You Don't Know What You Think You Know: Implicit Bias in Health Care and Health Education
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This document contains a presentation given by Meghan Benson on implicit bias in healthcare and health education. The objectives of the presentation are to define implicit bias, acknowledge how it can lead to unconscious categorization of groups, explore how implicit bias may impact healthcare delivery and education, recognize that implicit bias is malleable, and provide ways to recognize and combat implicit bias. The presentation defines implicit bias as attitudes or stereotypes that unconsciously affect our understanding and decisions. It discusses research showing implicit bias towards various social groups and how this bias can negatively impact patient outcomes and trust in healthcare providers. The presentation emphasizes that while implicit bias is shaped by our environment, we can work to "debias" ourselves through ongoing efforts to change associations and promote more
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You Don't Know What You Think You Know: Implicit Bias in Health Care and Health Education
- 1. Meghan Benson, MPH, CHES Director of Community Education meghan.benson@ppwi.org 608-251-6587 ext. 1 You Don’t Know What You Think You Know: Implicit Bias in Health Care & Health Education Safe Healthy Strong 2015 Conference June 5, 2015
- 2. I have received no support or commercial funding for this presentation, or for any products mentioned herein. Copyright © 2015 Planned Parenthood of Wisconsin, Inc.
- 3. Objectives 1. Define implicit bias recognizing that it is invasive and powerful in our society and that it impacts our individual attitudes, intentions, and behaviors toward others. 2. Acknowledge that implicit bias often leads to unconscious categorization of others as either “ingroup” or “outgroup” with the tendency of individuals to favor their own “ingroup.” Copyright © 2015 Planned Parenthood of Wisconsin, Inc.
- 4. Objectives 3. List ways in which implicit bias may impact the delivery of effective health care and the provision of effective health education. 4. Recognize that implicit bias is malleable by replacing old mental associations with new ones through the gradual unlearning of bias. 5. List ways in which individuals can immediately recognize and combat implicit bias in practice as well as ways to engage in the gradual “debiasing” over time. Copyright © 2015 Planned Parenthood of Wisconsin, Inc.
- 5. What is implicit bias? Implicit bias refers to the attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner Copyright © 2015 Planned Parenthood of Wisconsin, Inc. http://kirwaninstitute.osu.edu/wp- content/uploads/2014/03/2014-implicit-bias.pdf
- 6. What is implicit bias? These biases – which can be positive or negative – are activated involuntarily and without our awareness or intentional control These biases are different from known biases that we may choose to act on or choose to conceal from others They do not necessarily align with our declared beliefs or reflect the stances we would explicitly endorse We all have implicit biases! Copyright © 2015 Planned Parenthood of Wisconsin, Inc.
- 7. Implicit Bias Research Research has demonstrated implicit bias toward people based on perceived race, ethnicity, gender expression, age, physical disability, body size, and many more characteristics Copyright © 2015 Planned Parenthood of Wisconsin, Inc.
- 8. Implicit Bias Research Most people show unconscious favoritism toward their “ingroup,” which are people they perceive to be like them (e.g. the same race, the same age, the same gender, etc…), and bias toward others – those they unconsciously identify as “outgroup” Copyright © 2015 Planned Parenthood of Wisconsin, Inc.
- 9. Group Brainstorm Copyright © 2015 Planned Parenthood of Wisconsin, Inc. How might implicit bias impact the delivery of health care or health education?
- 10. Implicit Bias in Health Care Research Negative implicit bias on behalf of health care providers has been correlated with: Decreased client-centered communication More negative client perception of the health care provider or health care interaction Interpersonal treatment Communication with health care provider Trust in health care provider Health care provider’s contextual knowledge (e.g. client’s values and beliefs) Differences in clinical decision-making Copyright © 2015 Planned Parenthood of Wisconsin, Inc. http://kirwaninstitute.osu.edu/wp- content/uploads/2014/03/2014-implicit-bias.pdf
- 11. Implicit Bias in Health Care Research The ambivalent nature of contemporary racial prejudice may create a mismatch between a physician’s positive verbal behavior (a function of conscious egalitarian values) and negative non-verbal behavior (indicating implicit bias); this is likely to make a physician seem especially untrustworthy and duplicitous to those who are vigilant for cues of bias. (Dovidio & Fiske, 2012) Copyright © 2015 Planned Parenthood of Wisconsin, Inc.
