Racial Discrimination of Minority Population Groups in Relation to Health, Health Literacy, and Access to Health Care

Racial discrimination affects minority groups around the world and is known to have a negative impact on mental and physical health, which is a prerequisite for the emergence and persistence of health inequalities. Ethnic minorities suffer from shorter life expectancy, poorer access to healthcare services, and higher disease burden. There is a strong association between discrimination and adverse health outcomes, particularly those related to chronic non-communicable diseases (Berger, Sarnyai, 2014). Exposure of people to racial discrimination is an unacceptable violation of human rights and must be addressed, yet many forms and levels of racism require different policy approaches (Harris et al., 2006).

The Roma population currently constitutes the most numerous minority group in Europe. The goal of many policies is to mitigate the impacts of differences between minority and majority populations and to develop efforts to integrate Roma into majority society (Karasová, 2012). This paper aims to summarize the main aspects of the impact of discrimination on access of minority groups, in the context of the Slovak Republic, particularly marginalized Roma communities, to healthcare, and the direct and indirect consequences for their health status.

Background

Approximately 12–15 million Roma living in Europe are disadvantaged, and many are exposed to structural discrimination, social exclusion, and poverty. In particular, inequalities in access to healthcare services and provided care are among the main factors contributing to their social exclusion (Gavurová et al., 2014).

According to FRA (European Union Agency for Fundamental Rights), the factors influencing a patient’s health and access to care are as follows (Čurila, 2013):

1. Socioeconomic status,
2. Ethnic affiliation,
3. Age,
4. Sex,
5. Disability,
6. Migratory status.

Each person has the right to equal treatment and to health, and these two are inseparable because the right to health can be violated by discrimination in care on grounds such as sex, ethnic affiliation, age, or disability. When these characteristics intersect, it becomes multiple discrimination by a healthcare institution, which patients directly perceive in relation to their rights. Core patient rights linked to care include, among others:

• the right to information, meaning the right to complete information about their health status; about proposed medical procedures with their potential risks and benefits; about alternatives to proposed procedures, including the consequences of non-treatment; about diagnosis, prognosis, and progress in treatment;
• the right to an adequate explanation the patient can understand—meaning they must be involved in discussion about the care provided, and healthcare professionals should use language/expressions understandable to that individual;
• patients have the right to interpretation into their own language if they do not understand the language used in the EU; in a member state providing care, some form of interpretation should be available;
• the right to free choice, that is, to choose between different treatment approaches based on understandable provided information;
• the right to be treated with dignity, consistent with patients’ human rights (FRA, 2013).

The Constitution of the Slovak Republic also guarantees basic rights and freedoms to all people regardless of sex, skin color, race, language, religion, nationality, political opinion, or belonging to an ethnic group, economic status, or sex, and they may not be discriminated against for these reasons, whether positively or negatively (Huttová et al., 2012).

With worsened health among the Roma population and poorer socioeconomic status, inequalities in health are inseparably linked. Most health inequalities are the result of uneven effects of socioeconomic determinants in different social categories, which persist even in the wealthiest countries. These are systematic differences in their health, quality and access to care as it is provided to them. Social health inequalities arise as a result of power inequalities, that is, unequal social standing in social stratification. In general, such inequalities are viewed as unjust, not inevitable, and removable (Džambazovič, Gerbery, 2014).

Slovakia is among countries significantly burdened by health inequality problems, which mainly concern minority population groups living in areas with concentrated poverty (Gavurová et al., 2014).

Specifics of marginalized Roma communities

The Roma community differs from the majority society on most indicators of lifestyle (economic, social, cultural, etc.). Roma lifestyles are strongly shaped by a culture of poverty, which leads to a lower quality of life. This is manifested by shorter life expectancy, high prevalence of both acute and chronic diseases (Šupínová et al., 2015). The health status of Roma communities is the result of multiple factors: poorer availability of healthcare, lower care for their own health, insufficient personal and community hygiene standards, frequent alcoholism, inadequate housing standards, and low education (Šupínová et al., 2015; Rusnáková, Rochovská, 2016). Members of Roma communities often come from socially disadvantaged environments that do not provide enough stimuli supporting personality development. This low-stimulus/environmentally pathological setting does not support a child’s socialization; the adoption of work and hygiene habits; acquiring diverse knowledge and skills; the formation of a value hierarchy and socially appropriate behavioral norms that would correspond to the majority society. This means it is not supportive of adequate physical, psychological, and motor development, and children are often then assessed as developmentally immature for school (Čerešníková, 2015). Roma communities are among the population groups most affected by long-term poverty with characteristic intergenerational reproduction (Rusnáková, Rochovská, 2016).

