The Group-Based Medical Mistrust Scale: psychometric properties and association with breast cancer screening
Introduction
Breast cancer is the most commonly diagnosed cancer and the first and second leading cause of cancer death among Latina and African American women, respectively [1], [2]. Breast cancer mortality may be significantly reduced through regular cancer screening tests as recommended by the American Cancer Society (ACS), specifically annual mammography and clinical breast examination (CBE) in women age 40 and older, and CBE every 1 to 3 years in women younger than 40 [3], [4]. Research findings reveal ethnic differences in adherence to cancer screening guidelines. Latina women are less likely to report ever having a mammogram or CBE or a recent mammogram or CBE compared to White and African American women [5]. Moreover, repeat breast cancer screening (i.e., regular screening over consecutive years) among African American and Latina women has been reported to be lower compared to White women [6], [7]. It possible, then, that African American and Latina women are overrepresented among infrequent screeners and are therefore less likely to detect breast cancer at an earlier and more survivable stage. A number of barriers to cancer screening among African American and Latina women have been identified in the literature, including limited access to care (e.g., inability to pay for services, lack of access to facilities) [8], [9], [10], less knowledge about cancer and screening recommendations [6], [11], and fear of cancer screening procedures or a cancer diagnosis [12].
Medical mistrust as a barrier to breast cancer screening has received considerably less attention than the barriers mentioned above. The earliest empirical work on mistrust among African Americans focused on cultural mistrust, defined as a tendency to distrust Whites based upon a legacy of direct or vicarious exposure to racism or unfair treatment by Whites [13]. Such mistrust has been described as a “racism reaction” or healthy adaptation to a hostile social milieu and as such has a defensive function [14]. Based on the definition of cultural mistrust, medical mistrust may be defined as a tendency to distrust medical systems and personnel believed to represent the dominant culture.
Previous studies suggest that mistrust is a significant factor in the decision to obtain routine medical care, such as cancer screening. It has been reported that African American women express specific concerns about having a White physician that centered around the belief that White physicians communicate differently with African Americans [15]. Specifically, women reported beliefs that the advice or information given to African American women is inferior to that given to White women, is not truthful or forthcoming, and is often conveyed in an insensitive way. African American women also report avoiding hospitals and clinics or use them only as a last resort due to unsupportive behaviors and offensive comments made by health care providers [16]. This is accompanied by a sense that the complaints and ailments of African American patients are not taken seriously. Similar findings were reported for Latino adults in that lack of trust was reported to limit formal health care utilization [17]. A lack of confidence in medical techniques and procedures, specifically mammography, has also been reported by women of color due to past false negatives and beliefs that breast self-examination is more effective and reliable than a mammogram [18]. Although these findings lay a foundation for further study of medical mistrust, these studies are largely qualitative and descriptive, and all fail to use a standard measure that assesses this construct.
The Cultural Mistrust Inventory (CMI) [13] is one measure that has been used to investigate suspicion among African Americans in four domains: politics and law, education and training, business and work, and interpersonal relations. However, medical care is not included as a domain of the CMI and its exclusion is a potential problem in the use of this instrument to assess medical mistrust. As reviewed above, one's attitudes towards health care settings and professionals is a unique area of concern that may encompass several components including one's misgivings about (a) the intentions of health care providers, (b) inequities in the provision of medical treatment, (c) racially biased provider communications, and (d) the validity of current medical information and techniques. It may be argued that this conceptualization of medical mistrust warrants a measure that specifically targets these components. A measure of medical mistrust is further warranted by the legacy of previous medical research abuses, such as the Tuskegee Syphilis Study. The deception associated with the Tuskegee study in which 400 African American men were denied treatment for syphilis, as well as concerns about being treated as a “guinea pig,” frequently emerge in studies of African Americans' attitudes toward medical research [19], [20], [21], [22], [23], [24]. In light of this legacy, the study of mistrust of medical systems deserves a more tailored assessment tool.
The aim of the research reported here is to address the dearth of empirical work on medical mistrust by validating a new measure, the Group-Based Medical Mistrust Scale (GBMMS), and investigating its association with attitudes toward cancer screening and breast cancer screening practices. This measure is group-based in that it assesses the tendency to distrust those who do not belong to one's ethnic group and/or distrust systems that do not represent one's ethnic group based upon a legacy of racism or unfair treatment. Inasmuch as medical mistrust represents a lack of confidence in the treatment provided by medical systems as well as the information provided by these systems, individuals with greater mistrust would be expected to have greater doubts about the benefits and effectiveness of cancer screening. Therefore, convergent validity of the GBMMS will be determined by the measure's association with perceived disadvantages of cancer screening or cons and benefits of cancer screening or pros. Specifically, it is expected that the GBMMS will demonstrate a positive association with cancer screening cons and a negative association with cancer screening pros.
Convergent validity will also be determined by the association between medical mistrust and acculturation or the extent to which an ethnic group member participates in the cultural traditions, values, beliefs, assumptions, and practices of the dominant society [25]. Past research focusing on African American acculturation has proposed that certain interracial attitudes, specifically dislike and mistrust of Whites, are common among less acculturated (i.e., more traditional) African Americans and has conceptualized such attitudes an important dimension of African American culture that should be included in the assessment of acculturation [25], [26]. Therefore, overlap between acculturation and medical mistrust is expected such that lower acculturation scores will be associated with higher GBMMS scores. Lastly, concurrent validity will be examined through the association between medical mistrust and breast cancer screening adherence. In the current study, three adherence groups are examined: women who are adherent to screening guidelines, women who are nonadherent but report past screening, and women who are nonadherent and either report no previous screening or a long period since they were last screened. This last adherence group was deemed important to include as there is evidence that African American and Latina women are screened less frequently compared to other ethnic groups. It is hypothesized that mistrust will be associated with lower adherence to breast cancer screening recommendations.
Section snippets
Participants
Participants were 79 African American and 89 Latina women with no previous diagnosis of cancer. They were interviewed as part of the East Harlem Partnership for Cancer Awareness (EHPCA). The aim of the EHPCA is to increase cancer screening among East Harlem (located in Northern Manhattan, New York City) residents and other urban medically underserved groups. Individuals who were at least 18 years of age, able to provide informed consent, and lived, worked, and/or sought health care in East
Participant characteristics
Table 1 presents the sociodemographic information for the total sample, which was 47% African American and 53% Latina. Of the Latina participants, 47% completed the interview in English and 53% completed the interview in Spanish. Over half of the sample was low-income, with 50% reporting a household income of less than US$10,000 per year and 37% of the sample reporting less than a high-school education. Less than one third of the sample reported current employment. However, approximately two
Discussion
The current research examined the psychometric properties of the Group-Based Medical Mistrust Scale (GBMMS) in a sample of urban African American and Latina women. Results adequately support the scale's validity and relationship to breast cancer screening adherence.
The items of the GBMMS were reduced to three components labeled suspicion, group disparities in health care, and lack of support from health care providers. Together, these three components accounted for 60.5% of the total variance
Acknowledgements
Preparation of this manuscript was sponsored in part by grants from the National Cancer Institute (#U01-CA86107-01, #CA81137).
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