Understanding disparities in access to and quality of surgical care for African, Caribbean and Black communities in high-income countries with universal healthcare: a scoping review protocol
Understanding disparities in access to and quality of surgical care for African, Caribbean and Black communities in high-income countries with universal healthcare: a scoping review protocol
African, Caribbean and Black (ACB) communities experience disparities in health outcomes, with higher rates of chronic diseases, such as heart disease and stroke, and lower self-reported health status compared to their White counterparts. Barriers to timely access to healthcare services further exacerbate these inequities. Some studies link racialisation to surgical disparities and subpar surgical outcomes. However, the findings are diverse, and there is no synthesis of the evidence on disparities in surgical care for ACB patients in high-income countries with universal healthcare systems. The objective of the scoping review is to systematically describe, characterise and map the existing literature on disparities in the access to and quality of surgical care among ACB patients in high-income countries with universal healthcare systems, and to identify gaps in the literature on surgical access and quality of surgical care in ACB patients.
The scoping review will follow the Joanna Briggs Institute methodology and report according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. The search strategy will be customised for each database (MEDLINE, Embase, CINAHL, APA PsycINFO and Cochrane Library) using terms for ACB and surgery. Grey literature and references from included studies will be searched for additional sources, with no limitations on publication date or language. All study designs will be eligible. Two independent reviewers will screen titles, abstracts and full texts in duplicate for eligibility. One reviewer will chart data, with a second reviewer validating the data charted. The findings will be synthesised, quantitatively summarised using descriptive statistics and qualitatively analysed through thematic analysis.
Ethics approval is not required as the study utilises published data. The dissemination of the findings will inform future research and improve understanding of the surgical care experiences of ACB patients. Dissemination will target academics and healthcare professionals through publications, presentations and workshops.
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Healthcare disparities refer to differences in the quality of care received by equity-deserving groups who should have equal access to care and comparable treatment preferences or needs.1 African, Caribbean and Black (ACB) patients experience significant disparities in health outcomes, with higher rates of chronic diseases including heart disease and stroke, coupled with lower self-reported health status compared with their White counterparts.2 Moreover, systemic anti-Black racism has been shown to disproportionately worsen health outcomes for ACB populations even when compared with other racial minority groups.3 For example, Black women experience higher rates of fetal and perinatal losses and infant mortality compared with other racial groups.4 These disparities extend into surgical care, as some studies have linked minority status with surgical disparities (SD) and subpar surgical outcomes.5 Black individuals compared with White or Asian individuals have a lower likelihood of being recommended surgery.6 A Canadian study found that ACB patients are significantly less likely to receive kidney transplantation or living donor kidney transplantation compared with White patients.7
Structural racism in healthcare systems plays a significant role in perpetuating access and quality disparities, emphasising the need for interventions that directly address these systemic inequities.5 These inequities are observed across high-income countries with universal healthcare systems, including Canada, the United Kingdom and Australia. In Canada, ACB communities, shaped by both immigration and historical racial inequalities, face significant barriers to quality healthcare.8 9 In countries like the UK and Australia, ACB populations, often first- or second-generation immigrants, experience marginalisation in healthcare access, exacerbated by racial and ethnic disparities.10 11 These geographic and historical factors make it essential to evaluate ACB healthcare outcomes across these diverse regions, as the disparities are influenced not only by healthcare system structures but also by entrenched societal inequalities.
