Challenges and Opportunities for Clinician Implicit Bias Training: Insights from Perinatal Care Stakeholders

Introduction: In an attempt to address health inequities, many U.S. states have considered or enacted legislation requiring antibias or implicit bias training (IBT) for health care providers. California's “Dignity in Pregnancy and Childbirth Act” requires that hospitals and alternative birthing centers provide IBT to perinatal clinicians with the goal of improving clinical outcomes for Black women and birthing people. However, there is as yet insufficient evidence to identify what IBT approaches, if any, achieve this goal. Engaging the experiences and insights of IBT stakeholders is a foundational step in informing nascent IBT policy, curricula, and implementation. Methods: We conducted a multimethod community-based participatory research study with key stakeholders of California's IBT policy to identify key challenges and recommendations for effective clinician IBT. We used focus groups, in-depth interviews, combined inductive/deductive thematic analysis, and multiple techniques to promote rigor and validity. Participants were San Francisco Bay Area-based individuals who identified as Black or African American women with a recent hospital birth (n=20), and hospital-based perinatal clinicians (n=20). Results: We identified numerous actionable challenges and recommendations regarding aspects of (1) state law; (2) IBT content and format; (3) health care facility IBT implementation; (4) health care facility environment; and (5) provider commitment and behaviors. Patient and clinician insights overlapped substantially. Many respondents felt IBT would improve outcomes only in combination with other antiracism interventions. Health Equity Implications: These stakeholder insights offer policy-makers, health system leaders, and curriculum developers crucial guidance for the future development and implementation of clinician antibias interventions.


Implicit Bias Training
 Hospitals and alternative birth centers must provide implicit bias training for providers involved in the perinatal care of patients. Perinatal providers at these facilities must complete an initial training, then a refresher course every 2 years.Hospitals will issue certificates of completion. Training must be evidence-based and address: • Provider implicit bias, its effects, and steps to decrease it at individual and institutional levels.• Topics such as: health inequities, barriers to care and inclusion, cultural identity, provider-community relationships, communication, and reproductive justice (see page 2). The law does not say how long the training must be, how it should be taught, or how the law will be enforced. The law does not necessarily apply to workers who provide prenatal or postpartum care only outside of hospitals or ABCs.

Death Certificate Reporting
 The California Electronic Death Registration System will more precisely report when a patient was pregnant in relation to time of death.

CDPH Publication of Data
 CDPH will track and publish information on pregnancy-related deaths, and present data by region and race/ethnicity.

Patient Education
 Hospitals are required to provide patients with the following written information on admission: • That patients have a right to be free of discrimination.
• How to file a complaint with CDPH, CA Department of Fair Employment and Housing, or the Medical Board of California if they have experienced discrimination.

THE 10 REQUIRED TOPICS FOR SB464 IMPLICIT BIAS TRAINING
1. Identification of previous or current unconscious biases and misinformation.
2. Identification of personal, interpersonal, institutional, structural, and cultural barriers to inclusion.

3.
Corrective measures to decrease implicit bias at the interpersonal and institutional levels, including ongoing policies and practices for that purpose.
4. Information on the effects, including, but not limited to, ongoing personal effects, of historical and contemporary exclusion and oppression of minority communities.
5. Information about cultural identity across racial or ethnic groups.
6. Information about communicating more effectively across identities, including racial, ethnic, religious, and gender identities.
7. Discussion on power dynamics and organizational decision-making.
8. Discussion on health inequities within the perinatal care field, including information on how implicit bias impacts maternal and infant health outcomes.9. Perspectives of diverse, local constituency groups and experts on particular racial, identity, cultural, and provider-community relations issues in the community.[Overview SB464 handout] • Does anyone have questions they want to discuss about SB464?Or first impressions to share before we move on to some specific questions?

Participant experiences with bias or racism in healthcare
• Has provider bias or racism affected the care you have received?How?
• Has bias or racism in the health system affected the care you have received?

Relationship established
The relationship commenced with study recruitment and lasted for the duration of the focus group or interview.
We later sent information about study findings, including an online town hall, to former participants.

No Item
Guide questions/description 7.

Participant knowledge of the data collector
Participants understood the study team's goals, which were the goals of the study: To learn about challenges to and recommendations for clinician implicit bias training as required by CA Senate Bill 464 (SB464), with the goal of improving care and clinical outcomes for Black women and birthing people.

