Racial Discrimination in Health Care: Annotated Bibliography

Overview of Discrimination in Health Care Settings

Benjamins, M., & Whitman, S. (2014). Relationships between discrimination in health care and health care outcomes among four race/ethnic groups. Journal of Behavioral Medicine, 37, 402–413.

The researchers are based at the Sinai Urban Health Institute in Chicago, IL. Their study focuses on the ways in which discrimination impacts health care by comparing discrimination levels — both ethnic and racial — across four different ethnic groups. The study then analyzes the relationship between acts of discrimination and their consequences for health care services. An assessment is also made of ways in which mediators and moderators might be utilized to mitigate the risk of discrimination and its impact on care.

The method used by the researchers included the adoption of multivariate logistic regression models. The sample consisted of 1,700 individuals of white, Black, Mexican, and Puerto Rican descent. Of this sample, nearly a quarter reported having experienced health care discrimination. There was a consistent pattern evidencing that discrimination correlated with race. The types of discrimination cited by the sample included not receiving the care they required and not receiving adequate quality of care. The researchers suggest that further studies be conducted in order to address qualitative questions, such as "What happened or who was the perpetrator?" in cases of discrimination, so that a better assessment of the nature of the discrimination and its effects in health care can be developed (p. 411). This information can then be utilized to develop methods of intervention that might help curb this phenomenon.

This study is helpful in providing a quantitative assessment of discrimination in the health care industry, with some 25% of the sample reporting that they had experienced discrimination. The study is limited in terms of qualitative analysis, which the researchers themselves assert should be conducted so as to deepen understanding of the problem. Thus, there is a gap in qualitative literature regarding discriminatory practices among health care providers — a gap that might be filled by a study utilizing a phenomenological approach.

MacIntosh, T., Desai, M., Lewis, T., Jones, B., & Nunez-Smith, M. (2013). Socially-assigned race, healthcare discrimination and preventive healthcare services. PLoS One, 8(5): e64522.

The researchers are based in the Department of Emergency Medicine, the Department of Chronic Disease Epidemiology, the Robert Wood Johnson Foundation Clinical Scholars Program, the Department of Epidemiology, and the Global Health Leadership Institute, all at major research universities. The focus of the study is on the relationship between health care services and discrimination on the part of providers towards various racial groups. The manner in which these groups self-identify as belonging to a particular race is also examined in order to clarify the nature of race as a social construct. The method utilized was a cross-sectional analysis of responses from a sample drawn from seven different states plus Washington, D.C., categorized into three groups using a twofold classification of self-identified race and socially-assigned race — so as to determine whether there was any discrepancy between how individuals were perceived by society and how they perceived themselves. In total, more than 30,000 respondents participated in the survey.

The findings showed that individuals who self-identified as minorities perceived racial discrimination from health care providers more than any other group of respondents (compared to those who identified as white or as minority/white). Another finding was that minorities viewed as white by social standards received preventive vaccines more often than minorities viewed as minorities, and that individuals who report being perceived as white by society also faced less discrimination from health care providers.

This study supports the other sources in this literature review by pointing out how racial constructs impact the health care industry. One weakness, however, is that — as Browne et al. (2014) noted — racialized groups typically represent unreliable data. Thus this study is helpful for raising the issue of discrimination in health care, but it mainly serves to illustrate that racialized groups (minorities) feel discriminated against more than groups not viewed by society as minorities. The broader ramifications of this study remain unclear.

Ethnicity Data Collection and Healthcare Inequity

Browne, A., Varcoe, C., Wong, S., Smye, V., & Khan, K. (2014). Can ethnicity data collected at an organizational level be useful in addressing health and healthcare inequities? Ethnicity & Health, 19(2), 240–254.

The researchers are based in the School of Nursing and the Centre for Health Services and Policy Research at a major university in Vancouver, Canada. The study's focus is on a Canadian government initiative to collect data on the ethnicity of patients receiving health care from specific providers and organizations. The study's intent is to monitor and assess the "potential quality, utility and relevance of ethnicity data" as it pertains to authorities' ability to address health and health care inequities (p. 240). The researchers used a qualitative framework to collect data from a single city, conducting interviews with a sample of 104 patients, health care providers, and community leaders, with attention to diversity. The assessment of these interviews was carried out using interpretive thematic analysis.

