Defining the Black population in Canadian health research: a scoping review protocol

Abstract

Introduction

In the context of health research in Canada, various terms and labels have been employed to reference the Black population. This practice has had the unintended consequence of diminishing the comparability and efficiency of studies. Furthermore, using a broad term such as ‘Black’ may fail to encompass the diversity and intricacy of the ethnocultural backgrounds of people who are racialised as such. It may also obscure the subtleties of their experiences and health outcomes. This study aims to examine how health researchers have defined Black within the scope of their work and different labels used to identify the Black population in Canada.

Methods and analysis

We have developed and employed a comprehensive and sensitive search strategy to identify articles concerning the health and wellness of the Black population in Canada. Both peer-reviewed and grey literature will be searched. Original articles published in both English and French will be included. The screening process will consist of two stages: the title and abstract screening, followed by a thorough examination of full-text articles. Additionally, single citation tracking and manual search of reference lists will be conducted. Study characteristics and relevant information on the definition of the Black population will be extracted, followed by reflective thematic analysis and presentation of the key findings.

Ethics and dissemination

This review will not require ethical approval. We will disseminate the results through meetings with stakeholders. From the beginning, a knowledge translation approach was decided upon following consultation with citizen researchers and community champions. Our findings will also be disseminated through oral and poster presentations, peer-reviewed publications, and social media.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• As an inclusive form of knowledge exploration, this scoping review will encompass various pieces of evidence, such as empirical and grey literature; this will enable us to identify key concepts, terminologies/labels and trends in defining the Black population in health research in Canada comprehensively.

• The involvement of citizen researchers has occurred from the brainstorming phase of the scoping review. This participation augments the study’s relevance and validity as they have personal insights and connections with the topic under study.

• This review benefits from having insider authors who understand culture and dynamics and can, therefore, provide interpretative information that is accurate and contextual.

• Focusing on Canada will provide us with a detailed understanding of Black communities within a specific national context, which is crucial given the historical and socio-political nuances unique to Canada.

• Although we will follow the conventional methods for grey literature search, this type of literature is not consistently indexed and catalogued and often lacks standardised report formats. This may lead to potentially incomplete retrieval of relevant documents.

Introduction

Diversity is a hallmark of Canada’s identity, culture and social fabric. The country is established on the ancestral lands of ‘Indigenous Peoples’, which nowadays refers to three distinct people—First Nations, Métis and Inuit, reflecting their tremendous diversity through over 70 Indigenous languages.¹ The history of colonisation and slavery over centuries,^{2 3} and immigration policies that attract people worldwide have drastically changed Canada’s demographics.⁴ According to the latest Canadian census in 2021,⁵ Canada has an impressive array of over 450 distinct ethnic or cultural origins, a statistic determined through self-identification highlighting the significant diversity within its population. This diversity of racial identities and ethnicities has highlighted the importance of race-disaggregated data in the healthcare system for addressing health disparities, particularly in a context extending beyond the COVID-19 pandemic.⁶

There is an evolution in thinking about race and health outcomes. Historically, health research has conceptualised and managed race as a biological determinant of health.⁷ This is now recognised as being both discriminatory and harmful and there is a current emphasis on data collection and analysis of race as a social construct.^{8 9} This new perspective seeks to bridge existing healthcare disparities and ensure fair and equitable access to healthcare services for all.^{10 11} By shedding light on the unique health challenges faced by different groups, policymakers and healthcare practitioners can better tailor interventions and policies to improve health outcomes across diverse populations in Canada.¹¹ An example of a health challenge faced by some groups is anti-Black racism, which is now recognised as a social determinant of health, leading to inequalities in healthcare.¹²

In 2022, the Canadian Institute for Health Information (CIHI) established national standards for collecting race-based and Indigenous identity data in healthcare, aligning with standards developed by Statistics Canada (SC).¹³ At level one, the standards report race in eight categories namely Indigenous, Black, Eastern Asian, Latin America, Middle Eastern, South Asia, Southeast Asian and White. An individual can also select from these other options: ‘Another race category, ‘do not know’ and ‘prefer not to say’.¹³ It is noteworthy that this ‘other race category’ may account for the self-identification of 450 distinct ethnic or cultural origins previously indicated in the SC census.¹³ At level two, examples are provided for various populations falling into the eight categories of SC-CIHI, with three examples proposed for the Black population: African, African Canadian and Afro-Caribbean.¹³ However, it is important to note that the adoption of CIHI standards is optional and the implementation varies across the country.¹³ Additionally, in the context of health equity in Canada, ‘visible minority’ is often used interchangeably with ‘racialised communities’ to broadly categorise non-Caucasian individuals or those with non-white skin, except for Indigenous peoples.⁵ As a result, diverse groups with unique experiences are grouped together under this overarching category.

