<%BANNER%>

Procedural and Distributive Justice in the Healthcare System

Permanent Link: http://ufdc.ufl.edu/UFE0010504/00001

Material Information

Title: Procedural and Distributive Justice in the Healthcare System
Physical Description: Mixed Material
Copyright Date: 2008

Record Information

Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
System ID: UFE0010504:00001

Permanent Link: http://ufdc.ufl.edu/UFE0010504/00001

Material Information

Title: Procedural and Distributive Justice in the Healthcare System
Physical Description: Mixed Material
Copyright Date: 2008

Record Information

Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
System ID: UFE0010504:00001


This item has the following downloads:


Full Text

PAGE 1

PROCEDURAL AND DISTRIBUTIVE JUST ICE IN THE HEALTHCARE SYSTEM By CHARISSE P. WILLIAMS A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2005

PAGE 2

Copyright 2005 by Charisse P. Williams

PAGE 3

ACKNOWLEDGMENTS I would like to extend special thanks to one of my dearest and closest friends, Jocelyn Saferstein. She has been a friend, a mentor, and a constant supportI would not have been able to complete this project without her assistance. I would also like to extend a warm thanks to my inspiration, Dr. Beth-Anne Blue. I would also like to thank my committee, especially Dr. Mark Fondacaro, who spent endless hours guiding me through this process. Finally, I would like to thank my friends, especially my best friends, Davina, Adrienne, and Alicia. iii

PAGE 4

TABLE OF CONTENTS page ACKNOWLEDGMENTS .................................................................................................iii LIST OF TABLES .............................................................................................................vi ABSTRACT ......................................................................................................................vii CHAPTER 1 INTRODUCTION........................................................................................................1 2 LITRATURE REVIEW................................................................................................9 3 METHODS.................................................................................................................21 Participants.................................................................................................................21 Demographics.............................................................................................................21 HIPPA Training..........................................................................................................22 Materials.....................................................................................................................23 Healthcare Justice Inventory (Health Plan and Provider)...........................................23 Adherence to Treatment Measure...............................................................................25 4 RESULTS...................................................................................................................27 Factor AnalysisHCJI-Provider................................................................................27 Provider Subscales and Subjects Satisfaction with Provider....................................28 Treatment Adherence to Provider Recommendations................................................29 Factor AnalysisHCJI-Health Plan...........................................................................30 Health Plan Subscale and Subjects Satisfaction with Health Plan............................31 5 DISCUSSION.............................................................................................................35 APPENDIX A JUSTICE DIMENSIONS FOR THE HCJI-PROVIDER...........................................42 B DEFINTIONS OF PROCEDURAL AND DISTRIBUTIVE JUSTICE DIMENSIONS FOR THE HCJI-HEALTH PLAN....................................................45 C HEALTHCARE JUSTICE INVENTORY/ADHERENCE MEASURE...................48 iv

PAGE 5

LIST OF REFERENCES...................................................................................................62 BIOGRAPHICAL SKETCH.............................................................................................65 v

PAGE 6

LIST OF TABLES Table page 1 Items and Component Loadings for the Three HCJI-Provider Subscales................33 2 Multiple Regression Analysis Using the Three HCJI-Provider Procedural Justice Subscales to Predict Subjects Satisfaction with Provider.......................................33 3 Multiple Regression Analysis of the Three HCJI-Provider Procedural Justice Subscales to Predict Subjects Treatment Adherence to Providers Treatment Recommendations....................................................................................................34 4 Items and Component Loadings for the HCJI-Health Plan Subscale......................34 5 Multiple Regression Analysis Using the HCJI-Health Plan Procedural Justice Subscale to Predict Subjects Satisfaction with Health Plan....................................34 vi

PAGE 7

Abstract of Thesis Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science PROCEDURAL AND DISTRIBUTIVE JUSTICE IN THE HEALTHCARE SYSTEM By Charisse P. Williams May, 2005 Chair: Mark R. Fondacaro Department: Psychology This study presents the development of the Healthcare Justice Inventory (HCJI). One section focuses on the interactions between subjects and their providers (HCJI-Provider) while the other section focuses on the interactions between subjects and their health plan representatives (HCJI-Health Plan). The HCJI-Provider assesses subjects appraisals of their interactions with their providers along three procedural justice dimensions: Trust, Impartiality, and Participation. The HCJI-Health Plan assesses subjects appraisals along one main dimension: Impartiality. Overall, procedural justice dimensions were significantly related to subjects satisfaction with their provider, but not with their health plan representative. As predicted, procedural justice dimensions were significantly related to subjects adherence to providers treatment recommendations. vii

PAGE 8

CHAPTER 1 INTRODUCTION The influx of managed care organizations and modifications in health plan policies has caused significant changes in the healthcare system. Over the past few years, there has been increasing integration of providers, hospitals, and health plan organizations. In turn, increased integration has led to increased competition for consumers and the desire to learn more about their needs. These transformations have fueled concerns about potential constrictions being placed on healthcare decisions made by health plan companies and physicians (Families USA, 1997). Health plan companies must now understand how changes have affected the relationship between service providers and consumers. Health plan members face obstacles in communicating their needs, appraisals, and grievances; barriers can be exacerbated for those who are socially disadvantaged (Schlesinger, Mitchell, & Elbel, 2002). Health plan members have two options when dealing with inadequate treatment or service: exiting or switching health plans, or expressing their dissatisfaction (Schlesinger, Mitchell, & Elbel, 2002). However, these options may not be viable for individuals who receive health plan coverage through an employer or for those who utilize Medicare or Medicaid (Schlesinger, Mitchell, & Elbel, 2002). Additionally, cost considerations and limited options may prevent those who can switch from doing so (Schlesinger, Mitchell, & Elbel, 2002). Switching or leaving plans may potentially cause an interruption in healthcare that those with chronic or incapacitating illnesses can not endure. Finally, protocols for exiting or switching plans 1

PAGE 9

2 may be too complicated or confusing, prompting individuals to suffer silently (Schlesinger, Mitchell, & Elbel, 2002). Advances in medical technology have increased the complexity of healthcare decisions, which in turn has led to greater costs to the patient (Hughes & Larson, 1991). These actions create an environment where patient involvement has become increasingly more important; individuals are not just patients, but consumers in a complex and growing market. Empowering patients to have more involvement in healthcare decision-making affords the opportunity to be a more informed consumer. Knowledgeable consumers are better able to protect themselves from substandard care (Schlesinger, Mitchell, & Elbel, 2002). This prospect prompts health plan and managed care organizations to improve service and communication between themselves and members (Schlesinger, Mitchell, & Elbel, 2002). These issues amplify the importance of research regarding interactions between consumers and the healthcare system. During the past decade, there has been growth in research regarding patients interactions with healthcare providers and patients satisfaction with their healthcare (Fondacaro, Frogner, & Moos, 2005). Research has focused on how relationships with the healthcare system affect patient satisfaction and well-being (Fondacaro, Frogner, & Moos, 2005). For example, research completed on provider/patient relationships supports factors such as trust, personal respect, open communication regarding health status and treatment, and opportunities for voice in treatment decisions as being related to patient satisfaction (Fondacaro, Frogner, & Moos, 2005). Another part of the empirical research has focused on objective measures of

PAGE 10

3 quality of care and subjective measures regarding patient satisfaction (Fondacaro, Frogner, & Moos, 2005). Despite the important implications, theoretical approaches for conceptualizing healthcare research are still being formulated and there still remains a lack of empirical research in this area (Hughes & Larson, 1991; Schlesinger, Mitchell, & Elbel, 2002). Existing research is limited almost exclusively to provider/patient interactions, neglecting the relationship between health plan company and patient (Zheng, Hall, Dugan, Kidd, & Levine, 2002). Future research needs to expand to include interactions between patients and their health plans. Additionally, it is important to more fully examine wider dimensions of provider/patient and health plan company/patient relationships (Zheng et al. 2002). This study will also address a usually ignored area in the patient satisfaction literature: procedural and distributive justice (Fondacaro, Frogner, & Moos, 2005; Fondacaro, 1995; Murphy-Berman, Cross, & Fondacaro, 1999). Procedural justice is process-oriented and refers to the extent to which those involved in a decision-making process perceive it to be fair (Lind & Tyler, 1988; Thibaut & Walker, 1975). Distributive justice is outcome-oriented and refers to whether the outcome of a decision-making process was perceived to be fair (Deutsch, 1975; Lind & Tyler, 1988). Preliminary procedural justice research focused on voice within the context of the law (Thibaut & Walker, 1975) whereas distributive justice research focused on the employment context (Adams, 1963). However, procedural and distributive justice research has expanded to study consumers interactions in organizational, agency, political, and social settings (Tyler, 1989), including the healthcare system (Fondacaro,

PAGE 11

4 Frogner, & Moos, 2005; Hughes & Larson, 1991) and families (Fondacaro, Jackson, & Luescher, 2002). Procedural (and distributive) justice are multidimensional constructs (Fondacaro, Frogner, & Moos, 2005; Levanthal, 1980). Initial research by Thibaut and Walker (1975) empirically studied two facets of procedural justice: process and decision control. Process control refers to the guidelines and procedures utilized to reach a decision; it also encompasses how much voice individuals will have, including the opportunity to share their perspective (Thibault & Walker, 1975). Decision control refers to opportunities to directly control the factors influencing the outcome (Thibaut & Walker, 1975). Thibaut and Walker (1975) used an instrumental model to explain why individuals value voice and process control in a decision-making process (Thibaut & Walker, 1975). They posited it is valued because it provides an instrumental benefit through direct (decision control) and indirect (process control) influence over the outcome of the decision (Thibaut & Walker, 1975). However, recent findings suggest the instrumental approach may be incomplete, not fully capturing procedural justice in its entirety (Fondacaro, Frogner, & Moos, 2005; Tyler, Degoey, & Smith, 1996). Individuals also seem to be concerned with aspects of the decision-making process that are not instrumentally related to outcome (Fondacaro, Frogner, & Moos, 2005; Tyler, Degoey, & Smith, 1996). Additionally, procedural justice research has suggested individuals wish to be treated in a manner that reflects neutrality, lack of bias, accuracy, trustworthiness, consistency (across persons and time), personal dignity, respect, status recognition, and the opportunity to have decisions reconsidered or appealed to a higher authority

