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Racism in healthcare: a scoping review

Abstract

Background

Racism constitutes a barrier towards achieving equitable healthcare as documented in research showing unequal processes of delivering, accessing, and receiving healthcare across countries and healthcare indicators. This review summarizes studies examining how racism is discussed and produced in the process of delivering, accessing and receiving healthcare across various national contexts.

Method

The PRISMA guidelines for scoping reviews were followed and databases were searched for peer reviewed empirical articles in English across national contexts. No starting date limitation was applied for this review. The end date was December 1, 2020. The review scoped 213 articles. The results were summarized, coded and thematically categorized in regards to the aim.

Results

The review yielded the following categories: healthcare users’ experiences of racism in healthcare; healthcare staff’s experiences of racism; healthcare staff’s racial attitudes and beliefs; effects of racism in healthcare on various treatment choices; healthcare staff’s reflections on racism in healthcare and; antiracist training in healthcare. Racialized minorities experience inadequate healthcare and being dismissed in healthcare interactions. Experiences of racism are associated with lack of trust and delay in seeking healthcare. Racialized minority healthcare staff experience racism in their workplace from healthcare users and colleagues and lack of organizational support in managing racism. Research on healthcare staff’s racial attitudes and beliefs demonstrate a range of negative stereotypes regarding racialized minority healthcare users who are viewed as difficult. Research on implicit racial bias illustrates that healthcare staff exhibit racial bias in favor of majority group. Healthcare staff’s racial bias may influence medical decisions negatively. Studies examining healthcare staff’s reflections on racism and antiracist training show that healthcare staff tend to construct healthcare as impartial and that healthcare staff do not readily discuss racism in their workplace.

Conclusions

The USA dominates the research. It is imperative that research covers other geo-political contexts. Research on racism in healthcare is mainly descriptive, atheoretical, uses racial categories uncritically and tends to ignore racialization processes making it difficult to conceptualize racism. Sociological research on racism could inform research on racism as it theoretically explains racism’s structural embeddedness, which could aid in tackling racism to provide good quality care.

Peer Review reports

Background

This scoping review summarizes studies that look at how racism is discussed and produced in the process of delivering, accessing and receiving healthcare. Racism can be defined as a form of social formation embedded within a network of social, economic, and political entities in which groups of people are categorized and hierarchically ordered through a historical process of racialization [1]. Groups of people who are racialized as inferior, henceforth referred to as racialized minorities, are devalued, disempowered, and subjected to differential treatment in various institutions, including healthcare, resulting in negative material consequences affecting people’s living conditions, everyday lives, including access to healthcare and health outcomes [2]. We use the term minority herein to indicate groups of people who are minoritized as they are subjected to unequal power relations. Racism is a dynamic historical process that continuously undergoes change and finds new forms of political, social, cultural, or linguistic expressions [3]. In contrast to the official, recognized institutionalized racism that existed in most Western settings prior to the Second World War, contemporary racism persists through more normalized covert or invisible processes rather than explicit expressions of racism [4]. These processes operate at multiple interrelated levels, ranging from the individual to the structural within existing structures [5].

In healthcare, as in other institutions, racism continues to persist and constitutes a major barrier towards achieving equitable and responsive healthcare. This is documented by research showing differential and unequal processes of delivering, accessing, and receiving healthcare across various countries and healthcare indicators [2, 6] including diabetes care [7], mental healthcare [8], maternal healthcare [9], preventive vaccination [10], end-of-life care [11], cardiology care [12] and pain management [13]. Research has also documented that racialized minorities not only receive inadequate quality healthcare but are also viewed as less desirable healthcare users compared to majority groups [14]. A systematic scoping review of studies looking at healthcare users’ perspectives on racism in healthcare shows that racialized minority healthcare users are alienated due to racism and lack of empathy resulting in inadequate healthcare [15]. A meta-analysis [16] also shows that healthcare users who experience racism have higher odds of reporting lower trust in healthcare, lower satisfaction with care, and perceived quality of care. Meta-analysis reviews [17,18,19], as well as a scoping review of both qualitative and quantitative studies [20], show that healthcare staff produce racism unconsciously as they exhibit implicit racial bias, i.e., negative attitudes and stereotypes against racialized minorities relative to majority groups within the context of healthcare.

Although the volume of scientific research on the various ways racism affects healthcare has grown steadily [2], racism and its damaging effect on the livelihood and health of racialized minorities [21,22,23] persists and consequently constitute an injustice that needs to be addressed. Some systematic meta-analyses and scoping reviews regarding various dimensions of racism in healthcare have been conducted. These have examined evidence involving healthcare staff’s implicit racial bias [17,18,19,20], antiracist interventions in healthcare [24], healthcare users’ utilization of care [16], public health understanding of racism in healthcare [25], as well as other topics [26]. The importance of these reviews notwithstanding, these reviews focus on specific dimensions pertaining to racism in healthcare and hence do not examine the full extent of the existing evidence on racism in healthcare. We argue that to understand how racism is produced in healthcare, given that racism is a complex social formation that is embedded in structures of modern societies, a full overview of the various operative dimensions of racism is needed. Put in other words, focusing on racism as the object of research instead of specific topics, offers an in-depth understanding of the complex nature of racism that is not amenable to a more health topic specific review. To our knowledge, there have not been any reviews that have examined all empirical evidence on the topic of racism in healthcare. Conducting such a review is important in order to incorporate the growing number of articles on persistence of racism in healthcare. This calls for a description of the content of the studies in order to a) gain an overall comprehensive insight into what has been conducted regarding the various dimensions of racism in healthcare; b) through acquiring an overall picture of the research, identify existing knowledge gaps in the research that might aid researchers in explaining what further research is needed that can explain why racism continues to persist in healthcare. Since the topic of racism in healthcare extends over several disciplines and research methodologies [2], and in order to capture an overview of both the qualitative and quantitative research, we conducted a scoping review. Scoping reviews describe the characteristics of research, scope a body of literature, especially when a body of literature has not been comprehensively reviewed or when the literature is scattered and heterogeneous [27] as in the case of the topic herein. Noteworthy, is that we do not aim in this review to evaluate the strength of evidence of the reviewed articles, nor do we aim to evaluate the methodological rigor of the reviewed articles as is usually the case in meta-analyses. Rather, as delineated, the aim here is to describe the content of the research available on racism in healthcare and to identify existing knowledge gaps.

Before the material and methods of this scoping review are presented, a short note on terminologies used in this review is warranted. As this review includes articles from various national contexts, variations in what constitutes healthcare in these contexts exist. Therefore, for the purpose of this review, healthcare is defined as including health and dental care including medical and dental educational settings and elderly care but excludes military veteran care. Consequently healthcare staff are defined as a broad range of staff including nurses, dentists, midwives, physicians as well as other stakeholders related to the field of healthcare such as nursing aids and care givers. Healthcare users in this review are defined as all individuals who used the healthcare system as per the definition provided i.e., including medical and dental care. The review thus examines articles that look at how racism is discussed and produced in the process of delivering, accessing and receiving healthcare and not articles that look at the effects of racism on health outcomes or health status. The review therefore, aims to map all articles that focus on how racism is discussed and produced in healthcare including differential treatment due to racism, how racism affects healthcare interactions, experiences of racism and antiracist interventions as well as other aspects revealed by the review.

A wide variety of definitions exist in the literature concerning how to describe groups of people who are subjected to racism depending on the national contexts and on whether racial categories exist as legal categories in a given context. As an example, in the USA racial categories such as Black and White exist as legal categories while in many other European contexts, these categories are illegal [28]. In this review, and building on arguments made by Fanon [29] and Miles [30] on the importance of focusing on the process of racialization rather than ‘race’, the terms racialized minorities and majority groups are used to describe healthcare staff and users belonging to dominated and dominant groups. We use the term racialized minority to specify groups of people who are numerically a minority but who are also racialized as inferior in comparison to the majority groups and are thus subject to differential and unequal power relations and treatment in various institutional contexts. Although, we use the term racialized minority and majority in this review, the reviewed articles used a variety of different terminologies to indicate different ethnic groups. When results are reported from the reviewed articles in the Result section of this scoping review, we will use the terms that are used in the reviewed articles. Terms such as Black and White which indicate racial categories produced by historical racialization processes will be capitalized to indicate that they are social constructs. These terms are viewed as social constructs and they will be used if they are cited in the articles being reviewed when describing results. The use of these racial categories in the reviewed articles will be problematized in the Discussion section.

Materials and methods

A scoping review has been conducted to examine the empirical qualitative, quantitative and mixed method studies on racism in healthcare and to identify any research and knowledge gaps. For this scoping review, we followed the published PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analysis) extension for scoping reviews (PRISMA-ScR) [31] to define the context and the concepts, to search, formulate inclusion criteria, extract and chart data in flow charts.

This scoping review aims to answer the following research questions:

  1. 1)

    What is the content of studies that examine racism in healthcare? In other words, what do the studies tell us about racism in healthcare, including all aspects of racism in healthcare, as described in the introduction?

  2. 2)

    What are the existing research and knowledge gaps that current studies do not address in relation to racism in healthcare that may be useful in a) understanding how racism is produced in healthcare and b) how racism persists in healthcare.

Search strategy

Following the PRSIMA methodology, the search was conducted according to the following timeframe, databases and search terms:

  • Time frame: No starting date limitation was applied for this review but the end date was December 1, 2020 to allow the authors enough time to review the selected articles.

  • Data bases: the following databases and electronic journal collections were searched for English language studies: PubMed, PsycInfo, ASSIA and Scopus. These databases were chosen for being relevant for healthcare research (PubMed and PsycInfo); or multidisciplinary broad databases (Scopus) that cover all subject areas and are keywords databases; or databases that cover research on racism in healthcare in sociological research (ASSIA).

  • Search terms: The following search terms were used: Topic (racism* or racial* or racialization* or racialisation* or “racial bias” or discrimination* or “structural racism” or “structural discrimination” or “institutional discrimination” or “institutional racism” AND TOPIC: “healthcare”, “dental care”, “healthcare staff”, “healthcare professionals”, “healthcare providers”, “healthcare users”, “patients”. The choice of search terms used in this scoping review was conducted in consultation with an acadmic librarian specializing in public health research. After consultation with the librarian terms such as stereotypes, prejudice, culture and ethnicity were not included as search terms in this review as these terms do not necessarily reflect racism in healthcare and could result from other practices. Additionally, this scoping review is broad and including even broader search terms would result in a magnitude of results that would not necessarily have to do with racism so a decision was made by the authors to limit the search terms of this review. As this might have limited some results, this limitation will be presented in the discussion section.

Inclusion and exclusion criteria

Research papers in languages other than English were excluded. Only peer reviewed articles with empirical data were included. All literature reviews, conceptual and theoretical articles were excluded and no grey literature was included in this review. Studies of any design (qualitative, quantitative as well as mixed method studies i.e., studies that use both qualitative and quantitative methodology) that looked at racism in healthcare as per the explanation provided in the aim and definition of what constitutes racism in healthcare were included. All articles concerning the effects of racism on health status, racial health disparities and differential health outcomes were excluded from this study as this review is on racism in healthcare and not racial differences in health outcomes.

Data extraction and coding

The initial search was conducted using the selected search terms in the chosen databases. When the initial search was conducted, the search was limited to the selected date but also to English language, peer empirical reviewed articles as well as to articles that had full texts provided by our university library. As an example, using the search terms with its various iterations in the database ASSIA, generated 3149 initial hits (English peer reviewed articles with full texts). All the initial search hits from all databases were then collected in one file. The total number of articles from all databases after the initial search was 8312. Excel 2016 spreadsheet and Zotero software were used to store, organize and code the data. Duplicates were then removed and all remaining articles’ titles and abstracts were reviewed. The results are shown in the PRISMA flow chart in Fig. 1.

Fig. 1
figure 1

PRISMA diagram of the study selection process

Two reviewers screened all titles and abstracts to assess eligibility for inclusion. Articles were excluded based on the exclusion and inclusion criteria (remaining n = 639). All articles which included the search terms in their title and/or abstract were included in this stage. If it was unclear whether the article should be included or in case an abstract did not exist, the decision was made to include or exclude after reading the full article in question and after a discussion with all reviewers was conducted.

In the next stage, the full text of all of the articles that were selected were read and screened by two reviewers. Once the final set of articles were selected based on their relevance to the research question, articles were coded and categorized using Excel 2016 (remaining n = 213). All reviewers were involved in the coding process (see Fig. 1 and the PRSIMA checklist in additional file 1).

Data were summarized by year of publication, geographical location, aim of article, methods and key findings in relation to racism in healthcare. These summaries of all 213 articles are illustrated in additional file 2. If the method was not clearly stated in the reviewed article, this was reported in the table as unclear method section. However, this review will not look further into the methodology of the articles as it does not fall into the aim of the review. Since the aim of this scoping review is to give an overview of the content of the reviewed studies in relation to the various dimensions of racism in healthcare, the data were coded based on the key findings in relation to the topic herein. All authors discussed the coding of the data and consequently it was decided that the data would be classified into the categories illustrated in Fig. 2 below:

Fig. 2
figure 2

Diagram of categories and sub-categories of the result section

Results

Given that this review reports on findings from 213 articles, it is not possible to set out all the results of every article included. However, additional file 2 gives a summary of the main results in relation to racism in healthcare in all 213 articles that were scoped. The result sections starts with a short description of the main, general findings of the articles. This will be followed by an illustration of the categories and subcategories as demonstrated in Fig. 2.

Descriptive findings: characteristics of articles included

The oldest article included in the review was from 2001, which means that no article (found through the search process of this review and which met the inclusion criteria) was published prior to that date. From 2005, an increase in the number of published articles on racism is observed (Fig. 3), which indicates an increased academic interest in the subject. A sharp increase in the number of articles published per year was observed in 2019 and 2020 with an increase of 65% from 2018 to 2019.

Fig. 3
figure 3

Number of empirical articles on racism in healthcare published per year

Some of the general characteristics of the reviewed articles are described in Table 1 below including type of methodlogy, focus on racism and country of research.

Table 1 General characteristics of the reviewed articles

Below we illustrate the various categories and subcategories that resulted from our coding. Under each category descriptive general characteristics of each category is illustrated, followed by a description of the important content of the included article. Noteworthy, is that some articles are included in more than one category. Moroever, since this review has scoped a large number of articles, generating a lengthy result section, a summary diagram of the important results from the various categories is included in Fig. 4 below.

