Group-based medical mistrust and care expectations among black patients seeking addiction treatment

Highlights • Group-based medical mistrust (GBMMS) is rooted in awareness of past and present structural and interpersonal discrimination.• GBMMS has previously been linked to health disparities.• GBMMS is associated with black patients’ expectations of addiction treatment.• Treatment delays, anticipation of discrimination, lower adherence, and relapse may be related to GBMMS.• Group-based medical mistrust and care expectations among black patients seeking addiction treatment.

fied group-based medical mistrust as potentially relevant to Black patients' expectations of addiction treatment ( Hall et al., 2021 ). However, this study failed to test independent associations between group-based medical mistrust and expectations of care, necessitating additional exploration.
Group-based medical mistrust, defined as "a tendency to distrust medical systems and personnel believed to represent the dominant culture in a given society, " has been linked to health disparities ( Benkert et al., 2019 ). Mistrust involves the belief that an entity will not act in the patient's best interests or may work against them ( Williamson and Bigman, 2018   Note: Items with * were reverse scored. 'Ethnicity' used as a proxy for race to maintain consistency with prior research using GBMMS. treatment adherence, and poorer physical and mental health outcomes ( Moore et al., 2013 ;Shelton et al., 2010 ;Street et al., 2009 ). Outside addiction medicine, studies have found medical mistrust to be intertwined with experiences of racism. Endorsement of medical mistrust is associated with endorsement of racial discrimination ( Galvan et al., 2017 ;Williamson et al., 2019 ). Importantly, recent research by our group found that prior experiences of medical racism are associated with greater group-based medical mistrust and poorer expectations regarding addiction treatment ( Hall et al., 2021 ).
To date, associations between group-based medical mistrust and expectations of addiction treatment among Black patients remain untested. The present study aims to determine if group-based medical mistrust relates to poorer expectations of addiction treatment, particularly with regard to delays in care-seeking due to concern for racial discrimination, projected non-adherence, and fears of discrimination-precipitated relapse.

Design and study population
Participants were recruited from the Ohio State Wexner Medical Center (OSUWMC) addiction facility Talbot Hall and the OSUWMC Substance Use, Treatment, Education and Prevention Program (STEPP) clinic at McCampbell Hall. Addiction care at Talbot Hall includes comprehensive outpatient (partial hospitalization, intensive outpatient, group and individual counseling and medication management) treatment as well as medically supervised withdrawal for alcohol and substance use disorders. STEPP clinic offers outpatient addiction treatment, obstetric and postnatal care to pregnant people with substance use disorders. Although embedded in a university environment, neither facility is associated with student health and both primarily treat community members in OSUWMC's catchment area. Over 10-months in 2020, trained staff identified potential participants during routine medical assessments. Those describing their race as Black, African American, or Multiracial with Black or African American as a part of their identity were offered participation. Participants were at least 18 years old. Exclusion criteria were inability to consent, read or comprehend the questionnaire, or operate a tablet. Participants completed the survey on a tablet in private examination rooms. They provided verbal consent and were monetarily compensated.
The survey included the GBMMS ( Table 1 ), original questions about expectations of care regarding racial discrimination and addiction treatment, and demographic information. GBMMS includes twelve items which assess race-based medical mistrust ( Shelton et al., 2010 ). The items are divided among subscales (1) Lack of Support from Healthcare Providers; (2) Suspicion of Healthcare Providers and Medicine; and (3) Group-based Disparities in Healthcare. Response options range from 1 to 5 (strongly disagree to strongly agree). A detailed description of procedures and measures is available elsewhere ( Hall et al., 2021 ).
Spearman's rho correlations probed associations between GBMMS and expectations of care. All tests were two-tailed and deemed significant at < 0.01. Analyses were performed using SPSS (Version 27.0, SPSS. Inc.). OSUWMC Institutional Review Board approved this study.
Sample means and ranges for total GBMMS and GBMMS subscales were determined. Mean, minimum and maximum total GBMMS scores were 31.4 ± 9.4, 12.0 and 58.0. The lack of support from healthcare providers subscale (GBMMS LOS) had a mean of 8.2 ± 2.6 and a range of 3-15. The Suspicion subscale (GBMMS SUSP) had a mean of 14.0 ± 5.4 and ranged 6-28. Finally, the Group-based health disparities subscale (GBMMS DISP) mean was 11.8 ± and a range of 4-20.

GBMMS total
Spearman's rho analyses yielded moderate, positive, and statistically significant correlations between total GBMMS and original items "I would have gotten addiction treatment sooner if I did not have to worry about racial discrimination by healthcare workers " (hereafter delayed care seeking) (r s (141) = 0.599, p < .001), "I would not be surprised if I am discriminated against because of race or color during my addiction treatment " (hereafter anticipation of racial discrimination during addiction treatment) (r s (141) = 0.685, p < .001) and "If I am discriminated against during addiction treatment, I will be more likely to relapse " (hereafter concern for discrimination-precipitated relapse) (r s (141) = 0.413, p < .001). Weak and positive correlations were found between total GBMMS and "I would not follow the advice of an addiction treatment provider who seemed to hold discriminatory views about my race or color " (hereafter anticipation of discrimination-precipitated disengagement) (r s (141) = 0.353, p < .001).

