Does patient-provider racial/ethnic concordance influence ratings of trust in people with HIV infection?

Challenges Experienced by Black Women with Breast Cancer During Active Treatment: Relationship to Treatment Adherence

BACKGROUND

Although rates of death from breast cancer have declined in the USA for both Black and White women since 1990, mortality rates for Black women remain strikingly higher - 40% higher compared to White women (American Cancer Society 1). The barriers and challenges that may be triggering unfavorable treatment-related outcomes and diminished treatment adherence among Black women are not well understood.

METHODS

We recruited 25 Black women with breast cancer who were to receive surgery and chemotherapy and/or radiation therapy. Through weekly electronic surveys, we assessed types and severity of challenges across various life domains. Because the participants rarely missed treatments or appointments, we examined the impact of severity of weekly challenges on thoughts of skipping treatment or appointment with their cancer care team using a mixed-effects location scale model.

RESULTS

Both a higher average severity of challenges and a higher deviation of severity reported across weeks were associated with increased thoughts on skipping treatment or appointment. The correlation between the random location and scale effects was positive; thus, those women that reported more thoughts on skipping a dose of medicine or appointment were also more unpredictable with respect to the severity of challenges reported.

CONCLUSIONS

Black women with breast cancer are impacted by familial, social, work-related, and medical care factors, and these may in turn affect adherence to treatment. Providers are encouraged to actively screen and communicate with patients regarding life challenges and to build networks of support within the medical care team and social community that can help patients successfully complete treatment as planned.

Prospective Survey of Discrimination in Pregnant Persons and Correlation with Unplanned Healthcare Utilization

OBJECTIVE

To determine the association between lifetime exposure to discrimination and unplanned healthcare utilization in pregnant persons.

METHODS

This was a prospective cohort study of pregnant persons receiving care from 2021 to 2022. Primary data was collected from participants on sociodemographic factors and on Perceived Ethnic Discrimination Questionnaire (PED-Q), a validated 17-item scale measuring perceived lifetime interpersonal racial and ethnic discrimination in four domains: work/school, social exclusion, stigmatization, and threat. The primary outcome was unplanned healthcare utilization, defined as unplanned labor and delivery admissions, triage, Emergency Department, or urgent care visits. Bivariate and multivariate analyses were done to examine the association between lifetime exposure to discrimination and unplanned healthcare utilization.

RESULTS

A total of 289 completed the PED-Q and were included in the analysis. Of these, 123 (42.6%) had unplanned healthcare utilization. Mean (SD) of lifetime racial and ethnic discrimination was significantly higher in people with unplanned healthcare utilization compared to those with planned healthcare utilization [1.67 (0.63) vs 1.48 (0.45), p = 0.003]. Univariate analysis showed that lifetime racial and ethnic discrimination was significantly associated with unplanned healthcare utilization (OR 1.96, 95% CI 0.23-3.11). Significant associations were found between unplanned healthcare utilization and maternal age (p = 0.04), insurance type (p = 0.01), married status (p < 0.001), education (p = 0.013), household income (p = 0.001), and chronic hypertension (p = 0.004). After controlling for potential confounding factors, self-reported lifetime racial and ethnic discrimination remained significantly associated with higher odds of unplanned healthcare utilization (aOR 1.78, CI 95% 1.01-3.11).

CONCLUSION

We found that a higher level of self-reported lifetime racial and ethnic discrimination was associated with increased unplanned healthcare utilization during pregnancy.

Is patients' trust in clinicians related to patient-clinician racial/ethnic or gender concordance?

OBJECTIVE

To examine the relationship between patient-clinician concordance (racial/ethnic and gender) and patients' trust in their regular clinician.

METHODS

This mixed methods study used the 2019 U.S. Health Reform Monitoring Survey to examine concordance and patient trust in clinicians, and semi-structured interviews with 24 participants to explore patients' perceptions of how concordance relates to trust in their clinician.

