Public trust is earned: Historical discrimination, carceral violence, and the COVID ‐19 pandemic
PMCID: PMC10339167
PMID: 37279782
Abstract
Abstract Objective To assess whether knowledge of Tuskegee, the U.S. Immigration and Customs Enforcement (ICE) agency's detainment of children, and satisfaction with the George Floyd death investigation were associated with trust in actors involved in the development and distribution of coronavirus vaccines. Data Sources and Study Setting National survey with a convenience sample of Black ( n = 1019) and Hispanic ( n = 994) adults between July 1 and 26, 2021. Study Design Observational study using stratified adjusted logistic regression models to measure the association between ratings of the trustworthiness of actors involved in the development and distribution of coronavirus vaccines. Principal Findings Among Black respondents, lower satisfaction with the George Floyd death investigation was associated with lower trustworthiness ratings of pharmaceutical companies (ME: −0.09; CI: −0.15, 0.02), the FDA (ME: −0.07; CI: −0.14, −0.00), the Trump Administration (ME: −0.09; CI: −0.16, −0.02), the Biden Administration (ME: −0.07, CI: −0.10, 0.04), and elected officials (ME: −0.10, CI: −0.18, −0.03). Among Hispanic respondents, lower satisfaction was associated with lower trustworthiness ratings of the Trump Administration (ME: −0.14, CI: −0.22, −0.06) and elected officials (ME: −0.11; CI: −0.19, −0.02). Greater knowledge of ICE's detainment of children and families among Hispanic respondents was associated with lower trustworthiness ratings of state elected officials (ME: −0.09, CI: −0.16, 0.01). Greater knowledge of the US Public Health Service Study of Syphilis in Tuskegee was associated with higher trustworthiness ratings of their usual source of care (ME: 0.09; CI: 0.28, 0.15) among Black respondents (ME: 0.09; CI: 0.01, 0.16). Conclusions Among Black respondents, lower satisfaction with the George Floyd death investigation was associated with lowered levels of trust in pharmaceutical companies, some government officials, and administrators; it was not associated with the erosion of trust in direct sources of health care delivery, information, or regulation. Among Hispanic respondents, greater knowledge of the ICE detainments was associated with lower trustworthiness ratings of elected state officials. Paradoxically, higher knowledge of the Study of Syphilis in Tuskegee was associated with higher trustworthiness ratings in usual sources of care.
Full Text
The low early uptake of coronavirus vaccines among Black and Hispanic populations in the United States has been attributed to widespread medical mistrust rather than the misconduct of government and medical institutions.
,
,
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Group‐based knowledge of unequal treatment, neglect, and violence has led many to consider these institutions untrustworthy. Given the importance of laws and regulations in shaping health outcomes,
,
scholars have offered frameworks to expand analyses of institutional trust to distinguish between trust, distrust, mistrust, and trustworthiness and the important implications of each for public health and state actors.
,
,
,
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,
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Public perception of the trustworthiness (i.e., the perceived reliability of institutional actors to perform their duties or publicly stated commitments) of actors involved in the COVID‐19 pandemic response predates the pandemic. The reputations of these actors may have improved or worsened as a result of actions taken to address the pandemic. Yet, less is known about whether knowledge of historical and contemporary abuses, crimes, and discrimination perpetrated by these actors influences their trustworthiness among Black and Hispanic populations.
Discrimination experienced within the health care system is a known contributor to institutional mistrust.
For instance, despite mixed evidence, the US Public Health Service Study of Syphilis in Tuskegee has been repeatedly cited as a source of mistrust, particularly among Black Americans.
,
,
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,
,
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The United States has perpetrated or been complicit in health violence against Black, Hispanic, and Indigenous populations domestically and abroad (e.g., the sterilization of Native American women and girls through the Indian Health Service; the infection of prisoners, psychiatric patients, and sex workers to test the efficacy of penicillin in Guatemala), which led many to avoid health interventions proposed by actors perceived to act in partnership with those agencies and institutions.
,
,
,
,
Although knowledge of historical atrocities and common experiences of racial discrimination is known to have tangible health consequences,
,
this domain of knowledge has important behavioral consequences for public health actors that were underexplored during the COVID‐19 pandemic.
Public health researchers and scholars across multiple disciplines have found police violence—disproportionately against Black Americans—has myriad health consequences in need of intervention.
,
,
,
,
,
,
Research shows that indirect police contact exacerbates health risks for people living in highly surveilled neighborhoods,
,
,
,
, and the effects of this police contact have varied by gender.
,
,
,
Scholars have shown that routine exposure to police violence is linked to medical mistrust,
lower utilization of important health services,
,
and exacerbation of other known health disparities for youth and adults.
,
,
,
,
Sociolegal scholars have also begun examining how legal standards are being enforced to deter police misconduct,
,
,
,
,
,
,
,
and others are beginning to ask questions about how to use available 21st‐century technological innovations to regulate law enforcement behavior more expansively.
,
,
,
,
,
,
However, research examining the impact of police violence—or (dis)satisfaction with governmental responses to police violence—on the political behaviors of American citizens and residents remains scant, despite evidence demonstrating that knowledge of this violence also has important political consequences (particularly among racially minoritized populations).
,
,
Our instrument included adapted measures from the Uncovering COVID‐19 Experiences and Realities (UnCOVER) Study fielded by the Society, Health, and Racial Equity Lab at Tulane University from May to July 2020, as well as the COVID Collaborative Study fielded by Langer Research Associates.
