Believing in Justice for Self and Others: Independent and Interactive Effects on Perceived Healthcare Discrimination Among African Americans
- Open Access
- 11-12-2025
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Abstract
Racial discrimination in healthcare contributes to worse health outcomes (Babyar, 2018; Hamed et al., 2022). In the United States, these disparities are observed most starkly for African Americans, who very often receive inadequate or inferior healthcare stemming in part from racial discrimination, which contributes to disparities in premature mortality across the lifespan (Nelson, 2002; Penner et al., 2023). For example, as compared to White Americans, African Americans have almost three times the infant mortality rate, 40% higher mortality through middle adulthood (35 and 49 years), and life expectancy that is six years shorter (for review, Penner et al., 2023). These and numerous other racial health disparities are indeed attributable in part to racial bias against African Americans in healthcare (Cuevas et al., 2016; Penner et al., 2023). Namely and notably, African Americans have less access to preventive medical care (Copeland, 2005), and are thus less likely to receive timely, aggressive, and appropriate treatments for numerous illnesses, such as cancer and cardiovascular disease (Garrett et al., 2024; Kressin & Petersen, 2001).
Among African Americans, personal and vicarious experiences with healthcare systems are amalgamated as beliefs and attitudes toward healthcare, including perceived racial discrimination in healthcare (e.g., Benkert et al., 2006; Hausmann et al., 2010). These enduring beliefs about racism within healthcare can not only reflect lived experiences with unjust healthcare systems, but also the subjective evaluations of African Americans individuals about the caliber and injustice of healthcare. Beliefs about racial discrimination within healthcare can play a contributing role in ongoing racial health disparities through their potential to also influence the delivery, adequacy and use of healthcare resources and services (Hausmann et al., 2010; Powell et al., 2019). In turn, perceived racial discrimination in healthcare may be connected to antecedent psychosocial beliefs that aim to protect and better enable racial minorities to adaptively function in unjust social contexts, including healthcare systems (Brondolo et al., 2009). Connecting individual differences to perceived healthcare discrimination thus highlights a potential opportunity to better understand racial disparities in healthcare, and to potentially consider new interventions for improving both the quality and use of healthcare among racial minorities. In the present research, we connect beliefs about justice – specifically the belief in a just world for self and others (Lipkus et al., 1996) – to perceived racial discrimination in healthcare among African Americans. Specifically, we consider whether African Americans may simultaneously endorse and refute some forms of the belief in justice in self-serving ways to maintain and protect health. In doing so, we contribute to an emerging picture of complex associations between believing in justice and health-oriented outcomes among racial minorities (Lucas et al., 2024; Lucas, Lumley, Lucas et al., 2016a, b, 2018a, b; Major & Townsend, 2012).
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Perceived Racial Discrimination in Healthcare
Perceived racial discrimination in healthcare can be defined as individuals’ subjective perceptions and interpretations of unfair treatment in healthcare settings based on their race or ethnicity (Nong et al., 2020; Williams et al., 1997). This construct overlaps but is conceptually distinct from several other important phenomena. Most notably, this includes a conceptual distinction from objective healthcare discrimination—actual differential treatment that can be documented through behavioral observation or healthcare outcome disparities. Perceived racial discrimination in healthcare is also closely related to, yet conceptually distinct from institutional or systemic discrimination—policies, practices, and structural arrangements that disadvantage racial minorities regardless of individual actors’ intentions. Together, racial health disparities and institutional discrimination can also be considered from the perspective of structural racism—a multilevel system in which racist beliefs, norms, policies, and practices operate across institutions to create and maintain racial inequalities (Bailey et al., 2017). In healthcare specifically, structural racism can manifest through unequal distribution of healthcare facilities in predominantly African American neighborhoods, racial disparities in insurance coverage and healthcare financing, underrepresentation of African Americans in medical research and clinical trials, implicit biases in clinical decision-making algorithms, and also systemic barriers to healthcare access including transportation, work schedule inflexibility (Bailey et al., 2017; Penner et al., 2023). These structural factors create a context in which individual healthcare encounters are embedded, shaping both the objective quality of care African Americans receive and their subjective perceptions and expectations of healthcare experiences.
Beyond these facets of structural racism, perceived healthcare discrimination is also intertwined with, but unique from medical mistrust, which encompasses a generalized skepticism or distrust toward healthcare institutions, providers, or the medical system that can characterize both majority and minority social segments, and that is especially driven by fear of harm or exploitation of oneself or social group (for recent review, Shukla et al., 2025). Finally, and although perceived discrimination plays an important role in racial health disparities, it is conceptually distinct from the documented differences in health outcomes between racial groups, which can not only result from discrimination, but also reflect factors including socioeconomic inequality and differential healthcare access (Penner et al., 2023).
Crucially, while all these closely related phenomena are interconnected, our focus on perceived discrimination specifically examines how individuals subjectively experience and interpret their healthcare encounters through a lens of potential racial bias. Understanding perceived healthcare discrimination is critical because these perceptions may influence both the delivery and utilization of healthcare services (Hausmann et al., 2010; Powell et al., 2019). Namely, when African Americans perceive discrimination in healthcare settings, they may delay or avoid seeking care, show reduced adherence to medical recommendations, and experience poorer health outcomes (Cuevas et al., 2016). Moreover, perceived discrimination represents a psychological reality that shapes health behaviors independent of whether discrimination objectively occurred in any given instance. Thus, identifying psychological factors that influence these perceptions—such as justice beliefs—offers potential pathways to better understand and potentially improve healthcare experiences and outcomes among racial minorities.
