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Disability‐based discrimination and health: findings from an Australian‐based population study

Disability‐based discrimination and health: findings from an Australian‐based population study Stigma and discrimination are important determinants of population health and health inequalities. The detrimental mental health effects of self‐reported interpersonal discrimination are well established.1,2 Disability‐based discrimination is a day‐to‐day reality for many Australians with disability3,4 and is likely to have wide‐ranging effects on their health and social and economic circumstances.Discrimination is the avoidable, unfair treatment of social groups, and of individuals perceived as belonging to these groups, including groups based on characteristics such as gender, ethnicity and disability. Discrimination is conceptualised as a psychosocial stressor that heightens physiological responses (such as blood pressure and cortisol secretion), having downstream effects on health and wellbeing.2 Studies of self‐reported discrimination and health predominantly focus on racial and gender discrimination.2 Few studies have examined self‐reported discrimination among those with other stigmatised identities, such as people with a disability.5 There are few quantitative studies of self‐reported disability‐based discrimination and health internationally6 and none in Australia. There is an urgent need to understand the population prevalence of disability‐based discrimination and the related health impacts.In 2015, the Survey of Disability, Ageing and Carers (SDAC) collected the first Australian population‐based data on interpersonal disability‐based discrimination.7 We analysed data from 6,183 participants aged 15–64 years with disability. We estimated: 1) the prevalence of self‐reported inter‐personal disability‐based discrimination; 2) whether disability‐based discrimination varied by socio‐demographic characteristics; and 3) the associations between disability‐based discrimination and the self‐rated health and psychological wellbeing.MethodData sourceWe used the Confidentialised Unit Record Files of the SDAC 2015, a repeat cross‐sectional national survey conducted by the Australian Bureau of Statistics (ABS).7 The total sample size was 74,862. Our analysis is restricted to 40,872 working age adults (15–64‐year‐olds) of whom 15.1% (n=6,183) reported a disability.Disability measuresParticipants were defined as having a disability if they had a limitation, impairment or restriction in everyday activities that had lasted, or was likely to last, for a period of six months or more. The ABS uses a module with 149 questions to collect information on disability and originally classified participants disability as: profound, severe, moderate, mild, employment restriction, non‐specific restriction and no disability, based on the level of functioning in core activities (self‐care, mobility and communication). We further combined the profound and severe group in our analysis.8 Impairment type was classified by the ABS as: sight/hearing/speech, intellectual, physical, psychological, and acquired brain injury, with people able to be classified as having multiple types of impairment. For further detail of the original data source, see the SDAC Summary of Findings available from the ABS.7Disability‐Discrimination measureParticipants were asked “In the last 12 months do you feel that you have experienced discrimination or have been treated unfairly by others because of your [condition/s]?” (yes/no).Health outcome measuresGeneral health was assessed with one question asking, “In general would you say your health is excellent, very good, good, fair or poor?” Self‐reported health was then categorised as a binary variable (‘fair/poor’ versus ‘excellent/very good/good’). Psychological distress was assessed using the Kessler Psychological Distress Scale (K10),9 which has 10 questions that determine the level of anxiety and depression in the past four weeks (with a 5‐level response option). Responses were originally categorised into a continuous score (ranging from 10 to 50). For regression models, responses to the K10 were collapsed into ‘very high distress/high distress’ (scores from 10 to 21) versus ‘moderate/low distress’ (scores from 22 to 50), a classification that has been used previously.10AnalysisAnalyses were conducted in Stata 11.1.11 We estimated the population‐weighted prevalence of discrimination and used logistic regression to examine the association between discrimination and self‐rated health and psychological distress adjusting for age, sex, country of birth, disability severity, education, income and labour force status. As a sensitivity analysis, we also ran models that omitted people reporting psychological impairments (n=1,729) who may be more likely to report discrimination and poor mental and physical health.ResultsPrevalence of discriminationNearly 14% of people with disability aged 15 to 64 years reported disability‐based discrimination in the past year, with similar estimates for men and women (Table ). Younger people reported experiencing much higher levels than older people (20.4%, 15 to 24 years versus 9.4%, aged 55 to 64 years). The highest levels of discrimination were reported among those with a severe or profound restriction (21.6%) and the lowest levels were among those with no specific restriction (4.2%). People with intellectual or psychological impairments fared the worst; about one in four reported discrimination, whereas 14% of people with physical impairments reported discrimination.Population weighted percent of people experiencing discrimination due to their disability with 95% confidence intervals, ages 15 to 65 years.% Experiencing discrimination95% Confidence IntervalLower CIUpper CIAll persons13.812.814.9Sex   Males   Females 13.514.0 12.012.6 15.115.5Age   15–24   25–34   35–44   45–54   55–64 20.417.916.614.29.4 16.014.614.012.28.1 25.721.819.416.410.9Disability status   Profound/ severe   Moderate   Mild   Schooling/ employment restriction   No specific restriction 21.615.312.914.54.2 19.012.911.211.72.9 24.618.014.817.86.1Impairment type   Sight, hearing and speech   Intellectual   Physical   Psychological   Acquired brain injury   Other 17.325.114.425.422.018.5 14.821.213.222.817.616.9 20.129.515.728.127.020.3Accessibility and remoteness index of Australia (ARIA)   Major cities   Inner regional   Other 13.015.514.5 11.813.312.0 14.318.117.6Country of birth   Australia   Other English speaking   Other non‐English speaking 14.913.17.8 13.710.05.8 16.216.910.2Highest level of education   Bachelor or postgraduate degree   Certificate or diploma   Completed year 12   Some high school   Year 8 or below   Level not determined 12.514.514.213.013.918.8 10.212.811.311.110.012.5 15.116.517.515.018.927.4Labour force status   Employed full‐time   Employed part‐time   Unemployed   Not in the labour force 8.812.329.815.7 7.210.223.614.2 10.614.735.717.4Occupational skill level   Managers/ professionals/ technical & trades   Community & personal service/ clerical & admin   Sales/ machinery operators/ labourers   Not applicable 8.911.212.017.2 7.28.79.515.6 11.014.315.118.8Income quintile   First (highest)   Second   Third   Fourth   Fifth (lowest)   Unknown 8.610.215.217.215.011.2 6.37.812.715.112.48.9 11.613.118.119.418.014.0Nearly 30% of unemployed people reported discrimination, compared to 9% who were employed full‐time. For employed people, those in higher‐skilled occupations (managers) reported lower levels of discrimination (9%), while those in lower skilled occupations (e.g. sales) had slightly higher levels (13%). Discrimination was highest in people in the lowest 20% of household income distribution. People born in non‐English speaking countries reported lower levels of disability discrimination than those who were Australian‐born.Regression modelsDiscrimination was associated with increased odds of psychological distress (OR: 2.53, 95%CI: 2.11, 3.02) and poor self‐rated health (OR: 1.63, 95%CI: 1.37, 1.95) in models adjusted for potential confounders. The estimates were attenuated slightly when people with psychological impairments were excluded (psychological distress: OR: 2.21, 95%CI 1.75, 2.79 and poor general health: OR: 1.55, 95%CI: 1.22, 1.97).DiscussionIn this first Australian study of self‐reported interpersonal disability‐based discrimination, we found a moderate to strong association between disability‐based discrimination and self‐rated health and psychological distress. Our findings are similar to a Swedish study showing increased odds of psychological distress in relation to perceived disability discrimination (OR: 1.65, 95%CI 1.26, 2.17).6Disability‐based discrimination was relatively common, with 14% of people with disability reporting disability‐based discrimination in the past year. Discrimination was higher among people who were unemployed, in low‐status occupations, younger and living on lower incomes. People with severe disabilities and with psychological and intellectual impairments were more likely to report disability‐based discrimination.Our findings of higher levels of discrimination among some groups suggests that disability may intersect with other social categories and identities to increase the risk of disability‐based discrimination. People with more severe disabilities and with psychological and intellectual impairments fare poorly across a number of social and economic indicators such as housing, employment, education and income.8,12 The higher levels of discrimination they experience are likely to contribute