The ethical use, security and integrity of race data in health research are essential and should be ensured. The feedback obtained from consultations conducted by CIHI highlights the necessity of integrating specific components into the collection and utilisation of race-based and Indigenous identity data within healthcare.¹³ These include establishing protocols for data governance, fostering meaningful engagement with Indigenous and racialised groups and implementing procedures to ensure safe and respectful data collection practices.¹³ Presently, Indigenous data sovereignty principles, such as the Ownership Control Access Possession (OCAP) principles, are applied nationwide.¹⁴ To the best of our knowledge, Ontario is the single province where Black communities have devised the ‘Engagement, Governance, Access, and Protection (EGAP)’ framework for health data collected from Black communities, still terminologies are not addressed in this framework.¹⁵

The ‘Black’ population in Canada is diverse, with many experiences, cultural identities and ethnic backgrounds. From the latest Canada census, people who identify as Black constitute 4.3% of Canada’s total population and 16.1% of the racialised population.⁵ Their presence in Canada can be attributed to historical factors such as slavery, colonisation and migration.¹⁶ This implies that some Black communities have been in Canada for centuries, while others have only recently settled.¹⁷ These significant events have shaped not only the settlement but also the experiences and demographic composition of Black communities,⁵ which are vital to the field of health research. Remarkably, the census methods of Statistics Canada define the Black population to encompass over 300 distinct ethnic or cultural origins along with more than 450 mother tongues.⁵ Furthermore, a notable proportion within this Black population (25.6%) self-reported multiple ethnic or cultural heritages. Among the most reported origins were ‘African (no further clarification)’ (15.7%), ‘Jamaican’ (13.0%), ‘Haitian’ (10.8%) and ‘Canadian’ (5.9%).⁵ This diversity highlights the rich tapestry of ethnic identities within the Black community and underscores the complexities of its heritage.

In Canada, the social organisation of individuals who identify as Black is complex, as they establish communities, collectives or associations based on factors such as country of origin or smaller ethnic and tribal affiliations.18,20 Additionally, common goals, the desire to preserve culture and languages, and shared experiences contribute to the formation of social organisations.²¹ However, the Black communities also have unique historical diverse backgrounds, including descendants of enslaved Africans, Caribbean immigrants and more recent immigrants and refugees from more than 50 African countries.^{1 3} These diversities also unite to address overarching issues of racial equity, social justice and the counteraction of anti-Black racism.²²

From a researcher’s perspective, categorising and organising such a vast array of identities can be challenging, often resulting in the practice of grouping individuals with diverse ethnocultural backgrounds and histories, under broad umbrella terms such as ‘Black’,²³ ‘African’²⁴ or ‘African-Black-Caribbean’.²⁵ However, given the under-representation of Black populations in health and health services research,²⁶ the influence of a simplified and constantly changing approach to Black classification in health research in Canada still needs to be fully understood. Gaining a deeper understanding of Black population classification approaches is crucial for ensuring accurate representation, developing tailored health interventions and services, addressing health disparities and social determinants within and across Black communities and fostering meaningful community engagement and trust. Rather than relying on broad umbrella terms that fail to capture the nuances and diversity of Black identities, a more nuanced understanding of Black identities and classifications can inform culturally responsive research practices, equitable access to healthcare and the development of interventions that better serve the diverse needs of Black communities in Canada.

Cénat, in the concept paper titled ‘Who is Black? The urgency of accurately defining the Black population when conducting health research in Canada,’¹⁷ highlights the inadequacy of commonly used terminologies in health research to describe Black people in Canada. Some of the interchangeable terms they mentioned include ‘Black individuals, people, or communities’, ‘Black Canadians’, ‘African Canadian Caribbean’, ‘Black Africans’, ‘African-Caribbean or African and Caribbean communities’, ‘Black Nova Scotians’ and ‘Black ethnicity’.¹⁷ However, the reasons for selecting specific terms, the level of community engagement behind the development of the terms and the rationale behind the terminology need to be thoroughly explored to offer a more comprehensive understanding through a broader examination. The lack of clarity in the Black population definition can lead to improper extrapolation of the results and hinder our understanding of which subgroups within the Black community face more significant challenges or achieve success. In addition, the delivery of healthcare services will be mismatched since interventions cannot be tailored to people who need support most. By encouraging the accurate definition and identification of distinct groups within the Black population in health research, the goal is not to diminish or contribute to the harms of racism and racialisation. We are also not against the one-Black spirit, that is, a common enduring struggle and fight for racial equality throughout history.²² However, we are raising awareness of health researchers to better address community-specific needs and design interventions to promote health equity and well-being across diverse Black communities. The aim of this scoping review is to identify how the Black population is featured in Canadian health research and why researchers opt to choose different strategies to categorise, label or group together the Black population.

