Week 4 - Assignment: Assess Distributive Policy Administration at the Agency Level and Week 5 - Assignment: Evaluate the Political Backlash of Failed Policies
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JusticeperceivedthreatandvaccinationintentionintheUSA.pdf
Justice, perceived threat and vaccination
intention in the USA
Todd Lucas* and Jennifer Pierce
Wayne State University, Detroit, MI, USA
*Corresponding author. E-mail: [email protected]
Submitted 22 September 2015; revised 1 March 2016; accepted 14 April 2016
Summary
Guided by the Extended Parallel Process Model, this experiment demonstrates how perceived fair-
ness in health resource policy decisions can influence both the protective action and denial-oriented
health threat responses of policy affected individuals. Students from a large urban university in the
Midwestern USA (n¼127) read about a purported illness and were told about a vaccination that would soon be available to them through their university. The out-of-pocket cost of vaccination was
manipulated (distributive justice), as was the fairness of procedures used to determine this cost (pro-
cedural justice). When vaccination was low cost, procedural justice resulted in greater intention to be
vaccinated and also diminished reporting of compensatory health behaviors that could purportedly
supplant the need for vaccination. Ironically however, procedural justice resulted in lower vaccination
intention and exaggerated compensatory health behavior reporting when vaccination was high cost.
Crucially, this experiment demonstrates that perceived fairness may encourage both action-oriented
and fear control health threat response, and that health promotion behaviors such as vaccination may
be affected through interactive relationships of distributive and procedural justice that stem from
health policy decisions.
Key words: distributive justice, procedural justice, fair process effect, belief in a just world, extended parallel process
model, health communication; health locus of control vaccination, health behavior
Threats to health can create feelings of uncertainty that
motivate individuals to take protective action.
Alternatively, health threats may trigger use of fear con-
trol strategies that diminish feelings of vulnerability
without reducing risk of illness (Witte, 1992). Whether
and why individuals opt to engage in protective action
versus fear control response to threat comprises a long-
standing area of interest to health promotion scholars
and practitioners (e.g. Janis, 1958; Rosentock, 1966).
Accompanying theory and research highlight that cogni-
tive appraisals of risk are prominent in guiding threat re-
sponse (Kahneman, 2003), and that motivational and
social determinants of perceived illness risk can pro-
foundly influence health behavior decision-making
(Ditto and Croyle, 2003). Guided by the Extended
Parallel Process Model (EPPM; Witte, 1992), this ex-
perimental study extends consideration of the ways in
which social factors guide cognitive and behavioral re-
sponses to health threat. Specifically, we demonstrate
how the perceived fairness of health resource policies
can influence subsequent threat responses of affected in-
dividuals through EPPM-suggested pathways, and that
information about policy fairness may be communicated
to individuals both by the costs of associated health
VC The Author 2016. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: [email protected]
Health Promotion International, 2018;33:27–37
doi: 10.1093/heapro/daw045
Advance Access Publication Date: 18 June 2016
Article
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resources (distributive justice), as well as by the decision
processes used to determine these costs (procedural
justice).
THE EPPM AND PERCEIVED FAIRNESS
According to the EPPM, two response pathways connect
health threat to subsequent health behavior. Action-
oriented or ‘danger control’ responses encompass behav-
iors intended to objectively reduce a threat. Examples
include vaccinations, cancer screenings, and also pre-
ventative health behaviors such as sunscreen use.
Action-oriented responses typically occur when there is
both a high level of perceived threat and a high level of
threat response efficacy, as when a protective action
seems to be an effective and attainable means to reduc-
ing threat (Witte, 1992; Maloney et al., 2011).
Alternatively, individuals may engage in fear control
that merely reduces the negative emotional states accom-
panying a health threat. Fear control responses often
produce denial-oriented cognitions, as when individuals
profess to believe that a looming health threat is unlikely
or inconsequential, or that a suggested action-oriented
response will be ineffective at reducing threat (for re-
view, McQueen et al., 2013). Fear control responses can
also include compensatory threat perceptions and be-
haviors (e.g. Knauper et al., 2004; Heikkinen et al.,
2010). For example, individuals who forgo a suggested
vaccination may exaggerate protection afforded by
other preventative measures, such as hand-washing or
general healthy living. In contrast to action-oriented re-
sponse, fear control responses typically arise when there
is a high level of perceived threat but low action-
oriented efficacy (Maloney et al., 2011).
