Disaggregating ethnoracial disparities in physician trust

Social Science Research 54 (2015) 1–20

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Disaggregating ethnoracial disparities in physician trust Abigail A. Sewell ⇑ Emory University, United States University of Pennsylvania, United States

a r t i c l e

i n f o

Article history: Received 17 June 2014 Revised 31 May 2015 Accepted 25 June 2015 Available online 27 June 2015 Keywords: Race Trust Patient–physician relationship Medicine Doctors Medical sociology

a b s t r a c t 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. Ó 2015 Elsevier Inc. All rights reserved.

0. Introduction The patient–physician relationship is inherently unequal given the status differences between clinicians and help-seekers (Gilson, 2003; Kramer and Cook, 2004; Mechanic, 1998; Parsons, 1951). The absence of physician trust on behalf of ethnoracial (i.e., racial/ethnic) minorities is considered to be a key mechanism underlying health care disparities (LaVeist et al., 2000; Smedley et al., 2003). In fact, ample evidence shows that Blacks and Latinos hold less trust toward medical research, pharmaceuticals, health care facilities, and health care providers than Whites (Armstrong et al., 2006; Boulware et al., 2003; Corbie-Smith et al., 2002; Freimuth et al., 2001; Hughes-Halbert et al., 2006; Stepanikova et al., 2006). Lack of trust in physicians and health care matters in a broader sense because trust in medical actors is considered a contributing factor to help-seeking behavior when one becomes ill and to compliance behavior as one navigates the medical institution (Mechanic, 1998; Whetten et al., 2006). High levels of trust, moreover, have been linked to better self-rated health and more positive functional health across the life course (Barefoot et al., 1998). Inequalities in trusting medical actors by race and ethnicity, then, may partly contribute to ethnoracial inequalities in morbidity, mortality, and health care service use (Smedley et al., 2003). Yet, research evaluating ethnoracial differences in trusting personal physicians provides mixed evidence regarding both the magnitude and substantive nature of ethnoracial differences in physician trust. For instance, on one hand, unidimensional studies examining the perceived willingness of doctors to put their patients’ needs above all other considerations show Blacks are substantially less likely than Whites to trust personal physicians (Ahern and Hendryx, 2003; Doescher et al., 2000; Levinson et al., 2005; Patel and Chernew, 2007; Schnittker, 2004; Stepanikova et al., 2006). On the other hand, studies employing multi-dimensional scales of trusting personal physicians do not show evidence of less trusting affect

⇑ Address: Emory University, Department of Sociology, 204 Tarbutton Hall, 1555 Dickey Drive, Atlanta, GA 30322, United States. E-mail address: [email protected] http://dx.doi.org/10.1016/j.ssresearch.2015.06.020 0049-089X/Ó 2015 Elsevier Inc. All rights reserved.

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toward medical doctors among Blacks compared to Whites (Benjamins, 2006; Guffey and Yang, 2012; Musick and Worthen, 2008; Tai-Seale and Pescosolido, 2003). Meanwhile, Latino–White differences in physician trust have been found in unidimensional studies (Stepanikova et al., 2006) but have not been evaluated in multidimensional studies. These divergent sets of findings prompt an important question: Why do multidimensional studies of physician trust not detect ethnoracial differences in physician trust? If ethnoracial minorities are so overwhelmingly distrustful of medicine and, arguably by extension, physicians, then ethnoracial gaps should be evident regardless of the instrument employed. This ethnoracial physician trust paradox is the concern of this study. Recent studies argue that (dis)trust in the health care system cannot be translated to (dis)trust in physicians (Shoff and Yang, 2012). I argue that ethnoracial differences in medical system trust do not necessarily translate to ethnoracial differences in physician trust. The perspective that ethnoracial minorities are culturally predisposed to distrust must be questioned. Rather, as stated by Benjamin (2013) in a study of stem cell research, ‘‘distrust is socially produced in the everyday experiences of patient families in and outside of the clinic’’ (115). The approach taken to elucidating this paradox is primarily methodological, with substantive and theoretical implications, as it highlights the utility of disaggregating multidimensional physician trust scales. Using data from English-speaking respondents of the 2002 and 2006 General Social Surveys, this study adjudicates among the disparate findings of physician trust studies by evaluating measurement variance in a shortened form of a standard multi-dimensional ‘‘Trust in Physician’’ scale and its constituent disaggregated items (Anderson and Dedrick, 1990). Five dimensions of the patient–physician relationship are considered: honesty, fiduciary ethics (i.e., commitment to uphold the Hippocratic Oath), technical expertise, cultural authority, and interpersonal competence (Mechanic, 1998; Pescosolido et al., 2001). A commonly-used measure of confidence in medicine is employed as a comparison measure to capture social attitudes toward the larger health care system. Ethnoracial differences in the various forms of physician trust are evaluated both naïvely and holding constant sociodemographic factors. The ways ethnoracial hierarchies are inscribed into power-imbalanced clinical exchanges are discussed. 1. Literature review 1.1. Trust in the health care system Trust is an essential ingredient of social interactions characterized by high levels of uncertainty and vulnerability (Smith, 2010), such as those within the medical institution (Cook et al., 2004; Hall et al., 2001; Mechanic, 1998; Pearson and Raeke, 2000). Social conditions, such as race and ethnicity, constrain and shape the contour of interactions within and across ethnoracial groups (Ross et al., 2001). Race, in particular, influences the relationships people form with others (Link and Phelan, 1995). Racism creates dissimilarities in the life opportunities, lived experiences, and collective interests of individuals marked indelibly by phenotype (Bonilla-Silva, 1997; Omi and Winant, 1994). Moreover, racial stratification intensifies power imbalances already present in the interactions between patients and physicians (King, 1996). Racial stratification fosters racially distinct attitudinal profiles toward institutional gatekeepers of the goods and services of society (Bonilla-Silva, 1997), including toward the medical and scientific enterprises (Benjamin, 2013). Processes of inequality within and tangential to the medical system have placed racial and ethnic minorities in a position of high vulnerability to medical actors (Smedley et al., 2003; Whaley, 1998). For instance, the misuse and abuse of Black bodies in medical science is considered to have incited general mistrust and anxiety among Blacks toward medicine (Gamble, 1997; Thomas and Curran, 1999; White, 2005). Such mistrust and anxiety reflects a history of exploitation and benign neglect that Blacks have experienced at the hands of actors across the medical hierarchy (Beardsley, 1987; Jones, 1981; Nelson, 2011; Washington, 2006. In characterizing the medical attitudes of Blacks, Gamble (1997) suggests there is a spillover effect from Black’s general beliefs that their lives are devalued: ‘‘They perceive, at times correctly, that they are treated differently in the health care system solely because of their race, and such perceptions fuel mistrust of the medical profession’’ (1775–6). Social processes of inequality also place Latinos at a disadvantage in medical encounters. Recent studies indicate that experiments such as Tuskegee also occurred among Guatemaleans during the 1940s (Reverby, 2011), suggesting that Latinos may also have a collective memory of medical abuse and benign neglect. Moreover, Latinos have more limited English proficiency than non-Latinos – a factor that undermines trust via compromising the quality of patient–physician communication (Betancourt et al., 2003; McGorry, 1999). One study found that 82% of Latinas who participated in a focus group study cited language problems as a reason to withhold information from their physicians (Julliard et al., 2008). Because the presence of a third party heightens feelings of discomfort, fear, and vulnerability in a relationship that is already power-imbalanced, interpreters may also create more barriers to establishing trust between Latino patients in their doctors. In fact, Latinos may experience cultural dissonance with Western medical practices that mandate patients disclose confidential information and personal problems with clinicians (Echeverry, 1997). Still, researchers have not provided a systematic examination of how pan-ethnic inequalities influence the extension of trust to physicians within the medical encounters. For instance, research often lumps Latinos into the ‘‘Other’’ category or omits them from analysis altogether. Furthermore, among demographically-similar adults, no ethnoracial differences have been found in prior studies examining ethnoracial differences in confidence in leaders of medicine or general confidence in physicians (e.g., Alesina and La Ferrara, 2002; Benjamins, 2006). These findings call into question the assumption that ethnoracial inequalities in physician trust are ubiquitous and/or are a ready reflection of ethnoracial inequalities in medical distrust.