PAGE 12

5 (Levanthal, 1980; Tyler, 1989). Fondacaro, Jackson, and Luescher (2002) propose this may be based on the socio-ecological perspective that is rooted in the legal system and makes certain values important in society (equal treatment, opportunities to have voice, and to be treated with respect). Furthermore, legal scholars suggest consent, presumed to affirm human dignitary interests, is at the heart of traditional theories of procedural justice and due process (Fondacaro, Frogner, & Moos, 2005). One of the most interesting findings in the social justice literature is that individuals evaluate the treatment they received during a decision-making process (procedural justice) to be at least as important as the outcome (distributive justice); fair treatment has value in and of itself (Fondacaro, Frogner, & Moos, 2005; Fondacaro, 1995; Lind & Tyler, 1988). This finding is particularly robust in decision-making situations where there are limited resources and uncertain outcomes, which are two prevalent problems in the healthcare system (Fondacaro, Frogner, & Moos, 2005; Fondacaro, 1995; Lind & Tyler, 1988). Furthermore, procedural justice is especially salient in the context of the provider/patient relationship where patients foster an emotional connection with those who have decision-making authority (Fondacaro, Frogner, & Moos, 2005). This suggests that patient satisfaction and treatment adherence should be more strongly related to provider/patient interactions than to patient interactions with their health plan representatives (Fondacaro, Frogner, & Moos, 2005). Social justice theorists have consistently emphasized the importance of three distributive justice concepts: equity, equality, and need (Deutsch, 1975). Research supports that these three concepts are the primary principles utilized to evaluate the

PAGE 13

6 fairness of a decision-making outcome (Schwinger, 1990; Steil & Makowski, 1989). Equity refers to whether a decision-making outcome was deserved based upon past contributions (Deutsch, 1975, 1985; Schwinger, 1990; Steil & Makowski, 1989). This is based on the concept of proportionality (Deutsch, 1975, 1985; Schwinger, 1990; Steil & Makowski, 1989). Equality is based on dividing resources equally, without regard to prior contributions (Deutsch, 1975, 1985; Schwinger, 1990; Steil & Makowski, 1989). Need reflects the desire to base a decision-making outcome on meeting the needs of individuals (Deutsch, 1975, 1985; Schwinger, 1990; Steil & Makowski, 1989). Deutsch (1975) suggests that not only are these concepts (equity, equality, and need) distinctive, but they also have distinct implications for consequences on interpersonal relationship dynamics. Equity promotes competition whereas equality does not; equality is believed to promote cooperation and group harmony instead of competition (Deutsch, 1975). Need promotes well-being and personal development (Deutsch, 1975). Based upon these distributive justice concepts, it appears that healthcare decisions based upon need could increase patient well-being and satisfaction with the delivery of healthcare services (Fondacaro, Frogner, & Moos, 2005). Adherence to treatment is a part of the therapeutic process (Fondacaro, Frogner, & Moos, 2005). Given the greater depth and salience of the provider/patient relationship over the relationship between health plan companies and patients, it is expected that procedural justice factors like participation and voice would be more strongly related to patient adherence in the context of provider/patient relations and interactions than in the context of health plan representative/patient relations and interactions.

PAGE 14

7 This study will extend previous measures used to explore procedural and distributive justice in familial settings (Fondacaro, Jackson, & Luescher, 2002; Jackson & Fondacaro, 1999). This work will also expand earlier efforts to develop healthcare justice measures aimed at the improvement of the healthcare system and the delivery of services (Fondacaro, Frogner, & Moos, 2005; Murphy-Berman, Cross, & Fondacaro, 1999). Another purpose of this research is to contribute to the development of the Health Care Justice Inventory (HCJI-Health Plan and HCJI-Provider), a measure that can be used to describe how individuals feel about the fairness of the procedures applied in making healthcare decisions, both on the level of provider/patient and health plan representative/patient relations (Fondacaro, Frogner, & Moos, 2005). One of the objectives of this initial stage of research is to continue validation of the initial versions of the inventory. The first part of the HCJI-Health Plan asks individuals to describe an experience they had with their health plan representative in which a decision was made regarding their healthcare; they were then asked to rate the experience with respect to the decision-making process utilized to reach the outcome, and then the outcome itself. The HCJI-Health Plan concludes by asking individuals to rate their satisfaction with their health plan and their willingness to recommend the health pan to friends and family. The first part of the HCJI-Provider asked individuals to describe an experience they had with their healthcare provider and then rate the experience with respect to the decision-making process utilized to reach the outcome, and then the outcome itself. The HCJI-Provider concludes by asking individuals to rate their satisfaction with their

PAGE 15

8 healthcare provider and their willingness to recommend the provider to friends and family. Individuals also completed a treatment adherence measure. The Adherence measure asked individuals to describe their providers recommended treatment plan; afterwards they were asked to rate the frequency of treatment adherence and the level of difficulty in maintaining and establishing treatment adherence. This study will also expand on the work of Fondacaro, Frogner, and Moos (2005) in the following ways. First, as they recommend, additional items were added to both the HCJI-Health Plan and the HCJI-Provider sections to reliably assess the distributive justice dimension of need-based decision-making. Second, both sections of the HCJI will be administered to a new sample that is comprised of a different population of patients in an effort to evaluate whether the factors identified in the previous study (trust, impartiality, participation) can be replicated. Finally, additional measures to assess the extent to which procedural justice factors are related to adherence to treatment recommendations as well as patient satisfaction were added.

PAGE 16

CHAPTER 2 LITRATURE REVIEW A transformation in the healthcare system began approximately 25 years agomedical decision-making power shifted from healthcare providers to consumers (Rosenthal & Schlesinger, 2002). Medical consumerism was part of a social movement in the 1970s that gave control to patients in making their own decisions regarding their treatment and provider (Rosenthal & Schlesinger, 2002). This was reinforced by public and private policies and practices the healthcare system adopted (Rosenthal & Schlesinger, 2002). Because this created a competitive environment, more managed care organizations emerged and health plan policies began to cause significant changes in the healthcare system (Rosenthal & Schlesinger, 2002). Concerns over how modifications and changes affected the patients ability to make medical decisions started to arise (Rosenthal & Schlesinger, 2002). Invariably, questions emerged as to how the relationship between healthcare service providers and patients were evolving (Rosenthal & Schlesinger, 2002). Consumer empowerment encourages patients to express their dissatisfaction with healthcare services; however, barriers to empowerment still remain, especially for those who are underprivileged or otherwise disadvantaged (Schlesinger, Mitchell, & Elbel, 2002). For example, those who are recipients of public medical assistance may not be able to switch or exit their health plans (Schlesinger, Mitchell, & Elbel, 2002). Additionally, employers may only contract with one health plan company, making options to switch to a different plan impracticable or too costly for some patients 9

PAGE 17

10 (Schlesinger, Mitchell, & Elbel, 2002). Furthermore, patients may not want to terminate relationships with current providers or deal with potential lapses in treatment a health plan switch or exit could cause (Schlesinger, Mitchell, & Elbel, 2002). Therefore, a more feasible option is to express dissatisfaction with healthcare service providers (Schlesinger, Mitchell, & Elbel, 2002). In the era of managed care, many areas of the healthcare system, including how patients express or attempt to address their grievances, have been affected (Schlesinger, Mitchell, & Elbel, 2002). However, despite the complications shared healthcare decision-making may cause, it provides patients the opportunity to be more informed consumers in an expanding, competitive market (Schlesinger, Mitchell, & Elbel, 2002). Informed consumers can improve the delivery of services and the performance of the healthcare system (Rosenthal & Schlesinger, 2002). This motivates healthcare service providers to learn more about the patient in order to improve communication and service (Schlesinger, Mitchell, & Elbel, 2002). In order to discover more information about the patient and the patients involvement in the healthcare system, healthcare research has experienced rapid growth over the last few years (Fondacaro, Frogner, & Moos, 2005). The growth has been most evident in the areas of patient satisfaction with the delivery of healthcare services, the interactions between physician and patient, and the effect of the physician/patient relationship on health outcomes, well-being, and patient satisfaction with services (Fondacaro, Frogner, & Moos, 2005). Research has shown patient satisfaction to be related to various aspects of the provider/patient relationship (Pascoe, 1983). Additionally, patient satisfaction also serves as a predictor of health outcomes, healthcare

PAGE 18

11 utilization, and effectiveness of communication between provider and patient (Pascoe, 1983). While the previous research has been extremely important, gaps still need to be filled in order to continuously and more fully understand the patient as a decision-making consumer. As it stands, there has been no comprehensive theoretical framework utilized to research the healthcare system. Additionally, the majority of the research that has been completed has focused on limited aspects of healthcare services and the physician/patient relationship (Fondacaro, Frogner, & Moos, 2005). To address these concerns, researchers are beginning to utilize procedural and distributive justice as a framework for investigating and evaluating the physician/patient relationship more thoroughly (Fondacaro, 1995). Procedural and distributive justice are also being used to study the relationship between patients and their health plan companies (Fondacaro, 1995; Murphy-Berman, Cross, & Fondacaro, 1999). Procedural justice is process-oriented and refers to how individuals appraise fairness in a decision-making context and distributive justice is outcome-oriented and refers to how individuals appraise decision-making outcomes (Lind & Tyler, 1988; Tyler, Boeckmann, Smith, & Huo, 1997). Empirical research on procedural justice first focused on conflict resolution within the law (Thibaut & Walker, 1975). Initial procedural justice work provided a method to evaluate the processes and procedures used to resolve disputes in the relatively structured and formal context of the legal arena (Thibaut & Walker, 1975). This early research demonstrated that procedural justice was related to individuals fairness appraisals and willingness to accept decision outcomes (Lind & Tyler, 1988).

