Implicit-Bias Remedies: Treating Discriminatory Bias as a Public-Health Problem

Stronger color evasive racial ideologies predict lower likelihood of open adoption placement with same-sex couples

Although the adoption rate among same-sex couples has been increasing, limited research has focused on factors influencing decision making related to placing children with such couples, particularly from the standpoint of birth mothers. Additionally, there is a gap in the literature regarding how biases may influence birth mothers' decision to place their child with a same-sex couple. This study sought to examine the association between birth mothers' racial ideologies and their decision to voluntarily place their children with same-sex couples (n = 29) or mother-father couples (n = 354) during the adoption process. Results indicated that birth mothers with stronger color evasive racial attitudes were significantly less likely to place their children with same-sex couples. The need for additional research about the intersections among various forms of bias in the adoption process and the effect of potential interactions between homophobia and racism are discussed. Suggestions for professionals wishing to minimize homophobic and racist bias are provided.

Nurse judgements of hospitalized patients' safety concerns are affected by patient, nurse and event characteristics: A factorial survey experiment

AIM

To test the influences of patient, safety event and nurse characteristics on nurse judgements of credibility, importance and intent to report patients' safety concerns.

DESIGN

Factorial survey experiment.

METHODS

A total of 240 nurses were recruited and completed an online survey including demographic information and responses to eight factorial vignettes consisting of unique combinations of eight patient and event factors. Hierarchical multivariate analysis was used to test influences of vignette factors and nurse characteristics on nurse judgements.

RESULTS

The intraclass coefficients for nurse judgements suggest that the variation among nurses exceeded the influence of contextual vignette factors. Several significant sources of nurse variation were identified, including race/ethnicity, suggesting a complex relationship between nurses' characteristics and their potential biases, and the influence of personal and patient factors on nurses' judgements, including the decision to report safety concerns.

CONCLUSION

Nurses are key players in the system to manage patient safety concerns. Variation among nurses and how they respond to scenarios of patient safety concerns highlight the need for nurse-level intervention.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

Complex factors influence nurses' judgement, interpretation and reporting of patients' safety concerns.

IMPACT

Understanding nurse judgement regarding patient-expressed safety concerns is critical for designing processes and systems that promote reporting. Multiple event and patient characteristics (type of event and apparent harm, and patient gender, race/ethnicity, socioeconomic status, and communication approach) as well as participant characteristics (race/ethnicity, gender, years of experience and primary hospital area) impacted participants' judgements of credibility, degree of concern and intent to report. These findings will help guide patient safety nurse education and training.

REPORTING METHOD

STROBE guidelines.

PATIENT OR PUBLIC CONTRIBUTION

Members of the public, including patient advocates, were involved in content validation of the vignette scenarios, norming photographs used in the factorial survey and testing the survey functionality.

Healing Health Care Disparities: Development and Pilot Testing of a Virtual Reality Implicit Bias Training Module for Physicians in the Context of Black Maternal Health

Grounded in communication models of cultural competence, this study reports on the development and testing of the first module in a larger virtual reality (VR) implicit bias training for physicians to help them better: (a) recognize implicit bias and its effects on communication, patients, and patient care; (b) identify their own implicit biases and exercise strategies for managing them; and (c) learn and practice communicating with BIPOC patients in a culture-centered manner that demonstrates respect and builds trust. Led by communication faculty, a large, interdisciplinary team of researchers, clinicians, and engineers developed the first module tested herein focused on training goal (a). Within the module, participants observe five scenes between patient Marilyn Hayes (a Black woman) and Dr. Richard Flynn (her obstetrician, a White man) during a postpartum visit. The interaction contains examples of implicit bias, and participants are asked to both identify and consider how implicit bias impacts communication, the patient, and patient care. The team recruited 30 medical students and resident physicians to participate in a lab-based study that included a pretest, a training experience of the module using a head-mounted VR display, and a posttest. Following the training, participants reported improved attitudes toward implicit bias instruction, greater importance of determining patients' beliefs and perspectives for history-taking, treatment, and providing quality health care; and greater communication efficacy. Participants' agreement with the importance of assessing patients' perspectives, opinions, and psychosocial and cultural contexts did not significantly change. Implications for medical education about cultural competency and implicit bias are discussed.

Feeding Management and Palate Repair Timing in Infants with Cleft Palate with and without Pierre Robin Sequence: A Multisite Study

OBJECTIVES

Compare the feeding management practices in infants with cleft palate with and without Pierre Robin sequence (PRS) and determine if specific feeding difficulties or interventions predict delayed palate repair.

DESIGN

Retrospective cross-sectional study.

