Health impacts of racism

from

https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/national-guide/health-impacts-of-racism

1. Foundational Concepts

What is Racism?

• Occurs at multiple levels:
  • Structural
  • Institutional
  • Interpersonal
• Defined as systems causing:
  • Inequalities in power, resources, opportunities
• Based on socially constructed concept of “race”:
  • No biological basis
  • Used to devalue and marginalise groups
• Racialisation:
  • Categorising people based on appearance/ancestry/culture
  • Leads to stereotypes and discrimination

🔹 Historical Context (Australia)

• Aboriginal and Torres Strait Islander peoples:
  • Racialised and dehumanised during colonisation
  • Dispossession of land, culture, and resources
• Pre-colonisation:
  • Strong systems of culture, kinship, and connection to Country
• Colonisation impacts:
  • Ongoing intergenerational trauma
  • Disruption of:
    • Culture
    • Community
    • Identity
• Examples:
  • Stolen Generations → long-term trauma effects

🔹 Racism and Health Inequities

• Health disparities driven by:
  • Social determinants (housing, education, income)
  • Ongoing systemic racism
• Racism leads to:
  • Reduced access to:
    • Healthcare
    • Employment
    • Education
  • Increased exposure to:
    • Stress
    • Trauma
    • Violence

🔹 How Racism Affects Health

1. Direct physiological effects

• Activates stress response:
  • Sympathetic nervous system
  • HPA axis
• Leads to:
  • ↑ BP, glucose, inflammation
• Chronic exposure → allostatic load

2. Allostatic Load (Cumulative Stress)

• Biomarkers:
  • Cortisol, CRP, HbA1c, lipids, BP
• Associated with:
  • Cardiovascular disease
  • Diabetes
  • Cancer
  • Mental health disorders
  • Increased mortality

3. Psychosocial impact

• ↑ risk of:
  • Depression, anxiety
  • Psychological distress
  • Suicidal ideation

4. Behavioural impact

• Higher rates of:
  • Smoking
  • Alcohol dependence
  • Gambling

🔹 Evidence of Impact

• Dose–response relationship:
  • More discrimination → worse outcomes
• Associated with:
  • Poor self-rated health
  • Chronic disease (DM, CVD, HTN)
  • Cultural disconnection
• Strong association with:
  • Mental health issues
  • Reduced wellbeing

🔹 Racism in Healthcare

• Occurs at:
  • Bias in clinician behaviour
  • System barriers (access, cost, communication)
• Leads to:
  • Delayed care
  • Reduced trust
  • Poor adherence
  • Worse outcomes
• Recognised in:
  • Closing the Gap
  • National Aboriginal & Torres Strait Islander Health Plan

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Cultural Safety (Deep Understanding)

Definition

• Determined by patient experience, not clinician intent

Core Elements

• Self-reflection:
  • Biases
  • Privilege
  • Assumptions
• Power awareness:
  • GP–patient dynamic
• Respect for:
  • Culture
  • Identity
  • Community priorities

Practical GP Application

• Ask:
  • “What matters most to you in your care?”
• Avoid:
  • Assumptions about lifestyle or risk
• Recognise:
  • Cultural obligations may override medical priorities

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Trauma-Informed Care

Why important

• Aboriginal patients may have:
  • Historical trauma
  • Intergenerational trauma
  • Healthcare-related trauma

Core Principles

• Safety
• Trust
• Choice
• Collaboration
• Empowerment

Practical GP Actions

• Before exam:
  • Ask consent explicitly
• During consult:
  • Use calm tone, plain language
  • Allow pauses
• After:
  • Offer follow-up control
• Avoid:
  • Re-traumatisation (e.g. rushed care, authoritative tone)

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Clinical Recommendations

A. Cultural Safety Implementation

• Formal training (ongoing, not one-off)
• Reflective practice:
  • e.g. identity mapping
• Actively challenge:
  • Stereotypes
  • Bias

B. Self-Determination

• Shared decision-making:
  • Patient-led care planning
• Include:
  • Family/community if appropriate
• Respect:
  • Patient priorities

C. Practice Systems

• Culturally safe environment:
  • Visual cues (posters, flags)
• Staff training:
  • Mandatory
• Workforce:
  • Recruit Aboriginal staff

D. Complaints & Feedback

• Must be:
  • Safe
  • Accessible
  • Non-punitive
• Allow:
  • Anonymous feedback

E. Institutional Racism

• Monitor:
  • Access disparities
  • Outcomes
• Address:
  • Policy-level issues
• Embed in:
  • Continuous quality improvement

F. Community Partnership

• Engage with:
  • Local Aboriginal organisations
• Co-design services
• Avoid:
  • Tokenism

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Screening for Racism

Not routine screening

• Risks harm if:
  • No trust
  • No response capacity

When appropriate

• Established relationship
• Cultural safety present

How to ask

• Open-ended:
  • “Have there been stressors affecting your health, including how you’ve been treated by others?”

