Self-Reported Experience of Racial Discrimination and Health Care Use in New Zealand: Results From the 2006/07 New Zealand Health Survey

Objectives. We investigated whether reported experience of racial discrimination in health care and in other domains was associated with cancer screening and negative health care experiences.Methods. We used 2006/07 New Zealand Health Survey data (n = 12 488 adults). We used logistic regression to examine the relationship of reported experience of racial discrimination in health care (unfair treatment by a health professional) and in other domains (personal attack, unfair treatment in work and when gaining housing) to breast and cervical cancer screening and negative patient experiences adjusted for other variables.Results. Racial discrimination by a health professional was associated with lower odds of breast (odds ratio [OR] = 0.37; 95% confidence interval [CI] = 0.14, 0.996) and cervical cancer (OR = 0.51; 95% CI = 0.30, 0.87) screening among Maori women. Racial discrimination by a health professional (OR = 1.57; 95% CI = 1.15, 2.14) and racial discrimination more widely (OR = 1.55; 95% CI = 1.35, 1.79) were associated with negative patient experiences for all participants.Conclusions. Experience of racial discrimination in both health care and other settings may influence health care use and experiences of care and is a potential pathway to poor health.Racism is increasingly recognized as an important determinant of health and driver of ethnic health inequalities.1 Regardless of its health effects, racism breaches fundamental human rights and is morally wrong. It is important to understand how racism operates as a health risk to develop interventions that reduce ethnic inequalities in health within a context of eliminating racism.2Racism is an organized system that categorizes racial/ethnic groups and structures opportunity, leading to inequities in societal goods and resources and a racialized social order.3–5 Racism operates via institutional and individual practices (racial discrimination) and varies in form and type.6,7 The pathways whereby racism leads to poor health are also multiple, with direct and indirect mechanisms such as race-based assaults and violence, physiological and psychological stress mechanisms, differential exposures to health risk factors, differential access to and experiences of health care, and differential access to goods, resources, and power in society.6,8–10Research on racism and health, particularly self-reported racism, has increased. Self-reported experience of racism has been linked to multiple health measures (including mental and physical health outcomes and health risk factors) across a variety of countries and for different ethnic groups.10–12 Research on how self-reported experience of racism may negatively affect health has largely focused on racism as a stressor with mental and physical health consequences.10,13 Comparatively less evidence is available on how experience of racism may influence health service use,10 although this is another potentially important pathway to poor health.14,15Studies on the association between self-reported racism and health care experience and use have included racism experienced within the health care system, outside of the health care system, or both.16–19 Health care measures have included use of specific services such as cancer screening19–24 and receipt of optimal care,20,25 measures of unmet need,16,26 measures of adherence to care,17,27,28 and measures of satisfaction and experiences with care.18,29–31Various mechanisms have been suggested to explain how the experience of racism may negatively affect health care use, experiences of health care, and subsequent poor health. Experiences of racism within the health care system may influence health by shaping decision making of both providers and patients and influencing future health behaviors, including future health care use behaviors and potential disengagement from the health care system.14,18,26 Experiences of racism in wider society also may lead to general mistrust and avoidance of dominant culture institutions, including health care systems.15,30 This is supported by evidence that both experiences of racism and general discrimination within and outside of health care have been associated with negative health care use measures.15,16,19,22New Zealand has a population of approximately 4.4 million people, with the major ethnic groupings being Maori (indigenous peoples, 15% of the population), European (77%), Pacific (7%), and Asian (10%).32 Ethnic inequalities in health and socioeconomic status persist, with racism a potentially important contributor to these inequalities.33 Previous research in New Zealand has shown reported experience of racial discrimination by a health professional to be higher among non-European ethnic groups with experiences of racial discrimination in different settings associated with multiple health outcomes and risk factors.34In this study, we focused on the relationship between racial discrimination and health service use and experience, an area not previously examined in New Zealand. We provide important information on how racial discrimination may affect health care use as a possible pathway to poor health outcomes and ethnic health inequalities in New Zealand. In addition, our study contributes to the limited evidence on racial discrimination and health care internationally.Primary health care in New Zealand is available to all residents and is usually provided at general practices. Costs of visits are universally subsidized by government to enable lower patient copayments with additional limited provision for extra funding based on high need.35 Currently, 2 publicly funded national cancer screening programs are available.36 Breast cancer screening is free to all eligible women through BreastScreen Aotearoa. Cervical cancer screening usually incurs a fee and is available through patients’ usual primary care provider or specific cervical cancer screening providers.We specifically examined the association between self-reported experience of racial discrimination and the use of health care in 2 domains—cancer screening and negative patient perceptions of health care encounters. We hypothesized that experience of racial discrimination both within and outside the health care system may negatively affect how individuals use and experience health care.     

