Perceived discrimination was associated with refraining from seeking medical treatment independently of age, long‐term illness, low education and living alone. Perceived discrimination even in the absence of socioeconomic disadvantage was associated with threefold to ninefold increased odds for refraining from seeking medical treatment. The significant synergy effect of frequent discrimination and severe socioeconomic disadvantage on refraining from seeking medical treatment was more statistically consistent among women than among men. Perceived discrimination due to ethnicity/race, age, gender and religion was associated with refraining from seeking medical treatment. Perceived discrimination without any specified reasons was not associated with refraining from seeking medical treatment.
Results of this study support previous US findings on the association between racial discrimination and access to healthcare services.1,8,9,10,11
The fact that individuals who experienced discrimination even in a situation of favourable socioeconomic circumstances refrained from seeking medical treatment supports Sen's23
observation that “it is not so much what one has that is important but rather what one can do with what one has”. Individuals who refrained from seeking medical treatment owing to perceived discrimination reported financial limitations and also other factors such as negative experiences in the health sector as the reason for not seeking medical treatment. We found that individuals who reported frequent discrimination were more likely to report previous negative experiences (38% vs 25% among women and 43% vs 20% among men, p<0.001) than those who did not report any discrimination.
It is worthwhile highlighting the gender differences observed in this study. Discrimination because of ethnicity/race, religion, age and gender was relevant for both men and women in relation to not seeking required medical treatment. However, discrimination because of disability was relevant only for women. This supports the recent Swedish report which demonstrated a larger number of women than men with disabilities who experienced discrimination in relation to social services.24
Additionally, the statistically significant effects of discrimination and SDI on refraining from seeking medical treatment among women (and not clearly among men), highlight the vulnerable exposures of gendered discrimination in relation to social divisions premised on power and authority.25,26
We also found that women were more likely to report discrimination because of gender (11% vs 2%) and age (10% vs 8%) than men, indicating discrimination among women based on multiple reasons. These results indicate that the predominant types of adverse discrimination based on race/ethnicity, gender and age are relevant even in egalitarian societies such as that of Sweden.
The results of this study should be interpreted in consideration of its limitations and strengths. First, the cross‐sectional design of the study makes it difficult to draw conclusions on causal relationships. Second, the outcome measure (refraining from seeking required treatment) is general and examines a broad group of people, but this measure may not be equated to the professional definition of needed care. Nevertheless, we found significant associations of poor self‐rated health and long‐term illness with refraining from seeking required medical treatment (p<0.001). Additionally, subgroup analyses showed that the association between frequent discrimination and refraining from seeking medical treatment did not differ among healthcare users for the past 3 months (OR (men)
5.8, 95% CI 4.4 to 7.6 and OR (women)
5.1, 95% CI 4.1 to 6.3) compared with non‐users (OR (men)
5.8, 95% CI 4.2 to 78.0 and OR (women)
5.5, 95% CI 4.2 to 7.4). This finding supports previously documented associations between discrimination and treatment delays after being in contact with a doctor.27
Third, the measure of discrimination based on “treatment that makes people feel humiliated” may not capture “discrimination” as a concept.28
However, we found that individuals who did not indicate any specified reasons for discrimination based on defined social constructs of ethnicity/race, religion, age, gender or disability were not more likely to refrain from seeking medical treatment than those who did not report any discrimination. We found statistically significant correlations between different reasons (types) for discrimination and a dose–response association between increasing number of reported reasons and refraining from seeking medical treatment. These findings indicate clustering of multiple types of discrimination in some individuals that may influence their decisions of seeking medical treatment. In fact, we observed that individuals who indicated unspecified reasons gave examples such as their looks, style or attitude as reasons for discrimination. We also found that socioeconomic disadvantage was not associated with indicating “other” unspecified reasons (p
0.10) or not knowing the reason(s) for discrimination (p
0.55). Fourth, the non‐response rate was 37% and included a large proportion of men, socially disadvantaged individuals and inhabitants in metropolitan areas. Thus, results presented here are probably an underestimation of the magnitude of true effects between discrimination and refraining from seeking medical treatment.
