Development and testing of the health care system distrust scale

J Gen Intern Med. 2004 Jan;19(1):57-63. doi: 10.1111/j.1525-1497.2004.21146.x.


Background: Distrust of the health care system may be a significant barrier to seeking medical care, adhering to preventive health care and treatment regimens, and participating in medical research.

Objective: To describe the development and psychometric testing of an instrument (the Health Care System Distrust Scale) to measure distrust of the health care system.

Methods: Scale development involved 2 phases. In Phase 1, a pilot instrument was developed based on a conceptual model of health care-related distrust. Draft items were created using focus group sessions with members of the general public, literature review, and expert opinion. Draft items were pilot tested with 55 individuals waiting to be assigned to jury duty at the Municipal Court of Philadelphia. A priori, candidate items for elimination or revision included those with >5% missing data, extremely low or high interitem or item-total correlations, or those having a negative effect on the scale's internal consistency. In Phase 2, we conducted a survey of 400 prospective jurors to assess the reliability and validity of the final scale scores.

Results: In Phase 1, a 10-item scale was constructed that included 4 items measuring honesty, 2 items measuring confidentiality, 2 items measuring competence, and 2 items measuring fidelity. The participants in Phase 2 had a mean age of 41 years. Forty-three percent were African-American, 45% white, and 4% Hispanic. Scores on the Health Care System Distrust scale ranged from 12 to 46 with a possible range from 10 to 50. The mean score was 29.4 with a standard deviation of 6.33. No item had over 5% missing data. Internal consistency (Cronbach's alpha) was 0.75. Item-total correlations ranged from 0.27 to 0.57. Principal components analysis revealed 1 general component accounting for 32% of the variance. Nine of the variables had loadings higher than 0.40. As predicted, distrust of the health care system was higher among African Americans than whites and was inversely correlated with trust in personal physicians.

Conclusions: Initial testing suggests that we developed an instrument with valid and reliable scores in order to measure distrust of the health care system. Future research is needed to evaluate the validity and reliability of the Health Care System Distrust scale among diverse populations. This instrument can facilitate the investigation of the prevalence, causes, and effects of health care system distrust in the United States.

Publication types

  • Validation Study

MeSH terms

  • Adult
  • Attitude to Health*
  • Confidentiality
  • Delivery of Health Care / standards*
  • Female
  • Focus Groups
  • Health Services Research*
  • Humans
  • Male
  • Psychometrics
  • Trust*
  • United States