Health and Social Development, Faculty of (Okanagan)
Health and Exercise Sciences, School of (Okanagan)
DSpace
UBCO
Young, Renee
Master of Science - MSc
University of British Columbia
Type 2 Diabetes affects 9% of Canadians. With the inclusion of individuals living with undiagnosed Type 2 Diabetes or pre-diabetes this value rises to 30%. Indigenous Peoples in Canada have higher Type 2 Diabetes incidence and poorer outcomes compared to non-Indigenous individuals. Implicit and explicit biases towards Indigenous Peoples and people with Type 2 Diabetes in healthcare have been documented, impacting the quality of care they receive. This study evaluated biases of seventy-nine healthcare practitioners in the Interior Health Region of British Columbia towards Indigenous Peoples in Canada and their explicit attitudes towards people with Type 2 Diabetes. Explicit bias was assessed using the Attitudes about Treating People with Diabetes Scale and the Modern Prejudice Attitudes Towards Aboriginals Scale. Implicit bias was assessed using the Indigenous Peoples in Canada Implicit Association Test. Perceived enablers and disrupters to discriminatory behaviour in healthcare were assessed by open-ended questions and coded using the Theoretical Domains Framework. Results of implicit bias assessment showed 44.8% of respondents had slight to strong pro-European preference. Knowledge and education were identified as both enablers and disrupters of discriminatory behaviour, with impacts of colonization emerging as a major theme for enablers of this behaviour. Social influences were highlighted as a key domain for both enablers and disrupters of discriminatory attitudes. This study suggests that negative attitudes towards Indigenous Peoples and Type 2 Diabetes persist among Interior Health region of British Columbia healthcare practitioners. Anti-bias training should focus on increasing knowledge, addressing impacts of colonization, and shifting social dynamics within healthcare.
Healthcare Practitioners’ Bias Towards Type 2 Diabetes and Indigenous Populations by Renee Young BSc McGill University 2016 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in THE COLLEGE OF GRADUATE STUDIES (Health and Exercise Sciences) THE UNIVERSITY OF BRITISH COLUMBIA (Okanagan) October 2024 © Renee Young, 2024 ii The following individuals certify that they have read, and recommend to the College of Graduate Studies for acceptance, a thesis entitled: Healthcare Practitioners’ Bias towards Type 2 Diabetes and Indigenous Populations submitted by Renee Young in partial fulfillment of the requirements of the degree of Master of Science. Dr. Mary Jung, School of Health and Exercise Sciences Supervisor Dr. Katrina Plamondon, School of Nursing Supervisory Committee Member Dr. Kathy Rush, School of Nursing Supervisory Committee Member Dr. Amir Ardestani-Jaafari, Faculty of Management University Examiner iii Abstract Type 2 Diabetes affects 9% of Canadians. With the inclusion of individuals living with undiagnosed Type 2 Diabetes or pre-diabetes this value rises to 30%. Indigenous Peoples in Canada have higher Type 2 Diabetes incidence and poorer outcomes compared to non-Indigenous individuals. Implicit and explicit biases towards Indigenous Peoples and people with Type 2 Diabetes in healthcare have been documented, impacting the quality of care they receive. This study evaluated biases of seventy-nine healthcare practitioners in the Interior Health Region of British Columbia towards Indigenous Peoples in Canada and their explicit attitudes towards people with Type 2 Diabetes. Explicit bias was assessed using the Attitudes about Treating People with Diabetes Scale and the Modern Prejudice Attitudes Towards Aboriginals Scale. Implicit bias was assessed using the Indigenous Peoples in Canada Implicit Association Test. Perceived enablers and disrupters to discriminatory behaviour in healthcare were assessed by open-ended questions and coded using the Theoretical Domains Framework. Results of implicit bias assessment showed 44.8% of respondents had slight to strong pro-European preference. Knowledge and education were identified as both enablers and disrupters of discriminatory behaviour, with impacts of colonization emerging as a major theme for enablers of this behaviour. Social influences were highlighted as a key domain for both enablers and disrupters of discriminatory attitudes. This study suggests that negative attitudes towards Indigenous Peoples and Type 2 Diabetes persist among Interior Health region of British Columbia healthcare practitioners. Anti-bias training should focus on increasing knowledge, addressing impacts of colonization, and shifting social dynamics within healthcare. iv Lay Summary The goal of this work was to look at the conscious and subconscious biases of healthcare practitioners (HCPs) towards Indigenous Peoples in Canada and people with Type 2 Diabetes (T2D). Biases were assessed through an online survey that measures biases through questionnaires and an online computer test called an implicit association test. The tools in the survey helped us to understand the level of bias in HCPs working in the Interior Health Region of British Columbia (BC). HCPs were also asked their opinions on what helps and hinders providing unbiased care to their patients. It was found that most HCPs had some level of subconscious bias towards Indigenous Peoples in Canada. Overall HCPs reported that knowledge, impacts of colonization, and social influences all contribute to discriminatory behaviours in health care. This study aimed to understand bias in healthcare and provide insights on how to approach anti-bias training for HCPs. v Preface I declare that the creation of this thesis is the result of my own work. I performed the literature review that informed the choice of the methods, the harmonized ethics application, and the writing of this thesis. The ethics application was submitted to the UBC Okanagan Behavioural Research Ethics Board (UBC REB Number: H23-00945). Kyra Braaten facilitated the initial literature review that informed the conception of the initial research questions. I was responsible for the analysis of the quantitative data and qualitative data. Rebecca Reitsma acted as a second coder for the qualitative work. Natalie Grieves acted as a third coder during qualitative analysis. Dr. Kaela Cranston, and Kyra Braaten assisted with editing this thesis. Dr. Mary Jung was responsible for overseeing all aspects of this study as well as editing this thesis. Generative artificial intelligence was used as a reference to guide the procedural use of Qualtrics and SPSS, but it was not used in any other aspects in the creation of this thesis. vi Table of Contents Abstract ...................................................................................................................................... iii Lay Summary ............................................................................................................................. iv Preface ......................................................................................................................................... v Table of Contents ....................................................................................................................... vi List of Tables ............................................................................................................................ viii List of Figures ............................................................................................................................ ix Acknowledgements .................................................................................................................... x Dedication ................................................................................................................................... xi Chapter 1: Introduction .............................................................................................................. 1 1.1 Positionality and how I come to this work ....................................................................... 1 1.2 Bias ................................................................................................................................. 3 1.2.1 Bias in healthcare ..................................................................................................... 3 1.2.2 Implicit and explicit biases ........................................................................................ 5 1.2.3 Bias and diabetes ..................................................................................................... 9 1.2.4 Bias Toward Indigenous Peoples in Canada ......................................................... 12 1.2.5 Intersectionality of bias and health outcomes ........................................................ 14 1.3 A pragmatic approach to addressing biased behaviour ................................................ 16 1.4 Gaps in Literature ......................................................................................................... 22 1.5 Objectives ..................................................................................................................... 22 Chapter 2: Body of Thesis ...................................................................................................... 24 2.1 Methods ..................................................................................................................... 24 2.1.2 Recruitment ..................................................................................................... 25 2.1.3 Measurements ....................................................................................................... 26 2.1.3.1 Modern Prejudiced Attitudes Towards Aboriginals Scale (M-PATAS) ............ 26 2.1.3.2 Attitudes Towards treating People with Diabetes Scale (ATPDS) .................. 27 vii 2.1.3.3 Indigenous Peoples in Canada Implicit Associations Test (IPC-IAT) .............. 29 2.1.3.4 Open-Ended Questions ................................................................................... 30 2.2 Analysis .......................................................................................................... 31 2.2.1 Quantitative Analysis ............................................................................................. 32 2.2.2 Qualitative Content Analysis ................................................................................. 32 2.2.3 Theoretical Domains Framework (TDF) Coding .................................................... 33 2.3 Results ............................................................................................................. 34 2.4 Discussion ................................................................................................................. 62 2.5 Strengths ................................................................................................................... 68 2.6 Limitations ................................................................................................................. 69 2.7 Future directions ........................................................................................................ 71 2.8 Implications ............................................................................................................... 71 Chapter 3: Conclusion .............................................................................................................. 74 3.1 Conclusion ................................................................................................................. 74 3.2 Strengths and Limitations .................................................................................... 74 3.3 Future Directions ............................................................................................. 75 Bibliography ...................................................................................................................... 78 Appendices ................................................................................................................................ 98 Appendix A: Demographics ................................................................................................. 98 Appendix B: Modern Prejudice Items (Morrison et al 2009) ............................................. 101 Appendix C: Scale Items Assessing Attitudes toward Patients with T2D (Bennett & Puhl, 2023) ......................................................................................................................................... 102 Appendix D: TDF Domain Agreement Statements ........................................................... 104 viii List of Tables Table 1:Theoretical Domains Framework definitions and their constructs of behaviour (Cane et al., 2012) ..................................................................................................................................... 18 Table 2: Demographic Characteristics ........................................................................................ 36 Table 3: Results from M-PATAS ................................................................................................. 40 Table 4: Results from ATPDS ..................................................................................................... 43 Table 5: Results From IPC-IAT as Frequencies ......................................................................... 47 Table 6: Results from Pearson's Correlations between revised M-PATAS, ATPDS, and IPC-IAT .................................................................................................................................................... 48 Table 7: Results from Pearson's Correlations between M-PATAS, ATPDS, and IPC-IAT ......... 49 Table 8: Coded text for each major theme in enablers ............................................................... 52 Table 9: Coded text for each major theme in disrupters ............................................................. 57 Table 10: Text examples for domains coded in disrupters ......................................................... 61 Table 11: Text example for domains coded in enablers ............................................................. 61 ix List of Figures Figure 1: Interior Health Region Map (New to the region, 2013) ................................................ 25 Figure 2: Response rates for each measure ............................................................................... 35 Figure 3:Thematic map for enablers of discriminatory behaviour in healthcare.......................... 53 Figure 4: Thematic map for disrupters of discriminatory behaviour in healthcare....................... 56 Figure 5: Frequency of TDF domains coded for enablers of discriminatory behaviour............... 59 Figure 6: Frequency of TDF domains coded for disrupters of discriminatory behaviour............. 60 x Acknowledgements I would like to acknowledge the land upon which this work was done as the unceded, ancestral and stolen lands of the Syilx Peoples of the Okanagan Nation. I would also like to acknowledge the territories of Tŝilhqot’in, Secwépemc, Dãkelh Dené, St’át’imc, Nlaka’pamux, and Ktunaxa Nations in which this work was also conducted. I would like to acknowledge my privilege to live, work and play in their territory as an uninvited guest. I commit myself to truth and reconciliation and hold myself accountable, as a white person of settler ancestry and a health care worker, to address my own biases and how they may have or continue to impact the people I care for. I would also like to acknowledge my supervisor Dr. Mary Jung who provided me with the guidance and mentorship needed to conduct this research in a thorough and thoughtful manner. I appreciate the incredible opportunity Dr. Jung has provided me as a trainee In the Diabetes Prevention Research Group and I will carry what I have learned with me on my journey as a healthcare provider. Thank you to my committee member, Dr. Katrina Plamondon and Dr. Kathy Rush for providing integral insights that helped ensure this work was completed in a good way. Thank you as well to Dr. Amir Ardestani-Jaafari for generously agreeing to be my university examiner. I also want to thank the team at Well Living House for their collaboration on this project and allowing me to access their tool for this project. I want to thank all the DPRG past and present who have supported me in this work. A special thanks to Rebecca Reitsma and Kalea Cranston for their hard work and dedication to this study and thesis, without you this work would not have been possible. Finally, a thank you to my friends, family, partner and colleagues at Interior Health Authority for supporting me throughout this project. xi Dedication I would like to dedicate this work to all the Indigenous mentors I have had as a healthcare worker and all the Indigenous clients that I have and continue to serve. Your resilience in the face of adversity is endlessly moving and I hope my work in research and healthcare will contribute to a more peaceful and equitable world to move through. 1 Chapter 1: Introduction 1.1 Positionality and how I come to this work As a researcher, clinician and member of the population being studied, I feel that my approach to research aligns with that of pragmatic and constructivist paradigms. How I understand and evaluate the findings of research depends on the context from which it is derived. I am keenly interested in how to apply these findings in practical ways to benefit end-users and make research meaningful to those it impacts. This view of knowledge and its creation has largely been the result of my experiences, personal and professional, as a learner and an educator. I acknowledge that I do not have the personal or indirect experience of having T2D. I also can not purport to fully comprehend the trauma and lasting impacts of colonization on Indigenous communities and families. I come to this research, and its interpretation, with the lens of a person that experienced many privileges, and this will inevitably impact the findings and interpretation of data collected. I made efforts to collaborate with Indigenous scholars and educators while planning and interpreting this research and I am deeply grateful for their guidance. I am committed to ensuring this thesis contributes to the excellent work already being done in healthcare to address systemic inequities. I am a Registered Dietitian and Certified Diabetes Educator working on the unceded lands of Syilx Peoples of the Okanagan Nation. I am currently pursuing a Master’s of Science in Health and Exercise Sciences at the University of British Columbia in the Okanagan. I come to this work as an HCP of settler descent (Maritime Acadian settlers and Southwest Quebec French settlers). I have come to realize that my ancestors and I have been benefactors from the violent legacy of colonization which has led me to actively pursue opportunities to decolonize my practice. 