- 12. Implicit Bias in Health Care Research At least one study suggests that negative implicit bias may even have an impact on patient health outcomes Chae, Nuru-Jeter, & Adler (2012) found a significant increase in hypertension amongAfrican American men (ages 30-50) correlated to both implicit anti-Black bias on behalf of the patient as well as higher self-reports of discrimination Additional research is needed to determine if implicit bias impacts other health outcomes among this and other demographic groups Copyright © 2015 Planned Parenthood of Wisconsin, Inc.
- 13. Pair & Share Copyright © 2015 Planned Parenthood of Wisconsin, Inc. How might implicit bias impact other areas of work or fields of study?
- 14. Want to test your own implicit biases? Implicit AssociationTest (IAT) Project Implicit at Harvard University Copyright © 2015 Planned Parenthood of Wisconsin, Inc. https://implicit.harvard.edu/implicit/takeatest.html
- 15. Implicit Association Test (IAT) Measures the strength of associations between concepts (e.g. black people or gay people) and evaluations (e.g. good or bad) or stereotypes (e.g. athletic or clumsy) If we already have positive associations with certain concepts, the task of connecting those concepts to positive evaluations or positive stereotypes is easier and quicker – and vice versa Raises awareness about our own implicit biases Copyright © 2015 Planned Parenthood of Wisconsin, Inc. https://implicit.harvard.edu/implicit/takeatest.html
- 16. It’s how we’re wired… Brain imaging research has demonstrated that the unconscious structures of our brain activate when we express implicit bias New research suggests that fMRI scans may be even more reliable at recognizing implicit bias than behavioral tasks, such as the IAT Copyright © 2015 Planned Parenthood of Wisconsin, Inc.
- 17. It’s how we’re wired… Our brain is shaped by our life experiences: How, where, and by whom we were raised Interactions with friends, peers, and coworkers School, community, and religion Media and news are particularly influential Politics and policy Racism, homophobia, sexism, ageism, ableism, and other forms of bias and discrimination are prevalent in our society and in the institutions with which we interact Copyright © 2015 Planned Parenthood of Wisconsin, Inc.
- 18. It’s how we’re wired… This ability to quickly form associations in our brain between what we see in front of us and either a good or bad evaluation was probably very valuable at one point in human evolution… Copyright © 2015 Planned Parenthood of Wisconsin, Inc.
- 19. It’s how we’re wired… Copyright © 2015 Planned Parenthood of Wisconsin, Inc. http://brainsontrial.com/tag/race-bias/
- 20. It’s how we’re wired… Copyright © 2015 Planned Parenthood of Wisconsin, Inc. Amygdala • Plays a primary role in emotions, decision-making, and memory processing • Part of the brain’s “pleasure center” • Activated in “fight or flight” responses Fusiform gyrus • Plays a role in facial recognition • May also help with recognition of colors and words • Influences amygdala responses
- 21. …but it doesn’t mean we can’t change. Copyright © 2015 Planned Parenthood of Wisconsin, Inc. http://www.nature.com/neuro/journal/ v15/n7/abs/nn.3136.html
- 22. …but it doesn’t mean we can’t change. The physical connections that have been made in the unconscious structures of our brains over a lifetime to support implicit bias can be changed with long-term and ongoing efforts to change negative associations into positive ones Copyright © 2015 Planned Parenthood of Wisconsin, Inc.
- 23. …but it doesn’t mean we can’t change. Implicit biases come from the culture. I think of them as the thumbprint of the culture on our minds. Human beings have the ability to learn to associate two things together very quickly—that is innate. What we teach ourselves, what we choose to associate is up to us. - Dr. Mahzarin R. Banaji, quoted in Hill, Corbett, & Rose, 2010, p. 78 Copyright © 2015 Planned Parenthood of Wisconsin, Inc.
- 24. “Debiasing” Active and ongoing process that should continue throughout one’s career and even one’s life It has taken a lifetime to build and strengthen negative association, so it will also take some time to undo them and replace them with positive associations No one will be “debiased” through a one-time activity or a brief training Tips, tools, and suggestions for “debiasing” will be provided – putting those into practice are up to you! Copyright © 2015 Planned Parenthood of Wisconsin, Inc.
- 25. “Debiasing” Activities Activities that have demonstrated effectiveness in addressing implicit bias include: Learning about implicit bias Intergroup contact, including genuine interactions with those perceived as “outgroup” Putting yourself in other people’s shoes Internal motivation and a sense of personal responsibility to change your implicit biases Copyright © 2015 Planned Parenthood of Wisconsin, Inc.
