
==== Front
Int J Qual Health Care
Int J Qual Health Care
intqhc
International Journal for Quality in Health Care
1353-4505
1464-3677
Oxford University Press UK

39233448
10.1093/intqhc/mzae089
mzae089
Systematic Review
AcademicSubjects/MED00860
Anti-Indigenous racism in Canadian healthcare: a scoping review of the literature
Cooke Martin Department of Sociology and Legal Studies and School of Public Health Sciences, University of Waterloo, 200 University Ave W, Waterloo, ON N2L 3G1, Canada

Shields Tasha School of Public Health Sciences, University of Waterloo, 200 University Ave W, Waterloo, ON N2L 3G1, Canada

*Corresponding author. Department of Sociology and Legal Studies and School of Public Health Sciences, University of Waterloo, 200 University Ave W, Waterloo, OntarioN N2L 3G1, Canada. E-mail: cooke@uwaterloo.ca
Handling Editor: Dr. Paul O'Connor

7 2024
05 9 2024
05 9 2024
36 3 mzae08910 1 2024
12 5 2024
04 9 2024
19 8 2024
20 9 2024
© The Author(s) 2024. Published by Oxford University Press on behalf of International Society for Quality in Health Care.
2024
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Abstract

Health inequity between Indigenous (First Nations, Inuit, and Métis) peoples and other citizens is an important policy concern in Canada, as in other colonial countries. Racism in healthcare has been identified as contributing to poorer care and to worse outcomes. Despite a large literature regarding racism in other healthcare contexts, the dimensions of the existing literature on anti-Indigenous racism in Canadian healthcare are unclear. A scoping review examined the evidence of anti-Indigenous racist experiences in healthcare in the research literature, including the types of racist behaviours identified, settings studied, and Indigenous populations and geographic regions included. We identified English and French language journal articles on anti-Indigenous racism in Canadian healthcare settings in Scopus, PubMed, CINAHL, and the Bibliography of Indigenous Peoples in North America, and grey literature reports. A total of 2250 journal articles and 9 grey literature reports published since 2000 were included in screening, and 66 studies were included in the final review. Most used qualitative interviews with patients, but a large proportion included healthcare providers. Most were conducted in urban settings, a majority in Ontario or British Columbia, with mixed Indigenous populations. The largest proportion focussed on patient experiences with healthcare in general, rather than specific clinical contexts.

Most racist experiences identified were ‘covert’ racism, including patients feeling treated differently from non-Indigenous patients, being ignored, treated more slowly, or not believed. Stereotyping of Indigenous peoples as substance users, poor patients, or poor parents was also commonly reported. ‘Overt racism’, including the use of racist slurs, was not widely found. Some quantitative studies did use standardized or validated instruments to capture racist experiences, but most did not result in generalizable estimates of their prevalence. The few studies linking racism to health outcomes found that experiencing racism was related to reluctance to seek healthcare, potentially leading to higher unmet healthcare needs. Gender was the intersecting dimension most identified as shaping healthcare experiences, with Indigenous women and girls at risk to specific stereotypes. Some papers suggested that socio-economically disadvantaged Indigenous people were at the highest risk to experiencing racism. Types of anti-Indigenous racism identified in Canadian healthcare appear similar to those reported in other jurisdictions. Indigenous peoples facing multiple dimensions of disadvantage, especially gender and social class, may be the most likely to experience racism. It is likely that the experience of racism in healthcare has implications for Indigenous peoples’ health, mainly by reducing healthcare access.

Indigenous peoples
healthcare, racism
Canada
First Nations
Inuit
Métis
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pmcIntroduction

Racism experienced in hospitals, clinics, emergency rooms, and similar contexts has been identified as a problem in many countries, including Canada [1–3]. Unequal treatment of or discriminatory attitudes towards racialized patients can result in poorer health outcomes for several reasons. These might include racialized patients’ concerns being dismissed, ignored, or misunderstood by clinicians, racialized patients being given poorer care than non-racialized patients, or to racialized patients delaying or avoiding treatment [1].

In the Canadian context, Indigenous peoples’ health is a major concern. As in other colonial nations, the average health of Indigenous peoples (First Nations, Inuit, and Métis) is poorer than that of non-Indigenous citizens [4]. At least some of this inequity is likely to be related to experiences with clinical healthcare, including a lack of access, a lack of cultural appropriateness of the healthcare provided, and poorer treatment provided to Indigenous peoples [5, 6]. Two prominent cases have brought public attention to importance of anti-Indigenous racism in Canadian healthcare. In 2008, Brian Sinclair died in a Manitoba emergency room while waiting for care [7] and, in 2020, Joyce Echaquan passed away in a Quebec hospital having filmed herself being verbally abused by hospital staff [8]. Racist attitudes and behaviours have been identified as contributors to both of these tragic outcomes [9] and there have been subsequent calls to combat anti-Indigenous racism in clinical settings [7, 9, 10].

