In this integrated study population, we surmise that perceived discrimination may act as a dominant stressor that inhibits an individuals’ ability to adhere to medical recommendations. Among African Americans and whites, individuals who reported more lifetime discrimination experiences reported lower levels of health care utilization; specifically, more delays in seeking medical care and nonadherence to medical care recommendations even after adjustment for mistrust of health care organizations, medical comorbidities, and depression.
Participants who reported experiencing discrimination occurring during the past year were also more likely to report delays in seeking care and nonadherence to medical care after adjustment. Therefore, discrimination experiences, whether recent or not, were associated with health utilization. It is instructive to note that the relationship between discrimination and delay in seeking and medical nonadherence was similar among African Americans and whites, and in most models the odds ratio was greater for whites. While this may seem counterintuitive, it may be that because experiences of discrimination are less normative among whites, when they do experience discrimination, the association with behaviors is stronger. In addition, if discrimination acts as a dominant stressor, it is reasonable to believe that its impact on the behaviors of whites would be similar to its impact on the behaviors of African Americans.15
After final adjustment, discrimination specifically related to the medical care setting was not significantly associated with outcomes. This may be explained by the fact that reports of discrimination in getting medical care are infrequent. In the current study population, only 102 (7.3%) individuals reported ever experiencing discrimination in getting medical care with 70 (5.0%) reporting that discrimination occurred in the past year. Therefore, the statistical power to assess this association may be limited.
We studied the association between response to unfair treatment and health service use because previous work has shown that acceptance of unfair treatment is associated with poor health status (e.g., elevated blood pressure) particularly among African Americans who have experienced discrimination.12
Although previous work has not shown racial differences in internalization of unfair treatment,12
in this study, we found that African Americans were more likely to respond actively and whites were more likely to respond with acceptance to unfair treatment. In addition, in the current study, no association was seen between internalization of unfair treatment and delay in seeking and nonadherence to medical care. It is unclear why we did not observe an association; however, we could speculate that individuals who internalize unfair treatment (e.g., respond with acceptance) utilize health care services differently depending on individual behavior traits. For example, some may have higher rates of health care utilization solely because of poor health status while others have lower rates of health service use because they lack self-efficacy.
This study has several strengths. First, because the administered questionnaire contained various measures of physical and mental health, we were able to adjust for a variety of need, enabling, and predisposing factors including depression, comorbidities, medical mistrust, and transportation barriers in getting health care. Second, the study included a socioeconomically homogenous and racially integrated study population with almost equal proportions of African American and white residents. The African-American and white residents live in the same community and have the same geographic availability of health care providers. Third, we employed detailed and well-validated measures of perceived discrimination.
There are some limitations in the study methodology that should be mentioned. First, with a response rate of 42%, even though we have no reason to expect poor external validity, generalizability may be limited as the study was conducted in only two census tracts in Maryland. Because the study population is set within a highly integrated community, levels of perceived discrimination and other covariates may differ from samples in which there is less integration. Nonetheless, at least for disparities in chronic conditions, our study group found that results from the EHDIC sample yielded generally similar outcomes when compared with results from the National Health Interview Survey.28
A second limitation is that discrimination and delay/nonadherence measures were all self-reported and, thus, are subject to response and recall bias. Third, the study was cross-sectional, which prevents us from making causal inferences. A longitudinal study would provide stronger evidence for a causal association between lifetime discrimination experiences and delays in seeking and nonadherence to medical care.
Our study adds to the complex literature of perceived discrimination and health service utilization. Similar to previous research, we found that perceived discrimination has a negative association with health service utilization. However, this study makes a unique contribution to the literature in that we describe at least two new findings regarding the association between discrimination and health utilization. First, the association is independent of several factors related to health service utilization, including the report of medical mistrust. Second, in populations with similar socioeconomic and environmental exposures, the relationship is similar for whites and African Americans. There are also several implications of this study for further investigation. Future studies should quantify the association in similar and dissimilar populations in a longitudinal fashion. In addition, qualitative studies of individuals who perceive discrimination and do not seek medical care or adhere to recommendations made by health professionals may help elucidate the specific mechanisms. Finally, studies that include more detailed measures of interpersonal relationships in health care, other sociobehavioral factors such as locus of control, self-efficacy, and biological responses to stress, may help to elucidate the mechanism for observed links between perceived discrimination, health service utilization, and health outcomes.