Of considerable value, the EPPM suggests precise
cognitive and behavioral response pathways for explor-
ing how psychological and social variables might affect
a range of health behaviors and related outcomes. In this
study, we consider whether justice might act as an ante-
cedent psychosocial factor that affects the selection of
action-oriented versus fear control health threat re-
sponse. In the psychological literature, justice describes
perceptions of outcomes and allocations, as well as rules
and norms that govern such decisions, as fair or unfair
(for review, Jost and Kay, 2010). Available literature
supports that perceptions of justice have important im-
plications for individual health and well-being (for re-
view, Lucas and Wendorf, 2012). For example,
perceptions of fairness are linked to cardiovascular ill-
ness (Kivim€aki et al., 2005), stress (Tomaka and
Blascovich, 1994; Vermunt et al., 2007), health behavior
(Lucas et al., 2008) and mental well-being (e.g. Dzuka
and Dalbert, 2002; Lucas et al., 2011), as well as reac-
tions to persuasive health messages (Lucas et al., 2009).
However, many domains encompassing the justice–
health relationship have yet to be explored (e.g. Lawson
et al., 2009). Of current interest, it is yet unknown how
perceptions of justice guide illness risk appraisal and
ensuing health threat response. This includes reactions
to health resource policy decisions, where there is a con-
siderable potential for justice evaluations to direct the
use of both action-oriented and fear control threat
response.
JUSTICE AND HEALTH THREAT RESPONSE
In linking justice evaluations to health threat response,
one important issue encompasses the kinds of fairness
that are implicated in policy evaluations. In turn,
emerging literature suggests that perceptions of dis-
tributive and procedural justice may be especially im-
portant to individuals when evaluating health policies
(e.g. Thrasher et al., 2010). Distributive justice refers to
the perceived fairness of outcomes or resource alloca-
tions (Adams, 1965), whereas procedural justice refers
to the perceived fairness of decision processes used to
determine outcomes (Thibaut and Walker, 1975). A
core tenet of justice literature is that individuals make
unique judgments about the fairness of outcomes versus
procedures, and that both judgments can predict im-
portant cognitions and behaviors (e.g. Alexander and
Ruderman, 1987; for review, Jost and Kay, 2010).
Distributive and procedural justice have also been
shown to affect individual well-being in unique ways,
for example, through differential associations with
positive and negative affective tendencies (e.g. Lucas,
2009).
Of current interest, distributive justice provides one
useful criteria for understanding how individuals evalu-
ate health policies. Specifically, individuals may perceive
a vaccination policy to be high in distributive justice if
the policy ensures that a vaccination will be personally
attainable. Along these lines, recent research suggests
that difficult access to health resources by way of high
prices may be interpreted as a form of distributive injust-
ice (Rondan-Catalu~na and Martin-Ruiz, 2011), and that
fear control responses may be more prevalent when indi-
viduals perceive health resources to be unattainable
(Samper and Schwartz, 2013). Thus, one hypothesis
derived from emerging literature is that individuals will
view policies that specify costly health resources as dis-
tributively unjust, and this in turn will promote fear con-
trol threat response.
28 T. Lucas and J. Pierce
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Procedural justice suggests that individuals are likely
to also evaluate the fairness of a health policy based on
the deliberative procedures used to allocate health re-
sources. For example, and irrespective of determined re-
source allotments, a vaccination policy may be viewed
as procedurally unjust if an individual perceives that a
representative voice was not present during the policy-
setting decision process (Thibaut and Walker, 1975).
One important insight from justice literature is that fair
procedures often moderate reactions to distributive just-
ice. Of current relevance, this includes the potential for
procedural justice to alter associations between distribu-
tive justice and individual well-being (e.g. Tepper,
2001). In turn, a second and general hypothesis is that
the effect of perceived distributive justice on health
threat response will depend on simultaneously occurring
evaluations of procedural justice.
Presently, we consider two distinct procedural justice
moderator hypotheses. First, available literature high-
lights that procedural justice often bolsters satisfaction
with outcomes (Folger et al., 1979). In turn, one possi-
bility is that fair processes could enhance action-
oriented health threat responses when health policies
are high in distributive justice (i.e. specify low-cost
health resources). A concurrent possibility is that fair
processes might counter-intuitively discourage action-
oriented response. This somewhat ironic potential is
supported by theory and research that suggests unfair
procedures may better promote active coping responses
when outcomes are perceived to be unfair (e.g. Van den
Bos et al., 1999; Desai et al., 2011). Psychologically, a
fair decision process could communicate to individuals
that a health policy is legitimate, and that there may be
little recourse for correcting an unfair health resource
allocation. Thus, arriving at an unfair health resource
outcome by means of a fair decision process could en-
courage fear control.
