Perceived discrimination and psychological distress in nine countries of the former Soviet Union

Abstract

Background:

Perceived discrimination has been linked to worse mental health. However, little is known about this association in the countries of the former Soviet Union (fSU).

Aim:

To address this deficit, this study examined the link between perceived discrimination and psychological distress in nine fSU countries.

Methods:

Data were analyzed from 18,000 adults aged ⩾18 years obtained during the Health in Times of Transition (HITT) survey undertaken in Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia and Ukraine in 2010 and 2011. A single-item measure was used to assess discrimination. Psychological distress was measured with a 12-item scale. Logistic regression analysis and meta-analysis were used to examine associations.

Results:

After adjusting for all potential confounders, when using none/little discrimination as the reference category, moderate and strong discrimination were associated with significantly increased odds for psychological distress in the total population and in men and women separately with odds ratios ranging from 1.93 to 2.64. Meta-analysis based on country-wise estimates showed that the level of between-country heterogeneity was negligible.

Conclusion:

Perceived discrimination is associated with psychological distress in countries throughout the fSU. Quantitative and qualitative research is now warranted to determine its specific forms and impact on population health in individual fSU countries.

Keywords

Discrimination mental health Eastern Europe epidemiology

Introduction

Perceived discrimination, which has been defined as the ‘behavioral manifestation of a negative attitude, judgement, or unfair treatment towards members of a group’ (Pascoe & Smart Richman, 2009), is prevalent among disadvantaged groups in society, particularly among those with mental health problems. Both cross-county and individual country research has shown that the perception/experience of discrimination is common among individuals with a variety of mental health disorders such as depression, anxiety, bipolar disorder and schizophrenia (Brohan, Elgie, Sartorius, Thornicroft, & Group, 2010; Brohan, Gauci, Sartorius, Thornicroft, & Group, 2011; Hansson, Stjernsward, & Svensson, 2014; Lasalvia et al., 2013; Thornicroft et al., 2009). Importantly, this research has highlighted not only that discrimination can be experienced in a wide variety of contexts (e.g. in work and health care settings) (Hansson et al., 2014; Lasalvia et al., 2013; Thornicroft et al., 2009) but also that it can have a number of detrimental outcomes for those with mental health problems. For example, discrimination has been linked to isolation, withdrawal and loneliness (Drapalski et al., 2013; Switaj, Grygiel, Anczewska, & Wciorka, 2015); lower self-concept (Drapalski et al., 2013); mistrust in mental health services, and thus low service engagement (Clement et al., 2015) as well as increased self-stigma that may negatively affect clinical recovery (Mak et al., 2017).

It is important to note, however, that discrimination is not only a consequence of mental ill health but may also be a cause. For example, both cross-sectional and longitudinal research on ethnic groups in the United States has linked discrimination to an increased risk of various mental health outcomes including psychological distress (Brown et al., 2000), depressive symptoms/depression (Hwang & Goto, 2008; Schulz et al., 2006), generalized anxiety disorder (Soto, Dawson-Andoh, & BeLue, 2011), psychotic experiences (Oh, Yang, Anglin, & DeVylder, 2014) and suicidal behavior (Cheng et al., 2010). Similar findings have been observed among other disadvantaged groups including sexual minorities (Hatzenbuehler, McLaughlin, Keyes, & Hasin, 2010; Lee, Gamarel, Bryant, Zaller, & Operario, 2016), immigrants (Agudelo-Suarez et al., 2011), people with physical disabilities and illnesses (Bogart et al., 2011; Krnjacki et al., 2018) and older adults (Luo, Xu, Granberg, & Wentworth, 2012). These results are underpinned by findings from two meta-analyses linking perceived discrimination to an increased risk of poorer psychological/mental health (Pascoe & Smart Richman, 2009; Schmitt, Branscombe, Postmes, & Garcia, 2014).

