摘要：Objectives. We sought to find racial differences in the effects of trust in the health care system on preventive health service use among older adults. Methods. We conducted a telephone survey with 1681 Black and White older adults. Survey questions explored respondents' trust in physicians, medical research, and health information sources. We used logistic regression and controlled for covariates to assess effects of race and trust on the use of preventive health services. Results. We identified 4 types of trust through factor analysis: trust in one's own personal physician, trust in the competence of physicians' care, and trust in formal and informal health information sources. Blacks had significantly less trust in their own physicians and greater trust in informal health information sources than did Whites. Greater trust in one's own physician was associated with utilization of routine checkups, prostate-specific antigen tests, and mammograms, but not with flu shots. Greater trust in informal information sources was associated with utilization of mammograms. Conclusions. Trust in one's own personal physician is associated with utilization of preventive health services. Blacks' relatively high distrust of their physicians likely contributes to health disparities by causing reduced utilization of preventive services. Health information disseminated to Blacks through informal means is likely to increase Blacks' utilization of preventive health services. There is strong empirical evidence of health care disparities between Black and White Americans. Blacks are less likely than are Whites to receive many needed services, including routine preventive care. 1 – 5 The causes of disparities in health care are complex and have been the subject of considerable research; socioeconomic differences and structural characteristics (such as lack of access to care) are important sources of care disparities, and there is significant evidence that racial bias in the health care system is also a major factor in disparities in care between Blacks and Whites. 1 Blacks' distrust of physicians and the health care system may also contribute to health care disparities. Studies have demonstrated that Blacks exhibit less trust in the health care system. 6 – 9 There are a variety of mechanisms through which this distrust may occur, including Blacks' personal experiences with racism, their knowledge of a history of racism in the health care system—including circumstances in which Blacks were victimized, such as the Tuskegee Syphilis Study 10 – 12 —and social and cultural distance between Black patients and White physicians. 13 Taken together, these individual experiences constitute a broader cultural memory of abuse that may contribute to belief in conspiracy theories among Blacks. 14 , 15 Goertzel reported that belief in conspiracies was correlated with lack of interpersonal trust and that Blacks were more likely to believe in conspiracy theories than were Whites. 16 Trust plays a central role in all medical relationships and is an important contributor to positive therapeutic outcomes. 17 – 20 Lack of patient trust is associated with less doctor–patient interaction, poor clinical relationships that exhibit less continuity, reduced adherence to recommendations, worse self-reported health, and reduced utilization of health care services 17 – 22 ; thus, Blacks' relatively lower trust in the health care system puts them at greater risk of all these negative outcomes. When O'Malley et al. 22 evaluated respondents' answers to a global question assessing overall trust in personal physicians, they found that greater trust was associated with higher overall use of a number of preventive services among low-income Black women 41 years and older. However, little is known about whether distrust affects use of specific preventive services differently. Because trust in the health care system is conceived as consisting of a number of types and dimensions, 17 , 19 , 20 it is also possible that different aspects of trust may affect service use differently, thus warranting more detailed study of how the dimensions of trust may affect use of preventive services among various populations. Because of its likely origins in racial bias, Blacks' health care–related distrust may have somewhat different effects from that of Whites, perhaps manifesting as institutional distrust as opposed to interpersonal distrust. We explored these issues by examining the association of different aspects of health care–related trust with receipt of preventive health services among older Blacks and Whites. We focused on older adults because preventive services such as immunizations, routine physical examinations, and screening for cancer and other diseases can greatly reduce premature mortality and morbidity among this population and are critical to sustaining older adults' health. 23 Thus, disparities in receipt of preventive services are an especially strong contributor to disparities in health outcomes for older adults.