The researchers found that there are problematic issues relating to the quality of data provided by the interviews. This problem was compounded by their finding that those individuals most likely to be at the receiving end of the negative impact of inequity also provided some of the most problematic information in terms of data quality, and that there is little data to suggest discrimination is occurring. The researchers thus concluded that racialized groups typically provide unreliable data despite belonging to at-risk groups. They recommend better controls for measuring and collecting data from ethnocultural groups, and that a mechanism be devised to show correlation between perceptions of discrimination and ethnicity or race. Currently such a mechanism is absent from the literature, and this is a gap that needs to be addressed. This study is helpful for assessing the need in research for obtaining reliable qualitative data that is free of bias.

Racial Disparities in Pediatric Kidney Transplantation

Grace, B. S., Kara, T., Kennedy, S. E., & McDonald, S. P. (2014). Racial disparities in pediatric kidney transplantation in New Zealand. Pediatric Transplantation, 18, 689–697.

This study is conducted by researchers of the Australia and New Zealand Dialysis and Transplant Registry and the Discipline of Medicine in Adelaide, Australia. It addresses a gap in the literature relating to racial variance in transplantations and outcomes in New Zealand. New Zealand was chosen as the study location because of the country's unique demographic diversity. The sample consists of 215 patients under 18 years of age who underwent renal replacement therapy from 1990 to 2012. The findings showed that the highest percentage of transplant recipients consisted of Asian and European patients, while Pacific and Māori patients were only half as likely as European patients to receive a transplant. Patients of Pacific descent were most likely to have focal segmental glomerulosclerosis (FSGS), and no Pacific patients received a re-transplant after losing their initial grafts.

The findings also show that programs are in place to reduce the disparity among ethnicities by supporting appropriate donation pathways. This study is helpful for illustrating how health care services can be limited in providing needed transplant services and organs for specific minority groups. It also demonstrates that this limitation is being actively addressed within the health care community, as programs to generate more donors to meet the needs of these groups are encouraged by providers.

Patzer, R., Amaral, S., Klein, M., Kutner, N., Perryman, J., Gazmararian, J., & McClellan, W. (2012). Racial disparities in pediatric access to kidney transplantation: Does socioeconomic status play a role? American Journal of Transplantation.

This study examines the extent of racial disparities in renal transplants in the United States. It approaches the subject from the standpoint of the impact of socioeconomic conditions on racial groups in order to fill a gap in the literature where this particular factor has been underexamined. The researchers examine the relationship between race and socioeconomic status in a population of patients under 21 years of age from 2000 to 2008. Nearly 8,500 patients were included in the study; of that sample, 30% were Black, 27% were white-Hispanic, 44% were female, and 28% were from economically impoverished environments. Of this sample, over 60% were placed on waiting lists for transplant surgery, and just over 30% received a transplant. The study found that white individuals were most likely to receive a transplant.

The study is, however, inconclusive in explaining the disparities among different racial groups and affirms that socioeconomic status alone is not sufficient to understand or explain this phenomenon. While this study is helpful for contextualizing the issue, further research is required to explain the racial disparities involved in renal transplants among populations under 21.

Grubbs, V. (2007). Good for harvest, bad for planting. Narrative Matters, 232–237.

This narrative study focuses on a single case examining why a transplant was delayed even when a kidney appeared ready to be transferred. The physician at the center of this narrative case study found that race played a pivotal role in the delay. Specifically, the physician discovered that a patient was being made to wait because the "median wait time for cadaveric (deceased donor) kidneys is nearly twice as long for blacks as for whites" (p. 236). There was no special policy explicitly predicating this outcome; it was the result of structural mathematics of a racialized sort. The physician ultimately decided to donate his own kidney to the patient, as the patient was not receiving the available kidney that matched his blood type and the physician was himself a match.

While this narrative analysis is more qualitative in nature, it is helpful in understanding the conditions in which doctors and patients must operate, as racism pervades the health care system at every level and has been, in effect, institutionalized.