As for the number of Roma living in the Slovak Republic or in Europe, there are major discrepancies with reality, as many Roma identify themselves as members of another national minority. People of Roma origin identify themselves this way either out of personal conviction or out of fear of different treatment—discrimination (Rimárová, 2013). According to estimates, approximately one third of the total number lives in Roma settlements or ghettos isolated from the majority population. Some live in dwellings with the lowest hygiene standard, i.e. without water and electricity. Together with the fact that most of these residents have only basic education (or none) and live in overcrowded homes, this significantly affects their health status. It is known that low housing quality is associated with increased environmental risk and poor health status (Stupák et al., 2013). This exposure to air pollution is also linked, for example, to hypertension and asthma, and can subsequently lead to higher mortality from COVID-19 (or another illness) (Williams, Cooper, 2020). Multiple epidemiological studies show that Roma health status is worse than that of the majority (Rusnáková, Rochovská, 2016; Stupák et al., 2013; Bojko et al., 2018). In characterizing this, however, one must distinguish between integrated and segregated Roma. Fully or partially integrated Roma have a better health status compared with Roma living in settlements (Stupák et al., 2013). According to Mrosková et al. (2019), the level of integration/segregation affects anthropometric parameters in newborns. A retrospective study indicates that Roma newborns showed significantly lower values of all anthropometric parameters compared with non-Roma newborns. A higher degree of integration has a positive effect on newborn anthropometric data, meaning the worst parameters were recorded among segregated Roma newborns.

In Roma communities, very high perinatal and infant mortality has been observed over a long period, markedly worse than in the majority population. While infant mortality in the majority population was 8 ‰ in 2002–2012, it was 20 ‰ in the Roma community. The causes are pronounced differences in living conditions and lifestyle rooted in segregation, as well as use of healthcare (Šupínová et al., 2015; Bojko et al., 2018). One aspect of segregation is its spatial dimension: the location of a settlement can indicate what living conditions Roma experience, and what infrastructure and service availability is present. This perspective again suggests the worst situation in segregated settlements, improving as spatial integration increases (Rusnáková, Rochovská, 2016). In principle, settlements separated from the municipality are characterized by absolute poverty and poor quality of life, while in integrated settlements it is more relative poverty (Džambazovič, 2007).

Discrimination, its forms, and consequences

Racism is based on an unequal social relation between members of two groups. The basis of racism is a process that assigns social meaning to biological, cultural, or religious characteristics and, on that basis, creates groups that are thus homogenized. Racism, therefore, occurs when racial, cultural, economic, or social characteristics are used to explain inequalities, legitimize unequal treatment, or assign unequal value to different groups (Profant, 2019). Race is understood as a set of physical characteristics, skin color, and language. Differential treatment on the basis of race or racial discrimination (the behavioral expression of racism) is very common, even for example in the United States, where great racial diversity is characteristic. In the United States, racism creates physical and social isolation, barriers to opportunities that contribute to health inequalities (Carter et al., 2019). Here we can see an analogy with conditions affecting marginalized Roma communities in Slovakia, which push them to the social margins, provide insufficient opportunities, and thereby prevent integration, which leads to several factors affecting Roma health described in this article.

Discrimination is a socially structured phenomenon aimed at preserving privileges for members of dominant groups at the expense of deprivation for others (Harris et al., 2006). The majority’s perception of Roma difference as an ethnicity is a normal and natural group-forming process. It is not acceptable, however, when this perception of difference and vigilance turns into xenophobia. This occurs when the distinctness of a given ethnicity is associated with prejudice, resulting in stigma and subsequent institutional discrimination with strong distancing from them (Vašečka, 2011). Our implicit associations may lead to bias and then create negative evaluations based on certain attributes—for example, assuming a Black patient is less competent and therefore not prescribing certain treatment. In such cases we speak of implicit prejudice, which creates dissociation between what one believes and wants to do and the hidden influence of implicit associations on thoughts and behavior in a specific situation. In relation to healthcare provision, there is no legitimate reason for negative evaluation associated with membership in a particular group (FitzGerald, Hurst, 2017). Implicit bias in healthcare and clinical encounters is linked to poorer communication between doctor and patient and lower quality of care (Williams, Cooper, 2020).

