Pilot evaluation of the Health Organization and System Trustworthiness scale: reliability and validity testing

This study evaluated the reliability, validity, and measurement invariance of the Healthcare Organization and System Trustworthiness (HOST) scale, a tool designed to assess perceived trustworthiness in healthcare systems.

Exploratory and confirmatory factor analyses (EFA/CFA) were conducted to examine the scale's structure, while measurement testing assessed its consistency across demographic groups. Agreement with the Medical Mistrust Index (MMI) was evaluated using a Bland-Altman plot, and concurrent validity was explored through associations with seven outcomes, including vaccine hesitancy, uptake, and trust in government.

Data were collected from a national sample of 4,100 U.S. residents aged 18 years and older, with a diverse representation of race/ethnicity (25% Black, 24% Hispanic, 32% White) and LGBTQ identity (13% as cisgendered bisexual, 5% as cisgendered gay/lesbian, and 82% cisgendered straight).

The HOST scale demonstrated a unidimensional structure, high internal consistency (α = 0.80), and strong concurrent validity with the MMI (r = 0.52). Scalar invariance was established across gender, LGBTQ status and regular health care access. Weak invariance was observed across racial groups. Compared to the MMI, the HOST scale had stronger correlations with trust in vaccine-related actors (r = 0.71 vs. 0.14) and perceptions of government trustworthiness at the federal (r = -0.38 vs. -0.15), state (r = -0.40 vs. -0.09), and local levels (r = -0.42 vs. -0.11).

The HOST scale shows promise as a tool for assessing trustworthiness in healthcare systems, particularly in capturing perceptions of fairness, competence, and future expectations. While its strong predictive validity across diverse outcomes underscores its potential utility, further refinement and validation are necessary before broader application. Additional testing is recommended to explore its use in addressing health disparities and informing public health strategies.