This study will examine the association between perceived discrimination and psychological distress among the general population in nine countries of the former Soviet Union (fSU). As yet, there has been little research on discrimination or its correlates in the former Soviet countries (Winkler et al., 2017). However, there is some indication that this might be an important omission, especially as other research in the West has indicated that discrimination may also be prevalent in the general population and associated with detrimental outcomes (Kessler, Mickelson, & Williams, 1999). Indeed, multi-country studies, which have included fSU countries that have examined discrimination related to age (van den Heuvel & van Santvoort, 2011; Vauclair et al., 2015) and significant disability (Alonso et al., 2008), have reported not only relatively high rates of discrimination in this region but also differences in overall levels and in different forms of stigma and discrimination (Alvarez-Galvez & Salvador-Carulla, 2013; Ayalon, 2014). Importantly, other research within individual fSU countries has shown that discrimination on grounds of mental health (Krupchanka et al., 2017), disability (Phillips, 2002), ethnicity (Popov & Kuznetsov, 2008), sexual orientation (Wilkinson, 2013) and physical disease (HIV) (Amirkhanian, Kelly, & McAuliffe, 2003) is common, as is sexism (Erzikova & Berger, 2016; Knapp, DuBois, Hogue, Astakhova, & Faley, 2017). Moreover, as it is also known that the prevalence of mental ill health is comparatively high in some fSU countries (Ferrari et al., 2013; Van de Velde, Bracke, & Levecque, 2010), an examination of the association between discrimination and psychological distress in the general population might be particularly instructive, especially as an earlier study in Ukraine reported an association between comorbid mood and anxiety disorders and perceived stigma (including discrimination) (Alonso et al., 2008).

Given this knowledge gap, this study has two aims. (1) To determine whether there is an association between perceived discrimination and psychological distress among the general population in the fSU countries. As previous research has indicated that there may be differences in the association between discrimination and mental health outcomes between men and women (Assari & Lankarani, 2017; Banks, Kohn-Wood, & Spencer, 2006; Klonoff, Landrine, & Campbell, 2000; Lee et al., 2016; Schmitt, Branscombe, Kobrynowicz, & Owen, 2002), we also conducted a sex-stratified analysis. (2) To determine whether the association between perceived discrimination and psychological distress differs across fSU countries.

Materials and methods

Study sample

This study used data drawn from the Health in Times of Transition (HITT) survey. This cross-sectional survey collected data in nine fSU countries: Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Moldova, Russia and Ukraine in 2010 and from Kyrgyzstan in 2011 (due to political unrest). To obtain nationally representative samples, multi-stage random sampling with stratification by region and urban/rural settlement type was undertaken in each country. Random route procedures were used to select households from within primary sampling units (PSU) (approximately 100–200 per country). One person aged ⩾18 was randomly chosen to participate (determined by the nearest birthday) from each selected household. Face-to-face interviews were conducted by trained interviewers in the respondents’ homes using a standard questionnaire. Interviewees could respond in either their own national language or Russian in every country except for in Russia and Belarus, where all interviews were conducted in Russian. Exclusion criteria were being institutionalized, hospitalized, homeless, incarcerated, in the military or intoxicated when the survey was being conducted.

In total, 18,000 respondents were included in the survey. In six of the nine countries, the sample size was 1,800 respondents. However, to account for their larger and more regionally diverse populations, the sample size was increased in Russia and Ukraine (to 3,000 and 2,000 persons, respectively). The sample size was also larger in Georgia (n = 2,200) due to the need to make the sample more representative which resulted in a 400-person booster survey being undertaken toward the end of 2010. Across the countries, response rates ranged from 47% (Kazakhstan) to 83% (Georgia) (Roberts et al., 2013). Ethical approval for this study was obtained from the ethics committee at the London School of Hygiene and Tropical Medicine. The survey was undertaken in accordance with the ethical standards laid out in the 1964 Helsinki Declaration and its subsequent revisions with all respondents providing informed consent before participation.