RESULTS

Almost six in ten adults (59.8%) who had a regular clinician reported having trust in their clinician. White, Black, and Latino participants were similarly likely to report trust. Those with racial/ethnic concordant clinicians were 7.5 percentage points more likely to report trust than were those with non-concordant clinicians (62.4% vs 54.9%). This finding was consistent for men and women, and did not differ significantly across racial and ethnic groups. In interviews, while almost all participants described having trusted non-racial/ethnic concordant clinicians, several described immediately trusting concordant clinicians. In contrast, we did not observe a consistent relationship between patient-clinician gender concordance and trust.

CONCLUSION

The findings underscore the importance of increasing the number of Black and Latino clinicians, and also highlight that all clinicians need to work hard to build trust with patients from different racial/ethnic backgrounds.

Association between COVID-19 vaccine hesitancy and trust in the medical profession and public health officials

One's personal physician, national and state or local public health officials, and the broader medical profession play important roles in encouraging vaccine uptake for COVID-19. However, the relationship between trust in these experts and vaccine hesitancy has been underexplored, particularly among racial/minority groups where historic medical mistrust may reduce uptake. Using an April 2021 online sample of US adults (n = 3041) that explored vaccine hesitancy, regression models estimate levels of trust in each of these types of experts and between trust in each of these experts and the odds of being COVID-19 vaccine takers vs refusers or hesitaters. Interaction terms assess how levels of trust in the medical profession by race/ethnicity are associated with vaccine hesitancy. Trust in each expert is positively associated with trust in other experts, except for trust in the medical profession. Only trust in one's own doctor was associated with trust in the medical profession, as measured by factor scores derived from a validated scale. Lower levels of trust in experts were significantly associated with being either a hesitater or a refuser compared to being a taker. Black respondents had higher odds of being either a hesitater or a refuser compared to white respondents but the interaction with trust was insignificant. For Hispanic respondents only, the odds of being a hesitater declined significantly when trust in the medical profession rose. Mistrust in the medical profession, one's doctor and national experts contributes to vaccine hesitancy. Mobilizing personal physicians to speak to their own patients may help.

Causal Effect Analysis of Demographic Concordance of Physician Trust and Respect in an Emergency Care Setting

Objective

Patient perceptions of physician trust and respect are important factors for patient satisfaction evaluations. However, perceptions are subjective by nature and can be affected by patient and physician demographic characteristics. We aim to determine the causal effect on patient-physician demographic concordance and patient perceptions of physician trust and respect in an emergency care setting.

Methods

We performed a causal effect analysis in an observational study setting. A near-real-time patient satisfaction survey was sent via telephone to patients within 72 h of discharge from an emergency department (ED). Patient-trust-physician (PTP) and physician-show-respect (PSR) scores were measured. Patient and physician demographics (age, gender, race, and ethnicity) were matched. Causal effect was analyzed to determine the direct effect of patient-physician demographic concordance on PTP/PSR scores.

Results

We enrolled 1815 patients. The treatment effect of patient-physician age concordance on PTP scores was -0.119 (p = 0.036). Other treatment effect of patient-physician demographic concordance on patient perception of physician trust and respect ranged from -0.02 to -0.2 (p > 0.05).

Conclusion

Patient-physician age concordance may cause a negative effect on patient perception of physician trust. Otherwise, patient-physician demographic concordance has no effect on patient perceptions of physician trust and respect.

Use of Pre-exposure Prophylaxis Among People Who Inject Drugs: Exploratory Findings of the Interaction Between Race, Homelessness, and Trust

Scale-up of pre-exposure prophylaxis (PrEP) in people who inject drugs (PWID) remains suboptimal. Patient-level factors are often complex and may contribute to scale-up. Using cross-sectional data from 234 opioid-dependent patients on methadone who met eligibility criteria for PrEP, we conducted logistic regression analyses to assess potential moderators associated with being on PrEP (n = 60). Mean provider trust was significantly higher among Blacks vs Whites (39.4 vs 34.9; p = 0.002) and non-homeless vs homeless participants (37.5 vs 34.8; p = 0.008). Though race/ethnicity was not a significant moderator on provider trust and PrEP use, increased provider trust was marginally associated with increased PrEP use among Blacks (p = 0.058). Additionally, homelessness significantly moderated provider trust and PrEP use (p = 0.024). Provider trust among non-homeless participants was positively correlated with PrEP use (p = 0.013) but not among homeless participants. Strategies that promote provider trust in Blacks and non-homeless PWID on methadone may improve PrEP scale-up.

