1 INTRODUCTION

There is an urgent need for nursing to advance the study of discrimination and health to remedy systematic health inequalities (Krieger, 2012, 2020). Despite a growing interest in studying institutional discrimination and health by nurse researchers (Iheduru-Anderson et al., 2021), most inquiry focuses on interpersonal discrimination, or unequal treatment behaviors (Thurman et al., 2019). Institutional discrimination can appear so normalized that it is almost invisible although the effects are not. Such discrimination occurs in various forms such as institutional procedural discrimination or institutional racism. Studies are needed to explore institutional discrimination as a determinant of population health with an emphasis on the procedures, policies, and rules that create unequal systems and outcomes (Williams et al., 2019). Although efforts have been made to study and quantify institutional racism and its associations with physical and mental health outcomes (Groos et al., 2018), more nursing research is warranted. The need is to understand the various types of institutional discrimination from the point of views of those experiencing such discrimination.

This article focuses on an aspect of a larger longitudinal community-based participatory research (CBPR) study. This study examines institutional procedural discrimination, institutional racism, and other institutional discrimination, and their relationships with participants' health during a maternal and child health program in a municipal initiative (hereafter called the “Initiative”). The aims are to (1) describe 7-month changes in experiences of institutional procedural discrimination; (2) compare the health of participants between participants who experienced those types of institutional discrimination and those participants who did not; and (3) describe institutional racism and other institutional discrimination as reported by multicultural and multilingual participants in the Initiative.

To our knowledge, this is one of the first empirical studies in nursing that examines institutional procedural discrimination, institutional racism, and other institutional discrimination simultaneously. In the text below we briefly review the literature on institutional discrimination with definitions. We provide a background to the study in the context of the CBPR inquiry and summarize the results. We discuss these results and their implications for innovating nursing research.

1.1 Literature review

The research team searched the Cumulative Index of Nursing and Allied Health Literature (CINAHL) database to obtain current article abstracts published in academic journals between January 2017 and June 2021. English language abstracts were retrieved if the following search terms were in both the title and article abstract: structural racism (n = 58), institutional racism (n = 11), institutional discrimination (n = 5), structural discrimination (n = 3), or institutional procedural discrimination (n = 0). Of the abstracts found, specific articles focusing on nursing and defining or measuring the aforementioned terms were retrieved.

Most article abstracts were reviews, opinions, calls to action, commentaries, or conceptual articles. No articles were found with the search term of institutional procedural discrimination. Nurses from various specialties offered insights on structural racism. These specialties included public health (de Valpine & Lewis, 2021; Waite & Nardi, 2019), perinatal and neonatal (Scott et al., 2019), geriatric (Medina-Walpole, 2021), and academic nursing (Murray & Loyd, 2020; Nardi et al., 2020). Addressing bias in institutions was highlighted as an area of importance, especially institutional racism (Agyepong, 2021; Santos Ferreira et al., 2020; Thurman et al., 2019).

Few researchers completed data-based research. As an example of such, Randolph et al. (2020) described historical distrust of health services as a finding. Bower et al. (2020) identified perceptions of systems that perpetuated biased maternal health services, such as retail, justice, and school systems. More studies are needed that explore the actual health impacts of types of institutionalized discrimination, such as institutional procedural discrimination, institutional racism, and other institutional discrimination.

Two nurse-led research teams conducted systematic literature reviews. Thurman et al. (2019) found that researchers mostly focused on interpersonal experiences of discrimination and racism. They noted a lack of consistency in defining institutional racism. Nardi et al. (2020) also observed this and applied an ecological model of overlapping systems and suggested that institutional racism operates through organized “practices and policies” (p. 697).

