Using a communication approach to understand the antecedents of medical mistrust: Testing the ecological medical mistrust antecedents (EMMA) model
Medical mistrust, distrust in the motives of medical personnel and institutions, has been cited as a barrier to engagement in several positive health behaviors. It has been associated with decreased likelihood of engaging in routine health check-ups (Hammond, Matthews, Mohottige, Agyemang, & Corbie-Smith, 2010), undergoing cancer screenings (e.g., Thompson, Valdimarsdottir, Winkel, Jandorf, & Redd, 2004), adhering to treatment (e.g., Kalichman, Eaton, Kalichman, & Cherry, 2017) and becoming a registered organ donor (Morgan, Stephenson, Harrison, Afifi, & Long, 2008). As a result, medical mistrust is a pervasive barrier that cuts across health contexts and topics; this makes addressing medical mistrust a critical step towards improving health outcomes. Despite calls for investigation into medical mistrust (e.g., Adams & Simoni, 2016; Scharff et al., 2010), little work has been done, including within the field of communication, that explicitly examines medical mistrust as a phenomenon of interest. More specifically, there is a dearth of work examining the antecedents of medical mistrust. There is a single model in quantitative medical mistrust work that conceptualizes medical mistrust antecedents; however, this model neglects communication and was only designed to examine medical mistrust among Black men. A recent review of medical mistrust noted the lack of work in medical mistrust that examines antecedents and uses modeling techniques that allow for mediation to be investigated (Benkert, Cuevas, Thompson, Dove-Meadows, & Knuckles, 2019). To address these gaps, the current dissertation proposed a new model of medical mistrust – the Ecological Medical Mistrust Antecedents (EMMA) model, which posited that negative health-care socialization, negative health-care experiences, and racial discrimination experiences influence medical mistrust and that these relationships are mediated by perceived racism in health care and perceived financial corruption in health care. In doing so, this dissertation extends the literature on medical mistrust by: a) placing communication into the study of medical mistrust, particularly by looking at its role in antecedents; b) examining the role of mediated communication in medical mistrust; c) exploring the nuances of racial differences in medical mistrust; and d) examining the nuances of medical mistrust measures. Study 1 sought to test the measurement and structural components of the hypothesized EMMA model; a multigroup model was used in order to test EMMA across racial groups. In Study 1, Black (n = 204) and White (n = 232) participants completed a survey that assessed the constructs associated with the EMMA model. Results revealed partial support for EMMA. There was no support for negative health-care socialization (NHS), negative health-care experiences (NHE), or racial discrimination experiences (RDE) as latent constructs. Additionally, there was no support for the inclusion of negative health-care socialization variables (i.e., interpersonal socialization and media socialization) in the model. There was, however, support for other portions of the model. For instance, for both Black and White participants, there was an indirect effect of personal NHE on medical mistrust via perceived racism. For White participants, there were indirect effects for vicarious interpersonal NHE, personal RDE, and vicarious interpersonal RDE through perceived racism. Additionally, for both Black and White participants, both personal NHE and vicarious media NHE exerted indirect effects on medical mistrust via perceived financial corruption. Most notably, vicarious media RDE exerted an indirect effect on medical mistrust via perceived corruption for White participants, and an indirect effect via both perceived racism in health care and perceived financial corruption in health care for Black participants. Study 2 built upon Study 1 by utilizing an experimental design to examine the effects of news story content (i.e., mediated communication) on medical mistrust. In Study 2, Black participants (N = 410) were randomly assigned to view one of four news stories using a 2 (health care, non-health care) x 2 (racial discrimination, non-racial discrimination) between-subjects posttest only design, where health care content was depicted as lack of access (i.e., negative health care content). Study 2 focused on the role of mediated communication in medical mistrust and medical mistrust’s relationship to health intention outcomes. The results revealed that negative health content and racial discrimination content increased race-based medical mistrust but had no significant impact on general medical mistrust. Additionally, exposure to health-related racial discrimination stories resulted in higher levels of race-based medical mistrust than non-health, non-racial discrimination stories. Finally, only general medical mistrust was related to any health intention outcomes. Broadly, these findings point to: a) the feasibility of EMMA as a method of examining medical mistrust antecedents, b) differences in racial experiences that may translate to differences in the antecedents of medical mistrust, c) the importance of vicarious media racial discrimination experiences, and d) the need to further disentangle the relationship between general medical mistrust and race-based medical mistrust. Additional implications of these findings, as well as limitations and future research, are discussed.
medical mistrust, health communication, health disparities, health care, African Americans, racial discrimination, news, vicarious experiences
University of Illinois - Urbana-Champaign
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University of Illinois at Urbana-Champaign