PAGE 19

12 Distributive justice has been primarily studied in the context of employment (Adams, 1963). Distributive justice is concerned with how anything of value (i.e., resources) can be fairly distributed (Thibaut & Walker, 1975). Research interest has been slow to develop despite the fact the concept can be traced to Aristotle (Thibaut & Walker, 1975). Distributive justice is based on two aspects of resource allocation. One aspect focuses on how to distribute the resources fairly while the other aspect is concerned with how the allocation of resources affects the relationship between resource provider and resource recipient (Thibaut & Walker, 1975). Since this early work, procedural and distributive justice constructs have been studied in formal and informal decision-making contexts outside the legal system and workplace (Lind & Tyler, 1988) For example, organizations have to make decisions on information-gathering procedures, how to use information, and how decisions will be executed (Lind & Tyler, 1988). In fact, both formal organizations, such as courts and political institutions, and informal systems, such as families, need to make decisions regarding the decision-making process and the allocation of resources (Lind & Tyler, 1988). Although initial theoretical and empirical work tended to treat procedural and distributive justice as unidimensional, subsequent research has demonstrated the multidimensional nature of both. Both procedural and distributive justices are multidimensional constructs (Fondacaro, Jackson, & Luescher, 2002; Leventhal, 1980; Tornblom, 1992). Thibaut and Walker (1975) were first to empirically study process and decision control. Process control refers to the guidelines and procedures utilized to reach a

PAGE 20

13 decision. It also encompasses how much voice individuals will have, including the opportunity to share their perspective (Thibault & Walker, 1975). Decision control refers to opportunities to directly control the factors influencing the outcome (Thibaut & Walker, 1975). One of Thibaut and Walkers (1975) central themes was that procedures providing process control enhances evaluations of fairness. Thibaut and Walker (1975) contend process control promotes procedural justice because it promotes distributive justiceprocess control effects would disappear if disputants were informed that process control did not lead to distributive justice or the desired outcome. Furthermore, if disputants were granted decision control, process control would not be needed (Lind & Tyler, 1988). Thibaut and Walker (1975) concluded perceptions of procedural justice are a means to an end; that is, procedural justice has an instrumental impact on decision-making outcomes. However, subsequent research did not provide strong support for a unidimensional, instrumental model of procedural justice. Recent findings suggest the instrumental approach may be incomplete, not capturing procedural justice in its entirety (Tyler, Degoey, & Smith, 1996). Individuals also seem to be concerned with aspects of the decision-making process that are not instrumentally related to outcome (Tyler, Degoey, & Smith, 1996). Perceptions of justice are based on the process and procedures used to reach the outcome, and not just the outcome itselfacceptance or rejection of either positive or negative outcomes are based, in part, on perceptions of procedural fairness (Thibaut & Walker, 1975). Procedural justice judgments are based not only on how decisions are made, but also on the treatment received during the decision-making process (Lind &

PAGE 21

14 Tyler, 1988). This aspect of procedural justice helps to explain why there are some situations in which individuals receive favorable outcomes but are still dissatisfied; they may feel that they were treated unfairly during the decision-making process even though they received a favorable outcome (Lind & Tyler, 1988). Thibaut and Walkers (1975) instrumental approach is more central in legal settings (i.e. dispute resolutions where favorable outcomes are the main focus), but may be less relevant in other settings where additional factors are also important (Tyler, 1989). For example, when resources are limited and outcomes are uncertain, as they often are in the healthcare system, other criteria such as impartiality and opportunity to participate in decision-making may be important as well (Fondacaro, Frogner, & Moos, 2005; Lind & Tyler, 1988; Van den Bos, Lind, & Wilke, 2001). Subsequent research on the family and healthcare systems has confirmed the multidimensionality of procedural justice (Fondacaro, Jackson, & Luescher, 2002). Using factor analysis, Fondacaro, Jackson, and Luescher (2002) found that older adolescents rate the fairness of their interactions with parents along five distinct dimensions of procedural justice: personal respect, status recognition, process control, correction, and trust. Fondacaro, Frogner, and Moos (2005) found that patients rate their interactions with their healthcare providers along three empirically distinct dimensions of procedural justice: trust, impartiality, and participation. Distributive justice researchers initially presumed evaluations of outcome fairness were based almost exclusively on considerations of equitythat is, just outcomes should be proportionate to contributions or inputs (Lind & Tyler, 1988). However, research has demonstrated equity deals with distribution fairness as a unidimensional construct as

PAGE 22

15 opposed to a multidimensional approach (Levanthal, 1980). There are two other empirically distinct distributive justice criteria besides equity: equality and need (Deutsch, 1975). Research supports equity, equality, and need are the primary principles utilized to evaluate the fairness of a decision-making outcome (Schwinger, 1990; Steil & Makowski, 1989). These three variables also affect interpersonal relations (Deutsch, 1975). Equity refers to whether a decision-making outcome was deserved based upon what has been contributed in the past (Deutsch, 1975, 1985; Schwinger, 1990; Steil & Makowski, 1989). This is based on the concept of proportionality, which refers to the belief that individuals outcomes should be based on prior contributions (Deutsch, 1975, 1985; Schwinger, 1990; Steil & Makowski, 1989). Equity also promotes competition (Deutsch, 1975). Equality is based on dividing resources equally, without regard to prior contributions (Deutsch, 1975, 1985; Schwinger, 1990; Steil & Makowski, 1989). Equality promotes social cooperation and group harmony (Deutsch, 1975). Need reflects the desire to base a decision-making outcome on meeting the needs of individuals (Deutsch, 1975, 1985; Schwinger, 1990; Steil & Makowski, 1989). Need promotes personal well-being and development (Deutsch, 1975). A social ecological perspective suggests that the multidimensionality of procedural and distributive justice may be rooted in core values and principles of the legal system (i.e. equal treatment, opportunities to have voice, and to be treated with respect) (Fondacaro, Jackson, & Luescher, 2002). A social ecological model of procedural justice goes beyond intrapersonal explanations and focuses more on the relationships between individuals and social environments (Bronfenbrenner, 1979). These process values, while

PAGE 23

16 rooted in the macro-social context of the legal system, are values also present in other micro-social contexts of a given culture (Fondacaro, Jackson, & Luescher, 2002). Process judgments made in the course of social interaction are important determinants of attitudes and behavior (Lind & Tyler, 1988). Lind and Tyler (1988) have suggested that people are as or more interested in process and procedural issues as they are in outcomes. In many cases, process fairness judgments appear to occur independently of outcome (Lind & Tyler, 1988). A growing body of empirical research has established the way in which individuals are treated in the course of a decision-making process is at least as important as the outcome (Fondacaro Dunkle, & Pathak, 1998; Fondacaro, 1995; Lind & Earley, 1992; Thibaut & Walker, 1975; Tyler, 1989). The healthcare system provides a good environment for studying procedures, outcomes, and interpersonal relationships. However, there are distinct differences in the types of relationships among the various participants in the healthcare system. For example, the relationship between patient and provider is closer and provides more opportunity to foster a deeper connection than the relationship between the patient and the health plan representative (Fondacaro, Frogner, & Moos, 2005). Patients often develop stronger ties with providers and other practitioners who make healthcare decisions because of the personal and intimate nature of the relationship (Mechanic, 1996). Mechanic (1997) states this is due to the necessity of a strong relationship between provider and patient for therapeutic reasons (i.e. developing trust, accepting outcomes, following treatment plans). Furthermore, in the context of interpersonal relations, the provider/patient relationship is more unique and complex than the relationship between patient and health

PAGE 24

17 plan representative (Ong, DeHaes, Hoos, & Lammes, 1995). For example, the patient and provider are in non-equal roles; contact may be involuntary; the relationship will concern issues of utter importance that creates an emotional environment; and the relationship needs to be cooperative (Ong, et al., 1995). Depending upon the individual medical needs of the patient, providers contact with their patients can be frequent and life-altering (Ong, et al., 1995). However, in the context of healthcare coverage, a patient may have limited or no contact with a health plan representative. Therefore, health plan companies may focus on developing general good relations with all patients served. Health plan companies may focus on overall customer service provided because it may be unlikely a patient will reach the same health plan representative for every contact. Limited contact affects the ability for health plan representatives to develop a relationship with one particular patient. Therefore, health plan companies may focus on general principles of quality service and on fulfilling the mission(s) of the organization, which serves patients in direct and indirect ways. Health plan companies often have a public face, so evaluation is based upon the various employees who represent them and not on one particular person (Mechanic, 1996, 1997). Patients satisfaction with their provider may have an important influence on their well-being and behavior (Ong, et al., 1995). Utilizing patient satisfaction as an outcome measure is a frequent and well-recognized approach for understanding the relationship between provider and patient (Ong, et al., 1995). Provider behavior, especially information-giving, time spent discussing preventive care, high levels of chart review, and greater interview length have all been shown to be factors affecting patient

PAGE 25

18 satisfaction (Ong et al., 1995). Patient satisfaction also serves as predictor of treatment adherence and health status (Safran, 2003). Treatment decision-making and treatment adherence are integral aspects of the relationship between provider and patient (Ong, et al., 1995). By studying the relationship between provider and patient, information on improving treatment adherence by patients can be gained (Brown, Stewart, & Ryan, 2003). The patient/provider relationship is important to treatment adherence because this relationship is the main vehicle used to communicate treatment relevant information (Ong, et al., 1995). Therefore, treatment adherence should be a more salient consequence of the provider/patient relationship than of the relationship between patient and health plan representative. Patient adherence to treatment recommendations has been shown to be a key indictor of the effectiveness of the communication between patient and provider (Ong, et al., 1995). This is important because provider and patient communication is usually focused on discussing treatment planning. One of the outcome measures for evaluating effective communication between provider and patient is assessing how much voice patients perceive themselves to have (Ong et al., 1995). Voice in treatment planning and decision-making is an example of shared decision-making between provider and patientboth provider and patient contribute to creating treatment recommendations (Ong et al., 1995). Treatment recommendations comprise a healthy share of the provider and patient interaction (Brown, Stewart, & Ryan, 2003). Providing a treatment recommendation can be divided into the following interrelated issues: (1) information exchange or patient education, (2) finding common expectations for adherence, and (3) the patient and the

PAGE 26

19 providers manner or disposition, which includes interpersonal factors such as empathy and encouragement (Brown, Stewart, & Ryan, 2003). These relationship issues, coupled with procedural and distributive justice factors, can impact a patients adherence to the treatment recommendation(s). For example, previous healthcare research demonstrated the relationship between procedural justice factors such as participation and voice and increased treatment adherence (Sanderson, 2004). Fondacaro, Frogner and Moos (2005) found the distributive justice factor of need, rather than equity, which promotes competition, or equality, which fosters group cohesion, is related to patient satisfaction in the provider context. Need-based decision-making is more likely to promote personal well-beingpatient satisfaction has been demonstrated to be one potential index of well-being (Deutsch, 1975; Fondacaro, Frogner, & Moos, 2005; Fondacaro, Jackson, & Luescher, 2002; Steil & Makowski, 1989). Overall, patients want to participate in the decision-making process or to help make treatment decisions and are most satisfied when they feel their personal needs are met (Fondacaro et al., 2005; Sanderson, 2004). Many patients fail to follow treatment recommendations, despite considerable investment by both the provider and patient in determining a proper diagnosis and prognosis (Sanderson, 2004). Non-adherence leads to poorer outcomes for patients and substantial costs to society (Sanderson, 2004). This makes identifying factors related to non-adherence crucial to healthcare research. In general, this research project will help define and refine procedural and distributive justice healthcare assessment measures by exploring the relationship between patients and the healthcare system. The research project also expands a recent research