The pervasive effects of racism: experiences of racial discrimination in New Zealand over time and associations with multiple health domains

Self-reported experience of racial discrimination has been linked to a range of health outcomes in various countries and for different ethnic groups. This study builds on previous work in New Zealand to further investigate the prevalence of self-reported experience of racial discrimination by ethnicity, changes over time and associations with multiple health measures. The study uses data from the 2002/03 (n=12,500) and 2006/07 (n=12,488) New Zealand Health Surveys, nationally representative population-based surveys of adults (15+ years). Reported experience of racial discrimination was measured in both surveys and covered 5 items: experience of an ethnically motivated physical or verbal attack; and unfair treatment because of ethnicity by a health professional, in work, or when gaining housing. Ethnicity was classified as Maori, Pacific, Asian or European. Health indicators included measures of: mental health (SF36 mental health scale, psychological distress, doctor diagnosed mental health condition); physical health (self-rated health, SF36 physical functioning scale, cardiovascular disease); and health risk (smoking, hazardous drinking, excess body fat). Logistic regression was used to examine changes in prevalence of reported experience of racial discrimination over time and associations with health. Reported experience of racial discrimination increased between 2002/03 (28.1% ever) and 2006/07 (35.0% ever) among Asian peoples but remained largely unchanged for other ethnic groupings (Maori 29.5%, Pacific 23.0%, European 13.5%). Experience of racial discrimination was associated with all negative health measures except excess body fat. Where there were significant associations, a dose-response relationship was also evident. We conclude that racial discrimination experienced across a range of settings has the potential to impact on a wide range of health outcomes and risk factors. While ongoing research is needed to understand the multifarious nature of racism and the pathways by which it leads to poor health, it is feasible to monitor experiences of racial discrimination in national surveys.     

Iodine intake and status during pregnancy and lactation before and after government initiatives to improve iodine status,in Palmerston North,New Zealand: a pilot study

Iodine deficiency during pregnancy and lactation may adversely affect fetal and infant development. Two initiatives were introduced in New Zealand to prevent deficiency: (1) mandatory fortification of bread with iodised salt; and (2) provision of a subsidised iodine supplement (150 μg) for all pregnant and breastfeeding women. The aim of this study was to assess iodine intake and status among a self‐selecting sample of pregnant and lactating women in Palmerston North, both before and after the two initiatives. Pregnant and breastfeeding women were recruited before (n = 25 and 32; 2009) and after (n = 34 and 36; 2011) the initiatives. Iodine concentration was determined in 24‐h urine and breast milk samples using inductively‐coupled plasma mass spectrometry. Use of supplements and salt, knowledge of iodine deficiency, and awareness of the initiatives were determined by questionnaire. Median urine iodine concentration (UIC) was higher in 2011 compared with 2009 for both pregnant (85 and 47 μg L^?1) and breastfeeding (74 and 34 μg L^?1) participants; median UIC were below the cut‐offs for adequate iodine status. However, in 2011, the estimated daily iodine intake during pregnancy was 217 μg day^?1; 74% of women achieved the Estimated Average Requirement. Knowledge of the initiatives was low, only 28–56% were aware of the need for iodine supplements and only 15–22% were aware of the mandatory addition of iodised salt to bread. Despite initiatives, UIC of these women indicates iodine deficiency, however, dietary intakes appear adequate. Ongoing surveillance of supplement use and iodine status among pregnant and lactating women throughout New Zealand is needed to fully assess the efficacy of the initiatives. Alternative strategies may require evaluation to ensure all women have adequate iodine during pregnancy and breastfeeding.