How Healthcare Disparities Impact Health and Healthcare in Minority Patients and Communities?

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.

Conduct a search of literature relevant to the problem/topic. Identify a minimum of 4 references, most of which are randomized clinical trials. Only one opinion articles may be included.

Read the peer- reviewed articles with the focus of preparing a document that will compare and contrast the information in the articles you found. Copies of the articles used must be submitted with the final assignment.

The reader of your literature review should be able to clearly identify the gaps in the knowledge in the problem area as well as the purpose of the study you are proposing. You should be able to write enough to create an effective argument but not so much that the result looks padded. 

Prepare an Evidence Matrix using the template attached

Submission Instructions:

 

 Introduction must include:

  • Your PICOT question. (BREAK DOWN THE PICOT FOR THIS ASSIGNMENT USING MY QUESTION TITLE)
  • Purpose of or rationale for the scholarly project:
    • Provide an evidence-based explanation of why it is necessary to complete your scholarly project and what benefit will be gained (health promotion, fiscal, and efficiency).
  • Background on the problem or population of interest:
    • Using primary sources, provide data on your topic.
    • Providing the background will demonstrate the focused need for your project.
  • Significance of the problem to nursing and health care:
    • State how your problem or population of interest aligns with the larger interest of health care in the community.
    • Create a context to why your topic is important.
  • Benefit of the project to nursing practice:
    • State what will be gained from your project.
    • Describe the expected outcomes of your project to practice within your population and setting.
    • Relate the outcomes to evidence-based guidelines and outcomes.
    • Describe how your project may influence other populations or settings.

The assignment is 5-6pages in length and follows current APA format including citation of references.

Incorporate a minimum of 4 current (published within the last five years) scholarly journal articles or primary legal sources (statutes, court opinions) within your work.

Journal articles and books should be referenced according to the current APA style (the library has a copy of the APA Manual).

FOR THE EVIDENCE MATRIX: (I INCLUDED THE TEMPLATE FOR THE MATRIX)

The Evidence Matrix can help you organize your research before writing your literature review.  Use it to identify patterns and cohesions in the articles you have found similar methodologies?  common theoretical frameworks? It helps you make sure that all your major concepts covered.It also helps you see how your research fits into the context of the overall topic.

A literature review provides a summary of previous research on a topic that appraises, categorizes, and compares what has been previously published on a specific topic. It lets the author to synthesize and place into context the research and scholarly literature relevant to the topic. It helps to plan the different methods to a given question and reveals patterns. It forms the foundation for the author’s subsequent research and defends the significance of the new investigation.

The introduction should define the topic and set the stage for the literature review. It will include the author's perspective or point of view on the topic, how they have defined the scope of the topic (including what's not included), and how the review will be organized. It can point out overall trends, conflicts in methodology or conclusions, and gaps in the research.

In the body of the review, the author should organize the research into major topics and subtopics. These groupings may be by subject, type of research such as case studies, methodology such as qualitative, genre, chronology, or other common characteristics. Within these groups, the author can then discuss the evidences of each article and examine and compare the importance of each article to similar ones.

The conclusion will summarize the main findings of the review of literature supports or not the research to follow and may give direction for further research.

The list of references will include full citations for all the items mentioned in the literature review.

**PLEASE ATTACH A COPY OF A PLAGARISM AND AI REPORT , I HAVE TO TURN IN THIS ASSIGNMENT TO TURN IT IN **

*PLEASE ATTACH THE 4 SCHOLARLY ARTICLES USED*

BELOW I HAVE ATTACHED 4 ARTICLES TO USE AND YOU CAN INCLUDE 1 OTHER ARTICLE.

I HAVE ALSO INCLUDED THE TEMPLATE FOR THE EVIDENCE MATRIX CHART

I HAVE ALSO INCLUDED THE GRADING RUBRIC FOR THIS ASSIGNMENT

Evidence Matrix

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Name: ______________________________ Date: _____________________________

Author

Journal

Name/ Year of Publication

Research Design

Sample Size

Outcome Variables Measured

Quality

(A, B, C)

Results/Author’s Suggested Conclusion

Research Design Options: Quantitative, Qualitative, Systematic Review, Mixed Method Study

Outcome variables measured: what is the researcher trying to measure or investigate. The aim or objective of the study.

Quality is very subjective: This is your opinion so you cannot get this wrong. Choose from the following:

A: (High) Further research is very unlikely to change our confidence in the estimate of effect.

B: (Moderate) Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.

C: (Low) Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.

,

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 difficult to appease, dangerous

and were afraid of patients [42, 46], which in turn, made patients uncomfortable [26]. Some

African American patients were also denied medications due to race-based assumptions by

healthcare providers that they were drug users [32, 37]. In the same vein, patients concurred

and felt that providers treated them like a homogenous group without varying needs or beliefs

[44–46]. For instance, providers made sweeping generalizations that African American

patients had overactive sex lives [26, 29].

Perpetuation of racial fault lines by providers

Differential treatment of minority patients.

"I’m leaning towards more than the physician is empathizing more for the White patient because he has more of a connection with him‥ ‥ Most doctors who are very good doctors, and otherwise nice people, are simply doing less for the Black patient because they have this unconscious racism.”—Black primary care/internal medicine doctor in the US [27].

Healthcare providers professed that they were less empathetic towards minority patients [27,

33, 35], even losing their temper more easily [47], because they were less able to connect to

patients of a different race [27]. This is further exacerbated by the time constraint these provid-

ers face [33, 35], pressuring them to limit their interactions with minority patients uninten-

tionally [27]. Furthermore, some healthcare providers concurred that they viewed minorities

as more intimidating due to their appearance which limited their effort to engage with them or

offer therapy [8, 42]. They acknowledged their failure to understand the differing needs of

minority patients to administer individualized care [8, 35, 36, 40]. Instances of overt racism

were also reported by providers who observed that racial minorities were sometimes referred

to using racially derogatory labels [47]. These discriminatory healthcare encounters can per-

petuate racial fault lines which are currently unobvious problems that can eventually result in

further tension and conflicts between the minority and majority population. These fault lines

may have arose from fundamental differences in opinions, or underlying divisive issues tracing

back to the historical origins of White supremacy.

Shifting the blame onto minority patients.

“To be honest, some patients have a chip on their shoulder about colour and a lot of fuss is made up over nothing . . .I am sorry to say."—White registered nurse caring for Pakistani

patients in the UK [41].

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Providers frequently labelled minority patients as less compliant with treatment and felt that

they lacked ownership over their health [27, 35, 43, 45]. These providers tended to blame health

disparities [27, 36, 45], or unsuccessful treatments [41], on minority patients’ poor behaviours,

instead of unequal treatment arising from racism [35]. Some providers stated that they treated

all patients equally [33, 36], while others perceived minority patients to be oversensitive, holding

the view that these patients misinterpret innocent health encounters as racist due to their past

experiences of racism [26, 43]. Providers who denied racism also reported that minorities

played the race card unnecessarily [35, 41], which is the act of trying to gain sympathy or special

treatment because of their race [48], in some instances being oversensitive or victimizing them-

selves [35, 41]. Although research has hypothesized that minorities may respond with dispro-

portionate negativity to innocuous events, there is in fact conclusive evidence that reveals how

minorities experience microaggressions more frequently [49]. Thus, such perceptions by pro-

viders may lead to a lack of responsibility and inaction in addressing personal biases.

Discussion

To our knowledge, this is the first study to systematically review the perspectives on racism in

healthcare from ethnic minorities across different countries. Racial bias manifests in healthcare

delivery through the alienation of minority patients, labelling of minority patients and perpet-

uation of racial fault lines by healthcare providers. Importantly, ethnic minority groups are

heterogeneous populations in terms of their ethnicity, socio-demographic status, acculturation

level, and belief systems. While the findings should be taken with caution across different set-

tings, the collective examination of these individual experiences synthesizes commonalities

from disparate evidence, and clearly illuminates the different aspects of racial discrimination

in healthcare. With the elimination of racism at the forefront of the global agenda, urgent

assessment of existing measures is greatly warranted for healthcare providers to extend fair

and equal access to quality care for all patients so that vulnerable communities do not continue

to fall through the gaps. For the convenience of this review, the term “White” was used to col-

lectively describe people of pale skin, instead of “Caucasian” which has been found to be an

outmoded misnomer in racial nomenclature with little value in racial discussions.

In the included studies, both accounts of healthcare providers and minority patients cor-

roborated to show that minority patients were often subjected to labelling where assumptions

were made about their class, behaviours and needs [8, 26, 28, 29, 32, 34–37, 42, 44–46]. This

may be explained by research which demonstrates how under limited time and imperfect

information, confirmation bias occurs as providers fall back on innate beliefs associated with

patients’ social categories [50]. Providers should strive to avoid labelling of patients as it has

been reported that they often overapply such population statistics to individual patients [51],

even if the stereotypes were grounded on epidemiology. Additionally, minority patients per-

ceived less empathy from healthcare providers [31, 32, 34, 37, 46], which corresponded to pro-

viders’ perspective on the differential treatment of minority patients [8, 27, 33, 35, 36, 40, 42,

47]. These two themes have a causal relation where providers were less able to put themselves

in the shoes of minority patients to vicariously experience their circumstances, resulting in

them being less able to connect to minority patients and express empathy towards them. In

fact, barriers to empathy is highly prevalent in clinical settings; general practitioners claim that

protocol-driven care impede genuineness in communication and time pressure hinders com-

munication [52]. For instance, the heavier workload in emergency departments can cause high

tension situations which reduce empathetic abilities of healthcare providers [53]. Providers

should endeavour to communicate empathy and interact more deeply with minority patients

which has been shown to benefit patient health and is part of an evidence-based practice [54].

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The pigeonholing of minority patients may contribute to inadequate medical treatment like

exclusion from certain therapies [8, 32, 38, 42, 45, 46], or poor communication and service

from healthcare providers [8, 35, 36, 46]. This is supported by past systematic reviews which

found that providers’ innate prejudices often result in lower quality of care for racial minorities

[4, 55, 56]. Furthermore, perceived racism has been found to affect mental and physical health

negatively [57, 58], while breeding mistrust in minority patients who may respond by not com-

plying to treatment plans [14, 15]. This may eventually translate into worse health outcomes

for minority patients [28, 34, 42], reinforcing providers’ perceptions of them as being less

responsible for their health [27, 35, 43, 45], which perpetuates a vicious cycle. Providers should

actively perform self-reflection as objectively as possible beyond implicit bias assessments such

as the Implicit Association Test [59]. While there is only preliminary evidence on the efficacy

of self-reflection to reduce implicit bias [60], the action of observing and analysing oneself can

promote increased cognition of biased behaviours and is an important first step.

It is vital for healthcare providers to acknowledge that racism in healthcare continues to be

a pertinent problem and actively reflect on how their actions may affect the emotions and care

of minority patients. By committing the effort to understand the issue and address innate prej-

udices against other races, healthcare providers can avoid the tendency to label minority

patients under imperfect information or time constraint. Providers should also be more mind-

ful of their physical and verbal communication and avoid unequal treatment between minority

and majority patient group in terms of politeness, patience and willingness to engage in con-

versations. An increased sensitivity towards innocent situations where misunderstandings

could arise, such as minority patients getting skipped over, would ultimately aid in creating an

inclusive healthcare environment.

With a shift towards inclusivity, several countries have implemented frameworks to achieve

greater racial equality in healthcare (S2 Table). These interventions originate mainly from devel-

oped countries where there is significantly more literature documenting racial disparities in

healthcare, thus, increasing national awareness and priority in tackling these issues [61–66].

Most countries do not directly address racism towards patients but propose guidelines on

reducing health disparities among minorities [62–64, 66]. One of the common aims is to

increase racial and ethnic diversity in their healthcare workforce [62–64, 66]. Cross-cultural

exchanges among providers may address unfounded racial assumptions and dispel fear of

minorities [8, 26, 42, 46]. Some countries also seek to address inadequate medical treatment [8,

26, 34, 38], using evidenced-based guidelines for management of chronic diseases in racial

minorities [64, 66], and increasing minority health research [61, 66]. However, these measures

may not translate into individualized care for minorities as stereotypes of class and behaviors

remain unaddressed [8, 28, 32, 35–37, 46]. Several papers detail further plans to deliver timely,

patient-centered care to minorities and better communication [61, 64, 66]. Analysis of these

plans was limited due to the lack of quantifiable and definitive steps to achieve these goals. It is

important to note that without conscious efforts to address the innate tendency to alienate,

biased attitudes may continue to translate into clinical encounters with minorities through sub-

tle body language [26, 34], or hostile demeanour [31, 32, 34, 37, 46]. Additionally, only two pro-

grams outline goals of educating providers on racial discrimination [61, 65], while most

interventions focus solely on training providers’ cultural competency [62, 64–66]. Although cul-

tural incompetency is interlinked with perceived racism, it is important to note that they are

ultimately different issues and should not be conflated [67]. Cultural competency training alone

may not fully address providers’ unawareness of implicit biases, allowing racial color-blindness

and tendency to blame minorities for health disparities to persist [8, 26–29, 32–37, 42–46]

Overall, the measures to tackle racism in healthcare is a work in progress across all

nations. There is an urgent need for more concrete and actionable anti-racism programs

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like incorporating bias curriculum early into medical education and training [68], to signal

the strong commitment of institutions to tackle racism and close racial disparities in the

healthcare setting, spearheading a paradigm shift. Additionally, approaches should be

aimed at promoting interracial understanding through dialogue sessions or feedback chan-

nels for minority patients [69, 70], where difficult conversations on a sensitive topic can

take place safely. Improving interracial understanding would eliminate the various assump-

tions of minority patients that result in poorer medical treatment and service. Availability

of feedback channels for minority patients may also increase accountability for providers to

act in a non-discriminatory and professional manner, promote further dialogues about rac-

ism and decrease racial blindness.

The included studies in this paper originated mainly from Western countries [8, 26–46],

but there was a paucity of literature from the Asian perspective (S1 Table). Considering how

racism is similarly pervasive in many Asian countries, the lack of literature may be attributed

to underreporting as open discourse about highly sensitive topics like racism may be limited

by censorship which is more common among Asian countries [71, 72]. Therefore, further

qualitative research needs to be conducted to yield insights into the nature of racism that

minority patients face in Asian healthcare systems. By looking introspectively at Singapore, a

multiracial Asian society, as a case study, self-reflection into areas of success and improvement

for tackling racism may yield critical learning points to devise concrete ways forward in

achieving racial equality in healthcare. In 1969, after a series of deadly racial riots broke out

between Malays and Chinese in Singapore, governmental efforts to build a harmonious multi-

racial society were increased. Measures implemented included racial integration through con-

scription, racial quotas for housing estates, education to promote meritocracy by offering

equal opportunities for all races [73], and ensuring that minority races are represented in the

government through the Group Representation Constituencies (GRCs) [74]. Beyond anti-rac-

ism measures, governmental policies addressed larger racial disparities in the form of educa-

tion and housing, factors which can exacerbate discrimination or feelings of discrimination

[75]. The collective awareness of the fragility of racial harmony served as a significant driver in

making multiculturalism a core tenet of the nation’s social fabric. This multi-pronged

approach by the government translated into heightened race-consciousness among citizens

which has allowed Singapore to see marked improvements in race relations over the years with

better racial integration and less racial inequities [76, 77]. The key to addressing racism in

healthcare may extend beyond healthcare boundaries as governmental efforts to promote

multi-culturalism and address wider racial disparities in the form of housing, education and

income inequality could have a crucial impact on eliminating racism in all spheres, since class

and race prejudice are highly intertwined.

Limitations

Limitations should be taken into consideration when interpreting these results. Firstly, only

articles written in or translated into the English language were included. However, racial

minorities across Europe and Asia may not speak English, so relevant studies may have been

published in local languages only. Thus, the magnitude of racism in healthcare may be under-

estimated. Compared to African American minorities whose perspectives were well captured

due to the large number of studies from the United States, there were insufficient studies on

minorities receiving medical care in Asian countries whose experiences may differ and cannot

be accurately represented by the findings. Considering the paucity of data, more studies

including but not limited to various ethnic minorities in Asia and Aboriginal Australians

should be conducted in the future to better examine the experiences of these minority groups.

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PLOS ONE | https://doi.org/10.1371/journal.pone.0255936 August 31, 2021 9 / 15

Additionally, the differences in extent and forms of racism between developed and developing

countries are not explored here due to a lack of literature. Due to the lack of granularity of data

in the included studies on the SES of participants, further analysis, for instance, subgrouping

could not be conducted to better understand how SES may lead to perceptions of racism. With

race and ethnicity shown to be highly intertwined with SES, prejudicial behaviours of health-

care providers could arise from class discrimination, as corroborated by existing literature

which illustrates how patients with lower SES perceived decreased quality of care [78]. Thus,

SES is a confounder for the findings of this review. A largely inductive approach was under-

taken to analyse the extracted quotes with their contexts embedded. Unlike deductive analysis,

a pre-existing coding frame driven by researchers’ theoretical interest was not utilized. It is

important to note that researchers cannot free themselves of their theoretical and epistemolog-

ical commitments, and data are not coded in an epistemological vacuum. However, themes

derived from inductive analysis is driven by raw data, possibly providing a richer description

of minority’s experiences [79]. Lastly, the distinction between explicit and implicit bias, though

explored in the results, is often difficult to make due to the qualitative nature of the primary

data. Importantly, in a recent study by Daumeyer et al [80], he demonstrated that labels of

implicit bias in racial discussions may paradoxically reduce individual culpability for discrimi-

natory behaviour due to models of behavioural attribution where perpetrator of unintentional

racism is viewed as less morally responsible. Therefore, this study which focuses on the per-

spectives and experiences of minority patients, encourages providers to examine all biases to

take accountability for racially discriminatory behaviours.

Conclusion

This systematic review has analyzed the experiences of minority patients and has yielded

fresh insights on the forms of racial bias that minority patients continue to face today.

Though policy makers and healthcare institutions have attempted to reduce health dispari-

ties, racism continues to persist at the interpersonal level in an insidious and implicit form.

To protect the fundamental right to quality healthcare for all, healthcare institutions need to

urgently establish targeted anti-racism programs. As we head into a new decade, this review

serves as a call-to-action for institutions and providers to reflect deeply on racial injustices

that continue to plague global healthcare systems and to actively work towards offering

non-discriminatory and sensitive care, in the journey towards achieving racial equality and

dignity for all.

Supporting information

S1 Table. Characteristics of included papers.

(DOCX)

S2 Table. Overview of programs for racial equality in healthcare across countries.

(DOCX)

S1 File. Medline search.

(DOCX)

S2 File. PRISMA 2009 checklist.

(DOC)

S3 File. CASP qualitative checklist.

(DOCX)

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PLOS ONE | https://doi.org/10.1371/journal.pone.0255936 August 31, 2021 10 / 15

Acknowledgments

All authors have made substantial contributions to all of the following: (1) the conception and

design of the study, or acquisition of data, or analysis and interpretation of data, (2) drafting

the article or revising it critically for important intellectual content, (3) final approval of the

version to be submitted. No writing assistance was obtained in the preparation of the manu-

script. The manuscript, including related data, figures and tables has not been previously pub-

lished and that the manuscript is not under consideration elsewhere.

Author Contributions

Conceptualization: Cheng Han Ng, Chin Meng Khoo, Dujeepa D. Samarasekera, M. Kamala

Devi, Choon Seng Chong.

Formal analysis: Wilson Sim, Wen Hui Lim.

Investigation: Wilson Sim, Wen Hui Lim, Yip Han Chin, Clyve Yu Leon Yaow, Clare Wei

Zhen Cheong.

Methodology: Chin Meng Khoo, Dujeepa D. Samarasekera, M. Kamala Devi, Choon Seng

Chong.

Project administration: Cheng Han Ng.

Supervision: Cheng Han Ng, Chin Meng Khoo, Dujeepa D. Samarasekera, M. Kamala Devi,

Choon Seng Chong.

Visualization: Cheng Han Ng.

Writing – original draft: Wilson Sim, Wen Hui Lim.

Writing – review & editing: Wilson Sim, Wen Hui Lim, Cheng Han Ng, Yip Han Chin, Clyve

Yu Leon Yaow, Clare Wei Zhen Cheong, Chin Meng Khoo, Dujeepa D. Samarasekera, M.

Kamala Devi, Choon Seng Chong.

