit (less than 1 month, between 1 and 6 months, between 6 and 12 months, and greater than 12 months).

Analysis

All statistical analyses were conducted using STATA statistical software version 14.2 (Statacorp, 2015). Descriptive statistics were calculated for all study variables. ANOVAs were used to examine mean differences in patient-provider communication quality and medical mistrust by demographic characteristics. Significant ANOVA findings were further explored using post-hoc Tukey tests. Multivariable linear regression was used to examine the association between patient-provider communication quality and medical mistrust. In order to determine the unique variance in medical mistrust explained by patient-provider communication quality, the regression was conducted in two steps. The first step included only demographic covariates and the second step included demographic covariates and patient-provider communication quality. An a-priori significance level of .05 was used to denote statistical significance for all hypothesis-based tests. Missing data (n= 9, 5%) were addressed using listwise deletion.

Results

Univariate and bivariate analyses

Demographic characteristics of study participants are provided in Table 1. The majority of participants had completed at least some college (n = 152, 87%), were insured (n = 170, 98%), and reported being in good or better health (n = 157, 90%).

Table 1.

Demographic Characteristics of Study Participants (n= 174)

n (%)
Age (years)a
M, SD 21.1 (1.7)
Geographic regionb
West 58 (34)
Midwest 17 (10)
South 78 (46)
Northeast 18 (11)
Highest level of educationc
High school only 22 (13)
Some college 76 (44)
College degree or higher 75 (43)
Health insurance status
Uninsured 4 (2)
Insured 170 (98)
Self-rated health
Fair/worse 17 (10)
Good 105 (60)
Excellent 52 (30)
Last healthcare visitd
< 1 month 58 (34)
≥ 1 month, < 6 months 56 (33)
≥ 6 months, < 1 year 58 (34)
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Note. Percentages may not equal 100 due to rounding.

a

n = 172.

b

n =171.

c

n =173.

d

n =172.

Demographic correlates of medical mistrust

Bivariate associations between study variables are described in Table 2. The mean medical mistrust score was 3.07 (SD = 0.73). Corresponding to an average rating of “neutral”, the mean score indicates that on average, participants neither agreed nor disagreed with medical mistrust statements. Although omnibus tests observed statistically significant mean differences in medical mistrust by education level (F(2, 167) = 3.15, p = .046) and self-rated health (F(2, 168) = 3.34, p = .038), post-hoc mean comparisons did not find significant differences between any two education levels (p > .05) or between any two health ratings (p > .05).

Table 2.

Patient-Provider Communication Quality and Medical Mistrust by Demographic Characteristics (n=174)

Patient-provider communication
M (SD)		 p Medical mistrust
M (SD)		 p
Geographic region
West 3.13 (0.71) 2.96 (0.66)
Midwest 3.16 (0.51) 3.29 (0.67)
South 3.15 (0.73) 3.04 (0.81)
Northeast 3.29 (0.73) .871 3.31 (0.63) .184
Highest level of education
High school or less 3.25 (0.69) 3.30 (0.60)
Some college 3.24 (0.62) 2.93 (0.75)
College degree or higher 3.05 (0.77) .196 3.17 (0.75) .046*
Self-rated health
Fair or worse 3.03 (0.75) 3.34 (0.90)
Good 3.07 (0.72) 3.14 (0.72)
Excellent 3.37 (0.60) .036* 2.88 (0.67) .038*
Last healthcare visit
< 1 month ago 3.29 (0.59) 3.01 (0.68)
≥ 1 month, < 6 months ago 3.20 (0.69) 3.21 (0.69)
≥ 6 months, < 12 months ago 3.02 (0.77) .094 3.01 (0.82) .258
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Note. Associations with health insurance status could not be assessed due to the lack of variability in the sample (98% were insured).

*

p < .05.

**

p < .01.

***

p < .001.

Demographic Correlates of Patient-Provider Communication Quality

The mean patient-provider communication quality score was 3.18 (SD = 0.71), indicating that on average, participants felt that their healthcare providers usually listened carefully, respected their input, spent enough time with them, and explained things in a way they could understand. Significant mean differences in patient-provider communication quality were found across self-rated health categories (F(2, 170) = 3.40, p = .036). Participants who rated their health as excellent (M = 3.37, SD = 0.60) reported greater quality patient-provider communication than those who rated their health as good (M = 3.07, SD = 0.72, t(2.48) p = .037).

