Preventive Medicine 50 (2010) 86–92

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Perceived discrimination and health by gender, social class, and country of birth in aSouthern European country

Carme Borrell a,b,c,⁎, Carles Muntaner d, Diana Gil-González e, Lucia Artazcoz a,c, Maica Rodríguez-Sanz a,c,Izabella Rohlfs f,c, Katherine Pérez a,c, Mar García-Calvente g,c, Rodrigo Villegas a, Carlos Álvarez-Dardet e,c

a Agència de Salut Pública de Barcelona, Spainb Universitat Pompeu Fabra, Spainc CIBER Epidemiología y Salud Pública (CIBERESP), Spaind Center for Addictions and Mental Health and University of Toronto, Canadae Universidad de Alicante, Spainf Unitat de Planificació. CatSalut. Catalonia Health Department, Girona, Spaing Escuela Andaluza de Salud Pública, Spain

⁎ Corresponding author. Agència de Salut Pública d08023 Barcelona, Spain. Fax: +34 93 3686943

E-mail address: cborrell@aspb.cat (C. Borrell).

0091-7435/$ – see front matter © 2009 Elsevier Inc. Adoi:10.1016/j.ypmed.2009.10.016

a b s t r a c t

a r t i c l e i n f o

Available online 3 November 2009

Keywords:Social epidemiologyDiscriminationHealth outcomesSouthern EuropeGenderSocial Class

Objectives. This study aimed to examine the association between perceived discrimination and fivehealth outcomes in Spain as well as to analyze whether these relationships are modified by sex, country ofbirth, or social class.

Methods. We used a cross-sectional design. Data were collected as part of the 2006 Spanish HealthInterview Survey. The present analysis was restricted to the population aged 16–64 years (n=23,760). Fivedependent variables on health obtained through the questionnaire were examined. Perceived discriminationwas the main independent variable. We obtained the prevalence of perceived discrimination. Logisticregression models were fitted.

Results. Perceived discrimination was higher among populations originating from low income countriesand among women and showed positive and consistent associations with all poor health outcomes amongmen and with 3 poor health outcomes among women. Poor mental health showed the largest differencebetween people who felt and those who did not feel discriminated (prevalence for these 2 groups amongmen was 42.0% and 13.3%, and among women, was 44.7% and 22.8%). The patterns found were modified bygender, country of birth, and social class.

Conclusion. This study has found a consistent relationship of discrimination with five health indicators inSpain, a high-income Southern European country. Public policies are needed that aim to reduce discrimination.

© 2009 Elsevier Inc. All rights reserved.

Introduction

Social inequalities in health imply that health determinants suchas economic deprivation, discrimination, and hazardous living andworking conditions are accumulated by the most disadvantagedsocial groups (Krieger, 1999; Krieger, 2001; Kerbo, 1991). In thecase of Spain, recent changes in its social structure may haveincreased discrimination against various social groups. Spain wasunder the rule of a fascist dictatorship from 1939 to 1977, whenpolitical parties and trade unions were illegal. The recognition ofcivil liberties, including those related to women, was delayed untilthe end of the decade of the 1970s and early 1980s of the 20thcentury (Navarro and Shi, 2001). Additionally, immigration hasbeen one of the most important social changes in Spain. At the end

e Barcelona, Plaça Lesseps 1,

ll rights reserved.

of the 20th century, a wave of foreign immigration from low-income countries to Spain began and its rate increased markedly atthe beginning of the 21st century (11.3% of the population in 2008).The majority of these immigrants are from Latin American, EasternEuropean, and North African countries (Instituto Nacional deEstadística, 2009). The political history of Spain, the changes in itseconomic context and labor market, and the relentless increase ofimmigrant population of working age may influence the differentpatterns of discrimination, as well as its different impact onpopulation health compared with other countries.

