A Qualitative Study: New Zealand Medical Students’ Experience of Cognitive Bias Modification-Stereotype (CBM-S)—A Self-Run Digital Implicit Bias Training

A Qualitative Study: New Zealand Medical Students’ Experience of Cognitive Bias Modification-Stereotype (CBM-S)—A Self-Run Digital Implicit Bias Training | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A Qualitative Study: New Zealand Medical Students’ Experience of Cognitive Bias Modification-Stereotype (CBM-S)—A Self-Run Digital Implicit Bias Training Che-Wei Hsu, Alex Robbins, Tiana Cartwright This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5596294/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract In healthcare, it has been well-documented that marginalized communities face a higher risk of health problems due to inequitable opportunities, with implicit bias contributing a major role to this health inequity. In the present qualitative study, we aimed to complement a previous randomized control trial that examined Cognitive Bias Modification-Stereotype (CBM-S)—a self-run digital training for medical students targeting their implicit stereotype bias towards Māori, an indigenous population of New Zealand. We gathered feedback from New Zealand medical students’ experiences and acceptance of CBM-S in order to improve its implementation in medical education. Semi-structured group interviews were conducted with 20 students (in their 1st to 5th year of medicine), with 3–5 students per interview group. Qualitative analyses using framework and thematic analysis revealed six major thematic categories: Engagement; Understanding of CBM-S; Perceived impact of CBM-S; Application of CBM-S; Barriers and facilitators; Initial expectations of training , along with several nested sub-themes. By and large, CBM-S was perceived favorably by students on various aspects, including engagement, clarity, application, and effectiveness and relevance to clinical settings and stereotyping of Māori patients. Particularly, students appreciated the self-guided format and active involvement during the training, reporting a sense of independence, engagement, and feeling in control of the pace. Several helpful suggestions were made with including debriefing sessions, interactive discussion session, and ways to improve the delivery and engagement of CBM-S. The rich content that was obtained from the present study open up an avenue for improving CBM-S for future studies and application in medical education. cognitive bias modification implicit bias training medical education health inequity qualitative study interpretation bias Figures Figure 1 Figure 2 Introduction Implicit bias consists of mental processes that occur outside of our conscious awareness, which, in part, contributes to health disparities, particularly for marginalized social groups such as Indigenous communities, the elderly, individuals with disabilities, and members of the Rainbow community, among many others. In this context, health inequity can manifest as limited opportunities and unequal access to healthcare, resulting in poorer health outcomes (Baah et al., 2019). Researchers have introduced a novel, self-guided digital training suite known as cognitive bias modification for stereotypes (CBM-S; Hsu, 2023). CBM-S is a digital training designed to reduce biased interpretations of common clinical situations that involve medical students and Māori patients—an indigenous population of Aotearoa New Zealand (NZ). The training aims to promote helpful interpretations of clinical situations without requiring students to explicitly engage in critical self-reflections of existing beliefs or biases, which is a common method used in extant bias training (Lai et al., 2014). Empirical data have shown promising bias modification effects of CBM-S (Hsu & Akuhata-Huntington, 2024a); in the present qualitative study, we conducted focus group interviews to gather NZ medical students’ thoughts of CBM-S as an implicit stereotype bias training tool. Gathering rich feedback from students’ experience and acceptability of CBM-S would help improve the training’s application in medical education. Existing bias training initiatives tend to focus on people’s inherent stereotype beliefs toward marginalized groups. This is achieved through various means, including increasing people’s knowledge about the target marginalized group or providing counterstereotypical exemplars that refute preconceived beliefs and evaluations of that group (Macrae et al., 1994). Despite being common training methods, researchers have shown that these techniques have yielded small and transient effects in modifying beliefs (FitzGerald et al., 2019), likely due to the intrinsic nature of those beliefs (Kelly et al., 2005). Additionally, concentrating solely on beliefs in training could unintentionally undermine efforts to change the way individuals interpret contextual information. More specifically, it is known that stereotype beliefs and biased processes of contextual information may be qualitatively different (Allen et al., 2009; Hsu, 2023; von Hippel et al., 1995). For instance, a common (and unhelpful) stereotype belief about Māori patients is poor health habits, such as smoking or having a poor diet. Having this belief, however, does not always translate to biased processing of information that aligns with the belief. Information processing bias may occur only under specific conditions, such as when a person’s goals, task requirements, and the demands and ambiguity of the situation, align in a way that activate thoughts and behaviors that are consistent with beliefs (Allen et al., 2009; Ecker & Bar-Anan, 2019; Jones et al., 2009). Simply put, biased processing occurs when facts, evaluation, and goals align for a person to interpret a given situation in a way that makes sense, which does not solely depend on stereotype beliefs. In the above example, when working with a Māori patient with hypertension who presents in the clinic coughing; one doctor may hold a general belief that Māori has poor health habits and interpret the patient’s coughing as a result of long-term smoking; another doctor may hold the same belief about Māori health habits but instead, may attribute the coughing to a virus given the recent COVID-19 pandemic. On the basis of this fundamental difference between beliefs and processing bias, some researchers have explored trainings that target biased information processing. Cognitive Bias Modification-Stereotype (CBM-S) is a self-guided digital training that targets information procession bias (Hsu, 2023; Hsu & Akuhata-Huntington, 2024a). It is adapted from a class of evidence-based mental health intervention—Interpretation Bias Modification—designed to reduce negative interpretation bias commonly observed in people with mental health issues (Cristea et al., 2015). Hsu and Akuhata-Huntington (2024b) outlined this adaptation process, which involved a co-facilitation approach with inputs from medical students, Māori, and researchers, to co-develop CBM-S training scenarios using