Patient-provider communication quality as a predictor of medical mistrust

Results of the regression analyses are presented in Table 3. Step one, which consisted of demographic covariates only, was statistically significant and explained 11% of the variance in medical mistrust (F(9, 156) = 2.13, p = .030, R2 = 0.110). The inclusion of patient-provider communication quality in step two resulted in an additional 12.4% of explained variance (F(10, 154) = 4.70, p < .001, R2 = 0.234, ΔR2 = 0.124). Patient-provider communication quality was negatively associated with medical mistrust (b = −0.39, SE = 0.08, p < .001). For every one unit increase in patient-provider communication quality, medical mistrust scores decreased by .38 points. Education also emerged as a significant predictor in step two. Relative to not completing any college, completing some college was associated with lower medical mistrust (b = −0.37, SE = 0.17, p = .031).

Table 3.

Hierarchical Linear Regression Predicting Medical Mistrust (n=165)

b SE R2 p
Step 1 0.110
Geographic region (ref: South)
West −0.08 0.13 .553
Midwest 0.27 0.20 .185
Northeast 0.22 0.19 .247
Education level (ref: high school)
Some college −0.32 0.18 .079
College degree or higher −0.12 0.18 .507
Self-rated health (ref: fair/worse)
Good −0.08 .20 .687
Excellent −0.33 .22 .127
Last healthcare visit (ref: < 1 month ago)
≥ 1 month, < 6 months ago 0.21 0.14 .132
≥ 6 months, < 12 months ago −0.50 0.14 .718
Step 2 0.234
Patient-provider communication quality −0.39 0.08 > .001***
Geographic region (ref: South)
West −0.10 0.12 .386
Midwest 0.24 0.19 .211
Northeast 0.28 0.12 .116
Education level (ref: high school)
Some college −0.37 0.17 .031*
College degree or higher −0.20 0.17 .235
Self-rated health (ref: fair/worse)
Good −0.11 0.19 .558
Excellent −0.23 0.20 .264
Last healthcare visit (ref: < 1 month ago)
≥ 1 month, < 6 months ago 0.15 0.13 .251
≥ 6 months, < 12 months ago −0.17 0.13 .205
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*

p < .05.

**

p < .01.

***

p < .001.

Discussion

As healthcare providers seek to reduce medical mistrust and improve associated health outcomes, understanding predictors of medical mistrust, particularly as they may relate to provider actions, can be useful in informing practice. While young Black women have shared their perspectives on patient-provider communication quality and medical mistrust in qualitative studies examining healthcare experiences (Cuevas et al., 2016; Logan et al., 2021; Randolph et al., 2020; Rice et al., 2020), this study is one of the first to quantitatively examine the association between patient-provider communication quality and medical mistrust with a focused sample of young Black women.

Echoing the findings of previous qualitative studies (Altman et al., 2020; Mazul et al., 2017), our study quantitatively supports the idea that for Black women, specifically those aged 18–24, patient-provider communication quality is associated with medical mistrust. Healthcare providers seeking to reduce medical mistrust among young Black, woman-identified patients may consider communication quality as a potential avenue for intervention. In qualitative studies examining Black women’s healthcare experiences, participants have offered specific recommendations for improving provider communication quality including using accessible language (Mazul et al., 2017), providing sufficient details about treatment options and test results (Anderson et al., 2021), and engaging in collaborative decision making (Altman et al., 2020).

Existing literature examining healthcare experiences and medical mistrust among Black male populations suggests that perceived racism in the healthcare experience may mediate the relationship between patient-provider interaction quality and medical mistrust (Hammond, 2010). Indeed, qualitative research suggests that for both Black men and women, poor quality communication and perceived racism are closely related (Cuevas et al., 2016; Gary et al., 2015). Whether a provider’s actions are interpreted as racially motivated, however, appears to vary based on the participant’s perception. Future research should seek to further parse out the relationship by examining perceived racism as a potential mediator between patient-provider communication quality and medical mistrust among young Black women (Hammond, 2010).