SETTING

Seventeen cleft palate teams contributed data.

PATIENTS

414 infants were included in this study: 268 infants with cleft palate only and 146 infants with cleft palate and PRS.

PROCEDURES

Data were collected via parent interview and electronic health records.

MAIN OUTCOME MEASURES

Outcomes for the primary objective included categorical data for: history of poor growth, feeding therapy, milk fortification, use of enteral feeding, and feeding difficulties. The outcome for the secondary objective was age in months at primary palate repair.

RESULTS

Infants with PRS had a significantly higher prevalence of feeding difficulties (81% versus 61%) and poor growth (29% versus 15%) compared to infants with cleft palate only. Infants with PRS received all feeding interventions-including feeding therapy, milk fortification, and enteral feeding-at a significantly higher frequency. Infants with PRS underwent primary palate repair at a mean age of 13.55 months (SD = 3.29) which was significantly (P < .00001) later than infants with cleft palate only who underwent palate repair at a mean age of 12.05 months (SD = 2.36). Predictors of delayed palate repair included diagnosis of PRS as well as Hispanic ethnicity and a history of poor growth.

CONCLUSIONS

These findings can be used to establish clinical directives focused on providing early, multimodal feeding interventions to promote optimal growth and timely palate repair for infants with PRS.

Racial disparities in ALS diagnostic delay: a single center's experience and review of potential contributing factors

OBJECTIVE

Outcomes for amyotrophic lateral sclerosis (ALS) patients are improved with prompt diagnosis, earlier initiation of disease-modifying treatments, and participation in a multidisciplinary clinic. We studied diagnostic delay and disease severity at time of clinic presentation between Black and non-Hispanic Caucasian ALS patients.

METHODS

We performed a retrospective analysis of non-Hispanic Caucasian and Black ALS patients seen in the Virginia Commonwealth University Health System multidisciplinary ALS clinic between 2017 and 2023. Diagnostic delay, ALS Functional Rating Scale-Revised (ALSFRS-R) and upright forced vital capacity (FVC) scores at baseline appointment were collected. Patient's distance from clinic and affluency of residential neighborhood were evaluated.

RESULTS

We analyzed 172 non-Hispanic Caucasian and 33 Black ALS patients. Black patients had a 64% increase in diagnostic delay compared to non-Hispanic Caucasian patients. Black patients had a lower performance on ALSFRS-R (5.3 points, p < 0.001) and FVC (17.9 percentage points p < 0.001) at time of first clinic visit. Black patients lived closer to clinic, with higher proportion living in the city of Richmond, but in less affluent areas with lower median house income ($55,300 ± 22,600 vs $69,900 ± 23,700).

DISCUSSION

Our findings demonstrate a large racial difference in ALS diagnostic delay, and greater disease severity and lower respiratory function at time of diagnosis for Black ALS patients. Delay in diagnosis prolongs access to disease-modifying therapies, multidisciplinary care, durable medical equipment, and respiratory and nutritional support. Potential sources of these racial disparities include providers' implicit bias and structural racism.

Association between Patient Race and Ethnicity and Use of Invasive Ventilation in the United States

Rationale: Outcomes for people with respiratory failure in the United States vary by patient race and ethnicity. Invasive ventilation is an important treatment initiated based on expert opinion. It is unknown whether the use of invasive ventilation varies by patient race and ethnicity. Objectives: To measure 1) the association between patient race and ethnicity and the use of invasive ventilation; and 2) the change in 28-day mortality mediated by any association. Methods: We performed a multicenter cohort study of nonintubated adults receiving oxygen within 24 hours of intensive care admission using the Medical Information Mart for Intensive Care IV (MIMIC-IV, 2008-2019) and Phillips eICU (eICU, 2014-2015) databases from the United States. We modeled the association between patient race and ethnicity (Asian, Black, Hispanic, White) and invasive ventilation rate using a Bayesian multistate model that adjusted for baseline and time-varying covariates, calculated hazard ratios (HRs), and estimated 28-day hospital mortality changes mediated by differential invasive ventilation use. We reported posterior means and 95% credible intervals (CrIs). Results: We studied 38,258 patients, 52% (20,032) from MIMIC-IV and 48% (18,226) from eICU: 2% Asian (892), 11% Black (4,289), 5% Hispanic (1,964), and 81% White (31,113). Invasive ventilation occurred in 9.2% (3,511), and 7.5% (2,869) died. The adjusted rate of invasive ventilation was lower in Asian (HR, 0.82; CrI, 0.70-0.95), Black (HR, 0.78; CrI, 0.71-0.86), and Hispanic (HR, 0.70; CrI, 0.61-0.79) patients compared with White patients. For the average patient, lower rates of invasive ventilation did not mediate differences in 28-day mortality. For a patient on high-flow nasal cannula with inspired oxygen fraction of 1.0, the odds ratios for mortality if invasive ventilation rates were equal to the rate for White patients were 0.97 (CrI, 0.91-1.03) for Asian patients, 0.96 (CrI, 0.91-1.03) for Black patients, and 0.94 (CrI, 0.89-1.01) for Hispanic patients. Conclusions: Asian, Black, and Hispanic patients had lower rates of invasive ventilation than White patients. These decreases did not mediate harm for the average patient, but we could not rule out harm for patients with more severe hypoxemia.

