Perspectives on Racism in Health Care Among Black Veterans With Chronic Kidney Disease

Abstract

IMPORTANCEThe burden of chronic kidney disease (CKD) and end-stage kidney disease falls disproportionately on Black individuals in the US, with Black veterans experiencing substantial consequences, and only a portion of the disparities in health conditions and health care can be explained by nonbiological factors. Among Black individuals, racism is likely one of those factors, suggesting the need to examine the consequences of racism and the resulting social structures that establish and perpetuate these racial disparities. OBJECTIVE To investigate the health care experiences of Black veterans with CKD and identify and explore the racial discrimination encountered by this vulnerable population. DESIGN, SETTING, AND PARTICIPANTSThis qualitative study used semistructured interview guides to investigate the health care experiences of 36 Black veterans with CKD who received care at the Corporal Michael Crescenz Veterans Affairs Medical Center in Philadelphia, Pennsylvania, from October 2018 to September 2019. Interview transcripts were analyzed using applied thematic analysis. RESULTSAmong 36 Black veterans with CKD who characterized racism in the context of their care at a Veterans Affairs medical center, the mean (SD) age was 66.0 (7.8) years; 35 participants (97.2%) were male, 1 participant (2.8%) was female, and 19 participants (52.8%) were married. The mean (SD) duration of military service was 8.0 (7.0) years. Overall, 15 participants (41.7%) were not dependent on dialysis, and hypertension was the most common comorbidity (9 participants [25.0%]). Veterans described the ways in which racism produced emotional and physical stress, including psychological symptoms (eg, anger and hurt) and physiological symptoms (eg, headaches).Veterans described a strong sense of distrust in the health care system coupled with a need to be hypervigilant during clinical encounters. When encountering racism, veterans described bottling up their feelings, which sometimes led to maladaptive behavior (eg, substance use). Veterans also described individual and collective positive strategies (eg, faith) for coping with the stress of racism. CONCLUSIONS AND RELEVANCEIn this study, Black veterans with CKD experienced racism in the clinical setting that produced physical and emotional stress and a strong sense of distrust in the health care system. These findings highlight an important opportunity for education and training of health care professionals in the implementation of trauma-informed approaches to care as a means of addressing race-based stress and trauma.

Disparities in Wait Times for Care Among US Veterans by Race and Ethnicity

“…This finding underscores the critical importance of facility-level analyses for highlighting opportunities to reduce disparities and target quality improvement efforts. It will be important for further work to determine the extent to which these disparities are driven by patient (eg, unequal access to resources needed to use health care services) 54 or clinician factors (eg, delayed nonvital procedures, discriminatory practices). 55 …”

Understanding Health Disparities in Preeclampsia: A Literature Review

“…Though similar relationships describing racial bias and preeclampsia diagnostics are relatively understudied, medical bias likely plays a role in the disparate rates of preeclampsia in Black patients as discussed throughout this paper. This bias is inevitably perceived by patients, leading to mistrust of providers by certain racial groups 30 . While studies linking perceived racial bias and medical mistrust to preeclampsia specifically have not been performed, studies suggesting a multifaceted approach to improving maternal mortality for Black patients are hopeful that adverse pregnancy outcomes overall would be improved, perhaps including preeclampsia.…”

“…This bias is inevitably perceived by patients, leading to mistrust of providers by certain racial groups. 33 While studies linking perceived racial bias and medical mistrust to preeclampsia specifically have not been performed, studies suggesting a multifaceted approach to improving maternal mortality for Black patients are hopeful that adverse pregnancy outcomes overall would be improved, perhaps including preeclampsia. Such interventions include approaching patients with greater respect and compassion, improved continuity of care, preconception care, careful control of comorbidities, early involvement of cardiologic care, improved primary care, and targeted resource expansion for hospitals servicing Black populations.…”

A Study on CKD Progression and Health Disparities Using System Dynamics Modeling

“…A disproportionate number of Americans, mainly African Americans, die from CKD [ 6 ]. The issues of CKD health disparities have been discussed extensively in the related research work [ 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 ]. Moreover, individuals who might otherwise be denied medical care due to their socioeconomic situation, lack of insurance, or underinsurance can now receive it.…”