Racism against healthcare users in inpatient care: a scoping review

Racism has long been recognised as a social determinant of health [1, 2]. In addition to the different health effects of racial discrimination, a burgeoning focus in health policy-making and research has been the impact of racism in the healthcare system. Existing evidence has demonstrated the extent to which racialised healthcare users, and often staff, are exposed to racism in healthcare-related encounters [3, 4]. Two primary manifestations of racism in healthcare have consistently been identified: implicit bias in interpersonal encounters between healthcare providers and users, and structural forms of discrimination.

Implicit bias by healthcare providers, especially physicians [5‐7] has been found to be pervasive. A study from the USA, for instance, found that the racist assumptions of African Americans’ higher threshold for pain has led to their systematic undertreatment [8]. Similarly, a study of ethnic and racial discrimination among US veterans with pain identified a high level of dissatisfaction with regard to interactions with staff for Latinx patients, and with negative demeanour of staff for African American patients [9]. Implicit bias can also lead to differential treatment and diagnoses. For example, African Americans in forensic psychiatric hospitals are disproportionately more often diagnosed with highly stigmatised psychotic spectrum disorders as compared to white Americans [10].

Discrimination can have detrimental effects on patients’ decision-making capabilities and their trust towards physicians [9, 11]. It can negatively shape the doctor-patient relationship and patients’ satisfaction with healthcare delivery [11], which may in turn impact patients’ adherence to and engagement with treatment and thus ultimately exacerbate health inequities [11]. Indeed, a review of the perspectives of health professionals and patients on racism in healthcare has confirmed that implicit bias can lead to the further alienation of minoritised individuals from the public healthcare system as a whole [4]. This is especially the case as healthcare provider bias is often not acknowledged [12].

At the same time, existing research has found structural barriers to accessing care. A particular focus has been on barriers due to limited language skills [13‐15]. For instance, a study from the US context [16] examined the use of evidence-based healthcare services for chronic disease management by both Latinx and white patients. They found that white patients were more likely than Latinxs to access the recommended services for which they were eligible; however, when grouping study participants by language use, they found that English-speaking Latinxs were not significantly less likely to access those services. This was in stark contrast to those Latinx patients who spoke Spanish at home and were least likely to access the recommended services even after accounting for possible confounding variables. A similar study from the German context [14] determined that the lack of interpreters and the dearth of multilingual information constitutes a form of institutional or structural racism which can negatively affect patients’ communication, diagnostic procedures and treatment options. This can ultimately lead to the systematic disadvantage of migrants and their descendants, minimising their chances for access to and use of health-related services [17]. While this knowledge is crucial to addressing existing inequities, a limitation of existing research is that the focus is predominantly on recent immigrants and their families, equating racism with xenophobia and migration, and leaving unaddressed the multiple and interlocking forms of discrimination which are independent of citizenship and settlement status. Indeed, the focus on linguistic barriers, while important, misses the fact that racialised people experience racism independent of their linguistic capabilities, mother tongue or migration status.

A range of reviews and meta-analyses have been conducted to examine the nature and scope of racial discrimination in the healthcare system. While some have focused on specific aspects, for example implicit bias [5, 6, 18], anti-racist interventions [19] or public health understandings of structural racism [20], others have been more comprehensive [3]. These reviews have substantially contributed to the understanding of how racism operates in healthcare interactions, and the forms it can take. However, three dimensions appear to have only been marginally addressed.

First, most existing research has focused on outpatient services or has not been specific about the examined setting. This might be due to the overriding focus on implicit racial biases and their effects on the doctor-patient relationship, which is applicable across settings. However, we believe it is crucial to study the inpatient setting in more detail. This is, first, because there is mounting evidence that the work-related stress associated with inpatient care may fuel the stereotyping of patients and amplify discrimination [21]. Second, patients treated in inpatient settings might have different disease profiles and adhere to different treatment regimens, which might create diverging discriminatory practices and structures. Not least, the experiences of racism might differ in inpatient, enclosed settings where the option of leaving and choosing another provider might simply not exist. As such, it is critical to develop a deeper and more comprehensive understanding of how racism pans out in inpatient care, and the characteristics of this setting that are amenable to, or even fuel, discrimination.