transcripts of people’s real-life experiences. Scenarios are ambiguous and aimed at eliciting multiple interpretations from the same event, including an interpretation that captures common stereotyping of Māori in clinical settings. The theoretical basis of CBM-S is that individuals with implicit biases toward a social group tend to interpret ambiguous social situations in a way that aligns with their biases (Birtel & Crisp, 2015; Hsu, 2023; Sagar & Schofield, 1980). Scenarios omit the final word of each scenario (e.g., You wait for a ride outside the hospital. You see a Māori patient, Nikau smoking cigarette. You think unhealthy behaviours in Māori are… ) to create ambiguity. The biased interpretation in this instance might be “ You think unhealthy behaviours in Māori are common ”. The way CBM-S works is that medical students are presented with a set of scenarios, one at a time, to elicit their pre-existing biased interpretations pertaining to each scenario. To modify students’ interpretation bias, CBM-S presents students with a fragment of the final word, similar to a CAPTCHA (Completely Automated Public Turing test to tell Computers and Humans Apart) mechanism, for the students to solve. The resolution of the final word completes the scenarios and clarifies the ambiguity of the scenarios in a benign, non-stereotypical manner [e.g., You wait for a ride outside the hospital. You see a Māori patient, Nikau smoking cigarette. You think unhealthy behaviours in Māori are ov-rg-ner-lised (overgeneralised)]. Finally, a Yes/No question is asked to reinforce the non-stereotype interpretation (e.g., “Do all Māori smoke? Answer: No). See Fig. 1 for another example of a CBM-S training item. CBM-S offers numerous benefits compared to extant bias training methods. It is self-guided, does not require specialized expertise, is cost-effective, and can be easily accessed and implemented across different learning and professional environments. Additionally, the digitalized delivery may be especially helpful for medical students who fear negative judgment due to their personal beliefs or emotions, thereby impacting their willingness to participate fully and openly in training (Gonzalez et al., 2014, 2019; Hernandez et al., 2013). CBM-S, given its self-guided format, may also overcome the barrier of understaffing in the field of education, particularly where cultural experts are required. Unlike other implicit bias training methods, such as metacognition, fact provision, and group discussions, the method in which CBM-S addresses biases is in a more nuanced and indirect manner, which requires little effort to complete (Hirsch et al., 2018; Hsu & Akuhata-Huntington, 2024a). Furthermore, given the flexibility of CBM-S, training modules could expand to other marginalized communities, such as other ethnicity groups, the Rainbow community, older persons, and people with disability, to name a few (Hsu, 2023). Finally, CBM-S has been shown to have moderate to large effects in modifying students’ interpretation bias of clinically-relevant scenarios involving Māori patients. In a randomized control trial of a single session CBM-S training using a pre-post test study design (Hsu & Akuhata-Huntington, 2024b), 59 NZ medical students ranging from 1 st –5 th year in medicine were randomized to either the training or the control group. A battery of measures was administered, including assessments for interpretation bias, implicit and explicit bias, and stereotype beliefs. Results revealed that students’ interpretation bias scores reduced over time and at post-test in the training condition, but not the control group. To enhance the implementation and dissemination of CBM-S in medical education, it is crucial to examine medical students' subjective experience with CBM-S (Kilgour et al., 2016; Schneider & Preckel, 2017). In a previous study, we have gathered quantitative data on the acceptability and usability of CBM-S (Hsu & Akuhata-Huntington, 2024b). In that study, students rated the CBM-S training on acceptability and usability using a 7-point Likert scale. Results indicated that CBM-S is generally perceived by NZ medical students as a clear and easy to use training for targeting implicit bias. In the present study, we aim to gather a richer understanding of NZ medical students’ experience of CBM-S by collating feedback of their experience and acceptability of CBM-S. This study complements the previous CBM-S randomized controlled trial (i.e., Hsu & Akuhata-Huntington, 2024a). Methods Participant University medical students (N = 17) were recruited from on campus flyers and a NZ student job search website. Inclusion criteria to participate in the study were fluent English literacy and currently enrolled in medicine at a NZ medical school (University of Auckland or University of Otago). This included students who were enrolled in Early Learning in Medicine (Year 2 and Year 3 of medicine, which is pre-clinical training) and Advance Learning in Medicine (Year 4 to Year 6, where students rotate through various clinical placements). We did not consider Year 1 students for our study as the medical program in NZ offers Year 1 students more generalized papers related to health science rather than in medicine per se and not all Year 1 students enter medical school (officially, they are first year health science students). The range of demographic variations of participating students were unintentionally selected and based on students’ availability for attending group interviews (see Table 1 for students’ characteristics). Noteworthy is that the study captured a diverse sample of student backgrounds and characteristics, particularly with including students from different year groups and universities across NZ. Table 1 Demographic Characteristics of Students Student Characteristics Number of Students Year in Medicine Early Learning in Medicine (Year 2 and Year 3) 11 Advance Learning in Medicine (Year 4–Year 6) 9 Ethnicity Māori 1 NZ European 6 Asian Pasifika Other (Latin American, Iraqi, Australian, European, African) Gender 9 1 5 Male 3 Female 16 Other 1 University Program University of Otago 16 University of Auckland 4 Note. Some students identified with more than one ethnicity group; there are only two medical training programs in New Zealand Procedure A qualitative descriptive study designed was used in the present study. Students were invited to participate in group interviews. About a week prior to the interview, students completed a 16-item CBM-S training session to provide them with an overview of the training so that they could provide feedback on it. One researcher (CWH) conducted all the interviews online via Microsoft Teams with six independent groups consisting of 3–5 students. We followed a semi-structured interview format consisting of 10 primary questions (see Supplementary file). Interview questions were derived from two sources: 1) questions from the feedback survey on CBM-S reported in Hsu and Akuhata-Huntington (2024b) and 2) the interview guide from Leung et al.’s (2019) study—a