,
Since the COVID Collaborative study explicitly focused on Black and Hispanic respondents, we extend this work by restricting our final analytical sample to 1911 self‐identifying Black (n = 1019) and Hispanic (n = 994) respondents (see Table 1) with complete responses for our primary outcome variables, predictor variables, and covariates.
The outcome variables were the respondents' perceptions of the trustworthiness of actors involved in the development and distribution of the coronavirus vaccines, based on the survey items fielded during the COVID Collaborative Study.
Respondents were asked, “How trustworthy are each of these actors which at various points have been involved in the development and distribution of the coronavirus vaccine?” This question was answered using a five‐point Likert scale (completely, mostly, somewhat, not much, and not at all), evaluating the following actors: (1) “Drug companies working to create and test the vaccine”, (2) “The U.S. Food and Drug Administration (FDA)”, (3) “The Trump/Pence Administration”, (4) “The Biden/Harris Administration”, (5) “Your usual doctor or health care team (skip if you don't have one)”, (6) “Pharmacies and walk‐in clinics where people can get vaccinated”, and (7) “Elected officials in your state”. We categorized participant ratings of the trustworthiness of each actor as (a) completely, (b) mostly, (c) somewhat, or (d) not much/not at all. Higher values indicate greater within‐group perceptions of the trustworthiness of these actors.
We had three key predictor variables of interest (see Table 2). The first measured participants' working knowledge of the US Public Health Service Study of Syphilis in Tuskegee. Respondents were asked, “How much, if anything, have you heard or read about the United States Federal Government's Tuskegee Syphilis Study from 1932 to 1972, in which a group of Black men in Alabama who had syphilis was not told about it or treated for it?” using a five‐category ordinal variable with Likert response options: a great deal, a lot, a moderate amount, a little, and none. Higher values indicate higher levels of knowledge about the study. Response options were recoded to delineate between respondents who knew a great deal/a lot/a moderate amount and those who knew little/none (reference group). The literature is mixed on its assessment of the association between knowledge of the Tuskegee study and levels of trust and mistrust in medical institutions.
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We sought to assess whether knowledge of the study correlates with perceptions of trustworthiness, given the resurgence of the study in popular media as a reported cause of low trust leading to low early uptake of the coronavirus vaccines.
We measured several covariates based on existing literature describing the relationships between trust and health service use. Our covariates included race/ethnicity, sex, age, household income, health insurance status, highest level of educational attainment, physical and mental health status, whether they were born in the United States, the extent to which respondents viewed their destiny in life as linked to other members of their racial/ethnic group (i.e., linked fate), and political affiliation. We also include “linked fate” in this analysis to account for known predictors of carceral knowledge and trust in state actors from literature in political science.
,
The self‐identified race and ethnicity of the participant were measured using a specific procedure. First, participants were asked if they identified as “Hispanic/Latinx” using a binary indicator. Next, participants were asked to select which racial group(s) they identify with (e.g., American Indian/Native American/Alaska Native, Asian, Black/African American, Native Hawaiian or Pacific Islander, or White), and participants who selected “American Indian/Native American/Alaska Native” were also given the opportunity to list their tribal affiliation(s). Finally, we asked participants to select which race and/or ethnicity they most closely identify with (e.g., Black/African American, Hispanic/Latinx, Biracial/Multiracial) to inform our analytical categorization of individual participants who may have selected one or more racial/ethnic identities. Physical and mental self‐reported health status was assessed by asking participants whether, in general, they would rate their physical and mental health as poor, fair, good, very good, or excellent.
Respondents were asked to estimate their annual household income as <$24,999, $25,000–49,999, $50,000–99,999, $100,000–199,000, or $200,000 or more. Respondents reported their insurance status as having employer‐sponsored insurance (their own or that of a family member) (i.e., private), Medicaid (including Medicaid HMO/CMO), Medicare, other public insurance (e.g., Military Health Care or VA, Indian Health Service, and COBRA), or being uninsured. Participants were asked about their highest level of educational attainment, and their responses were categorized as less than high school, high school or GED, some colleges without a degree, or an associate degree or higher. Participants were also asked about their political affiliation (i.e., Republican, Democrat, Independent, or something else) and whether they were born inside or outside of the United States. The full survey instrument is included in the supplemental appendix B.
We calculated summary statistics to assess the distribution of within‐group responses for our outcomes, exposures, and covariates (Tables 1, 2, 3). Rather than test these hypotheses by comparing relative differences in means between racial and ethnic groups (e.g., Black vs. White respondents), we explored these associations among Black and Hispanic respondents with stratified adjusted logistic regression models. Initially, we ran our analyses using the raw data from the five‐point Likert scale as categorical variables; however, we ultimately analyzed these variables as dichotomous indicators to ease the analytical interpretation of our results (the results remained the same). We report the associations using marginal effects.
All data cleaning was conducted using R Studio Version 1.4.1106,
and statistical analyses were conducted in Stata version 16.1.
Our sample (Table 1) included a greater proportion of participants who identified as women among Black (63.6% vs. 36.9%) and Hispanic (67.1% vs. 32.9%) respondents. Most participants were born in the United States. Nearly half of Black (43.3%) and nearly a third of Hispanic (31.9%) participants reported household incomes less than or equal to $25,000 per year. Over half of Black (53%) and nearly half of Hispanic (49.8%) participants strongly agreed/agreed with the statement that their destiny is tied to the destiny of other people of their racial and ethnic group in the US.