Perceived racial discrimination is defined as minority patients’ perception of unfair or differential treatment because of race (Stepanikova, Oates, 2017). Minorities perceive racial discrimination in healthcare systems more frequently than the majority population (Hausmann et al., 2013).

Not all discrimination occurs at the individual level. Policies and regulations can also have a discriminatory character and are referred to as institutional racism. Individual discrimination combined with institutional racism can amplify the adverse effects of other health determinants, placing racial/ethnic minorities in double jeopardy (Shavers et al., 2012). Discrimination of Roma is in many cases both a cause and a consequence of their social exclusion and poverty (Nadácia otvorenej spoločnosti, 2011). Social exclusion is a sustained process of marginalization, isolation, and weakening of social ties, visible at both the individual and social-group levels. In this process individuals are pushed to the margins of society, and due to insufficient opportunities they cannot realize themselves in society. This includes unemployment, low education level, poverty, and the mutual interdependence of these factors. In the case of Roma communities, ethnicity additionally itself fuels exclusion (Karasová, 2012). According to a survey by the Open Society Foundation, Roma themselves experience discrimination in various forms. Generally, hostility of Slovak institutions is reinforced by stereotypical xenophobic attitudes. As the most frequent expression (more than 40%), passive aggression appears—specifically withholding, indifference, irritability, avoidance, and efforts to get rid of them. Verbal aggression is also frequently represented as increased volume of voice, shouting, and insults. Half of respondents perceive differential treatment by institutions, with prejudice and racism seen as the main reason. Two-thirds of children from Roma communities do not have the opportunity to attend extracurricular clubs because of segregation and discrimination by the majority. As a result, these children may suffer psychological deprivation, characterized by an inability to meet basic needs connected to sufficient meaningful stimulation, developing satisfactory peer relationships, and building self-confidence through honing newly acquired abilities and skills (Nadácia otvorenej spoločnosti, 2011). Family socioeconomic status, including interest in education, can significantly affect an individual’s health status, as education supports better employment prospects, thereby income and health (Gavurová et al., 2014).

Segregation in education and the reassignment of students with different needs to special schools is one of the biggest problems of Roma discrimination. The most consequential effect is that such discrimination affects not only education itself but also has a negative impact on their social integration (Huttová et al., 2012). The ultimate consequence is also the inability to build sufficient health literacy and communication skills. Difficulties understanding had strong positive associations with perceived discrimination among minorities. Their members also had higher likelihood of perceiving discrimination if they had poorer health. This reflects the fact that poor health is the result of inadequate healthcare provision due to belonging to a racial minority, as well as treatment throughout life (Abramson et al., 2015). Moreover, racial discrimination appears to show significant similarities with chronic social stress at hormonal and nervous-system levels. Since discrimination is subjectively experienced as stress, it leads to elevated cortisol and dysregulation of the hypothalamic-pituitary-adrenal axis, which mediates the effect of discrimination on allostatic load. The literature also describes potential neurobiological pathways through which discrimination affects mental health (Berger, Sarnyai, 2014). According to a 2019 meta-analysis, significant correlations exist between racial discrimination and health, with the strongest association found for mental health, then substance use, behavior, and physical health (Carter et al., 2019). It appears that overall discrimination itself, including racial discrimination, has adverse effects on the health and mental health of African Americans, including preclinical disease indicators, health behaviors—such as tobacco use, use of medical services, and adherence to prescribed regimens (Mouzon et al., 2016; Williams et al., 2019; Harris et al., 2006).

Within each racial group, socioeconomic status further stratifies health, with socially disadvantaged individuals suffering worse health compared with more privileged individuals (Stepanikova, Oates, 2017). Discrimination also affects the health of children and adolescents (Williams et al., 2019). Children begin to realize by roughly age ten that ethnic characteristics are linked to social advantages, such as differences in social class or prejudice and views based solely on ethnic-racial group membership. In a sample of Latin American adolescents, those reporting higher perceived ethnic-racial discrimination in 9th/10th grade showed a significantly slower rise in self-esteem compared with peers reporting lower discrimination. In a study of African American youth (10–11 years), racial discrimination was associated with greater engagement in risk-related sexual behavior eight years later. Simply put, harmful associations of ethnic membership and discrimination emerge in childhood and become evident across all ethnic-racial minority groups through adolescence (Umaña-Taylor, 2016). Experiences of racial discrimination are associated with lower trust in the healthcare system and its providers, poorer treatment compliance, and poorer health outcomes (Alcalá, Cook, 2018).

