Bias In Health Care Research Articles

An assessment of prevalence of Type 1 CFI rare variants in European AMD, and why lack of broader genetic data hinders development of new treatments and healthcare access.

Advanced age-related macular degeneration (AAMD) risk is associated with rare complement Factor I (FI) genetic variants associated with low FI protein levels (termed 'Type 1'), but it is unclear how variant prevalences differ between AMD patients from different ethnicities. Collective prevalence of Type 1 CFI rare variant genotypes were examined in four European AAMD datasets. Collective minor allele frequencies (MAFs) were sourced from the natural history study SCOPE, the UK Biobank, the International AMD Genomics Consortium (IAMDGC), and the Finnish Biobank Cooperative (FINBB), and compared to paired control MAFs or background population prevalence rates from the Genome Aggregation Database (gnomAD). Due to a lack of available genetic data in non-European AAMD, power calculations were undertaken to estimate the AAMD population sizes required to identify statistically significant association between Type 1 CFI rare variants and disease risk in different ethnicities, using gnomAD populations as controls. Type 1 CFI rare variants were enriched in all European AAMD cohorts, with odds ratios (ORs) ranging between 3.1 and 7.8, and a greater enrichment was observed in dry AMD from FINBB (OR 8.9, 95% CI 1.49-53.31). The lack of available non-European AAMD datasets prevented us exploring this relationship more globally, however a statistical association may be detectable by future sequencing studies that sample approximately 2,000 AAMD individuals from Ashkenazi Jewish and Latino/Admixed American ethnicities. The relationship between Type 1 CFI rare variants increasing odds of AAMD are well established in Europeans, however the lack of broader genetic data in AAMD has adverse implications for clinical development and future commercialisation strategies of targeted FI therapies in AAMD. These findings emphasise the importance of generating more diverse genetic data in AAMD to improve equity of access to new treatments and address the bias in health care.

Abstract 1020: Cancer health awareness through screening and education (CHANGE): Understanding community experience accessing cancer care

Abstract INTRODUCTION. Incidence and mortality rates for breast, prostate, and colorectal cancers all exceed national rates in Georgia and are higher among African Americans (AAs). Ensuring culturally competent and equitable health care delivery relies on creating an educated and engaged health care team. Patient stories are powerful examples of community-learned experiences and can be used to educate better providers and health care students who serve diverse populations, particularly when communicating risk and prevention of cancer. The goal of the CHANGE project is to provide a sustainable model of evidence-based cancer awareness through education - with an emphasis on prevention and early detection behaviors. We will develop a health disparities and culturally competent cancer care e-Learning curriculum for health care professionals, hematology-oncology fellows, residents, and medical students at the Medical College of Georgia. METHODS. Thirty community members and stakeholders (93% AA, 76% female, all adults) were recruited through public housing, healthcare clinics and providers, and community organizations. Vignettes describing patient access and care interactions were used in semi-structured interviews to guide conversations about experiences accessing care, attitudes towards cancer prevention, and community cancer beliefs. Interviews were recorded, professionally transcribed, and content analyzed using NVivo 12.0 by two independent raters. RESULTS. Three common themes emerged: accessibility of healthcare (transportation, finances, and difficulties in scheduling were primary barriers); cancer myths and cultural norms (no interpersonal discussion of cancer, seen as “taboo,” cancer will spread if cut into and cancer is contagious); and experience of racial bias in health care (historical racial bias and systemic racism; receipt of treatment and care perceived to be different due to race; lack of AA providers). CONCLUSION. This sample adequately represented those most at risk for cancer in Augusta, GA area. Their shared experiences will be used to design and inform an e-learning curriculum, in conjunction with education on health disparities across the state and specific to the local community. This will provide a comprehensive approach to provider education that will begin to improve patient care satisfaction and health outcomes. Citation Format: Marlo M. Vernon, Samantha Jones, Justin X. Moore, Steve S. Coughlin, Vahe Heboyan, Shakirah Clarke, Barbara Idun, Martha S. Tingen. Cancer health awareness through screening and education (CHANGE): Understanding community experience accessing cancer care [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 1020.

