Access to civil justice as a social determinant of health: a legal epidemiological cross-sectional study

Abstract

Background: Although it is widely acknowledged that access to civil justice (ATJ) is a key social determinant of health (SDOH), the existing literature lacks empirical evidence supporting ATJ as a SDOH for specific dimensions of health.

Methods: A legal epidemiological, cross-sectional, postal survey was conducted on n = 908 randomly sampled participants in Hong Kong in March 2023. Data collected were perceptions of the civil justice system, health, and sociodemographics. Perceived ATJ was assessed using a modified version of the Inaccessibility of Justice scale (IOJ) and Perceived Inequality of Justice scale (PIJ), i.e. the "modified IOJ-PIJ", consisting of 12 of the original 13 items from both scales divided into two subdomains: "procedural fairness", and "outcome neutrality". For health data, quality of life was assessed using the Hong Kong version of the Abbreviated World Health Organization Quality of Life questionnaire (WHOQOL-BREF(HK)), psychological distress (including symptoms of anxiety and depression) was assessed using the four-Item Patient Health Questionnaire (PHQ-4), and having comorbidities was assessed using Sangha's Self-Administered Comorbidity Questionnaire (SCQ). Structural equation modelling (SEM) was used to investigate the relationships between perceived ATJ and the measured health outcomes.

Results: SEM demonstrated that both subdomains for ATJ had significantly negative associations (B < 0; p < 0.05) with all quality-of-life subdomains, except for between outcome neutrality with social relationships; both subdomains for ATJ had significantly positive association (B > 0; p < 0.05) with both anxiety and depression; and, after adjusting for age, only "procedural fairness" had significantly positive association (B > 0; p < 0.05) with having comorbidities.

Conclusion: This study provided empirical evidence that ATJ is a SDOH for specific dimensions of health. The results of this study encourage laws, policies, and initiatives aimed at improving ATJ, as well as collaborative efforts from the legal and health sectors through health-justice partnerships, and from the broader community, to safeguard and promote public health by strengthening ATJ.

Keywords: Access to justice; Civil justice; Health-justice partnership; Hong Kong; Law for health; Medical-legal partnership; Social determinants of health.

Fig. 1

Hypothetical model describing the relationship between access to justice and quality of life

Fig. 2

Hypothetical model describing the relationship between perceived inaccessibility of justice and psychological distress

Fig. 3

Hypothetical model describing the relationship between perceived inaccessibility of justice and having comorbidities

Fig. 4

Structural model for HM1. Pro.Fair = Procedural fairness; Out.Neut = Outcome neutrality; Phy = Physical health; Psy = Psychological; Soc = Social relationships; Env = Environmental

Fig. 5

Structural model for HM2. Pro.Fair = Procedural fairness; Out.Neut = Outcome neutrality; Anx = Anxiety; Dep = Depression

Fig. 6

Structural model for HM3. Pro.Fair = Procedural fairness; Out.Neut = Outcome neutrality