Trust is one of the most important foundations in health care.

Trust in providers, treatments, and scientific evidence. But what does trust really mean in the context of health care today? And how does the language surrounding trust impact our view of the people, communities, and organizations served?

According to a new report from Edelman, trust is a key determinant of health for both individual and public health care decisions. The findings in this Edelman report validate just how crucial trust is, helping drive better health outcomes and confidence in the health system.

How WellSpan embedded trust-building in its vaccine rollout strategy to ensure equitable access

How trust impacts people's health

For the report, Edelman surveyed 10,000 participants from 10 countries, including the United States, Canada, Mexico, and Japan, between Feb. 10-18.

Overall, the report found that trust in the health ecosystem was one of the top determinants of good health behaviors, especially when it came to Covid-19 vaccination rates and preventive care. For example, 84% of American respondents with high trust in the health ecosystem were fully vaccinated compared with 46% of those with low trust.

In addition, people with higher trust in the health ecosystem were more likely to receive preventive care. In the United States, 81% of respondents with high trust had a checkup in the last year compared with 58% of those with low trust.

The report also found that people with higher trust were more supportive of public health measures over personal freedom, as well as more likely to accept changing recommendations from health officials.

The language surrounding trust

After analyzing this report, we began to wonder how our the language surrounding trust and mistrust can sometimes be used to place disproportionate blame on patients—particularly people from marginalized groups.

Consider the explanations of lower vaccination rates in the Black community. For nearly two years, we've repeatedly heard that mistrust is the reason this community has lower overall percentages of vaccine uptake. We don't deny that trust plays a role—it absolutely does. But there may be an implicit bias in these remarks, as it implicates marginalized individuals acting irrationally and making a bad decision in choosing not to seek care and immune protection. A similar type of implicit blame occurs when discussing interactions between patients and clinicians where the patient does not share all clinically relevant details with the provider (e.g., living conditions, transportation access, physical symptoms, etc.). In these examples and more, the problem is placed directly with the patient.

When we implicate the patient, it leads health care leaders to ask, "What can we do if they choose not to trust us?" There seems to be a bit of blame-shifting, which is made even more egregious by gaslighting. For example, some people discuss how mistrust in the Black community stems solely from the Tuskegee study. These conversations can involve covert (and sometimes overt) racist messaging about how people are dramatizing one incidence and are refusing to move on from something that took place 50 years ago. When marginalized communities experience these remarks, it only drives further mistrust. 

People often jump to examples from history that implicate very few of us, and they fail to consider how recent actions, both implicit and explicit, may be the reason for mistrust. Because here's the thing: the very existence of health disparities today is a clear sign that patients are likely receiving different care and are experiencing situations that would erode trust in their everyday care.

A recent study published in Health Affairs details this, revealing that Black patients were 2.54 times more likely to have negative descriptors in the EHR notes compared to white patients. Another study observed that Black patients were far less likely—by up to 26%—to receive newer, more effective, and now standard-of-care blood thinners for stroke prevention.

Changing how we think about trust

Health care leaders need to change how they think about trust. First step? Stop assuming that mistrust is irrational and not rooted in marginalized patients' contemporary experiences with health care.

Assuming irrationality places the burden on marginalized individuals to get over mistrust when it should in fact be the role of leaders to understand why mistrust has taken root in the first place. Health care leaders should assume that the responsibility for mistrust lies with stakeholders other than patients. Leaders should also presume that individuals from marginalized populations are acting rationally in mistrusting our institutions when they choose not to seek care or when they question the care given to them.

With this shift in mindset, leaders can focus on what their institution's role has been in creating mistrust. The health care industry often misdiagnoses mistrust as the reason people are not seeking care—so while tackling mistrust, it's important to investigate whether there are bigger structural barriers preventing access. (Hint: there absolutely are.) For example, service affordability and accessibility, locations of care, appointment times, transportation infrastructure, clear communications, technological gaps, and more.