After finding no article abstracts about institutional procedural discrimination in CINAHL, additional searches were conducted using social work, public health, and law databases. In the field of law, institutional procedural discrimination is based on procedural justice theory (Tyler, 1988), that suggests “that one's satisfaction with legal or clinical interactions is primarily influenced by the quality of the procedural experience rather than the outcome of the interaction” (Kopelovich et al., 2013, p. 114). Institutional procedural discrimination operates in organizational policies and practices, such as in the ways decisions are made. Institutional procedural discrimination focuses on institutional agreements concerning the types of decisions, timing of discussions, conditions, and deadlines to privilege one group over another in the process. The institutional procedural experience is shaped by the visible and invisible norms, rules, customs, and power relations embedded in how organizational policies are decided and administered. Institutional procedures can result in selecting, crediting, and awarding the time orientation, language, thinking processes, and value systems of the group in power in making these decisions (Kopelovich et al., 2013 & Tyler, 1988).

Institutional conditions create and sustain the policies and practices that constitute institutional racism. Williams et al. (2019) noted that institutional discriminatory practices and processes depend on groups within institutions creating and reinforcing discriminatory practices as norms. Institutional racism changes the institutional arrangements to limit the resources and services to those in the minority, and confer hidden privileges to majority members (Williams, 2018). Examples of resources might be funds or the time to complete work. Examples of services might be providing non-Western services and multilingual resources. Organizational practices can create hidden pathways for sustaining institutional racism or other types of discrimination beyond individual racial bias.

Other types of institutional discrimination may include ageism, ableism, religious intolerance, language bias, cultural xenophobia, colonialism, and Western domination of ideas and ways of being (Sundstrom & Kim, 2014; Waite & Nardi, 2019). That is, other institutional discrimination can be viewed as organizational-level discrimination embedded in institutional ways of being and institutional guidelines. Those ways of being and guidelines are based upon language, country of origin, culture, relationship-based working, gender, income, ability, thinking styles, and religion that privilege some groups over others.

Institutional procedural discrimination, institutional racism, and other institutional discrimination are separate, yet related concepts. The focus on institutional discrimination is different from a focus on discrimination as those individual actions of unequal treatment, exclusion, and marginalization (Williams, 2018). Scholars have called for a shift in focus from examining self-reported individual and discriminatory bias towards the interrogation of institutional norms (Groos et al., 2018; Williams, 2018). The overall purpose of this longitudinal CBPR was to examine three types of institutional discrimination and their relationship with health. The next section defines the types of institutional discrimination.

1.2 Definitions 1.2.1 Institutional procedural discrimination

Institutional procedural discrimination as rooted in procedural justice theory (Kopelovich et al., 2013) is defined as the institutional agreements about the types of decisions, timing of discussions, conditions, and deadlines to privilege one group over another in institutional processes.

1.2.2 Institutional racism

Institutional racism, within organizations in the United States, involves policies, practices, and procedures which privilege majority White racial groups (Carmichael & Hamilton, 1967; Dennis et al., 2021; Gee & Hicken, 2021). Thus, institutional racism is defined as the existence of systematic policies, laws, and practices that provide differential access to goods, services, and opportunities because of socially constructed racial identity.

1.2.3 Other institutional discrimination

Other institutional discrimination is defined as the other types of institutional policies and practices that impact differently or harm non-dominant groups based on language, country of origin, culture, relationship-based working, gender, income, ability, thinking style, and religion, resulting in differential access to goods, services, and opportunities (Sundstrom & Kim, 2014; Waite & Nardi, 2019).

2 METHODS 2.1 Study design and sample

This longitudinal CBPR study (Holkup et al., 2004; Vaughn et al., 2017) used a triangulated mixed-method design (Halcomb & Hickman, 2015). The researchers were funded to examine the impact of the Initiative's public health program on developing home-based programs. The study sample included 20 participants from nine community-based organizations (CBOs), with 1–3 participants from each CBO. The inclusion criteria were: (1) involvement in developing a home-based program in participating CBOs; (2) completing workshops, focus groups, self-report surveys, or follow-up individual interviews; and (3) willingness to permit information used in research. There were no exclusion criteria. A power analysis indicated 63.0% power (Cohen's d = 0.5) to detect a pre- and postdifference between April 2019 (n = 17) and November 2019 (n = 17) survey data. Some scholars suggest that acceptable power should be 80% or greater (Cohen, 2013), thus this study indicates fair or moderate power.