Second, the majority of existing research has examined the US context, especially discrimination against African Americans. This may well be due to the country’s history of transatlantic enslavement and racial violence [22], persistent anti-Black racism [23] as well as the size and scope of anti-racist scholarship across disciplines in the US. Not least, it may be the result of the availability of data segregated by racial/ethnic groups as mandated by the National Institutes of Health for clinical research [24]. However, the focus on the unique dynamics and historical context of the US encapsulates only a small part of how racism may manifest across different cultural and national contexts.

Third, we found that few existing reviews have thoroughly engaged with how intersectional perspectives have been adopted in the studies they analysed (e.g. [3]), or examined how the entanglements of race with other social categories such as gender or socio-economic status affect the experience of racism in healthcare. This, however, is crucial, as it has long been known that the intersections of multiple axes of discrimination not only produce layered but also unique experiences and health inequities [25, 26]. For example, it has been found that Black women have a higher risk of poor cardiovascular health compared to both Black men and white women [27]. This health outcome would have remained invisible using a single-category approach focusing either on race or on gender. As such, we aim to assess specifically how experiences of racism in interaction with sexism and other axes of discrimination have been described in the literature on racism in inpatient care.

The aim of this scoping review is therefore to map the evidence on racial discrimination experienced by people receiving treatment in inpatient settings (hospitals and rehabilitation facilities) or their caregivers in high-income countries, defined as having a gross national income per capita of $12,736 or more using the World Bank Atlas method [28]. Most high-income countries share colonial histories on which their wealth has been built such that their modern-day societies are shot through with racist, racialised and racialising structures and imaginaries [22, 29]. Naturally, they also significantly differ in terms of their precise historical trajectories and present-day effects, especially between former settler colonial states and other forms of colonial domination [30]. Sometimes postcolonial states or societies also have closer ties and more similarities with their former colonisers than former colonisers with each other, for instance a common cultural heritage, linguistic practices and political models [31, 32]. The exclusive focus on high-income countries is therefore somewhat arbitrary but borne of the need for feasibility. We thereby address specifically whether intersectional axes of discrimination have been taken into account, and, if yes, how so, when describing such experiences of racism. The results of this review will be utilised further to develop data collection instruments (surveys, topic guides for qualitative interviews) on experiences of racism in the German healthcare system.

This scoping review is part of a larger research project that sets out to empirically investigate experiences, situations, and interpretations of racism and racial discrimination in healthcare institutions in Germany, specifically in the inpatient sector. The project builds on the theoretical conceptualisations of everyday racism following Essed [33] and Terkessidis [34, 35]. Everyday racism is the often subtle but pervasive form of racism encountered by racialised people in routine everyday life. Essed thereby distinguishes between macro or structural-cultural properties of racism, and more interactional or interpersonal forms, which she refers to as “micro-inequities perpetuating the system” (1991: 38). The macro properties of racism encompass the racism engrained in government agencies, businesses and organisations responsible for legislation and policy-making; its effects can therefore be seen in labour policy, healthcare, education, or housing [33]. An example from the healthcare context might be the structurally entrenched lack of interpreters and multilingual and culturally appropriate information [14, 36] or the unequal spatial distribution of health services [37]. White-Means and Muruako (2023), for instance, found that metropolitan areas with a majority of spatially segregated, low-income and Black households are more likely to have disparities in access to primary breast cancer care than middle-income Black neighbourhoods or middle-income white neighbourhoods [37]. Examples of the everyday perpetuation of racism through individual practices include the implicit racial bias by healthcare providers [6], often leading to mistrust by people having experienced unequal treatment as a result of such bias [38]. However, Essed aptly stresses that such forms of racism are not the result of individual bias but rather the ways in which “the system is continually construed in everyday life” (1991: 38). In this context, it is worth pointing out that the explicit use of the terms race and racism are relatively rare in Europe as compared to the US. Many European countries use the euphemisms ‘ethnicity’ or ‘migration background’, themselves the result of colonial histories and racist labour policies [39], when describing racialised groups and the discrimination they experience. While such designations may not use purely biological but often cultural markers, they have become racialised as they are often regarded as unitary groups based on shared cultural traits [40]. As such, using analytical approaches focusing on race and racism is highly productive.

