Background: It is widely known that racial discrimination and disparities have existed in the United States across many realms and have had major implications on the structure of society, the economy, welfare and healthcare overall. As future healthcare providers, it is imperative that we understand the basis of discrimination within healthcare, to not only preserve equality within the system, but to provide evidence-based solutions to halt further injustice. In many US medical school curriculums and clinical training, medical students continually learn about the various diseases that differ in incidence, epidemiology, diagnosis and treatment across different races. Although we gain knowledge on genetics and other factors that could cause disparities, there is a need for further research from the public health standpoint to analyze if and how racial discrimination can have an impact. Our research group found that African American populations are extensively found to have disparities when compared to other racial groups, yet little is known about the potential role of racial discrimination on their medical treatment.

Methods: A scoping review was performed using the Preferred Reporting Items for Systematic Reviews and Metaanalyses (PRISMA) guidelines. Our search strategy utilized a computerized search of Embase and PsychINFO databases to identify articles published between 2010 and 2020 with the key search terms of “racial discrimination OR racial prejudice OR racial inequality” AND “therapy OR treatment” AND “women OR females OR girls”. Articles were included if they conducted quantitative research, focused on African Americans, Low SES, Morbidity, Mortality or prenatal care. Articles were excluded if qualitative, published before 2010, were not in English and only examined “perceived discrimination”. All members of the research team conducted the primary screen of abstracts for eligibility using the predefined inclusion and exclusion criteria. Four members of the research team then further screened to determine final inclusion or exclusion of each article, with disagreements resolved by the last author.

Results: Across 7 final articles, we found that rather than racial discrimination stemming from the healthcare system and its providers, other major themes emerged that may account for disparities in the medical treatment of African American women. The first and most highly implicated in causing differences in medical treatment was access to healthcare. Four studies analyzing breast cancer from the perspectives of BRCA1 genetic testing, Gene expression profile (GEP) testing, hormone-receptor subtype, and receival of surgical treatment, all found that the lack of testing and delays in treatment were partly attributable to lack of adequate insurance that covered preventative care and testing. African American women had significantly increased delays in receiving genetic testing and treatment for breast cancer compared to White women and feasibility seemed to have the greatest impact. In an area-level HCA model, despite having a high density of physicians, patients were still less likely to receive surgical treatment for breast cancer due to unemployment, poverty level, structural and cultural reasons. Another consistent finding with this theme was access to rehabilitation facilities, physical therapy, and other post-operative treatment for a total knee arthroplasty. The disparity of treatment for Black women was not significantly more than White patients, however, Black women had longer hospital stays, more intensive physical therapy and were treated with total knee arthroplasty later than White women on average. Overall, underutilization, unaffordability and delays in treatment tie into a larger theme of Socioeconomic Status (SES) contributing to disparities in the medical treatment of African American women in the Unites States. SES seemed to have a sizable role in the disparities found when Black women were compared to White women for breast cancer and ovarian cancer treatment. In another study that quantitatively analyzed racial segregation and disparities in breast cancer treatment, there was evidence that morbidity and mortality was ultimately affected as a result of SES. Black women who presented at an advanced stage were less likely to receive appropriate surgical and adjuvant treatment and were found to have lower overall and stage specific survival relative to White individuals. The final theme that emerged from the data found across all the articles, was that there was an evident lack of follow up care and communication with physicians that was contributing to treatment outcomes. For instance, BRCA genetic testing on its own does not have much value if patients do not follow up with their physicians for more frequent screening. Black women had the lowest rates of conversations with their physicians about genetic testing compared to non- Hispanic White and English-speaking Hispanics. Further, African American women are more likely diagnosed with ER/PR (Estrogen Receptor/ Progesterone Receptor) negative breast cancer, have more pathologic genetic factors, and worse prognoses, yet those receiving options for mastectomy were more hesitant to follow up.

Conclusions & Implications: Access to medical care, socioeconomic status and lack of patient follow up had a significant impact on the disparities found in the medical treatment of African American women. Rather than racial discrimination from the perspective of physicians, these factors seemed to affect the statistics of the studies finding any disparity between African American and White women. With this scoping review being limited to 2 databases, a need for a larger scoping review over many databases may be warranted and reveal more findings on the role of discrimination in treatment. Lastly, more public health research is needed within various races and among genders to identify how we can create solutions to inequalities within healthcare.