The present study
This research examined the potential for fairness evalu-
ations of health resource policies to direct the action and
denial-oriented health threat responses of policy affected
individuals. Students from the USA read about a ficti-
tious illness and were told about a health policy that
would soon make a vaccination available to them
through their university. Consistent with recent health
policy literature (Rondan-Catalu~na and Martin-Ruiz,
2011), distributive justice was manipulated by varying
the reported out-of-pocket cost students could expect to
pay if they wished to be vaccinated. Consistent with
justice literature (Thibaut and Walker, 1975),
procedural justice was manipulated by varying the ex-
tent to which student participation (i.e. voice) was re-
ported to exist in the vaccination pricing decision. We
measured perceived threat of illness and perceived cap-
acity to engage in other kinds of personally protective
health behaviors (compensatory behavior response effi-
cacy) as cognitive reactions to justice manipulations. In
addition, we measured distributive and procedural just-
ice beliefs in order to assess how justice attitudes were
affected. Finally, we measured intention to be vacci-
nated, as well as self-reports of two compensatory health
behaviors (diet and exercise) that students were told
could potentially supplant the need for vaccination.
Three specific hypotheses were evaluated. First, we
expected that students would perceive greater threat, be
more receptive to vaccination, and would report lower
compensatory response efficacy and health behavior
when the vaccination was low cost (i.e. high distributive
justice). Second, we anticipated a moderating effect of
procedural justice, such that a fair decision procedure
would increase perceived threat and vaccination inten-
tion when the vaccination was low cost, while also
decreasing reports of compensatory response efficacy
and behavior. Alternatively, we expected that a fair pro-
cedure would decrease perceived threat and vaccination
intention when the vaccination was high cost, while also
increasing compensatory response efficacy and behavior.
Third, with an eye towards literature that suggests
endorsing justice can comprise a compensatory threat
response (Lerner, 1980), we expected that a fair proced-
ure would increase justice beliefs when the vaccination
was high cost, relative to an unfair procedure.
METHODS
Participants and design
One hundred twenty-seven undergraduate students (91
women, 36 men) were recruited from a large, urban uni-
versity in the Midwestern USA to participate in this
study. Students ranged in age from 18 to 47 (M¼21.27, SD¼4.95). All participants were recruited from two large introductory psychology courses. Participation
occurred during a weekly small group session of the
course and all students received course credit in ex-
change for participation. The study received human sub-
jects approval from the university prior to commencing.
The study was conducted as a pencil and paper survey
using an experimentally manipulated 2 (fair versus un-
fair distributive justice) � 2 (fair versus unfair proced- ural justice) between-participants design, in which
Justice and vaccination 29
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students were randomly assigned to one of four experi-
mental conditions.
Procedure
This study utilized a modified version of the thioamine
acetylase deficiency (TAA enzyme) paradigm (Ditto and
Croyle, 2003). In its original form, this paradigm de-
scribes and purports to test individuals for the presence
of a fictitious enzyme deficiency. For current purposes,
students were not subjected to illness detection screen-
ing, but rather were told that TAA Enzyme Deficiency
was an illness caused by a virus for which a vaccination
would soon be available. Students were also told that
susceptibility to this virus appears to be related to a sed-
entary lifestyle and consumption of a high fat diet, such
that TAA Deficiency might also be prevented through
good health behavior. Students then read a short report
explaining that their university was considering adopt-
ing a vaccination program.
The distributive and procedural justice manipula-
tions were embedded in the program description. To
manipulate distributive justice, participants were either
led to believe that if the vaccination program were to be
adopted, the university would (low cost) or would not
(high cost) cover the 500$ out-of-pocket cost.
Procedural justice was manipulated by altering the ex-
tent to which representative voice was said to be present
in the cost setting decision (Thibaut and Walker, 1975).
Namely, students were led to believe that student senate
representation was (voice) or was not (no voice) con-
sulted prior to determining the cost of the vaccine.