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1.2. Trust in personal physicians Still, research has suggested that processes of social distance negate the positive impact that high-quality physician behavior (thoroughness of physical exams, attentiveness during visit, clarity of medical explanations) have on Blacks trusting their physicians (Schnittker, 2004). For instance, even upon accessing health services, minorities – directly through personal contact and indirectly through networks of friends and family – report more negative interactions with health care professionals than do Whites (Diala et al., 2000; Lillie-Blanton et al., 2000). Minority patients also report less participatory visits and more verbally dominant encounters with their physicians than do White patients (Cooper-Patrick et al., 1999; Saha et al., 1999). Minority patients in racially-discordant relationships report poorer clinical encounters in the health care system and express more concerns with unfair treatment in medicine than do minority patients in racially-concordant relationships (Cooper-Patrick et al., 1999; Saha et al., 1999; Schnittker and Liang, 2006). Yet, ethnoracial differences in physician trust persist despite the racial concordance of the patient–physician relationship (Schnittker and Liang, 2006; Sohler et al., 2007). While a good deal of research supports the claim that ethnoracially marginalized people are less trusting of medicine than Whites, research on whether such distrust/mistrust extends to personal physicians presents equivocal results. Two bodies of research have emerged. The first body of research draws mainly, but not exclusively, from fiduciary trust data, while the second body of research draws from multidimensional trust data. The remainder of this section reviews the evidence provided by each body of research and concludes with a critique of extant research. Due to the limited availability of physician trust research on Latinos, the research examined focuses primarily on Black–White differences in physician trust; however, research on Latino–White differences in physician trust is also considered, where available. 1.2.1. Support for ethnoracial differences in trusting personal physicians Given past histories of abuse and exploitation toward Black patients by medical actors (e.g., Tuskegee Syphilis Study, Henrietta Lacks, the Mississippi Appendectomy, gynecological experiments on slaves), ethnoracial differences in perceptions of the honesty of physicians are expected to be substantial. Blacks have been found to be less trusting of medical actors’ honesty about a range of ethical and privacy issues, including blood tests, experimentation, medication, public health information, and mistakes made during medical care (Armstrong et al., 2006, 2008; Whetten et al., 2006). Assessments of honesty with measures of mistrust in hospitals suggest that Blacks, more so than Whites, often perceive violations of their privacy (LaVeist et al., 2000). Honesty is reported to be an issue for Latinos also – specifically, focus groups of Latinas reported not trusting that their doctor would keep their medical information confidential (Julliard et al., 2008). Still, no research is available that assesses ethnoracial differences in trusting the honesty of one’s personal physician. Furthermore, the rise of managed care has fostered concerns with whether physicians are able to attend to institutionally-motivated fiscal concerns while placing their patients’ needs first (Caronna, 2011; Mechanic, 1998). Researchers suggest that concerns with increasing health care costs and the dominance of managed care system models may disproportionately impinge upon the health care experiences of minorities because they are often uninsured or underinsured (Schlesinger, 1987). For example, an early study reported that Blacks are more likely than Whites to believe the duration of their hospitalization is too short (Blendon et al., 1989). Recent studies of ethnoracial differences in trusting a physician’s fiduciary ethic suggests that minorities are concerned about the implications of managed care. Specifically, Levinson et al. (2005) find that Blacks and Latinos are less likely than Whites to believe that physicians prioritize patients over financial costs. However, the lower levels of fiduciary trust among Latinos documented in this study were only marginally significant. Using scales that aggregate measures of the fiduciary ideal of medicine with measures of more specific physician behaviors (e.g., whether one’s physician will provide references to a specialist, is influenced by health insurance rules, and might perform unnecessary tests or procedures), studies indicate that Blacks and Latinos are less trusting than Whites (Ahern and Hendryx, 2003; Doescher et al., 2000; Patel and Chernew, 2007; Schnittker, 2004). Yet, a study that disaggregates items of fiduciary trust scales indicates that Blacks and Whites are equally likely to trust in the fiduciary ideal of medicine (Stepanikova et al., 2006). Moreover, lower levels of fiduciary trust among Latinos compared to Whites are less pronounced for those surveyed in English than for those surveyed in Spanish. This study also indicates that no Latino–White fiduciary trust differences occurred once sociodemographic differences in correlates of trust are taken into consideration. 1.2.2. Lack of support for ethnoracial differences in trusting personal physicians Meanwhile, evidence of negative affect toward medicine among minorities has been difficult to replicate when scholars employ multidimensional trust in physician scales (Benjamins, 2006; Guffey and Yang, 2012; Tai-Seale and Pescosolido, 2003). Some studies suggest that Blacks may be more trusting of some medical actors than others. For instance, recent studies suggest that Blacks’ negative evaluations of medicine may be more related to concerns about the health care system rather than concerns about one’s personal physician (Armstrong et al., 2006; LaVeist et al., 2000). One study even suggests that non-Black minorities display more trust in their personal physician than Whites (Benjamins, 2006). However, this study aggregates all non-Black minorities into an ambiguous ‘‘Other’’ category that combines ethnoracial groups with diverse attachments to physicians and different resources to navigate the health care system. It is therefore unclear what proportion of this category is Latino, Asian, multiracial, or some other ethnoracial group. Less pronounced ethnoracial differences also have been found regarding trusting another ideal of medicine – that is, the belief that providers have an excellent sense of judgment (technical judgment) and are scientific experts (cultural authority).

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Studies of distrust in the health care system reveal no Black–White differences in assessments of the technical judgments physicians display during medical visits (Armstrong et al., 2008). In fact, during a period when the cultural authority of physicians declined rapidly for the general population, researchers revealed that Blacks held more favorable views of doctors in the 1990s than in the 1970s (Pescosolido et al., 2001). These findings provide additional evidence that there may be dimensions of the patient–physician relationship where Blacks and Latinos demonstrate more trust than comparable Whites. However, no studies have shown that Latinos do in fact exhibit more trust in physicians than Whites. 1.2.3. Critique of extant research When assessing ethnoracial differences in trusting personal physicians, most studies do not assess multiple dimensions of the patient–physician relationship as independent constructs. Instead, studies often employ scales that treat multi-dimensional items of the patient–physician relationship as reflecting a unidimensional trust construct (Anderson and Dedrick, 1990; Hall et al., 2002a; Kao et al., 1998). Multidimensional physician trust scales include evaluations of both the technical and interpersonal aspects of the patient–physician. While such evaluations may be tightly bound (Hall et al., 2001, 2002b; Mechanic, 1998; Pearson and Raeke, 2000), the social conditions of race independently shape the socioemotional cues exchanged between practitioner and patient (Johnson et al., 2004). Race also differentiates the likelihood that patients evaluate trust as a reflection of physician’s behaviors (Schnittker, 2004). Thus, minorities may hold a great deal of respect for their doctors yet still not feel as if their doctors really care about them. In alignment with this critique, a number of researchers note that there may be measurement variance across ethnoracial groups in the form of the underlying construct of trust (Hall et al., 2002b; Perreira et al., 2005). In the case of physician trust, the form of an underlying construct refers to the manifest indicators of physician trust that constitute the standard Trust in Physician scale, which is multidimensional in nature and includes items tapping both the values and competence ideals of the patient–physician relationship. This insight lays open the possibility that specific dimensions of physician scales might evidence ethnoracial differences in trust, even when scales as a whole do not (Hall et al., 2002a). Notably, Armstrong et al. (2008) show that the disaggregation thesis is useful for understanding Black–White differences in trusting the health care system. They show that Blacks are less trusting than Whites in the values of the health care system (e.g., whether the health care system lies to make money and experiments on patients without them knowing) but equally trusting as Whites are in the competence of the health care system. This kind of material/sociocultural bifurcation is also evident in studies of patient satisfaction. For example, a study disaggregating patient satisfaction scales illustrates that ethnoracial differences are most pronounced in interpersonal assessments of the patient–physician relationship that reflect a physician’s compassion for the patient rather than technical assessments of physicians (Jackson and George, 1998). Yet, no studies have indicated that such a divide exists in studies of physician trust. While no quantitative studies to date have assessed the role that ethnoraciality may have on trusting the interpersonal component of the patient–physician relationship, there is ample reason to believe that such a gap exists in regards to physician trust. First, focus group studies suggest that the ability of physicians to demonstrate empathy and caring contributes to whether Blacks and Latinos trust their physicians and view them as trustworthy (Jacobs et al., 2006; Julliard et al., 2008; Kaplan et al., 2006; Tucker et al., 2003). Second, Blacks and Latinos are more likely than Whites to report they feel disrespected by their health care providers (Blanchard and Lurie, 2004). Third, studies indicate that Blacks and Latinos are less satisfied with the quality of the care they receive from doctors (Doescher et al., 2000; LaVeist et al., 2000; Saha et al., 1999). Fourth, studies show that minorities receive less quality communication than Whites: Physicians are more likely to dominate conversations, less likely to speak of socioemotional topics, and less likely to exchange positive affective tones with minority patients than with White patients (Johnson et al., 2004; see also Cooper-Patrick et al., 1999; Julliard et al., 2008; Morales et al., 1999). Studies have shown that Latinos, particularly those with limited English proficiency, also report poorer communication with regards to providers explaining things clearly, showing respect, and spending time with a patient (Stepanikova et al., 2006; Tucker et al., 2003; Weech-Maldonado et al., 2003). Fifth and finally, medical encounters with minority patients display less signs of participatory decision-making than do medical encounters with White patients (Cooper-Patrick et al., 1999). 1.3. Expected relationships This study expects that ethnoracial differences in trusting physicians and the health care system should persist holding constant sociodemographic characteristics. Still, sociodemographic cleavages could partially account for ethnoracial differences in physician trust, since they serve as resources that can be deployed to more effectively navigate medical encounters (Andersen and Newman, 1973). For example, male gender, lower socioeconomic status, and younger age are linked to lower levels of trust in physicians (Doescher et al., 2000; Pearson and Raeke, 2000; Tai-Seale and Pescosolido, 2003). A measure of parental nativity is employed to proxy the effects of language problems and cultural dissonance (Stepanikova et al., 2006). Persons with two native parents are expected to have higher levels of trust than persons with more than one non-native parent. Engagement in religious and political organizations taps the extent to which individuals are connected to and willing to seek help from institutions. For example, regular religious service attendance and voluntary civic engagement are positively associated with both utilizing health services and trusting physicians (Ahern and Hendryx, 2003; Benjamins, 2006; Hendryx et al., 2002). Demographic, religious, and political attributes are considered controls in the analyses.

