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      Different faces of discrimination: perceived discrimination among homeless adults with mental illness in healthcare settings

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          Abstract

          Background

          Research on discrimination in healthcare settings has primarily focused on health implications of race-based discrimination among ethno-racial minority groups. Little is known about discrimination experiences of other marginalized populations, particularly groups facing multiple disadvantages who may be subjected to other/multiple forms of discrimination. Objectives: (1) To examine the prevalence of perceived discrimination due to homelessness/poverty, mental illness/alcohol/drug related problems, and race/ethnicity/skin color while seeking healthcare in the past year among racially diverse homeless adults with mental illness; (2) To identify whether perceiving certain types of discrimination is associated with increased likelihood of perceiving other kinds of discrimination; and (3) To examine association of these perceived discrimination experiences with socio-demographic characteristics, self-reported measures of psychiatric symptomatology and substance use, and Emergency Department utilization.

          Methods

          We used baseline data from the Toronto site of the At Home/Chez Soi randomized controlled trial of Housing First for homeless adults with mental illness (n = 550). Bivariate statistics and multivariable logistic regression models were used for the analysis.

          Results

          Perceived discrimination related to homelessness/poverty (30.4%) and mental illness/alcohol/substance use (32.5%) is prevalent among ethnically diverse homeless adults with mental illness in healthcare settings. Only 15% of the total participants reported discrimination due to race/ethnicity/skin color. After controlling for relevant confounders and presence of psychosis, all types of discrimination in healthcare settings were associated with more frequent ED use, a greater - 3 - severity of lifetime substance abuse, and mental health problems. Perceiving discrimination of one type was associated with increased likelihood of perceiving other kinds of discrimination.

          Conclusions

          Understanding the experience of discrimination in healthcare settings and associated healthcare utilization is the first step towards designing policies and interventions to address health disparities among vulnerable populations. This study contributes to the knowledge base in this important area.

          Trial registration number

          This study has been registered with the International Standard Randomized Control Trial Number Register and assigned ISRCTN42520374.

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          Most cited references70

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          Racial Differences in Physical and Mental Health: Socio-economic Status, Stress and Discrimination.

          This article examines the extent to which racial differences in socio-economic status (SES), social class and acute and chronic indicators of perceived discrimination, as well as general measures of stress can account for black-white differences in self-reported measures of physical and mental health. The observed racial differences in health were markedly reduced when adjusted for education and especially income. However, both perceived discrimination and more traditional measures of stress are related to health and play an incremental role in accounting for differences between the races in health status. These findings underscore the need for research efforts to identify the complex ways in which economic and non-economic forms of discrimination relate to each other and combine with socio-economic position and other risk factors and resources to affect health.
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            Racial/ethnic discrimination and health: findings from community studies.

            The authors review the available empirical evidence from population-based studies of the association between perceptions of racial/ethnic discrimination and health. This research indicates that discrimination is associated with multiple indicators of poorer physical and, especially, mental health status. However, the extant research does not adequately address whether and how exposure to discrimination leads to increased risk of disease. Gaps in the literature include limitations linked to measurement of discrimination, research designs, and inattention to the way in which the association between discrimination and health unfolds over the life course. Research on stress points to important directions for the future assessment of discrimination and the testing of the underlying processes and mechanisms by which discrimination can lead to changes in health.
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              On stigma and its consequences: evidence from a longitudinal study of men with dual diagnoses of mental illness and substance abuse.

              Numerous studies have demonstrated a strong connection between the experience of stigma and the well-being of the stigmatized. But in the area of mental illness there has been controversy surrounding the magnitude and duration of the effects of labeling and stigma. One of the arguments that has been used to downplay the importance of these factors is the substantial body of evidence suggesting that labeling leads to positive effects through mental health treatment. However, as Rosenfield (1997) points out, labeling can simultaneously induce both positive consequences through treatment and negative consequences through stigma. In this study we test whether stigma has enduring effects on well-being by interviewing 84 men with dual diagnoses of mental disorder and substance abuse at two points in time--at entry into treatment, when they were addicted to drugs and had many psychiatric symptoms and then again after a year of treatment, when they were far less symptomatic and largely drug- and alcohol-free. We found a relatively strong and enduring effect of stigma on well-being. This finding indicates that stigma continues to complicate the lives of the stigmatized even as treatment improves their symptoms and functioning. It follows that if health professionals want to maximize the well-being of the people they treat, they must address stigma as a separate and important factor in its own right.
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                Author and article information

                Contributors
                ASkos078@uottawa.ca
                OCampoP@smh.ca
                ZergerS@smh.ca
                ChambersC@smh.ca
                SusanGapka@yahoo.ca
                StergiopoulosV@smh.ca
                Journal
                BMC Health Serv Res
                BMC Health Serv Res
                BMC Health Services Research
                BioMed Central (London )
                1472-6963
                7 September 2014
                7 September 2014
                2014
                : 14
                : 1
                : 376
                Affiliations
                [ ]Centre for Research on Inner City Health, Li Ka-Shing Knowledge Institute, Keenan Research, Centre, St. Michael’s Hospital, Toronto, Canada
                [ ]Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
                [ ]Toronto People with Lived Experience Caucus, Toronto Local Advisory Committee, National Consumer Panel, Toronto, Canada
                [ ]Department of Psychiatry, University of Toronto, Toronto, Canada
                Article
                3490
                10.1186/1472-6963-14-376
                4176588
                25196184
                07ba41b5-a8a3-4766-94e6-5e10f7fa4040
                © Skosireva et al.; licensee BioMed Central Ltd. 2014

                This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 6 October 2013
                : 1 September 2014
                Categories
                Research Article
                Custom metadata
                © The Author(s) 2014

                Health & Social care
                racial discrimination,social discrimination,homeless persons,prejudice,racism,healthcare,adult,canada,mentally ill persons,substance-related disorders

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