4.1. Overview of the Literature
In total, 37 peer-reviewed articles were included in the review, with 12 empirical studies and 25 theoretical or conceptual papers. The empirical studies included the collection and analysis of data while theoretical or conceptual papers did not. Five conceptual papers described anti-racism interventions that were evaluated or in the process of being evaluated [19
]. Table 1
summarizes the results of the peer-reviewed literature outlined below. Six grey literature documents were included [24
]. A summary of the peer-reviewed articles and grey literature documents with detailed information and findings are presented in table format in Supplementary Materials
Only 40% of articles explicitly defined racism or a specific type or level of racism, such as institutional racism or systemic racism. One third (32%) provided definitions for related terms, including stereotype, discrimination, prejudice, cultural safety, cultural competence/awareness/safety, racial and ethnic disparities, and unconscious bias. A quarter of the articles (26%) had no explicit definition for either racism or any related terms, although they used these terms within the articles. Those that did provide definitions of racism varied and were noted.
Of the peer-reviewed articles, 12 (32%) explicitly focused on anti-racism interventions for Indigenous populations as a patient group (includes Aboriginal and Torres Strait Islander people, Maori, First Nations, Inuit, and Metis/Native Americans) and only 5 (14%) explicitly focused on Black populations as a patient group (includes Black and African American) [30
]. Twelve articles (32%) named other minority and racialized patient groups using terms like “minority groups”, “clients of colour”, “non-White”, “racial and ethnic minorities” and “socially stigmatized groups”.
There were a wide range of anti-racism interventions across different healthcare settings and provider groups. Almost half of the peer-reviewed articles focused on either nurses or physicians as healthcare provider groups (22% and 22%, respectively). Other articles focused on counsellors and psychologists (11%), social workers (3%) or pharmacists (3%), while 32% of articles did not specify a healthcare provider group. The anti-racism interventions were implemented across a range of settings, including hospitals (outpatients) (21%); network or regional level with direct patient reach (19%), such as the Henry Ford Health System in Michigan [33
]; primary care (14%) and community-based settings providing outpatient care (11%), such as the NSW Health Education Centre Against Violence [54
Anti-racism interventions were further stratified at differing socio-ecological levels. Table 2
outlines examples of anti-racism interventions in healthcare settings by intervention level.
included self-reflection tools, unconscious bias training and Implicit Association Tests that seek to make individuals aware of stereotypes about different racial groups that are unconsciously formed [30
]. This type of intervention or training is targeted at individual transformation relating to knowledge, attitudes and behaviours. Interpersonal-level interventions
focused on cultivating interactions (both formal and informal) between providers, patients and the provider–patient relationship that seek to address racial health disparities, mitigate harmful practices for racialized populations or address racist comments by clients [36
]. For example, the Maori Practice Model (Te Kapunga Putohe) [59
] was developed to integrate Maori practices into nursing practice and guide nurses in providing Maori-centred care to improve health outcomes for this population. Community-level interventions
focused on developing meaningful relationships between the healthcare organization and populations that the healthcare setting serves or the geographic community that the organization is situated within. These interventions involved actively establishing ongoing, meaningful partnerships with racialized communities, including Black, Indigenous and other racialized groups to begin to address racism in healthcare [23
]. Addressing institutional racism against Aboriginal people in hospitals needs committed physicians to engage, support, learn from and include Aboriginal community elders and members in discussion, planning and collaboration [56
]. Investing time and resources in this process is an integral part of anti-racism work. Organizational-level interventions
focused on structures and processes within an organization, including creating a consultation group, amending human resources policies, hosting workshops and conferences to effect organizational change [31
]. Language translation and culturally- or linguistically-appropriate services were heralded (erroneously) as anti-racist interventions in some articles [40
]. Policy-level interventions
focused on policies, regulations, processes which include frameworks, policies, guidelines and recommendations at a system level [12
]. For example, the National Health Service in the United Kingdom incorporated a workforce standard with indicators that compared metrics between “White and Black and minority ethnic” healthcare staff [53
]. A policy statement with three principles was released by the American Society of Health-System Pharmacists to reduce racial and ethnic disparities [42
]. These interventions are intended to provide broad-level mandates or guidance for uptake by stakeholders.
Many (62%) articles included interventions that were multi-level, i.e., targeted two or more levels. Most anti-racism interventions targeted the individual (54%), interpersonal (51%) and organizational (57%) levels. Only 21% of the peer-reviewed articles included an anti-racism intervention at the community-level and 24% included an intervention at the policy-level.
None of the included empirical studies targeted policy-level interventions and only two empirical studies included a community-level intervention [50
]. Four of the six grey literature documents implemented policy-level interventions [26
Some authors formed or identified recommendations, strategies, principles or lists of competencies for healthcare providers [21
]. These articles often provided valuable insights but varied with respect to follow-up action.
Many articles focused on developing a new or original tool, training, workshop or curricula to varying degrees of success [19
]. The evaluation of an Undoing Racism
] aimed at highlighting the role of racism in contributing to the Black–White gap in infant mortality found that the workshop was helpful in offering a common language and framework to discuss racism and identify changes to reduce disparities. However, results from 169 surveys noted that White respondents had fewer “likes” about the workshop compared to African Americans and were more likely to object to the perceived “confrontational style” of the workshop [31
Bennet and Keating [52
] identified key factors for effective race equity training, noting that “current approaches are fundamentally flawed”. These factors include whether the organization has a formal policy of anti-racism, established level of commitment, whether race equity training is voluntary or mandatory, the cost of attending, the (internal or external) facilitator’s qualifications, and whether the impact of the training is evaluated [52
]. Continuous, ongoing training was considered better than one-time training [46
]. Furthermore, training should avoid a “one size fits all” approach for staff which does not sufficiently address healthcare provider-specific issues [52
There were challenges with engaging healthcare providers in the training process. Debriefing discussions of the interactive training tool Privilege and Responsibility Curricular Exercise
] resulted in “divisive responses that facilitators had to challenge, such as denial, diversion, or anecdotal accounts questioning the existence of societal bias.” Anti-racism training needs to be ongoing, with the support of a skilled facilitator adept in this subject area [30
]. Importantly, “an unintended consequence of training providers to avoid explicit bias is that their implicit bias is activated” [34
]. One study identified that physicians “are the group least likely to attend” and make time for quality Aboriginal cultural orientation training [56
]. Nurses were identified as key players and advocates in addressing inequities, establishing culturally safe and competent practices through transparent processes [48
A mixed-methods study of a six-hour workshop on cultural competency with White, female occupational therapists found that study participants held significantly negative attitudes towards African Americans which were not ameliorated by the intervention [30
]. The results demonstrated that participants held strong, persistent beliefs and racist attitudes towards Black people, were resistant to change despite evidence presented, and attributed any health disparities to a perceived “deficit” within that group. A key recommendation was to offer training in short sessions, spaced at least one week apart to allow for processing time by participants [30
]. Papadopoulos, Tilki and Lees [21
] present 15 principles to consider for effective cultural competency training.