Inequities in health between Māori and Pākehā in New Zealand exist across almost all health measures. This includes inequities in access to and quality of health care.
The potential for ethnic bias by health professionals to contribute to ethnic health care inequities is receiving increasing attention internationally, and is an area that we need to pay more attention to in New Zealand.
So what is ethnic bias?
Ethnic bias refers to generally negative attitudes, feelings and beliefs about an individual because of the ethnic group they belong to and can influence behaviour, leading to discrimination. Biases are often described as either explicit (conscious and intentional) or implicit (automatic and outside our conscious awareness).
We learn these biases over a long period of time and they can become so ingrained that we are often not aware of them. The ethnic bias an individual has reflects values in wider society about particular ethnic groups and as such is part of a broader system of racism. For health professionals, ethnic bias can influence the way we think, feel and act towards patients because of their ethnicity.
In a recent research study, New Zealand medical students demonstrated ethnic bias (both explicit and implicit) favouring New Zealand Europeans compared to Māori. These findings were not surprising given that medical students are exposed to negative stereotypes about Māori in wider society and in their training institutions.
This is one of the few studies to directly examine ethnic bias among health professional groups in New Zealand.
However, it is unlikely that ethnic bias is confined to medical students. It probably also exists among qualified doctors and other health professionals. This is supported by research showing negative stereotypes and assumptions about Māori by health professionals, higher reporting of racism by health professionals among Māori and other non-European groups, and in the health care inequities we see by ethnicity in New Zealand.
Health professional ethnic bias can potentially impact on patient care. Research has shown that ethnic bias can affect health professional decision-making and the quality of interactions with patients (e.g. poorer communication with patients and poorer patient perceptions of encounters). These have subsequent implications for future receipt of and engagement with health care.
In addition, situations with higher pressure and cognitive load are more likely to activate our biases and these types of situations are not uncommon in healthcare.
Can you be biased without realising it?
The idea that our own attitudes and behaviours can contribute to health care inequity can be difficult to reconcile for health professionals, whose role it is to help their patients.
However, given the way bias works, it would also be naïve to think that it could not happen. While ethnic biases can be fairly entrenched, emerging research also shows that they can be changed.
The study we undertook among medical students is focussed on medical education and is helping to inform training in this area. However, there are steps that health providers and organisations more generally can take now.
An important first step is to be open to examining your potential for ethnic bias. As health providers, this includes being willing to reflect on your own assumptions and beliefs about ethnic groups and how this may impact the care you provide. Because it can be difficult to identify, things like peer review and monitoring your practice by ethnicity can be helpful.
You could also try an implicit association test (see link below), a computer-based test designed to explore implicit bias. This shows how you may automatically link concepts such as race/ethnicity and preference.
Strategies shown to reduce or mitigate the activation of ethnic bias include countering negative stereotypes through challenging cultural norms and exposing ourselves to alternative images and ways of thinking or talking about, in this case, Māori and Māori health e.g. reading Māori authors and histories of the area you work and live in, learning te reo, engaging with Māori organisations, and so on.
Other strategies shown to reduce bias in health care encounters include individuation (viewing patients as individuals rather than members of particular groups), empathy and perspective-taking, building partnerships with patients, and looking after your own wellbeing. It requires concerted and continued effort to change what can be deeply held beliefs and attitudes.
However, changes at the individual level are limited without changes at organisational and institutional levels. Health care organisations can support ethnic bias reduction by actively encouraging and creating organisational cultures that promote equity and are anti-discriminatory. They can provide education and training, and implement strategies to help reduce cognitive load such as adequate staffing and time with patients, supervision and support, and improved workflow.
Monitoring and providing feedback of performance to staff with regard to ethnic healthcare inequities is essential in identifying bias that is difficult to detect at the individual level. And addressing disparities in workforce representativeness and addressing hiring practices to minimise bias are also important.
While ethnic bias among health professionals may be unintentional, this does not absolve responsibility to address it. Ethnic bias is not unique to healthcare and occurs in many other areas such as education, justice and employment. Bias can also relate to factors other than ethnicity such as weight, gender, sexuality and socioeconomic status.
In order to provide equitable care, health professionals and health organisations must be open to examining their own assumptions and behaviours. We are often asking patients to make behavioural changes to improve their health. We should also expect this of ourselves.
Dr Ricci Harris is a public health physician and senior research fellow at the University of Auckland and the University of Otago.
For more information and some helpful tools, below is a list of useful resources:
- Harris et al. Ethnic bias and clinical decision-making among New Zealand medical students: an observational study. BMC Medical Education 2018; 18:18. DOI 10.1186/s12909-018-1120-7. Available at: https://bmcmededuc.biomedcentral.com/articles/10.1186/s12909-018-1120-7
- Implicit bias in health care. Quick Safety article from the Joint Commission. Available at: https://www.jointcommission.org/assets/1/23/Quick_Safety_Issue_23_Apr_2016.pdf
- Van Ryn M. Unintended Bias in Health Care: Stragetiges for providing more equitable care. Clinical and Health Affairs 2016; Mar/Apr:40-43. Available at: https://www.eiscience.org/health-care-strategies-providing-equitable-care/
- Institute for Healthcare Improvement website. Filmed interview with Prof. David Williams (Harvard University). What Is Health Equity, and Why Does It Matter? (http://www.ihi.org/education/IHIOpenSchool/resources/Pages/AudioandVideo/David-Williams-Don-Berwick-What-Is-Health-Equity-and-Why-Does-It-Matter.aspx).
- Project implicit (https://implicit.harvard.edu/implicit/) to learn more about implicit bias and take implicit association tests (IATs).