Critical Race Theory as Means to Improve Racial and Ethnic Diversity in Healthcare Settings

Abstract

An analysis of inequities in healthcare based on racial and ethnic differences, and the use of Critical Race Theory to analyze, and remediate these inequities through increasing diversity. This paper outlines the changing demographics of the United States, and the need to address increasing diversity in order to provide comprehensive, accurate, and unbiased data to clinicians and researchers, educators, and students.

The paper presents an outline of CRT, the methodologies used to apply it in healthcare settings, and the reasons why it is a necessary approach to identifying and remediating healthcare inequities. A review of the current inequities in healthcare in relation to racial and ethnic minority groups is provided, the need for diversity in research and clinical trials is discussed, and an explanation of how to used this data to remediate the issues is presented.

20 articles were selected to review and discuss the history of CRT in healthcare, and to present the current challenges facing diversity in healthcare and why increased diversity is necessary. The articles were picked based on the following search criteria: Use of CRT across a range of specialties, the inclusion of diversity as a focus of the research, and the inclusion of background data around racial bias in healthcare.

Keyword: Option 2, Race and Ethnic Diversity in Healthcare.

Introduction

Increasing ethnic and racial diversity in healthcare organizations leads to better outcomes for patients, and an increase in trust in the healthcare system. The need for ethnic diversity in healthcare is essential to insure positive patient outcomes. This diversity must include diversity in research studies, in education, and among healthcare providers. Critical Race Theory provides a template for increasing this diversity, by acknowledging institutional racism and addressing these issues in an intersectional and productive approach.

Case Studies/Review

The overall outcomes in healthcare environments are highly dependent on the need for accurate data, comprehensive and unbiased research, well trained medical professionals and a communicative relationship between healthcare providers and patients.

Context of Racism and Critical Race Theory

Historically Race has been used to define people as distinct differing groups based on shared physical characteristics or ancestry, however work in genetics has proven race to be more of a social construct. (Williams, Ford, Morse, & Feldman, 2020) Critical Race Theory explains the basis of these beliefs, founded on institutional racism, as the foundation for inequality between racial groups in regards to wealth, access to employment and healthcare, as well as other factors. (Williams, Ford, Morse, & Feldman, 2020) Critical Race theory is a multidisciplinary, race-equity methodology grounded in social justice that was first developed in legal studies, based on several different concepts including Public Health, Centering in the Margins, Critical Consciousness, Experimental Knowledge, Ordinariness, Praxis, Primacy Race Consciousness, and the Social Construct of Race. (Ford & Airhihenbuwa, Critical Race Theory, Race Equity, and Public Health: Toward Antiracism Praxis, 2010). The public health critical race praxis (PHCRP) is a framework developed by public health medical health providers and researchers that considers all research to be influenced by prior racial bias, thus pushing for an intersectional and critical analysis of these biases and assumptions. (Williams, Ford, Morse, & Feldman, 2020)

These concepts require the acknowledgment of previous research being conducted from a white or Eurocentric reference point, and the tendency for “colorblindness” to ignore legitimate differences among populations in the desire to appear “neutral”, shifting the dialogue from a majority group viewpoint, to referencing marginalized groups experiences. (Ford & Airhihenbuwa, Critical Race Theory, Race Equity, and Public Health: Toward Antiracism Praxis, 2010) In the field of Public health this new approach to research, and care allows for way to target inequalities among racial and ethnic lines. (Ford & Airhihenbuwa, Critical Race Theory, Race Equity, and Public Health: Toward Antiracism Praxis, 2010)

Disparities in Healthcare Settings

Modern Healthcare systems are focused highly on reform and improving the quality of access. Several recommendations made by the Institute of Medicine regarding quality of care, however equity has been one recommendation that hasn’t been fully realized. (Betancourt, Tan-McGrory, Flores, & Lopez, 2019) The Institute of Medicine defines healthcare disparities as differences in healthcare received by differing groups that are independent of group preferences or underlying healthcare needs. (Essing-Bot, Lamkaddem, Jellema, Nielsen, & Stronks, 2013)

Per the Annual National Healthcare Quality and Disparities Report (QDR), there exists a large and persistent disparity in healthcare outcomes. The QDR in 2016 highlighted showed a 60% worse percentage of care between White and African American populations, and a 43% worse percentage of care between Hispanic and Non-Hispanic White populations, as an example of the inequity in quality of healthcare provided. (Fiscella & Sanders, 2016). More recent QDR reports show that in 2019 these disparities, while better, still indicated disparity in care, with African American Populations still at a 40% disparity than whites, and a 33% disparity among Hispanics. (Agency for Healthcare Research and Quality, 2020)

