The main finding from this study is that, in unadjusted models, self-reported racial/ethnic discrimination in healthcare was associated with most measures of diabetes quality of care and complications, but not self-management. The effects of discrimination were attenuated or eliminated after controlling for an extensive range of covariates including sociodemographic, health status, and access to care variables. This reduction in the statistical association between self-reported discrimination and outcome variables suggests that much of the explanatory power of self-reported discrimination is accounted for by factors such as race, income and health status. Race in particular may attenuate the statistical association between discrimination and health outcomes, mainly because self-reports of discrimination are so strongly linked to the reporter’s race.
Self-reports of discrimination attempt to capture three inter-related phenomena: episodes of discrimination, perception of such events, and reporting of them. The ill health effects from discrimination in society (e.g. at work) are thought to be mediated by the chronic stress and mood disturbances associated with the perceptions
themselves (and subsequent disruption of autonomic and neuroendocrine systems) (36
). Yet, the ill health effects from discrimination in healthcare may be largely due to the occurrence
of discrimination, that is, the differential provision of healthcare services based on race/ethnicity. There is overwhelming evidence that racial/ethnic minorities, as a group, have more limited access to appropriate and comprehensive medical care (3
). Differential treatment has been documented in a range of clinical services, including patient/provider communication, preventive care, disease monitoring and treatment, and surgical procedures (3
). Thus, to the extent that race and socioeconomic status are inter-related proxies for such discrimination, one would expect the effect of self-reported healthcare discrimination to be diminished after adjusting for race and SES. Indeed, we found that associations between self-reported healthcare discrimination and diabetes care were attenuated by sociodemographic factors, primarily race and income.
Our study’s findings corroborate smaller previous studies which reported worse diabetes care (e.g. fewer HbA1c tests and eye exams) and intermediary diabetes outcomes (higher HbA1c values) among persons reporting healthcare discrimination (17
). Provider foot examinations was the one quality measure where we found no association with self-reported healthcare discrimination, which contrasts the findings of Ryan et al.’s study of diabetes patients (22
). Our findings contrast those from a Veterans Affairs (VA) study that found no association between self-reported discrimination and a composite measure of diabetes care (20
). The reasons for the differences between our study results and those from the VA are not clear, but may be due to the small sample size in the VA study (n=100), the use of VA medical records (vs. patient self-report) to assess quality of care, or the fact that no differences in diabetes care were found between African-Americans and Whites at the VA. Racial/ethnic minorities who receive comparable clinical care may be less likely to report discrimination within that system. We also found that persons who self-reported healthcare discrimination were more than twice as likely to report having diabetes-related foot disorders or retinopathy, two complications that are precursors to lower extremity amputations and blindness.
Self-reported discrimination was not associated with foot disorders after adjusting for sociodemographic factors, health status or healthcare access; self-reported discrimination was not associated with retinopathy after adjusting for health status. Diabetes complications are multifactorially determined, and healthcare delivery is only one of many causative factors.
We did not find associations between self-reported healthcare discrimination and diabetes self-management behaviors. We hypothesized that discrimination might harm health by compromising patients’ health behaviors. Patients might disengage from the health system (e.g. delay utilizing healthcare and not adhere to treatment plans for self-care), alter sleep patterns, and cope maladaptively by smoking (37
). However, we found that healthcare discrimination was unrelated to self glucose monitoring, self foot examinations, or participation in diabetes education. This may suggest that health behaviors are not a mechanism through which healthcare discrimination affects diabetes outcomes, or more likely, that healthcare discrimination affects aspects of self-care not measured in this study (e.g. nutrition, physical activity, tobacco use) (43
). Regardless, the lack of findings for self-care behaviors suggest that factors other than patient behaviors are the main source of differential outcomes from reported discrimination.
Our study has several limitations. First, the number of eligible states from the BRFSS dataset was limited. However, we do have representation from all four regions of the U.S., including metropolitan areas with high percentages of racial/ethnic minorities (e.g. Detroit). Second, self-reports are subject to reporting bias. However, self-reported diabetes measures have been validated (45
), and self-reported diabetes complications in our study were comparable to other national data (47
). Although self-report is the most commonly accepted method for assessing discrimination (48
), there are inherent biases in this approach; patients may not accurately perceive or report their healthcare experiences. However, the goal of this study was not to measure the accuracy
of patient perceptions, but rather to investigate potential associations between self-reports of healthcare discrimination and health outcomes. Although it was pilot-tested in 2002, the BRFSS instrument itself, like other self-report measures of discrimination, has not been validated to measure self-reported healthcare discrimination. Third, data were cross-sectional, so directionality cannot be assessed. For example, it is possible that patients who perceive or experience healthcare discrimination develop more complications, or
that patients with complications perceive or experience more discrimination.
In summary, we found that self-reported racial/ethnic discrimination in healthcare may be associated with worse diabetes care and more diabetes complications, but not compromised patient self-care behaviors. Our findings also suggest that other factors, such as sociodemographics, health status, and healthcare access, may play equally or more important roles in determining diabetes health disparities, and that a comprehensive, multi-faceted strategy is needed to effectively address health disparities in the U.S. Our study highlights the importance of understanding and addressing patient perceptions of racial discrimination in healthcare to reducing diabetes health disparities. More research is warranted to elucidate how healthcare discrimination impacts health, e.g., through biased allocation of healthcare resources, maladaptive patient coping strategies, or physiological reactions to racial stress. Finally, our paper focused on the potential effects of discrimination, and future research should include self-reported preferential treatment as a potential contributor to health disparities.