Black Veterans Report Stress When Receiving Kidney Care

Racism in the medical setting caused emotional and physical stress for Black veterans with chronic kidney disease (CKD), as well as a high sense of distrust in the healthcare system, a qualitative study suggests.

These data suggest that veterans were resentful, angry, and stressed due to the racism they experienced in the clinical setting. Some veterans also expressed distrust in the medical system and were hypervigilant during medical visits, indicative of post-traumatic stress disorder, reported Kevin A. Jenkins, PhD, of Corporal Michael J. Crescenz Veterans Affairs Medical Center in Philadelphia, Pennsylvania, and colleagues.

The findings were recently published in JAMA Network Open.

While similar perspectives on racism and kidney transplant have been reported, this study provides greater understanding for the nephrology community, noted Katherine M. Rizzolo, MD, of the University of Colorado School of Medicine in Aurora. "I think this really adds something to the literature because the questions they asked were really open-ended, and they were really able to explore the veterans' experiences, so I thought this was very additive and very necessary as we move into this space of understanding that racism is affecting health," Rizzolo told Medscape Medical News in a phone interview.

Racism Causes Physical, Emotional Stress

Researchers interviewed 36 Black veterans with chronic kidney disease who were receiving care at the Corporal Michael J. Crescenz Veterans Affairs Medical Center. The mean age of participants was 66 years and men comprised 97% of the study group. Nine participants had hypertension, the most common comorbidity in the study group, and 15 participants were not dialysis dependent.

Participants had a diagnosis of chronic kidney disease and fell into one of the following stages: post-transplant (stage 5 kidney disease), dialysis-dependent (stage 5 end-stage kidney disease, glomerular filtration rate (GFR) < 15 mL/min/1.73m²), or not dialysis dependent (stage 3, moderate, GFR, 30-59 mL/min/1.73m² or stage 4, severe, GFR, 15-29 mL/min/1.73m² kidney disease).

Using applied thematic assessment, the researchers evaluated interview transcripts.

"The interviewers and research assistants were racially concordant, meaning they were also African American, which I think is incredibly important. There's lots of documentation that patients are less likely to feel they have good care, and less likely to divulge information, if they are not being seen by someone of their own race," Rizzolo pointed out.

The qualitative data showed that veterans indicated how racism caused physical and emotional stress, for example, physiological symptoms such as headaches and psychological symptoms of hurt and anger.

The article also notes that veterans shared that they feel a need to be hypervigilant during medical visits and distrust the medical system.

Notably, hypervigilance is related to post-traumatic stress disorder, which is common among veterans in general.

These results offer a possible mechanism for how racism and trauma are related to racial inequalities in kidney disease and medicine more broadly, noted Tessa K. Novick, MD, of Dell Medical School at the University of Texas at Austin and Deidra C. Crews, MD, of Johns Hopkins University School of Medicine in Baltimore, Maryland, in an accompanying editorial. "Encounters with racism triggered a trauma-like response resulting in avoidance of health care and the occurrence of symptoms associated with chronic stress. For people with CKD, these responses could translate into inadequately controlled comorbidities and faster progression to kidney failure," they continued.

Racism Under the Microscope

"Putting racism under the microscope isn't something we have done a good enough job with in the chronic kidney disease space. What I wanted to do with this research was put racism under the microscope," Jenkins said in a phone interview.

This study demonstrates the need for a different approach to these patients. "We need to be more educated in trauma-informed care principles in order to take better care of these patients and allow them to feel more involved in their healthcare," Rizzolo said.

These findings also highlight a need for more diversity across medical teams, Rizzolo said. "Broadly, what we should take away from this is a need to see more diverse representation in our medical staff, not just among nephrology providers, but also among the dialysis techs and nurses. I think these patients would feel more supported and more active in their care if they saw someone like them in the provider role."

"It's incredibly important for us to think about the nephrology community and how we can make these patients, who have been historically marginalized, feel heard and supported in their kidney care," Rizzolo added.

Study limitations include that the data were gathered solely from patients at one center, interview questions suggest that patients faced racism and that racism is related to health, the cohort relied on the Veterans Health Administration for healthcare and their experience may differ from those who do not, and the study consisted mainly of male veterans, the researchers note.

Crews has reported being an adviser for Bayer outside of the scope of this research and receiving grants from Somatus and Baxter. Jenkins and Novick have reported no relevant financial relationships.

JAMA Netw Open. 2022;5(5):e2211900, e2211903. Full text, Commentary

Ashley Lyles is an award-winning medical journalist. She is a graduate of New York University's Science, Health, and Environmental Reporting Program. Previously, she studied professional writing at Michigan State University. Her work has taken her to Honduras, Cambodia, France, and Ghana and has appeared in outlets such as The New York Times Daily 360, PBS NewsHour, The Huffington Post, Undark, The Root, Psychology Today, Insider, and Tonic (Health by Vice), among other publications.

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