qualitative clinical study on bias modification for paranoid patients. The questions covered students’ overall experience of CBM-S, their thoughts on the training content, delivery and structure of CBM-S, what they found helpful and not so helpful, and a comparison of CBM-S to existing bias training programs. Invitation and open-ended questions were used to reduce researcher bias. To optimize data saturation, interviews were concluded once students indicated that they had no additional information to provide for each question and at the end of the interview. All interviews were recorded and transcribed verbatim. Students received a NZ$30 gift card for their participation. Data Coding and Analysis Qualitative analyses were used to directly capture and report the experiences and opinions of students to minimize researcher bias and avoid over-analyzing the data or imposing external interpretations. We adopted two qualitative analytical approaches: framework analysis (Gale et al., 2013) and thematic analyses (Braun & Clarke, 2006). First, framework analysis was used to identify themes and sub-themes that aligned with elements of people’s experiences with the CBM training, as found in previous studies (Hsu & Akuhata-Huntington, 2024b; Leung et al., 2019). Independently, each researcher (CWH, AR, TC) reviewed the interview transcripts to become familiar with the content and extract key ideas. From this, each researcher identified initial codes that aligned with the research questions to develop a coding framework. The interview data were then organized into themes and sub-themes according to these relevant codes. Next, we used thematic analysis to focus and identify data that did not fit into the initial framework. This process involved independently reviewing the data again, generating new codes, identifying emerging themes and sub-themes, and revisiting the transcripts to ensure that codes accurately reflected the content. The final step involved synthesizing all the themes and sub-themes, highlighting examples of students’ verbatim responses under each sub-theme, and validating and optimizing the accuracy of the analyses through cross-referencing among researchers. Results In our qualitative analyses, we found that some themes and subthemes were initially identified during framework analysis; thematic analysis revealed additional, unforeseen codes and themes. All-in-all, six major thematic categories emerged– Engagement; Understanding of CBM-S; Perceived impact of CBM-S; Application of CBM-S; Barriers and facilitators; Initial expectations of training . A number of nested sub-themes were identified with each overarching theme. Fig. 2 depicts the conceptual relation between the themes (circles) and sub-themes (boxes). Theme 1: Engagement and Acceptability This theme depicted students’ overall experience of CBM-S training and their level of engagement while completing the training. It included students’ perception toward the delivery and structure of the training, how easy or difficult they found the training to complete, and their level of enjoyment and interest in completing the training. Overall, students had a positive view of CBM-S and found the training both acceptable and engaging to use. Training Delivery and Structure Specific sub-themes regarding training delivery and structure that emerged from the interviews were: the delivery device (laptop or phone), delivery method (self-run or facilitated), delivery content (simple or detailed), and delivery frequency and duration (single session or multiple sessions). Delivery Device In general, most students did not notice much difference between using a laptop or phone to complete the training. A few students, however, appreciated the ease of using a laptop to complete the missing-letter word task and associated laptops with learning. “ I did mine on the laptop, so it was pretty easy as well. I’m not sure how it would work on a phone, but I think the laptop just makes the software easier to use. ” “ just did it on my phone and it was quite easy to move on..” “I don't think it would have made a difference, but I don't know. I kind of feel like when I use my phone to do, like, an activity like this, it's almost like I, like, more rushed through it and I don't take as much in, whereas I put more effort into something if it's, like, on my iPad or my laptop, I don't know. I just associate that more with, like, learning and stuff.” Delivery Method Most students expressed a preference for the self-guided format. They reported feeling more comfortable completing the training in their own space and valued the flexibility of controlling the pace. “ You’d feel like less, like if you were someone that had a lot of those unconscious biases at first, you might feel bad about that if you were in front of other people, but if you were alone in your room, you’d be like, oh, maybe I should check that.” “I think it's nice to have the freedom of, like, just doing it whenever, especially because, like, you have so many little things to do throughout the day or week or whatever. It's nice to be like, okay, I've got half an hour break here. I'll do it here. As opposed to, like, you know, having it less flexible.” “I think it’s good because you can just think about, think about it yourself, like it’s all stemming from you. Whereas if you’re doing it with other people or something, they can just say something and you can just say, oh, yea, true.” One student, however, noted that a disadvantage of this type of independent learning is maintaining adherence to the training. “Yeah. I think the disadvantage of doing it on your own is I think adherence.” Delivery Content Most students found the simplicity of CBM-S beneficial for engagement. Somes students, however, noted that this simplicity could hinder the effectiveness of the training, as users may skip the scenarios and directly guess the missing letter in the word task. “ I liked how you didn't have to, I don't know, use as much, like, mental power, I guess. Like it didn't take a lot of motivation to get through the quiz, which I like, so I think it'll be much easier for people to do it.” “…yeah, just the simplicity of it, really, like just being able to go through and how simple it was to read the stems and sort of. Yeah, I think the simplicity of it was quite good.” “Some of the scenarios is quite obvious as to what the word was without even reading this scenario because only one letter was missing. I wasn't sure if that was intentional to make it easy, but I think that could make some people just skip reading the scenario and just get on with the next question.” Delivery Frequency and Duration All students indicated a preference for multiple but shorter training sessions. “…But I think if you overload people, people can start to find things tedious, yeah.” “I think we'll need the warning for the 59 items, but I'm thinking, like, if it's 59, because you are kind of tired at the end, so it might be easier for the trainee to pick up bias because you are just not thinking…” “I’m