PAGE 27

20 study that focused on patients appraisals of healthcare providers and health plan company representatives (Fondacaro, Frogner, & Moos, 2005). This study provides a format for addressing other issues in the healthcare system regarding the patients experience; it will also identify characteristics of healthcare decision-making that encourage perceptions of procedural and distributive justice and patient satisfaction. This is achieved by further testing the Healthcare Justice Inventory as a valid and efficient measure of procedural and distributive fairness in the healthcare system. Finally, it is also important to identify potential factors related to treatment adherence. Based upon literature reviews and previous research, the following hypotheses for this study have been formulated: 1. Factor analysis will further support procedural justice as a multidimensional construct in the healthcare decision-making context, showing that patients use multiple, empirically distinct criteria to evaluate overall procedural fairness (Fondacaro, Frogner, & Moos, 2005; Fondacaro, Jackson, & Luescher, 2002). 2. Consistent with the findings of Fondacaro, Frogner, and Moos (2005), the criteria patients use to evaluate procedural justice in the healthcare context (with both providers and health plan representatives) will be comparable to criteria people use to evaluate procedural justice in the legal context. That is, individuals will be concerned about whether they are treated in a trustworthy manner that respects their human dignity (trust); whether they are treated in an even-handed and unbiased manner (impartiality); and whether they have voice and an opportunity to be heard (participation). 3. The relationship and interpersonal interactions between patient and provider are more likely to foster a deeper connection than exists between patient and a health plan representative/company. Therefore, multiple regression analyses will reveal that patient satisfaction will be more strongly tied to procedural justice factors in the context of interactions with their providers than interactions with health plan representatives (Tyler & Degoey, 1995). 4. Based on the hypothesis that procedural justice can be an ingredient of the treatment process, it is predicted that indices of procedural justice, in the provider context, will be significantly tied to treatment adherence.

PAGE 28

CHAPTER 3 METHODS Participants Due to the exploratory nature of the study, it was decided to recruit subjects from the University of Florida. Undergraduate subjects were recruited from the University of Floridas psychology research pool and through psychology classes. The research pool is comprised of students who need to participant in research as a course requirement; students in psychology classes were offered the opportunity to earn extra credit. Therefore, in lieu of financial compensation, subjects received academic credit for participation. After students completed the study, credit was granted in one of two ways: students were granted credit electronically through the Psychology Research Pools computerized systemthis approach was used for those who needed to participate in research projects for a course requirement. The other process included students receiving extra credit through their course instructor. The extra credit awarded was then factored into the students grade. (In both situations, awarded academic credit were not primary determinants in assessing the students final grade.) All subjects were treated in accordance with the Ethical Principles of Psychologists and Code of Conduct (American Psychological Association, 2002). Demographics The demographic portion asked subjects questions regarding their gender, age, marital status, college standing, ethnic background, employment status, and annual 21

PAGE 29

22 income. There were additional questions regarding the subjects medical conditions, hospitalizations within the past year, annual check-ups, and overall health status. Data was collected from 221 participants. Males comprised 32% of the sample while females comprised 68%. In terms of age, 1% was 17 years old, 44% were 18, 34% were 19, 11% were 20, and the remainder reported being 21 years of age or older. An overwhelming majority (99%) reported never being married while 1% reported being separated. For college standing, 67.5% were freshmen, 17% were sophomores, 10% were juniors, 5% were seniors, and .5% were graduate school students. The majority (62%) of participants were Caucasian, 1% were American Indian, 8% were Asian, 12% were African-American, 15% were Hispanic, and 2% were members of other racial/ethnic minority groups. Overall, participants reported not working (72%), with 27% working part-time and 1% working partand full-time. The vast majority of participants (95%) earned less than $10,000 per year while 5% reported an income between $10.000-19,999. Participants were also asked to rate their health status. Overall, 33% reported being in excellent health, 46% in very good health, 19% in good health, 1.5% in fair health, and .5% in poor health. HIPPA Training Due to the fact participants revealed healthcare information, research investigators who needed access to subject data completed University of Floridas HIPPA 102 General Knowledge (or Annual Review) Test of Knowledge. The test is a requirement for all students, staff, and faculty persons that have access to healthcare data. The test includes information regarding regulations and penalties regarding obtaining, maintaining, protection, removal, and storage of all healthcare data.

PAGE 30

23 After the completion of the study, data was gathered in boxes and transported to the home of the primary investigator where it was then stored in locked storage boxes. After the data collection phase of the study passed, data was transported and permanently stored in the lab of the supervising advisor where it was filed and secured. Materials Subjects received demographic questions and two inventories: the Healthcare Justice InventoryHealth Plan (HCJI-HP) and Provider (HCJI-P), and the Adherence to Treatment Inventory. Healthcare Justice Inventory (Health Plan and Provider) The first portion of the HCJI asked subjects to describe their health plan coverage. Subjects had the following options: Fee-for-Service, which means the subject pays out of pocket and then bills the insurance company; Health Maintenance Organization (HMO), which means the subject is required to choose a provider from a pre-arranged list created by the HMO; Preferred Provider Organization (PPO), which means the subject has a choice of providers but can use non-preferred services at a higher cost; being under their parents coverage; University of Floridas insurance carried through Scarborough Insurance, which offers three plans (A, B, and International Student); none and did not know. There were additional questions regarding length of time of the health plan membership and whether the insurance was provided through an employer or parents. Three sections followed that segment. In Section A, subjects were asked to describe an experience they had with their health plan representative within the last 12 months in which a decision was made regarding their healthcare. It was decided to have participants think about their own experience instead of reflecting on an imagined scenario in order to maximize the personal relevance of the subject. This decision was based on previous

PAGE 31

24 procedural justice research by Fondacaro, Jackson, and Luescher (2002) and Tyler and Degoey (1995). Section B asked subjects if the experience they described involved a routine healthcare visit or an emergency. In order to develop an integrated measure of both procedural and distributive justice to assess healthcare decision-making, many steps needed to be taken. All of the procedural and distributive justice items were based on prior empirical procedural and distributive justice research and a comprehensive literature review, drawing primarily from the research completed by Fondacaro, Frogner, and Moos (2005), Fondacaro, Jackson, and Luescher (2002), Murphy-Berman, Cross, and Fondacaro (1999), and Lind and Earley (1992). After the initial item development, the HCJI consisted of over 60 items. After pilot testing the preliminary drafts of these items, additional literature reviews, consulting, and further assessment and evaluation, the total number of items were reduced to 34. Professors and professionals proficient in research methodology then reviewed those items. After their review, the 34 items were revised and kept. Section C contains 28 procedural justice items. In Section C, subjects were asked to further reflect on the experience they described in Section B. Subjects rated the experience described on a 4-point scale ranging from 1 (strongly disagree) to 4 (strongly agree). Following the procedural justice items in Section C, subjects, still utilizing the same scale, were asked to rate eight distributive justice items by focusing on the outcome of the experience. A brief section in which subjects were presented with two items followed. The first item asked subjects to rate their satisfaction with their health plan from 1 (very dissatisfied) to 4 (very satisfied). The second item asked subjects if they would recommend their health plan to friends or family members on a scale ranging

PAGE 32

25 from 1 (definitely no) to 4 (definitely yes). This item concluded the HCJI-Health Plan. Subjects were then asked to repeat the measure, but instead of reflecting on an experience with their health plan representative, they were asked to reflect on an experience with their healthcare provider in which a decision had been made regarding their healthcare (HCJI-Provider). The HCJI-Health Plan and the HCJI-Provider are identical except for the appropriate wording differences. Adherence to Treatment Measure The Adherence Measure was a part of a Medical Outcome Study conducted by RAND. The Adherence Measure was created as a general measure of adherence by asking patients about their tendencies to adhere to treatment recommendations (DiMatteo, Hays, & Sherbourne, 1992). It was also created to facilitate better understanding as to why patients have difficulty adhering to treatment recommendations (DiMatteo, Hays, & Sherbourne, 1992). The Adherence Measure consists of three parts. In the first part, participants were provided a list of healthcare behaviors and were asked if their provider had recommended them as part of their treatment plan. The responses were either 1 (yes) or 2 (no). In the second section, subjects were asked how frequently they had completed recommended healthcare behaviors in the last 12 months. The range of responses ranged from 1 (none of the time) to 4 (all of the time). The last portion asked subjects how difficult it was to follow treatment recommendations on a scale ranging from 1 (difficult none of the time) to 4 (difficult all of the time). After participants completed the study, they were debriefed (either verbally or by a typed debriefing form) and asked if they had any questions regarding the study.

PAGE 33

26 Debriefing forms contained information on how to contact the primary investigator, the primary investigators supervisor, and the University of Floridas Institutional Review Board. Students were made aware they could contact the IRB, anonymously if they wished, if they felt their rights had been violated. Counseling and healthcare referral information was available for students if requested. Finally, subjects were thanked for their participation and subsequently awarded academic credit.

PAGE 34

CHAPTER 4 RESULTS Separate analyses were completed for the Provider and Health Plan sections of the Healthcare Justice Inventory (HCJI). Factor AnalysisHCJI-Provider Principal component analysis with varimax rotation was completed with the 26 procedural justice items from the HCJI-Provider. The number of factors sought was unconstrained. Based upon this analysis, the first four factors had eigenvalues greater than 1 (12.74, 2.29, 1.54, 1.07 respectively) and accounted for approximately 68% of the total variance. However, the fourth factor was unstable, with only one item loading at .4 or higher, so it was not included in subsequent analysis. Additionally, this decision was consistent with the scree plot, which suggested the retention of three rather than four factors. After the varimax rotation, the first factor accounted for approximately 28% of the variance, the second factor accounted for approximately 22% of the variance, and the third factor accounted for approximately 14% of the variance. Using .6 as the cut-off, 11 items loaded on the first factor, 8 on the second factor, and 5 on the third factor. Fondacaro, Frogner, and Moos (2005) reduced their initial item pool to construct shorter scales so each factor had an equal number of items. Based upon the third factor having 5 items load .6 or higher, it was decided the pool would be reduced to 15, with each factor containing 5 items. Due to the current analysis being conceptually compatible with the Fondacaro, Frogner, and Moos (2005) study, the 26 procedural justice items from the Provider 27

