Undoing the unspeakable: researching racism in Swedish healthcare using a participatory process to build dialogue

'You are making it sound like you are talking to a child': exploring community sentiment on developing and disseminating tailored sexual health education resources for migrants

Health communication is a critical component of public health, which includes health education resources. Resource effectiveness is improved where health literacy demands, including the cultural appropriateness of resources, match the intended audience. International guidelines support the tailoring of resources for migrants from culturally and linguistically diverse backgrounds (CaLD). Five focus groups (n = 18) and interviews (n = 9) with people from CaLD migrant backgrounds explored community perspectives on sexual health resources developed by a state department of health, specifically clarity, comprehensiveness, cultural appropriateness and strategies for dissemination. We identified three major thematic areas relating to simplicity, cultural norms and beliefs and dissemination. Participants recommended resource delivery in different formats as part of a broader intervention. Generally, sexual health information was deemed appropriate and easily understood. However, the resources used simplified language that participants reported was vague and inaccurate at times, potentially contributing to misinformation and reinforcing stigma relating both to the status of being a migrant and sexual health. Findings suggest the need for more nuanced health resource development beyond translation and language simplification. Resources developed in different formats, including different health literacy demands, using approaches that engage the target group in design and dissemination and contextualized within a comprehensive health promotion project, are likely to be more effective.

Training Psychology and Psychiatry Diversity Dialogue Facilitators

This article describes a Diversity Dialogue Facilitator Training Program for Trainees, an innovative project that prepares psychology and psychiatry learners to facilitate diversity dialogues with healthcare professionals (i.e., clinical and research faculty, staff, and learners) in academic healthcare settings. Through participating in this program, trainees learn to facilitate discussions in which participants reflect upon oppression, discrimination, and disparities; explore their biases; connect and exchange views with colleagues regarding challenging societal events; and delineate action steps for advancing equity, inclusion, social responsivity, and justice in their professional and personal lives. After outlining contextual factors that informed project development, implementation, and dissemination, the iterative process of creating and implementing the training curriculum is detailed, with the aim of offering a model for other academic health center-based training programs interested in establishing a similar initiative. Lessons learned also are shared with the hope of contributing to future efforts to advance training in diversity dialogue facilitation and expand the role of psychologists in medical settings.

Racialised staff-patient relationships in inpatient mental health wards: a realist secondary qualitative analysis of patient experience data

BACKGROUND

The current study is a secondary analysis of qualitative data collected as part of EURIPIDES, a study which assessed how patient experience data were used to improve the quality of care in National Health Service (NHS) mental health services.

OBJECTIVE

We undertook a detailed realist secondary qualitative analysis of 10 interviews in which expressions of racialisation were unexpectedly reported. This theme and these data did not form part of the primary realist evaluation.

METHODS

Interviews were originally conducted with the patients (18-65 years: 40% female, 60% male) from four different geographically located NHS England mental health trusts between July and October 2017. Secondary qualitative data analysis was conducted in two phases: (1) reflexive thematic analysis and retroduction; (2) refinement of context-mechanism-outcome configurations to explore the generative mechanisms underpinning processes of racialisation and revision of the initial programme theory.

FINDINGS

There were two main themes: (1) absence of safe spaces to discuss racialisation which silenced and isolated patients; (2) strained communication and power imbalances shaped a process of mutual racialisation by patients and staff. Non-reporting of racialisation and discrimination elicited emotions such as feeling othered, misunderstood, disempowered and fearful.

CONCLUSIONS

The culture of silence, non-reporting and power imbalances in inpatient wards perpetuated relational racialisation and prevented authentic feedback and staff-patient rapport.

CLINICAL IMPLICATIONS

Racialisation in mental health trusts reflects lack of psychological safety which weakens staff-patient rapport and has implications for authentic patient engagement in feedback and quality improvement processes. Larger-scale studies are needed to investigate racialisation in the staff-patient relationships.

Racism against racialized migrants in healthcare in Europe: a scoping review

BACKGROUND

Racism is frequently mentioned as a social determinant of migrants' health and a barrier to health services. However, in the European context, racism and its impact on racialized migrants' access to healthcare is remarkably under-researched. This scoping review makes a first step toward filling this void by mapping the existing literature on racial and ethnic discrimination against racialized migrants in healthcare in Europe, identifying evidence gaps, and offering recommendations for future research on this topic.