In reflecting on perceived racism, it is also important to note that while education level emerged as a significant predictor of medical mistrust in the model, these findings should not be interpreted as evidence that being distrustful of medical professionals is an uneducated position. Given the racial disparities in health outcomes and the history of medical racism, being suspicious of medical professionals and institutions may be a protective factor and survival strategy for young Black women (Benkert, Cuevas, et al., 2019; Whaley, 2001). In the current study, differences in mistrust by education level may reflect differences in health insurance literacy or access to resources (Edward et al., 2019). Those with greater health insurance literacy may be more likely to understand how to choose a covered provider and may feel more empowered to change providers in the event of a poor fit (Tilley et al., 2018).

Limitations

This study has a few limitations to note. As a cross-sectional study, these results cannot be used to make causal inferences about the relationship between patient-provider communication quality and medical mistrust. Similarly, due to the non-probabilistic sampling strategy, the results cannot be generalized to all young Black women. Participants referred members of their social networks, which may account for the limited variability in demographic characteristics. In addition, because literature suggests that individuals with higher medical mistrust may be less likely to engage with healthcare services, restricting our sample to women who had seen a healthcare provider in the last 12 months may have resulted in underestimated levels of medical mistrust. Although this decision was made to align with the recall period of the CAHPS, future studies may consider assessing patient-provider communication quality with a measure that has a wider recall period.

Additionally, because the GBMMS measures perceived mistreatment due to ethnic identity, participants may have reflected on nationality or cultural group membership instead of, or in addition to, the social construct of race (Phinney & Ong, 2007). For instance, young Black women belonging to a cultural group with specific values related to medical care may have reflected on how those with similar values have experienced the healthcare system (Omenka et al., 2020). Although specifying the component of ethnic identity on which participants reflected is beyond the scope of this study, future studies using the GBMMS may seek to replace the term ethnicity with race for additional clarity.

Lastly, because we did not collect data on provider characteristics, we were unable to examine how race concordance or discordance with providers may relate to perceived communication quality or the association between communication quality and medical mistrust. Existing literature suggests that race discordance is negatively associated with several markers of perceived communication quality (e.g., information giving, participatory decision-making, and supportiveness in conversations) (Shen et al., 2018). Research also suggests that for Black patients in race-discordant patient-provider relationships, communication quality may be particularly impactful in influencing adherence decisions (Schoenthaler et al., 2012). Thus, future studies may seek to further explore the role of race concordance as a potential moderating variable in the association between communication quality and medical mistrust as well.

Conclusion

Our findings highlight the importance of strong patient-provider communication in relation to medical mistrust among young Black women. Understanding this relationship may allow us to better train physicians and other healthcare providers in cultural humility and patient-centered communication. Rather than viewing medical mistrust as a cultural issue inherent to Black populations, healthcare providers may consider reflecting on their communication practices from an anti-racist lens and consider how their interactions may influence their patients’ beliefs about healthcare systems and providers.

These findings also highlight an important opportunity for social work involvement. Healthcare social workers can empower clients to directly communicate their communication-related needs and preferences to providers and can also work to increase patients’ awareness of their healthcare-related rights, such as the right to have treatment options clearly explained (National Library of Medicine, 2021). In addition, as members of interdisciplinary healthcare teams, social workers can advocate for patient-centered communication by drawing attention to the impact that communication quality can have on patients’ attitudes towards healthcare systems and providers.

Funding details.

This work was supported by the National Institute of Minority Health and Health Disparities, mentored training award F31MD012211, the University of Maryland, Baltimore, Institute for Clinical & Translational Science Award grant number 1UL1TR003098, and the National Institute of Mental Health of the National Institutes of Health under award number R25MH080665.

Footnotes

Disclosure statement. The authors have no potential competing interests to report.

Data availability statement.

Due to the nature of this research, participants of this study did not agree for their data to be shared publicly, so supporting data is not available.

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Associated Data

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Data Availability Statement

Due to the nature of this research, participants of this study did not agree for their data to be shared publicly, so supporting data is not available.

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