not really sure about the number of questions. Maybe, you know, yeah, it’s a good experience. But then at near the end it just started becoming like a pattern recognition thing rather than realising my own biases.” Ease of Use; Enjoyment and Interest By and large, students found the training easy to use, with clear presentation of the content. Some students praised the layout, mentioning that it was neatly organized with no overlapping buttons. Additionally, students appreciated the opportunity to actively engage in the training—as opposed to passively receiving information like in a lecture or workshop. “ It was pretty straight to the point” “… usually sometimes there's overlaps between buttons and it's hard to press, but I don't have a problem with that.” “ Think this is more sort of, like, practical, like, what you guys are saying about the other learning being passive. Like, what we've done, like, workshops and discuss things, I think you can sort of still sit back and just, like, take it all in, just listen to what they say. Like, yeah, whatever. I'll try not to be biased. I'll do my best. But then to go and have to do this training yourself and, you know, you actively have to go through and read all the scenarios and do it, I think you're sort of more prompted to put more in than you are in, like, a workshop or a lecture where you just sort of sit through and let it wash over you.” “Yeah, it was very much just like, click the buttons, like, go through it and, like, if it was something, like, compulsory, I probably would not have engaged even as much as I did for this, if that makes sense. If you had to type something in that would almost engage you more. For some students, the number of sessions may have hindered their engagement. “So the first sort of five or six questions, it was pretty good. It was good to know that I have some biases and things like that. But then after sort of questions six or seven or eight, from that point onwards, it started just becoming like a pattern recognition thing.” “…but it probably just drag on a little bit towards the end.” Theme 2: Understanding CBM-S This theme illustrated the clarity and understanding of navigating through the CBM-S training. It highlighted that some students experienced difficulties in identifying the final word in certain scenarios. “ I couldn't think of the exact word that they were looking for, but that's just because I had no idea what they were talking about.” “ I think I ended up doing random letters to try figure out what it was.” Some students were confused about how the training reduced stereotype interpretation bias and also noted that CBM-S might be better suited for proficient English speakers. “I couldn't exactly, like, pinpoint, like, how does this relate to the training we're supposed to do?” “Next thing I come up with is the English thing, but you're training the doctors in New Zealand, so you don't really need to think about it.” “…like what’s the point of the second part of that question? So I noticed sometimes the second part of the questions will be like the same as the first part….; It doesn’t feel as reinforcing, as if it was kind of slightly different, which makes something different that makes you think a little bit more.” Theme 3: Relevance of CBM-S This theme outlined the relevance of the training content and perceived effectiveness of CBM-S as a bias training tool for medical students. Two sub-themes emerged: 1) relevance to a medical setting and 2) capturing common Māori stereotype biases. Clinical Relevance Students reported that the training scenarios portrayed realistic medical situations, though some students noted that the scenarios seemed to assume bias, suggesting that CBM-S may not be effective for individuals who are not biased. “I thought that the clinical scenarios were super relevant and very, like, appropriate. And I sort of found myself, as I read through the scenario, I was thinking back to situations where I'd actually encountered that and things like that. And so I thought that the clinical scenarios were actually really good and sort of simple, but very realistic as well. Things like that could definitely happen in the hospital.” “It almost makes you not really want to buy into it because you're like, oh, this training is assuming the worst of me when the reality is, I think 95% of the time, we wouldn't be biased in that situation. So I think, yeah, it would be different if we were putting in a bias response and then it was calling us out, but it almost feels like it's calling us out when we wouldn't have been biased in the first place.” “I do relate to it quite a lot, especially there’s a few scenarios;…I was actually in my 4 th year. I was working in a hospital where there’s the community is like more than 50% Pasifika patients. So like it’s quite common in that scenario.” Stereotype Relevance Students found that most of the scenarios captured common (unhelpful) stereotypes toward Māori patients. “I think the scenarios that were given were, like, pretty most common stereotypes. I would say that we hear about our Māori people, that it was very relevant.” “The other scenarios, other than the fact that first one, because that confused me. I thought the scenarios that were given were quite relevant because there's stuff that I've heard and that's some of it. It's, like, similar, like, maybe to, like, my pacific culture a little bit, like, with stereotypes that we have down there.” “Yeah, I think when you don't recognize the stereotype, it's just I'm confused because I think, why are we asking this? Like, I think might have been the first question where they say a group of people come in with, like, red t-shirts and then the question was like, did you expect them to wear something green?” “There’s one question just that stood out to me about like I think it was something like there’s a group of family members all wearing the same shirt;…there would be some health professionals would be thinking, oh, yeah, it’s they’re part of a gang or something.” One student pointed out that having previous Māori cultural training helped them better understand the scenarios. “I mean, obviously it's very targeted towards that one thing. So that without all my other learning on Māori culture might be a little bit confusing, but because I've done both, it was very helpful.” Theme 4: Application of CBM-S This theme illustrated students’ perception of using CBM-S as a training tool for medical students to challenge and modify unhelpful Māori stereotypes in a clinical settings. Specifically, students compared CBM-S to other existing Māori cultural training programs, offering their appraisal and feedback on its effectiveness. Overall, most students supported the idea of a simple, self-run training like CBM-S to complement existing cultural training programs; they also found CBM-S effective in modifying stereotypes bias towards Māori. Appraisals of CBM-S Students appreciated CBM-S as a training tool, in particular the inclusion of contextual information presented