Data collector characteristics
Focus groups: The facilitator (LJ) identified as a Black woman and doula and was visible on screen.The PI and note-taker (SBG) identified as a white woman and was visible on screen.We expected that the presence of a white woman in the focus group might constrain discussion.The facilitator addressed this proactively and encouraged the participants to be as honest and critical as they would without a white person on the call.
Interviewer: Beyond her interest to contribute to scientific knowledge, the interviewer identified and reported no personal characteristics that we believe would contribute to bias in the interview encounter.The interviewer clarified that she had no formal relationship to the institution where clinician respondents worked.The interviewer has a first name common among white American women of her age group.When the topic of racial identity arose in interviews, the interviewer (re)identified herself as white.No interviewees expressed surprise at this disclosure.

Methodological orientation and Theory
We ground this descriptive qualitative study 2 in subtle/critical realism, acknowledging (a) subjectivity in respondents' and analysts' understandings and descriptions of reality and the socially-constructed nature of reality; and (b) the existence of a reality that analysts can work toward understanding through thoughtful study design, data collection, and triangulation in analysis.
Additionally, the study draws on tools and concepts from implementation science to try to understand and characterize the adoption, adaptation, and potential impact of novel antibias and/or antiracism interventions. to also try to recruit individuals who were likely less passionate or interested in these topics.We believe this gave us access to a broader range of perspectives and experiences than if we had recruited only the first/early phase of volunteers.

Method of approach
How were focus group participants approached?
We distributed study advertisements and information via widely-read California-based birth equity social media, such as Voices4BirthJustice and the social media channels of UC San Francisco's Preterm Birth Initiative.Interested candidates were invited to contact the study directly via phone, text, or email; or to use a QR code link to access a short screening survey that provided additional information about the study and collected their contact information.
Most candidates contacted us using the link/screening survey.
How were interview participants approached?
After receiving permission from departmental leaders at each facility, the principal investigator (SBG) sent an email with information about the study, eligibility criteria, and study activities, which departmental leadership forwarded to perinatal staff and clinician email lists.Interested candidates could email the PI directly or could follow a link to an online screener and contact form.
The PI contacted them directly to provide more information and invite them to participate.Candidates were given the option of scheduling directly with the PI or using a scheduling website (Calendy) to self-schedule.Nearly all used Calendly.
12. Sample size 20 Black women who had a recent hospital birth 20 perinatal clinicians 13.

Nonparticipation
Focus group participants: 37 individuals expressed interest by contacting us, most via the online screening survey website.

No Item
Guide questions/description 6 of those individuals were not eligible for the study because: • They were not based in the San Francisco Bay Area (4) • They contacted us after our recruitment window closed (2).
For the 31 who were eligible, the study co-investigator/lead community collaborator (LJ) reached out to provide more information about the study and informed consent, and to confirm interest.20 of 31 candidates ultimately participated in the focus groups, yielding a participation rate among candidates of 65%.
Proximate reasons for non-participation included the investigator's inability to make initial contact with the candidate (4), or to contact the candidate for subsequent focus group scheduling (7), potentially indicating candidates' lack of continued interest or lack of time.

Interview participants:
39 individuals expressed interest via email or online screener and provided their contact information to the PI.
6 of those 39 individuals were not eligible for the study because: • they did not work in a hospital-based perinatal setting (4); • they worked at a hospital where MEND had not initiated recruitment (1); or • they contacted the study after recruitment had concluded (1).
Of the 33 who were eligible, the PI employed purposive sampling to invite 28 to participate in an interview.20 of 28 invited individuals were ultimately interviewed, yielding a participation rate among invited candidates of 71%.
Proximate reasons for non-participation included PI's inability to make contact with the candidate for scheduling (7), potentially indicating candidates' lack of continued No Item Guide questions/description interest or lack of time. 1 individual self-scheduled an interview but did not attend and could not be contacted to reschedule.

Setting of data collection
Focus groups: Focus groups were conducted via Zoom, using personal computers, tablets, or mobile phones.Participants were asked to take the call in a private location.Participants were offered a digital device to use for the focus group if needed; none elected to use this option.

Interviews:
Semi-structured in-depth interviews were conducted via phone.Participants were asked to take the call in a private location.
Data collection at one site preceded the hospital's implementation, meaning that respondents discussed expected challenges and benefits based on their experience of their facility and other trainings.At the other site, data collection overlapped with the implementation of training, so respondents were able to represent both their expectations and reality of the trainings.