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,

Race, Healthcare, and Health Disparities: A Critical Review and Recommendations for Advancing Health Equity

Wendy L. Macias-Konstantopoulos, MD, MPH, MBA*†

Kimberly A. Collins, MD, MPH‡

Rosemarie Diaz, MD§

Herbert C. Duber, MD, MPH∥¶

Courtney D. Edwards, DNP, RN, CLN#

Antony P. Hsu, MD** Megan L. Ranney, MD, MPH††

Ralph J. Riviello, MD, MS‡‡

Zachary S. Wettstein, MD§§

Carolyn J. Sachs, MD, MPH∥∥

*Center for Social Justice and Health Equity, Department of Emergency Medicine, Boston, Massachusetts

†HarvardMedical School, Department of EmergencyMedicine, Boston,Massachusetts ‡Tampa General Hospital, Tampa, Florida §University of California-Los Angeles, Department of Emergency Medicine, Los Angeles, California

∥University of Washington School of Medicine, Department of Emergency Medicine, Seattle, Washington

¶Washington State Department of Health, Tumwater, Washington #Samford University, Moffett & Sanders School of Nursing, Birmingham, Alabama **Trinity Health Ann Arbor Hospital, Department of Emergency Medicine, Ypsilanti, Michigan

††Yale University, Yale School of Public Health, New Haven, Connecticut ‡‡University of Texas Health San Antonio, Department of Emergency Medicine, San Antonio, Texas

§§University of Washington School of Medicine, Department of Emergency Medicine, Seattle, Washington

∥∥Ronald Reagan-UCLA Medical Center and David Geffen School of Medicine at University of California-Los Angeles, Department of Emergency Medicine, Los Angeles, California

Section Editors: David Thompson, MD and Shahram Lotfipour, MD, MPH Submission history: Submitted August 15, 2022; Revision received April 17, 2023; Accepted May 24, 2023 Electronically published August 8, 2023 Full text available through open access at http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.58408

An overwhelming body of evidence points to an inextricable link between race and health disparities in the United States. Although race is best understood as a social construct, its role in health outcomes has historically been attributed to increasingly debunked theories of underlying biological and genetic differences across races. Recently, growing calls for health equity and social justice have raised awareness of the impact of implicit bias and structural racismon social determinants of health, healthcare quality, and ultimately, health outcomes. This more nuanced recognition of the role of race in health disparities has, in turn, facilitated introspective racial disparities research, root cause analyses, and changes in practicewithin themedical community. Examining the complex interplay between race, social determinants of health, and health outcomes allows systems of health to create mechanisms for checks and balances that mitigate unfair and avoidable health inequalities.

As one of the specialties most intertwined with social medicine, emergency medicine (EM) is ideally positioned to address racism in medicine, develop health equity metrics, monitor disparities in clinical performance data, identify research gaps, implement processes and policies to eliminate racial health inequities, and promote anti-racist ideals as advocates for structural change. In this critical review our aim was to (a) provide a synopsis of racial disparities across a broad scope of clinical pathology interests addressed in emergency departments—communicable diseases, non-communicable conditions, and injuries—and (b) through a race-conscious analysis, develop EM practice recommendations for advancing a culture of equity with the potential for measurable impact on healthcare quality and health outcomes. [West J Emerg Med. 2023;24(5)906–918.]

Keywords: health disparities; social determinants of health; structural racism; implicit bias.

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SOCIAL EMERGENCY MEDICINE AND POPULATION HEALTH

INTRODUCTION Social determinants of health (SDoH) as defined by the

US Centers for Disease Control and Prevention (CDC) are the conditions inwhich people live, learn, work, and play that are determined by the distribution of money, power, and resources and that affect a wide range of health and quality- of-life risks and outcomes.1 Influenced by the social construct of race, SDoH exert disparate impacts on the health of subpopulations. Economic disparities disproportionately place Black, indigenous, and people of color (BIPOC) within zones marked by substandard health promotion and excessive health risks. The compounding nature of adverse SDoH, such as housing instability, food insecurity, poor healthcare access, and hazardous exposures, has serious health implications. Health disparities are the profound downstream effect of the socioeconomic disadvantages that BIPOC endure under the moniker structural racism.

In addition to structural racism, implicit bias—defined as unconscious attitudes, positive or negative, toward a person, group, or idea—often leads to differential treatment based on perceived race.2,3 Implicit bias further restricts quality healthcare as a separate factor above and beyond inequities of structural racism. Emergency department (ED) data indicates that Black (vs White) patients have longer treatment wait times,4 longer lengths of stay,5 and lower triage acuity levels.6 Additionally, Black ED patients have a 10% lower likelihood of admission and 1.26 times higher odds of ED or hospital death than White patients.7

Research also suggests that physicians’ own implicit racial biases may contribute to disparities in healthcare quality and delivery.8–10

In this critical review we explore the complex effects of race, implicit bias, and structural racism on SDoH, healthcare quality and, ultimately, health outcomes. Although not intended as a comprehensive literature review on health disparities, this exercise informs a conceptual framework through which actionable steps and practice recommendations for emergency medicine (EM) are proposed as one part of a larger systemwide effort that requires thoughtful action and transformative policy to dismantle the hard-wired inequities of structural racism and advance health equity.

METHODS Critical Review Methodology

We conducted a broad-scope critical review of the extant health disparities literature across three areas of clinical pathology interest: communicable diseases; non- communicable conditions; and injuries. The review was conducted through a race-conscious lens to examine the impact of race on health outcomes and inform a conceptual framework for the development of actionable steps and practice recommendations.

Critical reviews include “a degree of analysis and conceptual innovation” resulting in a product capable of launching a new phase of evaluation.11 According to Grant and Booth, the critical review does not call for a systematic evaluation of all the literature related to a topic, but rather the emphasis is on the contribution of each piece of evidence included to the review’s conceptual product.11 As described by the Search, Appraisal, Synthesis, and Analysis framework, critical reviews are designed to identify key findings in the field of interest (health disparities literature), evaluate the evidence in accordance with its contribution (racial health disparities attributable to SDoH), synthesize the evidence in organized fashion (clinical pathology interests relevant to EM), and provide a conceptual output of analysis that contributes to the literature (actionable steps and practice recommendations).11

In this review we aimed to examine racial health disparities through the SDoH model and apply socioenvironmental theory12 and resource deprivation theory13 as race-conscious filters through which racial disparities data is analyzed and synthesized (Table 1). The analysis informed the conceptual framework through which we developed and propose actionable steps and practice recommendations.

RESULTS Communicable Diseases HIV/AIDS

Racial and ethnic disparities in the incidence and prevalence of HIV infection and AIDS have been documented in the US since the 1980s.14 Despite prevention, identification, and treatment advances, Black-White and Hispanic-White disease incidence disparities have increased since 1984. In 2013, Blacks andHispanics accounted for 46% and 21% of new HIV infections and 49% and 20% of new AIDS diagnoses despite representing 12% and 16% of the total US population, respectively.14 AlthoughHIV incidence rates have improved in recent decades, Blacks and Hispanics have benefitted less from antiretroviral therapy advancements.15 Incidence rates (IR) have declined with the advent of pre-exposure prophylaxis (PrEP); however, PrEP usage remains disparately low among Black (5.9%) and Hispanic (10.9%) adults with an indication as compared to Whites (42.1%).16,17

ED Actionable Steps: Increase access to HIV testing and referrals to PrEP and post-exposure prophylaxis.

Viral Hepatitis Hepatitis C virus (HCV) is the leading cause of liver

disease-related death in theUS.18Racial disparities in disease prevalence exist at a rate greater than twice that of Whites; Blacks in the US have the highest prevalence ratio (PR) of disease (PR 2.29, 95% confidence interval [CI] 1.94–2.70).18

Rates of treatment for chronic hepatitis C are also higher

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among Whites as compared to Black, Hispanic, and Asian individuals.19 Direct-acting antivirals (DAA) became available in 2014 and are achieving greater than 90% cure rates.20 Early research found that Black and Hispanic patients were less likely than Whites to benefit from DAA initiation (adjusted rate ratio [aRR] 0.7, 95% CI 0.7–0.8 and 0.8, 95% CI 0.7–0.9, respectively).21 Follow-up data from a national cohort found that these racial-ethnic gaps had closed by 2016; however, more recent data is needed to determine whether equitable access has persisted beyond initial evidence-driven efforts.20

ED Actionable Steps: Increase access to HCV testing and referrals to DAA treatment.

Sexually Transmitted Infections Disparities in sexually transmitted infections (STI) have

been described extensively in the literature. Rates of primary and secondary syphilis, HIV/AIDS, chlamydia, and gonorrhea among Blacks range from 5.4 to 17.8 times the rates among Whites in the US.22 The SDoH associated with increased STI prevalence have been discussed extensively, ranging from inequities in healthcare, income, incarceration, residential segregation, and substance use, among others.23,24 Importantly, prevalence must be interpreted within the context of STI screening, the odds of which are higher among Black and Hispanic women than their White counterparts (adjusted odds ratio [aOR] 2.56, 95% CI 2.60–3.10 and 1.42, 95% CI 1.39–1.46, respectively).25

ED Actionable Steps: Increase access to STI testing and ED-based treatment.

Diarrheal Disease An estimated 500,000 cases of shigellosis occur annually in

theUS.26 Incidence rates of infection per 100,000 are greatest among Black (7.2) and Hispanic (5.6) individuals as compared to Whites (2.6).26 Despite the preventable nature of shigellosis, an analysis of over 25,000 laboratory- confirmed cases reported to the CDC found a strong

association between its incidence and residence in areas marked by US Census Tract-level poverty and household crowding. Racial and ethnic IR disparities, however, persisted even after controlling for these socioeconomic indicators,26 and the rates of severe infection among adults are highest among Black persons.27 Similarly, Black (vs non- Black) infants<6 months in age had higher rates of diarrhea- associated hospitalizations that persisted even after the introduction of the rotavirus vaccines in 2006.28

EDActionable Steps: Educate patients and parents about transmission mechanisms andmitigation strategies (eg, hand hygiene, low-cost water treatment options, vaccination), and consider offering vaccination in the ED when necessary and reasonable.

Pandemic Respiratory Viral Infection Disparities exist among pandemic respiratory viral

infections, including influenza H1N1 and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), resulting in higher disease incidence and mortality among minority groups.29–31 Coronavirus disease 2019 (COVID-19) cases and hospitalization rates were 2.5-4.5 times higher among Black, Hispanic, and Native American populations than Whites. Through May 2021, COVID-19 deaths among Hispanic and Black populations were 17% and 10% greater, respectively, than expected by US population representation after controlling for age.32 Elevated COVID-19 infection and death rates have also been observed in socially disadvantaged counties with larger proportions of BIPOC.32,33 Among residents of a predominantly Black and Hispanic COVID-19 hotspot, very high and disparate positivity rates were observed among Black (68.5%) and Hispanic (65.3%) patients as compared to Whites (53%).34 Higher hospitalization rates for Blacks (60.2%) and Hispanics (62.3%) as compared toWhites (47.7%) were also observed, although there were no differences in admission rates to the intensive care unit.34

Mortality rates among COVID-19 inpatients also show BIPOC disparities.35,36 Recent CDC data shows higher mortality risk ratios for Native Americans (2.4), Hispanics

Table 1. Race-conscious analysis tools employed in critical review.

Socioenvironmental theory12 Resource deprivation theory13

Socioenvironmental theory holds that racial residential segregation is central to racial and ethnic health disparities. According to this theory, racial/ethnic minority groups have considerably different levels of health risk due to the multiple social and environmental factors that detrimentally impact their health within the context of longstanding residential segregation and its deeply rooted socioeconomic disadvantages.

Resource deprivation theory holds that the longstanding deprivation of resources experienced by racial/ethnic minority groups is central to racial and ethnic disparities. Due to chronic deprivation, racial/ethnic minority groups lack the necessary infrastructure to support health. Resources are not restricted to material possessions; they include education, employment, housing, neighborhood safety, and psychological wellbeing. According to evidence-based interpretations of this theory, gap closure cannot be achieved through equal distribution of resources, but rather targeted differential distribution of resources that levels the playing field for racial/ethnic minority groups.

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(2.3), and Blacks (1.9) compared to Whites.37 There are several reasons cited to explain the higher out-of-hospital mortality rates, disease burden, and severity of illness among BIPOC.36,38–40 Several authors have concluded that population-based disparities in COVID-19 hospital mortality are best explained by differential disease incidence, prevalence of comorbid conditions, and socioeconomic marginalization among Black and Hispanic individuals.34,39,40

Overall racial and ethnic disparities in COVID-19 risk, severity, morbidity, and mortality arise from a combination of social, economic, and health determinants.36,38 Due to economic strain, BIPOC are more likely to live in crowded housing (multigenerational or communal households) and densely populated neighborhoods. They are also more likely to work in consumer-facing public service industries and rely on public transportation, increasing their exposure risk. Additionally, higher rates of comorbidities (eg, heart disease, diabetes, hypertension, and obesity) increase BIPOC’s risk for severe COVID-19 disease. Barriers to health insurance and health services limit access to treatments and to accurate knowledge regarding SARS-CoV-2 transmission, prevention strategies, disease symptoms, and reasons for seeking care.41–43 Interestingly, despite the positive impact of Medicaid expansion on healthcare access, mortality, and disparities, one study failed to find an association between COVID-19 mortality and expansion vs non-expansion,44,45

likely reflecting a benefit negated by the heightened social risk of structural racism.

Disparities in vaccination coverage were evident by the end of April 2021. When all adult age groups were eligible, vaccination rates among Black (46.3%) and Hispanic (47.3%) adults were lower than among Whites (59%) and Asians (69.6%).46 Despite policies to ensure equitable COVID-19 vaccine access, vaccination hesitancy— originating from distrust in the medical establishment and resulting from longstanding systemic racism in healthcare and research—required community partnerships and concerted efforts by trusted sources of information to overcome the slower rates of vaccination among BIPOC.46

ED Actionable Steps: Increase access to viral testing, educate patients and parents about transmissionmechanisms and mitigation strategies (eg, masks, isolation, vaccination), and consider offering vaccination in the ED when necessary and reasonable.

Non-Communicable Conditions Acute Coronary Syndrome and Acute Myocardial Infarction

Disparities in acute coronary syndrome (ACS) care have been well-documented. Compared to White patients with door-to-balloon (DTB) times of 103.4 minutes, Black and Hispanic patients experience significantly longer DTB times

(122.3 and 114.8 minutes, respectively).47 Over the last decade, DTB times have improved significantly across all groups; however, Black Americans have a lower likelihood of experiencing DTB times <90 minutes48 and have experienced only a modest decline in recurrent hospitalization for acute myocardial infarction (AMI) compared toWhites.49 Black patients experience worse AMI outcomes with a five-year mortality rate of 29% compared to 18% among Whites.50

ED Actionable Steps: Consider protocolized ED triage and early management of potential ACS/AMI-related complaints beyond chest pain.

Type 2 Diabetes Mellitus Type 2 diabetes prevalence rates among Black (13.2%)

and Hispanic (12.8%) Americans are similar and higher than rates among Whites (7.6%).51 Well-controlled glycemia and hospitalization rates, quality indicators, are both worse among Black patients (37.6% and 26.5%, respectively) compared to Whites (44% and 16.1%, respectively).51 The marker of glycemic control, hemoglobin A1c (HgbA1c), is statistically worse among Black vs White patients (HgbA1c

9.1± 2.9% vs. 8.5± 2.2%, P = 0.001).52 Black and Hispanic patients have higher odds of diabetes-related ED visits (odds ratio [OR] 1.84, 95% confidence interval [CI] 1.7–2.0 and 1.60, 95% CI 1.4–1.8, respectively) than Whites.53

ED Actionable Steps: Educate patients about the complications of poor glycemic control and consider navigation partnerships with primary care for expedited post-ED visit, outpatient follow-up of patients with diabetes- related chief complaints and complications.

Hypertension Racial and ethnic disparities in hypertension are likely

multifactorial related to upstream SDoH, including access to healthcare, affordable medications, low-sodium foods, and safe green spaces for physical activity.54 Unique to Black patients, race-consciousness significantly increases diastolic blood pressure (BP), and the self-perception of having a lower social standing as a function of race is associated with medication non-adherence and higher systolic BP.54

Research has also demonstrated that Black and Asian patients have higher odds of a high BP reading at their last clinic visit (OR 0.36, 95% CI 0.21–0.60 and 0.40, 95% CI 0.16–0.97, respectively) and Black and American Indian/ Alaska Native patients have higher odds of an ED visit or hospitalization (OR 3.61, 95% CI 1.88–6.91 and 5.31, 95% CI 2.13–13.20, respectively).55

ED Actionable Steps: Educate patients about the complications of poor BP control and consider navigation partnerships with primary care for expedited post-ED visit, outpatient follow-up of patients with hypertension-related chief complaints and complications.

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End-stage Renal Disease Racial and ethnic disparities are profound in renal disease.

Black patients experience higher IRs of end-stage renal disease (ESRD) in adolescence, greater probability of progression to advanced disease stages before initiation of dialysis, lower likelihood of peritoneal vs hemodialysis treatment, lower likelihood of transplant waitlist placement, and longer waiting times for transplantation.56 Pediatric nephrology registry data found that among children who progressed to ESRD, 41.8% of White children received transplants compared to 16.3% and 27% of Black and Hispanic children, respectively, and 70% of White children were transplanted within two years of waitlist placement compared to 44% of Black pediatric patients.57 Subsequent analyses confirm the persistence of these disparities with Black and Hispanic less likely thanWhite children to receive preemptive transplants (8.7% and 14.2% vs 27.4%, respectively), and Black pediatric transplant recipients were less likely than White to experience allograft survival at five years (63% vs 80.8%, respectively).58

Similar disparities among non-White adult ESRD patients include lower rates of transplant referrals, delayed times to transplant waitlist placement, and longer wait times for transplant.56 National mortality statistics indicate Blacks experience significantly higher death rates from ESRD than Hispanic and White Americans (24.6 vs 11.1 and 12.1 age-adjusted death rate per 100,000, respectively).59

ED Actionable Steps: Advocate for increased access to dialysis, particularly for the uninsured, and consider navigation partnerships with nephrology and local dialysis centers for expedited post-ED visit, outpatient follow-up of patients with ESRD-related chief complaints and complications.

Obesity As a risk factor for heart disease, type 2 diabetes,

hypertension, and other chronic conditions, obesity poses a real challenge to population health management efforts. National data demonstrates that the highest prevalence of adult obesity occurs among Black Americans (38.4%) followed by Hispanics (32.6%) and Whites (28.6%).60 Much like hypertension, racial and ethnic disparities in obesity are multifactorial and require a multifaceted intervention to target social (food deserts), biological (hormone dysregulation secondary adverse childhood events), and behavioral (physical activity) determinants.61 Research has revealed a high burden of fast- food establishments within predominantly Black communities.62–64 Treatment disparities are also present with BIPOC demonstrating decreased responsiveness to weight-loss pharmacotherapy, decreased likelihood weight- loss center referral, and decreased likelihood of bariatric surgery.65

ED Actionable Steps: Consider partnerships with community programs focused on healthy lifestyle change and

prescribe vouchers to patients whose health would benefit from weight loss.

Mental Health Racial disparities in the management of psychiatric illness

have also come to the forefront in recent years. Rates of depression treatment are lower among Black and Hispanic patients as compared toWhite patients, who are half as likely and a third as likely, respectively, to receive care than White patients.66 According to the CDC, Black adults had the highest rates of mental health-related ED visits in 2018-2020, had longer EDwait times, and were less likely to be admitted or transferred to another hospital.67 An analysis of national data found that Black patients presenting to the ED with a psychiatric emergency have a greater probability of chemical sedation than White patients.68,69 Additionally, single- and multisite studies have found that Black69–71 and Hispanic patients71 are more likely to be physically restrained in the ED than White patients.

ED Actionable Steps: Use an equity lens to conduct a thorough review of policies related to restraint use, consider protocolized screening and management of agitation inclusive of early oral medication and withdrawal treatment, and consider navigation partnerships with hospital-based and community-based counseling services.