Most Black participants in our sample rated pharmaceutical companies (80.6%), the FDA (81.5%), the Biden Administration (79.6%), their usual doctor or health care team (84.0%), and pharmacies and walk‐in clinics where people can get vaccinated (84.1%) as trustworthy (i.e., completely/mostly/somewhat trustworthy) (Table 2). These same participants rated the elected officials in their state (66.2%) and the Trump Administration (33.2%) as not trustworthy (i.e., not much/not at all trustworthy). A similar pattern was observed among Hispanic participants. Most rated pharmaceutical companies (83.9%), the FDA (85.1%), the Biden Administration (76.3%), their doctor or health care team (84.7%), and vaccine clinics (85.6%) where they could obtain coronavirus vaccines as trustworthy. However, 55.4% of Hispanic participants rated the Trump Administration and 66.8% rated their state elected officials as not trustworthy.
Most Black (89.8%) and Hispanic (86.4%) participants had heard or read a lot about the death of George Floyd (Table 3). Most Black (63%) and nearly half of Hispanic (41.5%) respondents reported knowing a great deal/a lot/moderate amount about the Tuskegee Syphilis Study. Similarly, most Black (69.3%) and Hispanic (71.1%) participants reported knowing a great deal/a lot/a moderate amount about ICE's detainment of immigrant children and families. Overall, approximately half of Black respondents (50.6%) and 42.6% of Hispanic respondents reported not being satisfied with the outcome of the investigation into George Floyd's death.
Higher levels of knowledge of the US Public Health Service Study of Syphilis in Tuskegee were associated with rating doctors and health care teams as trustworthy (ME: 0.07; CI: 0.01, 0.13) among Black respondents (Table 4). Among Hispanic participants, higher levels of knowledge of ICE's detainment of children and families were associated with rating state elected officials as untrustworthy (ME: −0.09; CI: −0.16, 0.01), while higher levels of knowledge of the US Public Health Service Study of Syphilis in Tuskegee among these participants were associated with rating the Trump Administration as trustworthy (ME: 0.09; CI: 0.01, 0.16). We found no association between knowledge of the circumstances of George Floyd's death and ratings of trustworthiness among Black and Hispanic respondents.
Table 5 shifts the analytic focus from “knowledge” of the circumstances of George Floyd's death to “satisfaction” with the government's investigation of George Floyd's death. Among Black participants, on average, greater dissatisfaction in the Minnesota government's response to George Floyd's death by Derek Chauvin was associated with lower levels of trust in pharmaceutical companies (ME: −0.09; CI: −0.15, 0.02), the FDA (ME: −0.07; CI: −0.14, −0.00), the Trump Administration (ME: −0.09; CI: −0.16, −0.02), and elected officials in their state (ME: −0.10, CI: −0.18, −0.03). Similarly, lower levels of satisfaction in the investigation of George Floyd's death among Hispanic respondents were associated with lower trust in the Trump Administration (ME: −0.14, CI: −0.22, −0.06) and elected officials in their state (ME: −0.11; CI: −0.19, −0.02).
The US Public Health Service Study of Syphilis in Tuskegee is often cited as a signifier of historical medical racism and for the commonplace exploitation and mistreatment of Black Americans by medical institutions. Often, the study is invoked as an event that has undermined the trustworthiness of US medical institutions as well as countless other events that routinely occur during health care encounters.
Despite some studies that have reported that Black Americans tend to know very little about the study, most respondents in our study reported having heard or read a moderate to great deal about it. Our finding may be due to a resurgence of news coverage describing the study during the period the survey was administered and even before the pandemic.
,
,
In addition, previous studies have been underpowered or limited to individual cities or research settings. Our study attempted to address some of these shortcomings by recruiting a large national sample of participants. Paradoxically, we found greater knowledge of the US Public Health Service Study of Syphilis in Tuskegee was associated with higher ratings of trustworthiness for usual care teams with similar directions of association for other actors (though not statistically significant). This may be because measures of high SES (e.g., education) were associated with increased trustworthiness of actors (Supplemental Appendix B); more educated patients may be more aware of the Tuskegee study and more trusting of their usual care teams and other actors. That is, the association between trustworthiness and knowledge of the Tuskegee study may be correlational and not causal.
We also measured knowledge of the detainment of immigrant children and families in unsanitary conditions and overcrowded facilities operated by the U.S. Immigration and Customs Enforcement (ICE) agency. The ICE has maintained a detained population of 45,000 people across 131 of its listed facilities since 2003.
,
,
The detainments drew national attention in June 2019, when Customs and Border Patrol was holding more than 15,000 detainees in crowded holding cells above their capacity (4000).
Therefore, it is plausible that the actions of ICE are associated with lower ratings of trustworthiness of actors involved in the development and distribution of the coronavirus vaccines among Hispanic respondents (Hypothesis 3). We indeed found, among Hispanic respondents, that greater knowledge of these detainments was associated with lower trustworthiness ratings of state and local elected officials. State and local governments are key partners in the coordination and enforcement of federal immigration policy, and Hispanic ethnic groups from Mexico, Guatemala, and Honduras are disproportionally detained and deported.