to the poor social and economic outcomes.It is well documented that people with disabilities have poorer physical and mental health.13 Our findings that disability‐based discrimination is associated with higher psychological distress and poor self‐rated health suggests that disability‐based discrimination may be an important determinant of the poorer health outcomes.We used high quality population‐based data; however, because the study is cross‐sectional it is not possible to exclude reverse causation, although longitudinal studies have found perceived discrimination precedes poor health.1,2 It is possible that we have not controlled for important confounders. In addition, we relied on self‐report of experiences of disability discrimination that previous research has shown can be under and over‐reported.14 Another problem is that we only had measures for inter‐personal discrimination; structural or institutional discrimination (e.g. laws, policies) is also likely to be experienced at high levels and to have negative health, social and economic effects.In summary, we show high levels of disability‐based discrimination and demonstrate that discrimination has a moderate to strong association with poorer health. Disability‐based discrimination is an under‐recognised public health problem. Addressing disability‐based discrimination is likely to reduce social and economic disadvantage and improve the health of Australians with disability.Implications for public healthDisability‐based discrimination is an under‐recognised public health problem that is likely to contribute to disability‐based health inequities. Reducing disability‐related discrimination is likely to bring the social, economic and health benefits for Australians with disability and reduce welfare and health expenditure. Public health policy, research and practice needs to concentrate efforts on developing policy and programs that reduce discrimination experienced by Australians with disability.AcknowledgementsResearch funded by NHMRC Centre of Research Excellence grant in Disability and Health APP1116385 and a seed funding grant from the Disability Research Initiative at the University of MelbourneReferencesSchmitt MT, Branscombe NR, Postmes T, Garcia A. The consequences of perceived discrimination for psychological well‐being: A meta‐analytic review. Psychol Bull. 2014; 140(4):921–48.Pascoe EA, Smart Richman L. Perceived discrimination and health: A meta‐analytic review. Psychol Bull. 2009; 135(4):531–54.Australian Human Rights Commission. Willing to Work: National Inquiry into Employment Discrimination Against Older Australians and Australians with Disability. Sydney (AUST): AHRC; 2016.Department of Social Services. Shut Out: The Experience of People with Disabilities and Their Families in Australia. Canberra (AUST): Government of Australia; 2009.Krieger N. Discrimination and health inequities. Int J Health Serv. 2014; 44(4):643–710.Wamala S, Bostrom G, Nyqvist K. Perceived discrimination and psychological distress in Sweden. Br J Psychiatry. 2007; 190:75–6.Australian Bureau of Statistics. 4430.0 ‐ Disability, Ageing and Carers, Australia: Summary of Findings, 2015. Canberra (AUST): ABS; 2016.Kavanagh AM, Krnjacki L, Beer A, Lamontagne AD, Bentley R. Time trends in socio‐economic inequalities for women and men with disabilities in Australia: Evidence of persisting inequalities. Int J Equity Health. 2013; 12:73.Andrews G, Slade T. Interpreting scores on the Kessler Psychological Distress Scale (K10). Aust N Z J Public Health. 2001; 25(6):494–7.Feng X, Astell‐Burt T, Kolt GS. Do social interactions explain ethnic differences in psychological distress and the protective effect of local ethnic density? A cross‐sectional study of 226 487 adults in Australia. BMJ Open. 2013; 3(5). doi.org/10.1136/bmjopen‐2013‐002713STATA: Statistical Software. Version 11. College Station (TX): StataCorp; 2009.Kavanagh AM, Krnjacki L, Aitken Z, LaMontagne AD, Beer A, Baker E, et al. Intersections between disability, type of impairment, gender and socio‐economic disadvantage in a nationally representative sample of 33,101 working‐aged Australians. Disabil Health J. 2015; 8(2):191–9.Emerson E, Madden R, Graham H, Llewellyn G, Hatton C, Robertson J. The health of disabled people and the social determinants of health. Public Health. 2011; 125(3):145–7.Lewis TT, Cogburn CD, Williams DR. Self‐reported experiences of discrimination and health: Scientific advances, ongoing controversies, and emerging issues. Annu Rev Clin Psychol. 2015; 11:407–40. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australian and New Zealand Journal of Public Health Wiley

Disability‐based discrimination and health: findings from an Australian‐based population study

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Publisher
Wiley