METHODS

Following PRISMA guidelines, four databases were searched for empirical studies published in English between 1992 and 2022. Studies were included if they report findings on manifestations, experiences and/or impacts of racial or ethnic discrimination against racialized migrants in a healthcare setting in a European country. They were summarized by study characteristics (geographical scope, study design, research question and measures) and research findings were synthesized.

RESULTS

Out of 2365 initial hits, 1724 records were included in the title/abstract-screening, 87 records in the full text-screening, and 38 records in the data extraction. For many country and healthcare contexts, evidence on racism in healthcare is lacking. Most studies apply an explorative qualitative research design; comparability and generalizability of research results are low. Our analysis furthermore shows a near-exclusive research focus on racism on the interpersonal level as compared to institutional and structural levels. Our synthesis of study results identifies three interrelated ways in which racism manifests in and impacts migrants' healthcare: 1) general anti-migration bias, 2) health- and healthcare-related prejudice, and 3) differential medical treatment.

CONCLUSIONS

Our review underscores how racism reinforces inequities in healthcare access and quality for racialized migrants. It also highlights the need for more research on racism in Europe across a greater scope of country contexts, healthcare settings and migrant/racialized categories in order to understand specific forms of racism and capture race as a context-contingent social construct. It is critical that future research includes the consideration of individual-level racism as embedded in racism on institutional and structural levels. Methods and insights from other disciplines may help to critically examine concepts in light of underlying historical, sociopolitical and socioeconomic processes and structures, and to improve methods for researching racialization and racism in healthcare.

Discussing racism in healthcare: A qualitative study of reflections by graduate nursing students

AIM

The aim is to illustrate and analyse reflections from graduate nursing students over their experience of discussing racism in healthcare in an educational intervention.

DESIGN

A qualitative, descriptive design was adopted.

METHODS

Data were collected through written reflections and analysed through content analysis. In total, 81 students participated in the intervention; 39 paediatric and 42 public health care nursing students. Of those, 27 participants gave consent to have their written reflections included in the study.

RESULTS

Three main categories were developed in the content analysis of student reflections: (a) the implicit embeddedness of racism in healthcare organization; (b) the effect of racism on interactions with patients; and (c) a growing awareness of one's own understanding of racism. This study indicates that student nurses discussed racism as relevant to understanding good clinical practice for the benefit of patients and work-based wellbeing of staff. This recognition of the organizational nature of racism warrants nursing leaders and managers to include racism as a social determinant of health in the undergraduate and graduate curricula to educate the next generation of nursing about racism.

Discrimination in an "equal country"-a survey amongst Swedish final-year medical students

BACKGROUND

Discrimination due to gender and ethnicity has been found to be widespread in medicine and healthcare. Swedish and European legislation list seven discrimination grounds (age, sex, ethnicity, religion, sexuality, non-binary gender identity, and disability) which may intersect with each other; yet these have only been sparsely researched. The aim of this study was to assess the extent of discrimination, based on these seven discrimination grounds, amongst final-year medical students in Sweden.

METHODS

A web-based survey, based on the CHERRIES-checklist, was disseminated to course coordinators and program directors in charge of final year medical students at all seven medical schools in Sweden. Quantitative data were analyzed using descriptive statistics, Fisher's exact test, and logistic regression. Free-text answers were analyzed thematically using the "Master Suppression techniques" conceptual framework.

RESULTS

Of the 1298 medical students contacted, 247 (19%) took part in the survey. Almost half (n = 103, 42%) had experienced some form of discrimination, and this difference was statistically significant by gender (p = 0.012), self-perceived ethnicity (p < 0.001), country of birth other than Scandinavia (p < 0.001) and visible religious signs (p = 0.037). The most common type of discrimination was gender-based (in 83% of students who had experienced discrimination), followed by age (48%), and ethnicity (42%). In the logistic regression, women/non-binary gender (p = 0.001, OR 2.44 [95% CI 1.41-4.22]), country of birth not in Scandinavia (p < 0.001, OR 8.05 [2.69-24.03]), non-Caucasian ethnicity (p = 0.04, OR 2.70 [1.39-5.27]), and disability (p = 0.02, OR 13.8 [1.58-12040]) were independently associated with discrimination. Half of those who had experienced religion-based discrimination and nearly one-third of victims of ethnicity-based discrimination reported "large" or "extreme" impact of this. Clinical staff or supervisors were the most common offenders (34%), closely followed by patients and their relatives (30%), with non-Caucasian respondents significantly more likely to experience discrimination by patients (p < 0.001).