Response framework

• Validate:
  • “That sounds very difficult”
• Acknowledge:
  • Racism impacts health
• Support:
  • Referral / reporting pathways
  • Coping strategies

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Individual Risk Assessment

• Aboriginal status:
  • ❌ NOT a biological risk factor
• Instead:
  • Reflects:
    • Social disadvantage
    • Structural inequity

Clinical approach

• Assess:
  • Housing
  • Income
  • Education
  • Trauma
• Tailor:
  • Management to individual risk

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Race in Clinical Algorithms

• Problem:
  • May:
    • Overestimate risk OR
    • Delay care
• Mechanism:
  • Uses race as proxy for disadvantage
• Best practice:
  • Interpret cautiously
  • Prioritise individual assessment

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Implementation Tips

Clinician-level

• Continuous self-reflection
• Bias awareness
• Trauma-informed communication

Practice-level

• Staff training programs
• Safe environment design
• Aboriginal workforce inclusion

Patient-level

• Empowerment:
  • Know rights
  • Reporting racism
• Communication:
  • Clear, respectful, flexible

System-level

• Audit disparities
• Partner with community
• Policy advocacy

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Detailed + Practical Examples

1. Clinician-Level (Consult Room Behaviour)

A. Reflexive Practice (Core Skill)

• Ongoing self-reflection on:
  • Biases
  • Assumptions
  • Power dynamics

Examples

• After consult:
  • “Did I assume non-adherence without asking barriers?”
  • “Did I attribute risk to identity rather than circumstances?”
• Use tools:
  • Identity mapping (e.g. “8 ways” reflection)
• CPD:
  • Document reflections for annual requirements

B. Trauma-Informed Communication

• Principles:
  • Safety
  • Trust
  • Choice
  • Collaboration

Examples in consult

• Before exam:
  • “Would it be okay if I examine your abdomen?”
• During:
  • Explain each step before touching
• If distress:
  • “We can pause anytime if you’re uncomfortable.”
• Avoid:
  • Abrupt or directive tone

C. Validating Experiences of Racism

• When patient discloses racism:

Example responses

• Validation:
  • “That sounds really upsetting and unfair.”
• Acknowledgement:
  • “Experiences like that can definitely affect health.”
• Avoid:
  • Minimising (“Try not to think about it”)

D. Individualised Risk Assessment

• Replace assumptions with exploration

Instead of

• “Higher risk because Aboriginal”

Do

• Ask:
  • Housing stability
  • Access to food
  • Financial stress
  • Social supports

Example

• “Tell me a bit about your day-to-day living situation—anything making it harder to manage your health?”

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2. Consultation-Level Strategies

A. Building Trust Early

• First 1–2 minutes critical

Examples

• Open-ended:
  • “What’s most important for us to focus on today?”
• Acknowledge context:
  • “I understand healthcare hasn’t always felt safe for everyone.”

B. Shared Decision-Making (Self-Determination)

• Shift from directive → collaborative

Examples

• Instead of:
  • “You need to start insulin”
• Use:
  • “Here are a few options—what feels right for you?”
• Involve family/community:
  • “Would you like anyone else involved in decisions?”

C. Time Flexibility

• Recognise complexity

Examples

• Book:
  • Longer consults (e.g. double appointments)
• Allow:
  • Breaks during sensitive discussions
• Follow-up:
  • “Let’s take this step by step—we can revisit next visit.”

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3. Practice-Level Implementation

A. Creating a Culturally Safe Environment

• Visual + structural signals

Examples

• Waiting room:
  • Aboriginal flag, artwork
  • “Racism is not tolerated” signage
• Forms:
  • Respectful identification questions
• Staff behaviour:
  • Warm greeting, respectful tone

B. Staff Training (Mandatory + Ongoing)

• Not one-off “tick box”

Examples

• Annual:
  • Cultural safety workshops (AIDA-aligned)
• Include:
  • Role-play scenarios (racism disclosure)
• Debrief:
  • Practice meetings:
    • Discuss difficult consults
    • Reflect on bias

C. Workforce & Representation

• Improve cultural safety through staffing

Examples

• Recruit:
  • Aboriginal health workers
• Support:
  • Mentorship programs
• Include:
  • Cultural advisors where possible

D. Safe Feedback & Complaints System

• Must feel safe for patients

Examples

• Multiple options:
  • Verbal
  • Written
  • Anonymous box
• Staff response:
  • No defensiveness
• Provide info:
  • Human Rights Commission
  • “Call It Out” register

E. Monitoring & Quality Improvement

• Treat racism like any clinical risk factor

Examples

• Audit:
  • DNA rates by patient group
  • Preventive care uptake
• Identify:
  • Access gaps
• Act:
  • Adjust appointment systems
  • Improve outreach

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4. Community-Level Engagement

A. Building Partnerships

• Essential for culturally safe care

Examples

• Link with:
  • Local ACCHOs
  • Aboriginal liaison officers
• Referral pathways:
  • Cultural support programs
• Attend:
  • Community events (when appropriate)

B. Co-Design Services

• Avoid top-down decisions

Examples

• Ask community:
  • Preferred clinic hours
  • Service gaps
• Adapt:
  • Outreach clinics
  • Flexible booking systems

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