Copyright
© 2018 Public Health Association of Australia
ISSN
1326-0200
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1753-6405
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10.1111/1753-6405.12735
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29168323
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Abstract

Stigma and discrimination are important determinants of population health and health inequalities. The detrimental mental health effects of self‐reported interpersonal discrimination are well established.1,2 Disability‐based discrimination is a day‐to‐day reality for many Australians with disability3,4 and is likely to have wide‐ranging effects on their health and social and economic circumstances.Discrimination is the avoidable, unfair treatment of social groups, and of individuals perceived as belonging to these groups, including groups based on characteristics such as gender, ethnicity and disability. Discrimination is conceptualised as a psychosocial stressor that heightens physiological responses (such as blood pressure and cortisol secretion), having downstream effects on health and wellbeing.2 Studies of self‐reported discrimination and health predominantly focus on racial and gender discrimination.2 Few studies have examined self‐reported discrimination among those with other stigmatised identities, such as people with a disability.5 There are few quantitative studies of self‐reported disability‐based discrimination and health internationally6 and none in Australia. There is an urgent need to understand the population prevalence of disability‐based discrimination and the related health impacts.In 2015, the Survey of Disability, Ageing and Carers (SDAC) collected the first Australian population‐based data on interpersonal disability‐based discrimination.7 We analysed data from 6,183 participants aged 15–64 years with disability. We estimated: 1) the prevalence of self‐reported inter‐personal disability‐based discrimination; 2) whether disability‐based discrimination varied by socio‐demographic characteristics; and 3) the associations between disability‐based discrimination and the self‐rated health and psychological wellbeing.MethodData sourceWe used the Confidentialised Unit Record Files of the SDAC 2015, a repeat cross‐sectional national survey conducted by the Australian Bureau of Statistics (ABS).7 The total sample size was 74,862. Our analysis is restricted to 40,872 working age adults (15–64‐year‐olds) of whom 15.1% (n=6,183) reported a disability.Disability measuresParticipants were defined as having a disability if they had a limitation, impairment or restriction in everyday activities that had lasted, or was likely to last, for a period of six months or more. The ABS uses a module with 149 questions to collect information on disability and originally classified participants disability as: profound, severe, moderate, mild, employment restriction, non‐specific restriction and no disability, based on the level of functioning in core activities (self‐care, mobility and communication). We further combined the profound and severe group in our analysis.8 Impairment type was classified by the ABS as: sight/hearing/speech, intellectual, physical, psychological, and acquired brain injury, with people able to be classified as having multiple types of impairment. For further detail of the original data source, see the SDAC Summary of Findings available from the ABS.7Disability‐Discrimination measureParticipants were asked “In the last 12 months do you feel that you have experienced discrimination or have been treated unfairly by others because of your [condition/s]?” (yes/no).Health outcome measuresGeneral health was assessed with one question asking, “In general would you say your health is excellent, very good, good, fair or poor?” Self‐reported health was then categorised as a binary variable (‘fair/poor’ versus ‘excellent/very good/good’). Psychological distress was assessed using the Kessler Psychological Distress Scale (K10),9 which has 10 questions that determine the level of anxiety and depression in the past four weeks (with a 5‐level response option). Responses were originally categorised into a continuous score (ranging from 10 to 50). For regression models, responses to the K10 were collapsed into ‘very high distress/high distress’ (scores from 10 to 21) versus ‘moderate/low distress’ (scores from 22 to 50), a classification that has been used previously.10AnalysisAnalyses were conducted in Stata 11.1.11 We estimated the population‐weighted prevalence of discrimination and used logistic regression to examine the association between discrimination and self‐rated health and psychological distress adjusting for age, sex, country of birth, disability severity, education, income and labour force status. As a sensitivity