Eliminating Explicit and Implicit Biases in Health Care: Evidence and Research Needs

Health care providers hold negative explicit and implicit biases against marginalized groups of people such as racial and ethnic minoritized populations. These biases permeate the health care system and affect patients via patient–clinician communication, clinical decision making, and institutionalized practices. Addressing bias remains a fundamental professional responsibility of those accountable for the health and wellness of our populations. Current interventions include instruction on the existence and harmful role of bias in perpetuating health disparities, as well as skills training for the management of bias. These interventions can raise awareness of provider bias and engage health care providers in establishing egalitarian goals for care delivery, but these changes are not sustained, and the interventions have not demonstrated change in behavior in the clinical or learning environment. Unfortunately, the efficacy of these interventions may be hampered by health care providers’ work and learning environments, which are rife with discriminatory practices that sustain the very biases US health care professions are seeking to diminish. We offer a conceptual model demonstrating that provider-level implicit bias interventions should be accompanied by interventions that systemically change structures inside and outside the health care system if the country is to succeed in influencing biases and reducing health inequities. Expected final online publication date for the Annual Review of Public Health, Volume 43 is April 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Extended Implicit Bias: When the Metaphysics and Ethics of Implicit Bias Collide

It has recently been argued that to tackle social injustice, implicit biases and unjust social structures should be targeted equally because they sustain and ontologically overlap with each other. Here I develop this thought further by relating it to the hypothesis of extended cognition. I argue that if we accept common conditions for extended cognition then people’s implicit biases are often partly realized by and so extended into unjust social structures. This supports the view that we should counteract psychological and social contributors to injustice equally. But it also has a significant downside. If unjust social structures are part of people’s minds then dismantling these structures becomes more difficult than it currently is, as this will then require us to overcome widely accepted ethical and legal barriers protecting people’s bodily and personal integrity. Thus, while there are good grounds to believe that people’s biases and unjust social structures ontologically overlap, there are also strong ethical reasons to reject this view. Metaphysical and ethical intuitions about implicit bias hence collide in an important way.

Implicit Racial Attitudes and Associations Among Obstetricians in Hawaiʻi: 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.

What Bias Management Can Learn From Change Management? Utilizing Change Framework to Review and Explore Bias Strategies

This paper conducted a preliminary study of reviewing and exploring bias strategies using a framework of a different discipline: change management. The hypothesis here is: If the major problem of implicit bias strategies is that they do not translate into actual changes in behaviors, then it could be helpful to learn from studies that have contributed to successful change interventions such as reward management, social neuroscience, health behavioral change, and cognitive behavioral therapy. The result of this integrated approach is: (1) current bias strategies can be improved and new ones can be developed with insight from adjunct study fields in change management; (2) it could be more sustainable to invest in a holistic and proactive bias strategy approach that targets the social environment, eliminating the very condition under which biases arise; and (3) while implicit biases are automatic, future studies should invest more on strategies that empower people as “change agents” who can act proactively to regulate the very environment that gives rise to their biased thoughts and behaviors.

Perspectives Against Racism: educational and socialization efforts at the departmental level

The current heightened social awareness and anxiety triggered by escalating violence against Black Americans in the United States demands a safe space for reflection, education, and civil discourse within the academic setting. Too often there is an unmet need paired with a collective urgent desire to better understand the chronic existing structural, social, educational, and health inequities affecting disadvantaged populations, particularly Black Americans. In this perspective, the authors provide insight into a shared learning approach that provided a forum to discuss Perspectives Against Racism (PAR). Unlike existing top-down approaches, faculty, trainees, and staff were engaged in leading a series of focused discussions to examine unconscious bias, promote awareness of implicit biases, and reflect on individual and collective roles and responsibilities in working toward becoming antiracist. An existing 1-h graduate elective seminar course was dedicated to creating a space for learning, discussion, and exchange of ideas related to the experience and existence of racism (personal and institutional/systemic). A goal of each session was to go beyond didactics and identify mechanisms to implement change, at the level of the individual, department, and institution. This perspective of the shared experience may provide an adaptable framework that can be implemented in an academic setting at the departmental, center, or institutional level.