Fig. 4
figure 4

Summary diagram of the various categories of the result section

Healthcare users’ experiences of racism in healthcare

This section describes the content of articles that report on experiences of racialized minority healthcare users’ experiences of racism in healthcare including both their perceived racism in healthcare encounters as well as their reactions to racism. The section starts by giving some general descriptive characteristics of these studies followed by an overview of their important content.

Descriptive findings: characteristics of articles included

Of the 213 articles in this scoping review, 117 articles examine healthcare users’ experiences of racism in healthcare. Of these 69 are qualitative studies, 41 are quantitative and 7 use mixed methods. These include articles that have racism as their main focus as well as articles that do not have racism as their main focus and only report on racism in their abstract and result section.

Most of the articles that have racism as their main focus report on healthcare users’ experiences of racism in healthcare in general in a variety of contexts i.e., these articles do not look at specific healthcare settings or experiences related to specific treatments or illnesses. These include both qualitative articles [32,33,34,35,36,37,38,39,40] and quantitative studies [10, 41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62] and two mixed method studies [50, 63, 64].

Various national contexts are represented including the USA [32, 33, 37,38,39,40,41, 43, 46,47,48, 52, 54, 58, 59, 65]. Other articles are from Brazil [34], multi-European settings [36], Mexico [35], New Zealand [49], Canada [51] and France [57]. All the articles from outside the USA are qualitative articles except for the article from France.

Other articles examine experiences of racism within specific illnesses or healthcare contexts. These include qualitative articles looking at hypertension care in the USA [66], decision making processes in diabetes care in the USA [67], depression care in USA [68], HIV-care in USA [69,70,71,72], mental care in USA [73], cardiovascular disease care in USA [74], reproductive, maternal and perinatal healthcare in USA [75,76,77,78], and chronic renal failure care in Brazil [79]. Quantitative articles examine how experiences of racism in HIV-care [80, 81], sickle cell disease management in the USA [82] mental healthcare in UK [83] and in USA [8, 84], diabetes care in USA [85,86,87,88,89], dental care in the USA [90, 91] and maternal care in USA [92]. Two studies employ a mixed methodology and look at mental care [93], pain management [94], and heart failure therapy; all in USA [95].

Some of the articles that do not have racism as their main focus set out to examine experiences, perceptions, facilitators and barriers of racialized minority healthcare users’ with healthcare and healthcare encounters in various contexts, mostly outside of the USA. These include reports of racism in healthcare encounters in Canada [96,97,98,99,100,101], Australia [64, 102], the UK [103, 104], USA [105,106,107,108], India [109], Belgium [110], Malaysia [111], Spain [112] and Israel [113]. All of these articles use qualitative method except one article from the USA [105], and one mixed method article also from the USA [107].

Articles that do not have racism as their main focus and look at specific healthcare contexts or indicators examine the following: trust in healthcare in the USA [114], trust in physicians in the USA [115], experiences of chronic illness in Australia [116], burn injury in pediatric care in Australia [117], pediatric acute care in Canada [118], acute care in Australia [119], end of life care in the USA [120], mental healthcare [121] in the USA [122], reproductive, maternal and perinatal care in the USA [123,124,125,126,127,128], in Australia [129] and Canada [130], cancer care in the USA [131,132,133] and the UK [134], dental care in the USA [135], diabetes care in the USA [7, 136], sexual healthcare in the USA [137], and finally perceptions of patient centered care in the USA [138]. The majority of these articles are qualitative except for 5 articles [7, 114, 115, 129, 133, 139] as well as one mixed method article [121].

Racialized minority healthcare users examined in the reviewed articles

Studies focusing on specific racialized minorities examine mostly experiences of African Americans/Blacks in USA (n = 28) [7, 32, 33, 38, 39, 43, 45, 53, 55, 65, 67, 69, 71, 72, 75, 77, 78, 81,82,83, 93, 115, 120, 122, 127, 131, 140, 141]. Other studies in the USA look at Hispanics (n = 10), [47, 52, 54, 107, 108, 121, 135,136,137,138], American Indians [48, 85, 106], as well as other ethnicities such as Asian Americans [54, 114].

Other studies look at experiences of Indigenous people outside of USA (n = 16) [35, 51, 64, 64, 78, 96,97,98,99,100,101,102, 117, 118, 129, 130], Pakistani Muslims [103] and Sub-Saharan Africans [112, 113]. Some studies do not specify a minority category and use terms such as People of Color [37, 123,124,125,126], migrants/refugees [36, 57, 104, 110] and minorities [56, 58, 63].

Report of healthcare users’ encounters with racism in healthcare

Quantitative studies looking at reports of racism in healthcare that include both majority and racialized minorities (mostly African Americans) show that racialized minorities are more likely to report experiences of perceived racism and inadequate healthcare, compared to majority groups in various contexts such as in the USA [10, 46, 52, 58, 59, 80, 87, 142], New Zealand [49], and France [57]. These experiences of discrimination are reported in connection to mental healthcare in the USA [8].

Racialized minority healthcare users report being subjected to both overt and covert racism in healthcare interactions from healthcare staff in a number of studies. For example, qualitative studies from USA report that African American women report the use of racial slurs by healthcare staff [99, 127] as do Aboriginal women in Canada [101]. Racialised minority healthcare users also report being reprimanded in a way that felt unjustified and scolded by healthcare staff such as reported by African American women in the USA [33]. One study in the UK [143] also reports that experiences of racism in healthcare by racialized minorities (Pakistani community) is seen as a disruption of the principles of solidarity and equity of healthcare.

The reviewed articles report that racism is experienced in different ways. These include negative assumptions from healthcare staff towards racialized minority healthcare users. As an example qualitative studies show that African American healthcare users report that they perceive experiences of racism as avoidance of touch by healthcare staff [141], exclusion from decision making processes in healthcare interactions [7, 39, 67] as well as lack of respect [135]. Being scolded, treated rudely and with apathy by healthcare staff is reported in a number of qualitative studies e.g. by Hispanics and Latinas in USA [137, 138] and women of color also in USA [126]. Moreover, racialized minority healthcare users in other contexts outside of USA also share the same perceptions of being left out of decision making processes as well as being dismissed and discarded. For instance qualitative studies looking at people of non-European migrants in Sweden, Portugal and Germany [36] as well as in Belgium [110] report that these healthcare users feel that their symptoms and complaints are not taken seriously by healthcare staff. First Nation and Indigenous healthcare users in Canada [96, 100] and Indigenous people in Kerala India [109] also report being trivialized in healthcare encounters as demonstrated in qualitative studies.

Some of the qualitative studies that explore experiences of e.g. African Americans [40, 122, 128] and Aboriginals in Canada [101] also report that these groups perceive racism as institutional and connected to historical racism of their respective countries. Racism in healthcare is described as connected to the historical trajectories of colonialism, and connected to the historical struggle of minorities against racism and colonial structures [40, 101, 128]. Racism is moreover viewed as a common experience throughout their everyday interactions both in healthcare and outside [122].

Reports on healthcare users’ reactions to racism in healthcare

Qualitative studies show that experiences of racism by various racialized minority healthcare users are linked with feelings of frustration, sorrow, dismay and feeling insignificant as reported by e.g. Aboriginals in Australia [116] and African Americans [33, 68]. The qualitative studies also show that racialized minority healthcare users avoid seeking healthcare due to experiences of racism in healthcare services. For instance, in Spain and Brazil, Sub-Saharan African healthcare users and various other racialized minorities similarly report being afraid of the healthcare system due to experiences of racism in healthcare [34, 112] which may lead to healthcare users  preferring healthcare staff of the same ethnicity as themselves [76, 123]. Preference for healthcare staff of the same ethnicity as a result of experiences of racism by racialized minorities was also shown in a quantitative study from the USA [53].

As racialized healthcare users emphasize the role of trust and equality in healthcare [71, 134, 140], mistrust in healthcare staff [66, 115] and healthcare [69, 120] is a common reaction from healthcare users who experience racism. Quantitative studies from USA show that perceived racism is inversely associated with trust in healthcare staff and positively related to distrust in healthcare [45, 55, 114]. Quantitative studies also show that racism in healthcare experienced by racialized minorities is associated with higher levels of unmet needs, lower satisfaction with care as shown by a study from New Zealand [49] and another from Canada [51]. Additionally, the experience of racism in healthcare is associated with lower medication adherence in mental health illness in UK [83], increased likelihood of delaying both cholesterol screening visits [55] and dental exams in USA [91]. Moreover, other studies from USA show that the experience of racism in healthcare is also associated with an increased number of teeth lost among healthcare users [90], worse diabetes care [89] as well as avoiding initiating the process of kidney transplant evaluation [139]. However, perceived racism in healthcare in the USA, as shown in two study [85, 87] is not associated with lower frequency of the uptake of services for diabetes [85] and of diabetes medications for hyperglycemia [87].

Various coping mechanisms used by healthcare users were reported in the reviewed articles. Qualitative studies show that in USA, African American women use religious faith and the church to deal with racism in healthcare [120]. African American healthcare users also report acting assertively [33, 39] and employing respectability tactics (making providers aware of their social status, educational background etc.) to convince healthcare staff to take them seriously [39, 144]. African American women also describe conducting research on their illness as well as dressing well for consultations, taking initiatives and asking healthcare staff questions so as to be perceived as knowledgeable [115]. The importance of family and peer support is also reported as a way of coping with racism in healthcare. Other strategies such as recruiting healthcare staff from the same ethnicity is discussed by African Americans [116] as well as People of Color in general in USA [37].

Healthcare staff’s experiences of racism in healthcare

Twenty-seven articles explore racialized minority healthcare staff’s experience of racism in their workplace [50, 145,146,147,148,149,150,151,152,153,154,155,156,157,158,159,160,161,162,163,164,165,166,167,168,169,170]. Most of these article set out to examine healthcare staff’s experiences of racism, except for two articles that look at healthcare staff’s mental health issues in the workplace in USA [147], career progression [150, 151] and quality of healthcare provided to migrant elderly care residents [171].

All these studies were qualitative studies except for 4 quantitative studies [150, 154, 164, 168] and one mixed study [166]. Of these studies 7 studies explore experiences of racialized minority healthcare staff in USA [147,148,149,150, 152, 158, 161, 162, 165, 166, 168,169,170]. Other studies look at experiences of racialized minority healthcare staff in various national contexts including UK [145, 159, 160, 167], New Zealand [152, 164, 171], Canada [153, 163], Israel [50, 156], Finland [154, 168] and Sweden [155].

Racialized minority healthcare staff examined in the reviewed articles

These articles looked at a variety of minority groups. These included as reported by the articles, Blacks/African Americans in the USA [147, 148, 165, 169, 170], Blacks in UK [160] and Canada [163], overseas and immigrant healthcare staff in the UK [145, 159, 167], in Canada [153], Finland [154, 167] and Sweden [155]. Healthcare staff of Color are examined in the USA [146, 149, 166] as well as Hispanic in the USA [162], Filipina in the USA [161], Arabs in Israel [156, 172], Maori and Asian Pacific in New Zealand [164] and a combination of various racialized minorities  in New Zealand [152] and the USA [151].

Categories of healthcare staff examined in the reviewed articles

The reviewed articles examine different categories of healthcare staff. However, most examine nurses’ experiences of racism in healthcare [145, 149, 152, 153, 159,160,161,162, 168, 169]. Others examine both physicians and nurses [50, 156, 165, 170], physicians [154, 163, 166], medical settings’ members [147, 148], care workers [155, 158, 164, 167, 171], and oral maxillofacial surgeons [150].

Reports of healthcare staff’s experiences of racism in healthcare

Racialized minority healthcare staff describe incidents of racism by other staff members [150, 154, 162, 167, 170]. As an example, a study of immigrant physicians from Finland [154] and another of immigrant nurses from the UK [167] demonstrate that healthcare staff report being bullied by other healthcare staff in the workplace. Another study of African American nurses in the USA, report that these nurses demonstrate feelings of mistrust towards other healthcare staff due to experiences of racism [169] and discuss experiencing both overt and covert racism in the workplace. In Israel, blatant racism is experienced by nurses from healthcare users who refuse to be treated by Arab nurses with reports of both verbal and physical violence from healthcare users [156].

Nurses of color in the USA report undertaking excessive emotional labor and experiencing depletion due to racism from healthcare users [149]. Navigating racism in medical education in the USA is also reported to entail immense emotional labor [147]. In medical educational settings, medical students of racialized minorities in the UK report difficulties in navigating racism, which had an effect on their mental health. Feelings of racism in healthcare led to stress and mental health issues as reported by a study of immigrant nurses in Canada [153]. One study conducted in both the USA and New Zealand, report that racialized minority nurses suppress their ethnic identities in order to navigate their workplace due to lack of awareness by other nurses on issues of racism [152].

One study from Canada shows that when complaining about issues of racism to managers, nurses are framed as trouble-makers and their complaints are dismissed [153]. Lack of support from managers is also described in the USA by care workers [158] and in one case, majority nurses in the USA and New Zealand report they were punished for supporting racialized minority nurses who encountered racism [152]. As a consequence of the difficulties in reporting racism, some studies report that healthcare staff have to tolerate racism from healthcare users. As an example a study from the USA looking at Hispanic nurses experiences of racism [162], a study from New Zealand of migrant nurses [171] and a study of immigrant care workers in Sweden [155] report that these healthcare staff are expected to tolerate and absorb racism from healthcare users as the latter are sick and vulnerable. Moreover, Black nurses in the USA report having lost confidence in their abilities [160] since they are told that they are not good enough for their job. Experiences of exclusion from clinical teams and loss of job opportunities is also reported by overseas nurses in the USA [145].

Healthcare staff’s racial attitudes and beliefs

This category includes 33 articles, made up of 12 qualitative, 20 quantitative and one mixed method studies. A number of qualitative articles in various national contexts explore healthcare staff racial attitudes and beliefs. These include qualitative analyses that examine healthcare staff’s beliefs and perceptions in regards to various racialized minorities as well as quantitative analyses that examine healthcare staff’s implicit racial bias.

Qualitative articles that examine beliefs and perceptions of healthcare staff in regards to racialized minorities are all articles that have not primarily set out to examine racism. These articles mainly explore how healthcare staff perceive interactions with Roma people in Slovakia [173], Spain [174], Romania [175] and in multi-European contexts [176]. Moreover, these studies look at American Indians in the USA [106], African American women in the USA [177], Micronesian women in Hawai ‘i in the USA [178], Indigenous people in Australia [179], Asians in the UK [180, 181] as well as racialized minorities in general in Belgium [182], in Ireland [183] and in France [14].

