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 organisations earn back the trust of these communities?
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 organisations 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 organisations to understand what experiences led individuals to lose trust, how they might re-earn the trust of those individuals, and how organisations can prevent those events from happening again.
Now is an opportunity for organisations 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 organisations and sentiments around trust
2) Thirteen interviews with health executives, advocates, and academic experts to explore organisations’ strategies to repair and improve trust
In our virtual focus groups:
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:
In prior research with health care executives, we found that many were prioritising 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 organisations 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 strategising how to make changes. The executives we interviewed noted that more and more, their organisations are recognising 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 organisations, 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 organisations should do to earn back their trust.
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 organisations 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, organisations 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.
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 organisations can do to improve trust.
In addition, we interviewed 13 health equity experts from various US-based health care organisations to understand how the health care industry can leverage opportunities to rebuild 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
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)
Fifty-five per cent 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:
“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)
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 organisations, 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 TrustIDTM methodology here).
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.
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.”
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:
“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)
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 realising 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.
“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.
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 emphasised 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
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).
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:
From our interviews with executives, we found that organisations 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.
Amid uncertainty and change, health care stakeholders are looking for new ways to transform the journey of care. By focusing on the differentiated needs of plans and providers, our US Health Care practice helps clients transform uncertainty into possibility, and rapid change into lasting progress.