2.2 Overview of the program in the municipal public health initiative

The Initiative's program was to develop and implement home-based programs to promote healthier, more resilient families with children aged 0–5 years living in a Northwestern United States municipality. Home-based programs involving culturally congruent home visits are effective in providing support to families (Liu et al., 2019; Olds et al., 2014). The Initiative utilized the National Implementation Research Network (NIRN) model as an implementation science model (National Implementation Research Network, 2021), and funded NIRN consultants to teach this model to capacity building providers (CBPs). The NIRN model includes three components: (1) well-defined programs, (2) effective implementation, and (3) supportive environments to create improved outcomes. CBPs also focused on equity practices in their work with CBOs. The Initiative assigned CBP teams to address these three components: (1) a Well-Defined Program team; (2) a data support team together with an organizational capacity building team for the effective implementation component; and (3) a Supportive Environment team.

2.2.1 Monthly workshops

Phase I of the Initiative's program focused on developing the Well-Defined Home-Based Programs in 6 months (December 2018–May 2019). The Well-Defined Program CBP team provided six monthly workshops for participants to (1) create the racial equity theory of change; (2) adapt the NIRN practice profile for cultural responsiveness; (3) engage community stakeholders; (4) develop an implementation plan; (5) identify components of 2-year budget; and (6) mobilize a CBO-based design team to apply equity practices in their programs. The CBP team delivered workshop topics in English and presented topics in easily understandable ways for participant comprehension. CBO grantees were required to have at least two lead representatives who attended all capacity-building activities including monthly workshops. Biweekly meetings were held between the funding staff, CBP team, and a researcher. One author attended all workshops and wrote minutes. Phase II focused on home-based program implementation (started between June/July 2019 and November 2019). This study examined institutional procedural discrimination, institutional racism, and other institutional discrimination during Phase I and the beginning of Phase II.

2.3 Study process, protocol, and data collection

A university institutional review board approved the study and participants' informed consent was obtained. Research consent forms were originally developed in English and then translated into Arabic, Spanish, and Somali to help participants read consent information in the commonly identified languages of participants. Researchers explained the study using the consent forms, answered questions, and invited participation in March 2019. Seventeen participants from nine CBO's consented in March 2019; three participants were recruited before November 2019. Participants chose to sign the consent forms using the English language version. Given that this study was a part of a funded public health program, persons were offered $50 for each individual interview, focus group, survey, or survey session for program information regardless of their participation in research. This recognized participants' expertize and time. No in-person translators were provided during interviews, focus groups, or surveys because participants expressed confidence in listening (4.06 ± 0.90) and speaking (3.82 ± 0.8) in English. Also, no one requested in-person translation.

Researchers developed surveys by engaging participants for a 30-min to 1-hr interview to learn about their capacity-building experiences. Interviews with participants improved survey questions because keywords and phrases were offered for survey construction. This was done after researchers reviewed existing surveys for format and content. Surveys were first developed in English and translated into Arabic and Spanish by professional translators. The cross-cultural equivalence of the Arabic survey was checked by a second professional translator, and then pilot tested using cognitive interviewing techniques (DeMuro et al., 2012; Howlett et al., 2018) with a bilingual person. The cross-cultural equivalences of the Spanish and English surveys were checked by bilingual participants using cognitive interviewing techniques (DeMuro et al., 2012; Howlett et al., 2018). When asked, no one requested a Somali survey translation.

Surveys were in paper and online formats. Paper survey copies were completed during focus groups in April and November 2019 or by mail. Online surveys were also available via REDCap (Harris et al., 2009). Researchers were present at the April and November group sessions to answer survey questions. The surveys included both close-ended and open-ended questions as a result of participants' input. Participants asked for open comment boxes next to quantitative answers. Participants also added questions about institutional racism because some had observed that interpersonal racism would not sufficiently measure equity. Participants wanted their suggestions for program improvement to be heard.

