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19 minute read 05 August 2021

Rebuilding trust in health care

What do consumers want—and need—organizations to do?

Lack of trust in health care remains an issue, particularly among individuals who identify as Black, Asian, Hispanic, and Native American. How can health care organizations earn back the trust of these communities?

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Executive summary

Consumer and community trust in health care providers and institutions is critical for optimal health, as trust influences willingness to get crucial medical care, preventive screenings, and mental health care.¹ Trust between a patient and a health care provider is also linked to improved patient experience, health outcomes, and the patient’s perception of the care they receive.² However, it is also well documented that in the United States, not all communities feel the same level of trust with their health care providers. In 2021 there continues to be large disparities in trust by race/ethnicity. A critical area of focus for health equity—the fair and just opportunity for every individual to achieve their full potential in all aspects of health and well-being—is therefore rebuilding trust with racially and ethnically diverse communities.

A common misconception is that mistrust in health care relates mostly to historical atrocities. Tuskegee, Sims, and others play a role, but primarily assigning blame to these instances ignores the everyday racism. In the past year (since the death of George Floyd), more health care organizations are openly talking about the role they may have played in the loss of trust with some patients and communities—both historically and currently. It is crucial for organizations to understand what experiences led individuals to lose trust, how they might re-earn the trust of those individuals, and how organizations can prevent those events from happening again.

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Now is an opportunity for organizations to actively rebuild and earn back trust of their communities. But how? The Deloitte Center for Health Solutions conducted two streams of research to gain insights into the “current state” of trust in health care:

1) Focus groups with 525 individuals in the United States who identify as Black, Hispanic, Asian, or Native American to explore their experiences with health care organizations and sentiments around trust

2) Thirteen interviews with health executives, advocates, and academic experts to explore organizations’ strategies to repair and improve trust

In our virtual focus groups:

Fifty-five percent reported a negative experience where they lost trust in a health care provider.
Thirty-six percent have skipped or avoided care because they did not like the way the health care provider or their staff treated them.
After an experience where they lost trust, four out of five participants say there was nothing the provider/health system could do to make them returnto the same provider or health system.
Having a provider who has empathy, is culturally competent, and/or looks like them is a top priority. About half of the participants are willing to trade off access to convenient, in-person care with longer-distance travel or virtual visits to get a provider who looks like them/is culturally competent.

These findings highlight the importance of trust and its influence on people’s decisions about whether they go for care, where they go for it, and what experiences they will not tolerate. Improved experience is therefore critical for advancing health equity.

To improve interactions with health care providers, participants said they need to:

Have a voice when something goes wrong. Sixty-two percent of the participants want their local hospitals to ensure patients have a voice to relay their experiences and take action to address their problems.
Have access to providers who are culturally competent and/or look like them, talk like them/have shared life experiences.
- For Asian (59%) and Hispanic (53%) participants, having a provider who has empathy and is culturally competent is a top priority when choosing a provider.
- Two out of three participants who identify as Black or African American and half of Asian and Hispanic respondents say it is important to see a health care provider similar to them.
- Younger participants (aged 18–44 years) are more likely to say that having a health care provider with a similar background is important.

In prior research with health care executives, we found that many were prioritizing health equity through investments, governance, and resources.³ But despite well-intentioned efforts, trust remains an issue. From our interviews with executives, we found that organizations know that they not only need to make changes, but also take a humble step back and listen. A misstep in the past was to make assumptions on what their communities needed and wanted, instead of asking them. The link between trust and health care is not a new topic in research and academics, but the systems that deliver and pay for care are farther behind when it comes to discussing and strategizing how to make changes. The executives we interviewed noted that more and more, their organizations are recognizing the importance of trust, and to be most effective—hospital leadership should communicate the importance through actions and not just words. The interviewees said they are acknowledging the need for staff to be culturally competent about different life experiences, backgrounds, and languages. And ultimately, the entire care team can deliver better care if they have empathy, ask what patients prefer (language, for example) instead of assuming, and create a nonjudgmental environment.

There is an opportunity for health care organizations, in light of the imperative for health equity, to shape their strategies best if they understand the wide range of perspectives in their communities and what consumers want and what organizations should do to earn back their trust.

Health care organizations have a history of and current problem with mistrust

All physicians, and by association health systems, take an oath to “abstain from all intentional wrong-doing and harm” when they take the Hippocratic oath. However, whether intentionally or not, some providers and health care organizations are not abiding by this oath, and have contributed to the lack of trust that is prevalent across the US health care system.

Even more salient than historical atrocities, may perhaps be the daily subtle and unsubtle experiences of racism.⁴ Our research shows that people who identify as Black, Asian, or Hispanic feel as though their pain is often denied, they are not heard, and they are not treated well by staff and doctors. In these moments, patients are probably not thinking of historical atrocities, but rather thinking about how a system/provider has failed them and their communities.

