Mistrust in physicians kept some Black patients with diabetes from using these services during the pandemic.
The COVID pandemic has revealed racial disparities, including differences in who uses telehealth services. Before the pandemic, Black patients used telehealth services less often than white patients, but that gap widened substantially as telehealth became the primary way to see a doctor or medical professional. The disparity resulted in worse health outcomes for African Americans with diabetes.
Now Jefferson researchers find that a lack of trust in physicians’ abilities to diagnose and treat COVID-19 via telehealth is a significant factor for why African Americans with diabetes did not use telehealth services during the pandemic. The findings show that mistrust in physicians influences whether African Americans use healthcare services.
The new research further indicates that telehealth has the potential to reduce or enlarge healthcare inequities depending on whether issues like trust between physicians and patients are addressed.
Jefferson’s Health Nexus talked with lead researchers and geriatric psychiatrist, Dr. Barry Rovner, and emergency medicine physician Dr. Kristin Rising, about research they published in Population Health Management. They discuss what it will take to begin to close the gap and provide equitable health services for African Americans.
This interview has been edited for length and clarity.
Q: What were you hoping to find out through this research?
A: [Barry Rovner] We wanted to know how frequently Black patients were accessing telehealth and also what factors explained or contributed to the use of telehealth or not. We’re very conscious that Black patients have higher levels of distrust of doctors than whites, and we thought that might play a role in telehealth use.
The follow-up question was, when you compare people who do and do not use telehealth, what factors contribute to, in this case, not using it. Was it age? Education? Health beliefs?
Q: How did you go about finding an answer?
A: [BR] We accessed data and used surveys to ask about factors that could impact telehealth use. We looked at age, education, and health beliefs, but also literacy, depression, cognition, knowledge of COVID prevention and symptoms, and trust in physicians’ ability to diagnose COVID and treat via video visits.
Q: What did you find?
A: [BR] Notably, access to telehealth was not an issue. Over 90 percent of participants had the technology to use or access telehealth services. So that wasn’t it. That’s really important, because it’d be easy to say that lack of technology or internet access is the problem. But we found that wasn’t it. That’s not the issue.
It had nothing to do with age. It wasn’t related to gender, years of education or literacy. It had nothing to do with depression nor cognitive function.
The only things it had to do with were mistrust and living in a poor neighborhood … and living in a poor neighborhood, that’s a proxy for something else.
Q: Such as?
A: [Kristin Rising] If you live in a poor neighborhood, you may face near-constant struggle and distress, and perhaps experience discrimination and overall deprivation in your day-to-day world. If you’re living in that kind of situation, trying new things such as telehealth can feel overwhelming and unnecessary.
Q: What did patients not trust and why?
A: [BR] Participants had less trust in doctors’ ability to diagnose COVID and less trust in doctor’s ability to treat them using telehealth.
Research has shown that white doctors spend less time and are more likely to interrupt Black patients compared with white patients. They are less likely to even talk about telehealth with Black patients. So, there is a mistrust in doctors and the health system that they’re going to be discriminated against, that they’re not going to get the best care or the best treatment, and that doctors and health system don’t have their best interests at heart.
Q: What will it take to build that trust?
A: [BR] Having more Black doctors, or at least more Black people working on the frontlines and guiding patients would help open the doors to people accepting medical care. If you have a Black primary care doctor in whom you trust, then that doctor will facilitate the receiving of care from other aspects of the health system. But Black peers and community health workers can also facilitate access and use of health care.
[KR]: It will take developing the means for the healthcare system to deliver care where, when and how people need it, and having the flexibility to get care to them.
It will take acknowledging that social determinants of health really do determine health. When I talk with people in the emergency department about the barriers to managing their diabetes, I hear the fact that they can’t afford the medicine, that a husband and wife trade off who uses the insulin every day, or that they’re not going to be able to fill their medicine because they don’t have money for the co-pay, and their heat’s been turned off. It just goes on and on.
When patients reveal these immense and ongoing challenges, and we have no tools within the healthcare system to address them, it certainly doesn’t build patients’ trust that we are able and committed to helping them.
Addressing low trust will take time – we must truly listen to what patients need and be committed as a system and a society to developing solutions to address those needs. For telehealth specifically, it is important for us to recognize that there are a range of barriers to patients’ uptake of telehealth, and that patients need much more than just access to a telehealth-ready device.
Q: What else could help expand telehealth use for this population?
A: [KR] As part of the CARES Act, the Federal Communications Commission has poured millions of dollars to get devices in patients’ hands to address the access barrier to telehealth. Yet none of that money supports provision of assistance to patients to help them learn how to use these devices to engage in telehealth.
We need funders, policymakers, everyone to acknowledge and understand that there are more barriers to telehealth equity than just access. Our team refers to these barriers, which include things such as trust of and acceptability in telehealth, in aggregate as digital readiness.
If we really want to get people to a point of digital health equity, as health systems and as a greater society, we need to acknowledge people’s digital readiness needs and develop some creative approaches to addressing these needs.
We think we can get there, but we need to show that we’re invested in helping people feel safe and comfortable engaging in this new means of health care.
Article Reference: Barry W. Rovner, MD, Robin J. Casten, PhD, Anna Marie Chang, MD, MSCE, Judd E. Hollander, MD, and Kristin Rising, MD, MSHP. (2021) “Mistrust, Neighborhood Deprivation, and Telehealth Use in African Americans with Diabetes.” Population Health Management. DOI: 10.1089/pop.2021.0094