Belief in a Just World, Health, and Well-Being
Available literature shows that justice beliefs promote health and well-being (Dalbert, 2001; Elovainio et al., 2002; Lucas, 2020). Believing in justice may protect physical health in numerous ways, including through reducing susceptibility to illnesses that contribute to racial health disparities, such as cardiovascular and metabolic diseases (De Vogli et al., 2007; Kivimäki et al., 2005; Levine et al., 2017), and by encouraging engagement in health protection and prevention behaviors, such as cancer screening (Drolet & Lucas, 2021; Lucas, 2020; Lucas et al., 2009). Connections from believing in justice to enhanced mental well-being are also well supported (Bartholomaeus & Strelan, 2021; Lucas, 2020). Importantly, connections from believing in justice to physical and mental health appear to be casual and robust even when accounting for many socioeconomic variables and conceptually related individual differences (Kivimäki et al., 2005; Sutton & Douglas, 2005). Mechanistically, believing in justice may protect physical and mental health by enhancing coping with stress (Lucas et al., 2016b; Tomaka & Blascovich, 1994; Vermunt et al., 2007; Vermunt & Steensma, 2005). Indeed, justice beliefs have been linked to the release of cortisol in the face of stress (Lucas et al., 2016a, b; Vermunet et al., 2007), as well as biological indices of long-term coping, such telomere length and atherosclerosis (Epel et al., 2004; Maschino et al., 2024).
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A specific form of justice belief is the belief in a just world. According to Lerner (1980), individuals are motivated to see a world where people get what they deserve and deserve what they get. This belief in a just world (BJW) provides a sense of predictability and control in one’s daily life. Enabling this sense of personal control can contribute to adaptive coping and behavioral agency (Bartholomaeus & Strelan, 2019). Although the BJW is proffered to be a universal motivation possessed by all individuals, the strength of this motivation also varies due to socialization and life experience (Dalbert, 2001; Lerner, 1980). Consequently, there a measurable individual differences pertaining to the BJW (Hafer & Sutton, 2016).
Theoretical frameworks and empirical evidence indicate that individual differences in BJW function across different domains (Lipkus et al., 1996). These domains encompass perceptions of fair treatment toward other people (general justice for others) and evaluations of whether one receives deserved outcomes personally (personal justice for self). Studies demonstrate that justice beliefs regarding oneself versus others are not only psychometrically separate constructs (Lipkus et al., 1996), but also show only modest intercorrelations (e.g., Sutton et al., 2008) and appear consistently across different cultures (e.g., Bartholomeaus et al., 2023b; Lucas et al., 2016a, b). Furthermore, justice research confirms the empirical value of differentiating between self-focused and other-focused justice beliefs (Bègue & Bastounis, 2003, Dalbert, 1999; Lipkus et al., 1996; Sutton & Douglas, 2005; Sutton et al., 2008; Lucas et al., 2011).
Of present interest, beliefs about BJW for self and others tend to be correlated differentially with health and social attitude outcome measures—whereas beliefs about justice for others often better predict harsh social attitudes, beliefs about justice for the self usually predict better health and well-being (for review, Hafer & Sutton, 2016). Evaluations of healthcare attitudes and beliefs may also be governed by patterns of justice beliefs in self and others. For example, beliefs about justice for the self may be related to healthcare beliefs to the extent that timely and appropriate healthcare is directly relevant to one’s own health and well-being. Simultaneously, beliefs about justice for others may be linked to healthcare beliefs insofar as feelings about discrimination and mistrust may represent broader social attitudes about healthcare. Nevertheless, the extent to which this predictive dichotomy emerges in evaluating one’s healthcare has been thus far overlooked and remains largely unknown. Importantly, connections between justice beliefs and healthcare attitudes remain largely unexplored, despite healthcare representing a domain where justice cognitions may be particularly salient and consequential. Healthcare encounters involve assessments of fair treatment, deserved care quality, and equitable resource distribution—all domains where justice beliefs may significantly influence perceptions and behaviors. For racial minorities who can also face discrimination in healthcare systems, understanding how justice beliefs shape healthcare perceptions could illuminate previously unrecognized mechanisms contributing to health disparities.
Believing in Justice Among African Americans
Overlaying the dearth of research connecting justice beliefs to healthcare attitudes, research has also not yet considered how justice beliefs for self and others may function in healthcare evaluations for racial minorities. This deficiency exists against an emerging perspective that suggests salutogenic and social attitude links to justice may be especially complex for racial minority individuals. For example, a cultural perspective of justice and health has illustrated plausible unique linkages among African Americans, a group that may be especially attuned to justice thoughts and feelings, due to historical and ongoing experiences with social injustice (Brunson & Miller, 2006; Clark et al., 1999). Theoretical support for more complex associations with healthcare attitudes among African Americans than White Americans can also be gleaned from inconsistency frameworks, which highlight that well-being may be determined principally by degree to which social expectations are concordant with actual social experience (Major & Townsend, 2012; Proulx et al., 2012). With respect to justice, inconsistency frameworks highlight that alignment between one’s justice beliefs and personal experiences, rather than a rote endorsement of justice, may best confer well-being benefits (Lucas et al., 2016b; Major & Townsend, 2012). For African Americans especially, a view of justice that can accommodate injustice experiences, rather than a universal and unwavering commitment to the belief in justice, may be most critical to maintaining and protecting well-being.
Consistent with the above, the simultaneous endorsement of a belief in justice for self along with a weaker endorsement of a belief in justice for others is a specific pattern that may especially benefit coping and well-being among African Americans. For example, Lucas and colleagues (2018) demonstrated that among older African Americans, long-term stress coping was governed by an interactive relationship between beliefs about justice for self and others, such that coping was best enabled when a strong endorsement in a belief in justice for self was coupled with a relatively weak endorsement of the belief in justice for others. Other research reveals that among African Americans, a willingness to engage in recommended cancer screening may be linked to personal justice ascendency, the extent to which believing in justice for self exceeds the belief in justice for others (Drolet & Lucas, 2021). Furthermore, recent research supports a potential for cultural differences in this specific patterning of links to well-being. Namely, Lucas et al. (2024) showed that for both White and African Americans, a belief in justice for self is linked to greater positive affect and reduced negative affect. However, a belief in justice for others was related to greater negative affect among African Americans only.
Theoretically, coupling high levels of the BJW for self with lower levels of the BJW for others is consistent with arguments that the belief in a just world acts as a positive illusion, whereby individuals wish to see themselves in high regard, as having the ability to control their world, and an optimistic outlet, such as believing that bad events are less likely to happen to self than others (Taylor and Brown, 1988). These positive illusions serve to benefit personal well-being – although the need to maintain this belief can also result in harsh evaluations of others who meet with misfortune (Hafer & Sutton, 2016). Therefore, a high BJW for self and a low BJW for others is potentially self-serving and ultimately supportive of maintaining a protective positive illusion of self.