2 My personal motivation in research is to improve the equity of healthcare services in BC and beyond. In this project, I hope to contribute to equity in health by assessing the bias of HCPs, particularly in diabetes care, which is my area of interest and professional work. I began my career working in the non-profit sector as a food security coordinator in the Yukon territory. This is where I commenced my learning about how health disparities are systemically driven. My work there involved engaging with First Nations communities to hire and train community members to collect food costing data across the territory. The project was informed by community-based participatory research strategies and aimed to integrate community members into the research team as collaborators and decision makers in disseminating findings. After this experience I relocated to Ontario where I worked for the Southwest Ontario Aboriginal Health Access Center (SOAHAC) as a community dietitian for 3 years. In this position, I provided one-on-one nutrition care and group programming to members of Saugeen First Nation and Chippewas of Nawash (Neyaashiinigmiing) both on and off reserve. Throughout my career I have strived to deepen my understanding of the histories of Indigenous Peoples of Canada and the lasting impacts of colonization. Some of the training I have taken to improve the cultural safety in my practice includes San’yas Indigenous Cultural Safety Training and Indigenous Canada from University of Alberta. I continue my education as I move around Turtle Island by seeking opportunities to learn about the Indigenous caretakers in my local area and how they have persevered as nations in both historical and contemporary contexts. My personal journey in reconciliation involves committing myself to the improvement of healthcare for Indigenous Peoples in Canada, which is a major influence on the work I have completed. 3 1.2 Bias Bias can be defined as, “discrimination for, or against, a person or group, or a set of ideas or beliefs, in a way that is prejudicial or unfair.” (Webster et al., 2022) or “partiality: an inclination or predisposition for or against something” (APA Dictionary of Psychology, 2007). Biases are part of our cognitive processes and help expedite decision making by making associations between two or more objects. Biases that help us with expedient decision-making (heuristics), are seen as important cognitive adaptations in situations where choices must be made in a timely manner (Eva & Norman, 2005). However, there are situations where unbiased decision making is important, such as decisions in healthcare settings. It is important to understand the role biases play in the creation or perpetuation of health disparities in equity-owed populations. 1.2.1 Bias in healthcare Bias in healthcare is systemic and insidious. It has been established that bias in HCPs exists in relation to racialized populations and ethnicity (Beltrán et al., 2019; Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, 2003; Spencer & Grace, 2016), weight (Abbott et al., 2023; Baker et al., 2017; Ferrante et al., 2009; Forhan & Salas, 2013; Klobodu et al., 2022; Lawrence et al., 2021), sexual orientation (Casanova-Perez et al., 2022; Grant et al., 2011), and disability (VanPuymbrouck et al., 2020) and that these biases can have a negative impact on the provision of care (O’Sullivan & Schofield, 2018). Biases have obvious consequences on behaviours, such as clinical decision making and treatment in health care (Saposnik et al., 2016). Biases of HCPs towards an individual’s disease can also have significant impacts on their health outcomes. Examples from patients with HIV (Kay et al., 2018), lung cancer (Sriram et al., 2015) and diabetes (Kato et al., 2020) demonstrate how negative biases and resulting stigmatization from a HCP can negatively 4 impact a patient’s decision to accept treatment. Despite HCPs’ best intentions, stigma and implicit bias can reduce the quality of care delivered (Phelan et al., 2015). Stigmatized groups, including patients representing a cultural or ethnic minority and individuals living with obesity or type 2 diabetes (T2D) experience poor treatment, derogatory commentary, and prejudice in a variety of settings such as those where people access healthcare (Phelan et al., 2015). Stigmatization is associated with lower self-esteem, depression, and reduced quality of life, and can also affect a person’s perception of, and compliance with recommendations from HCPs (Phelan et al., 2015). Given the devastating consequences HCPs’ biases and resulting stigma have on the quality of care provided and the health outcomes of stigmatized groups, it is imperative to investigate both intentional and unintentional HCP biases and perpetuation of stigma. There has been progress made in addressing biases with many recent innovations in cultural sensitivity and anti-bias training. Bias can be reduced by enhancing skills to recognize and manage biases (Sukhera & Watling, 2018). A short educational video, and subsequent discussion on weight bias was found to immediately reduce explicit weight bias in a study on second and third year medical students (Poustchi et al., 2013). Reflective activities performed in a group has also been found to increase strategies to manage implicit bias among third year medical students (Teal et al., 2010). While these studies are promising they mostly examine medical students. While interventions to reduce bias have been conducted among practicing HCPs a systematic review identified that only four had been conducted in Canada (Hardy et al., 2023). In these studies 3 used mixed methods (Barnabe et al., 2021; Crowshoe et al., 2018; Hulko et al., 2021) and one used quantitative methods (Sauvé et al., 2022). All four studies delivered their interventions through workshops which ranged from half-day to full-day sessions. Hulko et al’s (2021) intervention also included 8-10 hours of online training prior to the workshop. The outcomes of these studies were measured using workshop transcripts or surveys to assess knowledge, skills, confidence, and satisfaction with the training. The review 5 concluded that none of the interventions included in the review demonstrated effectiveness in improving clinicians’ skills to engage in a culturally safe manner (Hardy et al., 2023). Additional systematic reviews also concluded a lack of evidence connecting cultural bias training to reduction in discriminatory behaviour in healthcare (Jongen et al., 2018; Truong et al., 2014). There is a paucity of research that assesses bias in HCPs that are not medical students, physicians, or nurses. Patients develop therapeutic relationships with several HCPs throughout their journey in the healthcare system. Within the context of T2D care, Diabetes Education Centers employ similar numbers of Registered Dietitians as they do Nurses, some also employ Social Workers to support people with T2D. Therefore, it is important to expand the evaluation of bias to all HCPs, to accurately reflect the culture of a healthcare organization. Considering the lack of effective interventions for reducing biased behavior and improvement of cultural safety of care provided by HCPs, alternative approaches to cultural competence and anti-bias training may be necessary for enhancing equity in healthcare. 1.2.2 Implicit and explicit biases Stigma or prejudice towards a particular group can stem from either implicit or explicit bias (Dovidio et al., 2002; Fotsch, 2021; Maina et al., 2018). Explicit biases are conscious thoughts reflecting a person’s beliefs and opinions about a certain group, while implicit bias refers to automatic attitudes that often occur unintentionally but still influence judgment, decisions, and behaviors (Phelan et al., 2014). Both explicit and implicit biases exist among various HCP towards factors such as weight (Lawrence et al., 2021) and ethnicity (Beltrán et al., 2019; Gopal et al., 2021). To understand how both types of bias impact HCP behaviors, we must measure both implicit and explicit bias. Implicit bias exists outside of conscious thought and thus cannot be self-reported, whereas explicit bias is self-reportable (Greenwald et al., 1998). Both types of bias influence behaviour, 6 however the mechanisms for this are unclear (Meissner et al., 2019). While explicit biases can be measured through questionnaires or surveys, implicit biases require a different approach to measurement. It is suggested that implicit biases are derived from past experiences that influence performance, even when individuals do not consciously remember those experiences (Greenwald & Banaji, 1995). A significant challenge in addressing HCPs’ biases is that they may not be aware due to the subconscious nature of implicit bias. However, work by Anthony G. Greenwald's offers a potential solution: to gauge the impact of subconscious (implicit) bias, one must indirectly measure how an individual's past experiences may influence their performance (Greenwald et al., 1998). Greenwald's research has led to the development of the Implicit Associations Test (IAT); a tool that indirectly measures implicit bias. Since its development in 1998, the IAT has been used to identify implicit bias in a variety of contexts such as race (Maina et al., 2018) and weight (Abbott et al., 2023; Baker et al., 2017). A quick search on google scholar shows that the IAT has been the primary topic of approximately 18,000 studies since 2014 which demonstrates its popularity as a tool to measure implicit associations. The IAT has also been a tool used to study racial bias in healthcare for over a decade (Maina et al., 2018). To calculate positive or negative implicit associations to a stimulus (i.e., a photo of a person of color), the IAT uses latency in response in making an evaluation (good/bad) of said stimulus (Greenwald et al., 1998). The results of this test do not imply that the a negative association is equal to hostility against a group, but rather the automatic associations made by the individuals taking the test (Greenwald et al., 2022). Bias measurements in HCPs require further consideration, due to the expectations of providing impartial care. Healthcare providers often report low levels of explicit racial bias which aligns with the typical egalitarian attitudes found within healthcare (Zestcott et al., 2016). However, when racial biases are measured, they can diverge with low reports of explicit bias and higher measures of implicit bias (FitzGerald & Hurst, 2017). While not expected to be congruent, large divergences between measures of explicit and implicit bias may reflect social 7 desirability bias. Social desirability bias is “a tendency to present reality to align with what is perceived to be socially acceptable” (Bergen & Labonté, 2020). Previous research also suggests that self-reported levels of biases do not always predict discriminatory behaviour (Hofmann et al., 2005). The contrast between reported explicit biases and indirectly measured implicit biases suggests that HCPs, despite denying prejudice, could still demonstrate biased behaviors due to implicit biases. These findings underscore the potential for implicit biases to influence HCPs' actions, even when they believe themselves to be unbiased. Therefore, when measuring socially undesirable biases, it may be beneficial to evaluate explicit and implicit biases concurrently to understand sources of discriminatory behaviour in populations such as HCPs. While implicit bias is valuable to measure because it reduces the influence of social desirability bias, the measurement of explicit bias is still important. Both implicit and explicit biases shape interpersonal interactions (Care et al., 2003) and therefore both influence on therapeutic relationships between HCPs and patients. A meta-analysis of 61 studies valuating explicit biases found that using strategies to increase the perceived privacy between researchers and participants (i.e., computerized surveys vs interviews) leads to more truthful self-reports about sensitive topics (Richman et al., 1999). This suggests that evaluating explicit biases towards less socially acceptable topics (i.e., racism towards Indigenous Peoples in Canada) in a confidential and self-administered survey might be a more appropriate and accurate means in which to assess explicit biases. In addition to the format of the measurements of bias, the validity of such tools is also of importance. Typically, the validity of psychometric tools is measured by assessing whether a tool is measuring what it says it will measure (Chiang et al., 2015). However the Modern Theory of Validity is more concerned about how the results of a measurement are interpreted (Goodwin & Leech, 2003). In the context of questionnaires and surveys, validation is demonstrated through the application of the tool and subsequent evaluation of different aspects of its validity 8 such as face, content and criterion validity (Chiang et al., 2015). There are validated tools that measure the level of explicit bias toward health conditions (Durso & Latner, 2008; T. Morrison & Kiss, 2017; Polonsky et al., 1995; Srinivas et al., 2018) and race (Henry & Sears, 2002). It is important to consider the evidence for the validity of tools assessing bias in HCPs because of how bias can evolve over time. For example in the case of racial bias, older tools used scale items that aligned with racial bias that was deemed socially acceptable at the time of their publication, however the face validity of these tools has changed with evolving social perceptions of racial bias (T. Morrison & Kiss, 2017). To measure the bias of HCPs, a tool should conform to the social context in which those HCPs are practicing. The validity of implicit measures is a point of contention within social psychology. Authors have argued that the IAT in particular has shown poor reliability in individual’s scores and poor predictive outcomes for behaviour (Blanton et al., 2009; Schimmack, 2021). The original authors of the IAT assert that the poor reliability found in studies are largely due to how correlations are interpreted and represented (Greenwald et al., 2015). Furthermore, others that defend the use of the IAT point to studies that show correlation between the aggregate race IAT scores of a population and the level of health disparities in that geographical location (Hehman et al., 2019; Payne et al., 2017). Additionally, a meta-analysis has shown small but positive correlations (average r= 0.24) between explicit measures and IATs that measure the same construct (Hofmann et al., 2005). Finally, the IAT is a tool widely used in health research to measure implicit bias in healthcare practitioners (Arif & Schlotfeldt, 2021; FitzGerald & Hurst, 2017) and has demonstrated validity in measuring relative association strengths (Greenwald et al., 2003, 2015; Greenwald & Nosek, 2001). While questions remain about which tools are the most useful in assessing bias in healthcare, in the absence of an established methodology (FitzGerald & Hurst, 2017), the IAT seems to be valuable and appropriate in the setting of an anonymous, self-administered survey. 9 1.2.3 Bias and diabetes People with T2D have reported feeling stigmatized as patients experiencing judgment and unfair treatment due to their disease (Browne et al., 2013). This stigmatization can have negative consequences on health outcomes because it can act as a psychological barrier to people with T2D opting to seek healthcare. It can also influence people living with T2D self-managing their disease. As one example, the experience of diabetes related stigma resulted in patients with T2D having negative insulin appraisals (Holmes-Truscott et al., 2018). Biases present in HCPs towards T2D is important to evaluate, not only because of the potential to perpetuate stigmatization, but because negative attitudes about T2D could lead to HCPs not adhering to standards of care (Larme & Pugh, 1998). Further, this can result in patient’s nonadherence to HCPs guidance and worse health outcomes. The consequence that both explicit and implicit bias has on the health outcomes of individuals with T2D is of major concern for health systems in Canada. One in three Canadians have prediabetes or diabetes (Diabetes Canada, 2018). In British Columbia (BC), the prevalence of diabetes in 2021 was 9.6%. Within the Interior Health region of BC, 9% of the population has received a diagnosis of diabetes. This regional percentage fails to consider prediabetes rates or undiagnosed cases; therefore, the true prevalence is likely to be higher. It is valuable to reflect on how HCP implicit and explicit biases impact care for people with T2D considering the prevalence and costs associated with this disease. Diabetic retinopathy is the leading cause of sight loss in Canada with over 60% of those with T2D developing some form of retinopathy (Public Health Agency of Canada, 2022). Diabetes also causes significant financial burden, with out-of-pocket cost for families in Canada as high as 16% of their family income (Diabetes Canada, 2023). These figures will continue to rise as diabetes becomes a rapidly growing health problem (Public Health Agency of Canada, 2022). 