through various real-life clinical scenarios. “I think the big thing was to make us aware of their culture and beliefs and just to give us an understanding so we can use it later on.” “We learn about Māori culture, and maybe that's coming in, like, ALM, maybe in the future for us, but, like, we don't really apply any of this or, like, in a real-life context, like, with the things we learn.” “A lot of us, we have a lot of unconscious biases from our training based on how we're trained to do snapshot judgments, but they're not always the best, especially if they're judging a person and not their actual condition. And so if it came to removing biases and helping people access health services, then I'm all for it, you know?” “I think CBM is really good. Like it’s a really easy way for someone to realise their biases and kind of try to help correct that. Like it’s not that like there’s ways to make the training, you know, very engaging and rather than just being fed information. It’s more like a, it’s kind of fun to be honest” Effectiveness of CBM-S Students found the training helpful in modifying stereotype bias by offering a more constructive and adaptive alternative interpretation of the scenarios. “I think there was a scenario where a group of Māori men came into a hospital and they said they were, like, shouting. And the question was, are they being disruptive? And I immediately thought, well, yeah, because they might have been in a fight or I don't know, but it said they weren't. And then it forced me to think they may have been shouting because they're in pain or they might have been hurt. So, yeah, like, things like that forced me to think of it in another way.” “I think some of them really got me thinking, like the one I told you about, about the shouting. Some of them were a little like the questions were too obvious, but, yeah, I don't mind that.” “Sometimes it would sort of feel like they want you to think, like, this one thing first, even though that wouldn't be your first thought initially. Like, the evidence that they perhaps present to you would be presented in a way that you'd think maybe one thing when usually you'd think another.” Comparisons with Existing Bias Training Students shared their thoughts on the similarities and differences between CBM-S and other Māori cultural and bias trainings. For the main part, students emphasized that CBM-S was a more targeted and focused training, specifically addressing common Māori stereotypes whereas existing cultural training programs were more about cultural immersion and promoting general cultural competency rather than focusing on stereotypes. “I think what's different is there's a more emphasis on understanding Māori culture and customs and the way they do things. Like, so the culture itself, whereas this training is more like one, like, stereotypes. And it's just kind of like, I don't know, applying it to more, like, real life stuff.” “ They sort of did cultural immersion so that they can prevent us from thinking about stereotypes and having that sort of bias. But because of that, I don't think we really explored any of the stereotypes that we've got today. So that's probably the main difference between the training, which, because that mainly focuses on the stereotypes only, and that's something we didn't cover .” “I don't think in the past they covered stereotypes specifically. I think they just wanted to give us a general, overall idea of Māori culture, but they didn't really go into anything in detail. So this was completely different area, I think .” “I don't think there's many opportunities to specifically look at stereotypes, which I think is very important. So, yeah, it's good to have a general overall idea, but it's also, yeah, I liked how it targeted those things that we might miss, but it becomes really important when we actually meet Māori patients.” “Yeah, I think the bias modification stuff is quite different to some of the cultural training because all the other stuff that I’ve done is always kind of been in like groups. So there’s one benefit is that you can kind of do it independently and work through your own like individual biases…” Theme 5: Initial Expectations of Training This theme was thematic related to the Theme 4, ‘Applications of CBM-S’. Students generally had no prior expectations but based their expectations on existing cultural or bias training experiences. “ I personally didn't really have any expectations of what it would be like. I was surprised when it said that you had to, like, insert the missing letter. Like, I thought it would be more of an active thing. Not that that was a bad thing, but I was just surprised by that.” “ I honestly didn't have many expectations going into it. I feel like I had sort of thoughts, like, hearing about the bias training. I think in the past, I can't remember what they're called, but we've had to do, like, um, certain activities online. You might know what these are, and you sort of, like, do repetitive things and you choose, like, a certain stereotype. Like, in this case, it was obviously ethnicity, but I remember doing it to see if you had a bias towards, like, overweight people ” (this student was likely referring to the Implicit Association Test) Theme 6: Barriers and Facilitators This theme explored the factors that students found either supportive or challenging during their CBM-S training session. Four sub-themes were identified: contextual information, performance feedback, outline of training, and training presentations. This theme is conceptually linked to all the other identified themes and could be seen as influencing or moderating the effects of those themes. In addition to identifying barriers and facilitating factors, students offered valuable suggestions for improving CBM-S as a bias training tool for medical students. These suggestions are summarized in Table 2. Contextual Information Students reported experiencing some difficulties in making sound clinical decisions regarding patient safety due to the limited information provided in the training scenarios. “There were some cases where it was really too short to get any information from it…Yeah, it's just one sentence and you can't really get much from that. And you can't really, like, respond appropriately because you don't have enough information.” “If there were more clues in the scenario about perhaps how the patients interacted with each other in the family or what kind of presentation of injury that they had. Some injuries are more likely to be abusive than others.” Feedback on Performance All students agreed that they would have appreciated receiving some kind of feedback on their performance and/or their biases in order to elicit a self-reflective process. “…getting, like, some feedback at the end, like, after you've done it” “…you did all these scenarios, but you never really, like, there was no sort of feedback on how you did” “But I did find something that was missing from the experience was, like, the feedback and discussion aspect, because as much as