Ethnic bias and clinical decision-making among New Zealand medical students: an observational study

An Exploration of the Goodness of Fit of Web-Based Tools for Māori: Qualitative Study Using Interviews and Focus Groups

BACKGROUND

Indigenous communities often have poorer health outcomes and services under traditional models of care. In New Zealand, this holds true for Māori people who are tāngata whenua (the indigenous people). Several barriers exist that decrease the likelihood of indigenous communities often have poorer health outcomes and poor service fit under traditional models of care, including access issues, systemic and provider racism, and a lack of culturally safe and responsive services. Web-based interventions (WBIs) have been shown to be effective in supporting mental health and well-being and can overcome some of these barriers. Despite the large number of WBIs developed, more investigation is needed to know how well WBIs fit with an indigenous worldview and how they meet the needs of indigenous communities so that a digitally based future does not drive social and health inequities.

OBJECTIVE

This study aims to explore the goodness-of-fit of WBIs of Māori individuals, the indigenous people of Aotearoa/New Zealand.

METHODS

We used interviews (n=3) and focus groups (n=5) with 30 Māori participants to explore their views about WBIs. Interviews were analyzed using reflexive thematic analysis by members of the research team.

RESULTS

Overall, there was a perception that the design of WBIs did not align with the Māori worldview, which centers around people, relationships, spirituality, and holistic views of well-being. A total of 4 key themes and several subthemes emerged, indicating that WBIs were generally considered a poor fit for Māori. Specifically, the themes were as follows: (1) WBIs are disconnected from the core values of te ao Māori (the Māori worldview), (2) WBIs could be helpful in the right context, (3) there are significant barriers that may make it harder for Māori to use WBIs than other groups, and (4) ways to improve WBIs to help engagement with Māori.

CONCLUSIONS

While WBIs are often considered a way to reduce barriers to care, they may not meet the needs of Māori when used as a stand-alone intervention. If WBIs are continued to be offered, developers and researchers need to consider how to develop WBIs that are responsive and engaging to the needs of indigenous communities rather than driving inequities. Ideally, WBIs should be developed by the people they are intended for to fit with those populations' world views.

Implicit racial bias among dental hygienists practicing in the United States

PURPOSE

Provider bias has been shown to be a contributing factor to racial and ethnic disparities observed in health care settings. The purpose of this study was to examine implicit racial bias among dental hygienists.

METHODS

A convenience sample of licensed and practicing dental hygienists within the United States was recruited through email and national dental hygiene social media groups via snowball sampling. A two-part survey design was used for data collection. Participants completed a 10-item demographic survey through an online platform and were then routed to the Race Implicit Association Test (IAT). Descriptive statistics and linear regression analyses were used to compare demographic data and implicit racial preference scores (d-scores).

RESULTS

Data from 404 licensed dental hygienists were included in this study. Over two-thirds (67.8%) of participants showed a preference for European Americans over African Americans. A significant difference was found between implicit racial preference scores and participant age (Estimate: 0.01, 95% CI: 0.00, 0.01), years worked comparing <5 years to 21 or more years (Estimate: 0.19, 95% CI: -0.30, -0.09) and race comparing non-White to White (Estimate: -0.17, 95% CI: -0.27, -0.07). No difference was found with task order, previous Race IAT experience, or previous self-reported implicit bias training.

CONCLUSIONS

Findings suggest that dental hygienists may harbor implicit racial preferences for European Americans over African Americans. Non-White participants had more positive implicit preferences toward African Americans compared to White participants. Further research is needed to determine the extent to which implicit racial biases contribute to disparities in oral health.

The impact of racism on subsequent healthcare use and experiences for adult New Zealanders: a prospective cohort study

BACKGROUND

Racism is an important determinant of health and driver of racial/ethnic health inequities. Experience of racism has been linked to negative healthcare use and experiences although most studies have been cross-sectional. This study examines the relationship between reported experience of racism and subsequent use and experience of health services.

METHODS

This is a prospective cohort study design. The 2016/2017 adult New Zealand Health Survey (NZHS) provided the sampling frame and baseline data on exposures, health status and confounders. This stand-alone study invited all exposed individuals to participate when sampled based on their reported experience of racism (ever), stratified by broad ethnic groupings (Māori, Pacific, Asian, European/Other). Equal numbers of unexposed participants were selected for invitation using propensity score matching (propensity to experience racism, based on key available predictive factors). Follow-up was one to two years after NZHS interview. Outcome variables (last 12 months) were: unmet healthcare need (overall, for mental health, for a general practitioner); satisfaction with usual medical centre; and experiences with general practitioners (explaining care, involvement in decision-making, treated with respect/dignity, confidence and trust). Logistic regression models examining the association between experience of racism (at baseline) and health service use and experience (at follow-up) used doubly-robust estimation to weight for propensity scores used in the sampling with additional adjustment for confounders.

