Social capital, anticipated ethnic discrimination and self-reported psychological health: A population-based study

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Abstract

This study investigates the association between anticipated ethnic discrimination and self-reported psychological health, taking generalized trust in other people into consideration. The 2004 Public Health Survey in Skåne, Sweden, is a cross-sectional postal questionnaire study including a total of 27,757 respondents aged 18–80 with a 59% response rate. Multivariate analyses of anticipated discrimination and self-reported psychological health were performed using logistic regressions in order to investigate the importance of possible confounders (age, country of origin, education and horizontal trust). Poor psychological health was reported by 13.0% of men and 18.9% of women, and 44.8% and 44.7%, respectively, reported that 50% or more of employers would discriminate according to race, colour of skin, religion, or cultural background. Respondents in younger age groups, born abroad, with high education, low trust and high levels of self-reported anticipated discrimination, had significantly higher levels of poor self-reported psychological health. There was a significant association between anticipated discrimination and low horizontal trust. After multiple adjustments for age, country of origin and education, the addition of trust in the model reduced the odds ratio of poor self-reported psychological health in the “most employers” category from 1.8 (1.4–2.1) to 1.5 (1.3–1.9) among men and from 2.2 (1.8–2.6) to 1.8 (1.5–2.2) among women. Generalized trust in other people may be a confounder of the association between anticipated discrimination and poor psychological health. Anticipated discrimination may have effects on the mental health of not only the affected minorities, but also on the mental health of the general population.

Introduction

During the past 60 years Sweden has been a country of net immigration. The increasing number of immigrants has resulted in a focus on the health of different ethnic groups. The health of immigrant groups may be affected by previous experiences in the country of birth, factors associated with the act of migration as well as conditions in the new country. Migrant studies have demonstrated that mortality and risk factors for cardiovascular disease (CVD) increase following immigration (Sundquist & Johansson, 1997; Sundquist & Winkleby, 1999; Williams, 1993; Winkleby, Robinson, Sundquist, & Kraemer, 1999). The risk of overweight and obesity seems to increase with the number of years in the new country in some immigrant groups in southern Sweden (Lindström & Sundquist, 2005). Poor self-reported health (Lindström Sundquist, & Östergren, 2001), overweight/obesity (Lindström & Sundquist, 2005), low leisure-time physical activity (Lindström & Sundquist, 2001) and lack of access to a regular physician (Axén & Lindström, 2002) have also been reported to be more prevalent in some immigrant groups than in the reference group born in Sweden.

One explanation for ethnic differences in health and health related behaviours may be ethnic discrimination according to race, colour of skin, religion or culture in the country of immigration. The only working general definition of ethnicity is that it involves the common consciousness of shared origins and traditions, according to the Oxford Concise Dictionary of Politics (McLean & McMillan, 2003). Discrimination may occur in two forms in relation to the legal system of a particular country. One form of discrimination is de jure discrimination, which is discrimination mandated by law. The other is de facto discrimination, which is not mandated by law but sanctioned by custom and practise (Krieger, 2000). One example of de jure discrimination was the Jim Crow laws, which denied African Americans access to facilities and services used by white Americans (Jaynes & Williams, 1989). Under-representation of coloured people and white women in clinical trials constitutes an example of de facto discrimination (King, 1996; Sechzer et al., 1994). The term structural discrimination refers to the totality of ways in which societies foster discrimination, while the term interpersonal discrimination refers to discrimination in concrete situations (Krieger, 2000).

In Sweden ethnic discrimination occurs as de facto and not de jure discrimination. The present study thus exclusively deals with the anticipation of de facto discrimination, both structural and interpersonal.