Injuries Environmental Hazard-Related Injuries

Ambient fine-particulate matter exposure (PM 2.5) is a risk factor for a host of conditions including reactive airway disease, coronary artery disease, and cerebrovascular disease.72 The inequitable distribution of hazardous sites, namely industrial facilities, utilities, and landfills, is one of the greatest concerns in the field of environmental justice. Extensive literature has demonstrated that non-Whites are more likely to reside near stationary sources of PM, with Black Americans experiencing a higher burden of PM exposure than Whites and the general population.73

Racial disparities in hazardous exposure burden are not a recent phenomenon. The 1987 groundbreaking study that first exposed the disproportionate co-location of toxic waste sites and minority communities found that three of every five Black and Hispanic Americans lived in such conditions.74

The National Research Council conducted a study that observed greater prevalence of health problems— spontaneous abortions, birth defects, heart disease, gastric cancer, leukemia, and Hodgkin’s lymphoma—among those living in proximity to highly toxic chemicals and carcinogens (eg, benzene, polychlorinated biphenyls, mercury, arsenic, and lead).75 Geo-mapping of hazardous sites found that a disproportionate number of towns overburdened by toxic sources were also home to high proportions of BIPOC, a robust positive predictor of hazardous waste site locations.76

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ED Actionable Steps: Increase syndromic surveillance collaborations with public health departments for early detection and community notification of hazardous conditions, and advocate for targeted policy interventions by highlighting the harmful health impacts on local communities.

Long-bone Fractures Black and Hispanic patients are less likely to receive

opioid analgesia for acute pain in the ED and opioid prescriptions at discharge compared to White counterparts.77–79 Research shows that although average pain scores do not differ between White and non-White patients with long-bone fractures (LBF), White patients are more likely to receive opiates (70% vs 50%, P < 0.001).78

Among children presenting for EDmanagement of LBF, the data is similar: Black andHispanic childrenwere less likely to receive opioid analgesics (aOR 0.86, 95% CI 077–0.95 and 0.86, 95% CI 0.76–0.96, respectively) and less likely to achieve optimal pain reduction (aOR 0.78, 95%CI 0.67–0.90 and 0.80, 95% CI 0.67–0.95, respectively).80

ED Actionable Steps: Consider protocolized ED triage and earlymanagement of LBF, including adequate analgesia dosing schedules.

Firearm Injuries Firearm violence is a public health epidemic in the US. In

2018, firearms were the leading method of homicide and suicide, major causes of premature death. Per the CDC, 39,707 Americans died from firearm violence in 2019, averaging 109 deaths per day and comprising 60% suicides, 35% homicides, and 1.4% law enforcement interventions.81

While most firearm suicide deaths impact Whites and American Indian/Alaska Natives, homicides disproportionately plague BlackAmericans. In 2018, firearm homicides were highest among Blacks. Black males and females aged 20–34 years died by firearm homicide at nearly 17 times higher and nearly six times higher rates than their White counterparts, respectively. Among youth aged 0–19, Blackmales had the highest firearm homicide rate at 14 times higher than their White peers. American Indian/Alaska Native male youth had the second highest youth homicide rate. Black males are disproportionately killed by law enforcement intervention with firearms at a rate 1.71 times that of non-Hispanic White males.82

ED Actionable Steps: Remain informed of local firearm injury statistics and advocate for adequate policy responses by highlighting the harmful health impacts on local communities.

DISCUSSION Across clinical pathology interests and in almost every

area studied, BIPOC communities experience worse patient care and health outcomes. Contrary to historical medical

teachings, there is no biological evidence for the concept of race as a genomic human subspecies to explain health disparities.83,84 Rather, it is the social interpretation of people in a race-conscious society that disparately impacts health.85 The system of structuring opportunity and assigning value, based on assumptions about groups of people with certain physical attributes, systematically privileges some while disadvantaging others and undergirds the deadly problem of structural racism. Compounding the well-recognized theory of resource deprivation among racially/ethnically segregated communities (eg, quality primary education, adequate housing, green space) is socioenvironmental theory, which points to acts of commission that inequitably pose health risks (eg, air pollution,72,73 toxic waste,74–76 and fast- food,62–64 alcohol,86

and tobacco outlets87). Physicians must acknowledge the insidious health threat

that implicit biases and structural racism pose. Disproportionate levels of socioeconomic disadvantage, social vulnerability, and poor health outcomes are manifestations of long-established and deeply entrenched racial segregation and racial deprivation. One could argue that the adverse health effects of structural racism over the centuries have created a far greater public health crisis than the COVID-19 pandemic, and yet beyond their identification, they have not received the attention they demand. Perhaps, in future years, our collective response to the volatile sociopolitical events of the last five years will be viewed as the force that changed the narrative. Many academic medical centers have created executive positions focused on equity, diversity, and inclusion and have worked to implement educational curricula aimed at dismantling structural racism.88

The question that remains today— how do we as individuals and collectively as an institution and specialty best advance social justice and health equity? —demands thoughtful actions and transformative policies. A recent scoping review found 37 published intervention papers with only a third including empirical research.89 Clearly, the implementation science behind this massive multi-pronged process will take time to develop,90 but there appears to be sufficient direction to propose potential actionable steps (Table 2) and practice recommendations.

LIMITATIONS As critical reviews focus on advancing thought through

conceptual innovation following an analysis of the literature, the methodology, by design, does not necessitate an exhaustive comprehensive review of the literature nor the same systematicity and quality assessment as in other more structured review approaches.11 Additionally, the objective of the conceptual product of a critical review is to propose a new phase of research within the field in question,11 and as a result, the actionable steps and practice recommendations

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Table 2. Potential actionable steps for emergency physicians.

Communicable diseases

1. DPH-funded, community partnerships for pop-up screening clinics in the community designed to provide rapid testing and counseling regarding treatment initiation for HIV, hepatitis C, and STIs.

2. DPH-funded, community partnerships for pop-up vaccination clinics in the community designed to provide testing, vaccination, and transmission-mitigation education in the community.

3. Self-guided education and peer education about the increased risk for severe COVID-19 and other respiratory and diarrheal morbidity and mortality among ethnic and racially diverse populations.

4. Empower patients with a thorough understanding of communicable diseases, including natural course of illness, methods of transmission, transmission prevention, and reasons for returning; discharge counseling techniques may include discharge nursing teach-back or read-back of instructions.

5. DPH-medical-community partnerships designed to focus efforts in areas of high transmission risk when planning resource distribution of testing, treatment, and vaccination supplies related to COVID-19 and other pandemic-related illnesses.

Non-communicable conditions

1. Educate EPs about long-standing racial and ethnic gaps in ED-based care and health outcomes; and promote opportunities for implicit bias training.

2. Develop equity metrics, monitor clinical performance data on quality measures, identify inequities in clinical and research, and implement process and policy changes to close disparity gaps.

3. Support health equity initiatives at the individual, departmental, and organizational levels that aim to educate patients about certain medical conditions (eg, hypertension, diabetes), early warning signs of serious complications (eg, acute coronary syndrome, renal failure), and available treatment options; educational strategies may involve smart documents and waiting room video educational modules.

4. Support and partner with existing patient care navigator and community health worker programs to engage patients beyond the index ED visit and ensure medication and treatment plan adherence, outpatient follow- up scheduling, and regular assessments of any barriers to disease control.

5. Partner with local community organizations designed to promote healthy lifestyle (eg, smoking cessation, nutritional food planning, local farm food collaborative, reduced-fee gym memberships, etc).

Injuries 1. Consider the potential environmental determinants of lung inflammation and injury in BIPOC patients with difficult-to-control asthma symptoms; educate patients about PM and its relationship to asthma and counsel them on preventative measures and importance of maintenance medication adherence.

2. Support and advocate for state and federal legislation and policy aimed at prevention of toxic waste dumping, containment efforts, periodic testing of soil and water supplies, increased testing for environmental exposures among communities living in high-risk exposure areas, and investment in industrial waste decontamination, safer housing, and quality medical care for affected communities.

3. Self-guided education and peer education about the signs and symptoms of toxicity due to common hazardous waste contaminants, and the available treatments.

4. Provide opioid analgesia for acute severe pain in the ED based on likely diagnosis, objective measures of pain, and optimal pain reduction (at least a 2-level reduction in pain score for initial treatment).

5. Support epidemiologic and narrative research of firearm violence, both nonfatal injuries and deaths, to better understand risk and protective factors as the basis for intervention.

6. Use the results of epidemiologic and narrative research to partner with communities to develop and implement effective interventions especially targeted at high-risk youth and young adults of color.

7. Partner with existing programs and personnel that have operated trauma center resources for community and firearm violence to extend their inpatient work to reach a greater proportion of those in need by developing and implementing ED protocols to identify, counsel, and refer at-risk populations.

8. Educate EPs on the effective counseling of populations at disproportionate risk for community and firearm violence and incorporate smart discharge phrases into the electronic health record system.

9. Develop strong collaborations with community groups and social services to whom the ED could transition primary and secondary prevention; incorporate these referrals into discharge materials.

10. Encourage state and federal legislation and policy aimed at decreasing firearm homicides and nonfatal injuries (eg, decrease access to illegal firearms, increase federal funding for research on firearm violence, decrease the production of violent video games andmedia and replace themwith games in which the protagonist must save lives rather than kill to win).

BIPOC, Black, indigenous and people of color; DPH, Department of Public Health; ED, emergency department; EP, emergency physician; PM, particulate matter; STIs, sexually transmitted infections.

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made have yet to be proven effective but instead serve as a starting point for a new phase of implementation science.

CONCLUSION The suggested actionable steps and following practice

recommendations constitute the conceptual product of this critical review, demanding a new phase of implementation and evaluation research that identifies effective strategies and best practices for mitigating racial health inequities. Emergency physicians, as individuals and organizational leaders, can act from several positions in the social structure:

A. Societal members 1. Participate in local, state, and federal government

forums advocating for health through resources and advantages historically inaccessible to BIPOC: a. Affordable, safe housing b. Food security (ie, sufficient, safe, and nutritious

sustenance) c. Firearm safety, neighborhood safety, and

support for survivors of violence d. Health-promoting lifestyle (eg, green space and

density restrictions on fast-food, tobacco, and alcohol outlets)

e. Comprehensive community health centers with expanded hours of operations

2. Developmeaningful individual and organizational partnerships with antiracist stakeholders and communities (ie, Black Lives Matter, White Coats for Black Lives, etc).

3. Engage leadership and representatives of first responder agencies in upholding the value of every human life.

B. Stewards of medicine 1. Engage medical leadership in changing

organizational culture to one that consistently prioritizes equity, addresses inequities in clinical and professional spaces, and recognizes the systematic advantage of privilege.

2. Create permanent positions accountable to equity, diversity, and inclusion initiatives91 and ensure core leadership articulates diversity as an institutional priority and dialogues constructively with all relevant stakeholders.92

3. Increase BIPOC representation within the pipeline and across all organizational strata.93

4. Identify racial disparities and their sources within the system, conduct root cause analyses, and implement strategies to remedy inequities.94

Describe, document, and proactively work to mitigate the health impact of racism.95

5. Draft policies and enforce protocols for dealing with race-based aggression by patients and other staff.

6. Educate medical personnel through multimodal continuous medical education on trauma- informed care, anti-racism practice, and cultural humility.96

7. Offer medical education curricula and periodic trainings for students, residents, community physicians, and faculty that include the following:93,97

a. SDoH: Although the prospective, patient- oriented outcome is sparse, many medical schools and residency programs have adopted SDoH curriculum, which may lead to measurable changes in the future98 and is a stated priority of the Institute of Medicine.99

Comprehensive training materials are free and available on the web.100

b. Cultural humility training to address implicit bias, stereotypes, and prejudice.101

c. Anti-racism and trauma-informed care training to improve patient care communication and bedside skills.

8. Evaluate the impact of educational programs on patient care and health outcomes to curate efforts.102 Disseminate evidence-based best practices.

9. Endeavor as an institution and specialty to eliminate racialized conceptions of disease susceptibility (eg, casting Blacks as innately diseased and dehumanizing their suffering).103

C. ED staff 1. Develop equity metrics, monitor clinical

performance data, identify clinical and research gaps, and implement process and policy changes to eliminate health disparities.

2. Abandon the practice of stating the patient’s race in the narrative of the history and physical as it has minimal benefit, risks introducing bias, and is offensive to minority physicians.104

3. Cease the use of correction formulas that use race as a proxy for pathology when their use furthers health inequities.105

4. Make deliberate efforts to treat racial groups similarly on individual and population levels as a concrete first step in ameliorating racial health disparities. Although physicians undoubtedly carry implicit racial biases equal to the general population, there is some evidence that emergency physicians show less implicit racial bias than the general population.106

5. Address racist patient attitudes professionally even when these cause moral distress.107 Addressing

Volume 24, No. 5: September 2023 Western Journal of Emergency Medicine913

Macias-Konstantopoulos et al. Race, Healthcare, and Health Disparities: A Critical Review and Recommendations

racism and attempting to rebuild therapeutic alliances is part of the leadership and professionalism that emergency physicians must emulate.

D. Hospital executives Institutional leaders must assure appropriate ED ancillary staffing and address hospital policies (eg, inpatient census levels, direct and transfer admissions) that result in ED crowding, medical error, morbidity and mortality, and staff demoralization.108

Emergency physicians are experts in rapid cognition or thin-slicing, but with that practice comes the expression of latent stereotypes and biases that require a deliberate “bias-check” pause to better understand the patient and, thus, achieve better outcomes.109 Research has demonstrated that overstressing physicians beyond reasonable levels is associated with increases in implicit bias.110

E. Clinical caregivers 1. Employ a trauma-informed care approach with

individual patient interactions.111 The BIPOC communities suffer under the pervasiveness of historical and personal trauma as well as the psychological trauma inflicted by law enforcement killings of unarmed Blacks.112

Moreover, BIPOC minorities are exposed daily to stressful and traumatic events at much great rates than the general population.113 To adopt the trauma-informed care framework: a. Abandon power imbalances common in

traditional, paternalistic doctor-patient dynamics.

b. Empower patients to be partners in treatment decisions.

c. Offer patients validation, explanation, and choice.

d. Practice cultural humility, an orientation to care that is based on self-reflexivity, appreciation of patients' lay expertise, openness to sharing power and knowledge with patients, and desire to learn from patients.114

2. Recognize and counter potentially racist clinical decisions by doing the following: a. Follow evidence-based race-blind admission

and surgical criteria. b. Provide professional peer-to-peer feedback

with coaching on delivery of difficult conversations.115

c. Build race-blind analgesia protocols.116

d. Create policies to address interprofessional microaggressions and patient-to-clinician racism. Micro- and macroaggressions

contribute to burnout and must be combated to ensure inclusion and career longevity.117,118

In conclusion, from amedical standpoint, there is only one race—the human race—and we must recognize and counter our implicit biases. As fellow humans, we must acknowledge that structural racism drives health inequities, and as emergency physicians we can choose to address it by employing any or all the actions and recommendations proposed herein.

Address for Correspondence: Wendy L Macias-Konstantopoulos, MD, Center for Social Justice and Health Equity, Department of EmergencyMedicine, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street Zero Emerson, Suite 3B, Boston, Massachusetts 02114. Email: [email protected]

Conflicts of Interest: By theWestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. No author has professional or financial relationships with any companies that are relevant to this study. There are no conflicts of interest or sources of funding to declare.

Copyright: © 2023 Macias-Konstantopoulos et al. This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) License. See: http:// creativecommons.org/licenses/by/4.0/

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Western Journal of Emergency Medicine Volume 24, No. 5: September 2023918

Race, Healthcare, and Health Disparities: A Critical Review and Recommendations Macias-Konstantopoulos et al.

  • Race, Healthcare, and Health Disparities: A Critical Review and Recommendations for Advancing Health Equity
    • INTRODUCTION
    • METHODS
      • Critical Review Methodology
    • RESULTS
      • Communicable Diseases
        • HIV/AIDS
        • Viral Hepatitis
        • Sexually Transmitted Infections
        • Diarrheal Disease
        • Pandemic Respiratory Viral Infection
      • Non-Communicable Conditions
        • Acute Coronary Syndrome and Acute Myocardial Infarction
        • Type 2 Diabetes Mellitus
        • Hypertension
        • End-stage Renal Disease
        • Obesity
        • Mental Health
      • Injuries
        • Environmental Hazard-Related Injuries
        • Long-bone Fractures
        • Firearm Injuries
    • DISCUSSION
    • LIMITATIONS
    • CONCLUSION
    • REFERENCES

,

SYSTEMATIC REVIEW Open Access

An overview of reviews on strategies to reduce health inequalities Nathaly Garzón-Orjuela1* , Daniel Felipe Samacá-Samacá1, Silvia Catalina Luque Angulo1, Carmen Verônica Mendes Abdala2, Ludovic Reveiz3 and Javier Eslava-Schmalbach1,4

Abstract

Background: Governments are incentivized to develop and implement health action programs focused on equity to ensure progress with effective strategies or interventions.

Objective: Identify and synthesize strategies or interventions that facilitate the reduction of health inequalities.

Methods: A systematic search strategy was carried out up until August 2019 in MEDLINE (Ovid), Embase (Elsevier), Cochrane Database of Systematic Reviews, LILACS, Scopus, Scielo and Epistemonikos. In addition, a snowball strategy was used. Literature reviews (LRs) of experimental and quasi-experimental studies were included. The identified interventions and outcomes were categorized based on the recommendation by the Cochrane group in “Effective Practice and Organization of Care”. The quality of the included LRs was evaluated using the AMSTAR 2 tool.

Results: Four thousand ninety-five articles were identified, of which 97 were included in the synthesis of evidence. Most of the studies included focused on the general population, vulnerable populations and minority populations. The subjects of general health and healthy lifestyles were the most commonly addressed. According to the classification of the type of intervention, the domain covered most was the delivery arrangements, followed by the domain of implementation strategies. The most frequent group of outcomes was the reported outcome in (clinical) patients, followed by social outcomes.

Conclusion: The strategies that facilitate the reduction of health inequalities must be intersectoral and multidisciplinary in nature, including all sectors of the health system. It is essential to continue generating interventions focused on strengthening health systems in order to achieve adequate universal health coverage, with a process of comprehensive and quality care.

Keywords: Health equity, Strategies, Health status disparities, Systematic review

Background The reduction of health inequalities, described as the differences in health among people or society [1, 2], is a key issue on the global agenda [3]. The implementation of health policies and programs is intended to improve the health conditions of the population in aspects rele- vant to public policy, based on prioritized needs, and

which must be resolved in the short, medium or long term. When implementing these health policies and pro- grams, there is the possibility that the implementation will help to reduce inequalities in health (or at least not to increase them through implementation). Taking into account that equity is one of the objectives of sustainable development (OSD) [3], that it has been linked to the justice concept, redistribution of wealth and income, good governance, empowerment, and transparency [4]. Among those OSD, health inequities have been increas- ing in recent years [5] that means a climb in the

© The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

* Correspondence: [email protected] 1Grupo de Equidad en Salud, Facultad de Medicina, Universidad Nacional de Colombia, Bogotá, Colombia Full list of author information is available at the end of the article

Garzón-Orjuela et al. International Journal for Equity in Health (2020) 19:192 https://doi.org/10.1186/s12939-020-01299-w

differences in health that are avoidable, unjust and un- needed [1, 2]. Equity in health defined as the lack of health disparities that “are systematic, potentially avoidable dif- ferences in health—or in the major socially determined in- fluences on health—between groups of people who have different relative positions in social hierarchies according to wealth, power, or prestige” [6]. Overall, this concept is becoming strategic, where possible, for the implementa- tion of health policies and programs at a global level. Decision makers are aware of the need to reduce

health inequalities [7]. However, putting it into practice is not easy due to the high amount of information evi- denced in the literature that making the process of choice difficult for decision-makers [8]. Barsanti et al. [9] state that despite the priority of governments to reduce health inequalities, clear objectives are often lacking, as well as impact evaluation systems to demonstrate the ef- fectiveness of actions and interventions. Currently, governments are incentivized to develop and

implement health action programs focused on equity to en- sure progress with effective strategies, where identify actions on social determinants of health through interventions in the health, economic and education sectors, by mean of design- ing a plan to resources to set priorities and crafting solutions, dedicating time, and political attention [10]. For this reason, actions such as the identification, synthesis and transfer of scientific knowledge are required, a process that requires transparent and reproducible research methods that allow evidence to be evaluated more efficiently [9]. Also, some au- thors have develop overview of reviews focused on strategies to implement evidence-based interventions in low-income countries [11] or to implement and evaluation of health pro- motion services and programs to improve cultural compe- tency [12]. As a result, the objective of this overview of reviews was to identify and synthesize the strategies or inter- ventions that facilitate the reduction of health inequalities.