Understanding Medical Distrust Among African American/Black and Latino Persons Living With HIV With Sub-Optimal Engagement Along the HIV Care Continuum: A Machine Learning Approach

Medical distrust is a potent barrier to participation in HIV care and medication use among African American/Black and Latino (AABL) persons living with HIV (PLWH). However, little is known about sociodemographic and risk factors associated with distrust. We recruited adult AABL PLWH from low socio-economic status backgrounds with insufficient engagement in HIV care (N = 512). Participants completed structured assessments on three types of distrust (of health care providers, health care systems, and counter-narratives), HIV history, and mental health. We used a type of machine learning called random forest to explore predictors of trust. On average, participants were 47 years old (SD = 11 years), diagnosed with HIV 18 years prior (SD = 9 years), and mainly male (64%) and African American/Black (69%). Depression and age were the most important predictors of trust. Among those with elevated depressive symptoms, younger participants had less trust than older, while among those without depression, trust was greater across all ages. The present study adds nuance to the literature on medical distrust among AABL PLWH and identifies junctures where interventions to build trust are needed most.

Racial/ethnic concordance between patients and researchers as a predictor of study attrition

RATIONALE

The differential attrition of racial/ethnic minority participants in clinical research is a major threat to advancing medical and behavioral science.

OBJECTIVE

Our aim was to examine the influence of racial/ethnic concordance between participants and research staff on study attrition.

METHOD

Data were pooled from participants and clinical research coordinators (CRCs) in six longitudinal studies of respiratory illness. Dyads were classified as concordant if the patient and CRC were of the same racial/ethnic group. Multilevel modeling examined the effect of racial/ethnic concordance on attrition at the first and one-year follow-ups.

RESULTS

Spanish language, lower education, and greater depressive symptoms predicted greater attrition, but these effects disappeared in adjusted models. Race/ethnicity, age, gender and health literacy did not predict attrition. Contrary to hypotheses, attrition was greater among concordant than discordant dyads: Attrition was almost five times greater at first follow-up for Black and Hispanic participants in concordant dyads, and almost four times greater at one year.

CONCLUSIONS

Racial/ethnic concordance between participant and CRCs was related to greater attrition in a highly diverse sample of adults with respiratory illness. Differential attrition of racial/ethnic minorities is a major threat to advancing public health. Interactions with research staff may be critical to bridging the disparities gap.

Physician Mistrust, Medical System Mistrust, and Perceived Discrimination: Associations with HIV Care Engagement and Viral Load

Medical mistrust is an important risk factor for many health outcomes. For individuals with HIV and substance use co-morbidities, mistrust may influence engagement with health care, and affect overall health and transmission risk. Medical mistrust can be measured by an individual's mistrust of his/her physician, or mistrust of the medical system. This study examined both types of mistrust among 801 substance-using individuals with uncontrolled HIV infection. The aims were to determine how physician mistrust, medical system mistrust, and discrimination experiences were associated with engagement in HIV primary care. Findings indicated higher levels of physician mistrust, but not medical system mistrust, were associated with a longer time since the last visit to an HIV provider. Longer time since seeing an HIV care provider was associated with higher viral load. This study refines our understanding of the relationship between mistrust and HIV care engagement for a large, diverse sample of substance-using individuals.

Medical Mistrust in Black Breast Cancer Patients: Acknowledging the Roles of the Trustor and the Trustee