Effectively reducing racism in healthcare is almost certainly aided by an understanding of its characteristics. In other contexts, including Europe [11], the USA [3], and internationally [1, 2], there have been efforts to identify the types of racist behaviours that have been experienced by patients, the clinical settings in which they have been studied, and how racism might be connected to specific harms or poorer health outcomes. In some cases, this has included the measurement of the prevalence of racism [2]. It is unclear, however, how researchers have engaged with the question of anti-Indigenous racism in clinical healthcare in Canada, and what aspects of the issue have been documented.

Background

The causes of health disparities between Indigenous and non-Indigenous Canadians are complex and involve distal historical and political conditions as well as proximate factors such as access to safe housing, nutritious food and healthy environments [5]. Clinical healthcare is an important setting in the reproduction these inequities, both because of greater need for care experienced by Indigenous peoples and the fact that aspects of the content, quality and delivery of care are shaped by colonial histories and contemporary power, affecting outcomes for Indigenous patients [6, 10].

Anti-Indigenous racism in healthcare potentially operates at multiple socio-ecological levels. At the broadest social-structural level, the orientation of healthcare to Western ‘biomedical’ practices and the unavailability of ‘culturally safe’ services or of healthcare providers who have knowledge of Indigenous peoples and their needs, can lead to inappropriate or ineffective treatment and potentially to Indigenous patients deciding not to seek care [6]. At the individual level, racism is implicated in the individual-level interactions of patients with the system and experiences of ‘everyday racism’ [12, 13], including behaviours that systemically disadvantage Indigenous or other racialized patients.

There is a large literature regarding everyday racism in healthcare, most of it focussing on the US context [1, 3]. This literature describes the types of racism experienced by racialized patients, including the application of stereotypes or negative assumptions by clinicians, being treated rudely or disrespectfully, or being denied care [1]. In the USA [14] and Australia [15], there have been attempts to quantify the prevalence of racism in healthcare, either in specific clinical settings or more generally.

A recent review of the qualitative literature regarding Indigenous people’s experiences with Canadian healthcare found evidence of supportive interactions with clinicians as well as negative experiences, some of which appear to reflect racist attitudes or beliefs held by healthcare workers [16]. Despite the considerable academic research into the Canadian healthcare system and its relation to Indigenous peoples, important questions regarding anti-Indigenous racism in Canadian healthcare remain. These include whether there are reliable measures of the prevalence of racist experiences, whether there are specific clinical or geographic settings in which experiences of racism are more common, and whether, from an intersectional perspective [17], there are axes of discrimination that potentially intersect with indigeneity to affect healthcare experiences.

Research objectives

We had several research objectives, which came out of discussions with potential knowledge users in government, who sponsored a related unpublished report. The first was to identify what types of anti-Indigenous racist experiences in healthcare have been identified and what geographic contexts, populations, and clinical settings have been included in this research. The second was to identify whether there are intersecting aspects of social location (e.g. sex/gender, age, and income) leading to higher risk of racism, or which might affect how racism is experienced. Lastly, we wished to report the evidence regarding the prevalence of anti-Indigenous racism in Canadian healthcare and the effects of racism on Indigenous peoples’ health.

Methods

We took a scoping review approach, appropriate for understanding the characteristics of and gaps in a literature that spans disciplines and methodologies [18, 19]. We followed PRISMA guidelines for reporting scoping review studies [20]. A protocol was not registered.

Identifying relevant studies

The search included studies published between 2000 and April 2024. The year 2000 was chosen as the earliest point because of the changing political and academic discourse regarding Indigenous peoples in Canada, and a desire to reflect the current state of the literature. Databases included Scopus, PubMed, CINAHL, and the Bibliography of Indigenous Peoples in North America (BIPNA). Search terms were identified with the assistance of an academic librarian, developed for Scopus and translated to the PubMed system using the Medical Subject Headings (MeSH) system. The strategy was constructed using a modified PICO (population, intervention, context, outcomes) formulation in which the population was Indigenous peoples, the context was Canada, the ‘intervention’ was the use of healthcare, and the outcome of interest was the experience of racism (Supplementary Appendix Table S1). A search for grey literature was undertaken using Google to identify reports produced by governments, Indigenous organizations, or non-governmental organizations. Initial searches were completed between February 1 and 15 March 2023. A subsequent search on 22 April 2024 updated the results.