Healthcare and minority health

Racial/ethnic minorities suffer disproportionate morbidity and mortality from oncological, cardiovascular diseases, diabetes mellitus, and stroke (Shavers et al., 2012), low birth weight, smoking, and generally poor health (Stepanikova, Oates, 2017). The very experience of racial discrimination is linked to negative outcomes such as increased mortality, mental illness, cancer, hypertension, cardiovascular disease, obesity, and risky health behavior (Alcalá, Cook, 2018). Precise health statistics for the Roma population are not collected in Slovakia due to anti-discrimination measures. Even with the state’s interest in removing health differences, empirical knowledge and survey results indicate worse health among Roma compared with Slovakia’s majority population. Worse reproductive health among Roma and increased infectious disease occurrence in areas with high Roma population density have been demonstrated (Šupínová et al., 2015). Access to healthcare is difficult for Roma due to low awareness, discrimination, and financial as well as cultural and language barriers (Bojko et al., 2018). Roma women in particular report, almost three times more often than individuals from the majority population, ethnicity as an obstacle to access to healthcare (Hubková et al., 2014). One reason for this group’s not seeking medical help may be medication costs (a financial barrier related to workplace discrimination) and transportation in less developed districts as an element of spatial segregation, but also a financial barrier related to transport costs (Bojko et al., 2018). Roma themselves identified insufficient funds for medicines and transport to healthcare institutions as barriers, but also negative experiences and fear of hostile approaches by healthcare workers or lack of trust in them (Hubková et al., 2014).

Previous experiences of racial discrimination undermine trust in the healthcare system, thereby deterring individuals from future interactions with the healthcare system. Overall, racial minorities have lower trust in healthcare systems. These patterns of discrimination are important because they account for racial differences in perceived quality of care and trust in providers, showing that experiences of discrimination play a major role in a person’s subjective evaluation of healthcare (Alcalá, Cook, 2018). Higher mistrust in healthcare is also explained among African Americans by greater burdens of racial discrimination experiences than among White individuals (Armstrong et al., 2013).

In the U.S., high maternal mortality among Black women is an example of structural and systemic racism. Black women have a 3–4 times greater likelihood of dying during childbirth than White women. Studies have shown that it is not social determinants but race-based discrimination that influences whether a mother dies during pregnancy. Even White women with Black partners are more likely to experience poor treatment by healthcare providers compared with White women with White partners. In addition, chronic stress significantly contributes to adverse maternal outcomes for Black women. Stress from exposure to racial and gender discrimination, as well as lifetime trauma from accumulated adverse experiences, contributes to poorer birth outcomes for Black women. When Black women receive healthcare, quality is often lower. It is likely that communication from the provider will not be sufficiently adequate or understandable to the patient; they also do not have the opportunity to participate in decisions about the care provided, and they have a higher chance of experiencing racial discrimination (Baptiste et al., 2020). Racial minorities experience worse interactions with healthcare providers compared with the majority population, including lower-quality communication, less participation in decision-making, and greater likelihood of perceived discrimination during visits to healthcare institutions (Attanasio, Hardeman, 2019).

Differences in health are influenced by a broad range of factors, one of which is poorer care provided to minority individuals after entering the healthcare system. The 2005 National Healthcare Disparities Report stated that White patients receive better healthcare than 53% of Hispanic population, 43% of African Americans, 38% of American/Alaska Native, and 22% of patients from the Pacific and Asian regions (Shavers et al., 2012). Compared with Whites, Black patients have lower trust in doctors and higher perceived interpersonal and institutional discrimination (Hausmann et al., 2013). A key point is that distorted and misinterpreted self-reports of these experiences may occur due to internalized racism. Members of minority groups themselves may accept negative treatment as legitimate, deserved, or nondiscriminatory even with equal exposure to racism, because of internalized beliefs about their own difference (Harris et al., 2006). Perceived racial discrimination is more frequent among Blacks and Native Americans than among Whites, while perceived racial privilege is less frequent compared with Whites. Together with that, higher income and education among Whites again contributed to increased perception of privileged treatment, whereas this pattern did not hold among Blacks. This suggests that socioeconomic status is an important social determinant of perceived privilege and perceived discrimination in healthcare, but its role differs by racial affiliation. Although discrimination occurs in different life situations, in healthcare settings it is especially alarming due to its negative impact on preventive care. Patients who perceive such discrimination tend to avoid preventive care, delay medical examinations and treatment, or do not use healthcare services at all. They also report poorer communication from doctors and lower satisfaction with care, which may lead to poorer adherence to treatment plans (Stepanikova, Oates, 2017).