RESULTS

The study had 2010 participants. Experience of racism (ever) at baseline was associated with higher overall unmet need at follow-up (adjusted OR (aOR) = 1.71, 95% CI 1.31, 2.23), with similar patterns for other unmet need measures. Experience of racism was associated with higher dissatisfaction with a usual medical centre (aOR = 1.41, 95% CI 1.10, 1.81) and with higher reporting of negative patient experiences.

CONCLUSION

In line with how racism structures oppression, exposure to racism is largely felt by non-European groups in Aotearoa New Zealand. Experiences of racism potentially lead to poorer healthcare and healthcare inequities through higher unmet need, lower satisfaction and more negative experiences of healthcare. The health system has a critical role to play in addressing racism within healthcare and supporting societal efforts to eliminate racism and ethnic inequities.

A scoping review to identify and organize literature trends of bias research within medical student and resident education

BACKGROUND

Physician bias refers to the unconscious negative perceptions that physicians have of patients or their conditions. Medical schools and residency programs often incorporate training to reduce biases among their trainees. In order to assess trends and organize available literature, we conducted a scoping review with a goal to categorize different biases that are studied within medical student (MS), resident (Res) and mixed populations (MS and Res). We also characterized these studies based on their research goal as either documenting evidence of bias (EOB), bias intervention (BI) or both. These findings will provide data which can be used to identify gaps and inform future work across these criteria.

METHODS

Online databases (PubMed, PsycINFO, WebofScience) were searched for articles published between 1980 and 2021. All references were imported into Covidence for independent screening against inclusion criteria. Conflicts were resolved by deliberation. Studies were sorted by goal: 'evidence of bias' and/or 'bias intervention', and by population (MS or Res or mixed) andinto descriptive categories of bias.

RESULTS

Of the initial 806 unique papers identified, a total of 139 articles fit the inclusion criteria for data extraction. The included studies were sorted into 11 categories of bias and showed that bias against race/ethnicity, specific diseases/conditions, and weight were the most researched topics. Of the studies included, there was a higher ratio of EOB:BI studies at the MS level. While at the Res level, a lower ratio of EOB:BI was found.

CONCLUSIONS

This study will be of interest to institutions, program directors and medical educators who wish to specifically address a category of bias and identify where there is a dearth of research. This study also underscores the need to introduce bias interventions at the MS level.

Patient representation in New Zealand general practice and rural health case-based teaching: a quality improvement exercise

Introduction Healthcare inequity disproportionately affects minority populations in Aotearoa New Zealand. Healthcare providers may contribute to inequity due to their biases. Medical education can unintentionally promote biases by reinforcing stereotypes or limiting exposure to diversity. Teaching staff from the Department of General Practice and Rural Health suggested a need to review current teaching materials to ascertain if they have the potential to contribute to this bias. Aim The aim of this study was to review case-based teaching material to determine its representation of the New Zealand population, and whether there is potential to contribute to implicit bias. Methods Document analysis of 135 cases used to teach fourth- and fifth-year medical students in the Department of General Practice and Rural Health, Otago Medical School was performed. Demographic, clinical and social features of each case were recorded and analysed. Results Cases typically included patient age (129/135, 95.6%), sex (127/135, 94.1%) and occupation status (91/136, 66.9%). Ethnicity (31/135, 23.0%), living situation (55/135, 40.7%), relationship status (57/135, 42.2%) and sexual orientation (52/135, 40.0%) were less frequently defined. Cases typically represented the population majority norms. Discussion Case-based teaching materials require regular review and updating to match population demographics. There is potential to improve representation of diversity, and hence cultural safety, though review and revision of written teaching cases.

Implicit Racial Attitudes and Associations Among Obstetricians in Hawai'i: a Pilot Study

INTRODUCTION

Pacific Islanders living in Hawai'i with ancestral ties to islands in the western Pacific region of Micronesia are common targets of uninhibited forms of prejudice in multiple sectors, including healthcare. Whether the explicit societal-level attitudes toward this group are reflected in implicit attitudes among healthcare providers is unknown; therefore, we designed a pilot study to investigate this question. Our study measures implicit racial bias toward Pacific Islanders from Micronesia among Obstetrician-Gynecologists (OB-GYNs) in Hawai'i.