,
George Floyd's death led to one of the largest social movements in US history and brought unprecedented international attention to police brutality (e.g., excessive force, false imprisonment, wrongful search and seizure). His death further challenged the trustworthiness of the people empowered by the state to ensure the safety of American citizens—the police—which may have increased suspicion of all agents of the state working to protect the health and safety of people living in the U.S. We tested whether greater dissatisfaction with the response to the death of George Floyd was associated with lower trustworthiness ratings. We found most Black and Hispanic respondents had heard moderate to a great deal about George Floyd's death, and nearly a third of respondents were not satisfied with how Minnesota state and local government officials handled the investigation into his death. Among Black respondents, greater dissatisfaction in the response to his death was associated with lower trustworthiness ratings for pharmaceutical companies, the Trump/Pence administration, and state elected officials. Among Hispanic respondents, greater dissatisfaction in the response to George Floyd's death was associated with lower trustworthiness ratings of the Trump Administration and state elected officials, exclusively. Previous work has found that individual and vicarious experiences with police officers may fuel general mistrust of law enforcement and governmental actors.
While George Floyd's death may represent a more salient contemporary event, many speculate that harmful historical events also shape perceptions of the contemporary trustworthiness of government institutions.
These events are only a few of many recent and historical circumstances and events that may influence public trust in government, public health, and medical institutions. While we found lowered levels of trust in government officials and administrations, we did not find evidence of the erosion of trust in direct sources of health care delivery, information, or regulation: usual sources of care, vaccine clinics, or the FDA. This may be due to a number of factors—the perceived nonpolitical nature of healthcare, the increased interpersonal interactions within healthcare, the duration of relationships within healthcare, or other factors. One meta‐analysis of 39 studies found trust often increases with the duration of relationships and frequency of contact.
Trust in public and private institutions depends on their trustworthiness. Public health practitioners rely on a wellspring of trust in emergencies when the general population must act quickly (e.g., using masks and taking vaccines) to stop the spread of disease. But this trust must be earned by improving the trustworthiness of institutions. The erosion of trust through untrustworthy actions of one institution or system (e.g., the criminal legal system) may spill over to other distinct institutions and systems (e.g., health care).
Our findings suggest an association between perceptions of trustworthiness in the people and institutions involved in the development and distribution of coronavirus vaccines and events that erode trust in American institutions. Trustworthiness varied between actors in government and health care institutions with differential associations with historical and contemporary atrocities among Black and Hispanic respondents. Respondents generally rated their doctors and health care teams, pharmacies and walk‐in clinics, and the FDA as trustworthy. They rated elected officials and the Biden and Trump administrations as less trustworthy. Future research should assess whether similar contemporary experiences within and beyond health systems have an impact on trust in doctors and health care teams. Improving the trustworthiness of American institutions for Black and Hispanic populations in the U.S. is not only essential to an improved response to future pandemics but also to creating cultures of health that produce equitable outcomes for all populations.
Sections
"[{\"pmc\": \"PMC10339167\", \"pmid\": \"37279782\", \"reference_ids\": [\"hesr14187-bib-0001\", \"hesr14187-bib-0002\", \"hesr14187-bib-0003\", \"hesr14187-bib-0004\", \"hesr14187-bib-0005\", \"hesr14187-bib-0006\", \"hesr14187-bib-0007\", \"hesr14187-bib-0008\", \"hesr14187-bib-0009\", \"hesr14187-bib-0010\", \"hesr14187-bib-0011\", \"hesr14187-bib-0012\", \"hesr14187-bib-0013\", \"hesr14187-bib-0014\", \"hesr14187-bib-0015\"], \"section\": \"INTRODUCTION\", \"text\": \"The low early uptake of coronavirus vaccines among Black and Hispanic populations in the United States has been attributed to widespread medical mistrust rather than the misconduct of government and medical institutions.\\n, \\n, \\n, \\n Group\\u2010based knowledge of unequal treatment, neglect, and violence has led many to consider these institutions untrustworthy. Given the importance of laws and regulations in shaping health outcomes,\\n, \\n scholars have offered frameworks to expand analyses of institutional trust to distinguish between trust, distrust, mistrust, and trustworthiness and the important implications of each for public health and state actors.\\n, \\n, \\n, \\n, \\n, \\n, \\n, \\n, \\n Public perception of the trustworthiness (i.e., the perceived reliability of institutional actors to perform their duties or publicly stated commitments) of actors involved in the COVID\\u201019 pandemic response predates the pandemic. The reputations of these actors may have improved or worsened as a result of actions taken to address the pandemic. Yet, less is known about whether knowledge of historical and contemporary abuses, crimes, and discrimination perpetrated by these actors influences their trustworthiness among Black and Hispanic populations.