In the last decade, the evidence showing the relationship betweendiscrimination andhealth has increased (Williams et al., 2003; Krieger,2000; Paradies, 2006;Williams et al., 2008; Ahmed et al., 2007; Zucker,Landry, 2007; Krieger, 2005; Pascoe and Smart Richman, 2009;Williams and Mohammed, 2009). Although the evidence is notconclusive, different studies have shown how social class and race orethnicity canmodify the patterns of perceived discrimination's impacton health (Paradies, 2006; Karlsen and Nazroo, 2002; Krieger et al.,

87C. Borrell et al. / Preventive Medicine 50 (2010) 86–92

1993; Forman, 2003; Harris et al., 2006; Kelaher et al., 2008). Themajority of studies on the impact of discrimination in health have beencarried out in theUSA. Research in Europe and elsewhere is very scarceand particularly in Southern Europe is almost non-existent (Krieger,2000; Paradies, 2006; Pascoe and Smart Richman, 2009; Williams andMohammed, 2009), although several articles have been published inSpain studying patterns of discrimination and health in immigrants(Agudelo-Suarez et al., 2009; Llacer et al., 2009) Moreover, themajority of studies to date analyze selected populations and a reducednumber of health outcomes. The present article tries to fill these gaps.Our objectives thus are to examine the association between perceiveddiscrimination and five health outcomes in Spain as well as to analyzewhether these relationships are modified by sex, country of birth, orsocial class.

Methods

Study population, sample, and data collection

We used a cross-sectional design. The population frame was the 2006Spanish population not living in any institution. Data were collected as part ofthe 2006 Spanish Health Interview Survey, which is representative of thewhole population living in households. The total number of peopleinterviewed older than 16 years was 29,476. Data were collected throughface-to-face interviews at home between June 2006 and June 2007(Ministerio de Sanidad y Consumo, 2006). The present analysis was restrictedto the population aged 16–64 years (n= 23,760) because only 1% of thepopulation older than 64 years (n= 59) declared having experienceddiscrimination and also to ensure a working age population that was morehomogeneous.

Variables

Dependent variablesWe considered five dependent variables.

- Self-reported health status was measured through a single question:“Would you say your overall health is very good, good, fair, poor, or verypoor?” This is a broad indicator of health-related well-being (Segoviaet al., 1989) and has also proved to be a good predictor of mortality(Idler and Benyamini, 1997). A dichotomous outcome variable wascreated (1=fair, poor, or very poor; 0=very good, good).

- Mental Health was measured with the 12-item version of the GeneralHealth Questionnaire (GHQ-12) (Goldberg, 1972). This is a screeninginstrument widely used to detect risk of current, diagnosable psychiatricdisorders. We used a two-point scoring method, rating a problem asabsent (0) or present (1). The responses were summed, and theparticipants scoring 3 or more were classified as having poor mentalhealth (Goldberg, 1978).

- Hypertension was assessed by a question about whether they sufferedfrom hypertension during the last year. Self-reported hypertension hasproved to have a good agreement with medical records (Kehoe et al.,1994; Okura et al., 2004) and with individual blood measurements(Vargas et al., 1997).

- Smoking status grouped as current smokers (daily as well as non-dailysmokers) and non-smokers. Past smokers were considered non-smokers.

- Unmet need for medical care was measured through the answer to thequestion: “In the last 12 months, has there been any time when youneeded medical care but could not get it?” (yes, no).

Independent variables

a) Discrimination: we used a discrimination questionnaire based on thatdesigned by Krieger et al. (2005) asking whether the interviewee had“during the last year experienced discrimination, been prevented fromdoing something or been hassled or made to feel inferior because of his/her sex, ethnicity or country of birth, educational level or social class,sexual orientation or religion.” If the answer was yes, they were thenasked what types of discrimination (sex, country of birth, social class,sexual orientation, religion) they had suffered in the following 6