Methods Criteria for considering studies for this overview of literature reviews Inclusion criteria Literature reviews (LRs) of experimental and quasi- experimental studies, in English and Spanish, evaluating strategies or interventions focused on reducing health inequalities or inequities. It was restricted to publication date within the last 5 years (January 2014 to July 2019), owing to the amount of information provided in the lit- erature and the recommendation by the Cochrane group on the maintenance and periodic updating of LRs [13].

Exclusion criteria LRs with unclear methodology specifically the search method for identification of information (i.e. narrative review).

Search method for identification of information A systematic search strategy was performed in the fol- lowing electronic databases: MEDLINE (Ovid), Embase (Elsevier), Cochrane Database of Systematic Reviews – CDSR (Wiley platform), LILACS (Virtual Health Library – VHL), Scopus, Scielo and Epistemonikos. The search strategy was composed of key concepts related to “health education”, “health planning”, “training”, “healthcare dis- parities”, “health inequities”, “health inequalities”, and other terms that can see in Additional file 1. In addition, a manual “snowball” search was performed by reviewing the list of bibliographic references of the selected studies and Google Scholar.

Collection and synthesis of information An initial review by title and summary of potentially eli- gible studies was performed by three of the authors. Subsequently the full text of the preselected studies was revised for its final inclusion. A data extraction form was designed in which including information of the included studies relating to types of studies included in the re- view, type of population, intervention, comparator, health outcomes, reduction of health inequalities and main conclusions. The data was synthesized narratively. The interventions identified were categorized based on the EPOC taxonomy (Effective Practice and Organization of Care) developed by the Cochrane EPOC group, which consists of classifying health system interventions into four domains of intervention (Table 1) with their re- spective subdomains and categories, which provide a structure for the classification of evidence regarding in- terventions or strategies to reduce health inequalities [14]. Likewise, the outcomes evidenced were classified into the categories recommended by the Cochrane EPOC group [15]. Additionally, to provide an overview of the evidence

on health inequalities, a graphic synthesis was generated using the method adapted by BIREME in the “Inter- national Initiative for Impact Evaluation (3ie – https:// www.3ieimpact.org)”. As a result, an evidence map, and an interactive online platform were obtained that allow users to explore the evidence base. In the evidence map, the bubbles are the intersections between the interven- tions and the findings, which denote the existence of at least one review (the larger the bubble, the greater the volume of evidence). The color of each bubble repre- sents the type of evidence and a confidence rating. In the online version, hovering over a bubble displays a list of the evidence for that cell. The links for these studies lead to registration in a database of the Virtual Health Library (VHL). Users can filter the evidence by type, confidence rating, region, country, study design, and population. To generalizing and standardization of type of population of each review included and added in the

Garzón-Orjuela et al. International Journal for Equity in Health (2020) 19:192 Page 2 of 11

evidence map, it was based on the eligibility criteria ori- ginal of each review if it was not clear, the final decision was done through a consensus among the authors after evaluating the full-text.

Quality assessment The quality of the LR included for the synthesis of evidence was evaluated using the AMSTAR 2 tool for reviews that included randomized or non-randomized studies of health interventions [16]. Due to the evidence map includes the type of evidence and a confidence rating, the overall score result of AMSTAR 2 was classified in high, moderate, and low quality with the online “AMSTAR stands for A MeaS- urement Tool to Assess systematic Reviews” [17].

Results After removing duplicates, a total of 4095 references were identified. After reviewing the full text, 98 studies were included in the synthesis of evidence (Fig. 1). Add- itional file 2 shows the list of excluded studies. The charac- teristics of the included studies and the overall result of the quality assessment are detailed in Additional file 3.

Evidence map From the characterization of the included studies, an evidence map was developed, which graphically distrib- utes these studies according to a matrix with 38 inter- ventions and 39 findings that can be observed in Fig. 2 and at the following link: https://public.tableau.com/pro- file/bireme#!/vizhome/desigualdades-en-salud-en/evi- dence-map. In this evidence map, it is shown that 10 of the included RSs displayed a high level of confidence, in- cluding outcomes of access to medical care, costs, health care, reduction of inequalities, promotion and preven- tion, among others. Most of the included studies focused on the general

population (including any age group, or focused on the community in general), vulnerable populations (margin- alized groups and sex workers, among others) and mi- nority populations (ethnic or racial group). The topics of general health (26.5%) and healthy lifestyles (16.3%) were the most addressed by the included LRs. Additionally,

63.3% of the strategies evidenced in the LR were focused on the health sector and 36.7% were of an intersectoral nature (Additional file 3). According to the classification of the type of interven-

tion by the EPOC taxonomy [14], the most covered do- main in LRs was the domain of service provision, followed by the domain of implementation strategies (Table 2).

Delivery arrangements intervention Of the total of LRs that included the delivery arrange- ments domain, eight displayed a high quality [18–25]. The two most frequent categories in this domain were “coordination of care and management of care pro- cesses”, and “who provides care and how the health care workforce is managed”. In addition, the most common subcategories were care pathways and self-management (Table 2). In the case of self-management or self-care, the main

focus was on interventions related to weight loss and the promotion of physical activity [26, 27], through interven- tions focused on lifestyle changes and behavioral coun- seling that have shown positive results in weight loss and diet modification [28, 29]. Likewise, it was evident in vulnerable populations that multi-component and personally tailored interventions based on counseling are more effective for glycemic control and the reduction of inequalities in oral health [30, 31]. In addition, the interventions of expansion or change

of roles/tasks in care included the creation of medical- legal associations for the continuous search for patient well-being [32], community-based peer support where improvements in health literacy were observed for vul- nerable populations [33], and nutritional interventions promoting healthy lifestyles aimed at indigenous popula- tions, in which the community was encouraged to be in- volved in the design, implementation, and evaluation of interventions for their own well-being [34–36]. Regarding the category of the use of information and

communication technologies, reviews were found show- ing positive results specifically in the reduction of body mass index in the obese population, through the use of

Table 1 Defining the domains of the types of interventions

Domains Definition

Delivery arrangements Interventions aimed at generating changes in how, when and where health care is organized, as well as who provides care services.

Financial arrangements Interventions aimed at seeking changes in how insurance funds and plans are raised, how services are purchased, and the use of financial incentives or disincentives.

Governance arrangements Interventions related to rules or processes that affect the way powers are exercised, particularly with respect to authority, responsibility, openness, participation and coherence.

Implementation strategies Interventions designed to provoke changes in health care organizations, as well as the behavior of health professionals or the use of health services by users.

Source: Effective Practice and Organisation of Care (EPOC) Taxonomy. Cochrane Effective Practice and Organisation of Care. 2015 [14]

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text messages or calls [37], as well as computerized cognitive-behavioral interventions for the management of anxiety and/or depression for people living in rural and remote areas [38]. Similarly, it was shown that the implementation of interventions using audiovisual media, such as videoconferences and telemedicine, con- tribute to the health care of older adults since they help informed decision-making [18, 39]. It was also shown that this category of intervention had a positive effect on vulnerable populations with the use of educational strat- egies at home, telemedicine, text message reminders, calls and other technological contributions that facilitate access to health by improving the quality of life of pa- tients and their caregivers [40–42]. Regarding the category of “where care is provided and

changes in the healthcare environment,” several reviews included interventions that focused on improving access to healthcare services by connecting healthcare profes- sionals to work or educational institutions, or directly to the homes of vulnerable populations with geographic difficulties or who had been displaced, to provide access

health care [43–45]. In this context, subjects such as healthy eating in the school environment in low-income countries [36], assessment and rapid testing for the hu- man immunodeficiency virus in street dwellers or disad- vantaged women [19, 46], medical visits for detection of colorectal, breast and cervical cancer [47–51], and in- formed advocacy measures in the community to pro- mote cardiovascular disease protective factors [27, 52] had positive effects when implemented in places where there are concentrations of disadvantaged groups, thus improving access to health care.

Financial arrangements intervention The six LRs that included the financial arrangements domain were of an average quality [26, 43, 50, 53–55]. The category of “mechanisms for the payment of health services” was the most common within this domain (Table 2), which focused on providing financial support to disadvantaged groups to guarantee health care – for example, transportation aid (pay- ing for transport tickets or reimbursement of tickets) to so- cioeconomically disadvantaged groups, improving access to

Fig. 1 Flow diagram (PRISMA)

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the different care services [53]. Interventions with economic incentives accompanied by other types of interventions were also found, aiming to provide a comprehensive package such as self-care interventions and technology management, which improve access to diagnostic cancer detection proce- dures [26] or tuberculosis [43].

Governance arrangements intervention Governance arrangements domain was identified in seven of the included studies, one of high quality [25] and three of medium quality [53, 56, 57]. Interventions aimed at public policy in health or organizations were identified, where the construction of social networks and organizational interventions carried out in work

environments improve health conditions, decrease hours and work stress, as well as health inequalities [25, 53].

Implementation strategies Sixty two LRs were included in the implementation strategies domain, of which six were of high quality [18, 22–24, 58, 59]. The category of interventions targeting specific practices and conditions was the most frequent (Table 2). Among these, effective strategies were identi- fied in oral health care in the immigrant population [60] and the reduction of infant mortality in low- and middle-income countries [45]. Some programs aimed at specific conditions such as unemployment and its im- pact on health issues, such as reemployment and rapid

Fig. 2 Evidence map. Source: BIREME, based on the characterization of each literature review (LR) included

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Table 2 Classification of the interventions identified in the included LRs

Types of intervention n (%)a

– Delivery arrangements (domain) 77 (78.6)

• Coordination of care and management of care processes (category) 38 (49.4)

▪ Care pathways (subcategory) 26 (113)

▪ Integration the provision of different healthcare services (subcategory) 9 (39.1)

▪ Disease management (subcategory) 5 (21.7)

▪ Case management (subcategory) 3 (13)

▪ Communication between providers (subcategory) 3 (13)

▪ Continuity of care (subcategory) 2 (8.7)

▪ Multidisciplinary team of healthcare workers (subcategory) 1 (4.3)

• Who provides care and how the health care workforce is managed (category) 33 (42.9)

▪ Self-management (subcategory) 17 (65.4)

▪ Role expansion or task shifting (subcategory) 16 (61.5)

• Information and communication technology (category) 16 (20.8)

▪ Technology based methods to transfer healthcare information and support the delivery of care (subcategory) 11 (100)

▪ Health information systems (subcategory) 3 (27.3)

▪ Telemedicine (subcategory) 3 (27.3)

▪ Smart home technologies (subcategory) 1 (9.1)

• Where care is provided and changes in the healthcare environment (category) 16 (20.8)

▪ Site of service delivery (subcategory) 10 (83.3)

▪ Changes to the physical or sensory healthcare environment, by adding or altering equipment (subcategory) 3 (25)

▪ Visits by health workers to different locations (subcategory) 2 (16.7)

▪ Arrangements for transporting patients from one place to another (subcategory) 1 (8.3)

• How and when care is provided (category) 7 (9.1)

▪ Quality and safety systems (subcategory) 3 (50)

▪ Coordination of care among different providers (subcategory) 2 (33.3)

▪ Group versus individual care (subcategory) 1 (16.7)

▪ A reduction or increase in time to access a healthcare intervention (subcategory) 1 (16.7)

– Financial arrangements (domain) 7 (6.1)

• Mechanisms for payment of health services (category) 6 (85.7)

▪ Voucher schemes (subcategory) 6 (100)

• Insurance schemes (category) 1 (16.7)

▪ Community-based health insurance (subcategory) 1 (100)

– Governance arrangements (domain) 7 (7.1)

• Authority and accountability for health policies (category) 6 (85.7)

▪ Community mobilization (subcategory) 3 (50)

▪ Patients’ rights (subcategory) 2 (33.3)

▪ Policies to manage absenteeism (subcategory) 2 (33.3)

• Authority and accountability for health professionals (category) 1 (14.3)

▪ Authority and accountability for the quality of the practice (subcategory) 1 (100)

– Implementation strategies (domain) 62 (63.3)

• Interventions targeted at specific types of practice, conditions or settings (category) 45 (72.6)

▪ Practice and setting (subcategory) 36 (100)

▪ Health conditions (subcategory) 11 (30.6)

• Interventions targeted at healthcare workers (category) 28 (45.2)

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job search, showed positive effects on outcomes such as quality of life [61]. These interventions were mainly aimed at indigenous,

immigrant, maternal and child populations, and people of low socioeconomic levels. In addition, it was shown that in the population of pregnant women, multifaceted strategies are effective to improve prenatal controls, assisted childbirth and breastfeeding, but conditioned to the characteristics of each population [23, 62]. Regarding interventions aimed at health workers, it

was noted that strategies focused on improving adher- ence to clinical practice guidelines lead to better results in primary care, specifically in the reduction of cardio- vascular disease risk factors [52]. Likewise, the involve- ment of community participants as health agents in the implementation of the strategies shows reductions in maternal and infant mortality in low and middle income countries [63], in addition to improving access and coverage to health services in vulnerable populations with chronic diseases [34, 64]. In addition, three of the included studies evaluated the

impact of “tailored” implementation strategies and health policies on equity. The interventions were aimed at tobacco control in adults, adolescents, and the general population [65–67]. In general, the increase in tobacco taxes improved equity both at the population level and at the individual level [65–67]. Likewise, it was found that interventions tend to be more effective at high eco- nomic levels, so a special approach is required according to social class and vulnerable population to avoid in- creasing the gap in health inequalities [65–67]. Regarding the classification of the results, the outcome

of equity was an inclusion criterion of the present re- view, so the classification of the outcomes was made in accordance with the other categories recommended by the Cochrane group of EPOC [15]. In Fig. 3, it can be seen that the most frequent group of outcomes was the reported outcome in (clinical) patients, followed by the

social outcomes, and utilization, coverage and access outcomes.

Discussion Main findings The present review identified a large amount of existing literature on strategies or interventions that facilitate the reduction of health inequalities, which allowed a robust body of information to be put together that could help in health decision-making. Within the results, the wide variety of health conditions and intervened sectors with the aim of reducing health inequalities was highlighted, which reinforces the fact that the problem of inequalities occurs throughout the health system, and implies that work in reducing inequalities is intersectoral and multi- disciplinary [68]. Most of the studies included focused on the general population, vulnerable populations, and minority populations. The subjects of general health and healthy lifestyles were the most addressed. According to the classification of the type of intervention, the domain covered most was the delivery arrangements, followed by the domain of implementation strategies. The most frequent group of outcomes was the reported outcome in (clinical) patients, followed by social outcomes. The classification of strategies that facilitate the reduc-

tion of health inequalities identified in the present study were consistent with the three approaches described by Díez E and Peirò R [69], regarding strategies aimed at re- ducing health inequalities. The authors describe as a first approach those strategies aimed at the area of policies with economic changes, such as the increase in tobacco taxes, education policies aimed at vulnerable popula- tions, economic aid, and community care in geographic- ally remote areas, among others. In their second approach they group strategies for reforms in work and housing. Finally, in their third approach they include those strategies that promote an equal distribution of risk factors using the universalization of care and access

Table 2 Classification of the interventions identified in the included LRs (Continued)

Types of intervention n (%)a

▪ Communities of practice (subcategory) 9 (34.6)

▪ Tailored interventions (subcategory) 8 (30.8)

▪ Patient-mediated interventions (subcategory) 4 (15.4)

▪ Educational meetings (subcategory) 3 (11.5)

▪ Educational outreach visits, or academic detailing (subcategory) 3 (11.5)

▪ Adherence of clinical practice guidelines (subcategory) 2 (7.7)

▪ Routine patient-reported outcome measures (subcategory) 2 (7.7)

▪ Inter-professional education (subcategory) 2 (7.7)

▪ Educational materials (subcategory) 1 (3.8)

Source: authors based on the information extracted from the literature reviews (LRs) included a n = total of domains, categories or subcategories contained in the interventions identified in the LR. Percentage = n / total of LR

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systems through telemedicine, cultural approaches and intersectoral actions to improve lifestyles, educate the community and reduce risky behaviors [69].

Findings by types of intervention In addition, the included studies were oriented to a greater degree to strategies in the domain of delivery ar- rangements, where the strengthening of the coordination of care and management of care processes was displayed, which could be demonstrated by current efforts to trans- form the health system based on equity. Moreover, the need to strengthen health systems to achieve adequate access and universal health coverage is emphasized, as well as the guarantee of a comprehensive and high- quality care process to improve the states of health and well-being of the population [70]. In relation to the findings, care pathway-oriented strat-

egies were the most common within this domain, highlighting the existence of interventions aimed at self- management in health, with positive results in particular topics such as weight loss or promotion of lifestyle changes [26–29]. In this sense, there is a significant interest in the strategies that seek to change the role in health care, which allow the inclusion of other partici- pants to be involved in the health system and granting them an important role in maintaining it, such as self- care by patients and caregivers, the integration of entities and managers at the community level, or the creation and participation of medical-legal groups [71]. The second most frequent domain was that of imple-

mentation strategies, especially those directed at specific types of practice, conditions or environments, which highlighted the need to recognize the contextual condi- tions that influence the adequate maintenance of health, in particular living and working conditions as social de- terminants of health [52, 61]. These strategies aimed at improving these conditions have positive results, reaf- firming the need to understand the individual as a sub- ject within a social context that affects the quality of

their well-being. These results are similar to those de- scribed in the review of systematic reviews of strategies to implement evidence-based interventions in low- income countries of Pantoja T et. al. 2017, where most of the available evidence focused on strategies aimed at health workers and health care recipients [11]. In addition, although there is a large variation in the

types of strategies implemented, it is important to high- light the presence of interventions that recognize the in- trinsic characteristics of the disadvantaged population. The implementation of these types of strategies encour- ages the acquisition of healthy styles and habits, which removes the focus of health from the disease and places it on the promotion and maintenance of health [12]. Additionally, some studies agree with the results on the integration of strategies based on the use of technologies and guided education, which showed positive results, particularly in clinical decision-making, consolidation and strengthening of health systems [70, 72]. EPOC taxonomy permits a structure for the classifica-

tion of different interventions or strategies that help re- duce health inequalities. This taxonomy proposed by the Cochrane Organization is aligned with the objectives of various groups aimed at reducing health inequality, such as “Cochrane Child Health Field, Cochrane Public Health Review Group, Cochrane Developmental, Psycho- social and Learning Problems Group”, which analyze the interventions in order to improve professional practices and the offer of health services, through continuing edu- cation of professionals and facilities in insurance for pa- tients [73]. However, despite the clarity of the EPOC taxonomy for the inclusion of the various interventions, a problem that limits the use of this tool was identified, and is related to the high variability in the information reported in the different studies, the level of detail used to describe the strategies, the variability in the language used by the authors who report the results [71] and in general the quality of the studies included in the system- atic reviews analyzed. Therefore, a need has arisen for a

Fig. 3 Classification of the outcomes identified in the literature reviews. Source: authors, based on the information extracted from the literature reviews (LRs) included Percentage = sum of each category of outcome contained in the interventions identified in the LR/total LR

Garzón-Orjuela et al. International Journal for Equity in Health (2020) 19:192 Page 8 of 11

process of awareness regarding the reporting of results and necessary details in intervention studies, which allow for sufficient understanding at the methodological level and therefore the reproducibility of the results. Finally, it is recommended that academia, policy-

makers, and practitioners develop and implement health action programs focused on equity to reduce health in- equalities through strategies or interventions focused on the care pathway, intersectoral and multidisciplinary that including all sectors of the health system.

Conclusion The main strategies that facilitate the reduction of health inequalities focus on general health issues and the im- pact on healthy lifestyles, allowing us to observe that the objective is not only focused on the disease but also on the care pathway, that varies by illnesses, disease pat- terns, locality and multiple factors involved. In addition, these strategies must be intersectoral and multidisciplin- ary in nature, including all sectors of the health system. It is essential to continue generating interventions fo- cused on strengthening health systems to achieve ad- equate universal health coverage, with a comprehensive and high-quality care process that leads to the reduction of health inequalities.

Supplementary information Supplementary information accompanies this paper at https://doi.org/10. 1186/s12939-020-01299-w.

Additional file 1. Evidence search report in electronic databases.

Additional file 2. List of studies excluded and reasons for their exclusion.