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.

Talent denied: Equity and excellence gaps in STEMM

In principle, there could be STEMM talent everywhere if there were sufficient and adequate opportunities and learning resources everywhere. The reality, however, is that the likelihood of developing one's talent in STEMM is tied to membership in social groups. In this contribution, we explore the implications of this statement with multiple examples for different social groups and for different stages of talent development. We propose an educational framework model for analyzing equity gaps in STEMM talent development that identifies and systematizes the unequal and inequitable distribution of resources and opportunities as the proximal cause of the emergence of such equity gaps. Furthermore, we discuss important aspects for closing equity gaps in STEMM talent development. We argue that-similar to public health approaches-the focus in establishing equity in STEMM talent development should be on prevention rather than intervention. We discuss the importance of the cooperation of societal subsystems and argue for the use of adequate methods of disparity detection for creating equal opportunities. We also outline why preventive strategies are crucial for the creation of resource parity and explain why outcome standards should be considered obligatory.

Contribution of Health Care Practitioner and Maternity Services Factors to Racial Disparities in Alabama: A Qualitative Study

OBJECTIVE

Black patients are three times more likely to die of pregnancy-related causes than White patients in the United States, and Alabama has the third worst maternal mortality rate in the nation. We sought to identify health care practitioner and maternity service factors contributing to disparities in Alabama, as well as potential strategies to address these contributors.

METHODS

We conducted key informant interviews with obstetricians, nurses, doulas, lactation counselors, health system administrators, and representatives of professional organizations who deliver maternity care to racially and ethnically diverse patients in Alabama. The interview guide was developed using Howell's conceptual framework on racial and ethnic disparities in severe maternal morbidity and mortality. Adopting a thematic analysis approach, we coded and analyzed transcripts using NVivo 12 software. Open coding and selective coding were conducted to identify themes related to health care practitioner- and maternity services-level determinants.

RESULTS

Overall, 20 health care practitioners or administrators were interviewed. Primary themes related to health care practitioners included implicit bias and explicit racism, lack of communication and lack of positive patient-health care practitioner relationships, lack of cultural sensitivity, and variation in clinical knowledge and experience. Primary themes related to maternity services included lack of accessibility, inadequate quality and content of care, lack of continuity of care, discriminatory facility policies, and workforce shortages and lack of diversity. Strategies suggested by participants to address these factors included bias trainings for health care practitioners, improvements in racial and interdisciplinary diversity in the maternity workforce, and evidence-based interventions such as group prenatal care, disparities dashboards, simulation trainings, early warning signs criteria, and coordinated care.

CONCLUSION

We gained diverse perspectives from health care practitioners and administrators on how maternity health care practitioner and maternity health services factors contribute to inequities in maternal health in Alabama. Strategies to address these contributing factors were multifaceted.

Blinding to Circumvent Human Biases: Deliberate Ignorance in Humans, Institutions, and Machines

Inequalities and injustices are thorny issues in liberal societies, manifesting in forms such as the gender-pay gap; sentencing discrepancies among Black, Hispanic, and White defendants; and unequal medical-resource distribution across ethnicities. One cause of these inequalities is implicit social bias-unconsciously formed associations between social groups and attributions such as "nurturing," "lazy," or "uneducated." One strategy to counteract implicit and explicit human biases is delegating crucial decisions, such as how to allocate benefits, resources, or opportunities, to algorithms. Algorithms, however, are not necessarily impartial and objective. Although they can detect and mitigate human biases, they can also perpetuate and even amplify existing inequalities and injustices. We explore how a philosophical thought experiment, Rawls's "veil of ignorance," and a psychological phenomenon, deliberate ignorance, can help shield individuals, institutions, and algorithms from biases. We discuss the benefits and drawbacks of methods for shielding human and artificial decision makers from potentially biasing information. We then broaden our discussion beyond the issues of bias and fairness and turn to a research agenda aimed at improving human judgment accuracy with the assistance of algorithms that conceal information that has the potential to undermine performance. Finally, we propose interdisciplinary research questions.

