1. The effects of performance evaluations and trust on popular strategies for dealing with uncertainty about the outcome of critical surgery Dr Neil Munro Lecturer in Chinese Politics Violence towards healthcare professionals: an assessment of causes, frequency, prevention and solutions University of Chicago Center, Beijing September 17-18, 2013. School of Social and Political Sciences, University of Glasgow, Adam Smith Building, Bute Gardens, Glasgow G12 8RT. Email: Neil.Munro@glasgow.ac.uk www.gla.ac.uk/petu 1

2. Key Issue Why is there violence towards health care professionals? Understanding reasons for behaviour is often the key to stopping it. If widespread, it may point to a crisis in the relationship between the medical profession and the general public. Outline –Key concepts –Data –Survey item: strategies to improve outcome of critical surgery –Independent variables: performance evaluations & trust –Effects on choice of strategy –Implications for understanding violence in health care settings 2

3. Key concepts Agency dilemma: patients are principals, doctors are their agents. How can patients ensure that the doctor offers as far as possible the same treatment as they would administer to themselves if they were the patient? Exit: a strategy for resolving the dilemma by changing the doctor or health care provider for another one, presumed to be more loyal to the patients interests Voice: a strategy for resolving the dilemma by speaking or acting to influence the behaviour of the doctor or health care provider Particularism: a strategy for resolving the dilemma which helps a particular patient but not others in a similar situation. –VIOLENCE is a particularistic form of voice-in-action. 3

4. Table 1. Three Dimensions of Strategy UniversalisticParticularistic VoiceExitVoiceExit Proactive Make a formal complaint Change provider Pay a bribe, Ask the provider to change their decision Use connections to find another provider Passive Accept the treatment without resolving the dilemma, Dont know, Give up treatment 4 Source: adapted from Hirschman, A. O. (1970). Exit, Voice and Loyalty: Responses to Decline in Firms, Organizations and States. Cambridge, MA, Harvard University Press.

5. 5 Why use violence? Violence implies a step change in degree of conflict. Violence is qualitatively different from other forms of voice. It is a transgression of universal norms of acceptable social behaviour. Two kinds of logic can be used to explain it (March & Olsen 1989): –Logic of consequences (egocentric logic): violence will help me get what I want, and consequences for me are acceptable; therefore, I will use it. –Logic of appropriateness (socio-tropic logic): there are rules of conduct in my subculture under which violence is regarded as an appropriate response in certain circumstances.

6. Performance Evaluations, Trust and Utilization of Health Care in China Survey, 2012-13. Funded by the UK Economic and Social Research Council, Grant No. ES/J011487/1. nationwide survey in 31 provinces on mainland China fieldwork carried out 1 November 2012 to 17 January 2013 target population: mainland citizens age 18 to 70 residing for more than 30 days in family dwellings GPS Assisted Area Sampling Method Sample of 5,424 dwellings: 3,684 valid interviews Response rate of 67.9 per cent More information at http://www.gla.ac.uk/petuhttp://www.gla.ac.uk/petu Data

7. Figure 1 Strategies to Improve Chances of Successful Surgery B22. If your friend needed a life-saving operation but the surgeon in a public hospital told them that he could not guarantee that the operation would be successful, what would you advise the patient to do? (One answer). (% replies) 7 Source: Performance Evaluations, Trust and Utilization of Health Care in China Survey, fieldwork 1 November 2012-17 January 2013, N=3680.

8. Figure 2a. Perceived Prevalence of Overprescribing Source: Performance Evaluations, Trust and Utilization of Health Care in China Survey, 2012-13. C21. Some people say medical ethics is a big problem in this country, but others say such reports are just exaggerated. Judging from your own personal experience, how likely do you think it is that you would encounter the following types of situations in city or county hospitals around here? a) Prescribing medicines not covered by insurance even when effective alternatives covered by insurance are available. 8

9. Figure 2b. Perceived Prevalence of Taking Hongbao Source: Performance Evaluations, Trust and Utilization of Health Care in China Survey, 2012-13. b). …Taking bribes (red envelopes or hongbao) for treatment which has already formally been paid for. 9

10. Figure 2c. Perceived Prevalence of Unnecessary Testing Source: Performance Evaluations, Trust and Utilization of Health Care in China Survey, 2012-13. c). …Requiring comprehensive check-ups from patients even when the diagnosis is perfectly clear. 10

11. So how do people respond to uncertainty? 11 Dependent variable: which strategy does respondent prefer? Key independent variables: Performance evaluations: health system as a whole skills & competence of doctors Trust in health care institutions (global trust) Perceived likelihood of unethical practices (fidelity) Comparisons between public & private Controlling for: demographics, education, urbanization, hukou, self-assessed health, difficulty paying health bills, local government spending per capita

12. Figure 3a. Impacts of Odds of Using Voice Source: Generalized linear mixed model for data in Figure 1, N=3,506. * Impact on logged risk ratio relative to reference category, computed by multiplying multinomial logistic regression coefficients by the mean of the independent variables. Impacts not significant at.05 level are not shown. Impact* Overall satisfaction with health care system Agricultural hukou Local govt expenditure per capita 12

13. Figure 3b. Impacts on Odds of Using Particularistic Strategies Source: Generalized linear mixed model for data in Figure 1, N=3,506 Impact* * Impact on logged risk ratio relative to reference category, computed by multiplying multinomial logistic regression coefficients by the mean of the independent variables. Impacts not significant at.05 level are not shown. Overall satisfaction with health care system Unethical practices likely Education Agricultural hukou Struggles to pay family medical bills 13

14. Figure 3c. Impact on Odds of Using Exit Strategies Source: Generalized linear mixed model for data in Figure 1, N=3,506. Impact* * Impact on logged risk ratio relative to reference category, computed by multiplying multinomial logistic regression coefficients by the mean of the independent variables. Impacts not significant at.05 level are not shown. Unethical practices likely Private treat- ment better Age in deciles Educ- ation Agricul- tural hukou Struggles to pay family medical bills Local govt expenditure per capita 14

15. Key Findings (System performance) People who are satisfied with performance of the health care system as a whole, are more likely to: use voice (ask the doctor to change treatment & make complaints) use connections to get a referral. (Medical ethics) People who think unethical medical practices are widespread are more likely to: pay hongbao go to a private hospital. (Trust) People who trust hospitals are less likely to complain to the hospital administration. (Clinical performance) People who are satisfied with the skills & competence of hospital doctors are more likely to complain. 15

16. A theory about reasons for violence Unsuccessful surgery can cause people to lose those they love and on whom they depend. Patients regard payment, especially informal payment, as creating an obligation on doctors to resolve a health care problem. Failure to fulfil that obligation is a violation of norms of reciprocity. Reciprocity is a strong norm in Chinese culture. Violence towards health care professionals is an extreme expression of moral indignation about unfulfilled reciprocal obligations. Evidence is circumstantial: need detailed case studies 16