A number of quantitative articles describe healthcare staff’s racial bias in healthcare encounters [61, 184,185,186,187,188,189,190,191,192,193,194,195,196,197,198,199,200,201,202]. All of these articles are conducted in the USA except for one article from France [197], and two from New Zealand [187, 192]. A variety of categories of healthcare staff are examined in these articles including surgeons [191], pediatrians [195, 196], physicians [61, 188, 189, 193, 198, 200], medical students [185,186,187, 192], nurses [191], and various other categories of staff [184, 197, 199, 202].

Reports of healthcare staff’s racial attitudes and beliefs

Qualitative studies suggest there is a tendency to homogenize racialized minorities [174, 181, 183]. In the USA, Black men are judged as uneducated and less reliable by both White and Black healthcare staff [13]. In the UK, a study found that majority healthcare staff tend to homogenize racialized minority healthcare users, view Asian minorities as holding irrational religious beliefs, while at the same time denying the existence of racism [181]. In a study in Spain, healthcare staff have been shown to have negative perceptions towards Roma women subjected to intimate partner violence [174]. Additionally, in Belgium and France healthcare users belonging to racialized minorities, especially Muslims, are seen as problematic and frustrating [14, 182]. A study in Ireland shows that healthcare staff perceive healthcare users from racialized minorities in maternal care as demanding, too emotional and dramatic [183].

Quantitative studies show that healthcare staff from the USA have implicit racial bias in favor of Whites even when they primarily state that they do not have such bias (e.g. Haider et al., 2014, 2015) [190, 191]. A study in the USA shows that implicit racial bias favoring Whites increase at the emergency department when the department is overcrowded with healthcare users [194]. Yet another study from the USA shows that implicit racial bias increases with increased healthcare staff burnout [188]. Another study from the USA showed implicit racial bias in favor of Whites healthcare users, both adults and children [195], while another study, also from the USA shows that female and African American physicians exhibit less implicit racial bias than men and White physicians [200]. Studies from New Zealand also show that medical students exhibit implicit racial bias in favor of Europeans and against Maori groups [187, 192]. Two studies in this review found that French physicians do not exhibit implicit racial bias [197] and pediatrician residents in the USA exhibit weaker implicit bias in comparison to existing findings for other groups of professionals [200]. In general, studies found explicit racial bias to be less common than implicit racial bias [192].

Effects of racism in healthcare on various treatment choices

This category includes 14 articles. All of these articles are from conducted in the USA and are quantitative except one mixed method article [95]. These articles examine the effect of racism in a variety of treatment choices. These treatment choices include various parts of healthcare including maternal and reproductive healthcare [203, 204], pediatric care [205], cardiovascular diseases [12, 95], end of life care [11], medical decisions in the emergency unit [61], oncology care [206] and immunotherapy [207]. In addition, other articles examine pain management [13, 208,209,210], HIV prophylaxis [211], atrial fibrillation treatment and dialysis treatment [212] and admission rate in an emergency unit [196].

Reports on the effects of racism on treatment choices

According to a quantitative study from the USA, Black women are more likely than White women to receive general anesthesia for cesarean delivery and to receive no analgesia for vaginal delivery [204]. Another study from the USA also shows that Black and Latinx healthcare users have lower rates of admission to the cardiology service compared to White patients [12]. Moreover, a study from the USA looking at stroke prevalence and treatment among various ethnicities found that Hispanics and Blacks have the highest risk of stroke in the population but are less likely to be prescribed anticoagulant medications than Whites [212]. In regards to end of life care, a study from the USA shows that Black healthcare users receive more burdensome end of life care in comparison to White healthcare users [11].

Another study from the USA that found implicit racial bias towards Whites in the emergency unit also found that implicit racial bias is associated with less serious diagnosis in regards to Black and Hispanic healthcare users when the emergency unit is crowded [61]. Another study from the USA looking at oncologists found that oncologists who measure high in implicit racial bias have shorter interactions with Black patients [206].

Moreover, a study from the USA also shows that White male physicians prescribe less pain medications to Black healthcare users compared to White users [208] and that healthcare professionals perceive Blacks to be biologically different than Whites and thus having differential reactions to pain [210]. Other studies from the USA also report differential pain management for Black healthcare users [13, 209] as well as less likelihood for prescribing HIV prophylaxis treatment for Black healthcare users [211]. Moreover, another study from the USA shows that African American are less likely to receive treatment with immunotherapy compounds independent of their insurance status [207]. A study from the USA shows that Newborn–physician racial concordance is associated with a significant improvement in mortality for Black infants and that these positive effects of physician newborn racial concordance manifest strongly in more complicated cases and when hospitals deliver more Black newborn [203]. Not all studies report differential treatment. For instance one studye from the USA found no racial differences in the admission rate in the emergency unit between various ethnic groups [196].

Healthcare staff’s reflections on racism in healthcare

There are 15 articles that examine healthcare staff’s reflections on racism in healthcare [98, 155, 172, 213,214,215,216,217,218,219,220,221,222,223,224]. All of these articles are qualitative and are conducted in a variety of national contexts including the USA [214, 219, 222], Canada [217, 221, 224], Australia [216, 218, 220], UK [213], Sweden [155, 215], South Africa [223] and Israel [172].

Most of the articles examine various categories of healthcare staff. Articles examining specific categories of healthcare staff include articles examining nurses [172, 213, 215, 218] and care workers [155]. These articles explore general perceptions of racism in healthcare and do not focus on a specific ethnicity regarding the healthcare staff that are included.

Reports on healthcare staff’s reflections on racism in healthcare

In the UK [213], Canada [217], and the USA [219] studies show that healthcare staff tend to construct themselves as neutral and impartial and have difficulty in accepting that prejudice is part of healthcare interactions [213]. Similarly a study of nurses and physicians in Israel reports that the interviewed healthcare staff generally frame medicine as rational, neutral and based on objectivity [172] and that racism is seen as a matter of individual experiences rather than structural. In Sweden, a discrepancy between racialized minority and majority care givers is reported [155], regarding their views on racism in healthcare. While racialized minority care givers reflected on racism in healthcare, majority healthcare care givers tended to dismiss racism as existing in healthcare interactions. A Canadian study shows that healthcare staff who spent time working with Indigenous people show a more nuanced understanding of Indigenous people’s realities [221].

Studies from Australia report conflicting perceptions on racism in healthcare. While some studies show that healthcare staff are aware of racism as part of the Australian healthcare system specifically towards aboriginal healthcare users [69, 220], another study shows that healthcare staff are unable to define racism and that they often conflate racism with gender discrimination [218]. A study from the USA demonstrates that healthcare staff thought of ‘race’ as biological rather than a social construct [214].

Antiracism training in healthcare

This review included 15 studies that evaluated various antiracist training programs and workshops for healthcare staff including students [225,226,227,228,229,230,231,232,233,234,235,236,237,238,239]. All articles are from research conducted in the USA except one article from the UK [234] and 2 from Australia [231, 239].

Most of these articles are quantitative (n = 7) [225,226,227, 230, 233, 235, 237]. Others used either qualitative methods (n = 5) [229, 232, 234, 236, 238] or were mixed methods (n = 3) [228, 231, 239].

Most of the antiracist training was conducted among medical students [225,226,227, 233,234,235, 239]. Other training was conducted in medical settings among faculty members [230, 231, 237, 238], among nurses [232], among physicians [236], and among various groups of healthcare staff [228, 229].

Reports on training on antiracism in healthcare

Difficulties in discussing racism in healthcare are reported in most of the studies. A qualitative study from the USA shows that medical faculty members do not discuss racism in healthcare in their workplace [238] and are uncomfortable about discussing racism. Another qualitative study from the USA illustrates that nurses Whiteness constituted a barrier in regards to teaching about racism in healthcare [232]. Another qualitative study from the USA also illustrates this difficulty and shows that healthcare staff found that discussions around racism as a structural and persistence issue was polarizing [229]. Similarly, a qualitative study from the UK demonstrates that there was generally an inadequate awareness of the meaning of multicultural care among medical students [234]. A quantitative study among various medical students from the USA [235] shows that students who graduated from an interdisciplinary pre-health curriculum identified relationships between structural factors and health outcomes more than pre-medicine science majors did.

Quantitative studies from the USA evaluating antiracist training show better understanding of racism in healthcare after the intervention [235], increased confidence and comfort in discussing and addressing racism [225, 227, 228, 233] and greater interest in receiving more antiracist training (Bi et al., 2020; Perdomo Joanna et al., 2019) [226, 237]. Healthcare staff who participate in antiracist interventions exhibit greater empathy towards racialized minorities according to a study in the USA [230] and one from Australia [239]. However, the study from Australia shows that while medical students demonstrate somewhat changed perceptions towards Aboriginal people and are more likely to challenge stereotypes, issues around racism were not resolved [239]. Moreover, the study from the USA [230] did not illustrate any change in healthcare staff’s implicit racial bias post-intervention as compare to pre-intervention.

Discussion

This scoping review only includes English-language empirical articles examining racism in healthcare globally. To our knowledge, this is the first scoping review that reviews both qualitative and quantitative studies that explore racism in healthcare in various countries. The coding of the included articles showed that articles examine healthcare users’ and healthcare staff’s experiences of racism in healthcare, healthcare racial attitudes, and beliefs, effects of racism in healthcare on various treatment choices, healthcare staff’s reflections on racism in healthcare as well as articles examining antiracism training in healthcare.

Healthcare and national contexts notwithstanding, various racialized minorities seem to share commonalities in the way they experience racism as per the reviewed articles, especially regarding the more covert type of racism. Racialized minorities perceive their experiences of racism as consisting of inadequate care and a dismissal of their symptoms and suffering, a lack of respect, and a lack of power to negotiate in healthcare interactions [7, 36, 240, 241]. These experiences of racism result in a loss of trust in healthcare, higher unmet needs [242], and subsequently delaying seeking healthcare [243]. Moreover, studies report that healthcare staff tend to homogenize racialized minority healthcare users, to view them as irrational, difficult and frustrating, and as too emotional and dramatic [14, 181, 182]. Studies looking at implicit racial bias show that healthcare staff may exhibit racial bias in favor of majority groups [191, 244], such that minorities receive deprioritized diagnoses and treatment that [61]. Studies that look at differential treatment between racialized minorities and majority groups also illustrate inadequate care regarding various treatment choices such as pain medications, HIV prophylaxis [211], cardiovascular disease [95], perinatal care [203], end of life care [11], and other indicators [209, 245]. Moreover, racialized minority healthcare staff also experience racism both from healthcare users and other healthcare staff [149, 158]. There is an expectation that racism from healthcare should be tolerated, resulting in emotional depletion and mental health issues, as healthcare staff often do not find space to discuss their experiences of racism in their workplace [153].

While racism persists in healthcare and operates in various dimensions, healthcare staff nonetheless construct themselves and the healthcare they provide as objective and neutral [172, 213, 217, 219]. Studies show that healthcare staff find it difficult to discuss racism and accept racism as part of healthcare interactions. While some studies show some healthcare staff awareness of racism as a structural issue in healthcare [221], confusion regarding how to define racism and ‘race’ is also apparent [69, 220]. This is also shown by studies that evaluate antiracist training. Healthcare staff participating in such training often state that they do not discuss racism in their workplace and find it uncomfortable to discuss racism [232, 238]. Although antiracism training shows that healthcare staff exhibit greater empathy towards racialized minorities, it is unclear whether such educational efforts effectively alter racial bias and attitudes.

Knowledge gaps in the reviewed articles

Lack of articles on racism in healthcare in European contexts

The articles reviewed here are dominated by research from the USA, which constitutes 67% of the articles scoped, followed by UK and Canada (7%). The domination of data from the USA may be explained by the availability of racial category data in the USA. In the USA, ‘race’ is a legal category, enabling data to be readily available for research, which is not the case in many European countries. The small number of European studies, mainly from the UK, shows that racism in healthcare is also a problem in these countries. However, with the exception of the UK, it is presently difficult to offer any conclusive evidence of racism in healthcare in Europe. This lack of evidence regarding racism exists despite evidence of racial/ethnic inequalities between foreign-born healthcare users and natives in Europe [246] and reports of discontent and othering processes in healthcare encounters. This could be due to the sensitive and politicized nature of racism and the construction of Europe as exceptional and antiracist [28, 247]. With the rejection of ‘race’ as a scientific category, following the Second World War, ‘race’ and racism have been largely occluded from European social formations, political and public discourse [247], while integration of migrants has been the main policy focus [248]. This focus on integration, with racism constructed as an issue of the past, makes discussions around racism in Europe difficult [249]. This difficulty informs research on racism in healthcare and is reflected in the seemingly sparse research in Europe on the issue in contrast to the USA, where discussions around racism are more common. In addition to this, many of the articles that reported on racism in healthcare from European settings did not set out to examine racism in healthcare. For instance, research setting out to examine barriers to and facilitators for racialized minorities seeking in healthcare in European settings, ended up reporting racism since racialized minorities discussed experiencing racism. This reflects that racism is experienced but may be under researched due to the difficulties of discussing racism in a European setting. Hence, there is a need to do more research regarding racism in healthcare in European settings both from the perspectives of healthcare users and healthcare staff.