Methods and analysis

Design

The scoping review will be conducted based on a six-stage framework that was initially described by Arksey and O'Malley²⁷ and further modified by Levac et al.²⁸ Those stages are (1) identification of the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data, (5) collating, summarising and reporting results and (6) consultation stage.²⁷ A scoping review was chosen because one of its aims is to showcase the evidence available on a particular concept, specifically when definitions might be ambiguous or contested, helping to establish a clear understanding of terminologies.²⁹

Stage 1: identifying the research questions

The research question is crucial in the process of conducting a scoping review as it guides all subsequent steps. It dictates the scope, focus and direction of the review, ensuring that each stage is aligned with the overarching research inquiry.²⁷ To ensure comprehensive coverage of the topic, research questions are intentionally broad.^{27 28} We held several meetings with our research team and members of the community. During these discussions, we identified inconsistencies in terminologies and recruitment processes for the Black population. As a result, we decided to conduct a literature review to raise awareness among health researchers about this issue. As a result, we came up with this scoping review idea and the corresponding research questions. We identified that the current literature was unclear about who is Black in Canada. We decided to extensively scrutinise the literature to understand better how health researchers define this population in their studies. Thus, the following overlapping questions were generated to guide this scoping review throughout:

1. How do health and wellness researchers in Canada define the Black population?

2. What terminologies and labels do researchers use to identify and categorise the Black population in Canadian health studies?

3. What justifications, if any, are provided for selecting such terminologies or labels to categorise the Black population?

4. What are the processes and mechanisms, if any, used to recruit the Black population and assign specific terminologies to different population groups or categories?

Stage 2: identifying relevant studies

This phase focuses on identifying pertinent studies through a well-defined search strategy.²⁷ It involves selecting relevant search terms, specifying databases to be accessed, setting a time frame and considering language and other parameters.^{27 28}

The search strategy

In order to identify literature on the Black population in Canada, a comprehensive set of search terms was developed. First, we brainstormed an extensive list of relevant keywords and synonyms related to the Black population. These keywords included ‘Black’, ‘African Canadian’, ‘African-born’, ‘Afro-Caribbean’ and ‘Black minority’. The research team, comprised of experts in the subject area, provided input on additional population terms.

The next step was to perform a scoping test on all draft search terms in a large database to refine the terms. The search results were analysed to determine if there were any gaps in the articles found relevant to the topic. Through this iterative process, the search terms were expanded to include phrases like ‘African ancestry’, ‘Caribbean immigrants’ and ‘visible minorities’.

The final list contained over 50 population search terms reflecting the diversity of Black communities in Canada (Box 1). Using this rigorous search term identification process ensured that all relevant literature would be captured in the scoping review. A Boolean operator 'OR' will link each category of keywords, followed by the Boolean operator 'AND' to link all these keywords with the term Canada or Canadian provinces, respectively (Box 1). Our method for identifying additional publications involves reviewing the reference lists of relevant primary papers and reviews using the citation pearl-growing method.³⁰ The research team collaborated closely with a librarian, seeking their expertise to refine and optimise their research strategy. Together, we discussed the initial approach and parameters, allowing the librarian to provide valuable insights and recommendations. Following this consultation, the team revised and finalised their search strategy, incorporating the librarian’s feedback. This involved refining the selection of search terms, identifying relevant databases and ensuring the alignment of the strategy with the research objective.

Box 1. List of search keywords.

African-related terms

African American OR African Canadian OR African Community OR Africa-born OR African-born OR African individuals OR African population OR African people OR African persons OR African ancestry OR African descent OR African origin OR (Black OR African OR Caribbean Francophone) OR African immigrants OR African refugees OR African migrants OR African Caribbean OR Africa).

Black-related terms

Black OR Black People OR Black Community OR Black minority OR Black ethnic OR Black Canadian OR Black individuals OR Black population OR Black People OR Black persons OR Black immigrants OR Black refugees OR Black.

