Background
According to the stigma concept of Link and Phelan [
1] discrimination is the last component of the stigma process that starts with labelling human differences and linking labelled persons to negative stereotypes. Hence, discrimination describes behaviours that act to endorse and reinforce stereotypes, and disadvantage labelled and stigmatized individuals by differential treatment [
2]. Discrimination can occur on an interpersonal (i.e. discrimination played out between individuals in everyday life) or a structural level (i.e. discrimination by policies, regulations, and constitutional practice). Human differences that are relevant for stigma are socially selected [
1]. In this respect, individuals are potentially discriminated if they have certain characteristics. These characteristics can be related to sex/gender, race/ethnicity, age, socio-economic status (SES), disability or specific diseases [
2]. It has consistently been shown that perceived discrimination is associated with multiple adverse health outcomes [
3,
4]. Thus, discrimination is an important public health issue that is often discussed as an aspect of health inequities [
5‐
7].
Despite this uncontested relevance, there is a lack of research on the experiences of discrimination in health care [
8,
9]. Discrimination in health care can also be structural (e.g. access barriers for patients with a low SES) or interpersonal (e.g. reduced quality of health care communication with low SES patients). The latter is also referred to as provider-based discrimination (i.e. discrimination by occupational groups designated to provide service) [
2]. A study examining perceived discrimination in primary health care in 30 European countries found that overall 7% of the respondents felt discriminated in the last 12 months in a primary care practice, with a range between 1.4% and 12.8% in the different countries [
10]. In a recent study of Nong et al. [
8], 21.4% of the respondents reported that they had experienced discrimination in the U.S. health care system. Racial/ethnic discrimination was the most common type, followed by discrimination based on educational or income level, weight, sex, and age. Women, younger people and lower income groups were more likely to experience discrimination. As it has been shown that perceived discrimination varies between countries and health care systems [
10], results yielded in one country cannot be generalized or transferred to another.
In terms of Germany, a recent review revealed that research on discrimination in health care is scarce [
9,
11]. The few empirical studies are often limited to regional samples, single aspects of discrimination (e.g. race/ethnicity or age), or specific sectors of health care. In a current study of Bartig et al. [
12], it was found that 4% of individuals with a migration history reported (very) frequent discrimination experiences in health or long term care. However, it remained unclear whether in fact the migration history was the reason for perceived discrimination. There are also scattered indications for discrimination in health care among older people and individuals with disability, mental illness, overweight, and a low SES [
9], but overall, there is a lack of research in Germany providing an overview.
Against this background, in the present study, the following research questions were addressed: (1) How often do people in Germany report having been discriminated in health care due to different reasons? (2) Which socio-demographic groups are most afflicted by perceived discrimination in health care?
Results
Table 1
Sample characteristics (N = 2,201)a
Age (years) (0) | |
18–40 | 721 (32.7) |
41–59 | 743 (33.7) |
≥ 60 | 737 (33.5) |
Sex (0) | |
Female | 1124 (51.1) |
Male | 1077 (48.9) |
Migration background (37) | |
No | 1670 (77.2) |
1st generation | 159 (7.4) |
2nd generation | 335 (15.5) |
Income (326) | |
1st quartile (highest) | 471 (25.1) |
2nd quartile | 466 (24.9) |
3rd quartile | 481 (25.7) |
4th quartile (lowest) | 457 (24.3) |
Education (64) | |
Highest | 459 (21.5) |
High | 367 (17.2) |
Intermediate | 655 (30.6) |
Low | 656 (30.7) |
Distribution of the socio-demographic characteristics (age, sex, migration history, income, and education) in the analysed sample is documented in Table
1.