Measures

Psychological distress (dependent variable)

This was measured with a 12-item scale that has been used in several previous studies of psychological distress in the fSU countries (Stickley, Koyanagi, Roberts, & McKee, 2015; Stickley et al., 2013). Participants were asked to respond yes/no to whether they had recently experienced: (1) an inability to concentrate, (2) insomnia, (3) feelings of being under constant strain, (4) feeling an inability to overcome difficulties, (5) loss of confidence in oneself, (6) nervous shaking or trembling, (7) frightening thoughts coming into your mind, (8) spells of exhaustion or fatigue, (9) feelings of stress, (10) feelings of loneliness, (11) feelings of impossibility to influence things and (12) feeling that life is too complicated. As locus of control was also examined in this study, Item 11 was removed from the scale. The yes responses were summed across the individual items to create a scale score that could range from 0 to 11, where higher scores indicated greater distress (Cronbach’s alpha for the total sample = .80, ranging from .69 in Kyrgyzstan to .84 in Georgia). In keeping with prior studies, the current analysis dichotomized the scale (Roberts, Abbott, & McKee, 2010) so that those with the highest scores, that is, 9–11 were classified as suffering from (high) psychological distress.

Perceived discrimination (independent variable)

Following the lead of Kessler et al. (1999) who highlighted the subjective nature of reporting discrimination, we use the term perceived discrimination. This was assessed by asking respondents about the extent they agreed/disagreed with the statement, ‘I often have the feeling that I am being treated unfairly’. Answer options were agree, quite agree, rather disagree and disagree. These answers were categorized in the following manner, agree = ‘Strong’ discrimination, quite agree = ‘Moderate’ discrimination and rather disagree/disagree = ‘None/little’ discrimination. The use of unfair treatment as a marker of discrimination accords with earlier research (Williams, Yan, Jackson, & Anderson, 1997).

Covariates

Information was included on demographic variables and other factors which past research has indicated may be important for the association between discrimination and mental health (Chou, 2012; Jang, Chiriboga, & Small, 2008). Specifically, demographic information was obtained on sex, age (in three categories: 18–34, 35–59, ⩾60 years) and education (complete and incomplete higher education = High, completed secondary = Middle and incomplete secondary and primary or no education = Low education). Marital status was divided into three categories: married/cohabiting, never married (single) and divorced/widowed. Location was categorized as either urban or rural. Information on household finances was obtained with a question which asked, ‘How would you describe the economic situation of your household at the present time’ with response options very good, good (categorized as ‘good’) average, and bad, very bad (categorized as ‘bad’). Self-rated health was dichotomized into very good/good/fair (scored 0) and very poor/poor (scored 1). Social support was assessed with questions which enquired about having someone who can listen when needed, help out in a crisis or who could provide comfort when required. Using yes (scored 1) and no (scored 0) answer options, respondents’ scores were summed so that those who scored 3 were categorized as having a ‘High’ level of social support, those who scored 1–2 were deemed to have a ‘Middle’ level of social support, while those who scored 0 were classified as having ‘Low’ social support. Locus of control was assessed with a statement which read, ‘I feel that what happens in my life is often determined by factors beyond my control’. Response options were agree (categorized as having ‘Low’ control), quite agree (‘Middle’ control) and rather disagree and disagree (‘High’ control). Information was also obtained on two health behaviors – smoking and alcohol consumption. Those who answered yes to the question ‘Do you smoke at least one cigarette per day?’ were categorized as daily smokers. Alcohol use was assessed with a question which asked about the frequency of consuming alcoholic drinks of any type with categories that ranged from every day to never. Everyone who reported any frequency other than never was categorized as an alcohol user.

