Mistrust in health care runs deep, is personal, and needs to be addressed now

By Heather Nelson, senior manager, Deloitte Consulting LLP

I grew up in the northwest suburbs of Chicago surrounded by science. Initially, I wanted to attend medical school. However, a public-health engineering course during my sophomore year of college inspired me to combine my love of science with my passion for social justice. I wound up writing my senior thesis on environmental injustice in communities of racially and ethnically diverse people.

The environment in which we live has a direct impact on our health and well-being. Excessive exposure to air pollution, hazardous chemicals, unsafe water, and lead-based paint are structural environmental threats that are more prevalent in low-income, vulnerable communities. These environmental factors—along with other social and economic drivers of health—can impact health equity beyond health care delivery. This can include elevated rates of asthma and heart disease, learning disabilities, and other health issues. Decades of structural inequity, environmental injustice, and bias and racism in health care have helped to erode the level of trust that many people have in the health care delivery system.

Deloitte’s Center for Health Solutions recently conducted three anonymous online focus groups with 525 consumers who identified themselves as Black, Hispanic, Asian, or Native American. We wanted to understand the level of trust they place in the health care delivery system. We also interviewed 13 health equity experts from various US-based health care organizations to find out how the health care sector might rebuild trust among those patient populations.

The whole notion of trust is fundamental to improving the health and well-being of people who live in vulnerable communities. Trust was certainly eroded by historic events such as the U.S Public Health Service (USPHS) Syphilis Study at Tuskegee in the 1960s and ’70s. But distrust of the health care delivery system is often magnified by personal experiences.

How important is trust? More than half of our participants told us about a negative experience where they lost trust in a health care provider. The vast majority of them (nearly 80%) said there was nothing that provider could do that would convince them to return. While some people said they would seek care elsewhere, more than one-third of our participants admitted they have skipped or avoided care because they didn’t like the way a clinician or staff member treated them. That is a troubling percentage given how such a decision could compound a serious health condition.

We spoke with people who said they often didn’t feel respected by health care professionals or didn’t think health care professionals were actively listening when they described symptoms and experiences. One survey participant said she didn’t receive the correct treatment because her doctor discounted her symptoms. She said repeated visits were needed before the issue was resolved.

While I wasn’t completely surprised by our findings, it was disheartening to see such issues are still prevalent in 2021. It hurts when I hear some of the same stories that were common when I was growing up 35 years ago.

Four strategies that could help restore trust

We have been measuring health disparities for decades. While we have accumulated volumes of data, the lack of meaningful action is profound. The tide could be turning. Health disparities that were underscored by the pandemic—combined with racial injustices highlighted by the murder of George Floyd a year ago—have sparked more serious conversations about health equity. While this is encouraging, it will likely take a lot to move the needle.

We asked health equity leaders what health care organizations could do to rebuild trust among racially or ethnically diverse patient populations. Here are four strategies: 

1. Focus on hiring a diverse and inclusive clinical staff: More than half of US physicians are white, while just 5% are Black, and 6% are Latinx. While it might be difficult to recruit racially or ethnically diverse physicians, hospitals and health systems should try to build diversity into their care teams and overall staff. The executives who lead those organizations should also consider cultural empathy and inclusivity training for all clinical staff. One executive told us that some universities are realizing they need to incorporate anti-racism training into their medical school curriculum. 
2. Promote apps and services that help consumers identify diverse clinicians: Our survey participants said they prefer to see clinicians who are of the same background or ethnicity. In our focus groups, more than half of the participants said it was important to see a health care provider who looks like them, talks like them, is from their community, or has shared life experiences. Black Doctors of South Florida—a provider-directory company, helps to connect Black patients to Black doctors, specialists, and other clinicians. HUED is a platform that connects individuals to health care providers who understand their cultural, physical, and mental needs. The goal is to give prospective patients easy access to care from people who look like them. Ayana is a virtual health app that matches users to licensed mental health care professionals based on their culture, race, and experiences.
   
3. Partner with trusted groups in the community: Previous research shows that some individuals are more willing to get care through a non-traditional health partner, such as a community center, barbershop, religious gathering, or even a public health agency. Partnering with safe, trusted fixtures in a community could help health systems establish trust through a relatable forum and provide culturally appropriate public health messaging, which often results in better health outcomes. For example, a 2018 study found that 64% of Black men brought their blood pressure to normal levels after a barbershop-based health intervention, compared with only 12% of the control group.¹ The Biden administration announced the “Shots at the Shop” initiative, which involved engaging Black-owned barbershops and salons across the country to educate and vaccinate people in areas with low vaccination rates.²
   
4. Listen to patients: Traditional patient surveys might not be a large enough platform. Our focus-group participants said it was important that health systems give patients a way to voice their concerns and opinions and to feel that they were heard. A patient who had a bad experience, for example, should have a place to anonymously provide feedback. People will likely be willing to interact with a brand or health care delivery system if they believe their concerns will be heard, that action will be taken, and that they will be able to see the result.
   

Some hospital and health system leaders still have blind-spots and might not think trust is an issue for the populations they serve. Unless and until organizations move beyond that type of thinking, mistrust will likely continue. Trust is a critical enabler, and efforts to improve health equity and outcomes will likely not happen without it.

However, based on some of my recent discussions, leaders in the health care space appear eager to educate themselves about health equity and health disparities and improve trust with patients who might have had negative experiences. We are seeing newly created positions dedicated to addressing those issues, and many of these executives have accountability as well as a seat at the executive table. Over the past year, these issues have been a part of nearly every discussion we’ve had with senior health care executives.

It will be important for them to keep in mind that trust is not something that happens overnight. It is earned over a long time through a series of interactions. For many people, trust in the health care delivery system is personal.

The Deloitte Health Equity Institute

Endnotes:

1. A cluster-randomized trial of blood-pressure reduction in Black barbershops, The New England Journal of Medicine, April 5, 2018

2. Offering beer, babysitting and barbershop outreach, the White House launches new initiatives to boost vaccinations, Washington Post, June 2, 2021

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