PAGE 35

28 section were also reduced to 15. The same items from the Fondacaro, Frogner, and Moos (2005) study were used to construct the shorter subscales. This was done because all of the items they used to construct their subscales also loaded at .6 or higher on the factors used for this project. The 15 items retained from the initial item pool were subjected to principal component analysis with varimax rotation. The number of factors used was unconstrained. As with the Fondacaro, Frogner, and Moos (2005) study, three factors with eigenvalues greater than 1 emerged. The first factor, labeled Trust, had five items load .6 or higher. The second factor, labeled Impartiality, also had five items with loadings .6 or higher; this was the same for the third factor, labeled Participation. The Trust subscale was comprised of five items which reflected the comfort subjects had with their provider handling their situation, the honesty of the provider, and the provider providing them with as much information as possible about their medical condition(s) and treatment alternatives. The Impartiality factor was comprised of five items reflecting the provider treating the subject in an unbiased and non-discriminatory manner. The Participation factor reflected the subjects ability to participate and have voice in the decision-making, including aspects of process and decision control. Provider Subscales and Subjects Satisfaction with Provider Subjects satisfaction with their provider was evaluated based on the mean ratings subjects provided for two questions regarding their satisfaction with their provider and their willingness to recommend their provider to friends and/or family members. All three of the Provider procedural justice scales (Trust-P, Impartiality-P, and Participation-P) were significantly related to the global index of subjects satisfaction with their provider (rs = .57, .72, .58, respectively, all ps < .01). Multiple regression analyses, with

PAGE 36

29 the three predictors being the three Provider procedural justice scales, were conducted. The criterion was subjects satisfaction with their provider. All three of the procedural justice predictors (Trust-P, Impartiality-P, and Participation-P) accounted for unique variance in subjects satisfaction with their provider (betas = .50, .17, .20, respectively, all ps <. .01). Thus, subjects who indicated their provider was trustworthy, impartial, and allowed them to participate in healthcare decisions reported higher levels of satisfaction with their provider. Overall, the three scales accounted 58% of the variance in subjects satisfaction with their provider. Treatment Adherence to Provider Recommendations Subjects treatment adherence was evaluated based on the mean ratings subjects provided for five questions regarding their ability to adhere to their providers treatment recommendations. All three of the Provider procedural justice scales (Trust-P, Impartiality-P, and Impartiality-P) were significantly related to the global index of subjects treatment adherence to provider recommendations (rs = .27, .30, .15, respectively, all ps < .01). Multiple regression analyses, with the three predictors being the three Provider procedural justice scales (Trust-P, Impartiality-P, and Participation-P) were conducted, with the criterion being subjects treatment adherence. Trust-P and Impartiality-P accounted for unique variance in subjects adherence to provider treatment recommendations (betas = .18 and .22 respectively, ps < .01). Thus, subjects who indicated their provider was trustworthy and impartial, reported higher levels of treatment adherence with their providers treatment recommendations. Overall, the two scales accounted for 11% of subjects treatment adherence to provider recommendations.

PAGE 37

30 Factor AnalysisHCJI-Health Plan The original plan was to follow the same procedures utilized for the HCJI-Provider for the HCJI-Health Plan. However, results from the factor analysis did not support using this approach. The 26 procedural justice items from the HCJI-Health Plan were subjected to principal component analysis with varimax rotation, with the number of factors sought not constrained. Based upon this analysis, the first five factors had eigenvalues greater than 1 (7.83, 5.17, 1.97, 1.32, 1.03 respectively) and accounted for approximately 67% of the total variance. However, the fourth and fifth factors were not stable, with only one item loading at .6 or higher for each, so they were not included in subsequent analyses. The third factor had three items load at .6 or higher, but the items were not congruent with each other. That is, the items were not cohesive thus making the items non-interpretable. Two items reflected subjects desire to participate in decision-making, while one item reflected subjects desire to be treated with dignity. The second factor also contained 3 items that were not cohesive. Two items reflected subjects desire to have participation in decision-making, while the other item reflected how much trust they had in their health plan representative. Therefore, the second and third factors were not included in subsequent analyses. The first factor was the only one to have congruent items that were interpretable. Additionally, there was no supporting evidence for more than one factor. Based on this, the only justice construct that could be used for the HCJI-Health Plan was Impartiality. Eleven items loaded at .6 or higher for the first factor. Of the 11, 8 items reflected subjects desire to have their health plan representative treat them in an impartial manner during decision-making. In order to remain consistent with the Fondacaro, Frogner, and Moos (2005) study, the same five items used to construct their Impartiality-HP scale was

PAGE 38

31 used to construct an Impartiality-HP scale for the current project. This could be done because the items they used previously also loaded .6 or higher in the current analysis. The Impartiality factor was comprised of five items reflecting the health plan representative treating the subject in an unbiased and non-discriminatory manner. Health Plan Subscale and Subjects Satisfaction with Health Plan Subjects satisfaction with their health plan was evaluated based on the mean ratings subjects provided for two questions regarding their satisfaction with their health plan and their willingness to recommend their health plan to friends and/or family members. The Impartiality-HP procedural justice scale was negatively related to the global index of subjects satisfaction with their health plan (rs = .-.223, ps < .01). Due to this inverse relationship being a unique finding, there is no literature to explain its occurrence. In effort to understand this finding, several procedures were completed. First, the data set was compared to the raw data to see if there had been a computing error or a problem with the transfer of the data; however, no errors were found. Second, the data set was checked for human errorthis consisted of ensuring certain items in the data set had been reverse coded. When no human error was found, statistical analyses were run again, several times. Once again, no errors were found. Finally, several correlations were completed to see if Impartiality-HP was correlated with treatment adherence, and the three Provider procedural justice scalesthe correlations were also run with Health Plan satisfaction. All of the correlations were shown to be positive except for the relationship between Impartiality-HP and Health Plan satisfaction. Therefore, it was concluded this was a true finding. Due to the absence of inverse relationships in the justice literature, only subjective opinion can be used in effort to explain this unique relationship. For one, it could be a

PAGE 39

32 sampling issue. The majority of the sample reported infrequent contact with their health plan representatives as well as limited involvement with health plan representatives when problems arise (the majority of the sample reported still being apart of their parents insurance). Additionally, the items used to assess both Health Plan satisfaction and Impartiality-HP may not fully capture the essence of satisfaction or impartiality in this context. Future efforts to re-examine this relationship need to be done, which may include revising the questions assessing satisfaction and impartiality or developing other measures to assess the relationship between subject and health plan. Future research should concentrate on collecting more data that would solely investigate the relationship between subject and health plan representatives.

PAGE 40

33 Table 1. Items and Component Loadings for the Three HCJI-Provider Subscales Subscales Component Loadings Trust-P You accepted your providers decision. .773 You felt comfortable with the way your provider handled the situation. .806 You fully agreed with the solutions that you and your provider arrived at .789 The decision was based on as much good information and informed opinion as possible. .817 Your provider was honest with you .742 Impartiality-P Your provider probably treated you worse than other patients because of your personal characteristics. .860 Your provider was biased against you .759 Your provider probably gave you less respect than other patients. 714 You were treated as if you didnt matter .763 Your provider showed little concern for you as an individual. .658 Participation-P You had a choice to reject your providers recommendation. .735 You felt you had personal control over the decision that was made .709 You could have had the decision reconsidered. .654 4. You felt you had personal control over how the situation was handled. .693 5. Your provider asked about your preferences for what should be done. .739 Table 2. Multiple Regression Analysis Using the Three HCJI-Provider Procedural Justice Subscales to Predict Subjects Satisfaction with Provider Satisfaction with Provider Trust-P .50** Impartiality-P .17** Participation-P .20** Adjusted R 2 .58** Note Entries are standardized beta weights; ** p < .01.

PAGE 41

34 Table 3. Multiple Regression Analysis of the Three HCJI-Provider Procedural Justice Subscales to Predict Subjects Treatment Adherence to Providers Treatment Recommendations Treatment Adherence Trust-P .18** Impartiality-P .22** Participation-P .06 Adjusted R 2 .11** Note Entries are standardized beta weights; ** p < .01. Table 4. Items and Component Loadings for the HCJI-Health Plan Subscale Subscale Component Loadings Impartiality-HP Your health plan representative probably treated you worse than other health plan members because of your personal characteristics. .780 Your health plan representative was biased against you. .831 Your health plan representative probably gave you less respect than other health plan members. .654 You were treated as if you didnt matter. .687 Your health plan representative showed little concern for you as an individual. .772 Table 5. Multiple Regression Analysis Using the HCJI-Health Plan Procedural Justice Subscale to Predict Subjects Satisfaction with Health Plan Satisfaction with Health Plan Impartiality-HP -.223 Adjusted R 2 .05** Note Entries are standardized beta weights; ** p < .01.

PAGE 42

CHAPTER 5 DISCUSSION One of the objectives in this research project was to continue to demonstrate the Healthcare Justice Inventory as a reliable and valid measure of procedural and distributive justice in the healthcare system. The first section of the HCJI focuses on the interactions between subjects and healthcare providers (HCJI-Provider). The other section focuses on interactions between subjects and health plan representatives (HCJI-Health Plan). Each section of the HCJI assesses subjects appraisals of their interactions with either their healthcare provider or health plan representative along dimensions of procedural and distributive justice. Generally, the four predictions were supported by the results of this study. The first prediction was factor analysis would reveal subjects evaluated procedural justice in the provider context as a multidimensional construct. Factor analysis produced three main interpretable procedural justice dimensions in the provider context: trust, impartiality, and participation. However, in the health plan context, only one interpretable dimension, impartiality, emerged. Future research needs to focus on developing other dimensions for the HCJI-Health Plan. For example, the HCJI-Health Plan section may not fully capture the procedural justice dimensions. That is, there may be other procedural justice items not used in this measure that more accurately describe procedural justice dimensions. Another possible avenue may be to re-evaluate the procedural justice items used in the HCJI-Health Plan for potential revision in order to create more distinct procedural justice dimensions. 35

PAGE 43

36 However, an advantage to developing parallel sections of the HCJI is that it provides a valuable tool for examining the extent to which changes in healthcare decision-making are tied to changes in subjects appraisals of their healthcare providersthis is achieved because at least one of the three main procedural justice dimensions are common in both the provider and the health plan context. This commonality makes it possible to compare subjects appraisals of procedural justice in both the provider and health plan contexts. However, in addition to assessing the common dimensions of trust, impartiality, and participation, future research should focus on developing additional, distinct dimensions for both the provider and health plan sections of the HCJI. For instance, in the provider and subject relationship, which is more personal and emotional than the relationship between subject and health plan representative, other procedural justice factors may be more significant. For example, being treated with personal respect and dignity may be more important in the provider decision-making context, while accuracy and correction may be more important in a health plan decision-making context. Furthermore, the Provider and Health Plan sections only shared one subscale, which was the Impartiality subscale. Therefore, it appears as if the dimensions of procedural justice for the Provider and Health Plan subscales tap different experiences for subjects in the healthcare system. That is, while subjects appraisals of their interactions with their provider and health plan representatives are related, subjects do make distinctionsthese distinctions potentially have direct influences on health-related outcomes. For example, interactions with health plan representatives and providers may be vastly differenta negative interaction with a health plan representative and positive

PAGE 44

37 appraisals of providers can co-exist. However, it is important to understand how appraisals of health plans (e.g. interactions with health plan representatives and with managed care organizations) link to appraisals of providers (Mechanic, 1996, 1997). Consistent with the second hypothesis, the results indicated subjects used criteria to evaluate procedural fairness in the provider context that was similar to criteria people use to evaluate procedural fairness in a legal context. The criteria used are trust (whether subjects are treated in a manner that affirms their personal dignity and trust), impartiality (whether subjects are treated in a neutral and non-discriminatory manner), and voice (whether subjects have an opportunity to be heard or participate in decision-making) (Fondacaro, Frogner, & Moos, 2005). This is consistent with Bronfenbrenners (1979) social ecological model which suggests microsocial behaviors are rooted in macrosocial institutions. Subject/provider and subject/health plan representative interactions are examples of microsocial behaviors being rooted in a macrosocial institution like the legal system. The legal system provides people the opportunity to judge procedural fairnessthis then causes people to implement similar procedural fairness evaluations in a microsocial context like the healthcare system. For the third hypothesis, the three procedural justice factors (Trust-P, Impartiality-P, and Participation-P) for the HCJI-Provider were strongly tied to patient satisfaction. This was true for both the overall amount of variance accounted for in patient satisfaction and in terms of the number of predictors accounting for unique variance in subjects satisfaction with their providers.

