Invisible barriers: investigating implicit bias in healthcare delivery and clinical psychology training pathways

Abstract

Implicit bias has been identified as a potential contributor to disparities in healthcare delivery and workforce representation. This thesis explores implicit bias across two domains: its relationship with differential healthcare outcomes (Chapter 1) and its potential influence on access to clinical psychology training in the UK (Chapter 2).

Chapter 1 presents a systematic review of 30 studies examining whether healthcare professionals hold implicit biases and whether these biases are associated with differential healthcare outcomes. The review identified consistent evidence of implicit bias across domains such as race/ethnicity, socioeconomic status, bodyweight, gender, and sexual orientation, with biases almost always directed against minoritised groups. However, the relationship between implicit bias and healthcare outcomes was complex and context-dependent. Although 21 studies reported group-based disparities in treatment or outcomes, only 12 found a direct or partial association with implicit bias. The review highlights the need for more ecologically valid, intersectional, and geographically diverse research using validated bias measures.

Chapter 2 reports an experimental study investigating whether the race of a mock interviewee influences interviewers’ candidate ratings for clinical psychology training, and whether unconscious bias training impacts this. Participants (n = 55), all eligible to sit on UK DClinPsy selection panels, were randomised to interview either a White or Asian actor, with or without prior bias training. Despite pre-existing pro-White bias on the Implicit Association Test (IAT), Asian candidates received significantly higher scores on several selection domains, with no main effect of training. While this finding was not explained by bias scores, it raises questions about overcorrection or social desirability. Training increased bias awareness but did not reduce implicit bias or significantly influence interview behaviour.
Together, these findings highlight the prevalence of implicit bias and its varied impact on practice. Addressing healthcare inequities and workforce diversity requires both individual and systemic approaches, including bias-aware training, structural reform, and more rigorous evidence.

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Identifiers

ORCID for Sarah-Jane Cockburn: orcid.org/0000-0001-6652-5510

ORCID for Catherine Brignell: orcid.org/0000-0001-7768-6272

ORCID for Catherine Brignell: orcid.org/0000-0001-7768-6272

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