METHODS

We developed 4 new implicit association tests (IATs) to measure implicit attitudes and associations (i.e., stereotypes) toward Pacific Islanders from Micronesia in 2 conditions: (1) Micronesians vs. Whites and (2) Micronesians vs. Japanese Americans. Participants were practicing OB-GYNs in Hawai'i. The study was conducted online and included survey questions on demographic and physician practice characteristics in addition to IATs. The primary outcome was the mean IAT D score. Associations between IAT D scores and demographic and practice characteristics were also analyzed.

RESULTS

Of the 49 OB-GYNs, 38 (77.6%) were female, mean age was 40 years, 29.5% were Japanese, 22.7% were White, and none were from a Micronesian ethnic group. The mean IAT D score in the Micronesian vs. White condition (N = 29) was 0.181, (SD: 0.465, p < 0.05) for the Attitude IAT and 0.197 (SD: 0.427; p < 0.05) for the Stereotype IAT.

CONCLUSION

The findings from this pilot suggest a slight degree of implicit bias favoring Whites over Micronesians within this sample of OB-GYNs and warrant a larger investigation into implicit biases toward this unique and understudied Pacific Islander population.

Anti-Indigenous bias of medical school applicants: a cross-sectional study

BACKGROUND

Structural and interpersonal anti-Indigenous racism is prevalent in Canadian healthcare. The Truth and Reconciliation Commission calls on medical schools to address anti-Indigenous bias in students. We measured the prevalence of interpersonal anti-Indigenous bias among medical school applicants to understand how the medical school selection process selects for or against students with high levels of bias.

METHODS

All applicants to a single university in the 2020-2021 admissions cycle were invited to participate. Explicit anti-Indigenous bias was measured using two sliding scale thermometers. The first asked how participants felt about Indigenous people (from 0, indicating 'cold/unfavourable' to 100, indicating 'warm/favourable') and the second asked whether participants preferred white (scored 100) or Indigenous people (scored 0). Participants then completed an implicit association test examining preferences for European or Indigenous faces (negative time latencies suggest preference for European faces). Explicit and implicit anti-Indigenous biases were compared by applicant demographics (including gender and racial identity), application status (offered an interview, offered admission, accepted a position), and compared to undergraduate medical and mathematics students.

RESULTS

There were 595 applicant respondents (32.4% response rate, 64.2% cisgender women, 55.3% white). Applicants felt warmly toward Indigenous people (median 96 (IQR 80-100)), had no explicit preference for white or Indigenous people (median 50 (IQR 37-55), and had mild implicit preference for European faces (- 0.22 ms (IQR -0.54, 0.08 ms)). There were demographic differences associated with measures of explicit and implicit bias. Applicants who were offered admission had warmer feelings toward Indigenous people and greater preference for Indigenous people compared to those were not successful.

CONCLUSIONS

Medical school applicants did not have strong interpersonal explicit and implicit anti-Indigenous biases. Outlier participants with strong biases were not offered interviews or admission to medical school.

Racism in healthcare: a scoping review

BACKGROUND

Racism constitutes a barrier towards achieving equitable healthcare as documented in research showing unequal processes of delivering, accessing, and receiving healthcare across countries and healthcare indicators. This review summarizes studies examining how racism is discussed and produced in the process of delivering, accessing and receiving healthcare across various national contexts.

METHOD

The PRISMA guidelines for scoping reviews were followed and databases were searched for peer reviewed empirical articles in English across national contexts. No starting date limitation was applied for this review. The end date was December 1, 2020. The review scoped 213 articles. The results were summarized, coded and thematically categorized in regards to the aim.

RESULTS

The review yielded the following categories: healthcare users' experiences of racism in healthcare; healthcare staff's experiences of racism; healthcare staff's racial attitudes and beliefs; effects of racism in healthcare on various treatment choices; healthcare staff's reflections on racism in healthcare and; antiracist training in healthcare. Racialized minorities experience inadequate healthcare and being dismissed in healthcare interactions. Experiences of racism are associated with lack of trust and delay in seeking healthcare. Racialized minority healthcare staff experience racism in their workplace from healthcare users and colleagues and lack of organizational support in managing racism. Research on healthcare staff's racial attitudes and beliefs demonstrate a range of negative stereotypes regarding racialized minority healthcare users who are viewed as difficult. Research on implicit racial bias illustrates that healthcare staff exhibit racial bias in favor of majority group. Healthcare staff's racial bias may influence medical decisions negatively. Studies examining healthcare staff's reflections on racism and antiracist training show that healthcare staff tend to construct healthcare as impartial and that healthcare staff do not readily discuss racism in their workplace.