CONCLUSIONS

Discrimination appears to be frequent in medical school, even in one of the world's "most equal countries". Discrimination is most commonly gender- or ethnicity-based, with ethnicity- and religion-based discrimination appearing to have the largest impact. Future research should continue to evaluate discrimination from an intersectional perspective, adapted for local contexts and legislations.

Healthcare encounters between asylum seekers and health professionals in Maltese primary care

Background

There is a substantial body of literature that discusses the problematic nature of asylum seeker healthcare in several European countries. However, little is known about how asylum seekers experience primary healthcare in Malta.

Aim

This paper draws on a qualitative study that aimed to explore the nature of healthcare encounters between asylum seekers and healthcare professionals in Maltese primary healthcare and the contextual processes which influence these interactions.

Methodology

The study utilised critical ethnography, informed by postcolonial theory. Data were collected through observation of encounters between healthcare professionals and asylum seekers (130 hours) and in-depth interviews with asylum seekers ( n11), cultural mediators ( n4) and Maltese healthcare professionals ( n7).

Results

Thematic analysis of the combined data resulted in three themes: ‘the impact of seeking refuge’, ‘seeking mutual understanding’ and ‘seeking resolution’. Healthcare encounters between asylum seekers and professionals are characterised by ‘othering’ practices, pre-conceived expectations and mutual mistrust. These are shaped by a complex interplay of factors, including damaging experiences of migration, derogatory political and public discourses and inadequate resources.

Conclusion

In Maltese primary care, healthcare encounters are highly problematic for both patients and professionals. Nurses could take the lead in developing services to assess complex needs and aid asylum seekers in navigating the healthcare system.

Racism in healthcare: a scoping review

BACKGROUND

Racism constitutes a barrier towards achieving equitable healthcare as documented in research showing unequal processes of delivering, accessing, and receiving healthcare across countries and healthcare indicators. This review summarizes studies examining how racism is discussed and produced in the process of delivering, accessing and receiving healthcare across various national contexts.

METHOD

The PRISMA guidelines for scoping reviews were followed and databases were searched for peer reviewed empirical articles in English across national contexts. No starting date limitation was applied for this review. The end date was December 1, 2020. The review scoped 213 articles. The results were summarized, coded and thematically categorized in regards to the aim.

RESULTS

The review yielded the following categories: healthcare users' experiences of racism in healthcare; healthcare staff's experiences of racism; healthcare staff's racial attitudes and beliefs; effects of racism in healthcare on various treatment choices; healthcare staff's reflections on racism in healthcare and; antiracist training in healthcare. Racialized minorities experience inadequate healthcare and being dismissed in healthcare interactions. Experiences of racism are associated with lack of trust and delay in seeking healthcare. Racialized minority healthcare staff experience racism in their workplace from healthcare users and colleagues and lack of organizational support in managing racism. Research on healthcare staff's racial attitudes and beliefs demonstrate a range of negative stereotypes regarding racialized minority healthcare users who are viewed as difficult. Research on implicit racial bias illustrates that healthcare staff exhibit racial bias in favor of majority group. Healthcare staff's racial bias may influence medical decisions negatively. Studies examining healthcare staff's reflections on racism and antiracist training show that healthcare staff tend to construct healthcare as impartial and that healthcare staff do not readily discuss racism in their workplace.

CONCLUSIONS

The USA dominates the research. It is imperative that research covers other geo-political contexts. Research on racism in healthcare is mainly descriptive, atheoretical, uses racial categories uncritically and tends to ignore racialization processes making it difficult to conceptualize racism. Sociological research on racism could inform research on racism as it theoretically explains racism's structural embeddedness, which could aid in tackling racism to provide good quality care.