The National Academy of Medicine (NAM) defines quality care as care that is safe, timely, effective, efficient, equitable and patient-centred.12–14 Applying Donabedian’s structure-process-outcome framework,15 surgical quality can be operationalised by evaluating three key domains. First, structural quality reflects the adequacy of resources, including equipment, staffing levels and facility infrastructure, available to support surgical care. Second, process quality assesses adherence to evidence-based guidelines and protocols in surgical procedures and patient management. Finally, outcome quality is measured by analysing patient health status postsurgery, specifically monitoring metrics such as complication rates, mortality, length of stay and associated healthcare expenditure.15 16 High-quality surgical care is thus demonstrated when sufficient resources support guideline-adherent processes, leading to favourable patient outcomes.17 However, the NAM identified deficiencies in the healthcare systems’ ability to provide safe, effective and patient-centred care, revealing a ‘quality chasm’.13 The pressures placed on healthcare professionals—busy wards, high patient load and patient acuity—can result in mistakes that compromise patient safety.18 These challenges not only affect the quality of care provided but also intersect with broader issues of surgical accessibility. Access to surgery is defined as the timely utilisation of surgical services, leading to optimal health outcomes, free from excessive burdens. This is measured by evaluating if the right patient gains entry at the appropriate initial access point and receives the correct workup and treatment from the right surgical team, in the right setting, at the right time.19 Access to surgical care encompasses the timely availability of necessary surgical services, influenced by geographic proximity, insurance status and ability to receive interventions without delays.5 Achievement of access is evaluated by assessing health outcomes and service utilisation, ensuring that differences are not due to socioeconomic factors.20 Long wait times, particularly for specialised surgeries such as orthopaedic, plastic and neurosurgery, contribute to poorer health outcomes and increased healthcare expenses.21
While these systemic issues affect all patients, understanding their impact on specific populations is crucial for improving overall healthcare quality. However, addressing the ‘quality chasm’ is complicated by researchers aggregating all non-White minorities into a singular category to compare against White individuals.22 While racial and ethnic disparities in surgical outcomes have been well-documented in the USA—with Black populations often reported as a distinct category—this level of disaggregation is not consistent across all studies and countries. In many studies globally, race and ethnicity data are either not collected or are grouped under broad categories like ‘ethnic minority’ or Black, Asian and Minority Ethnic, limiting the ability to identify outcomes specific to ACB populations.23 Aggregating data often perpetuates the misconception that disparities arise from biological or genetic differences, rather than the effects of structural racism and inequities embedded in healthcare systems.24 For example, systematic reviews have shown that non-White populations are often excluded or underrepresented in health research and clinical trials, including cardiovascular and vaccine studies.25 This has resulted in limited evidence on health outcomes among distinct racial groups, such as ACB communities. This lack of differentiation is problematic for ACB populations, whose distinct challenges and outcomes in accessing and receiving quality surgical care are obscured when data is lumped together and compared with White populations.26
In light of these issues, there is a need to understand the specific experiences and outcomes of ACB populations in accessing and receiving high-quality surgical care.27 28 Whether similar trends shaping disparities in surgical outcomes, for any type of surgical procedure, exist across high-income countries with universal healthcare is unknown. Given the lack of reviews on this topic, synthesising existing evidence is essential to identify barriers and facilitators that will ultimately improve knowledge about surgical access and quality for ACB populations. A preliminary search was conducted in PROSPERO, Open Science Framework, MEDLINE and the Cochrane Database of Systematic Reviews, revealing that no current or in-progress systematic reviews or scoping reviews on this topic exist. Evidence is needed to understand the gaps in SD and facilitators to improve care and health outcomes.
The objectives of this study are to:
Scoping review methodology has been selected because the objective of this study is to identify, characterise and map the literature.29 This methodology is valued for its systematic and rigorous approach to mapping the literature and identifying gaps,30 especially in the context of ACB patients’ access to and quality of surgical care. The scoping review will follow the Joanna Briggs Institute methodology31 and will be reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews.32
To the authors’ knowledge, there are no validated search strategies for the ACB population. However, prior systematic and scoping reviews serve as a valuable starting point for shaping our approach. For instance, Cénat et al examined cancer disparities among Black individuals in Canada,33 Pedersen et al reviewed perceptions of prostate cancer in Black African and Black Caribbean men34 and Alloh et al explored diabetes management in Black African immigrants compared with other populations.35 These studies will guide the search strategy for the population (ACB) search terms.
The search strategy will be developed in consultation with a research librarian (DL), with expertise in scoping reviews and the research team. An initial search was conducted in July 2024, and an updated search will be performed at the end of April 2025 to include additional terms related to trauma care and anaesthesia. Data extraction, analysis and synthesis are planned for completion by August 2025. The search terms and relevant synonyms related to the population of interest (ACB patients) and the exposure of interest (surgical care) will be used to identify sources of evidence using titles, abstracts and subject headings. Surgery terms will be developed and mapped against the essential and emergency surgery taxonomies outlined in the Disease Control Priorities report.36 Search terms will include keywords and structured language (eg, MeSH within MEDLINE) tailored for each database which includes MEDLINE, Embase, Cochrane Library, CINAHL and APA PsycINFO (table 1). To structure the search strategy, the Boolean operator ‘AND’ will be used to connect different concepts; ‘OR’ will be used to combine multiple terms within each concept. To minimise publication bias, grey literature sources will be searched, including reports produced by national and international organisations responsible for guiding the care of surgical patients and conference proceedings (eg, OpenGrey, WHO, Web of Science and OECD websites). Google Scholar and preprint servers, including medRxiv and SSRN, will also be searched for relevant sources. References of included studies will be searched to identify additional evidence sources.