In tandem to viewing justice as a positive illusion, cultural theory (ref?) supports the possibility that justice beliefs can be both positively and negatively associated with wellness through differential links with justice beliefs for self and others. On one hand, believing the world is fair to oneself provides a universal coping resource by reassuring individuals that the world is orderly and predictable. Believing in justice for oneself may be similarly helpful to racial minorities, who may indeed benefit from the sense of control of viewing the world as personally fair provides. However, marginalized individuals might additionally benefit from being less accepting of a broader belief in justice, which may better reflect unique experiences with social marginalization. Indeed, stress-coping cultural frameworks, such as John Henryism (James et al., 1992), explicitly highlight that among African Americans, personal accountability, and endurance (i.e., a belief in justice for self), are necessary to overcome many decidedly unfair life obstacles (i.e., belief in general injustice). However, no research to date has considered whether this cultural enshrined patterning of believing in justice might be observed when considering healthcare.
Overlaying a dearth of research in healthcare contexts, the BJW can also operate as an ideology that reinforces social inequality and system justification (Jost & Hunyady, 2005). Research demonstrates that stronger BJW, particularly for others, correlates with political conservatism and reduced support for social change (Jost & Hunyady, 2005). By attributing outcomes to what individuals deserve, BJW can legitimize existing social hierarchies and inequalities, leading to blame toward disadvantaged groups and resistance to policies that would reduce inequality (Halabi et al., 2015; Lima-Nunes et al., 2013). For members of minority groups, endorsing BJW thus presents a psychological paradox: while personal justice beliefs may provide coping benefits, general justice beliefs could lead to acceptance or naturalization of structural inequalities that disadvantage one’s own group. This tension—between individual-level adaptive functions and group-level implications—is particularly acute for African Americans, whose collective experiences with systemic racism might make uncritical endorsement of justice beliefs maladaptive at the community level, even if personally protective.
The Present Research
We conducted two studies that examined how believing in for the BJW for self and others independently and interactively affect healthcare attitudes among African Americans, including perceived racial discrimination in healthcare. In study 1, we considered links from BJW for self and others to personally experiencing discrimination when receiving healthcare—a hitherto overlooked aspect of health in the justice literature, with notable implications for racial health disparities. In study 2, we attempted to replicate and expand this consideration by also measuring perceived personal control in healthcare, as well as trust in the healthcare system.
Study 1
In Study 1, our objective was to initially demonstrate how believing in BJW for self and others are linked to experiences of healthcare discrimination. To this end, we assessed both the independent and interactive effects of believing in justice for self and others. As outcomes, we measured self-reported instances of healthcare discrimination, as well as the personal health impacts of these experiences. Our guiding hypotheses were that believing in justice for self would be negatively associated with experiencing and being impacted negatively by healthcare discrimination. Additionally, and with an eye towards recent justice literature (Lucas et al., 2018a, b), we hypothesized a moderator effect, such that believing in justice for self would be especially associated with lower perceived healthcare discrimination when the belief in justice for others was weak. This interactive hypothesis was guided by both viewing the BJW as a positive illusion and inconsistency theoretical frameworks, which support that African Americans might simultaneously endorse and reject specific beliefs about justice, and an effort to better align lived experiences with justice beliefs.
Method
Participants & Procedure
Participants were 197 African Americans (Mage = 37.03, SD = 11.76) recruited through Amazon’s Mechanical Turk (MTurk), an online platform where “requesters” can provide tasks to “workers” in exchange for payment. MTurk samples provide valid data equivalent to those in controlled research settings (Buhrmester et al., 2011) and to be more attentive to instructions than traditional college student samples (Hauser & Schwarz, 2016). A survey was posted to MTurk that contained the BJW belief measures and measures of healthcare discrimination and effects of discrimination. Upon completion of the survey, participants were provided a unique respondent ID, which they entered in MTurk to receive a small ($2.00 USD) payment. Sample sociodemographic characteristics are reported in Table 1.
Table 1
Studies 1 and 2 sample characteristics
Study 1 (N = 197) | Study 2 (N = 220) | |
|---|---|---|
Gender | ||
Male | 75(38.07) | 85(38.64) |
Female | 122(61.93) | 135(61.36) |
Ethnicity | ||
No | 185(93.91) | 215(97.73) |
Yes | 12(6.09) | 5(2.27) |
Education | ||
Less than high school | -- | 1(0.45) |
High school graduate | 18(9.14) | 25(11.36) |
Some college | 49(24.87) | 58(26.36) |
2-year degree | 23(11.68) | 28(12.73) |
4-year degree | 80(40.61) | 76(34.55) |
Professional or graduate degree | 27(13.71) | 32(14.55) |
Employment | ||
Employed full time | 106(53.81) | 142(64.55) |
Employed part time | 39(19.80) | 30(13.64) |
Unemployed looking for work | 35(17.77) | 29(13.18) |
Unemployed not looking for work | 7(3.55) | 5(2.27) |
Retired | 6(3.05) | 8(3.64) |
Disabled | 4(2.03) | 6(2.73) |
Measures
Table 2 reports means, standard deviations, internal consistency coefficients, and bivariate associations for all study 1 variables.
