The consequences of racism extend into all sectors of society including health and healthcare. This essay specifically considers the effects of racism on psychological outcomes. Effects of racism on physical health, healthcare utilisation and exposure to health-damaging or health-benefiting factors and the resulting impact on psychological outcomes have also been described.
Racism can be understood as the combination of prejudice, that is, preconceived, usually negative feelings towards individuals based on that person’s group membership, and unequal power relations (Paradies et al. 2015). Describing the manifestation of this definition often leads to dividing racist action into systemic, interpersonal, and internalised racism. Systemic racism can be defined as organised systems, policies, or practices within society causing avoidable and unfair inequalities across racial groups. Interpersonal racism describes interactions between individuals such as threats, insults and aggressions. Internalised racism is the integration of racist attitudes into one’s worldview (Paradies et al. 2015; Berman et al. 2008).
Racism and resulting psychological outcomes:
The relationship between racism and health outcomes were explored in a systematic review that included 293 studies. This review established that poorer mental health, such as depression, anxiety, and psychological stress, was associated with racism (Paradies et al. 2015). Racism was specifically associated with increased suicidal ideation, planning and attempts; furthermore, increased incidence of post-traumatic stress disorder was also associated with racism (Paradies et al. 2015). Observations in this review were consistent with findings from a study with 1,139 participants that discovered individuals who experience racism were at a higher risk of psychological distresses including depression and anxiety (Williams et al. 1997).
Self-reported racism has been linked to lower self-esteem. Low self-esteem has been associated with various psychological difficulties such as increased anxiety, depression, and loneliness, and can result in increased health-damaging behaviour (Paradies et al. 2015). One pathway that can explain the relationship between racism and poor psychological health is the increased exposure to health-damaging risk factors. Discrimination has been associated with higher rates of alcohol abuse and smoking (Paradies et al. 2015). Furthermore, racism results in reduced access to good housing, education and decreased engagement in health-protective behaviour including good sleep habits and exercise (Paradies et al. 2015). Poor health behaviour has been associated with poor mental health outcomes (Sellers et al. 2009). Understanding the relationship between racism and health-damaging behaviour and the resulting impact on mental health outcomes can create an opportunity to intervene.
Racism, physical health outcomes, and resulting psychological outcomes
Poor physical health has been established as a cause of poor mental health, especially chronic physical conditions, through various pathways (Verhaak et al. 2005). The relationship between racism and poor physical health is less consistently observed than that between racism and mental health. A meta-analytic review discovered an increased risk of hypertension and breast cancer in individuals who have experienced discrimination or racism (Pascoe et al. 2009). A further study observed increased prevalence of physical health conditions such as hypertension and respiratory diseases in individuals who have experienced verbal or physical racial abuse (Karlsen et al. 2001). Further associations with racism and poor physical health are physical injuries and trauma from racially motivated violent acts (Paradies et al. 2015). Physical injuries and trauma can also exacerbate mental health conditions (Verhaak et al. 2005). Understanding the impact of racism on physical health and the resulting impact on mental health is important in fully exploring the relationship between racism and psychological outcomes.
Racism, health service quality and resulting psychological outcomes
Effective relationships between patients and their healthcare providers result in improved mental health and symptom resolution (Stewart 1995). Therefore, assessing the impact of racism on patients’ perception of the health systems and providers is valuable when considering the resulting impact on patient mental health. A meta-analysis of 52 studies reported an association between racism and poorer patient experiences of healthcare services including decreased trust in the healthcare system, satisfaction, and quality of communication from healthcare providers. Additionally, an association between racism and delayed healthcare was demonstrated. However, there was no observed relationship between racism and health service utilisation, physical examinations, and admission to services (Jehonathan et al. 2017). This suggests patients experiencing racism continue to utilise health services, despite the increased risk of negative experiences from healthcare services and providers, perhaps due to an increased need for services as demonstrated by reduced mental health outcomes (Paradies et al. 2015).
A narrative review of mental health disparities among minority ethnic populations in the United Kingdom reported that these populations have lower rates of initiation and retention with mental health services compared to their counterparts; this can be attributed to various factors including perceived discrimination (Vahdaninia et al. 2020). This review demonstrated that clinicians’ conversations with this population were less likely to be friendly, and patient involvement with clinical decisions was likely to be reduced (Vahdaninia et al. 2020).
Racial discrimination in healthcare settings influences patients' future engagement with available services, adherence to recommendations, and the perceived quality of relationships with healthcare providers (Jehonathan et al. 2017). Past experiences of racism in healthcare settings and other societal areas can result in feelings of threat and racism-related vigilance, which independently are considered health risk factors (Paradies et al. 2015). A systematic review exploring racism in healthcare systems observed racist beliefs and behaviour amongst healthcare providers. Racial bias can be implicit and explicit, the former being an example of racial discrimination without provider awareness, and can influence communication with the patient and management decisions (Jehonathan et al. 2017).
Psychological conditions are multifactorial and are impacted by various influences; poor mental health has been associated with reduced physical health, decreased access to high quality health services, and exposure to health-damaging behaviour; racism has been shown to influence each of these factors (Verhaak et al. 2005; Stewart 1995; Vahdaninia et al. 2020). These pathways may be part of the explanation of the association between racism and poor psychological outcomes. A holistic approach is required to address the relationship between racism and poor mental health which should include reduced exposure to health risk factors, increased understanding of the relationship between physical health and racism, and improved access to high quality of care that includes excellent communication and trust between the practitioner and the patient. Nonetheless, efforts need to be focused on tackling racism at its root as this is the primary prevention to the negative psychological impact that individuals exposed to racism face.
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