Williams and Cooper (2020) described COVID-19 as a magnifying glass that magnified the pandemic of racial/ethnic health differences. The current COVID-19 pandemic has further deepened health differences between ethnic and socioeconomic groups. Non-communicable diseases are key factors in this magnified gap because they disproportionately affect vulnerable groups. A vulnerable population with non-communicable diseases is disproportionately affected by COVID-19 itself. Therefore, prevention and control strategies for chronic non-communicable diseases must be adjusted to better respond to these double threats among vulnerable patients (Mobula et al., 2020). The situation in Roma communities during the pandemic led to strengthened negative attitudes toward Roma. A large amount of hostile speech toward them circulated on social networks. The NGO Človek v ohrození stated that the complex access to healthcare among members of marginalized Roma communities causes greater vulnerability to COVID-19 due to their overall poorer health. Another important factor in their vulnerability is very low or no income, which prevented them from securing protective equipment. The shift to distance learning affected all children in preschool, primary, secondary, and higher education. For children from socially disadvantaged environments (which undoubtedly include children from marginalized Roma communities), this represented an additional educational disadvantage. As much as 44% of children aged 6–11 live in overcrowded households with limited learning opportunities. 32,000 children have no internet access and therefore cannot participate in online education (FRA, 2020), which, as mentioned above, is a key social determinant of health that influences not only an individual’s position in social stratification but also health literacy and appropriately informed future health decisions and risk behavior.

Even though racial/ethnic health differences have narrowed by half over the previous century, this progress is painfully slow and needs to be accelerated. Failure to protect the most vulnerable members of society harms not only racial/ethnic minorities themselves but increases the risk of disease spread in the population and can have devastating effects on health and the economy. Differences in health are not the fault of members of individual minority groups, but reflect social policies and systems that create health differences in “good times” and amplify them in times of crisis (Williams, Cooper, 2020).

Interventions

Differences in trust in the healthcare system vary by race and reflect different cultural experiences of Black and White people, as well as expectation differences (Boulware et al., 2003). Multiple factors contribute to racial differences in medical care, but unconscious bias among healthcare workers contributes to deficits in the quality of care provided (Williams, Wyatt, 2015). Therefore, one of the most important competencies for healthcare professionals is the ability to communicate adequately with patients. Effective communication between healthcare worker and patient is a key component of a safe and high-quality healthcare system (Alsheikh, Iqbal, 2020). Multiple studies have demonstrated the existence of implicit bias among physicians and nurses in a similar degree as in the general population, concerning characteristics such as race/ethnicity, sex, socioeconomic status, age, mental illness, weight, AIDS, and patients with brain injury. Some studies also found that doctors’ estimates of patients’ socioeconomic status were influenced by race, meaning they assumed lower SES for patients with Black skin (FitzGerald, Hurst, 2017).

Public policies should focus on raising awareness through health education counselors, various anti-discrimination measures, financial support to overcome barriers to accessing healthcare services, and overall improvement of living conditions, housing, and basic infrastructure, as well as increasing the cultural and language competencies of healthcare personnel (Bojko et al., 2018). It is necessary to implement policies that ensure a sufficient number of individuals from all racial, ethnic, and social groups are protected from adverse social determinants (Williams, Cooper, 2020). Policies and interventions to reduce this perception should focus on structural and systemic factors, including societal inequalities in income, education, and access to healthcare, and should be tailored to account for race-specific experiences with healthcare (Stepanikova, Oates, 2017). Focusing on structural racism offers a concrete and feasible approach to improving health equity (Bailey et al., 2017). Finally, initiatives are needed to shift healthcare systems from being fundamentally disease-treatment oriented toward providing timely, quality care for everyone, tailored to the culture and context of each patient (Williams, Cooper, 2019).