Ethical implications of implicit bias in nursing education

Nurses possess the responsibility of promoting equality and diversity by treating all patients, families, and colleagues with respect and dignity. This responsibility includes providing culturally informed care and practicing within the ethical principles of autonomy, justice, beneficence, veracity, and nonmaleficence. Implicit biases impact nursing education and subsequent interactions between student nurses and patients and hinder effective communication. Patients who have experienced implicit bias in health care may come to expect negative interactions in the future. Nurse educators hold the responsibility of preparing nursing students to deliver care to diverse populations by guiding them to recognize their responses to cultural differences. Awareness of students’ implicit biases is the first step in incorporating efforts to overcome them. A gap exists in nursing education which illustrates the lack of inclusion of implicit bias in the curriculum. The purpose of this paper is to examine the ethical implications of implicit bias in nursing education. Ethical principles are presented and discussed in the context of implicit bias and nursing education. Recommendations for incorporating strategies of identification and awareness of implicit bias into the nursing curriculum are discussed. The inclusion of the implications of implicit bias in the nursing curriculum provides opportunities for educators to direct students to develop plans to recognize the damaging effects of implicit bias and become aware of behaviors that become barriers to patient interactions. The results of this education include improved patient outcomes and the delivery of culturally appropriate care.

Color lines: Disparities in pharmacy treatment, education, and practice

Color lines: Disparities in pharmacy treatment, education, and practice

Using Critical Race Theory to Understand Trial Participation Among Black Individuals With Systemic Lupus Erythematosus: A Qualitative Study of Patients and Caregivers.

Black patients with systemic lupus erythematous (SLE) experience greater disease incidence and severity than White patients, and yet they are underrepresented in SLE clinical trials. We applied Critical Race Theory to qualitatively explore the influence of racism on the underrepresentation of Black patients in SLE clinical trials and to develop a framework for future intervention. We conducted focus group sessions in Chicago and Boston with Black adults (ages ≥18 years) with SLE and their caregivers. We queried the participants about their knowledge regarding clinical trials, factors that might motivate or hinder trial participation, and how race and experiences of racism might impact clinical trial participation. Focus group responses were transcribed verbatim and analyzed thematically. We held 4 focus groups (n = 31 participants); 20 participants had SLE, and 11 were caregivers. All participants were Black, 90% were women, and the mean age was 54 years. Qualitative analyses revealed several themes that negatively impact trial participation, including mistrust related to racism, concerns about assignment to placebo groups, strict study exclusion criteria, and SLE-related concerns. Factors that motivated trial participation included recommendations from physicians and reputable institutions, a desire to help the greater good, and culturally sensitive marketing of trials. Actions to improve clinical trial participation among Black individuals should focus on reframing how trial information is presented and disseminated and on reevaluating barriers that may restrict trial participation. Additionally, researchers must acknowledge and respond to the presence of racial bias in health care. Community-academic partnerships may help build trust and reduce fears of mistreatment among Black individuals with SLE.

743Determinants of childhood mortality sex ratios in low- and middle-income countries

Abstract Background Child mortality sex ratios may reflect community preferences and gender discrimination in health care. We assessed differences between observed and expected sex ratios of under-five mortality and their association with contextual factors. Methods Full birth histories from Demographic and Health Surveys and Multiple Indicator Cluster Surveys (2010–2018) in 77 countries were used to estimate under-five mortality sex ratios (male-to-female). Expected sex ratios and their residuals (difference of observed from expected) were derived from a fractional polynomial model, adjusted for overall mortality. Higher male-to-female residuals indicate lower likelihood of discrimination against girls. The same approach was used for 720 subnational regions from 75 countries. Associations between residuals and national gender and development indices, and with survey-derived child health care indicators were tested using Spearman’s correlation. Results Greater positive residuals were found in countries with higher Gross National Product per capita (rho=0.26), women older age at first marriage (rho=0.36), Human Development Index (rho = 0.23), and the Women, Peace and Security Index (rho=0.25). The Gender Inequality Index, which indicates less discrimination among women, was inversely correlated with the residuals (rho=-0.30). None of the survey-based indicators of gender bias in health care were significantly associated with the residuals, either at national or subnational levels. Conclusion Contextual variables measured at country level are associated with the sex ratio of under-five mortality. Key messages In more developed societies there is less evidence of gender bias in child deaths.