Article selection

Using Covidence systematic review software (Veritas Health Innovation, Melbourne, Australia) articles were screened by two reviewers (authors) for relevance of title and abstract. Studies that did not meet inclusion criteria were removed. If reviewers were unsure as to the relevancy of the article, it was included to be reviewed in full. At the second stage, the full text articles were reviewed by the authors and were excluded if they were not empirical or if their focus was on structural issues such as a lack of services or unaffordability, rather than interpersonal racism. Articles to be included in the final review were identified based on consensus between the authors after reviewing the articles together and discussing merits of inclusion or exclusion.

Charting the data

Extraction using Covidence software was completed by two individuals, (author and another research team member). Materials were charted by one author to identify the Indigenous populations (First Nations, Inuit, or Métis), clinical settings of focus, the study methods used and characteristics of the study participants (e.g. age, genders, or specific patient types) and the types of racist experiences identified in the studies. NVivo qualitative analysis software V.14 (Lumivero, Denver Colorado) was used to assist charting.

Results

Search results

The database search identified 2249 journal articles (Fig. 1). Eight hundred and thirty-two duplicates were removed. One additional journal article was identified from the references of included articles and nine grey literature reports were added. One thousand three hundred and twelve studies were removed after title and abstract screening and 49 removed at the full-text stage. A total of 66 studies were included in the final review. Supplementary Appendix Table S2 describes the included studies.

Figure 1 PRISMA study selection diagram.

Study designs and settings

Study designs and populations of focus are summarized in Table 2. Most were qualitative [10, 18, 21–64], eight were quantitative [65–72] and 11 were mixed methods [6, 47, 73–82]. All but two [27, 82] of the qualitative and mixed methods studies used interviews, focus groups or sharing circles with patients or patients’ caregivers, community members or clinicians. All quantitative and mixed methods studies used surveys.

Table 2. Example accounts of racist behaviours identified in the qualitative articles.

