Healthcare staff's racialized talk: The perpetuation of racism in healthcare.

Research points to the existence of racial bias and beliefs among healthcare staff but does not explicate accounts of racialization in healthcare and the day-to-day utterances that have racializing effects excluding minoritized users' right to care. This study understands racism as structural and embedded in societies and institutions, including healthcare, as well as in interactions and talk. Through excavating accounts of healthcare staff's talk that devalues minoritized users, this study posits talk as reflective and constitutive of the dominant structure of racism within which it is situated. Drawing on qualitative interviews with 58 staff in Sweden, the study delineates three categories through which racialized talk differentiates between minoritized and majoritized users. These are: Characterizing minoritized users as 'bad' users, Characterizing minoritized users' health complaints as unworthy and finally, Devaluing minoritized users as justification for suboptimal and differential care. Healthcare staff accounts show that continuous racialization of minoritized users maintains existing power-relations representing Western users as civilized and non-Western users as uncivilized and problematic. Through reiteration, these practices of exclusion become invisible, normalized, and assume the status quo. It is imperative to address racialization as it has implications for the core ethics of 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.

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, racial and regional inequalities in access to COVID-19 vaccine, testing and hospitalization: Implications for eradication of the pandemic.

The COVID-19 pandemic has made visible inequalities as exemplified by unequal access to COVID-19 vaccine across and within countries; inequalities that are also apparent in rates of testing, disease, hospitalization and death from COVID-19 along class, ethnic and racial lines. For a global pandemic such as the COVID-19 to be effectively addressed, there is a need to reflect on the entrenched and structural inequalities within and between countries. While many countries in the global north have acquired more vaccines than they may need, in the global south many have very limited access. While countries in the global north had largely vaccinated their populations by 2022, those in the global south may not even complete vaccinating 70% of their population to enable them reach the so-called herd immunity by 2024. Even in the global north where vaccines are available, ethnic, racialized and poor working classes are disproportionately affected in terms of disproportionately low rates of infection and death. This paper explores the socio-economic and political structural factors that have created and maintain these disparities. In particular we sketch the role of neoliberal developments in deregulating and financializing the system, vaccine hoarding, patent protection and how this contributes to maintaining and widening disparities in access to COVID-19 vaccine and medication.

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.

Conceptualizing impact in community-based participatory action research to engage communities in end-of-life issues.

Background: A health promotion approach to end-of-life (EoL) care is gaining traction internationally. However, there is a lack of evaluations of the impact of this approach, particularly regarding community-based initiatives. Conceptualizations of impact in participatory action research (PAR) may contribute to understanding ways in which impact can be investigated in community-based health promotion approaches to EoL issues. We aim to investigate impact and the process of impact development in our community-based PAR project, Studio DöBra, a Swedish health promotion initiative to engage communities in EoL issues. Methods: We do this through a qualitative framework analysis expanding on Banks et al.'s theory of co-impact in PAR, based on longitudinal empirical data of Studio DöBra. Studio DöBra was developed in partnership with a range of community organizations and engaged children (9 years old) and older adults (most 80+) with topics related to dying, death, and loss through arts activities. The analyzed empirical data reflect the perspectives of community-partners and academic partners from interviews and meetings spanning 4.5 years. Findings: We present a model of impact development consisting of impact on individual and group development, action-oriented impact, and strategy-oriented impact; ways they relate to and evolve from one another; and how they may be affected by contextual influences. Conclusion: Besides contributing to conceptualizations of impact in PAR, findings contribute a community perspective to the limited literature investigating the impact of health promotion initiatives related to EoL issues.

From fear to fight: Patients experiences of early mobilization in intensive care. A qualitative interview study.

Introduction: Early mobilization (EM) in intensive care is frequently used to prevent physical and psychological complications, with promising results. However, the patient´s perception of EM has been sparsely investigated. Pe: To investigate the experience of EM in patients treated in intensive care. Md: Nineteen former patients who had been treated in intensive care were interviewed. The interviews were analyzed using qualitative, inductive content analysis. Rs: The analysis resulted in three categories; 1) Facing the impossible - a too demanding situation; 2) Struggling successfully on the way back; and 3) Need of having dedicated supporters. Con: A considerable variety of experiences of EM were described in this study, both negative and positive. Prominent features were that pleasant emotions and great physical effort occurred simultaneously and that interaction and cooperation with the caregivers was paramount. To regain independence was another prominent feature, with EM considered to be of great importance in the recovery process. Moving to an upright position and ambulating appears to be beneficial to both body and mind. EM should therefore be among the first priorities in intensive care. EM should be practiced with respect and support, while encouraging and challenging the patient to strive for independence.

