Michigan: Implicit (Unconscious) BiasPage 8 of 11

7. Research on Implicit Bias in Access and Delivery of Healthcare

Research looks at how biases can arise in information processing, decision-making, and behavior in ways that are reinforced by historical, cultural, institutional, and interpersonal factors. Interventions consider the importance of the broader social context and address forces that contribute to inequities (Elek and Miller, 2021).

The All of Us Research Program is a national effort to accelerate health research by exploring the relationship between lifestyle, environment, and genetics. The goal is to build a national database from at least one million participants (Mapes et al., 2020).

All of Us has formally designated the following groups as historically underrepresented:

  • Those who have inadequate access to medical care.
  • People under the age of 18 or over 65.
  • People with an annual household income at or below 200% of the federal poverty level.
  • People with cognitive or physical disabilities.
  • Those with less than a high school education or equivalent.
  • Members of a sexual or gender minority or are intersex.
  • People living in rural or non-metropolitan areas (Mapes et al., 2020).

The UNITE initiative was established by the National Institutes of Health to identify and address structural racism within the scientific community. UNITE aims to establish an equitable and civil culture within the biomedical research enterprise and reduce barriers to racial equity in the biomedical research workforce. To reach this goal, UNITE identifies opportunities, makes recommendations, and develops and implements strategies to increase inclusivity and diversity in science. (NIH, 2022, March 2).

Measuring Implicit Bias

Measures of implicit bias rely on the assumption that automatic associations between two concepts will influence behavior in a measurable way (e.g., reaction time, sweat). Two of the most common implicit measures are (1) the Implicit Association Test (IAT) and (2) sequential priming procedures (Elek and Miller, 2021).

The Implicit Association Test

Implicit bias, which can influence provider communication patterns and clinical decision-making 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).

The IAT is primarily used in research studies but is often used in educational 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 Implicit Association Tests that are designed to measure attitudes and beliefs that people may be unwilling or unable to report.

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 a useful tool 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 should 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 based on evidence demonstrating that when two concepts are associated in a person’s memory, the presentation of 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

A simple questionnaire can be used to assess individual biases (NCCC, Nd).

Do my biases:

  1. Impact the amount of time I spend with patients?
    ___ Yes   ___ No
  2. Influence how I communicate with patients and their families?
    ___ Yes   ___ No
  3. Hamper my capacity to feel and express empathy toward my patients?
    ___ Yes   ___ No
  4. Affect the types of treatment and medications I recommend?
    ___ Yes   ___ No
  5. Interfere with my capacity to interact positively with my patients and their families?
    ___ Yes   ___ No

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.