title: Examining the complexity and variation of health care system distrust across neighborhoods: Implications for preventive health care.
abstract: OBJECTIVE
  Recently, the institutional performance model has been used to explain the increased distrust of health care system by arguing that distrust is a function of individuals' perceptions on the quality of life in neighborhood and social institutions. We examined (1) whether individuals assess two dimensions of distrust consistently, (2) if the multilevel institutional performance model explains the variation of distrust, and (3) how distrust patterns affect preventive health care behaviors.
  
  
  METHODS
  Using data from 9,497 respondents in 914 census tracts (neighborhoods) in Philadelphia, we examined the patterns of how individuals evaluate the competence and values distrust using the Multilevel Latent Class Analysis (MLCA), and then investigated how neighborhood environment factors are associated with distrust patterns. Finally, we used regression to examine the relationships between distrust patterns and preventive health care.
  
  
  RESULTS
  The MLCA identified four distrust patterns: Believers, Doubters, Competence Skeptics, and Values Skeptics. We found that 55 % of the individuals evaluated competence and values distrust coherently, with Believers reporting low levels and Doubters having high levels of distrust. Competence and Values Skeptics assessed distrust inconsistently. Believers were the least likely to reside in socioeconomically disadvantaged and racially segregated neighborhoods than other patterns. In contrast to Doubters, Believers were more likely to use preventive health care, even after controlling for other socioeconomic factors including insurance coverage.
  
  
  CONCLUSIONS
  Our findings suggest that distrust patterns are function of neighborhood conditions and distrust patterns are associated with preventive health care. This study provides important policy implications for health care and future interventions.
authors.affiliation: Department of Sociology, Center for Social and Demographic Analysis, University at Albany, State University of New York, 315 Arts and Sciences Building, 1400 Washington Avenue, Albany, NY 12222, tyang3@albany.edu.
authors.forename: Tse-Chuan
authors.initials: TC
authors.lastname: Yang
authors.affiliation: Department of Sociology, Michigan State University, 316 Berkey Hall, East Lansing, MI 48824, USA, ichiench@msu.edu.
authors.forename: I-Chien
authors.initials: IC
authors.lastname: Chen
authors.affiliation: Department of Sociology, Population Research Institute, Penn State University, 612 Oswald Tower, University Park, PA 16802, USA, ajn164@psu.edu.
authors.forename: Aggie J
authors.initials: AJ
authors.lastname: Noah