Abstract
Purpose Provider bias has been shown to be a contributing factor to racial and ethnic disparities observed in health care settings. The purpose of this study was to examine implicit racial bias among dental hygienists.
Methods A convenience sample of licensed and practicing dental hygienists within the United States was recruited through email and national dental hygiene social media groups via snowball sampling. A two-part survey design was used for data collection. Participants completed a 10-item demographic survey through an online platform and were then routed to the Race Implicit Association Test (IAT). Descriptive statistics and linear regression analyses were used to compare demographic data and implicit racial preference scores (d-scores).
Results Data from 404 licensed dental hygienists were included in this study. Over two-thirds (67.8%) of participants showed a preference for European Americans over African Americans. A significant difference was found between implicit racial preference scores and participant age (Estimate: 0.01, 95% CI: 0.00, 0.01), years worked comparing <5 years to 21 or more years (Estimate: 0.19, 95% CI: −0.30, −0.09), and race comparing non-White to White (Estimate: −0.17, 95% CI: −0.27, −0.07). No difference was found with task order, previous Race IAT experience, or previous self-reported implicit bias training.
Conclusion Findings suggest that dental hygienists may harbor implicit racial preferences for European Americans over African Americans. Non-White participants had more positive implicit preferences toward African Americans compared to White participants. Further research is needed to determine the extent to which implicit racial biases contribute to disparities in oral health.
- implicit bias
- implicit racial preference
- race
- Implicit Association Test
- dental hygienists
- health equity
- health care delivery
INTRODUCTION
Health disparities adversely affect Black, Indigenous, and People of Color (BIPOC) who have continually faced systemic and institutionalized racism, historical discrimination, and exclusion based on race or ethnicity.1-3 Oral health disparities play a critical role in overall health. According to the Centers for Disease Control and Prevention (CDC), non-Hispanic Blacks, Hispanics, and American Indians/Alaska Natives have poorer oral health outcomes compared with other racial and ethnic groups in the United States (US).4 Implicit biases may affect delivery of health care, contributing to health disparities among BIPOC.1,5-6
Implicit bias is the unconscious association of perceptions, attitudes, and stereotypes that may affect decisions and behaviors based on race, ethnicity, age, gender, gender identity, and sexual orientation.7-9 Effectively addressing the role of implicit bias in oral health care delivery and promoting racial health equity requires examining policies and practices on both institutional and individual levels.1 Acknowledgement of implicit biases within the health care system is a key first step in reducing health disparities among BIPOC.3,10
Significant research has been conducted on the effects of implicit racial bias among medical providers and delivery of health care.5,7,11 Multiple studies have shown the negative effects of medical providers’ implicit biases with quality of patient care, treatment decisions, health outcomes, and patient-provider interactions.5,12-15 When a clinician’s implicit bias prevents them from seeing the patient as more than their perceived demographic, patient interactions, the delivery of care, and missed diagnoses can impact the quality of care.14 Considering the role that implicit bias has been shown to play in the delivery of medical care, these same biases may have the same impact on the delivery of oral health care services.6,16
Similar with findings from implicit bias studies of health care providers, studies of implicit biases among dental professionals suggest implicit racial bias influences clinical decisions, patient-provider relationships, and patient adherence to recommended treatment.17-18
In dentistry, dental care treatment and impact of bias has been studied. Researchers investigated if explicit and implicit racial bias influenced treatment planning recommendations between root canal therapy (RCT) or extraction (EXT) for White and Black patients with irreversible pulpitis. The researchers concluded that dentists’ clinical decision for RCT versus EXT were influenced by the race of the patient, demonstrated by recommending RCT for White patients and EXT for Black patients.17
Negative discriminatory experiences such as cultural or language barriers, insensitivity from health or dental staff, and implicit bias can collectively influence patient mistrust, non-compliance of treatment recommendations, and underutilization of health and dental services at the institutional level.18 Research regarding the emotional impact of racial discrimination and the association with underutilization of dental services shows that implicit bias has an effect on the patient-provider relationship.18 According to the researchers, findings suggest that racial discrimination should be viewed as a social determinant of oral health. The researchers recommended future research focus on why, how, and to what extent perceived discrimination impacts the lives of BIPOC.18