10 As prevalence of T2D increases, more Canadians will have to interact with the health care system and HCPs to receive treatment. This means that therapeutic relationships between HCPs and individuals with T2D will continue to be vital to the management of this public health crisis. A recent study looking at biases in physicians that specialize in diabetes care reported that one third of the physicians surveyed perceived patients with T2D as lazy, noncompliant, and having low motivation for lifestyle change (Bennett & Puhl, 2023). It seems probable that such judgmental accusations may influence the interactions between patients and their provider. It also appears likely that such perceptions impact how physicians approach treatment options for people with T2D. For example, while making positive diet and exercise behaviour changes are recommended in Diabetes Canada’s Practice Guidelines for achieving T2D remission (MacKay et al., 2022), the perception held by HCPs that people with T2D are unmotivated could disincline HCPs from prescribing such diet and exercise interventions or programs. From the same study on physicians, the likelihood of exhibiting bias towards people living with T2D was directly associated with the frequency in which they treated people with T2D. Specifically, physicians that worked with a higher percentage of patients with T2D expressed less empathy and greater belief that T2D is controllable (Bennett & Puhl, 2023). Combined, these findings suggest that despite having more experience with this population, and knowledge about this condition, practitioners are still at risk of exhibiting unfavorable bias in treating people with T2D. HCPs’ attitudes have obvious consequences in T2D care, as evidenced by the stigma people with T2D experience in healthcare settings. A qualitative study that interviewed individuals with T2D reported that some participants experienced diabetes related stigma from HCPs while receiving care (Browne et al., 2013). Not only do individuals with T2D experience HCP bias related to their disease, but they are also likely to experience HCP bias towards weight. A survey of 1227 adults with T2D showed that when respondents experienced weight stigma from their HCP they also reported high levels of diabetes related distress and poor quality interactions with their HCPs (Puhl et al., 2020). The majority of people with T2D also 11 have overweight or obesity, therefore the highly correlated stigmatization of weight and diabetes are important because of the negative impact weight stigma has on diabetes outcomes like glycemic control (Potter et al., 2015). The study of bias in healthcare has been largely limited to physicians and nurses (Tajeu et al., 2018), which does not accurately capture the full extent of therapeutic relationships that a person with T2D has within the healthcare system. People with T2D are often connected to a wide range of HCPs, from their primary care providers, to specialized nurses and allied health professionals. The importance of interprofessional team-based care is supported by the Chronic Care Model which is recommended in the Canadian Clinical Practice Guidelines for Diabetes (Clement et al., 2018). The importance of a team-based approach is demonstrated by the results from large trials which have shown the integral role that allied health professionals (Registered Dietitians) play in behavioural interventions (Wylie-rosett & Delahanty, 2002). Therefore, the inclusion of a broader range of HCPs is important when evaluating the nature of bias in the provision of T2D care. In Canada, licensed health professionals with eight hundred hours in diabetes education can become a Certified Diabetes Educator (CDE) through the Canadian Diabetes Educator Certification Board (CDECB). As part of this literature review, I conducted an initial scan of all approved educational resources for CDEs to identify equity, diversity, and inclusion (EDI) training as well as awareness of weight or T2D stigma. There was no specific training for CDEs regarding these topics in any of the educational material provided for those studying to become a CDE. Any training on EDI, or stigma associated with diabetes, is left up to CDEs to obtain. It has been suggested that reducing bias in healthcare should be a shared responsibility between HCPs organizations, and systems (Phelan et al., 2015). There are many regulatory bodies for health professionals that have been incorporating standards of practice that address bias in healthcare (College of Dietitians of British Columbia, 2021). This shift in healthcare systems to prioritizing health equity has resulted in, oftentimes optional, educational resources for 12 practitioners, however, their effectiveness in reducing biases and improving healthcare outcomes has yet to be adequately assessed (Hardy et al., 2023; Truong et al., 2014). Assessing bias in HCPs such as CDE’s and registered dietitians can help to create awareness of the presence of bias in practice and support the need for further education. Education to reduce negative implicit and explicit attitudes may lead to improved health outcomes for stigmatized groups accessing diabetes care. 1.2.4 Bias Toward Indigenous Peoples in Canada Studies that have investigated the impacts of bias towards chronic disease in healthcare have also established the need for further investigation into HCPs’ bias and its influence on health outcomes for equity-deserving populations. The influence of bias in healthcare is demonstrated by the global inequities of diabetes prevalence, morbidities and mortalities especially for Indigenous populations (Agarwal et al., 2023). The report “In Plain Sight” (IPS) describes the impact of bias towards Indigenous Peoples in healthcare in BC, Canada. This report detailed the experiences of Indigenous Peoples in BC encountering bias in healthcare and how their interactions with the healthcare system negatively impacted their well-being. Accounts from patients, survey data, and interviews with HCPs in the report highlights discriminatory behaviour committed by HCPs and proposes that biases that lead to discrimination are instilled within the healthcare system itself (BC Ministry of Health, 2020). The IPS report highlights how prejudices are experienced by Indigenous Peoples in BC and what concrete changes need to be made to address Indigenous-specific racism in healthcare. Advancing cultural humility and safety education and being responsive and culturally safe at the point of care were priorities identified in the report. There are currently many health authorities in BC that are implementing the recommendations of this report, such as improving 13 reporting systems for incidence of racial discrimination and implementing cultural safety training for staff (The Indigenous Health and Reconciliation (IHR) Division, 2022). The increase in cultural safety is imperative for Indigenous patients to receive equitable care. But how do we educate those that are not aware of their bias? It can be difficult to assess racial bias in healthcare through self-report because HCPs typically report an absence of bias in their work with patients (Zestcott et al., 2016). The IPS report provides evidence of racial bias in health care in Canada, demonstrating that there is a gap between the experienced discrimination of people receiving healthcare and HCPs’ identification of their own biases. The gap between HCPs perceived biases and their measured biases is a subject requiring further probing; some have suggested that burnout may be a contributor (Bennett & Puhl, 2023). HCPs’ motivations to address their biases remains unknown. The education for equity framework (E4E) aims to assist HCPs in engaging with Indigenous patients with T2D by directing HCPs to re-center their clinical relationship through reflection on biases (Crowshoe et al., 2019).This directive needs to be operationalized and continuously evaluated through cultural safety training for HCPs. Cultural safety training and raising awareness of biases in HCPs are important steps toward improving equity, but it also poses a question about the effectiveness of these programs in addressing the clinical outcomes of bias in healthcare. Training to address bias in HCPs, including Indigenous cultural safety and inclusivity in care, has recently emerged, but their efficacy in changing bias, attitudes, and behaviours has not yet been demonstrated. Systematic reviews of anti-bias training and cultural competency training have noted that little is known about the long term outcomes or the efficacy of these trainings for HCPs (Hardy et al., 2023; Ricks et al., 2022; Truong et al., 2014). There is also a lack of consensus on methods to providing these trainings (Ricks et al., 2022). These findings suggest that the current approach to educating and evaluating changes in bias may need to shift to be practical and accessible to HCPs. 14 1.2.5 Intersectionality of bias and health outcomes Considering how bias can impact an individual’s well-being through stigmatization of their health status, we must also contemplate the multiplicative effect racial bias has on those with chronic disease and Indigenous identity. In the broader Canadian context, Indigenous Peoples are among those with the highest risk for developing T2D and its associated complications. Indigenous Peoples in Canada have an incidence rate of diabetes that is 3 to 5 times higher than the general population (Crowshoe et al., 2018). In BC, Indigenous Peoples have a prevalence of T2D that is 1.3 times higher than the general population (BC Ministry of Health, 2020). In the Interior Health Region of BC, Indigenous Peoples make up 9.1% of the total population (Nations & Communities, n.d.). While interpreting these statistics we must also consider how data has been collected and how undiagnosed individuals are not captured. The disparity in health outcomes may not be entirely captured in these prevalence rates. These statistics, and potential underreporting, are particularly alarming considering the bias that exists in healthcare towards individuals with T2D and Indigenous identity. Assessing biases of HCPs towards individuals who hold intersectional biases against T2D, and Indigeneity may provide a deeper understanding of the obstacles to equitable diabetes care. Positive relationships with HCPs have been shown to be considered essential to addressing the legacy of colonialism in Indigenous health (Jacklin et al., 2017). These findings come from a qualitative study identifying that humility, empathy and patience are desirable characteristics of HCPs to foster positive therapeutic relationships (Jacklin et al., 2017). In another qualitative study looking at HCPs’ perceptions of challenges faced by Indigenous Peoples in healthcare, there was an emphasis on the systemic sources of racism. Themes around unwelcoming environments, stereotyping and stigma, and practices informed by racism were identified by HCPs as the main sources of biased care (Wylie & McConkey, 2019). When comparing these two viewpoints - the 15 perceptions of Indigenous Peoples identifying their needs from a therapeutic relationship versus that of HCPs who identified systemic challenges, it is evident that there is a lack of acknowledged personal accountability on the part of HCPs. HCP bias has resulted in fatal harm in healthcare in Canada. In 2008 Brian Sinclair, an Anishnaabe man living in Winnipeg, was not perceived by medical staff as someone needing immediate care. He succumbed to his preventable death from an infection in the ER waiting room after waiting there unattended for 34 hours (McCallum & Perry, 2018). Joyce Echaquan, a mother, wife, and daughter, died on September 2020 at the age of 37, after being admitted to a Quebec hospital (Kamel, 2020). During her stay HCPs involved in her care labelled her as a drug user, shamed her and made other denigrating remarks (Kamel, 2020). The coroner's report indicated her passing was a consequence of systemic racism (Kamel, 2020). During the inquest after her death the nurse in charge of her care still denied that she held any bias (Kamel, 2020). These are just two of the many known cases in which racism and stigmatization resulted in harm and death in the Canadian healthcare system. The literature supports that racism is embedded within the healthcare system. One study of medical students from the University of Alberta found that students are often exposed to negative stereotypes of Indigenous Peoples during their training and acknowledge these stereotypes are rooted in racism, however they also believed there to be some truth in the stereotypes (Ly & Crowshoe, 2015). There are studies that examine the unique experience of Indigenous Peoples in regard to their diabetes. One qualitative study that conducted interviews with Indigenous adolescents with T2D reported experiences of feeling HCPs blamed them for their diagnosis (Wicklow et al., 2021). These experiences point to the need for HCPs to re-center their therapeutic relationships with Indigenous patients and utilize reflective practices to confront their positionality within the colonial healthcare system (Crowshoe et al., 2019). While acknowledging racism exists in the healthcare context is important, it is also important that HCPs reflect on how their practices may 16 play a role in perpetuating discrimination. Without understanding one’s individual role in upholding systemic racism, it is likely that harm to Indigenous Peoples in Canada will continue. To understand how biases in healthcare are affecting the health of equity-owed groups such as Indigenous peoples of Canada, it is important to evaluate racial biases, and those towards T2D which add additional barriers to well-being in this population. This is due to the intersectional assumption that “Intersecting systems of power catalyze social formations of complex social inequalities …” (Collins, 2015). The approach to evaluating how being Indigenous or a person with T2D may lead to compounding biases in this study was implemented by investigating the relationship between the biases held by HCPs. This allowed us to identify different power systems affecting health and identity pose compounded challenges within Indigenous communities. This study aimed to add to the evidence that bias continues to be a significant barrier to effective diabetes care and served as an opportunity to reflect on how these biases may be addressed. 1.3 A pragmatic approach to addressing biased behaviour While the advancement in cultural safety training in HCPs has been an important research topic, as previously mentioned there is limited support for any training that will result in improved patient outcomes. In this project, I explored how to address this discrepancy between the educational approaches to cultural safety taken thus far and tangible outcomes like patient care. I investigated this from a behavioural perspective by surveying HCPs on how they would address discriminatory behaviours driven by bias. One of the tools I used to support this endeavor is the theoretical domains framework (TDF). This framework was developed with the intent to understand influences on HCPs’ behaviour (Atkins et al., 2017). The TDF has been used in many studies that look at how HCPs 17 implement evidenced based recommendations (Bussières et al., 2012; Francis et al., 2009; Murphy et al., 2014; Tavender et al., 2014) This theoretical framework distills 33 theories on behaviour change into 14 domains that are comprised of constructs that influence behaviour (see Table 1) which serve as scaffolding to understand behaviour from cognitive, social, affective and environmental perspectives (Atkins et al., 2017). The TDF can be used in a variety of ways to understand behaviour and it also provides a common language to use when discussing aspects influencing behaviour. One way that the TDF is commonly used to understand and develop behaviour change interventions in healthcare settings is to map the TDF domains to the Behaviour Change Wheel (BCW)(Michie et al., 2014). The BCW is a framework that distills the TDF domains into three domains of capability, opportunity and motivation (Richardson et al., 2019). The BCW uses these three domains as the overarching determinants of behaviours and can link components of behaviour to specific intervention functions that may be most effective in addressing the target behaviour. (Michie et al., 2011). The use of the TDF to identify determinants of behaviour and subsequent mapping of the TDF domains to the BCW allows researchers to identify which components of behaviours must change to influence the target behaviours (Richardson et al., 2019). While education of health professionals about cultural safety is paramount, these frameworks may illuminate other factors that influence biased behaviour from the perspective of healthcare professionals. The results of this type of analysis can provide insights into what factors influence the discriminatory behaviour in healthcare and this knowledge could be applied in future projects to understand how to address these behaviours in a systematic and evidence-based way. 18 Table 1:Theoretical Domains Framework definitions and their constructs of behaviour (Cane et al., 2012) Domain (definition1) Constructs 1. Knowledge Knowledge (including knowledge of condition /scientific rationale) (An awareness of the existence of something) Procedural knowledge Knowledge of task environment 2. Skills Skills (An ability or proficiency acquired through practice) Skills development Competence Ability Interpersonal skills Practice Skill assessment Professional identity 3. Social/Professional Role and Identity (A coherent set of behaviours and displayed personal qualities of an individual in a social or work setting) Professional role Social identity Identity Professional boundaries Professional confidence Group identity Leadership Organisational commitment 4. Beliefs about Capabilities Self-confidence 19 Table 1:Theoretical Domains Framework definitions and their constructs of behaviour (Cane et al., 2012) Domain (definition1) Constructs (Acceptance of the truth, reality, or validity about an ability, talent, or facility that a person can put to constructive use) Perceived competence Self-efficacy Perceived behavioural control Beliefs Self-esteem Empowerment Professional confidence 5. Optimism Optimism (The confidence that things will happen for the best or that desired goals will be attained) Pessimism Unrealistic optimism Identity 6. Beliefs about Consequences Beliefs (Acceptance of the truth, reality, or validity about outcomes of a behaviour in a given situation) Outcome expectancies Characteristics of outcome expectancies Anticipated regret Consequents 7. Reinforcement Rewards (proximal / distal, valued / not valued, probable / improbable) (Increasing the probability of a response by arranging a dependent relationship, or contingency, between the response and a given stimulus) Incentives Punishment Consequents 20 Table 1:Theoretical Domains Framework definitions and their constructs of behaviour (Cane et al., 2012) Domain (definition1) Constructs Reinforcement Contingencies Sanctions 8. Intentions Stability of intentions (A conscious decision to perform a behaviour or a resolve to act in a certain way) Stages of change model Transtheoretical model and stages of change 9. Goals Goals (distal / proximal) (Mental representations of outcomes or end states that an individual wants to achieve) Goal priority, Goal / target setting Goals (autonomous / controlled) Action planning Implementation intention 10. Memory, Attention and Decision Processes Memory (The ability to retain information, focus selectively on aspects of the environment and choose between two or more alternatives) Attention Attention control Decision making Cognitive overload / tiredness 11. Environmental Context and Resources Environmental stressors (Any circumstance of a person's situation or environment that discourages or encourages the development of skills and abilities, independence, social competence, and adaptive behaviour) Organisational culture /climate Salient events / critical incidents 21 Table 1:Theoretical Domains Framework definitions and their constructs of behaviour (Cane et al., 2012) Domain (definition1) Constructs Person x environment interaction Barriers and facilitators 12. Social influences Social pressure (Those interpersonal processes that can cause individuals to change their thoughts, feelings, or behaviours) Social norms Group conformity Social comparisons Group norms Social support Power Intergroup conflict Alienation Group identity Modelling 13. Emotion Fear (A complex reaction pattern, involving experiential, behavioural, and physiological elements, by which the individual attempts to deal with a personally significant matter or event) Anxiety Affect Stress Depression Positive / negative affect 22 Table 1:Theoretical Domains Framework definitions and their constructs of behaviour (Cane et al., 2012) Domain (definition1) Constructs Burn-out 14. Behavioural Regulation Self-monitoring (Anything aimed at managing or changing objectively observed or measured actions) Breaking habit Action planning 1.4 Gaps in Literature There is a lack of evidence that explores the attitudes in HCPs towards people with T2D and Indigenous peoples in Canada. Without reflexive and iterative practices to evaluate and address bias in healthcare, it is not likely that HCPs are aware of the extent of their biases. This poses a challenge in creating meaningful interventions targeting the biases that contribute to discriminatory behaviour, since it misses the opportunity to have HCPs reflect on their own biases and contribution to systemic discrimination in healthcare. There is also limited research to describe the perceptions of HCPs toward the barriers and facilitators to providing unbiased care which may provide insight for evidenced based cultural safety or anti-bias training programs. 