An investigation of implicit bias about bending and lifting

Objectives Previous studies in a high-income country have demonstrated that people with and without low back pain (LBP) have an implicit bias that bending and lifting with a flexed lumbar spine is dangerous. These studies present two key limitations: use of a single group per study; people who recovered from back pain were not studied. Our aims were to evaluate: implicit biases between back posture and safety related to bending and lifting in people who are pain-free, have a history of LBP or have current LBP in a middle-income country, and to explore correlations between implicit and explicit measures within groups. Methods Exploratory cross-sectional study including 174 participants (63 pain-free, 57 with history of LBP and 54 with current LBP). Implicit biases between back posture and safety related to bending and lifting were assessed with the Implicit Association Test (IAT). Participants completed paper-based (Bending Safety Belief [BSB]) and online questionnaires (Tampa Scale of Kinesiophobia; Back Pain Attitudes Questionnaire). Results Participants displayed significant implicit bias between images of round-back bending and lifting and words representing “danger” (IATD-SCORE: Pain-free group: 0.56 (IQR=0.31–0.91; 95% CI [0.47, 0.68]); history of LBP group: 0.57 (IQR=0.34–0.84; 95% CI [0.47, 0.67]); current LBP group: 0.56 (IQR=0.24–0.80; 95% CI [0.39, 0.64])). Explicit measures revealed participants hold unhelpful beliefs about the back, perceiving round-back bending and lifting as dangerous (BSBthermometer: Pain-free group: 8 (IQR=7–10; 95% CI [7.5, 8.5]); history of LBP group: 8 (IQR=7–10; 95% CI [7.5, 9.0]); current LBP group: 8.5 (IQR=6.75–10; [7.5, 9.0])). There was no correlation between implicit and explicit measures within the groups. Conclusions In a middle-income country, people with and without LBP, and those who recovered from LBP have an implicit bias that round-back bending and lifting is dangerous.

The Mark of Villainy

Why is it often so easy to identify the villain in a movie just by the way they look? Visual narratives exploit a mechanism that generates aversion towards people who look different. Being “different” by definition is in relation to a statistical norm, whether the difference concerns body size, skin color, hair styles, gender, visible physical disabilities, or facial anomalies. We often associate unattractive faces or faces with anomalies with poor character or negative personality traits. The evidence that most people harbor (implicit) biases against others who visibly differ from the norm is overwhelming, while people who approximate a statistical average within a population are regarded as beautiful and morally good. While we do not yet understand the (neuro-)biological and cognitive bases of these stereotypes, some recent neuroimaging evidence suggests that people not only pay greater attention to faces with anomalies but also simultaneously inhibit social and emotional responses.

Implicit Bias and Multilingual Assessment in School-Based Speech-Language Pathologists

Purpose: The purpose of this research was (a) to examine school-based speech-language pathologists' (SLPs') implicit attitudes toward immigrants and how these relate to prioritization and use of best practices when assessing multilingual children and (b) to determine if key demographic factors relate to the use and prioritization of these best practices. Method: Eighty-six certified SLPs ranked how they prioritize and use best practices in multilingual assessments and completed an online immigrant Implicit Association Test. Results: The majority of participants exhibited a strong implicit bias against immigrants (median D-score of 0.84, interquartile range: 0.49), but no significant relationship was found between increasing bias and lower prioritization or use of best practices. Increased years working as an SLP and increasingly distant personal relationships to immigration were related to lower prioritization and use of some best practices. An unexpected association included increased reported use of interpreters with increasing implicit bias against immigrants. Conclusions: This research found a strong implicit bias against immigrants among participating school-based SLPs, consistent with previous work detailing health professionals' preferences for ingroups over outgroups. It adds to the call for further research into the impact of implicit biases on clinical practice, and the methods and merits of addressing implicit biases in targeted populations such as SLPs. This study also identified demographic factors associated with decreased prioritization and use of certain best practices when assessing multilingual children. More work is needed to learn how to mitigate these factors to ensure culturally sensitive clinical practice. Supplemental Material https://doi.org/10.23641/asha.16799638