The Insidiousness of Unconscious Bias in Schools

From the article by Seth Gershnson and Thomas S. Dee at Brookings:

Humans frequently make automatic decisions at a subconscious level. The human brain’s capacity for reflexive decisionmaking is what Nobel Laureate Daniel Khaneman calls “System 1” (as opposed to the more analytical, thoughtful, deliberate decision making of “System 2”) in the best-selling “Thinking, Fast and Slow.” This evolutionary adaptation was, and is, sometimes necessary for survival. However, these automatic responses occur via the rapid processing of new information through existing patterns of thought. Thus, because our automatic responses are shaped by our lived experiences and the broader social contexts in which we live and work, a pervasive byproduct of reflexive decisionmaking is unconscious bias (UB), which is also referred to as implicit bias or implicit social cognition.

Specifically, UB is the phenomenon in which stereotypes, positive or negative, influence decisions and behaviors without the individual consciously acting on the stereotype or being aware that he or she is doing so. Moreover, UB can occur even when individuals know or believe the stereotype to be false.

The insidiousness of UB is that it can create self-fulfilling prophecies that create and perpetuate inequities between in- and out-groups, even when the initial stereotype was incorrect (and there was no pre-existing difference between in- and out-group members). This post outlines some promising interventions we identify in a recent report, commissioned by Google’s Computer Science Education Research Division, that can short-circuit the recursive processes and self-fulfilling prophecies triggered by UB.

In this report, we argue that the consequences of UB may be particularly salient in the hierarchical environments of schools. Specifically, UB likely perpetuates socio-economic, gender, and racial gaps in educational outcomes such as academic performance, engagement with school, course and major choice, and persistence in higher education, particularly among historically disadvantaged and underrepresented groups such as low-income and racial-minority students. These gaps in educational outcomes then manifest in corresponding workplace disparities in pay, promotions, and employment.

Indeed, there is ample evidence of UB in educational settings, both in experimental labs and “in the field” with real individuals who were unaware of their participation in an experiment. For example, Moss-Racusin and colleagues conducted a lab experiment in which science faculty at research universities reviewed fictitious applications for a hypothetical lab assistant position and systematically rated male “applicants” higher than otherwise-identical female “applicants.” In a similar field experiment, Milkman and colleagues emailed meeting requests from fictitious prospective doctoral students to professors and found that white male “students” received more, and faster, responses than female and non-white students, particularly in higher-paying STEM careers like computer science and engineering. A recent field experiment conducted by one of us and colleagues found that the instructors of online courses were nearly twice as likely to respond to discussion-forum comments placed by students who were randomly assigned white-male names. Consistent with a UB interpretation, the pro-male bias was observed among both male and female faculty in these studies. The K-12 context is also ripe with suggestive, quasi-experimental evidence of pervasive UB in the form of systematic grading biases and student-teacher racial match effects.

Additionally, individuals from stereotyped out-groups themselves react negatively to seemingly innocuous environmental factors, such as the demographic composition of a classroom, the race or sex of an instructor or proctor, and even the design and decoration of the classroom. One example of this is the phenomenon of stereotype threat, whereby the mere threat of being stereotyped by a white (male) instructor, even when no outright bias is expressed, may distract black (female) students, ultimately leading to poor performance on exams and even disengagement from school.

Read the full article.


Doctors’ biases mean black men don’t get the same treatment in healthcare

From the article on Medical Xpress:

A new qualitative study has shown that previous bias and fear of black men likely result in them not getting the same healthcare as white male patients.

Published by the Journal of Racial and Ethnic Health Disparities, the study by Marie Plaisime, a 2014 graduate of Drexel University’s Dornsife School of Public Health and current Howard University student, found that health providers largely perceive black male patients with bias, fear and discomfort.

These findings in “Healthcare Providers’ Formative Experiences with Race and Black Male Patients in Urban Hospital Environments” back up past quantitative studies that found that black men are less likely to receive cardiac medical procedures such as cardiac catheterizations and coronary angioplasties compared to white men presenting with identical symptoms.

Plaisime’s work on this study was conducted under Jennifer Taylor, PhD, associate professor in the Dornsife School of Public Health.

“Racial bias in healthcare is worrying because one of the higest values of medical practice is to ‘do no harm,'” Taylor said. “Whether explicit or implicit, our racial biases can direct patients to different and unequal treatments that do not make them whole. No one goes into medicine wanting this to happen, so we must look at both our personal and professional socialization to check in on how those experiences may influence our actions as caregivers.”

Participants in the study included physicians, nurses and medical students from two urban university hospitals in the United States. Interviews were conducted with them to gather qualitative data on how formative childhood, personal and professional experiences with race and black men influences interactions with male, black patients today.