Research on racism in healthcare is descriptive, ahistorical and atheoretical

The research on racism in healthcare is fragmented and scattered across disciplines and healthcare contexts. Thirty-seven percent of the included articles did not set out to examine racism in healthcare and hence framed their research in terms other than racism. Nevertheless, the majority of the remaining 67% of the articles that had racism as their main focus, except a few articles [14, 32, 35, 36, 43, 46, 48, 50, 51, 53, 69, 76, 91, 96, 98, 102, 118, 123, 127, 142, 148, 149, 152, 156, 160, 162, 165, 169, 172, 175, 189, 192, 218, 221,222,223,224, 241, 250,251,252,253,254,255,256] lacked a conceptualization of racism and ‘race’ and did not include a definition of these concepts. As research lacks a way to define and conceptualize racism in healthcare, the majority of the studies treat ‘race’ and racial categories as real, ahistorical, and pre-constituted categories. There is a general lack of attention to and illustration of the historical context within which these racial categories have been formulated. Put in other words, research tends to study ‘race’ instead of looking at racialization processes and the resulting racism that subsequently constructs an idea of ‘race’ (Nazroo et al., 2020). Furthermore, studies, especially quantitative studies from the USA looking at differential treatment across racial categories, tend to conflate the terms ‘race’ and ethnicity. For instance, Black and White are considered racial categories in the USA, while Hispanic is considered an ethnic category [257]. In the reviewed articles, these categories are often examined together. Since these categories are, for the most part, not defined, it is unclear why they were chosen, what they mean and what the results that show differential treatment along these categories convey in regards to racialization processes in healthcare. Robert Miles [30] argues that racism is a historical process of domination where racialization is a central part of modern societies. Omi and Winant [258] define racialization as ‘the sociohistorical process by which racial categories are created, inhabited, transformed, and destroyed (…) Race is a matter of both social structure and cultural representation’ (p: 55–56). As such, racism operates in a wider system of racialization in which racial categories are produced and given meaning within racial hierarchies [259]. Robert Miles suggests that a way to understand and conceptualize racism is to view it as a process of racialization rather than invoking ‘race’ since ‘race’ is by default a vacuous ontological category that is produced by racism [30]. When ‘race’ is invoked in a non-critical and ahistorical manner, there is a risk of producing racial categories as fixed and unchanging biological classifications instead of the unstable social constructs that they are. Moreover, without a historical understanding of the meaning-making of racial categories, it becomes problematic since there is a risk that racialization is emphasized and reproduced in research.

Ahistorical and atheoretical approaches to research entails that many of the studies included in this scoping review frame their research around the specific illnesses/diseases or symptoms that they study rather than around racism. For instance, studies that look at HIV prophylaxis, e.g. [211] or opioid prescription [260] would frame their study around these specific illnesses rather than racism. While this is a valid way of framing studies, the consequence of this in regards to the general nature of the research is that the object of research becomes the illness or condition studied rather than racism itself which remains untheorized. While it is important to document inequalities in treatment and health indicators, it is well established that racism is an integral part of modern institutions and structures [1]. Research around racism in healthcare needs to move beyond describing the existence of racism to theoretically explaining and conceptualizing how racism actually works in healthcare and the racialization processes that lead to material inequalities in healthcare. In order to do this, research on racism in healthcare should engage with sociological research regarding the meaning-making of racial categories and racialization processes.

This review confirmed that the dominant professional discourse in healthcare portrays healthcare staff as ‘natural history scientists’ who are not affected by bias, as reflected by the discrepancy between healthcare staff’s image of themselves as objective on the one hand [172, 213, 217, 219], despite evidence of of racial bias [185, 187, 261] as well as healthcare users’ experience of racism in healthcare settings [32, 38] on the other hand. For the most part, this discrepancy is left underexplored as the main focus of articles is to document experiences of racism. Sociological research on racial denial (van Dijk, 1992; van Dijk, 1999) [262, 263], colorblind racism, and racism without racists [4] may aid in explaining why racism remains a difficult issue to discuss, even in USA where a majority of studies of this topic are conducted. Sociological research on contemporary racism may also illuminate why some articles show that healthcare staff tend  to deny the existence of racism in healthcare even with evidence of racial inequalities. ‘Racism without racists’ understanding of contemporary racism [4] offers a framework that explains how racism persists in healthcare interactions even when healthcare staff constructs themselves and healthcare as neutral. Hence, sociological research on racism and racialization may help research on racism in healthcare to examine how racial inequality can be reproduced through supposedly non-racial practices such that colorblind racism can become normalized in healthcare.

Research on antiracism in healthcare and future implications

There has been a huge increase in the volume of research on racism in healthcare from 2017 onwards, amounting to more than 100 articles that were found through this review. This is positive as it reflects an academic increase in the topic of racism in healthcare. However, this increase in volume does not imply an improved quality since these articles report on the same dimensions of racism that have already been reported on in previous years, even when they report on different healthcare contexts. The research remains descriptive, ahistorical and lacking definitions of key concepts. However, an exception to this is an increasing, although still limited, amount of research on antiracism interventions in healthcare. This research is an emerging dimension essential in dealing with racism in healthcare and needs to be further developed. However, this research remains atheoretical as well. If racism is often produced through unconscious processes as evidenced by research showing the existence of implicit racial bias of healthcare staff, how will antiracist interventions speak to the unconscious nature of racism? Some of the studies examining antiracist training show that although healthcare staff’s empathy towards racialized minorities increases after these interventions and that healthcare staff feel more comfortable discussing racism, racism remains a polarizing issue [239, 264].

Additionally, one study shows that implicit racial bias pre-and post-intervention remains significantly unchanged [230], which is to be expected if racism is understood as an outcome of historical processes and deeply embedded in social institutions. The question remains as to how to design and implement effective antiracist interventions in healthcare. Nazroo [6] argues that ‘any consideration of racism must necessarily focus on the structural, macro, level (…) Here, the legacies of historical regimes of colonialism, race-based slavery and apartheid interact with current processes of globalisation, migration and governance, continuing to shape present day inequalities in accessing key economic, physical and social resources’ (p: 265). As such, antiracism training and intervention must find a way to solicit reflections of these historical regimes over a longer period. One way of doing this is to implement educational strategies within medical, educational and organizational settings to make visible structures of racial domination and to have continuous conversations and dialogues on the issue of racism and its intersections with other systems of domination.

Limitation of this review

Although the review followed a systematic method, it is possible that not all articles were incorporated. Additionally, as articles were only included if the search terms were used in the abstract or title, articles which discussed racism in the text without naming it in the title or abstract may have been excluded. Furthermore, articles discussing racism that used terms other than racism or discrimination such as bias, prejudice and stereotypes were also not included in this review. No screening of references in the included articles was conducted. The results of this review are based on English-language empirical research reports, which excludes articles in languages other than English that may discuss racism. This partially explain why the majority of the articles are from English speaking countries.

Conclusion and key recommendations

Research on racism in healthcare show that racism operates in various dimensions between healthcare staff and users and affects treatment and diagnosis in various health indicators. In Fig. 5 above, key recommendations on future research on racism based on the results of the review, are provided. There has been an increase in the volume research from 2017 onwards. However, research is mainly descriptive, atheoretical, and uses racial categories critically, as if they were fixed and ahistorical. Hence, research tends to ignore racialization processes in healthcare and makes it difficult to conceptualize racism in healthcare and understand how racism is produced in healthcare. Research on racism in healthcare could benefit from sociological research on racism and racialization to explain how overt racism is produced and how racism is normalized and hidden behind supposedly non-racial practices in healthcare. Additionally, research is dominated by the USA, and it is imperative that research is also conducted in other geopolitical contexts.

Fig. 5
figure 5

Key recommendations for future research on racism in healthcare

Availability of data and materials

All articles included in this review are available in a table included as an additional file.

References

  1. Bonilla-Silva E. Rethinking racism: Toward a structural interpretation. Am Sociol Rev. 1997;62(3):465–80.

    Article  Google Scholar 

  2. Williams DR, Lawrence JA, Davis BA. Racism and Health: Evidence and Needed Research. Annu Rev Public Health. 2019;40(1):105–25.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Omi M, Winant H. Racial Formation in the United States. 3rd ed. New York: Routledge; 2014. p. 344.

    Book  Google Scholar 

  4. Bonilla-Silva E. Racism without Racists: Color-Blind Racism and the Persistence of Racial Inequality in America. 3rd ed. Lanham: Rowman & Littlefield Publishers; 2009. p. 318.

    Google Scholar 

  5. Gee GC, Ford CL. STRUCTURAL RACISM AND HEALTH INEQUITIES: Old Issues, New Directions<a href="fn001"><span class="sup">1</span></a>. Bois Rev Soc Sci Res Race. 2011;8(1):115–32.

    Article  Google Scholar 

  6. Nazroo JY, Bhui KS, Rhodes J. Where next for understanding race/ethnic inequalities in severe mental illness? Structural, interpersonal and institutional racism. Sociol Health Illn. 2020;42(2):262–76.

    Article  PubMed  Google Scholar 

  7. Ochieng JM, Crist JD. Social Determinants of Health and Health Care Delivery: African American Women’s T2DM Self-Management. Clin Nurs Res. 2021;30(3):263–72.

    Article  PubMed  Google Scholar 

  8. Gabbidon J, Farrelly S, Hatch SL, Henderson C, Williams P, Bhugra D, et al. Discrimination attributed to mental illness or race-ethnicity by users of community psychiatric services. Psychiatr Serv. 2014;65(11):1360–6.

    Article  PubMed  Google Scholar 

  9. Smith E, Sundstrom B, Delay C. Listening to Women: Understanding and Challenging Systems of Power to Achieve Reproductive Justice in South Carolina. J Soc Issues. 2020;76(2):363–90.

    Article  Google Scholar 

  10. MacIntosh T, Desai MM, Lewis TT, Jones BA, Nunez-Smith M. Socially-Assigned Race, Healthcare Discrimination and Preventive Healthcare Services. PLOS ONE. 2013;8(5):e64522.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Perry LM, Walsh LE, Horswell R, Miele L, Chu S, Melancon B, et al. Racial Disparities in End-of-Life Care Between Black and White Adults With Metastatic Cancer. J Pain Symptom Manage. 2021;61(2):342-349.e1.

    Article  PubMed  Google Scholar 

  12. Eberly LA, Richterman A, Beckett AG, Wispelwey B, Marsh RH, Cleveland Manchanda EC, et al. Identification of Racial Inequities in Access to Specialized Inpatient Heart Failure Care at an Academic Medical Center. Circ Heart Fail. 2019;12(11):e006214.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Tucker Edmonds B, McKenzie F, Austgen MB, Ashburn-Nardo L, Matthias MS, Hirsh AT. Obstetrical Providers’ Management of Chronic Pain in Pregnancy: A Vignette Study. Pain Med Malden Mass. 2017;18(5):832–41.

    Google Scholar 

  14. Morel S. Inequality and discrimination in access to urgent care in France ethnographies of three healthcare structures and their audiences. Soc Sci Med. 2019;232:25–32.

    Article  PubMed  Google Scholar 

  15. Sim W, Lim WH, Ng CH, Chin YH, Yaow CYL, Cheong CWZ, et al. The perspectives of health professionals and patients on racism in healthcare: A qualitative systematic review. PLOS ONE. 2021;16(8):e0255936.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. Ben J, Cormack D, Harris R, Paradies Y. Racism and health service utilisation: A systematic review and meta-analysis. PloS One. 2017;12(12):e0189900.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  17. FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics. 2017;1(18):19.

    Article  Google Scholar 

  18. Hall WJ, Chapman MV, Lee KM, Merino YM, Thomas TW, Payne BK, et al. Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review. Am J Public Health. 2015;105(12):e60-76.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Paradies Y, Truong M, Priest N. A Systematic Review of the Extent and Measurement of Healthcare Provider Racism. J Gen Intern Med. 2014;29(2):364–87.

    Article  PubMed  Google Scholar 

  20. Maina IW, Belton TD, Ginzberg S, Singh A, Johnson TJ. A decade of studying implicit racial/ethnic bias in healthcare providers using the implicit association test. Soc Sci Med. 1982;2018(199):219–29.

    Google Scholar 

  21. Karlsen S, Nazroo JY. Fear of racism and health. J Epidemiol Community Health. 2004;58(12):1017–8.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Discrimination KN, Inequities H. Int J Health Serv. 2014;44(4):643–710.

    Article  Google Scholar 

  23. Kwame McKenzie KB. Institutional racism in mental health care. Br Med J BMJ Int Ed Lond. 2007;334(7595):649–50.

    Article  Google Scholar 

  24. Hassen N, Lofters A, Michael S, Mall A, Pinto AD, Rackal J. Implementing Anti-Racism Interventions in Healthcare Settings: A Scoping Review. Int J Environ Res Public Health. 2021;18(6):2993.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Castle B, Wendel M, Kerr J, Brooms D, Rollins A. Public Health’s Approach to Systemic Racism: a Systematic Literature Review. J Racial Ethn Health Disparities. 2019;6(1):27–36.

    Article  PubMed  Google Scholar 

  26. Jones KM, Power ML, Queenan JT, Schulkin J. Racial and Ethnic Disparities in Breastfeeding. Breastfeed Med. 2015;10(4):186–96.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Peters M, Godfrey C, Khalil H, McInerney P, Parker D, Soares CB. Guidance for conducting systematic scoping reviews. Int J Evid Based Healthc. 2015;13(3):141–6.

    Article  PubMed  Google Scholar 

  28. Möschel M. Race in mainland European legal analysis: towards a European critical race theory. Ethn Racial Stud. 2011;34(10):1648–64.

    Article  Google Scholar 

  29. Fanon F. Black Skin, White Masks. London. Pluto Press; 1967.

  30. Miles R. Racism. London. Routledge; 1989.

  31. Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med. 2018;169(7):467–73.

    Article  PubMed  Google Scholar 

  32. Abrums M. Faith and feminism: how African American women from a storefront church resist oppression in healthcare. ANS Adv Nurs Sci. 2004;27(3):187–201.

    Article  PubMed  Google Scholar 

  33. Benkert R, Peters RM. African American women’s coping with health care prejudice. West J Nurs Res. 2005;27(7):863–89.

    Article  PubMed  Google Scholar 

  34. Chauhan A, de Wildt G, da Virmond M CL, Kyte D, de Galan NG A, Prado RBR, et al. Perceptions and experiences regarding the impact of race on the quality of healthcare in Southeast Brazil: a qualitative study. Ethn Health. 2020;25(3):436–52.

    Article  PubMed  Google Scholar 

  35. Dörr NM, Dietz G. Racism against Totonaco women in Veracruz: Intercultural competences for health professionals are necessary. PLOS ONE. 2020;15(1):e0227149.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  36. Hamed S, Thapar-Björkert S, Bradby H, Ahlberg BM. Racism in European Health Care: Structural Violence and Beyond. Qual Health Res. 2020;16:1049732320931430.

    Google Scholar 

  37. Howard SD, Lee KL, Nathan AG, Wenger HC, Chin MH, Cook SC. Healthcare Experiences of Transgender People of Color. J Gen Intern Med. 2019;34(10):2068–74.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Okoro ON, Hillman LA, Cernasev A. “We get double slammed!”: Healthcare experiences of perceived discrimination among low-income African-American women. Womens Health [Internet]. 2020 Aug 28 [cited 2021 Apr 15];16. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7457641/

  39. Ross PT, Lypson ML, Kumagai AK. Using Illness Narratives to Explore African American Perspectives of Racial Discrimination in Health Care. J Black Stud. 2012;43(5):520–44.