Author Response: Sex, Race, and Risk of Dementia Diagnosis After Traumatic Brain Injury Among Older Veterans

Thank you for the thoughtful comment on our article,1 Dr. Roberts. We agree that racial bias in health care is pervasive and must be addressed. We hope that our work draws attention to this issue and highlights the need for research aimed at identifying and mitigating disparities.

Complexity and Stigma of Pediatric Obesity.

Weight stigma is rooted in a fundamental misunderstanding of the origins of obesity, wherein the interplay of behavioral, environmental, genetic, and metabolic factors is deemphasized. Instead, the widespread societal and cultural presence of weight stigma fosters misconceptions of obesity being solely a result of unhealthy personal choices. Weight stigma is pervasive in childhood and adolescence and can affect individuals throughout their life. Although the prevalence of pediatric obesity remains high throughout the world, it becomes increasingly important to understand how weight stigma affects weight and health outcomes in children and adolescents with overweight or obesity, including in those with rare genetic diseases of obesity. We identified and reviewed recent literature (primarily published since 2000) on weight stigma in the pediatric setting. Articles were identified with search terms including pediatric obesity, weight bias, weight stigma, weight-based teasing and bullying, and weight bias in health care. In this narrative review, we discuss the stigma of pediatric obesity as it relates to the complex etiology of obesity as well as describe best practices for avoiding bias and perpetuating stigma in the health care setting.

Innovations in U.S. Health Care Delivery to Reduce Disparities in Maternal Mortality Among African American and American Indian/Alaskan Native Women

Despite spending more on health care than any other country, the United States has the worst maternal mortality rate among all developed nations. African American and American Indian/Alaskan Native women have the worst outcomes by race, representing a stark health disparity within the country. Contributing factors disproportionately experienced by these minority populations include challenges of access to consistent and high-quality prenatal care, prevalence of underlying conditions, toxic stress due to systemic racism, and unconscious bias in health care. While many of these factors lie upstream in the lives of women, and seemingly beyond the scope of the clinical walls, the downstream health care delivery system can serve as a vital part of the solution via innovative practices, community-based collaborations, and by serving as advocates for the communities served. Such alignments between clinicians, community leaders, policymakers, and patients that extend beyond the health system can serve as the missing piece needed within the clinic to reverse the trajectory of maternal mortality for American women, especially those from traditionally underserved populations.

"We're a Little Biased": Medicine and the Management of Bias through the Case of Contraception.

There is a wealth of literature demonstrating the presence of bias throughout the American health care system. Despite acknowledging such presence, however, little is known about how bias functions within medical encounters, particularly how providers grapple with bias in their patient counseling and decision-making. We explore such processes through the case of contraceptive counseling, a highly raced, classed, and gendered context. In-depth interviews with 51 health care providers reveal that providers use four primary strategies to navigate and minimize bias in their care-using scientific rationale, employing "safe" biases, standardizing counseling, and implementing patient-centered care. Paradoxically, using these strategies can exacerbate rather than resolve bias. Understanding these bias management strategies reveals provider-held biases, how they manifest within appointments, and the potential consequences for patients' health autonomy. Such knowledge informs interventions that promote contraceptive use among women in the United States, addresses bias in health care broadly, and thus ultimately helps combat health disparities.