Plaisime and her team found themes across the interviews that were reflective of personally-mediated racism and concluded with findings of how the perception of black males and cognitive dissonance appear to influence providers’ approaches with black male patients.

Both black and white medical providers who were interviewed described examples when black male patients were treated differently based on race.

For example, one physician noted, “I’ve had … a black patient who I think had not been offered a procedure because of either where he was economically or where he was assumed to be economically because of his race. He clearly needed to be catheterized for his presentation and it was suggested that we do medical management. I spoke with the cardiologist and as soon as we started talking, he said, ‘Oh well, of course, we’ll cath’ him.’ And so, like that, it changed… certainly have enough anecdotal experience to think that people are probably [being] treated differently based on race.”

Furthermore, white providers described experiencing a sense of fear or discomfort and discussed their lack of exposure to black males. In contrast, black providers shared their frustration with media portrayal of black men, the pressure they feel to avoid confirming negative stereotypes associated with black culture, and instances of patients discriminating against them.

Read the full article.

Addressing Mental Health in African Americans Through FAITH

From the article by Dr. Tiffany Haynes on the NIMHD Insights Blog:

Rural African Americans are disproportionately exposed to numerous stressors, such as poverty, racism, and discrimination,  that place them at risk for experiencing elevated levels of depressive symptoms. Elevated levels of depressive symptoms can lead to a host of negative outcomes, including poor management of chronic illnesses (e.g., hypertension, diabetes), poor social and occupational functioning, and development of clinical depression. Although effective treatments for decreasing depressive symptoms exist, structural barriers (e.g., lack of available services, transportation) and perceptual barriers (e.g., stigma, fear of misdiagnosis) impede the use of traditional mental health services within these communities, resulting in a significant unmet psychiatric need. Failure to develop culturally appropriate strategies to provide adequate, timely care to rural African Americans can result in a significant public health crisis.

African American churches have been identified as potential venues for providing depression education and treatment for rural African Americans. Within the African American rural community, churches represent a key portal through which as much as 85% of the community can be reached. Churches have been used to address physical health outcomes in those communities, but few have focused primarily on addressing mental health outcomes. Through the NIMHD-funded project entitled “Faith Academic Initiatives to Transform Health (FAITH) in the Delta,” our partnership, consisting of faith community leaders and University of Arkansas for Medical Science researchers, conducted formative work in the Arkansas Delta. Data suggested that community members consider elevated depressive symptoms to be a significant unmet need. Furthermore, community members suggested that attempts to improve depressive symptoms should do the following:

  1. Provide education about depressive symptoms. Recognizing when depressive symptoms become a clinical problem is the first step toward receiving adequate treatment. However, rural African Americans report difficulties in differentiating between normal sadness and clinically significant depressive symptoms. Providing education about depressive symptoms allows rural African Americans to make informed treatment decisions.
  2. Address the role that stress from social inequities plays in the development and maintenance of depressive symptoms. Rural African Americans correctly realize that prolonged exposure to stress caused by social inequities is a significant factor in the development and maintenance of depressive symptoms. Treatments that conceptualize depressive symptoms as normal reactions to stress are more culturally acceptable in rural African American communities.
  3. Find ways to increase social support for those experiencing depressive symptoms. Stigma is a significant concern in rural communities. Rural African Americans experiencing depressive symptoms tend to socially isolate themselves, which, in turn, can worsen depressive symptoms.
  4. Provide mental health interventions in community-based settings. Residents suggest that offering mental health services in community settings, such as churches, would allow residents to receive treatment in less stigmatizing places and improve access to mental health care.

Read the full article.

Communities in Action: Pathways to Health Equity

From the blog article by the Robert Wood Johnson Foundation:

Americans today live shorter, sicker lives than people in other developed countries, and, across the nation, health varies by income, education, race and ethnicity, and geography. Warning that the United States will pay the high price in lost lives, wasted potential and squandered potential resources until these gaps are closed, a comprehensive report from the National Academies of Sciences, Engineering, and Medicine (NASEM) calls for leaders across sectors to make health equity a priority for the nation.

Why Does Health Equity Matter?

When health equity is achieved, “everyone has the opportunity to attain full health potential, and no one is disadvantaged from achieving this potential because of social position or any other socially defined circumstance,” the report says. And ensuring that opportunity is crucial not just for individuals, but also for the nation’s economic and growth prospects, for its national security and for its communities’ well-being and vibrancy.