CONCLUSIONS

The USA dominates the research. It is imperative that research covers other geo-political contexts. Research on racism in healthcare is mainly descriptive, atheoretical, uses racial categories uncritically and tends to ignore racialization processes making it difficult to conceptualize racism. Sociological research on racism could inform research on racism as it theoretically explains racism's structural embeddedness, which could aid in tackling racism to provide good quality care.

A Brief Online Implicit Bias Intervention for School Mental Health Clinicians

Clinician bias has been identified as a potential contributor to persistent healthcare disparities across many medical specialties and service settings. Few studies have examined strategies to reduce clinician bias, especially in mental healthcare, despite decades of research evidencing service and outcome disparities in adult and pediatric populations. This manuscript describes an intervention development study and a pilot feasibility trial of the Virtual Implicit Bias Reduction and Neutralization Training (VIBRANT) for mental health clinicians in schools-where most youth in the U.S. access mental healthcare. Clinicians (N = 12) in the feasibility study-a non-randomized open trial-rated VIBRANT as highly usable, appropriate, acceptable, and feasible for their school-based practice. Preliminarily, clinicians appeared to demonstrate improvements in implicit bias knowledge, use of bias-management strategies, and implicit biases (as measured by the Implicit Association Test [IAT]) post-training. Moreover, putative mediators (e.g., clinicians' VIBRANT strategies use, IAT D scores) and outcome variables (e.g., clinician-rated quality of rapport) generally demonstrated correlations in the expected directions. These pilot results suggest that brief and highly scalable online interventions such as VIBRANT are feasible and promising for addressing implicit bias among healthcare providers (e.g., mental health clinicians) and can have potential downstream impacts on minoritized youth's care experience.

Social inequalities over the lifecourse and healthy ageing in Aotearoa/New Zealand: differences by Māori ethnicity and gender

Lifecourse approaches to healthy ageing recognise that health in older age is affected by long-term cumulative inequalities between socio-economic status (SES), gender and ethnicity groups, which begin in childhood. Combining longitudinal survey data with lifecourse history interviews from 729 older New Zealanders aged 61–81 (mean = 72, standard deviation = 4.5), we tested a lifecourse model of predictors of physical, mental and social health in older age. Latent growth curve and mediation analysis showed that the link between childhood SES and late-life health (over 10 years) was mediated by education, occupation and adult wealth. To account for the moderating effects of gender and ethnicity, we modelled the effects for sub-groups separately (225 non-Māori women, 158 Māori women, 219 non-Māori men and 127 Māori men). Childhood SES was an important predictor of later-life health, mediated by education and adult SES for all participants and for non-Māori men. However, there were significantly different pathways for Māori men and for women. Māori men and women and non-Māori women did not attain the same health benefits from higher childhood SES and education as non-Māori men. Findings point to the importance of considering the mediators of lifelong impacts on health in older age, and recognition of how membership of different socially structured groups produces different pathways to late-life health.

Insights Into Provider Bias in Family Planning from a Novel Shared Decision Making Based Counseling Initiative in Rural, Indigenous Guatemala

Race, ethnicity, and indigenous status should be considered as potential drivers of provider bias in family planning services globally. Efforts to confront provider bias in family planning counseling should include concrete strategies that promote provider recognition of biases and longitudinal curriculums that allow for sustained feedback and self-reflection.

Revisiting the trajectory of medical students' empathy, and impact of gender, specialty preferences and nationality: a systematic review

BACKGROUND

Empathy allows a physician to understand the patient's situation and feelings and respond appropriately. Consequently, empathy gives rise to better diagnostics and clinical outcomes. This systematic review investigates the level of empathy among medical students across the number of educational years and how this level relates to gender, specialty preferences, and nationality.

METHOD

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), the authors conducted a systematic search of studies published between February 2010 and March 2019 investigating the level of empathy among medical students. The databases PubMed, EMBASE, and PsycINFO were searched. Studies employing quantitative methodologies and published in English or Scandinavian language and examining medical students exclusively were included.

RESULTS

Thirty studies were included of which 24 had a cross-sectional and 6 a longitudinal study design. In 14 studies, significantly lower levels of empathy were reported by increase in the number of educational years. The remaining 16 studies identified both higher, mixed and unchanged levels. In 18 out of 27 studies it was reported that females had higher empathy scores than males. Only three out of nine studies found an association between empathy scores and specialty preferences. Nine out of 30 studies reported a propensity towards lower mean empathy scores in non-Western compared to Western countries.

CONCLUSION

The results revealed equivocal findings concerning how the empathy level among medical students develops among medical students across numbers of educational years and how empathy levels are associated with gender, specialty preferences, and nationality. Future research might benefit from focusing on how students' empathy is displayed in clinical settings, e.g. in clinical encounters with patients, peers and other health professionals.