Study	Quote	
‘Lessened as a person’	
Benoit (2022)	‘I was at the doctor’s office, I dislocated my arm, and they kept putting my chart down, and my son was waiting for me at home, at his place, and it was like […] why are these people putting my chart down to the bottom? I’ve been waiting like everybody else, how come they keep putting my chart down?’	
Jacklin (2017)	‘We got all the way there and this doctor, it seemed like he was prejudiced or something, “oh it doesn’t look like there’s anything wrong with you.” Didn’t examine my back or nothing and said “see ya.” […] Some places you do get treated poorly because of our skin colour.’	
Nelson & Wilson (2018)	‘Depends on which pharmacy you go to…. as soon as they see me, they always say, “okay, how are you going to pay for this?” Ifind it… labeling [me as a First Nations person]…. and I find them, I’m sure they don’t mean to, but they always… make me feel like I’m lower than I am. As a person. Because they always ask, like, “how are you going to pay for this? You even got money?”’	
Feeling treated differently	
Browne and Fiske (2001)	‘It seemed like any time I go to a doctor I would have to be well dressed. I have to be on my best behavior and talking and I have to sound educated to get any kind of respect…If I was sicker than a dog and if I didn’t want to talk and I didn’t care how I sounded or whatever, I’d get treated..like lower than low. But if I was dressed appropriately and spoke really well, like I usually do, then I’d get treated differently..But why do I have to try harder to get any kind of respect? You know, why do I have to explain?’	
Not feeling believed	
Browne and Fiske (2001)	‘A lot of these nurses, when they see Native people coming, they always tell them, “No, this is no problem; you shouldn’t worry about it” and send them on their way; then they get more sick. I don’t know..but some of these nurses that work in the clinics, they’re really intimidating. They assume that nothing’s wrong with you’.	
Lam et al. (2023)	‘For example, in one of the open-ended response questions, one of our participants wrote, “I have been treated as though I would be a drug user trying to get meds to get high. My sister was treated the same way to the detriment of her health. She was in kidney failure and the medical personnel failed to treat this because they assumed that she was trying to get meds to abuse them”.’	
Stereotyping by healthcare providers	
Browne (2005)	‘It is in their culture to have a lot of violence, stabbing, alcohol abuse…more than what you see in other cultures.’ She also reiterated that this ‘doesn’t mean that all Native people are drinking or in violent situations’ but that there seemed to be more of those issues in First Nations culture.	
Browne (2005)	For example, a nurse reflecting on a challenging discharge-planning process for a First Nations woman from a reserve community commented: ‘She didn’t take care of any of her own responsibilities [at home]. She didn’t look after her own child. Now, I know that is a cultural thing.’	
Ly and Crowshoe (2015)	‘I told one of my preceptors that [endocrinology was] what I was interested in and he said, oh, you don’t want to deal with those people [Aboriginal diabetics] .. it’s so challenging to work with people who don’t care about their health and don’t want to manage their condition.’	
Fear of child apprehension	
Monchalin et al. (2020)	‘Because I identify… I’m very clear. [The Service Providers] ask you how you identify ethnicity-wise. I’m like we’re Indigenous…I just feel like I’m being policed sometimes, even when I go take my kids for their checkups.’	
Use of racial slurs	
McCall et al. (2020)	‘Um, I get calls, um, people call me a “squaw who has AIDS” and, you know, you probably deserve it because squaws deserved dying, you know, “Since we can’t kill you all off, you might as well die off by AIDS.”’	
Dismissal of traditional medicine, knowledge, or ceremony	
Wright et al. (2020)	‘Mothers who had experienced racism or discrimination in the health care system found it very difficult to trust nurses in future interactions. Nurses were sometimes viewed as “Western” and as being dismissive of Indigenous practices such as traditional medicine: “…you explain it to your doctor… they look at you like your friggin” crazy. Like, What do you mean you don’t need medication? You need a ceremony?’’	
Monchalin et al. (2020)	‘I had to go to emergency … and they … asked … if I took anything, and I had drank a certain kind of tea before I went …so I just said, “Oh, well I just drank this tea because I thought it would clear my congestion. And I had a fever and it was just an infection I needed I get treated…and they said,” Oh, well, where did you learn that? “And I said,” Oh, well it’s just a traditional medicine. I’m Métis. So, we just…we had it in my house and I just drank it.“And… there was some sort of comment about [Métis] not being real [by the doctor and resident doctor] …”It’s kind of like an Indian but not really totally real’… and I think he kind of meant mixed. Like that’s what he meant by not real. But at that point I was like I don’t want to get in this discussion with you while I’m having a fever and just … needing antibiotics’	
Gifford et al. (2023)	‘We had some resistance when it comes to ceremonies, but we actually worked through that because I think that they just need to be reminded that they, under the Hospital Act, that they have to provide space for ceremony.’ (Gifford et al., 2023, p. 391)	
Health impacts of racism	
Goodman et al. (2017)	‘I reached out on my right side and it really hurt. I went to […] the doctor and she told me to walk it off. I went to sleep and woke up and thought I was dying - big pain in my chest. I collapsed a lung. I think she thought I wanted painkillers, but I was really hurt.’	
Nelson and Wilson (2018)	P1: ‘I had a tubal pregnancy… and it erupted but I didn’t know it was a tubal pregnancy. And they just shut me in the Emergency room and just left me…. The next morning they take me in to do an ultrasound, and then it’s like, “oh my god, you’re internally bleeding, and we need to go in for emergency surgery right now.”… The tube erupted, and they were soaking the blood out with towels, right? And so if they would have left me much longer…’
P2: ‘You would have bled to death.’	
Southern Chiefs’ Organization, (2021)	‘Nurse’s at emergency thought I was only there for drugs when I thought I was having a heart attack, Paramedics thought I was on drugs when I was having a panic or angina attack, they kept badgering me to be honest, I kept telling them I wasn’t, they even took a test on me and didn’t tell me what they were doing, I finally went to hospital.’	
Painful Treatment		
Hole et al. (2015)	‘This one nurse came over and she starts to—she didn’t say anything to me—she just said, “Give me your arm, put your arm out like this,” and “I need to take some blood.” Then pretty soon she was looking for a vein, couldn’t find a vein. So, then she went over here on the left arm and she was looking for a vein there. So, anyways, she couldn’t really find a vein, but she started using the needle over and over again; she wasn’t saying anything—not explaining … I started getting stressed’ cuz she wasn’t talking to me but she was really in a hurry … I think she tried two or three times in this arm, and I, I was bruised, and then finally she said, “Oh, for heaven’s sake.” She says [to another nurse passing by], “I can’t find a vein.” Finally, they got a vein but neither one of them spoke to me. I was just poked and prodded being told, “Give me this arm or that arm.” It felt like I was being treated kind of roughly. It felt like I wasn’t even a human being,’ cuz they had, neither one of them, had said a word to me.’	
Phillips-Beck et al. (2020)	‘We had some incidents with the foot care nurse that she kind of got rough with patients Well, she comes in like every 3 or 5 months. She kind of did like the toes or whatever, like the snip snap or whatever or accidentally, she caused injuries. She was rushed all the time and people like their feet soaked first, she used to just start, dry, you know, not soften the nail or anything. She just did it and she was nipping, drilling skin just, she was coming in really in a fast pace and she was just trying to get her job just in and out.’	
Southern Chiefs’ Organization, 2021	‘I had a broken rib and they called security because I was in excruciating pain and was told to shut up and then purposely grabbed from my broken rib area and dragged out on my back while all the [non-Indigenous] people just watched it all happen. And yes, there was video camera’s [there] but they are [there] to protect the staff.’	
Intersecting dimensions (income)	
Smith et al. (2006)	‘Lots of the time they don’t feel comfortable [at the mainstream health agency]. It’s not a culturally acceptable place. The rules are very rigid. You have to come at a certain time. They [agency staff] don’t understand the difficulty of getting rides, they don’t understand how appointments can be missed .. and also they [Aboriginal parents] feel they’re being judged on the way the baby looks, or how they talk or .. health nurses assume they’re stupid or they’re slow and they can’t read, or, you know, these sorts of things.’	
Wylie and McConkey (2019)	“I know I have told you to monitor your sugars, what happened? Are you eating well and then the patient says, ‘Oh, I can’t afford good, healthy food. It’s expensive, so I can only afford starch or eating pasta, I can’t afford to buy vegetables.’ (AH11P)	