- 26. Client-Centered Communication Centering communication around the client has the potential to remove – or at least distance – your own biases from the dialogue Respectful of client autonomy Collaborative Empowering Copyright © 2015 Planned Parenthood of Wisconsin, Inc.
- 27. Client-Centered Communication in Sexual & Reproductive Health Open-ended questions or statements “Please tell me more about why you feel that way about birth control.” Affirmations “Being the best mom you can be for your kids right now is really important to you.” Reflections “It’s hard for you to make this decision because you don’t think your family or friends would approve.” Summaries (see next slide for example) Copyright © 2015 Planned Parenthood of Wisconsin, Inc.
- 28. Client-Centered Communication in Sexual & Reproductive Health Open-ended questions or statements Affirmations Reflections Summaries “You’ve made up your mind that you want to start using a more effective method of birth control, even though you hear at church that you shouldn’t try to prevent a pregnancy this way. Being able to take care of your kids and doing what is best for your health is also really important to you and your family.You feel confident that this is one thing you can do right now to help with that.” Copyright © 2015 Planned Parenthood of Wisconsin, Inc.
- 29. Resources & References Kirwan Institute. (2015). Implicit Bias Research Review, 2014. Columbus, OH: The Ohio State University.Accessed at http://kirwaninstitute.osu.edu/wp- content/uploads/2014/03/2014-implicit-bias.pdf. Chae DH, Nuru-Jeter AM, & Adler NE. (2012). Implicit racial bias as a moderator of the association between racial discrimination and hypertension: a study of midlife African American men. Psychosomatic Medicine, 74(9), 962-964. Dovidio JF & Fiske ST. (2012). Under the radar: how unexamined biases in decision-making processes in clinical interactions can contribute to health care disparities. AmericanJournal of Public Health, 102(5), 945-952. Hill C, Corbett C, & Rose A. (2010). Why So Few?Women in Science, Technology, Engineering, and Mathematics. Washington, D.C.:AAUW. Kubota JT, Banaji MR, & Phelps EA. (2012).The neuroscience of race. Nature Neuroscience, 15, 940-948. Copyright © 2015 Planned Parenthood of Wisconsin, Inc.
- 30. Please send any feedback or questions to Meghan Benson at meghan.benson@ppwi.org.Thank you! Copyright © 2015 Planned Parenthood of Wisconsin, Inc.
Editor's Notes
- Provide a personal example of known biases: For example, I grew up in West Virginia, and saw many people around me choosing to act on know biases toward people of color. As a child and adolescent, I heard racial slurs and saw people displaying the Confederate flags with only some vocal resistance from the broader community. Luckily, I had a parents, friends, a church, and a neighborhood that rejected discrimination and overt racism. However, I was absolutely still exposed to implicit bias towards all sorts of individuals and groups from peers, community, family, news, and other types of media that I continue to recognize and combat today. Provide a more specific, personal example of implicit bias: For me, another apparent example of implicit bias that I possess is toward people with face tattoos. My parents and grandparents are very judgmental towards people with any tattoos, so clearly this is a learned behavior. My own positive experiences with many friends and acquaintances with tattoos – NOT on their faces – has caused by bias about tattoos to be more limited, but I still harbor this bias. This is also a fairly acceptable bias to have, although cultural attitudes toward people with tattoos has significantly shifted over the course of my life, and I am sure that will continue. I am addressing my own bias because I (logically) know that there is nothing inherently wrong with people who have face tattoos, but I still currently have a very instinctive negative reaction when I see face tattoos.
- Extensive research on implicit bias – in particular, implicit racial bias – has been conducted in the criminal justice system. In the past few years, a number of studies on implicit bias in the health care field have been published. However, the impact of implicit bias on other fields – including primary and secondary education as well as health education (when not provided in the context of health care) – have remained under-evaluated. http://www.westsidestory.com/site/level2/lyrics/jet_movie.html
- Decreased client-centered communication was observed when the amount of time the provider spent talking increased, and the amount of time the patient spent talking decreased. The spirit behind client-centered communication is trusting that individuals are an experts on their own lives and that they have both the autonomy and the internal motivation to support healthy decision-making. When client-centered communication decreases, what does this say about how we view the patient? Negative client perception was measured through patient-reported feelings about how the provider interacted and communicated with them as well as how much they trusted the provider after the interaction and how culturally-competent their care was. MOST health care providers in these studies – regardless of their own race and ethnicity – harbored more negative bias toward Black individuals and more positive bias toward white individuals. While much research on implicit bias has focused on Black-versus-white bias, an increasing body of evidence supports that more negative bias may be felt toward other people of color, such as Latinos. This phenomenon is NOT unique to health care providers, although much research on the impact of implicit bias has been conducted with physicians as well as within the criminal justice system with juries, judges, and law enforcement. Research conducted more broadly across communities has found similar negative bias toward people of color and positive bias toward white people. Additional research is needed in the area of education to understand how the implicit biases of teachers impacts their interactions with students as well as student outcomes. Beyond race and ethnicity, we harbor implicit biases toward other perceived characteristics. Negative biases have been demonstrated toward people who we perceive as women, gender non-conforming, gay, overweight, disabled, very young or very old, and more.