Potential influence of nurses' implicit racial bias on maternal mortality

Stark disparities persist in maternal mortality and perinatal outcomes for Black and other birthing people of color, such as Native Americans, and their newborns compared to White people in the United States. An increasing body of research describes the phenomenon of implicit racial bias among providers and how it may affect communication, treatment decisions, the patient care experience, and health outcomes. This synthesis of literature reviews and distills current research on the presence and influence of implicit racial bias among nurses as it may relate to maternal and pregnancy-related care and outcomes. In this paper, we also summarize what is known about implicit racial bias among other types of healthcare providers and interventions that can mitigate its effects, identify a gap in research, and recommend next steps for nurses and nurse researchers.

Effects of Mass Shootings on Mental Illness Stigma in the United States

Although the vast majority of people with mental illness (PWMI) are not violent, Americans tend to think they are more dangerous than the general population. Because negative media portrayals may contribute to stigma, we used time-series analyses to examine changes in the public's perceived dangerousness of PWMI around six mass shootings whose perpetrators were reported to have a mental illness. From 2011 to 2019, 38,094 U.S. participants completed an online study assessing implicit and explicit perceived dangerousness of PWMI. There were large, upward spikes in perceived dangerousness the week of the Sandy Hook mass shooting that were relatively short-lived. However, there was not a consistent pattern of effects for other events analyzed, and any other spikes observed were smaller. Effects tended to be larger for explicit versus implicit perceived dangerousness. Sandy Hook seemed to temporarily worsen perceived dangerousness of PWMI, but this pattern was not observed for other mass shootings.

A 3D framework of implicit attitude change

According to early theories, implicit (automatic) social attitudes are difficult if not impossible to change. Although this view has recently been challenged by research relying on experimental, developmental, and cultural approaches, relevant work remains siloed across research communities. As such, the time is ripe to systematize and integrate disparate (and seemingly contradictory) findings and to identify gaps in existing knowledge. To this end, we introduce a 3D framework classifying research on implicit attitude change by levels of analysis (individual vs. collective), sources of change (experimental, ontogenetic, and cultural), and timescales (short term vs. long term). This 3D framework highlights where evidence for implicit attitude change is more versus less well established and pinpoints directions for future research, including at the intersection of fields.

Implicit trauma identity associations in treatment-seeking U.S. military personnel do not predict or change in response to cognitive processing therapy for PTSD

OBJECTIVE

This study evaluated implicit associations (i.e., associations in memory that are automatically activated and difficult to control consciously) related to trauma and one's self in the context of a clinical trial for active duty service members seeking treatment for posttraumatic stress disorder (PTSD). Previous studies with nontreatment-seeking community samples found that implicit trauma identity associations were associated with PTSD symptoms even after controlling for amount of trauma exposure and self-reported negative cognitions about the self. This study extended prior work by evaluating whether trauma-related implicit associations were associated with PTSD and depressive symptoms in a clinical sample seeking treatment for PTSD, predicted PTSD treatment response, or changed over the course of treatment.

METHOD

This secondary analysis examined implicit trauma identity associations using data from a clinical trial evaluating a variable-length adaptation of cognitive processing therapy for military personnel. Participants were 127 active duty U.S. military personnel (13.4% women) seeking PTSD treatment. Implicit trauma identity associations were evaluated at baseline and posttreatment. Study hypotheses and data analysis plan were preregistered.

RESULTS

Contrary to predictions, baseline implicit trauma identity associations were not significantly associated with baseline PTSD or depressive symptoms and did not predict treatment response. Implicit trauma identity associations did not change significantly in response to treatment.

CONCLUSIONS

More tailoring of implicit trauma measures for military personnel and/or treatment-seeking patients may be needed. The measure may lack sensitivity to change in response to treatment and have reduced utility in treatment-seeking samples with high symptom burden and less variability in symptoms. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Ten simple rules for socially responsible science

Guidelines concerning the potentially harmful effects of scientific studies have historically focused on ethical considerations for minimizing risk for participants. However, studies can also indirectly inflict harm on individuals and social groups through how they are designed, reported, and disseminated. As evidenced by recent criticisms and retractions of high-profile studies dealing with a wide variety of social issues, there is a scarcity of resources and guidance on how one can conduct research in a socially responsible manner. As such, even motivated researchers might publish work that has negative social impacts due to a lack of awareness. To address this, we propose 10 simple rules for researchers who wish to conduct socially responsible science. These rules, which cover major considerations throughout the life cycle of a study from inception to dissemination, are not aimed as a prescriptive list or a deterministic code of conduct. Rather, they are meant to help motivated scientists to reflect on their social responsibility as researchers and actively engage with the potential social impact of their research.