Fifth, because healthcare management and administration takes place at county council level, hypothetically this level may affect the individual probability of refraining from seeking medical treatment. However, we also ran multilevel logistic regression analysis29
with individuals at the first level, municipalities at the second level and counties at the third level, and found that the municipality‐level and especially the county‐level components of variance were very small (ie, very close to 0) in both men and women. The ORs for the associations between the individual variables and refraining from seeking medical treatment from multilevel regression analyses were almost identical to those obtained by single‐level logistic regression that did not consider the county and municipality levels (table available from authors on request).
The strengths of this study include the use of a large dataset that represents the normal population, and a generic measure of perceived discrimination addressing all groups in Swedish society. In addition, as recommended previously,18
the major social constructs, race/ethnicity, religion, gender/sex, disability, age and sexual orientation were specifically addressed as reasons for perceived discrimination. According to our knowledge, this is the first European study where the association between perceived discrimination and refraining from seeking required medical treatment are analysed simultaneously with socioeconomic disadvantage in a large population‐based sample.
We developed the SDI that includes economic hardships, position in the labour market and being unable to economically support oneself, which reflects both material standards and a broad perspective on socioeconomic circumstances. We have validated the SDI measure and found moderate internal reliability.30
We also found consistently significant associations between SDI and lack of access to dental care services independent of educational and occupational status. Thus, this index seems to indicate substantial policy implications and reflects a broader understanding of one's socioeconomic circumstances than using single measures of socioeconomic position, which has recently been criticised in health research.31,32
The fact that individuals who experienced both discrimination and socioeconomic disadvantage had the largest odds for refraining from seeking required medical treatment raises key equity issues in health policies in Sweden.33
This is because the Swedish healthcare system is almost entirely publicly financed and delivered on the basis of equity principles of “care on equal terms”.34
Findings on statistically significant associations between general perceived discrimination and discrimination specific to healthcare setting and refraining from seeking required medical treatment have implications on policies and strategies geared towards minimising discrimination. Results suggest that discrimination occurring at micro and macro levels in the Swedish society seem to influence people's choices for seeking medical treatment, which may cause worsen health in the long run. As demonstrated previously, discrimination is associated with choices regarding seeking care and also with treatment delays, partly due to the lack of trust in healthcare.27
The findings in this study call for a public health strategy that highlights and tackles perceived discrimination in order to enhance equitable access to medical treatment and other healthcare services.4,6,35,36
Thus, society‐wide interventions to counteract bias, prejudice and unfair treatment in society are needed. In addition, healthcare‐specific interventions such as training of healthcare providers and inclusion of ethics training focusing on social justice and human rights in medical and nursing training curriculum would be useful.27,36,37,38,39
What is already known
- Access to healthcare services, including access to medical treatment, has been documented to vary according to socioeconomic position, gender and race/ethnicity.
- The interaction between perceived discrimination and socioeconomic disadvantages have not been investigated.
What this paper adds
- This is the first national population‐based study to show associations of both perceived discrimination and socioeconomic disadvantage with refraining from seeking medical treatment.
- Perceived discrimination even in the absence of socioeconomic disadvantage was associated with refraining from seeking required medical treatment.
- Particularly for women, the combination of both discrimination and socioeconomic disadvantage resulted in a much stronger effect on refraining from seeking medical treatment than the simple sum of their independent effects.
- Strategies to counteract bias, prejudice and unfair treatment in society, in particular within the healthcare setting, are needed.
- The goal towards equitable access to healthcare services cannot be achieved without specific public health strategies that confront and tackle discrimination, particularly in the healthcare setting.
In conclusion, perceived discrimination is associated with refraining from seeking required medical treatment independent of socioeconomic resources. The goal towards “care on equal terms” cannot be achieved without specific public health strategies that confront and tackle discrimination in society and specifically in a healthcare setting.