Additional file 3. Characteristics of studies included in the evidence synthesis.

Abbreviations LRs: Literature reviews; EPOC: Effective Practice and Organization of Care; CDSR: Cochrane Database of Systematic Reviews; VHL: Virtual Health Library

Acknowledgments Not applicable.

Disclaimer The opinions expressed in this manuscript are the sole responsibility of the authors and do not necessarily reflect PAHO views.

Authors’ contributions All authors conceived and designed the study, analyzed and syntheses the information. All authors participated to the manuscript edits and revisions and approved the final version.

Funding Pan American Health Organization. Evidence and Intelligence for Action in Health. Washington

Availability of data and materials Not Applicable.

Ethics approval and consent to participate Not Applicable.

Consent for publication Not Applicable.

Competing interests All authors declare that they have no competing interests.

Author details 1Grupo de Equidad en Salud, Facultad de Medicina, Universidad Nacional de Colombia, Bogotá, Colombia. 2Centro Latinoamericano y del Caribe de Información en Ciencias de la Salud, BIREME/OPS/OMS, São Paulo, Brazil. 3Evidence and Intelligence for Action in Health Department, Pan American Health Organization, Washington DC, USA. 4Hospital Universitario Nacional de Colombia, Bogotá, Colombia.

Received: 18 May 2020 Accepted: 13 October 2020

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29. Melvin CL, Jefferson MS, Rice LJ, Nemeth LS, Wessell AM, Nietert PJ, et al. A systematic review of lifestyle counseling for diverse patients in primary care. Prev Med (Baltim). 2017;100:67–75 Available from: http://link.springer.com/1 0.1007/s10903-013-9968-4.

30. Butel J, Braun KL. The role of collective efficacy in reducing health disparities: a systematic review. Fam Community Health. 2019;42:8–19.

31. Nathan AG, Marshall IM, Cooper JM, Huang ES. Use of decision aids with minority patients: a systematic review. J Gen Intern Med. 2016;31:663–76.

32. Martinez O, Boles J, Muñoz-Laboy M, Levine EC, Ayamele C, Eisenberg R, et al. Bridging health disparity gaps through the use of medical legal partnerships in patient care: a systematic review. J Law Med Ethics. 2017;45: 260–73.

33. Harris J, Springett J, Croot L, Booth A, Campbell F, Thompson J, et al. Can community-based peer support promote health literacy and reduce inequalities? A realist review. Public Health Res. 2015;3:1–192.

34. Banna J, Bersamin A. Community involvement in design, implementation and evaluation of nutrition interventions to reduce chronic diseases in indigenous populations in the U.S.: a systematic review. Int J Equity Health. 2018;17(1):116.

35. Coughlin SS, Smith SA. Community-based participatory research to promote healthy diet and nutrition and prevent and control obesity among African-

Americans: a literature review. J Racial Ethn Health Disparities. 2017;4:259– 68.

36. Oliver-Williams C, Brown E, Devereux S, Fairhead C, Holeman I. Using mobile phones to improve vaccination uptake in 21 low- and middle-income countries: systematic review. JMIR Mhealth Uhealth. 2017;5:e148.

37. Pratt CA, Loria CM, Arteaga SS, Nicastro HL, Lopez-Class M, de Jesus JM, et al. A systematic review of obesity disparities research. Am J Prev Med. 2017;53:113–22. https://doi.org/10.1016/j.amepre.2017.01.041 Elsevier Inc.

38. Vallury KD, Jones M, Oosterbroek C. Computerized cognitive behavior therapy for anxiety and depression in rural areas: a systematic review. J Med Internet Res. 2015;17:e139.

39. Batsis JA, Dimilia PR, Seo LM, Fortuna KL, Kennedy MA, Blunt HB, et al. Effectiveness of ambulatory telemedicine care in older adults: a systematic review; 2019. p. 1–13.

40. Hu D, Juarez DT, Yeboah M, Castillo TP. Interventions to increase medication adherence in African-American and Latino populations: a literature review. Hawaii J Med Public Health. 2014;73:11–8.

41. Anderson-Lewis C, Darville G, Mercado RE, Howell S, Di Maggio S. mHealth technology use and implications in historically underserved and minority populations in the United States: systematic literature review. JMIR Mhealth Uhealth. 2018;6(6):e128.

42. Parker S, Prince A, Thomas L, Song H, Milosevic D, Harris MF. Electronic, mobile and telehealth tools for vulnerable patients with chronic disease: a systematic review and realist synthesis. BMJ Open. 2018;8:e019192 Available from: http://bmjopen.bmj.com/lookup/doi/10.1136/bmjopen-2017-019192.

43. Hamilton K, Tolfree R, Mytton J. A systematic review of active case-finding strategies for tuberculosis in homeless populations. Int J Tuberc Lung Dis. 2018;22:1135–44 Available from: http://www.ingentaconnect.com/content/1 0.5588/ijtld.17.0784.

44. Lee-Tauler SY, Eun J, Corbett D, Collins PY. A systematic review of interventions to improve initiation of mental health care among racial- ethnic minority groups. Psychiatr Serv. 2018;69:628–47.

45. Byrne A, Hodge A, Jimenez-Soto E, Morgan A. What works? Strategies to increase reproductive, maternal and child health in difficult to access mountainous locations: a systematic literature review. PLoS One. 2014;9(2):e87683.

46. Robinson JL, Narasimhan M, Amin A, Morse S, Beres LK, Yeh PT, et al. Interventions to address unequal gender and power relations and improve self- efficacy and empowerment for sexual and reproductive health decision-making for women living with HIV: a systematic review. PLoS One. 2017;12:1–19.

47. Luque JS, Logan A, Soulen G, Armeson KE, Garrett DM, Davila CB, et al. Systematic review of mammography screening educational interventions for Hispanic women in the United States. J Cancer Educ. 2019;34:412–22.

48. Rees I, Jones D, Chen H, Macleod U. Interventions to improve the uptake of cervical cancer screening among lower socioeconomic groups: a systematic review. Prev Med (Baltim). 2018;111:323–35.

49. Clifford A, Mccalman J, Bainbridge R, Tsey K. Interventions to improve cultural competency in health care for indigenous peoples of Australia, New Zealand, Canada and the USA: a systematic review. Int J Qual Health Care. 2015;27:89–98.

50. Barley EA, Borschmann RD, Walters P, Tylee A. Interventions to encourage uptake of cancer screening for people with severe mental illness. Cochrane Database Syst Rev. 2016;7 Available from: http://doi.wiley.com/10.1 002/14651858.CD009641.pub3.

51. Man LC, DiCarlo M, Lambert E, Sifri R, Romney M, Fleisher L, et al. A learning community approach to identifying interventions in health systems to reduce colorectal cancer screening disparities. Prev Med Rep. 2018;12:227– 32. https://doi.org/10.1016/j.pmedr.2018.10.009 Elsevier.

52. Rodrigues AL, Ball J, Ski C, Stewart S, Carrington MJ. A systematic review and meta-analysis of primary prevention programmes to improve cardio- metabolic risk in non-urban communities. Prev Med (Baltim). 2016;87:22–34. https://doi.org/10.1016/j.ypmed.2016.02.011 Elsevier Inc.

53. Starbird LE, DiMaina C, Sun CA, Han HR. A systematic review of interventions to minimize transportation barriers among people with chronic diseases. J Community Health. 2019;44:400–11. https://doi.org/10. 1007/s10900-018-0572-3 Springer US.

54. Blanchard AK, Prost A, Houweling TAJ. Effects of community health worker interventions on socioeconomic inequities in maternal and newborn health in low-income and middle- income countries: a mixed-methods systematic review; 2019. p. 1–11.

55. Kim K, Choi JS, Choi E, Nieman CL, Joo JH, Lin FR, et al. Effects of community-based health worker interventions to improve chronic disease

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management and care among vulnerable populations: a systematic review. Am J Public Health. 2016;106:3–28.

56. Jia L, Yuan B, Huang F, Lu Y, Garner P, Meng Q. Experiencia, intersubjetividad y existencia. Hacia una teoría-práctica de la Etnografía. Run Arch para las Ciencias del Hombre. 1994;21:347–80.

57. Tovar A, Renzaho AMN, Guerrero AD, Mena N, Ayala GX. A systematic review of obesity prevention intervention studies among immigrant populations in the US. Curr Obes Rep. 2014;3:206–22.

58. Gardner F, Leijten P, Mann J, Landau S, Harris V, Beecham J, et al. Could scale-up of parenting programmes improve child disruptive behaviour and reduce social inequalities? Using individual participant data meta-analysis to establish for whom programmes are effective and cost-effective. Public Health Res. 2017;5:1–144.

59. Goudet SM, Griffiths PL, Bogin BA, Madise NJ. Nutritional interventions for preventing stunting in children (0 to 5 years) living in urban slums in low and middle-income countries (LMIC). Cochrane Database Syst Rev. 2015; Available from: http://doi.wiley.com/10.1002/14651858.CD011695.

60. Skeie MS, Klock KS. Dental caries prevention strategies among children and adolescents with immigrant-or low socioeconomic backgrounds-do they work? A systematic review. BMC Oral Health. 2018;18:1–12.

61. Van Rijn RM, Carlier BE, Schuring M, Burdorf A. Work as treatment? The effectiveness of re-employment programmes for unemployed persons with severe mental health problems on health and quality of life: a systematic review and meta-analysis. Occup Environ Med. 2016;73:275–9.

62. Ashman AM, Brown LJ, Collins CE, Rollo ME, Rae KM. Factors associated with effective nutrition interventions for pregnant indigenous women: a systematic review. J Acad Nutr Diet. 2017;117:1222–1253.e2. https://doi.org/ 10.1016/j.jand.2017.03.012 Elsevier Inc.

63. Pinzón Flórez CE, Díaz-Quijano DM, Yáñez Álvarez I, Mesa DC. Effectiveness of community workers on preventive measures to maternal and child health in low and middle income countries: systematic review of the literature. Rev Salud Uninorte [Internet]. Scieloco. 2015;31:309–28. Available from: http://rcientificas.uninorte.edu.co/index.php/salud/article/view/7621/75 76.

64. Verhagen I, Steunenberg B, De Wit NJ, Ros WJG. Community health worker interventions to improve access to health care services for older adults from ethnic minorities: a systematic review. BMC Health Serv Res. 2014;14:1–8.

65. Brown T, Platt S, Amos A. Equity impact of European individual-level smoking cessation interventions to reduce smoking in adults: a systematic review; 2013. p. 551–6.

66. Brown T, Platt S, Amos A. Equity impact of interventions and policies to reduce smoking in youth: systematic review; 2014. p. 1–8.

67. Brown T, Platt S, Amos A. Equity impact of population-level interventions and policies to reduce smoking in adults: a systematic review. Drug Alcohol Depend. 2014;138:7–16. https://doi.org/10.1016/j.drugalcdep.2014.03.001 Elsevier Ireland Ltd.

68. Plamondon KM, Caxaj CS, Graham ID, Bottorff JL. Connecting knowledge with action for health equity: a critical interpretive synthesis of promising practices. Int J Equity Health. 2019;18:1–10.

69. Díez E, Peirò R. Intervenciones para disminuir las desigualdades en salud. Gac Sanit. 2004;18:158–67 scieloes. Available from: http://scielo.isciii.es/scielo. php?script=sci_arttext&pid=S0213-91112004000400025&nrm=iso.

70. Inequities and barriers in health systems. Pan Am. Heal. Organ. Available from: https://www.paho.org/salud-en-las-americas-2017/?p=59. Cited 2019 Nov 14.

71. Mazza D, Bairstow P, Buchan H, Chakraborty SP, Van Hecke O, Grech C, et al. Refining a taxonomy for guideline implementation: results of an exercise in abstract classification. Implement Sci. 2013;8:1.

72. Watkins K, Wood H, Schneider CR, Clifford R. Effectiveness of implementation strategies for clinical guidelines to community pharmacy: a systematic review. Implement Sci. 2015;10:151 Available from: http://implementationscience. biomedcentral.com/articles/10.1186/s13012-015-0337-7.

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Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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  • Abstract
    • Background
    • Objective
    • Methods
    • Results
    • Conclusion
  • Background
  • Methods
    • Criteria for considering studies for this overview of literature reviews
      • Inclusion criteria
      • Exclusion criteria
    • Search method for identification of information
    • Collection and synthesis of information
    • Quality assessment
  • Results
    • Evidence map
    • Delivery arrangements intervention
    • Financial arrangements intervention
    • Governance arrangements intervention
    • Implementation strategies
  • Discussion
    • Main findings
    • Findings by types of intervention
  • Conclusion
  • Supplementary information
  • Abbreviations
  • Acknowledgments
  • Disclaimer
  • Authors’ contributions
  • Funding
  • Availability of data and materials
  • Ethics approval and consent to participate
  • Consent for publication
  • Competing interests
  • Author details
  • References
  • Publisher’s Note

,

1374  |  Health Serv Res. 2019;54:1374–1388.

Health Services Research

wileyonlinelibrary.com/journal/hesr

1  | INTRODUC TION

Racial and ethnic differences in health, in which socially disadvantaged racial populations have worse health than whites, are large, pervasive across a broad range of outcomes, and persistent over time.1 They exist for the onset of disease, as well as the severity and course of illness. Socioeconomic status (SES)—whether measured by income, education, occupational status, or wealth—is a strong predictor of vari‐ ations in health and has often been viewed as the driver of racial ineq‐ uities in health. Research finds that although SES predicts variations in

health status within each racial group, racial disparities persist at every level of SES.2 There is a large and growing body of empirical evidence indicating self‐reports of discrimination are race‐related aspects of so‐ cial experience that can have negative effects on health. This paper provides an overview of research on self‐reported discrimination and health, as well as health care utilization. It begins by situating research on racial discrimination and health within the larger context of re‐ search on racism and health. Importantly, self‐reported experiences of discrimination are one mechanism by which racism affects health, and these exposures can be best understood and effectively addressed

DOI: 10.1111/1475‐6773.13222

S P E C I A L I S S U E : E X P E R I E N C E S O F D I S C R I M I N A T I O N I N A M E R I C A

Understanding how discrimination can affect health

David R. Williams PhD, MPH1,2  | Jourdyn A. Lawrence MPH1  | Brigette A. Davis MPH1 | Cecilia Vu MPH1

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. © 2019 The Authors. Health Services Research published by Wiley Periodicals, Inc. on behalf of Health Research and Educational Trust

1Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts 2Department of African and African American Studies, Department of Sociology, Harvard University, Cambridge, Massachusetts

Correspondence David R. Williams, PhD, MPH, Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA. Email: [email protected]

Funding information W.K. Kellogg Foundation, Grant/Award Number: P0131281

Abstract Background: To provide an overview of the empirical research linking self‐reports of racial discrimination to health status and health service utilization. Methods: A review of literature reviews and meta‐analyses published from January 2013 to 2019 was conducted using PubMed, PsycINFO, Sociological Abstracts, and Web of Science. Articles were considered for inclusion using the Preferred Reporting Items for Systematic Review and Meta‐Analyses (PRISMA) framework. Results: Twenty‐nine studies met the criteria for review. Both domestic and interna‐ tional studies find that experiences of discrimination reported by adults are adversely related to mental health and indicators of physical health, including preclinical in‐ dicators of disease, health behaviors, utilization of care, and adherence to medical regimens. Emerging evidence also suggests that discrimination can affect the health of children and adolescents and that at least some of its adverse effects may be ame‐ liorated by the presence of psychosocial resources. Conclusions: Increasing evidence indicates that racial discrimination is an emerging risk factor for disease and a contributor to racial disparities in health. Attention is needed to strengthen research gaps and to advance our understanding of the optimal interventions that can reduce the negative effects of discrimination.

K E Y W O R D S

discrimination, health, health disparities, mental health, racism

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WILLIAMS et AL.

within the context of the role of racism in health. The paper then high‐ lights key findings in this burgeoning literature.

2  | BACKGROUND AND THEORETIC AL FR AME WORK

Figure 1 illustrates the multiple components of racism and the ways in which these components can affect health. Racism is viewed as a dynamic societal system that is shaped by and reshapes other so‐ cial institutions such as the political, legal, and economic systems.3‐6 Central to racism, in the US context, is a hierarchical ideology that the dominant white group uses to categorize and rank social groups into races with whites being superior compared to other races. There are three major pathways that link racism to inequities in society and health. The first pathway by which racism operates is cultural racism.6 This refers to the embedding of the inferiority of blacks and other nonwhites into the belief systems, images, and norms of the larger culture that leads to widespread negative beliefs (stereotypes) and attitudes (prejudice) that devalue, marginalize, and subordinate nonwhite racial populations. Cultural racism creates a larger ideo‐ logical environment within which the system of racism can flourish. It initiates and sustains racial prejudice and negative racial stereo‐ types that can lessen support for egalitarian policies, trigger health‐ damaging psychological responses in stigmatized persons such as internalized racism and stereotype threat, and facilitate explicit and implicit biases that restrict access to desirable resources, including medical care.6

The second pathway is institutional or structural racism. We use these terms interchangeably to refer to societal structures and policies that reduce access of the socially stigmatized to desirable opportunities and resources in society.5 The system of racism devel‐ ops and sustains policies and structures that empower the dominant group to differentially allocate desirable societal opportunities and resources to racial groups regarded as inferior. Residential segre‐ gation is one example of an institutional mechanism of racism that adversely affects health in multiple ways.7,8 The forced removal and relocation of American Indians to reservations is another example of institutionalized isolation of a marginalized racial population. Segregation is a critical determinant of SES, as it reduces access to quality elementary and high school education, preparation for higher education, and access to employment opportunities. One na‐ tional study found that the elimination of segregation would erase black‐white differences in income, education, and unemployment, and reduce racial differences in single motherhood by two‐thirds.9 SES, in turn, is a strong predictor of variation in health and risk fac‐ tors that affect health. Segregation can also lead to increased expo‐ sure to multiple psychosocial, physical, and chemical stressors linked to neighborhood and housing conditions, including crime, violence, and air pollution. It can also affect access to and the quality of local services, ranging from medical care to municipal services.

The third pathway through which racism operates is through in‐ dividual‐level discrimination. Stigmatized racial groups experience

differential treatment (discrimination) directed at them by both social institutions and individuals. Considerable scientific evidence docu‐ ments the persistence of objectively assessed individual discrim‐ ination in contemporary society. A review of audit studies—those in which researchers carefully select, match, and train individuals to be equally qualified in every respect but to differ only in race— provide striking examples of contemporary racial discrimination.10 Discrimination has been documented in renting apartments, purchas‐ ing homes and cars, obtaining mortgages and medical care, applying for insurance, and hailing taxis. Such incidents of discrimination can lead to reduced access to a broad range of societal resources and opportunities. Figure 1 indicates that the persistence of stark racial inequities in multiple domains of society can confirm racial stereo‐ types and stigma, and thus serve to reinforce the system of racism. Moreover, the pathways by which racism affect are interrelated and mutually reinforcing.11

The lower panel of Figure 1 serves to further unpack how indi‐ vidual‐level discrimination can affect health. The focus here is on a subset of incidents of individual discrimination that is perceived by the individual. According to social stress theory, perceived discrim‐ ination is a type of stressor that, like other psychosocial stressors, is adversely related to a broad range of physical and mental health outcomes.12,13 A recent study, for example, documented that self‐re‐ ported experiences of discrimination are associated with neural func‐ tioning in ways that mirror patterns observed for other psychosocial stressors (eg, greater spontaneous amygdala activity and greater connectivity between the amygdala and other regions of the brain including the thalamus).14 The lower panel of Figure 1 delineates how discriminatory incidents of which the individual is aware can trigger appraisal and affective reactions that can be experienced as stressful life exposures, and they have a cascade of negative effects on health.15 They can lead to negative emotions that can adversely affect psychological well‐being, leading to symptoms of distress and increasing the risk of discrete psychiatric disorders. These negative emotions can also lead to biological dysregulation that can contrib‐ ute to indicators of subclinical disease and chronic physical illness.15 Coping with negative emotional states can also lead to increases in risky health behaviors, including declines in the utilization of and en‐ gagement with health care services. Figure 1 also acknowledges that in the face of exposure to discrimination, individuals and groups can respond in ways that can neutralize at least some of the negative effects of discrimination.