Most studies (n = 50) collected data from Indigenous patients selected based on their use of health services, although 21 collected data from community members in general. Twenty-seven papers included perspectives of clinician or non-clinician service providers. One [27] was a study of news coverage of racist incidents. Most of the studies focussed on urban areas, and First Nations were the Indigenous population most often included. Western Canadian provinces, especially British Columbia, were most often represented (Table 1).

Table 1. Study characteristics.

	Number of studies		Number of studies	
Study design		Regions included		
Qualitative	47	Newfoundland and Labrador	1	
Quantitative	8	New Brunswick	1	
Mixed methods	11	Nova Scotia	4	
Perspectives represented		Prince Edward Island	0	
Patients	50	Ontario	15	
Parents/caregivers/family	11	Quebec (including Nunavik)	5	
Community members	21	Saskatchewan	3	
Elders	3	Manitoba	5	
Service or healthcare providers	34	Alberta	10	
Students	2	British Columbia	24	
Indigenous populations included		Northwest Territories	1	
Indigenous or Aboriginal, unspecified	20	Yukon	1	
First Nations	34	Nunavut	1	
Inuit	17	Canada (national)	7	
Métis	19	Unspecified Western Canada	6	
		Unspecified Atlantic provinces	1	
Geographic context				
Urban	42	Healthcare settings included		
Rural	20	General healthcare	32	
Reserve/FN Community	18	Hospital, including Emergency department (ED)	14	
Mixed/unspecified	15	Specialized care	9	
Outside of reserves	1	Community health centre	11	
Gender identities included		Clinic or physician’s office	8	
Women and men	46			
Women only	12			
Men only	0			
Transgender	8			
Two spirit	7			
Note: Some totals do not sum to 66. Some studies appear in more than one category, and some are unclassified.

The largest number of studies reviewed [32] examined anti-Indigenous racism in healthcare in general, without focussing on a specific setting. Fourteen focussed on racism in hospital settings, including emergency departments. Eleven examined community health services, such as community clinics, and 18 focused on experiences in specialist clinics, including diabetes management and maternal health (Table 1).

Covert racism: Feeling ‘lessened as a person’ [31]

The experiences most often identified in the studies reviewed were various types of ‘covert’ racism [79]. Fifty-five of 66 studies reported Indigenous people feeling that they were generally not treated well by healthcare providers. Specific types of behaviours identified included feeling ignored, feeling treated differently from other patients, feeling as though they had been treated more slowly, or not being listened to or believed by clinicians. Examples are presented in Table 2.

In 28 studies, respondents reported feeling ignored or left untreated, for reasons that they interpreted as related to Indigenous identity. Similarly, 12 studies reported people’s experiences of feeling that they had been treated more slowly than other patients, presumably because they were Indigenous. Fifteen included reports of Indigenous patients not being believed about their health conditions, and particularly regarding the pain that they were experiencing (Table 2).

Stereotyping

Forty of the studies reviewed described Indigenous patients’ feeling of having been stereotyped by healthcare workers. This included 29 that reported clinicians or others assuming incorrectly that patients had been using alcohol or drugs. Browne (2005) found that some nurses held stereotypes of Indigenous patients as potentially violent, as well as susceptible to alcohol abuse [23]. Clinician-held stereotypes of Indigenous people as difficult patients, uneducated about health issues or unwilling to comply with treatment, were identified in seven studies [23, 26, 29, 30, 35, 65, 82]. In some studies respondents reported feeling as though healthcare workers believed that Indigenous patients felt ‘entitled’ and willing to ‘abuse the system’, which included drug-seeking behaviour [23, 24, 31–33, 35, 45, 58, 62, 80, 82–84] (Table 2).