\"}, {\"pmc\": \"PMC10339167\", \"pmid\": \"37279782\", \"reference_ids\": [\"hesr14187-bib-0016\", \"hesr14187-bib-0017\", \"hesr14187-bib-0018\", \"hesr14187-bib-0019\", \"hesr14187-bib-0020\", \"hesr14187-bib-0021\", \"hesr14187-bib-0022\", \"hesr14187-bib-0023\", \"hesr14187-bib-0024\", \"hesr14187-bib-0025\", \"hesr14187-bib-0026\", \"hesr14187-bib-0027\", \"hesr14187-bib-0028\", \"hesr14187-bib-0029\", \"hesr14187-bib-0030\", \"hesr14187-bib-0031\"], \"section\": \"INTRODUCTION\", \"text\": \"Discrimination experienced within the health care system is a known contributor to institutional mistrust.\\n For instance, despite mixed evidence, the US Public Health Service Study of Syphilis in Tuskegee has been repeatedly cited as a source of mistrust, particularly among Black Americans.\\n, \\n, \\n, \\n, \\n, \\n, \\n, \\n The United States has perpetrated or been complicit in health violence against Black, Hispanic, and Indigenous populations domestically and abroad (e.g., the sterilization of Native American women and girls through the Indian Health Service; the infection of prisoners, psychiatric patients, and sex workers to test the efficacy of penicillin in Guatemala), which led many to avoid health interventions proposed by actors perceived to act in partnership with those agencies and institutions.\\n, \\n, \\n, \\n, \\n Although knowledge of historical atrocities and common experiences of racial discrimination is known to have tangible health consequences,\\n, \\n this domain of knowledge has important behavioral consequences for public health actors that were underexplored during the COVID\\u201019 pandemic.\"}, {\"pmc\": \"PMC10339167\", \"pmid\": \"37279782\", \"reference_ids\": [\"hesr14187-bib-0032\", \"hesr14187-bib-0033\", \"hesr14187-bib-0034\", \"hesr14187-bib-0035\", \"hesr14187-bib-0036\", \"hesr14187-bib-0037\", \"hesr14187-bib-0038\", \"hesr14187-bib-0039\", \"hesr14187-bib-0040\", \"hesr14187-bib-0041\", \"hesr14187-bib-0042\", \"hesr14187-bib-0039\", \"hesr14187-bib-0043\", \"hesr14187-bib-0044\", \"hesr14187-bib-0045\", \"hesr14187-bib-0046\", \"hesr14187-bib-0039\", \"hesr14187-bib-0047\", \"hesr14187-bib-0040\", \"hesr14187-bib-0042\", \"hesr14187-bib-0043\", \"hesr14187-bib-0048\", \"hesr14187-bib-0049\", \"hesr14187-bib-0050\", \"hesr14187-bib-0051\", \"hesr14187-bib-0052\", \"hesr14187-bib-0053\", \"hesr14187-bib-0054\", \"hesr14187-bib-0055\", \"hesr14187-bib-0056\", \"hesr14187-bib-0057\", \"hesr14187-bib-0058\", \"hesr14187-bib-0059\", \"hesr14187-bib-0060\", \"hesr14187-bib-0061\", \"hesr14187-bib-0062\", \"hesr14187-bib-0063\", \"hesr14187-bib-0064\", \"hesr14187-bib-0065\", \"hesr14187-bib-0066\", \"hesr14187-bib-0067\"], \"section\": \"INTRODUCTION\", \"text\": \"Public health researchers and scholars across multiple disciplines have found police violence\\u2014disproportionately against Black Americans\\u2014has myriad health consequences in need of intervention.\\n, \\n, \\n, \\n, \\n, \\n, \\n Research shows that indirect police contact exacerbates health risks for people living in highly surveilled neighborhoods,\\n, \\n, \\n, \\n, and the effects of this police contact have varied by gender.\\n, \\n, \\n, \\n Scholars have shown that routine exposure to police violence is linked to medical mistrust,\\n lower utilization of important health services,\\n, \\n and exacerbation of other known health disparities for youth and adults.\\n, \\n, \\n, \\n, \\n Sociolegal scholars have also begun examining how legal standards are being enforced to deter police misconduct,\\n, \\n, \\n, \\n, \\n, \\n, \\n, \\n and others are beginning to ask questions about how to use available 21st\\u2010century technological innovations to regulate law enforcement behavior more expansively.\\n, \\n, \\n, \\n, \\n, \\n, \\n However, research examining the impact of police violence\\u2014or (dis)satisfaction with governmental responses to police violence\\u2014on the political behaviors of American citizens and residents remains scant, despite evidence demonstrating that knowledge of this violence also has important political consequences (particularly among racially minoritized populations).\\n, \\n, \\n\\n\"}, {\"pmc\": \"PMC10339167\", \"pmid\": \"37279782\", \"reference_ids\": [\"hesr14187-bib-0068\", \"hesr14187-bib-0069\", \"hesr14187-tbl-0001\"], \"section\": \"Instrument and sample\", \"text\": \"Our instrument included adapted measures from the Uncovering COVID\\u201019 Experiences and Realities (UnCOVER) Study fielded by the Society, Health, and Racial Equity Lab at Tulane University from May to July 2020, as well as the COVID Collaborative Study fielded by Langer Research Associates.\\n, \\n Since the COVID Collaborative study explicitly focused on Black and Hispanic respondents, we extend this work by restricting our final analytical sample to 1911 self\\u2010identifying Black (n\\u2009=\\u20091019) and Hispanic (n\\u2009=\\u2009994) respondents (see Table\\u00a01) with complete responses for our primary outcome variables, predictor variables, and covariates.\"}, {\"pmc\": \"PMC10339167\", \"pmid\": \"37279782\", \"reference_ids\": [\"hesr14187-bib-0069\"], \"section\": \"Measures\", \"text\": \"The outcome variables were the respondents' perceptions of the trustworthiness of actors involved in the development and distribution of the coronavirus vaccines, based on the survey items fielded during the COVID Collaborative Study.\\n Respondents were asked, \\u201cHow trustworthy are each of these actors which at various points have been involved in the development and distribution of the coronavirus vaccine?\\u201d This question was answered using a five\\u2010point Likert scale (completely, mostly, somewhat, not much, and not at all), evaluating the following actors: (1) \\u201cDrug companies working to create and test the vaccine\\u201d, (2) \\u201cThe U.S. Food and Drug Administration (FDA)\\u201d, (3) \\u201cThe Trump/Pence Administration\\u201d, (4) \\u201cThe Biden/Harris Administration\\u201d, (5) \\u201cYour usual doctor or health care team (skip if you don't have one)\\u201d, (6) \\u201cPharmacies and walk\\u2010in clinics where people can get vaccinated\\u201d, and (7) \\u201cElected officials in your state\\u201d. We categorized participant ratings of the trustworthiness of each actor as (a) completely, (b) mostly, (c) somewhat, or (d) not much/not at all. Higher values indicate greater within\\u2010group perceptions of the trustworthiness of these actors.