As referenced above, in 2003 a study from the Institute of Medicine identified disparities in treatment among minority groups. This study is the basis for much of the focus of remediating disparities in healthcare. In particular Hispanic groups faced significant cultural, linguistic, and cultural barriers. A lack of trust of traditionally white medical professionals, and cultural norms that have Hispanic groups seeking alternative treatments has contributed to a higher rate of diabetes and obesity. (Juckett, 2013) It’s essential to be culturally aware, and respectful of the cultural challenges facing Hispanic groups. Alternative care preferences should be addressed, and acknowledged by physicians in order to build trust with the community. (Juckett, 2013)

Breaking down the differences based on categories, there is significant disparity of care in chronic disease control, including management of high blood pressure, blood sugar, cholesterol, and HIV. Some contributing factors to these results include patient-provider communication, literacy rates, and trust in medications. (Fiscella & Sanders, 2016) It has been documented that clinicians tend to have implicit racial bias when it comes to dealing with chronic pain or pain management in some racial and ethnic groups, particularly when it comes to the Black community. (Fiscella & Sanders, 2016)

The Infectious Disease workforce, along with other specialties, is not representative of the diversity in the general population of the US, with less than 12% of the workforce being either African American or Hispanic. This under representation presents challenges in outreach to patient populations of racial and ethnic minorities. This is because many of these groups prefer to interact with healthcare providers that are representative of their own cultural or racial identities. (Marcelin, Manne-Goehler, & Silver, 2019) Racial minority groups also face increased challenges in healthcare education, with few students likely to be rewarded with membership in honor societies such as Alpha Omega Alpha. There is also a lower likelihood of ethnic minorities reaching senior ranks across different specialties. (Marcelin, Manne-Goehler, & Silver, 2019)

An example of disparity of care can be found in the lower rates of knee replacement surgery due to Osteoarthritis among Black patients. Previous assumptions attributed this lower rate of replacement to a preference among Black patients to seek nonsurgical treatments for their issues, despite the likelihood of poorer outcomes. Additional research, using the PHCRP has shown that increased education to patients, using non-technical terminology, tailored to health literacy, can mitigate these differences in outcomes. (Williams, Ford, Morse, & Feldman, 2020)

The COVID-19 Pandemic has shown how inequities in healthcare can lead to poor outcomes for Racial and Ethnic patient groups. Higher rates of death and infection among ethnic and racial minorities can be partly attributed to societal discrepancies, in particular the communication of strategies to mitigate the spread of Covid 19, such as social distancing and mask mandates, that are messaged in ways to appeal to majority groups. (Ford, Addressing Inequities in the Era of COVID-19, 2020) These prevention strategies, specified for the White populations in the US, have failed to properly inform or convince various ethnic minority groups to utilize the strategies. In addition, no consideration was given to vaccine distribution in socioeconomically disadvantaged areas, that tend to have a higher percentage of Ethnic and Racial minorities. (Ford, Addressing Inequities in the Era of COVID-19, 2020)

In addition to the differences in prevention strategies, ethnic minorities and migrants face differences in healthcare access, socioeconomic challenges, and lack of access to preventative care that increase the chances of severe disease related to Covid-19. It is well known that many ethnic minorities reside in economically disadvantaged areas with lack of easy access to transportation or healthcare resources. Cost of preventative care is also a blocker for these groups. (Greenaway, et al., 2020)

Studies in the US have shown that readmission rates and length of stay rates are higher among racial and ethnic minority populations. Studies done in other Western nations, such as the Netherlands also show that ethnic minorities report poorer health and higher healthcare use. While other western nations are not as heterogenous as the US, they do have large concentrations in urban areas and face similar challenges that are found in large urban centers in the US. (de Bruijne, et al., 2013)

Studies in Hong Kong mirror examples found in Western Nations. Hong Kong is a city with a diversity of Ethnic and Racial populations. South Asian populations have grown steadily over the last decade. There was a lack of culturally competent care among physicians in Hong Kong, leading to poorer outcomes for patients that were of South Asian descent. In addition, Patient and Provider interactions suffered, due to the lack of diversity among providers. Language barriers proved to be an issue, and a bias among providers toward South Asians , regarding hygiene and other cultural assumptions also led to poorer results. (Vandan, Wong, Lee, Yip, & Fong, 2020) Increased diversity among healthcare workers would lead to fewer such assumptions, due to increased frequency of interactions.