PAGE 45

38 However, for the Health Plan section, a unique result was found. The Impartiality-HP subscale was negatively related to subjects satisfaction with their health plan. Subsequent analyses were conducted to ensure no human or statistical error was made however, the unique finding stood. The inverse relationship can not be easily explained because there is no precedent for this relationship in the patient satisfaction or health plan literature. Future research should be conducted to see whether these unexpected findings can be replicated. For the last hypothesis, it was predicted that the procedural justice factors would be significantly tied to treatment adherence. Two of the three procedural justice scales (Trust-P and Impartiality-P) were found to be significantly tied to subjects treatment adherence to providers recommendations. Trust-P and Impartiality-P both accounted for unique variance in subjects treatment adherencethat is, subjects who considered their providers to be both trustworthy and impartial reported higher levels of adherence. This is not only an interesting finding, but carries many implications for future training of healthcare providers. Utilizing procedural justice factors as predictors of treatment adherence sets up a framework for future studies not only on treatment adherence, but other areas including health-related outcomes. This research project has complemented the Fondacaro, Frogner, and Moos (2005) study considerably, progressing the HCJI to advanced stages of development and refinement. While this project has continued to validate findings made in the previous study, there were limitations. First, the subjects used in the research project were drawn from the University of Floridas psychology research pool. While this provided a robust sample, an overwhelming majority of the sample was young and healthy. If subjects are

PAGE 46

39 in relatively healthy states, there will be less interaction not only with providers, but it would also limit subjects interactions with health plan representatives. Furthermore, the sample was not diverse% of the sample reported being between the ages of 17-20 years of age. Additionally, only .5% of the sample reported being in poor health. The study consisted of more females (68%) than males (32%) with the majority of the sample being Caucasian (62%)only 38% reported being an ethnic or racial minority. Obviously, this is not a fair representation of the population, so there are limits to generalizability. Future research efforts should focus on targeting a more diverse and representative sample of subjects. It would also prove beneficial to have a sample with a wider range of health issues and health statuses. For example, treatment adherence may be easier for subjects who do not have complicated treatment plans or serious or chronic health concerns. Also, additional efforts should focus on refining the procedural justice items for the HCJI-Health Plan section. Future research should also focus more extensively on patients appraisals of distributive justice in their interactions with providers and health plan representatives. While this research project focused primarily on procedural justice, both sections of the HCJI (Provider and Health Plan) included a limited number of distributive justice items. The inclusion of more distributive justice items to assess interactions between subjects and providers and subjects and health plan representatives could offer additional information for the unique findings presented in this project. Overall, this research project has extended the development and validation of measures to assess procedural and distributive justice in the healthcare system. This has

PAGE 47

40 been achieved by assessing interactions between subjects and their providers and subjects and their health plan representatives. The results of this project suggest the importance of conducting additional research to further the development and refinement of both the procedural and distributive justice dimensions in both the Provider and Health Plan sections of the HCJI. While Fondacaro, Frogner, and Moos (2005) focused more on the prediction of patient satisfaction, the current research project focused on predicting both patient satisfaction and treatment adherence. It is important to note there is considerable promise in investigating procedural justice as a predictor of treatment adherence. Whereas previous research has linked procedural justice to appraisals of distributive justice outcomes, this project has shown significant ties between procedural justice and treatment adherence. Subjects who stated they found their provider to be trustworthy and impartial reported higher levels of treatment adherence. This has noteworthy implications for the healthcare system in regards to increasing treatment adherence. Many individuals involve in the healthcare system fail to follow provider recommendations (Sanderson, 2004). In order to better understand the reasons why, it becomes critical to examine relational aspects between the provider and patient. Identifying factors related to adherence can increase the likelihood of better health outcomes for patients. Longitudinal research also needs to be done to more fully investigate and capture the links between procedural and distributive justice and treatment adherence; more specifically, research should also focus on these relationships in the context of overall health status of chronically ill patients over time. Mental health providers should also be included among healthcare providers. Finally, future research should also assess the

PAGE 48

41 consequences of procedural and distributive justice in the healthcare context for both physical and mental health.

PAGE 49

APPENDIX A DEFINTIONS OF PROCEDURAL AND DISTRIBUTIVE JUSTICE DIMENSIONS FOR THE HCJI-PROVIDER PROCEDURAL JUSTICE Voice: refers to whether all phases of the decision making process reflect the basic concerns, values, and outlook of individuals affected by the process. 1. Your provider listened to you. 8. Your provider asked for your input before a decision was made. 15. Your provider did not pay attention to what you had to say. 22. Your provider asked about your preferences for what should be done. Neutrality : refers to whether a decision making authority creates a "level playing field" by demonstrating even-handed treatment and lack of bias. 2. Your provider treated you in an impartial manner. 9. Your provider was open to your point of view. 16. Your provider was biased against you. Accuracy: refers to whether decision making is based on as much good information and informed opinion as possible. 3. Your provider handled the situation in a very thorough manner. 10. Your provider handled the situation in a very careless manner. 17. The decision was based on as much good information and informed opinion as possible. Trust: refers to a persons beliefs about the good intentions or motives of someone with decision making authority. 4. Your provider did something improper. 11. Your provider was honest with you. 18. You felt comfortable with the way your provider handled the situation. Copyright 2002, Mark R. Fondacaro, University of Florida, Gainesville, Florida, and Rudolf H. Moos, Stanford University Medical Center and VA Palo Alto Health Care System, Menlo Park, California. 42

PAGE 50

43 Personal Respect: refers to whether the process is compatible with the fundamental moral and ethical values accepted by the individual. 5. Your provider treated you with respect. 12. Your provider showed little concern for you as an individual. 19. Your provider treated you with dignity. Status Recognition: refers to the extent to which an authority figure treats a person as a valued member of the group. 6. You were treated as if you didnt matter. 13. You were treated as a valued patient of your providers practice. 20. Your provider probably gave you less respect than other patients. Consent: refers to whether the person participated voluntarily in decision making. 7. You accepted your providers decision. 14. You fully agreed with the solutions that you and your provider arrived at. 21. You had a choice to reject your providers recommendation. Consistency: refers to whether decision making procedures are consistent across persons and over time. 27. Your provider probably treated you worse than other patients because of your personal characteristics. Correction: refers to whether opportunities exist to modify and reverse decisions made at various points in the process. 28. You could have had the decision reconsidered. Process Control: refers to a person's control over the presentation of information or evidence. 23. You felt you had personal control over how the situation was handled. Decision Control: refers to an individual's control over the actual decision made. 24. You felt you had personal control over the decision that was made. Global Procedural Fairness: refers to an individual's appraisal of the overall fairness of the decision making process. 25. Overall, your provider treated you fairly. Procedural Satisfaction: refers to whether the individual was satisfied with the decision making process.

PAGE 51

44 26. Overall, you were satisfied with the way your provider treated you during decision making. DISTRIBUTIVE JUSTICE Need: refers to whether the decision making outcome is based on meeting the needs of the individuals involved. 29. The decision was based on meeting your health needs. Equity: refers to whether the decision making outcome is based on the individuals prior contribution. 33. The decision was influenced by what was covered in your health plan. Equality: refers to whether the decision making outcome is based on dividing resources equally, regardless of input. 34. The decision was based on treating all patients equally. Global Outcome Fairness: refers to whether, all in all, the outcome of the situation was fair. 30. All in all, the decision was fair to you. Outcome Satisfaction: refers to whether the individual was satisfied with the decision making outcome. 31. Overall, you were very satisfied with the decision. Outcome Favorability: refers to whether the outcome of decision making was favorable to the interests of the individual. 32. The decision was very favorable to you.

PAGE 52

APPENDIX B DEFINTIONS OF PROCEDURAL AND DISTRIBUTIVE JUSTICE DIMENSIONS FOR THE HCJI-HEALTH PLAN PROCEDURAL JUSTICE Voice: refers to whether all phases of the decision making process reflect the basic concerns, values, and outlook of individuals affected by the process. 1. Your health plan representative listened to you. 8. Your health plan representative asked for your input before a decision was made. 15. Your health plan representative did not pay attention to what you had to say. 22. Your health plan representative asked about your preferences for what should be done. Neutrality: refers to whether a decision making authority creates a "level playing field" by demonstrating even-handed treatment and lack of bias. 2. Your health plan representative treated you in an impartial manner. 9. Your health plan representative was open to your point of view. 16. Your health plan representative was biased against you. Accuracy: refers to whether decision making is based on as much good information and informed opinion as possible. 3. Your health plan representative handled the situation in a very thorough manner. 10. Your health plan representative handled the situation in a very careless manner. 17. The decision was based on as much good information and informed opinion as possible. Trust: refers to a persons beliefs about the good intentions or motives of someone with decision making authority. 4. Your health plan representative did something improper. 11. Your health plan representative was honest with you. 18. You felt comfortable with the way your health plan representative handled the situation. Copyright 2002, Mark R. Fondacaro, University of Florida, Gainesville, Florida, and Rudolf H. Moos, Stanford University Medical Center and VA Palo Alto Health Care System, Menlo Park, California. 45

PAGE 53

46 Personal Respect: refers to whether the process is compatible with the fundamental moral and ethical values accepted by the individual. 5. Your health plan representative treated you with respect. 12. Your health plan representative showed little concern for you as an individual. 19. Your health plan representative treated you with dignity. Status Recognition: refers to the extent to which an authority figure treats a person as a valued member of the group. 6. You were treated as if you didnt matter. 13. You were treated as a valued member of your health plan. 20. Your health plan representative probably gave you less respect than other health plan members. Consent: refers to whether the person participated voluntarily in decision making. 7. You accepted your health plan representatives decision. 14. You fully agreed with the solutions that you and your health plan representative arrived at. 21. You had a choice to reject your health plan representatives recommendation. Consistency: refers to whether decision making procedures are consistent across persons and over time. 27. Your health plan representative probably treated you worse than other health plan members because of your personal characteristics. Correction: refers to whether opportunities exist to modify and reverse decisions made at various points in the process. 28. You could have had the decision reconsidered. Process Control: refers to a person's control over the presentation of information or evidence. 23. You felt you had personal control over how the situation was handled. Decision Control: refers to an individual's control over the actual decision made. 24. You felt you had personal control over the decision that was made. Global Procedural Fairness: refers to an individual's appraisal of the overall fairness of the decision making process. 25. Overall, your health plan representative treated you fairly.