situations: “at work, getting a job, at home discriminated by his/herpartner, at home discriminated by others, getting medical care, on thestreet or in a public setting,” answering in terms of the Likert scale: never,sometimes, often, constantly. Only 1% of the sample aged 16–64 years didnot answer this question. Hence, we created an indicator of perceiveddiscrimination (yes/no) and also a score to measure the level of perceiveddiscrimination. The score was obtained by adding all the items of any typeof discrimination and of any situation. “Sometimes” had a value of 1,“often” a value of 2, and “constantly” had a value of 3. The total sum of thescores can range from 0 (no perceived discrimination) to 90 (if all 5 typesand 6 situations had been declared as “constantly”). Among the peoplediscriminated, 49.2% had a score of 1; 36.5%, 2–3; 11.1%, 4–6; and 3.2%,more than 6. Based on these results, we created a 4-level categoricalvariable: none, 1, 2–3, 4 or more.b) Gender, social class, and country of birth: we included these stratifyingvariables in order to explore if patterns of the relationship of discrimi-nation with health outcomes changed in the different strata (Krieger,2000; Borrell et al., 2007). Social class was assigned according to thehighest occupation of the household (Krieger et al., 1999; Borrell et al.,2004) and measured with a widely used Spanish adaptation of the BritishRegistrar General classification (Domingo-Salvany et al., 2000); the sixoriginal classes were collapsed into two groups: non-manual and manual.Country of birthwas obtained through the country of birth. Itwas categorizedas “Spanish-born”, “born in some other rich country” (EU-15 countries andthose countries with human development indexes larger or equal to 0.9(United Nations Development Programme)), and “born in a low incomecountry” (all other countries). Due to the small sample size, the examinationof thedifferentpatternsof relationshipofdiscriminationandhealthoutcomesby country of birth was limited to those born in Spain or in low incomecountries.c) Confounding variables were age, marital status (single, married orcohabitating, widowed, divorced or separated), social support, assessedby the Duke profile (Broadhead et al., 1988), which was validated in Spain(Bellon et al., 1996), categorized in 4 quartiles, and body mass index:[Declared weight (in kilograms)/declared height (in meters)2], used toadjust the models where hypertension was the dependent variable (Gee,2002), categorized as b20, 20 to b25, 25 to b30, ≥30.

Missing values of independent variables are included in Table 1.

Data analysis

All the analyses were done separately for men and women and includedweights derived from the complex sample design. A description of all thevariables was done.

We described the prevalence of poor health outcomes comparing personswith different levels of perceived discrimination. Differences between theprevalence of health outcomes by whether discrimination had beenperceived or not (i.e., 2 categories) were assessed with a Chi-square test. Tocompare the prevalence of poor health status by different levels of the scoreof perceived discrimination, we performed a Chi-square test of linearity.

Multivariate logistic regression models were fitted to determine theassociations (adjusted odds ratios aOR) between the dependent variablesand each variable of perceived discrimination adjusting for age (continuous),marital status (Arber, 1997), and social support (Duke Profile) (Borrell et al.,2007; Gee, 2002), the hypertensionmodel also included bodymass index (Gee,2002) and the unmet need for medical care model included self-perceivedhealth (in 2 categories) (Wamala et al., 2007b) as a controlling variable. Inorder to examine whether there was an increase in aOR of poor health statuswith increasing levels of the score of discrimination, we also fitted logisticregression models with discrimination score expressed as an ordinal variable.In the next step of the analysis, additionally, logistic regression models werefitted for the different categories of social class and country of birth because ourhypothesis was that the relationship of discrimination with health outcomesmay be modified by these variables.

Results

The prevalence of perceived discrimination during the year priorto the interview was 4.8% of men and 7.7% of women (Table 1). Themajority of them had a score of 1 implying that they had perceivedonly one type of discrimination and in one situation.

Table 1Distribution of the sample and prevalence of perceived discrimination by dependent and independent variables; men and women 16–64 years of age, Spain 2006.

