For this assignment, you will prepare a 5 to 6 page review of the literature pertinent and to use that review to propose a methodology to address the problem.

RESEARCH ARTICLE

The perspectives of health professionals and

patients on racism in healthcare: A qualitative

systematic review

Wilson SimID 1☯, Wen Hui Lim1☯, Cheng Han NgID

1, Yip Han Chin1, Clyve Yu Leon Yaow1,

Clare Wei Zhen Cheong1, Chin Meng Khoo1,2, Dujeepa D. SamarasekeraID 3, M.

Kamala DeviID 4, Choon Seng ChongID

1,5*

1 Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore, 2 Division of

Endocrinology, Department of Medicine, National University Hospital, Singapore, Singapore, 3 Centre for

Medical Education, Yong Loo Lin School of Medicine, National University of Singapore, Singapore,

Singapore, 4 Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of

Singapore, Singapore, Singapore, 5 Division of Colorectal Surgery, Department of Surgery, University

Surgical Cluster, National University Hospital, Singapore, Singapore

☯ These authors contributed equally to this work.

* [email protected]

Abstract

Objective

To understand racial bias in clinical settings from the perspectives of minority patients and

healthcare providers to inspire changes in the way healthcare providers interact with their

patients.

Methods

Articles on racial bias were searched on Medline, CINAHL, PsycINFO, Web of Science. Full

text review and quality appraisal was conducted, before data was synthesized and analyti-

cally themed using the Thomas and Harden methodology.

Results

23 articles were included, involving 1,006 participants. From minority patients’ perspectives,

two themes were generated: 1) alienation of minorities due to racial supremacism and lack of

empathy, resulting in inadequate medical treatment; 2) labelling of minority patients who

were stereotyped as belonging to a lower socio-economic class and having negative behav-

iors. From providers’ perspectives, one theme recurred: the perpetuation of racial fault lines

by providers. However, some patients and providers denied racism in the healthcare setting.

Conclusion

Implicit racial bias is pervasive and manifests in patient-provider interactions, exacerbating

health disparities in minorities. Beyond targeted anti-racism measures in healthcare set-

tings, wider national measures to reduce housing, education and income inequality may mit-

igate racism in healthcare and improve minority patient care.

PLOS ONE

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OPEN ACCESS

Citation: Sim W, Lim WH, Ng CH, Chin YH, Yaow

CYL, Cheong CWZ, et al. (2021) The perspectives

of health professionals and patients on racism in

healthcare: A qualitative systematic review. PLoS

ONE 16(8): e0255936. https://doi.org/10.1371/

journal.pone.0255936

Editor: Luisa N. Borrell, City University of New York

Graduate School of Public Health and Health

Policy, UNITED STATES

Received: February 19, 2021

Accepted: July 27, 2021

Published: August 31, 2021

Copyright: © 2021 Sim et al. This is an open

access article distributed under the terms of the

Creative Commons Attribution License, which

permits unrestricted use, distribution, and

reproduction in any medium, provided the original

author and source are credited.

Data Availability Statement: All relevant data are

within the manuscript and its Supporting

Information files.

Funding: The author(s) received no specific

funding for this work.

Competing interests: The authors have declared

that no competing interests exist.

Introduction

In recent times, massive anti-racism protests around the world, following the unjust death of

Mr George Floyd at the hands of a police officer in the United States, have called for greater

scrutiny of existing racial injustices across all institutions, including within the public health

sphere. Racial health disparities have been long standing, as evidenced by the landmark report

from the Institute of Medicine (IOM) in 2003. Minorities were documented to receive fewer

procedures and poorer quality medical care than the majority, even after controlling for con-

founders [1]. The severity of racial health inequities is further reflected in the COVID-19 pan-

demic where racism in healthcare has been purported to be a significant driving force of the

disproportionately high mortality rates in minorities [2]. In a recent article by Devakumar

et al, racism was declared to be a public health emergency of global concern [3], supported by

literature which presents pronounced evidence on unequal healthcare delivery for minority

groups in the US [4, 5].

Although over the years, increased awareness of racism have prompted denouncement of

overtly racist actions, multiple studies have reported observations of subtle, aversive racism

among physicians [6, 7]. This has been found to impact treatment decisions, corroborated by lit-

erature which revealed that even after controlling for confounding variables such as severity of

illness, insurance, and income, Black males are less likely to receive medical procedures com-

pared to their White counterparts [8]. Such interpersonal racism has been observed to pervade

various healthcare domains. In dentistry, although patients presented with similar symptoms,

there was a greater likelihood of Black patients being offered tooth extraction instead of restor-

ative root canal treatment, reflecting unconscious racial bias in treatment planning decisions [9].