1.5 Objectives This study aimed to fill this gap in research by answering the following questions: 23 1. What explicit biases do HCPs working in the Interior Health Region of British Columbia (BC) have toward people with T2D? 2. What is the level of implicit and explicit bias in HCPs towards Indigenous Peoples in HCPs in the Interior Health Region of BC, and does it correlate with biases toward T2D? 3. What are HCPs in the Interior Health Region of BC’s perceptions of enablers and disrupters of discriminatory behaviours while providing care to Indigenous patients with T2D? Hypotheses: 1. It was hypothesized that a majority of HCPs would exhibit negatively biased attitudes towards patients with T2D. 2. Based on previous research (Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, 2003), HCPs would have similar level of implicit bias (moderately pro-white) as the general public. A majority of HCPs would self-report that they hold modern forms of prejudice towards Indigenous Peoples, similar to undergraduate students in Canada (Brockman & Morrison, 2016). Finally, the relationship between explicit bias towards T2D and implicit and explicit bias towards Indigenous Peoples in Canada would exhibit small positive correlations. 3. HCPs may list environmental factors, as previously seen in literature such as limited time spent with clients, as being barriers to providing unbiased care (Wylie & McConkey, 2019). 24 Chapter 2: Body of Thesis 2.1 Methods The methods of this research were guided by constructivist and pragmatic paradigms. Constructivist paradigms insinuate that knowledge is created based on the perspectives of those making the observations (Schwandt, 1994). Pragmatic paradigms of research focus mainly on action and its relationship with knowledge creation. Pragmatic research approaches believe that knowing and action are inseparable processes that inform each other, you cannot have knowing without action (Goldkuhl, 2012). These two seemingly juxtaposed paradigms were blended in this study to allow for knowledge creation that is rooted in HCPs perspectives but also aims to provide insights on how to improve behaviours. This study incorporated both quantitative and qualitative methodologies. These methodologies were both chosen for their practical application in the context of an online survey and from the perspective of the author who, as an HCP, was interested in representing the data as they interpreted it to be intended by the participants. 25 2.1.2 Recruitment Recruitment for this study focused on HCPs that worked within the Interior Health Region of BC (See Figure 1). The inclusion criteria were determined through participant self-selection, meaning all those who deemed themselves as meeting the study requirements filled out the survey. Inclusion criteria included: licensed healthcare providers working within Interior Health Authority (IHA) region, working with patients who have or are at risk of T2D, can complete the survey on a computer, and can read and write English. Recruitment materials, including posters and emails, were distributed through IHA listservs as well as direct contact through email from the research team to relevant HCP groups (for example, diabetes educators, primary care providers, senior leadership in chronic disease management within IHA). An allied health’s listerv was also utilized to capture more HCPs from allied health (Gerry’s List- Registered Dietitians). As part of the recruitment strategy, recruitment Figure 1: Interior Health Region Map (New to the region, 2013) 26 materials encouraged eligible individuals to pass along recruitment information to HCPs they thought would also be eligible. All recruitment materials had a direct link to the Qualtrics survey where HCPs could fill out the survey on their own personal time and devices. The survey begins with demographic questions about age, ethnicity, gender, sex, and years or experience as a clinician and with clients with T2D and Indigenous identity. The next part of the survey includes questions from two validated scales: the Modern Prejudice Attitudes Towards Aboriginals Scale (M-PATAS) and the Attitudes Towards Treating People with Diabetes Scale (ATPDS). Following those scales the participants were asked to follow an external link to complete the Indigenous Peoples in Canada Implicit Association Test (IPC-IAT) and return to the survey page to input their results into the survey. Finally, the participants were provided a prompt asking about discriminatory behaviours in health care and asked two open-ended questions, which they could respond to in open text boxes. 2.1.3 Measurements 2.1.3.1 Modern Prejudiced Attitudes Towards Aboriginals Scale (M-PATAS) The existence of validated tools to assess the explicit biases held by HCPs toward Indigenous Peoples in Canada is limited. The goal of this study was to use a tool that had been validated in the Canadian population, given that racism towards Indigenous Peoples in Canada is historically rooted within the country’s distinctive colonial past. The Modern Prejudiced Attitudes Towards Aboriginals Scale (M-PATAS) and Old-fashioned Prejudice Towards Aboriginals Scale (O-PATAS) were developed by Morrison and colleagues (2008) to address the gap in research that existed around assessment of prejudice toward Indigenous Peoples in Canada. The O-PATAS and M-PATAS scales were developed in accordance with modern prejudice theory where ‘old-fashioned’ prejudice refers to those that consider Indigenous Peoples as inferior and ‘modern’ prejudices are those which invalidate experiences of racism and consider Indigenous Peoples undeserving of restitution (T. Morrison & Kiss, 2017). It was 27 suggested by Morrison et al (2008) in a study of 391 university students that both the O-PATAS and M-PATAS had been found to illicit responses that were not influenced by social desirability bias (Brockman & Morrison, 2016). These tools were further validated as measures of prejudice in a study of 367 Canadian undergraduate students (Nesdole et al., 2015). The M-PATAS was chosen for this project over the O-PATAS because modern prejudices are likely to persist in the population of study since they are more subtle than the prejudices in the O-PATAS (T. Morrison & Kiss, 2017). The M-PATAS consists of 14 scale items which were informed by some of the most prevalent modern stereotypes about Indigenous Peoples from both Indigenous and non-Indigenous perspectives, as well as the experiences of prejudice from Indigenous perspectives (M. Morrison et al., 2008). See appendix B for scale items. Participants in this study were asked to rate their agreement on a likert scale of 1-7 with each item (1=strongly disagree, 3=slightly disagree, 4=slightly agree, 6=strongly agree, 7= prefer not say). The M-PATAS was used to examine explicit negative attitudes that HCPs hold about Indigenous Peoples in Canada. Valid M-PATAS scores range from 14-84 and will be considered a continuous variable for this analysis. The higher the score past the mid-point (49.0) the more that participant agreed with stereotypes and the scores trending below the midpoint indicated less agreement. 2.1.3.2 Attitudes Towards treating People with Diabetes Scale (ATPDS) Perceptions about disease states has been a topic of extensive research in the last few decades with validated tools being developed and used in the HCP population to understand perceptions of weight (Allison et al., 1991) and mental health (Kassam et al., 2012). However, there are limited measures that particularly assess the perceptions of HCPs as it applies to the treatment of people with T2D. The Attitudes about Treating Patients with Diabetes Scale (ATPDS), developed by Bennett & Pugh (2023), is a modified version of the Attitudes towards People Living with Obesity Scale (ATOPS) which substitutes the word obesity in the scale items 28 with T2D. This was the only scale found in the literature that explicitly measures HCP perceptions about patients with T2D. It should be noted that Bennett and Puhl omitted the fourth subscale “preparedness to treat T2D” from analysis in their study due to low internal consistency, therefore this subscale was omitted in this study as well. This modified scale also included an additional subscale of five questions that mirrored the question format of ATOPS; this subscale was labelled ‘Perception of patient compliance’ and was included in this study as well. The subscales included in Bennett and Puhl’s analysis included those that assess lack of empathy, dislike for caring for people with T2D, perceived negative norms, professional attitudes about T2D, and perceptions of patient compliance (Bennett & Puhl, 2023). This newly adapted scale has been used in a study to compare perceptions about patients with T2D in internal medicine and endocrinology specialists (Bennett & Puhl, 2023). This tool was chosen as it was adapted from a validated tool that assesses HCP perceptions about obesity (Allison et al., 1991). This measure has demonstrated reliability, with Cronbach alpha α= 0.92 and reliability of subscales ranging from α= 0.73-0.92. For the purpose of this study the subscale ‘professional attitudes about T2D’ was not included as it did not focus on explicit attitudes towards patients and more so reflected HCP beliefs about themselves as providers. The current study used the following subscales in the final survey: lack of empathy, dislike for caring for people with T2D, perceived negative norms, and perceptions of patient compliance. The resulting questionnaire included in this study consisted of twenty-three scale items (See appendix C for a copy of the scale items). In completing this portion of the survey, participants provided a rating of their agreement with each item on a 6-point scale (1 = strongly disagree, 5 = strongly agree, 6 = prefer not to say). The subscale ‘Perceptions of patient compliance’ items were rated on a different 6-point scale (1 = not at all, 3 = somewhat, 5 = very much, 6=prefer not to say). The use of a modified version of Bennett and Puhl’s scale (ATPDS) was used to reduce participant burden and capture HCP explicit perceptions of patients with T2D. 29 2.1.3.3 Indigenous Peoples in Canada Implicit Associations Test (IPC-IAT) Measures to assess implicit bias vary however the most common measured used, especially when studying HCP racial bias is the IAT (Hamed et al., 2022). In this project implicit bias was assessed using the Indigenous Peoples in Canada Implicit Associations Test (IPC-IAT). The IPC-IAT is a tool that was based off Greenwald and colleagues’(1998) work with the original Implicit associations test (Klopfer, 2020). The IAT has been validated as a measure of the strength of association of an object with a positive or negative evaluation (Cunningham et al., 2001). This test measures the latency in responses and implies that delayed responses are related with difficulty in making an association. For example, in the Race IAT from Harvard Implicit Project (Greenwald et al., 1998), if a participant takes a longer time to associate a positive word like ‘Joy’ with the category African American then that would mean the participant does not strongly associate positive evaluations with African Americans. Typically, this test is performed in sets of multiple trials called blocks where associative tasks are completed. There is debate around the validity of the IAT as a predictor of behaviour (Meissner et al., 2019). However, meta analyses have found that implicit measures are predictive of behaviour and the IAT is a validated tool to measure implicit bias (Greenwald et al., 2022). Furthermore, IATs are often used in the literature to assess HCP bias (FitzGerald & Hurst, 2017; Gopal et al., 2021; Zestcott et al., 2016). For the purposes of this study, the IAT will be used to evaluate the types of associations that HCPs make with Indigenous Peoples of Canada. The version of the IAT used in this survey was borrowed with permission from the action research team of Well Living House at St, Micheal’s hospital in Toronto, Canada. This adapted IAT was developed as a part of Dr. Kristina Klopfer’s PhD studies at University of Toronto and is part of a larger three-armed randomized control trial study titled, “Reconciling Relationships: Piloting an Interactive Health Care Professional Indigenous Cultural Safety Training Intervention at St. Michael’s Hospital”. One of the results of Dr. Klopfer and Well Living House’s work was the creation of an IAT that 30 used photos that would be representative of Indigenous Peoples in Canada (Klopfer, 2020). This tool employed both the recommendations of the original authors of the IAT for the process and algorithms used, as well and the recommendations derived from Indigenous partnerships which are explained in depth in Dr. Klopfer’s thesis (Klopfer, 2020). The IPC-IAT represented the only measure specific to Indigenous Peoples of Canada, and as such, was the ideal measure of implicit associations for this study. The scoring of this tool produces a z-score which can be a value ranging from -2 to +2 with positive values associated with stronger European preference and negative values associated with stronger Indigenous preference. Participants that complete the IPC-IAT are provided with a categorical result based on their Z-Score (strong, moderate, slight or little preference for Indigenous or European faces). While the Z-score data for the test was requested for this study, due to time and personnel constraints only categorical results could be obtained. Participants completing this study accessed this tool through a link in the survey which redirected them to the IPC-IAT website where they would complete the test and receive their categorical result. After completing the test participants returned to the survey and input their results from the test into the survey in categorical format. These results were then converted into numeric format ranging from 1-8 (1 = Strong Pro-Indigenous preference, 8 = Strong Pro-European preference) with any value above 4 being indicative of preference for European faces. 2.1.3.4 Open-Ended Questions The open-ended questions aimed to understand the facilitators and barriers that HCPs perceive around discriminatory behaviour in healthcare. The following is the prompt and questions posed to the participants in the study: In the In Plain Sight Report, a report that addressed Indigenous specific racism and discrimination in British Columbia health care, the following behaviours in healthcare were 31 reported by Indigenous patients and healthcare workers and non-Indigenous healthcare workers: Unacceptable personal interactions Longer wait times/ Denial of service Not believing/minimizing concerns Inappropriate/ No pain management Rough treatment Medical mistakes Lack of recognition/ respect regarding cultural protocols The following are proposed questions to assist in understanding the behaviour of reflecting on bias while interacting with people with T2D and Indigenous identity: In your view: 1. What makes the above behaviours possible in health care in BC? 2. How can these behaviours be disrupted when providing diabetes care to Indigenous Peoples in BC?” The responses to these questions were captured in open-text boxes and the analysis of the resulting data is described in the analysis section of this document. 2.2 Analysis The following describes how the quantitative and qualitative data were analyzed from this study. The quantitative analysis plan was devised to answer research questions one and two and the qualitative analysis was employed to provide insight into the last research question in this study. 