Integrating Cultural Humility into the Medical Education Curriculum: Strategies for Educators

Issue: The framework of cultural humility, which emphasizes curiosity and self-reflection over mastery, was identified over 20 years ago as a way to address implicit bias in health care, an important factor in health disparities. Despite growing interest from researchers and educators, as well as the urgent call to adopt these values, the foundational elements of cultural humility remain challenging to teach in medical education and have not yet been widely adopted. Evidence: Health disparities persist throughout the United States among a growing population of diverse patients. The cultural humility framework undermines power imbalances by encouraging the clinician to view their patient as an expert of their own experience. This approach strengthens relationships within the community, illuminates racial and historical injustices, and contributes to equitable care. However, recent reviews have shown that humility-based principles have yet to be widely integrated into cultural curricula. Based on available evidence, this article introduces the foundational concepts of cultural humility with the aim of helping medical educators better understand and implement the principles of cultural humility into undergraduate medical education. Implications: Cultural humility is a powerful and feasible adjunct to help student physicians cultivate effective tools to provide the best patient care possible to an increasingly diverse patient population. However, there is little known about how best to implement the principles of cultural humility into existing undergraduate medical education curricula. The analyses and strategies presented provide educators with the background, instructional and curricular methods to enable learners to cultivate cultural humility. Future systematic research will need to focus on investigating design, implementation and impact.

The Impact of Racial Bias in Patient Care and Medical Education: Let's Focus on the Educator.

IntroductionRacial bias in health care is well documented. Research shows the presence of racial bias among health care providers. There is a paucity of workshops focused on racial bias effects in health professions educators.MethodTwo to three workshops were delivered to a diverse group of clinical educators from three programs at a major academic institution. Each workshop included a brief multimedia presentation followed by a facilitated group discussion. Participants completed the online Implicit Association Test (IAT), a baseline demographic questionnaire, and a brief post-then-pre questionnaire.ResultsTwenty-four faculty participated in the study (six physicians, eight nurse practitioners, 10 physician assistants). Nineteen (90%) were women, 18 (86%) were White, nine (43%) had more than 10 years of experience as educators, and seven (35%) had previously participated in a biases program. Seventeen completed the IAT. Sixteen educators agreed or strongly agreed that bias has a significant impact on patients' outcomes at the end of the workshop compared to 17 before the workshop. Seventeen educators agreed or strongly agreed that recognizing their own racial bias would positively alter their teaching practice after the workshop compared to 15 before the workshop.DiscussionThis series of workshops was created to fill a gap regarding the impact of racial bias on patient outcomes, health disparities, and health professions education. The impact of racial bias in health professions education and the long-term impact of awareness and knowledge of racial bias in education are areas needing further evaluation.

Perceptions of the COVID-19 Vaccines and Rationale Surrounding the Decision to Vaccinate Among Pregnant Women of color in the United States: Lessons Learned From Four Focus Groups

Background Prior to the COVID-19 pandemic, the United States was facing a maternal health crisis grounded in health disparities. People of color have been disproportionately burdened by COVID-19. Simultaneously, maternity patients are at higher risk of severe complications and death due to COVID-19 infection. In spite of this, COVID-19 vaccination rates among pregnant women are low, and they are lowest among non-Hispanic Black women. To understand barriers and inform public health actions, this paper describes knowledge about COVID-19 infection in pregnancy, perceived infection risk, and reasons for vaccinating or not vaccinating against COVID-19 among pregnant women of color. Methods Four virtual focus group discussions were held with 32 participants in the United States. Two groups included women who had received at least one COVID-19 vaccine dose and two included those who stated they had not been vaccinated, but were considering it. Results Findings showed that both unvaccinated and vaccinated participants were knowledgeable about the risks of COVID-19 infection in pregnancy and were taking prevention precautions. Perceived benefits of vaccination included having a healthy pregnancy and baby, reduced stress about COVID-19 infection, and resuming social activities. All vaccinated participants reported having conversations with providers about vaccination, but the same provider engagement was not found among the unvaccinated. Concerns about the vaccines centered on bias in health care and vaccine safety. Conclusion Since vaccination benefits included having a healthy pregnancy and delivery, information about how the vaccines improve maternal and infant outcomes should be incorporated into health messaging. Addressing the historical and current racist practices in healthcare is critical to improve care and to improve trust in the health care system. Because health care provider engagement appears to be important for patient vaccination decisions, efforts should be made to support providers to talk to pregnant patients in culturally-sensitive ways about COVID-19 vaccines in pregnancy.