analysis, we also ran models that omitted people reporting psychological impairments (n=1,729) who may be more likely to report discrimination and poor mental and physical health.ResultsPrevalence of discriminationNearly 14% of people with disability aged 15 to 64 years reported disability‐based discrimination in the past year, with similar estimates for men and women (Table ). Younger people reported experiencing much higher levels than older people (20.4%, 15 to 24 years versus 9.4%, aged 55 to 64 years). The highest levels of discrimination were reported among those with a severe or profound restriction (21.6%) and the lowest levels were among those with no specific restriction (4.2%). People with intellectual or psychological impairments fared the worst; about one in four reported discrimination, whereas 14% of people with physical impairments reported discrimination.Population weighted percent of people experiencing discrimination due to their disability with 95% confidence intervals, ages 15 to 65 years.% Experiencing discrimination95% Confidence IntervalLower CIUpper CIAll persons13.812.814.9Sex   Males   Females 13.514.0 12.012.6 15.115.5Age   15–24   25–34   35–44   45–54   55–64 20.417.916.614.29.4 16.014.614.012.28.1 25.721.819.416.410.9Disability status   Profound/ severe   Moderate   Mild   Schooling/ employment restriction   No specific restriction 21.615.312.914.54.2 19.012.911.211.72.9 24.618.014.817.86.1Impairment type   Sight, hearing and speech   Intellectual   Physical   Psychological   Acquired brain injury   Other 17.325.114.425.422.018.5 14.821.213.222.817.616.9 20.129.515.728.127.020.3Accessibility and remoteness index of Australia (ARIA)   Major cities   Inner regional   Other 13.015.514.5 11.813.312.0 14.318.117.6Country of birth   Australia   Other English speaking   Other non‐English speaking 14.913.17.8 13.710.05.8 16.216.910.2Highest level of education   Bachelor or postgraduate degree   Certificate or diploma   Completed year 12   Some high school   Year 8 or below   Level not determined 12.514.514.213.013.918.8 10.212.811.311.110.012.5 15.116.517.515.018.927.4Labour force status   Employed full‐time   Employed part‐time   Unemployed   Not in the labour force 8.812.329.815.7 7.210.223.614.2 10.614.735.717.4Occupational skill level   Managers/ professionals/ technical & trades   Community & personal service/ clerical & admin   Sales/ machinery operators/ labourers   Not applicable 8.911.212.017.2 7.28.79.515.6 11.014.315.118.8Income quintile   First (highest)   Second   Third   Fourth   Fifth (lowest)   Unknown 8.610.215.217.215.011.2 6.37.812.715.112.48.9 11.613.118.119.418.014.0Nearly 30% of unemployed people reported discrimination, compared to 9% who were employed full‐time. For employed people, those in higher‐skilled occupations (managers) reported lower levels of discrimination (9%), while those in lower skilled occupations (e.g. sales) had slightly higher levels (13%). Discrimination was highest in people in the lowest 20% of household income distribution. People born in non‐English speaking countries reported lower levels of disability discrimination than those who were Australian‐born.Regression modelsDiscrimination was associated with increased odds of psychological distress (OR: 2.53, 95%CI: 2.11, 3.02) and poor self‐rated health (OR: 1.63, 95%CI: 1.37, 1.95) in models adjusted for potential confounders. The estimates were attenuated slightly when people with psychological impairments were excluded (psychological distress: OR: 2.21, 95%CI 1.75, 2.79 and poor general health: OR: 1.55, 95%CI: 1.22, 1.97).DiscussionIn this first Australian study of self‐reported interpersonal disability‐based discrimination, we found a moderate to strong association between disability‐based discrimination and self‐rated health and psychological distress. Our findings are similar to a Swedish study showing increased odds of psychological distress in relation to perceived disability discrimination (OR: 1.65, 95%CI 1.26, 2.17).6Disability‐based discrimination was relatively common, with 14% of people with disability reporting disability‐based discrimination in the past year. Discrimination was higher among people who were unemployed, in low‐status occupations, younger and living on lower incomes. People with severe disabilities and with psychological and intellectual impairments were more likely to report disability‐based discrimination.Our findings of higher levels of discrimination among some groups suggests that disability may intersect with other social categories and identities to increase the risk of disability‐based discrimination. People with more severe disabilities and with psychological and intellectual impairments fare poorly across a number of social and economic indicators such as housing, employment, education and