Statistical analysis

Descriptive statistics of the sample characteristics and stratified by psychological distress were initially calculated where differences were assessed with chi-square tests. Logistic regression analysis was used to assess the association between perceived discrimination and psychological distress. Pooled analyses using the overall and sex-stratified samples were conducted. Two analyses were performed. In Model 1, a bivariate analysis was undertaken to examine the ‘base’ association between discrimination, each variable and psychological distress. In Model 2, a multivariable analysis was performed where the analysis was adjusted for all the variables in the model. To control for the effects of location, dummy variables were created for the countries and included in all of the analyses. Separate analyses were then performed for each country that also used two models. In Model 1, the bivariate association between discrimination and psychological distress was examined. In Model 2, a multivariable analysis was performed controlling for all of the variables in the analysis.

To assess whether there is between-country heterogeneity in the association between perceived discrimination and psychological distress, we conducted a meta-analysis based on country-wise estimates adjusted for all factors in Model 2 mentioned above. Pooled estimates were obtained by combining the estimates for moderate discrimination (vs none/little discrimination) and severe discrimination (vs none/little discrimination) separately for each country into a fixed effect meta-analysis with Higgin’s I² statistic being calculated. Higgin’s I² shows the extent of heterogeneity between countries that is not due to sampling error. Less than 30% heterogeneity is deemed as being negligible, while significantly more than 50% indicates notable heterogeneity (Higgins & Thompson, 2002). The results are presented as odds ratios (OR) with 95% confidence intervals (CIs). A p value of <.05 was considered as being statistically significant. Analyses were performed with SPSS version 21.0 and Stata version 14.0.

Results

Perceived discrimination was common, with 38.1% of respondents reporting that they had experienced any discrimination (Table 1). Furthermore, 5.2% of the respondents reported psychological distress. There was a dose–response association between the level of discrimination and psychological distress, with the prevalence of psychological distress being over four times greater among those who reported strong discrimination compared to none or little discrimination. There were significant differences in psychological distress for all of the other study variables. Specifically, psychological distress was associated with female sex, older age, low education, being divorced/widowed, rural location, bad household finances, poor self-rated health, low social support and locus of control and not smoking or using alcohol.

Table 1.

Sample characteristics and by prevalence of psychological distress.

Characteristic	Number (%)		Psychological distress		p value
Characteristic	Number (%)		No (%)	Yes (%)	p value
Discrimination					<.001
None/little	10,751	(61.9)	97.1	2.9
Moderate	3,750	(21.6)	93.2	6.8
Strong	2,866	(16.5)	88.1	11.9
Sex					<.001
Male	7,829	(43.5)	96.9	3.1
Female	10,171	(56.5)	93.1	6.9
Age (years)					<.001
18–34	6,801	(37.8)	97.8	2.2
35–59	7,789	(43.3)	94.7	5.3
⩾60	3,410	(18.9)	88.6	11.4
Education level					<.001
High	4,942	(27.5)	96.7	3.3
Middle	10,669	(59.4)	95.0	5.0
Low	2,345	(13.1)	89.7	10.3
Marital status					<.001
Married	11,130	(62.1)	95.7	4.3
Never married	3,692	(20.6)	97.5	2.5
Divorced/widowed	3,114	(17.4)	88.0	12.0
Location
Urban	10,865	(60.4)	95.2	4.8	.001
Rural	7,135	(39.6)	94.1	5.9
Household finances					<.001
Good	3,985	(22.4)	98.0	2.0
Average	10,196	(57.3)	96.3	3.7
Bad	3,616	(20.3)	86.8	13.2
Self-rated health					<.001
Very good/good/fair	14,634	(81.5)	97.7	2.3
Very poor/poor	3,311	(18.5)	81.3	18.7
Social support					<.001
High	15,205	(87.1)	95.7	4.3
Middle	1,666	(9.6)	91.3	8.7
Low	583	(3.3)	83.6	16.4
Locus of control					<.001
High	6,574	(38.0)	97.8	2.2
Middle	6,195	(35.8)	94.7	5.3
Low	4,545	(26.3)	90.7	9.3
Daily smoking					<.001
Yes	4,643	(25.8)	96.6	3.4
No	13,345	(74.2)	94.1	5.9
Alcohol use					<.001
Yes	12,072	(68.2)	95.7	4.3
No	5,617	(31.8)	93.0	7.0
Psychological distress
Yes	883	(5.2)	–	–
No	16,049	(94.8)	–	–
Country					<.001
Armenia	1,800	(10.0)	94.1	5.9
Azerbaijan	1,800	(10.0)	97.4	2.6
Belarus	1,800	(10.0)	95.3	4.7
Georgia	2,200	(12.2)	93.1	6.9
Kazakhstan	1,800	(10.0)	97.6	2.4
Kyrgyzstan	1,800	(10.0)	94.5	5.5
Moldova	1,800	(10.0)	91.4	8.6
Russia	3,000	(16.7)	95.5	4.5
Ukraine	2,000	(11.1)	94.2	5.8