Empowering communities with health promotion labs: result from a CBPR programme in Malmö, Sweden

Health promotion is thus not only a participatory practice, but a practice for empowerment and social justice. The study describes findings from a community-based participatory and challenge-driven research program. that aimed to improve health through health promotion platform in an ethnically diverse low-income neighbourhood of Malmö, Sweden. Local residents together with lay health promoters living in the area were actively involved in the planning phase and decided on the structure and content of the program. Academic, public sector and commercial actors were involved, as well as NGOs and residents. Empowerment was used as a lens to analyse focus group interviews with participants (n=322) in six co-creative health-promoting labs on three occasions in the period 2017-2019. The CBPR interview guide focused on the dimensions of participation, collaboration and experience of the activities. The CBPR approach driven by community member contributed to empowerment processes within the health promotion labs: Health promotors building trust in social places for integration, Participants motivate each other by social support and Participants acting for community health in wider circle. CBPR Health promotion program should be followed up longitudielly with community participants to be able to see the processes of change and empowerment on the community level.

"Just Throw It Behind You and Just Keep Going": Emotional Labor when Ethnic Minority Healthcare Staff Encounter Racism in Healthcare

Encountering racism is burdensome and meeting it in a healthcare setting is no exception. This paper is part of a larger study that focused on understanding and addressing racism in healthcare in Sweden. In the paper, we draw on interviews with 12 ethnic minority healthcare staff who described how they managed emotional labor in their encounters with racism at their workplace. Data were analyzed using thematic analysis. The analysis revealed that experienced emotional labor arises from two main reasons. The first is the concern and fear that ethnic minority healthcare staff have of adverse consequences for their employment should they be seen engaged in discussing racism. The second concerns the ethical dilemmas when taking care of racist patients since healthcare staff are bound by a duty of providing equal care for all patients as expressed in healthcare institutional regulations. Strategies to manage emotional labor described by the staff include working harder to prove their competence and faking, blocking or hiding their emotions when they encounter racism. The emotional labor implied by these strategies could be intense or traumatizing as indicated by some staff members, and can therefore have negative effects on health. Given that discussions around racism are silenced, it is paramount to create space where racism can be safely discussed and to develop a safe healthcare environment for the benefit of staff and patients.

Designing an education intervention for understanding racism in healthcare in Sweden: development and implementation of anti-racist strategies through shared knowledge production and evaluation

An educational intervention, based on qualitative evidence of racism in healthcare, is described. Using vignettes from a previous project, interviews were conducted to gather qualitative evidence of racism in healthcare settings from a wide range of healthcare staff in Sweden. From this interview material, case studies were devised that were subsequently presented to trainee healthcare professionals, in a seminar discussion. After the seminar, trainees responded to reflective questions. The order of work, as well as the materials used, are described. This intervention was successful in facilitating discussion about racism in an educational context, despite the difficult nature of these conversations for some participants.

Ethnic minority patients in healthcare from a Scandinavian welfare perspective: The case of Denmark

The Scandinavian welfare states are known for their universal access to healthcare; however, health inequalities affecting ethnic minority patients are prevalent. Ethnic minority patients' encounters with healthcare systems are often portrayed as part of a system that represents objectivity and neutrality. However, the Danish healthcare sector is a political apparatus that is affected by policies and conceptualisations. Health policies towards ethnic minorities are analysed using Bacchi's policy analysis, to show how implicit problem representations are translated from political and societal discourses into the Danish healthcare system. Our analysis shows that health policies are based on different ideas of who ethnic minority patients are and what kinds of challenges they entail. Two main issues are raised: First, ethnic minorities are positioned as bearers of 'culture' and 'ethnicity'. These concepts of 'othering' become both explanations for and the cause of inappropriate healthcare behaviour. Second, the Scandinavian welfare states are known for their solidarity, collectivism, equality and tolerance, also grounded in a postracial, colour-blind and noncolonial past ideology that forms the societal self-image. Combined with the ethical and legal responsibility of healthcare professionals to treat all patients equally, our findings indicate little leeway for addressing the discrimination experienced by ethnic minority patients.