Students then completed a series of outcome assessments
and were fully debriefed on the use of deception about
the fictitious illness and the corresponding vaccination
program. Each participant was required to acknowledge
in writing that they understood that deception was used.
Measures
Manipulation checks
To ensure the fidelity of manipulations, all participants
completed distributive and procedural justice manipula-
tion checks. Items were answered using a nine-point
Likert-type scale that ranged from 1 (definitely not true)
to 9 (definitely true). The distributive justice manipula-
tion was assessed with two items that included ‘Students
will see the out of pocket expense of the TAA vaccin-
ation as fair’ and ‘The out of pocket cost of the TAA
vaccination to students is fair’. The procedural justice
manipulation was assessed with two items that included
‘Student concerns were sufficiently considered by the
university board of health in deciding how much to
charge students for vaccination’ and ‘Students were
given sufficient voice by the university board of health in
the process of deciding how much to charge for vaccin-
ation’. Manipulation check items were averaged for
both distributive justice ( r¼0.77, p < 0.001) and pro- cedural justice (r¼0.50, p < 0.001).
Distributive and procedural justice beliefs
To assess the effects of manipulations on general justice
attitudes, all students completed an eight-item measure
of distributive and procedural justice beliefs as an out-
come (Lucas et al., 2007). This measure assessed dis-
tributive justice beliefs, comprised of the general belief
that outcomes and allocations are fair (e.g. ‘People usu-
ally receive outcomes that they deserve’), as well as pro-
cedural justice beliefs, encompassing general beliefs
about the deservedness of rules and treatment (e.g.
‘People are generally subjected to processes that are
fair’). Each subscale is indicated by four items that are
rated using a Likert-type scale ranging from 1 (strongly
disagree) to 7 (strongly agree). Separate scores were
computed by averaging items for distributive justice be-
liefs (a ¼ .87) and well as procedural justice beliefs (a ¼ 0.86), with higher scores indicating a stronger belief in
justice for both subscales.
Perceived threat
Threat cognitions included three-item measures of per-
ceived severity (e.g. ‘How serious would a diagnosis of
TAA Deficiency be to you?’) and perceived susceptibility
(e.g. ‘How worried are you about developing TAA
Deficiency?’). All items were answered using a nine-
point Likert-type response scale that ranged from 1 (not
at all) to 9 (very), with higher scores indicating
greater perceived severity and susceptibility. Scales were
created by averaging the three items, and both scales dis-
played strong internal consistency (a¼0.88; 0.85, respectively).
Compensatory response efficacy
Compensatory response efficacy—individuals’ beliefs
about their capacity to control their own health and
avoid illness on their own—was assessed using the
multidimensional health locus of control scale (Wallston
et al., 1978). This 18-item health attribution measure
contains three 6-item subscales. ‘Internal’ measures
one’s belief that internal (personal) factors are respon-
sible for well-being (e.g. ‘I am in control of my health’).
‘Powerful others’ measures one’s belief that health is
determined by important others such as doctors (‘Health
professionals control my health’). ‘Chance’ measures
30 T. Lucas and J. Pierce
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one’s belief that health and illness are matters of luck
(e.g. ‘If it’s meant to be I will stay healthy’). Chance and
powerful others subscales were reverse coded for the
current research, such that higher scores on all three sub-
scales indicated a stronger personal health locus. All
items were rated using a Likert-type scale ranging from
1 (strongly disagree) to 6 (strongly agree). Subscale
scores were created by averaging the appropriate items,
and all three scales displayed moderate to strong internal
consistency (a ¼ 0.79; 0.59; 0.63, respectively).
Compensatory health behavior
Compensatory health behaviors included two-item
measures of diet (e.g. ‘Do you always maintain a healthy
diet?’) and exercise (e.g. ‘Overall, would you say that
you live an active lifestyle?’). These items were answered
using a nine-point Likert-type response scale that ranged
from 1 (not at all) to 9 (very). Scale scores were created
by averaging two-item measures for both diet ( r¼0.80, p < 0.001) and exercise (r¼0.67, p < 0.001).
Vaccination intention
Vaccination intention was assessed as a single item that
asked ‘If available, how likely is it that you would want
to receive a vaccination for TAA Deficiency from the
university?’ This item was answered using a nine-point
Likert-type response scale that ranged from 1 (not at all)
to 9 (very).