Racial and ethnic minorities also have less access to mental healthcare resources than majority groups do, and also face lower quality of care when they are able to access mental health resources. It’s necessary to increase diversity in the mental healthcare workforce in order to provide more equitable and better quality care. (Lokko, Chen, Parekh, & Stern, 2016)

The basis of Critical Race Theory is to address the problems minority populations face due to previous attempts to generalize healthcare based on a standard developed by addressing majority groups. One issue that is highlighted by this is the rate of Dementia among different racial and ethnic groups. Studies show that Dementia rates were higher among African Americans, even though the rates of misdiagnosis were higher, showing a possible larger burden to African American groups as compared to Whites. The data suggests additional care must be taken to address imaging and diagnosis disparities in this field. (Mayeda, Glymour, Quesenberry, & Whitmer, 2016)

Diversity in Research and Clinical Trials

Medical research, in particular clinical trials of new treatments and medicines, is needed in order to determine the safety and efficacy of new therapies. The possibility of subgroups having different results than mainstream “majority” populations is why diversity in medical research is important. Of 167 new molecular treatments approved by the FDA between 2008 and 2013 there was a 20 percent difference in results among racial or ethnic groups. (Clark, et al., 2019) Furthermore the research identified five critical barriers in research, these are mistrust, a lack of comfort with the clinical trail process, fear, lack of information, the stigma of being involved in the study, time and access constraints, and lack of awareness of trials. The research concluded that in order to overcome these barriers, greater care must be made to reach out to diverse patients, as well as having more diverse investigators, referring physicians, and clinical coordinators. (Clark, et al., 2019)

A study conducted by the Veterans Health Administration (VHA) highlights ongoing unconscious bias and disparities awareness among providers. The goal of the study was to prompt healthcare providers to reduce disparities. Using the Bernard Winder Theory of Social behavior, which states that the response to an event by individuals, includes determining the cause of the event. The assumption being that if a provider attributes the cause of an issue to be something that is inherent with the patient’s ethnicity, they would be less likely to address the disparity than if they realized the factors were external, thus addressable by them. The conclusions of the study showed that racial and ethnic minority patients received lower quality of care, and those providers that recognized the disparities based on external factors had higher patient satisfaction results than those who didn’t. (Gollust, et al., 2018) Increased diversity among providers would further increase patient outcomes, due to an increased understanding of the reasons for racial disparity.

Using the Data to Remediate Disparities

Data shows that 98% of senior management in healthcare systems are composed of non-Hispanic White individuals. This data also suggests that certain specialties in specific fields, such as Plastic Surgery. Studies in diversity in the field of Plastic Surgery saw little improvement over a decade. Improving diversity in these areas is essential to opening access to minority populations. (Nair & Adetayo, 2019)

As with any other organization or systems, health care systems are defined, and dependent, on the leadership and employees that are involved. The push to address inequities has been ongoing since 2003’s report regarding over 175 studies that proved racial and ethnic disparities. The conclusions then indicated a greater need for healthcare systems to mirror the general population in regards to ethnic and racial diversity, both from a healthcare worker and leadership perspective. (Betancourt, Green, Carrillo, & Ananeh-Firempong, 2003)

Additional factors affecting disparities in healthcare are tied to Low Health Literacy, Cultural differences, trust in the system, and stereotyping among providers. These issues can be mitigated by an increased diversity in the workforce. Language barriers, mistrust and cultural misunderstandings would not be as significant issues if there were greater representation among providers from ethnic and racial minorities. If the composition of healthcare providers were as diverse as the general population, all providers would be exposed to different racial and ethnic minorities on a professional level, thus leading to mitigation of these stereotypes.(Betancourt, Tan-McGrory, Flores, & Lopez, 2019)

Addressing disparities among Hispanic groups requires environments that are welcoming to Hispanic populations, including bilingual literature and posters, recognition of culturally specific holidays, and increased representation of Hispanic staff and healthcare workers. (Juckett, 2013) The growth of Hispanic populations in the US, expected to be 30% of the US population by 2050, requires healthcare systems to address the inequities currently present. (Juckett, 2013) Becoming sensitive to the needs of Hispanic populations will also allow healthcare systems to expand that sensitivity to African American and AAPI groups as well. Demographic changes to the US are not limited to just Hispanic populations, and data suggest all ethnic and racial minorities face some degree of disparity in healthcare outcomes. (Betancourt, Green, Carrillo, & Ananeh-Firempong, 2003)

The ACR Commission for Women and General Diversity has identified efforts to increase diversity have led to overall improvements in patient care. Additionally, data suggests that minority physicians tend to serve in traditionally underserved areas. Increased diversity among faculty also allows healthcare students to learn from mentors that have a wider view of lived experiences than is currently possible, thus leading to better outcomes. (Betancourt, Tan-McGrory, Flores, & Lopez, 2019)