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Focusing on the English-speaking population, this study analyzes constituent items of a standard Trust in Physician scale separately to characterize ethnoracial differences in medical trust. Given past research suggesting that Blacks may display more negative affect toward the disembodied health care system than toward embodied personal physicians, this study hypothesizes that Black–White differences in trusting the health care system will be larger than Black–White differences in trusting personal physicians. Given the language and cultural barriers that Latinos face and ethnoracial differences in demographic factors, this study hypothesizes that Latinos will be less trusting than Whites of all aspects of the medical encounter – including extending trust to physicians and the health care system. This study will also explore the extent to which Blacks and Latinos hold dissimilar attitudes toward their physicians and the medical institution and the factors responsible for Black–Latino trust differences. It is expected that Blacks and Latinos hold similar trust views toward personal physicians; however, differences that may exist between the groups should be an artifact of sociodemographic differences between the groups (e.g., Blacks are less likely to have immigrant parents and, therefore, may hold more favorable attitudes toward personal physicians than Latinos). 2. Materials and methods 2.1. Data Data for this study come from the 2002 and 2006 General Social Surveys (GSS) conducted by the National Opinion Research Center (Davis and Smith, 2009). The 2002 and 2006 GSS used a full probability sample of persons of 18 years of age or over living in non-institutional arrangements within the 48 contiguous states of the U.S. In 2002, GSS only sampled English-speaking persons. In 2006, GSS also sampled Spanish-speaking persons. Face-to-face interviews of approximately 1½ hours were conducted between March and May of 2002 and 2006. Assessments of general physicians are derived from a random sub-sample of 2728 respondents given questions from the Mental Health Module. An assessment of social attitudes toward medicine is derived from random sub-samples of 2792 respondents given rotating core questions from the GSS Base Module. Final sample sizes are 2558 for physician trust items (93.8% of original sample) and 2715 for the confidence in medicine item (97.2% of original sample). Respondents with invalid data on the dependent and independent variables are excluded across the two survey years. Respondents dropped from the analysis have less years of education and are more likely to identify as Democrats (analysis available upon request). The response rate for the 2002 GSS is 70.1%, while the response rate for the 2006 GSS is 71.2%. 2.1.1. Dependent variables Trust in physicians is measured by a series of statements about the medical care they are receiving now (or would expect if they sought care). These are adapted from Anderson and Dedrick’s (1990) Trust in Physician scale. A shortened scale is employed because only a limited number of items gauging attitudes toward general physicians are asked in multiple years of the GSS. Five conceptual dimensions of the patient–physician relationship are considered: Honesty; Fiduciary Ethic; Technical Judgment; Cultural Authority; and Interpersonal Competence. The Honesty dimension is assessed by agreement with the statement, ‘‘I trust my doctor to tell me if a mistake was made about my treatment.’’ The Fiduciary Ethic dimension is assessed by agreement with the statement, ‘‘I trust my doctor to put my medical needs above all other considerations when treating my medical problem.’’ The Technical Judgment dimension is assessed by agreement with the statement, ‘‘I trust my doctor’s judgment about my medical care.’’ The Cultural Authority dimension is assessed by agreement with the statement, ‘‘My doctor is a real expert in taking care of medical problems like mine.’’ The Interpersonal Competence dimension is assessed by disagreement with the statement, ‘‘I doubt my doctor really cares about me as a person.’’ Respondents were asked to answer questions concerning their primary care physicians, as such it can be assumed that respondents answered questions about physician trust concerning health care primarily, but not exclusively, for physical health conditions. Each physician trust statement was coded originally on a 5-point scale (1 = strongly agree, 2 = agree, 3 = neither agree nor disagree, 4 = disagree, and 5 = strongly disagree). Respondents’ answers were coded ‘‘don’t know’’ if they volunteered this response. Hence, these respondents are dropped from subsequent analyses. Respondents who refused to provide a response to the statements are also dropped from the analyses. Items are coded so that more positive responses reflect more trust in physicians. Factor analysis of the five items does, in fact, indicate a single underlying dimension with little variation in the factor loadings (Cronbach’s alpha (a) = .75). A summary scale was constructed by dividing the sum of responses by five. Evaluations of confidence in medicine are used to capture social attitudes toward the health care system. GSS prompts [coding in brackets]: ‘‘I am going to name some institutions in this country. As far as the people running these institutions are concerned, would you say you have a great deal of confidence [3: High Trust], only some confidence [2: Middle Trust], or hardly any confidence at all [1: Low Trust] in them?’’ Prior studies have employed GSS confidence items to evaluate social attitudes toward institutions (Alesina and La Ferrara, 2002; Pescosolido et al., 2001). Table 1 presents descriptive statistics for all dependent variables. 2.1.2. Ethnoracial group membership Ethnoracial group membership is measured by two mutually-exclusive dummy indicator variables – Black non-Latino (herein referred to as ‘‘Black’’) and any race Latino (herein referred to as ‘‘Latino’’). The reference category for each

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Table 1 Descriptive statistics for analytical samples, 2002 and 2006 General Social Survey.

Pooled 2002 2006

Sample for physician trust items Observations

Sample for trust in health care system Observations

2558 1275 1283

2715 851 1864

Median/mean (%) Dependent variables Trust in physician scale Honestya Fiduciary ethica Technical judgmenta Cultural authoritya Interpersonal competencea Confidence in medicinea Ethnoracial status Blackb Latinob Whiteb,c Control variables Married (0 = unmarried)b Full-time worker (0 = not full-time worker)b No. of people in household Parent (0 = no children)b Female (0 = male)b Male (0 = female)b Age of respondent Years of education

a b c

Min

Max

1 1 1 1 1 1 1

5 5 5 5 5 5 3

3.8 4.0 4.0 4.0 4.0 4.0 2.0

15.3 7.7 76.9

0 0 0

1 1 1

46.7 50.7

0 0

3.9 4.0 4.0 4.0 4.0 4.0 2.0

2.4 72.2 57.8 42.2 46.7 13.5

Standard deviation 0.8

1.4

17.2 2.8

Median/mean (%)

Standard deviation

Min

Max

1 1 1 1 1 1 1

5 5 5 5 5 5 3

14.1 11.2 74.7

0 0 0

1 1 1

1 1

46.1 52.2

0 0

1 1

1 0 0 0 18 1

11 1 1 1 89 20

2.4 71.6 56.6 43.4 47.0 13.4

1 0 0 0 18 0

11 1 1 1 89 20

0.7

1.4

17.1 3.1

Subjective class identification Lower class (0 = other)b Working class (0 = other)b Middle/upper classb,c South (0 = non-south)b Two parents born in U.S. (0 = other)b Religious service attendancea Has ever voted (0 = never voted)b

6.3 43.8 49.9 37.6 83.9 3.0 74.5

0 0 0 0 0 0 0

1 1 1 1 1 8 1

6.3 45.6 48.1 37.3 82.4 3.0 72.8

0 0 0 0 0 0 0

1 1 1 1 1 8 1

Political party affiliation Democratb Republicanb Independentb,c

33.9 28.7 37.4

0 0 0

1 1 1

32.3 26.5 41.2

0 0 0

1 1 1

Median values shown. Percentages shown. Reference category.

ethnoracial dummy is White non-Latino. Ethnoracial group membership is classified by the respondent using procedures followed in the decennial U.S. Census. Fifteen percent of the sample is classified as Black, and 8% of the sample is classified as Latino. 2.1.3. Control variables To account for the time elapsed between survey years and for sources of measurement error associated with differences in the coding of trust responses between the two surveys, a dummy indicator for the 2002 survey year is included as a control variable (reference category = 2006 survey year) in all analyses. In the 2002 Mental Health module, the middle response category of the trust statements was labeled ‘‘neither agree nor disagree’’ (instead of ‘‘uncertain’’), and both ‘‘agree’’ and ‘‘disagree’’ categories were preceded by ‘‘somewhat’’ (e.g., ‘‘somewhat agree’’). Supplemental analyses indicate that the survey year indicator could capture the effects of time and survey measurement error. Though the effect of year was significant (F = 20.04, p < .001), the effects of correlates of trust were consistent across years of the GSS (F = 0.67, p = .733). Thus, the 2002 and 2006 GSS samples are pooled for the following analyses. To assess the role of ethnoracial differences in sociodemographic correlates of trust, covariates measured consistently for marital, work, and parental status, household size, gender, age, education, subjective class identification, region, parental nativity, religious service attendance, voting behavior, and political party affiliation are included (see Table 1). Measures that tap sociodemographic differences between Blacks and Whites include marital status (1 = married, 0 = other); work status

