Applied Racial/Ethnic Healthcare Disparities Research Using Implicit Measures.

Many healthcare disparities studies use the Implicit Association Test (IAT) to assess bias. Despite ongoing controversy around the IAT, its use has enabled researchers to reliably document an association between provider implicit prejudice and provider-to-patient communication (provider communication behaviors and patient reactions to them). Success in documenting such associations is likely due to the outcomes studied, study settings, and data structure unique to racial/ethnic healthcare disparities research. In contrast, there has been little evidence supporting the role of providers' implicit bias in treatment recommendations. Researchers are encouraged to use multiple implicit measures to further investigate how, why, and under what circumstances providers' implicit bias predicts provider-to-patient communication and treatment recommendations. Such efforts will contribute to the advancement of both basic social psychology/social cognition research and applied health disparities research: a better understanding of implicit social cognition and a more comprehensive identification of the sources of widespread racial/ethnic healthcare disparities, respectively.

Strategies for enhancing research in aging health disparities by mentoring diverse investigators.

INTRODUCTION: The Resource Centers for Minority Aging Research (RCMAR) program was launched in 1997. Its goal is to build infrastructure to improve the well-being of older racial/ethnic minorities by identifying mechanisms to reduce health disparities. METHODS: Its primary objectives are to mentor faculty in research addressing the health of minority elders and to enhance the diversity of the workforce that conducts elder health research by prioritizing the mentorship of underrepresented diverse scholars. RESULTS: Through 2015, 12 centers received RCMAR awards and provided pilot research funding and mentorship to 361 scholars, 70% of whom were from underrepresented racial/ethnic groups. A large majority (85%) of RCMAR scholars from longstanding centers continue in academic research. Another 5% address aging and other health disparities through nonacademic research and leadership roles in public health agencies. CONCLUSIONS: Longitudinal, team-based mentoring, cross-center scholar engagement, and community involvement in scholar development are important contributors to RCMAR's success.

Physician Racial Bias and Word Use during Racially Discordant Medical Interactions.

Physician racial bias can negatively affect Black patients' reactions to racially discordant medical interactions, suggesting that racial bias is manifested in physicians' communication with their Black patients. However, little is known about how physician racial bias actually influences their communication during these interactions. This study investigated how non-Black physicians' racial bias is related to their word use during medical interactions with Black patients. One hundred and seventeen video-recorded racially discordant medical interactions from a larger study were transcribed and analyzed using Linguistic Inquiry and Word Count (LIWC) software. Physicians with higher levels of implicit racial bias used first-person plural pronouns and anxiety-related words more frequently than physicians with lower levels of implicit bias. There was also a trend for physicians with higher levels of explicit racial bias to use first-person singular pronouns more frequently than physicians with lower levels of explicit bias. These findings suggest that non-Black physicians with higher levels of implicit racial bias may tend to use more words that reflect social dominance (i.e., first-person plural pronouns) and anxiety when interacting with Black patients.

Do Patients and Oncologists Discuss the Cost of Cancer Treatment? An Observational Study of Clinical Interactions Between African American Patients and Their Oncologists.

PURPOSE: Financial toxicity negatively affects patients with cancer, especially racial/ethnic minorities. Patient-oncologist discussions about treatment-related costs may reduce financial toxicity by factoring costs into treatment decisions. This study investigated the frequency and nature of cost discussions during clinical interactions between African American patients and oncologists and examined whether cost discussions were affected by patient sociodemographic characteristics and social support, a known buffer to perceived financial stress. Methods Video recorded patient-oncologist clinical interactions (n = 103) from outpatient clinics of two urban cancer hospitals (including a National Cancer Institute-designated comprehensive cancer center) were analyzed. Coders studied the videos for the presence and duration of cost discussions and then determined the initiator, topic, oncologist response to the patient's concerns, and the patient's reaction to the oncologist's response. RESULTS: Cost discussions occurred in 45% of clinical interactions. Patients initiated 63% of discussions; oncologists initiated 36%. The most frequent topics were concern about time off from work for treatment (initiated by patients) and insurance (initiated by oncologists). Younger patients and patients with more perceived social support satisfaction were more likely to discuss cost. Patient age interacted with amount of social support to affect frequency of cost discussions within interactions. Younger patients with more social support had more cost discussions; older patients with more social support had fewer cost discussions. CONCLUSION: Cost discussions occurred in fewer than one half of the interactions and most commonly focused on the impact of the diagnosis on patients' opportunity costs rather than treatment costs. Implications for ASCO's Value Framework and design of interventions to improve cost discussions are discussed.

The effects of racial attitudes on affect and engagement in racially discordant medical interactions between non-Black physicians and Black patients.

