Graduate School Form 30 Updated 12/26/2015 PURDUE UNIVERSITY GRADUATE SCHOOL Thesis/Dissertation Acceptance This is to certify that the thesis/dissertation prepared By Nicole A. Hollingshead Entitled EXAMINING THE INFLUENCE OF HISPANIC ETHNICITY AND ETHNIC BIAS ON MEDICAL STUDENTS’ PAIN DECISIONS For the degree of Doctor of Philosophy Is approved by the final examining committee: Adam T. Chair Leslie Ashburn-Nardo, Ph. Gerardo Maupomé, Ph.
To the best of my knowledge and as understood by the student in the Thesis/Dissertation Agreement, Publication Delay, and Certification Disclaimer (Graduate School Form 32), this thesis/dissertation adheres to the provisions of Purdue University’s “Policy of Integrity in Research” and the use of copyright material. Approved by Major Professor(s): Adam T. Approved by: Nicholas J. 6/20/2016 Head of the Departmental Graduate Program Date EXAMINING THE INFLUENCE OF HISPANIC ETHNICITY AND ETHNIC BIAS ON MEDICAL STUDENTS’ PAIN DECISIONS A Dissertation Submitted to the Faculty of Purdue University by Nicole A.
Hollingshead In Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy August 2016 Purdue University Indianapolis, Indiana ii ACKNOWLEDGEMENTS I would like to thank Adam T., for his guidance and mentorship throughout this project. I would also like to express gratitude to my committee, Leslie Ashburn-Nardo, Ph., Jesse Stewart, Ph., and Gerardo Maupomé., for their thoughtful feedback and contributions. This research was supported by the American Psychological Association Division 38: Health Psychology Research Award, National Institutes of Health (R01MD008931), and an IUPUI Clinical Psychology Department Research Award. Finally, I would like to thank my husband, Cody, and my family for their unwavering support and love.
iii TABLE OF CONTENTS .Page LIST OF TABLES. iiv LIST OF FIGURES .…… 12 Hypothesis 1: Pain management decisions. 13 Hypothesis 2: Ethnic bias. 15 Hypothesis 3: Influence of ethnic bias on pain management decisions.
40 iv LIST OF TABLES Table. Participants’ demographic characteristics. Characteristics of participants’ idiographic ratings. 37 v LIST OF FIGURES Figure.
Example of virtual humans. Interaction of ethnicity and implicit ethnic bias on opioid treatment ratings. 39 vi ABSTRACT Hollingshead, Nicole A., Purdue University, August 2016. Examining the Influence of Hispanic Ethnicity and Ethnic Bias on Medical Students’ Pain Decisions.
Major Professor: Adam T. Hispanic patients receive disparate pain care compared to non-Hispanic White (NHW) patients. Healthcare providers’ ethnic bias may be one reason for pain disparities. This investigation sought to determine the influence of Hispanic ethnicity and ethnic bias on chronic pain management decisions.
During an online experiment, 97 medical students made pain assessment and opioid treatment decisions for Hispanic and NHW virtual human patients with chronic pain. They also completed explicit and implicit measures of ethnic bias. Individual-level analyses found that 31% and 36% of participants demonstrated large effect sizes (dz>.50), indicating that patient ethnicity strongly influenced their pain assessment and opioid treatment decisions, respectively. At the group level of analysis, participants’ decisions did not differ significantly between NHW and Hispanic patients (all p values >.
Participants did not report significant explicit ethnic bias (t[96]=1.19; Hispanic mean rating=77.7]; NHW mean rating=75.4]) but demonstrated a small-to-moderate implicit preference for NHWs relative to Hispanics (Mean=. Patient ethnicity and implicit ethnic bias had an interactive effect on opioid treatment decisions (F[1, 95]=5.02); however, the direction of the effect was not as hypothesized. Participants with higher implicit ethnic bias gave significantly higher opioid ratings to Hispanics relative to NHWs (p=.05), whereas participants with lower bias gave marginally higher opioid ratings to NHWs relative to Hispanics (p=. Participants with higher vs.
lower implicit ethnic bias differed only in their treatment ratings for NHW patients, such that participants with lower bias gave significantly higher opioid ratings to NHW patients than did participants with higher bias (p<. This investigation found that approximately one-third of participants made significantly different chronic pain management decisions for Hispanic vs. Participants’ implicit ethnic bias interacted with their opioid treatment decisions but not as expected. Future investigations should measure healthcare providers’ stereotypes about Hispanic patients with pain as this may better predict their pain decisions.