PAGE 54

47 Procedural Satisfaction: refers to whether the individual was satisfied with the decision making process. 26. Overall, you were satisfied with the way your health plan representative treated you during decision making. DISTRIBUTIVE JUSTICE Need: refers to whether the decision making outcome is based on meeting the needs of the individuals involved. 29. The decision was based on meeting your health needs. Equity: refers to whether the decision making outcome is based on the individuals prior contributions. 33. The decision was influenced by the amount you contribute to your health plan. Equality: refers to whether the decision making outcome is based on dividing resources equally, regardless of input. 34. The decision was based on treating all health plan members equally. Global Outcome Fairness: refers to whether, all in all, the outcome of the situation was fair. 30. All in all, the decision was fair to you. Outcome Satisfaction: refers to whether the individual was satisfied with the decision making outcome. 31. Overall, you were very satisfied with the decision. Outcome Favorability: refers to whether the outcome of decision making was favorable to the interests of the individual. 32. The decision was very favorable to you.

PAGE 55

48 APPENDIX C HEALTHCARE JUSTICE INVENTORY/ADHERENCE MEASURE UFID #:_____________ DIRECTIONS: Please use your initials for the code. Fill out your UFID number on the booklet Please fill the follo wing questions on your booklet: Question 2 Second part of Question 6, if applicable Parts 1,2, and 3 of Question 8, if applicable Second part of Question 9, if applicable Question 10, if applicable Todays date Question 17 Question 58 All other questions should be filled out on the Scantron provided! If a question does not apply to you, skip it. Debriefing forms will be available when you complete the survey. Thank you for your participation! Background Information A B 1. Sex Male Female 2. When were you born? ___________ ___________ ___________ Month Day Year 3. What is your current marital status? A B C D E Never Married Separated Divorced Widowed Married

PAGE 56

Code:__________ 49 4. What is your college standing? (A) freshman (B)sophomore (C) junior (D) senior (E) grad school 5. What is your ethnic background? A B C D E F American Asian Black Hispanic White Other Indian or Latino 6. Are you currently working for pay either full-time or part-time? A B C D No Yes, partYes, fullYes, fulltime only time only and part-time If No how long has it been since y ou were ___________ or __________ employed? months years 7. What are your own annual earnings before taxes (wages, salary, commissions)? A D G Less than $10,000 $30,000 39,999 $60,000 69,999 B E H $10,000 19,999 $40,000 49,999 $70,000 or more C F $20,000 29,999 $50,000 59,999 8. Do you have any medical conditions or ailments, or any problems with emotions or behavior, such as depression, excessive drinking, severe memory problems, or trouble with the law? A B Yes No If Yes: a. Write in the name of the condition(s) in the space below. b. Indicate if it began in the last year. Did it begin in Name of Condition the last year? Yes No I_______________________ _________________ II_______________________ _________________

PAGE 57

Code:__________ 50 III ____________________________ ____________ A B 9. Were you hospitalized for any reason in the last year? Yes No If Yes: Altogether, how many days were you hospitalized in the last year ? ___________ days 10. During the last 12 months not counting checkups, how many times have you seen a doctor? ___________ times 11. In general, would you say your health is: A B C D E Excellent Very Good Good Fair Poor 12. What is t odays date? _______________

PAGE 58

Code:__________ 51 HEALTHCARE JUSTICE INVENTORYHEALTH PLAN This survey asks questions about your heal thcare and your experi ence with your current health plan. Please answer each question as accura tely as you can. If a question does not apply to you, please write N/A (Not A pplicable) in the margin next to the question. If you do not wish to answer a question, please circle the num ber of that question so that we know you have intentionally skipped it. Part I: Your Health Plan 13. Which of the following best de scribes your current health plan? a. Fee-for-Service (I pay my doctor and then bill my insurance company.) b. Health Maintenance Organization/HMO (I have pre-paid health coverage, and am required to use participating providers for all health services.) c. Preferred Provider Organization/PPO (I have a choice of doctors a nd hospitals as part of my health plan. I may use nonpreferred services, but at a higher cost.) d. I am still under my parents insurance. e. Student Healthcare Insurance _____Plan A _____Plan B _____Plan I f. none 0-6 6-12 13-24 2-5 5+ Months Months Months Years Years 14. How long have you been a member A B C D E of this plan? Yes No AB 15. Is your health plan provided th rough your employer? 16. Is your health plan provided thr ough your parents? Copyright 2002, Mark R. Fondacaro, University of Florida, Gainesville, Florida, and Rudolf H. Moos, Stanford University Medical Center and VA Palo Alto Healthcare System, Menlo Park, California.

PAGE 59

Code:__________ 52 17. Section A We would like to learn about your reactions to how your current health plan makes decisions about your healthcare. Please describe an experience you had with your health plan representative in the last 12 m onths in which a decision was made about your healthcare (for example, whether the plan would cover a partic ular medication or surg ical procedure). Please describe the situation: Section B Please answer the following questions about the situation. Yes No AB 18. Did this situation involve a rout ine healthcare visit? 19. Did the situation involve an emergency? Section C Please rate the situation you desc ribed on each item on a scale from A (strongly disagree) to D (strongly agree). Strongly Mainly Mainly Strongly Disagree Disagree Agree Agree 20. Your health plan representative A B C D listened to you. 21. Your health plan representative treated you in an impartial manner. 22. Your health plan representative handled the situation in a very thorough manner. 23. Your health plan representative did something improper.

PAGE 60

Code:__________ 53 Strongly Mainly Mainly Strongly Disagree Disagree Agree Agree 24. Your health plan representative A B C D treated you with respect. r r r r 25. You were treated as if you didnt matter. r r r r 26. You accepted your health plan rep resentatives decision. r r r r 27. Your health plan representative asked for your input before a d ecision was made r r r r 28. Your health pla n representative was open to your point of view. r r r r 29. Your health plan representative handled the situation in a very careless manner. r r r r 30. Your he alth plan representative was honest with you. r r r r 31. Your health plan representative showed little concern for you as an individual. r r r r 32. You were treated as a valued health plan member. r r r r 33. You fully agreed with the solutions that you and your health plan representative arrived at. r r r r 34. Your health plan representative did not pay attention to what you had to say. r r r r 35. Your health plan representative was biased against you. r r r r

PAGE 61

Code:__________ 54 Strongly Mainly Mainly Strongly Disagree Disagree Agree Agree 36. The decision was based on as much A B C D good information and informed opinion as possible. 37. You felt comfortable with the way your health plan representative handled the situation. 38. Your health plan representative treated you with dignity. 39. Your health plan representative probably gave you less respect than other health plan members. 40. You had a choice to reject your health plan representatives recommendation. 41. Your health plan representative asked about your preferences for what should be done. 42. You felt you had personal control over how the situation was handled. 43. You felt you had personal control over the decision that was made. 44. Overall, your health plan representative trea ted you fairly. 45. Overall, you were satisfied with the way your health plan representative treated you during decision making. 46. Your health plan representative probably treated you worse than other health plan members because of your personal characteristics. 47. You could have had the decision reconsidered.

PAGE 62

Code:__________ 55 Now, we would like you to focus on the OUTCOME of the situation you listed above. Strongly Mainly Mainly Strongly Disagree Disagree Agree Agree 48. The decision was based on meeting A B C D your health needs. 49. All in all, the decision was fair to you. 50. Overall, you were very satisfied with the decision. 51. The decision was very favorable to you. 52. The decision was influenced by the amount you contribute to your health plan. 53. The decision was based on treating all health plan members equally. 54. Your needs were not met. 55. Regardless of effort or input, the outcome here was based on meeting your needs. _____________________________________________________________________________ Very Mainly Mainly Very Dissatisfied Dissatisfied Satisfied Satisfied 56. Now, please rate your A B C D satisfaction with your health plan.... Definitely Probably Probably Definitely No No Yes Yes _____ 57. Finally, would you be A B C D willing to recommend your health plan to friends or family members?

PAGE 63

Code:__________ 56 HEALTHCARE JUSTICE INVENTORYHEALTHCARE PROVIDER This survey asks questions about your healthcare and your experience with your current doctor or other healthcare provider (for example, nurse practitioner, physicians assistant, etc.). Please answer each question as accurately as you can. If a question does not apply to you, please write N/A (Not Applicable) in the margin next to the question. If you do not wish to answer a question, please circle the number of that question so that we know you have intentionally skipped it. 58. Section A We would like to learn about your reactions to how your current doctor or other healthcare provider makes decisions about your healthcare. Please describe an experience you had with your doctor or another healthcare provider in the last 12 months in which a decision was made about your healthcare (for example, switching from one medication to another, running a diagnostic test, having an operation vs. no operation, etc.) Please describe the situation: ______________________________________________________________________________ Section B Please answer the following questions about the situation. Yes No AB 59. Did this situation involve a routine healthcare visit? 60. Did the situation involve an emergency?

PAGE 64

Code:__________ 57 Section C Please rate the situation you described on each item on a scale from A (strongly disagree) to D (strongly agree). Strongly Mainly Mainly Strongly Disagree Disagree Agree Agree A B C D 61. Your provider listened to you. 62. Your provider treated you in an impartial manner. 63. Your provider handled the situation in a very thorough manner. 64. Your provider did something improper. 65. Your provider treated you with respect. 66. You were treated as if you didnt matter. 67. You accepted your providers decision. 68. Your provider asked for your input before a decision was made. 69. Your provider was open to your point of view. 70. Your provider handled the situation in a very careless manner. 71. Your provider was honest with you. 72. Your provider showed little concern for you as an individual. 73. You were treated as a valued patient of your providers practice.