The association between physicians' and patients' racial attitudes and poorer patient-physician communication in racially discordant medical interactions is well-documented. However, it is unclear how physicians' and patients' racial attitudes independently and jointly affect their behaviors during these interactions. In a secondary analysis of video-recorded medical interactions between non-Black physicians and Black patients, we examined how physicians' explicit and implicit racial bias and patients' perceived past discrimination influenced their own as well as one another's affect and level of engagement. Affect and engagement were assessed with a "thin slice" method. For physicians, the major findings were significant three-way interactions: physicians' affect and engagement were influenced by their implicit and explicit racial bias (i.e., aversive racism), but only when they interacted with patients who reported any incidence of prior discrimination. In contrast, patients' affect was influenced only by perceived discrimination. Theoretical and clinical implications of current findings are discussed.

A disparity of words: racial differences in oncologist-patient communication about clinical trials.

BACKGROUND: African Americans are consistently underrepresented in cancer clinical trials. Minority under-enrolment may be, in part, due to differences in the way clinical trials are discussed in oncology visits with African American vs. White patients. OBJECTIVE: To investigate differences in oncologist-patient communication during offers to participate in clinical trials in oncology visits with African American and White patients. METHODS: From an archive of video-recorded oncology visits, we selected all visits with African American patients that included a trial offer (n = 11) and a matched sample of visits with demographically/medically comparable White patients (n = 11). Using mixed qualitative-quantitative methods, we assessed differences by patient race in (i) word count of entire visits and (ii) frequency of mentions and word count of discussions of clinical trials and key elements of consent. RESULTS: Visits with African American patients, compared to visits with White patients, were shorter overall and included fewer mentions of and less discussion of clinical trials. Also, visits with African Americans included less discussion of the purpose and risks of trials offered, but more discussion of voluntary participation. DISCUSSION AND CONCLUSIONS: African American patients may make decisions about clinical trial participation based on less discussion with oncologists than do White patients. Possible explanations include a less active communication style of African Americans in medical visits, oncologists' concerns about patient mistrust, and/or oncologist racial bias. Findings suggest oncologists should pay more conscious attention to developing the topic of clinical trials with African American patients, particularly purpose and risks.

Patient- and Family-Centered Care as an approach to reducing disparities in asthma outcomes in urban African American children: A review of the literature.

We thank Cathy Eames (Director, Library Services, Detroit Medical Center) for valuable input and assistance with the search strategy. Funding for this research was supported by a grant from Children's Hospital of Michigan Research Foundation (Principal Investigator: Terrance L. Albrecht, Ph.D.). BACKGROUND: Patient- and family-centered care (PFCC) has the potential to address disparities in access and quality of healthcare for African American pediatric asthma patients by accommodating and responding to the individual needs of patients and families. STUDY OBJECTIVES: To identify and evaluate research on the impact of family-provider interventions that reflect elements of PFCC on reducing disparities in the provision, access, quality, and use of healthcare services for African American pediatric asthma patients. METHODS: Electronic searches were conducted using PubMed, CINAHL, and Psyclnfo databases. Inclusion criteria were peer-reviewed, English-language articles on family-provider interventions that (a) reflected one or more elements of PFCC and (b) addressed healthcare disparities in urban African American pediatric asthma patients (≤18years). RESULTS: Thirteen interventions or programs were identified and reviewed. Designs included randomized clinical trials, controlled clinical trials, pre- and post-interventions, and program evaluations. CONCLUSIONS: Few interventions were identified as explicitly providing PFCC in a pediatric asthma context, possibly because of a lack of consensus on what constitutes PFCC in practice. Some studies have demonstrated that PFCC improves satisfaction and communication during clinical interactions. More empirical research is needed to understand whether PFCC interventions reduce care disparities and improve the provision, access, and quality of asthma healthcare for urban African American children. ELECTRONIC DATABASES USED: PubMed, CINAHL, and Psyclnfo ABBREVIATIONS: AA-African American: CCT-Controlled clinical trial; ED-Emergency Department; ETS-Environmental tobacco smoke; FCC- Family Centered Care; PFCC-Patient and Family Centered Care; RCT- Randomized, controlled trial.

Reducing Racial Health Care Disparities: A Social Psychological Analysis.

Large health disparities persist between Black and White Americans. The social psychology of intergroup relations suggests some solutions to health care disparities due to racial bias. Three paths can lead from racial bias to poorer health among Black Americans. First is the already well-documented physical and psychological toll of being a target of persistent discrimination. Second, implicit bias can affect physicians' perceptions and decisions, creating racial disparities in medical treatments, although evidence is mixed. The third path describes a less direct route: Physicians' implicit racial bias negatively affects communication and the patient-provider relationship, resulting in racial disparities in the outcomes of medical interactions. Strong evidence shows that physician implicit bias negatively affects Black patients' reactions to medical interactions, and there is good circumstantial evidence that these reactions affect health outcomes of the interactions. Solutions focused on the physician, the patient, and the health care delivery system; all agree that trying to ignore patients' race or to change physicians' implicit racial attitudes will not be effective and may actually be counterproductive. Instead, solutions can minimize the impact of racial bias on medical decisions and on patient-provider relationships.

Within-group health disparities among Blacks: the effects of Afrocentric features and unfair treatment.

