California: Implicit Bias for Healthcare Providers (341)Page 6 of 10

5. Evaluating the Presence of Implicit Bias in Healthcare

Evaluating the presence of implicit bias starts by collecting and analyzing data and examining outcomes for different racial, ethnic, and socioeconomic groups. Information gathered from surveys, interviews, and focus groups can help healthcare leaders identify the presence of bias within their organizations.

Reviewing healthcare policies and procedures helps an organization evaluate the extent of potential barriers to access or discriminatory practices. Comparing data and findings from California to national benchmarks for healthcare access and delivery can help identify significant disparities (KHIP, 2020).

According to a 2023 California Health Policy Survey, half of Californians report skipping or delaying healthcare due to cost in the past 12 months. Of those who skipped or delayed care, half of them say their condition got worse as a result. More than a third report having medical debt, and of those, about 20% report owing $5,000 or more. Californians with lower incomes are more likely than those with higher incomes to report medical debt (Bailey et al., 2023).

In terms of equity, more than half of Californians experienced at least one negative interaction with a healthcare provider in the last few years. Black and Latino/x Californians were more likely to report having negative experiences than White and Asian Californians (Bailey et al., 2023).

Measuring Implicit Bias

Measures of implicit bias rely on the assumption that automatic associations between two concepts will influence behavior in a measurable way. Two of the most common implicit measures are (1) the Implicit Association Test (IAT) and (2) sequential priming procedures (Elek and Miller, 2021). Bias questionnaires are also commonly used to help healthcare providers identify and acknowledge conscious and unconscious biases.

The Implicit Association Test

Implicit bias is often measured with the Implicit Association Test (IAT), a publicly available response latency test that pairs images and value-laden words (Gonzalez et al., 2021). Although primarily used in research, the IAT can be useful in other settings as an interactive exercise intended to illustrate implicit bias. A variety of IATs (e.g., on gender, sexuality, race, religion, weight, skin tone, age, disability, and more) are available for free from Harvard’s Project Implicit (Elek and Miller, 2021).

Project Implicit: Identifying Bias

Project Implicit has developed a series of IATs are designed to measure associations that either reinforce or contradict your conscious beliefs. An IAT may suggest that you have implicit associations based on race, religion, sexual orientation, age, disability, or other criteria. IATs can be useful in identifying potential biases, attitudes, and associations, but these tests alone should not be expected to overcome the impact of biases of the test taker.

How do IATs Work?

The IAT measures the strength of associations between concepts (e.g., African American people, gay people) and evaluations (e.g., good, bad) or stereotypes (e.g., athletic, clumsy). When performing an IAT, you are asked to quickly sort words into categories that are on the left- and right-hand side of the computer screen by pressing different keys.

A person is said to have an implicit preference for thin people, for example, if the person is faster to respond when the word “thin” is connected to “good” words, such as “happy” or “wonderful,” rather than “bad” words, such as “painful” or “terrible.”

What Should I Know Before Taking the IAT?

Project Implicit recommends that IATs be used as an educational tool to develop awareness of implicit preferences and stereotypes, not as a tool for making judgments, such as whether to hire a person. However, research has shown that individuals who are made aware of their implicit biases may be motivated to avoid letting the biases affect their behaviors.

Source: DOJ, Nd.

Sequential Priming Procedures

Sequential priming procedures are intended to demonstrate that when two concepts are associated in a person’s memory, one of those concepts facilitates the recall or recognition of the other. For example, when people are presented with one concept (e.g., a picture of an apple), they are faster at identifying the next concept (e.g., a picture of a banana) when they associate the two concepts in memory (e.g., as fruits). Priming procedures work even if the primes are flashed on a screen so quickly that they are not consciously detected by the respondent (Elek and Miller, 2021).

In one common use of this tool, respondents are briefly presented with a Black or White face immediately before a positive or negative target word appears on the screen. They must then identify, as quickly as possible, the meaning of the presented word as “good” or “bad.” Respondents with racial bias more quickly identify negative words as “bad” and more slowly identify positive words as “good” when that word appears immediately after the presentation of a Black face (Elek and Miller, 2021).

Bias Questionnaires

Bias questionnaires are self-assessment tools designed to help healthcare providers identify and acknowledge conscious and unconscious biases. Bias questionnaires can cover various types of biases, such as racial and ethnic biases, gender biases, age biases, and others. The questions vary in format, but most commonly include Likert-scale items or open-ended prompts. The results can be used for individual reflection and self-improvement or as part of ongoing diversity and cultural competence training in healthcare organizations. The goal is to promote awareness and reduce the impact of bias on patient care and outcomes.

The following questionnaire, developed by the National Center for Cultural Competence at Georgetown University is an example of a simple tool that can be used to self-assess individual biases (NCCC, Nd).

Do you ever perceive that you are less comfortable with patients who are of a different race than you?
___ Yes   ___ No

Do you know whether (or believe that) your colleagues and other staff with whom you routinely work think that your attitudes and behaviors demonstrate bias? If so, are you open to discussing these issues with them to elicit their point of view?
___ Yes   ___ No

Have patients or their families, directly or through surveys, raised concern about your attitude or the way you communicate with them?
___ Yes   ___ No

Answering yes to any of these questions indicates that you could benefit from interventions to confront and mitigate the impact of bias within your practice setting.