Table 1
MEDLINE draft search terms
Studies will be included if they describe or explore outcomes related to access to or quality of surgical care, and related synonyms, for ACB patients in high-income countries with universal healthcare. The search strategy will be designed to capture publications from all countries; however, for the purpose of this review, only high-income countries with universal healthcare systems, as defined by the Fraser Institute’s 2021 report, will be included. These countries include Australia, Austria, Belgium, Canada, Czech Republic, Denmark, Finland, France, Germany, Greece, Iceland, Ireland, Israel, Italy, Japan, Korea, Latvia, Lithuania, Luxembourg, Netherlands, New Zealand, Norway, Portugal, Slovenia, Spain, Sweden, Switzerland and the United Kingdom.37 While the USA does not meet the eligibility criteria due to the absence of a universal healthcare system, its publications will be included in the title and abstract screening phase. These publications will then be excluded during the full-text review under a separate exclusion criterion. This approach will allow us to track and compare publication volumes from the USA with other countries in the final analysis. To be as inclusive as possible, the study will include any type of surgery. Surgical outcomes may include but are not limited to surgical wait times, length of hospital stay, operative and/or postoperative complications, readmission and cost. Additionally, studies that describe factors related to the healthcare system, socio-cultural factors and patient-related factors will be eligible. All study designs are eligible, including qualitative, quantitative and mixed-methods studies, reports and policy documents. Reviews (systematic, scoping, narrative) will be eligible, but primary evidence sources will be prioritised; the studies included in the reviews will be included if they meet eligibility criteria and the reviews will be excluded because of duplicate data. Conference abstracts, commentaries and editorials will be excluded. No restrictions will be placed on the year or language of publication. Searches on preprint servers will be limited to the past 5 years, and for Google Scholar, only the first 20 pages of results will be screened.
Covidence, a web-based software,38 will be used to organise and manage screening for eligibility. First, all duplicated studies will be removed. Then, two independent reviewers will screen titles, abstracts and full-text manuscripts in duplicate for eligibility. To ensure reliability between reviewers, a training process for screening will take place before screening commences at each stage; a subset of evidence sources (approximately 20 for title and abstract screening and 10 for full-text screening) will be reviewed by all reviewers.39 The selection process will include meetings at the beginning, midpoint and end to address any challenges or uncertainties related to study selection. These discussions will allow for the clarification and discussion of uncertainties and ensure the relevance of abstracts for full-text review. Following these meetings, two reviewers will independently assess the full-text articles for eligibility.40 If disagreements cannot be reconciled between the two reviewers, a third reviewer will be consulted to make the final decision on eligibility.40
The SD and the PROGRESS-Plus frameworks will be used to guide the data charting form. The SD framework identifies five critical domains to understanding surgical care inequities across patient trajectories: patient factors, provider factors, system and access issues, clinical care and quality and postoperative care and rehabilitation.5 These themes collectively examine how demographic characteristics, socioeconomic status, implicit provider biases, institutional policies and postoperative support contribute to SD experienced by minority populations.5 The PROGRESS-Plus framework is used in systematic and scoping reviews to identify characteristics that influence health opportunities and outcomes.41 It includes eight core domains—place of residence, race/ethnicity/culture/language, occupation, gender/sex, religion, education, socioeconomic status (SES) and social capital—along with additional ‘plus’ factors such as personal characteristics (e.g., age, disability), relational features (e.g., family dynamics) and time-dependent disadvantages (e.g., transitions in care).41
A standardised data charting form, informed by the SD and PROGRESS-Plus frameworks, will be developed by the research team. To develop the data charting form, a preliminary form that reflects the objectives of the study will be developed, then refined based on the included studies (table 2). The data abstracted will include bibliographic data, study data (country and setting, study aims and objectives, study design, patient population, eligibility criteria and surgery) and outcomes (wait times, mortality rates and length of stay), as detailed in table 2 and online supplemental file X. For study outcomes, details about the outcome measurement and the estimates for each outcome stratified by ACB group and comparator groups will be extracted. Two independent trained reviewers will conduct pilot testing of the form using a subset of data sources meeting eligibility criteria (approximately five).40 Based on pilot testing outcomes, the standardised form will be refined iteratively until the authors are content with its ability to capture applicable data.42 One reviewer will abstract data from the included studies, with a second reviewer validating the data abstracted. Any disagreements will be resolved between the reviewers, with a third reviewer consulted if necessary.