A recent study on color-blind ideology and racial attitudes using the Color-Blind Racial Attitudes Scale (CoBRAS) found that dental hygienists held a moderate unawareness of racism.19 African American and Hispanic participants were more aware of blatant racial issues. Older dental hygiene participants (age 60+ years) scored higher overall on CoBRAS compared to younger participants (18-29 years old). Younger participants (18-29 years old) had lower unawareness of institutional racism compared to those 45-59 years old and 60+ years old, who showed moderate unawareness. From these findings, the researchers emphasized the need for more research to gain knowledge and awareness of how color-blindness can impact dental hygiene care.19
While CoBRAS has been used to examine one form of implicit bias, color-blind racial attitudes, another instrument used for examining implicit bias is the Implicit Association Test (IAT). The IAT is a widely used and validated instrument to show biases that are unrecognized (i.e., implicit) and that may differ from what one consciously believes (i.e., explicit).12 The IAT has been used in health care, educational settings, and psychological sciences.5,16,20 Meta-analyses have shown the IAT to have good reliability and incremental predictive validity.21-23 Even with the substantial evidence of validity, some researchers have questioned the reliability and validity of the instrument.24-26 However, despite concerns, most studies in racial/health care disparities use the IAT to assess implicit bias of health care providers,5,16 and it has been recommended that researchers wishing to study automatic judgement use the IAT as a first choice of measurement.27
In oral health care, the perceptions, attitudes, and actions of dental hygienists can affect the patient-provider relationship including shared decisions and treatment goals, interpersonal communication, and trust. A gap exists in the literature related to the extent of implicit racial bias among dental hygienists. The purpose of this study was to explore whether there were implicit racial biases among dental hygienists employed in clinical practice settings, and if biases varied by sociodemographic characteristics.
METHODS
This descriptive study was reviewed and determined to be exempt by the Idaho State University Human Subjects Committee (IRB-FY2021-250). A convenience sample of licensed and practicing dental hygienists in the US was recruited via national dental hygiene social media groups and through electronic mail, using snowball sampling for ease of data collection. Administrators or moderators of the selected social media groups were contacted for approval to post the survey invitation, unless the group forum was open to public discussion. The survey invitation was also distributed through electronic mail to the entire membership directory of the American Dental Hygienists’ Association, colleagues, and current dental hygiene graduate students, alumni, and faculty from one university. All groups were asked to forward the invitation to others in their contact list. Email invitations were sent twice during the eight weeks the survey link was open. To be included in the study, participants had to be licensed to practice dental hygiene in the US and work at least one day a week in a clinical setting caring for patients.
The survey invitation contained a secure link that took participants directly to the website that hosted the survey. The landing page for the site showed informed consent details. Participants indicated their consent by advancing to the next page to initiate the study. A demographic survey was administered through online survey software (Qualtrics; Provo, UT, USA). Upon completion of the demographic survey, participants were routed to the Race IAT, hosted securely by Project Implicit, Inc®, a non-profit organization contracted to host and manage the website through secure servers at Harvard University (Project Implicit; Cambridge, MA, USA).28 The estimated time for participants to complete the study was 10 minutes.
Survey Instruments
A two-part survey design was used for data collection. The first part was a 10-item demographic survey. Demographics collected included sex, age, race/ethnicity, geographic location, education level, employment setting, weekly days worked, years of professional experience, previous IAT experience, and previous implicit bias training. Race/ethnicity options were listed with instructions to select all that apply: American Indian/Alaska Native, Asian, Hispanic/Latinx, Native Hawaiian/Pacific Islander, Black/African American, White/Caucasian, and Other/Unknown, which was further categorized as White and non-White due to small sample sizes among non-White participants. This is separate from how the IAT categorizes descriptive scores for race, which is European American and African American.