2.4 Study instruments 2.4.1 Demographics

Participants described their personal life, educational, and work conditions such as length of time working at their CBO in months. They also provided the number of years they had been working with diverse communities and the number of other Initiative grants obtained by their CBO. Regarding anticipated grant work, participants answered how many months they believed it would take for them to develop a meaningful program and how many months were needed for the meaningful modification. They rated their confidence on a 5-point Likert scale about some of the technical skills required for grant participation such as listening and speaking in meetings, reading materials, completing written deliverables, and other assignments. They reported how many workshops they attended and how much additional time they spent doing the Initiative's program work “on top of” regular paid or volunteer work.

2.4.2 Institutional procedural discrimination

The research team applied CBPR processes (Holkup et al., 2004; Vaughn et al., 2017) to develop the institutional procedural discrimination survey. Researchers discussed with participants how the Initiative's program could help them and how well they understood the expected work. During these conversations, participants described being discriminated against. Researchers used this information to develop the institutional procedural discrimination survey. The first four survey items of the institutional procedural discrimination survey measured institutional procedural discrimination experiences during home-base program development such as procedures being changed without permission, words on documents being changed without explanation, cultural ways not being respected when they were known, and having meetings and materials based on Western culture. The last eight items of the institutional procedural discrimination survey measured being treated differently due to racial identity, nationality, English as a second language, gender, religious identity, age, sexual orientation, and income (e.g., “I was treated as not as well because of my age while doing this project”). Participants answered each item using “yes” or “no” replies in April and in November 2019.

2.4.3 Patient-Reported Outcomes Measurement Information Systems-10

The Patient-Reported Outcomes Measurement Information Systems-10 (PROMIS-10) global health survey included self-rated health items (Abma et al., 2021; Hays et al., 2009). The four-item global physical health portion of the PROMIS-10 global health survey measured physical health, physical functioning, pain intensity, and fatigue. The four-item global mental health portion of the PROMIS-10 global health survey measured overall quality of life, mental health, satisfaction with social activities and relationships, and emotional problems. PROMIS-10 also included items on general health and social roles. The question about general health was, “In general, would you say your health is…” The question about social roles was, “In general, please rate how well you carry out your usual social activities and roles.” Participants answered items using a 5-point Likert Scale ranging from poor (1) to very good (5) in April and in November 2019. Mean scores were used, and higher scores indicated better health. Cronbach's α values were 0.45 for global physical health and 0.61 for global mental health for the current study. Cronbach's α of less than 0.50 can be interpreted as poor, ∼0.60 as fair, ∼0.70 as moderate, and 0.80–0.90 as strong (Panayides, 2013). This means that global physical health had a low degree of internal consistency and global mental health had a fairly acceptable degree of internal consistency (Field, 2009; Tavakol & Dennick, 2011) for this study.

2.4.4 Initiative-related health

The research team co-developed the Initiative Program Related Health survey with participants to describe participants' perceptions about how their health was impacted through to November 2019. The 4-item survey measured the impact on participants' quality of life, physical health, mental health, and satisfaction. Participants answered each item using a 5-point Likert Scale ranging from not at all (1) to very much (5). Mean scores were used, and higher scores indicated more impact. Cronbach's α was 0.72 for the current study meaning that this was a moderate degree of internal consistency (Tavakol & Dennick, 2011). Two open-ended questions were added in November 2019 because researchers received comments from participants that the Initiative's program was impacting their health. The research team asked, if you want to share, please provide us an example of how this project impacted your health positively? And if you want to share, please provide us an example of how this project impacted your health negatively?