Conclusion

Racism is one of the main determinants of health and also the “engine” of ethnic inequalities in health. Therefore, policies and programs must emerge that are aimed at addressing racism and eliminating these inequalities. This must clearly include the healthcare sector and the broader public (Harris et al., 2006). Racial discrimination must be viewed not only as a public health problem but as a humanitarian crisis (Baptiste et al., 2020). Since every person has equal rights under the Constitution, it is unacceptable that current-level health inequalities remain reality and go unnoticed and without active intervention. Multiple studies demonstrate the impact of discrimination on physical and mental health, which deepens with age. It is clear that certain inequalities will always be present due to natural social stratification, yet there is no rational reason for the persistence of ethnic-racial health inequalities. It is important to shape programs and policies focused on integrating minority groups into the majority society, removing barriers, and eliminating prejudices, or preferably preventing the formation of these prejudices through school education in diverse social settings for children. Not least, education of healthcare workers—already during professional training—should be an integral part of the educational process. Finally, home upbringing is important in shaping young people’s attitudes, where the cycle of discrimination for any reason begins and ends. The key is therefore coordinated action on all fronts:

• parental upbringing,
• school education,
• diversity in school environments,
• education of healthcare workers that enables gradual removal of barriers faced by minority groups in access to healthcare and thereby reducing health differences.

This means that solving fundamental social inequalities and healthcare access requires long-term investments in transforming values, laws, and policies (Baptiste et al., 2020).

Authors: Mgr. Lívia Kaňuková doc. MUDr. Kvetoslava Rimárová, CSc., mim. prof.***

The work was supported by 3 KEGA grant projects of the Ministry of Education, Science, Research and Sports of the Slovak Republic KEGA 007/UPJŠ-4/2018; KEGA 008 UPJŠ-4/2020; KEGA 010UPJŠ-4/2021 and 2 internal projects of UPJŠ VVGS IPEL 2020/1485 and VVGS IPEL 2020/1662.

List of bibliographic references

ABRAMSON, Corey M. – HASHEMI, Manata – SÁNCHEZ-JANKOWSKI, Martín. 2015. Perceived discrimination in U.S. healthcare: Charting the effects of key social characteristics within and across racial groups. In Preventive Medicine Reports. 2015, 2, 615-621.

ALCALÁ, Héctor, E – COOK, Daniel M. 2018. Racial Discrimination in Health Care and Utilization of Health Care: A Cross-Sectional Sudy of California Adults. In Journal of General Internal Medicine. 2018, 33, 1760-1767.

ALSHEIKH, Mona – IQBAL, Muhammad Zafar. 2020. Communication Skills for Medical Professionals: Perspectives from the Middle East. In Effective Medical Communication. 215-225.

ARMSTRONG, Katrina – PUTT, Mary – HUGHES HALBERT, Chanita – GRANDE, David et al. 2013. Prior Experiences of Racial Discrimination and Racial Differences in Health Care System Distrust. In Med Care. 2013, 51 (2), 144-150.

ATTANASIO, Laura B. – HARDEMAN, Rachel R. 2019. Declined care and discrimination during the childbirth hospitalization. In Soc Sci Med. 2019, 232: 270-277.

BAILEY, Zinzi D. – KRIEGER, Nancy – AGÉNOR, Madina et al. 2017. Structural racism and health inequities in the USA: evindence and interventions. In The Lancet. 2017, 389 (10077), 1453-1463.

BAPTISTE, Diana-Lyn – JOSIAH, Nia A. – ALEXANDER, Kamila A. Et al. 2020. Racial discrimination in health care: An „us“ problem. In Journal of Clinical Nursing. 2020, 29 (23-24), 4415-4417.

BERGER, Maximus – SARNYAI, Zoltán. 2014. „More than skin deep“: stress neurobiology and mental health consequences of racial discrimination. In The International Journal on the Biology of Stress. 2015, 18, 1-10.

BOJKO, Marek – HIDAS, Slavomír – MACHLICA, Gabriel – SMATANA, Martin. 2018. Inklúzia Rómov je potrebná aj v zdravotníctve. In Inšitút finančnej politiky: Komentár. 2018/23.

BOULWARE, L. Ebony – COOPER, Lisa A. – RATNER, Lloyd E. Et al. 2003. Race and Trust in the Health Care System. In Public Health Reports.