Play Elements as Mechanisms in Intergenerational Arts Activities to Support Community Engagement with End-of-Life Issues.

Talking about dying, death, and loss may be difficult. Arts offer alternative ways of engaging with end-of-life (EoL) issues, but little is known about the means through which this occurs. In this article, we aim to explore mechanisms in arts activities that support community engagement with EoL issues, based on the community-based participatory action research project Studio DöBra. Studio DöBra was developed to support community engagement with EoL issues through intergenerational arts workshops involving community partners, children, and older adults. Initial analysis with community partners indicated the importance of play elements in arts activities. Continued analysis was therefore abductive, using play theory and qualitative data from Studio DöBra arts activities. Through iterative examination of theory and data, we modified play theory as we identified mechanisms supporting community engagement with EoL issues in arts activities. Findings can contribute to theory-building that can inform arts activities supporting community engagement with EoL issues.

Navigating power dynamics in engaging communities in end-of-life issues - Lessons learned from developing community-based intergenerational arts initiatives about death and loss.

Lack of community engagement in end-of-life issues and age-segregation in Swedish society motivated us to develop Studio DöBra, a community-based intergenerational arts initiative to support community engagement in end-of-life issues and develop intergenerational meeting places. Representatives from several community organizations formed a project group with first author MK, to develop Studio DöBra. Based on analysis of exploratory interviews with professionals involved in other, similar initiatives and data from Studio DöBra development, we discuss challenges related to power dynamics in developing initiatives to engage communities in end-of-life issues, and how these can inform the development of similar initiatives.

"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.

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.

Death, loss and community-Perspectives from children, their parents and older adults on intergenerational community-based arts initiatives in Sweden.

Studio DöBra is a community-based initiative in which children (9 y/o) and older adults (mostly 80+) engaged with topics related to dying, death and loss through shared arts activities (e.g. collage, sculpture, games). In an ageing society, Sweden's end-of-life (EoL) care is increasingly professionalised and specialised, but there is little community involvement. One goal of Studio DöBra was therefore to support community engagement with EoL-related topics. Another goal was to create opportunities for interaction between children and older adults as there are few intergenerational meeting places. Two iterations of Studio DöBra were developed (2016, 2018) in different Swedish cities, utilising a community-based participatory research approach. Project groups comprised first author MK and representatives of community organisations such as meeting places for older adults, after-school centres and artistic organisations. Each iteration engaged eight children and eight older adults in a series of five workshops. This article investigates how children and older adults motivate their participation, their experiences of participating and ways in which they were affected by participation. We also investigate how parents reflect on their child's participation in Studio DöBra. Older adults, children and their parents were interviewed after each Studio DöBra. An inductive qualitative process guided by interpretive description was used to analyse the transcripts. Findings indicate that participants acted as individuals with agency in connecting across generations and in creating spaces for engaging with EoL-topics, not only in Studio DöBra but also in their social networks. Participants reflected on a changing sense of community through new intergenerational connections and social activities, and expressed a desire to maintain these. However, participants indicated sustainability challenges related to lacking agency in maintaining these spaces and sense of intergenerational community, as they rely on support from community organisations.

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

BACKGROUND: Racism is difficult to discuss in the context of Swedish healthcare for various cultural and administrative reasons. Herein, we interpret the fragmentary nature of the evidence of racialising processes and the difficulty of reporting racist discrimination in terms of structural violence. METHODS: In response to the unspeakable nature of racism in Swedish healthcare, we propose a phased participatory process to build a common vocabulary and grammar through a consultative framework involving healthcare providers and service users as well as policy-makers. These stakeholders will be involved in an educational intervention to facilitate discussion around and avoidance of racism in service provision. DISCUSSION: Both the participatory process and outcomes of the process, e.g. educational interventions, will contribute to the social and political conversation about racism in healthcare settings. Creating new ways of discussing sensitive topics allows ameliorative actions to be taken, benefitting healthcare providers and users. The urgency of the project is underlined.