\"}, {\"pmc\": \"PMC10339167\", \"pmid\": \"37279782\", \"reference_ids\": [\"hesr14187-tbl-0002\", \"hesr14187-bib-0023\", \"hesr14187-bib-0024\"], \"section\": \"Measures\", \"text\": \"We had three key predictor variables of interest (see Table\\u00a02). The first measured participants' working knowledge of the US Public Health Service Study of Syphilis in Tuskegee. Respondents were asked, \\u201cHow much, if anything, have you heard or read about the United States Federal Government's Tuskegee Syphilis Study from 1932 to 1972, in which a group of Black men in Alabama who had syphilis was not told about it or treated for it?\\u201d using a five\\u2010category ordinal variable with Likert response options: a great deal, a lot, a moderate amount, a little, and none. Higher values indicate higher levels of knowledge about the study. Response options were recoded to delineate between respondents who knew a great deal/a lot/a moderate amount and those who knew little/none (reference group). The literature is mixed on its assessment of the association between knowledge of the Tuskegee study and levels of trust and mistrust in medical institutions.\\n, \\n We sought to assess whether knowledge of the study correlates with perceptions of trustworthiness, given the resurgence of the study in popular media as a reported cause of low trust leading to low early uptake of the coronavirus vaccines.\"}, {\"pmc\": \"PMC10339167\", \"pmid\": \"37279782\", \"reference_ids\": [\"hesr14187-bib-0065\", \"hesr14187-bib-0070\", \"hesr14187-bib-0071\", \"hesr14187-supitem-0002\"], \"section\": \"Measures\", \"text\": \"We measured several covariates based on existing literature describing the relationships between trust and health service use. Our covariates included race/ethnicity, sex, age, household income, health insurance status, highest level of educational attainment, physical and mental health status, whether they were born in the United States, the extent to which respondents viewed their destiny in life as linked to other members of their racial/ethnic group (i.e., linked fate), and political affiliation. We also include \\u201clinked fate\\u201d in this analysis to account for known predictors of carceral knowledge and trust in state actors from literature in political science.\\n, \\n The self\\u2010identified race and ethnicity of the participant were measured using a specific procedure. First, participants were asked if they identified as \\u201cHispanic/Latinx\\u201d using a binary indicator. Next, participants were asked to select which racial group(s) they identify with (e.g., American Indian/Native American/Alaska Native, Asian, Black/African American, Native Hawaiian or Pacific Islander, or White), and participants who selected \\u201cAmerican Indian/Native American/Alaska Native\\u201d were also given the opportunity to list their tribal affiliation(s). Finally, we asked participants to select which race and/or ethnicity they most closely identify with (e.g., Black/African American, Hispanic/Latinx, Biracial/Multiracial) to inform our analytical categorization of individual participants who may have selected one or more racial/ethnic identities. Physical and mental self\\u2010reported health status was assessed by asking participants whether, in general, they would rate their physical and mental health as poor, fair, good, very good, or excellent.\\n Respondents were asked to estimate their annual household income as <$24,999, $25,000\\u201349,999, $50,000\\u201399,999, $100,000\\u2013199,000, or $200,000 or more. Respondents reported their insurance status as having employer\\u2010sponsored insurance (their own or that of a family member) (i.e., private), Medicaid (including Medicaid HMO/CMO), Medicare, other public insurance (e.g., Military Health Care or VA, Indian Health Service, and COBRA), or being uninsured. Participants were asked about their highest level of educational attainment, and their responses were categorized as less than high school, high school or GED, some colleges without a degree, or an associate degree or higher. Participants were also asked about their political affiliation (i.e., Republican, Democrat, Independent, or something else) and whether they were born inside or outside of the United States. The full survey instrument is included in the supplemental appendix\\u00a0B.\"}, {\"pmc\": \"PMC10339167\", \"pmid\": \"37279782\", \"reference_ids\": [\"hesr14187-tbl-0001\", \"hesr14187-tbl-0002\", \"hesr14187-tbl-0003\", \"hesr14187-bib-0072\", \"hesr14187-bib-0073\", \"hesr14187-bib-0074\"], \"section\": \"Analytic approach\", \"text\": \"We calculated summary statistics to assess the distribution of within\\u2010group responses for our outcomes, exposures, and covariates (Tables\\u00a01, 2, 3). Rather than test these hypotheses by comparing relative differences in means between racial and ethnic groups (e.g., Black vs. White respondents), we explored these associations among Black and Hispanic respondents with stratified adjusted logistic regression models. Initially, we ran our analyses using the raw data from the five\\u2010point Likert scale as categorical variables; however, we ultimately analyzed these variables as dichotomous indicators to ease the analytical interpretation of our results (the results remained the same). We report the associations using marginal effects.\\n All data cleaning was conducted using R Studio Version 1.4.1106,\\n and statistical analyses were conducted in Stata version 16.1.\\n\\n\"}, {\"pmc\": \"PMC10339167\", \"pmid\": \"37279782\", \"reference_ids\": [\"hesr14187-tbl-0001\"], \"section\": \"RESULTS\", \"text\": \"Our sample (Table\\u00a01) included a greater proportion of participants who identified as women among Black (63.6% vs. 36.9%) and Hispanic (67.1% vs. 32.9%) respondents. Most participants were born in the United States. Nearly half of Black (43.3%) and nearly a third of Hispanic (31.9%) participants reported household incomes less than or equal to $25,000 per year. Over half of Black (53%) and nearly half of Hispanic (49.8%) participants strongly agreed/agreed with the statement that their destiny is tied to the destiny of other people of their racial and ethnic group in the US.