Attitudes and beliefs in Swedish midwives and obstetricians towards obesity and gestational weight management

BackgroundGestational weight interventions are important in maternity care to counteract adverse pregnancy events. However, qualitative findings indicate potential obstacles in the implementation of interventions due to the sensitivity of the subject and existing obesity stigma. Pregnant women have reported disrespectful or unhelpful communication, while some midwives seem to avoid the topic, as not to upset women. This descriptive study aimed to provide knowledge about maternity care providers’ beliefs about obesity, and their attitudes towards gestational weight management.MethodA web survey was emailed to Swedish maternity care clinics. Existing questionnaires, “Beliefs About Obese People” (BAOP), “Perceived weight bias in health care” and “Attitudes toward obese patients” was used, supplemented with questions formulated for this study. An open free-text question allowed participants to provide a deeper and more nuanced picture of the topic.Results274 respondents (75% midwives and 25% obstetricians) participated. One third of respondents found obesity to be a more sensitive topic than smoking or alcohol habits, and 17% of midwives agreed to the statement: “I sometimes avoid talking about weight so as not to make the pregnant woman worried or ashamed”. Having had training in motivational interviewing seemed positively associated with midwives’ inclination to talk about body weight, especially with women with obesity (p = .001), whereas years of working experience were not associated. Having received obesity education increased confidence in providing adequate information, but still only 46% felt they had enough knowledge to provide diet and exercise advice to pregnant women with obesity. Qualitative data revealed great empathy for women with obesity, and a wish to have more obesity education and access to other professionals.ConclusionSwedish maternity care staff displayed empathy for women with obesity and found gestational weight interventions important, but almost one fifth of midwives sometimes avoid the subject of body weight for fear of upsetting women. Education about obesity facts, training in person-centered communication, i.e. motivational interviewing, and access to dieticians may facilitate gestational weight management implementation.

How Clinicians and Educators Can Mitigate Implicit Bias in Patient Care and Candidate Selection in Medical Education.

In an attempt to help us navigate a complex world, our unconscious minds make certain group associations on the basis of our experiences. Physicians are not immune to these implicit associations or biases, which can lead physicians to unknowingly associate certain demographic groups with negative concepts, like danger, noncompliance, and lower competence. These biases can influence clinical decision making in ways that potentially harm patients and may unfairly influence the medical school, residency, and fellowship application processes for candidates in certain underrepresented groups. To minimize the potential negative impact of implicit biases on patient care and diversity in the medical profession, physician-leaders have a responsibility to understand biases and how to consciously override them. This article discusses the potential impact of implicit bias in health care and student/trainee selection and reviews research-proven tools to reduce implicit bias in one-on-one interactions.

Disparities in Care: The Role of Race on the Utilization of Physical Restraints in the Emergency Setting.

Race-based bias in health care occurs at organizational, structural, and clinical levels and impacts emergency medical care. Limited literature exists on the role of race on patient restraint in the emergency setting. This study sought to examine the role of race in physical restraint in an emergency department (ED) at a major academic medical center. Retrospective chart analysis was performed, querying all adult ED visits over a 2-year period (2016-2018) at Massachusetts General Hospital. The associations between race and restraint and selected covariates (sex, insurance, age, diagnosis, homelessness, violence) were analyzed. Of the 195,092 unique ED visits by 120,469 individuals over the selected period, 2,658 (1.4%) involved application of a physical restraint by health care providers. There was a significant effect of race on restraint (p<0.0001). The risk ratio (RR) for Asian patients compared to white patients was 0.71 (95% confidence interval [CI]=0.55 to 0.92, p=0.009). The RR for Black patients compared to white patients was 1.22 (95% CI=1.05 to 1.40, p=0.007). Visits with patients having characteristics of male sex, public or no insurance, younger age, diagnoses pertaining to substance use, diagnoses pertaining to psychotic or bipolar disorders, current homelessness, and a history of violence were more likely to result in physical restraint. There was a significant effect of race on restraint that remained when controlling for sex, insurance, age, diagnosis, homelessness, and history of violence, all of which additionally conferred independent effects on risk. These results warrant a careful examination of current practices and potential biases in utilization of restraint in emergency settings.

Biases in the evaluation of self-harm in patients with disability due to spinal cord injury.

