Exploring discrimination and racism in healthcare: a qualitative phenomenology study of Dutch persons with migration backgrounds

The Netherlands has a legal obligation for its citizens to have healthcare insurance and to provide equal access to healthcare services.1–5 Nonetheless, ethnic health disparities persist, and people with a migration background have poorer health outcomes than the native population.1–5 The non-European migrant population accounts for approximately 14.5% of the population of the Netherlands, primarily comprising individuals from Morocco, Türkiye, Suriname, Indonesia and the Dutch Antilles.4 This population group is at higher risk for and shows a higher prevalence of mental health problems, communicable and non-communicable diseases and higher mortality rates than those with a Western or Dutch ethnic background.1–4

Various factors contribute to ethnic health disparities, including contextual variables such as educational level, access to healthcare services, community health and factors related to the healthcare provider and patient. While current literature often attributes ethnic health inequities to low socioeconomic status, ethnic background and comorbidities such as obesity and diabetes,5 6 disparities persist even after controlling for these variables.3 7 8 There is a prevalent assumption that the heightened risk of poor health outcomes among non-Western ethnic groups stems from genetic or ethnic differences.6 However, race and ethnicity are sociopolitical terms and do not inherently indicate biological differences that increase disease risk among populations.6 Therefore, attributing health disparities to race or ethnicity is problematic.6 Many underlying societal factors contribute to these health inequities,9 including the significant role of racism and discrimination (see box 1 for definitions).10–14 However, the key role of discrimination and racism in accounting for health inequities is often overlooked.8 11–13 15 16 Discrimination, whether implicit, explicit or institutional, negatively impacts the quality of healthcare services and contributes to poor mental and physical health and inequalities in accessing healthcare.8 11 16–22

Box 1

This paper adapts the American Psychology Association (APA) Dictionary of Psychology definition (https://dictionary.apa.org) of the below listed terms.

Discrimination: ‘The differential treatments or outcomes that are unfavourable towards a group or an individual according to some aspect of their actual or perceived identity, such as race, religion, nationality, physical ability, gender, sexual orientation, class, or social status’.

While discrimination is a broader term encompassing unfair treatment based on aforementioned characteristics, racism specifically focuses on unfair treatment based on so called race, skin tone ethnicity.

Racism: ‘A form of prejudice that assumes that the members of racial categories have distinctive characteristics and that these differences result in some groups being inferior to others. Racism generally includes negative emotional reactions to members of the group, acceptance of negative stereotypes, and racial discrimination against individuals; in some cases it leads to violence’.

Ethnicity: ‘A social categorisation based on an individual’s membership in or identification with a particular cultural or ethnic group’.

Race: ‘A socially defined concept sometimes used to designate a portion, or ‘subdivision’, of the human population with common physical characteristics, ancestry, or language. The term is also loosely applied to geographic, cultural, religious, or national groups. The significance often accorded to racial categories might suggest that such groups are objectively defined and homogeneous; however, there is much heterogeneity within categories, and the categories themselves differ across cultures. Moreover, self-reported race frequently varies owing to changing social contexts and an individual’s possible identification with more than one race’.

Depending on the context (Europe vs the USA or Global North vs the Global South), the social construct of race is often used interchangeably with the social construct of ethnicity when discussing racism. While racism and ethnicity-based discrimination are two slightly different concepts.6

A worldwide commission on Racism, Structural Discrimination and Global Health worked on the manifestations of discrimination and racism in healthcare and their potential effects on health. Manifestations and impact varied per region or country and had yet to be fully understood.23 A recent Lancet Series has provided empirical evidence of the relationship between racism, xenophobia, discrimination and health, underscoring the need for further research on their impact on healthcare.24 There is no evidence that findings from this Series would not be valid in the Netherlands. It is, therefore, pivotal to document the manifestation of discrimination and racism from a patient perspective rather than relying solely on theoretical concepts. The lived experiences of patients who faced discrimination and racism in healthcare settings have provided valuable perspectives that theoretical concepts alone cannot fully explain.25

Little European research has been available on the characteristics and contribution of discrimination and racism towards ethnic minorities and how this has been perceived from a patient’s perspective.26–29 The same applies to the Netherlands, where on a government level, policymakers have aimed to provide equal access to healthcare, fight discrimination and institutional racism and reduce ethnic health disparities. Therefore, this study has two main objectives. The first objective is to identify characteristics and manifestations of discrimination and racism in healthcare as perceived by Dutch patients with a migration background. The second objective is to examine how the aforementioned form of social injustice impacts the participants. An online survey was administered to obtain these goals, enabling the collection of a relatively large sample size for qualitative research.

This post was originally published on https://bmjopen.bmj.com