PERCEIVED DISCRIMINATION, SOCIOECONOMIC DISADVANTAGE AND REFRAINING FROM SEEKING MEDICAL TREATMENT IN NIGERIA
To analyse the association between perceived discrimination and refraining from seeking required medical treatment and the contribution of socioeconomic disadvantage.
Design and setting
Data from the Swedish National Survey of Public Health 2004 were used for analysis. Respondents were asked whether they had refrained from seeking required medical treatment during the past 3 months. Perceived discrimination was based on whether respondents reported that they had been treated in a way that made them feel humiliated (due to ethnicity/race, religion, gender, sexual orientation, age or disability). The Socioeconomic Disadvantage Index (SDI) was developed to measure economic deprivation (social welfare beneficiary, being unemployed, financial crisis and lack of cash reserves).
Swedish population‐based survey of 14 736 men and 17 115 women.
Both perceived discrimination and socioeconomic disadvantage were independently associated with refraining from seeking medical treatment. Experiences of frequent discrimination even without any socioeconomic disadvantage were associated with three to nine‐fold increased odds for refraining from seeking medical treatment. A combination of both frequent discrimination and severe SDI was associated with a multiplicative effect on refraining from seeking medical treatment, but this effect was statistically more conclusive among women (OR = 11.6, 95% CI 8.1 to 16.6; Synergy Index (SI) = 2.0 (95% CI 1.2 to 3.2)) than among men (OR = 12, 95% CI 7.7 to 18.7; SI = 1.6 (95% CI 1.3 to 2.1)).
The goal of equitable access to healthcare services cannot be achieved without public health strategies that confront and tackle discrimination in society and specifically in the healthcare setting.
Access to healthcare services is an important determinant of health.1 However, access to healthcare services is conditioned by coverage2 and various factors including socioeconomic circumstances,1,3,4 care‐seeking behaviours and the behaviours of healthcare providers.5,6,7 Previous studies from the US and UK have demonstrated ethnic discrimination can limit access to healthcare services among minority ethnic groups.7,8,9,10,11 However, there is a scarcity of studies on the effects of other forms of discrimination on access to healthcare services and other determinants of health. In Sweden12 and the US13 racial discrimination has been associated with limited participation in the labour market and unfavourable socioeconomic circumstances. However, the modifying effects of socioeconomic disadvantage on the association between discrimination and access to healthcare services have been analysed less often.7Generally, public health research on the effects of perceived discrimination on health and its determinants, including access to healthcare services, is still in its infancy in many European countries, particularly in the Nordic countries.
In Sweden, the commonly discussed forms of discrimination have been gender and disability. Recently, discrimination due to ethnic background, sexual orientation or age has come up in political debates. Currently, there are legislations against institutional discrimination (because of sex, disability, ethnic background and sexual orientation); however, there are no systematic mechanisms to monitor the occurrence of discrimination.13 More so, the effects of discrimination on health and its determinants are not well documented.
Sweden’s public health policy is based on the principle of equality and care on equal terms for all irrespective of social position.14 In addition, Sweden has universal health insurance, where 94% of the healthcare system is publicly financed. The remaining 6% that is not publicly financed is related to non‐traditional alternative medical treatments or plastic surgery unrelated to medical problems.
A fundamental principle is that the healthcare provision and financing for the entire population is the responsibility of the public sector. The 21 county councils have the primary responsibility of financing, administering and delivering healthcare services to inhabitants. Thus, it is assumed that all Swedish inhabitants should be able to access the care that they need, regardless of class, gender, ethnicity/race, religion or disability.
Over the past 20 years, Sweden has changed from a homogeneous to a multicultural society, with about 20% of the population now consisting of immigrants from other countries. There are contradicting results on whether individuals born outside Sweden overutilise or underutilise the healthcare services.15,16 It should be noted that healthcare utilisation may be different from seeking required medical care.
In this study, we attempted to investigate the association between perceived discrimination and refraining from seeking required medical treatment. We hypothesised that perceived discrimination interacts with socioeconomic disadvantage to increase the odds of refraining from seeking medical treatment.
Data from the Swedish National Survey of Public Health 2004 were used for analyses. This survey was carried out by Statistics Sweden in collaboration with a number of healthcare regions and county councils in Sweden, and with the coordination of the Swedish National Institute of Public Health, Stockholm, Sweden. The total study population comprised a randomly selected sample of 33 328 individuals (15 406 men and 17 922 women) aged 18–84 years. In Sweden healthcare fees are subsidised by the state, and are waived for people under 21 years. Therefore people under 21 years were not included in the analyses. In total, we investigated 14 736 men (mean (SD) age 52 (17) years) and 17 115 women (mean (SD) age 51 (17) years).
Collection of data
Data were collected within a 3‐month period during spring 2004, and was based on a postal self‐administered questionnaire linked to the registry data from Statistics Sweden. The response rate was 63%. Among those who did not respond, 1.9% of the questionnaires were returned due to wrong address or protected address, 0.7% could not participate because of various reasons, 1.1% declined, 0.6% returned empty (uncompleted) questionnaires, 0.5% of the questionnaires were completed by the wrong person and the rest did not respond at all.
The questionnaires were scanned and a dataset was established. Data from the completed questionnaire were further controlled for errors and inconsistencies using a well‐established method developed by Statistics Sweden and tested against the official registry data.18 Missing data were completed by the use of weighting procedures based on related answers from other completed questions, and by the use of weighting procedures based on calibration method developed by Statistics Sweden.17 Respondents were informed about data linkage with the registry data. This study was approved by the Department of Data Inspection, the Research Ethical Committee at the Swedish National Board of Health and Welfare (20031208) and the ethical committee at Karolinska Institutet, Stockholm, Sweden (DNR 2005/1146‐31). The committees conformed to the principles embodied in the Declaration of Helsinki.
Refraining from seeking medical treatment was based on the question “During the past three months have you considered yourself to be in need of medical treatment but refrained from seeking it?” Alternative answers were “yes” or “no”.
The main determinant, perceived discrimination, was measured in the context of unfair treatment that results in feeling of humiliation or inferiority. This measure included frequency of and reasons for discrimination, which is a modified version of Williams Frequency of perceived discrimination was based on the question “During the past 3 months have you been treated in a way that made you feel humiliated?” Alternative answers were “no” (none), “yes, once” (some) or “yes, several times (frequent)”. Participants who experienced any form of discrimination were also asked to give one or more reasons that was/were attributed to this perceived discrimination. Alternative choices were ethnic background, sex/gender, sexual orientation, age, disability, religion, other or don’t know.
In an attempt to measure structural discrimination in this survey, we asked respondents who had reported any form of discrimination to indicate where this occurred. Alternative choices included private setting, welfare institutions, police and healthcare setting. In this paper, we focus on the discrimination experienced in healthcare setting.
We developed a Socioeconomic Disadvantage Index (SDI), which combines several indicators of economic deprivation to broadly describe the individual’s underlying socioeconomic conditions. SDI was based on four variables: (1) being on social welfare at the moment of the survey, (2) being currently unemployed, (3) having a financial crisis (difficulties paying ordinary bills such as food or rent for the past 12 months) or (4) lacking cash reserves (difficulty to get hands on 15 000 SEK (about US$ 1800) within a week if needed). All the four binary indicators were summed up, resulting in a range of 0–4 points. SDI was categorised as “none” (if the sum was equal to 0), “mild” (if the sum was 1) and “severe” (if the sum was between 2 and 4).