32 2.2.1 Quantitative Analysis The M-PATA, ATPDS and the IPC-IAT were used in the quantitative analysis. Specifically, Pearson Correlations were performed were between each explicit measure (M-PATAS and ATPDS) and the implicit measure (IPC-IAT). Significance was set at p<0.05 with a two tailed test. The scores of the M-PATAS were calculated by adding the values for each scale item. The response option “prefer not to say” was imputed as a neutral value of 3.5 (between 3[Somewhat disagree] and 4 [Somewhat agree] on a scale of 1 to 6). The mean scores were interpreted accordingly with values over 3.5 being in agreement and less than 3.5 being in disagreement with the statements in the M-PATAS. Results for the ATPDS were calculated as means at the subscale level and then those means were averaged for the overall scale result. The overall ATPDS results was expressed as the mean of all means of the subscales, as done in a previous study (Bennett & Puhl, 2023). This study differed slightly as “prefer not to say” response options were offered for all scale items. The responses containing “prefer not to say” were not used in the summation of any subscale or total scale mean calculations for the ATPDS. As per recommendations from the developers of the IPC-IAT, the results from the IPC-IAT were converted to dummy values on a scale of 1-8 (with scores from 1-4 indicative of Strong, Moderate, Slight and Little to no pro-Indigenous preference; respectively, and 5-8 indicative of Little to no, Slight, Moderate, and Strong pro-European preference; respectively). 2.2.2 Qualitative Content Analysis The data collected from the open-ended questions that probed respondents about their perceptions of enablers and disrupters of discriminatory behaviour was first analyzed through content analysis. Content analysis was conducted in alignment with previous work (Braun & 33 Clarke, 2006; Hsieh & Shannon, 2005; Vaismoradi et al., 2016) and involved both the author, Renee Young (RY) and research trainee, Rebecca Reitsma (RR). The choice to begin with content analysis arose from the author’s research paradigm of constructivism, which purports that knowledge is contextual and is created by individuals via dynamic processes of interacting with their social surroundings (Appleton & King, 2002). To maintain this approach, content analysis had to begin and end before the Theoretical Domains Framework (TDF) coding could commence. This sequence of coding, using an inductive approach followed by a deductive approach, was used to avoid the inadvertent influences of the framework while searching for themes that arose organically from the data. The qualitative data included in the analysis was collected prior to April 23rd at 10h00. This cut-off point was made due to time constraints and resulted in 54 and 51 unique responses for both enablers and disrupters of discriminatory behaviour, respectively. To begin, RY and RR independently immersed themselves in the data and developed a timeline for coding. RR assisted RY in developing initial codes, after which RY and RR discussed and challenged each other on codes generated. RY then refined initial codes further which led to the creation of the final thematic maps for both disrupter and enablers to discriminatory behaviours. Thematic maps were reviewed by RY and RR and agreed that the maps were representative of their interpretations of the data. This process occurred over the course of approximately three weeks with three meetings between RY and RR. 2.2.3 Theoretical Domains Framework (TDF) Coding TDF coding began after thematic maps were created. The process for TDF coding was guided by steps laid out by Atkins et al (2017), and by previous work in the Diabetes Prevention Research Group (DPRG) Lab. Coding began with RY and RR meeting to create coding guidelines which resulted in a list of statements of how the TDF would be applied to this particular set of data. The process of coding included creation of summary statements made for 34 each response and coding that statement into the appropriate domains based on the coding guidelines (see Appendix D) developed by RY and RR, as recommended by the original authors (Atkins et al., 2017). To begin coding, approximately 25% of the data for enablers and disrupters was transferred into an excel sheet for RY and RR to independently code each response according to the TDF. RY and RR met after coding the first 20% of the data to reconcile coding, calculate agreement and review coding guidelines. Kappa (the agreement of present codes) and Pabak (agreement of codes not present) scores are often used in TDF coding to help inform about the reliability of the coding (Atkins et al., 2017). Frequent meetings to discuss coding and calculate agreement (Kappa and Pabak) are recommended to assess whether the coding guidelines created are adequate (Atkins et al., 2017). However, disagreement in coding is expected, as the interpretation of data is influenced by the coders’ worldview. Overall, the calculation of agreement served as an important exercise in reflexivity in the coding process. RY requested research trainee, Natalie Grieves (NG) to act as a third coder to reconcile coding when consensus could not be met. Coding guidelines were adjusted and then RY and RR proceeded to code the rest of the data independently. Agreement was calculated again at approximately 40% and 100% of the responses being coded. The same process of obtaining the agreement described above was performed at each of the following consensus meetings. 2.3 Results This section presents the results of the demographic data and then proceeds with the results of the analyses performed as described in the previous section. The data for each measure was also presented descriptively due to the small sample size. The response rate for 35 each part of the survey varied, making the sample sizes for each measure different as well. Figure 2 shows the response rates for each section of the survey. Figure 2: Response rates for each measure 2.3.1 Demographics The population of study was primarily made up of female sex and feminine presenting individuals. Most of the respondents were allied health professionals or nurses. The majority of respondents also selected Western European as their ethnicity with only five respondents reporting Indigenous as their ethnicity or identity. In terms of experience, the majority (43%) reported that they had between 5 to15 years working as an HCP and 41.8% had the same years of experience working with people with T2D and Indigenous Peoples. Most respondents reported that more than 20% of their clientele were people with T2D, meanwhile a majority 79 responses M-PATAS + ATPDS 36 reported less than 20% of their clientele were Indigenous and had T2D. This seems to imply that the population in this study does not have extensive experience with Indigenous Peoples. This may align with the population statistics in the Interior Health Region, of BC, since 8.8% of this region identifies as Indigenous (Medical Health Officer Report, 2019). The sample in this study did not have a representative proportion of Indigenous respondents with 5.6% reporting Indigenous identity. However, this study sample did have over representation of self-identified ethnic minority individuals (South Asian, Southeast Asian, East Asian) compared to the 5.6% percent within the Interior Health region (Medical Health Officer Report 2019). Table 2 presents the demographic characteristics for the study participants. Table 2: Demographic Characteristics Demographic Variable Percent (n=79) Occupation Primary Care (MD, NP) Nurses (LPN, RN) Allied Health (SW, RD, OT, PT etc.) Certified Diabetes Educator Other (Paramedic, student etc.) 5.1%30.4%54.4% 17.7%8.9% Years in practice working as HCP 0-3 years 25.3% 3-5 years 10.1% 5-15 years 43.0% 37 Table 2: Demographic Characteristics Demographic Variable Percent (n=79) 15+ years 21.5% Prefer not say 0% Years in practice working with people with diabetes 0-3 years 25.3% 3-5 years 13.9% 5-15 years 41.8% 15+ years 17.7% Prefer not say 1.3% Years in practice working with Indigenous Peoples 0-3 years 25.3% 3-5 years 13.9% 5-15 years 41.8% 15+ years 19.0% Prefer not say 0% Percent of Clients with T2D 0-19% 17.7% 20-39% 31.6% 38 Table 2: Demographic Characteristics Demographic Variable Percent (n=79) 40-59% 24.1% 60-79% 15.2% 80-100% 10.2% Percent of Clients with T2D and Indigenous 0-19% 75.9% 20-39% 17.7% 40-59% 2.5% 60-79% 3.8% 80-100% 0% Sex Female 94.9% Male 3.8% Prefer not say 1.3% Gender Primarily masculine 3.8% Primarily feminine 93.7% Prefer not say 2.5% Have you taken Cultural Safety Training? Yes 83.5% No 12.7% Prefer not say 3.8% Indigenous Identity 39 Table 2: Demographic Characteristics Demographic Variable Percent (n=79) First Nations 5.1% Not indigenous 92.4% Métis 1.3% Prefer not say 1.3% Ethnicity East Asian 7.8% East European 7.8% Indigenous 5.6% Middle Eastern 5.6% South Asian 4.4% Southeast Asian 2.2% West European 60.0% Other 6.7% Do not know 2.2% 2.3.2 M-PATAS Seventy-nine participants completed the M-PATAS. Agreement with the items was determined by whether they rated a question as Somewhat agree (4), Agree (5), or Strongly agree (6). Disagreement was assumed when participants chose Somewhat disagree (3), Disagree (2), or Strongly disagree (1). Four of the fourteen statements (items 2, 12,13, 14) were reverse scored so that those that agreed to items like “Indigenous Peoples still need to protest for equal rights” were not scored as agreeing with racist statements. Responses were summed 40 leading to the total score for the scale. The midpoint for the scale was 49, with numbers higher than the midpoint indicating agreement with stereotypes and lower numbers indicating disagreement with stereotypes. Most respondents disagreed with the stereotypes in most statements except for items 10 and 11 which state “Indigenous people should NOT have reserved placements in universities unless they are qualified” and “Indigenous people should pay taxes just like everyone else.” A substantial proportion (29.5% and 43.2%, respectively) of respondents agreed with statements 10 and 11. Two of the respondents were deemed as outliers and removed from correlational analysis. From the remaining 77 respondents, the mean score of the M-PATAS across all respondents was 36.24, indicating an average disagreement with the statements in the scale. The responses that are not presented in Table 3 are those that responded with prefer not say as this was computed as a neutral response. See Table 3 for M-PATAS results. These results suggest that, on average, the respondents to this survey exhibited low levels of explicit biases toward Indigenous Peoples in Canada. Table 3: Results from M-PATAS Scale item Percent agree(n) Percent disagree(n) Canada needs to stop apologizing for events that happened to Indigenous Peoples many years ago. 12.8(10) 87.2 (68) Indigenous Peoples still need to protest for equal rights. * 86.9(66) 13.2(10) 41 Table 3: Results from M-PATAS Scale item Percent agree(n) Percent disagree(n) Indigenous Peoples should stop complaining about the way they are treated and simply get on with their lives. 2.2 (2) 97.5 (76) Indigenous Peoples should simply get over past generations’ experiences at residential schools. 1.1 (1) 98.7(76) Indigenous Peoples seem to use their cultural traditions to secure special rights denied to non-Indigenous Canadians. 7.7 (6) 92.3 (72) Many of the requests made by Indigenous Peoples to the Canadian government are excessive. 7.7 (6) 92.3 (72) Special places in academics programmes should NOT be set aside for Indigenous students. 10.2 (8) 89.9 (71) Indigenous Peoples should be satisfied with what the government has given them. 3.9 (3) 96.1 (74) It is now unnecessary to honour treaties established with Indigenous Peoples. 1.3 (1) 98.7 (74) 42 Table 3: Results from M-PATAS Scale item Percent agree(n) Percent disagree(n) Indigenous people should NOT have reserved placements in universities unless they are qualified. 29.5 (23) 70.5(55) Indigenous people should pay taxes just like everyone else. 43.2 (32) 56.8 (42) The government should support programmes designed to place Indigenous people in positions of power. * 87.8(65) 12.2 (9) Non-Indigenous people need to become sensitive to the needs of Indigenous peoples. * 100 (76) 0(0) Government agencies should make every effort to meet the needs of Indigenous peoples. * 94.7 (72) 5.3 (4) (n=77) Average Sum Score= 36.24 Asterisk (*) denotes reverse scored items, note responses of “prefer not say” not captured in table, hence total n between agree and disagree to do not always add to n=79. Additional analysis was completed with the M-PATAS, excluding the items that had higher agreement. The results of that analysis found an average score of 31.2 (n=79, Std. Dev= 5.5) which would again be below the new midpoint of 42. 43 2.3.3 ATPDS The results of the ATPDS are presented as percentage of respondents who agreed or disagreed with each statement (Table 4). This method of presenting the data was chosen as this is how the results of the scale were presented by Bennett and Puhl in the original paper (Bennett & Puhl, 2023). All responses that indicated agreement included responses of either Strongly agree or Somewhat agree. All responses that indicated disagreement included responses of either Strongly disagree or Somewhat disagree. The remaining responses were neutral. Overall, respondents demonstrated low levels of negative explicit biases towards people with T2D. Table 4: Results from ATPDS Average score Percent Agree (n) Percent Disagree ATPDS Scale Items and subscales Subscale – Lack of empathy 1.29 I feel that it is important to treat patients with type 2 diabetes with compassion and respect. 100% (79) 0% Patients with type 2 diabetes lack motivation to make lifestyle changes. 6.4% (5) 74.7% (59) Patients with type 2 diabetes tend to be lazy. 0% (0) 88.6% (70) It is difficult to feel empathy for a patient with type 2 diabetes. 1.3% (1) 97.5% (77) Treating a patient with type 2 diabetes repulses me 0% (0) 98.7(78) 44 Table 4: Results from ATPDS Average score Percent Agree (n) Percent Disagree Subscale dislike for caring 1.53 Patients with type 2 diabetes are often non-compliant with treatment recommendations. 3.8% (3) 83.5% (66) Treating a patient with type 2 diabetes is more emotionally draining than treating a non-diabetic patient 8.9% (7) 75.9% (60) Treating a patient with type 2 diabetes is more stressful than treating a non-diabetic patient 11.4% (9) 78.5% (62) Treating a patient with type 2 diabetes is more frustrating that treating a patient without this disease. 5.1% (4) 81% (64) Patients with type 2 diabetes can be difficult to deal with. 7.6% (6) 65.8% (52) I would rather treat a non-diabetic patient than a patient with type 2 diabetes. 6.4% (5) 73.4% (58) I often feel frustrated with patients who have type 2 diabetes 2.5% (2) 91.1% (72) I dislike treating patients with type 2 diabetes. 1.3(1) 96.2(76) 45 Table 4: Results from ATPDS Average score Percent Agree (n) Percent Disagree I feel disgust when treating a patient with type 2 diabetes. 0% 100% (79) I feel more irritated when I am treating a patient with type 2 diabetes than a non- non-diabetic patient. 0% 100% (79) Subscale: Perceived negative norms 2.33 I have heard/witnessed other professionals in my field make negative comments about patients with type 2 diabetes. 57.7% (45) 37.2% (29) Health care providers feel uncomfortable when caring for patients with type 2 diabetes. 13% (10) 66.2(51) My colleagues tend to have negative attitudes toward patients with type 2 diabetes. 10.4% (8) 75.3% (58) Perceptions of patient compliance 2.43 Not at all-slightly Very- Extremely How much do you enjoy/do you enjoy counseling and working with patients with type 2 diabetes? 6.5% (5) 68.8% (53) 46 Table 4: Results from ATPDS Average score Percent Agree (n) Percent Disagree In general, how successful do you think patients with type 2 diabetes can be in making behavior changes? 6.3% (5) 77.2% (61) How much confidence do you have that patients with type 2 diabetes can maintain weight loss, once it is achieved? 20.8% (16) 33.8(26) In general, how motivated do you think patients with type 2 diabetes are to change their diet? 17.7% (14) 53.2% (42) In general, how compliant do you think patients with type 2 diabetes are with treatment recommendations? 13.9% (11) 51.9% (41) Average score of subscales 1.89 Percent agreement or disagreement with scale items of the ATPDS and Subscale average scores. Scoring on scale of 1-6 (1= strongly disagree 3= neither disagree nor agree ,5= strongly agree, 6= prefer not say) 2.3.4 IPC-IAT A total of 49 participants with valid IPC-IAT results were collected during the recruitment period. The results of the IPC-IAT are displayed as frequencies in Table 5. Results from the IPC-IAT were categorical in nature ranging from Strong Pro-European Preference to Strong Pro-Indigenous Preference. As seen in the Table 5, there were no Strong Pro-Indigenous 47 Preference results. It is also seen that 22 out of the 49 participants exhibited some (Slight-Strong) Pro-European Preference. Table 5: Results From IPC-IAT as Frequencies Preference Percent Strong pro-European 12.2% Moderate pro-European 6.1% Slight pro-European 26.5% Little to no pro-European 18.4% Little to no pro-Indigenous 10.2% Slight pro-Indigenous 16.3% Moderate pro-Indigenous 10.2% 2.3.5 Correlations Between Measures Overall, there were no significant correlations found between any measures. There was no significant relationship between the M-PATAS and the ATPDS (r= 0.18, p=0.12). There was no significant relationship between the ATPDS and the IPC-IAT (r= -.01, p=0.96) or between the M-PATAS and the IPC-IAT (r= -.05, p=0.72). All Pearsons’s correlations between quantitative measure can been seen in Table 6. The results indicate that there were no significant correlations between explicit measures of prejudice towards Indigenous Peoples in Canada and People with T2D. There were also no correlations found between implicit bias towards Indigenous Peoples in Canada and both explicit biases measured in the current study. There were two outliers within the M-PATAS results that were excluded due to their influence on the assumptions (normality) that needed to be met to run the statical analysis. The correlation 48 run on the M-PATAS and the other measures were performed on 77 responses after 2 outliers were excluded from analysis. Caution should be taken when interpreting these correlations as the test was likely underpowered to detect any relationships due to the sample size. Correlations were also run with a revised version o the M-PATAS which excluded items 10 and 11 from analysis due to the large proportion of agreement exhibited in the sample. Table 7 shows the results of the correlations between the ATPDS, IPC-IAT and the Revised M-PATAS. Table 6: Results from Pearson's Correlations between revised M-PATAS, ATPDS, and IPC-IAT Revised MPATAS Score ATPDS Score IPC-IAT Results IPC-IAT Results Pearson Correlation -0.12 -0.01 1 Sig. (2-tailed) 0.41 0.96 N 47 49 Revised MPATAS Score Pearson Correlation 1 0.11 -0.53 Sig. (2-tailed) 0.37 0.72 N 75 48 ATPDS Score Pearson Correlation 0.11 1 -0.01 Sig. (2-tailed) 0.37 0.96 N 75 49 49 Table 7: Results from Pearson's Correlations between M-PATAS, ATPDS, and IPC-IAT MPATAS Score ATPDS Score IPC-IAT Results IPC-IAT Results Pearson Correlation -0.05 -0.01 1 Sig. (2-tailed) 0.72 0.96 N 48 49 MPATAS Score Pearson Correlation 1 0.18 -0.53 Sig. (2-tailed) 0.12 0.72 N 77 48 ATPDS Score Pearson Correlation 0.18 1 -0.01 Sig. (2-tailed) 0.12 0.96 N 77 49 2.3.6 Qualitative Content Analysis Qualitative content analysis performed collaboratively between RY and RR and resulted in the following thematic maps (Figure 3 and Figure 4), created by RY. The overarching themes found in the data describing the enablers and disrupters to discriminatory behaviour are described in this section, as well as their subthemes, with special consideration of the context in which these themes seem to present themselves in the data. The data had many themes and 50 subthemes which were categorized as influencing behaviours at the societal level, health organization level, and HCP level. The tree metaphor has been use to describe Indigenous Social Determinants of Health and was chosen for this data because of its use in report ‘Understanding Indigenous Health Inequalities Through a Social Determinants Model’ (Loppie & Wein, 2022) to describe how prejudice and racism manifests as a systemic determinant of health of Indigenous Peoples in Canada which leads to the negative health outcomes. As described in the Loppie and Wein’s report, “While offering a simple metaphor, trees actually symbolize complex, interrelated structures, systems, and processes. Trees also represent dynamic cycles through which resources are constituted by foundational roots, then transported through the trunk and stems, to influence the growth and maintenance of the tree and its products” (Loppie & Wein, 2022).The roots of these trees represent the structural and societal influences of discriminatory behaviour, the trunk represents the organizations that act as a vessel for these structural sources of discrimination and the leaves represent the level of the individual HCPs who can be proliferators of systemically driven discriminatory care. 2.3.6.1 Enablers The overarching themes of the enablers of discriminatory care were Lack of knowledge of Indigenous culture, history or culturally safe care; Impacts of Colonialism; Organizational Culture; Uncertain; and Response to circumstance. Themes with example quotes are presented in Table 8. Lack of knowledge of Indigenous culture, history, or culturally safe care was identified in the text only at the HCP level. Respondents discussed how a lack of knowledge around cultural practices and/or the historical violence of colonization impacted care provision to Indigenous clients. Some also referred to a lack of knowing where to access this information. 