Men (n= 12,019) Women (n= 11,741)

Distribution (%) Prevalence discrimination (%) P-value Distribution (%) Prevalence discrimination (%) P-value

Dependent variablesSelf-perceived healthGood 77.5 4.0 68.3 6.5Poor 22.5 7.5 b0.001 31.7 10.6 b0.001

Mental healthGood 80.1 3.2 71.1 5.8Poor 13.9 13.3 b0.001 23.2 14.3 b0.001Missing value 6.0 5.7

HypertensionNo 85.0 4.8 85.8 7.9Yes 14.4 4.8 0.521 13.7 6.7 0.055Missing value 0.6 0.5

SmokingNo 60.6 3.9 70.3 7.3Yes 39.4 6.2 b0.001 29.7 8.8 b0.001

Unmet need medical careNo 96.9 4.6 94.8 7.3Yes 3.1 12.0 b0.001 5.2 16.7 b0.001

Independent variablesSocial classI 13.3 2.6 12.3 8.2II 13.8 3.3 13.2 7.0III 26.0 4.4 25.8 5.3IV 37.5 5.4 39.4 8.5V 8.3 9.5 b0.001 8.0 11.5 b0.001Missing value 1.1 1.3

Country of birthSpain 85.9 3.3 84.3 5.7High income countries 2.1 5.1 2.1 8.1Low income countries 11.7 16.1 b0.001 13.3 21.1 b0.001Missing value 0.3 0.3

Age group15–24 15.7 5.0 15.2 8.225–34 25.7 6.7 24.7 10.835–49 35.0 4.4 34.8 7.850–64 23.6 3.3 b0.001 25.3 4.5 b0.001

Marital statusSingle 42.7 5.3 32.0 9.6Married 52.4 4.2 59.4 6.3Widowed 0.7 0.0 2.7 4.8Separated, divorced 3.8 8.7 b0.001 5.5 14.4 b0.001Missing value 0.4 0.4

Social support (Duke profile)—QuartilesQ1 less 25.6 7.3 24.6 12.0Q2 21.5 5.4 21.1 8.1Q3 25.0 2.7 26.6 5.7Q4 more 21.5 2.9 b0.001 22.3 5.2 b0.001Missing value 6.4 5.4

Body mass indexb20 3.1 6.1 12.2 9.620 to b25 38.2 5.6 45.2 8.025 to b29 40.7 3.9 24.2 7.1≥30 13.5 4.6 0.002 11.6 7.7 0.005Missing value 4.5 6.8

DiscriminationDiscriminationNo 94.2 – 91.3 –

Yes 4.8 – 7.7 –

Missing value 1.0 – 1.0 –

Discrimination (score)0 94.2 – 91.3 –

1 2.5 – 3.7 –

2–3 1.7 – 2.8 –

≥4 0.6 – 1.2 –

Missing value 1.0 1.0

Total 100.0 4.8 100.0 7.7

Unweighted numbers of cases: men=8832, women=12,811.P-value of the Chi-square test comparing the prevalence of discriminations in the different groups.

88 C. Borrell et al. / Preventive Medicine 50 (2010) 86–92

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More than half of the population belonged to non-manual (I, II, III)social classes. The proportions of men and women who had been bornin low income countries were 11.7% and 13.3%, respectively. Themajority of the population was single or married. In both sexes,perceived discrimination was more prevalent in the young population,in people from social class V (non-qualified manual), from low incomecountries, separated or divorced and with less social support (Table 1).

Prevalence of discrimination was highest among people from lowincome countries, butwhereas amongmen from those countries itwashigher among non-manual people (22.0%), amongwomen the patternwas the reverse (22.7 among manual females). Spanish-born non-manual men had the lowest prevalence of perceived discrimination(2.7%) (Table 2). Discrimination due to ethnic group or country of birthwas more prevalent in persons from low income countries, mainly innon-manual social class men and manual social class women. Manualsocial class women from low income countries suffered morediscrimination when looking for a job, in the workplace, at homewith their partner, in gettingmedical care, and in public settings. Non-manual social class men from low income countries suffered morediscrimination when looking for a job, in the workplace, and in publicsettings.

Perceived discrimination (yes/no) was associated with all depen-dent variables amongmen and to all variables except hypertension andsmoking among women at multivariate level (Table 3). Poor mentalhealth showed the largest difference between people who felt andthosewho did not feel discriminated. The prevalence for these 2 groupsamong men was 42.0% and 13.3% (adjusted OR=4.19, 95% CI: 3.47–5.06), and among women, was 44.7% and 22.8% (adjusted OR=2.51,95% CI: 2.17–2.91). Interestingly a consistent gradient was found in theprevalence of poor health outcomes by levels of discrimination, exceptfor hypertension. In the multivariable models, for all dependentvariables, except hypertension and smoking among women, as thescore of perceived discrimination increased, the aOR rose.