Data show the costs of current health inequities: The report estimates that racial health disparities alone are projected to cost health insurers $337 billion between 2009 and 2018. The impact on national security is also high, with some 26 million young adults unqualified to serve in the U.S. military because of persistent health problems, or because they are poorly educated or have been convicted of a felony.

…The Cost of Inequality

  • In 2015, the percentage of low-birthweight infants in the U.S. rose for the first time in seven years.
  • Racial health disparities alone are projected to cost health insurers $337 billion between 2009 and 2018.
  • Health care spending accounted for 17.5 percent of GDP in 2014.
  • In 2014, VA-enrolled veterans accounted for 17.9 percent of suicide deaths among U.S. adults.
  • People with disabilities are more than twice as likely not to receive medical care because of cost.

Read the full article.

Lack of Sidewalks is a Health Issue

From the Op-Ed by Amie Gray Koch in The News & Observer:

During my daily visits to ill patients throughout Durham County, it is staunchly apparent that many low income neighborhoods often predominately high in racial and ethnic minorities, have no proper functional sidewalks. As a nurse practitioner who provides home visits to patients I see a blatant disparity in Durham neighborhoods. My patients who are in dire need of food, transportation and mobility assistance are often the ones living in housing that is not wheelchair or walker friendly, far from grocery stores, without sidewalks and have living environments that even getting in and out of the front door is an overwhelming challenge. In 2016 Thornton et al. published a study identifying low-income neighborhoods and neighborhoods with a high proportion of racial and ethnic minorities had poorer aesthetics, had fewer sidewalks and crosswalks. Sidewalks are needed to get safely to the bus stops, grocery stores, health care appointments and to be connected with social and spiritual support.

Utilizing public transportation may be the only means of transportation for many residents in the low income neighborhoods, however there are limited sidewalks to get to transit access locations, which is a serious crisis for those requiring the use of a cane, walker or wheelchair.

Having access to a suitable grocery store with fresh healthy foods is important for health. In many low income neighborhoods adequate grocery stores are a privilege that is not a reality, so residents need to walk to public transit, then to a grocery store, or succumb to what is available at a smaller store with fewer healthy choices, often which are more expensive. Installing sidewalks could improve health, access to grocery stores as well as improving self-worth.

Healthy lifestyle is nearly impossible when there is no access to sidewalks, parks and ability to safely exercise. As a health care provider, after going into the homes of patients I now realize, if people have limited transportation or a home that is not easily manageable with their physical ability as well as no sidewalks, it is highly unlikely for a person to be able to achieve the exercise health care providers request. It was found by 2016 Thronton et al. that sidewalk quality, crosswalks, and neighborhood aesthetics may affect residents’ physical activity.

Read the full article.

Useful Resources: Considering the Impact of Proposed Legislation on Populations of Color

In the the third report from its Race for Results Case Study Series, the Annie E. Casey Foundation describes the use of racial equity impact assessment tools to improve policy making. The report focuses on four areas:

  • Why it is critical to measure the impact of any proposed legislation or change in policy on communities of color.
  • How racial equity impact assessments can lead to smarter and more targeted public investments.
  • How racial equity impact assessments keep decision-making focused on data and facts, not assumptions and long-held subjective beliefs.
  • How advocating and using racial equity impact assessments can position leaders and elected officials as strong champions of equity.

Download the report to learn more.

Attending To The ‘Human Element’ Is Key To Keeping Patients Healthy

From the article by Shefali Luthra on Kaiser Health News:

Racial minorities and lower-income people typically fare far worse when it comes to health outcomes. And figuring out why has long been one of health care’s black boxes. Forthcoming research may help shed light on what’s driving those inequities — and how the system can fix them.

What is needed? Better bedside manner, so patients actually trust their doctors. Communication that is easily understood by everyday people. And transparency about what medical care costs, plus a willingness to discuss how price points fit into consumers’ health decisions.

Those ideas were highlighted in a white paper presented recently at a health communication conference sponsored by the Centers for Disease Control and Prevention. The findings, which will be published in full later this fall, are based on interviews with 100 health professionals and 65 “disadvantaged patients,” along with a nationally representative survey of 4,000 consumers. The examination is part of a larger project funded by the Robert Wood Johnson Foundation, a health-focused nonprofit. It was conducted by the Altarum Institute, a research and consulting organization.

The paper suggests that “implicit bias” — doctors and nurses subtly or subconsciously treating some patients differently than others — or patients’ perception of it could have consequences for people’s health. Patients who felt that they had experienced bias based on factors like race, income or insurance were less likely to follow advice about medication, for instance, and ended up sicker in the long run.