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.

Integrating new knowledge into practice: An evaluation study on a continuing education for Swedish child health nurses on non-synostotic plagiocephaly.

AIM: The aim of this study was to assess what knowledge on non-synostotic plagiocephaly prevention and reversal intervention and control group nurses imparted to parents and parents integrated in infant care. DESIGN: A group of nurses participated in a continuing education on non-synostotic plagiocephaly in one-to-one or small group sessions at their workplace and received guidelines to follow. An evaluation was conducted with 35 intervention group and 15 control group nurses by asking them two open-ended questions 1 year later; 181 intervention group and 90 control group parents were also asked two open-ended questions and to rate their infant's head shape. METHODS: Data were collected during the year 2013. Qualitative content analysis and case-by-case analysis were conducted using a process-oriented approach. RESULTS: Intervention group nurses imparted both regular and newly introduced knowledge on positioning strategies to parents. Intervention group parents who perceived severe cranial asymmetry when infants were 3-4 months old reported implementing regular and new infant positioning recommendations.

Powerlessness, Normalization, and Resistance: A Foucauldian Discourse Analysis of Women's Narratives On Obstetric Fistula in Eastern Sudan.

Eastern Sudan has high prevalence of female circumcision and child marriage constituting a risk for developing obstetric fistula. Few studies have examined gender roles' relation with obstetric fistula in Sudan. To explore the associated power-relations that may put women at increased risk for developing obstetric fistula, we conducted nine interviews with women living with obstetric fistula in Kassala in eastern Sudan. Using a Foucauldian discourse analysis, we identified three discourses: powerlessness, normalization, and covert resistance. Existing power-relations between the women and other societal members revealed their internalization of social norms as absolute truth, and influenced their status and decision-making power in regard to circumcision, early marriage, and other transformative decisions as well as women's general behaviors. The women showed subtle resistance to these norms and the harassment they encountered because of their fistula. These findings suggest that a more in-depth contextual assessment could benefit future maternal health interventions.

Perspectives and experiences of new migrants on health screening in Sweden.

BACKGROUND: In Sweden, migrants from countries considered to have a high burden of certain infectious diseases are offered health screening to prevent the spread of these diseases, but also identify their health needs. However, very little is known about their experiences and perceptions about the screening process. This study aimed at exploring these perceptions and experiences in order to inform policy and clinical practice. METHOD: Using an interpretive description framework, 26 new migrants were interviewed between April and June 2013 in four Swedish counties. Thematic analysis was used to analyze data. RESULTS: The three themes developed include: new country, new practices; new requirements in the new country; and unmet needs and expectations. Participants described what it meant for them to come to a new country with a foreign language, new ways of communicating with caregivers/authorities and being offered health screening without clarification. Participants perceived health screening as a requirement from the authorities to be fulfilled by all newcomers but conceded that it benefits equally the host society and themselves. However, they also expressed concern over the involvement of the Migration Board staff and feared possible collaboration with health service to their detriment. They further stated that the screening program fell short of their expectations as it mainly focused on identifying infectious diseases and overlooked their actual health needs. Finally, they expressed frustration over delay in screening, poor living conditions in reception centers and the restrictive entitlement to care. CONCLUSIONS: Migrants are aware of their vulnerability and the need to undergo health screening though they view it as an official requirement. Thus, those who underwent the screening were more concerned about residency rather than the actual benefits of screening. The issues highlighted in this study may limit access to and uptake of the screening service, and compromise its effectiveness. To maximize the uptake: (1) linguistically and culturally adapted information is needed, (2) other screening approaches should be tried, (3) trained medical interpreters should be used, (4) a holistic and human right approach should be applied, (5) the involvement of migration staff should be reconsidered to avoid confusion and worries. Finally, to improve the effectiveness, (6) all migrants from targeted countries should be offered screening and efforts should be taken to improve the health literacy of migrants and the living conditions in reception centers.