The second part of the survey used the Race IAT to collect implicit racial bias data among dental hygienists. The IAT is an effective tool for raising awareness about implicit racial preferences and potential bias.29,30 This computer-based instrument measures the strength of association between concepts (e.g., faces of African origin or Black people, faces of European origin or White people) and evaluations (e.g., good, bad) or stereotypes (e.g., lazy, smart). The IAT measures implicit associations by having the participants quickly sort words into categories that are on the left (“E” key) and right (“I” key). There are five sets (blocks) to the IAT. First, participants sort words relating to the concepts (e.g., Black people, White people) into categories. Second, participants sort words relating to the evaluation (e.g., good, bad). In the third block of the IAT, the categories are combined, and the participant is asked to sort both concept and evaluation words (e.g., Black people + good). The fourth block switches the placement of the concept from left (“E” key) to right (“I” key) and vice versa. This block in the IAT is important because increasing the number of trials can minimize the effects of memorization or practice. In the fifth and final block of the IAT, the categories are combined in a way that is opposite to what they were before (e.g., the sorted word and image are switched). The IAT score is based on how quickly a participant sorts the words in the third part of the IAT versus the fifth part of the IAT. The difference in the time it takes to quickly sort and pair the images and words correctly shows the strength of automatic association and is reported as a d-score. The main concept behind the IAT effect is participant performance is faster when highly associated categories share a response key.29
The d-score results of the Race IAT are an implicit bias measure and are categorized based on automatic preference scores ranging from little to no racial preference (0-0.14); slight European American preference (0.15-0.34); moderate European American preference (0.35-0.64); strong European American preference (<0.65). Scores in the negative range are categorized in the same degree and indicate an African American preference.29,30
Differing views regarding the validity and reliability of the IAT instrument have been expressed in the literature.24,26 However, a large body of research supports the validity of the IAT.21,27,30
Studies have evaluated the test-retest reliability of the IAT and noted the range value from 0.27 to 0.62 with an IAT average of 0.56 and a high internal consistency of 0.80.23,31-35 Accumulated evidence shows the wide use and high predictive validity of the Race IAT. A meta-analysis showed the IAT measures (r=0.236) had greater predictive validity than did self-report measures (r=0.117) of Black-White interracial behavior.21 In these studies, the predictive validity of the IAT measures (attitudes and stereotypes) significantly exceeds that of explicit measures (self-reporting).21,23,35
Statistical Analysis
To examine implicit racial biases among respondents, d-scores were calculated via the IAT algorithm.30 The IAT d-scores were then categorized to assess participants’ racial preferences between African Americans and European Americans. Linear regressions examined the associations between IAT d-scores and respondent demographic characteristics. All statistical analyses were performed via a statistical software program (R software, version 4.0.2).
RESULTS
There were 615 dental hygienists who participated in the online survey. Of those surveys, 211 were unusable, yielding a final analytic sample of 404 participants. Respondents were mostly female (n=394, 98.5%), non-Hispanic White (n=324, 80.4%), and worked in private practice (n=271, 67.4%) (Table I). There was a wide range of education levels, years worked, and region in which participants lived. Over half of participants (n=224, 55.4%) reported previous training on implicit biases.
Characteristics among dental hygienists across the United States (n=404)
Most respondents (n=274; 67.8%) showed preference for European Americans over African Americans; 18.3% (n=74) showed little to no preference between the two groups (Table II). The average d-score was 0.31+0.41 indicating slight preference for European Americans over African Americans. The assigned task order in which participants completed their first task in the IAT was evenly split, as either “White + good” or “Black + good” (Table I). Age and race were significantly associated with IAT d-scores (Table 3). For every 1-year increase in age, there was a subsequent 0.01 increase in the d-score (R2=0.02). Those with less than 5 years of work experience scored 0.19 fewer points on the IAT compared to those with 21 or more years of experience. Non-White participants scored 0.17 fewer points on the IAT compared to White participants. There were no associations between IAT d-scores and highest level of education, region, practice type, days worked per week, task order, previously taking the IAT test, or previous training on biases.