Caribbean, Sub-Saharan and West Indian terms

Afro-Caribbean community OR Afro-Caribbean individuals OR Afro-Caribbean population OR Afro-Caribbean people OR Afro-Caribbean persons OR Caribbean OR Black-Caribbean OR Caribbean ancestry OR Caribbean descent OR Caribbean origin OR West Indian OR West Indian Canadian OR Caribbean immigrants OR Caribbean refugees · Caribbean migrants OR Sub-Saharan immigrants OR Sub-Saharan refugees OR Sub-Saharan people OR Sub-Saharan migrants OR Black Caribbean OR Caribbean Canadians.

Canada and Canadian province-related terms

Canada OR Canadian OR Alberta OR Ontario OR British Columbia OR Manitoba OR New Brunswick OR Newfoundland and Labrador OR Nunavut OR Northwest Territories OR Nova Scotia OR Prince Edward Island OR Quebec OR Saskatchewan OR Yukon.

Databases for search

The search will focus on peer-reviewed academic databases and grey literature. Various academic databases will be searched, namely MEDLINE (Ovid), PsycINFO, EMBASE, PubMed, CINAHL, Scopus and others. Google Scholar, ProQuest, OAISter, organisational and community websites will be searched for the grey literature. Table 1 displays the list of academic and grey literature databases that will be employed during the search. Any additional eligible articles not captured in the initial database search will be searched in the reference lists of all included articles. Details of the search strategies are provided in online supplemental appendix tables 1-4.

Table 1. Search databases and resources.

Peer-reviewed literature	Grey literature
• Health Sciences:	• Academic-focused search engines:
1. MEDLINE (Ovid)	1. Google Scholar
2. EMBASE	2. ProQuest (theses and dissertations)
3. CINAHL Plus with Full text	3. OAISter
4. PsycINFO	• Health sciences:
• Social Sciences:	4. Canadian Institutes of Health Research (CIHR)
5. Sociological Abstracts	5. Canadian Institute for Health Information (CIHI)
6. Social Work Abstracts	6. Canadian Public Health Association (CPHA)
7. SocINDEX with Full text	7. Public Health Agency of Canada (PHAC)
• Education:	Communityorganisations
8. Education Research Complete	The alliance for healthier communities
9. Web of Science	The Black Health Equity Group
10. Scopus	Health research council for people of African Decent
11. Canadian Research Index (CRI)
12. Canadian Reference Centre (CRC)

Stage 3: studies selection

The review will include qualitative, quantitative and mixed-methods studies related to health in English and French with no date restrictions. The research questions determined inclusion and exclusion criteria for finding relevant articles (Box 2).

Box 2. Inclusion and exclusion criteria.

Inclusion

• Studies included the Black population.

• Studies conducted in Canada/include the Canadian population.

• Health and wellness domain (studies concerning clinical, population and public health).

• Reported race, ethnicity-specific outcomes or findings.

Exclusion

• Not original studies (eg, literature reviews, editorials and commentaries).

• Biomedical studies (eg, genetics, biochemistry studies).

Screening of articles

All articles identified through the comprehensive search will be exported to Covidence³¹ to manage and combine articles and remove duplicates.³² Grey literature will follow the same process, but grey articles will be managed with Mendeley citation manager and Excel sheets. Once duplicate articles (online supplemental appendix figure 1) are removed, the remaining articles will be reviewed for relevance and eligibility in two steps: (1) title and abstract screening and (2) full-text screening (online supplemental appendix figure 1).³² Two reviewers will independently screen the title and abstract to decide on the inclusion/exclusion of an article. An exercise of 50 randomly selected titles and abstracts will first be conducted to confirm that both reviewers consistently apply the inclusion/exclusion selection criteria. Any disagreement between the two initial reviewers will be resolved by a third reviewer.

A full-text review will be conducted for abstracts that meet eligibility criteria at the title-abstract screening. Also, we will review full-text abstracts that need more outcome information to help determine eligibility. The same two reviewers will conduct a second round of independent review. Once a full-text review of the articles has been completed, the articles that meet the criteria will be considered for data extraction. In both levels of screening, the reviewers will resolve any disagreement through consensus; if they cannot agree, a third reviewer will act as an arbitrator.

Stage 4: charting the data

In this stage, the key information is charted.²⁸ Below is a data extraction chart for information abstraction from the identified studies (box 3).

Box 3. A data extraction chart to extract information from identified studies.