3  | METHODS

3.1 | Search strategy

Reviews were identified through a search of PubMed, PsycINFO, Sociological Abstracts, and Web of Science. Reviews were eligi‐ ble for inclusion if they were focused reviews or meta‐analyses, in English, published from January 2013 to the present, extend‐ ing the systematic review and meta‐analysis published by Paradies and colleagues.16 The following keywords were used: (racism* OR

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WILLIAMS et AL.

social discrimination*) OR (race* OR racial*) AND discriminat*)) AND (systematic*[sb] OR systematic*[ti] OR review*[ti] OR review*[sb] OR meta‐analysis*[ti]). The bibliographies of included studies were manually examined to identify additional reviews and meta‐analyses.

3.2 | Inclusion criteria

Two of us (JAL, CV) reviewed titles and abstracts of the traced articles followed by a full‐text review to check inclusion criteria using the Covidence systematic review software.17 A third author (DRW) acted as a tiebreaker regarding study selection and inclu‐ sion. A review was eligible for inclusion if it satisfies the following criteria: (a) evaluated studies examining self‐reported racial/eth‐ nic discrimination or studies that examined perceived discrimina‐ tion broadly, and (b) examined health or health‐related outcomes. This is consistent with the finding that adverse health effects of

discrimination are generally evident, irrespective of whether an incident is linked to a general perception of bias or unfair treat‐ ment or to discriminatory experiences attributed to race/ethnicity or other stigmatized social statuses.18,19 The outcomes were men‐ tal health, including positive psychological well‐being, indicators of physical health and risk factors, health behaviors, and health service utilization.

4  | RESULTS

Of 1189 articles screened, based on the criteria for inclusion, two authors (JAL, CV) completed title and abstract screening for 922 unique studies, identifying 32 for full‐text review. An additional study was identified for inclusion (n = 33) from a review of bibliog‐ raphies. A total of 29 reviews were extracted for analysis (Table 1).

F I G U R E 1   The House that Racism Built

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WILLIAMS et AL.

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om s

Po si

tiv e

(r =

.2 90

; 9 5%

C I:

0. 23

5, 0

.3 43

)

C ar

te r,

RT .,

et a

l (2

01 9)

M en

ta l a

nd p

hy si

ca l

he al

th 24

2 M

en ta

l: 20

0 Ph

ys ic

al :

48 C ul

tu ra

l: 88 Su

bs ta

nc e

us e:

2 3

C ro

ss ‐s

ec tio

na l

Lo ng

itu di

na l*  

A dv

er se

m en

ta l h

ea lth

(e g,

a nx

ie ty

, d ep

re ss

io n,

h os

til ‐

ity , a

ng er

, s tr

es s,

p sy

ch ol

og ic

al d

is tr

es s)

, p hy

si ca

l he

al th

(e g,

b lo

od p

re ss

ur e,

B M

I, se

lf‐ re

po rt

ed h

ea lth

), an

d su

bs ta

nc e

us e

(e g,

a lc

oh ol

, s m

ok in

g, p

ol ys

ub ‐

st an

ce u

se ) o

ut co

m es

O ve

ra ll:

p os

iti ve

(r =

.1 6,

P <

.0 1)

M en

ta l:

po si

tiv e

(r =

.2 1,

P <

.0 1)

Su bs

ta nc

e us

e: p

os iti

ve (r

= .1

6, P

< .0

1) Ph

ys ic

al : p

os iti

ve (r

= .0

7, P

< .0

1)

C ar

te r,

RT .,

et a

l (2

01 7)

M en

ta l a

nd p

hy si

ca l

he al

th 10

5 C

ro ss

‐s ec

tio na

l Lo

ng itu

di na

l*   A

dv er

se m

en ta

l h ea

lth , p

hy si

ca l h

ea lth

, a nd

s ub

st an

ce

us e

O ve

ra ll:

p os

iti ve

(r =

.1 7;

9 5%

C I:

0. 15

, 0.

20 )

M en

ta l:

po si

tiv e

(r =

.2 0;

9 5%

C I:

0. 17

, 0 .2

4) Ph

ys ic

al : p

os iti

ve (r

= .0

9; 9

5% C

I: 0.

03 ,

0. 14

) Su

bs ta

nc e

us e:

n ul

l ( r =

.1 2;

9 5%

C I:

−0 .0

2,

0. 25

)

de F

re ita

s, D

F. , e

t a l

(2 01

8) M

en ta

l h ea

lth 51

C ro

ss ‐s

ec tio

na l

Lo ng

itu di

na l*  

Ps yc

ho lo

gi ca

l d is

tu rb

an ce

, d ep

re ss

io n,

a nx

ie ty

, ps

yc ho

si s,

p er

ce iv

ed s

tr es

s, e

xt er

na liz

in g

be ha

vi or

, se

lf‐ es

te em

, p os

iti ve

e va

lu at

io n

of li

fe , s

el f‐

ef fic

ac y,

w

el l‐b

ei ng

p sy

ch ol

og ic

al a

da pt

at io

n

O ve

ra ll:

p os

iti ve

(r =

.1 7;

9 5%

C I:

0. 15

, 0.

20 )

M en

ta l:

po si

tiv e

(r =

.2 0;

9 5%

C I:

0. 17

, 0 .2

4) Ph

ys ic

al : p

os iti

ve (r

= .0

9; 9

5% C

I: 0.

03 ,

0. 14

) Su

bs ta

nc e

us e:

n ul

l ( r =

.1 2;

9 5%

C I:

−0 .0

2,

0. 25

)

H op

ki ns

, P D

., Sh

oo k,

N

J. (2

01 7)

A nx

ie ty

24 C

ro ss

‐s ec

tio na

l G

en er

al a

nx ie

ty d

is or

de r o

r s oc

ia l a

nx ie

ty d

is or

de r

Po si

tiv e:

1 00

% (n

= 3

) O

ne s

tu dy

fo un

d a

po si

tiv e

as so

ci at

io n

w ith

g en

er al

a nx

ie ty

d is

or de

r a m

on g

a sa

m pl

e of

o nl

y A

fr ic

an A

m er

ic an

s

Jo ne

s, K

P. , e

t a l

(2 01

6) M

en ta

l a nd

p hy

si ca

l he

al th

90 O

f t he

4 4

pr im

ar y

sa m

pl es

ob

ta in

ed , 4

/4 4

w er

e fr

om

ex pe

rim en

ta l s

tu di

es

Ps yc

ho lo

gi ca

l h ea

lth , p

hy si

ca l h

ea lth

Po si

tiv e:

p hy

si ca

l h ea

lth (r

= .1

9; 9

5% C

I: 0.

07 ‐0

.2 1)

; p sy

ch ol

og ic

al h

ea lth

(r =

.3 0;

95

% C

I: 0.

15 ‐0

.3 6)

K irk

in is

, K .,

et a

l (2

01 8)

Tr au

m a

28 p

ap er

s 44

a ss

o‐ ci

at io

ns

C ro

ss ‐s

ec tio

na l:

93 %

(n =

2 6)

Lo ng

itu di

na l:

7% (n

= 2

) PT

SD , d

is so

ci at

io n,

o th

er m

ea su

re s

of tr

au m

a, a

nd

ra ce

‐b as

ed tr

au m

at ic

s tr

es s

sy m

pt om

s Po

si tiv

e: 7

0% (3

1/ 44

a ss

oc ia

tio ns

)

Le w

is e

t a l (

20 15

) M

en ta

l d is

or de

rs 12

C ro

ss ‐s

ec tio

na l

D SM

‐I V

d is

or de

rs (d

ep re

ss io

n, a

nx ie

ty , e

at in

g,

ps yc

ho tic

) Po

si tiv

e as

so ci

at io

n w

ith d

is or

de rs

In ve

rs e

as so

ci at

io n

w ith

d ep

re ss

io n,

a nx

i‐ et

y fo

r A si

an im

m ig

ra nt

s

(C on

tin ue

s)

14756773, 2019, S2, D ow

nloaded from https://onlinelibrary.w

iley.com /doi/10.1111/1475-6773.13222 by Jasm

ine Sm ith – Saint T

hom as U

niversity , W iley O

nline L ibrary on [01/07/2024]. See the T

erm s and C

onditions (https://onlinelibrary.w iley.com

/term s-and-conditions) on W

iley O nline L

ibrary for rules of use; O A

articles are governed by the applicable C reative C

om m

ons L icense

1378  |     Health Services Research

WILLIAMS et AL.

D is

cr im

in at

io n

st ud

y Fo

cu s

N o.

p ap

er s

in cl

ud ed

St ud

y de

si gn

H ea

lth o

ut co

m es

Fi nd

in gs

Pa ra

di es

, Y .,

et a

l (2

01 5)

M en

ta l a

nd p

hy si

ca l

he al

th 29

3 C

ro ss

‐s ec

tio na

l: 89

.8 %

Lo ng

itu di

na l:

9. 0%

O th

er : 1

.2 %

N eg

at iv

e m

en ta

l h ea

lth (i

e, d

ep re

ss io

n, d

is tr

es s,

s tr

es s,

an

xi et

y, in

te rn

al iz

in g,

n eg

at iv

e af

fe ct

, P TS

D , s

om a‐

tiz at

io n,

s ui

ci de

id ea

tio n/

a tt

em pt

s, o

th er

m en

ta l

he al

th s

ym pt

om s,

g en

er al

m en

ta l h

ea lth

, o ve

ra ll

ne ga

tiv e

m en

ta l h

ea lth

); po

si tiv

e m

en ta

l h ea

lth (i

e,

se lf‐

es te

em , c

on tr

ol , l

ife s

at is

fa ct

io n,

p os

iti ve

a ff

ec t,

w el

l‐b ei

ng , o

ve ra

ll po

si tiv

e m

en ta

l h ea

lth );

ph ys

ic al

he

al th

(i e,

B P,

h ea

rt c

on di

tio ns

, o ve

rw ei

gh t,

di ab

et es

, m

is c.

); ge

ne ra

l h ea

lth

N eg

at iv

e: n

eg at

iv e

m en

ta l h

ea lth

(r =

− .2

3;

95 %

C I:

−0 .2

4, −

0. 21

); po

si tiv

e m

en ta

l he

al th

(r =

− .1

3; 9

5% C

I: −0

.1 6,

− 0.

10 );

ge ne

ra l h

ea lth

(r =

− .1

3; 9

5% C

I: −0

.1 8,

−0

.0 9)

; p hy

si ca

l h ea

lth (r

= −

.0 9;

9 5%

C I:

−0 .1

2, −

0. 06

)

Po tt

er , L

N .,

et a

l (2

01 9)

D ai

ly m

en ta

l h ea

lth 25

Lo ng

itu di

na l (

da ily

d ia

ry

st ud

ie s)

Po or

m en

ta l h

ea lth

in d

ai ly

li fe

(e g,

d ep

re ss

iv e

sy m

p‐ to

m s,

n eg

at iv

e af

fe ct

, s om

at ic

s ym

pt om

s, a

ct iv

e co

pi ng

)

Po si

tiv e:

p oo

r m en

ta l h

ea lth

(1 0/

11 ; 9

1% )

Sc hm

itt , M

T. , e

t a l

(2 01

4) Ps

yc ho

lo gi

ca l

w el

l‐b ei

ng 32

8 fo

r th

e fir

st

re se

ar ch

qu

es tio

n an

d 54

fo

r t he

se

co nd

C ro

ss ‐s

ec tio

na l a

nd lo

ng i‐

tu di

na l f

or th

e fir

st m

et a‐

an al

ys is

a nd

e xp

er im

en ta

l st

ud ie

s on

ly fo

r t he

s ec

on d

m et

a‐ an

al ys

is

Ps yc

ho lo

gi ca

l w el

l b ei

ng , b

ro ad

ly c

on st

ru ct

ed (i

e,

m oo

d, s

el f‐

es te

em , a

nx ie

ty , d

ep re

ss io

n, li

fe s

at is

fa c‐

tio n,

a ff

ec t,

ot he

r m ea

su re

s of

m en

ta l h

ea lth

)

N eg

at iv

e: p

sy ch

ol og

ic al

w el

l‐b ei

ng

(r =

−. 21

; 9 5%

C I:

−0 .2

2, −

0. 19

)

Tr ia

na , M

C .,

et a

l (2

01 5)

M en

ta l a

nd p

hy si

ca l

he al

th 79

C ro

ss ‐s

ec tio

na l

Lo ng

itu di

na l*  

Ps yc

ho lo

gi ca

l h ea

lth (i

e, s

tr es

s, m

en ta

l h ea

lth , a

nx ie

ty ,

ne ga

tiv e

af fe

ct , s

el f‐

es te

em , l

ife s

at is

fa ct

io n,

a nd

de

pr es

si on

); ph

ys ic

al h

ea lth

(i e,

b lo

od p

re ss

ur e,

b od

ily

pa in

, g en

er al

p hy

si ca

l h ea

lth , i

lln es

s, d

ru g

or a

lc oh

ol

us e)

N eg

at iv

e: p

sy ch

ol og

ic al

h ea

lth (r

= −

.1 2,

ρ

= −0

.1 4)

; p hy

si ca

l h ea

lth (r

= −

.0 6,

ρ

= −0

.0 7)

Po si

tiv e:

c op

in g

be ha

vi or

(r =

.1 7,

ρ =

0 .2

0)

V in

es , A

I., e

t a l (

20 17

) M

en ta

l h ea

lth 85

C ro

ss ‐s

ec tio

na l

Lo ng

itu di

na l*  

M en

ta l h

ea lth

w as

n ot

s pe

ci fie

d, b

ut in

cl ud

es P

TS D

, de

pr es

si on

. m ed

ia to

rs /

co nf

ou nd

er s:

a gg

re ss

io n,

co

pi ng

& p

er so

na lit

y, in

te rn

al iz

ed p

sy ch

re sp

on se

(e g,

se

lf‐ es

te em

), ex

te rn

al s

up po

rt iv

e bu

ff er

s

C on

di tio

na l/m

ix ed

: n o

pe rc

en ta

ge b

re ak

‐ do

w n

of tr

en ds

Ph ys

ic al

h ea

lth

Be rn

ar do

, C D

., et

a l

(2 01

7) A

di po

si ty

10 Lo

ng itu

di na

l: 10

0% W

ei gh

t c ha

ng e;

w ai

st c

irc um

fe re

nc e

ch an

ge ; B

M I

ch an

ge ; b

ec om

e ob

es e;

re m

ai n

ob es

e W

ei gh

t c ha

ng e:

p os

iti ve

W ai

st c

irc um

fe re

nc e

ch an

ge : 1

p os

iti ve

, 3

nu ll

BM I c

ha ng

e: 2

p os

iti ve

, 2 n

ul l

Be co

m e

ob es

e: p

os iti

ve Re

m ai

n ob

es e:

n ul

l

TA B

LE 1

  (C

on tin

ue d)

(C on

tin ue

s)

14756773, 2019, S2, D ow

nloaded from https://onlinelibrary.w

iley.com /doi/10.1111/1475-6773.13222 by Jasm

ine Sm ith – Saint T

hom as U

niversity , W iley O

nline L ibrary on [01/07/2024]. See the T

erm s and C

onditions (https://onlinelibrary.w iley.com

/term s-and-conditions) on W

iley O nline L

ibrary for rules of use; O A

articles are governed by the applicable C reative C

om m

ons L icense

     |  1379 Health Services Research

WILLIAMS et AL.

D is

cr im

in at

io n

st ud

y Fo

cu s

N o.

p ap

er s

in cl

ud ed

St ud

y de

si gn

H ea

lth o

ut co

m es

Fi nd

in gs

Bl ac

k, L

L. , e

t a l (

20 15

) Ph

ys ic

al h

ea lth

19 C

ro ss

‐s ec

tio na

l Lo

ng itu

di na

l*   H

ea rt

d is

ea se

ri sk

fa ct

or s

(ie , C

RP (C

‐r ea

ct iv

e pr

ot ei

n) ;

co ro

na ry

c al

ci um

p os

iti ve

s ta

tu s;

IM T

(c ar

ot id

in

tim a‐

m ed

ia th

ic kn

es s)

; a rt

er ia

l p la

qu e;

c or

on ar

y ar

te ry

c al

ci fic

at io

n) ; b

lo od

p re

ss ur

e (a

nd in

ci de

nc e

of

hy pe

rt en

si on

); ad

ve rs

e bi

rt h

ou tc

om es

; c an

ce r/

tu m

or

in ci

de nc

e; w

ei gh

t c ha

ng e

(a nd

b od

y fa

t d is

tr ib

u‐ tio

n) ; o

th er

o ut

co m

es (i

e, a

ll‐ ca

us e

m or

ta lit

y (A

C M

); Ep

st ei

n‐ Ba

rr v

iru s

re ac

tiv at

io n

(E BV

); fr

eq ue

nc y

of

co m

m on

c ol

ds /p

hy si

ca l i

lln es

se s

(c ol

d) )

H ea

rt d

is ea

se ri

sk fa

ct or

s: n

ul l (

3/ 3)

Bl oo

d pr

es su

re : n

ul l (

3/ 3)

A dv

er se

b irt

h ou

tc om

es : n

ul l (

1/ 6)

; p os

iti ve

(5

/6 )

C an

ce r/

tu m

or in

ci de

nc e:

c on

di tio

na l o

n co

nt ex

t o f d

is cr

im in

at io

n (1

/2 );

po si

tiv e

(1 /2

) W

ei gh

t c ha

ng e:

p os

iti ve

(1 /2

); ne

ga tiv

e (1

/2 )

O th

er h

ea lth

o ut

co m

es : A

C M

: n ul

l ( 1/

1) ;

EB V:

p os

iti ve

(1 /1

); C

ol d:

p os

iti ve

(1 /1

)

Bu ss

e, D

., et

a l (

20 17

) St

re ss

27 Ex

pe rim

en ta

l: 37

% (n

= 1

0) Lo

ng itu

di na

l: 7%

(n =

2 )

C ro

ss ‐s

ec tio

na l:

56 %

(n =

1 5)

H yp

ot ha

la m

ic ‐p

itu ita

ry ‐a

dr en

al (H

PA ) a

xi s:

s al

iv ar

y an

d aw

ak en

in g

co rt

is ol

; d eh

yd ro

ep ia

nd ro

st er

on e

(D H

EA );

co rt

ic ot

ro pi

n‐ re

le as

in g

ho rm

on e

Sa liv

ar y

co rt

is ol

: 1 /2

p os

iti ve

; 1 /2

n eg

at iv

e C

or tis

ol a

w ak

en in

g re

sp on

se : 1

/1 p

os iti

ve N

ul l:

co rt

ic ot

ro pi

n‐ re

le as

in g

ho rm

on e;

af

te rn

oo n

D H

EA

D ol

ez sa

r, C

M .,

et a

l (2

01 4)

H yp

er te

ns io

n 44

C ro

ss ‐s

ec tio

na l,

lo ng

itu di

na l,

ex pe

rim en

ta l d

es ig

ns *  

H yp

er te

ns iv

e st

at us

; b lo

od p

re ss

ur e

Po si

tiv e:

h yp

er te

ns iv

e st

at us

(z =

0 .0

5;

95 %

C I:

0. 01

, 0 .0

9) , n

ig ht

tim e

am bu

la to

ry

bl oo

d pr

es su

re (z

= 0

.1 5;

9 5%

C I:

0. 04

, 0.

19 )

N ul

l: bl

oo d

pr es

su re

(s ys

to lic

: z =

0 .0

1; 9

5%

C I:

−0 .0

1, 0

.0 3)

(d ia

st ol

ic : z

= 0

.2 ; 9

5% C

I: −0

.0 1,

0 .0

3)

Ko ro

us , K

M .,

et a

l (2

01 7)

C or

tis ol

16 Ex

pe rim

en ta

l: 25

% (n

= 4

) N

on ex

pe rim

en ta

l: 75

%

(n =

1 2)

C ur

re nt

c or

tis ol

, d iu

rn al

c or

tis ol

, c or

tis ol

re ac

tiv ity

, av

er ag

e co

rt is

ol Po

si tiv

e (r

= .0

40 ; 9

5% C

I: 0.