Similarly, in cardiology, minority patients were less likely to be referred for cardiac catheteriza-

tion despite residents being presented with standardized hypothetical patients [10]. In the general

hospital setting, Black patients’ pain were also often underestimated and undertreated by resi-

dents who held false beliefs that Black patients have higher pain tolerance than other patients

[11]. Studies have consistently shown that these negative experiences of racism not only create

undue stress for minorities [12], but fuel deep mistrust in the healthcare system, therefore perpet-

uating a vicious cycle of poor health outcomes [12, 13]. Racism has been associated with poorer

medication adherence and underutilization of healthcare services by minority patients [14, 15].

Recognizing that racism unfairly penalizes minorities, policy statements and funding have

been increasingly directed towards addressing institutional racism in medical care [16].

Despite these measures, little headway has been made in achieving racial equality. Thus, this

has brought attention to racial discrimination at the interpersonal level stemming from health-

care providers’ explicit and implicit racial biases [17]. To date, quantitative studies and system-

atic reviews have presented well-founded evidence of unconscious bias in physicians against

minority races but fail to inform the nature of prejudicial behaviours in the healthcare system.

Conversely, qualitative studies which capture the experiences of minority patients can increase

awareness of patient-provider racism in the healthcare system to inspire changes in how

healthcare providers treat minority patients. Hence, we sought to conduct a systematic review

of qualitative studies to shed light on racial bias in the healthcare system in order to attenuate

health disparities among minorities and address racism as a healthcare crisis.

Materials and methods

Search strategy

This qualitative systematic review was conducted in accordance to the Preferred Reporting

Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [18] and ENTREQ

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[19]. The following electronic databases were systematically searched from inception till 25

June 2020: Medline, CINAHL, PsycINFO, and Web of Science Core Collection. The search

strategy is attached in S1 File. Articles deemed potentially relevant underwent a title and

abstract sieve, followed by a full text review for inclusion by two independent authors. The

final inclusion of the articles was based on consensus between the two authors.

Study selection and eligibility criteria

Authors individually identified studies that met the following inclusion criteria: 1) qualitative

or mixed methods methodology, 2) perceptions of racial bias or racial blindness from patient

or provider perspectives; and 3) studies related to racial disparity in the healthcare setting.

Only original, peer-reviewed articles written in or translated into the English language were

considered. Commentaries, letters to the editor, reviews, conference abstracts, and grey litera-

ture were excluded. Two authors independently conducted full text review and any disagree-

ments were discussed till a consensus was reached.

Data extraction and analysis

The data extraction sheet included origin and year of publication, objective, methodology,

demographics (race and ethnicity of majority and minority, gender, age, sample size) of par-

ticipants and primary findings from the included articles. Coding was carried out verbatim

only for quotes from patients and providers to depict the minority experience in healthcare

delivery. Thematic synthesis was employed to review the data, using the Thomas and

Harden framework which comprises three stages of detailed synthesis: line-by-line coding

of the primary text, construction of descriptive themes, and the development of analytical

themes [20–24]. According to Thomas et al, the inductive approach allows for the most

empirically grounded and theoretically interesting factors arising directly from the raw data

rather than a priori expectations or models. The primary text was first extracted and orga-

nized into a structured proforma, before inductively derived codes were cross examined

with the raw data, given context and original authors’ interpretations. During this process,

the original authors’ interpretations were taken into account to minimize bias as researchers

may intuitively search for data that confirm his/her personal experience and beliefs. This

phase of the analysis was equally iterative, moving back and forth between the codes and the

original articles to ensure the robustness of the analytical process. Subsequently, descriptive

themes were independently formed based on repeated readings of the mutually agreed

codes to identify and group recurrent ideas. The descriptive themes were then further

refined until a consensus was reached. Analytical themes were distilled by forming a rela-

tional quality among descriptive themes to synthesize fresh perspectives and explanations

beyond primary data. Discussions were held between authors for clarification and compari-

son of primary findings and final synthesis.

Quality assessment

Quality appraisal of included studies was conducted by using the Critical Appraisal Skills Pro-

gramme (CASP) [25]. The CASP Checklist consists of 10 items developed to assesses the trust-

worthiness, relevance and results of published papers. Quality assessment was independently

conducted by two authors, with disagreements being resolved by discussion until consensus

were reached. The results of quality assessment did not result in exclusion of any studies, but

were instead used to add to the collective rigor of the synthesis. The PRISMA 2009 Checklist

(S2 File) was used to ensure the completeness of this review.

