Health care barriers, racism, and intersectionality in Australia
Introduction
Amidst a long history of massive social and scientific efforts towards constructing and legitimizing race as a biologically valid category, including the widespread politics of eugenics in Europe and the Americas in the late 19th and early 20th centuries (Levine and Bashford, 2010), the concept of racism emerged as an important counter-narrative for explaining racial inequities (Duckitt, 2010). It was not until the beginning of the 1980s, however, that a consistent body of work began to thoroughly examine racism as a public health issue, with lasting impacts on the health of disadvantaged social groups (Krieger, 2014). Since then, the persistence of racism across time and place, together with its strong association with population patterns of health, well-being, and health inequities, has been characterized as one of the greatest public health challenges of our times. Through the development of varied frames of reference, empirical studies have systematically shown that racism is both a powerful driver of physical and mental health outcomes (Paradies et al., 2015), and a factor that underlies health inequities among dominant and subordinate racial categories (Krieger and Sidney, 1996).
While a large corpus of research examines the causes of racial disparities in health, existing scholarship is limited in four respects. First, few existing studies have the external validity required to determine the extent to which health-related outcomes are attributable to racism. Second, most large-scale studies of the health effects of racism focus on inequities between Blacks and Whites in the U.S. A third limitation concerns the dearth of studies examining how race works with other axes of inequality (e.g. gender) and other forms of discrimination (e.g., gender discrimination) to structure health outcomes. Fourth, few studies have examined the ways in which racial discrimination affects perceived access to health care.
Using the Australian context as a case study, we ask: (1) To what extent do perceptions of racial discrimination predict respondents’ barriers to health care?; (2) Does the relationship between perceptions of racial discrimination and barriers to health care differ for high and low status groups?; and (3) To what extent do perceptions of racial discrimination work with other forms of discrimination to structure barriers to health care? Throughout this article, we use the term “racism” to refer to a macro-level system that “is manifested in societies through the unequal distribution of power (resources, opportunities, benefits, capacities etc.),” and “racial discrimination” or “perceived racism” to refer to the interpersonal interactions that maintain or reinforce power differentials, as well as their consequences (Paradies, 2016, 1).
Existing research shows that racism works through a variety of micro- and macro-level processes to structure health outcomes. Studies focusing on the micro-level conceptualize racism as a social stressor, and emphasize cognitive, physiological, and emotional factors (Pascoe and Smart Richman, 2009). At the macro-level, researchers conceptualize the health effects of racism as resulting from multifaceted and intertwined processes, including exposure to economic and social deprivation, socially inflicted trauma, and inadequate health care (Krieger, 2014, Paradies, 2006). Conceptualizing health inequities from an “ecosocial” perspective, Krieger (2014) highlights the ways in which the health effects of institutionalized and interpersonal racism accumulate over the lifecourse, as well as over generations. According to this perspective, individuals “literally biologically embody exposures arising from our societal and ecological contexts” (Krieger, 2014, 73). In the aggregate, this embodiment gives rise to population patterns of health and disease that are structured not only by race, but also gender, sexuality, and class.
Research in the U.S. shows that Blacks receive significantly lower-quality health care than do Whites. Black patients are less likely undergo coronary artery bypass, less likely to receive kidney transplantations, for example, and also experience greater delays in transfer between healthcare facilities (Penner et al., 2014, Phelan and Link, 2015). The strong connections between racism and health care also extend beyond the realm of individual-level experiences. At the societal level, the concentration of racial minorities in communities lacking high-quality healthcare facilities creates racially patterned barriers to high-quality care, as do occupational structures in which racial minorities are concentrated in low-paying jobs with less flexible work-schedules (Krieger, 2014, Phelan and Link, 2015).
Scholarship investigating the link between perceived racism and health care is limited by an almost exclusive focus on patients’ race and the consequences of racial bias among physicians, leaving the effects of perceived racism on barriers to health care an under-researched topic in the field. A handful of studies show that racial discrimination may lead to disengagement with, and avoidance of, general (Lee et al., 2009) and dental care (Jamieson et al., 2013). Tanner et al. (2014) examined both race- and sexuality-based discrimination on access to health care, and found that sexuality-based discrimination, but not racial discrimination, was associated with perceiving access to urgent care as poor or fair.