Table 2
Means, standard deviations, reliability coefficients, and bivariate associations
Mean | SD | 1. | 2. | 3. | 4. | 5. | |
|---|---|---|---|---|---|---|---|
Study 1 (N = 197) | |||||||
1. Justice for Self | 3.83 | 1.09 | 0.91 | ||||
2. Justice for Others | 3.21 | 1.06 | 0.69*** | 0.91 | |||
3. Experience Discrimination | 2.22 | 0.90 | − 0.29*** | − 0.22** | 0.95 | ||
4. Impact of Discrimination | 2.51 | 1.05 | − 0.16* | − 0.11 | 0.68** | 0.91 | |
Study 2 (N = 220) | |||||||
1. Justice for Self | 3.82 | 1.19 | 0.92 | ||||
2. Justice for Others | 3.17 | 1.14 | 0.61*** | 0.90 | |||
3. Experience Discrimination | 2.20 | 0.99 | − 0.34*** | − 0.16* | 0.96 | ||
4. Healthcare Power Beliefs | 4.40 | 1.19 | 0.51*** | 0.39*** | − 0.46*** | 0.90 | |
5. Trust in Healthcare System | 2.68 | 0.81 | 0.36*** | 0.53*** | − 0.45*** | 0.51** | 0.87 |
BJW for Self and Others
Participants completed two 6-item justice beliefs scales for self and for others (Lipkus et al., 1996). Participants were asked to rate the extent to which they believe they personally are treated fairly and get what they deserve (e.g. “I feel that I get what I am entitled to have”) and others are treated fairly and get what they deserve (e.g., “I feel that people get what they are entitled to have”) on a 6-point scale ranging from 1 = strongly disagree to 6 = strongly agree. Items were averaged to calculate justice beliefs for self (α = 0.91) and justice beliefs for others (α = 0.91) variables.
Experiencing Discrimination in Healthcare
The Everyday Discrimination Scale (Williams et al., 1997) was adapted to measure experiences of discrimination in healthcare (Pekk et al., 2011). Participants were instructed to “Please think about all the times in your life when you’ve gotten healthcare. When getting healthcare, how often have any of the following things happened to you because of your race, ethnicity, or color?” and answered nine items related to experiences of discrimination in healthcare. Example items include: “You are treated with less courtesy than other people” and “A doctor or nurse acts as if he or she is better than you.” Items were rated on a 5-point scale (1 = never to 5 = always) and were averaged into a single score (α = 0.95), with higher scores reflecting more frequent healthcare discrimination.
Impact of Discrimination in Healthcare
Participants reported the effects of discrimination on health decisions and outcomes. Specifically, they were asked “On average, did your experience(s) of being treated unfairly getting healthcare due to your race/ethnicity result in the following outcomes?” and were presented with nine outcomes, such as “Made you avoid getting routine medical checkups,” “Resulted in poorer physical health,” and “Increased financial burden.” All items were on a 5-point scale ranging from 1 = definitely no to 5 = definitely yes. An average effects of discrimination variable was calculated, with higher scores indicating more negative effects of discrimination (α = 0.91).
Overview of Statistical Analyses
Effects of BJW for self and others were examined using hierarchical multiple regressions. Prior to analyses, BJW for self and for others were mean-centered, and a self x others interaction term was calculated by multiplying the two mean-centered justice beliefs variables. Separate hierarchical multiple regressions were then conducted for healthcare discrimination and effects of discrimination. In the first step, the main effects of the two BJW beliefs measures were entered. In step two, the two-way self x others interaction was entered. We assessed R square change for each step and individual beta weights. Simple slopes were examined for significant interactions, where we probed low and high BJW beliefs for others separately at the mean, and at ± 1 SD
Results
Multiple regression results are reported in Table 3. There was no main effect of BJW for others on self-reported healthcare discrimination experiences (β = − 0.036, t = − 0.380, p =.704). However, there was a significant effect of BJW for self (β = − 0.260, t = −2.732, p =.007), where greater BJW for self were related to fewer experiences of healthcare discrimination. This main effect was qualified by a significant self x others interaction (β = 0.174, t = 2.456, p =.015). As seen in Fig. 1 (left), there was no effect of BJW for self on experiencing healthcare discrimination when the accompanying BJW for others was strong (β = − 0.059, t = − 0.470, p =.639). However, stronger BJW for self was associated with experiencing less healthcare discrimination when the belief in justice for others was weak (β = − 0.334, t = −3.383, p =.001). Believing in a stronger BJW for self was also associated with experiencing less healthcare discrimination at the mean level of BJW others (β = − 0.196, t = −2.012, p =.046). For health discrimination impact, there were no significant main effects of BJW for self (β = − 0.182, t = −1.425, p =.156) or BJW for others (β = 0.026, t = 0.205, p =.838), nor was there a significant interaction (β = 0.049, t = 0.568, p =.571).
Table 3
Study 1: justice beliefs and healthcare discrimination multiple regressions
Experience of healthcare discrimination | Impact of healthcare discrimination | |
|---|---|---|
Step 1 Model Δ r2 | 0.082** | 0.026 |
Self | − 0.260* | − 0.182 |
Others | − 0.036 | 0.026 |
Step 2 Model Δ r2 | 0.028* | 0.002 |
Self x Others | 0.174* | 0.049 |
Fig. 1
Studies 1 and 2: believing in BJW for self and others predicting experience of healthcare discrimination
Discussion
Study 1 confirmed the hypothesis that a stronger BJW for self would be negatively associated with self-reported experiences of healthcare discrimination. Study 1 also confirmed the hypothesized moderating effect, wherein believing in justice for self was most strongly negatively associated with perceived healthcare discrimination when the accompanying belief in justice for others was weak. These independent and interactive associations resonate with recent justice literature that has similarly shown that a strong BJW for self coupled with comparatively diminished general justice beliefs may be beneficial to health and well-being among American Americans (Drolet & Lucas, 2021; Lucas et al., 2018a, b, 2024). Although directionally similar, significant main and moderated effects of believing in justice were not observed on effects of healthcare discrimination. This finding is possibly attributable to conceptualization and measurement of discrimination impact, which may not have been sensitive enough to capture these occurrences, as suggested by the overall low mean for this measure. Nonetheless, one potential for direction for future research suggested by Study 1 is whether believing in justice might more strongly connect to perceived susceptibility to adverse health and wellness outcomes than to perceived severity.