Racism in European Health Care: Structural Violence and Beyond

Research shows how racism can negatively affect access to health care and treatment. However, limited theoretical research exists on conceptualizing racism in health care. In this article, we use structural violence as a theoretical tool to understand how racism as an institutionalized social structure is enacted in subtle ways and how the "violence" built into forms of social organization is rendered invisible through repetition and routinization. We draw on interviews with health care users from three European countries, namely, Sweden, Germany, and Portugal to demonstrate how two interrelated processes of unequal access to resources and inequalities in power can lead to the silencing of suffering and erosion of dignity, respectively. The strength of this article lies in illuminating the mechanisms of subtle racism that damages individuals and leads to loss of trust in health care. It is imperative to address these issues to ensure a responsive and equal health care for all users.

'If there were doctors who could understand our problems, I would already be better': dissatisfactory health care and marginalisation in superdiverse neighbourhoods

How people in community settings describe their experience of disappointing health care, and their responses to such dissatisfaction, sheds light on the role of marginalisation and underlines the need for radically responsive service provision. Making the case for studying unprompted accounts of dissatisfaction with healthcare provision, this is an original analysis of 71 semi-structured interviews with healthcare users in superdiverse neighbourhoods in four European cities. Healthcare users spontaneously express disappointment with services that dismiss their concerns and fail to attend to their priorities. Analysing characteristics of these healthcare users show that no single aspect of marginalisation shapes the expression of disappointment. In response to disappointing health care, users sought out alternative services and to persuade reluctant service providers, and they withdrew from services, in order to access more suitable health care and to achieve personal vindication. Promoting normative quality standards for diverse and diversifying populations that access care from a range of public and private service providers is in tension with prioritising services that are responsive to individual priorities. Without an effort towards radically responsive service provision, the ideal of universal access on the basis of need gives way to normative service provision.

What matters in health (care) universes: delusions, dilutions, and ways towards universal health justice

The presumed global consensus on achieving Universal Health Coverage (UHC) masks crucial issues regarding the principles and politics of what constitutes "universality" and what matters, past and present, in the struggle for health (care) justice. This article focuses on three dimensions of the problematic: 1) we unpack the rhetoric of UHC in terms of each of its three components: universal, health, and coverage; 2) paying special attention to Latin America, we revisit the neoliberal coup d'état against past and contemporary struggles for health justice, and we consider how the current neoliberal phase of capitalism has sought to arrest these struggles, co-opt their language, and narrow their vision; and 3) we re-imagine the contemporary challenges/dilemmas concerning health justice, transcending the false technocratic consensus around UHC and re-infusing the profoundly political nature of this struggle. In sum, as with the universe writ large, a range of matters matter: socio-political contexts at national and international levels, agenda-setting power, the battle over language, real policy effects, conceptual narratives, and people's struggles for justice.

Invisibility of Racism in the Global Neoliberal Era: Implications for Researching Racism in Healthcare

This paper describes the difficulties of researching racism in healthcare contexts as part of the wider issue of neoliberal reforms in welfare states in the age of global migration. In trying to understand the contradiction of a phenomenon that is historical and strongly felt by individuals and yet widely denied by both institutions and individuals, we consider the current political and socioeconomic context of healthcare provision. Despite decades of legislation against racism, its presence persists in healthcare settings, but data on these experiences is rarely gathered in Europe. National systems of healthcare provision have been subject to neoliberal reforms, where among others, cheaper forms of labor are sought to reduce the cost of producing healthcare, while the availability of services is rationed to contain demand. The restriction both on provision of and access to welfare, including healthcare, is unpopular among national populations. However, the explanations for restricted access to healthcare are assumed to be located outside the national context with immigrants being blamed. Even as migrants are used as a source of cheap labor in healthcare and other welfare sectors, the arrival of immigrants has been held responsible for restricted access to healthcare and welfare in general. One implication of (im)migration being blamed for healthcare restrictions, while racism is held to be a problem of the past, is the silencing of experiences of racism, which has dire consequences for ethnic minority populations. The implications of racism as a form of inequality within healthcare and the circumstances of researching racism in healthcare and its implication for the sociology of health in Sweden are described.