1 INTRODUCTION Chronic pain is a public health burden that affects over 100 million Americans (Institute of Medicine, 2011). The number of individuals experiencing chronic pain exceeds the number of people with cancer, heart disease and diabetes combined (Institute of Medicine, 2011). Chronic pain is defined as pain that persists beyond 3-6 months or the “expected period of healing” (pg. Chronic pain is difficult to manage, and treatment often includes both pharmacological (e., opioid medications, non-steroidal anti-inflammatory drugs [NSAIDS]) and non-pharmacological (e., physical therapy, diet and exercise) modalities (Chou et al., 2007; Institute of Medicine, 2011).
Although chronic pain is widely prevalent, many patients receive inadequate pain management (Breivik, Collett, Ventafridda, Cohen, & Gallacher, 2006; Brennan, Carr, & Cousins, 2007); this is particularly true for racial/ethnic minorities (Anderson, Green, & Payne, 2009; Meghani, Byun, & Gallagher, 2012; Tait & Chibnall, 2014). To date, the pain disparities literature has focused largely on non-Hispanic Black (NHB) and non- Hispanic White (NHW) differences. Clinical investigations have found that NHB patients are less likely than NHW patients to be treated with analgesic medication, particularly opioids, for chronic pain (Chen et al., 2005; Meghani, Byun, et al., 2012; Morasco, Duckart, Carr, Deyo, & Dobscha, 2010; Tamayo-Sarver, Hinze, Cydulka, & 2 Baker, 2003). Providers’ racial bias has been identified as one reason for these differences in treatment (Anderson et al., 2009; Green et al., 2003; Meghani, Byun, et al., 2012; Mossey, 2011; Tait & Chibnall, 2014).
Hispanic Americans are also at risk for suboptimal pain care. There is some evidence to suggest that Hispanics are at risk of having their pain underassessed by healthcare providers (Anderson et al. Hispanics also receive less treatment for their pain, particularly opioid medications, than their NHW counterparts (Meghani, Byun, et al., 2012; Todd, Deaton, D’Adamo, & Goe, 2000). A 2012 meta-analysis found that, compared to NHW patients, Hispanics were 22% less likely to receive an opioid prescription for any type of pain and 30% less likely to receive an opioid for non-traumatic/nonsurgical pain (Meghani, Byun, et al.
Reasons for these disparities have not yet been elucidated. This is striking given that the Hispanic population is one of the fastest growing demographic groups in the U. and face significant barriers to healthcare (Brown, Ojeda, Wyn, & Levan, 2000; Ennis, Rios-Vargas, & Albert, 2011). Compared to NHWs, NHBs, Asians, and American Indians/Alaskan Natives, Hispanics have the largest proportion of individuals living in poverty and the highest rates of being uninsured (Brown et al.
One national survey found that Hispanic ethnicity and speaking Spanish were significant predictors of lower access to chronic pain treatment (Nguyen, Ugarte, Fuller, Haas, & Portenoy, 2005). In addition, Hispanics are more often employed in occupations that predispose them to pain (Anderson, Hunting, & Welch, 2000; Institute of Medicine, 2009; U. Bureau of Labor Statistics, 2012). These factors can lead to prolonged pain and suffering for Hispanics, which can be compounded by inadequate pain care.
3 Little is known about the provider factors that contribute to pain treatment disparities for Hispanic patients. Providers’ attitudes about Hispanics likely contribute to these disparities. Dual Process Models of decision making posit that individuals may hold explicit and implicit attitudes that are contradictory (e., they may explicitly deny ethnic bias, while implicitly preferring NHWs relative to Hispanics; Burgess, van Ryn, Crowley-Matoka, & Malat, 2006; Evans, 2008). Previous investigations of racial bias have found that many individuals endorse explicit egalitarian attitudes about race while holding implicit racial biases (Dovidio & Fiske, 2012).