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(1 = full-time worker, 0 = other); parental status (1 = have children, 0 = no children); household size (family sizes more than 10 collapsed into highest category); gender (1 = females, 0 = males); age (1st and 2nd order polynomial term for years of life lived); education (years of school completed); a categorical measure of lower or working class identification (reference category = middle or upper class); region (1 = Southerner, 0 = non-Southerner); and parental nativity (1 = has two native parents, 0 = has one or two non-native parents). Ethnoracial differences in religiosity are measured using a 9-category ordinal variable assessing frequency of religious service attendance (0 = never, 1 = less than one time a year, 2 = about 1–2 times a year, 3 = several times a year, 4 = about once a month, 5 = 2–3 times a month, 6 = nearly every week, 7 = every week, 8 = several times a week). Ethnoracial differences in political factors are measured by voting behavior (1 = ever voted, 0 = never voted) and a categorical measure of Democratic or Republican political party affiliation (reference category = Independent or Other party). Sociodemographic variables are included as they may be confounders of ethnoracial differences in physician trust (see Expected Relationships section of Literature Review). 2.2. Methods of analysis This study examines ethnoracial differences in trust toward physicians using a shortened Trust in Physician Scale and its constituent items (Anderson and Dedrick, 1990). Trust in the health care system is evaluated using a measure of confidence in leaders of institutions. Models for ordered limited dependent variables are employed to hold constant the effects of ethnoracial differences in demographic, political, and religious characteristics on the Trust in Physician scale, the five (5) Trust in Physician items, and trust in the health care system. Case weights are used to adjust for differential sampling probabilities among individuals across survey year (WTSSALL). Estimation procedures and hypothesis testing account for both probability weights and robust standard errors. First, this study examines unadjusted ethnoracial differences (Black non-Latino vs. White non-Latino; any race Latino vs. White non-Latino) in trusting physicians and the health care system with the dummy indicators for Black and Latino respondents. To compare the magnitude of ethnoracial differences across trust items, the likelihood of affirming trust in physicians and confidence in medicine is considered. The Unadjusted model includes an indicator of racial group membership for Blacks and Latinos (Reference category: Whites). Second, ethnoracial differences in trusting physicians and the health care system are examined, holding constant sociodemographic characteristics. The Adjusted model includes controls for survey year, marital status, full-time worker status, number of people in household, parental status, female sex, age & age squared, years of education, subjective class status, Southern region, parental nativity, religious service attendance, voting behavior, and political party affiliation. For the analytical sample, listwise deletion on dependent and control variables are applied. The sample size for the trust in physician items is 2558, while the sample size for the trust in the health care system item is 2715. Sample sizes vary because the trust in the health care system item is a part of the rotating core of the GSS and, thus, is not asked of all respondents in the topical modules. Since the response categories for the trust outcomes are ordered, the appropriateness of using nominal regression models is considered (Agresti, 2010). A Brant test indicated that the ordinal model violated the parallel lines/proportional odds regression assumption when assessing proportional odds due to race (Long and Freese, 2006) with regards to multiple dimensions of the patient–physician relationship in one or both of the models considered. Accordingly, this study provides estimates of racial differences in physician trust using a partial parallel lines regression model – otherwise known as a partial generalized ordered logit model (Williams, 2006) or the partial proportional odds model (Peterson and Harrell, 1990). Odds ratios are shown, where values above 1 indicate more trust and values below 1 indicate less trust. T-statistics are in parentheses. Weighted parameters are provided. Consistent parameters across comparison categories indicate that the parallel lines assumption is not violated. Inconsistent parameters across comparison categories indicate that the parallel lines assumption is violated and, thereby, suggests that an ordinal model is inappropriate for analyzing a particular outcome. The equation for the partial parallel lines regression model is:

gðPrðY 6 ijxÞÞ ¼ ai þ b01 x1 þ b02i x2 þ ðCi b3 Þ0 x3 ;

i ¼ 1; . . . ; k

where the b1 are the parallel line (equal slope) parameters, the b21 . . . b2k are k vectors of unequal slope (unconstrained) parameters, and the b3 are the constrained slope parameters whose constraints are provided by the diagonal Ci matrix. According to this specification, the parameters for ethnoraciality (coefficients indicating Black/White and Latino/White differences in affirmative responses) can be either unconstrained or constrained. Consistent parameters across comparison categories indicate that the parallel lines assumption is not violated at a 0.05 statistical significance level. 3. Results 3.1. A standard scaling approach Table 2 provides estimates of ethnoracial differences in trust using a standard approach – the Trust in Physician scale. The three ethnoracial groups assessed are referred to as Blacks (Black non-Latinos), Whites (White non-Latinos), and Latinos (Latinos of any racial/ethnic group). Weighted least squares regression provides mean differences in the scores from the trust scale between Blacks and Whites and between Latinos and Whites. Using a standard scaling approach, both Black–White and

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Table 2 Regression of trust in medical actors on ethnoracial group status: 2002 and 2006 General Social Survey. Unadjusted Beta/SE Trust in physician scale (N = 2558) Black 0.06 (0.04) Latino 0.23* (0.05) Greater than strongly disagree OR/Z

Greater than disagree OR/Z

Greater than neither/uncertain OR/Z

Greater than agree OR/Z

1.02 (0.15) 0.79 (1.52)

1.02 (0.15) 0.79 (1.52)

1.02 (0.15) 0.79 (1.52)

0.37* (2.52) 0.62*** (3.57)

0.89 (0.50) 0.62*** (3.57)

0.78 (1.40) 0.62*** (3.57)

0.96 (0.26) 0.62*** (3.57)

Technical judgment Black 0.78 (1.82) Latino 0.59*** (3.66)

0.78 (1.82) 0.59*** (3.66)

0.78 (1.82) 0.59*** (3.66)

0.78 (1.82) 0.59*** (3.66)

Cultural authority Black 1.15 (1.16) Latino 1.42 (0.48)

1.15 (1.16) 2.51* (2.36)

1.15 (1.16) 1.14 (0.68)

1.15 (1.16) 0.65* (2.10)

Interpersonal competence Black 0.44*** (3.56) Latino 0.51*** (4.54)

0.72* (2.14) 0.51*** (4.54)

0.66** (3.10) 0.51*** (4.54)

0.72* (2.28) 0.51*** (4.54)

Trust in physician items (N = 2558) Honesty Black 1.02 (0.15) Latino 0.79 (1.52) Fiduciary ethic Black Latino

Greater than hardly any OR/Z Confidence in medicine (N = 2715) Black 0.58** (3.00) Latino 1.13 (0.86)

Greater than only some OR/Z 0.84 (1.24) 1.13 (0.86)

Note: Trust in physician scale employs a weighted least squares model. Trust in physician items and confidence in medicine item employs a partial parallel lines regression model. Odds ratios shown for partial parallel lines regression model, where values above 1 indicate more trust and values below 1 indicate less trust. Consistent parameters across comparison categories indicate that the parallel lines assumption is not violated. Reference category is White NonLatino. Standard errors (SE) and z-statistics shown in parentheses for appropriate models. * p < 0.05. ** p < 0.01. *** p < 0.001.

Latino–White differences in trust are in the expected direction – negative. On average, Latinos and Blacks are less trusting of physicians than Whites. However, only Latino–White trust differences are statistically significant (b = 0.20; p < 0.001). The standard scaling approach suggests that the Black–White trust gap is minute (less than a tenth of a standard deviation change in the Trust in Physician scale), while the Latino–White gap is substantial (almost a third of a standard deviation change in the Trust in Physician scale). 3.2. Disaggregation approach Table 2 also provides estimates of ethnoracial differences in trust using a disaggregation approach – five Trust in Physician items. The Confidence in Medicine measure is a comparison item that allows a reasonable expectation of what ethnoracial differences should look like were (dis)trust in personal physicians to follow (dis)trust in the health care system. Using a disaggregation approach, Black–White trust differences are in various directions; mostly, Black–White trust