CARTER, Robert T. – JOHNSON, Veronica E. – KIRKINIS, Katherine – ROBERSON, Katheryn – MUCHOW, Carie – GALGAY, Corinne. 2019. A Meta-Analytic Review of Racial Discrimination: Relationships to Health and Culture. In Race and Social Problems, 11, 15-32 (2019).

ČEREŠNÍKOVÁ, Miroslava. 2015. Sociokultúrne úskalia pri posudzovaní školskej zrelosti rómskych detí (v kontexte tvorby sociálnych sietí obyvateľov marginalizovaných rómskych komunít). In MAIEROVÁ, Eva et al. PhD Existence: Česko-slovenská psychologická konference pro doktorandy a o doktorandech. Olomouc: 2015. ISBN 978-80-244-4694-3.

ČURILA, Dušan. 2015. Aplikácia antidiskriminačného zákona v zdravotníctve. In KOTÁSEK, J. Dny práva. Brno: 2012. ISBN 978-80-210-6319-8.

DŽAMBAZOVIČ, Roman - GERBERY, Daniel. 2014. Sociálno-ekonomické nerovnosti v zdraví: sociálno-ekonomický status ako determinant zdravia. In Sociológia, 46, 2014, č. 2.

DŽAMBAZOVIČ, Roman. 2007. Priestorové aspekty chudoby a sociálneho vylúčenia. In Sociológia, 39, 2007, č.5. 432-458.

FITZGERALD, Chloe – HURST, Samia. 2017. Implicit bias in healthcare professionals: a systematic review. In BMC Medical Ethics. 2017, 18 (19).

FRA. 2013. Inequalities and multiple discrimination in acces to and quality healthcare. Luxembourg: Publications of the European union, 2013. ISBN 978-92-9239-022-8. FRA. 2020. Implications of COVID-19 pandemic on Roma and Travellers communities.

GAVUROVÁ, Beáta - SOLTES, Vincent - SOLTÉS, Michal. 2014. Meranie zdravia a zdravotných rizík vo vybraných rómskych osadách na Slovensku – fakty a reflexie. In Nerovnosť a chudoba v Európskej únii a na Slovensku II, 2014.

HARRIS, Ricci – TOBIAS, Martin – JEFFREYS, Mona et al., 2006. Rasicm and Health: The relationship between experience of racial discrimination and health in New Zealand. In. Social Science Medicine. 2006, 63 (6), 1428-1441.

HAUSMANN, Leslie R.M. – KWOH, C. KENT – HANNON, Michael J. – IBRAHIM, SAID. A. 2013. Perceived Racial Discrimination in Health Care and Race Differences in Physician Trust. In Race Soc Probl (2013) 5:113–120

HUBKOVÁ, Beáta – TKÁČIKOVÁ, Soňa – GUZY, Juraj – MAREKOVÁ, Mária – HEPA-META tím. Health of Roma in eastern Slovakia. Individual and Society, 2014, Vol. 17, No. 1.

HUTTOVÁ, Jana – GYÁRFÁŠOVÁ - Olga, SEKULOVÁ, Martina. 2012. Segregácia alebo inklúzia Rómov vo vdelávaní: Voľba pre školy? Bratislava: Nadácia otvorenej spoločnosti, 2012. 270 s. ISBN 978-80-89571-06-2.

KARASOVÁ, Alena. 2012. Alternatívy sociálnej inklúzie marginalizovaných rómskych komunít do majoritnej spoločnosti. In Humanum. ISSN 1898-8431, 2012, 9 (2), 155-166.

MOBULA, Linda M. – HELLER, David J. – COMMODORE-MENSAH, Yvonne et al. 2020. Protecting the vurnerable during the COVID-19: Treating and preventing chronic disease disparities. In Gates Open Res. 2020, 4 (25).

MOUZON, Dawne, M. – TAYLOR, Robert Joseph – WOODWARD, Amanda Toler – CHATTERS, Linda M. 2017. Everyday Racial Discrimination, Everyday Non-Racial Discrimination, and Physical Health Among African-Americans. In Journal of Ethnic Cultural Diversity in Social Work. 2017, 26 (1-2), 68-80.