Presence of nonparticipants
Focus groups: Facilitators occasionally observed non-participants in participants' presence, typically related to childcare needs.These individuals did not participate in focus group discussions.

Interviews:
The interviewer observed no non-participants; interviewees reported none.

Description of sample
Focus groups were conducted August 2021 to November 2021.Focus group participants (n = 20) identified as Black women, with 1 reporting additional racial identities.

No Item Guide questions/description
Interviews were conducted August 2021 to March 2022.The interview sample was diverse in self-identified race and clinical role; all identified as women (n = 20).
See Table 1 for more information.

Interview guide
The focus group facilitator used a semi-structured focus group guide that had been developed and pilot-tested prior to initiating focus groups.
The interviewer used a semi-structured interview guide that had been developed and pilot-tested prior to interviews.
For both approaches/samples: To enhance study rigor and the validity of the data, the interviewer/facilitator (SBG) took detailed notes on key topics during the interviews/focus groups and presented her understanding of these data back to the respondents at the end of the research encounter for the respondent to clarify, correct, and/or affirm.These key topics focused on specific challenges and recommendations for clinician implicit bias training.
See Supplement B for focus group guide; Supplement C for interview guide.

18.
Repeat data collection There were no repeat focus groups or interviews.

Audio/visual recording
With respondent permission we digitally recorded all focus groups/interviews and had them professionally transcribed.Identifying information was removed before analysis.

Field notes
Field notes were taken during the focus groups and interviews and included among study data.
The interviewer/facilitator (SBG) created structured analytic case summaries for each research encounter that reflected the respondents' perspectives and experiences on No Item Guide questions/description challenges, opportunities, and recommendations for clinician IBT, among other topics.

Duration
Focus groups lasted approximately 90 minutes.

Data saturation
The research team discussed data saturation, specifically whether we had collected enough data to answer our main questions, at multiple points throughout the project.The insights for which we sought to reach saturation concerned domains of challenges to and recommendations for clinician implicit bias training.We feel we have reached saturation on these points.

Transcripts returned
We did not return transcripts to participants.However, as described above (#17), the PI/interviewer checked her understanding of key points with respondents.

Number of data coders
For the indexing of topics and the coding described in the attached paper, there were 3 coders: EC, SZ, SBG.

Description of the coding tree
The major codes relevant to this paper were: After the conclusion of data collection, EC, SZ, and SBG established high-level topic codes to use to label excerpts of the transcripts related to challenges and recommendations, and the domains in which they occurred (see #25).They used these to excerpt data for a subsequent phase of focused thematic data analysis to understand manifestations of specific types of challenges and recommendations within these domains.They reread excerpts numerous times, wrote analytic notes 9 , and reviewed notes and output collectively.
Over the course of multiple discussions, SZ, EC, SBG inductively developed and refined their description and organization of themes regarding challenges and recommendations for effective IBT.We looked for nuance and disconfirming evidence to assess and hone our interpretation. 10,11We resolved the small number of differences of interpretation via group discussion and refinement of concepts.
The coding team presented their analysis, the organization of domain-specific themes, and a wide range of data to community advisor collaborators (LJ, JH, BP) who agreed with and affirmed their analysis.
An audit trail was maintained throughout to capture analytic processes and decisions.
27. Software Atlas.ti and Excel

Participant checking
Participant checking of key insights, including all factors participants raised as hindering or potentially supporting IBT effectiveness, occurred during the focus groups and interviews as described above (#17).

Quotations presented
Were participant quotations presented to illustrate the themes / findings?Was each quotation identified?e.g.participant number

No Item Guide questions/description
We include participant quotations to illustrate recommendation-focused themes and findings in Table 3.
Quotes from participants are identified by a code denoting participant number (e.g.01), source of data (patient focus groups [FG], clinician interviews [IV]), and clinician participant site (site A, site B)

Data and findings consistent
Was there consistency between the data presented and the findings?

Clarity of major themes
Were major themes clearly presented in the findings?