51 Impacts of colonialism was a theme identified in responses that discussed how the legacy of colonization has impacted the realities of Indigenous Peoples at the structural, organizational, and individual levels of healthcare. References to systemic sources of discrimination often refer to how care is structured from a colonial perspective. The subtheme identified at the systemic level, Inequities outside of healthcare, was demonstrated through text that described how influences external to health organizations create the context for discrimination to be possible. Examples of these external influences generally referred to socioeconomic opportunities like a deficit of housing and need for living wages as enablers of discrimination. Organizational references to impacts of colonialism described how these structural influences present themselves within the organization of health care. Subthemes at the organizational level, Lack of Indigenous representation and Power imbalance, were reflected by text that described how not having Indigenous representation within the organization and the inherent imbalance of power between HCPs and patients perpetuate discrimination. Finally, the individual references to impacts of colonialism at an individual level discuss the stereotypes and biases held by HCPs as a result of these systemic and organizational influences. This was reflected in the text that attributed the HCPs own biases, lack of experience with Indigenous Peoples and perception of their own power over patients as enablers of discrimination. Organizational culture as an overarching theme contained subthemes: Lack of person centered care, Lack of resources or support leading to burnout and Lack of consequences or ineffective reporting processes. This theme and its subthemes were reflected in the data when respondents reported incidents where they felt they did not have support or adequate resources from the organization to address discrimination, they could not effectively report discrimination, or the organization did not support the person-centered care needed to address discriminatory behaviours. 52 Uncertainty arose as a theme from a few responses that indicated a lack of awareness of how discriminatory behaviours could persist within healthcare settings. The Response to circumstance theme evolved from responses that reported discriminatory behaviour was reaction to behaviours of patients, again this theme was not frequently found across the text as others however there were enough responses, and it seemed important to represent this viewpoint of HCPs in the thematic maps. The thematic map in Figure 3 also captures the subthemes found within major themes . Figure 3:Thematic map for enablers of discriminatory behaviour in healthcare 53 Table 8: Coded text for each major theme in enablers Theme (Subtheme) Example Quote(s) Impacts of Colonialism Deeply ingrained bias and racism, of which the health professionals are often not aware they have. Our Canadian society has deeply ingrained racism towards Indigenous people that is even picked up by refugees and immigrants within weeks of arriving to Canada (I have seen this firsthand, and have tried to address this in friends who arrived as refugees.). It's also endemic in some health care settings more than others, and it can be difficult to call people out in those more toxically racist settings Organizational Culture (Lack of Person-center Care, Lack of Resources Leading to Burnout) More established medical professionals are from an older generation and they are used to doing things a certain way, and their beliefs and actions can be passed onto their students and the cycle continues Lack of time and high workload that lead to reflexive and automatic behaviours instead of being present and empathetic, lack of support to staff from management in terms of 1x1 meeting or staff meeting to address when the staff feels uncomfortable about their peers handling of client etc. Lack of Knowledge Lack of cultural safety, understanding of the intergenerational effects of colonization, making assumptions, lack of understanding/knowledge of cultural protocols or not knowing where/how we can learn about them Response to Circumstances Abusive behaviors by staff have been in response to abusive behaviors by the patient regardless of religion, ethnicity or gender. Uncertainty I am not sure how these behaviors would be possible. Our Healthcare system should be designed in a way that this is not possible. 54 2.3.6.2 Disrupters The overarching themes that arose from the text included Knowledge and education; Person centered care and re-balancing power; Self-reflection and motivation to understand personal bias; Healthcare needs reforming; Other systems need reforming; Equal treatment; and Uncertain or resigned. The thematic map for disrupters can be seen in Figure 4 and themes with example quotes are presented in Table 9. Knowledge and education presented itself as a theme at the organizational level and at the individual level. This theme was identified in the data through texts that described how knowledge about Indigenous cultural practices, history and culturally safe care could help disrupt discriminatory behaviours. Person centered care and re-balancing power was an overarching theme at the individual level that presented in text that described how a focus on centering the patient’s needs and wishes in their care plan and shifting the dynamic of power within therapeutic relationships would help address discrimination in healthcare. Self-reflection and motivation to understand personal bias was a theme found in the text at the individual level which illustrated how the act of reflecting on personal biases continuously and having the desire to engage with this as a continuous practice would help to address discriminatory behaviours. The theme found only at the organizational level, Healthcare system needs reforming, contained subthemes of Indigenous feedback and representation, Manageable workloads, Improved access and Indigenous specific supports, Consequences, Creating culturally safe workplace and Person-centered care and rebalancing power. Notably one of these subthemes, Person-centered care and rebalancing power, was an overarching theme at the individual level, but the text presented this subtheme in relation to how person-centered care and rebalancing of power was a result of the organizational structure. The other subthemes were depicted in the 55 text as the health organization’s need to increase Indigenous representation in the workforce or through collaborations, the need for more manageable workloads to allow for discriminatory behaviours to be addressed, needs for improved access to care and support for Indigenous patients, more effective consequences for discriminatory behaviour and the organization prioritizing a culturally safe workplace to help address discrimination in healthcare. Other systems need reforming was recognized at the systemic level and illustrated in text that reviewed how basic needs of Indigenous Peoples need to be address at the systemic level. This theme captured how HCPs saw that systemic problems that impacted equity outside of healthcare were drivers of discrimination within healthcare. Uncertain or resigned and Equal treatment were overarching themes at the individual level and were found when respondents reported that providing the same treatment to everyone would address discrimination, or that discrimination was inevitable or that they did not see a solution to discrimination in healthcare. 56 Figure 4: Thematic map for disrupters of discriminatory behaviour in healthcare 57 Table 9: Coded text for each major theme in disrupters Theme (Subthemes) Example Quote(s) Knowledge and education Ongoing efforts to inform and engage in culturally safe practices in health care settings and specific workplaces is an important start. I've seen in my own workplace that having managers and other key staff speak positively about the local Indigenous community and build relationships there (including inviting cultural leaders and elders to come for events to educate staff about Indigenous worldviews and culture in a hands-on and fun way on paid time, and inviting staff to join visits to the local Indigenous community for meet-and-greet and tours) helps shift the group mindset towards Indigenous peoples. Knowledge plus relationship goes a long way to dispel ignorance and bias. Person-centered care Taking time to listen to clients story, empowering their narrative of what physical, emotional and social changes need to take place to support adequate or good management is key. Self-Reflection and motivation to understand personal bias Providers should actively challenge common stereotypes of Indigenous people and minimize prejudice when providing patient care. Health care system needs changing (Culturally Safe Workplaces, Feedback from Indigenous Communities, Workload) Establishing a culturally safe workplace in this way also allows Indigenous allies to speak more boldly because they feel safe to do so, thus further shifting the workplace culture. We can also seek feedback from indigenous peoples to find out how they perceived the care they received and educate ourselves to improve outcomes. health care providers being given manageable workloads and enough time to actually listen to patients/clients 58 Table 9: Coded text for each major theme in disrupters Theme (Subthemes) Example Quote(s) Equal treatment/uncertainty or resignation Unfortunately, I feel there will always be discrimination whether intentional or not. All medical professionals should be taking an oath to provide quality care to each patient with integrity, humility, honesty and compassion regardless of race. Other systems need reforming Universal Basic Income 2.3.7 TDF coding and agreement 2.3.7.1 Coder Agreement Coder agreement before reconciliation was of the first 20% of responses was moderate to substantial (Landis & Koch, 1977) with agreement on domains not coded being substantial (Pabak=0.69) and agreement on domains coded was moderate (Kappa= 0.46). This led the author to continue with double coding of another 20% the data. Then after this round of coding the agreement of coded domains was substantial (Kappa=0.71) and the agreement of domains not coded was almost perfect (Pabak=.83; (Landis & Koch, 1977). At this point, RY continued with the rest of the coding independently. The results of the TDF coding and frequency of the domains coded for both enablers and disrupters are shown below (Figures 5-6). 2.3.7.2 Frequency of Coded TDF Domains Though the frequency of the codes does not represent the importance of each domain it does show how common the domains are presented across the data. Some domains coded in 59 the highest frequency for enablers were Environmental Context and Resources (48) and Social Influences (42) (Figure 5). For disrupters (Figure 6), Environmental Context and Resources (35), and Social influences (32) were also most frequently coded, with Knowledge (31) being a close third. Figure 5: Frequency of TDF domains coded for enablers of discriminatory behaviour 60 Figure 6: Frequency of TDF domains coded for disrupters of discriminatory behaviour Samples of the coded text for each frequently coded domain are found in the Tables 10-11. 61 Table 10: Text examples for domains coded in disrupters Table 11: Text example for domains coded in enablers 62 2.4 Discussion The objectives of this study were to understand the levels of bias that HCPs within the Interior Health Region have towards people with T2D and Indigenous Peoples in Canada. It was also an aim to understand if and how these biases are related to one another. We also aimed to explore HCPs’ perceptions about how discriminatory behaviours towards Indigenous Peoples with T2D in care are enabled or how they could be disrupted. The study results demonstrated that, on average, HCPs had low levels of explicit bias towards Indigenous peoples, and people with T2D, and little to no implicit bias towards Indigenous Peoples. However, the descriptives statistics reveal that there were some stereotypes about Indigenous Peoples held by HCPs and almost 45% of respondents held some level of implicit bias in favour of European faces. The qualitative portion of this study found that HCPs viewed discriminatory behaviour being enabled in health care via environmental contexts and resources, social influences and (lack of) knowledge. HCPs also reported that to disrupt this behaviour both the environment and social contexts needed to change as well as improved knowledge of Indigenous culture and unbiased and culturally safe care. These findings highlight how explicit and implicit biases are present in HCPs. Furthermore, these findings highlight how use of abductive analysis is useful to deepen our understanding of how HCPs perceive discriminatory behaviours in healthcare. The quantitative measures in this study illuminated the level of explicit and implicit biases that HCPs in the Interior Health region of BC hold towards Indigenous Peoples and people with T2D. While there were no significant correlations between the measures, there were important relationships and outcomes to consider among the results from the quantitative measures. The presence of implicit and explicit biases towards Indigenous Peoples and specific negative attitudes about people with T2D were important findings. The coexistence of these 63 attitudes could have potential to exacerbate health disparities for Indigenous peoples in Canada. The levels of implicit versus explicit bias towards Indigenous Peoples revealed a divergence in how HCPs reported their bias and how they responded subconsciously to the visual stimulus of Indigenous versus European faces. HCPs disagreed with most stereotypes about Indigenous Peoples in the M-PATAS but a majority still held implicit bias about Indigenous Peoples. The divergence between how people perceive their own bias and how their implicit biases present themselves is not novel. Other authors have observed this divergence and have coined it Implicit-Explicit Discrepancy (IED) (Muschalik et al., 2019). This divergence between implicit and explicit bias might be a result of concerns about self-presentation, preference for consistency in cognition or consistency in content of measures for implicit and explicit biases (Muschalik et al., 2019). In the current study, correlations were not significant however the discrepancy between the frequency of implicit associations indicating preference for European faces and the general lack of agreement with Indigenous stereotypes might be explained by previous research. The desire for HCPs to present themselves as unbiased can certainly have impacted the results of the M-PATAS. Additionally, the M-PATAS itself may have not accurately measured more modern stereotypes held in Canadian society, since it was created prior to some major sociological developments over the last decade which may have influenced how public attitudes and biases towards Indigenous Peoples are expressed. Explicit biases about treating people with T2D in this population were also, on average, not negative except for the two items of the ATPDS where there was substantial agreement. A majority of HCPs agreed with the statement “I have heard/witnessed other professionals in my field make negative comments about patients with type 2 diabetes.” And approximately a fifth of respondents were not confident that people with T2D could maintain weight loss. The first statement reveals how HCPs perceive the negative norms that exist in healthcare towards 64 patients with T2D. This finding is confirmed in previous research that has recognised diabetes stigma as a common experience in healthcare settings as experienced by people with T2D (Speight et al., 2024). This could also suggest that HCPs feel comfortable reporting biases in colleagues but do not report their own due to social desirability bias. The second statement indicates that a substantial number (>20%) of HCP do not believe that people can maintain weight loss which is of concern given that sustained weight loss is associated with glycemic reduction and recently associated with T2D remission (MacKay et al., 2022). The assumption that individuals with T2D can not be successful in weight loss maintenance has the potential to bias HCPs from delivering care that adheres to best practices that are supported through literature. As previously discussed, intersectionality of different identities can have multiplicative effects on the health of marginalised groups (Kelly, 2009). This study revealed that some negative explicit attitudes about T2D and Indigenous peoples in Canada exist within this sample of HCPs and there is also a substantial presence of implicit attitudes about Indigenous Peoples in Canada. The implication of these explicit and implicit biases existing in HCPs means that Indigenous Peoples are forced to contend with these attitudes and beliefs when trying to access care. While the identity of the HCPs themselves in the study was not statistically examined, it is notable that the majority of participants in this study are highly educated, of European ethnicity, and female. These identities likely have an impact on how HCPs responded and their capability to provide insight on the issue of racial discrimination in healthcare. Abductive analysis using qualitative content analysis and coding to the TDF, was employed to shed light on how HCPs enablers and disruptors to discriminatory behaviours in healthcare. 