    Article  Google Scholar 

  40. Subban JE, Terwoord NA, Schuster RJ. With or without intent: how racial disparities prevent effective implementation of care. J Nutr Health Aging. 2008;12(10):770S-775S.

    CAS  PubMed  Google Scholar 

  41. Alcalá HE, Ng AE, Gayen S, Ortega AN. Insurance Types, Usual Sources of Health Care, and Perceived Discrimination. J Am Board Fam Med. 2020;33(4):580–91.

    Article  PubMed  Google Scholar 

  42. Benjamins MR, Middleton M. Perceived discrimination in medical settings and perceived quality of care: A population-based study in Chicago. PloS One. 2019;14(4):e0215976.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  43. Bleich SN, Findling MG, Casey LS, Blendon RJ, Benson JM, SteelFisher GK, et al. Discrimination in the United States: Experiences of black Americans. Health Serv Res. 2019;54(Suppl 2):1399–408.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Chen FM, Fryer GEJr, Phillips RLJr, Wilson E, Pathman DE. Patients’ Beliefs About Racism, Preferences for Physician Race, and Satisfaction With Care. Ann Fam Med. 2005;3(2):138–43.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Cuevas AG, O’Brien K. Racial centrality may be linked to mistrust in healthcare institutions for African Americans. J Health Psychol. 2019;24(14):2022–30.

    Article  PubMed  Google Scholar 

  46. Farrell A. Contested and mistreated? Contested racial identities and unfair treatment due to race. Ethn Racial Stud. 2020;43(9):1581–99.

    Article  Google Scholar 

  47. Findling MG, Bleich SN, Casey LS, Blendon RJ, Benson JM, Sayde JM, et al. Discrimination in the United States: Experiences of Latinos. Health Serv Res. 2019;54(Suppl 2):1409–18.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Findling MG, Casey LS, Fryberg SA, Hafner S, Blendon RJ, Benson JM, et al. Discrimination in the United States: Experiences of Native Americans. Health Serv Res. 2019;54(S2):1431–41.

    Article  PubMed  PubMed Central  Google Scholar 

  49. Harris RB, Cormack DM, Stanley J. Experience of racism and associations with unmet need and healthcare satisfaction: the 2011/12 adult New Zealand Health Survey. Aust N Z J Public Health. 2019;43(1):75–80.

    Article  PubMed  Google Scholar 

  50. Keshet Y. Ethnic discordance: Why do some patients prefer to be treated by physicians from other ethnic groups? Soc Sci Med [Internet]. 2019 Aug;235. Available from: https://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2019-45224-001&site=ehost-live

  51. Kitching GT, Firestone M, Schei B, Wolfe S, Bourgeois C, O’Campo P, et al. Unmet health needs and discrimination by healthcare providers among an Indigenous population in Toronto, Canada. Can J Public Health Rev Can Santé Publique. 2019;111(1):40–9.

    Article  Google Scholar 

  52. López-Cevallos DF, Harvey SM. Foreign-Born Latinos Living in Rural Areas are more likely to Experience Health Care Discrimination: Results from Proyecto de Salud para Latinos. J Immigr Minor Health. 2016;18(4):928–34.

    Article  PubMed  Google Scholar 

  53. Malat J, Hamilton MA. Preference for Same-Race Health Care Providers and Perceptions of Interpersonal Discrimination in Health Care. J Health Soc Behav. 2006;47(2):173–87.

    Article  PubMed  Google Scholar 

  54. McMurtry CL, Findling MG, Casey LS, Blendon RJ, Benson JM, Sayde JM, et al. Discrimination in the United States: Experiences of Asian Americans. Health Serv Res. 2019;54(Suppl 2):1419–30.

    Article  PubMed  PubMed Central  Google Scholar 

  55. Powell W, Richmond J, Mohottige D, Yen I, Joslyn A, Corbie-Smith G. Medical mistrust, racism, and delays in preventive health screening among African-American men. Behav Med. 2019;45(2):102–17.

    Article  PubMed  Google Scholar 

  56. Rhee TG, Marottoli RA, Van Ness PH, Levy BR. Impact of Perceived Racism on Healthcare Access Among Older Minority Adults. Am J Prev Med [Internet]. 2019 Feb 14 [cited 2019 Feb 27]; Available from: http://www.sciencedirect.com/science/article/pii/S0749379718323419

  57. Rivenbark J, Ichou M. Discrimination in healthcare as a barrier to care: experiences of socially disadvantaged populations in France from a nationally representative survey. BMC Public Health. 2020;20:31.

    Article  PubMed  PubMed Central  Google Scholar 

  58. Schulson LB, Paasche-Orlow MK, Xuan Z, Fernandez A. Changes in Perceptions of Discrimination in Health Care in California, 2003 to 2017. JAMA Netw Open. 2019;2(7):e196665.

    Article  PubMed  PubMed Central  Google Scholar 

  59. Shepherd SM, Willis-Esqueda C, Paradies Y, Sivasubramaniam D, Sherwood J, Brockie T. Racial and cultural minority experiences and perceptions of health care provision in a mid-western region. Int J Equity Health. 2018;17(1):33.

    Article  PubMed  PubMed Central  Google Scholar 

  60. Solnick RE, Peyton K, Kraft-Todd G, Safdar B. Effect of Physician Gender and Race on Simulated Patients’ Ratings and Confidence in Their Physicians: A Randomized Trial. JAMA Netw Open. 2020;3(2):e1920511.

    Article  PubMed  PubMed Central  Google Scholar 

  61. Stepanikova I. Racial-ethnic biases, time pressure, and medical decisions. J Health Soc Behav. 2012;53(3):329–43.

    Article  PubMed  Google Scholar 

  62. Stepanikova I, Oates GR. Perceived Discrimination and Privilege in Health Care: The Role of Socioeconomic Status and Race. Am J Prev Med. 2017;52(1S1):S86-94.

    Article  PubMed  PubMed Central  Google Scholar 

  63. Almond AL. Measuring racial microaggression in medical practice. Ethn Health. 2019;24(6):589–606.

    Article  PubMed  Google Scholar 

  64. Mithen V, Kerrigan V, Dhurrkay G, Morgan T, Keilor N, Castillon C, et al. Aboriginal patient and interpreter perspectives on the delivery of culturally safe hospital-based care. Health Promot J Aust Off J Aust Assoc Health Promot Prof. 2021;32(Suppl 1):155–65.

    Article  Google Scholar 

  65. Sacks TK. Performing Black womanhood: a qualitative study of stereotypes and the healthcare encounter. Crit Public Health. 2018;28(1):59–69.

    Article  Google Scholar 

  66. Greer TM. Perceived racial discrimination in clinical encounters among African American hypertensive patients. J Health Care Poor Underserved. 2010;21(1):251–63.

    Article  PubMed  Google Scholar 

  67. Peek ME, Odoms-Young A, Quinn MT, Gorawara-Bhat R, Wilson SC, Chin MH. Race and shared decision-making: perspectives of African-Americans with diabetes. Soc Sci Med 1982. 2010;71(1):1–9.

    Google Scholar 

  68. Progovac AM, Cortés DE, Chambers V, Delman J, Delman D, McCormick D, et al. Understanding the Role of Past Health Care Discrimination in Help-Seeking and Shared Decision-Making for Depression Treatment Preferences. Qual Health Res. 2020;30(12):1833–50.

    Article  PubMed  Google Scholar 

  69. Freeman R, Gwadz MV, Silverman E, Kutnick A, Leonard NR, Ritchie AS, et al. Critical race theory as a tool for understanding poor engagement along the HIV care continuum among African American/Black and Hispanic persons living with HIV in the United States: a qualitative exploration. Int J Equity Health. 2017;16(1):54.

    Article  PubMed  PubMed Central  Google Scholar 

  70. Quinn K, Bowleg L, Dickson-Gomez J. “The fear of being Black plus the fear of being gay”: The effects of intersectional stigma on PrEP use among young Black gay, bisexual, and other men who have sex with men. Soc Sci Med. 2019;232:86–93.

    Article  PubMed  PubMed Central  Google Scholar 

  71. Quinn K, Dickson-Gomez J, Zarwell M, Pearson B, Lewis M. “A gay man and a doctor are just like, a recipe for destruction”: How racism and homonegativity in healthcare settings influence PrEP uptake among young Black MSM. AIDS Behav. 2019;23(7):1951–63.

    Article  PubMed  PubMed Central  Google Scholar 

  72. Randolph SD, Golin C, Welgus H, Lightfoot AF, Harding CJ, Riggins LF. How Perceived Structural Racism and Discrimination and Medical Mistrust in the Health System Influences Participation in HIV Health Services for Black Women Living in the United States South: A Qualitative, Descriptive Study. J Assoc Nurses AIDS Care JANAC. 2020;31(5):598–605.

    Article  PubMed  Google Scholar 

  73. Holley LC, Tavassoli KY, Stromwall LK. Mental Illness Discrimination in Mental Health Treatment Programs: Intersections of Race, Ethnicity, and Sexual Orientation. Community Ment Health J. 2016;52(3):311–22.

    Article  PubMed  Google Scholar 

  74. Woodard LD, Hernandez MT, Lees E, Petersen LA. Racial differences in attitudes regarding cardiovascular disease prevention and treatment: A qualitative study. Patient Educ Couns. 2005;57(2):225–31.

    Article  PubMed  Google Scholar 

  75. Davis D-A. Obstetric Racism: The Racial Politics of Pregnancy, Labor, and Birthing. Med Anthropol. 2019;38(7):560–73.

    Article  PubMed  Google Scholar 

  76. Janevic T, Piverger N, Afzal O, Howell EA. “Just Because You Have Ears Doesn’t Mean You Can Hear”—Perception of Racial-Ethnic Discrimination During Childbirth. Ethn Dis. 2020;30(4):533–42.

    Article  PubMed  PubMed Central  Google Scholar 

  77. Kalata M, Kalata K, Yen H, Khorshid A, Davis T, Meredith J. Community perspectives on the racial disparity in perinatal outcomes. J Matern-Fetal Neonatal Med Off J Eur Assoc Perinat Med Fed Asia Ocean Perinat Soc Int Soc Perinat Obstet. 2020;13:1–6.

    Google Scholar 

  78. Mehra R, Boyd LM, Magriples U, Kershaw TS, Ickovics JR, Keene DE. Black Pregnant Women “Get the Most Judgment”: A Qualitative Study of the Experiences of Black Women at the Intersection of Race, Gender, and Pregnancy. Womens Health Issues Off Publ Jacobs Inst Womens Health. 2020;30(6):484–92.

    Article  Google Scholar 

  79. Santos Ferreira RB, de Camargo CL, da Silva Barbosa MI, Silva Servo ML, Carneiro Oliveira MM, Leite Leal JA. Implications of institutional racism in the therapeutic itinerary of people with chronic renal failure. Investig Educ En Enfermeria. 2020;38(2):e7.

    Google Scholar 

  80. Attanasio L, Kozhimannil KB. Patient-reported communication quality and perceived discrimination in maternity care. Med Care. 2015;53(10):863–71.

    Article  PubMed  PubMed Central  Google Scholar 

  81. Irvin R, Wilton L, Scott H, Beauchamp G, Wang L, Betancourt J, et al. A study of perceived racial discrimination in black men who have sex with men (MSM) and its association with healthcare utilization and HIV testing. AIDS Behav. 2014;18(7):1272–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  82. Haywood C, Diener-West M, Strouse J, Carroll CP, Bediako S, Lanzkron S, et al. Perceived Discrimination in Health Care is Associated with a Greater Burden of Pain in Sickle Cell Disease. J Pain Symptom Manage. 2014;48(5):934–43.

    Article  PubMed  PubMed Central  Google Scholar 

  83. Chakraborty A, King M, Leavey G, McKenzie K. Perceived racism, medication adherence, and hospital admission in African-Caribbean patients with psychosis in the United Kingdom. Soc Psychiatry Psychiatr Epidemiol. 2011;46(9):915–23.

    Article  PubMed  Google Scholar 

  84. Sonik RA, Creedon TB, Progovac AM, Carson N, Delman J, Delman D, et al. Depression treatment preferences by race/ethnicity and gender and associations between past healthcare discrimination experiences and present preferences in a nationally representative sample. Soc Sci Med [Internet]. 2020 May;253. Available from: https://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2020-36344-001&site=ehost-live

  85. Gonzales KL, Lambert WE, Fu R, Jacob M, Harding AK. Perceived racial discrimination in health care, completion of standard diabetes services, and diabetes control among a sample of American Indian women. Diabetes Educ. 2014;40(6):747–55.

    Article  PubMed  Google Scholar 

  86. Lyles CR, Karter AJ, Young BA, Spigner C, Grembowski D, Schillinger D, et al. Correlates of patient-reported racial/ethnic health care discrimination in the Diabetes Study of Northern California (DISTANCE). J Health Care Poor Underserved. 2011;22(1):211–25.

    PubMed  Google Scholar 

  87. Lyles CR, Karter AJ, Young BA, Spigner C, Grembowski D, Schillinger D, et al. Patient-reported racial/ethnic healthcare provider discrimination and medication intensification in the Diabetes Study of Northern California (DISTANCE). J Gen Intern Med. 2011;26(10):1138–44.

    Article  PubMed  PubMed Central  Google Scholar 

  88. Lyles CR, Karter AJ, Young BA, Spigner C, Grembowski D, Schillinger D, et al. Provider factors and patient-reported healthcare discrimination in the Diabetes Study of California (DISTANCE). Patient Educ Couns. 2011;85(3):e216-224.

    Article  PubMed  PubMed Central  Google Scholar 

  89. Peek ME, Wagner J, Tang H, Baker DC, Chin MH. Self-reported racial discrimination in health care and diabetes outcomes. Med Care. 2011;49(7):618–25.

    Article  PubMed  PubMed Central  Google Scholar 

  90. Muralikrishnan M, Sabbah W. Is Racial Discrimination Associated with Number of Missing Teeth Among American Adults? J Racial Ethn Health Disparities. 2021;8(5):1293–9.

  91. Sabbah W, Gireesh A, Chari M, Delgado-Angulo EK, Bernabé E. Racial Discrimination and Uptake of Dental Services among American Adults. Int J Environ Res Public Health. 2019;16(9):1558.