"The fairer the better?" Use of potentially toxic skin bleaching products.

BACKGROUND: Skin bleaching is a widespread phenomenon in spite of their potentially toxic health effects. OBJECTIVES: This study aimed to determine if such products are used in Sweden in particular by pregnant women, furthermore to explore immigrant women's view skin bleaching. METHODS: 455 pregnant women completed a questionnaire, which were statistically analysed. Focus groups and individual interviews were conducted with immigrant women, content analysis was used to assess the data. RESULTS: Skin bleaching products were used by 2.6% of pregnant women, significantlly more by women born in non-European countries. Motivating factors were associated with the concept of beauty together with social and economic advantages. The women had low awareness of the potential health risks of the products. Regulations on the trade of skin bleaching products have not effectively reduced the availability of the products in Sweden nor the popularity of skin bleaching. CONCLUSION: There is need for further research especially among pregnant women and possible effects on newborns. Products should be tested for toxicity. Public health information should be developed and health care providers educated and aware of this practice, due to their potential negative health implications.

Making and unmaking ethnicities in the Rwandan context: implication for gender-based violence, health, and wellbeing of women.

OBJECTIVES: To examine ethnicity and gender violence in Rwanda from cultural and historical perspectives and explore the encounters between cultural beliefs and practices and the new gender equality policy and programs and the implications of the particular encounters to the health of women. DESIGN: The study is a qualitative drawing from the growing range of interactive approaches and methods within an ethnographic framework of the research design. Twenty individual interviews, six focus group discussions and two 'community mobilization' dialogs were conducted. RESULTS: Violence has continued and there is a conflict between cultural tradition, the de-ethnicization, and gender equality policies. Some of the gender violence preventive programs are influenced by the ethos of the traditional norms, and therefore unwittingly perpetuate gender-based violence. CONCLUSIONS: In spite of the progress that Rwanda has made in political empowerment of women, it still seems a long way before real gender equality is achieved. It seems that women's empowerment is not only just an opportunity for political participation but also this is important. It is also about the capacity to make effective choices and to translate them into desired actions and outcomes, unfettered by cultural sanctions. Universalised, top-down gender policy programs have not furnished all women with the necessary capacity to make decisions that affect their traditionally all important reproductive functions; to challenge the embedded gender imbalance; and to strive for a holistic wellbeing of their families, where they play a central role. Indeed, some of the policies could have negative implications to the health of women, in particular, with sexually transmitted infections, including HIV and AIDS.

'Not men enough to rule!': politicization of ethnicities and forcible circumcision of Luo men during the postelection violence in Kenya.

BACKGROUND: As a contribution to ongoing research addressing sexual violence in war and conflict situations in the Democratic Republic of Congo, Kenya and Rwanda, this paper argues that the way sexual violence intersects with other markers of identity, including ethnicity and class, is not clearly articulated. Male circumcision has been popularized, as a public health strategy for prevention of HIV transmission, although evidence of its efficacy is disputable and insufficient attention has been given to the social and cultural implications of male circumcision. METHODS: This paper draws from media reporting and the material supporting the prosecutor at the International Criminal Court case against four Kenyans accused of crimes against humanity, to explore the postelection violence, especially forcible male circumcision. RESULTS: During the postelection violence in Kenya, women were, as in other conflict situations, raped. In addition, men largely from the Luo ethnic group were forcibly circumcised. Male circumcision among the Gikuyu people is a rite of passage, but when forced upon the Luo men, it was also associated with cases of castration and other forms of genital mutilation. The aim appears to have been to humiliate and terrorize not just the individual men, but their entire communities. The paper examines male circumcision and questions why a ritual that has marked a life-course transition for inculcating ethical analysis of the self and others, became a tool of violence against men from an ethnic group where male circumcision is not a cultural practice. CONCLUSION: The paper then reviews the persistence and change in the ritual and more specifically, how male circumcision has become, not just a sexual health risk, but, contrary to the emerging health discourse and more significantly, a politicized ethnic tool and a status symbol among the Gikuyu elite. In the view of the way male circumcision was perpetrated in Kenya, we argue it should be considered as sexual violence, with far-reaching consequences for men's physical and mental health.