Extraction date

Authors(s)

Title

Journal

Publication type (peer-reviewed/grey literature)

Study aims

Study objective

Study design

Study approach (quantitative/qualitative/mixed)

Study setting/province

Study population

Sample size

Health or wellness topics/conditions examined

Black labels/terminologies

Reasons/justification for choosing terminologies

Strategies for grouping/recruiting the Black population

Race used as a social or biological determinant

Community engagement

Reviewer comments

This stage consists of charting key information. To extract data from each study, a data charting form is developed.^{27 28} A ‘narrative review’ or ‘descriptive analytical’ method will be used to extract contextual or process-oriented information from each study.^{27 28}

Stage 5: collating, summarising and reporting results

A numerical analysis of the extent and nature of studies using tables and charts will be presented.27,30 The extracted texts will be imported and processed using NVivo 14, a software specialised in qualitative data analysis. We will take an inductive approach to data analysis by conducting the reflective thematic analysis (RTA) of Braun and Clarke³³ with six stages: familiarisation with data, generating codes, constructing themes, revising and defining themes, and writing up. RTA is described as a method by which a researcher will ‘explore and develop an understanding of patterned meaning across the dataset’ with the aim of producing ‘a coherent and compelling interpretation of the data, grounded in the data’.³⁴

Stage 6: consultation

In this stage, knowledge user and stakeholder involvement can provide insights that go beyond the literature and suggest additional references.²⁷ The literature on scoping reviews is constantly evolving, and it is now being considered to incorporate the ways of ‘knowing, being, and doing’ of the population of interest for a better understanding of the evidence that is of importance to them.³⁵ This implies that consultation with the population of interest throughout the scoping review is necessary.³⁵ By doing so, we can improve the likelihood of applying the knowledge gained and implementing culturally appropriate evidence-based strategies in practice.³⁵ This can help enhance the safety of populations facing health disparities. As part of this review, members of Black community are participating and providing valuable insights into the study.

Discussion and anticipated outcomes

This scoping review aims to identify how the Black population has been defined and studied in Canadian health research. Determining how the Black population is conceptualised might provide insight into how our knowledge of the community is formed and thereby contribute to or challenge epistemic biases. Specifically, the scoping review will explore labels and terminologies used in health research and how those terminologies have been changing over time. The review will also identify whether the researchers devised different reasons for consistently using specific terminologies or labels. Additionally, mechanisms and processes used to recruit the Black population and assign specific terminologies to different population groups will be explored to understand how health researchers apply the inclusion and exclusion criteria to this population or assign the Black population to different communities.

The definition of Black in health research introduces ambiguity and raises questions regarding the criteria and rationale behind health researchers' selection of terminologies and participant recruitment within the Black population. Health researchers need to develop a nuanced understanding of the diverse backgrounds and experiences of the Black population in Canada. By acknowledging and considering variations in factors such as length of residency in Canada, country of origin and language, researchers can better identify and recruit specific populations in line with their research aims and objectives. Furthermore, coping skills and resilience may play a significant role in shaping individual experiences among racialised populations.³⁶ Consequently, developing a targeted and customised research approach that fosters a more equitable research environment is imperative.

A growing number of research studies are increasingly focusing on Black communities in Canada and other Western countries, particularly since the rise of the Black Lives Matter movement.^{37 38}

This scoping review will shed light on different labels being used and the underlying reasons behind them. It will delve into the challenge of finding a common term to describe Black individuals in Canadian health research and the equity-related consequences of this practice. Furthermore, this scoping review is poised to initiate discussions that may encourage health researchers to collaborate in establishing standardised guidelines and strategies for conducting research within the Black population in Canada. Additionally, the review will offer recommendations for future research in this area.

Ethics and dissemination

This study will not require ethics clearance. We are committed to taking a community-engaged approach to disseminate the results. We understand the importance of engaging with stakeholders to disseminate any research results, and we will plan meetings with them. From the beginning, a knowledge translation approach was decided on following consultation with citizen researchers and community champions. We define citizen researchers as individuals from the community who engage directly and play a more active role in the research process. They can be volunteers or casually employed research participants.³⁹ We will prepare and present posters and oral presentations at academic conferences and community events. Reports will be published in peer-reviewed and electronic journals, making our findings accessible to a broad audience. In addition, we plan on sharing the results on relevant websites and social media platforms such as X and Facebook.

Patient and public involvement

From the very beginning of our research, we collaborated with the community partners to assess our research hypothesis and create the protocol. We met regularly to discuss the intended research and get constructive criticism on our questions. Community partners will also actively participate in the interpretation of our findings and will lead the knowledge mobilisation initiatives, including the development of infographics, pamphlets and other materials for disseminating information, as well as the kinds of processes to employ for knowledge exchange. For knowledge translation, they will mobilise their ties with the larger community.