The causal mechanisms by which ethnic discrimination causes poor health or disease include increased risk of economic and social deprivation (at work, at home, in the neighbourhood and other relevant socio-economic regions), increased risk of exposure to toxic substances and hazardous conditions (pertaining to physical, chemical and biological agents at work, at home and in the neighbourhood), increased risk of socially inflicted trauma (mental, physical or sexual, ranging from verbal to violent at home, at work, in the neighbourhood or in society at large), targeted marketing of legal and illegal psychoactive substances (alcohol, tobacco, other drugs) and other commodities (e.g. junk food) and inadequate health care by health care facilities and by specific providers (access to health care, diagnosis and treatment) (Krieger, 2000). Self-rated (physical and psychological) health has been shown to be associated with the self-reported experiences of being unfairly treated because of one's race or ethnicity (Karlsen & Nazroo, 2002; Schulz et al., 2006; Williams, Neighbors, & Jackson, 2003). The present study exclusively deals with the anticipation of socially inflicted discrimination in relation to mental or psychological health. The pathway of socially inflicted mental or psychological trauma and its effects on health may entail two causal mechanisms, one physical/physiological and one psychological.

First, perceiving or anticipating ethnic discrimination provokes fear and anger among many people, although not among all. The physiology of fear (“flight-or-fight” response) mobilizes lipids and glucose to increase energy supplies and sensory vigilance. It also produces transient elevations in blood pressure. Chronic triggering of these physiologic pathways leads to sustained hypertension (Krieger (1990), Krieger (2000); Krieger & Sidney, 1996). Second, psychological or mental health may also be afflicted (Gee, Ryan, Laflamme, & Holt, 2006; Sellers, Bonham, Neighbors, & Amell, 2006; Taloyan, Johansson, Johansson, Sundquist, & Kocturk, 2006).

It should be emphasized that a person's anticipation of discrimination is not completely equivalent to being actually exposed to or perceiving discrimination, although this variable is rather close to the variable “perceived discrimination” which has been found to be a strong predictor of psychological and mental distress in 42 samples of immigrant teenagers in 13 countries (Berry, Phinney, Sam, & Vedder, 2006). The majority population or population segments in power may also anticipate discrimination even in a society with very clear legislation against discrimination.

Anticipation is based on both individual experience and on a social construct based on the collective experience and interpretation of the world as a social group rather than the experience of individuals. Sense of insecurity in the neighbourhood in southern Sweden, is for instance, most prevalent among older women, the demographic group that is the least afflicted by violence (Lindström, Lindström, Moghaddassi, & Merlo, 2006). Anticipation of socially inflicted discrimination may still plausibly cause poor health by both the causal mechanisms mentioned above, although only few studies have dealt with this phenomenon. Psychological health may be the most important pathway by which anticipation of ethnic discrimination causes poor health.

Interpersonal as well as structural discrimination according to race, colour of skin, religion and cultural background occurs in Sweden, for instance, in the labour market (Neergaard, 2006) as well as in the health care system (Groglopo & Ahlberg, 2006). The odds ratios of self-reported lack of access to a regular physician were 5.52 (1.90–16.03) among women born in Arabic speaking countries and 2.14 (1.28–3.58) among women born in “other countries” (outside Europe, the middle east and Latin America) after multivariate adjustments (reference group women born in Sweden) in a study in southern Sweden. No significant ethnic differences were observed for men (Axén & Lindström, 2002). Discrimination according to race, colour of skin, religion and cultural background thus plausibly occurs although all sorts of discrimination are prohibited by law in Sweden and a particular institution of ombudsman against discrimination has been installed.

Perceived discrimination has been shown to be associated with mental distress in a study on Kurdish immigrants in Sweden (Taloyan et al., 2006). A strong association between ethnicity and poor self-reported health which seemed to be mediated by socio-economic status (SES), poor acculturation and discrimination was observed in another Swedish study on immigrants from Poland, Turkey and Iran (Wiking, Johansson, & Sundquist, 2004). After adjustment for age and long-term illness, frequent experiences of discrimination were associated with increased likelihood of psychological distress in the Swedish National Survey of Public Health in 2004 (Wamala, Boström, & Nyqvist, 2007). No studies have been conducted in Sweden on anticipation of discrimination and its effects on health to our knowledge

Several studies support the recommendation to use specific instead of global items to assess experiences of discrimination. Rather than asking about racial or gender discrimination in general, it would probably be more informative to assess specific types of experiences of discrimination, e.g. at school, in restaurants and in employment interview situations (Bobo, Zubrinsky, Johnson, & Oliver, 1995; Feagin & Sikes, 1994; Krieger, 2000).