Table 4 presents the results by country of birth and social class.Most prevalence of poor health outcomes was higher among peoplewho declared to have perceived discrimination. The magnitude of theassociation between perceived discrimination and health wasconsistently higher across all the health outcomes analyzed amongnon-manual social class men from low income countries as comparedwith their manual counterparts. Among women born in Spain and inlow income countries, therewere no different patterns of associations.

Table 2Number of cases and prevalence (%) of perceived discrimination. Prevalence (%) of perceiv

Number of cases and prevalenceof discrimination

Prevalence of discrimination bytype of discrimination

No. of casesdeclaring perceiveddiscrimination

Prevalence ofdiscrimination

Bysex

By country ofbirtha

By social clor educatiolevel

MenSpainNon-manual 155 2.7 0.3 0.5 1.1Manual 177 4.1 0.3 1.0 1.7

Low income countriesNon-manual 75 22.0 1.2 22.0 2.6Manual 144 14.1 1.3 13.0 1.1

WomenSpainNon-manual 306 5.7 3.5 0.4 1.4Manual 246 5.7 2.6 0.8 1.6

Low income countriesNon-manual 65 15.8 5.1 12.6 2.7Manual 246 22.7 4.0 20.0 3.7

Men and women, 16–64 years of age, stratified by country of birth and social class, Spain 2Number of cases are weighted.One person can declare more than one type and situation of discrimination.

a By country of birth or ethnicity.

Discussion

The main findings of our study were as follows: (a) perceiveddiscrimination was higher among migrants from low-incomecountries and among women; (b) perceived discrimination showedpositive and consistent associations with the majority of poor healthoutcomes; (c) a consistent gradient was foundwith these associationssignificantly increasing as the level of the discrimination scoreincreased; and (d) these patterns were modified by gender, countryof birth, and social class.

Strengths and limitations

This study has several strengths. First of all, it is the first study ofthis kind conducted in a Southern European country, representing thewhole country, it includes a variety of health outcomes and its resultsare analyzed taking into account different forms of social inequality(gender, social class, and country of birth).

One limitation is that the cross-sectional design limits the ability tomake causal inferences and we cannot rule out the possibility that theperception of discrimination might have been influenced by priorhealth status (mainlymental health) (Alonso et al., 2008).However, theresults found in this study are very consistent across many healthoutcomes. Additionally, we found a consistent gradient with increasingprevalence of poor health corresponding to increasing levels ofdiscrimination.Moreover, someprospective studies have alsodescribedthe association between perceived discrimination and mental health(Paradies, 2006; Williams and Mohammed, 2009; Schulz et al., 2006).

Discrimination and health

It is necessary to mention that the declared perceived discrim-ination is low compared to other studies. The acknowledging ofdiscrimination depends on social, cultural, and economic character-istics, in the case of Spain discrimination has not yet been construedas a social problem, therefore it is difficult to compare theprevalence found with the results of other countries. In the studyby Llacer et al. (2009) done with Ecuadorian immigrants, prevalencewas higher than that corresponding to people from low incomecountries in our study, but the population they included is notcomparable with ours.

ed discrimination by type and situation of discrimination.

Prevalence of discrimination bysituation of discrimination

assnal

By sexualorientation

Byreligion

Gettinga job

Atwork

At home:partner

At home:other

Gettingmedicalcare

Publicsetting

0.2 0.1 0.3 1.5 0.0 0.1 0.2 0.90.2 0.2 1.0 1.8 0.2 0.1 0.5 1.6

0.0 1.2 7.6 9.1 0.0 0.0 2.9 17.00.1 1.5 4.9 6.5 0.2 0.1 0.7 7.5

0.2 0.1 1.4 3.0 0.5 0.6 0.5 1.60.2 0.1 1.5 1.9 0.9 0.5 0.7 1.6

0.5 0.7 6.8 3.6 0.5 0.5 1.5 9.50.7 0.7 12.1 7.6 2.5 0.5 4.3 12.7

006.