Table 2
Perceived discrimination in health care due to different reasons in Germany (N = 2,201)
Age | 199 (9.0) |
Sex/gender | 56 (2.5) |
Racism Migration history Religion Language problems Colour of skin | 89 (4.0) 37 (1.7) 25 (1.1) 48 (2.2) 10 (0.5) |
Disability/health issues Disability Overweight Mental illness/addiction | 330 (15.0) 47 (2.1) 248 (11.3) 111 (5.0) |
Socio-economic status Income Education Occupation | 196 (8.9) 156 (7.1) 41 (1.9) 53 (2.4) |
At least one type of discrimination | 586 (26.6) |
Table
2 shows the number of respondents who reported having been discriminated in health care due to the different reasons under study. Perceived discrimination due to age (9%) was more frequent than due to gender or sex (2.5%). Discrimination due to the different aspects of racism ranged between 0.5% (due to colour of skin) and 2.2% (language problems). 4% of the respondents reported at least one of the four aspects. Perceived discrimination due to overweight was most frequent (11.3%). Altogether, 15% of the respondents reported having been discriminated in health care due to health issues or disability. Among the characteristics of the SES, income was most frequently mentioned as a reason for being discriminated (7.1%). More than one quarter (26.6%) of the respondents reported at least one of the 12 types of discrimination.
Table 3
Socio-demographic factors of respondents and perceived discrimination in health care (%, N = 1,875-2,201)
| Age | p* | Sex/ gender | p* | Racism1 | p* | Socio-economic status2 | p* | Disability/ health issues3 | p* | At least one type of discrimination | p* |
Age in years 18–40 41–59 60+ | 14.6 3.2 9.5 | < 0.001 | 5.1 1.7 0.8 | < 0.001 | 6.0 3.8 2.4 | 0.003 | 9.4 10.5 6.9 | 0.046 | 18.7 17.0 9.2 | < 0.001 | 34.3 27.6 18.2 | < 0.001 |
Sex Male Female | 5.2 12.7 | < 0.001 | 0.8 4.2 | < 0.001 | 3.8 4.3 | 0.581 | 8.4 9.4 | 0.376 | 10.3 19.4 | < 0.001 | 20.8 32.5 | < 0.001 |
Migration background No 1st generation 2nd generation | 8.8 4.4 12.6 | 0.009 | 2.3 1.3 4.5 | 0.037 | 2.6 11.3 7.8 | < 0.001 | 8.7 6.9 10.7 | 0.329 | 15.0 11.3 16.1 | 0.351 | 25.7 23.3 32.8 | 0.016 |
Income 1st quartile 2nd quartile 3rd quartile 4th quartile | 7.4 10.1 9.1 9.5 | 0.529 | 2.1 2.6 2.9 2.9 | 0.869 | 2.5 5.4 3.5 4.4 | 0.146 | 6.1 7.3 7.5 14.0 | < 0.001 | 10.4 13.3 17.0 19.3 | 0.001 | 21.2 25.7 26.8 33.8 | < 0.001 |
Education Highest High Intermediate Low | 9.6 12.0 9.0 7.9 | 0.186 | 3.9 6.0 2.0 0.5 | < 0.001 | 4.1 5.4 3.1 4.7 | 0.262 | 7.4 9.8 9.0 10.4 | 0.393 | 11.5 11.5 15.4 19.6 | < 0.001 | 24.6 27.8 26.4 29.5 | 0.307 |
Age-related discrimination was more often reported by young respondents (18 to 40 years), females, and 2nd generation migrants (Table
3). Younger people, females and respondents with high education more often perceived discrimination due to gender or sex. Perceived racist discrimination (including migration, religion, language problems, and skin colour) was more pronounced among younger respondents and those with a migration history. People who were younger than 60 years and individuals with low income (4th quartile) felt more often discriminated due to their SES (according to income, education, and occupation). Perceived discrimination due to health issues or disability (disability, overweight, mental illness, and addiction) was significantly associated with lower age, female sex, lower income, and lower education. Finally, the rate of those who reported at least one type of discrimination was increased among younger people, females, 2nd generation migrants, and respondents with a low income.