2.4.5 Institutional racism and overall institutional discrimination

In November 2019, questions were added about institutional racism and other institutional discrimination because study participants told researchers that they were experiencing those types of discrimination. Institutional racism was measured with the question, “Did you experience institutional racism (the existence of systematic policies or laws and practices that provide differential access to goods, services, and opportunities of society by race) during the capacity-building process?” Other institutional discrimination was measured with the question, “Did you experience any other institutional discrimination (language, country of origin, culture, relationship-based working, gender, income, ability, thinking style, religion) during the capacity-building process?” Possible responses for both questions were “yes”, “no”, “not sure”, or no answer. Respondents also wrote their comments.

2.5 Data analysis

The data were analyzed using IBM SPSS (Version 25). Data entry was verified by two research team members independently and then selectively checked by a third team member. To describe participants, descriptive statistics were used, including means, standard deviations, frequencies, and percentages.

The first aim, describing 7-month changes in experiences of institutional procedural discrimination, was analyzed by dichotomizing participants' responses into two groups, “yes” and “no.” Then, the number of “yes” responses from the institutional procedural discrimination survey were calculated for the first four individual items in April and in November 2019, separately. To maintain confidentiality, responses were aggregated for the 8-items that asked about discrimination according to identity. A Wilcoxon signed-rank test was then used to analyze total “yes” responses in April 2019 and the total “yes” responses in November 2019 with a significance set at p = 0.05.

The second aim, comparing the health of participants between those who experienced types of institutional discrimination and those who did not, was analyzed by comparing participants' health according to “yes” and “no” responses about institutional procedural discrimination, institutional racism, and other institutional discrimination. Means and standard deviations of global physical health, global mental health, overall health, social roles, and Initiative program-related health items were calculated for each group. Similar data analysis was conducted for institutional racism and other institutional discrimination, using “yes” and “no” responses. Participants' open-ended responses to the positive and negative impacts of the Initiative's program on their health were also analyzed using inductive content analysis (Prior, 2020).

For the third aim, describing participants' experiences of institutional racism and other institutional discrimination, responses were analyzed using inductive content analysis (Prior, 2020) and by matching “yes” or “no” answers with participants' written comments. Three research team members: (1) identified units of analysis; (2) reviewed the data as a whole; (3) coded comments by categories; (4) grouped comments; and (5) finalized groups and selected exemplar quotes.

3 RESULTS 3.1 Demographics

Participants completed surveys as they felt comfortable. Seventeen out of twenty participants provided demographics including six directors, seven full-time staff, and four part-time staff and volunteers (Table 1). Overall, participants were well educated and experienced in multicultural, multilingual work. Most had graduate school education (52.9%, n = 9), or had some college, technical school, or graduated college (41.2%, n = 7). Nine spoke at least two languages. Sixteen participants had worked at the CBO for about 5 years and seventeen had worked with diverse communities for about 14 years. When asked about their confidence in fulfilling the technical skills required for grant participation, 17 participants were easily (4) or neutrally (3) able to listen (4.06 ± 0.90) and speak (3.82 ± 0.81) at the workshops, write assignments (3.53 ± 0.94), and read the materials (3.29 ± 1.05). Twelve said they were involved with an average of 4.25 different Initiative grants. Overall, participants spent an average of 18.85 ± 11.26 h (range: 4.67–37.50) completing homework (outside of normal reimbursed hours) necessary for contract deliverables after the monthly workshops. Two out of seventeen identified as White only, others were from diverse immigrant, racial or cultural backgrounds. There were significant correlations between: (1) length of time working at the CBO in months and time spent doing homework after the monthly workshops (r = 0.72, p < 0.05); (2) years working with diverse communities, and number of Initiative grants (r = −0.74, p < 0.01); and (3) years working with diverse communities and time spent doing homework after the monthly workshops (r = 0.70, p < 0.05).

