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/implicit. 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 Preferred WhitesPreferred Blacks Whites93.56.5 Asians7624 Blacks6238 Hispanics1000 Black & White7030

16. Skintone Preference Distribution IAT Skintone Preferred Light Skin Preferred Dark Skin Whites8317 Asians8515 Blacks5941 Hispanics1000 Black & White4357

17. Cultural Competency and Implicit A ssociation 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.