A.A. Sewell / Social Science Research 54 (2015) 1–20

9

differences are not statistically significant. The Black–White trust gap is significant for two of the five dimensions of trust in physicians – fiduciary ethic and interpersonal competence — and for the confidence in medicine measure. For each of these items, the parallel lines regression assumption is violated. The violation of the parallel lines assumptions means that racial gaps in physician trust are particularly salient for certain response categories in ways that refute a linear representation of racial trust differences. Overall, Blacks are less trusting than Whites that their physician will put their needs above all else and that their physician cares about them as a person. They are also less likely than Whites to affirm that leaders of the health care system should be extended confidence. The violation of the parallel lines assumption indicates that Black–White differences in trust/confidence are not consistent across all response categories – for example, Blacks are not equally less likely to respond with ‘‘strong disagreement’’ in a physician’s fiduciary ethic as they are ‘‘disagreement.’’ With regards to fiduciary ethic, for instance, Blacks are 63% less likely than Whites to strongly disagree with the medical ideal that physicians put their patients needs above all else. The implications of the parallel lines violation are important to consider. Specifically, this substantial Black–White difference in the likelihood of strong disagreement with the fiduciary ethic of the patient–physician relationship is masked in traditional ordinal models, as Black–White differences in affirming more positively worded response categories (e.g., ‘‘disagreement’’) are smaller in magnitude. Assumptions that the Black–White gap in fiduciary ethic is the same regardless of what response categories are compared, then, would result in an interpretation that Blacks and Whites emit similar views concerning this ideal of medicine – a pattern that has been noted in previous research (Stepanikova et al., 2006). Similarly, Black–White differences in the interpersonal confidence ideal of the patient–physician relationship and in confidence toward leaders of medicine are largest along the most negative category affirming trust. Together, these findings might suggest that Blacks are more likely to express extreme negative responses in regards to specific medical ideals – that is, the interpersonal efficaciousness of personal physicians and assessments of the overall health care system. However, given that gaps in ‘‘strong agreement’’ are absent, these findings do not suggest that Blacks are simply more likely to respond at the extreme ends of a response scale, as is suggested might be an underlying phenomenon by Doescher et al. (2000). Rather, I would conclude that they strongly disagree that physicians can be trusted in regards to aspects of the patient– physician relationship that represent key faultlines of race and medicine. In other words, these category-specific findings represent substantive realities, rather than mere methodological constructions. Using a disaggregation approach, most Latino–White trust differences are in the expected direction. In fact, the Latino– White trust gap is significant for four of the five dimensions of physician trust evaluated – fiduciary ethic, technical judgment, cultural authority, and interpersonal competence. Yet, Latinos exhibit similar confidence levels toward leaders of medicine as do Whites. For the most part, Latino–White physician trust differences do not violate the parallel lines assumptions. Regardless of the response category comparison, Latinos are less trusting than Whites that their physicians put their needs above all else (OR = 0.62; Z = 3.57), that their physician’s judgment is sound (OR = 0.59; Z = 3.66), and that their physician cares about them as a person (OR = 0.51; Z = 4.54). The differences between Latinos and Whites along these dimensions of the patient– physician relationship are large and substantial: Latinos are at least 40% less likely than Whites to exhibit trusting attitudes in these 3 ideals of the patient–physician relationship. Latinos’ views of the cultural authority of physicians, however, are more variegated. Latinos are more likely than their White counterparts to express at least neutral/uncertain affect about whether their personal physician is a scientific expert. However, they are less likely to express strong affirmation for this aspect of the patient–physician relationship. A comparison of the most extreme category of affirmation (‘‘strongly agree’’) indicates that Latino–White differences in cultural authority are most similar to Latino–White differences in fiduciary ethic, albeit more positive (Table 2). Overall, the partial parallel lines regression parameters speak to lower levels of trust in the cultural authority of physicians among Latinos than among Whites. Nonetheless, Latinos’ view the cultural authority of physicians more favorably than they do their physicians’ fiduciary ethic, technical judgment, and interpersonal competence. 3.3. The role of ethnoracial differences in sociodemographic correlates of trust Ethnoracial differences in sociodemographic characteristics play an important role in Latino–White trust differences (Table 3). Together, Latinos’ younger age, lower levels of parental nativity, and lower levels of civic participation situate Latinos as less trusting than Whites in the omnibus physician trust scale and in affirmations that their physician will put their needs above all else (fiduciary ethic). Once such factors are considered, Latino–White differences in trusting the fiduciary ethic of personal physicians are reduced to non-significance. Likewise, Black–White differences in having confidence in medicine are a function of ethnoracial differences in sociodemographic factors. Specifically, Blacks’ lower levels of education and lower likelihood of identifying as middle/upper class situate Blacks as less confident in leaders of medicine than Whites. Once such factors are considered, Black–White differences in trusting the health care system are reduced to non-significance. However, ethnoracial differences in sociodemographic factors are not completely responsible for ethnoracial differences in trusting medicine. For instance, while the Latino–White gap in trusting whether one’s physician really cares about a patient as a person is reduced by 30%, the Latino–White gap remains significant (OR = 0.63; Z = 2.85). Similarly, the Latino–White technical judgment gap is reduced by considering sociodemographic correlates of trust but remains statistically significant (OR = 0.69; Z = 2.12).

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Table 3 Regression of trust in medical actors on ethnoracial group status, holding constant sociodemographic factors: 2002 and 2006 General Social Survey. Beta/SE Trust in physician scale (N = 2558) Black 0.09 (0.05) Latino 0.15 (0.06) Greater than strongly disagree OR/Z

Greater than disagree OR/Z

Greater than neither/uncertain OR/Z

Greater than agree OR/Z

0.91 (0.60) 0.88 (0.76)

0.91 (0.60) 0.88 (0.76)

0.91 (0.60) 0.88 (0.76)

0.33** (2.90) 0.72 (1.95)

0.79 (0.97) 0.72 (1.95)

0.69* (1.98) 0.72 (1.95)

0.89 (0.78) 0.72 (1.95)

Technical judgment Black 0.67* (2.57) Latino 0.69* (2.12)

0.67* (2.57) 0.69* (2.12)

0.67* (2.57) 0.69* (2.12)

0.67* (2.57) 0.69* (2.12)

Cultural authority Black 1.00 (0.01) Latino 1.80 (0.76)

1.00 (0.01) 2.87** (2.61)

1.00 (0.01) 1.18 (0.79)

1.00 (0.01) 0.73 (1.39)

Interpersonal competence Black 0.44*** (3.37) Latino 0.63** (2.85)

0.77 (1.61) 0.63** (2.85)

0.64** (3.13) 0.63** (2.85)

0.69* (2.28) 0.63** (2.85)

Trust in physician items (N = 2558) Honesty Black 0.91 (0.60) Latino 0.88 (0.76) Fiduciary ethic Black Latino

Greater than hardly any OR/Z Confidence in medicine (N = 2715) Black 0.83 (1.21) Latino 1.21 (0.98)

Greater than only some OR/Z 0.83 (1.21) 1.21 (0.98)

Note: Trust in physician scale employs a weighted least squares model. Trust in physician items and confidence in medicine item employs a partial parallel lines regression model. Odds ratios shown, where values above 1 indicate more trust and values below 1 indicate less trust. Consistent parameters across comparison categories indicate that the parallel lines assumption is not violated. Reference category is White Non-Latino. Standard errors (SE) and zstatistics in parentheses. All models include control for survey year, marital status, full-time worker status, number of people in household, parental status, female sex, age & age squared, years of education, subjective class status, Southern region, parental nativity, religious service attendance, voting behavior, and political party affiliation. * p < 0.05. ** p < 0.01. *** p < 0.001.

Moreover, neither the magnitude nor significance of the Black–White interpersonal competence gap is affected by ethnoracial differences in sociodemographic factors. Blacks remain over 30% less likely to strongly affirm that their doctors really care about them as a person. Furthermore, Blacks remain much less likely than Whites to endorse positive attitudes toward the fiduciary ethic of the patient–physician relationship. For this dimension of physician trust, the Black coefficient continues to violate the parallel lines regression assumption, which suggests that the substantial gap between Blacks and Whites on this aspect of the medical encounter is not a result of ethnoracial differences in sociodemographic factors. In some aspects of the medical encounter, however, ethnoracial differences in trusting physicians are more pronounced among sociodemographically-similar respondents. Holding constant ethnoracial differences in demographic, religious, and political correlates of trust, Blacks are less trusting of their physician’s technical judgment than Whites (OR = 0.67; Z = 2.57). Among sociodemographically-similar respondents (especially, Blacks and Whites with similar parental nativity status, Southern geographical residence, religious service attendance, and political party affiliation), Blacks are 33% less likely

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A.A. Sewell / Social Science Research 54 (2015) 1–20 Table 4 Summary of results from regression models: 2002 and 2006 General Social Survey. Black–White gap

a b c

Latino–White gap

Unadjusted

Adjusted

Unadjusted

Adjusted

Trust in physician scale

No difference

No change

Less trusting

Gap explained by sociodemographicsa

Trust in physician items Honesty Fiduciary ethic Technical judgment Cultural authority Interpersonal competence Confidence in medicine

No difference Less trusting No difference No difference Less trusting Less trusting

No change No change Gap strengthenedb No change No change Gap explained by sociodemographicsc

No difference Less trusting Less trusting Less trusting Less trusting No difference

No change Gap explained by sociodemographicsa Gap attenuated Gap attenuated Gap attenuated No change

Sociodemographic attributes of consequence are age, parental nativity, and civic participation. Sociodemographic attributes of consequence are parental nativity, geographical residence, religious service attendance, political party affiliation. Sociodemographic attributes of consequence are education and subjective class identification.

than Whites to trust the technical judgment of personal physicians. A summary of the effects of sociodemographic factors on Black–White and Latino–White trust differences can be found in Table 4. Supplementary analysis (available upon request) indicates that sociodemographic factors account for differences in physician trust among ethnoracial minorities. Latinos are less trusting of physicians than Blacks for the general Trust in Physician scale and for two of the five dimensions of physician trust evaluated – fiduciary ethic and cultural authority. Yet, Latinos exhibit more confidence in medicine than Blacks. Supplemental analysis indicates that Black–Latino differences in trusting physicians and having confidence in medicine are a function of ethnoracial differences in parental nativity. Specifically, Blacks and Latinos with two parents born in the U.S. exhibit similar trust levels toward physicians and similar confidence levels toward medicine. However, Latinos with one or more non-native parents report significantly less trust and confidence than comparable Blacks. Thus, even differences in trust among minorities are a function of factors related to ethnoracial stratification. 4. Conclusions This study finds that ethnoracial physician trust gaps are variegated: They are contingent upon the item used to epitomize the patient–physician relationship. The paper identifies assorted Black–White and Latino–White differences in trusting personal physicians that obscures ethnoracial differences in physician trust when standard scaling approaches are employed. While ethnoracial inequalities and sources of identity are implicated in medical exchanges and outcomes, past research offers mixed evidence for the direction and magnitude of the Black–White and Latino–White gaps in trusting physicians and the health care system. No evidence for the direction and magnitude of Black–Latino gaps in trusting such medical actors has been provided. The findings reported here take the standard scale approach into consideration but augments such analysis with a disaggregation approach. Overall, the paper speaks to the importance of disaggregating physician trust scales to improve researchers’ abilities to characterize ethnoracial gaps in trusting medical actors. Three findings are of import. First, ethnoracial differences in trusting physicians have been thwarted by standard use of a scaling approach. Primarily, a scaling approach aggregates dimensions of the patient–physician relationship that evidenced countervailing directions for the Black–White trust in physicians gap. In fact, the overall effect of Black ethnoracial group membership on physician trust was thwarted by non-significant parameters, such as those represented by the dimensions of cultural authority, technical judgment, and honesty. Moreover, overall Black–White differences are thwarted by variance in the ethnoracial gap across ordered response categories, as was shown in the case of the fiduciary ethic dimension. Higher levels of uncertainty/ambivalence among Blacks along the fiduciary ethic and interpersonal competence dimensions of the patient–physician relationship appear, in the linear model, as more positive affect. Yet, uncertainty/ambivalence itself is a troubling indicator of disconnect between patient and physician – one that is more likely to occur along certain dimensions for Blacks than for Whites. This study, then, is in line with, but extends, a recent study of the GSS (Zheng, 2015) showing that racial differences in attitudes toward doctors are contingent upon the underlying issue scale items tap: Minorities are less likely to believe that doctors are ethical but, depending on the measures employed, more or equally likely to believe in the authority of doctors (Zheng, 2015). Second, aggregating dimensions of the patient–physician relationship disallows researchers from identifying the domains of the medical encounter that are made problematic by ethnoracial stratification. Similarly, given lower levels of trust in the health care system among Blacks, compared to Whites, aggregating attitudes toward different medical stimuli also works to obscure important information about how Blacks deploy trust as they navigate the health care system. Importantly, Blacks and Latinos are less likely than Whites to believe that their doctors really care about them as a person. Prior studies demonstrate that social distance processes negatively influence the extent of mutual communication and understanding that occurs in cross-racial patient–physician relationships with Black patients (Cooper-Patrick et al., 1999; Johnson et al., 2004; Saha et al., 1999). However, no studies of trusting medical actors have assessed the Black–White and Latino–White gaps along this dimension of the medical encounter. This study indicates that minorities’ reduced trust in this aspect of the patient–