In study 2, we aimed to extend study 1 findings in multiple ways. First, we sought to replicate both main and moderating effects of BJW for self and others on experiencing healthcare discrimination. Second, we sought to explore additional healthcare-related attitudes and beliefs that could further enrich connections to justice beliefs. Specifically, and consistent with the notion that the BJW for self may serve to as a positive illusion enhancing perceptions of control, we measured healthcare power beliefs—encompassing perceived personal control over the amount and quality of healthcare that one receives. We also measured trust in the healthcare system as a discrimination-linked and health-related social attitude. As in Study 1, we expected a main effect of BJW for self on healthcare discrimination experiences, which would be qualified by a moderating effect of believing in BJW for others. Additionally, to the extent the BJW for self is a positive illusion that encompasses a sense of order and control over one’s own life experiences, we expected that healthcare power beliefs would be especially strongly connected to BJW for self. Finally, to the extent that trust in the healthcare system embodies a health-related social attitude, we expected that the BJW for others would be especially strongly associated. Given study 1 did not reveal a significant association between believing in justice and the impact/severity of healthcare discrimination, we focused on experiences of healthcare discrimination in study 2.
Study 2
Method
Participants & Procedure
Participants were 220 African Americans (Mage = 36.90, SD = 11.49). Participants were recruited once more through MTurk to complete an online survey that contained measures of justice beliefs, healthcare discrimination, trust in healthcare systems, and healthcare power beliefs. Participants all received a small ($2.00 USD) financial compensation for their participation. Sample sociodemographic characteristics are reported in Table 1.
Measures
Table 2 reports means, standard deviations, internal consistency coefficients, and bivariate associations for all study 2 variables.
BJW Beliefs
The same justice beliefs for self (α = 0.92) and others (α = 0.90) scales from Study 1 were used in Study 2.
Experiencing Discrimination in Healthcare
Participants completed the same measure of healthcare discrimination from Study 1 (α = 0.96).
Healthcare Power Beliefs
Participants completed the Sense of Power scale to assess healthcare power beliefs (Anderson et al., 2012). Participants were told to think about their interactions with doctors when getting healthcare in the United States and then responded to eight items that measured their personal sense of power (e.g., “I can get them to listen to what I say”) on a 7-point scale (1 = strongly disagree; 7 = strongly agree). Four items were reverse scored, and an average healthcare power variable was calculated (α = 0.90), with higher scores reflecting a stronger sense of power.
Revised Healthcare System Distrust
Trust was measured using eight items from the Revised Healthcare System Distrust Scale (Shea et al., 2008). This measure assessed perceived competence (e.g., “Patients receive high-quality medical care from the healthcare system”) and values (e.g., “The healthcare system puts making money above patients’ needs”) of the healthcare system on a 5-point scale from 1 = strongly disagree to 5 = strongly agree. All items were averaged into one overall trust variable (α = 0.87), where higher scores indicated greater levels of trust.
Overview of Statistical Analyses
Structural equation path analysis was used to examine relationships between BJW for self and others and indices of healthcare power beliefs, healthcare discrimination, and trust in healthcare system. Analyses were performed using LISREL 8.80 and maximum likelihood estimation analyzing the covariance matrix. The BJW for self and others and their interaction were modeled as observed variables, as were healthcare power beliefs, experience with healthcare discrimination, and healthcare trust. Acceptable fit was indicated by a non-significant chi-square goodness of fit test, Nonnormed Fit Index (NNFI) (Bentler & Bonett, 1980) and Comparative Fit Index (CFI) (Bentler, 1990) values above 0.90, and also Root Mean Square Error of Approximation (RMSEA) (Browne & Cudeck, 1993) and Standardized Root Mean Square Residual (SRMR) (McDonald & Ho, 2002) values below 0.08 (Hoyle, 1995). Given our larger sample size, we expected chi-square indices to be significant. Therefore, we gave greater consideration to other indices.
To determine the best fitting model, we began with a fully specified model, in which we allowed correlations between BJW for self and others, and between trust in healthcare system, healthcare discrimination, and healthcare power beliefs across. We then specified a series of alternative models by removing one pathway at a time and comparing the trimmed model to the prior and more fully specified model. We thus relied on deterioration model comparison (Chen, 2007), and the more parsimonious model was retained for subsequent model comparisons if fit was unchanged when removing a pathway. We considered model fit to be unchanged if Dc2 was not significant (p >.05) and DCFI was less than 0.010 (Chen, 2007).
Results
Identifying the Appropriate Structural Model
Fit statistics and chi-square differences for all structural models are reported in Table 4. Our initial model with paths from BJW for self, BJW for others, and the self x others justice interaction to trust in healthcare system, healthcare discrimination, and healthcare power beliefs provided acceptable fit according to all indices. Removing the paths from BJW for self to trust, BJW for others to power and discrimination, and self x others to power and trust enhanced model fit. Eliminating the paths from BJW for self to power and discrimination, BJW for others to trust, and self x others to discrimination reduced model fit. Thus, we selected a final model with paths from BJW for self to power and discrimination, BJW for others to trust, and self x others to discrimination.
