Mechanisms that perpetuate health disparities: physician stereotypes & bias
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Purpose: Although Asian Americans are the only racial group for whom cancer is the leading cause of death, colorectal cancer screening is consistently lower than that of White Americans. Physicians also recommend colorectal cancer screening to Asian Americans at nearly half the rate as White Americans. This study tests a mechanism that may underlie low recommendation rates. I based my hypothesis on a conceptual model that integrates the literature on information processing and decision making with Asian American stereotypes. Methods: I conducted an online study of primary care physicians and measured their cancer screening referral behavior in response to clinical vignettes. I used the existing Asian Attitude Implicit Association Test (IAT) and developed a new Health Attitude IAT to measure implicit attitudes about Asian American foreignness and health advantages, respectively. Explicit attitudes about these constructs were also assessed through self-report. I used binary logistic regression models to evaluate the association of attitudes about Asian Americans foreignness and health advantage with screening recommendation. Results: My sample included 167 physicians (23% response rate). I found strong implicit bias that Asians are foreign (Cohen’s d = 1.09) and strong implicit bias favoring a white health advantage (Cohen’s d = -0.86). There were weaker explicit biases that Asians are foreign (Cohen’s d = 0.62). Explicit beliefs about health advantage favored Asians (Cohen’s d = 0.73). Physician race, age and gender were significant moderators of bias score. .I found no evidence of a race based screening disparity and no association between implicit or explicit bias scores and making a cancer screening recommendation. Conclusions: Foreign and health advantage biases exist among a sample of physicians, but may not influence cancer screening recommendation behavior. Physicians demonstrated both implicitly and explicitly held attitudes that Asian Americans are perpetual foreigners. Physicians also reported explicit beliefs that Asian Americans have health advantages relative to other races. Implicitly, their attitudes indicated that White Americans are a healthier group. Further research should address whether race-based cancer screening disparities persist in real world settings, both in terms of screening completion, and physician recommendation. If disparities still exist, alternate explanatory mechanisms should be identified.