In this study anticipated discrimination by employers, i.e. the anticipation that employers would not employ someone for reasons of race, colour of skin, religion or cultural background, is investigated in relation to self-reported psychological health. This item on anticipated discrimination was the one available in the 2004 public health questionnaire in Skåne, southern Sweden. The strength of this item is that it is rather specific in relation to both category of actor (employer) and situation. The weakness is that other items concerning other situations in which discrimination may plausibly occur also might have been included in the 2004 public health questionnaire.

During the most recent decades the debate concerning ethnic discrimination in Sweden has been focused mainly on the access of different ethnic groups to employment on the labour market. The reason is that more recent waves of immigration in Sweden have been dominated by refugee immigration instead of, as previously, labour immigration. Participation in the active work force and the possibility to acquire a job on the regular labour market has been identified as the key factor in the fight to eradicate the social isolation and segregation and economic marginality experienced by some ethnic groups in Sweden (Lundh & Ohlsson, 1999). It is obvious that employers play a crucial role in this process.

Social capital is a social and contextual factor that has been suggested to affect health. A society with high levels of social capital is characterized by high civic engagement and high social participation among its citizens, high generalized (horizontal) trust in other people, high levels of institutional (vertical) trust and generalized reciprocity (Putnam (1993), Putnam (2000)). Social capital works both horizontally, i.e. between individuals, and vertically, i.e. between individuals and institutions (Narayan, 2002; Narayan & Cassidy, 2001).

Social capital has been analysed at the macro (countries and regions), meso (neighbourhoods), micro- (social participation/social network of the individual) as well as psychological (trust) levels (Macinko & Starfield, 2001). Some authors study social capital as a contextual trait of society (Putnam, 2000; Woolcock, 2001). Other authors study social capital in a micro perspective as social relations in the local environment or as the nature of trust relations between individuals (Coleman, 1990; Fukuyama, 1995). The present study will be restricted to an individual level analysis due to a lack of relevant contextual information (neighbourhoods smaller than cities/municipalities and/or workplaces) in the data.

Social capital has been suggested to promote health by several causal pathways including a decrease in psychosocial stress, more healthy behaviours mediated by benevolent norms and values, increased access to health care and amenities and a decrease in the risk of violent crime (Kawachi Kennedy, & Glass, 1999). Social capital may also affect health by the psychological pathway which promotes self-esteem, social competence, self-confidence and sense of coherence (Berkman & Glass, 2000). In Sweden, poor psychological health has, for instance, been shown to be associated with aspects of social capital such as generalized trust in other people, also referred to as horizontal trust, and social participation (Lindström, 2004).

Social capital is also related to discrimination, including discrimination according to race, colour of skin, religion and cultural background. Robert D. Putnam reports that the variable most strongly associated with high social capital and high generalized (horizontal) trust in other people in the USA is the proximity to the Canadian border. The further south in the USA, the lower the levels of generalized trust in other people. This can most plausibly be explained by the history of slavery and, later, a decade after the American civil war (1861–1865) and up until the 1950s and 1960s legal/de jure (Jim Crow laws) and structural discrimination in the American south, particularly the deep south, according to Putnam (2001). This US example is given because the association between discrimination and trust is so empirically well documented, not because of any particular similarities between the history of the USA and Sweden.