Table 4
Study 2: justice beliefs and healthcare discrimination models and comparisons
Model | χ2 | df | NNFI | CFI | RMSEA | SRMR | |
|---|---|---|---|---|---|---|---|
1. All Justice Predicting Power, Discrimination, and Trust | 0.00 | 0 | 1.00 | 1.00 | 0.000 | 0.000 | |
2. Mode1 with Self Justice to Trust Removed | 0.95 | 1 | 1.00 | 1.00 | 0.000 | 0.013 | |
3. Model 2 with Self Justice to Discrimination removed | 16.86 | 2 | 0.741 | 0.965 | 0.184 | 0.049 | |
4. Model 2 with Self Justice to Power removed | 31.77 | 2 | 0.462 | 0.928 | 0.261 | 0.062 | |
5. Model 2 with Other Justice to Trust removed | 59.05 | 2 | 0.000 | 0.852 | 0.361 | 0.166 | |
6. Model 2 with Other Justice to Discrimination removed | 0.95 | 2 | 1.00 | 1.00 | 0.000 | 0.013 | |
7. Model 6 with Other Justice to Power removed | 4.41 | 3 | 0.984 | 0.997 | 0.046 | 0.030 | |
8. Model 7 with Self x Other to Trust removed | 4.61 | 4 | 0.995 | 0.999 | 0.027 | 0.030 | |
9. Model 8 with Self x Other to Discrimination removed | 13.14 | 5 | 0.944 | 0.981 | 0.086 | 0.043 | |
10. Model 8 with Self x Other to Power removed | 5.54 | 5 | 1.00 | 1.00 | 0.022 | 0.037 | |
Model Comparisons | Δχ 2 | ΔCFI |
|---|---|---|
1 vs. 2 | 0.95 | 0.000 |
2 vs. 3 | 15.91* | 0.035* |
2 vs. 4 | 30.82* | 0.072* |
2 vs. 5 | 58.10* | 0.148* |
2 vs. 6 | 0.00 | 0.000 |
6 vs. 7 | 3.46 | 0.003 |
7 vs. 8 | 0.20 | − 0.002 |
8 vs. 9 | 8.53* | 0.018* |
8 vs. 10 | 0.93 | − 0.001 |
Path Estimates of Final Structural Model
The path estimates for the selected model are shown in Fig. 2. The correlation between BJW for self and others, as well as the correlation between BJW for others and the BJW for self x justice for others interaction, were positive and significant. The correlation between BJW for self and the self x BJW for others interaction was not significant. There was a significant positive correlation between trust in the healthcare system and healthcare power beliefs, and significant negative correlations between healthcare discrimination and trust in healthcare system and healthcare power beliefs. Of greater interest, BJW for self was significantly associated with greater healthcare power beliefs and lower healthcare discrimination, whereas BJW for others was significantly associated with greater trust in healthcare systems. The BJW for self x BJW for others interaction was significantly associated with greater healthcare discrimination. As with Study 1, we examined cases one standard deviation above and below the mean of the BJW for others to probe the interaction. As seen in Fig. 1 (right), when the BJW for others was high, there was only a marginally significant effect of BJW for self on healthcare discrimination (β = − 0.206, t = −1.838, p =.067). When BJW for others was low, there was a significant and stronger effect of BJW for self on healthcare discrimination (β = − 0.472, t = −5.290, p <.001), such that greater BJW for self were associated with fewer experiences of healthcare discrimination. There was also a significant effect of BJW for self on healthcare discrimination at the mean level of BJW for others (β = − 0.339, t = −4.116, p <.001).
Fig. 2
Selected model examining effects of justice beliefs for self and others on healthcare power beliefs, discrimination, and trust
Discussion
Study 2 replicated both the independent and interactive effects of believing in justice obtained in study 1. Specifically, believing in the BJW for self was again negatively associated with self-reported experiences of healthcare discrimination. However, this effect was qualified by a moderating effect of believing in justice for others, wherein the BJW for self was most strongly negatively associated with perceived healthcare discrimination when the accompanying BJW for others was weak. Beyond replicating these links, study 2 provided two new contributions: (1) believing in BJW for self was connected to stronger healthcare power beliefs, and (2) believing in BJW for others was associated with greater trust in the healthcare system. Taken together, findings provide additional texture in linking beliefs about justice to perceived healthcare delivery, while further underscoring the complex associations between believing in justice and health-oriented outcomes among racial minorities.
Findings for healthcare power beliefs seem aligned with a long-standing justice literature that holds believing in justice encompasses a positive illusion that can enhance health by providing a sense of control over one’s world. Along these lines, the BJW for self may act as a form of stress coping, and as a psychological lever than can create agency towards performing beneficial health behaviors. Thus, findings for healthcare power beliefs both align with and may add to the justice literature in suggesting the positive illusion-health enhancing pathway is especially robust for the belief in personal justice, which may be broadly observed via connections to a wide range health and wellness-oriented outcomes, including perceived control over healthcare among African Americans.
Results for trust in healthcare are more nuanced. On one hand, findings align with justice literature to the extent that believing in justice for others is typically more strongly connected to social attitude measures. To this end, our findings suggest that trust in the healthcare system may be better construed as a health-oriented social attitude, or a social interaction variable, than as a direct measure of personal health. We also found that the BJW for others was associated with more rather than less trust in the healthcare system. This directional link is noteworthy in the sense that justice literature has shown that believing in justice more generally tends to promote endorsement of harsh social attitudes. One possibility is that trusting the healthcare system might be construed as a callous social attitude among racial minorities. Alternatively, the connection to healthcare system trust could indeed represent a link to the BJW for others that is positively valanced. This latter possibility highlights a potentially noteworthy finding that is ripe for future exploration. For example, justice research has shown that believing in justice for others is linked to callous social attitudes especially when considering the fairness of outcomes (i.e., distributive justice for others), whereas the belief in fair rules and treatment of others (i.e., procedural justice for others) may be positively connected (Lucas et al., 2018). It could be that these divergences are reflected by connections between the BJW for others and healthcare system trust among African Americans, especially to the extent that African Americans may be especially attuned to procedural justice.
Another complexity illustrated by the connection to healthcare system trust is the potential for the BJW for others to operate as a double-edge sword for racial minority health in and of itself. Specifically, the conjoint effect of believing in BJW for self and others on perceived healthcare discrimination highlights that healthcare beliefs may be especially positively valanced when the BJW for others is less strongly endorsed. Yet, the observed connection to healthcare system trust suggests an ostensibly positive impact on healthcare attitudes when the BJW for others is more strongly endorsed. Thus, our findings reveal that believing in justice for others carries a potential to simultaneously enhance and diminish positive healthcare attitudes. We note, however, that an important and unresolved question concerns whether lower perceived discrimination and greater trust in healthcare are indeed “positive” healthcare attitudes when endorsed by racial minority individuals. For example, one possibility is that trusting the healthcare system might represent a form of system justification (Jost & Hunyady, 2005) among racial minorities—wherein stronger BJW for others reflects ideological acceptance of existing institutional arrangements, even those that may not serve one’s group’s interests. This interpretation suggests that BJW for others might reduce vigilance toward discrimination and could lead to complacency with lower quality services. From this perspective, the positive association between BJW for others and healthcare trust might not be unambiguously beneficial, as it could reflect internalization of dominant ideologies that legitimize health inequalities (Halabi et al., 2015).”
