The Role of Bias by Emergency Department Providers in Care for American Indian Children

Background: American Indian children have high rates of emergency department (ED) use and face potential discrimination in health care settings. Objective: Our goal was to assess both implicit and explicit racial bias and examine their relationship with clinical care. Research Design: We performed a cross-sectional survey of care providers at 5 hospitals in the Upper Midwest. Questions included American Indian stereotypes (explicit attitudes), clinical vignettes, and the Implicit Association Test. Two Implicit Association Tests were created to assess implicit bias toward the child or the parent/caregiver. Differences were assessed using linear and logistic regression models with a random effect for study site. Results: A total of 154 care providers completed the survey. Agreement with negative American Indian stereotypes was 22%-32%. Overall, 84% of providers had an implicit preference for nonHispanic white adults or children. Older providers (50 y and above) had lower implicit bias than those middle aged (30-49 y) (P = 0.01). American Indian children were seen as increasingly challenging (P = 0.04) and parents/caregivers less compliant (P = 0.002) as the proportion of American Indian children seen in the ED increased. Responses to the vignettes were not related to implicit or explicit bias. Conclusions: The majority of ED care providers had an implicit preference for non-Hispanic white children or adults compared with those who were American Indian. Provider agreement with negative American Indian stereotypes differed by practice and respondents' characteristics. These findings require additional study to determine how these implicit and explicit biases influence health care or outcomes disparities.