income.8,12 The higher levels of discrimination they experience are likely to contribute to the poor social and economic outcomes.It is well documented that people with disabilities have poorer physical and mental health.13 Our findings that disability‐based discrimination is associated with higher psychological distress and poor self‐rated health suggests that disability‐based discrimination may be an important determinant of the poorer health outcomes.We used high quality population‐based data; however, because the study is cross‐sectional it is not possible to exclude reverse causation, although longitudinal studies have found perceived discrimination precedes poor health.1,2 It is possible that we have not controlled for important confounders. In addition, we relied on self‐report of experiences of disability discrimination that previous research has shown can be under and over‐reported.14 Another problem is that we only had measures for inter‐personal discrimination; structural or institutional discrimination (e.g. laws, policies) is also likely to be experienced at high levels and to have negative health, social and economic effects.In summary, we show high levels of disability‐based discrimination and demonstrate that discrimination has a moderate to strong association with poorer health. Disability‐based discrimination is an under‐recognised public health problem. Addressing disability‐based discrimination is likely to reduce social and economic disadvantage and improve the health of Australians with disability.Implications for public healthDisability‐based discrimination is an under‐recognised public health problem that is likely to contribute to disability‐based health inequities. Reducing disability‐related discrimination is likely to bring the social, economic and health benefits for Australians with disability and reduce welfare and health expenditure. Public health policy, research and practice needs to concentrate efforts on developing policy and programs that reduce discrimination experienced by Australians with disability.AcknowledgementsResearch funded by NHMRC Centre of Research Excellence grant in Disability and Health APP1116385 and a seed funding grant from the Disability Research Initiative at the University of MelbourneReferencesSchmitt MT, Branscombe NR, Postmes T, Garcia A. The consequences of perceived discrimination for psychological well‐being: A meta‐analytic review. Psychol Bull. 2014; 140(4):921–48.Pascoe EA, Smart Richman L. Perceived discrimination and health: A meta‐analytic review. Psychol Bull. 2009; 135(4):531–54.Australian Human Rights Commission. Willing to Work: National Inquiry into Employment Discrimination Against Older Australians and Australians with Disability. Sydney (AUST): AHRC; 2016.Department of Social Services. Shut Out: The Experience of People with Disabilities and Their Families in Australia. Canberra (AUST): Government of Australia; 2009.Krieger N. Discrimination and health inequities. Int J Health Serv. 2014; 44(4):643–710.Wamala S, Bostrom G, Nyqvist K. Perceived discrimination and psychological distress in Sweden. Br J Psychiatry. 2007; 190:75–6.Australian Bureau of Statistics. 4430.0 ‐ Disability, Ageing and Carers, Australia: Summary of Findings, 2015. Canberra (AUST): ABS; 2016.Kavanagh AM, Krnjacki L, Beer A, Lamontagne AD, Bentley R. Time trends in socio‐economic inequalities for women and men with disabilities in Australia: Evidence of persisting inequalities. Int J Equity Health. 2013; 12:73.Andrews G, Slade T. Interpreting scores on the Kessler Psychological Distress Scale (K10). Aust N Z J Public Health. 2001; 25(6):494–7.Feng X, Astell‐Burt T, Kolt GS. Do social interactions explain ethnic differences in psychological distress and the protective effect of local ethnic density? A cross‐sectional study of 226 487 adults in Australia. BMJ Open. 2013; 3(5). doi.org/10.1136/bmjopen‐2013‐002713STATA: Statistical Software. Version 11. College Station (TX): StataCorp; 2009.Kavanagh AM, Krnjacki L, Aitken Z, LaMontagne AD, Beer A, Baker E, et al. Intersections between disability, type of impairment, gender and socio‐economic disadvantage in a nationally representative sample of 33,101 working‐aged Australians. Disabil Health J. 2015; 8(2):191–9.Emerson E, Madden R, Graham H, Llewellyn G, Hatton C, Robertson J. The health of disabled people and the social determinants of health. Public Health. 2011; 125(3):145–7.Lewis TT, Cogburn CD, Williams DR. Self‐reported experiences of discrimination and health: Scientific advances, ongoing controversies, and emerging issues. Annu Rev Clin Psychol. 2015; 11:407–40.

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Australian and New Zealand Journal of Public Health – Wiley

Published: Jan 1, 2018

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