Statistical analysis
A series of 2 (distributive justice: fair/low cost versus un-
fair/high cost) � 2 (procedural justice: fair/voice versus unfair/no voice) ANOVAs was conducted to assess the
effects of justice manipulations. LSD comparison was
used to probe the simple effects of significant distribu-
tive � procedural justice interactions. Univariate ANOVAs were performed on manipulation checks, dis-
tributive and procedural justice beliefs, and vaccination
intention, while mixed ANOVAs were performed on
perceived threat, compensatory response efficacy and
compensatory health behavior. For mixed ANOVAs, the
repeated measures factor was comprised of susceptibility
and severity ratings for perceived threat, health locus of
control subscales for compensatory response efficacy,
and diet and exercise subscales for compensatory health
behavior. Independent samples t-tests revealed no gen-
der differences for justice beliefs, perceived threat, vac-
cination intention or compensatory health behavior
(p’s > 0.23). However, compensatory response efficacy
was higher among men than women (Mmale¼3.05; SD¼0.52; Mfemale¼2.81; SD¼0.49; d¼0.48). Thus,
the subsequently reported analysis for compensatory re-
sponse efficacy was also conducted separately for men
and women.
RESULTS
Manipulation checks
For the distributive justice manipulation check, only the
main effect of the distributive justice manipulation was
significant, F (1, 123)¼124.55, p < 0.001, g2 partial
¼ 0:50. As expected, the cost of vaccination was perceived
to be fairer for students assigned to the low cost condi-
tion (Mlow cost¼6.97; SD¼2.33; Mhigh cost¼2.88; SD¼1.82; d¼1.96). Likewise, only the main effect of the procedural justice manipulation was significant for
the procedural justice manipulation check, F (1, 123)¼ 23.45, p < 0.001, g2
partial ¼ 0:16. Also as expected, the
decision process was perceived to be significantly fairer
to students assigned to the high procedural justice condi-
tion (Mvoice¼5.70; SD¼2.44; Mno voice¼3.69; SD¼ 2.29; d¼0.85).
Perceived threat and compensatory response efficacy
For perceived threat, the within-subjects effect was also
significant, F (1, 123)¼236.93, p < 0.001, g2 partial
¼ 0:66. In general, students perceived the severity of TAA
Enzyme Deficiency to be greater than susceptibility to it
(Mseverity¼6.58; SD¼1.77; Msusceptibility¼3.64; SD¼1.80, d¼1.65). Of greater interest, the hypothe- sized between-subjects effect of the distributive justice
manipulation was significant, F (1, 123)¼8.12, p¼0.005, g2
partial ¼ 0:062. Confirming the first hypoth-
esis, and consistent with motivated denial, students per-
ceived TAA Enzyme Deficiency to be more threatening
when the vaccination was low cost (Mlow cost¼5.45; SD¼1.26; Mhigh cost¼4.78; SD¼1.51, d¼0.48). However, interpretation of this main effect was qualified
by the second hypothesis, concerning a distributive x
procedural justice interaction, F (1, 123)¼7.62, p¼0.007, g2
partial ¼ 0:058. As seen in Table 1 and
Figure 1, students in the low cost condition perceived
TAA enzyme deficiency to be marginally more threaten-
ing when procedural justice was high than when
procedural justice was low (Mvoice¼5.81, SD¼0.94; Mno voice¼5.13, SD¼1.43; p¼0.053, d¼0.58). Conversely, students in the high-cost condition per-
ceived TAA enzyme deficiency to be marginally less
threatening when procedural justice was high than when
procedural justice was low (Mvoice¼4.45, SD¼1.33; Mno voice¼5.11, SD¼1.63; p¼ 0.054, d¼�0.44).