it was, we told, like, yes or no, you don't really know why or how.” Outline of Training Students highlighted the need for a summary on how the training works and evidence of the training’s effectiveness. “Well, I mean, like, I knew how to do it, but I was kind of like, what are they? What are you trying to achieve from this?” “If the training is like, you know, evidence based and there's a, you know, there's a reason to why it's passive and why there's so many, then I'd put that, like, on the front page and be like, yeah, this will take you 15-20 minutes, but it is shown to actually work. And this is why we're doing it this way, because otherwise, I think you're not going to get the buy in.” “Yeah, I think like maybe an instruction to the students before they start training be like think about the answer in your mind and then after that, they click next and then the word comes up.” Training Presentation Students highlighted several aspects that they found helpful or challenging regarding the presentation of CBM-S. “ A few questions were, like, repetitive. Like, so maybe if you could have different questions, maybe.” “I liked how there was a practice at the beginning. If that wasn't there. I may have been a little confused on what they wanted” “Yeah, like, if I were to think about it, because actually I want to go back and think about that. Like, it would be cool, too, but yeah.” “I think instead of, like, an underscore, it was a dash. I think it would be more clear if it was like, an underscore.” Table 2 Practical Recommendations for the Future Advancement of CBM-S Informed by Student Feedback Recommendations Students’ Responses CBM-S Training Scenarios Associate CBM-S with related existing medical curriculum and/or bias training modules “But if you have it associated with something, so you're expecting it, I think you'll get better engagement and you won't get people hating it like we did with the retain knowledge tests” “…a good way would be doing at the start of each run or each attachment.” Having relatable scenarios across training items to create more context and better flow “Yeah, yeah. And then it just flows a bit nicer, and it would feel like more like one scenario. You'd learn more about that context.” “Maybe the scenarios could be more sort of make it more related to the actual attachment, so then people feel more kid of related. So there’s something like surgery, then you make it in like a surgical setting. If it’s like a GP, then you make it more like a community setting” Scenarios reflective of personal experiences: “I think back to the training we've had during our clinical years, and often it's like hearing people's personal stories. It actually leaves, like, a lasting impact. Like, if I had someone sitting in front of me saying that, yeah, you know, I went into the hospital and I experienced this and this and this, and it was really bad, then that would make me sort of think twice and make me think, okay, these assumptions still happen, whereas, like, sort of quick online training.” Incorporating videos or audio to accompany text-based scenarios to increase the amount peripheral information + engagement “ …if you had, like, a little video clip of it, then you could understand a whole lot more of the context.” “…when I do a survey, I prefer if it was more visually stimulating” “Maybe having like some pictures or something in it might help break it up a little bit more or kind of make it more like feel less like it’s dragging on as much” Training Delivery and Structure Shorter but more regular spaced-out sessions. Collated feedback from students suggested a 10-30 training items per training session, with one student noting that ,ore training items may help improve the effectiveness of CBM-S “Yeah, I reckon 30 would be my. Where I would just tap out after that.” “I think, like, maybe 20 a month would work best. Just because. So much to do right now.” “Probably 8, maximum 10” “around 12 or something like that” “ I think if you're doing something that's so passive, you probably need the numbers to, like, actually work.” Cultural training, in general, should be included earlier in medical training, but also reintroducing similar concepts throughout medical training “I think pretty early on, like, we do the cultural immersion in ELM, too. So I think either in ELM 2 or 3 might as well start getting exposed to those and being aware of them before you go into hospital.” “if the students are in clinical years, maybe at the start of each of their attachments;…in Auckland, we usually do like six or seven clinical attachments across the whole year. So maybe like six or seven at the start of each attachment just to kind of like a reset like a refresher kind of thing.” Human Input and Self-reflections Self-run format of the training facilitated engagement but having someone to discuss the training scenarios with may also be beneficial “I feel like if it's more sort of a discussion, collaborative approach rather than just like, yes or no questions on your own, not getting sort of any real feedback after. Yeah, I think there's a bit more scope for, like, being aware and learning from your bias. There is more like collaboration and that sort of stuff.” Open box to replace the Yes/No question with an open response to combat the limited information in the brief training scenarios “Maybe like, an interesting question afterwards would be: what information would you need to make a judgment about this person, about whether this was a case of abuse? What more would you need?” Discussion session to debrief after receiving the CBM-S training would be. “ Some people might need to talk about it or debrief afterwards, which you could make it a part of that, or you could make it like a part of an EPE session or a Māori session.” Feedback on their performance and/or their biases in order to elicit a self-refectory process. “…you did all these scenarios, but you never really, like, there was no sort of feedback on how you did” Open box to replace the missing letter word task to combat the limited information in the brief training scenarios “… just maybe leaving it kind of like a blank space and, like, saying to the students, this is how many letters are in the word, but not necessarily giving as many words, if that makes sense. Because in a way, it doesn't skew them to think of, like, absolute protective factors, but also doesn't completely negate the bias that the activity is trying to minimize” Discussion Summary of Results In the present study, we reported the perspectives of Aotearoa New Zealand medical students’ experience of Cognitive Bias Modification-Stereotypes (CBM-S)—a digital training suite designed to reduce implicit stereotyping of an indigenous population of NZ, Māori (Tangata Whenua, people of the land). Several aspects of the training received positive feedback, and helpful suggestions were made for improving the training’s quality and delivery. The training received positive feedback on various aspects, including its engagement, clarity, application, and