Table 3Prevalence of poor health outcomes (%) by different levels of perceived discrimination and multivariate association (adjusted odds ratios) between different levels of perceiveddiscrimination and health outcomes.

Poor self- perceived health Poor mental health Hypertension Smoking Unmet need for medical care

Prevalence aOR (95% CI) Prevalence aOR (95% CI) Prevalence aOR (95% CI) Prevalence aOR (95% CI) Prevalence aOR (95% CI)

MenDiscriminationNo 21.8 1 13.3 1 14.5 1 38.9 1 2.9 1Yes 35.0a 2.15 (1.78–2.60)b 42.0a 4.19 (3.47–5.06)b 14.5 1.40 (1.07–1.82)c 50.9a 1.51 (1.27–1.79)d 7.7a 2.15 (1.54–3.01)b

Discrimination(score)0 21.8 1e 13.3 1e 14.5 1e 38.9 1e 2.9 1e

1 37.0 2.20 (1.70–2.84)b 35.9 3.12 (2.38–4.08)b 13.7 1.10 (0.76–1.60) 48.8 1.37 (1.09–1.74) d 6.5 1.80 (1.11–2.91)c

2–3 29.9 1.88 (1.37–2.57)b 46.7 5.28 (3.93–7.09)b 16.2 2.01 (1.31–3.08)d 55.6 1.85 (1.40–2.45)b 8.3 2.39 (1.41–4.03)d

≥4 40.5a 2.79 (1.71–4.56)b 51.4a 6.20 (3.82–10.0)b 14.9 1.44 (0.70–2.99) 45.9a 1.24 (0.78–1.97) 10.8a 2.96 (1.38–6.37)d

WomenDiscriminationNo 30.7 1 22.8 1 13.9 1 29.4 1 4.7 1Yes 43.2a 2.00 (1.73–2.32)b 44.7a 2.51 (2.17–2.91)b 11.8a 1.15 (0.92–1.45) 33.7a 1.06 (0.92–1.23) 11.2a 2.02 (1.60–2.55)b

Discrimination(scores)0 30.7 1e 22.8 1e 13.9 1 29.4 1 4.7 1e

1 43.2 1.95 (1.59–2.40)b 43.2 2.46 (2.00–3.03)b 10.6 0.98 (0.70–1.37) 34.4 1.12 (0.91–1.37) 7.9 1.41 (0.98–2.04)2–3 40.1 1.75 (1.39–2.21)b 40.9 2.12 (1.68–2.67)b 13.8 1.30 (0.92–1.85) 34.8 1.13 (0.90–1.43) 10.8 2.05 (1.42–2.94)b

≥4 50.7a 2.98 (2.10–4.22)b 58.6a 4.04 (2.82–5.78)b 10.9 1.40 (0.79–2.48) 28.5a 0.76 (0.52–1.11) 22.1a 4.06 (2.63–6.26)b

Men and women, 16–64 years of age, Spain 2006.aOR, adjusted odds ratio; 95% CI, 95 % confidence interval of the aOR.Models are adjusted by age, social support, and marital status. The hypertension model is also adjusted by body mass index. The unmet need for medical care model is also adjustedby self-perceived health status.

a pb0.05 (comparison of prevalence between levels of discrimination) (Chi-square or, when more than 2 categories, Chi-square of linearity).b pb0.001.c pb0.05.d pb0.01.e pb0.05 (test of linearity of OR).