MROSKOVÁ, S. - SCHLOSSEROVÁ, A. - KOVAĽ, J. - REĽOVSKÁ, M. 2019. Vplyv etnicity a miery integrácie/segregácie rómskeho etnika na antropometrické parametre u ich novorodencov, narodených v oblasti severovýchodu Slovenska. In Česko-slovenská pediatrie. ISSN 1805-4501, 2019, 74 (6): 359-365.

NADÁCIA OTVORENEJ SPOLOČNOSTI. 2011. Iná realita: chudoba, sociálna deprivácia a užívanie inhalantov v rómskych osídleniach na východnom Slovensku. Bratislava: 2011. 185 s. ISBN 978-80-89571-00-0.

PROFANT, Tomáš. 2019. Rasizmus v rozvoji a rozvojovej spolupráci. In Medzinarodní vztahy, 55 (1): 1-20.

RIMÁROVÁ, Kvetoslava. 2013. Prehľad výsledkov štúdií zdravotného stavu minoritnej rómskej populácie v oblasti rastu detí, vplyvu na graviditu a frekvencie infekčných ochorení. In SIEGFRIED, Leonard, MAREKOVÁ, Mária, MAJERNÍK, Jaroslav. Zborník odborných a vedeckých príspevkov projektov zo štrukturálnych fondov Európskej únie. Košice: 2013. ISBN 978-80-8152-073-0, s. 159-167.

RUSNÁKOVÁ, Jurina - ROCHOVSKÁ, Alena. 2016. Sociálne vylúčenie, segregácia a životné stratégie obyvateľov rómskych komunít z pohľadu teórie zdrojov. In Geografický časopis. ISSN 2453-8787, 68 (2016), 3, 245-260.

SHAVERS, Vickie L. – FAGAN, Pebbles – JONES, Dionne et al. 2012. The State of Research on Racial/Ethnic Discrimination in The Receipt of Health Care. In American Journal of Public Health. 2012.

STEPANIKOVA, Irena – OATES, Gabriela R. 2017. Perceived Discrimination and Privilege in Health Care: The Role of Socioeconomic Status and Race. In American Journal of Preventive medicine. 2017, 52 (1), 1, S86-S94.

STUPÁK, M. - STUPÁKOVÁ, N. - VESELÁ, J. - GUZY, J. - MAREKOVÁ, M. 2013. Zdravotný profil marginalizovaných rómskych komunít na Slovensku. In SIEGFRIED, Leonard, MAREKOVÁ, Mária, MAJERNÍK, Jaroslav. Zborník odborných a vedeckých príspevkov projektov zo štrukturálnych fondov Európskej únie. Košice: 2013. ISBN 978-80-8152-073-0, s. 85-90.

ŠUPÍNOVÁ, Mária - HEGYI, Ladislav - KLEMENT, Cyril. 2015. Zdravotný stav Rómov na Slovensku. In Hygiena. ISSN 1803-1048, 2015, 60 (3), 116-119.

UMAÑA-TAYLOR, Adriana J. 2016. A Post-Racial Society in Which Ethnic-Racial Discrimination Still Exists and Has Significant Consequences for Youths‘ Adjustment. In Current Directions in Psychological Science. 2016, 25 (2), 111-118.

VAŠEČKA, Imrich. 2011. Sociálne vylúčené rómske zoskupenia a nezamestnanosť ich členov. In Pokrízová obnova SR: Zvyšovanie zamestnanosti a inklúzia Rómov. In MUŠINKA, Alexander – BENČ, Vladimír. Prešov, 2011. ISBN 978-80-89356-30-0. 104-114.

WILLIAMS, David R. – COOPER, Lisa A. – 2019. Reducing Racial Inequities in Health: Using What We Already Know to Take Action. In International Journal of Environmental Research and Public Health. 2019, 16(4), 606.

WILLIAMS, David R. – COOPER, Lisa A. 2020. COVID-19 and Health Equity – A New Kind of „Herd Immunity“. In JAMA. 2020, 323 (24): 2478-2480.

WILLIAMS, David R. – LAWRENCE, Jourdyn A. – DAVIS, Brigette A. – VU, Cecilia. 2019. Understanding how discrimination can affect health. In Health Services Research. 2019, 54 (S2): 1374-1388.

WILLIAMS, David R. – WYATT, Ronald. 2015. Racial Bias in Health Care and Health, Challenges and opportunities. In JAMA. 2015, 314 (6), 555-556.