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physician relationship represents a salient point of contention within medical exchanges. This study is in alignment with studies reporting the disrespect minorities convey they feel from authority figures of medicine (Blanchard and Lurie, 2004). Moreover, this study is also in alignment with historical studies that note that the expressive needs of Black patients are not met within the confines of the traditional patient–physician relationship (Skipper et al., 1968). Third, Latino–White differences in trusting physicians are substantial. They are even more substantial than Black–White differences in trusting physicians. The Latino–White trust gap is found consistently to be larger than the Black–White gap. Moreover, this study shows that Black–Latino trust gaps are a function of ethnoracial differences in parental nativity, which is an understudied component of ethnoracial stratification. These findings are in alignment with prior studies that illustrate Latino–White fiduciary trust differences are larger among Spanish-speaking respondents than among English-speaking respondents. These findings extend such research to other dimensions of the medical encounter. These findings, particularly those regarding the multivariate effect of parental nativity, are in alignment with scholars who note that linguistic and cultural barriers serve to increase the social distance of Latinos from their physicians and cultivate dissatisfaction with the quality of services (Julliard et al., 2008; Tucker et al., 2003). Yet, these findings in regards to Latinos are surprising given extant research. Much of the existing literature only discusses why minorities are less trusting than Whites, primarily focusing on Black–White differences, and assumes consistency in distrust across dimensions of the patient–physician relationship. In doing so, the previous literature has created homogenous non-White ethnoracial groups (e.g., Zheng, 2015), whereas the results of this study show important forms of heterogeneity among minorities. These assumptions are, in part, an artifact of research design, as most studies include only 2 or 3 ethnoracial groups or attend to ethnic differences among racialized groups (e.g., the effect of language on Latino–White differences [Stepanikova et al., 2006]). This study takes the perspective that ethnoracial differences in trust may exist for different reasons for different ethnoracial groups (i.e., a legacy of historical abuse for Blacks and cultural reasons for Latinos). In fact, Latino–White differences in physician trust may be larger because Latinos are affected by the same factors as Blacks (e.g., deprived socioeconomic status), as well as cultural factors mentioned in the manuscript (e.g., language). Overall, however, there is no a priori reason in the extant literature to expect differences among ethnoracial minorities nor is there a priori reason in the extant literature to expect inconsistencies in the ethnoracial trust gap across dimensions of the patient–physician relationship. Previous research does, however, find evidence of non-significant effects on specific dimensions of physician trust, such as cultural authority (Pescosolido et al., 2001), and preliminary evidence that Latino–White differences in fiduciary trust are larger than Black–White differences (Stepanikova et al., 2006). This study, then, serves to buttress research that indicates similarities between ethnoracial minorities and White and formally examines the magnitude of, and rationale for, the Black–Latino gap in physician trust for an array of trust ideals. These non-differences and intragroup minority gaps reflect substantive realities rather than pure methodological issues or spurious effects. There are several limitations to this study. First, the GSS includes a limited set of variables to measure physician trust. For instance, a shortened Trust in Physician scale must be employed, as only five items are asked in more than one wave of the GSS. These five items, thus, can only provide singular indicators of the five dimensions of physician trust evaluated in this study. Research would benefit from having multiple indicators of each of the five dimensions of physician trust examined. Moreover, among these five items, only one of the items was negatively worded – interpersonal competence, which is the dimension where the largest ethnoracial differences were found. Perhaps, a scale that included more negatively worded items would produce larger ethnoracial differences in physician trust, reflecting greater affirmations of distrust rather than lower affirmations of trust among ethnoracial minorities. Second, the GSS traditionally has been a sample of English-speaking adults. However, in 2006, the Spanish-speaking population was also sampled. Research indicates that physician trust levels are lower among Latinos who are Spanish-speaking (Stepanikova et al., 2006). A similar relationship may also exist among non-English speaking Blacks. For instance, it is possible that lower levels of trust among Latinos are a function of the fact that they are more likely to be Spanish-speaking. The fact that Black–Latino differences in trust were found to be a function of parental nativity speaks to this possibility somewhat. Latinos with one or more parents born outside the U.S. may be more likely to speak Spanish. However, neither of these patterns could be evaluated with this study, as a Spanish-speaking indicator could only be ascertained in one of the two waves of the GSS assessed. Third, while the GSS does have indicators of nationality that would allow a disaggregation of both ethnoracial groups along this important dimension of ethnicity, sample sizes are too small to evaluate ethnoracial group by nation-state background. For instance, there are less than 200 Latinos in the final sample of this study, which covers two waves of the GSS. While Latinos can be further classified by whether they are descendants of Cuba, Mexico, Puerto Rico, or another Latin American country, any further disaggregation of this ethnoracial group by nation-state background reduces the power to detect differences substantially. Research would benefit from having a larger sample of ethnoracial minorities assessed Trust in Physician items. Fourth, there are a number of missing variables of importance to a study of ethnoracial differences in physician trust. Namely, affirmations of physician trust vary by type of health insurance, usual source of care, continuity of care, and health literacy (Doescher et al., 2000; Hall et al., 2001, 2002b; Kao et al., 1998; Lee and Lin, 2010). For instance, the insured tend to report higher levels of trust in physicians and the health care system, but ethnoracial minorities are less likely to be insured (Doescher et al., 2000; Smedley et al., 2003). Accordingly, the ethnoracial differences in trust identified through the disaggregation approach could, in fact, represent ethnoracial differences in health insurance status. However, the GSS did not ascertain health insurance information from the sample of respondents asked the physician trust. Moreover, the GSS does

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not ascertain usual source of care, the recentness/frequency of visits to a personal physician in the past year, or health literacy of the same respondents who were provided physician trust items. As such, the analysis is limited by the larger research design. Research would benefit from examining whether health care quality, broadly speaking, or health literacy are mediating factors of ethnoracial differences in physician trust. In sum, this analysis uncovers a notable degree of complexity in ethnoracial trust gaps among Whites, Blacks, and Latinos. A theory of race and trust is proposed based on the findings of the study: The presence of ethnoracial differences along specific dimensions of the patient–physician relationship reflects the ways that ethnoracial stratification transforms standard health care processes. Studies indicate that power-imbalances within most medical encounters are most likely to impact interpersonal aspects of the medical visit that hinge upon the communication skills of physicians. For instance, trust is developed only in the presence of mutual respect and personalizing interactions that demonstrate a physician cares about a

Table A1 Partial parallel lines model for regression of honesty on racial group membership, holding constant sociodemographic attributes: 2002 and 2006 General Social Survey, N = 2558.