03 8‐

0. 11

7)

Le w

is , T

T. , e

t a l

(2 01

4) C

ar di

ov as

cu la

r he

al th

38 26

c ro

ss ‐s

ec tio

na l

12 lo

ng itu

di na

l/c oh

or t o

r un

sp ec

ifi ed

Li fe

st yl

e fa

ct or

s (e

g, s

m ok

in g,

p hy

si ca

l a ct

iv ity

, a lc

oh ol

in

ta ke

); hy

pe rt

en si

on a

nd b

lo od

p re

ss ur

e; b

io m

ea s‐

ur es

(e g,

o be

si ty

, C ‐r

ea ct

iv e

pr ot

ei n,

c or

on ar

y ar

te ry

oc

cl us

io n)

C on

di tio

na l:

lif es

ty le

fa ct

or s;

re st

in g

bl oo

d pr

es su

re /h

yp er

te ns

io n;

b io

m ea

su re

s Po

si tiv

e: a

m bu

la to

ry b

lo od

p re

ss ur

e

Lo ck

w oo

d, K

G .,

et a

l (2

01 8)

C ar

di ov

as cu

la r

he al

th 21

C ro

ss ‐s

ec tio

na l,

lo ng

itu di

na l,

ex pe

rim en

ta l d

es ig

ns *  

C ar

di ov

as cu

la r r

ea ct

iv ity

(i e,

b lo

od p

re ss

ur e,

h ea

rt

ra te

, h ea

rt ra

te v

ar ia

bi lit

y, to

ta l p

er ip

he ra

l r es

is ta

nc e,

pr

ee je

ct io

n pe

rio d,

c ar

di ac

o ut

pu t);

H PA

a xi

s (ie

, di

ur na

l c or

tis ol

s lo

pe );

im m

un e

(ie , C

‐r ea

ct iv

e pr

ot ei

n,

in te

rle uk

in , m

on oc

yt e

ch em

oa tt

ra ct

an t p

ro te

in ,

tu m

or n

ec ro

si s

fa ct

or , i

nt er

fe ro

n) , n

eu ra

l a ct

iv ity

G en

er al

ly p

os iti

ve a

ss oc

ia tio

ns fo

r C V

D

re ac

tiv ity

, f la

tt er

d iu

rn al

c or

tis ol

s lo

pe s,

sy

st em

ic in

fla m

m at

io n,

a nd

n eu

ra l a

ct iv

ity

in th

e br

ai n

re gi

on s

co ns

is te

nt w

ith e

xp o‐

su re

to p

sy ch

os oc

ia l s

tr es

s

TA B

LE 1

  (C

on tin

ue d)

(C on

tin ue

s)

14756773, 2019, S2, D ow

nloaded from https://onlinelibrary.w

iley.com /doi/10.1111/1475-6773.13222 by Jasm

ine Sm ith – Saint T

hom as U

niversity , W iley O

nline L ibrary on [01/07/2024]. See the T

erm s and C

onditions (https://onlinelibrary.w iley.com

/term s-and-conditions) on W

iley O nline L

ibrary for rules of use; O A

articles are governed by the applicable C reative C

om m

ons L icense

1380  |     Health Services Research

WILLIAMS et AL.

D is

cr im

in at

io n

st ud

y Fo

cu s

N o.

p ap

er s

in cl

ud ed

St ud

y de

si gn

H ea

lth o

ut co

m es

Fi nd

in gs

H ea

lth b

eh av

io rs

D es

al u,

J M

., et

a l

(2 01

9) A

lc oh

ol u

se 27

C ro

ss ‐s

ec tio

na l:

85 %

Lo ng

itu di

na l:

15 %

C on

su m

pt io

n; b

in ge

/h ea

vy d

rin ki

ng ; a

t‐ ris

k dr

in k‐

in g;

a lc

oh ol

u se

d is

or de

rs (A

U D

); ne

ga tiv

e dr

in ki

ng

co ns

eq ue

nc es

Po si

tiv e:

c on

su m

pt io

n (r

= .1

2; 9

5% C

I: 0.

08 , 0

.1 7)

; b in

ge d

rin ki

ng (r

= .0

6; 9

5%

C I:

0. 02

, 0 .1

0) ; a

t‐ ris

k dr

in ki

ng (r

= .1

4;

95 %

C I:

0. 06

, 0 .2

3) ; n

eg at

iv e

dr in

ki ng

co

ns eq

ue nc

es (r

= .2

5; 9

5% C

I: 0.

09 , 0

.4 2)

N ul

l: AU

D (r

= .1

0; 9

5% C

I: −0

.0 1,

0 .2

0)

G ilb

er t,

PA .,

et a

l (2

01 6)

A lc

oh ol

u se

97 C

ro ss

‐s ec

tio na

l: 80

% Lo

ng itu

di na

l: 18

% Ex

pe rim

en ta

l: 2%

A lc

oh ol

‐r el

at ed

o ut

co m

es (n

um be

r o f d

rin ks

p er

m

on th

, p as

t 2 w

ee ks

o f b

in ge

d rin

ki ng

, p as

t w ee

k/

30 d

ay s/

y ea

r o f a

lc oh

ol u

se , p

as t 2

m on

th s

of

w ee

ke nd

d rin

ki ng

, d rin

ki ng

‐r el

at ed

p ro

bl em

s, p

as t‐

ye ar

a lc

oh ol

u se

, p as

t 3 0/

90 d

ay s

of b

in ge

d rin

ki ng

, dr

in ki

ng d

eb ut

, a lc

oh ol

u se

d is

or de

r, lif

et im

e al

co ho

l us

e, h

az ar

do us

d rin

ki ng

, c ur

re nt

a lc

oh ol

u se

, a lc

oh ol

us

e di

so rd

er )

Po si

tiv e:

4 5%

(n =

1 4)

N ul

l: 32

% (n

= 1

0) C

on di

tio na

l: 23

% (n

= 7

)

Sl op

en , N

., et

a l

(2 01

6) Sl

ee p

17 Lo

ng itu

di na

l: 29

% (n

= 5

[1

da ily

d ia

ry ])

C ro

ss ‐s

ec tio

na l:

71 %

(n =

1 2)

Po or

s le

ep o

ut co

m es

(i e,

d ur

at io

n, e

ff ic

ie nc

y, s

le ep

la ‐

te nc

y, w

ak e

af te

r s le

ep o

ns et

, R EM

s le

ep , l

ig ht

s le

ep ,

st ag

e 3

an d

4 sl

ee p)

Po si

tiv e:

s le

ep d

iff ic

ul tie

s or

in so

m ni

a (1

6/ 16

; 1 00

% );

po or

s le

ep q

ua lit

y (7

/7 ;

10 0%

)

H ea

lth c

ar e

ut ili

za tio

n

Be n,

J .,

et a

l ( 20

17 )

H ea

lth c

ar e

ut ili

za tio

n Re

vi ew

: 8 3

M et

a‐ an

al ‐

ys is

: 5 9

C ro

ss ‐s

ec tio

na l:

96 .4

% Lo

ng itu

di na

l: 3.

6% H

ea lth

s er

vi ce

e xp

er ie

nc es

[H SE

] ( ie

, c om

m un

ic at

io n;

sa

tis fa

ct io

n/ pe

rc ei

ve d

qu al

ity o

f c ar

e; tr

us t;

so m

e co

m bi

na tio

n of

th es

e) H

ea lth

s er

vi ce

u til

iz at

io n

[H SU

] ( ie

, h av

in g

ex am

in a‐

tio ns

, s cr

ee ni

ng s,

c he

ck s,

e tc

; u pt

ak e

of tr

ea tm

en ts

, m

ed ic

at io

ns , v

ac ci

na tio

ns ; h

os pi

ta l v

is its

a nd

a dm

is ‐

si on

s to

E Rs

; d el

ay in

g he

al th

c ar

e; in

su ra

nc e

co ve

r‐ ag

e; s

om e

co m

bi na

tio n

of th

es e)

H SE

: n eg

at iv

e H

SU : c

on di

tio na

l o n

ou tc

om e,

n eg

at iv

el y

as so

ci at

ed w

ith u

pt ak

e of

tr ea

tm en

ts a

nd

se ek

in g

he al

th c

ar e;

n o

as so

ci at

io n

fo r t

he

ot he

r m ea

su re

s

G as

to n,

G B.

, e t a

l (2

01 3)

H IV

tr ea

tm en

t ad

he re

nc e

16 Q

ua lit

at iv

e A

nt ire

tr ov

ira l m

ed ic

at io

n or

m ed

ic al

s el

f‐ ca

re

ad he

re nc

e D

is cr

im in

at io

n se

rv es

a s

a ba

rr ie

r t o

m ed

i‐ ca

l c ar

e, p

oo re

r s el

f‐ ra

te d

he al

th , l

ow er

se

lf‐ ca

re a

dh er

en ce

, l es

s sa

tis fa

ct io

n w

ith

ca re

, g re

at er

d ep

re ss

iv e

sy m

pt om

s

TA B

LE 1

  (C

on tin

ue d)

(C on

tin ue

s)

14756773, 2019, S2, D ow

nloaded from https://onlinelibrary.w

iley.com /doi/10.1111/1475-6773.13222 by Jasm

ine Sm ith – Saint T

hom as U

niversity , W iley O

nline L ibrary on [01/07/2024]. See the T

erm s and C

onditions (https://onlinelibrary.w iley.com

/term s-and-conditions) on W

iley O nline L

ibrary for rules of use; O A

articles are governed by the applicable C reative C

om m

ons L icense

     |  1381 Health Services Research

WILLIAMS et AL.

D is

cr im

in at

io n

st ud

y Fo

cu s

N o.

p ap

er s

in cl

ud ed

St ud

y de

si gn

H ea

lth o

ut co

m es

Fi nd

in gs

C hi

ld re

n an

d ad

ol es

ce nt

s

A lh

us en

, J L.

, e t a

l (2

01 6)

M at

er na

l a nd

c hi

ld

he al

th 15

Q ua

lit at

iv e:

2 7%

(n =

4 )

Q ua

nt ita

tiv e:

7 3%

(n =

1 1)

Pr et

er m

b irt

h; lo

w b

irt h

w ei

gh t;

sm al

l‐f or

‐g es

ta tio

na l‐

ag e

ne w

bo rn

; a cc

es s

to a

nd q

ua lit

y of

p re

na ta

l c ar

e Pr

et er

m b

irt h

(q ua

nt s

tu di

es : 5

): 3/

5 nu

ll;

2/ 5

po si

tiv e

Lo w

b irt

h w

ei gh

t ( qu

an t s

tu di

es : 3

): 2/

3 po

si tiv

e; 1

/3 n

ul l

Sm al

l‐f or

‐g es

ta tio

na l‐a

ge : p

os iti

ve In

iti at

io n

of p

re na

ta l c

ar e

(q ua

nt s

tu di

es :1

): nu

ll

Be nn

er A

D . e

t a l

(2 01

8) So

ci oe

m ot

io na

l, ac

ad em

ic , a

nd

be ha

vi or

al h

ea lth

21 4

C ro

ss ‐s

ec tio

na l

Lo ng

itu di

na l*  

So ci

oe m

ot io

na l w

el l‐b

ei ng

(d ep

re ss

io n,

in te

rn al

iz in

g sy

m pt

om s,

p os

iti ve

w el

l‐b ei

ng , s

el f‐

es te

em );

ac a‐

de m

ic (a

ch ie

ve m

en t,

sc ho

ol e

ng ag

em en

t, m

ot iv

at io

n) ;

be ha

vi or

al (e

xt er

na liz

in g

be ha

vi or

s, ri

sk y

se x

be ha

v‐ io

rs , s

ub st

an ce

u se

, d ev

ia nt

p ee

r a ff

ili at

io ns

)

Ra ci

al d

is cr

im in

at io

n w

as p

os iti

ve ly

a s‐

so ci

at ed

w ith

d ep

re ss

io n,

in te

rn al

iz in

g sy

m pt

om s,

e xt

er na

liz in

g be

ha vi

or s,

ri sk

y se

x be

ha vi

or s,

s ub

st an

ce u

se , d

ev ia

nt

pe er

a ff

ili at

io ns

a nd

n eg

at iv

el y

as so

ci at

ed

w ith

s el

f‐ es

te em

, a ca

de m

ic a

ch ie

ve m

en t,

sc ho

ol e

ng ag

em en

t, ac

ad em

ic m

ot iv

at io

n

H ea

rd G

ar ris

N J

et a

l (2

01 8)

C hi

ld h

ea lth

(i nf

an t

he al

th o

ut co

m es

, m

en ta

l h ea

lth ,

so ci

oe m

ot io

na l

he al

th , h

ea lth

c ar

e ut

ili za

tio n,

p hy

si ca

l he

al th

, c og

ni tiv

e de

ve lo

pm en

t, an

d yo

ut h

he al

th )

30 C

as e‐

co nt

ro l (

10 %

), cr

os s‐

se c‐

tio na

l ( 27

% ),

an d

lo ng

itu di

na l

(5 3%

)

In fa

nt h

ea lth

o ut

co m

es (p

re te

rm b

irt h,

c or

tis ol

re ac

tiv ‐

ity , b

irt hw

ei gh

t); m

en ta

l h ea

lth (d

ep re

ss iv

e sy

m p‐

to m

s, a

nx ie

ty , s

ub st

an ce

u se

, w el

l‐b ei

ng , a

nx ie

ty );

so ci

oe m

ot io

na l h

ea lth

(e xt

er na

liz in

g an

d in

te rn

al iz

in g

be ha

vi or

, s oc

io em

ot io

na l d

iff ic

ul tie

s, s

el f‐

es te

em ,

po si

tiv e

be ha

vi or

); he

al th

c ar

e ut

ili za

tio n

(fr eq

ue nc

y of

s ic

k ch

ild v

is its

); ph

ys ic

al h

ea lth

(B M

I, ge

ne ra

l c hi

ld

ill ne

ss , w

ei gh

t f or

a ge

); co

gn iti

ve d

ev el

op m

en t (

sp at

ia l

ab ili

ty );

yo ut

h he

al th

o ut

co m

es (d

ep re

ss iv

e)

C ar

eg iv

er ra

ci al

d is

cr im

in at

io n

is a

ss oc

ia te

d w

ith p

re te

rm b

irt h

in 4

/7 s

tu di

es , c

or tis

ol

re ac

tiv ity

in 1

/1 s

tu dy

, a nd

b irt

hw ei

gh t

in 6

/9 s

tu di

es o

bs er

vi ng

c hi

ld o

ut co

m es

. W

ith in

p os

tb irt

h, c

ar eg

iv er

p at

hw ay

: c ar

‐ eg

iv er

ra ci

al d

is cr

im in

at io

n is

a ss

oc ia

te d

w ith

d ep

re ss

iv e

sy m

pt om

s in

1 /7

s tu

di es

, an

xi et

y in

1 /3

, s ub

st an

ce u

se in

1 /2

, w

el l‐b

ei ng

in 1

/1 , d

ep re

ss iv

e sy

m pt

om s

in 1

/7 , e

xt er

na liz

in g

in 7

/1 0,

in te

rn al

iz in

g be

ha vi

or in

4 /7

, s oc

io em

ot io

na l d

iff ic

ul ‐

tie s

in 2

/2 , s

el f‐

es te

em in

1 /1

, p os

iti ve

b e‐

ha vi

or in

1 /4

, f re

qu en

cy o

f s ic

k ch

ild v

is its

in

1 /2

, B M

I i n

1/ 1,

g en

er al

c hi

ld il

ln es

s in

1 /2

, w ei

gh t f

or a

ge in

1 /1

, a nd

s pa

tia l

co gn

iti ve

a bi

lit y

in 1

/1 in

c hi

ld o

ut co

m es

; w

ith in

p os

tb irt

h, o

th er

p at

hw ay

: c ar

eg iv

er

ra ci

al d

is cr

im in

at io

n w

as a

ss oc

ia te

d w

ith

de pr

es si

ve s

ym pt

om s

in 1

/2 s

tu di

es in

ch

ild o

ut co

m es

TA B

LE 1

  (C

on tin

ue d)

(C on

tin ue

s)

14756773, 2019, S2, D ow

nloaded from https://onlinelibrary.w

iley.com /doi/10.1111/1475-6773.13222 by Jasm

ine Sm ith – Saint T

hom as U

niversity , W iley O

nline L ibrary on [01/07/2024]. See the T

erm s and C

onditions (https://onlinelibrary.w iley.com

/term s-and-conditions) on W

iley O nline L

ibrary for rules of use; O A

articles are governed by the applicable C reative C

om m

ons L icense

1382  |     Health Services Research

WILLIAMS et AL.

D is

cr im

in at

io n

st ud

y Fo

cu s

N o.

p ap

er s

in cl

ud ed

St ud

y de

si gn

H ea

lth o

ut co

m es

Fi nd

in gs

Pr ie

st N

. e t a

l ( 20

13 )

M en

ta l a

nd p

hy si

ca l

he al

th (n

eg a‐

tiv e

an d

po si

tiv e

m en

ta l h

ea lth

, ne

ga tiv

e an

d po

si ‐

tiv e

ge ne

ra l h

ea lth

, ph

ys ic

al h

ea lth

, ne

ga tiv

e an

d po

si ‐

tiv e

pr eg

na nc

y,

be ha

vi or

p ro

bl em

s,

w el

l‐b ei

ng , h

ea lth

‐ re

la te

d be

ha v‐

io rs

, h ea

lth c

ar e

ut ili

za tio

n)

12 1

2% C

as e‐

co nt

ro l,

78 %

C

ro ss

‐s ec

tio na

l, an

d 20

%

lo ng

itu di

na l

N eg

at iv

e m

en ta

l h ea

lth (a

nx ie

ty , d

ep re

ss io

n, d

is tr

es s,

ho

pe le

ss ne

ss , l

on el

in es

s, n

eg at

iv e

se lf‐

es te

em ,

po st

tr au

m at

ic s

tr es

s, p

sy ch

ol og

ic al

d is

tr es

s, s

oc ia

l an

d em

ot io

na l d

iff ic

ul tie

s, s

om at

ic s

ym pt

om s,

s tr

es s,

su

ic id

e, m

en ta

l h ea

lth p

ro bl

em s)

; p os

iti ve

m en

ta l

he al

th (e

m ot

io na

l a dj

us tm

en t,

ps yc

ho lo

gi ca

l a dj

us t‐

m en

t, ps

yc ho

lo gi

ca l a

da pt

io n,

re si

lie nc

e, s

el f‐

es te

em ,

se lf‐

w or

th , s

oc ia

l a nd

a da

pt iv

e fu

nc tio

ni ng

); ph

ys ic

al

he al

th (b

lo od

p re

ss ur

e, c

hi ld

ho od

il ln

es se

s, c

om ‐

m on

c hi

ld ho

od il

ln es

se s,

in su

lin re

si st

an ce

, o be

si ty

, ph

ys ic

al s

ym pt

om s)

; g en

er al

h ea

lth ; n

eg at

iv e

ge ne

ra l

he al

th (f

ee lin

g un

ha pp

y, fe

el in

g un

he al

th y,

h ea

lth

pr ob

le m

s) ; p

os iti

ve g

en er

al h

ea lth

(s el

f‐ ra

te d

he al

th );

w el

l‐b ei

ng (g

en er

al h

ea lth

, H rQ

oL , l

ife s

at is

fa ct

io n,

w

el l‐b

ei ng

); ne

ga tiv

e pr

eg na

nc y

(L BW

, p re

te rm

b irt

h,

V LB

W );

po si

tiv e

pr eg

na nc

y (b

irt h

w ei

gh t,

ge st

at io

na l

ag e)

; b eh

av io

r p ro

bl em

s (A

D H

D , a

gg re

ss io

n, b

eh av

io r

pr ob

le m

s, c

on du

ct p

ro bl

em s,

d el

in qu

en t b

eh av

‐ io

r, de

vi an

ce , e

m ot

io na

l a nd

b eh

av io

ra l p

ro bl

em s,

ex

te rn

al iz

in g,

in te

rn al

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4.1 | Discrimination and mental health

A 2015 meta‐analysis by Paradies and colleagues16 found over 300 articles on racial discrimination and health published through 2013, with the association between discrimination and mental health stronger than for physical health. Although 8 out of every 10 stud‐ ies came from the United States, there were publications from 19 other countries. Discrimination was significantly associated with poorer mental health outcomes (eg, depression, anxiety, psycho‐ logical stress, r = −.23) and positive mental health outcomes (eg, self‐esteem, life satisfaction, control, well‐being, r = −.13). The meta‐ analysis found that the effect sizes for the association between perceived discrimination and mental health were stronger in cross‐ sectional studies than in longitudinal ones and in nonrepresentative samples than in representative ones.

