标题：Experiences and Perceptions of Medical Discrimination Among a Multiethnic Sample of Breast Cancer Patients in the Greater San Francisco Bay Area, California
摘要：Objectives. We conducted qualitative interviews with breast cancer survivors to identify themes related to institutional, personally mediated, and internalized discrimination in the medical setting. Methods. We conducted 7 focus groups and 23 one-on-one interviews with a multiethnic sample of breast cancer survivors randomly selected from a population-based registry covering the Greater San Francisco Bay Area, California. Results. Participants reported experiencing different forms of medical discrimination related to class, race, and language. Among African Americans, participants reported experiencing internalized discrimination and personal or group discrimination discrepancy—perceiving discrimination against them as a racial/ethnic group, yet not perceiving or discussing personal experiences of discrimination. Among Asian immigrants, participants reported experiencing institutional and personally mediated overt types of discrimination, including lack of access to quality and readily available translation services. Our results also indicated well-established coping mechanisms in response to discrimination experiences in both groups. Conclusions. Participants reported experiencing medical discrimination at all 3 levels, which may have deleterious health effects through the biopsychosocial stress pathway and through active coping mechanisms that could lead to delayed- or underutilization of the health care system to avoid discrimination. Breast cancer is the cancer most commonly diagnosed among women in the United States. 1 Racial/ethnic disparities in the survivorship experience, including diagnosis, treatment, quality-of-life, and survival, have been documented. 2–5 For example, breast cancer survival differences between African Americans and non-Hispanic Whites are among the most striking and consistent of health disparities. 1 Research also suggests that certain racial/ethnic groups like African Americans, Latinas, and Asians are more likely to be diagnosed with late-stage disease. 6–9 However, prognostic factors including socioeconomic status, access to care, and biological factors, to the extent that they have been examined, do not fully explain the observed differences. 10 Research frameworks encompassing a multilevel framework that considers the interactions among social and biological factors, within a historical and ecological perspective (i.e., a socio-ecological framework 11) are needed to examine underlying institutional and societal forces that contribute to health disparities. 12 There has been a growing interest in examining health impacts from discrimination, 13 the process by which members of a defined social group are treated unfairly because of their membership in that group. 14 For example, studies have suggested that racial minorities receive fewer referrals for specialty services and poorer quality health care than Whites, after controlling for a number of confounders including socioeconomic status, gender, age, health insurance, and stage of illness. 15–17 Studies suggest that some of this may be the result of provider prejudice and medical mistrust on the part of the patient. 15,16,18 At least 3 pathways have been proposed by which discrimination may impact health. First, discrimination can lead to socioeconomic inequities, which can affect health (e.g., compromising access to care and quality of care and causing disproportionate environmental exposures to toxins). Second, discrimination can increase chronic stress. Chronic and severe social stress trigger the stress-response system, activating adaptive physiologic mechanisms, which, over time, degrades the body’s ability to properly regulate biological systems, resulting in adverse health consequences. 19,20 Increasingly, studies have shown that exposure to racial discrimination is associated with numerous physiological disturbances, 21 including overcirculation of stress hormones, 22 which, among other outcomes, is linked to an uninhibited inflammatory response. 23 Chronic inflammation has been associated with breast cancer recurrence and mortality. 24 Third, discrimination can restrict access to goods and services. Discrimination experienced in health care settings may inadvertently influence individuals to avoid using needed health care. 25 The psychological model of stigma-induced identity threat posits that an individual who has experienced discrimination that threatens his or her identity will have involuntary responses (e.g., anxiety and vigilance). 26 In turn, the individual may engage in a variety of voluntary coping mechanisms, including engagement (i.e., fight) or disengagement (i.e., flight) strategies. In accordance with the disengagement strategy, an individual who has experienced discrimination may avoid mainstream institutions, such as the health care system, where they fear they may be discriminated against. African Americans, Latinos, and Asians have been found to report more medical mistrust 27 and provider discrimination, which is associated with lower satisfaction with care 28,29 and delayed health utilization. 30 Some studies have found an association among perceived discrimination, screening mammography, 31,32 and health care utilization. 33,34 As mentioned previously, discrimination may also restrict health care services because of provider bias and differences in referral for specialty services. 16,18 Whereas there is growing research on the subject of whether discrimination influences health, 21,35–42 few studies have investigated the link between discrimination and breast cancer, 43 although plausible links are evident. To our knowledge, no studies have investigated the extent of medical discrimination among breast cancer patients. We applied a multilevel concept of discrimination based on Jones’44 3-level framework for understanding racism, in which institutionalized racism is defined as the structural and differential access to goods, services, and opportunities within a society; personally mediated racism encompasses differential assumptions about and actions toward others on the basis of race; and internalized racism is the acceptance of negative assumptions about their own abilities and worth by members of the stigmatized group. The intent of this qualitative research was to explore experiences of medical discrimination among breast cancer patients that would inform future research aimed at understanding the impact of discrimination on breast cancer outcomes.