General Discussion
Justice literature supports that believing in justice carries positive effects on physical health and mental well-being. This includes salutogenic benefits that accrue not only from the intrinsic motivation to defend a view of the world as fair and just, but also from dispositional tendencies to believe in justice (Hafer & Sutton, 2016), especially including a belief that the world is personally fair (Bartholomaeus & Strelan, 2019). However, justice and health literature has illuminated more recently that there are complex relationships between believing in justice and health among racial minority individuals, whose lived experiences may link to simultaneously endorsing and rejecting particular forms of the belief in justice (Drolet & Lucas, 2021; Lucas et al., 2018a, b, 2024). Guided by these literatures, we examined whether and how believing in justice for oneself and for others would be connected to healthcare attitudes among African Americans—a racial minority group for whom justice cognitions may be especially salient (Brunson & Miller, 2006; Jackson et al., 2006), and a critical health domain that has been relatively overlooked in the available justice literature. We expected that the BJW for self would be associated with less perceived healthcare discrimination, and that this connection would be strongest when the BJW for others was comparatively weak. Our findings were consistent with this moderator prediction, providing more evidence that balancing beliefs about justice and injustice may play a critical role in maintaining health for racial minority individuals, including African Americans. Thes findings add support to the view that aligning beliefs about justice to one’s lived experiences—rather than a rote endorsement of the belief in justice—may best propel the personal health and wellness protection afforded by justice-oriented beliefs (Lucas et al., 2016b; Major & Townsend, 2012).
An important applied consideration emerges from connecting beliefs about justice to evaluation of healthcare—a hitherto largely overlooked linkage in prior research on justice and health. In forging this connection, the current research links justice-related beliefs to an important health context that may be particularly relevant to better understanding and addressing racial health disparities, especially to the extent that beliefs about justice may be uniquely connected to health behavior and health-oriented social attitudes among racial minorities. In turn, new intervention prospects may stem from the present findings. This potential is bolstered by research that has shown justice-oriented cognition and emotion can be readily and temporarily activated through a variety of brief intervention methods (Lucas et al., 2020). These include methods to temporarily activate beliefs about justice for self and for others prior to engaging in specific health and social contexts (Lucas et al., 2020, 2023). Injustice-oriented cognitions may also be activated through these methods, which may be a critical additional ingredient in preparing interventions for use with racial minority populations. (e.g., (Lucas et al., 2014, 2023). Indeed, some research shows that acknowledging injustices may be an effective vehicle for promoting health and social wellness in underserved communities (Kwate, 2014).
Although intriguing, intervention prospects must be considered alongside important ethical tensions and risks. Namely and notably, our findings suggest caution in developing and deploying psychosocial health interventions that only seek to strengthen or activate justice cognitions among African Americans, which could not only prove ineffective towards reducing healthcare disparities, but could result in ironic and harmful consequences (Lucas et al., 2009). Interventions targeting justice beliefs among African Americans must navigate a delicate balance between empowering individual agency and potentially legitimizing structural inequalities. Specifically, strengthening personal justice beliefs (BJW for self) might enhance individual health behaviors and coping, but could simultaneously reduce motivation for collective action or structural change, if it leads individuals to attribute health outcomes primarily to personal deservingness rather than systemic factors (Jost & Hunyady, 2005). This risk is particularly acute if interventions strengthen general justice beliefs (BJW for others), which could promote acceptance of unjust healthcare systems and reduce appropriate vigilance toward discrimination. Therefore, ethically responsible interventions must carefully consider both individual and collective implications. This includes whether enhancing personal justice beliefs might undermine collective consciousness of systemic injustice or reduce support for structural healthcare reforms. Interventions must also consider the potential to foster appropriate as opposed to maladaptive healthcare trust, with the latter encompassing vulnerability to accepting lower-quality care and deflecting attention from necessary system-level interventions to reduce actual discrimination. Finally, interventions must consider the likely potential for within-group heterogeneity, including how racial identity and other individual differences might moderate whether justice belief interventions are empowering or potentially harmful to racial minority individuals (Cooke & Few-Demo, 2021; Lucas et al., 2016a, b).
One potential intervention approach that could address these ethical tensions and risks concerns dual-level interventions that simultaneously acknowledge and explicitly name structural racism in healthcare, while also supporting adaptive personal justice beliefs that enable agency within unjust systems (Lucas et al., 2021, 2023, 2025). For example, interventions might help individuals distinguish between appropriate vigilance toward discrimination (maintaining critical awareness of systemic injustice) and adaptive personal control beliefs (maintaining confidence in one’s ability to navigate and advocate within healthcare systems). This approach resonates with concepts like critical consciousness (Kwate, 2014), which emphasize awareness of systemic inequalities as a foundation for both individual empowerment and collective action. Importantly, such interventions are likely to be most effective when developed in partnership with African American communities, and when justice beliefs are explicitly positioned as tools for navigating unjust systems rather than as endorsements of those systems.
Beyond suggesting potential for novel and culturally-aligned psychosocial interventions, findings highlight a critical need and a potential benefit from recognizing and reducing racial discrimination in healthcare encounters (Penner et al., 2014, 2023). To the degree justice beliefs are linked to evaluations of racial discrimination in healthcare and may also confer greater uptake of preventive and other beneficial healthcare services, non-discriminatory and culturally competent healthcare encounters could reduce further racial health disparities in part by supporting and sustaining the belief in justice. For example, a stronger lived experience of justice in healthcare could fortify beneficial connections to personal justice beliefs. In turn, one additional contribution of the findings may rest in connecting justice beliefs to justice in healthcare more broadly, including the ability to craft novel multilevel interventions that could simultaneously address provider or system-level healthcare interventions as a means of enabling the belief in personal justice, in addition to directly targeting justice beliefs through individual-level (i.e., patient-facing) interventions.