\"}, {\"pmc\": \"PMC10339167\", \"pmid\": \"37279782\", \"reference_ids\": [\"hesr14187-tbl-0002\"], \"section\": \"RESULTS\", \"text\": \"Most Black participants in our sample rated pharmaceutical companies (80.6%), the FDA (81.5%), the Biden Administration (79.6%), their usual doctor or health care team (84.0%), and pharmacies and walk\\u2010in clinics where people can get vaccinated (84.1%) as trustworthy (i.e., completely/mostly/somewhat trustworthy) (Table\\u00a02). These same participants rated the elected officials in their state (66.2%) and the Trump Administration (33.2%) as not trustworthy (i.e., not much/not at all trustworthy). A similar pattern was observed among Hispanic participants. Most rated pharmaceutical companies (83.9%), the FDA (85.1%), the Biden Administration (76.3%), their doctor or health care team (84.7%), and vaccine clinics (85.6%) where they could obtain coronavirus vaccines as trustworthy. However, 55.4% of Hispanic participants rated the Trump Administration and 66.8% rated their state elected officials as not trustworthy.\"}, {\"pmc\": \"PMC10339167\", \"pmid\": \"37279782\", \"reference_ids\": [\"hesr14187-tbl-0003\"], \"section\": \"RESULTS\", \"text\": \"Most Black (89.8%) and Hispanic (86.4%) participants had heard or read a lot about the death of George Floyd (Table\\u00a03). Most Black (63%) and nearly half of Hispanic (41.5%) respondents reported knowing a great deal/a lot/moderate amount about the Tuskegee Syphilis Study. Similarly, most Black (69.3%) and Hispanic (71.1%) participants reported knowing a great deal/a lot/a moderate amount about ICE's detainment of immigrant children and families. Overall, approximately half of Black respondents (50.6%) and 42.6% of Hispanic respondents reported not being satisfied with the outcome of the investigation into George Floyd's death.\"}, {\"pmc\": \"PMC10339167\", \"pmid\": \"37279782\", \"reference_ids\": [\"hesr14187-tbl-0004\"], \"section\": \"RESULTS\", \"text\": \"Higher levels of knowledge of the US Public Health Service Study of Syphilis in Tuskegee were associated with rating doctors and health care teams as trustworthy (ME: 0.07; CI: 0.01, 0.13) among Black respondents (Table\\u00a04). Among Hispanic participants, higher levels of knowledge of ICE's detainment of children and families were associated with rating state elected officials as untrustworthy (ME: \\u22120.09; CI: \\u22120.16, 0.01), while higher levels of knowledge of the US Public Health Service Study of Syphilis in Tuskegee among these participants were associated with rating the Trump Administration as trustworthy (ME: 0.09; CI: 0.01, 0.16). We found no association between knowledge of the circumstances of George Floyd's death and ratings of trustworthiness among Black and Hispanic respondents.\"}, {\"pmc\": \"PMC10339167\", \"pmid\": \"37279782\", \"reference_ids\": [\"hesr14187-tbl-0005\"], \"section\": \"RESULTS\", \"text\": \"Table\\u00a05 shifts the analytic focus from \\u201cknowledge\\u201d of the circumstances of George Floyd's death to \\u201csatisfaction\\u201d with the government's investigation of George Floyd's death. Among Black participants, on average, greater dissatisfaction in the Minnesota government's response to George Floyd's death by Derek Chauvin was associated with lower levels of trust in pharmaceutical companies (ME: \\u22120.09; CI: \\u22120.15, 0.02), the FDA (ME: \\u22120.07; CI: \\u22120.14, \\u22120.00), the Trump Administration (ME: \\u22120.09; CI: \\u22120.16, \\u22120.02), and elected officials in their state (ME: \\u22120.10, CI: \\u22120.18, \\u22120.03). Similarly, lower levels of satisfaction in the investigation of George Floyd's death among Hispanic respondents were associated with lower trust in the Trump Administration (ME: \\u22120.14, CI: \\u22120.22, \\u22120.06) and elected officials in their state (ME: \\u22120.11; CI: \\u22120.19, \\u22120.02).\"}, {\"pmc\": \"PMC10339167\", \"pmid\": \"37279782\", \"reference_ids\": [\"hesr14187-bib-0075\", \"hesr14187-bib-0024\", \"hesr14187-bib-0076\", \"hesr14187-bib-0077\", \"hesr14187-supitem-0002\"], \"section\": \"DISCUSSION\", \"text\": \"The US Public Health Service Study of Syphilis in Tuskegee is often cited as a signifier of historical medical racism and for the commonplace exploitation and mistreatment of Black Americans by medical institutions. Often, the study is invoked as an event that has undermined the trustworthiness of US medical institutions as well as countless other events that routinely occur during health care encounters.\\n Despite some studies that have reported that Black Americans tend to know very little about the study, most respondents in our study reported having heard or read a moderate to great deal about it. Our finding may be due to a resurgence of news coverage describing the study during the period the survey was administered and even before the pandemic.\\n, \\n, \\n In addition, previous studies have been underpowered or limited to individual cities or research settings. Our study attempted to address some of these shortcomings by recruiting a large national sample of participants. Paradoxically, we found greater knowledge of the US Public Health Service Study of Syphilis in Tuskegee was associated with higher ratings of trustworthiness for usual care teams with similar directions of association for other actors (though not statistically significant). This may be because measures of high SES (e.g., education) were associated with increased trustworthiness of actors (Supplemental Appendix\\u00a0B); more educated patients may be more aware of the Tuskegee study and more trusting of their usual care teams and other actors. That is, the association between trustworthiness and knowledge of the Tuskegee study may be correlational and not causal.