In the pooled analysis, both moderate and strong discrimination were associated with increased odds for psychological distress in the total sample and for men and women separately in the bivariate analysis (Model 1, Table 2). In the multivariable analysis, adjusting for other covariates attenuated these associations, but both moderate and strong discrimination continued to be significantly associated with psychological distress across the three groups, with strong discrimination associated with 2.3–2.6 times higher odds for psychological distress and moderate discrimination doubling the odds for psychological distress (Model 2). Other predictors of psychological distress that were common to men and women included poor self-rated health, bad household finances, low social support and locus of control. However, while increasing age was associated with higher odds for psychological distress in women, this association was not observed for men.

Table 2.

Association between perceived discrimination and psychological distress for the total population and men and women in nine countries of the former Soviet Union.

Characteristic	Total		Men		Women
	Model 1	Model 2^†	Model 1	Model 2^‡	Model 1	Model 2^≠
	OR (95% CI)	OR (95% CI)	OR (95% CI)	OR (95% CI)	OR (95% CI)	OR (95% CI)
Discrimination
None/little	Ref.	Ref.	Ref.	Ref.	Ref.	Ref.
Moderate	2.44 (2.05-2.91) ^c	1.99 (1.63-2.42) ^c	2.22 (1.57-3.15) ^c	1.93 (1.31-2.85) ^b	2.44 (1.98-2.99) ^c	2.01 (1.59-2.53) ^c
Strong	4.42 (3.73-5.22) ^c	2.55 (2.09-3.12) ^c	4.11 (2.98-5.68) ^c	2.35 (1.61-3.45) ^c	4.47 (3.66-5.44) ^c	2.64 (2.09-3.35) ^c
Sex (female)	2.28 (1.96-2.67) ^c	1.72 (1.39-2.12) ^c	–	–	–	–
Age
18–34	Ref.	Ref.	Ref.	Ref.	Ref.	Ref.
35–59	2.50 (2.05-3.04) ^c	1.46 (1.14-1.88) ^b	2.04 (1.43-2.90) ^c	1.33 (0.82-2.15)	2.62 (2.06-3.33) ^c	1.50 (1.12-2.02) ^b
⩾60	5.69 (4.65-6.97) ^c	1.61 (1.20-2.15) ^b	4.62 (3.20-6.66) ^c	1.59 (0.92-2.75)	5.87 (4.59-7.51) ^c	1.63 (1.15-2.30) ^b
Education level
High	Ref.	Ref.	Ref.	Ref.	Ref.	Ref.
Middle	1.61 (1.33-1.93) ^c	1.04 (0.84-1.28)	1.46 (1.03-2.08) ^a	1.04 (0.69-1.56)	1.68 (1.35-2.10) ^c	1.05 (0.82-1.35)
