Examining Implicit Racial Attitudes among College Students in Hawai'i, a Project of the Hawai'i Implicit Bias Initiative.

For the past 2 decades, investigations into implicit racial bias have increased, building evidence on the impact of bias on health and health care for many minority communities in the US. However, few studies examine the presence and impacts of implicit bias in Hawai'i, a context distinct in its history, racial/ethnic diversity, and contemporary inequities. The absence of measures for major racialized groups, such as Native Hawaiians, Pacific Islanders, and Filipinos, impedes researchers' ability to understand the contribution of implicit bias to the health and social disparities observed in Hawai'i. The purpose of this study was to measure bias toward these underrepresented groups to gain a preliminary understanding of the implicit racial bias within the distinctive context of this minority-majority state. This study measured implicit racial bias among college students in Hawai'i using 3 implicit association tests (IATs): (1) Native Hawaiian compared to White (N = 258), (2) Micronesian comparedto White (N =257), and (3) Filipino compared to Japanese (N = 236). Themean IAT D scores showed implicit biases that favored Native Hawaiiansover Whites, Whites over Micronesians, and Japanese over Filipinos. Multipleregression was conducted for each test with the mean IAT D score as theoutcome variable. The analysis revealed that race was a predictor in the vastmajority of tests. In-group preferences were also observed. This investigationadvances the understanding of racial/ethnic implicit biases in the uniquelydiverse state of Hawai'i and suggests that established social heirarchies mayinfluence implicit racial bias.

Identifying the Physical and Emotional Needs of Health Care Workers in Hawai`i During the COVID-19 Pandemic.

A mixed-methods study was performed to identify the physical and emotional needs of Hawai`i health care workers during the COVID-19 pandemic, and the degree to which these needs are being met by their clinic or hospital. Qualitative interviews and demographic surveys were conducted with two cohorts of health care workers. Cohort 1 (N=15) was interviewed between July 20 - August 7, 2020, and Cohort 2 (N=16) between September 28 - October 9, 2020. A thematic analysis of the interview data was then performed. Participants' primary concern was contracting the illness at work and transmitting it to their families. Solo practitioners working in outpatient clinics reported more financial challenges and greater difficulty obtaining PPE than those employed by hospitals or group practices. While telehealth visits increased for both inpatient and out-patient settings, the new visit type introduced new barriers to entry for patients. The study findings may serve to better understand the effect of COVID-19 on health care workers and support the development of hospital and clinic procedures. Further research into the impacts of COVID-19 on nurses in Hawai`i is recommended.

Implicit Racial Attitudes and Associations Among Obstetricians in Hawai'i: a Pilot Study.

INTRODUCTION: Pacific Islanders living in Hawai'i with ancestral ties to islands in the western Pacific region of Micronesia are common targets of uninhibited forms of prejudice in multiple sectors, including healthcare. Whether the explicit societal-level attitudes toward this group are reflected in implicit attitudes among healthcare providers is unknown; therefore, we designed a pilot study to investigate this question. Our study measures implicit racial bias toward Pacific Islanders from Micronesia among Obstetrician-Gynecologists (OB-GYNs) in Hawai'i. METHODS: We developed 4 new implicit association tests (IATs) to measure implicit attitudes and associations (i.e., stereotypes) toward Pacific Islanders from Micronesia in 2 conditions: (1) Micronesians vs. Whites and (2) Micronesians vs. Japanese Americans. Participants were practicing OB-GYNs in Hawai'i. The study was conducted online and included survey questions on demographic and physician practice characteristics in addition to IATs. The primary outcome was the mean IAT D score. Associations between IAT D scores and demographic and practice characteristics were also analyzed. RESULTS: Of the 49 OB-GYNs, 38 (77.6%) were female, mean age was 40 years, 29.5% were Japanese, 22.7% were White, and none were from a Micronesian ethnic group. The mean IAT D score in the Micronesian vs. White condition (N = 29) was 0.181, (SD: 0.465, p < 0.05) for the Attitude IAT and 0.197 (SD: 0.427; p < 0.05) for the Stereotype IAT. CONCLUSION: The findings from this pilot suggest a slight degree of implicit bias favoring Whites over Micronesians within this sample of OB-GYNs and warrant a larger investigation into implicit biases toward this unique and understudied Pacific Islander population.