\"}, {\"pmc\": \"PMC10339167\", \"pmid\": \"37279782\", \"reference_ids\": [\"hesr14187-bib-0078\", \"hesr14187-bib-0079\", \"hesr14187-bib-0080\", \"hesr14187-bib-0081\", \"hesr14187-bib-0082\", \"hesr14187-bib-0083\"], \"section\": \"DISCUSSION\", \"text\": \"We also measured knowledge of the detainment of immigrant children and families in unsanitary conditions and overcrowded facilities operated by the U.S. Immigration and Customs Enforcement (ICE) agency. The ICE has maintained a detained population of 45,000 people across 131 of its listed facilities since 2003.\\n, \\n, \\n The detainments drew national attention in June 2019, when Customs and Border Patrol was holding more than 15,000 detainees in crowded holding cells above their capacity (4000).\\n Therefore, it is plausible that the actions of ICE are associated with lower ratings of trustworthiness of actors involved in the development and distribution of the coronavirus vaccines among Hispanic respondents (Hypothesis 3). We indeed found, among Hispanic respondents, that greater knowledge of these detainments was associated with lower trustworthiness ratings of state and local elected officials. State and local governments are key partners in the coordination and enforcement of federal immigration policy, and Hispanic ethnic groups from Mexico, Guatemala, and Honduras are disproportionally detained and deported.\\n, \\n\\n\"}, {\"pmc\": \"PMC10339167\", \"pmid\": \"37279782\", \"reference_ids\": [\"hesr14187-bib-0084\", \"hesr14187-bib-0076\"], \"section\": \"DISCUSSION\", \"text\": \"George Floyd's death led to one of the largest social movements in US history and brought unprecedented international attention to police brutality (e.g., excessive force, false imprisonment, wrongful search and seizure). His death further challenged the trustworthiness of the people empowered by the state to ensure the safety of American citizens\\u2014the police\\u2014which may have increased suspicion of all agents of the state working to protect the health and safety of people living in the U.S. We tested whether greater dissatisfaction with the response to the death of George Floyd was associated with lower trustworthiness ratings. We found most Black and Hispanic respondents had heard moderate to a great deal about George Floyd's death, and nearly a third of respondents were not satisfied with how Minnesota state and local government officials handled the investigation into his death. Among Black respondents, greater dissatisfaction in the response to his death was associated with lower trustworthiness ratings for pharmaceutical companies, the Trump/Pence administration, and state elected officials. Among Hispanic respondents, greater dissatisfaction in the response to George Floyd's death was associated with lower trustworthiness ratings of the Trump Administration and state elected officials, exclusively. Previous work has found that individual and vicarious experiences with police officers may fuel general mistrust of law enforcement and governmental actors.\\n While George Floyd's death may represent a more salient contemporary event, many speculate that harmful historical events also shape perceptions of the contemporary trustworthiness of government institutions.\\n\\n\"}, {\"pmc\": \"PMC10339167\", \"pmid\": \"37279782\", \"reference_ids\": [\"hesr14187-bib-0085\"], \"section\": \"DISCUSSION\", \"text\": \"These events are only a few of many recent and historical circumstances and events that may influence public trust in government, public health, and medical institutions. While we found lowered levels of trust in government officials and administrations, we did not find evidence of the erosion of trust in direct sources of health care delivery, information, or regulation: usual sources of care, vaccine clinics, or the FDA. This may be due to a number of factors\\u2014the perceived nonpolitical nature of healthcare, the increased interpersonal interactions within healthcare, the duration of relationships within healthcare, or other factors. One meta\\u2010analysis of 39 studies found trust often increases with the duration of relationships and frequency of contact.\\n\\n\"}, {\"pmc\": \"PMC10339167\", \"pmid\": \"37279782\", \"reference_ids\": [\"hesr14187-bib-0047\"], \"section\": \"CONCLUSION\", \"text\": \"Trust in public and private institutions depends on their trustworthiness. Public health practitioners rely on a wellspring of trust in emergencies when the general population must act quickly (e.g., using masks and taking vaccines) to stop the spread of disease. But this trust must be earned by improving the trustworthiness of institutions. The erosion of trust through untrustworthy actions of one institution or system (e.g., the criminal legal system) may spill over to other distinct institutions and systems (e.g., health care).\\n Our findings suggest an association between perceptions of trustworthiness in the people and institutions involved in the development and distribution of coronavirus vaccines and events that erode trust in American institutions. Trustworthiness varied between actors in government and health care institutions with differential associations with historical and contemporary atrocities among Black and Hispanic respondents. Respondents generally rated their doctors and health care teams, pharmacies and walk\\u2010in clinics, and the FDA as trustworthy. They rated elected officials and the Biden and Trump administrations as less trustworthy. Future research should assess whether similar contemporary experiences within and beyond health systems have an impact on trust in doctors and health care teams. Improving the trustworthiness of American institutions for Black and Hispanic populations in the U.S. is not only essential to an improved response to future pandemics but also to creating cultures of health that produce equitable outcomes for all populations.\"}]"
Metadata
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