We know that patients are less likely to return for care after having a negative experience with a health care provider or staff. Rebuilding that trust is essential as the link between trust and health outcomes is well established. When physicians and patients share a trusted relationship, we see improvement in cholesterol screening, patient understanding of cancer risk, and patient perceptions of treatment decisions.⁵ When trust is earned over multiple positive interactions with patients who felt previously mistreated, this can contribute to improved health equity.

In our research with health care executives on health equity, organizations acknowledge that they need to do better at improving trust. Many have invested heavily in their communities and determinants of health (DOH). However, despite these efforts, there are still challenges with trust. Where is the disconnect? And what do communities really need to have an improved relationship with the health care institution? We explored this in our research with 525 individuals who identify as Black, Hispanic, Asian, or Native American in the spring of 2021.

Methodology

Deloitte’s Center for Health Solutions ran three anonymous, online research focus groups with a convenience sample of 525 consumers who identified as Black, Asian, Hispanic, or Native American in the United States in the spring of 2021. Participants were recruited through an established vendor using vetted panels.

The majority of respondents identified as Black, followed by Hispanic, Asian, and Native American. We aimed for participant variety based on age, gender, education, annual household income, and geography. However, our sample is not representative of the country’s population nor of these characteristics.

We asked participants a mix of open-ended and multiple-choice questions exploring trust and how it impacts their decisions around how they access care, what trust means to them, and what organizations can do to improve trust.

In addition, we interviewed 13 health equity experts from various US-based health care organizations to understand how the health care industry can leverage opportunities to rebuild trust.

What we learned:

Why trust matters: Respondents weigh in on their health care experiences, what trust means, and what happens after they have lost trust.

Findings from our focus group discussions emphasized that there are still multiple areas where trust needs to be repaired and inequities acknowledged before health care systems can credibly move ahead on the road to health equity.

“We (in the health care industry) have a very tall hill to climb, and trust has to be at the core, given the past injustices to Black bodies. It will take time and investments, more than just money.” — Vice president, US health equity and community wellness, pharmaceutical industry

Access to high-quality care remains an issue

Nearly one in four participants (figure 1) do not think they have access to high-quality care. This sentiment is amplified among our Hispanic and Black participants, only half of whom feel they have access to high-quality care.

Of those who feel they don’t, some said they don’t have good health insurance. Others do not have access to good health care facilities and resources in their communities. Some said lack of quality was related to specific experiences with a doctor.

For example, one respondent said, “Most of the time I don’t feel like the doctor is really paying attention to what my condition is. They just want to move you through the system as fast as they can for more profit.”— Focus group participant (Hispanic/Latino, male, 55–64-year-old)

How common is mistrust in health care? Does it change behavior?

Fifty-five percent of our focus group participants said they were subject to a negative health care experience that led them to lose trust in their health care provider. Reasons for this erosion of trust included their health care providers discounting their symptoms, not listening to them, being culturally insensitive, providing incorrect information, and not engaging with or caring for them. One respondent said, “The doctor discounted the symptoms I was experiencing, and therefore resolution of the issue took much longer and required repeated visits.”

— Focus group participant (Black or African American, female, 55–64-year-old)

These experiences matter and contribute to consumers’ behavior in response. Consider:

More than a third of the participants said they skipped or avoided care because they did not like the way the health care provider or their staff treated them.
Nearly 80% of the participants said they would not return to the same provider if they had an experience where they lost trust.

“I would never return. My health is too important, and I would rather find another provider.”

— Focus group participant (Black, female, 45–54-year-old)

Differences in “signals” of trust measures

A separate Deloitte survey found that on average, white respondents find health systems more trustworthy than Asian, Black, or Latino respondents across four components or “signals” of trust. The biggest differences by race/ethnicity were ratings on the health systems’ humanity and reliability (see figure).

Deloitte surveyed 6,000 consumers between December 2020 and March 2021 to understand consumer sentiment on certain components or “signals” of trust for specific health care organizations, including health systems.⁶ On a scale of 1–7, with 7 being the best score, the respondents rated a set of specific health systems on each “signal of trust”—transparency, humanity, capability, and reliability (definitions provided in endnote).⁷ Compared to white respondents, Black, Latino, and Asian respondents, on average, gave lower ratings on each trust signal (see figure). Asian respondents rated health systems, on average, higher than Black and Latino respondents, but still lower than white respondents. The differences were statistically significant (see more about Deloitte’s quantitative HX TrustID^TM methodology here).

Many are willing to trade off convenience to see someone who is “like them.”

About half of the participants are willing to trade off in-person visits and closer location to see a provider who relates to them and understands their needs.

Participants told us they are willing to make the following trade offs if they cannot find a “similar” provider in their area (figure 2):

o More than half of the participants who identify as Asian (56%) and Black (55%) are willing to travel farther.

o Half or more who identify as Hispanic (54%) and Black (49%) are willing to use virtual visits, as are 41% of Asians.