Unadjusted Black Latino Constant Adjusted Black Latino 2002 Survey year (0 = other) Married (0 = unmarried) Full-time worker (0 = not full-time worker) Household population (centered at 1) Parent (0 = no children) Female (0 = male) Age centered at 18 (in decades) Age squared, centered (in decades) Years of education Lower class (0 = other) Working class (0 = other) South (0 = non-south) Two parents born in U.S. (0 = other) Religious service attendance Has ever voted (0 = never voted) Democrat (0 = other) Republican (0 = other) Constant

Greater than strongly disagree

Greater than disagree

Greater than neither/ uncertain

Greater than agree

0.02 (0.13) 0.23 (0.15)

0.02 (0.13) 0.23 (0.15)

0.02 (0.13) 0.23 (0.15)

0.02 (0.13) 0.23 (0.15)

2.75

1.67

0.95

0.92

0.09 (0.15) 0.13 (0.17) 0.86*** (0.20) 0.00 (0.10) 0.06

0.09 (0.15) 0.13 (0.17) 0.48*** (0.12) 0.00 (0.10) 0.06

0.09 (0.15) 0.13 (0.17) 0.00 (0.10) 0.00 (0.10) 0.06

0.09 (0.15) 0.13 (0.17) 0.85*** (0.11) 0.00 (0.10) 0.06

(0.10) 0.04 (0.04) 0.04 (0.12) 0.06 (0.09) 0.97*** (0.23) 0.14*** (0.04) 0.06* (0.03) 0.48* (0.19) 0.17 (0.09) 0.16 (0.09) 0.19 (0.13) 0.03* (0.02) 0.01 (0.11) 0.34** (0.11) 0.60** (0.23)

(0.10) 0.04 (0.04) 0.04 (0.12) 0.06 (0.09) 0.54*** (0.14) 0.09*** (0.02) 0.00 (0.02) 0.48* (0.19) 0.17 (0.09) 0.16 (0.09) 0.19 (0.13) 0.03* (0.02) 0.01 (0.11) 0.34** (0.11) 0.47** (0.15)

(0.10) 0.04 (0.04) 0.04 (0.12) 0.06 (0.09) 0.40*** (0.12) 0.06*** (0.02) 0.02 (0.02) 0.48* (0.19) 0.17 (0.09) 0.16 (0.09) 0.19 (0.13) 0.03* (0.02) 0.01 (0.11) 0.34** (0.11) 0.15 (0.12)

(0.10) 0.04 (0.04) 0.04 (0.12) 0.06 (0.09) 0.24* (0.11) 0.04* (0.02) 0.05* (0.02) 0.48* (0.19) 0.17 (0.09) 0.16 (0.09) 0.19 (0.13) 0.03* (0.02) 0.01 (0.11) 0.34** (0.11) 0.35** (0.12)

3.18

1.99

1.21

1.06

Note: Betas reported. Standard errors in parentheses. * p < 0.05. ** p < 0.01. *** p < 0.001.

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A.A. Sewell / Social Science Research 54 (2015) 1–20

minority patient and has compassion for the social problems he or she is encountering (Kaplan et al., 2006; Sheppard et al., 2004). The hierarchical nature of medical encounters makes communication a key component of the patient–physician relationship that can build or destroy trust (Cook et al., 2004; van Ryn, 2002). The implications of these findings for understanding power-imbalanced dynamics in other institutions that rely on communication (e.g., pedestrian–police, student–teacher, defendant–judge) are important to explore. What do the findings mean as it relates to improving racial disparities in health care utilization? A key point made by Bonilla-Silva (1997) is extended to the study of physician trust: Since a racialized social system fosters distinct ideological and cultural meanings of institutions and individuals, ethnoracial inequality is inscribed into institutional processes through the manners in which race shapes components of interaction. Notably so, ethnoracial differences in physician trust were largest along the interpersonal competence dimension of the medical encounter. Accordingly, these findings suggest that

Table A2 Partial parallel lines model for regression of fiduciary ethic on racial group membership, holding constant sociodemographic attributes: 2002 and 2006 General Social Survey, N = 2558.

Unadjusted Black Latino Constant Adjusted Black Latino 2002 Survey year (0 = other) Married (0 = unmarried) Full-time worker (0 = not full-time worker) Household population (centered at 1) Parent (0 = no children) Female (0 = male) Age centered at 18 (in decades) Age squared, centered (in decades) Years of education Lower class (0 = other) Working class (0 = other) South (0 = non-south) Two parents born in U.S. (0 = other) Religious service attendance Has ever voted (0 = never voted) Democrat (0 = other) Republican (0 = other) Constant

Greater than strongly disagree

Greater than disagree

Greater than neither/ uncertain

Greater than agree

1.00* (0.40) 0.48*** (0.13)

0.12 (0.23) 0.48*** (0.13)

0.25 (0.18) 0.48*** (0.13)

0.04 (0.14) 0.48*** (0.13)

4.21

2.49

1.64

0.65

1.12** (0.39) 0.33 (0.17) 0.15 (0.33) 0.00 (0.10) 0.05

0.23 (0.24) 0.33 (0.17) 0.20 (0.16) 0.00 (0.10) 0.05

0.37* (0.19) 0.33 (0.17) 0.48*** (0.12) 0.00 (0.10) 0.05

0.12 (0.15) 0.33 (0.17) 0.99*** (0.10) 0.00 (0.10) 0.05

(0.10) 0.02 (0.04) 0.16 (0.12) 0.12 (0.09) 1.27** (0.44) 0.21** (0.07) 0.03 (0.02) 0.13 (0.21) 0.09 (0.09) 0.09 (0.09) 0.17 (0.14) 0.01 (0.02) 0.21 (0.11) 0.32** (0.11) 0.30** (0.11)

(0.10) 0.02 (0.04) 0.16 (0.12) 0.12 (0.09) 0.66*** (0.18) 0.09*** (0.03) 0.03 (0.02) 0.13 (0.21) 0.09 (0.09) 0.09 (0.09) 0.17 (0.14) 0.01 (0.02) 0.21 (0.11) 0.32** (0.11) 0.30** (0.11)

(0.10) 0.02 (0.04) 0.16 (0.12) 0.12 (0.09) 0.32* (0.14) 0.06** (0.02) 0.03 (0.02) 0.13 (0.21) 0.09 (0.09) 0.09 (0.09) 0.17 (0.14) 0.01 (0.02) 0.21 (0.11) 0.32** (0.11) 0.30** (0.11)

(0.10) 0.02 (0.04) 0.16 (0.12) 0.12 (0.09) 0.07 (0.11) 0.03 (0.02) 0.03 (0.02) 0.13 (0.21) 0.09 (0.09) 0.09 (0.09) 0.17 (0.14) 0.01 (0.02) 0.21 (0.11) 0.32** (0.11) 0.30** (0.11)

5.47

3.18

1.43

1.64

Note: Betas reported. Standard errors in parentheses. * p < 0.05. ** p < 0.01. *** p < 0.001.

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A.A. Sewell / Social Science Research 54 (2015) 1–20

patients’ perceptions of the interpersonal competence of physicians are a key contributor to ethnoracial inequities in utilization. Because ethnoracial minorities are more likely to believe that physicians do not care about them as a person, they may be less likely to seek help for medical problems, comply and adhere to physician’s orders, and persist with difficult treatments. In this way, ethnoracial differences in utilization patterns may reflect the disconnection minority patients feel from their doctor, rather than mere cultural beliefs. To alleviate the disconnection that ethnoracial minorities exhibit with the health care system, attention must be paid not only to developing cultural-sensitivity among doctors, but also to developing an anti-racist praxis from which physicians treat patients. How ethnoracial minority patients navigate the health care system reflects how they perceive the interactions within the health care system. The patient–physician relationship is not unlike intergroup interactions that may occur outside of the medical system, which suffer from miscues and biases that concretize the social distance between minorities and whites. Future research would benefit from employing stratified samples and/or interaction terms to assess heterogeneity among Table A3 Partial parallel lines model for regression of technical judgment on racial group membership, holding constant sociodemographic attributes: 2002 and 2006 General Social Survey, N = 2558.

Unadjusted Black Latino Constant Adjusted Black Latino 2002 Survey year (0 = other) Married (0 = unmarried) Full-time worker (0 = not full-time worker) Household population (centered at 1) Parent (0 = no children) Female (0 = male) Age centered at 18 (in decades) Age squared, centered (in decades) Years of education Lower class (0 = other) Working class (0 = other) South (0 = non-south) Two parents born in U.S. (0 = other) Religious service attendance Has ever voted (0 = never voted) Democrat (0 = other) Republican (0 = other) Constant

Greater than strongly disagree

Greater than disagree

Greater than neither/ uncertain

Greater than agree

0.25 (0.14) 0.54*** (0.15)

0.25 (0.14) 0.54*** (0.15)

0.25 (0.14) 0.54*** (0.15)

0.25 (0.14) 0.54*** (0.15)

4.08

2.88

1.98

0.55

0.40* (0.15) 0.37* (0.17) 0.45 (0.36) 0.02 (0.11) 0.01

0.40* (0.15) 0.37* (0.17) 0.06 (0.20) 0.02 (0.11) 0.01

0.40* (0.15) 0.37* (0.17) 0.62*** (0.14) 0.02 (0.11) 0.01

0.40* (0.15) 0.37* (0.17) 0.71*** (0.10) 0.02 (0.11) 0.01

(0.10) 0.04 (0.04) 0.21 (0.12) 0.74 (0.39) 0.30** (0.10) 0.05*** (0.02) 0.02 (0.02) 0.11 (0.72) 0.08 (0.10) 0.07 (0.09) 0.23 (0.15) 0.03 (0.02) 0.28* (0.12) 0.31** (0.11) 0.14 (0.11)

(0.10) 0.04 (0.04) 0.21 (0.12) 0.40* (0.20) 0.30** (0.10) 0.05*** (0.02) 0.02 (0.02) 0.61 (0.36) 0.08 (0.10) 0.07 (0.09) 0.23 (0.15) 0.03 (0.02) 0.28* (0.12) 0.31** (0.11) 0.14 (0.11)

(0.10) 0.04 (0.04) 0.21 (0.12) 0.07 (0.15) 0.30** (0.10) 0.05*** (0.02) 0.02 (0.02) 0.76** (0.26) 0.08 (0.10) 0.07 (0.09) 0.23 (0.15) 0.03 (0.02) 0.28* (0.12) 0.31** (0.11) 0.14 (0.11)

(0.10) 0.04 (0.04) 0.21 (0.12) 0.20* (0.10) 0.30** (0.10) 0.05*** (0.02) 0.02 (0.02) 0.17 (0.22) 0.08 (0.10) 0.07 (0.09) 0.23 (0.15) 0.03 (0.02) 0.28* (0.12) 0.31** (0.11) 0.14 (0.11)

4.14

2.93

1.51

1.32

Note: Betas reported. Standard errors in parentheses. * p < 0.05. ** p < 0.01. *** p < 0.001.