Yes Clarity of minor themes
Is there a description of diverse cases or discussion of minor themes?Yes

Focus Group Guide, with associated probes, for Patient Stakeholder Participants in the MEND study
Thank you.For the rest of the discussion, we're going to be asking you questions to learn what is and isn't working for Black women and birthing people at hospitals, how to make it better, and how a recent law may or may not help.As we talk through all of this, 10. Information on reproductive justice.Created by the MEND Study, UC San Francisco (2021) Supplement B. 1. Facilitator introductions & informed consent 2. Participant experiences & context • Please introduce yourself and describe your experience when you were last at a hospital for something related to pregnancy or birth.pleasekeep in mind your experiences, what you want, and what you think needs to happen to improve maternity care for Black women and birthing people.3.Implicit bias in healthcare / Overview SB464 & requirementsCalifornia's new law, Senate Bill 464 / The California Dignity in Pregnancy and Childbirth Act, requires clinicians who care for pregnant and birthing people to take implicit bias training.The goal of these new laws is to improve health outcomes for Black women and birthing people.For our conversation, we will define implicit bias as unconscious prejudices, attitudes, and stereotypes that clinicians may have about certain people or groups.Implicit bias training is a training designed to reduce or weaken these biases.

perspectives on how/why IBT would or would not change their care, outcomes; and how it aligns with what they value
5. Patient

Supplement C. Interview Guide, with associated probes, for Perinatal Clinician Stakeholder Participants in the MEND study 1. Interviewee context
For the purposes of this conversation, we will consider implicit bias to be unconscious prejudices, attitudes, and stereotypes that individuals may have about certain people or groups.IBT tries to reduce these biases.o What are a few words or feelings that come to mind when you think about IBT? o Have you heard about the California bill SB464?What do you know about it?
▪ In advance of our meeting I sent an overview of the new state policy, SB464.I'll take a moment to review key aspects of it with you… [Review handout] 3. Feelings about the new legislation o How do you feel about SB464's IBT requirement?▪ In your experience [or when you imagine yourself doing it] what do you think has been [will be] a difficult or uncomfortable part of this training?o Has your hospital told you how you and your colleagues should fulfill the IBT that SB464 requires?o Will you [continue to] participate in these trainings?Why or why not?What will your involvement look like? 4.

How responsive clinicians think SB464 is to the needs of Black women and birthing people and the factors that could improve their clinical outcomes
When you think about IBT for your hospital, what could go wrong?What are the challenges?In what ways might it fail to improve the care or outcomes of Black women and birthing people?o Reflecting on your past experiences with IBT, what are some ways you feel it "worked"?How did it improve patient care or outcomes?o When you think about IBT at your hospital, what might help it to improve care for Black women and birthing people?What would this look like?What advice do you have for hospitals or labor & delivery leadership who want to improve clinical outcomes for Black women and birthing people?o What advice do you have for state lawmakers who want to improve clinical outcomes for Black women and birthing people?
o When you think about this hospital, do you feel clinician bias affects clinical outcomes for Black women and birthing people?How? o Do you think racism-either individual or structural-affects care outcomes for Black women and birthing patients?How? o I'm going to ask you two survey-type questions and then ask you to talk through your answers: ▪ How much do you think that the SB464-mandated IBT will improve clinicians' relationships with Black women and birthing people at your hospital?▪ How much do you think that the SB464-mandated IBT will improve the clinical outcomes of Black women and birthing people at your hospital o Have you heard about a time when a Black women or birthing patient had a negative experience or clinical outcome at your hospital?What do you think caused it?5. Feasibility and effectiveness of SB464 o Reflecting on your past experiences with IBT or similar training, what are some ways you feel it did not "work"?How or why did it not improve patient care or outcomes?o ▪ What could your hospital or colleagues do to help it succeed?▪ Is there anything else you would you recommend?o How, if at all, do you feel that these trainings have affected you or your practice?How do you feel it has affected your colleagues?The labor & delivery floor overall?o If you were going to measure (or evaluate) the effects of IBT, what would be important to measure?o I'd like to check the notes I took about what we're considering the challenges, opportunities, and recommendations of IBT with you… [Check interpretation] 6. Recommendations to improve care outcomes for Black women and birthing people o Thinking more broadly here, when you think about labor & delivery leadership, hospital leadership, or state lawmakers, what recommendations do you have for improving clinical outcomes for Black women and birthing people?o Do you have any other advice for hospital or labor & delivery leadership as they begin to implement these IBT trainings?o

Summary of Study Methods per Consolidated Criteria For Reporting Qualitative Studies (COREQ). 1
The methods description immediately below refers to data collection for both the interview and focus group branches of the MEND study (Multi-Stakeholder Engagement with State Policies toAdvance Antiracism in Maternal Health).When information varies by format, it is presented separately within the category.