Authors also reported Indigenous people feeling that they had been ‘heavily scrutinized’ as parents [42] or that it was assumed that they were poor caregivers [85] (Table 2). In six studies reviewed, Indigenous parents reported fear that interactions with healthcare services could result in their children being apprehended by child protection agencies [24, 29, 34, 40, 42, 50].

Use of racist slurs

The literature reviewed did not include many reports of such ‘overt’ racism [79]. In three studies respondents reported patronizing behaviour by healthcare workers and being referred to as ‘your kind’ or ‘you people’ [22, 26, 82] in a ‘racial attack’ [26]. Two studies included reports of Indigenous women being called a ‘squaw’ by healthcare workers [74, 76] (Table 2).

Dismissal of traditional medicine, knowledge, or ceremony

In seven studies, Indigenous patients felt that Indigenous approaches to healing and wellness were dismissed or treated with a lack of respect [26, 41, 58, 59, 63, 82, 84]. In a study of Indigenous parents’ experiences with a neonatal care unit, one mother reported having her request for a ceremony dismissed [51] (Table 2).

Prevalence of racism

Ten of the mixed-methods and quantitative studies included measures of racism prevalence, although only seven reported estimates specifically related to healthcare and Indigenous peoples (Table 3). These studies varied regarding the questions used to collect experiences of racism and their sampling methodologies (Table 3). Three used validated measures of racist experiences [71, 77, 78], including the Everyday Discrimination Scale and the Discrimination in Medical Settings Scale [86], the Perceptions of Racism Scale [87] the Index of Race-Related Stress [88], and the Measures of Indigenous Racist Experience scale [89]. The design of these studies did not allow for population estimates of the prevalence of racist experiences, however.

Table 3. Quantitative measures of anti-Indigenous discrimination in Canadian healthcare.

Study	Population	Reported measure of racism or discrimination	Reported prevalence	
Sharma et al. (2023)	Non-probabilistic sample of Indigenous youth (14–30 years) in British Columbia who used criminalized substances other than Cannabis	Measure of Indigenous Racism Experience (MIRE) scale [89]	79% reported experiencing interpersonal racism in at least one setting. Not reported separately for healthcare settings.	
Lam et al. (2023)	Convenience online sample of Manitoba residents aged ≥30 years who had experienced or witnessed racism in the previous year	Percent reporting that they ‘experience discrimination’ in various settings (including health care)	Percent reporting experiencing discrimination in health care:
64% of Indigenous respondents
Indigenous men: 54.7% yes, 45.3% no
Indigenous women: 70.7% yes, 29.3% no
48% of ‘other ethnic identities’
13% of Caucasian.	
Varcoe et al. (2022)	Indigenous and non-Indigenous emergency department patients in 3 British Columbia hospitals	Everyday Discrimination Scale [97] and Discrimination in Medical Settings Scale [86].	21.5% experienced some discrimination. No separate estimates for Indigenous patients.	
Southern Chiefs’ Organization (2021)	Convenience online survey of Manitoba First Nations people.	Percent reporting having experienced racism in Manitoba health care.

Percent reporting having witnessed a family member or loved one ‘discriminated against or treated badly’ because of their race in the health care system.

	71.79% experienced racism themselves.

79.53% witnessed a family member or loved ones experience racism.

	
Benoit et al. (2019)	Purposive sample of 90 Indigenous women in Toronto and Thunder Bay	Perceptions of Racism Scale (PRS) [87] and Index of Race-Related Stress (IRRS)—Brief Version (B) (IRRS-B) [88]	‘Given the limited accounts of racist events in health services in the qualitative data, we did not complete a comparison with the PRS items’.	
Environics (2010)	Urban Indigenous adults (≥18 years) in 11 cities	Percent reporting experience [with non-Indigenous healthcare system] in the past 12 months was generally positive or generally negative.

Percent of those reporting generally negative experience with non-Aboriginal services in the past 12 months was due to being poorly treated.

	1. 82% positive, 15% negative
2. First Nations: 50% Inuit: 48% Métis: 36%	
First Nations Centre (2003)	First Nations adults (≥18 years) living on or near reserves in provinces and territories, except Nunavut	Percent reporting having been ‘treated unfairly or inappropriately by a health care provider in the last twelve months, because they are Aboriginal’.	15% (95 CI: ±2.83%)a	
Hahmann and Kumar (2022)	First Nations living off reserve, Inuit and Métis, as well as non-Indigenous (≥18 years) in provinces	Percent reporting discrimination by a health care professional based on various factors (e.g. ethnicity/culture, religion, language, or sexual orientation) during the pandemic

Percent reporting discrimination by a health care professional based on Indigenous identity during the COVID-19 pandemic

	First Nations (11.0%, 95 CI: 9.3, 12.9).