Table 1. Demographics of participants from community-based organizations (n = 17) Characteristics n % Roles Director 6 35.3 Staff (full time) 7 41.2 Staff & volunteer (part-time) 4 23.5 Highest level of schooling Some college, technical school, or graduated college 7 41.2 Graduate school and beyond 9 52.9 No answer 1 5.9 Have you developed a program before? No 4 23.4 Yes 11 64.8 No answer 2 11.8 Birthplace United States 8 47.1 Outside of the United States 9 52.9 Social groups White 2 11.8 Immigrants, Black, Indigenous, Latinx, Asian, or People of Color 15 88.2 In general, would you say you (and your family living with you) have more money than you need, just enough for your needs, or not enough to meet your needs? More money than you need 3 17.6 Just enough for your needs 11 64.8 Not enough money for needs 3 17.6 Perceived net finances. How much money would you have left over if you turned all your assets (jewelry, car, house, etc.) into cash and paid off your bills? Be in serious debt 6 35.3 Break even 4 23.5 Have money left over 6 35.3 No answer 1 5.9 Work and initiative characteristics Mean SD Months working at the organization (n = 16) 60.07 56.44 Years working with diverse communities (n = 17) 13.59 10.20 Total number of Initiative grants per CBO (n = 12) 4.25 1.14 How many languages do you speak? (n = 9) 2.11 0.33 Total number of languages spoken by clients of the CBO 28 Different languages Characteristics related to grant work N % Is the work related to capacity building added on top of your regular work that you are doing in the agency? No 1 5.9 Yes 14 82.3 Somewhat 1 5.9 No answer 1 5.9 Did you know you would have four capacity-building providers? No 15 88.2 Yes 1 5.9 No answer 1 5.9 Did you know the grant would have a 6-month Phase I to develop a new program or practice? No 3 17.6 Yes 14 82.4 Characteristics related to time, and ease of information Mean SD Time in months to create a meaningful, new program (n = 10) 9.30 3.97 Time in months to create a meaningful, program modification (n = 7) 5.86 3.67 Ease of information: How easy was it for you to do the following? (n = 17) Read the materials 3.29 1.05 Listen at the workshop 4.06 0.90 Speak at the workshop 3.82 0.81 Write the deliverables/assignments 3.53 0.94 Abbreviation: CBO, community-based organization. 3.2 Institutional procedural discrimination

As depicted in Table 2, the total number of “yes” responses of institutional procedural discrimination from April 2019 to November 2019 decreased from 38 (18.6%) to 24 (11.8%), although it was not statistically significant. Also, the number of participants who reported at least one out of 12 institutional procedural discrimination items in April (88.0%, n = 15) and November (82.0%, n = 14) did not decrease significantly.

Table 2. Changes of “Yes” replies for institutional procedural discrimination (N = 20) Statements Institutional procedural discrimination April 2019 (n = 17) November 2019 (n = 17) Number of total yes replies (% of participants) Number of total yes replies (% of participants) Institutional procedural discrimination total of yes replies 38 (18.6%) 24 (11.8%) I was told things would happen one way and then it changed without my permission to another way 12 (70.6%) 10 (58.8%) All meetings and materials presented were based on Western culture so I had difficulty understanding the worka 8 (47.1%) 11 (64.8%) Words on my documents were changed and I do not know why 2 (11.8%) 2 (11.8%) When my different cultural ways of doing things were shared, the project did not support my way 4 (23.5%)b 0 (0.0%)b I was treated not as well because of… my racial identity, nationality, use of English, gender, religious identity, age, sexual orientation, income/economy, or so forthc 12 (8.8%)d 1 (0.7%)d aAll meetings and materials refer to the workshops using the National Implementation Research Network model from December 2018 to May 2019. bWilcoxon signed-rank test showed a significant difference between April 2019 and November 2019. Z = −2.00, p < 0.05. cParticipants could check multiple items about not being treated as well because of racial identity, nationality, use of English, gender, or other characteristics. Replies are combined for confidentiality. dWilcoxon signed-rank test showed trend of decrease between April 2019 and November 2019. Z = −1.89, p = 0.06.

In April 2019, the most common “yes” reply was for the statement, “I was told things would happen one way and then it changed without my permission to another way” (70.6%, n = 12). In November 2019, the most common “y