Limitations
Several limitations suggest a cautious interpretation of the present research, as well as future directions. Foremost, our studies are correlational. This limitation is offset by experimental and longitudinal research showing beliefs about justice are a causal determinant of individual health and well-being (Bartholomaeus et al., 2023a; De Vogli et al., 2007; Kivimäki et al., 2005). Nevertheless, multiple alternative interpretations of our findings merit consideration. One alternative explanation is reverse causality: rather than justice beliefs shaping discrimination perceptions, experiences with healthcare discrimination may lead individuals to adopt specific patterns of justice beliefs as an adaptive response. For instance, African Americans who frequently experience discrimination might maintain strong personal justice beliefs (BJW for self) as a protective coping mechanism while simultaneously developing weaker general justice beliefs (BJW for others) that better align with their lived experiences of societal injustice. This interpretation would be consistent with inconsistency frameworks (Major & Townsend, 2012) but would position discrimination as the driver rather than the consequence. A second alternative involves third variable explanations. For example, personality characteristics such as optimism, neuroticism, or general negative affectivity could independently influence both justice beliefs and perceptions of discrimination. Individuals high in optimism might endorse stronger personal justice beliefs and simultaneously perceive less discrimination due to positive interpretive biases. Similarly, socioeconomic status could influence both constructs: individuals with greater resources might develop stronger justice beliefs through positive life experiences while also having access to higher-quality healthcare that involves less discrimination. A third possibility involves reciprocal relationships. Namely, justice beliefs and discrimination perceptions may mutually reinforce one another over time in cyclical patterns. Initial discrimination experiences might weaken general justice beliefs, which could then lead to heightened sensitivity to subsequent discrimination, further weakening justice beliefs, and so on. Conversely, strong personal justice beliefs might initially buffer discrimination perceptions, leading to more positive healthcare interactions, which then strengthen those beliefs. Fourth, measurement artifacts could contribute to observed relationships. Both justice beliefs and perceived discrimination rely on self-report, introducing potential for shared method variance. Additionally, the cognitive accessibility of justice concepts during survey completion might temporarily influence how individuals interpret and report discrimination experiences, inflating associations. Future research could employ multiple methodological approaches to disentangle these alternatives. These include: (1) longitudinal designs tracking both justice beliefs and discrimination perceptions over time, including before, during, and after significant healthcare encounters; (2) experimental manipulation of justice-related cognitions prior to evaluating healthcare discrimination perceptions; (3) measurement of potential third variable personality traits, cognitive styles, and markers of healthcare quality; and (4) daily diary or ecological momentary assessment methods to examine temporal dynamics of these constructs in naturalistic contexts.
Beyond the correlational nature of these data, several additional limitations warrant further consideration. First, the studies included only one racial minority group. Accordingly, future research should examine generalizability of findings to other minorities and cultural groups (Bartholomaeus et al., 2024; Maschino et al., 2024; Thomas & Rodrigues, 2020). Second and related, our studies did not probe the potential for within-group variability among African Americans. This notably includes that we did not consider racial identity as an individual difference moderator, despite theoretical reasons to expect it might substantially influence the relationships we observed. Ethnic-racial identity encompasses awareness of one’s group membership, and also the personal meaning, significance, and evaluation ascribed to that identity (Sellers et al., 1998). African Americans with high racial identity might maintain critical awareness of systemic racism (weaker BJW for others) while simultaneously developing strong personal justice beliefs (strong BJW for self) as an adaptive strategy specifically for navigating discriminatory systems. Conversely, those with assimilationist ideologies might endorse both personal and general justice beliefs more uniformly. Additionally, individuals whose racial identity includes strong beliefs about collective action might experience different relationships between BJW and healthcare perceptions compared to those focused on individual mobility. These possibilities suggest that the patterns we observed represent average effects that likely mask considerable within-group heterogeneity based on how individuals understand and experience their racial identity (Sellers & Shelton, 2003). Future research should incorporate measures of racial identity to better understand for whom and under what conditions different patterns of justice beliefs are most adaptive.
A third limitation is that although our studies utilized flagship measures of believing in BJW for self and others that are widely used and well established, the conceptualization and measurement of justice beliefs is nonetheless multidimensional and multifaceted. Many alternative justice belief conceptualizations and measurement options could provide additional insights. For example, beliefs about BJW for self and others can be further parsed by beliefs about distributive and procedural justice (Lucas et al., 2011), which could lend additional theoretical clarity and empirical precision in linking justice beliefs to healthcare attitudes (Aberson, 2003; Richard & Kirby, 1997). Fourth and related, while considering justice individual differences can suggest underlying cognitive and motivational processes, we did not include measures of these variables. Future studies may consider including additional mechanistic measures that can better illuminate underlying psychological processes, such as approach-avoidance motivations that could be differentially connected to believing in BJW for self and others (e.g., van Prooijen et al., 2006).
Finally, we only included self-report measures of healthcare discrimination. Future studies could deploy methods to objectively measure healthcare interactions and outcomes, with an eye towards capturing links from justice beliefs to both explicit and implicit measures of racial discrimination in healthcare settings. Related, future research could link experiences of healthcare discrimination to racial health disparities by including objective measures of health and health behavior (e.g., Hagiwara et al., 2013). It is plausible that acts of racial discrimination that are experienced as most egregious could have the most profound effects on health behavior.
Conclusion
This research adds to a growing literature that suggests believing in justice may be associated with health and well-being in complex ways among racial minorities, including African Americans. Our findings align with a long-standing justice literature that shows believing in the BJW for self can produce positive health effects, and we extend this literature in linking personal justice beliefs to lower perceived discrimination in receiving healthcare among African Americans—an overlooked health context with implications for racial health disparities (see also Lucas et al., 2018a, b; Maschino et al., 2024). Findings also align with emerging theory and research that suggests nuanced links from believing in justice to health-oriented attitudes and outcomes among racial minorities. This includes specific couplings of justice and injustice beliefs to best protect health and enable beneficial health behavior. Crucially, this study also provides new insight in revealing that healthcare attitudes, including perceived racial discrimination in healthcare settings, could comprise a channel through which beliefs about justice impact racial health disparities. Complex associations between believing in justice and healthcare are evident when the beliefs about justice for oneself are parsed from believing the world to be fair for others and may be especially evident among racial minority groups such as African Americans, whose experiences with social justice likely fortify unique and culture-specific connections between believing in justice and healthcare attitudes. Better understanding how justice-related thoughts and emotions connect to use of and experiences with healthcare among racial minorities may advance psychological theory and research that aims to better understand racial and ethnic health disparities, including through informing interventions and social policies that consider justice evaluations.
Declarations
Competing Interests
The authors declare no competing interests.
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