Perceived discrimination was associated with quality of care measures in this nationally representative sample of US Latinos. However, this association was much stronger among US-born Latinos than among the foreign born. Of all correlates of quality, discrimination had the strongest effect as one in five persons reporting perceived discrimination from medical personnel within the past 2 years. We looked at two measures of discrimination, one a measure of general discrimination, the Detroit Area Study (DAS) discrimination scale, and the other a measure of perceived discrimination from doctors or medical personnel. In a model of self-reported quality of care for US-born Latinos, with both discrimination measures as independent variables, the DAS scale was significantly associated with quality of care (after controlling for sociodemographics and health status), but perceived doctor discrimination was not. In the same model for foreign-born Latinos, only doctor discrimination was associated with self-reported quality of care. In models of the quality of doctor-patient communication, both discrimination measures were significant for the US born, but for the foreign born, both were marginally nonsignificant.
The finding of a greater association between perceived discrimination and self-reported quality of care measures in the US born compared to the foreign born has several possible explanations. The first possibility is that US-born Latinos experience more discrimination than foreign-born Latinos because they interact more closely with non-Latinos in the US and seek health care in the same settings as non-Latinos—and that the care they receive in these settings is below the level that they perceive non-Latinos receive.
The second possibility is that US-born Latinos because of their English-language abilities and greater understanding of US culture are more vigilant in monitoring their patient-provider relationship and are better able perceive when receipt of lower quality of care is connected to discrimination than are foreign-born Latinos. It may be that foreign-born Latinos are “protected” from perceiving discrimination. Other studies have suggested a similar protective factor of lower acculturation.5,32,33
Previous authors have suggested ethnic identity as one of many possible buffers of discrimination, and foreign-born Latinos may benefit from this factor.34,35
However, in this study, we did not find associations among discrimination and education, age or income that were found in prior studies of discrimination.36
The third possibility is that among US-born Latino there is a larger subgroup of “pessimists” regarding their life in the US than among the foreign born—and these pessimists rate their experiences in general more negatively—so they have perceptions both of more discrimination and of lower quality of health care.
Based on our results, the third possibility seems the least likely. We found that levels of perceived discrimination from doctors or medical staff to be similar among the US born and the foreign born. If there were more “pessimists” among the US born, there should be a larger proportion reporting discrimination in the health-care setting among the US born than among the foreign born. The strongest association that we found was between perceived doctor or medical staff discrimination and doctor-patient communication in the US born. This seems to support the second possibility that US-born Latinos are better able to perceive the connection between discrimination and lower quality of care when it exists. The strong association between general discrimination (as measured on the DAS scale) and self-reported lower quality of care among the US born seems to support the first possibility—those with the most interaction with US culture experience both more discrimination and a perceived lower relative quality of care.
Still a fourth possible explanation explaining why US born Latinos who perceive discrimination report lower quality of care could be that they have switched providers in the previous year. It is likely that many Latinos experienced discrimination prior to the year in which the health-care quality questions referred to. This in turn may explain for the higher rates of perceived discrimination as well as the lower rates of perceived quality of health care received.
The association this study found between poor self-reported health status and perceptions of discrimination from doctors or medical staff is of concern. In Piette et al.’s 37
work with diabetic patients, a similar association was found where 14% of the study’s participants reported experiencing health-care discrimination during the prior year, including discrimination due to their race (8%), education or income (9%), age (7%) and sex (10% of women). In the present study, respondents with poorer health status reported more than three and a half times the rate of discrimination in the health-care context.
The study is cross-sectional, and arguments of causation cannot be made. The mean of general discrimination assessed on the DAS scale is relatively low; on average, discriminatory experiences are occurring only a few times a year, and only about one in five Latinos reported any discrimination from doctors or medical personnel in the past 2 years. The question remains whether such a small level of discrimination can be clinically significant. However, it may be that attributes of poor quality of care and poor patient-provider communication, such as rushed care, rudeness, or arrogance on the part of doctors or medical staff, are associated in respondents’ minds with perceived discrimination. The connection between general discrimination not necessarily in a medical setting and quality of care may be even more tenuous.
Looking at general discrimination and discrimination in a medical setting jointly in models as we have done may give some insight into possible factors explaining the association. Although the DAS discrimination scale and the doctor discrimination measure had a strong positive association with each other, they were not so collinear as to create problems in the models presented here; when the discrimination terms were included in the models separately, results were similar.
As in all telephone surveys, the representativeness of the study sample to Latinos in general can be questioned. Wave 2 follow-up was also limited in this study; due to financial constraints there was a short time window for completing callbacks. However, our analysis of the Wave 2 sample compared to the rest of the Wave 1 showed no significant differences on any demographic characteristic. Sample size may have been a greater limitation. Our sample size was insufficient to fully dissect the associations among general discrimination, doctor discrimination and quality of care and to identify the subgroups within the nativity groups that were responsible for the overall associations found.