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

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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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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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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