|
| A) | A legal system that explicitly discriminates based on race | ||
| B) | Overt prejudice expressed by one person toward another | ||
| C) | An individual provider's unconscious negative assumptions about patients of color | ||
| D) | The cumulative effect of policies, institutions, and resource allocation that produce racially inequitable outcomes |
Structural racism refers to the totality of ways in which societies foster racial discrimination through mutually reinforcing systems of housing, education, employment, media, healthcare, and criminal justice [7]. It describes cumulative and compounding effects of an array of factors that systematically privilege White people and disadvantage people of color. Structural racism does not require individual racist actors. It functions through the policies, laws, and institutional practices that have become normalized over time (Table 1) [8].
| A) | The patient's cultural background makes her less likely to accurately report symptoms. | ||
| B) | Pre-eclampsia is clinically identical across all patient populations and easy to detect. | ||
| C) | Research documents that women of color are more likely to have their pain and symptoms underestimated or dismissed by providers. | ||
| D) | Prenatal care quality is determined primarily by individual patient compliance. |
HEALTHCARE-SPECIFIC DISPARITIES: CONNECTING HISTORY TO TODAY
| Domain | Historical Policy | Present-Day Impact | ||
|---|---|---|---|---|
| Primary care access | Hospital segregation, unequal facility distribution | Black and Hispanic communities more likely to rely on emergency departments for primary care needs. | ||
| Maternal health | Historical dismissal of Black women's pain, exclusion from nurse-midwifery training | Black women are two to three times more likely to die from pregnancy-related causes than White women. | ||
| Behavioral health | Criminalization of addiction and mental illness, disproportionately affecting communities of color |
| ||
| Preventive services | Lack of community-based providers, insurance gaps | Lower rates of cancer screening, vaccination, and chronic disease monitoring in minority communities |
| A) | The increased likelihood that Black patients will delay seeking care due to transportation barriers | ||
| B) | The physiological process by which chronic exposure to racial stress accelerates biological aging in Black Americans | ||
| C) | The gradual erosion of provider communication skills over time without continuing education | ||
| D) | The cumulative effect of seasonal illness patterns on historically underserved communities |
Contributing structural factors include inadequate access to prenatal care, higher rates of uninsurance, lower rates of continuity of care, and the biological effects of chronic racial stress (known as weathering), which accelerates physiological aging in Black women [22].
| A) | structural barrier to care. | ||
| B) | example of patient non-compliance. | ||
| C) | communication failure between providers. | ||
| D) | individual bias on the part of the referring physician. |
Structural barriers, including lack of insurance, provider shortages in underserved areas, transportation challenges, and lack of time off work, all contribute to lower rates of preventive service utilization in minority communities. These are not preferences; they are consequences of systems that allocate resources inequitably.
| A) | Providers lack adequate training in communication techniques. | ||
| B) | Trust is a personal preference that varies randomly across populations. | ||
| C) | Patients who distrust providers are more likely to have poor health literacy. | ||
| D) | Distrust in communities of color reflects a historically documented pattern of mistreatment by healthcare institutions. |
Research consistently demonstrates that patients of color report lower levels of trust in the healthcare system, lower satisfaction with care, and less confidence that providers take their concerns seriously [26]. This is not irrational; it is a learned, evidence-based response to a documented history of mistreatment and neglect. Patient distrust is itself a downstream effect of structural racism, and addressing it requires more than communication skills training for individual providers. It requires system-level investment in building trustworthy institutions.
| A) | It acknowledges genetic differences between racial groups. | ||
| B) | It may delay nephrology referral and transplant listing for Black patients. | ||
| C) | It gives Black patients an unfair clinical advantage. | ||
| D) | It requires additional documentation in the medical record. |
Vyas and colleagues examined several widely used algorithms, including [9]:
Estimated glomerular filtration rate (eGFR): The race-adjusted eGFR formula historically calculated a higher kidney function score for Black patients than for White patients with the same creatinine level, potentially delaying referral for nephrology evaluation and kidney transplant listing.
Vaginal birth after cesarean (VBAC) calculator: The algorithm assigned lower probability of successful vaginal delivery to Black and Hispanic women, influencing clinical recommendations without a sound biological basis.