“We for a long time have neglected the human element,” said Chris Duke, director of Altarum’s Center for Consumer Choice in Health Care, and the white paper’s author. “The number one predictor of patient satisfaction is if your nurse listened to you. We neglect this at our great peril.”

Duke stressed that the research isn’t enough to draw conclusions about causality — that feeling disrespected causes worse health. But the study builds on years of investigation that suggests implicit bias and how patients perceive it could contribute to differences in health outcomes.

Insurance status was the largest predictor of how patients viewed their doctor-patient interaction, Duke said. People on Medicaid, the state-federal health insurance program for low-income people, or who were uninsured, were more likely to perceive disrespect than those with private insurance or Medicare, which provides coverage for senior citizens and some disabled people. Income was the next predictor for how well people felt they were treated. After that came race.

Meanwhile, racial minorities and low-income people also were more likely to be sensitive to concerns about a doctor’s bedside manner, and to seek out someone they thought would treat them well, Duke noted.

Often, these patients cue in on subtle behaviors, such as the doctor not making eye contact or not asking questions about their symptoms and health conditions, their lifestyle or their preferences on how to manage a disease. But that can be enough, Duke said, to keep people from seeking care, or following through on medical advice.

Read the full article.


Patient Navigators: The Missing Link to Increasing Minority Participation in Cancer Clinical Trials

From the  article on the NIMHD website:

A study conducted by the University of Alabama at Birmingham (UAB) and funded by the National Institute on Minority Health and Health Disparities that promotes the inclusion of minorities in cancer clinical trials has been selected by the American Society of Clinical Oncology to be featured in Clinical Care Advances 2016, an annual review of major advances in clinical cancer research.

The study, led by Mona Fouad, M.D., MPH, director of the UAB Minority Health and Health Disparities Research Center, focuses on the use of patient navigators as a liaison between medical staff and patients, to inform and enroll eligible African American cancer patients into clinical trials.

Dr. Fouad stated this model came as a result of the staggering disparities in clinical cancer research, currently fewer than 10 percent of patients enrolled in cancer clinical trials are minorities.

To achieve accurate results, cancer clinical trials require participation of individuals from all cultural and ethnic backgrounds, however enrollment and retention of minority groups often proves challenging.

“We started with the patient navigation model to assist under-resourced patients in our cancer center,” said Fouad. “We’ve been using patient advocates for the last two decades to promote cancer screening, but then we started thinking, ‘Well, what if they have a positive test?’ ‘How do we link them to the care needed to start treatment?’”

Patient advocates were trained to become patient navigators as a way to steer patients in the right direction to locate resources and enlist the best possible care to treat their cancer diagnosis.

“We were successful in providing this model to help patients comply and complete their cancer care, and when we accomplished that, the compliance rate was as high as 95 percent in low-income populations. So then we thought, why don’t we test this model to see not only if it helps patients to access care, but can it educate them about clinical trials as well,” said Fouad.

Fouad admitted that while many patients were reluctant at first, they came around to the idea once it was explained in detail and resources were provided to make clinical trial involvement easier for them.

“What we found by doing this is that a lot of minority patients are scared about therapeutic trials. They believe that they are experiments, and some were reluctant due to the times they’d have to be available for the trials, so the navigators were able to help with those reservations,” stated Fouad, explaining the navigators were trained to identify resources to aid trial participants.

“Navigators connected patients with social workers and did what they could to make sure all the patient had to focus on was their care and involvement in the clinical trial,” said Fouad.

While it is generally the job of medical staff to offer clinical trials to every eligible patient, the study revealed that protocol is not always followed with minority or lower socioeconomic patients.

“Sometimes, even the physician, if they know there is a patient coming from a rural area or having difficulty traveling, they tend to just not offer them clinical trials because they don’t want to increase the burden on the patient or they think the patient is not going to be a compliant participant, so, unintentionally, they just won’t offer them the trials,” said Fouad.

Read the full article.

This doctor breaks down language and cultural barriers to health care

Excerpts from the article by Kimbriell Kelly in the Washington Post:

….His experiences as a young immigrant proved pivotal for [Eliseo] Pérez-Stable, who grew up to become a physician and scientist, whose research has documented the impact of language barriers and other issues on the health of Latinos. At 64, he leads the National Institutes of Health’s division for funding and guiding minority health research.

“From this stage, I can see the opportunity to shape the field and promote the development of the next generation in minority health and health disparities,” he said last week as he marked his first year as director of the National Institute on Minority Health and Health Disparities.

Some of his motivation dates to childhood. At that first school, he never learned English but excelled in math because numbers were their own familiar language. He moved to Pittsburgh once his parents arrived, where he was called racist nicknames, asked if he knew about refrigerators and teased about his favorite baseball player, Roberto Clemente.