effectiveness and relevance to medical training and stereotyping of Māori patients. By and large, students found the training simple to use with a well-organized user interface, which echoes previous quantitative rating data on CBM-S (Hsu & Akuhata-Huntington, 2024b ). The simplicity of the training, however, was reported with the caveat that the simple design may hinder the training’s modification effects because students might complete the training without reading the training scenarios. Students did not express a clear preference for completing the training on a laptop or a phone. However, some students felt that laptops might be easier for completing the word task and associated laptops more closely with learning. In regards to content relevance, students indicated that CBM-S scenarios captured common Māori stereotypes that are often observed in clinical settings, which likely reflects the co-facilitated approach with medical students and Māori participants that researchers adopted in generating training scenarios (Hsu & Akuhata-Huntington, 2024b ). Leung et al. ( 2019 ), who also adopted a co-facilitated approach to develop CBM training scenarios for biased paranoid thoughts revealed findings that were consistent with the results of the present study. Additionally, unlike existing cultural trainings, which promote understanding of Māori culture and values, students reported that CBM-S targets stereotype bias. Taken together, students consistently agreed that CBM-S can be an effective and applicable educational tool for reducing implicit bias towards Māori patients among medical students. Self-guided Training Students expressed appreciation for the self-run format and their active involvement in the training (i.e., completing the word task), reporting a sense of independence, engagement, and feeling in control of the pace of the training. This sense of autonomy and engagement can be explained through a self-determination theory lens, which posits that when individuals experience autonomy, it strengthens their self-efficacy and intrinsic motivation, resulting in greater engagement (Bakker et al., 2016 ; Ryan & Deci, 2000 ). In Leung et al.'s ( 2019 ) study on CBM for paranoia, participants expressed a greater sense of autonomy for the self-guided training format compared to the expert-facilitated training. In addition to a greater sense of control and independence, students in our study reported that the self-directed format reduced their need for impression management, as they felt less pressure to respond in ways that would be seen favorably by others. Empirical evidence has shown that medical students may resist implicit bias training, especially when discussions focus on emotionally charged topics describing systemic discrimination, institutional racism, and health inequities. For example, Gonzalez et al. ( 2019 ) found that American medical students expressed resistance to implicit bias training, in part, due to shame and fear of being negatively evaluated by other students in class. Wear and Aultman ( 2005 ) found that many of their Year 4 medical students struggled to engage with topics such as inequality and oppression, suggesting that this difficulty stemmed from students’ resistance to confronting these issues. These basic findings of students’ resistance on inequity issues, bias, and racism have been replicated in other medical education studies (Gonzalez et al., 2014; Hernandez et al., 2013 ; Teal et al., 2010 ). Facilitator/Peer Interaction While students value the self-guided and self-paced nature of the training, they have suggested several ways to integrate CBM-S within a structure that includes supportive human interaction, an element that was missing in the original CBM-S approach. For instance, students welcomed the idea of having opportunities for debriefing or discussion sessions with their peers or a facilitator at the end of the training; another suggestion was to receive feedback on their performance during the training to help foster self-awareness and consolidate their learning. These recommendations align with existing literature, which emphasizes that students often appreciate the inclusion of educator and peer support or interaction in digital trainings and that having human input improves engagement (Edelbring et al., 2020 ; Henry et al., 2020 ). Students also thought that incorporating a debriefing or discussion session could help address the challenges in balancing competing and complementary decision-making processes as a result of limited contextual information that the training scenarios provided. More specifically, students raised concerns about issues of making sound judgements when confronted with common unhelpful stereotypes about Māori (e.g., child abuse is a Māori issue; Maydell, 2017 ) conflicted with potential risk issues (e.g., actual child abuse). Clinical decisions are typically guided by two systems (based on the dual-process theory; Epstein, 1994 ): System 1, which handles intuitive decision-making that uses limited information, while System 2 involves more deliberate and thoughtful analysis taking contextual details into account to make informed choices. System 1 is more susceptible to cognitive biases, so encouraging the use of System 2 in clinical decision-making could help reduce this tendency (Tay et al., 2016 ). Offering debriefing or discussion sessions following a self-run CBM-S training may encourage System 2 processing. In addition to the debriefing or discussion sessions for balancing competing decision-making processes, students also suggested the following: 1) CBM-S runs in parallel to existing bias or cultural trainings, which likely already has a discussion component; 2) accompany text-based scenarios with videos or audios to provide a richer perspective in the training scenarios; 3) include a prompt to encourage self-reflection (e.g., “ an instruction to the students before they start training be like think about the answer in your mind…” ); and 4) include an open text box as a part of the follow-up question to allow students to share their thoughts and self-reflect on the scenarios, which is vital for learning and challenging biases (Sabin et al., 2022 ). In previous studies on CBM, participants have recommended the inclusion of a similar self-reflective component (Beard et al., 2012 ; Leung et al., 2019 ). An important point to note about CBM-S is that consciously reflecting on one’s biases may not be necessary for the training to be effective. CBM-S was not intended to encourage self-reflection in students. Instead, it focuses on the unconscious learning of rules that shapes interpretation, thereby helping to reduce stereotype biases. Nevertheless, we recommend that future updates to CBM-S could at least offer students a platform for debriefing or discussion sessions. Delivery and Engagement Given the typical heavy study load that medical students face, they expressed a preference for shorter but more frequent training sessions to balance both engagement and effectiveness. Students