"I Think It's Institutional Racism:" Pediatric Social Workers' Explanations of Racial Disparities in Kidney Transplant Access for Black Children in the United States.

BACKGROUND

Black children in the US with ESKD experience higher mortality, lower transplant rates, and longer time on dialysis than other children. Prior research on health disparities in adult kidney patients often emphasizes patient-level psychosocial factors, yet little is known about how providers understand these inequities for children. This study explored pediatric dialysis and transplant social workers' explanations for racial disparities affecting US black children in kidney transplant access.

METHODS

Semi-structured interviews were conducted with 16 pediatric dialysis and transplant social workers from across the US. Participants were recruited through professional listservs and direct outreach to pediatric nephrology programs. Interview transcripts were analyzed using thematic analysis informed by ecological systems theory.

RESULTS

Four primary themes emerged: lack of resources, family composition, distrust, and systemic racism. The barriers to transplant that black children face are not limited to the patient-level microsystem as previously described in the literature but rather persist across all ecological system layers. Social workers identified microsystem level barriers as having mesosystem level impact when provider bias leads to judgment about transplant readiness. Social workers named systemic racism as a barrier that transcends all levels of the ecological system, from microaggressions to provider bias to race "corrections" in clinical algorithms to white supremacy to the legacy of slavery.

CONCLUSIONS

Findings suggest that transplant evaluation processes may reinforce structural racism. Unlike prior studies emphasizing patient-level explanations, participants identified healthcare systems as key contributors to inequity. Further research should seek the voices of black patients and identify interventions to improve equity.