Table 4
Associations between socio-demographic factors of respondents and perceived discrimination in health care: Odds ratios, (confidence intervals), and significances (N = 1,840)
| Age | Sex/gender | Racism1 | Socio-economic status2 | Disability/health issues3 | At least one type of discrimination |
Age in years 18–40 41–59 60+ | 1.00 0.16 (0.09–0.28)*** 0.55 (0.36–0.82)** | 1.00 0.52 (0.26–1.06) 0.17 (0.06–0.51)** | 1.00 0.54 (0.30–0.99)* 0.30 (0.15–0.61)** | 1.00 1.21 (0.80–1.83) 0.72 (0.45–1.15) | 1.00 0.62 (0.44–0.87)** 0.27 (0.19–0.40)*** | 1.00 0.64 (0.49–0.84)** 0.34 (0.25–0.47)*** |
Sex Male Female | 1.00 2.59 (1.83–3.67)*** | 1.00 7.30 (3.22–16.53)*** | 1.00 1.16 (0.72–1.88) | 1.00 1.24 (0.89–1.72) | 1.00 2.30 (1.75–3.02)*** | 1.00 2.07 (1.67–2.57)*** |
Migration background No 1st generation 2nd generation | 1.00 0.52 (0.23–1.20) 1.27 (0.84–1.94) | 1.00 0.57 (0.12–2.64) 1.19 (0.58–2.44) | 1.00 5.44 (2.80-10.54)*** 2.78 (1.58–4.87)*** | 1.00 0.86 (0.42–1.73) 1.17 (0.76–1.81) | 1.00 0.69 (0.37–1.27) 1.13 (0.79–1.61) | 1.00 0.93 (0.60–1.44) 1.38 (1.04–1.83)* |
Income 1st quartile 2nd quartile 3rd quartile 4th quartile | 1.00 1.42 (0.88–2.30) 1.14 (0.70–1.86) 1.10 (0.67–1.80) | 1.00 1.48 (0.60–3.61) 1.71 (0.72–4.08) 1.31 (0.54–3.21) | 1.00 2.35 (1.13–4.87)* 1.45 (0.67–3.16) 1.47 (0.68–3.17) | 1.00 1.15 (0.68–1.93) 1.19 (0.70-2.00) 2.28 (1.41–3.67)*** | 1.00 1.24 (0.82–1.87) 1.51 (1.01–2.25)* 1.56 (1.05–2.33)* | 1.00 1.24 (0.90–1.70) 1.23 (0.89–1.68) 1.56 (1.14–2.13)** |
Education Highest High Intermediate Low | 1.00 1.35 (0.82–2.21) 1.03 (0.63–1.66) 1.29 (0.76–2.19) | 1.00 1.40 (0.68–2.89) 0.56 (0.24–1.27) 0.22 (0.06–0.77)* | 1.00 1.17 (0.57–2.42) 1.02 (0.49–2.12) 1.69 (0.81–3.55) | 1.00 1.14 (0.68–1.93) 1.10 (0.67–1.82) 1.36 (0.81–2.29) | 1.00 0.92 (0.58–1.48) 1.49 (0.99–2.25) 2.70 (1.76–4.14)*** | 1.00 1.12 (0.79–1.59) 1.26 (0.91–1.73) 1.88 (1.34–2.64)*** |
Nagelkerke’s R2 | 0.114 | 0.182 | 0.092 | 0.036 | 0.107 | 0.094 |
Table
4 shows the results of the multiple logistic regression analyses with the socio-demographic predictors being introduced as predictors simultaneously. In terms of age-related discrimination, the two older age groups were significantly less likely to report discrimination compared to the youngest group (18 to 40 years) after adjustment for all other socio-demographic factors. Moreover, women were about 2.6 times more likely to perceive discrimination due to age than men. Regarding perceived sexist discrimination in health care, people aged 60 years and older as well as people having a low education were significantly less likely to report this. Female respondents had a more than 7 times increased likelihood compared to males. Probability of perceiving racist discrimination was increased among 1st (odds ratio 5.44) and 2nd generation migrants (odds ratio 2.78) (compared to people without migration background) as well as respondents belonging to the 2nd highest income quartile (odds ratio 2.35) while it was significantly decreased among the two higher age groups (odds ratio 0.30 and 0.54). SES-related discrimination was significantly increased in the lowest income group in comparison to the highest income group. The two older age groups were significantly less likely to report discrimination due to health issues or disability compared to the youngest group, while females were more likely. Likelihood of perceived discrimination in this regard was increased among lower income and education groups. The summarized indicator of perceived discrimination was significantly associated with all socio-demographic characteristics of the respondents showing strongest relation with age and sex. Explained variance (Nagelkerke’s R
2) ranged between 4% and 18% depending on the indicator of perceived discrimination.
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