Métis (8.1%, 95 CI: 6.8, 9.8)

Inuit (18.6%b, 95 CI: 11.5, 28.8).

First Nations (6.0%, 95 CI: 4.7, 7.6).

Métis (1.3%b, 95 CI: 0.8, 2.0)

Inuit (12.9 % b, 95 CI: 6.8, 23.0)

	
Kitching et al. (2020)	First Nations, Inuit and Métis (15 and older) in Toronto	Percent reporting ever having ‘been treated unfairly (e.g. treated differently, kept waiting) by a health professional (e.g. doctor, nurse, etc.) because you are Aboriginal?’	28.5% (95 CI: 20.4%, 36.5%)	
Turpel-Lafond (2020)	Indigenous people in British Columbia	Percent reporting having ever experienced or observed discrimination in healthcare, based on ancestry or origin.	67% of Indigenous respondents
5% of non-Indigenous respondents	
Notes

a General confidence interval reported for the survey, not this particular measure.

b Study indicates, ‘Use with caution due to wide confidence intervals’.

Three studies in Table 3 used a sampling method and estimation procedure that could produce valid estimates of the experience of racism in a population [66, 68, 75]. The measures of racism differed between these studies, as did the timeframes of the measurement and the populations covered.

Health impacts of racism

None of the quantitative studies reviewed estimated associations between experiences of racism in healthcare and specific health outcomes or illnesses. Twenty-three reported Indigenous people being reluctant to seek care (examples in Table 2). One quantitative study found having experienced racism in healthcare was associated with higher risk of having unmet healthcare needs. For those without regular access to a family physician and who experienced racism, the odds of reporting unmet healthcare needs were over five times the odds for those who did not experience racism (OR: 5.2, 95%CI: 1.2, 22.3) [75]. For those with a family physician, the odds of having unmet healthcare need were more than double for those who experienced discrimination (OR: 2.3, 95%CI: 0.8, 6.6) [75].

Several studies reported patients’ perceptions of impacts on their health. In seven qualitative studies, patients reported complications or worsening conditions that they believed could be attributed to not receiving appropriate care because of racism [24, 31, 60, 62, 63, 82, 84]. In another three studies, respondents reported being misdiagnosed [33, 60, 74] and seven reported severe or intense pain that they believed to be a result of a lack of appropriate care [24, 31, 37, 60, 74, 82, 84]. In one study, an Indigenous patient reported having come close to death because of lack of treatment [60]. In five, patients reported overly rough treatment causing pain, and in four, respondents believed that others had died [24, 31, 62, 82]. The study of news articles describing patient experiences in the Northwest Territories reported 17 instances in which death was an outcome [27].

Intersecting dimensions of social location

Several papers specifically mentioned the importance of taking an intersectional approach to understanding the issue, and how gender, age, dis/ability, or social class might shape experiences with healthcare [22, 24, 31, 45, 61, 69, 70, 77, 80, 83]. In the literature reviewed, gender was most often the dimension of focus, especially in relation to maternity or neonatal care [43, 44, 47, 50, 51]. Some studies suggested gender as a key dimension affecting how racism was experienced, with Indigenous women and girls at risk to ‘misogynistic stereotyping’ as poor mothers, as sexually permissive [49, 74] or ‘passive’ [24].

Two papers dealt specifically with the role of socio-economic status or social class in Indigenous peoples’ experiences of racism [45, 77]. Both concluded that those most socio-economically disadvantaged were at the highest risk to discriminatory practices in healthcare. Other papers had a focus on subpopulations that were particularly disadvantaged, including people with HIV/AIDS [38], without permanent housing [37], and living in the ‘inner city’ [31].

Discussion

Statement of principal findings

The results of this review indicate that the majority of the empirical evidence on anti-Indigenous racism in Canadian healthcare is qualitative in nature and presents accounts of Indigenous peoples feeling as though they had been, or were likely to be, treated less well than non-Indigenous patients. Several themes were clear. Indigenous patients reported feeling ignored or not listened to and believed they were subject to stereotyping by clinical staff. Stereotypes included Indigenous peoples as potentially violent, poor patients or poor caregivers of children, and likely to misuse substances. Some studies included reports from healthcare personnel who had also observed the stereotyping of Indigenous peoples. Although there were no studies reviewed, which produced quantitative associations of the experience of racism in healthcare and specific health outcomes, the qualitative studies strongly suggest that the experience of racism can lead to reluctance to seek treatment.