90 C. Borrell et al. / Preventive Medicine 50 (2010) 86–92

Perceived discrimination showed positive and consistent associa-tions with the majority of poor health outcomes, as has been describedin other studies (Paradies, 2006;Williams andMohammed, 2009; Llaceret al., 2009; Borrell et al., 2007). Moreover, the associations betweendiscrimination and indicators of poor health found in this study aresupported by studies conducted in other countries (Krieger, 2000;Paradies, 2006; Pascoe and Smart Richman, 2009; Williams andMohammed, 2009).Mental health is themost commonly studied healthvariable (Paradies, 2006; Pascoe and Smart Richman, 2009; WilliamsandMohammed, 2009). In our study, poormental healthwas the healthoutcomewith the highest odds ratios of associationwith discriminationand the prevalence among discriminated people almost reached 50%.The embodiment of experiences of discrimination expressed throughpoor mental health can be explained because perceiving discriminationprovokes fear and anger, becoming a chronic stressor (Krieger, 2000;Pascoe and Smart Richman, 2009; Wamala et al., 2007a). Anothervariable associated with discrimination was poor self-perceived health,which summarizes the experience of psychological and physical distress(Idler and Benyamini, 1997) and has also been related to discrimination.

Our study found an association between perceived discriminationand hypertension among men but not among women. The scientificevidence is not conclusive about this association. Hypertension hasbeen related to discrimination previously (Krieger, 1999). In theParadies review of racism and health, 59 of the 79 studies wherehypertension was analyzed did not find an association (Paradies,2006). Williams and Mohammed highlight that although acuteexperiences of stress are related to increase in blood pressure, therelationship between racism and hypertension remains elusive. Inmany studies, the relationship is maintained for several subgroups butnot for the total sample (Williams and Mohammed, 2009).

Smokingwas associatedwithdiscrimination amongmen in generalbut only among non-manual social class Spanish-born women. Thehighest prevalence of smoking was found among non-manual socialclass men from low income countries (69.7%). As has been stated

before, smoking can be a coping response to the psychosocial stressassociated with discrimination (Williams and Mohammed, 2009;Borrell et al., 2007; Bennett et al., 2005; Landrine and Klonoff, 2000).

Although Spain has a National Health Service, and thus universalaccess to health services, discrimination was associated with unmetneed for medical care. Probably, perceived discrimination or eveninstitutional racismmaybe a barrier to care for somepopulations as hasbeen described in other studies that have found a relationship betweendiscrimination and health care seeking and adherence behaviors(Trivedi and Ayanian, 2006; Van Houtven et al., 2005; Williams andMohammed, 2009; Wamala et al., 2007; Van Houtven et al., 2005).

Discrimination was higher among immigrant populations from lowincome countries, and they felt discriminated mainly because of theircountry of birth. The scopeof social rights andopportunities indifferentpublic settings could be undermined by discrimination towards non-Spanish ethnic groups, as hasbeenobserved in other studies (Pager andShepherd, 2008). Two studies conducted in Spain based on theimmigrant population found that poor mental health was associatedto discrimination (Agudelo-Suarez et al., 2009; Llacer et al., 2009). Inone of these studies, using a qualitative approach, participants reportedinstances of discrimination in their community and working life,characterized by experiences of racism, mistreatment, and precariousworking conditions in comparison to the Spanish-born population(Agudelo-Suarez et al., 2009). Among women, sexism was also animportant type of discrimination.

Interestingly, among men from low income countries, theassociation between perceived discrimination and health was moreconsistent among non-manual men who declared that they had beendiscriminated because of their country of birth and mainly in a publicsetting but also when looking for a job and at work. The majority ofthese men were younger than 40 years, with secondary education orhigher, married and from Latin America. Probably, men of highersocial classes in their country of birth, who in many cases are likely tobe a privileged minority there, experiments a higher health impact

Table 4Prevalence of poor health outcomes (%) by perceived discrimination and multivariate association (adjusted odds ratios) between perceived discrimination and health outcomes in persons from different social classes and countries of birth.