A meta‐analysis of 51 studies in Europe highlights growing in‐ ternational evidence. Across diverse ethnic populations, positive associations were found between ethnic discrimination and emo‐ tional distress, as well as inverse associations with positive markers of well‐being, such as self‐esteem and self‐efficacy.20 Several recent reviews continue to document an inverse association between dis‐ crimination and good mental health.21‐27 For example, a 2014 review reported the results of two meta‐analyses focused on the association between discrimination and well‐being.28 Discrimination, in the first meta‐analysis, was associated with poorer well‐being (self‐esteem, depressive and anxiety symptoms, psychological distress, and life satisfaction), with the association being somewhat weaker for posi‐ tive outcomes than negative ones. The observed associations (effect sizes) were larger for disadvantaged groups compared to advantaged groups (eg, women vs men) and for children than for adults. They were also evident in both cross‐sectional and longitudinal analyses. In the second meta‐analysis, the researchers examined experimental data for studies relating the manipulation of discrimination to indi‐ cators of well‐being. The study found a significant negative effect (d = −0.25) of multiple exposures to discrimination on well‐being. A single event of discrimination was not adversely related to well‐ being. Research also indicates that exposure to discrimination can ad‐ versely affect the personality characteristics of adults. Longitudinal analyses in two national studies, the Health and Retirement Survey and the Midlife in the United States Study (MIDUS), found that in‐ cident discrimination was associated with increases in neuroticism (negative emotions) and declines in agreeableness (trusting) and in conscientiousness (organization and discipline).29

One review documented that in addition to discrimination being positively associated with measures of depression, anxiety symp‐ toms, and psychological distress, it is also associated with increased risk of defined psychiatric disorders.18 For example, in the National Study of American Life (NSAL), among African American and Caribbean Black adults 55 years and older, both racial and nonra‐ cial chronic Everyday Discrimination was positively associated with increased risk of any lifetime (LT) disorder, as well as LT mood and anxiety disorders.30 It was also associated with an increased risk of depressive symptoms and serious psychological distress. Similarly,

in the National Latino and Asian American Study (NLAAS), Everyday Discrimination was associated with an increased risk of psychiatric disorders, but the association was stronger among Mexicans than for Puerto Ricans.31 In the same study, Everyday Discrimination was associated, in multivariate models, with increased odds of any DSM‐ IV disorder (odds ratio [OR] = 1.90), depressive disorder (OR = 1.72), and anxiety disorder (OR = 2.24) among Asian Americans.32 Another review documented a positive association between discrimination and PTSD or other indicators of trauma in 70 percent of the associ‐ ations examined.33

Research also reveals that the accumulation of experiences of discrimination over time is associated with an increased risk of men‐ tal health problems. For example, in the Study of Women Across the Nation (SWAN), the levels of Everyday Discrimination were assessed six times over 10 years.34 It found that women who experienced the highest accumulation of experiences of discrimination over time, domains, and attributes (race/ethnicity, sex, or other) reported the highest levels of depressive symptoms. This pattern was evident for all women (black, Chinese, Hispanic, and white), regardless of their race or ethnic group. Similarly, a study in the United Kingdom ex‐ amined the cumulative, longitudinal effects of racial discrimination on mental health of ethnic minorities.35 The study found evidence of a dose‐response relationship between the cumulative discrimi‐ nation measure (number of experiences and number of time points exposed) and a scale of nonspecific psychological distress.

Most of the early studies of discrimination were cross‐sectional. In addition, the extent to which observed associations between dis‐ crimination and mental health outcomes were due to unmeasured psychological factors remained unclear. These concerns have been addressed in recent research.18 Although the majority of studies of discrimination and health are still cross‐sectional, there are a grow‐ ing number of prospective studies that link changes over time in discrimination to increases in symptoms of distress and depression. One review of 25 daily diary, longitudinal studies found that over 90 percent of the time, discriminatory events on a given day were as‐ sociated with increased symptoms of distress.36 A few studies have also documented that the association between discrimination and mental health remains robust after adjustment for potential psycho‐ logical confounders such as neuroticism, social desirability, hostility, and negative affect.18

4.2 | Discrimination and physical health

In the Paradies meta‐analysis model, racial discrimination was sig‐ nificantly associated with poorer general health (r = −.13) and poorer physical health (r = −.09).16 Research also reveals that discrimina‐ tion is associated with multiple indicators of adverse cardiovascular disease (CVD) outcomes and risk factors of CVD. A 2014 paper37 reviewed the research on self‐reported discrimination and CVD published between 2011 and 2013. It found that most studies fo‐ cused on hypertension, smoking, and other health behaviors, with few studies on cardiovascular endpoints. However, one study docu‐ mented that self‐reported discrimination was associated with more

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severe coronary artery obstruction among veterans undergoing car‐ diac catherization, for blacks but not whites.38 A review of discrimi‐ nation and physical health among black women found few significant associations for indicators of CVD, highlighting the need to better understand the conditions under which the stress of discrimination has adverse health effects.39

A 2017 review of 10 longitudinal studies found evidence of a consistent association between self‐reported discrimination and body mass index (BMI), waist circumference, and incidence of obesity.40 The associations between experiences of discrimination and adiposity were predominantly linear, and racial discrimination was also significantly associated with changes in BMI and waist circumference among women, but not men. Nonetheless, racial discrimination was significantly associated with the incidence of obesity overall.

Research has also focused on some of the specific pathways that may link exposure to discrimination to changes in health status. A meta‐analysis of discrimination and cortisol output found a small positive association.41 Another review of 21 studies of discrimina‐ tion and the HPA axis found that discrimination has both positive and negative associations with salivary cortisol.42 An additional review of 21 studies focused on multisystem responses to discrimination and found strong consistent associations between discrimination and CVD and HPA axis reactivity, but less consistent associations for immune responses.43

Another subclinical indicator of heart disease that has been ex‐ amined in relationship to discrimination is intima‐media thickness (IMT). An early study found that discrimination was positively as‐ sociated with IMT.44 Recent analyses of data from the SWAN study assessed everyday discrimination six times over 10 years and as‐ sessed its relationship with intima‐media thickness.45 It found that the average levels of discrimination in years 0, 1, 2, 3, 7, and 10 were associated with higher IMT levels at year 12. The association was significant only for white women and not for black, Hispanic, and Chinese women, even though black and Chinese women reported higher levels of discrimination than whites. There is a need to better understand which indicators of discrimination will be predictive of specific health outcomes, for particular population subgroups.

From the earliest studies of discrimination, there has been an increasing interest in the association between discrimination and blood pressure. A recent comprehensive review and meta‐analysis of the association between self‐reported discrimination and hyper‐ tension identified 44 studies.46 It found a small, significant associ‐ ation between perceived discrimination and hypertension. Larger effect sizes observed were between perceived discrimination and nighttime ambulatory systolic (SBP) and diastolic blood pressure (DBP), especially among blacks. Prior research had found that African Americans are more likely than whites to manifest a blunted blood pressure decline during sleep, a pattern that is predictive of an increased risk for cardiovascular mortality and other outcomes. This review indicated that exposure to discrimination contributes to the decrease in blood pressure dipping during sleep, which results in ele‐ vated levels of nighttime blood pressure among blacks. It is currently

not clear if the association between discrimination and SBP and DBP is independent of its association with obesity. In the SWAN study, exposure to Everyday Discrimination predicted increases in SBP and DBP over 10 years of follow‐up, even after adjusting for known sociodemographic, behavioral, and medical risk factors. However, consistent across multiple racial groups, when a measure of adipos‐ ity (either waist circumference or BMI) was added to the model, the association was no longer significant.47

Several recent studies have examined the association between discrimination and inflammation. Among African Americans in the MIDUS study, experiences of discrimination were associated with increased emotional dysregulation (venting and denial) and with in‐ creased biological dysregulation, as measured by increases in three indicators of inflammation (interleukin‐6, e‐selectin, and c‐reactive protein).48 Another recent study found that lifetime discrimination but not chronic everyday discrimination was associated with in‐ creased risk of four markers of inflammation in multivariate mod‐ els.49 Another recent article on discrimination and inflammation found that the associations varied by gender and the indicator of inflammation.50

These findings highlight the need to better understand how the different types of discrimination combine to affect health.

Recent analyses have also examined discrimination in relation‐ ship to other indicators of biological functioning. Allostatic load (AL) is a measure of multisystem dysregulation. In the MIDUS study, this index sums 24 indicators of risk scores across seven physiological systems.51 Analyses of data from African Americans in the MIDUS study found that after adjusting for demographic factors, SES, med‐ ication use, cigarette smoking, alcohol use, and mental health symp‐ toms, Everyday Discrimination was associated with higher AL scores. Also, attributions of Everyday Discrimination to race were not more strongly linked to AL than attributions linked to other social statuses. Another recent study has shed light on the pathways that might link discrimination to AL.52 In this study, African Americans had higher levels of allostatic load (11 indicators of physiological functioning) and discrimination than their white peers. Discrimination was as‐ sociated with elevated AL scores. However, this association was fully mediated by measures of anger and poor sleep. Another re‐ cent study using national data from the HRS linked higher levels of Everyday Discrimination with lower telomere length for blacks but not whites.53

4.3 | Discrimination and health behaviors

Recent reviews indicate that there is a behavioral pathway linking experiences of discrimination to health, with exposure to discrimina‐ tion predictive of engaging in more high‐risk behaviors and fewer health‐promoting activities. For example, a 2016 systematic review found 97 studies published between 1980 and 2015 that examined the association between discrimination and alcohol use.54 Most studies focused on African Americans and most found positive as‐ sociations between increased experiences of discrimination, alco‐ hol consumption, and other drinking‐related problems. The review

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noted that there was considerable variation in quality across the studies and the need for more longitudinal data collection and the use of representative samples. Similarly, a 2019 meta‐analytic re‐ view of 27 studies of African Americans found a positive association between discrimination and alcohol consumption, binge drinking, at‐risk drinking, and negative consequences.55 Discrimination was unrelated to alcohol use disorder. Earlier reviews found that experi‐ ences of discrimination were associated with increased risk of ciga‐ rette smoking and drug use.19,56

A 2016 review found 17 studies that examined the association between discrimination and sleep (sleep duration and quality), and every study found at least one positive association between expo‐ sure to discrimination and poor sleep.57 Most studies were cross‐ sectional in design (12 of 17); however, three were prospective studies, one was a natural experiment, and one utilized a nine‐day diary component.

4.4 | Discrimination and health care

Another pathway linking discrimination to poor health status is the potential of experiences of discrimination to lead to reduced health care‐seeking behaviors and adherence to medical regimens. A re‐ cent review and meta‐analysis of studies of racism and health ser‐ vice utilization identified 83 papers for review and 59 papers for meta‐analysis.58 Major findings included that persons reporting ex‐ periences of racial discrimination had two to three times the odds of being less trusting of health care workers and systems, perceiv‐ ing lower quality of and satisfaction with care, and expressing less satisfaction with patient‐provider communication and relationships. Experiencing racism was also associated with delays in seeking health care and reduced adherence to medical recommendations, although these outcomes were not frequently assessed. Findings related to the use of health services were mixed and mostly not sta‐ tistically significant. The review also noted important methodologi‐ cal limitations in the research. Many of the measures used to assess discrimination were brief (<25 percent of papers used measures with nine or more items) and over 50 percent of the measures used did not specify a timeframe regarding exposure to racism. A review of 16 qualitative studies examined the role of discrimination in adherence to treatment among persons with HIV.59 It was found that exposure to discrimination was associated with less adherence to antiretrovi‐ ral medication, less self‐care, and lower levels of satisfaction with care.

4.5 | Discrimination in children and adolescents

Although much of the early research on discrimination and health focused on adult populations, there has been an increasing atten‐ tion in recent years to the role of discrimination in health outcomes for children and adolescents. A 2013 review identified 121 studies (with 461 outcomes) that examined the association between dis‐ crimination and health among persons 0‐18 years old.60 Indicators of mental health status were the most frequently assessed. Exposure

to discrimination was positively associated with symptoms of anxi‐ ety and depression, aggression, internalizing behavior, externalizing behavior, and conduct problems. Discrimination was also inversely associated with indicators of positive mental health, such as life satisfaction, resilience, self‐esteem, and quality of life. Consistent with the literature on adults, a positive association was found be‐ tween discrimination and poor health practices (alcohol use, drug use, and smoking) in 51 percent of 74 tests. Discrimination was also positively related to poor pregnancy or birth‐related outcomes, such as low birth weight and preterm birth. Research also indicates that adolescents experience discrimination in online contexts. One study, for example, found that after adjustment for age, gender, ethnicity, other adolescent stress, and offline discrimination, online discrimi‐ nation was positively related to depressive symptoms and anxiety symptoms among 14‐ to 18‐year olds.61

A 2018 meta‐analysis of 214 studies examined racial/ethnic dis‐ crimination and adolescent outcomes.62 It found that there were moderate positive associations between discrimination and multi‐ ple indicators of socioemotional distress (eg, depressive symptoms or effects) and internalizing symptoms (eg, anxiety, loneliness, and somatic symptoms). Discrimination was also inversely related to in‐ dicators of positive well‐being (eg, life satisfaction, prosocial behav‐ iors, and self‐control), as well as general self‐esteem and self‐worth. The review also included 73 studies that examined the association between discrimination and academic performance. Small‐to‐mod‐ erate inverse associations were evident between discrimination and school engagement (eg, attendance), motivation (eg, academic efficacy), and achievement (eg, GPA). This review also documented behavioral pathways among adolescents. There were 71 studies assessing the association between discrimination and risky health behaviors. Small‐to‐moderate positive associations were evident for discrimination with substance abuse, externalizing behaviors (eg, delinquency and anger), affiliation with deviant peers, and risky sex‐ ual behaviors (eg, unprotected sex). The analysis also found that for socioemotional distress, associations were stronger for Asian and Latino adolescents compared to African Americans. Another signifi‐ cant moderating effect observed was for the developmental period. Associations with socioemotional distress were stronger in early ad‐ olescence (age 10‐13) than late adolescence, and for academics, they were stronger in mid‐adolescence than early adolescence.

A recent study of Latino adolescents illustrates the complex pathways between discrimination and mental health. Using three waves of data, it found that racial/ethnic discrimination predicted increases in symptoms of depression and anxiety.63 It also found that outward anger expression was a significant mediator, with greater racial/ethnic discrimination associated with more frequent outward anger expression. Anger expression, in turn, was associated with higher levels of anxiety and depression. This study suggests the pos‐ sibility that prevention and intervention efforts around managing anger could reduce at least some of the negative effects of racial discrimination on Latino youths' mental health.

A few studies have also reported that adverse effects of discrimi‐ nation experienced as an adolescent are predictive of physical health

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outcomes in early adulthood. For example, a study of 331 black ad‐ olescents from nine rural counties in Georgia found that youth with high and stable perceived racial discrimination at age 16, 17, and 18 had higher levels of multisystem biological dysregulation as mea‐ sured by stress hormones (cortisol, epinephrine, and norepineph‐ rine), systolic and diastolic blood pressure, inflammation, and weight by age 20.64 A recent review of 30 longitudinal studies found that vicarious discrimination (ie, experiences of discrimination that occur in the life of adults in a child's social network or others with whom the child identify) can adversely affect the health of the target child both prenatally and postbirth.65

4.6 | Discrimination and disparities in health

Most studies of discrimination and health have not examined the contribution that these exposures make to account for racial dispari‐ ties in health. However, a few studies in the United States and in‐ ternationally have documented that perceived discrimination makes an incremental contribution over SES in accounting for racial/ethnic inequities in mental health and self‐reported measures of physical health. This pattern has been evident in community and national studies in the United States, New Zealand, Australia, and South Africa.56

Recent studies provide further evidence of the role of discrimi‐ nation in contributing to racial inequities. One study examined SES trajectories over a 33‐year period and their relationship to discrimi‐ nation and self‐rated health.66 It found that increased SES for whites is associated with lower reported discrimination. In contrast, for blacks and Hispanics, upward mobility is associated with increased exposure to discrimination compared to their socioeconomically stable peers. Importantly, exposure to discrimination explained a large part of the black/white gap in self‐rated health (but not the Hispanic/white gap). A study in the United Kingdom also assessed the role of discrimination in ethnic inequalities in mental health.35 In cross‐sectional and longitudinal analyses, they found that adjusting for socioeconomic disadvantage and racial discrimination eliminated ethnic inequalities in mental health for some ethnic groups in the United Kingdom but not for others.

4.7 | Individual and collective protective and resilient responses

Figure 1 also indicates that targets of discrimination are not passive actors but can respond in individual and collective ways to minimize the negative effects of racism. Lewis and colleagues18 have reviewed the limited evidence pointing to a number of resources that have been shown to cushion at least some of the negative effects of expo‐ sure to discrimination on health. For example, prospective analyses in national studies have shown that religious beliefs and behavior can reduce some of the negative effects of discrimination on health. Other evidence reviewed revealed that there is limited evidence that mindfulness (ie, nonjudgmental attention and awareness) can also reduce the negative effects of discrimination on mental health

problems, as measured by depressive symptoms. Finally, research also finds emotional support from family, friends, and supportive professionals can also buffer the adverse impacts of exposure to dis‐ crimination on health.

There is still much to be learned about the full range of protective factors that can ameliorate the negative effects of discrimination on health and the conditions that maximize the health‐protective ef‐ fects of such resources. Relatedly, we need a serious and sustained program of research that would guide us in identifying the interven‐ tions that enhance civility and respect for stigmatized groups in our society. There is also a serious need for societal interventions to be developed and implemented to reduce and ultimately eliminate so‐ cietal prejudice and discrimination. Such research is currently in its infancy.67 We also need more systematic attention to the extent to which efforts that seek to comprehensively address the social de‐ terminants of health can reduce exposure to racism and its negative consequences.68

5  | DISCUSSION

This review of research on discrimination and health points to many areas that would benefit from further investigation. Prior reviews indicate that methodological limitations that need to be addressed include the overreliance on cross‐sectional studies and refining the measurement approaches to maximize comprehensiveness and ac‐ curacy in the assessment of discrimination.56 This would require greater attention to capturing the critical stressful dimensions of discriminatory experiences, including the severity, chronicity, and duration of these experiences. There is a need to expand assessment to capture discrimination in multiple domains (eg, race, sex, gender, sexual orientation, stigmatized religious status, and SES), and to extend analyses to assess how exposure in more than one domain relate to each other and combine to affect the adverse impact of discrimination on physical and mental health.5 Emerging evidence suggests that utilizing an intersectionality framework that examines associations between discrimination and health, with the simultane‐ ous consideration of multiple social categories, leads to larger as‐ sociations than when only a single social category is considered.69 Given the increasing evidence of the adverse impacts of discrimi‐ nation early in life, there is also growing awareness of the need to better understand how discriminatory experiences emerge and ac‐ cumulate over the life course and combine with other stressful expe‐ riences to affect physical and mental health.70

6  | CONCLUSION

This article has provided a glimpse of the growing empirical evi‐ dence linking self‐reported experiences of discrimination to health. This area of study is only about three decades old. While there is much that we need to learn and important limitations that need to be addressed, the range of health outcomes associated with

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discrimination is impressive, and the incidence of multiple popu‐ lations being affected by discrimination, both domestically and globally, is striking. It is now clear that discrimination is a newly emerging risk factor for a broad range of health outcomes that may make an important contribution to understanding racial and ethnic variations in health and health care utilization. This body of research is a reminder that a broad range of psychosocial factors in homes, neighborhoods, workplaces, and schools can be critical determinants of health, and that improving health and reducing inequities in health will likely require interventions outside of the traditional domains of health policy.

ACKNOWLEDG MENTS

Joint Acknowledgment/Disclosure Statement: Sandra Krumholz for assistance with preparation of the manuscript. Preparation of this manuscript was supported in part by the W.K. Kellogg Foundation.

ORCID

David R. Williams https://orcid.org/0000‐0002‐8654‐6228

Jourdyn A. Lawrence https://orcid.org/0000‐0003‐4162‐9860

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SUPPORTING INFORMATION

Additional supporting information may be found online in the Supporting Information section.

How to cite this article: Williams DR, Lawrence JA, Davis BA, Vu C. Understanding how discrimination can affect health. Health Serv Res. 2019;54:1374–1388. https ://doi. org/10.1111/1475‐6773.13222

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