In addition, in this review we draw on intersectionality scholarship, which focuses on the intersectional effects of multiple forms of discrimination and regimes of power [41]. The concept of intersectionality has become increasingly popular in public health as it provides a lens to identify the unique and complex health inequities faced by groups at multiple axes of discrimination [42, 43]. An intersectional approach thus allows not only for a more detailed understanding of health inequities, but also for the development of more targeted public health interventions to reduce these.

An overview of the studies included in this review is provided in Table 1.

To our knowledge, this is the first scoping review that explored the specifics of racism in inpatient care in several high-income countries, and focused on the consideration and operationalisation of intersectionality. While US-American studies continue to set the terms of discussion, not least due to the general availability of data on race and ethnicity, other high-income countries, including Canada, Australia, New Zealand and the UK, also examine racism in their own healthcare systems. Nationally-specific understandings of racism and priorities vis-à-vis underserved communities are evident in the research; for instance, in Canada, Australia and New Zealand most articles examined the experiences of indigenous communities and their barriers to accessing quality care. For articles from the US, a key concern was the racial disparities between Black and white Americans (as well as, to a lesser extent, Latinx patients), representing the key racialised tensions in the country. In Germany, where racial data is not routinely collected and an awareness of indigenous, non-immigrant racialised groups is only evolving [96], the one article we found focused on the experiences of recent immigrants and refugees.

Absent from the literature were studies from other European countries as well as studies focussing on a wider variety of racialised and disadvantaged groups, especially native born, non-immigrants. The former is surprising as research on racism in healthcare in the Nordic countries such as Sweden [3, 97‐99] is growing rapidly. However, other European countries also exhibit stark disparities in healthcare access and utilisation between different social groups, and especially between recent immigrants and naturalised citizens [100]. This is testament to the continued “absent presence” of race in Europe [101]. Here, the post-war rejection of race as a scientific category simultaneously rendered the discussion of racism a highly sensitive, and often ignored, endeavour. Instead, research and social policy have predominantly focused on issues around migration and the ‘integration’ of recent immigrants. The most immediate consequence of this paradigm is a lack of evidence on racism, including in healthcare, in Europe more broadly. Moreover, the sparse evidence that does exist is drawn from studies on forced migrants and refugees. Native populations who are also racialised are rarely examined, limiting the knowledge and understanding of nationally-specific dynamics of racism in European healthcare.

In the articles we identified, intersectional dimensions were only considered to a limited extent, though of course this may also be due to the precise search terms used for this review. Research employing similar concepts such as misogynoir (e.g. [102]) or focusing on the discrimination of two-spirit people in healthcare (e.g. [103]) could not be identified. This means that our analysis is limited to those articles that explicitly used an intersectional approach and may have missed important other perspectives. While quantitative studies usually used several variables to adjust for different racial groups, adjustment does not fully comply with an intersectional framework that postulates the unique experiences produced by intersecting axes of oppression in a non-additive way [104‐106]. Moreover, intersectionality necessitates not only the analysis of intersecting identities but also of processes and structural forms of discrimination in order to understand the macro-level drivers of inequity [107]. Intersectionality scholarship in public health has recently been gaining traction, and a range of new methods and techniques to operationalise an intersectional framework have been developed [104, 108‐110]. Research examining racism in the healthcare sector would benefit from an engagement with this literature to produce a more detailed and comprehensive understanding of the effects of interactions of racism with other axes of discrimination. This would also allow for more targeted interventions tackling racism in healthcare.