    Article  PubMed Central  Google Scholar 

  92. Attanasio LB, Hardeman RR. Declined care and discrimination during the childbirth hospitalization. Soc Sci Med. 2019;232:270–7.

    Article  PubMed  Google Scholar 

  93. Alang SM. Mental health care among blacks in America: Confronting racism and constructing solutions. Health Serv Res. 2019;54(2):346–55.

    Article  PubMed  PubMed Central  Google Scholar 

  94. Hausmann LRM, Jones AL, McInnes SE, Zickmund SL. Identifying healthcare experiences associated with perceptions of racial/ethnic discrimination among veterans with pain: A cross-sectional mixed methods survey. PLoS ONE. 2020;15(9):e0237650.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  95. Breathett K, Yee E, Pool N, Hebdon M, Crist JD, Knapp S, et al. Does Race Influence Decision Making for Advanced Heart Failure Therapies? J Am Heart Assoc. 2019;8(22):e013592.

    Article  PubMed  PubMed Central  Google Scholar 

  96. Browne AJ, Fiske J-A. First Nations women’s encounters with mainstream health care services. West J Nurs Res. 2001;23(2):126–47.

    Article  CAS  PubMed  Google Scholar 

  97. Thurston WE, Coupal S, Jones CA, Crowshoe LF, Marshall DA, Homik J, et al. Discordant indigenous and provider frames explain challenges in improving access to arthritis care: a qualitative study using constructivist grounded theory. Int J Equity Health. 2014;13(1):46.

    Article  PubMed  PubMed Central  Google Scholar 

  98. Wylie L, McConkey S, Corrado AM. Colonial Legacies and Collaborative Action: Improving Indigenous Peoples’ Health Care in Canada. Int Indig Policy J. 2019;10(5). Available from: https://www.proquest.com/docview/2461931987/abstract/4FB37BFF120442B9PQ/1

  99. Poudrier J, Mac-Lean RT. We’ve fallen into the cracks: Aboriginal women’s experiences with breast cancer through photovoice. Nurs Inq. 2009;16(4):306–17.

    Article  PubMed  Google Scholar 

  100. Goodman A, Fleming K, Markwick N, Morrison T, Lagimodiere L, Kerr T. “They treated me like crap and I know it was because I was Native”: The healthcare experiences of Aboriginal peoples living in Vancouver’s inner city. Soc Sci Med. 2017;178:87–94.

    Article  PubMed  PubMed Central  Google Scholar 

  101. Varcoe C, Brown H, Calam B, Harvey T, Tallio M. Help bring back the celebration of life: a community-based participatory study of rural Aboriginal women’s maternity experiences and outcomes. BMC Pregnancy Childbirth. 2013;29(13):26.

    Article  Google Scholar 

  102. Hole RD, Evans M, Berg LD, Bottorff JL, Dingwall C, Alexis C, et al. Visibility and voice: Aboriginal people experience culturally safe and unsafe health care. Qual Health Res. 2015;25(12):1662–74.

    Article  PubMed  Google Scholar 

  103. Cortis JD. Perceptions and experiences with nursing care: A study of Pakistani (Urdu) communities in the United Kingdom. J Transcult Nurs. 2000;11(2):111–8.

    Article  CAS  PubMed  Google Scholar 

  104. Kang C, Tomkow L, Farrington R. Access to primary health care for asylum seekers and refugees: a qualitative study of service user experiences in the UK. Br J Gen Pract. 2019;69(685):e537–45.

    Article  PubMed  PubMed Central  Google Scholar 

  105. Cruz D, Rodriguez Y, Mastropaolo C. Perceived microaggressions in health care: A measurement study. PLoS ONE. 2019 Feb 5;14(2). Available from: https://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2019-07008-001&site=ehost-live

  106. Hulen E, Hardy LJ, Teufel-Shone N, Sanderson PR, Schwartz AL, Begay RC. Community Based Participatory Research (CBPR): A Dynamic Process of Health care, Provider Perceptions and American Indian Patients’ Resilience. J Health Care Poor Underserved. 2019;30(1):221–37.

    Article  PubMed  PubMed Central  Google Scholar 

  107. Jacquez F, Vaughn L, Zhen-Duan J, Graham C. Health Care Use and Barriers to Care among Latino Immigrants in a New Migration Area. J Health Care Poor Underserved. 2016;27(4):1761–78.

    Article  PubMed  Google Scholar 

  108. Lightfoot AF, Thatcher K, Simán FM, Eng E, Merino Y, Thomas T, et al. “What I wish my doctor knew about my life”: Using photovoice with immigrant Latino adolescents to explore barriers to healthcare. Qual Soc Work. 2019;18(1):60–80.

    Article  PubMed  Google Scholar 

  109. George MS, Davey R, Mohanty I, Upton P. “Everything is provided free, but they are still hesitant to access healthcare services”: why does the indigenous community in Attapadi, Kerala continue to experience poor access to healthcare? Int J Equity Health. 2020;19(1):105.

    Article  PubMed  PubMed Central  Google Scholar 

  110. Lafaut D, Coene G. “I was trying to speak to their human side” coping responses of Belgium’s undocumented migrants to barriers in health-care access. Int J Migr Health Soc Care. 2020;16(3):253–67.

    Article  Google Scholar 

  111. Loganathan T, Rui D, Ng C-W, Pocock NS. Breaking down the barriers: Understanding migrant workers’ access to healthcare in Malaysia. PLOS ONE. 2019;14(7):e0218669.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  112. Pérez-Urdiales I, Goicolea I, Sebastián MS, Irazusta A, Linander I. Sub-Saharan African immigrant women’s experiences of (lack of) access to appropriate healthcare in the public health system in the Basque Country, Spain. Int J Equity Health. 2019;18(1):59.

    Article  PubMed  PubMed Central  Google Scholar 

  113. Gebreyesus T, Gottlieb N, Sultan Z, Ghebrezghiabher HM, Tol W, Winch PJ, et al. Barriers to contraceptive careseeking: the experience of Eritrean asylum-seeking women in Israel. Ethn Health. 2020;25(2):255–72.

    Article  PubMed  Google Scholar 

  114. Hong HC, Lee H, Collins EG, Park C, Quinn L, Ferrans CE. Factors affecting trust in healthcare among middle-aged to older Korean American women. BMC Womens Health. 2018;18(1):109.

    Article  PubMed  PubMed Central  Google Scholar 

  115. Jacobs EA, Rolle I, Ferrans CE, Whitaker EE, Warnecke RB. Understanding African Americans’ Views of the Trustworthiness of Physicians. J Gen Intern Med. 2006;21(6):642–7.

    Article  PubMed  PubMed Central  Google Scholar 

  116. Aspin C, Brown N, Jowsey T, Yen L, Leeder S. Strategic approaches to enhanced health service delivery for Aboriginal and Torres Strait Islander people with chronic illness: a qualitative study. BMC Health Serv Res. 2012;8(12):143.

    Article  Google Scholar 

  117. Coombes J, Hunter K, Mackean T, Holland AJA, Sullivan E, Ivers R. Factors that impact access to ongoing health care for First Nation children with a chronic condition. BMC Health Serv Res [Internet]. 2018 Jun 14 [cited 2019 Feb 26];18. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6001071/

  118. Wright AL, Jack SM, Ballantyne M, Gabel C, Bomberry R, Wahoush O. Indigenous mothers’ experiences of using acute care health services for their infants. J Clin Nurs. 2019;28(21–22):3935–48.

    Article  PubMed  Google Scholar 

  119. Garrett PW, Dickson HG, Lis-Young, Whelan AK, Roberto-Forero. What do non-English-speaking patients value in acute care? Cultural competency from the patient’s perspective: A qualitative study. Ethn Health. 2008;13(5):479–96.

    Article  PubMed  Google Scholar 

  120. Turner WL, Wallace BR, Anderson JR, Bird C. The last mile of the way: Understanding caregiving in African American families at the end-of-life. J Marital Fam Ther. 2004;30(4):427–38.

    Article  PubMed  Google Scholar 

  121. Cabassa LJ, Gomes AP, Meyreles Q, Capitelli L, Younge R, Dragatsi D, et al. Primary health care experiences of hispanics with serious mental illness: a mixed-methods study. Adm Policy Ment Health. 2014;41(6):724–36.

    Article  PubMed  PubMed Central  Google Scholar 

  122. Mishra SI, Lucksted A, Gioia D, Barnet B, Baquet CR. Needs and Preferences for Receiving Mental Health Information in an African American Focus Group Sample. Community Ment Health J. 2009;45(2):117–26.

    Article  PubMed  Google Scholar 

  123. Altman MR, Oseguera T, McLemore MR, Kantrowitz-Gordon I, Franck LS, Lyndon A. Information and power: Women of color’s experiences interacting with health care providers in pregnancy and birth. Soc Sci Med 1982. 2019;238:112491.

    Google Scholar 

  124. Altman MR, McLemore MR, Oseguera T, Lyndon A, Franck LS. Listening to Women: Recommendations from Women of Color to Improve Experiences in Pregnancy and Birth Care. J Midwifery Womens Health. 2020;65(4):466–73.

    Article  PubMed  Google Scholar 

  125. Edwards BN, McLemore MR, Baltzell K, Hodgkin A, Nunez O, Franck LS. What about the men? Perinatal experiences of men of color whose partners were at risk for preterm birth, a qualitative study. BMC Pregnancy Childbirth. 2020;20(1):91.

    Article  PubMed  PubMed Central  Google Scholar 

  126. McLemore MR, Altman MR, Cooper N, Williams S, Rand L, Franck L. Health care experiences of pregnant, birthing and postnatal women of color at risk for preterm birth. Soc Sci Med. 1982;2018(201):127–35.

    Google Scholar 

  127. Salm Ward TC, Mazul M, Ngui EM, Bridgewater FD, Harley AE. “You learn to go last”: perceptions of prenatal care experiences among African-American women with limited incomes. Matern Child Health J. 2013;17(10):1753–9.

    Article  PubMed  Google Scholar 

  128. Smith E, Sundstrom B, Delay C. Listening to women: Understanding and challenging systems of power to achieve reproductive justice in South Carolina. J Soc Issues. 2020;76(2):363–90.

    Article  Google Scholar 

  129. Brown SJ, Gartland D, Weetra D, Leane C, Francis T, Mitchell A, et al. Health care experiences and birth outcomes: Results of an Aboriginal birth cohort. Women Birth J Aust Coll Midwives. 2019;32(5):404–11.

    Article  Google Scholar 

  130. Wright AL, Ballantyne M, Wahoush O. Caring for indigenous families in the neonatal intensive care unit. Nurs Inq. 2020;27(2):e12338.

    Article  PubMed  Google Scholar 

  131. Acree ME, McNulty M, Blocker O, Schneider J, Williams H ‘Herukhuti’ S. Shared decision-making around anal cancer screening among black bisexual and gay men in the usa. Cult Health Sex [Internet]. 2019 Mar 29; Available from: https://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2019-18559-001&site=ehost-live

  132. Agénor M, Bailey Z, Krieger N, Austin SB, Gottlieb BR. Exploring the Cervical Cancer Screening Experiences of Black Lesbian, Bisexual, and Queer Women: The Role of Patient-Provider Communication. Women Health. 2015;55(6):717–36.

    Article  PubMed  Google Scholar 

  133. Gonzales FA, Sangaramoorthy M, Dwyer LA, Shariff-Marco S, Allen AM, Kurian AW, et al. Patient-clinician interactions and disparities in breast cancer care: the equality in breast cancer care study. J Cancer Surviv Res Pract. 2019;13(6):968–80.

    Article  Google Scholar 

  134. Marlow LAV, McGregor LM, Nazroo JY, Wardle J. Facilitators and barriers to help-seeking for breast and cervical cancer symptoms: A qualitative study with an ethnically diverse sample in London. Psychooncol. 2014;23(7):749–57.

    Article  Google Scholar 

  135. Velez D, Palomo-Zerfas A, Nunez-Alvarez A, Ayala GX, Finlayson TL. Facilitators and Barriers to Dental Care Among Mexican Migrant Women and Their Families in North San Diego County. J Immigr Minor Health. 2017;19(5):1216–26.

    Article  PubMed  Google Scholar 

  136. Amirehsani KA, Hu J, Wallace DC, Silva ZA, Dick S, West-Livingston LN, et al. US Healthcare Experiences of Hispanic Patients with Diabetes and Family Members: A Qualitative Analysis. J Community Health Nurs. 2017;34(3):126–35.

    Article  PubMed  PubMed Central  Google Scholar 

  137. Morales-Alemán MM, Ferreti G, Scarinci IC. “I Don’t Like Being Stereotyped, I Decided I Was Never Going Back to the Doctor”: Sexual Healthcare Access Among Young Latina Women in Alabama. J Immigr Minor Health. 2020;22(4):645–52.

    Article  PubMed  PubMed Central  Google Scholar 

  138. Bergman AA, Connaughton SL. What is patient-centered care really? Voices of Hispanic prenatal patients. Health Commun. 2013;28(8):789–99.

    Article  PubMed  Google Scholar 

  139. Hamoda RE, McPherson LJ, Lipford K, Jacob Arriola K, Plantinga L, Gander JC, et al. Association of sociocultural factors with initiation of the kidney transplant evaluation process. Am J Transplant Off J Am Soc Transplant Am Soc Transpl Surg. 2020;20(1):190–203.

    Article  Google Scholar 

  140. Agénor M, Bailey Z, Krieger N, Austin SB, Gottlieb BR. Exploring the cervical cancer screening experiences of black lesbian, bisexual, and queer women: The role of patient-provider communication. Women Health. 2015;55(6):717–36.

    Article  PubMed  Google Scholar 

  141. Greer TM. Age influences the effects of provider racial biases on treatment adherence and blood pressure control for African American hypertensive patients. J Health Care Poor Underserved. 2016;27(2):604–21.

    Article  PubMed  Google Scholar 

  142. Stepanikova I, Oates GR. Dimensions of Racial Identity and Perceived Discrimination in Health Care. Ethn Dis. 2016;26(4):501–12.

    Article  PubMed  PubMed Central  Google Scholar 

  143. Cortis JD. Culture, values and racism: Application to nursing. Int Nurs Rev. 2003;50(1):55–64.

    Article  CAS  PubMed  Google Scholar 

  144. Sacks TK. Race and gender concordance: Strategy to reduce healthcare disparities or red herring? Evidence from a qualitative study. Race Soc Probl. 2013;5(2):88–99.