Cardiac risk calculators: Race is embedded in several tools in ways that may alter risk stratification.
| A) | Educate patients about the importance of keeping appointments | ||
| B) | Document no-show rates for performance review purposes | ||
| C) | Advocate for extended clinic hours, reduced co-pays, and transportation assistance while connecting current patients to available resources | ||
| D) | Refer patients to a patient navigator who can counsel them on self-motivation strategies |
APPROACHES TO ADDRESS THE IMPACT OF STRUCTURAL RACISM IN HEALTH CARE
| Action | Description | |||
|---|---|---|---|---|
| Individual-Level Actions: What Clinicians Can Do | ||||
| Screen for social needs | Use validated tools (e.g., PRAPARE, AHC-HRSN) to identify food insecurity, transportation barriers, housing instability, and other social needs at the point of care | |||
| Use person-centered communication |
| |||
| Recognize and interrupt implicit bias |
| |||
| Address race-based clinical algorithms |
| |||
| Document social needs | Record identified social needs in the patient record to support care coordination and continuity | |||
| Advocate for patients | Navigate system barriers on behalf of patients (e.g., expediting referrals, connecting with social work, escalating unmet needs) | |||
| Engage in ongoing learning | Commit to continuing education on structural racism, health equity, and culturally responsive care | |||
| Organizational-Level Actions: What Health Systems Can Do | ||||
| Review policies for disparate impact | Regularly audit policies related to scheduling, discharge planning, referral processes, and resource allocation for unintended inequitable effects | |||
| Stratify quality metrics by race and ethnicity | Move beyond aggregate outcome reporting to identify disparities within the patient population | |||
| Invest in language access | Ensure robust interpreter services, translated materials, and multilingual staffing | |||
| Create accountability structures | Tie equity metrics to leadership performance goals and organizational dashboards | |||
| Diversify the workforce | Implement evidence-based strategies to recruit, retain, and advance providers and staff from under-represented groups | |||
| Partner with communities | Develop formal community advisory structures that give historically marginalized communities genuine influence over healthcare decisions | |||
| Assess the built environment | Evaluate service lines, facility locations, and hours of operation through an equity lens | |||
| A) | Training providers to avoid discussing race during clinical encounters | ||
| B) | Removing race and ethnicity fields from patient intake forms to reduce bias | ||
| C) | Encouraging providers to treat all patients the same, regardless of background | ||
| D) | Stratifying quality metrics by race and ethnicity to identify and address disparities |
APPROACHES TO ADDRESS THE IMPACT OF STRUCTURAL RACISM IN HEALTH CARE
| Action | Description | |||
|---|---|---|---|---|
| Individual-Level Actions: What Clinicians Can Do | ||||
| Screen for social needs | Use validated tools (e.g., PRAPARE, AHC-HRSN) to identify food insecurity, transportation barriers, housing instability, and other social needs at the point of care | |||
| Use person-centered communication |
| |||
| Recognize and interrupt implicit bias |
| |||
| Address race-based clinical algorithms |
| |||
| Document social needs | Record identified social needs in the patient record to support care coordination and continuity | |||
| Advocate for patients | Navigate system barriers on behalf of patients (e.g., expediting referrals, connecting with social work, escalating unmet needs) | |||
| Engage in ongoing learning | Commit to continuing education on structural racism, health equity, and culturally responsive care | |||
| Organizational-Level Actions: What Health Systems Can Do | ||||
| Review policies for disparate impact | Regularly audit policies related to scheduling, discharge planning, referral processes, and resource allocation for unintended inequitable effects | |||
| Stratify quality metrics by race and ethnicity | Move beyond aggregate outcome reporting to identify disparities within the patient population | |||
| Invest in language access | Ensure robust interpreter services, translated materials, and multilingual staffing | |||
| Create accountability structures | Tie equity metrics to leadership performance goals and organizational dashboards | |||
| Diversify the workforce | Implement evidence-based strategies to recruit, retain, and advance providers and staff from under-represented groups | |||
| Partner with communities | Develop formal community advisory structures that give historically marginalized communities genuine influence over healthcare decisions | |||
| Assess the built environment | Evaluate service lines, facility locations, and hours of operation through an equity lens | |||
| A) | Increase the frequency of discharge phone calls for all patients equally | ||
| B) | Survey individual providers about their discharge communication practices | ||
| C) | Benchmark the overall rate against national averages and celebrate if it meets the target | ||
| D) | Stratify the readmission data by race, ethnicity, insurance type, and preferred language to identify differential outcomes |
Standard quality improvement approaches measure outcomes at the population level but may not stratify data by race, ethnicity, language, or other equity-relevant characteristics. Equity-focused quality improvement (EFQI) builds on established quality improvement methods by explicitly examining whether improvements are distributed equitably [31]. The Institute for Healthcare Improvement's framework for achieving health equity recommends that organizations [31]:
Make a commitment to health equity as a strategic priority
Build infrastructure to support equity work
Address the multiple determinants of health
Eliminate racism and other forms of oppression
Partner with community
| A) | the provider's implicit bias is driving discharge decisions. | ||
| B) | structural racism can produce inequitable outcomes independent of individual intent. | ||
| C) | discharge planning is not influenced by race in most health systems. | ||
| D) | this disparity is likely explained by differences in insurance coverage alone. |
Structural racism is a system, not a sentiment. It operates through policies, laws, institutional practices, and resource allocation decisions, not only through individual attitudes or prejudice. It produces racially inequitable outcomes whether or not individual actors intend to cause harm [1,7].