Studies indicate that Black patients report higher medical mistrust compared to their White counterparts. However, little is known about factors associated with higher medical mistrust among Black breast cancer patients. We examined predictors of medical mistrust and relationships between medical mistrust, subscales of mistrust, and process of care factors to identify opportunities to promote positive healthcare interactions between the trustees (e.g., providers) and Black breast cancer patients, or the trustors. A secondary analysis was conducted of survey data from 210 Black women with confirmed diagnosis of invasive breast cancer. Participants completed telephone surveys consisting of questions pertaining to sociodemographics, attitudes, and beliefs about medical care and breast cancer treatments. Multiple linear regression determined factors associated with medical mistrust and mistrust subscales. Most participants (61%) were over the age of 50 and currently single (64.8%). Women with greater medical mistrust reported less satisfaction with the trustee's technical ability (p < 0.0001) and greater satisfaction with their own propensity to access care (p < 0.05). Additionally, women with public insurance demonstrated greater mistrust (p < 0.01) and suspicion (p < 0.05) than women with private insurance, and women with less education reported greater perceived discrimination than women who have at least a bachelor's degree. Findings from this study may inform future endeavors to educate providers on ways to effectively interact with and treat Black breast cancer patients. Opportunities to develop interventions that address and tackle issues of mistrust as reported by Black patients may contribute to ongoing efforts to reduce health disparities.

Study protocol for investigating physician communication behaviours that link physician implicit racial bias and patient outcomes in Black patients with type 2 diabetes using an exploratory sequential mixed methods design

INTRODUCTION

Patient-physician racial discordance is associated with Black patient reports of dissatisfaction and mistrust, which in turn are associated with poor adherence to treatment recommendations and underutilisation of healthcare. Research further has shown that patient dissatisfaction and mistrust are magnified particularly when physicians hold high levels of implicit racial bias. This suggests that physician implicit racial bias manifests in their communication behaviours during medical interactions. The overall goal of this research is to identify physician communication behaviours that link physician implicit racial bias and Black patient immediate (patient-reported satisfaction and trust) and long-term outcomes (eg, medication adherence, self-management and healthcare utilisation) as well as clinical indicators of diabetes control (eg, blood pressure, HbA1c and history of diabetes complication).

METHODS AND ANALYSIS

Using an exploratory sequential mixed methods research design, we will collect data from approximately 30 family medicine physicians and 300 Black patients with type 2 diabetes mellitus. The data sources will include one physician survey, three patient surveys, medical interaction videos, video elicitation interviews and medical chart reviews. Physician implicit racial bias will be assessed with the physician survey, and patient outcomes will be assessed with the patient surveys and medical chart reviews. In video elicitation interviews, a subset of patients (approximately 20-40) will watch their own interactions while being monitored physiologically to identify evocative physician behaviours. Information from the interview will determine which physician communication behaviours will be coded from medical interactions videos. Coding will be done independently by two trained coders. A series of statistical analyses (zero-order correlations, partial correlations, regressions) will be conducted to identify physician behaviours that are associated significantly with both physician implicit racial bias and patient outcomes.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Virginia Commonwealth University IRB. Study results will be disseminated through publications in peer-reviewed journals and presentations at conferences. A novel Medical Interaction involving Black Patients Coding System from this project will be made publicly available.

The differences between medical trust and mistrust and their respective influences on medication beliefs and ART adherence among African-Americans living with HIV

OBJECTIVE

The purpose of this study was to examine the relationships between medical mistrust and trust and to determine if these measures differentially predict antiretroviral therapy (ART) medication adherence for African-American adults living with HIV.

DESIGN

A total of 458 HIV positive African-Americans completed a cross-sectional survey.

MAIN OUTCOME MEASURES

Self-reported ART adherence was collected using the visual-analog scale. The Beliefs About Medicines Questionnaire was used to assess medication necessity and concern beliefs.

RESULTS

All measures of medical mistrust and trust were significantly negatively correlated, ranging from r = -.339 to -.504. Race-based medical mistrust significantly predicted medication necessity and concern beliefs, whereas general medical mistrust only significantly predicted medication concerns. Both measures of trust significantly predicted medication necessity beliefs and medication concerns. Higher levels of race-based medical mistrust predicted lower medication adherence, whereas, neither trust in own physician nor trust in health care provider significantly predicted medication adherence. However, trust in own physician significantly predicted medication necessity beliefs, which predicted medication adherence.

CONCLUSION

Trust and mistrust are not simply opposites of one another. These findings provide evidence for the complexity of understanding the relationship between health care trust, mistrust and patient-related health beliefs and behaviours.