However, these findings may not extend to attitudes towards Hispanics. Hispanic individuals endure explicit discriminatory attitudes in the U., particularly in regards to their perceived disinterest in integrating culturally into U., speaking Spanish) and their immigration status (Chavez, 2013). These explicit views have been used to promote anti-immigration laws and reinforce unfair hiring practices (Chavez, 2013; Institute of Medicine, 2009). One survey found that NHW laypersons explicitly rated Hispanics as more “unintelligent”, “violent”, “lazy”, “welfare dependent”, and “unpatriotic” relative to NHWs (Wilson, 1996).
To the investigator’s knowledge, only one study has measured healthcare providers’ ethnic bias. That investigation found primary care providers did not report explicit ethnic bias but displayed an implicit preference for NHWs relative to Hispanics (Blair et al. Additional studies are needed to better understand healthcare providers’ ethnic bias, in particular, and the extent to which this bias is associated with their pain decisions. Because previous ethnic disparities studies were observational in nature and lacked experimental control, it is unclear whether pain management disparities were due to the patients’ ethnic group per se or due to other clinically-relevant variables (e., 4 language barriers, access to care barriers).
Previous research examining racial disparities have relied on experimental methods to help rule out such confounds (Hirsh et al., 2013; Hollingshead, Matthias, Bair, & Hirsh, 2014; Stepanikova, 2012). To date, only one pain- related study has examined Hispanic ethnicity using experimental methods (Tamayo- Sarver, Dawson, et al. The results indicated that providers made similar opioid recommendations for a Hispanic, NHW, and NHB patient presenting with either migraine headache, low back pain, or ankle fracture (Tamayo-Sarver, Dawson, et al. However, that study used a traditional paper-pencil vignette approach, included only 3 text-based vignettes (1 Hispanic, 1 NHW, 1 NHB), and did not examine judgments about pain assessment.
These limitations raise concerns about the ecological validity and generalizability of their findings. Novel experimental methodology, such as lens model design and virtual human (VH) technology, can help address these limitations and facilitate a better understanding of ethnic disparities in pain care. In the current study, I used experimental methods to examine the influence of Hispanic ethnicity on medical students’ chronic pain assessment and opioid treatment decisions. I also measured medical students’ explicit and implicit ethnic bias in order to examine the influence of ethnic bias on their chronic pain management decisions.
I hypothesized that: [1] participants will give lower pain assessment and opioid treatment ratings to Hispanic patients relative to NHW patients, [2] participants will express explicit and implicit ethnic bias towards Hispanics relative to NHWs, and [3] participants with higher ethnic bias will demonstrate greater disparities in their pain management decisions for Hispanic vs. NHW patients than participants with lower ethnic bias. 5 METHODS Participants Medical students were recruited from Midwestern medical schools via e-mail. Medical students were chosen because they are currently engaged in aspects of patient care and will be independent physicians in the near future.
Participants were informed that the purpose of the study was to examine how healthcare providers make chronic pain management decisions but were not given information about the aims or hypotheses. In order to be eligible for the study, interested participants had to: [1] be 18 years of age or older, [2] be currently enrolled as a medical student, [3] have access to a computer with high speed internet, and [4] confirm their university affiliation by responding to the screening items with a university email address. Procedure Eligible participants accessed the online study using a unique username and were directed to one of two online versions of the study. After logging in, all participants were asked to give informed consent and provide demographic information.
Participants were then directed to either an instructions page and asked to make chronic pain management decisions for 8 VH patients or completed the explicit and implicit measures of ethnic bias; participants then completed the remaining task. Finally, participants were asked to guess 6 at the purpose of the investigation. The study took no more than 1 hour to complete and participants were compensated with a $30 Amazon.com e-gift card. Methodology This investigation employed a lens model design.
Lens model designs are well- suited for examining medical decision making, as they require multiple ratings for each patient-type and allow for more reliable results (Doherty & Kurz, 1996; Wigton, 1996). The lens model design of the current study allowed for a quantitative estimate of how influential ethnicity was in participants’ decisions, while holding other confounding variables constant (Wigton, 1996).
