title: Development and testing of study tools and methods to examine ethnic bias and clinical decision-making among medical students in New Zealand: The Bias and Decision-Making in Medicine (BDMM) study.
abstract: BACKGROUND
  Health provider racial/ethnic bias and its relationship to clinical decision-making is an emerging area of research focus in understanding and addressing ethnic health inequities. Examining potential racial/ethnic bias among medical students may provide important information to inform medical education and training. This paper describes the development, pretesting and piloting of study content, tools and processes for an online study of racial/ethnic bias (comparing Māori and New Zealand European) and clinical decision-making among final year medical students in New Zealand (NZ).
  
  
  METHODS
  The study was developed, pretested and piloted using a staged process (eight stages within five phases). Phase 1 included three stages: 1) scoping and conceptual framework development; 2) literature review and identification of potential measures and items; and, 3) development and adaptation of study content. Three main components were identified to assess different aspects of racial/ethnic bias: (1) implicit racial/ethnic bias using NZ-specific Implicit Association Tests (IATs); (2) explicit racial/ethnic bias using direct questions; and, (3) clinical decision-making, using chronic disease vignettes. Phase 2 (stage 4) comprised expert review and refinement. Formal pretesting (Phase 3) included construct testing using sorting and rating tasks (stage 5) and cognitive interviewing (stage 6). Phase 4 (stage 7) involved content revision and building of the web-based study, followed by pilot testing in Phase 5 (stage 8).
  
  
  RESULTS
  Materials identified for potential inclusion performed well in construct testing among six participants. This assisted in the prioritisation and selection of measures that worked best in the New Zealand context and aligned with constructs of interest. Findings from the cognitive interviewing (nine participants) on the clarity, meaning, and acceptability of measures led to changes in the final wording of items and ordering of questions. Piloting (18 participants) confirmed the overall functionality of the web-based questionnaire, with a few minor revisions made to the final study.
  
  
  CONCLUSIONS
  Robust processes are required in the development of study content to assess racial/ethnic bias in order to optimise the validity of specific measures, ensure acceptability and minimise potential problems. This paper has utility for other researchers in this area by informing potential development approaches and identifying possible measurement tools.
authors.affiliation: Te Kupenga Hauora Māori, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland, New Zealand.
authors.forename: Ricci
authors.initials: R
authors.lastname: Harris
authors.affiliation: Te Kupenga Hauora Māori, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland, New Zealand.
authors.forename: Donna
authors.initials: D
authors.lastname: Cormack
authors.affiliation: Te Kupenga Hauora Māori, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland, New Zealand. e.curtis@auckland.ac.nz.
authors.forename: Elana
authors.initials: E
authors.lastname: Curtis
authors.affiliation: Te Kupenga Hauora Māori, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland, New Zealand.
authors.forename: Rhys
authors.initials: R
authors.lastname: Jones
authors.affiliation: Dean's Department, University of Otago Wellington, PO Box 7343, Wellington, New Zealand.
authors.forename: James
authors.initials: J
authors.lastname: Stanley
authors.affiliation: Māori/Indigenous Health Institute (MIHI), University of Otago Christchurch, PO Box 4345, Christchurch, New Zealand.
authors.forename: Cameron
authors.initials: C
authors.lastname: Lacey
mesh_terms: D001291:Attitude of Health Personnel; D000066491:Clinical Decision-Making; D005006:Ethnicity; D005178:Faculty; D005260:Female; D054625:Healthcare Disparities / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D009520:New Zealand; D016730:Program Development; D015397:Program Evaluation / Q000379:methods*; D063505:Racism / Q000523:psychology* / Q000706:statistics & numerical data*; D013337:Students, Medical / Q000523:psychology*
keywords: Bias; Ethnic; Healthcare; Medical students; New Zealand; Pilot; Pretesting; Racial; Study development