Non-technical skill assessments across levels of US surgical training.

BACKGROUND: To ensure safe patient care, regulatory bodies worldwide have incorporated non-technical skills proficiency in core competencies for graduation from surgical residency. We describe normative data on non-technical skill ratings of surgical residents across training levels using the US-adapted Non-Technical Skills for Surgeons (NOTSS-US) assessment tool. METHODS: We undertook an exploratory, prospective cohort study of 32 residents-interns (postgraduate year 1), junior residents (postgraduate years 2-3), and senior residents (postgraduate years 4-5)-across 3 US academic surgery residency programs. Faculty went through online training to rate residents, directly observed residents while operating together, then submitted NOTSS-US ratings on specific resident's intraoperative performance. Mean NOTSS-US ratings (total range 4-20, sum of category scores; situation awareness, decision-making, communication/teamwork, leadership each ranged 1-5, with 1=poor, 3=average, 5=excellent) were stratified by residents' training level and adjusted for resident-, rater-, and case-level variables, using mixed-effects linear regression. RESULTS: For 80 operations, the overall mean total NOTSS-US rating was 12.9 (standard deviation, 3.5). The adjusted mean total NOTSS-US rating was 16.0 for senior residents, 11.6 for junior residents, and 9.5 for interns. Adjusted differences for total NOTSS-US ratings were statistically significant across the following training levels: senior residents to interns (6.5; 95% confidence interval, 4.3-8.7; P < .001), senior to junior residents (4.4; 95% confidence interval, 2.5-6.2; P < .001), and junior residents to interns (2.1; 95% confidence interval, 0.3-3.9; P = .017). Differences in adjusted NOTSS-US ratings across residents' training levels persisted for individual NOTSS-US behavior categories. CONCLUSION: These data and online training materials can support US residency programs in determining competency-based performance milestones to develop surgical trainees' non-technical skills.

Hospital Disparities between Native Hawaiian and Other Pacific Islanders and Non-Hispanic Whites with Alzheimer's Disease and Related Dementias.

Objective: To compare important indicators of quality of care between Native Hawaiians and other Pacific Islanders (NHOPIs) and non-Hispanic Whites (NHWs) with Alzheimer's disease and related dementias (ADRD). Methods: We used the Health Care Cost and Utilization Project, Hawaii State Inpatient Databases, 2010-2014. They included 10,645 inpatient encounters from 7,145 NHOPI or NHW patients age ≥ 50 years, residing in Hawaii, and with at least one ADRD diagnosis in the discharge record. Outcome variables were inpatient mortality, length of hospital stay, and hospital readmission. Results: NHOPIs with ADRD had, on average, a hospital stay of .94 days less than NHWs with ADRD but were 1.16 times more likely than NHWs to be readmitted. Discussion: These patterns have important clinical care implications for NHOPIs and NHWs with ADRD as they are important indicators of quality of care. Future studies should consider specific contributors to these differences in order to develop appropriate interventions.

A Culture-Based Family-Centered Health Navigation Intervention for Chronic Disease Management in Native Hawaiians.

Greater medical and psychological concerns coupled with disparities in income and education and experiences with cultural distress have created an unprecedented demand for health and mental health services for Native Hawaiians. With 75% of the healthcare system moving to a value-based system within the next 2 years, a low-cost workforce that brings added value will be in high demand. The addition of community health navigators to an existing integrated patient-centered medical home may result in a culturally congruent, preventive, and responsive model of wellness that promotes health equity. The purpose of this paper is to discuss the culturally-based navigation framework we used to implement a pilot program in an integrated primary care setting, describe the intervention that was used, and examine the lessons learned throughout the process. Outcomes will be provided at a later date. We believe that our model will not only redesign an existing clinical practice but also will provide a reproducible model that can be translated into other settings to increase the health care utilization among Native Hawaiians and lead to improved outcomes.

