Cultural Competency, Race and Skintone Bias Among Pharmacy, Nursing, and Medical Students: Implications for Addressing Health Disparities

1
Cultural Competency, Race and Skintone Bias Among
Pharmacy, Nursing, and Medical Students
Implications for Addressing Health Disparities

• Shelley White-Means, Zhiyong Dong, Meghan
  Hufstader, and Lawrence T. Brown
• Academy Health Annual Research Meeting
• Washington, DC
• June 10, 2008

2
Resolving Health Disparities

• The United States health care system is disparate
  and based on race and ethnicity.
• IOM report, Unequal Treatment, asserts that
  clinical decision-making has the potential to
  result in health disparities.
• It further notes that social cognitive processes
  may operate to influence patients and providers
  conscious and unconscious perceptions of each
  other and affect the structure, process, and
  outcomes of care.

3
Resolving Health Disparities

• Figure 1-1 Differences, Disparities, and
  Discrimination Populations with Equal Access to
  Healthcare.
• Source Gomes and McGuire, 2001.

4
Evidence Linking Clinical Decisionmaking
Health Disparities

• Schulman et al., (1999) study of physicians
  recommendations for cardiac catheterization
• Physicians were 40 less likely to refer African
  Americans for cardiac catheterization.
• Race and sex of the patient affected physicians
  decisions to refer patients, even after
  accounting for symptoms and clinical
  characteristics.
• findings may suggest bias on the part of the
  physician and...could be the result of
  subconscious perceptions rather than deliberate
  actions or thoughts.

5
Evidence Linking Clinical Decisionmaking
Health Disparities

• van Ryn and Burke (2000)
• Physicians in clinical settings were asked to
  rate patients based on intelligence,
  pleasantness, independence, responsibility,
  tendencies to exaggerate discomfort, likelihood
  of compliance, and other personal characteristics
  of patients.
• The authors conclude that physician treatment
  decisions are influenced by their own
  stereotyping of black patients risk for
  noncompliance, intelligence, and adequacy of
  social support, as well as affiliative feelings.

6

• The primary objectives of this study are to
• measure, compare, and contrast objective and
  subjective cognitive processes among
  pre-professional pharmacy, nursing, and medical
  students, and
• discern potential implications for educational
  interventions and public policy addressing health
  disparities across professional services.

7
Cultural Competency Instrument

• Office of Minority Health (2001) defines cultural
  competency as a set of congruent behaviors,
  attitudes, and polices that come together in a
  system, agency, or among professionals that
  enables effective work in cross-cultural
  situations.
• Self-perceived cultural competency provides an
  objective measure of provider cognitive processes
  as they relate to persons of diverse backgrounds.
  
• We use a tool developed and validated by Assemi,
  Cullander, and Hudmon, a 12-item battery of
  questions regarding unique aspects of cultural
  competency.

8
Sample Questions from Assemis Instrument

• How confident are you about your ability to
• Accurately define and describe the difference
  between ethnicity, culture, and race
• Feel comfortable interacting with people of
  diverse backgrounds
• Identify the influence of stereotypes on your
  thoughts, feelings, and behaviors towards
  different groups of people while providing
  patient care or education
• Elicit a patients perspective of illness during
  a patient encounter or consultation
• Elicit a patients perspective of healing and
  medication therapy during a patient encounter or
  consultation

9
Implicit Association Test (IAT)

• The Implicit Association Test (IAT) includes
  cognitive tasks to identify implicit attitudes
  about race, skin color, politics, gender, age and
  other characteristics of persons in ones social
  environment. See https//implicit.harvard.edu/imp
  licit.
• Race and skintone IATs measure introspectively
  unidentified and unconscious bias regarding race
  and skintone.
• Positive values of the race IAT denote this type
  of preference, with increases in the magnitude of
  the number indicating stronger preferences.
  Negative values denote a preference for blacks.

10
Implicit Association Test (IAT)
11
Stimuli and Response
European American Or Good
African American Or Bad
Click e if the words to the left of the picture
correspond with the stimuli and click i if the
words to the right of the picture correspond
12
Data

• Part of a multi-year study designed to assess
  levels of cultural competency and implicit bias
  among pre-professionals enrolled in pharmacy,
  medicine, and nursing colleges.
• In Fall, 2005, first, third and fourth year
  pharmacy, medicine, and nursing students
  participated in an on-line survey.
• Respondents completed Assemis Cultural
  Competency instrument and the race, skin tone and
  age IAT tests.
• 189 pharmacy students, 26 nursing students, and
  115 medical students.

13
Results (Cultural Competency)

• There were insignificant differences in mean
  cultural competency by college major overall
  mean (42.05) and possible range (12 to 60)
• 42.11 for pharmacy
• 42.09 for medicine
• 41.06 for nursing.
• There were significant differences in cultural
  competency by race/ethnicity.

14
Results (Cultural Competency)

• Non-Hispanic blacks and Hispanics in the colleges
  of Medicine and Pharmacy had significantly higher
  cultural competency scores than non-Hispanic
  whites.
• In contrast, 3rd and 4th year Medicine and
  Pharmacy students who reported that they were
  both black and white had significantly lower
  cultural competency scores than non-Hispanic
  whites.
• Nursing students who reported that they were both
  black and white had significantly higher scores
  than non-Hispanic whites.
• Supporting a role for formal professional
  education, first year pharmacy students had lower
  cultural competency scores than 3rd and 4th year
  pharmacy students.

15
Race Preference Distribution
IAT Race IAT Race IAT Race
  Preferred Whites Preferred Blacks
Whites 93.5 6.5
Asians 76 24
Blacks 62 38
Hispanics 100 0
Black White 70 30
16
Skintone Preference Distribution
IAT Skintone IAT Skintone IAT Skintone
  Preferred Light Skin Preferred Dark Skin
Whites 83 17
Asians 85 15
Blacks 59 41
Hispanics 100 0
Black White 43 57
17
Cultural Competency and Implicit Association

• Cultural Competency and Implicit Association are
  unique measures capturing different aspects of
  how provider behavior may influence health
  disparities.
• The two measures are negatively correlated, with
  those indicating the strongest preference for
  whites having the lowest values of cultural
  competency.
• While pre-professionals in medicine, pharmacy and
  nursing exhibit cultural competency, they also
  exhibit implicit race and skintone biases that
  are associated with preference for whites vs.
  blacks and for those with light skin vs. dark
  skin.

18
Study Implications

• Educational emphasis on cultural competency alone
  may not be sufficient in preparing
  pre-professionals in addressing health
  disparities solutions.
• Curricula design in cultural competency and
  research on health disparities will be advanced
  by understanding the factors that contribute to
  cultural competence and to bias.