Prospective Teachers’ Beliefs About Human Intelligence in a Turkish Sample

Research consistently reports a moderate to a strong relationship between intelligence and academic performance. For about a century, the concept of intelligence has often been used in the definition of giftedness and the identification of gifted students along with other data sources, although some experts are against it. An understanding of prospective teachers' beliefs about intelligence is important to unearth how they perceive intelligence and giftedness. We replicated Warne and Burton's (2020) study with 157 prospective Turkish teachers. They were selected using an online convenience sampling method from various departments of a faculty of education. Of the participants, 72.6% were female and 27.4% were male. We adapted Warne and Burton’s (2020) survey, translating it to Turkish and administered it online to understand the prospective teachers’ beliefs about intelligence as well as to examine if these beliefs differ across cultures. We found that the prospective teachers’ understanding was mostly in line with the original study as well as the mainstream views of intelligence. We also found similar results to the original study, regarding the components of intelligence. Like the original study, the Turkish sample showed an understanding of the relationship between education and intelligence; however, the items about biological and genetic influences on intelligence, the plausible causes of group differences, the life outcomes of intelligence, and a cross-cultural comparison of intelligence had a low response uniformity in both studies. Similar findings across samples may be attributed to common, popular views as well as similar textbooks or other resources used in both cultures. The samples (e.g., educational level and age) may be partially responsible for the differences in the findings across both cultures.

Racial and Ethnic Differences in Internal Medicine Residency Assessments

Importance

Previous studies have demonstrated racial and ethnic inequities in medical student assessments, awards, and faculty promotions at academic medical centers. Few data exist about similar racial and ethnic disparities at the level of graduate medical education.

Objective

To examine the association between race and ethnicity and performance assessments among a national cohort of internal medicine residents.

Design, Setting, and Participants

This retrospective cohort study evaluated assessments of performance for 9026 internal medicine residents from the graduating classes of 2016 and 2017 at Accreditation Council of Graduate Medical Education (ACGME)-accredited internal medicine residency programs in the US. Analyses were conducted between July 1, 2020, and June 31, 2022.

Main Outcomes and Measures

The primary outcome was midyear and year-end total ACGME Milestone scores for underrepresented in medicine (URiM [Hispanic only; non-Hispanic American Indian, Alaska Native, or Native Hawaiian/Pacific Islander only; or non-Hispanic Black/African American]) and Asian residents compared with White residents as determined by their Clinical Competency Committees and residency program directors. Differences in scores between Asian and URiM residents compared with White residents were also compared for each of the 6 competency domains as supportive outcomes.

Results

The study cohort included 9026 residents from 305 internal medicine residency programs. Of these residents, 3994 (44.2%) were female, 3258 (36.1%) were Asian, 1216 (13.5%) were URiM, and 4552 (50.4%) were White. In the fully adjusted model, no difference was found in the initial midyear total Milestone scores between URiM and White residents, but there was a difference between Asian and White residents, which favored White residents (mean [SD] difference in scores for Asian residents: -1.27 [0.38]; P < .001). In the second year of training, White residents received increasingly higher scores relative to URiM and Asian residents. These racial disparities peaked in postgraduate year (PGY) 2 (mean [SD] difference in scores for URiM residents, -2.54 [0.38]; P < .001; mean [SD] difference in scores for Asian residents, -1.9 [0.27]; P < .001). By the final year 3 assessment, the gap between White and Asian and URiM residents' scores narrowed, and no racial or ethnic differences were found. Trends in racial and ethnic differences among the 6 competency domains mirrored total Milestone scores, with differences peaking in PGY2 and then decreasing in PGY3 such that parity in assessment was reached in all competency domains by the end of training.

Conclusions and Relevance

In this cohort study, URiM and Asian internal medicine residents received lower ratings on performance assessments than their White peers during the first and second years of training, which may reflect racial bias in assessment. This disparity in assessment may limit opportunities for physicians from minoritized racial and ethnic groups and hinder physician workforce diversity.

Neural Basis of Prejudice and Prejudice Reduction

Social prejudices, based on race, ethnicity, gender, or other identities, pervade how we perceive, think about, and act toward others. Research on the neural basis of prejudice seeks to illuminate its effects by investigating the neurocognitive processes through which prejudice is formed, represented in the mind, expressed in behavior, and potentially reduced. In this article, we review current knowledge about the social neuroscience of prejudice regarding its influence on rapid social perception, representation in memory, emotional expression and relation to empathy, and regulation, and we discuss implications of this work for prejudice reduction interventions.