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Blacks and Latinos in both levels of trust and factors that mediate trust. Future research would also benefit from methodological designs that ascertain both physician race and multi-dimensional trust. Research designs should also include a larger sample of Blacks and Latinos to assess multi-dimensional trust scales. Moreover, future research would benefit by more clearly delineating the ways that the interpersonal competence of doctors can be improved using a culturally-sensitive, anti-racist lens toward the care of the ethnoracially marginalized.

Acknowledgments The paper was supported by a National Science Predoctoral Fellowship, a Ford Foundation Predoctoral Fellowship, and a Ronald E. McNair Graduate Fellowship to the author while in the Department of Sociology at Indiana University and a Vice Table A4 Partial parallel lines model for regression of cultural authority on racial group membership, holding constant sociodemographic attributes: 2002 and 2006 General Social Survey, N = 2558.

Unadjusted Black Latino Constant Adjusted Black Latino 2002 Survey year (0 = other) Married (0 = unmarried) Full-time worker (0 = not full-time worker) Household population (centered at 1) Parent (0 = no children) Female (0 = male) Age centered at 18 (in decades) Age squared, centered (in decades) Years of education Lower class (0 = other) Working class (0 = other) South (0 = non-south) Two parents born in U.S. (0 = other) Religious service attendance Has ever voted (0 = never voted) Democrat (0 = other) Republican (0 = other) Constant

Greater than strongly disagree

Greater than disagree

Greater than neither/ uncertain

Greater than agree

0.14 (0.12) 0.35 (0.75)

0.14 (0.12) 0.92* (0.39)

0.14 (0.12) 0.13 (0.20)

0.14 (0.12) 0.43* (0.20)

4.36

2.56

1.22

0.92

0.00 (0.14) 0.59 (0.77) 0.04 (0.45) 0.02 (0.10) 0.05

0.00 (0.14) 1.05** (0.40) 0.48** (0.18) 0.02 (0.10) 0.05

0.00 (0.14) 0.17 (0.21) 0.38*** (0.11) 0.02 (0.10) 0.05

0.00 (0.14) 0.31 (0.22) 0.82*** (0.10) 0.02 (0.10) 0.05

(0.10) 0.01 (0.04) 0.13 (0.11) 1.15* (0.46) 0.28** (0.10) 0.05* (0.02) 0.01 (0.02) 0.12 (0.19) 0.12 (0.09) 0.06 (0.09) 0.19 (0.13) 0.04 (0.07) 0.18 (0.11) 0.39*** (0.11) 0.16 (0.46)

(0.10) 0.01 (0.04) 0.13 (0.11) 0.19 (0.17) 0.28** (0.10) 0.03 (0.02) 0.01 (0.02) 0.12 (0.19) 0.12 (0.09) 0.06 (0.09) 0.19 (0.13) 0.03 (0.03) 0.18 (0.11) 0.39*** (0.11) 0.66** (0.22)

(0.10) 0.01 (0.04) 0.13 (0.11) 0.05 (0.12) 0.28** (0.10) 0.04* (0.01) 0.01 (0.02) 0.12 (0.19) 0.12 (0.09) 0.06 (0.09) 0.19 (0.13) 0.06** (0.02) 0.18 (0.11) 0.39*** (0.11) 0.14 (0.14)

(0.10) 0.01 (0.04) 0.13 (0.11) 0.25* (0.11) 0.28** (0.10) 0.06*** (0.01) 0.01 (0.02) 0.12 (0.19) 0.12 (0.09) 0.06 (0.09) 0.19 (0.13) 0.01 (0.02) 0.18 (0.11) 0.39*** (0.11) 0.29* (0.13)

5.30

2.86

0.91

1.77

Note: Betas reported. Standard errors in parentheses. * p < 0.05. ** p < 0.01. *** p < 0.001.

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Provost’s Postdoctoral Fellowship to the author while in the Population Studies at the University of Pennsylvania. A previous draft of this paper was the winner of the 2008 Graduate Student Paper Competition for the Health, Health Policy, and Health Services Division of the Society for the Study of Social Problems (SSSP).

Appendix A See Tables A1–A6.

Table A5 Partial parallel lines model for regression of interpersonal competence on racial group membership, holding constant sociodemographic attributes: 2002 and 2006 General Social Survey, N = 2558.

Unadjusted Black Latino Constant Adjusted Black Latino 2002 Survey year (0 = other) Married (0 = unmarried) Full-time worker (0 = not full-time worker) Household population (centered at 1) Parent (0 = no children) Female (0 = male) Age centered at 18 (in decades) Age squared, centered (in decades) Years of education Lower class (0 = other) Working class (0 = other) South (0 = non-south) Two parents born in U.S. (0 = other) Religious service attendance Has ever voted (0 = never voted) Democrat (0 = other) Republican (0 = other) Constant

Greater than strongly disagree

Greater than disagree

Greater than neither/ uncertain

Greater than agree

0.81*** (0.23) 0.68*** (0.15)

0.33* (0.16) 0.68*** (0.15)

0.42** (0.14) 0.68*** (0.15)

0.33* (0.15) 0.68*** (0.15)

2.95

1.58

0.83

0.65

0.82*** (0.24) 0.46** (0.16) 0.62** (0.20) 0.15 (0.09) 0.01

0.26 (0.16) 0.46** (0.16) 0.32** (0.12) 0.15 (0.09) 0.01

0.45** (0.14) 0.46** (0.16) 0.31** (0.10) 0.15 (0.09) 0.01

0.37* (0.16) 0.46** (0.16) 0.98*** (0.10) 0.15 (0.09) 0.01

(0.09) 0.20** (0.06) 0.12 (0.11) 0.17 (0.09) 0.35** (0.11) 0.02 (0.01) 0.03* (0.02) 0.09 (0.32) 0.14 (0.09) 0.08 (0.09) 0.13 (0.12) 0.03 (0.02) 0.26* (0.11) 0.31** (0.10) 0.27* (0.11)

(0.09) 0.05 (0.04) 0.12 (0.11) 0.17 (0.09) 0.17 (0.10) 0.02 (0.01) 0.03* (0.02) 0.18 (0.22) 0.14 (0.09) 0.08 (0.09) 0.13 (0.12) 0.03 (0.02) 0.26* (0.11) 0.31** (0.10) 0.27* (0.11)

(0.09) 0.01 (0.04) 0.12 (0.11) 0.17 (0.09) 0.11 (0.10) 0.02 (0.01) 0.03* (0.02) 0.27 (0.21) 0.14 (0.09) 0.08 (0.09) 0.13 (0.12) 0.03 (0.02) 0.26* (0.11) 0.31** (0.10) 0.27* (0.11)

(0.09) 0.00 (0.04) 0.12 (0.11) 0.17 (0.09) 0.05 (0.10) 0.02 (0.01) 0.03* (0.02) 0.08 (0.22) 0.14 (0.09) 0.08 (0.09) 0.13 (0.12) 0.03 (0.02) 0.26* (0.11) 0.31** (0.10) 0.27* (0.11)

3.16

0.82

0.55

2.57

Note: Betas reported. Standard errors in parentheses. * p < 0.05. ** p < 0.01. *** p < 0.001.

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Table A6 Partial parallel lines model for regression of confidence in medicine on racial group membership, holding constant sociodemographic attributes: 2002 and 2006 General Social Survey, N = 2715.

Unadjusted Black Latino Constant Adjusted Black Latino 2002 Survey year (0 = other) Married (0 = unmarried) Full-time worker (0 = not full-time worker) Household population (centered at 1) Parent (0 = no children) Female (0 = male) Age centered at 18 (in decades) Age squared, centered (in decades) Years of education Lower class (0 = other) Working class (0 = other) South (0 = non-south) Two parents born in U.S. (0 = other) Religious service attendance Has ever voted (0 = never voted) Democrat (0 = other) Republican (0 = other) Constant

Greater than hardly any

Greater than only some

0.55** (0.18) 0.12 (0.14)

0.17 (0.14) 0.12 (0.14)

2.21

0.45

0.18 (0.15) 0.19 (0.19) 0.08 (0.09) 0.09 (0.10) 0.13 (0.10) 0.05 (0.04) 0.32 (0.18) 0.11 (0.09) 0.56*** (0.10) 0.09*** (0.01) 0.11*** (0.02) 0.62** (0.20) 0.23* (0.10) 0.05 (0.09) 0.00 (0.15) 0.02 (0.02) 0.13 (0.12) 0.27* (0.11) 0.31** (0.11)

0.18 (0.15) 0.19 (0.19) 0.08 (0.09) 0.09 (0.10) 0.13 (0.10) 0.05 (0.04) 0.03 (0.12) 0.11 (0.09) 0.56*** (0.10) 0.09*** (0.01) 0.01 (0.02) 0.62** (0.20) 0.23* (0.10) 0.05 (0.09) 0.00 (0.15) 0.02 (0.02) 0.13 (0.12) 0.27* (0.11) 0.31** (0.11)

1.17

0.02

Note: Betas reported. Standard errors in parentheses. * p < 0.05. ** p < 0.01. *** p < 0.001.

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