Suicide is a global problem and accurate assessment of risk for self-harm is critical. Even morally principled clinicians can manifest bias when assessing self-harm in patients with physical disabilities such as spinal cord injury (SCI). Assessment of self-harm is an obligation for health care clinicians and overestimating or underestimating risk may undermine a patient's trust in their care, possibly leading to less engagement, increased apathy about having an interest in living, and less adherence to healthy treatment options. Introduces readers to three biases that can impact decision-making regarding a patient with a disability when assessing the patient's risk for self-harm: (1) ineffectual bias, (2) fragile friendliness bias, and (3) catastrophe bias. These preconceptions are derived from a mix of paternalism, projection, low expectations, pity, and infantilization. In this paper, we explain how each bias can affect clinical decision-making regarding diagnosis, treatment, prognosis, and prevention for patients with SCI within a common case scenario. Readers can employ personal reflection and potential self-application when they encounter individuals with SCI in and outside clinical settings. Unchecked biases toward the disabled and patients with SCI can undermine ethical caregiving. Biases are habits of mind and thoughtful clinical and education interventions can improve clinical practice. The literature on health care bias with other minority groups is instructive for investigating biases related to patients with disabilities, and especially for clinicians outside of rehabilitation medicine.

A mixed-method simulated patient approach to explore implicit bias in health care: A feasibility study in community pharmacy

Implicit bias is prejudice shown towards an individual or group without consciously meaning to do so. This bias may occur due to age, race, and gender among other factors. Implicit bias has been examined and identified in a variety of health care professionals, primarily using Implicit Association Tests. To date, literature has not examined implicit bias using covert simulated patients in a naturalistic setting, or in practicing community pharmacists. To develop and pilot a novel method for exploring and reporting on implicit racial bias by community pharmacists in their practice setting. Four female actors of different racial and ethnic backgrounds (Caucasian Australian, East Asian, Middle Eastern, South Asian) completed simulated patient visits at eight community pharmacies in Sydney, Australia between February-March 2019. Actors provided scripted requests for assistance with symptoms or products relating to women's health ailments (cystitis, dysmenorrhea, emergency contraception, vaginal thrush) at a rate of one visit per pharmacy per week. Visits were audio-recorded. Semi-structured interviews were conducted with actors immediately post-visit. Transcriptions of visits and interviews were analyzed through discourse analysis. Thirty-two vists were completed. Discourse analysis identified 3 discursive frames of 'caring', 'neutral, and 'abrupt' and enabled identification of potential differences between pharmacists when responding to actors of different racial and ethnic backgrounds. Consultation length, number of products sold, and number of questions asked did not significantly differ between visits. This novel method proved feasible and future work could adapt this method to different practitioners and simulated patient demographics to explore different types of implicit bias in a number of naturalistic settings.

Combining SOAP Notes With Guided Reflection to Address Implicit Bias in Health Care.

Combining SOAP Notes With Guided Reflection to Address Implicit Bias in Health Care.

Impact of a Discussion Series on Race on Medical Student Perceptions of Bias in Health Care

Racial bias in health care is increasingly recognized as a factor in health inequities, yet there is limited research regarding medical school education around race and racism and its impact on medical students. The purpose of this study was to understand attitudes of medical students on race and racism in health care and to study the impact of participation in a voluntary structured program on race and racism. First-year medical students had the opportunity to participate in a series of discussions (10 hours total) on race and racism. A 10-question survey addressing comfort, knowledge, and the adequacy of education on race and racism was sent to all first-year medical students (n=61/180, response rate 34%), and was administered to series participants (n=23/25, response rate 92%) in a pre/post format. Participant and nonparticipant attitudes were similar at baseline, with the exception that participants were less likely to feel that the medical school curriculum provided adequate education on race and racism, and reported higher levels of knowledge around these issues. Following the discussion series, participants showed significant changes regarding knowledge and awareness, as well as comfort level discussing race and racism. Participants were more likely than nonparticipants to think that the curriculum should include more discussion on race and racism. Postparticipation analysis demonstrated significant increases in comfort level, knowledge, and awareness in discussion of race and racism.