Disaggregating ethnoracial disparities in physician trust

Past research yields mixed evidence regarding whether ethnoracial minorities trust physicians less than Whites. Using the 2002 and 2006 General Social Surveys, variegated ethnoracial differences in trust in physicians are identified by disaggregating a multidimensional physician trust scale. Compared to Whites, Blacks are less likely to trust the technical judgment and interpersonal competence of doctors. Latinos are less likely than Whites to trust the fiduciary ethic, technical judgment, and interpersonal competence of doctors. Black-Latino differences in physician trust are a function of ethnoracial differences in parental nativity. The ways ethnoracial hierarchies are inscribed into power-imbalanced clinical exchanges are discussed.

Developing the HIV Workforce: The MATEC Clinician Scholars Program

Engaging new clinical providers in the HIV workforce is a critical need due to rapidly evolving treatment paradigms, aging out of existing providers, and special population needs. The 1-year competency-based Clinician Scholar Program for minority-serving providers with limited HIV care experience was individually tailored for each provider (n = 74), mostly nurse practitioners, physicians, and clinical pharmacists. Baseline and endpoint self-assessments of clinical knowledge and skills showed significant improvements in all 11 targeted competencies, particularly in managing antiretroviral medications, screening and testing methods, incorporating prevention into HIV care, understanding risk reduction methods, and describing current care standards. Faculty mentor assessments also showed significant improvement in most competencies. Additional benefits included ongoing access to mentorship and training, plus sustained engagement in local and statewide HIV care networks. Our intensive mentoring program model is replicable in other AIDS Education and Training Centers and in other structured training programs.

Barriers to health-care and psychological distress among mothers living with HIV in Quebec (Canada)

Health-care providers play a major role in providing good quality care and in preventing psychological distress among mothers living with HIV (MLHIV). The objectives of this study are to explore the impact of health-care services and satisfaction with care providers on psychological distress in MLHIV. One hundred MLHIV were recruited from community and clinical settings in the province of Quebec (Canada). Prevalence estimation of clinical psychological distress and univariate and multivariable logistic regression models were performed to predict clinical psychological distress. Forty-five percent of the participants reported clinical psychological distress. In the multivariable regression, the following variables were significantly associated with psychological distress while controlling for sociodemographic variables: resilience, quality of communication with the care providers, resources, and HIV disclosure concerns. The multivariate results support the key role of personal, structural, and medical resources in understanding psychological distress among MLHIV. Interventions that can support the psychological health of MLHIV are discussed.

Making Me Feel Comfortable

Trust ( confianza) is an important component of patient-centered care and culturally competent care and a major element in the Hispanic culture. The aim of this study was to conceptualize the process of the development of interpersonal trust by hospitalized patients in their nurses. Using the grounded theory method, English-speaking Mexican American patients ( N = 22) were interviewed. The core category was Making Me Feel Comfortable. The cyclical process included a beginning stage (Having Needs, Relying on the Nurse), middle stage (Coming Across to Me, Taking Care of Me, Connecting), and end point (Feeling Confianza) with two outcomes (Confiding in the Nurse, Taking Away the Negative). Anytime there was a negative element during the middle stage, this element halted any further development of trust with the nurse. Unique findings were related to Hispanic cultural values of familism and personalismo. The findings have implications which impact patient safety and quality care.

Cultural identity and patient trust among older American Indians

BACKGROUND

Patients' trust in healthcare providers and institutions has been identified as a likely contributor to racial-ethnic health disparities. The likely influence of patients' cultural characteristics on trust is widely acknowledged but inadequately explored.

OBJECTIVE

To compare levels of patients' trust in primary care provider (interpersonal trust) with trust in healthcare organizations (institutional trust) among older American Indians (AIs), and determine associations with cultural identity.

DESIGN

Patient survey administered following primary care visits.

PARTICIPANTS

Two-hundred and nineteen American Indian patients ≥ 50 years receiving care for a non-acute condition at two clinics operated by the Cherokee Nation in northeastern Oklahoma.

MAIN MEASURES

Self-reported sociodemographic and cultural characteristics. Trust was measured using three questions about interpersonal trust and one measure of institutional trust; responses ranged from strongly agree to strongly disagree. Finding substantial variation only in institutional trust, we used logistic generalized estimating equations to examine relationships of patient cultural identity with institutional trust.