Matching consumers with providers

The number of apps and services that help consumers identify doctors who look like them, talk like them, or share their life experiences are increasing by the day. From “matchmakers” to candid review forums to virtual mental health care, the venues to connect with a doctor/provider of one’s preference is becoming easier.

• 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. They have a mission to “change patient care outcomes for 50,000 Black and Latinos by 2025.” The site offers patient reviews and helps identify the best provider for the individual user.

• Ayana Therapy is a virtual health app that matches users to licensed mental health care professionals based on their culture, race, and experiences.

• Black Doctors of South Florida is bringing a “behind the scenes” Black network to the forefront. The product is a searchable directory to identify Black physicians. The founder, Adrienne Hibbert, came up with the idea when she was pregnant with her first child, about 15 years ago. As a Black woman, she did not feel welcome in her local hospital with a white obstetrician. Hibbert identified that others would probably want the same as her: someone who understands her background, the foods that she eats, and “someone who understands my upbringing and things that my grandma used to tell me.”

How do we rebuild trust? What do consumers want and how can health care organizations deliver?

Consumers seek providers who have empathy. They want to feel safe and understood, not judged.

It is important, particularly among the Black respondents in our research, to see health care providers who look like them, talk like them, and/or have shared life experiences. In our focus groups, more than half of the participants feel it is important to see a health care provider who looks like them, talks like them, is from their community, or has shared life experiences.

Two-thirds of participants who identify as Black or African American say it is important to see a health care provider who looks, talks, is from the same community, or has experiences like them (figure 3).

Participants said that it is important because a provider from a similar background would:

Make them feel more comfortable
Understand their symptoms better
Not make general assumptions
Not be too judgmental

“Having a doctor with a similar background that resembles me may have the doctor avoid making general assumptions regarding my health. They may take more time in deciphering my symptoms and how to address [them].”

— Focus group participant (Black, female, 25–34-year-old)

Boosting the number of diverse providers is important, but not enough

It is clear from our research and others’, that many patients prefer to see a provider who looks like them/talks like them. But diversity among physicians in the United States is limited. Based on the latest figures⁸ of the overall US physician workforce, 56% are white, 17% are Asian, 6% are Hispanic, and 5%, Black.

And it’s even more disparate for mental health professionals: 86% are white, 5% Hispanic, 5% Asian, and 4% African American.⁹ It is certainly important to recruit a more diverse workforce, but by 2042—just over 20 years away—the combined minority population is set to become the majority in the United States.¹⁰ Based on these numbers, it will be difficult for the physician workforce to mirror the population in the near future.

Changing the face of the physician workforce will be an ongoing longer-term effort. However, there are things we can do in the meantime. For example: one approach is hiring a more diverse staff that can deliver team-based care. This approach allows nurses and other support staff to care for the patients, along with the physician who may not be of the same ethnicity or background as each patient. Another important step is changing medical school curriculums.

A call for medical schools to teach all students to treat patients as they would want to be treated themselves. Some universities are realizing they need to revamp their medical school curriculum to incorporate antiracism training. One of the interviewed executives said that at their medical school, students are now learning to talk to patients about their entire lives, not just their bodies, with questions like:

• Have you ever felt discriminated against?

• Do you feel safe communicating your needs?

Other executives highlighted the importance of medical students learning about racism in health care, ideally in the first year of medical school. In addition, they should learn how to communicate with patients from various cultures and backgrounds. This shift is essential for creating a more equitable health system.

What qualities of trust matter most in a health care provider relationship?

“I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.” – Hippocratic oath

For centuries, doctors have been taking the Hippocratic oath, which includes the above promise. More than 2,000 years later, we find that this very sentiment is an essential quality to develop a trusted relationship with a patient.

Focus group respondents said that genuine care for patient well-being and empathy, kindness, and fairness as well as the ability to clearly explain medical care and treatment decisions are the most important qualities they seek in a health care provider (figure 4). The need for empathy matters more to Black and younger respondents.

Consumers want a platform to voice their needs, concerns, and experiences with wrongdoing.

In our focus groups, the most important advice for health systems was to “ensure that patients have a way to voice” their concerns and opinions if they had a negative experience and were not treated respectfully, and see that the complaint “is acted upon” (figure 5). The health equity experts we interviewed also emphasized the importance of health systems listening to their communities and centering them while providing care.

“It’s important to be able to listen to our communities and center them. Dismantling our policies and current practices that limit participation or understanding of our communities is going to be important.”

— Vice president for health, nonprofit advocacy organization

Consumers may be more willing to get care and preventive services through a trusted community partnership with a health system.