“I think my experiences as an immigrant child, my efforts at assimilation and the experiences of the external world in the late 1960s shaped my perspective on society,” he said.

…Pérez-Stable began doing research in the 1980s, when he was a professor of medicine at the University of California at San Francisco. The city’s racial and ethnic disparities were clear to him; certainly, there was no empowered Latino community as he had known growing up in Miami and attending college and medical school there.

“You’d walk into UCSF, and the only people of color you would see would be behind the desk or the custodians,” he said. “There were very few physicians who were minority.”

He studied tobacco use among Latinos and the effectiveness of smoking-cessation policies, the impact of informal translators on Latino health, minority aging and cancer prevention among Latinos.

“At the time, people were saying you quit smoking for your own health,” he said. “And what we discovered in working with Latinos … was that the big motivator was going to be not just for their own health, but also for [their family and] others around them.”

His research on interpreters found that communication barriers made it difficult to understand a patient’s symptoms and therefore treat their diseases. Errors were made, and ad-hoc interpreters, such as family members or office assistants who happened to speak the language, were being used instead of professional interpreters.

“Documenting empirically that it was better to not do that, I think, was an important step to provide evidence for policy changes,” Pérez-Stable said.

Pérez-Stable had been in the Bay Area for 37 years, treating patients and conducting research, when he received a call for applicants to head the National Institutes of Health’s lead organization on minority health. The outgoing director, John Ruffin, was retiring after nearly a quarter-century at NIH.

As part of the hiring process, leaders there asked about Pérez-Stable’s vision. He wanted to bring the social sciences more under the umbrella of the medical sciences, he told them, to better study health disparities. He envisioned research to show how people’s socioeconomic status and everyday lives affect their health. He wanted to know whether being a victim of abuse, for example, or struggling with food insecurity, poverty or family tension, has a biological impact on long-term health.

“Being stressed-out as a baby for whatever reason, or having bad events happen to you as a young child, may trigger changes in biology that may lead to disease when you’re 40 or 50,” Pérez-Stable explained recently, sitting in his sunlight-flooded office in Bethesda, about 15 minutes from NIH’s main campus.

…Pérez-Stable started his new job last September. Created in 2010, his institute is the newest at NIH, and its second-smallest, with a $281 million budget for research, training and public education. Some of the grant money is set aside in a program to target underresearched institutions. For example, in 2014 the institute funded a $15.5 million grant to Morehouse School of Medicine in Atlanta to expand its capacity to conduct research on minority health and health disparities.

Similarly, in 2016, a $9.5 million grant was awarded to Florida International University to conduct community-based research to reduce high rates of HIV.

…In his role at NIH, he’s intent on providing grants toward causes he has long supported.

“I would like to … establish a greater depth and credibility and acceptance of the science of minority health and health disparities,” he said. “So that people say, yeah, this is important to know what happens in the human behavior, human biology; to understand what the factors of race, ethnicity and socioeconomic status are on how the brain functions, or how childhood experiences affect adult health.”

Read the full article.

Overcoming Lower-Income Patients’ Concerns About Trust And Respect From Providers

From the blog post by Chris C. Duke and Christine Stanik on Health Affairs Blog:

For our Right Place, Right Time research initiative, launched in January 2016, we interviewed vulnerable patients, including low-income patients, the uninsured, family caregivers, and non-English speakers, to learn their most urgent concerns about the health care system and the information they need to make health decisions. We expected to hear that health care information was too confusing and price information was difficult to find—and we have—but the issue lower-income participants were most passionate about surprised us: they reported widespread distrust of the health care system and the feeling that they were seen as “less than” by health care professionals.

For many lower-income participants, trust and respect were their primary concern with the health care system, even more than the quality of the health care they received. Participants felt they were treated with less respect because of their income, insurance status, and race. This is consistent with past research finding that distrust in the health care system is high, and strongly associated with poor health.

In contrast, middle-income study participants did not report many negative experiences with providers, and those with negative interactions did not feel they were being targeted or discriminated against. It was as if lower- and middle-income patients had experienced two different health care systems.

Lower-income participants gave examples of a lack of trust and respect, including providers avoiding eye contact, speaking condescendingly, showing physical disgust when touching patients, brushing off patient concerns and symptoms, and ignoring adverse events that patients reported from prescribed treatments. Most of this criticism was directed at physicians of all types, and less directed at nurses and other provider types, who were perceived as having more in common with patients and as having no financial motivations in providing care. It was clear from participants’ descriptions that these events colored the entire patient experience and were highly influential in determining the care they later sought and received.

Read the full blog post.