By far, most of the experiences of racism documented in the literature were ‘covert’ rather than ‘overt.’ The main characteristic of covert or ‘subtle’ discrimination is that it is difficult to identify [90] and that those experiencing it cannot be sure, for example, whether a long time spent in a waiting room was due to racism or some other reason. This does not suggest that these experiences are less serious than the overt abuse experienced by Joyce Echaquan [8]. Covert discrimination is real in its effects on health and likely results in reluctance of Indigenous peoples to seek care, as described in the studies we reviewed. Moreover, the life experiences of Indigenous peoples, especially those occupying disadvantaged positions on axes of gender, social class, or dis/ability, might well lead them to expect racist treatment in healthcare, either because of personal experience or that of others—so-called ‘vicarious’ racism [91]. As Hole et al. put it, ‘…regardless of the intentions of the nursing staff, these experiences were understood by participants as forms of structural violence, which are products of racism and colonialism’ [32]. The reports of racist experiences in healthcare should therefore be taken as reflection of these broader issues in Canadian healthcare institutions and society in general. They support ‘structural’ accounts of racism, in which racist systems continue to exist, despite individual actors not professing outwardly racist beliefs [92].

Interpretations within the context of the wider literature

The types of racism experienced in interactions with Canadian healthcare by Indigenous peoples were like those experienced by other racialized groups in other contexts. In particular, a recent international review of racism in healthcare, which also included some studies reviewed here, found that being treated rudely or with apathy was widely reported, and that racialized minority patients in several contexts had the perception of being ‘dismissed’ or not being taken seriously in healthcare interactions [1]. Reviews have also found stereotyping to be a commonly reported aspect of interpersonal racism in healthcare in other contexts, and this includes stereotyping of racialized patients as being less compliant with treatment, potentially abusing substances, and being ‘difficult’ [1, 2].

Implications for policy, practice, and research

The literature we reviewed generally supports the identification of anti-Indigenous racism as a serious and potentially widespread problem in Canadian healthcare. Indigenous patients’ accounts of feeling ignored, poorly treated, or stereotyped should inform efforts to improve services, including incorporating Indigenous-specific content in clinician training (e.g. 93, 94) as well as ‘cultural safety’ approaches that seek to redress structural power imbalances between patients and providers [60, 95].

Nonetheless, we can identify gaps in this literature, the filling of which would better inform efforts to address the problem. The existing qualitative research did not examine whether there were important differences in the experiences of First Nations, Inuit, or Métis peoples with racism, although some of the quantitative papers suggested that the prevalence of discrimination was unequal in these groups [66]. Regarding the quantitative literature, there are presently no national estimates of the experience of racism, separately for First Nations, Inuit, and Métis, which could be generalized to all regions of Canada, and the studies that exist do not use standardized measures of the experience of racism. A study in New Zealand has demonstrated the feasibility of monitoring self-reported racism in a national survey, measuring change over time as well as associations between the experience of racism and various health outcomes [96]. These are potentially important for understanding how racism in Canadian healthcare night change over time, and the efficacy of efforts to reduce it.

Strengths and limitations

To our knowledge, this is the first review to summarize the extant literature regarding anti-Indigenous racism in Canadian healthcare, and important problem for policy and health equity. The limitations are shared by other scoping reviews—we relied on the available databases and search engines, and it is possible that we have omitted important articles. Our interpretation of the materials is subject to our own bias. We hope this was mitigated by having two reviewers, although the coding was primarily done by a single author.

Conclusion

We find that most of the existing literature on anti-Indigenous racism in Canadian healthcare is qualitative and reports patient experiences that include dismissal and the application of stereotypes, similar to those identified in other jurisdictions. From an intersectionality perspective, it appears as though Indigenous peoples facing multiple dimensions of structural disadvantage, including on dimensions of gender and social class, might be the most likely to experience racism, and it is likely that the experience of racism in healthcare has implications for Indigenous peoples’ health, mainly by reducing healthcare access. Continuing to study the experience of Indigenous peoples with Canadian healthcare is important for identifying measures to reduce racism and potentially measuring their effectiveness.

Supplementary Material

mzae089_Supp

Acknowledgements

A related, unpublished review was conducted on behalf of Strategic Research and Data Innovation Branch (SRDIB) and Indigenous Services Canada (ISC). We are grateful for their comments on that project. Jackie Stapleton provided guidance on the search strategy. Ornell Douglas assisted with early charting of the materials.

Author contributions

The paper was conceived by M.C., who wrote the first draft. T.S. conceived the search strategy. Both authors screened and reviewed the papers. T.S. was responsible for the coding. Both authors reviewed and contributed to drafts.

Supplementary data

Supplementary data is available at IJQHC online.

Conflict of interest

None declared.

Funding

None.

Data availability

Not applicable.
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