    Article  Google Scholar 

  145. Allan HT, Cowie H, Smith P. Overseas nurses’ experiences of discrimination: A case of racist bullying? J Nurs Manag. 2009;17(7):898–906.

    Article  PubMed  Google Scholar 

  146. Almanza J, Karbeah J, Kozhimannil KB, Hardeman R. The Experience and Motivations of Midwives of Color in Minnesota: Nothing for Us Without Us. J Midwifery Womens Health. 2019;64(5):598–603.

    Article  PubMed  Google Scholar 

  147. Arday J. Understanding Mental Health: What Are the Issues for Black and Ethnic Minority Students at University? Soc Sci. 2018;7(10):196.

    Article  Google Scholar 

  148. Beard KV, Julion WA. Does race still matter in nursing? The narratives of African-American nursing faculty members. Nurs Outlook. 2016;64(6):583–96.

    Article  PubMed  Google Scholar 

  149. Cottingham MD, Johnson AH, Erickson RJ. “I Can Never Be Too Comfortable”: Race, Gender, and Emotion at the Hospital Bedside. Qual Health Res. 2018;28(1):145–58.

    Article  PubMed  Google Scholar 

  150. Criddle T-R, Gordon NC, Blakey G, Bell RB. African Americans in Oral and Maxillofacial Surgery: Factors Affecting Career Choice, Satisfaction, and Practice Patterns. J Oral Maxillofac Surg Off J Am Assoc Oral Maxillofac Surg. 2017;75(12):2489–96.

    Article  Google Scholar 

  151. Fowler BA. Facilitators and barriers to leadership and career opportunities in minority nurses in public health departments. Public Health Nurs. 2020;37(6):821–8.

    Article  PubMed  Google Scholar 

  152. Giddings LS. Health disparities, social injustice, and the culture of nursing. Nurs Res. 2005;54(5):304–12.

    Article  PubMed  Google Scholar 

  153. Hagey R, Choudhry U, Guruge S, Turrittin J, Collins E, Lee R. Immigrant nurses’ experience of racism. J Nurs Scholarsh Off Publ Sigma Theta Tau Int Honor Soc Nurs. 2001;33(4):389–94.

    CAS  Google Scholar 

  154. Heponiemi T, Hietapakka L, Lehtoaro S, Aalto A-M. Foreign-born physicians’ perceptions of discrimination and stress in Finland: a cross-sectional questionnaire study. BMC Health Serv Res. 2018;18(1):418.

    Article  PubMed  PubMed Central  Google Scholar 

  155. Jönson H. Is It Racism? J Gerontol Soc Work. 2007;49(4):79–96.

    Article  PubMed  Google Scholar 

  156. Keshet Y, Popper-Giveon A. Race-based experiences of ethnic minority health professionals: Arab physicians and nurses in Israeli public healthcare organizations. Ethn Health. 2018;23(4):442–59.

    Article  PubMed  Google Scholar 

  157. Ko M, Dorri A. Primary Care Clinician and Clinic Director Experiences of Professional Bias, Harassment, and Discrimination in an Underserved Agricultural Region of California. JAMA Netw Open. 2019;2(10):e1913535.

    Article  PubMed  PubMed Central  Google Scholar 

  158. Lampley-Dallas VT, Mold JW, Flori DE. Perceived needs of African-American caregivers of elders with dementia. J Natl Med Assoc. 2001;93(2):47–57.

    CAS  PubMed  PubMed Central  Google Scholar 

  159. Larsen JA. Embodiment of discrimination and overseas nurses’ career progression. J Clin Nurs. 2007;16(12):2187–95.

    Article  PubMed  Google Scholar 

  160. Likupe G, Archibong U. Black African nurses’ experiences of equality, racism, and discrimination in the National Health Service. J Psychol Issues Organ Cult. 2013;3(S1):227–46.

    Article  Google Scholar 

  161. Lin L-C. Filipina nurses’ transition into the US hospital system. J Immigr Minor Health. 2014;16(4):682–8.

    Article  PubMed  Google Scholar 

  162. Moceri JT. Hispanic nurses’ experiences of bias in the workplace. J Transcult Nurs Off J Transcult Nurs Soc. 2014;25(1):15–22.

    Article  Google Scholar 

  163. Mpalirwa J, Lofters A, Nnorom O, Hanson MD. Patients, Pride, and Prejudice: Exploring Black Ontarian Physicians’ Experiences of Racism and Discrimination. Acad Med J Assoc Am Med Coll. 2020;95(11S Association of American Medical Colleges Learn Serve Lead: Proceedings of the 59th Annual Research in Medical Education Presentations):S51-7.

    Article  Google Scholar 

  164. Paine S-J, Harris R, Stanley J, Cormack D. Caregiver experiences of racism and child healthcare utilisation: cross-sectional analysis from New Zealand. Arch Dis Child. 2018;103(9):873–9.

    Article  PubMed  Google Scholar 

  165. Plaisime MV, Malebranche DJ, Davis AL, Taylor JA. Healthcare Providers’ Formative Experiences with Race and Black Male Patients in Urban Hospital Environments. J Racial Ethn Health Disparities. 2017;4(6):1120–7.

    Article  PubMed  Google Scholar 

  166. Serafini K, Coyer C, Speights JB, Donovan D, Guh J, Washington J, et al. Racism as Experienced by Physicians of Color in the Health Care Setting. Fam Med. 2020;52(4):282–7.

    Article  PubMed  Google Scholar 

  167. Stevens M, Hussein S, Manthorpe J. Experiences of racism and discrimination among migrant care workers in England: Findings from a mixed-methods research project. Ethn Racial Stud. 2012;35(2):259–80.

    Google Scholar 

  168. Wesołowska K, Elovainio M, Komulainen K, Hietapakka L, Heponiemi T. Nativity status and workplace discrimination in registered nurses: Testing the mediating role of psychosocial work characteristics. J Adv Nurs. 2020;76(7):1594–602.

    Article  PubMed  Google Scholar 

  169. White BJ, Mentag NM, Kaunda BR. African American Nurses Describe Experiences of Mistrust and Trust While in Nursing School. Nurs Educ Perspect. 2020;41(3):157–62.

    Article  PubMed  Google Scholar 

  170. Wingfield AH, Chavez K. Getting In, Getting Hired, Getting Sideways Looks: Organizational Hierarchy and Perceptions of Racial Discrimination. Am Sociol Rev. 2020;85(1):31–57.

    Article  Google Scholar 

  171. Ngocha-Chaderopa NE, Boon B. Managing for quality aged residential care with a migrant workforce. J Manag Organ. 2016;22(01):32–48.

    Article  Google Scholar 

  172. Keshet Y, Popper-Giveon A. Neutrality in medicine and health professionals from ethnic minority groups: The case of Arab health professionals in Israel. Soc Sci Med. 2017;174:35–42.

    Article  PubMed  Google Scholar 

  173. Belak A, Bobakova DF, Geckova AM, van Dijk JP, Reijneveld SA. Why don’t health care frontline professionals do more for segregated Roma? Exploring mechanisms supporting unequal care practices. Soc Sci Med [Internet]. 2020;246. Available from: https://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2020-11244-001&site=ehost-live

  174. Briones-Vozmediano E, La Parra-Casado D, Vives-Cases C. Health providers’ narratives on intimate partner violence against Roma women in Spain. Am J Community Psychol. 2018;61(3–4):411–20.

    Article  PubMed  Google Scholar 

  175. Kühlbrandt C. Confronting racism in family planning: a critical ethnography of Roma health mediation. Sex Reprod Health Matters. 2019;27(1):1571324.

    PubMed  Google Scholar 

  176. Heaslip V, Vanceulebroeck V, Kalkan I, Kömürcü N, Solanas IA. Student nurse perceptions of Gypsy Roma Travellers; A European qualitative study. Nurse Educ Today. 2019;1(82):1–7.

    Article  Google Scholar 

  177. Wint K, Elias TI, Mendez G, Mendez DD, Gary-Webb TL. Experiences of Community Doulas Working with Low-Income. African American Mothers Health Equity. 2019;3(1):109–16.

    Article  PubMed  Google Scholar 

  178. Delafield R, Elia J, Chang A, Kaneshiro B, Sentell T, Pirkle CM. Perspectives and Experiences of Obstetricians Who Provide Labor and Delivery Care for Micronesian Women in Hawai‘i: What Is Driving Cesarean Delivery Rates? Qual Health Res. 2020;30(14):2291–302.

    Article  PubMed  Google Scholar 

  179. Power T, Lucas C, Hayes C, Jackson D. ‘With my heart and eyes open’: Nursing students′ reflections on placements in Australian, urban Aboriginal organisations. Nurse Educ Pract. 2020;1(49):102904.

    Article  Google Scholar 

  180. Cortis JD. Meeting the needs of minority ethnic patients. J Adv Nurs. 2004;48(1):51–8.

    Article  PubMed  Google Scholar 

  181. Vydelingum V. Nurses’ experiences of caring for South Asian minority ethnic patients in a general hospital in England. Nurs Inq. 2006;13(1):23–32.

    Article  PubMed  Google Scholar 

  182. Claeys A, Berdai-Chaouni S, Tricas-Sauras S, De Donder L. Culturally Sensitive Care: Definitions, Perceptions, and Practices of Health Care Professionals. J Transcult Nurs. 2020;5:1043659620970625.

    Google Scholar 

  183. Lyons SM, O’Keeffe FM, Clarke AT, Staines A. Cultural diversity in the Dublin maternity services: The experiences of maternity service providers when caring for ethnic minority women. Ethn Health. 2008;13(3):261–76.

    Article  PubMed  Google Scholar 

  184. Blair IV, Steiner JF, Fairclough DL, Hanratty R, Price DW, Hirsh HK, et al. Clinicians’ implicit ethnic/racial bias and perceptions of care among Black and Latino patients. Ann Fam Med. 2013;11(1):43–52.

    Article  PubMed  PubMed Central  Google Scholar 

  185. Burgess DJ, Hardeman RR, Burke SE, Cunningham BA, Dovidio JF, Nelson DB, et al. Incoming Medical Students’ Political Orientation Affects Outcomes Related to Care of Marginalized Groups: Results from the Medical Student CHANGES Study. J Health Polit Policy Law. 2018; 44(1):113–46.

  186. Burke SE, Dovidio JF, Perry SP, Burgess DJ, Hardeman RR, Phelan SM, et al. Informal Training Experiences and Explicit Bias against African Americans among Medical Students. Soc Psychol Q. 2017;80(1):65–84.

    Article  PubMed  PubMed Central  Google Scholar 

  187. Cormack D, Harris R, Stanley J, Lacey C, Jones R, Curtis E. Ethnic bias amongst medical students in Aotearoa/New Zealand: Findings from the Bias and Decision Making in Medicine (BDMM) study. PloS One. 2018;13(8):e0201168.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  188. Dyrbye L, Herrin J, West CP, Wittlin NM, Dovidio JF, Hardeman R, et al. Association of Racial Bias With Burnout Among Resident Physicians. JAMA Netw Open. 2019;2(7):e197457.

    Article  PubMed  PubMed Central  Google Scholar 

  189. Hagiwara N, Dovidio JF, Eggly S, Penner LA. The effects of racial attitudes on affect and engagement in racially discordant medical interactions between non-Black physicians and Black patients. Group Process Intergroup Relat. 2016;19(4):509–27.

    Article  PubMed  PubMed Central  Google Scholar 

  190. Haider AH, Schneider EB, Sriram N, Dossick DS, Scott VK, Swoboda SM, et al. Unconscious race and class bias: its association with decision making by trauma and acute care surgeons. J Trauma Acute Care Surg. 2014;77(3):409–16.

    Article  PubMed  Google Scholar 

  191. Haider AH, Schneider EB, Sriram N, Scott VK, Swoboda SM, Zogg CK, et al. Unconscious Race and Class Biases among Registered Nurses: Vignette-Based Study Using Implicit Association Testing. J Am Coll Surg. 2015;220(6):1077-1086.e3.

    Article  PubMed  Google Scholar 

  192. Harris R, Cormack D, Stanley J, Curtis E, Jones R, Lacey C. Ethnic bias and clinical decision-making among New Zealand medical students: an observational study. BMC Med Educ. 2018;18(1):18.

    Article  PubMed  PubMed Central  Google Scholar 

  193. Hausmann LRM, Myaskovsky L, Niyonkuru C, Oyster ML, Switzer GE, Burkitt KH, et al. Examining implicit bias of physicians who care for individuals with spinal cord injury: A pilot study and future directions. J Spinal Cord Med. 2015;38(1):102–10.

    Article  PubMed  PubMed Central  Google Scholar 

  194. Johnson TJ, Hickey RW, Switzer GE, Miller E, Winger DG, Nguyen M, et al. The Impact of Cognitive Stressors in the Emergency Department on Physician Implicit Racial Bias. Acad Emerg Med Off J Soc Acad Emerg Med. 2016;23(3):297–305.

    Article  Google Scholar 

  195. Johnson TJ, Winger DG, Hickey RW, Switzer GE, Miller E, Nguyen MB, et al. Comparison of Physician Implicit Racial Bias Toward Adults Versus Children. Acad Pediatr. 2017;17(2):120–6.

    Article  PubMed  Google Scholar 

  196. Kerner J, McCoy B, Gilbo N, Colavita M, Kim M, Zaval L, et al. Racial Disparity in the Clinical Risk Assessment. Community Ment Health J. 2020;56(4):586–91.

    Article  PubMed  Google Scholar 

  197. Khosla NN, Perry SP, Moss-Racusin CA, Burke SE, Dovidio JF. A comparison of clinicians’ racial biases in the United States and France. Soc Sci Med. 2018;1(206):31–7.

    Article  Google Scholar 

  198. Oliver MN, Wells KM, Joy-Gaba JA, Hawkins CB, Nosek BA. Do physicians’ implicit views of African Americans affect clinical decision making? J Am Board Fam Med JABFM. 2014;27(2):177–88.

    Article  PubMed  Google Scholar 

  199. Puumala SE, Burgess KM, Kharbanda AB, Zook HG, Castille DM, Pickner WJ, et al. The Role of Bias by Emergency Department Providers in Care for American Indian Children. Med Care. 2016;54(6):562–9.

    Article  PubMed  PubMed Central  Google Scholar 

  200. Sabin JA, Rivara FP, Greenwald AG. Physician implicit attitudes and stereotypes about race and quality of medical care. Med Care. 2008;46(7):678–85.