Several mechanisms likely underlie the links between discrimination and perceived barriers to health care. In general, individuals' perceptions and anticipation of discrimination are positively associated with healthcare system distrust (A. D. Moore et al., 2013), which reduces the likelihood of seeking medical advice, utilizing preventive health services, and perceiving the healthcare system as accessible. Patients' prior experiences with discrimination in the healthcare system may also be associated with lower ratings of health care quality, and this may feed back into higher perceptions of reduced access to care. Additionally, after facing discrimination in other systems (e.g., the educational or justice systems), individuals may be reluctant to expose themselves to similar experiences in the healthcare system. More indirectly, experiencing discrimination may reduce the time and energy needed to access health care (Richman and Lattanner, 2014). This can also occur through avoidance behaviors. Perceiving discrimination or harassment on public transportation, for example, could lead to avoidance of this domain, which might then limit individuals’ access to health care.
Intersectionality is a theoretical perspective which highlights the ways in which multiple systems of inequality work with and through one another, at multiple levels of society (Collins, 2000, Zinn and Dill, 1996). At the core of intersectionality is the contention that the a priori centralization of one system of inequality, social status, or identity, obscures the ways in which systems of inequality co-constitute and mutually reinforce one another (Crenshaw, 1989, Hankivsky, 2012). Studies that rely on a single-axis approach often contribute to “intersectional invisibility” (Purdie-Vaughns and Eibach, 2008), wherein a person or group holding multiple disadvantaged social statuses may be made “invisible,” relative to those characterized by a single disadvantaged status.
Most intersectional studies of health emphasize intersecting statuses and identities. Studies reveal that groups with multiple disadvantaged statuses (e.g., Black women) often – though not always – experience poorer health outcomes than groups with a single disadvantaged status (Calabrese et al., 2015). Intersectional research focusing specifically on discrimination emphasizes that individuals with multiple disadvantaged statuses frequently perceive multiple forms of discrimination (Grollman, 2014, Harnois, 2014), as well as forms of discrimination that are not reducible to a single axis of inequality (Crenshaw, 1989). Evidence increasingly suggests that, compared to those who perceive discrimination along a single axis of inequality, those who perceive multiple forms of discrimination tend to experience worse health outcomes (Bastos et al., 2014, Grollman, 2014, Szymanski and Owens, 2009).
By focusing on the intersection of multiple social statuses, intersectionality draws attention not only to the various forms of discrimination, but also to the ways in which the consequences of any particular form of discrimination may vary for high and low status groups. Though there are important differences among them, low status groups (e.g., women, low SES individuals) tend to have less power, less control over their environment, and are less able to avoid situations in which subsequent instances of discrimination may occur (Ridgeway, 2014). Individuals in low status groups often have fewer social, economic, and psychological resources to deal with the potential consequences of stressful events such as discrimination (Pearlin and Schooler, 1978, Ridgeway, 2014, Szymanski and Owens, 2009). Moreover, the consequences of discrimination accumulate over the lifecourse, and may take an especially large toll on disadvantaged social groups (Krieger et al., 2008). Taken together, these theories highlight (1) the combined effects of multiple forms of discrimination as experienced by disadvantaged groups, and (2) the possibility that the consequences of perceived racism differ across multiple axes of inequality.
As previously noted, most research on the health effects of racism has focused on the U.S. The same holds true for studies of intersectionality. Both lines of research rest on the premise that race and other social hierarchies are organized through diverse social realities (Collins, 2000). Yet, we know comparatively little about intersectionality and health-related inequities outside of the U.S.
Racial discrimination is a particularly important social determinant of population health in societies with historical and contemporary structural and cultural racism in which the social values, norms, and practices of one group are considered superior to others (Augoustinos and Every, 2015). In Australia, this group is represented by White Australian-born heterosexual middle-class males. As a result, the values, norms, and practices of, for example, non-European immigrant groups are marginalized and stigmatized, supporting structurally racialized practices and policies, e.g., attitudes towards, and treatment of, asylum-seekers from non-English speaking countries (Canetti et al., 2016). Such ‘othering’ then influences judgments institutionalized within the health care system, e.g., implicit bias of health care providers (Hall et al., 2015).