History of interpersonal racism by healthcare workers
The statement "I have personally been treated poorly or unfairly by doctors or healthcare workers because of my ethnicity " was strongly correlated with anticipation of racial discrimination during addiction treatment (r s (141) = 0.718, p < .001) and moderately correlated with delayed care seeking (r s (141) = 0.526, p < .001), anticipation of discrimination-precipitated disengagement (r s (141) = 0.521, p < .001) and concern for discrimination-precipitated relapse (r s (141) = 0.542, p < .001). Fig. 1 illustrates the correlates of Group-Based Medical Mistrust (GBMMS), history of interpersonal racism by healthcare workers (HIRHW) and expectations of racial discrimination in addiction treatment.

Discussion
This study provides compelling initial evidence that group-based medical mistrust is associated with self-reported delayed care seeking, anticipation of racial discrimination during addiction treatment, anticipation of discrimination-precipitated disengagement and discrimination-precipitated relapse among Black patients with substance use disorders. All hypothesized associations between medical mistrust and care expectations were confirmed. Total GBMMS, all GB-MMS subscales, and the GBMMS item eliciting personal history of medical racism were robustly associated with expectations of racial discrimination and addiction treatment. Delayed care seeking was moderately associated with total GBMMS and subscales measuring perceived lack of support by healthcare workers, suspicion, and awareness of group-based health disparities. Anticipation of racial discrimination during addiction treatment was strongly associated with prior experiences of racial mistreatment during healthcare. Moderate associations with anticipated discrimination were noted with total GBMMS, lack of support by healthcare workers, suspicion and group-based health disparities subscales. Finally, concern for discrimination-precipitated relapse was moderately correlated with total GBMMS, suspicion and personal history of racial discrimination by healthcare workers.
Our findings add to the growing body of literature linking medical mistrust to health inequality across multiple contexts ( Benkert et al., 2019 ). Stereotype threat, or the idea that actions are interpreted by a preexisting framework, usually refers to racially minoritized groups who confirm the negative behavior ascribed to their group ( Spencer et al., 2016 ). Through this lens, past experiences with providers may relate to expectations of discrimination and mistrust; a premise that was largely born out by the data. However, surprisingly, total GBMMS and suspicion and disparity subscales were only weakly associated with anticipation of discrimination-precipitated disengagement. Of all things that were associated with medical mistrust -expecting discrimination, delaying care, concern for relapse -not listening to providers, was the least likely. This finding suggests a possible aperture for engagement whereby there might be a persistent hope and expectation for care, separate from medical mistrust and expectations of racial discrimination, that could provide an opportunity to break the pattern of stereotype threat.
In examining the strongest associations found, a personal history of racism and the suspicion subscale were most strongly correlated with anticipation of racial discrimination during addiction treatment. This finding demonstrates that when entering the therapeutic alliance between patients of color and addiction medicine treatment services it is important to consider personal experiences of racism and associated trauma. Patient-centered communication (partnering with the patient through empathic reflective listening) is an approach that might improve the therapeutic alliance and reduce suspicion . Additionally, although this study did not examine provider race, studies outside of addiction medicine have found patient-doctor race concordance led to greater patient satisfaction scores, presentation to care, and health outcomes ( Hill et al., 2018 ;LaVeist and Nuru-Jeter, 2002 ;LaVeist et al., 2003 ). In the United States, the addiction workforce is predominantly White and an increase in addiction treatment providers belonging to under-represented minorities is needed Jordan and Jegede, 2020 . Future work should examine the effects of addiction workforce diversity on group-based medical mistrust and addiction treatment outcomes.
Our study was limited by its cross-sectional design which prevented testing correlations between medical mistrust and clinical outcomes. Other limitations center on the unclear generalizability of our findings given the setting (urban Midwestern academic health system serving a large, racially and socioeconomically diverse catchment area) and sample (treatment-seeking participants). It is possible that samples drawn from other geographic locales or from non-treatment seeking populations might differ in medical mistrust and individual and structural barriers to addiction treatment. Future prospective cohort studies should examine baseline GBMMS scores in relation to measurable aspects of addiction treatment such as access, adherence and longitudinal outcomes.
In conclusion, the present study demonstrates that group-based medical mistrust is associated with self-reported delayed care seeking, anticipation of racial discrimination during addiction treatment, anticipation of discrimination-precipitated disengagement and concern for discrimination-precipitated relapse. However, non-adherence to treatment was the least strongly correlated with the GBMMS offering an opportunity for engagement. GBMMS can be utilized by providers to increase understanding of how structural and interpersonal racism stand as important barriers to addiction treatment for Black patients. By addressing these obstacles providers can offer more equitable care.

Role of funding source
Dr. Hall received funding from the Recognizing and Eliminating Disparities in Addiction through Culturally Informed Healthcare (REACH) program. The REACH Program is made possible by funding to the Academy of Addiction Psychiatry (AAAP) from the Substance Abuse and Mental Health Services Administration (SAMHSA) grant no. 1H79TI08135801. The views expressed in this publication do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. government. The funder had no role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the article for publication.

Declaration of Competing Interest
The authors declare no conflicts of interest.