Justice and vaccination 31
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For compensatory response efficacy, Mauchly’s test
of sphericity was significant (p < 0.001). Therefore, in-
terpretations were based on the Greenhouse-Geisser
statistic. The within-subjects effect of compensatory re-
sponse efficacy was significant, F (1.73, 213.15) ¼ 6.32, p¼0.003, g2
partial ¼ 0:049, indicating overall mean dif-
ferences between health locus of control subscales. No
main effect of distributive justice was found. However,
the second hypothesis concerning a distributive � pro- cedural interaction was notable, F (1, 123)¼3.09, p¼0.081, g2
partial ¼ 0:025. As seen in Table 1 and
Figure 1, use of procedural justice produced no differ-
ence in compensatory response efficacy when the
vaccination was low cost (Mvoice¼4.05; SD¼0.50; Mno voice¼4.12; SD¼0.43; p ¼ 0.62, d ¼ �0.15). However, compensatory response efficacy was greater
in the high procedural justice condition than in the low
procedural justice condition when the vaccination was
high cost (Mvoice¼4.28; SD¼0.59; Mno voice¼4.03; SD¼0.48; p ¼ 0.050, d ¼ 0.46). Considering men and women separately revealed that the distributive x pro-
cedural justice interaction was more evident for women,
F (1, 87)¼3.49, p¼0.065, g2 partial
¼ 0:039, than for men, F (1, 32)¼0.36, p¼0.85, g2
partial ¼ 0:001.
Justice beliefs
There were no significant effects of justice manipula-
tions on distributive justice beliefs. However, the
hypothesized distributive � procedural justice manipula- tion interaction was significant for procedural justice
beliefs, F (1, 123)¼8.41, p¼0.004, g2 partial
¼ 0:064. As seen in Table 1 and Figure 1, students in the low cost
condition reported marginally weaker procedural justice
beliefs when procedural justice was high than when
procedural justice was low (Mvoice¼3.36; SD¼1.19; Mno voice¼3.83; SD¼1.07; p ¼ 0.092, d ¼ 0.42). In contrast, students in the high-cost condition reported
stronger procedural justice beliefs when procedural just-
ice was high than when procedural justice was low
(Mvoice¼3.97; SD¼0.95; Mno voice¼3.33; SD¼1.09; p ¼ 0.017, d¼0.63). Thus, the hypothesis that a fair procedure would increase justice beliefs when the vac-
cination was high cost relative to an unfair procedure
when the vaccination was high cost was confirmed.
Compensatory health behavior and vaccination intention
The within-subjects effect of compensatory health be-
havior was significant, F (1, 123)¼82.83, p < 0.001, g2
partial ¼ 0:40. In general, students self reported higher
levels of exercise than healthy diet (Mexercise¼5.96, SD¼2.16; Mdiet¼4.30, SD¼2.17; d¼0.77). Unexpectedly, the main effect of the procedural justice
manipulation was also significant, F (1, 123)¼4.61, p¼0.034, g2
partial ¼ 0:036. Students reported better
health behavior when procedural justice was high
(Mvoice¼5.49; SD¼1.69; Mno voice¼4.79; SD¼2.04; d¼0.37). Of greater interest, the main effect of proced- ural justice was qualified by the hypothesized distribu-
tive x procedural justice interaction, F (1, 123)¼10.93, p¼0.001, g2
partial ¼ 0:082. As seen in Table 1 and
Figure 2, students in the low cost condition reported less
compensatory health behavior when procedural justice
was high than when procedural justice was low, though
this difference was not significant (Mvoice¼5.12, SD¼ 1.63; Mno voice¼5.49, SD¼1.91; p¼0.42, d¼�0.21). Conversely, students in the high-cost condition reported
greater compensatory health behavior when procedural
justice was high than when procedural justice was low
(Mvoice¼5.81; SD¼1.69; Mno voice¼4.06; SD¼1.95; p < 0.001, d¼0.96). Thus, the interaction pattern once again supported the second hypothesis.
The hypothesized main effect of distributive justice
was again significant for vaccination intention, F (1,
123)¼17.04, p < 0.001, g2 partial
¼ 0:122. In further sup- port of the first hypothesis, students expressed less inten-
tion to be vaccinated when the vaccination was high
cost (Mlow cost¼6.06; SD¼2.53; Mhigh cost¼4.17; SD¼2.79; d¼0.71). Once again, this effect was qualified by the hypothesized distributive x proced-
ural justice interaction, F (1, 123)¼5.23, p¼0.024,
Table 1: Mean outcome responses as a function of
distributive and procedural justice
Procedural justice beliefs High PJ Low PJ
High DJ 3.36(1.19) 3.83(1.07)
Low DJ 3.97(0.95) 3.33(1.09)
Perceived threat High PJ Low PJ
High DJ 5.82(0.94) 5.13(1.43)
Low DJ 4.45(1.33) 5.11(1.63)
Compensatory response efficacy High PJ Low PJ
High DJ 4.05(0.50) 4.12(0.43)
Low DJ 4.28(0.59) 4.03(0.48)
Compensatory health behavior High PJ Low PJ
High DJ 5.12(1.63) 5.49(1.91)
Low DJ 5.81(1.69) 4.06(1.95)
Vaccination intention High PJ Low PJ
High DJ 6.72(2.39) 5.48(2.54)
Low DJ 3.73(2.60) 4.63(2.94)
Notes. DJ, distributive justice (high DJ, low cost; low DJ, high cost).