Australia has an ethnically diverse population, with 28% of residents born overseas, and an additional 20% for whom at least one parent was born overseas. The most common country of origin for Australians born overseas is the United Kingdom (5%), New Zealand (2.5%), China (2.2%), India (1.9%) and Philippines (1%). Aboriginal and Torres Strait Islanders, in contrast, comprise approximately 3% of the total Australian population. Overall, about 20% of Australia's current population are either first or second generation immigrants from non-English speaking countries who may be racially and ethnically stigmatized (e.g., China, Philippines, India) (Australian Bureau of Statistics, 2016). While about 20% of Australians reporting at least one experience of racial discrimination over a year, this figure is much higher for Indian (39%), Chinese (39%), South Korean (55%), Kenyan (67%), Zimbabwean (75%) or South Sudanese (77%) migrants (Markus, 2016). The regularity of racial discrimination experiences also varies considerably by racial background. For example, 4% of migrants from the United Kingdom reported racial discrimination often (most weeks) compared to 12% of migrants from South Sudan. Types of racist experiences also vary by country of birth, such that for those from the United Kingdom, for example, verbal abuse is the most common, while for Australians from non-English speaking backgrounds, unfair treatment at work, physical assault, property damage are also commonly reported (Markus, 2016).
It is within this cultural context of Australia that we examine the link between racial discrimination and health care barriers. In terms of the healthcare system more broadly, Australia has a comprehensive system that provides universal access to a range of mental and physical health services, including interpreting for non-English speakers. Doctors may not refuse treatment to any individuals in Australia, regardless of their level of private health insurance. Public hospital services are free of charge, and access to primary care costs an average of only $5 per visit (Russell and Doggett, 2015).
Based on previous research, we hypothesize that, controlling for socio-demographic characteristics and health-related factors, racial discrimination will be positively associated with perceived barriers to health care (H1). Our intersectional approach complicates this general hypothesis, though. Specifically, we hypothesize that the effect of perceived racial discrimination will be particularly severe for low status groups, including women, sexual minorities, and low socioeconomic status (SES) individuals (H2). We further hypothesize that perceived barriers to health care will be structured not only by respondents' perceptions of racial discrimination, but also by respondents’ perceptions of class-, gender-, and sexuality-based discrimination (H3).
Section snippets
Study design and sample
The data come from the 2014 Australian General Social Survey (AGSS), a nationally representative survey of individuals aged 15 and older, living in 12,932 private dwellings.
Main explanatory variables – reports of discrimination
Respondents were first asked, “In the past 12 months …, do you feel that you have experienced discrimination or have been treated unfairly by others?” Those who answered “yes,” were subsequently asked to explain why the mistreatment occurred: “Thinking about your most recent experience of discrimination in Australia, do you
Participant characteristics
Table 1 shows the sample descriptive statistics. Approximately 51% of respondents were women, 3% of respondents identified as sexual minorities, 31% were born outside Australia or indicated they had difficulty speaking English, and over 25% of the sample indicated their main source of income for the past two years had been the government. The average age was similar across the groups (≅ 47 years), except for sexual minorities, and unmarried participants, who showed lower mean ages (≅ 37 years).
Discussion
This population-based study examined how perceptions of racial discrimination function with and through other systems of inequality to structure perceived barriers to health care in contemporary Australia. Drawing from intersectionality and ecosocial theories, we hypothesized that, controlling for socio-demographic characteristics and health-related factors, respondents who perceived experiencing racial discrimination would report greater barriers to health care (H1). We further hypothesized
Acknowledgements
João L Bastos received an award for excellence in research achievement from the Brazilian National Council for Scientific and Technological Development (CNPq), grant number 303857/2015-3. The Brazilian Coordination for the Improvement of Higher Education Personnel (CAPES) awarded a postdoctoral scholarship to João L Bastos, process number 88881.119350/2016-01, which also helped write this article.
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