PAGE 65

Code:__________ 58 Strongly Mainly Mainly Strongly Disagree Disagree Agree Agree 74. You fully agreed with the solutions A B C D that you and your provider arrived at. 75. Your provider did not pay attention to what you had to say. 76. Your provider was biased against you. 77. The decision was based on as much good information and informed opinion as possible. 78. You felt comfortable with the way your provider handled the situation. 79. Your provider treated you with dignity. 80. Your provider probably gave you less respect than other patients. 81. You had a choice to reject your providers recommendation. 82. Your provider asked about your preferences for what should be done. 83. You felt you had personal control over how the situation was handled. 84. You felt you had personal control over the decision that was made. 85. Overall, your provider treated you fairly. 86. Overall, you were satisfied with the way your provider treated you during decision making. 87. Your provider probably treated you worse than other patients because of your personal characteristics. 88. You could have had the decision reconsidered.

PAGE 66

Code:__________ 59 Now, we would like you to focus on the OUTCOME of the situation you listed above. Strongly Mainly Mainly Strongly Disagree Disagree Agree Agree 89. The decision was based on meeting A B C D your health needs. 90. All in all, the decision was fair to you. 91. Overall, you were very satisfied with the decision. 92. The decision was very favorable to you. 93. The decision was influenced by what was covered in your health plan. 94. The decision was based on treating all patients equally. 95. Your needs were not met. 96. Regardless of effort or input, the outcome here was based on meeting your needs. ________________________________________________________________________ Very Mainly Mainly Very Dissatisfied Dissatisfied Satisfied Satisfied 97. Now, please rate your A B C D satisfaction with your provider. Definitely Probably Probably Definitely No No Yes Yes _____ 98. Finally, would you be A B C D willing to recommend your provider to friends or family members?

PAGE 67

Code:__________ 60 Yes No AB 110. Follow a low salt diet? 111. Follow a low-fat or weight loss diet? 112. Follow a diabetic diet? 113. Take prescribed medication? 114. Check your blood for sugar? 115. Take part in a cardiac rehabilitation program? 116. Exercise regularly? 117. Socialize more than usual with others? 118. Cut down on the alcohol you drink? 119. Stop or cut down on smoking? 120. Check your feet for minor bruises, injuries, and ingrown toenails? 121. Cut down on stress in your life? 122. Use relaxation techniques like biofeedback or self-hypnosis? 123. Carry something with sugar in it as a source of glucose for emergencies? 124. Carry medical or health supplies needed for your self-care?

PAGE 68

Code:__________ 61 How often have you done each of the following in the past 12 months? None of Some of Most of All of the time the time the time the time A B C D 125. Follow a low salt diet? 126. Follow a low-fat or weight loss diet? 127. Follow a diabetic diet? 128. Take prescribed medication? 129. Check your blood for sugar? 130. Take part in a cardiac rehabilitation program? 131. Exercise regularly? 132. Socialize more than usual with others? 133. Cut down on the alcohol you drink? 134. Stop or cut down on smoking? 135. Check your feet for minor bruises, injuries, and ingrown toenails? 136. Cut down on stress in your life? 137. Use relaxation techniques like biofeedback or self-hypnosis? 138. Carry something with sugar in it as a source of glucose for emergencies? 139. Carry medical or health supplies needed for your self-care? How often was each of the following statements true for you during the last 12 months? None of Some of Most of All of the time the time the time the time A B C D 140. I had a hard time doing what my provider suggested I do. 141. I followed my providers suggestions exactly. 142. I was unable to do what was necessary to follow my providers treatment plans. 143. I found it easy to do the things my provider suggested I do. 144. Generally speaking, how often during the past 12 months were you able to do what your provider told you? Copyright 1992, DiMatteo, Hays, and Sherbourne

PAGE 69

LIST OF REFERENCES Adams, J.S. (1963). Toward an understanding of inequity. Journal of Abnormal and Social Psychology, 67, 422-436. American Psychological Association (2002). Ethical principles of psychologists and code of conduct. American Psychologist, 57, 1060-1073. Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature and design. Cambridge, MA: Harvard University Press. Brown, J.B., Stewart, M., & Ryan, B.L. (2003). Outcomes of patient-provider interactions. In T.L. Thompson, A. Dorsey, & K.I. Mitler (Eds.), Handbook of Health Communication. London: L. Erlbaun Associates. Deutsch, M. (1975). Equity, equality, and need: What determines which value will beused as the basis of distributive justice? Journal of Social Issues, 31, 137-149. Deutsch, M. (1985). Distributive justice: A social-psychological perspective. New Haven, CT: Yale University Press. DiMatteo, M. R., Hays, R. D., & Sherbourne, C. D. (1992). Adherence to cancer regimens: Implications for Treating the Older Patient. Oncology, 6(2), Supplement, 50-57. Families USA. (1997). HMO consumers at risk: States to the rescue. Washington, DC: Families USA Foundation. Fondacaro, M.R. (1995). Toward a synthesis of law and social science: Due process and procedural justice in the context of national heath care reform. Denver Law Review, 72(2), 303-358. Fondacaro, M.R., Dunkle, M., & Pathak, M. (1998). Procedural justice in resolving family disputes: A psychosocial analysis of individual and family functioning in late adolescence. Journal of Youth Adolescence, 27, 101-119. Fondacaro, M., Fogner, B., & Moos, R. (2005). Justice in health care decision making: Patients appraisals of health care providers and health plan representatives. Social Justice Research, 18, 63-81. 62

PAGE 70

63 Fondacaro, M.R., Jackson, S.L., & Luescher, J. (2002). Toward the assessment of procedural and distributive justice in resolving family disputes. Social Justice Research, 15, 341 371 Hughes, T.E. & Larson, L.N. (1991). Patient involvement in health ca re: A procedural justice viewpoint. Medical Care, 29 (3), 297 303. Jackson, S.L., & Fondacaro, M.R. (1999). Procedural justice in resolving family conflict: Implications for youth violence prevention. Law & Policy, 27, 101 127 Levanthal, G.S. (1980). What should be done with equity theory? New approaches to the study of fairness in social relationships. In K. Gergen, M. Greenberg, & R.Willis (Eds.), Social Exchange. New York: Plenum. Lind, E.A., & Earley, P.C. (1992). Procedural justice and culture. Social psychological approaches to responsibility and justice: The view across cultures [Special issue]. International Journal of Psychology, 27 (2), 227 242. Lind, E.A. & Tyler, T.R. (1988). The social psychology of procedural justice. NY: Plenu m Press. Mechanic, D. (1996). Changing medical organization and the erosion of trust. The Milbank Quarterly, 74, 171 189. Mechanic, D. (1997). Managed care as a target of distrust. The Journal of the Medical Association, 277, 1810 1811. Murphy Berman, V., Cross, T., & Fondacaro, M.R. (1999). Fairness and health care decision making: Testing the group value model of procedural justice. Social Justice Research, 12 (2), 117 129. Ong, L.M.L., De Haes, J.C.J.M., Hoos, A.M., & Lammes, F.B. (1995). Doctor patient communication: A review of the literature. Social Science & Medicine, 40, 903 918. Pascoe, G.C. (1983). Patient satisfaction in primary care: A literature review and analysis. Evaluation and Program Planning, 6, 185 210. Rosenthal, M., & Schlesinger, M. ( 2002). Not afraid to blame: The neglected role of blame attribution in medical consumerism and some implications for health policy. The Milbank Quarterly, 80 (1), 41 95. Sanderson, C. A. (2004). Health Psychology. Hoboken, NJ: John Wiley & Sons, Inc. Safran D.G. (2003). Defining the future of primary care: What can we learn from patients? Annals from Internal Medicine, 138, 248 255.

PAGE 71

64 Schlesinger, M., Mitchell, S., & Elbel, B. (2002). Voices unheard: Barriers to expressing Dissatisfaction to health plans. The Milbank Quarterly, 80(4), 709-755. Schwinger, T. (1990). Just allocation of goods: Decisions among three principles. In:G. Mikula (Ed.), Justice and Social Interaction (pp. 95-125). Huber, Bern: Switzerland. Steil, J.M. & Makowski, D.G. (1989). Equity, equality, and need: A study of the patterns and outcomes associated with their use in intimate relationships. Social Justice Research, 3, 121-137. Thibaut, J., & Walker, L. (1975). Procedural justice. Hillsdale, NJ: Erlbaum. Tornblom, K.Y. (1992). The social psychology of distributive justice. In: K. Scherer (Ed.), Justice: Interdisplinary Perspectives (pp. 77-236). Cambridge, MA: Cambridge University Press. Tyler, T. R. (1989). The psychology of procedural justice: A test of the group-value model. Journal of Personality and Social Psychology, 57(5), 830-838. Tyler, T. R., Boeckmann, R., Smith, H., & Huo, Y. (1997). Social justice in a diverse society. Boulder, Colorado: Westview Press. Tyler, T. R., & Degoey, P. (1995). Community, family, and the social good: The psychological dynamics of procedural justice and social identification. In G. B. Melton (Ed.), The individual, the family, and social good: personal fulfillment in times of change (Vol. 42. pp. 53-91). Lincoln, NE: University of Nebraska Press. Tyler, T.R., Degoey, P., & Smith, H. (1996). Understanding why the justice of group procedures matters: A test of the psychological dynamics of the group value model. Journal of Personality and Social Psychology, 70(5), 913-930. Van den Bos, K., Lind, E. A., & Wilke, H. A. M. (2001). The psychology of procedural and distributive justice viewed from the perspective of fairness heuristic theory. In R. Cropanzano (Ed.), Justice in the workplace: From theory to practice: Vol. 2., Mahwah, NJ: Lawrence Erlbaum. Zheng, B., Hall, M.A., Dugan, E., Kidd, K.E., & Levine, D. (2002). Development of a scale to measure patients trust in health insurers. Health Services Research, 37(1), 188-202).

PAGE 72

BIOGRAPHICAL SKETCH I was born in Detroit, Michigan, on February 9, 1977. I remained in Detroit until I went to the University of Michigan in Ann Arbor, Michigan. I graduated in May, 1995 with dual Bachelor of Art degrees in psychology and communications. After graduation, I remained in Ann Arbor for two additional years, working with at-risk youth and pregnant and parenting teenage mothers. I joined the Department of Psychology at the University of Florida as a counseling psychology graduate student in June of 2001. I completed my Master of Science degree in May of 2005. 65