This study used data from a national population-representative survey to look at the experiences of people who are socially disadvantaged due to gender, immigration, race/ethnicity, and religion, within the healthcare setting in France. We examined rates of reported discrimination and how they may explain disparities in rates of foregoing healthcare among those groups. Overall, our findings suggest that discrimination in healthcare is associated with foregoing medical care, and that this is especially important for women and people in minority racial or religious groups.
More specifically, our results suggest three main points. First, we showed that disadvantaged social groups – particularly women, immigrants, those of African origin, and Muslim religion – are more likely to have experienced discrimination in healthcare settings. The population prevalence of discrimination of 3.9%, which was in line with prior research across more than 30 European countries documenting national rates of discrimination in primary care between 1.4 and 12.8% [32], obscures the heterogeneity across groups, with rates nearly doubling for disadvantaged groups. For many of these groups, this finding is consistent with a broad base of existing literature, as they have been shown to face higher risks of discrimination in French society. Immigrants and their children from Sub-Saharan Africa, North Africa, and the French overseas territories report higher rates of perceived discrimination, measured through both general and setting-specific discrimination questions (at school, on the labor or housing markets, etc.) [33]. These minority groups also face racism more frequently [34]. Among religious groups, our observation of a high rate of discrimination against Muslims in the healthcare system echoes previous findings of discrimination in other settings [33], especially the labor market [35], and high levels of anti-Muslim prejudice in French society overall [36]. In contrast, there seems to be a specificity of the healthcare setting for women. Our findings are consistent with qualitative evidence showing that women tend to report discrimination in healthcare settings more often than men [37], but differ from findings in other settings (school, the labor and housing markets) where women are less likely to perceive discrimination [33]. One possible factor contributing toward this setting-specificity could be the higher rate of healthcare utilization by women, which would in turn increase their exposure to the possibility of experiencing discrimination within that setting.
Second, our analysis documented disparities in the rates of foregoing medical care across populations of social disadvantage due to gender, immigration, race/ethnicity, and religion. Many of the groups with higher rates of foregoing healthcare were the same as those who reported higher rates of discrimination in healthcare – women, immigrants (though second-generation, rather than first), people with origins in Africa or Overseas France, and Muslims. Other groups with comparatively high rates of foregoing healthcare were those with mixed origins, and those who reported as “Other Religion”. For some groups, these findings are in line previous research on foregoing care: for example, there is evidence of higher rates of foregoing healthcare among adult women in Sweden and adolescent girls in the USA [18, 38]. Similarly, prior research has consistently documented higher rates of foregoing care among disadvantaged racial and ethnic minority groups in the US [39, 40]. However, there is less existing research on migrant generation and foregoing care, and our finding of higher rates of foregoing care among second-generation immigrants in France differs from a study of immigrant children in the USA, which documented higher rates of foregone care for first-generation immigrants, but not second-generation [41]. We are not aware of other reports of foregone healthcare by religion.
Finally, we examined the potential explanatory role of experiences of discrimination in the healthcare setting on foregoing healthcare. We found reports of discrimination to be robustly linked with foregoing care: in our fully adjusted model of foregoing care, discrimination in the healthcare setting was associated with an average 14 percentage-point increase in the predicted probability of foregoing care. Of note, this contrasts with a prior study that found the link between discrimination and decreased healthcare utilization to be explained by socioeconomic status [16]. These findings can also be considered alongside a USA-based study that found discrimination to be associated with more frequent healthcare visits [13] together, these studies are consistent with the model described in this paper, in which healthcare need (observed as frequency of visits) is an enabling factor for discrimination in healthcare, which results in a higher likelihood of foregoing future care [28]. Overall, findings in this study are consistent with existing research on discrimination as a barrier to healthcare: in addition to the previously mentioned Swedish study linking discrimination with foregone healthcare, qualitative research from Spain has described experiences of discrimination as a factor limiting access to healthcare [42], and experiences of discrimination have been linked to avoiding dental care in Australia [43].
We also contextualized this relationship by determining the potential proportion of disparities in foregoing care that could be explained by experiences of discrimination in healthcare. Groups for whom discrimination explained an especially large proportion of disparities in foregone care were people with origins in Sub-Saharan Africa (32%) and Muslims (26%). Also of note were women (17%); although the proportion explained was lower for women than for some other groups, the fact that they constitute half of the population points toward a large potential effect of discrimination when considered at the level of French society. Interestingly, the proportion of the disparity in foregoing care for second-generation immigrants explained by discrimination was small (8%). Taken together with the findings by region of origin, this suggests that discrimination may be of particular importance for healthcare utilization among immigrants who are more readily racialized based on their appearance and face higher levels of racism already.
This study has a number of limitations that should be noted. First, this was cross-sectional and thus no causal inference regarding discrimination and foregoing healthcare can be made – it is for this reason that results are framed in terms of the potential explanatory nature of discrimination. Future studies should consider possible natural experiments or other quasi-experimental designs in order to more rigorously test any causal relation between discrimination and foregoing healthcare. Second, we used a single-item measure of discrimination in healthcare settings, framed as being treated poorly compared to other patients. It is possible that a different assessment of discrimination, such as an adapted version of the Everyday Discrimination Scale [44], would reveal a different pattern of rates of discrimination. Third, we did not examine the specific type of healthcare that individuals reported having foregone, and thus do not know to what extent the foregone care was necessary. Finally, although this study was nationally representative of France, findings may be dependent on the societal dynamics and healthcare setting specific to France at that time (2008–2009), and consequently not generalizable to other settings. However, the rates of both discrimination in healthcare settings and of foregoing care are generally similar to those described in Sweden [18] – which has a different healthcare system and a more homogenous population – suggesting that similar trends may exist at least in other parts of Europe. Further, given the contemporary increase in far-right voting and associated anti-immigration politics in France, we would hypothesize that our estimates here represent lower bounds for experiences of discrimination in the present.
With these potential limitations in mind, the implications of this study can be discussed. We observe disparities between social groups in terms of discrimination in healthcare settings – a negative phenomenon itself – as well rates of foregone healthcare, an important hurdle in the functioning of any health system [45]. The affected groups represent large sections of French society (e.g., women, major immigrant groups, etc.), suggesting a substantial burden when considered at the national level. These disparities stand in opposition to the global goals of health equity [46,47,48], and should be considered in the discussion and design of interventions and health policies. Suggested interventions to reduce discrimination in healthcare settings include provider-level interventions, grounded in psychology research, that aim to improve provider understanding of bias and increase perspective-taking and empathetic behaviors [49], such as an intervention involving feedback on biased behaviors and interactions with a virtual patient that may reduce racial bias in pain medicine prescribing [50]. More systemic actions include policies that increase organizational accountability for discrimination, or social marketing campaigns that aim to shift population norms with anti-discrimination messaging [51]. The robust linkage between experiences of discrimination and foregoing healthcare observed in this study, especially among women, immigrants of African origin, and Muslims, adds additional context to the web of barriers that people in socially disadvantaged groups face and points to potential high-priority groups around which interventions may be structured.