Previous research shows that some individuals are more willing to get care through a nontraditional health partner, such as a community center, barbershop, religious gathering, or even a public health agency. Through community partnerships with safe, trusted fixtures in a community, health systems can establish more 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.¹¹ The Biden administration announced the “Shots at the shop” initiative, which involved engaging barbershops and salons owned by Black people across the country to educate and vaccinate people in areas with low vaccination rates.¹²

Barbershops are just one example of a safe, trusted fixture in a community. In our focus groups, most participants said they trust community health centers (67%) and community organizers (59%) as possible partners. More Black respondents are trusting of religious organizations (51%), while more Hispanic (49%) and Asian (46%) respondents trust state and local agencies (figure 6).

Health systems need to offer patients and their community more power to voice their concerns and a place to do so.

One clear message from our research is that patients/communities need more seats at the table. And interviewed executives gave some ideas on how health organizations can amplify their patients’ voices. For example:

Have a clear platform for patients who had a bad experience with a doctor via a supervisor, a phone number or an online platform specifically for feedback, or even suggestion boxes (or an online version of them) for patients to provide feedback anonymously.
Get ahead before things could go wrong:
- Include patient voices in planning. Patient advisory councils are important, but even more seats at the table are important for discussing topics such as patient experience and community needs.
- Offer a chaperone during physical exams as well as an interpreter. A patient request for a chaperone is widely accepted in today’s health care system.¹³
- Encourage patients to feel comfortable bringing an advocate or family or friends. Studies show that accompanying family and friends can serve as patient advocates and that their presence has a positive influence on building rapport and increasing patient participation.¹⁴
- Ask for positive feedback on physicians who are doing well and use them as advocates/allies in improving trust and experience.

Conclusion

From our interviews with executives, we found that organizations are prioritizing health equity and know that they need to make real changes, but also need to take a humble step back and listen in order to understand the wide range of perspectives in these groups and ultimately understand what consumers want and need organizations to do to earn back trust.

Carole A. Robinson, “Trust, health care relationships, and chronic illness: A theoretical coalescence ,” Global Qualitative Nursing Research 3 (2016); Johanna Birkhäuer et al., “Trust in the health care professional and health outcome: A meta-analysis ,” PLoS ONE 12 (2017), no. 2.View in Article
Penn Medicine News. “Study Finds Patients Prefer Doctors Who Share Their Same Race/Ethnicity," accessed July 29, 2021. View in Article
Kulleni Gebreyes et al., Mobilizing toward health equity: Action steps for health care organizations, Deloitte Insights, May 26, 2021.View in Article
COVID Collaborative, “Coronavirus vaccination hesitancy in the Black and Latinx communities,” November 2020.View in Article
Simar Singh Bajaj and Fatima Cody Stanford, “Beyond Tuskegee—Vaccine distrust and everyday racism,” New England Journal of Medicine , February 4, 2021.View in Article
Leslie Read and Shane Giuliani. “Consumer Trends in Health Care," Deloitte, accessed July 29, 2021.View in Article
Humanity: Demonstrates empathy and kindness towards me and treats everyone fairly.

Capability: Delivers quality products, services, and/or experiences.

Transparency: Openly shares all information, motives, and choices in straightforward and plain language.

Reliability: Consistently and dependably delivers upon promises it makes.
View in Article
AAMC, “Diversity in medicine: Facts and figures 2019,” accessed July 13, 2021.View in Article
Rina Raphael, "This app matches marginalized communities to therapists who share their background", FastCompany, August 12, 2019.View in Article
Sam Roberts, “Minorities in U.S. set to become majority by 2042 ,” New York Times , August 14, 2008.View in Article
Ronald G. Victor et al., “A cluster-randomized trial of blood-pressure reduction in Black barbershops,” New England Journal of Medicine 378 (2018): pp. 1291–301.View in Article
Tyler Pager, Lena H. Sun, and John Wagner, “Offering beer, babysitting and barbershop outreach, the White House launches new initiatives to boost vaccinations,” Washington Post , June 2, 2021.View in Article
AMA, “Use of chaperones ,” accessed July 13, 2021.View in Article
J. B. Brown et al., "Roles and influence of people who accompany patients on visits to the doctor," Conadian Family Physician 44 (1998): pp. 1644-50.View in Article

Project team: Wendy Gerhardt provided invaluable guidance on shaping the project, interpreting findings, and editing sections of the paper. Hemnabh Varia contributed significantly to the planning, question development, research, analysis, and writing.

Acknowledgments: The authors would like to thank Kulleni Gebreyes, Melinda Nowak, Natasha Buckley, Negina Rood, Laura DeSimio, Marilyn Zubak, Nicole Nodi, David Levin, and the many others who contributed their insights and ideas to this project.

This study would not have been possible without our research participants who graciously agreed to participate in the focus group discussions and the interviews. They were generous with their time and insights.

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Rebuilding trust in health care

What do consumers want—and need—organizations to do?