    Article  PubMed  Google Scholar 

  201. Shin RQ, Smith LC, Welch JC, Ezeofor I. Is Allison more likely than Lakisha to receive a callback from counseling professionals? A racism audit study Couns Psychol. 2016;44(8):1187–211.

    Article  Google Scholar 

  202. White-Means S, Dong Z, Hufstader M, Brown LT. Cultural competency, race, and skin tone bias among pharmacy, nursing, and medical students: implications for addressing health disparities. Med Care Res Rev MCRR. 2009;66(4):436–55.

    Article  PubMed  Google Scholar 

  203. Greenwood BN, Hardeman RR, Huang L, Sojourner A. Physician–patient racial concordance and disparities in birthing mortality for newborns. Proc Natl Acad Sci. 2020;117(35):21194–200.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  204. Tangel VE, Matthews KC, Abramovitz SE, White RS. Racial and ethnic disparities in severe maternal morbidity and anesthetic techniques for obstetric deliveries: A multi-state analysis, 2007–2014. J Clin Anesth. 2020;65:109821.

    Article  PubMed  Google Scholar 

  205. Leech TGJ, Irby-Shasanmi A, Mitchell AL. “Are you accepting new patients?” A pilot field experiment on telephone-based gatekeeping and Black patients’ access to pediatric care. Health Serv Res. 2019;54(S1):234–42.

    Article  PubMed  Google Scholar 

  206. Penner LA, Dovidio JF, Gonzalez R, Albrecht TL, Chapman R, Foster T, et al. The Effects of Oncologist Implicit Racial Bias in Racially Discordant Oncology Interactions. J Clin Oncol Off J Am Soc Clin Oncol. 2016;34(24):2874–80.

    Article  Google Scholar 

  207. Verma V, Haque W, Cushman TR, Lin C, Simone CB, Chang JY, et al. Racial and Insurance-related Disparities in Delivery of Immunotherapy-type Compounds in the United States. J Immunother Hagerstown Md 1997. 2019;42(2):55–64.

    Google Scholar 

  208. Burgess DJ, Phelan S, Workman M, Hagel E, Nelson DB, Fu SS, et al. The effect of cognitive load and patient race on physicians’ decisions to prescribe opioids for chronic low back pain: a randomized trial. Pain Med Malden Mass. 2014;15(6):965–74.

    Article  Google Scholar 

  209. Hirsh AT, Hollingshead NA, Ashburn-Nardo L, Kroenke K. The interaction of patient race, provider bias, and clinical ambiguity on pain management decisions. J Pain. 2015;16(6):558–68.

    Article  PubMed  PubMed Central  Google Scholar 

  210. Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. PNAS Proc Natl Acad Sci U S Am. 2016;113(16):4296–301.

    Article  CAS  Google Scholar 

  211. Calabrese SK, Earnshaw VA, Underhill K, Hansen NB, Dovidio JF. The impact of patient race on clinical decisions related to prescribing HIV pre-exposure prophylaxis (PREP): Assumptions about sexual risk compensation and implications for access. AIDS Behav. 2014;18(2):226–40.

    Article  PubMed  PubMed Central  Google Scholar 

  212. Waddy SP, Solomon AJ, Becerra AZ, Ward JB, Chan KE, Fwu C-W, et al. Racial/Ethnic Disparities in Atrial Fibrillation Treatment and Outcomes among Dialysis Patients in the United States. J Am Soc Nephrol JASN. 2020;31(3):637–49.

    Article  PubMed  Google Scholar 

  213. Aranda K. Community nurses’ talk of equality and the discursive constitution of selves. J Adv Nurs. 2005;51(2):131–9.

    Article  PubMed  Google Scholar 

  214. Bell HS, Odumosu F, Martinez-Hume AC, Howard HA, Hunt LM. Racialized risk in clinical care: Clinician vigilance and patient responsibility. Med Anthropol. 2019;38(3):224–38.

    Article  PubMed  Google Scholar 

  215. Cuesta M, Rämgård M. Intersectional perspective in elderly care. Int J Qual Stud Health Well-Being. 2016;11:30544.

    Article  PubMed  Google Scholar 

  216. Freeman T, Baum F, Mackean T, Ziersch A, Sherwood J, Edwards T, et al. Case study of a decolonising Aboriginal community controlled comprehensive primary health care response to alcohol-related harm. Aust N Z J Public Health. 2019;43(6):532–7.

    Article  PubMed  Google Scholar 

  217. Garneau AB, Browne AJ, Varcoe C. Understanding competing discourses as a basis for promoting equity in primary health care. BMC Health Serv Res. 2019;19(1):1–11.

    Google Scholar 

  218. Grant J, Guerin PB. Mixed and misunderstandings: An exploration of the meaning of racism with maternal, child, and family health nurses in South Australia. J Adv Nurs. 2018;74(12):2831–9.

    Article  PubMed  Google Scholar 

  219. Nelson SC, Hackman HW. Race matters: perceptions of race and racism in a sickle cell center. Pediatr Blood Cancer. 2013;60(3):451–4.

    Article  PubMed  Google Scholar 

  220. Rix EF, Barclay L, Wilson S, Stirling J, Tong A. Service providers’ perspectives, attitudes and beliefs on health services delivery for Aboriginal people receiving haemodialysis in rural Australia: a qualitative study. BMJ Open. 2013;3(10):e003581.

    Article  PubMed  PubMed Central  Google Scholar 

  221. Sylvestre P, Castleden H, Denis J, Martin D, Bombay A. The tools at their fingertips: How settler colonial geographies shape medical educators’ strategies for grappling with anti-Indigenous racism. Soc Sci Med [Internet]. 2019 Sep;237. Available from: https://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2019-53442-001&site=ehost-live

  222. Vanidestine T, Aparicio EM. How Social Welfare and Health Professionals Understand “Race”, Racism, and Whiteness: A Social Justice Approach to Grounded Theory. Soc Work Public Health. 2019;34(5):430–43.

    Article  PubMed  Google Scholar 

  223. Wildschut G, Mayers PM. Conflict, Complicity, and Challenges: Reflections on the South African Truth and Reconciliation Commission Health Sector Hearing. J Nurs Scholarsh Off Publ Sigma Theta Tau Int Honor Soc Nurs. 2019;51(3):299–307.

    Google Scholar 

  224. Wylie L, McConkey S. Insiders’ insight: Discrimination against indigenous peoples through the eyes of health care professionals. J Racial Ethn Health Disparities. 2019;6(1):37–45.

    Article  PubMed  Google Scholar 

  225. Adelekun AA, Beltrán S, Carney J, Lett LA, Orji WU, Rider-Longmaid E, et al. Recognizing Racism in Medicine: A Student-Organized and Community-Engaged Health Professional Conference. Health Equity. 2019;3(1):395–402.

    Article  PubMed  PubMed Central  Google Scholar 

  226. Bi S, Vela MB, Nathan AG, Gunter KE, Cook SC, López FY, et al. Teaching Intersectionality of Sexual Orientation, Gender Identity, and Race/Ethnicity in a Health Disparities Course. MedEdPORTAL J Teach Learn Resour [Internet]. 2020 [cited 2021 Apr 20];16. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7394350/

  227. Bright HR, Nokes K. Impact of a Discussion Series on Race on Medical Student Perceptions of Bias in Health Care. Primer Leawood Kan. 2019;3:29.

    Google Scholar 

  228. Browne AJ, Varcoe C, Ford-Gilboe M, Nadine Wathen C, Smye V, Jackson BE, et al. Disruption as opportunity: Impacts of an organizational health equity intervention in primary care clinics. Int J Equity Health. 2018;17(1):154.

    Article  PubMed  PubMed Central  Google Scholar 

  229. Burgess DJ, Bokhour BG, Cunningham BA, Do T, Eliacin J, Gordon HS, et al. Communicating with providers about racial healthcare disparities: The role of providers’ prior beliefs on their receptivity to different narrative frames. Patient Educ Couns. 2019;102(1):139–47.

    Article  PubMed  Google Scholar 

  230. Chapman MV, Hall WJ, Lee K, Colby R, Coyne-Beasley T, Day S, et al. Making a difference in medical trainees’ attitudes toward Latino patients: A pilot study of an intervention to modify implicit and explicit attitudes. Soc Sci Med. 2018;199:202–8.

    Article  PubMed  Google Scholar 

  231. Doran F, Wrigley B, Lewis S. Exploring cultural safety with nurse academics Research findings suggest time to “step up.” Contemp Nurse. 2019;55(2–3):156–70.

    Article  PubMed  Google Scholar 

  232. Holland AE. The lived experience of teaching about race in cultural nursing education. J Transcult Nurs. 2015;26(1):92–100.

    Article  PubMed  Google Scholar 

  233. Hope JM, Lugassy D, Meyer R, Jeanty F, Myers S, Jones S, et al. Bringing Interdisciplinary and Multicultural Team Building to Health Care Education: The Downstate Team-Building Initiative. Acad Med. 2005;80(1):74–83.

    Article  PubMed  Google Scholar 

  234. Kai J, Bridgewater R, Spencer J. “‘Just think of TB and Asians’, that’s all I ever hear”: Medical learners’ views about training to work in an ethnically diverse society. Med Educ. 2001;35(3):250–6.

    Article  CAS  PubMed  Google Scholar 

  235. Metzl JM, Roberts DE. Structural competency meets structural racism: race, politics, and the structure of medical knowledge. Virtual Mentor VM. 2014;16(9):674–90.

    Article  PubMed  Google Scholar 

  236. Nelson SC, Prasad S, Hackman HW. Training providers on issues of race and racism improve health care equity. Pediatr Blood Cancer. 2015;62(5):915–7.

    Article  PubMed  Google Scholar 

  237. Perdomo J, Tolliver D, Hsu H, He Y, Nash KA, Donatelli S, et al. Health Equity Rounds: An Interdisciplinary Case Conference to Address Implicit Bias and Structural Racism for Faculty and Trainees. MedEdPORTAL. 2019;15:10858.

    Article  PubMed  PubMed Central  Google Scholar 

  238. Sylk S-S, Jacqueline M, Francesca D, Joseph S. “I Didn’t Know What to Say”: Responding to Racism, Discrimination, and Microaggressions With the OWTFD Approach. MedEdPORTAL. 2019;16:10971.

    Google Scholar 

  239. Thackrah RD, Thompson SC. Confronting uncomfortable truths: Receptivity and resistance to Aboriginal content in midwifery education. Contemp Nurse. 2013;46(1):113–22.

    Article  PubMed  Google Scholar 

  240. Peek ME, Odoms-Young A, Quinn MT, Gorawara-Bhat R, Wilson SC, Chin MH. Racism in healthcare: Its relationship to shared decision-making and health disparities: A response to Bradby. Soc Sci Med. 2010;71(1):13–7.

    Article  PubMed  PubMed Central  Google Scholar 

  241. Ross PT, Lypson ML, Kumagai AK. Using illness narratives to explore African American perspectives of racial discrimination in health care. J Black Stud. 2012;43(5):520–44.

    Article  Google Scholar 

  242. Harris RB, Cormack DM, Stanley J. Experience of racism and associations with unmet need and healthcare satisfaction: the 2011/12 adult New Zealand Health Survey. Aust N Z J Public Health. 2019;43(1):75–80.

    Article  PubMed  Google Scholar 

  243. Powell W, Richmond J, Mohottige D, Yen I, Joslyn A, Corbie-Smith G. Medical Mistrust, Racism, and Delays in Preventive Health Screening Among African-American Men. Behav Med Wash DC. 2019;45(2):102–17.

    Article  Google Scholar 

  244. Johnson TJ, Winger DG, Hickey RW, Switzer GE, Miller E, Nguyen MB, et al. Comparison of Physician Implicit Racial Bias Toward Adults Versus Children. Acad Pediatr. 2017;17(2):120–6.

    Article  PubMed  Google Scholar 

  245. Burgess DJ, Ding Y, Hargreaves M, van Ryn M, Phelan S. The Association between Perceived Discrimination and Underutilization of Needed Medical and Mental Health Care in a Multi-Ethnic Community Sample. J Health Care Poor Underserved Baltim. 2008;19(3):894–911.

    Article  Google Scholar 

  246. Blom N, Huijts T, Kraaykamp G. Ethnic health inequalities in Europe. The moderating and amplifying role of healthcare system characteristics. Soc Sci Med. 2016;158:43–51.

    Article  PubMed  Google Scholar 

  247. Goldberg DT. Racial Europeanization: Ethnic and Racial Studies: Vol 29, No 2. J Ethnic and Racial Stud. 2006;29:331–64.

    Article  Google Scholar 

  248. Borevi K. From multi-culturalism to assimilation? Swedish integration policy from a European perspective. Statsvetensk Tidskr [Internet]. 2011 [cited 2017 Mar 1];113(1). Available from: http://www.pjos.org/ojs/index.php/st/article/view/8312

  249. Bradby H, Thapar-Björkert S, Hamed S, Ahlberg BM. Undoing the unspeakable: researching racism in Swedish healthcare using a participatory process to build dialogue. Health Res Policy Syst. 2019;17(1):43.

    Article  PubMed  PubMed Central  Google Scholar 

  250. Bell HS, Odumosu F, Martinez-Hume AC, Howard HA, Hunt LM. Racialized Risk in Clinical Care: Clinician Vigilance and Patient Responsibility. Med Anthropol. 2019;38(3):224–38.

    Article  PubMed  Google Scholar 

  251. Brown SJ, Gartland D, Weetra D, Leane C, Francis T, Mitchell A, et al. Health care experiences and birth outcomes: Results of an Aboriginal birth cohort. Women Birth J Aust Coll Midwives. 2019;32(5):404–11.

    Article  Google Scholar 

  252. Browne AJ, Varcoe C. Critical cultural perspectives and health care involving Aboriginal peoples. Contemp Nurse. 2006;22(2):155–67.

    Article  PubMed  Google Scholar 

  253. Davis D-A. Narrating the Mute: Racializing and Racism in a Neoliberal Moment. Souls. 2007;9(4):346–60.

    Article  Google Scholar 

  254. Larsen JA. Embodiment of discrimination and overseas nurses’ career progression. J Clin Nurs. 2007;16(12):2187–95.

    Article  PubMed  Google Scholar 

  255. Popper-Giveon A, Keshet Y. The secret drama at the patient’s bedside—Refusal of treatment because of the practitioner’s ethnic identity: The medical staff’s point of view. Qual Health Res. 2018;28(5):711–20.