65 The key themes that were coded in the abductive analysis involved topics around environmental factors, knowledge, social influences, impacts of colonialism and organizational culture. Environmental factors were identified in overarching themes for both qualitative content analysis and TDF coding. In qualitative content analysis the themes such as Organizational Culture and Healthcare system needs reforming, were identified as key influences of how discriminatory behaviour was enabled and potential areas where this behaviour could be disrupted, respectively. TDF coding found similar results in the frequently coded domain of Environmental context and resources as an enabler and disrupter of behaviours. These findings point to the perception that HCPs see themselves as part of a larger system that is constantly influencing their behaviors and has the power to do so in a positive or negative way, when it comes to discriminatory behaviour in healthcare. Knowledge, or lack thereof, was identified in qualitative content analysis to disrupt discriminatory behaviours and as an enabler to this behaviour. In TDF coding, the Knowledge domain was more prominent as a disrupter. These themes and domain show that HCPs recognize how knowledge (or lack of) is an important factor to address for equitable care to be provided. Environmental context and resources and Knowledge TDF domains have also been coded in a qualitative systematic review looking at barriers that effect T2D management of care (Rushforth et al., 2016). It appears that increasing knowledge about Indigenous culture, personal biases and evidenced based guidance for T2D management are vital to HCPs in addressing discriminatory care. The theme of Impacts of colonialism as an enabler to discriminatory behaviour in care was an important theme that presented itself in this work through qualitative content analysis. This theme was presented within the contexts of the individual, the organization, and systemically. This shows how HCPs perceive discriminatory behaviour as a result of multiple 66 systems at work. This points to the need to address all contexts that influence HCPs behaviours to address discriminatory behaviour successfully. Organizational culture was coded as an enabler in qualitative content analysis with the theme Healthcare systems needs changing seeming mirroring this theme as a disruptor. Both themes seem to indicate the need for Indigenous representation and feedback, person-centered care and improved workload and resources for HCPs within the organizational culture and structure. The identification of these themes and domains appears to imply that the respondents recognized how interpersonal interactions and organizational structures are both important influences on discriminatory behaviours. The idea that interpersonal relationships influence behaviour is further supported by the common coding of Social influences as both and enabler and disrupter to discriminatory HCP behaviours. HCPs seemed to recognize how interpersonal relationships between colleagues and their patients influence discriminatory behaviours. These abductive coding results, and similar findings in literature, show how the key factors of environment, social influences, colonialism and knowledge are important to address in HCPs to contend with discrimination in care. There were also unique findings between inductive and deductive coding. TDF coding reflected the overarching domains that influence behaviours but in qualitative content analysis it organically evolved to organize the themes at different levels of HCP, organization and society. The process of TDF coding did not capture how environmental or social influences are experienced on the organizational level versus the individual level. Qualitative content analysis captured more aspects of individuals responsibilities for discriminatory behaviours. This demonstrates that HCPs may be able to recognize how they play an individual role in the perpetuation of discrimination in healthcare based on disease status or Indigenous identity. 67 However, the TDF coding was essential in providing practical insights into discriminatory behaviours. To operationalize the information found in this study the domains of the TDF can be mapped onto intervention functions of the Behaviour Change Wheel (BCW) (Michie et al., 2011). Initial mapping of the key TDF domains of knowledge, environmental context and resources and social influences would most effectively be addressed through intervention functions of education, training, restriction, environmental restructuring, enablement and or modelling. These intervention functions seemingly closely relate to the themes identified in the disrupters of discriminatory behaviour. The intervention function of modelling could be linked to the subthemes of Indigenous representation. The intervention functions of education and training were reflected in the themes of knowledge and education and reflection and motivation to understand personal bias. Lastly the intervention functions of environmental restructuring and enablement seemed to link to the themes of the healthcare system needs reforming, and other systems need reforming. The identified intervention functions were supported by the inductive analysis which suggests that the use of these intervention functions and further behavioural analysis using the BCW to link to policy categories, behaviour change techniques and mechanisms of action would be useful for future interventions addressing discriminatory behaviour in healthcare. The use of both qualitative and quantitative methods to approach the research questions in this study provided the opportunity not only to assess biases, but also to understand HCPs’ perceptions to enabling and disrupting discriminatory/biased care towards patients with T2D and Indigenous patients. The results from the qualitative and quantitative methods have commonality in that HCPs often identify influences of behaviour external to themselves. This may be due to HCPs desire to maintain a certain perception of themselves as an unbiased observer of discrimination around them, rather than situate themselves as part of the organizational structure they purport to be an enabler of this discrimination. This would require acknowledgement that they perform this behaviour but from the data it appears most do not feel 68 that they do perform biased behaviours or hold biased views toward Indigenous peoples or people with T2D. While in qualitative content analysis HCPs could identify individual factors influencing behaviour they mostly reflected on how HCPs as a group should address personal bias. There were no responses detailing experiences in addressing their own biases. The biases assessed in this study will be compounded for Indigenous patients who also have T2D. Indigenous Peoples with T2D as previously reviewed, are at a disadvantage of accessing mainstream healthcare solely based on their identity. The affirmation that negative norms around diabetes exists within healthcare can only serves to further exacerbate health disparities for this population. The results of this study add further support for the necessity to pursue effective and lasting interventions to attenuate biases in HCPs to foster equity in health care. 2.5 Strengths This study had many strengths including multiple measurements of biases and abductive analysis of the perspectives of HCPs on discriminatory behaviours. The use of validated tools in the measurement of explicit biases allows for comparison of results to previous and future research. The addition of qualitative analysis provided further context of how discrimination may be successfully approached from the perspective of the population exhibiting the target behaviours. The abductive analysis lent strength to this study by allowing for perspectives of HCPs to be identified thematically. The sequential coding to the TDF captured how these perspectives may be explored further through behavioural analysis and allows for mapping onto the BCW. By using both types of coding researchers were able to obtain a robust understanding of the HCPs perspectives and pragmatically constructive results which can inform future interventions. Additionally, the fact that one of the coders in this study is a part of the population 69 being studied also lent strength to the coding process. RY’s experience as an HCP and Diabetes Educator provided insights that were valuable when interpreting this data since they were able to interpret from the perspective of a HCP. Having an HCP as a researcher in this project allowed for meaningful reflexivity during the qualitative analysis that allowed the coders to better understand the data as participants intended it. Lastly a strength of this study included its broad recruiting to all HCPs that provide car to those with T2D as this likely better reflects the broad range of therapeutic relationships developed by people accessing care. 2.6 Limitations Some considerations for improvement in this study include the need for more updated tools and frameworks, large sample size and access to raw data from the IPC-IAT to allow for comparison to other studies. The M-PATAS, as previously mentioned potentially could be revised as a measure of modern prejudice as it was created over a decade ago (M. Morrison et al., 2008). There is a potential that the items in this scale are no longer relevant to how people in Canada express stereotypes about Indigenous Peoples. As previously mentioned, the original authors of the M-PATAS , acknowledged that explicitly held prejudice can change over time based on social acceptability (M. Morrison et al., 2008). Given that over a decade has passed since the creation of the M-PATAS, social acceptability of the expressed prejudice in this tool may have changed as well. This measure was chosen as it was the only validated tool found to examine explicit prejudice towards Indigenous Peoples in Canada. The version of the TDF used in this study did not effectively capture how power and identity played a role in how discriminatory behaviours are enabled or disrupted in the view of HCPs. There are other approaches in applying the TDF for better integration of intersectional approaches to behaviour research (Etherington et al., 2020). In future studies it would be beneficial to use the intersectionality enhanced TDF for this study. 70 The small sample size in this study also limited its statistical power which did not allow for further analysis into how participant characteristics may have influenced the outcomes. Recruitment is a challenge for many researchers and was found to be difficult due to the targeting of HCPs through health authority emails. There were many operational delays in collaborating with the health authority which made the dissemination of this survey less effective. This sample size limits the ability of this work to reject the null hypothesis and points to the need for more investigation into how biases may be measured in this population to accurately reflect the reality of experienced prejudice and racism faced by users of the healthcare system. It should also be noted that this sample had limited experience with Indigenous Peoples in practice. This characteristic of this sample may have impacted the results and could be due to the avoidance of seeking healthcare due to discrimination from Indigenous Peoples in healthcare in BC (BC Ministry of Health, 2020). Finally, the results of the IPC-IAT are typically expressed in scores that are calculated according to algorithms recommended by the original developers of the tool (Klopfer, 2020). These scores were not accessible to the researchers in this study as the tool was hosted by an external institution. The external institution did not have the personnel to assist with data transfer and so it was agreed that the results of the IPC-IAT would be used categorically. This limited the present study’s ability to compare the results of this population to others in literature. Lastly, participants in this study volunteered to complete the survey and so their choice to complete the study may have indicated that they felt they could respond in a socially desirable way. This could imply that a limitation of this study is that it would not capture those who might demonstrate higher levels of bias due to the fact that it was voluntary. 71 2.7 Future directions This study contributed to the understanding of biases in HCPs and how HCPs themselves perceive the enablers and disrupters of discriminatory behaviour. However, there are considerations for future studies that may help to address the limitations of the current study. The topic of biases is an established area of science however it is also constantly evolving. New tools and approaches to understanding biases are necessary as our society’s perceptions and understandings evolve. Future studies may consider the development of a new scale to measure the modern stereotypes within HCPs in British Columbia. Geography and historical relationships to the Indigenous Peoples of a particular area in Canada may influence how and what stereotypes are considered common, developing a tool that considers this and the social acceptability of explicit expressions of prejudice would be worthwhile. It might be beneficial when applying analysis like the original TDF to further analyze with the intersectionality enhanced TDF (Etherington et al., 2020) and how behaviours are influenced within a domain at different structural levels. It may be helpful in future analysis to pair the intersectionality enhanced TDF with social ecological models to help form more nuanced understandings of discriminatory behaviour. Mapping this enhanced framework to the BCW and its linked intervention functions, policy categories and mechanisms of action would assist in future creation of intersectional anti-bias and cultural safety training interventions for this population. 2.8 Implications This study was exploratory in nature and shed light on the level of biases held within this study population and HCPs’ perceptions of how to address them. The appreciation of personal biases is not the only step needed to address discrimination in healthcare but it can be an important part of the process (Gopal et al., 2021). This study is the only study to our knowledge that has evaluated these biases towards Indigenous Peoples and people 72 with T2D together. The results of the quantitative data show that there are biases that need to change within HCPs to provide unbiased and culturally safe care in the Interior Health Region of BC. The qualitative results of the study point to the need for further self-reflection within the healthcare field to understand personal biases and how biases are shaped and need for them to be addressed at the individual, organizational and systemic levels. The results of this study have the potential to be analyzed further to help cultural safety and antibias training programmers in developing evidence-based interventions for discriminatory behaviours in healthcare in the Interior Health Region of BC. According to this study, there is the potential to create an evidence-based intervention that will target discriminatory behaviours by focusing on social, knowledge and environmental influences of these behaviours. Intervention functions that focus on education, training, restriction, environmental restructuring, enablement and or modelling will likely be more effective in future interventions attempting to address discriminatory behaviours. This study can only be applied to HCPs working within the Interior Health Region of BC since the context within which this study was conducted is unique and has its own historical, geographical, and contemporary relationships with Indigenous Peoples and healthcare systems. It should also be noted that, although these preliminary quantitative results presented here are indicative of low levels of explicit biases towards T2D and Indigenous Peoples in Canada, this does not negate the fact that explicit biases persist in this population as evidenced in the IPS report. As mentioned in the limitations section, explicit prejudice attitudes can and likely do change with time, and this coupled with the constraints of social desirability bias and high prevalence of previous cultural safety training may have influenced results of this study on explicitly reported biases. Some of the quantitative results, specifically two individual scale items, suggested that there still exist socially acceptable forms of explicit prejudice towards Indigenous Peoples and people with T2D, in alignment with the IPS. The qualitative findings clearly support the findings of the IPS, with HCPs 73 expressing how they viewed racial bias in healthcare as a pervasive and systemic problem that is supported by the culture of healthcare systems and societal structures in BC. As with all research, it is crucial to not come to conclusions on the basis of one single study. This Master’s thesis represents a single study that requires replication, further elaboration, and much further research to