- Those who are the most vigilant for cues of bias are those who have first-hand experience with bias and discrimination. What might negative non-verbal behaviors look like? Not maintaining eye contact Not facing the patient Crossing arms Frowning Seeming impatient (checking watch, tapping fingers or feet) Tone and volume of voice Length of time talking
- The authors of this study suggest that implicit bias and racial discrimination should be taken into consideration when assessing risk for hypertension with this particular demographic group.
- For those who aren’t health care providers.
- WARNING: The IAT may demonstrate biases that we don’t think we have or we don’t want to have. This can be uncomfortable, even upsetting. You may disagree with the findings. Additionally, the IAT is part of a bigger research study. While it is anonymous, they will ask for demographic information as well as your perceptions about the tasks – did you find them challenging? Frustrating? Engaging? Did you agree with the findings? Etc…
- Additional studies are needed to corroborate these findings and assess how brain imaging could be used to better understand or combat implicit bias. Functional MRI (fMRI) has its limitations, including measuring blood flow to neurons AFTER those neurons are activated (meaning there is a delay in sensing the actual neuron activity) and only taking pictures every few seconds. The brain process what our eyes see in under 1/5 of a second, so an fMRI scan could certainly miss certain moments of neural activation (particularly those that are quick to arise and fleeting). Neither the IAT or fMRI is the “end all be all” of understanding or combatting the process of unconscious bias, but they are a start, providing us with tools to help us further understand and address this phenomenon.
- REMEMBER: Our brain is also shaped by trauma.
- Taking more than a second to evaluate this situation was probably the difference between life and death. For most of us today, we have the privilege of never – or at least very, very rarely – being in these situations. However, the structures of the human brain that allow us to remember that this particular animal (and probably any other animal with sharp teeth that is growling at us) is dangerous and that we should run (or fight) took a long, long time to develop. These structures do continue to serve important functions today, but they are also the reason that we are so susceptible to the formation of implicit bias as a result of the culture and society with which we interact.
- This PBS special “Brains on Trial with Alan Alda” utilizes neuroscience to better understand implicit racial bias.
- The “pleasure center” or “reward system” of brain includes the limbic system (i.e. nucleus accumbens, medial forebrain bundle, ventral tegmental area), and is closely connected to the prefrontal cortex. The hippocampus of the brain retrieves memories of stimuli, which – in cases of perceived danger - triggers the amygdala to alert the hypothalamus, which triggers the fight or flight response in the autonomic nervous system.
- Anterior Cingulate Cortex (ACC) – Activates when conflict within the individual is elicited; for example, when categorizing color words (such as “red” or “blue”) that are written in a different color (e.g. “red” is written with blue ink) Dorsolateral Prefontal Cortex (DLPFC) – Involved with “executive functions” of the brain or management of cognitive processes – including working memory, cognitive flexibility, and planning Being aware of existence of implicit bias and any potential emotional and physical reactions to it – e.g. increased heart rate, heavier breathing, increased eye movement, pupil dilation, goosebumps, etc… – allows the ACC and PFC to mitigate these responses with “higher level” thinking.
- The ability to alter these connections in the brain is called “neuroplasticity.” Until about a decade ago, it was believed that neuroplasticity severely diminished during the process of aging, making it difficult for adults to weaken old connections and reform or strengthen new ones. However, research has demonstrated that although neuroplasticity may decrease somewhat after childhood and adolescence, adults continue to have this ability throughout their lives. Yes, you can teach an old dog new tricks! Long-term, ongoing efforts to change these unconscious associations that have formed over a lifetime is referred to as “debiasing.”
- Also mention research around exposure to “counter-stereotypic” examples.
- In the meantime… It’s not about you, it’s about them.
- “Fake it until you make it…” ???