A Preliminary Study of the Relationship between Perceived Racism and Cardiovascular Reactivity and Recovery in Native Hawaiians.

Native Hawaiians, compared to other ethnic groups in Hawai'i, have significantly higher mortality rates and die at a younger average age from cardiovascular disease (CVD). This may be partially explained by elevated cardiovascular responses to racial stressors. Our study examined the degree to which blood pressure (BP) and heart rate (HR) reactivity and recovery, and ratings of subjective distress to racial stressors, differ as a function of Native Hawaiian college students' levels of perceived racism. This study had three phases. Phase 1 involved the development of a blatant and subtle racial stressor. Phase 2 involved assigning 132 students into high- or low-perceived racism groups based on scores on two perceived interpersonal racism measures. Phase 3 involved a psychophysiology laboratory experiment conducted with 35 of the 132 students. BP, HR, and subjective distress were measured during exposure to the blatant and subtle racial stressors. Systolic blood pressure (SBP) recovery following exposure to both stressors was significant for both groups. Although not significant, three trends were observed among the high-perceived racism group, which included: (1) greater reactivity to exposure to the subtle stressor than to the blatant stressor, (2) incomplete HR recovery following exposure to both stressors, and (3) incomplete SBP and diastolic blood pressure recovery following exposure to the subtle stressor. Participants also reported significantly greater subjective distress following exposure to the blatant than to the subtle stressor. Specific interventions, such as increased self-awareness of physiological responses to racial stressors, targeted at at-risk individuals are necessary to reduce a person's risk for CVD.

The effects of perceived racism on psychological distress mediated by venting and disengagement coping in Native Hawaiians.

BACKGROUND: Studies have linked perceived racism to psychological distress via certain coping strategies in several different racial and ethnic groups, but few of these studies included indigenous populations. Elucidating modifiable factors for intervention to reduce the adverse effects of racism on psychological well-being is another avenue to addressing health inequities. METHODS: We examined the potential mediating effects of 14 distinct coping strategies on the relationship between perceived racism and psychological distress in a community-based sample of 145 Native Hawaiians using structural equation modeling. RESULTS: Perceived racism had a significant indirect effect on psychological distress, mediated through venting and behavioral disengagement coping strategies, with control for age, gender, educational level, and marital status. DISCUSSION: The findings suggest that certain coping strategies may exacerbate the deleterious effects of racism on a person's psychological well-being. CONCLUSION: Our study adds Native Hawaiians to the list of U.S. racial and ethnic minorities whose psychological well-being is adversely affected by racism.

A Community-Based Participatory Research Guided Model for the Dissemination of Evidence-Based Interventions.

BACKGROUND: Dissemination is a principle within community-based participatory research (CBPR); however, published research focuses on the dissemination of findings from CBPR projects but less on dissemination of interventions developed through CBPR approaches. To disseminate an evidence-based lifestyle intervention tailored for Native Hawaiians and other Pacific Islanders, the PILI 'Ohana Project (POP), an 11-year CBPR initiative, developed an innovative dissemination model. OBJECTIVES: The community-to-community mentoring (CCM) model described in this paper extends the application of CBPR values and principles used in intervention development to intervention dissemination. METHODS: The CCM model combines a CBPR orientation with the diffusion of innovation theory, the social cognitive theory, and key concepts from community organizing and community building to address the multilevel factors that influence uptake of an evidence-based intervention (EBI). Grounding the model in CBPR principles provides benefits for intervention dissemination and integrates a focus on community benefits and capacity building. CONCLUSIONS: By establishing co-equal, mutually beneficial relationships at the core of the CCM model, opportunities are created for building critical consciousness, community capacity, and social capital. More research is needed to determine the effectiveness of this model of intervention dissemination which may enhance diffusion of CBPR interventions and empower communities in the process.