In systems with political discrimination political equality between the men defined as citizens runs parallel with the exclusion (discrimination) of the “others”, i.e. those with no political or other rights as citizens (Warren, 1999). A negative association between social capital expressed as generalized (horizontal) trust in other people and ethnic discrimination is thus what we would expect. However, it should be remembered that although such an association may be plausible it is not completely unproblematic.

As already mentioned, Putnam argues that there is a very strong north–south gradient in generalized (horizontal) trust in other people in the USA which is inversely related to the extent to which structural discrimination occurs and legal and structural discrimination has occurred historically (Putnam, 2001). On the other hand, Putnam and other political science scholars also describe strong trends of decreasing generalized (horizontal) trust in other people and, paradoxically, less ethnic discrimination (at least legal discrimination) in the USA during the past decades (Inglehart, 1999; Putnam, 2000). This may seem paradoxical, although the levels of generalized (horizontal) trust in other people is most probably also affected by a wide range of factors other than ethnic discrimination. Furthermore, the time trend in the development of social capital measured as formal and informal social networks (Rostila, 2007) and generalized trust in other people (Rothstein, 2003) in Sweden does not show the same pronounced decline as in the USA. Still, the US example demonstrates that generalized trust in other people may be regarded as a confounder and not a mediator of the association between anticipated discrimination and psychological health. In this study generalized trust in other people is also regarded as a confounder and not a mediator of the association between anticipated discrimination and psychological health.

Social capital measured as different aspects of social participation/social activities has previously been shown to be significantly lower in some ethnic groups in Sweden (Lindström, 2005a), but the association with aspects of anticipated or perceived ethnic discrimination has not been investigated.

Aspects of anticipated or perceived ethnic discrimination have been shown to afflict different aspects of psychological or mental health (Gee et al., 2006; Sellers et al., 2006; Taloyan et al., 2006). Social capital in the form of generalized (horizontal) trust in other people has already been reported to be significantly inversely associated with poor psychological health in Scania in southern Sweden. Generalized (horizontal) trust in other people also significantly differs by age and socio-economic factors such as education (Lindström, 2004). However, the association between the anticipation of ethnic discrimination and social capital, in this study for reasons of availability measured as trust, and the effect of anticipated discrimination on mental health remain to be explored.

The aim of this study is to investigate the association between anticipated ethnic discrimination and self-reported psychological health, taking generalized (horizontal) trust in other people into consideration as a confounder in the final analysis.

Section snippets

Study population

Data from the 2004 Public Health Survey in Skåne in southern Sweden were used. A postal questionnaire was sent out to a random sample of 47,621 persons aged 18–80 years during the autumn (September–December) of 2004. Two letters of reminder were sent to the respondents, and a subsequent phone call was made to the remaining non-respondents. A total of 27,757 respondents returned complete answers (right persons in the household according to age and sex answered the questionnaire). The response

Results

The demographic characteristics of the sample population are summarized in Table 1. The distributions of self-reported psychological health, demographic, education, horizontal and anticipated discrimination variables were rather similar between men and women, although a 13.0% proportion of the men and 18.9% of the women rated their psychological health as poor. Almost 12% of the respondents were born in other countries than Sweden. The prevalence of high education was 32.5% among men and 38.9%

Discussion

This study has investigated the relationship between anticipated discrimination and self-reported psychological health, taking generalized trust in other people into consideration as a confounder in the final model. Anticipated discrimination and low generalized (horizontal) trust in other people are both significantly associated with poor self-reported psychological health. The bivariate inter-correlations between anticipated discrimination, generalized (horizontal) trust in other people and

Conclusion

Anticipated discrimination and low horizontal trust are associated with each other, and they are both significantly associated with poor self-reported psychological health. Generalized trust in other people may be a confounder of the association between anticipated discrimination and poor psychological health. The results also suggest that the anticipation of discrimination according to race, colour of skin, religion and cultural background by employers may have effects on the mental health of

Acknowledgements

This study was funded by the Swedish ALF Government Grant Dnr. M:B 39 921/2006 and The research funds of Malmö University Hospital.

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