PJ, procedural justice (high PJ, voice; low PJ, no voice).
SDs given in parentheses.
32 T. Lucas and J. Pierce
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g2 partial
¼ 0:041. As seen in Table 1 and Figure 2, the interaction once again supported the second hypothesis;
students in the low cost condition expressed a margin-
ally significant greater intention to be vaccinated when
procedural justice was high than when procedural just-
ice was low (Mvoice¼6.72; SD¼2.39; Mno voice¼5.48; SD¼2.54; p¼ 0.066, d ¼ 0.50). Conversely, students in the high-cost condition expressed less intention to be
vaccinated when procedural justice was high than
when procedural justice was low, although this simple
effect was not significant (Mvoice¼3.73; SD¼2.60; Mno voice¼4.63; SD¼2.94; p¼ 0.171, d ¼ 0.32).
DISCUSSION
This experimental study extends current knowledge of
the ways in which social factors influence health behav-
ior decision-making. Namely, evaluations of distributive
and procedural justice can possibly direct both action-
oriented and fear control responses to a potential health
Fig. 1: Mean procedural justice beliefs, perceived threat and compensatory response efficacy as a function of justice conditions.
Error bars represent 61 SE.
Justice and vaccination 33
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threat. Aligned with recent research that suggests indi-
viduals may interpret difficult access to health resources
by way of high prices as a form of distributive injustice
(Rondan-Catalu~na and Martin-Ruiz, 2011), and that
fear control responses may be more prevalent when
health resources are perceived to be unattainable
(Samper andd Schwartz, 2013), students exhibited more
action-oriented threat response when the cost of vaccin-
ation was perceived to be fair (i.e. high distributive just-
ice). Of greater interest, we also observed a significant
moderating effect of procedural justice on health threat
response. Although a fair allocative procedure enhanced
action-oriented response when vaccination was low
cost, fair processes engendered fear control responses
when vaccination was high cost. Thus, the current re-
search suggests that effects of distributive justice on
health threat response may be qualified by the use of
procedural justice.
Theoretically, this research builds on prior work that
has identified both a conciliatory (e.g. Folger et al., 1997)
and an ironic (e.g. Van den Bos et al., 1999) moderating
potential of procedural justice. With an eye toward avail-
able literature, the conciliatory capacity of procedural
justice in the low cost context may be attributable to
group valuation functions of procedural justice. For ex-
ample, fair processes may have communicated to students
that they are valued and respected members of their uni-
versity, which furthered their receptivity to vaccination.
The contrasting and ironic effect of procedural justice in a
low distributive justice context suggests that fair and un-
fair processes also provide risk information to individuals
when health resources are unfairly allocated. Along these
lines, we suggest that fair processes may convey a sense of
existential threat when access to a protective health re-
source is difficult or scarce, especially to the extent that
fair processes could suggest legitimacy and little recourse
correcting an unfair policy allocation (see also Van den
Bos et al., 1999). In turn, fair processes may promote fear
control rather than action-oriented response when health
resources are unfair.
Another theoretical contribution of the current
works stems from connecting justice theory and research
to the EPPM. Specifically, this study demonstrates that
perceptions of justice derived from health policy deci-
sions may operate through health cognition channels
suggested by the EPPM to alter health threat response.
In doing so, the current results highlight that justice
evaluations resulting from health resource policy deci-
sions may act as an antecedent psychological determin-
ant of health threat response that feeds into cognitive
mechanisms suggested by the EPPM. Interestingly, we
also observed that experimental justice manipulations
altered procedural justice beliefs. Future research might
ascertain whether changes in justice beliefs could act as
a proximal mechanism within the EPPM that precedes
links to action and fear control threat responses.
Fig. 2: Mean compensatory health behavior and vaccination intention as a function of justice conditions. Error bars represent 61
SE.