3 questions to help diagnose your role in mistrust

If mistrust remains a key barrier to equitable access and outcomes, here are 3 questions to diagnose your role:

1. If mistrust is a key barrier, what reasons have we given this community to mistrust us?

   Think about both your institution's history and present-day situation. Look back 10, 50, 100 years ago, but don't forget to assess how you operate today. Here are a few of the many areas to explore in your institution's history and current operations: segregation and barring of clinicians and patients of color, discriminatory treatment such as under-prescribing medication for Black patients, suing low-income patients for not paying for care, and more.

2. Have we ever publicly acknowledged and taken responsibility for shortcomings?

   Building a space for trust means embracing the humility necessary to admit wrongdoing and take responsibility for shortcomings—both big and small. Take Cone Health's apology as an example. They publicly apologized for a segregation lawsuit. And while this does not absolve the harm committed, it is the first step in building a more trustworthy institution. As James Baldwin wrote, "Not everything that is faced can be changed. But nothing can be changed until it is faced."

3. How can we meaningfully partner with community members and existing trust brokers?
   Trust is not simply given. It is earned. And earning trust requires time to build relationships and commitment to listening to and following the lead of the very community members who are most marginalized and mistrustful of your institution today. And while it's easy to jump to trying to build trust from scratch, there are almost undoubtedly community members and organizations who have been harnessing trust at the grassroots level for a long time. They have a lot of wisdom and rapport in these spaces, and we believe that working with a community rather than for a community is key. This parallels what we see in the Edelman report, which narrows in on the value of 'going local' where levels of trust are low. 

4 ways health care organizations can build trust

To build trust and confidence in the health ecosystem, the Edelman report offers four recommendations for employers and health systems, including:

1. Overcoming the information barrier

   According to the report, 65% of respondents said they are not taking care of their health as well as they should, with the two largest obstacles being cost (50%) and a lack of or confusing information (47%).

   Currently, only 50% of respondents said they routinely consume health information from major news organizations, corporations, or other sources. In addition, 61% of respondents said they are confident in their ability to make informed health care decisions for themselves and their families—a 10 percentage point decrease since January 2017.

   To bridge the information divide, the report recommends relying on local voices, such as people's doctors, employers, and families and friends, for those with less trust in the health system and expert voices, such as national health authorities for those with more trust.

2. Building trust across the whole health ecosystem

   More than half of respondents said the pandemic made them less confident in the health care system's ability to handle major health crises. In addition, 55% said they were concerned about medical science becoming politicized.

   According to the report, it is important to build trust in the health ecosystem as a whole. Among the respondents, 71% said health companies should build and maintain trust in their country's health system. To do this, respondents said health companies should work to address pollution (69%), poverty and income inequality (66%), climate change (65%), the high cost of nutritious food (62%), and racial injustice (60%).

3. Embracing the employer role in health outcomes

    In addition to national health authorities, more than half of respondents said their employers were one of the most believable sources of health care information. Almost 80% of respondents also said they expect their employers to play a meaningful role in their health.

   To help ensure their workers are healthy, respondents said employers should create healthy office environments (66%), implement health policies (66%), provide health incentives and information (62%), and offer mental health support and prevent burnout (47%)

4. Preparing for the next public health crisis
   Finally, to build resilience for the next public health crisis, the report recommends health organizations take action to address health disparities, such as climate, poverty, and racial justice. 

Parting thoughts

The words we choose—and how we use them—matter deeply.

It can quite literally save lives and improve overall care outcomes, especially among marginalized populations. Trust is not built overnight but rather through consistent acts of humility, listening, and shared spaces of community engagement. Working with diverse communities is the only way forward. The opportunity to listen, learn, and help is often hidden in plain sight. People want to be seen and heard for who they are. When we facilitate safe and trustworthy spaces, we learn how to best help an entire community. A leader must take this to heart.

Advisory Board's Solomon Banjo helped contribute to this article.

(Adams, Becker's Health IT, 3/10; 2022 Edelman Trust Barometer Special Report: Trust and Health, 3/10)