Low	3.26 (2.62-4.05) ^c	1.15 (0.88-1.51)	2.29 (1.49-3.52) ^c	0.80 (0.47-1.34)	3.69 (2.86-4.75) ^c	1.32 (0.96-1.82)
Marital status
Married	Ref.	Ref.	Ref.	Ref.	Ref.	Ref.
Never married	0.60 (0.47-0.75) ^c	1.15 (0.86-1.53)	0.69 (0.48-1.00) ^a	1.35 (0.81-2.24)	0.59 (0.44-0.80) ^b	1.03 (0.71-1.48)
Divorced/widowed	3.07 (2.64-3.57) ^c	1.25 (1.03-1.52) ^a	2.80 (1.98-3.95) ^c	1.17 (0.74-1.84)	2.67 (2.25-3.17) ^c	1.25 (1.00-1.56) ^a
Location (rural)	1.20 (1.04-1.38) ^a	1.01 (0.85-1.20)	1.42 (1.08-1.88) ^a	1.26 (0.91-1.75)	1.16 (0.98-1.37)	0.95 (0.78-1.16)
Household finances
Good	Ref.	Ref.	Ref.	Ref.	Ref.	Ref.
Average	1.91 (1.48-2.45) ^c	1.28 (0.97-1.68)	1.58 (1.04-2.40) ^a	1.12 (0.71-1.79)	2.04 (1.49-2.80) ^c	1.36 (0.97-1.91)
Bad	7.67 (5.95-9.89) ^c	2.33 (1.74-3.12) ^c	5.56 (3.61-8.58) ^c	1.71 (1.03-2.86) ^a	8.42 (6.13-11.57) ^c	2.60 (1.82-3.73) ^c
Self-rated health (poor)	10.28 (8.85-11.93) ^c	5.54 (4.59-6.68) ^c	12.75 (9.59-16.96) ^c	8.93 (6.21-12.84) ^c	8.65 (7.25-10.32) ^c	4.71 (3.78-5.87) ^c
Social support
High	Ref.	Ref.	Ref.	Ref.	Ref.	Ref.
Middle	2.19 (1.80-2.66) ^c	1.35 (1.08-1.70) ^b	2.28 (1.58-3.30) ^c	1.58 (1.04-2.40) ^a	2.16 (1.71-2.73) ^c	1.27 (0.97-1.67)
Low	4.32 (3.38-5.52) ^c	1.87 (1.38-2.53) ^c	4.59 (2.89-7.31) ^c	2.08 (1.15-3.75) ^a	4.19 (3.13-5.61) ^c	1.81 (1.27-2.58) ^b
Locus of control
High	Ref.	Ref.	Ref.	Ref.	Ref.	Ref.
Middle	2.37 (1.93-2.92) ^c	1.65 (1.32-2.07) ^c	2.25 (1.55-3.28) ^c	1.39 (0.92-2.11)	2.32 (1.82-2.98) ^c	1.76 (1.34-2.31) ^c
Low	4.52 (3.71-5.52) ^c	2.37 (1.89-2.97) ^c	4.04 (2.80-5.83) ^c	2.06 (1.36-3.13) ^b	4.45 (3.50-5.64) ^c	2.50 (1.91-3.27) ^c
Daily smoking (yes)	0.58 (0.48-0.69) ^c	0.99 (0.78-1.26)	0.91 (0.69-1.18)	0.92 (0.67-1.28)	0.82 (0.59-1.12)	1.14 (0.78-1.67)
Alcohol use (yes)	0.46 (0.39-0.53) ^c	0.91 (0.76-1.08)	0.68 (0.48-0.95) ^a	0.92 (0.64-1.33)	0.49 (0.42-0.59) ^c	0.91 (0.74-1.12)

Model 1: bivariate analysis; Model 2: multivariable analysis.

All odds ratios (ORs) and 95% confidence intervals (CIs) marked in bold font are statistically significant.

†

The analysis included 15,230 participants.

‡

The analysis included 6,696 men.

≠

The analysis included 8,534 women.

p < .05; ^bp < .01; ^cp < .001.