KEY RESULTS

Ninety-five percent of patients reported trusting their individual provider, while only 46 % reported trusting their healthcare institution. Patients who strongly self-identified with an AI cultural identity had significantly lower institutional trust compared to those self-identifying less strongly (OR: 0.6, 95 % CI: 0.4, 0.9).

CONCLUSIONS

Interpersonal and institutional trust represent distinct dimensions of patients' experience of care that may show important relationships to patients' cultural characteristics. Strategies for addressing low institutional trust may have special relevance for patients who identify strongly with AI culture.

Non-verbal communication between primary care physicians and older patients: how does race matter?

BACKGROUND

Non-verbal communication is an important aspect of the diagnostic and therapeutic process, especially with older patients. It is unknown how non-verbal communication varies with physician and patient race.

OBJECTIVE

To examine the joint influence of physician race and patient race on non-verbal communication displayed by primary care physicians during medical interviews with patients 65 years or older.

DESIGN, SETTING, AND PARTICIPANTS

Video-recordings of visits of 209 patients 65 years old or older to 30 primary care physicians at three clinics located in the Midwest and Southwest.

MAIN MEASURES

Duration of physicians' open body position, eye contact, smile, and non-task touch, coded using an adaption of the Nonverbal Communication in Doctor-Elderly Patient Transactions form.

KEY RESULTS

African American physicians with African American patients used more open body position, smile, and touch, compared to the average across other dyads (adjusted mean difference for open body position = 16.55, p < 0.001; smile = 2.35, p = 0.048; touch = 1.33, p < 0.001). African American physicians with white patients spent less time in open body position compared to the average across other dyads, but they also used more smile and eye gaze (adjusted mean difference for open body position = 27.25, p < 0.001; smile = 3.16, p = 0.005; eye gaze = 17.05, p < 0.001). There were no differences between white physicians' behavior toward African American vs. white patients.

CONCLUSION

Race plays a role in physicians' non-verbal communication with older patients. Its influence is best understood when physician race and patient race are considered jointly.

Applying the theory of planned behavior to explore HAART adherence among HIV-positive immigrant Latinos: elicitation interview results

OBJECTIVE

This study explored influences on intention to adhere to highly active antiretroviral therapy (HAART) among immigrant Latinos living with HIV/AIDS in the southeastern USA.

METHODS

Our community-based participatory research (CBPR) partnership completed individual in-depth interviews with 25 immigrant Latinos, based on the theory of planned behavior (TPB), to explore beliefs toward HAART adherence and HIV testing.

RESULTS

Participants identified (a) seven outcomes of treatment adherence (e.g., "feeling good" and "controlling the virus"), (b) six groups of persons influencing adherence (e.g., family, partner/spouse), and (c) nine impediments to adherence (e.g., appointment scheduling, side effects of treatment). Fear of deportation, perceived costs of services, and barriers to communication emerged as impediments to both HAART adherence and HIV testing.

CONCLUSION

The findings suggest the utility of TPB in identifying factors to enhance HAART adherence among immigrant Latinos. Future research should explore the extent to which these identified TPB components quantitatively influence adherence intention and immunological and virological outcomes.

PRACTICE IMPLICATIONS

Culturally congruent interventions for immigrant Latinos may need to focus on facilitators of adherence, influential referent groups, and destigmatizing HIV/AIDS.

Satisfaction with health care among Latinas

Despite growing interest in disparities in access to health care, relatively little is known about different facets of care among Latinas, their satisfaction with the care they receive, and the predictors of satisfaction. This study examined whether various health care access and context factors, the quality of the patient-physician interaction, and medical mistrust predict satisfaction with health care among Latina immigrants in New York City. Structured interviews were conducted with 220 Latinas predominantly from the Dominican Republic and aged 40 years or over. Of the access to health care variables examined, greater waiting time predicted dissatisfaction with health care. Greater quality of the patient-physician interaction predicted less dissatisfaction. The effect of the patient-physician interaction on dissatisfaction was mediated, in part, by waiting time. The results illustrate the important role of specific health care factors in satisfaction with care.