Implicit bias distribution among dental hygienists across the United States (n=404)
Linear regression examining the association between d score and participant characteristics among dental hygienists (n=404)
DISCUSSION
Findings suggest that dental hygienists practicing in the US have a slight preference for European Americans over African Americans, which is consistent with previously published studies among medical and dental health care professionals.6,9,36-38 According to 2020 data from the US Census Bureau, 95.3% of dental hygienists were female and non-Hispanic White (78.8%) with a median age of 42.9 years.39 Therefore, participant demographic characteristics of sex and race mimicked those of the dental hygienist workforce in the US.
This study also found that IAT d-scores increased with increasing age, which may suggest greater levels of implicit bias in older populations. This finding is comparative to previous research suggesting aging may cause practitioners to rely more on stereotypes and neglect mindfulness,19,40,41 as aging decreases suppression of prejudicial thoughts or actions from consciousness, allowing implicit bias to be more easily expressed.40 However, this finding should be interpreted with caution as the R2 was 0.02, indicating that only 2% of the variability in d-score could be attributed to age.
Additionally, participant race played a significant role in implicit racial preference scores (d-scores). This study found compared to White participants, non-White participants had more positive implicit preferences toward African Americans, which is consistent with previous research.9,36-38 Previous studies investigating implicit intergroup, or in-group, bias found that implicit bias is more likely to be exhibited toward non-members of a group.6,42
Although half of participants reported some form of previous implicit bias training or education prior to IAT utilization, only 18% of respondents had little to no preference for either race. Results from this study suggest that participants with implicit bias education or training still exhibit a preference for European Americans over African Americans. Previous bias training had no effect on the IAT racial bias d-scores. This finding illustrates the importance of integrating recognition and management of racial preferences and providing diverse experiences within dental hygiene education. This may create early awareness to these biases and active prevention of implicit biases.
Oral health care professionals may benefit from this study by recognizing how dental hygienists’ racial preferences could influence implicit racial bias; while further research is needed to understand how dental hygienists’ racial preferences may affect the patient-provider relationship, clinician decision-making, and oral health disparities. The oral health care delivery system can be evaluated, modified, and improved to recognize implicit racial bias and the impact on dental hygiene diagnoses, treatment, and the patient-provider relationship. Appropriate policy and education interventions can be designed to increase self-awareness, reflection, and mindfulness of how implicit bias influences health outcomes.
Limitations and Future Research
This study is not without limitations. A convenience sample was used, which impacts the representative nature of the sample and limits generalizability of results. Participants were predominantly female and included few underrepresented minority dental hygienists (19.6% non-White); however, this reflects the lack of racial and ethnic diversity in the dental hygiene workforce in the US.39 Surveys were distributed via email and through national dental hygiene social media groups; as a result, not all dental hygienists had access to or were informed of the opportunity to participate in this study. Further, no power analysis was conducted to determine an appropriate sample size needed for the significance level, statistical power, and effect size.
Research examining implicit and explicit racial bias with a larger and more diverse participant group is suggested to increase the understanding of racial attitudes and unconscious biases of dental hygienists. Future studies should also focus on the context and content of implicit bias education or training interventions specifically designed for oral health care professionals to assist with understanding and mitigating personal bias and stereotypes.
CONCLUSION
Participants’ average implicit racial preference scores revealed a slight preference for European Americans over African Americans. Non-White participants had more positive implicit preferences toward African Americans compared to White participants. Further research is needed to confirm these findings, and to determine the extent to which implicit racial biases affect dental hygiene care and contribute to disparities in oral health.
ACKNOWLEDGEMENT
This study was conducted in partial fulfillment of the Master of Science degree in Dental Hygiene, Idaho State University, Pocatello, ID, USA.
Footnotes
NDHRA priority area, Professional development: Occupational health (determination and assessment of risks).
DISCLOSURES
The authors declare there are no conflicts of interest. Funding for this project was provided by the National Center for Dental Hygiene Research & Practice, Inc., and Crest and Oral-B, Procter & Gamble; Cincinnati, OH, USA.
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author upon reasonable request. The data are not publicly available due to privacy or ethical restrictions.
- Received April 27, 2023.
- Accepted September 1, 2023.
- Copyright © 2023 The American Dental Hygienists’ Association