While we identified a range of different articles examining experiences of racism in inpatient care, few of them delved deeper into the specifics of this setting. This may not be surprising as healthcare users may not differentiate between inpatient and outpatient settings when describing their experiences. Our review of the published literature has shown, however, that inpatient settings exhibit a range of specific structures and conditions that produce unique experiences and forms of racism, including varying admission, hospitalisation and referral rates, spatial segregation, and the threat by other healthcare users. As such, future research ought to examine these structures in more detail in order to gain a more comprehensive understanding of how racism operates in the inpatient setting.

This is also imperative in order to eventually develop more embedded and targeted anti-racist interventions for health policy-making and practice. Hassen et al. [19] have suggested six key requirements for any such intervention to be successful: an explicit, shared language of anti-racism; a thorough commitment on the side of the institutional leadership; a multi-level approach that includes policy and organisational interventions; transparency and accountability mechanisms; long-term and meaningful partnerships with racialised communities; and the investment in ongoing and mandatory anti-racist education and training. Based on our review, we suggest two additional, specific interventions for the inpatient care sector, following the tenets of everyday racism encompassing both interactional and structural-cultural forms of racism. First, to counter the implicit bias in non-clinical decision-making over room allocation, wait times and the spatial division of patients, any anti-racist intervention such as training for staff aiming to promote anti-racism must not only be offered to medical and nursing professionals but also include support staff such as receptionists and nursing aides. Any such training should include the critical reflection of how the staff’s own positionalities, including positionalities shaped by privilege, affect their interaction with racialised healthcare users. Targeted to the specific healthcare institution, such trainings can help develop a deeper understanding of different forms of racism prevalent in the respective individuals’ working contexts. Moreover, as limited time and a stressful working environment can accelerate the use of prejudices and stereotypes at all levels, better overall working conditions are crucial to reducing racial discrimination. Second, existing research on racism as experienced by healthcare users has largely focused on staff, clinical and non-clinical, as perpetrators of this racism. However, this review has demonstrated that fellow patients can be another source of experiences of racism leading to the further alienation of racialised healthcare users from the healthcare system and exacerbate health inequities as these users withdraw from therapy or treatment. Future anti-racist interventions must therefore also target the threat of interpersonal racism emanating from a range of actors in the healthcare system beyond the focus on professional staff. A robust and low-threshold complaints structure or ombudsman for discrimination should be structurally anchored at the institutional level, ideally offering multilingual counselling and advice. Such services can provide immediate support, engage in advocacy and point the person concerned towards the next steps. It is important that these services are located on the premises of the hospital or rehabilitation centre, ideally centrally located and easily accessible, as patients treated there may have longer stays and impaired mobility, preventing them from seeking advice elsewhere. To build trust, ensure continuous support and strengthen ties with affected communities, these services should also be linked to existing advocacy and community organizations.

This scoping review has examined the existing literature on racism in inpatient care (hospitals and rehabilitation centres) in high-income countries, with a specific focus on how intersectional dimensions have been taken into consideration. Analysing 47 articles, it identified three main specifics of racism in inpatient care: varying hospitalisation, admission and referral rates; the spatial segregation of healthcare users along racialised criteria, and discrimination by fellow healthcare users. As such, this review has illuminated an understudied phenomenon with important implications not only for future research but also health policy-making and practice.

Intersectional dimensions were rarely taken into account; while the majority of papers provided a demographic description of study samples, only one study used an explicitly intersectional framework focusing not only on the unique effects of intersecting axes of discrimination but also on their structural drivers. Here, too, this review has shown that more in-depth research is needed on the intersectional entanglements of racism in inpatient care.