Prior research on the impact of Afrocentric features on health has focused primarily on a single feature, skin color. We explored the effects of two other Afrocentric features (lip thickness, nose width) on Blacks' health status and whether unfair treatment mediates any relationship between these features and health. A secondary analysis of a prior study of Black patients' health was conducted. Patients with strong (high lip and high nose ratios) and weak (low lip and low nose ratios) Afrocentric features (i.e., congruent features) had poorer health than patients with incongruent features. Unlike findings for skin color, congruence of features rather than strength predicted health. Congruence predicted perceived unfair treatment in the same manner. Importantly, perceived unfair treatment mediated the relation between Afrocentric features and health. The study suggests that even subtle differences in Afrocentric features can have serious long-term health consequences among Blacks. Clinical implications of the findings are discussed.

A social psychological approach to improving the outcomes of racially discordant medical interactions.

BACKGROUND: Medical interactions between Black patients and non-Black physicians are less positive and productive than racially concordant ones and contribute to racial disparities in the quality of health care. OBJECTIVE: To determine whether an intervention based on the common ingroup identity model, previously used in nonmedical settings to reduce intergroup bias, would change physician and patient responses in racially discordant medical interactions and improve patient adherence. IINTERVENTION: Physicians and patients were randomly assigned to either a common identity treatment (to enhance their sense of commonality) or a control (standard health information) condition, and then engaged in a scheduled appointment. DESIGN: Intervention occurred just before the interaction. Patient demographic characteristics and relevant attitudes and/or behaviors were measured before and immediately after interactions, and 4 and 16 weeks later. Physicians provided information before and immediately after interactions. PARTICIPANTS: Fourteen non-Black physicians and 72 low income Black patients at a Family Medicine residency training clinic. MAIN MEASURES: Sense of being on the same team, patient-centeredness, and patient trust of physician, assessed immediately after the medical interactions, and patient trust and adherence, assessed 4 and 16 weeks later. KEY RESULTS: Four and 16 weeks after interactions, patient trust of their physician and physicians in general was significantly greater in the treatment condition than control condition. Sixteen weeks after interactions, adherence was also significantly greater. CONCLUSIONS: An intervention used to reduce intergroup bias successfully produced greater Black patient trust of non-Black physicians and adherence. These findings offer promising evidence for a relatively low-cost and simple intervention that may offer a means to improve medical outcomes of racially discordant medical interactions. However, the sample size of physicians and patients was small, and thus the effectiveness of the intervention should be further tested in different settings, with different populations of physicians and other health outcomes.

Racial Healthcare Disparities: A Social Psychological Analysis.

Around the world, members of racial/ethnic minority groups typically experience poorer health than members of racial/ethnic majority groups. The core premise of this article is that thoughts, feelings, and behaviors related to race and ethnicity play a critical role in healthcare disparities. Social psychological theories of the origins and consequences of these thoughts, feelings, and behaviors offer critical insights into the processes responsible for these disparities and suggest interventions to address them. We present a multilevel model that explains how societal, intrapersonal, and interpersonal factors can influence ethnic/racial health disparities. We focus our literature review, including our own research, and conceptual analysis at the intrapersonal (the race-related thoughts and feelings of minority patients and non-minority physicians) and interpersonal levels (intergroup processes that affect medical interactions between minority patients and non-minority physicians). At both levels of analysis, we use theories of social categorization, social identity, contemporary forms of racial bias, stereotype activation, stigma, and other social psychological processes to identify and understand potential causes and processes of health and healthcare disparities. In the final section, we identify theory-based interventions that might reduce ethnic/racial disparities in health and healthcare.

The Experience of Discrimination and Black-White Health Disparities in Medical Care.

The current study of Black patients focuses on how discrimination contributes to racial disparities in health. The authors used a longitudinal methodology to study how perceived past discrimination affects reactions to medical interactions and adherence to physician recommendations. In addition, they explored whether these reactions and/or adherence mediate the relationship between discrimination and patients' health. The participants in this study were 156 Black patients of low socioeconomic status at a primary care clinic. Patients completed questionnaires on their current health, past adherence, and perceived past discrimination. Then, they saw a physician and rated their reactions to the visit. Four and 16 weeks later they reported on their adherence to physician recommendations and overall health. Perceived discrimination was significantly and negatively associated with patient health, reactions to the physician, and adherence. Path analyses indicated that adherence mediated the relationship between discrimination and patient health, but patient reactions to the interaction did not.

Disparities and distrust: the implications of psychological processes for understanding racial disparities in health and health care.

This paper explores the role of racial bias toward Blacks in interracial relations, and in racial disparities in health care in the United States. Our analyses of these issues focuses primarily on studies of prejudice published in the past 10 years and on health disparity research published since the report of the US Institute of Medicine (IOM) Panel on Racial and Ethnic Disparities in Health Care in 2003. Recent social psychological research reveals that racial biases occur implicitly, without intention or awareness, as well as explicitly, and these implicit biases have implications for understanding how interracial interactions frequently produce mistrust. We further illustrate how this perspective can illuminate and integrate findings from research on disparities and biases in health care, addressing the orientations of both providers and patients. We conclude by considering future directions for research and intervention.