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Results

Electronic search results identified a total of 4,018 articles. 3,078 remained after duplicate

removal and 165 articles were selected for full text review, of which 23 articles met the

inclusion criteria. (Fig 1) In total, there were 1,006 participants which comprised 727

healthcare users and 249 healthcare providers. The age of participants ranged from 24 to

89 years old. The included studies were conducted in 6 different countries: 15 in the

United States [8, 26–39], 3 in the United Kingdom [40–42], 2 in Australia [43, 44], 1 in

Canada [45], Spain [46] and Hong Kong [47] respectively. 11 studies reported findings

from the African American community, 2 each from the Pakistani, Indigenous Austra-

lian and South Asian communities and 1 each from the African Caribbean, Latin Ameri-

can, Native American, Roma and Iranian communities. The characteristics of the

included papers are presented in S1 Table. The quality of included articles by CASP can

be found in S3 File. In the thematic synthesis of codes regarding the perpetuation of

racial bias in healthcare delivery, 2 analytical themes were generated from minority

patient perspective: alienation of minority patients, labelling of minority patients while 1

analytical theme was generated from healthcare provider perspective: perpetuation of racial fault lines by providers.

Fig 1. PRISMA flow diagram.

https://doi.org/10.1371/journal.pone.0255936.g001

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Alienation of minority patients

Racial supremacism.

“I was feeling like he was trying to belittle me and my intellect.” -Minority patient of unspeci-

fied race in the US [34].

Minority patients reported that they were often stereotyped to be of lower intelligence, elabo-

rating on how providers doubted their ability to understand information [26, 34, 46], and did

not provide sufficient information regarding their treatment, leaving them feeling uninformed

[26, 28, 46]. Minority patients felt that their intellect was belittled [34], when providers spoke

to them in an overly simplified manner or forced views upon them [26, 46]. Additionally, they

echoed the sentiment that healthcare providers were condescending towards them. This per-

ception arose due to the raised voices, curt tone and dismissive mannerisms when healthcare

providers attended to the minority patients [26, 29, 31, 34, 40, 45]. In areas where the White

community is the majority, minority patients further observed that healthcare providers were

significantly more polite to White patients [31, 34, 45], but more disrespectful towards them

[31, 32, 34, 37, 39, 40, 46]. Minority patients were also subjected to overt racism from providers

in the forms of rude facial expressions [40], reluctance to make skin contact during medical

examinations [28, 32, 41], avoidance of eye contact and cold body language [26, 34]. This

resulted in feelings of being belittled, hated or embarrassed [26, 34, 40, 45].

Less empathetic care received.

“They feel that (nurses) do not want to bother with them. They are not wanted. They feel that nurses are not liking them. Sometimes, what nurses do is not obvious but it is underhand.

Those (patients) who cannot speak English get into trouble, and they get a bit bullied as well.”—Pakistani patient in the UK [40].

Minority patients reported that healthcare providers ignored or rushed them during their clini-

cal interactions [32, 40, 41, 44, 47]. Some patients further stated that they received less priority

and were unfairly skipped over by patients of perceived privileged races [29, 31, 32, 34, 38]. Like-

wise, other minority patients felt that they were treated more harshly, with accounts of rough

physical treatment from healthcare providers [34]. While healthcare providers engaged patients

from the majority community with cheerful and sociable conversations, their dispositions

became more formal or hostile when interacting with minority patients [31, 32, 34, 37, 46].

Labelling of minority patients

Assumptions of class.

“I’m suppose to look like I got some money, cause if a Black person come in there dirty or look- ing ragged then that is the kind of treatment. You looking poor, and raggedy then you gonna get some raggedy treatment.”—Black patient in the US [26].

Most minority patients recalled being stereotyped as having low socioeconomic status [26, 28,

34, 46], less educated [46], having poor living conditions [26], or needing financial support

[34]. They also recounted being judged more harshly for their appearance and felt compelled

to dress well for better treatment [26]. They felt that providers assumed they were unable to

afford medical services [28, 46], and consequently, gave half-hearted medical treatments [26,

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34], such as not offering the full range of treatment options [8, 38]. On the other hand, there

was a small number of patients who did not perceive racial discrimination in their clinical

encounters. They felt that providers focused on treating their illnesses, without taking into

account their skin colour [30, 45]. Most of these patients were Iranian immigrants of higher

socioeconomic status (SES) [30], suggesting the role of SES in affecting perceptions of racism.

Assumptions of negative behaviours.

“But . . .he was a huge, darker skinned Black male, and I think that people saw him as intimi- dating. And it was just easier to just kind of bypass him and do the minimal that you had to do.”—Black registered nurse in the US [8].

Minority patients reported that providers perceived them to be di