Discussion

The inequities in healthcare outcomes among racial and ethnic lines have been long studied. The results of increasing diversity, not just in the employment of healthcare professionals, but in research and education have proven that outcomes improve. These results would not have been studied in detail if the framework of CRT hadn’t been applied to healthcare, allowing physicians to study racial disparities in healthcare outcomes and how racism directly correlates to them. This included the deeply seeded bias and racism present in education, research, and patient health services. (Williams, Ford, Morse, & Feldman, 2020)

Members of ethnic and racial minority groups face linguistic barriers in many cases, by increasing diversity among healthcare providers, this barrier can be mitigated. (Juckett, 2013) In addition to linguistic barriers, there are cultural and racial stereotypes among white medical professionals that lead to reduced outcomes for minority groups. Again, increasing diversity, along with cultural sensitivity training, mitigates these barriers. (Harrison, et al., 2019)

The application of Critical Race Theory allows the healthcare community to address these inequities in healthcare in a holistic approach. By addressing Race Consciousness, the theory addresses biases based on the assumptions that race consciousness is indicative of racisms, or that “colorblindness” is indicative of a lack of racism. Both assumptions have further led to inequities in care and research. (Ford & Airhihenbuwa, Critical Race Theory, Race Equity, and Public Health: Toward Antiracism Praxis, 2010) The CRT also seeks to “Center the Margins” or shift the perspective, of addressing inequities, towards ethnic and racial minorities perspectives instead of from the perspective of the majority group. (Ford & Airhihenbuwa, Critical Race Theory, Race Equity, and Public Health: Toward Antiracism Praxis, 2010) This approach requires the inclusion of racial and ethnic minorities in researching and addressing inequities. The concept of Praxis in CRT is a process of ensuring investigators are focused on equity while carrying out their research and practices in healthcare, through mutual discussion of “Lived” experiences of marginalized communities. (Ford & Airhihenbuwa, Critical Race Theory, Race Equity, and Public Health: Toward Antiracism Praxis, 2010)

This process of addressing and acknowledging racism and bias also includes acknowledging the disparate economic and social situations that marginalized groups experiences as a result of institutional racism and implicit biases. Healthcare doesn’t negate that many immigrant groups or ethnic and racial minorities don’t have access to the same resources as majority groups. Studies acknowledging these issues are designed to take them into account and address them as factors in research and education. (Sue & Dhindsa, 2006)

This increased diversity in research studies, and in educational opportunities, and the Healthcare workforce have proven to be essential for increasing healthcare outcomes for racial and ethnic minority populations, not just in the US, but worldwide.

Conclusion

The application of Critical Race Theory in addressing known racial and ethnic inequities in healthcare has proven to be a good framework for remediating these issues. Research studies in Public Health, Infectious Diseases, Rheumatology, and Psychiatry have utilized CRT to try and bring equity in healthcare. The studies references show that increasing racial diversity in healthcare education, research, and practice have led to slow and steady improvements. The intersectional approach to improving healthcare outcomes should be continued and expanded in order to fully mitigate current disparities, especially since the demographics of the US will continue to change.

References

Agency for Healthcare Research and Quality. (2020). National Healthcare Quality and Disparities Report. Rockville, MD: .AHRQ Publication.

Betancourt, J. R., Green, A. R., Carrillo, J. E., & Ananeh-Firempong, O. (2003, July-August). Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care. Public Health Rep, pp. 293–302.

Betancourt, J. R., Tan-McGrory, A., Flores, E., & Lopez, D. (2019, April 16). Racial and Ethnic Disparities in Radiology: A Call to Action. Journal of the American College of Radiology, pp. 547–553.

Clark, L. T., Watkins, L., Pina, I. L., Elmer, M., Akinboboye, O., Gorham, M., . . . Regnante, J. (2019, May). Increasing Diversity in Clinical Trials: Overcoming Critical Barriers. Current problems in cardiology, pp. 148–172.

de Bruijne, M. C., Rosse, F. V., Uiters, E., Droomers, M., Suurmond, J., Stronks, K., & Essink-Bot, M.-L. (2013, December 23). Ethnic variations in unplanned readmissions and excess length of hospital stay: a nationwide record-linked cohort study. European journal of public health, pp. 964–971.

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Vandan, N., Wong, J. Y., Lee, J. J., Yip, P. S., & Fong, D. Y. (2020, March 28). Challenges of healthcare professionals in providing care to South Asian ethnic minority patients in Hong Kong: A qualitative study. Health & social care in the community, pp. 591–601.

Williams, J. N., Ford, C. L., Morse, M., & Feldman, C. (2020, November). Racial Disparities in Rheumatology Through the Lens of Critical Race Theory. Rheumatic diseases clinics of North America, pp. 605–612.

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