A country-wise analysis showed that moderate discrimination was associated with higher odds for psychological distress in six of the nine countries with the overall effect based on a meta-analysis resulting in over two times higher odds for psychological distress (OR: 2.06, 95% CI: 1.67–2.54) (Figure 1). Strong discrimination was associated with significantly increased odds for psychological distress in every country except Ukraine with the overall association based on a meta-analysis resulting in almost 2.7 times higher odds for psychological distress across countries (OR: 2.67, 95% CI: 2.15–3.30). The degree of heterogeneity for both moderate and strong discrimination was negligible, indicating consistent across-country effects (the full results from the separate country bivariate and multivariable analyses are presented in online Appendix 1).

Figure 1.

Meta-analysis of the association between moderate and strong perceived discrimination and psychological distress in nine countries of the former Soviet Union: (a) Moderate discrimination versus None/little and (b) Strong discrimination versus None/little.

Discussion

This study examined the association between perceived discrimination and psychological distress in nine fSU countries. The experience of discrimination was common in the sample with over 20% of respondents reporting that they had experienced a moderate degree of discrimination and over 15% a strong degree of discrimination. An association between perceived discrimination and psychological distress was observed for the total population and for men and women separately, with discrimination being associated with over two times higher odds for reporting psychological distress. Moreover, either moderate or strong perceived discrimination was associated with increased odds for psychological distress in every country, with higher odds being observed for those who reported stronger discrimination. The associations were similar across countries as assessed by Higgin’s I². Indeed, discrimination, together with poor self-rated health, was the most consistent predictor of psychological distress across the countries (see online Appendix 1).

The descriptive analysis showed that 38.1% of the sample reported some form of discrimination. Other studies from the United States that have used nationally representative data have reported figures ranging from 33.5% (lifetime) to 46% (any) (Kessler et al., 1999; Puhl, Andreyeva, & Brownell, 2008), although the prevalence of perceived discrimination was much lower in the countries participating in the European Social Survey (that included Russia and Ukraine) (Alvarez-Galvez & Salvador-Carulla, 2013). However, making comparisons between studies is fraught with difficulty as there can be differences in terms of question wording, the form(s) of discrimination examined/time frame involved (day-to-day or lifetime), the age of the respondents and their willingness to report discrimination in different contexts. A recent multi-country study from Europe showed, for example, that the prevalence of perceived discrimination can vary both between and within countries depending on the specific form of discrimination being examined (age, gender, ethnicity) (Ayalon, 2014). Nonetheless, the finding that almost 4 in every 10 respondents in this study reported experiencing some form of discrimination seems to confirm research from within the individual countries that perceived discrimination may be common in these fSU countries.

Some earlier studies have indicated that there may be a difference in the association between perceived discrimination and mental health between men and women, with most (Kessler et al., 1999; Klonoff et al., 2000; Lee et al., 2016; Schmitt et al., 2002) but not all (Assari & Lankarani, 2017) studies indicating that the association may be stronger in women. However, this research has also highlighted the potential complexity of these associations by showing that sex differences might also depend on the particular outcome being studied (Banks et al., 2006). Our results, however, accord with those from an earlier study in Sweden, where both men and women who reported either some or frequent perceived discrimination in the previous 3 months had significantly higher odds for psychological distress than those who had not experienced discrimination (Wamala, Bostrom, & Nyqvist, 2007). That study also reported that the same forms of discrimination were linked to psychological distress in both men and women (i.e. ethnic background, sexual orientation and disability), but that only men experienced psychological distress due to their gender/sex (Wamala et al., 2007). Although more research is needed, it is possible that this latter finding might conflict with what is happening in the fSU countries. In particular, in the post-Soviet period, the increasing emergence of patriarchy has been observed in countries such as Kazakhstan and Kyrgyzstan (Werner, 2009), while in Russia, a process of ‘neomasculinism’ has been reported (Johnson & Saarinen, 2013), which has been linked to women experiencing discrimination both in terms of their employment and in the workplace (Hawkins & Knox, 2014; Knapp et al., 2017).

