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Health Insurer Trust Scale


B. Zheng, M.A. Hall, E. Dugan, K.E. Kidd, D. Levine (2002)

Background and Development:

Following the development of a conceptual model of trust (Hall et al. 2001) the HITS was developed and validated in a national sample (n=410) and further used in a regional (North Carolina) sample (n=2020) of HMO members. The 11-item scale has four components reflecting overlapping aspects of insurance organizations: Fidelity, Competence, Honesty, and Confidentiality. Each item is scored on a 5-point scale (strongly agree,…, strongly disagree) with reverse scoring for some negatively worded items. People using government programs such as Medicaid or the Veterans Administration, or receiving free care at clinics or hospitals were included in the national survey. Internal reliability was excellent for both the national and regional samples (Cronbach’s alpha = 0.92 and 0.89, respectively). Two-month test-retest reliability in the regional sample was good (correlation=0.76). As measures of external validity, in both samples HITS score is significantly correlated with physician trust, general satisfaction with health care, insurer satisfaction, and intent to switch insurers. Having enough choice in selecting plans and an absence of dispute with the insurer also correlate significantly with HITS score.

Assessment in Elderly Populations:

This instrument has not been tested with elderly populations.

Assessment in Minority Populations:

This instrument has not been tested with minority populations.

Subsequent Studies:

Hall et al. (2002) used the HITS and the WFTS to measure patient trust in response to HMO information regarding physician incentives..

Design Strengths and Weaknesses:

Factor analysis was effectively used to minimize the number of items for the final scale without decreasing reliability below an excellent criteria. This survey instrument shows good to excellent reliability and validity. Validation, however, was by comparison with self-reported attitudes and not objective measures. Non-English speakers were excluded from the surveys. Minorities and elderly made up small percentages of the survey populations.

Contact Information:

A copy of the HITS can be obtained from the author at no charge.
Mark A. Hall, J.D.
Professor of Law and Public Health
Wake Forest University Medical School
Department of Public Health Sciences
Winston-Salem NC 27157-1063


Hall, M.A., E. Dugan, B. Zheng, and A.K. Mishra (2001) Trust in physicians and medical institutions: What is it, can it be measured, and does it matter? The Milbank Quarterly, 79(4): 613-639.

Hall, M.A., E. Dugan, R. Balkrishnan, and D. Bradley (2002) How disclosing HMO physician incentives affects trust. Health Affairs 21(2), 197-206.

Zheng, B., M.A. Hall, E. Dugan, K.E. Kidd, D. Levine (2002) Development of a scale to measure patients’ trust in health insurers.  Health Services Res. 37 (1), 187-202.

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