understand the complexity of implicit and explicit biases in healthcare providers working within the Interior of BC. The future implication of this work will also be the result of collaborations with the Indigenous Cultural Safety Team (ICST) within Interior Health Authority. As part of this work the author connected with the ICST to help inform how these results should be interpreted and translated into knowledge translation products to disseminate to Interior Health Authority HCPs. This initiative will be supported by the Kelowna General Hospital Foundation’s generous grant. The results of the collaboration with ICST will inform the goals of the knowledge translation product(s) and ensure their alignment with the goals of the ICST. 74 Chapter 3: Conclusion 3.1 Conclusion T2D is a disease of concern for populations across the globe. In Canada, 30% of the general population has or is at risk of developing T2D in their lifetime (Diabetes Canada, 2023). Indigenous Peoples are at higher risk of having T2D and developing complications from it (Diabetes Canada, 2023). Inequity in health is complex and has roots in colonialism that have rippling effects on how individuals receive healthcare in Canada. Biases in HCPs are a potential source for poor healthcare outcomes for marginalized populations (Hall et al., 2015; Sim et al., 2021), since stereotypes and attitudes that HCPs have may influence how they interact with the object of their biases (Gopal et al., 2021). Additionally, attitudes that HCPs have about people with T2D can add additional layers of discrimination for people with intersecting identities of being Indigenous and having T2D. Many HCPs would not consider themselves biased and often hold egalitarian views (Byrne & Tanesini, 2015). However, biases can exist on conscious and subconscious levels, and impacts behaviour. Discriminatory behaviour is widespread in healthcare and there are many reports of how experiencing this discrimination has impacted health outcomes for Indigenous Peoples across BC (BC Ministry of Health, 2020). To understand how biases may be influencing the health outcomes of Indigenous people with T2D it is important to understand what biases HCPs have, whether they are aware they have them or not. 3.2 Strengths and Limitations This study had many strengths in its breadth of assessment tools and how the results could be applied in practical ways. The use of validated tools to measure biases lends strength to the results and allows for comparison of results with other literature. The use of abductive analysis also allowed for the translation of the data into informative revelations which can be 75 applied in the development of future behavioural interventions around discrimination in health care. There were also some limitations to this study primarily around the sample size, use of categorical data and need for updated tools. This sample size was underpowered to detect relationships in the measures or perform regression analysis with the demographic information. The use of categorical data in analysis of the IPC-IAT results may have limited researchers’ abilities to compare results to other studies and limited the collection of data since some respondents did not input their data for the test. If the researchers had access to the raw data for the IPC-IAT, there potentially would have been more responses to collect since this would have eliminated non-response errors and could have ensured accurate reporting of the test results. This limitation was largely due to personnel shortages in the team that delivers this test. Lastly, the use of the M-PATAS was both a strength and a limitation since it has been validated in Canadian populations however as mentioned previously it may already be outdated in terms of the modernity of the stereotypes used about Indigenous Peoples in Canada. Future studies may consider the creation and validation of a similar tool informed by people with lived experience in British Columbia. 3.3 Future Directions To address the limitation of this study and operationalize the results further there are a few methodological and analytical considerations for future research. The development of locally contextualized and modernized assessment of explicit biases towards Indigenous Peoples may be beneficial to ensure that the explicit biases captured by these tools accurately reflects the historical and contemporary context of the relationship between Indigenous Peoples and colonial systems in BC. It should also be taken into 76 consideration how results from explicit bias measures are presented in future studies. While using averages and sums of scales allow for certain statistical analysis to be completed, it is also important to review the results descriptively and with an in-depth perspective. As seen in this study, despite low average levels of explicit biases and lower levels of implicit bias compared to previous studies, there were potentially confounding factors within the characteristics of the sample such as previous cultural safety training, experience with diverse patient groups and social desirability of responses. Future work should aim to develop methods or analytical processes that address these concerns to accurately present the levels of biases within HCPs. Future research may also consider further mapping the results of this study onto the BCW to facilitate the development of evidenced-based interventions targeting discriminatory behaviour in healthcare within the Interior Health Region of BC. The results of this study will be used to develop knowledge translation products in collaboration with Interior Health Authority to distribute to HCPs in their employ. The goal will be to inform HCPs of the results as well as discuss other implications it may have for the Indigenous Cultural Safety team in charge of cultural safety training within the Interior Health Region of BC. 3.4 Conclusions This study has shed light on the level of explicit and implicit biases HCP have towards some patients they treat. While the null hypotheses could not be rejected in this study, we found that HCPs exhibit low levels of biases on average, but a substantial proportion hold some biases or stereotypes about Indigenous Peoples and those with T2D. A notable portion of HCP were found to agree that Indigenous Peoples should pay taxes like everyone else (43.2%) and that they should not have reserved placements in universities, unless qualified (29.5%). A 77 remarkable amount agreed that they have heard other professionals speak negatively about people with T2D (57.7%) and disagreed that people with T2D could maintain weight loss (20.8%). Implicit bias was low on average in this population however 44.8% did demonstrate some level of implicit bias in favour of European faces. These findings point towards the need for further investigation into how the presence of these attitudes may impact care given to Indigenous Peoples with T2D. TDF coding revealed Social influences and Environmental Context and Resources as enablers and Knowledge, Social influences and Environmental Context and Resources disrupters of discriminatory care. Content analysis identified how colonialism has enabled discrimination at the levels of individuals, the health care organization and the society. Content analysis also showed that there many opportunities to disrupt discrimination at the level of the individual (knowledge, self-reflection , person-centered care) and the organization as a whole ( culture change, feedback from Indigenous communities, workload etc.). 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What is your current occupation (Eligibility) (Check all that apply) Primary Healthcare Provider (General Practice MD, Nurse Practitioner) MD in specialty area Nurse (LPN/RPN, RN) Allied Health (OT/PT, Pharmacist, RD, Social Worker etc.) Certified Diabetes Educator of any profession 2. How many years have you practiced in your current occupation? 0-3 years 3-5 years 5-15 years 15+ years 3. Have you taken any cultural safety training in the past? Yes – specify (open text) No 4. What is your year of birth? Enter year Prefer not to say Do not know 99 5. Which best describes your current gender identity (this may be the same or different than your sex at birth)? Select all that apply. Exploring my gender identity Female or primarily feminine Indigenous or other cultural gender identity (e.g., Two-Spirit) Male or primarily masculine Neither male nor female (e.g. gender non-conforming, gender fluid, non-binary, etc.) Another option (please specify) Prefer not to say 6. What sex were you assigned at birth, meaning on your original birth certificate? Female Male Undetermined Another option (please specify) Prefer not to say 7. Which of the following best describes your ethnic origins, meaning your cultural or ethnic ancestry which may be the same or different than your citizenship, nationality, or place of birth? Select all that apply. African African American Caribbean Central American East Asian Eastern European Indigenous (e.g. First Nation, Métis, and/or Inuit) 100 Latin(x) Middle Eastern Oceania South American South Asian Southeast Asian Western European Another option (please specify) Prefer not to say Do not know 8. How many years have provided service for clients/patients that have Type 2 Diabetes? a. 1-5 years b. 5-10 years c. 10-15 years d. 15+ years 9. What percentage of clients/patients, on average, do you see with Type 2 Diabetes? a. 0-19% b. 20-39% c. 40-59% d. 60-79% e. 80-100% 10. What percentage of patients with diabetes that you see, identify as Indigenous? a. 0-19% b. 20-39% c. 40-59% d. 60-79% e. 80-100% 101 Appendix B: Modern Prejudice Items (Morrison et al 2009) 1. Canada needs to stop apologizing for events that happened to Indigenous Peoples many years ago. 2. Indigenous Peoples still need to protest for equal rights.* 3. Indigenous Peoples should stop complaining about the way they are treated and simply get on with their lives. 4. Indigenous Peoples should simply get over past generations’ experiences at residential schools. 5. Indigenous Canadians seem to use their cultural traditions to secure special rights denied to non-Indigenous Canadians. 6. Many of the requests made by Indigenous people to the Canadian government are excessive. 7. Special places in academics programmes should NOT be set aside for Indigenous students. 8. Indigenous Peoples should be satisfied with what the government has given them. 9. It is now unnecessary to honour treaties established with Indigenous Peoples. 10. Indigenous Peoples should NOT have reserved placements in universities unless they are qualified. 11. Indigenous Peoples should pay taxes just like everyone else. 12. The government should support programmes designed to place Indigenous Peoples in positions of power. * 13. Non-Indigenous Peoples need to become sensitive to the needs of Indigenous Peoples. * 14. Government agencies should make every effort to meet the needs of Indigenous Peoples. * Note. Items that are marked with an asterisk require reverse-scoring. Response format is: 1 = strongly disagree; 2 = disagree; 3 = somewhat disagree; 4 = somewhat agree; 5= agree; 6= strongly agree. 102 Appendix C: Scale Items Assessing Attitudes toward Patients with T2D (Bennett & Puhl, 2023) 1. I feel that it is important to treat patients with type 2 diabetes with compassion and respect. 2. Patients with type 2 diabetes lack motivation to make lifestyle changes. 3. Patients with type 2 diabetes tend to be lazy. 4. It is difficult to feel empathy for a patient with type 2 diabetes. 5. Treating a patient with type 2 diabetes repulses me 6. Patients with type 2 diabetes are often non-compliant with treatment recommendations. 7. Treating a patient with type 2 diabetes is more emotionally draining than treating a non-diabetic patient 8. Treating a patient with type 2 diabetes is more stressful than treating a non-diabetic patient 9. Treating a patient with type 2 diabetes is more frustrating that treating a patient without this disease. 10. Patients with type 2 diabetes can be difficult to deal with. 11. I would rather treat a non-diabetic patient than a patient with type 2 diabetes. 12. I often feel frustrated with patients who have type 2 diabetes 13. I dislike treating patients with type 2 diabetes. 14. I feel disgust when treating a patient with type 2 diabetes. 15. I feel more irritated when I am treating a patient with type 2 diabetes than a non- non-diabetic patient. 16. I have heard/witnessed other professionals in my field make negative comments about patients with type 2 diabetes. 17. Health care providers feel uncomfortable when caring for patients with type 2 diabetes. 18. My colleagues tend to have negative attitudes toward patients with type 2 diabetes. 103 5-point Likert scale for Q1-18: (1=strongly disagree, 5=strongly agree). Agreement for Q1-18 = Responses of “Agree” or “Strongly Agree” 19. How much do you enjoy/do you enjoy counseling and working with patients with type 2 diabetes? 20. In general, how successful do you think patients with type 2 diabetes can be in making behavior changes? 21. How much confidence do you have that patients with type 2 diabetes can maintain weight loss once it is achieved? 22. In general, how motivated do you think patients with type 2 diabetes are to change their diet? 23. In general, how compliant do you think patients with type 2 diabetes are with treatment recommendations? 5-point Likert scale for Q19-23 (1 = not at all, 3 = neither agree nor disagree, 5 = very much) Agreement for Q19-23 = Responses of “Somewhat” or “Very Much”. 104 Appendix D: TDF Domain Agreement Statements The Theoretical Domains Framework (v1 [15] and v2 [16]) with definitions and component constructs (Atkins et al., 2017) Domains + “Belief statement” Constructs 1. Knowledge (An awareness of the existence of something) Belief statement: “I need more knowledge (about bias, colonialism etc) in order to reduce discriminatory behaviours. “ Knowledge (including knowledge of condition/scientific rationale) Procedural knowledge Knowledge of task environment 2. Skills (An ability or proficiency acquired through practice) “I need more practice or development of skills to implement changes to discriminatory behaviour. “ Skills Skills development Competence Ability Interpersonal skills Practice Skill assessment 3. Social/professional role and identity (A coherent set of behaviours and displayed personal qualities of an individual in a social or work setting) “A HCPs view of themselves as an HCP and their role in care provision impacts how they view their role in address discriminatory behaviours.” Professional identity Professional role Social identity Identity Professional boundaries Professional confidence Group identity Leadership Organisational commitment 4. Beliefs about capabilities (Acceptance of the truth, reality or validity about an ability, talent or facility that a person can put to constructive use) Self-confidence Perceived competence Self-efficacy 105 “I believe that I can change discriminatory behaviour in care.” Perceived behavioural control Beliefs Self-esteem Empowerment Professional confidence 5. Optimism (The confidence that things will happen for the best or that desired goals will be attained) “I am confident that HCPs can change their discriminatory behaviour” Optimism Pessimism Unrealistic optimism Identity 6. Beliefs about Consequences (Acceptance of the truth, reality, or validity about outcomes of a behaviour in a given situation) “I believe that if discriminatory behaviour is performed that there are serious consequences of those actions” Beliefs Outcome expectancies Characteristics of outcome expectancies Anticipated regret Consequents 7. Reinforcement (Increasing the probability of a response by arranging a dependent relationship, or contingency, between the response and a given stimulus) “There are systems in place to incentivize HCPs to not be discriminatory towards patients” Rewards (proximal/distal, valued/not valued, probable/improbable) Incentives Punishment Consequents Reinforcement Contingencies Sanctions 8. Intentions (A conscious decision to perform a behaviour or a resolve to act in a certain way) “ I and other HCPs always intend to not behave in discriminatory manners” Stability of intentions Stages of change model Transtheoretical model and stages of change 9. Goals (Mental representations of outcomes or end states that an individual wants to achieve) “Knowing what non-discriminatory care looks like and the steps need to get there help me avoid discriminatory behavior “ Goals (distal/proximal) Goal priority Goal/target setting Goals (autonomous/controlled) Action planning 106 Implementation intention 10. Memory, attention and decision processes (The ability to retain information, focus selectively on aspects of the environment and choose between two or more alternatives) “Having the capacity to make decisions and not be overloaded , will reduce discriminatory behaviour” Memory Attention Attention control Decision making Cognitive overload/tiredness 11. Environmental context and resources (Any circumstance of a person’s situation or environment that discourages or encourages the development of skills and abilities, independence, social competence and adaptive behaviour) “My environment at work and in society influences my behaviour with patients” Environmental stressors Resources/material resources Organisational culture/climate Salient events/critical incidents Person × environment interaction Barriers and facilitators 12. Social influences (Those interpersonal processes that can cause individuals to change their thoughts, feelings, or behaviours) “My interactions with groups and individuals and perceived social norms influences my behaviour with clients” Social pressure Social norms Group conformity Social comparisons Group norms Social support Power Intergroup conflict Alienation Group identity Modelling 13. Emotion (A complex reaction pattern, involving experiential, behavioural, and physiological elements, by which the individual attempts to deal with a personally significant matter or event) “How I feel in the moment, impacts my behaviour with clients” Fear Anxiety Affect Stress Depression 107 Positive/negative affect Burn-out 14. Behavioural regulation “My ability to self-monitor my behaviour changes my behaviour with clients.” Self-monitoring Breaking habit Action planning
Thesis/Dissertation
eng
Health and Exercise Sciences
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivatives 4.0 International
Graduate
Jung, Mary E.
Healthcare practitioners’ bias towards type 2 diabetes and indigenous populations
Text