We examined the availability of data on the prevalence, trends, mechanisms, and institutional policies and practices associated with racial/ethnic discrimination in health care settings. Although there were a number of studies that described race/ethnicity based discriminatory behaviors, attitudes, biases and preferences that could potentially contribute to discriminatory health care we found no studies that specifically addressed the US prevalence or trends. Also, relatively absent were studies that addressed how institutional racism impacts the health care received by racial/ethnic minority patients.
None of the measures used in the reviewed studies captured information on all 3 aspects of effective measures as described by Kressin et al. (i.e., assessed the actual occurrence of or potential for discriminatory events, impact of discriminatory events among individuals who experienced them, and the effect if any, on the patients’ interactions with their health care provider).26
There was also wide variation in the length of time for which discrimination was assessed (i.e., lifetime, varying time intervals), which would be expected to greatly influence the reported prevalence of perceived discrimination and adds to the difficulty in comparing rates across studies. Furthermore, many of the studies that examined perceived racial discrimination in health care settings provided little, if any, information about the specific actions perceived to be discriminatory, specific context in which the discriminatory act occurred (e.g., emergency room, doctors office, or health clinic), or the specific perpetrator (e.g., nurse, office staff, or physician), which would be helpful in developing targeted interventions.
Unconscious biases and stereotyping that can underlie decision-making contribute to the difficulty of assessing the actual impact of race/ethnic discrimination in health care settings on access to and receipt of optimal care. Whereas patients are a good source of information about perceived discriminatory provider behaviors, system characteristics perceived to be discriminatory, and the personal consequences of perceived discrimination, they may be unknowledgeable about the standard of care for their disease or condition. Provider and other staff surveys that examine their observations of practices within their institutions therefore may be a better source of information on the prevalence of racial/ethnic discrimination in health care settings and its association with the receipt of health care.
Findings from the reviewed studies suggest that racial/ethnic discrimination may be prevalent in health care settings and potentially influence the health care received by minority patients. However, little is known about the national prevalence or trends in race/ethnicity-based discrimination in US health care systems. This situation results in part from the fact that Federal statistics on racial/ethnic discrimination in the United States are primarily limited to findings from audit programs for housing, hate crimes, and other complaints filed with US agencies such as the Equal Employment Opportunity Commission (EEOC) and the Fair Housing Commission.28
In the absence of federally mandated surveillance, much of what we know about the receipt of discriminatory health care comes from small research studies that focus on racial/ethnic disparities in receipt of treatment and outcomes, and that are not generally designed to provide information on what, if any, portion of observed disparities is a result of racial/ethnic discrimination. Accurate measurement and tracking of the incidence and prevalence of prejudice, bias, and other discriminatory attitudes in health care settings, therefore, is not only important to increasing the visibility of discrimination as a health risk but will help clarify its relationship to racial/ethnic disparities in health outcomes.91
There is a continuing need for innovative methodology, better instrumentation, and strategies for identifying racial/ethnic and other types of discrimination in health care settings, particularly because of the somewhat subjective manner in which health care is delivered. For example, Shields et al. were successful in using actors (standardized patients) portraying patients with stage IV lung cancer to evaluate patient-centered communication.92
Using standardized patients to monitor receipt of discriminatory care in a manner similar to housing and employment audits might be a feasible method for directly assessing racial discrimination in health care receipt. There is also a need to create data resources that facilitate tracking of reports of the receipt of discriminatory care and to establish a system of accountability that facilitates positive change.
An interesting area for future investigation is the role of stereotype threat defined as “being at risk of confirming, as self-characteristic, a negative stereotype about one’s group.”93(p797)
A number of racial/ethnic stereotypes are prevalent in health care settings.77,79,84,94-96
Stereotype threat in the clinical setting is posited to be more likely to occur when features of the setting make prevailing stereotypes of minority patients salient.94
However, only 1 research study within the review period examined the impact of stereotype threat on the receipt or utilization of health care. In a review of studies on stereotype threat, Burgess et al.94
concluded that stereotype threat in clinical settings contributed to treatment nonadherence and influenced patient outcomes. Stereotype threat also resulted in impaired communication between patients and providers, with patients discounting feedback and disengaging by avoiding going to the doctor and exhibiting the stereotyped behavior which, in turn, reinforced provider beliefs and their clinical decision-making.94
Of note, our review only included studies published in English on US populations from 2008 to November 1, 2011 that focused on racial/ethnic discrimination occurring in health care settings. Therefore, other studies are likely to exist that may provide insight into available measures, prevalence, trends, and systematic factors that were not examined in this review. In addition, because we were interested in data sources and measures currently used by researchers as evidenced by the published literature, we only evaluated surveys used in the reviewed studies.
Future Research Directions
The existing literature suggests that racial/ethnic discrimination may be prevalent in US health care settings but more research including national studies are needed. Several gaps in the research literature were also identified and should be considered for future research studies. As Gee97
suggests, there is a need to address discrimination at both the interpersonal and structural levels. Doing so will help us to understand how discrimination operates within health care settings while identifying targets for intervention. Studies should include systematic examinations of patient-physician interactions, particularly as they relate to communication styles and nonverbal behaviors that have the potential to elicit the perception of discrimination among diverse patients. Although it is possible that some providers purposely engage in discriminatory care, unconscious bias among well-meaning providers is the more likely culprit. Additional research is needed that explores whether and under what conditions the implicit attitudes of providers affect the quality of the medical care delivered to racial/ethnic minority patients. Physicians who are trained to be aware of implicit biases can be sensitized to their potential for bias,77,79,94,96
which may encourage self-regulation77
and facilitate decision-making based on the specific needs and resources available to individual patients.
There is also need to assess how racial/ethnic discrimination faced by racial/ethnic minority health providers within their work-places (i.e., hospitals and clinics) influence the availability of minority health care providers, and as a consequence, minority patient perception of the accessibility of appropriate care.
The introduction of health care reform, which has provisions that affect access to and the composition of health insurance plans, hospital availability, and other federal policies; provides a unique opportunity for research on the effect of health system policies on the receipt of discriminatory care. In recognition of the need for additional research, The National Cancer Institute (NCI) has recently reissued the program announcement “The Effect of Racial/Ethnic Discrimination on Healthcare Delivery
for investigators interested in pursuing research in this topic area.