Medical Mistrust and Less Satisfaction With Health Care Among Native Americans Presenting for Cancer Treatment

Cancer mortality rates for Native Americans are among the highest of all racial and ethnic groups in the United States.1–3 Investigators have also reported other cancer-related disparities among Native Americans, such as lower rates of screening utilization1 and higher rates of advanced-stage disease at presentation.1,2,4–6 Furthermore, Native Americans in the Northern Plains region of the U. S. have age-adjusted mortality rates that are significantly higher than rates for Whites for certain cancers for which effective screening tests exist, such as cervical cancer (79% higher), colorectal cancer (58% higher), and prostate cancer (49% higher).7 A growing literature regarding health disparities has begun to illuminate causes for differences in health outcomes for various racial and ethnic groups.8,9 Root causes of such disparities are multiple. They arise from patient-, physician-, and health care system related factors. For Native Americans, patient-related factors may include mistrust of physicians or hospitals or lack of knowledge/health literacy concerning preventable diseases;10–12 physician-related factors may include lack of cultural competency in caring for this racial/ethnic group; and health-system-related factors may include issues related to the unique health care system (and its funding status) under which many Native Americans receive health care.13–15 However, scant literature focuses specifically on Native American health disparities and few studies have specifically sought to study causes of disparities disfavoring Native American cancer patients. Patient-related factors contributing to disparities include socioeconomic status, cultural differences, and limited health care literacy. Many interventions aimed at overcoming these impediments require trust between health care providers and vulnerable populations. Mistrust of and dissatisfaction with the health care system have been most thoroughly investigated as barriers for African American patient populations.16–19 Evidence exists that Native Americans also feel mistrust of health care providers and dissatisfaction with their health care experiences.20,21 However, no studies have been conducted that examine these attitudes among Native American cancer patients. Data exploring trust and perceptions of health care are critical in helping to formulate interventions in this vulnerable population. Effective clinical care for Native Americans requires understanding and sensitivity regarding attitudes and beliefs about health care. In 2003, a review of the Rapid City Regional Hospital (RCRH) (Rapid City, South Dakota) tumor registry (1990–2000) revealed that 50% of Native Americans presenting with breast, colorectal, prostate, cervical, or lung cancer presented with stage III–IV disease, compared with only 36% of non–Native Americans presenting with those cancers having the disease at an advanced stage.4,5 The RCRH is a regional facility that provides secondary and tertiary cancer care for approximately 60,000 adult Native Americans living on nearby reservations, in surrounding rural communities, and in Rapid City itself. In 2003, RCRH was awarded a Cancer Disparities Research Partnership (CDRP) grant to study the causes of cancer-related racial and ethnic disparities and to develop effective interventions to eliminate these disparities. Since that time, a multi-faceted, community-based participatory research and intervention effort has been forged to explore root causes of racial and ethnic disparities in Rapid City and surrounding areas, promote screening and prevention, enroll Native Americans in clinical trials, and provide patient navigation through cancer treatment.4,5,22 As part of this effort, we undertook a comparative study to examine mistrust and satisfaction with the health care system and to determine whether there are differences in these attitudes by race. We hypothesized that Native American cancer patients mistrust the health care system more and perceive the health care system more negatively than White patients.