34 T. Lucas and J. Pierce
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An additional and important contribution stems from
examining how evaluations of distributive and proced-
ural justice affect ensuing thoughts about justice. As
hypothesized, individuals increased justice beliefs in re-
sponse to a high cost vaccination when procedural justice
was also high. This result corroborates that individuals
may be especially threatened by health policies that are
low in distributive justice but high in procedural justice.
Moreover, this result aligns with available justice litera-
ture that suggests individuals often endorse justice atti-
tudes as a compensatory response to threat (for review,
Hafer & Bègue, 2005). Interestingly, policy manipula-
tions affected procedural justice beliefs but not distribu-
tive justice beliefs. Though somewhat unexpected, this
finding aligns with recent literature that suggests health
behavior may be more robustly connected to procedural
than distributive justice measures (e.g. Lucas et al.,
2008). Future research will be needed to ascertain
whether thoughts about procedural justice are indeed
more reactive to health policy evaluations than thoughts
about fair outcomes (see also Lucas and Goold, 2008).
Several additional directions for future research are
further suggested. First, future research may reveal add-
itional nuance with expanded measurement of con-
structs suggested by existing justice frameworks. For
example, conciliatory effects of procedural justice could
be further examined by including measures of trust and
respect, while the ironic potential of procedural justice
could be examined by including measures or manipula-
tions of perceived existential threat, such as fear and
angst (e.g. Lucas et al., 2014). In similar fashion, fair-
ness heuristic theory (Lind, 2001) asserts that experienc-
ing uncertainty can fundamentally motivate evaluations
of fairness, and that individuals may scrutinize distribu-
tive and procedural justice in order to help make sense
of the ambiguous social structures and relationships af-
fecting them (Lind and Van den Bos, 2002). It could be
that the presently observed effects of distributive and
procedural justice on health threat response are effect-
ively characterized as a heuristic and sense-making use
of justice information. In addition to a broadened con-
sideration of available theoretical frameworks, measure-
ment of constructs suggested by the EPPM could also be
expanded, e.g. by including measures of action-oriented
response efficacy in addition to compensatory response
efficacy. In tandem, justice may intersect with other in-
dividual differences characteristics that similarly direct
health threat response, such as political orientation
(Mesch and Schwirian, 2015). A third future direction
concerns exploring characteristics of different illnesses
or other public health threats as they relate to justice.
For example, procedural justice may augment either
action or fear control responses, but perhaps only for
outbreaks of illnesses that seem familiar or menacing to
potentially affected individuals.
Some limitations suggest a cautious interpretation.
First, this research relied on a sample of university
undergraduates from a single country. Although helpful
in allowing us to specify a familiar institution as the
source of policy justice in our experimental design, it is
unknown whether the current pattern of results would
be observed in other populations. Future research must
consider the effects of justice on health threat response
in other nations, especially to the extent that health re-
source policies and decision processes may be character-
ized by considerable cross-national differences, as may
justice perceptions (e.g. Lucas et al., 2016). Second, al-
though hypothesized moderator relationships were gen-
erally significant, results were also characterized to
some extent by instances of marginal statistical signifi-
cance. We are somewhat reassured in that marginal sig-
nificance generally occurred when probing simple
effects, which suggests that it may be attributable to di-
minished sample sizes. Moreover, we obtained moderate
to large effect sizes in all instances of marginal signifi-
cance (Cohen, 1988). Nevertheless, future studies will
be needed to replicate the current findings to ensure that
the observed patterns of health threat response are re-
producible. This also includes assessing the potential for
gender differences in the effects of justice on health
threat response; gender was shown to alter the influence
of justice on compensatory response efficacy, though a
relatively small number of male participants precluded a
more thorough examination of gender differences. A
related limitation is that we did not include a measure to
assess the believability of our modified TAA enzyme
paradigm. Results may have been further bolstered had
it been possible to identify and exclude skeptical partici-
pants from analyses. Although a limiting feature, we can
at least point to available literature that supports the
validity and credibility of the TAA enzyme paradigm
(for review, Ditto and Croyle, 2003). Limitations not-
withstanding, this study provides an important first step
in identifying justice as a social factor that influences
perceived risk of illness and related health threat re-
sponse. Considering factors related to distributive and
procedural justice may be practically useful to health
promotion scholars and practitioners who wish to facili-
tate adaptive utilization of protective health actions.
ACKNOWLEDGEMENTS
We thank Pete Grostic, Chris Steffke and Robert Terback for
assistance with data collection.
Justice and vaccination 35
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