摘要：Objectives. We investigated whether health care system distrust is a barrier to breast and cervical cancer screening and whether different dimensions of distrust—values and competence—have different impacts on cancer screening. Methods. We utilized data on 5268 women aged 18 years and older living in Philadelphia, Pennsylvania, and analyzed their use of screening services via logistic and multinomial logistic regression. Results. High levels of health care system distrust were associated with lower utilization of breast and cervical cancer screening services. The associations differed by dimensions of distrust. Specifically, a high level of competence distrust was associated with a reduced likelihood of having Papanicolaou tests, and women with high levels of values distrust were less likely to have breast examinations within the recommended time period. Independent of other covariates, individual health care resources and health status were associated with utilization of cancer screening. Conclusions. Health care system distrust is a barrier to breast and cervical cancer screening even after control for demographic and socioeconomic determinants. Rebuilding confidence in the health care system may improve personal and public health by increasing the utilization of preventive health services. Cancer is a leading cause of death in the United States. Approximately 1.5 million Americans are diagnosed with cancer per year and 1 in 4 deaths are attributed to cancer. 1 Among women, an estimated 192 000 breast and 11 000 cervical cancer cases are detected each year, and in 2009 more than 40 000 women died of breast cancer and approximately 4000 of cervical cancer. 1 To effectively reduce the morbidity and mortality resulting from breast and cervical cancer, efforts need to be made to increase the proportion of women who comply with screening recommendations 2 ; according to a recent report, a third of women are not in compliance with screening guidelines for breast cancer, and more than a fifth are not in compliance for cervical cancer. 3 Our goal was to investigate whether health care system distrust (hereafter referred to as distrust) is a barrier to breast and cervical cancer screening. The late 20th century saw many changes in the theoretical underpinnings of research on health in general and women's health in particular. The prevailing biomedical model was criticized for ignoring social determinants of health, such as social class, gender roles, and poverty, 4 and health determinants models that incorporated multiple social, economic, and demographic dimensions were embraced. 5 – 7 The multiple determinants of health perspective emphasizes the relationships between socioeconomic factors and health outcomes, 4 but the role of psychological factors (i.e., depression and distrust) in cancer screening has only recently been recognized. 8 – 11 Relatively little is known about whether distrust affects health outcomes, and specifically whether it influences cancer screening behaviors among women. 11 Americans’ overall confidence in their health care system has declined markedly in recent decades. In 2010, only 34% of adults reported “a great deal” of confidence in the health system, down from over 70% in 1966. 12 More than 80% of Americans, however, held high levels of trust in their personal physicians or providers, 13 a paradox that has been widely documented in the literature. 14 – 17 Previous studies suggest that trust in physicians is associated with seeking timely medical care, maintaining appropriate health care, and adhering to medical advice, 18 – 20 but it is unclear whether trust or its converse, distrust, affects the adoption of preventive health services among women. 11 The emerging distrust research in health care shows that distrust is a multidimensional concept. 21 – 23 For example, Shea et al. used focus groups, pilot testing, and a telephone survey to develop a highly reliable 9-item distrust scale that includes 2 subscales: competence distrust and values distrust. 22 Competence distrust is expected to be high when the quality of service fails to meet patient expectations and does not improve health. Values distrust is expected to be high when the integrity of the health care system is questioned (e.g., ethical issues, financial priorities, transparency of care). Although dimensions of distrust may influence the use of preventive health services in different ways, little research has addressed this issue explicitly. A range of individual characteristics has been found to be associated with the use of breast and cervical cancer screening, including age, 5 , 24 race/ethnicity, 11 , 25 socioeconomic factors, 5 , 24 marital status, 5 , 11 , 24 and availability and utilization of health care resources. 11 , 24 Access to insurance and health care providers is associated with higher likelihood of interaction with the health care system and has been hypothesized to be related to levels of distrust and to individuals’ health-related behaviors. 26 Personal health status has been found to be related to levels of distrust, 27 although the underlying causal mechanisms have not been well documented. Evidence concerning the association of health status with use of preventive health services is inconclusive. 11 An important contribution of our study is the investigation of the association of distinct aspects of distrust—values distrust and competence distrust—with receipt of 2 preventive health services for adult women: the Papanicolaou (Pap) test for cervical cancer and clinical breast examination to screen for breast cancer. We tested the following 2 hypotheses: after we controlled for individual socioeconomic and demographic characteristics, (1) high levels of distrust are associated with low utilization of cancer screening services and (2) the negative relationship between distrust and cancer screening utilization holds for the values and competence dimensions of distrust.