Poor self- perceived health Poor mental health Hypertension Smoking Unmet need for medical care

Prevalence aOR (95% CI) Prevalence aOR (95% CI) Prevalence aOR (95% CI) Prevalence aOR (95% CI) Prevalence aOR (95% CI)

Men SpainNon-manualNo discrimination 18.1 1 13.4 1 14.6 1 34.5 1 2.4 1Discrimination 27.7a 1.65 (1.14–2.41)b 43.6a 4.45 (3.11–6.38)c 7.1a 0.41 (0.21–0.79)b 45.2a 1.48 (1.07–2.05)d 11.0a 3.87 (2.30–6.72)c

ManualNo discrimination 27.0 1 14.0 1 16.7 1 44.9 1 3.0 1Discrimination 52.0a 3.40 (2.45–4.73)c 49.7a 5.57 (3.99–7.78)c 20.9 1.60 (1.06–2.41)d 54.8a 1.38 (1.02–1.88)d 7.3a 1.87 (1.01–3.46)d

Men low income countriesNon-manualNo discrimination 15.0 1 13.9 1 9.7 1 34.1 1 1.5 1Discrimination 32.0a 2.82 (1.48–5.44)b 38.4a 3.79 (2.04–7.06)c 24.0a 3.91 (1.52–10.09)b 69.7a 4.54 (2.53–8.15)c 6.6a 7.62 (1.54–37.75)d

ManualNo discrimination 24.3 1 10.8 1 5.1 1 40.0 1 4.9 1Discrimination 22.2 0.86 (0.56–1.34) 33.6a 4.05 (2.61–6.29)c 10.3a 3.69 (1.79–7.60)c 43.1a 1.02 (0.71–1.47) 5.6 1.32 (0.59–2.98)

Women SpainNon-manualNo discrimination 25.3 1 20.7 1 11.4 1 28.5 1 4.5 1Discrimination 35.6a 1.71 (1.33–2.20)c 39.0a 2.14 (1.67–2.75)c 10.5 1.18 (0.77–1.79) 36.1a 1.30 (1.02–1.67)d 10.5a 2.06 (1.38–3.08)c

ManualNo discrimination 37.3 1 25.3 1 17.5 1 31.7 1 4.9 1Discrimination 52.8a 2.39 (1.80–3.16)c 47.5a 2.63 (1.99–3.48)c 15.6 1.14 (0.76–1.69) 41.9a 1.27 (0.97–1.66) 10.2a 1.64 (1.04–2.59)d

Women low income countriesNon-manualNo discrimination 31.4 1 12.3 1 12.7 1 21.6 1 8.4 1Discrimination 38.5a 1.52 (0.85–2.70) 46.6a 5.82 (2.99–11.3)c 10.8 0.84 (0.34–2.08) 15.4 0.55 (0.26–1.16) 3.1 0.39 (0.09–1.73)

ManualNo discrimination 33.5 1 28.8 1 12.8 1 28.2 1 4.2 1Discrimination 41.9a 1.57 (1.15–2.14)b 49.0a 2.45 (1.79–3.35)c 12.2 1.11 (0.70–1.78) 27.2 0.97 (0.68–1.31) 14.6a 3.32 (2.00–5.53)c

Men and women, 16–64 years of age, Spain 2006.Models are adjusted by age, social support, and marital status. The hypertension model is also adjusted by body mass index. The unmet need for medical care model is also adjusted by self-perceived health status.aOR, adjusted odds ratio; 95% CI, 95 % confidence interval of the aOR.

a pb0.05 (comparison of prevalence between levels of discrimination, Chi-square).b pb0.01.c pb0.001.d pb0.05.

91C.Borrell

etal./

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92 C. Borrell et al. / Preventive Medicine 50 (2010) 86–92

related to being discriminated in the new country when their socialposition experiences downward mobility.

Conclusions and recommendations

This study has found, for the first time in a Southern Europeancountry, a consistent relationship of discrimination with five healthindicators. Public policies directed to ameliorate the effects on healthof discrimination are needed in Spain, and which aim to reducediscrimination through organizational changes. Discrimination bygender and country of birth are among the main potential targets forsuch policies.

Conflict of interestThere are no conflicts of interest.

Acknowledgments

This study was partially funded by «CIBER Epidemiología y SaludPública» (Spain) and by the “Ministerio de Sanidad y Consumo–Observatorio de Salud de la Mujer, Dirección General de la Agencia deCalidad–y Ministerio de Ciencia e Innovación– Instituto de SaludCarlos III” (Spain).

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