Communities of color? Client-to-client racial concordance in the selection of mental health programs for Caucasians and African Americans

A discrete-choice logit model was applied to study the determinants of mental health provider choice using data from a large urban county in the Northeast US. The study subjects were 9,544 adult Medicaid recipients who received outpatient treatment from the 20 Community Mental Health Center (CMHC) programs in 2001. In addition to a conventional set of variables representing client and provider characteristics, the regression model included several interaction terms to examine whether racial concordance level among patients influences the choice of an outpatient program. The results revealed that racial concordance among the clients seems to be a factor in choosing a program. In particular, Caucasian clients are much more likely to select a program with a higher percentage of Caucasian clients, even though they have to travel further. More generally, our results suggest that program choice may be driven more by the racial composition of the clients served than by spatial proximity to the program.

Influence of trust on HIV diagnosis and care practices: a literature review

Delays in accessing HIV health care and failure to adhere to providers' advice are common. Patient trust is critical to an individual's willingness to seek care and follow the physician's advice. Conversely, patient distrust can diminish the patient's health status. The trust literature is reviewed in an attempt to determine its effect on HIV care. In the HIV literature reviewed, greater trust in health care providers was associated with improved accessing of and remaining in care. Interventions to enhance patient trust have been tested, with no changes in the levels of trust being found. Few studies were rigorous enough to assess causality or temporal relation. It is not clear whether there is a causal association between patient trust and HIV health care outcomes. As these relationships are better understood, interventions can be designed to increase health-promoting behaviors.

The association of stigma with self-reported access to medical care and antiretroviral therapy adherence in persons living with HIV/AIDS

BACKGROUND

The stigma of HIV-infection may profoundly affect the lives of persons living with HIV/AIDS (PLHA). However few studies have examined the association of HIV stigma with multiple components of HIV treatment and care.

OBJECTIVES

To estimate the association between HIV stigma and: self-reported access to care, regular source of HIV care, and antiretroviral therapy adherence; and to test whether mental health mediates these associations.

DESIGN

Cross-sectional study.

PARTICIPANTS

202 PLHA living in Los Angeles County in 2007.

MEASUREMENTS

Participants completed an anonymous survey, assessing internalized HIV stigma (28-items, alpha = 0.93), self-reported access to medical care (six items, alpha = 0.75), regular source of HIV care, and antiretroviral therapy (ART) adherence.

RESULTS

One-third of participants reported high levels of stigma; 77% reported poor access to care; 42.5% reported suboptimal ART adherence; and 10.5% reported no regular source of HIV care. In unadjusted analysis, those reporting a high level of stigma were more likely to report poor access to care (OR = 4.97, 95% CI 2.54-9.72), regular source of HIV care (OR = 2.48, 95% CI 1.00-6.19), and ART adherence (OR = 2.45, 95% CI 1.23-4.91). In adjusted analyses, stigma was significantly associated with poor access to care (OR = 4.42, 95% CI 1.88-10.37), but not regular source of HIV care or ART adherence. Mental health mediated the relationship between stigma and ART adherence, but not poor access to care or regular source of HIV care.

CONCLUSIONS

The association of stigma with self-reported access to care and adherence suggests that efforts to improve these components of HIV care will require a better understanding of the possible effects of stigma and its mediators.

A 41-year-old African American man with poorly controlled hypertension: review of patient and physician factors related to hypertension treatment adherence

Mr R is an African American man with a long history of poorly controlled hypertension and difficulties with adherence to recommended treatments. Despite serious complications such as hypertensive emergency requiring hospitalization and awareness of the seriousness of his illness, Mr R says at times he has ignored his high blood pressure and his physicians' recommendations. African Americans are disproportionately affected by hypertension and its complications. Although most pharmacological and dietary therapies for hypertension are similarly efficacious for African Americans and whites, disparities in hypertension treatment persist. Like many patients, Mr R faces several barriers to effective blood pressure control: societal, health system, individual, and interactions with health professionals. Moreover, evidence indicates that patients' cognitive, affective, and attitudinal factors and the patient-physician relationship play critical roles in improving outcomes and reducing racial disparities in hypertension control.