There was a strong and consistent association between discrimination and psychological distress with some form of perceived discrimination being associated with increased odds for psychological distress in each of the countries, with the meta-analysis showing that there was only a negligible level of between-country heterogeneity. This is a noteworthy finding for several reasons. First, it extends our understanding of the factors that are associated with mental ill health in the fSU countries (Roberts et al., 2010). This is important given the comparatively high levels of poor mental health in some of these countries. Second, as perceived discrimination was a predictor of psychological distress in every country, this suggests that levels of stigma toward disadvantaged groups such as people with mental illness may be high in the countries in this region (Winkler et al., 2017), and that in some instances, this discrimination might not only be elevated due to individual-level discrimination among the general public in these countries (Dietrich et al., 2004) but that it might also have a structural element to it as previously suggested (Krupchanka et al., 2017). This finding also indicates that discrimination might be an especially important factor for poor mental health in these countries. Third, given the deleterious effects of even moderate levels of discrimination on psychological well-being in many of these countries, the results of this study highlight the urgent need for more research to be undertaken on discrimination in all these fSU countries. In particular, both quantitative and qualitative research is needed to further elucidate how the different forms and facets of discrimination impact various groups, resulting in negative health effects.

A detailed discussion of the mechanisms that may link perceived discrimination and psychological distress is beyond the scope of this study, although it is widely acknowledged that discrimination is a stressor that may have both physiological and psychological effects (Clark, Anderson, Clark, & Williams, 1999), with an earlier study suggesting that both biological (stress response) and health behavior changes may be important for poorer health (Pascoe & Smart Richman, 2009). Indeed, perceived discrimination has been linked to the underuse of needed physical and mental health services (Burgess, Ding, Hargreaves, van Ryn, & Phelan, 2008), which might result in worse mental health. It is also possible that specific aspects of discrimination such as social avoidance might be important as perceived discrimination has been linked to an increased risk for loneliness (Sutin, Stephan, Carretta, & Terracciano, 2015) which in turn has also been found to predict psychological distress in the fSU countries (Stickley et al., 2013).

It is important to note that this study has a number of limitations. The question assessing discrimination suffered from several deficits including not referring to a specific time period, the form of discrimination or how often it occurred. Future research should use more detailed instruments. Given the potentially sensitive nature of this phenomenon, it is also possible that some social desirability bias might have led to underreporting of discrimination, although an earlier study from South Africa indicated that socially desirable responding was not important in the discrimination–psychological distress association (Williams et al., 2008). Similarly, by excluding individuals who were institutionalized, hospitalized and homeless from participating in the survey, it is possible that we excluded those who might have been subject to especially high levels of discrimination, which might have affected our estimates. In addition, certain small geographic regions of some countries were excluded due to geopolitical insecurity (e.g. South Ossetia in Georgia and Transnistria in Moldova) and it is possible that there may have been greater levels of discrimination and psychological distress in such areas. Finally, given that this was a cross-sectional study, it was not possible to establish causality or the direction of the observed associations. This may have been problematic as a recent longitudinal study among older adults found that depression predicted the reporting of perceived age discrimination but not vice versa, suggesting that mood might affect the perception of events (Ayalon, 2018).

Conclusion

This study has shown that perceived discrimination is prevalent in the fSU countries and is an important predictor of worse mental health independent of factors such as locus of control and social support. Given this, an important next step is prospective research among both the general population and disadvantaged groups to better understand the association between discrimination and mental (and physical) health outcomes so that interventions can be formulated to ameliorate the deleterious effects of this phenomenon on population health in the countries in this region.

Supplemental Material

Supplemental_Material – Supplemental material for Perceived discrimination and psychological distress in nine countries of the former Soviet Union

Supplemental material, Supplemental_Material for Perceived discrimination and psychological distress in nine countries of the former Soviet Union by Andrew Stickley, Hans Oh, Ai Koyanagi, Mall Leinsalu, Zui Narita, Bayard Roberts and Martin McKee in International Journal of Social Psychiatry

Footnotes

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

ORCID iDs

Andrew Stickley

Hans Oh

Supplemental material

Supplemental material for this article is available online.

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