Table 2
Data abstraction framework
Study characteristics, including study design, study location, sample size, mixed sample or not and outcomes measured, will be synthesised using descriptive statistics. Quantitative data will be synthesised using descriptive statistics and narratively,43 including proportions (percentages), means (SD) and medians (IQR) will be used to summarise data. Differences in outcomes between ACB and comparison groups will be classified into broad categories: 'increase,' 'decrease' or 'no difference,' ensuring systematic and transparent data organisation across diverse study designs. Qualitative data will be synthesised using a thematic synthesis approach in line with Thomas and Harden’s three-stage methodology.44 The research team will map the evidence to various stages of the surgical care continuum (preoperative, perioperative and postoperative) to offer insights into the specific points in the surgical care continuum where the ACB population experiences disparities. Stata 18 will be used to synthesise quantitative data,45 and NVivo 12 will be used to synthesise qualitative data.
A patient partner will be recruited to participate in all stages of the project as a reviewer, analyst, interpreting findings, cowriting the manuscript and disseminating findings. Their role will also involve guiding and informing the team, particularly in dissemination strategies and other pertinent areas such as offering their expertise from lived experience as an ACB patient.
Research indicates that racial minority patients, compared with their White counterparts, encounter reduced access to care, lower satisfaction rates, fewer medically necessary treatments and procedures and delays in follow-up care.46–49 Furthermore, socioeconomically disadvantaged and rural populations encounter lower-quality hospital-based care. This includes receiving fewer minimally invasive surgeries when clinically indicated and facing restricted access to high-volume hospitals.50 51 SD manifest at various points along a patient’s healthcare journey; they could include disparities in preoperative access to surgical care, intraoperative quality of care and postoperative outcomes.52 Racial and social disparities persist,53 54 and ACB populations face disproportionate challenges across various socioeconomic indicators.55–58 These disparities are rooted in systemic factors, such as racism, colonialism and segregation, exacerbating ACB people’s vulnerability to poor health outcomes and limited access to essential services.8 9
Improving our understanding about barriers and facilitators ACB populations face to high-quality surgical care is crucial for improving surgical outcomes. The findings of the scoping review will shape new research directions aimed at developing strategies to alleviate barriers and enhance facilitators to high-quality surgical care within ACB communities in high-income countries with universal healthcare. These insights are intended to equip interested parties—such as policymakers, healthcare providers and community advocates—with the knowledge needed to make informed decisions and craft evidence-based strategies specifically tailored to address the unique needs of ACB surgical patients. Ultimately, by amplifying the voices of marginalised communities and advocating for equitable healthcare access, this inquiry contributes to the broader goal of achieving healthcare equity and improving the well-being of ACB populations.
There are some limitations that should be considered. First, while the search strategy will be designed to prioritise sensitivity over specificity to ensure broad coverage of the literature, it is possible that some relevant studies may not be captured. To mitigate this, we will include grey literature, such as MedArchives, and conduct hand-searching of included references. Second, due to the heterogeneity between study designs, synthesising the evidence may be challenging; however, synthesising estimates (meta-analysis) is beyond the scope of a scoping review. This study is a crucial first step in understanding the range of existing study designs and could inform future research focused on synthesising the evidence. Finally, variability in healthcare systems and differences in how surgical access and outcomes are reported across high-income countries with universal healthcare may pose challenges in comparing and interpreting findings across studies. Despite this limitation, capturing data from a diverse range of countries also serves as a strength as it broadens the scope of the review.
The objective of this scoping review is to synthesise and map existing evidence, requiring no direct interaction with human participants and thus exempt from ethics approval. The primary objectives of dissemination in this study are twofold: first, to inform future research endeavours and priorities pertinent to the surgical care experiences of ACB patients and, secondly, to enhance knowledge and understanding surrounding the unique needs and challenges faced by individuals within this demographic group. The dissemination efforts will target three key interested parties: academics and researchers working in surgical care and/or healthcare equity and healthcare professionals and service providers involved in delivering surgical services. Dissemination strategies include peer-reviewed publication, conference presentations, plain language summarises/reports and infographics.
Not applicable.