suggested range of 10–30 items per session, which was a shorter training session compared to the 40-item session used in Leung et al. ( 2019 ). To enhance engagement and retain effectiveness, our students also suggested that CBM-S be introduced earlier in medical curriculum, linked to other topics within the medical curriculum or clinical attachments, incorporate unique and relatable scenarios, and include a visual alongside the text-based scenarios. Embedding CBM-S training into existing curriculum may provide a natural integration of debriefing or discussion sessions. Although the feedback was mostly positive, a few students struggled to understand how the training worked and found some items challenging to read and complete. Some students were unsure about how CBM-S modified stereotype bias; other students discussed including more information about the training, such as the evidence supporting CBM-S to explain how the training scenarios work to reduce biases. Interestingly, it has been documented that people hold different ideas about the meaning of ‘evidence-based practice’, with many people believing that these interventions are rigid, impersonal, and not tailored to individual needs (Becker et al., 2016 ; Carman et al., 2010 ; Tanenbaum, 2008 ). Future improvements to CBM-S could include additional information of how CBM-S works without explicitly labeling the training as ‘evidence-based’. Study Limitations There were some notable improvements that could be made to our study. First, having one interviewer may have hindered the amount of information received with no additional prompts from another interviewer. Furthermore, having a single interviewer may also increase the risk of bias and hinder the rigor of the data. Related to this point is that, since some of the researchers in the current study were also developers of CBM-S, researcher bias may exist. The research team took steps to minimize potential bias by actively seeking refutational data during the analysis. Additionally, the development of themes and sub-themes was an ongoing process, with continuous revisions and adjustments made by three researchers until a final agreement was reached. Taken together, these methodological approaches likely helped minimize researcher bias. Nevertheless, we honor a post-positivist perspective and acknowledge that complete objectivity is unlikely because researchers' perceptions, biases, and assumptions may inevitably influence both the questions posed and the interpretation of the data in this study (Guba & Lincoln, 1994 ). Second, there is a possibility that students’ responses were susceptible to social desirability given the overlap between the researcher who conducted the interviews and his role as a lecturer in the medical school (CWH). Of note, it was identified that the lecturer had only taught one of the students involved in the study at the time of the interviews and that 20% of participants were from a different university. Finally, our findings were collapsed across feedback from students in both ELM and ALM, which may be skewed as ALM students would have had more clinical experience and greater exposure to stereotyping of marginalized communities in a clinical setting. However, the relatively equal number of students in both year groups may have helped to mitigate this potential skew. Conclusions The present study explored New Zealand medical students’ experiences and acceptability of Cognitive Bias Modification-Stereotype (CBM-S), a digital training designed to reduce implicit stereotype bias towards marginalized groups—specifically Māori, an indigenous population of New Zealand. A previous randomized control trial has shown promising bias modification effects of CBM-S in the same context. Through semi-structured group interviews with 20 medical students, six major themes emerged: Engagement, Understanding, Perceived Impact, Application, Barriers and Facilitators, and Initial Expectations . Overall, CBM-S was well-received, with students appreciating its self-guided format and relevance to clinical practice. Students also found CBM-S engaging, easy to use, and thought the training materials were relevant to clinical practice and in addressing implicit stereotype bias towards Māori patients. Suggestions for improvement included incorporating debriefing and interactive discussion sessions and ways to enhance the delivery and engagement of CBM-S. These findings offer valuable insights to enhance CBM-S for future medical education and professional development applications. Statements and Declarations Competing interests: The authors declare that there is no conflict of interest regarding the publication of this manuscript. The authors have no conflict of interest related to the employment or financial and non-financial interests concerning this manuscript. Funding This study was funded by the Medical Education Research Fund (MERF), Otago Medical School (grant number N/A). Ethics approval: This study received institutional ethical approval (University of Otago 22/063) and was conducted in accordance with the ethical principles outlined in the 1964 Declaration of Helsinki or its later amendments or comparable ethical standards. Consent to participate and publish : Informed consent was obtained from all participants prior to their involvement in the study. Declarations Competing interests: The authors declare that there is no conflict of interest regarding the publication of this manuscript. The authors have no conflict of interest related to the employment or financial and non-financial interests concerning this manuscript. Funding: This study was funded by the Medical Education Research Fund (MERF), Otago Medical School (grant number N/A). Ethics approval: This study received institutional ethical approval (University of Otago 22/063) and was conducted in accordance with the ethical principles outlined in the 1964 Declaration of Helsinki or its later amendments or comparable ethical standards. Consent to participate and publish: Informed consent was obtained from all participants prior to their involvement in the study. Data availability: Qualitative data analysis is available at https://tinyurl.com/CBMSQualdata Author Contribution Conceptualization: C.W. Hsu, Z. Akuhata-Huntington• Methodology: C.W. Hsu, Z. Akuhata-Huntington, A. Robbins, T. Cartwright• Software: C.W. Hsu• Validation: C.W. Hsu• Formal Analysis: C.W. Hsu, A. Robbins, T. Cartwright• Investigation: C.W. Hsu• Resources: C.W. Hsu, Q. Liu• Data Curation: C.W. Hsu, A. Robbins, T. Cartwright• Writing – Original Draft: C. W. Hsu• Writing – Review & Editing: C.W. Hsu, A. Robbins, T. Cartwright• Visualization: C. W. Hsu• Supervision: C. W. Hsu• Project Administration: C.W. Hsu• Funding Acquisition: C.W. Hsu, Q. Liu, L. Heath, C. C. Lin, S, Chambers, Z. Akuhata-Huntington Acknowledgement We would like to acknowledge and express our gratitude to Dr Qian Liu, Higher Education Development Centre, University of Otago for his guidance in developing the interview protocol and questions; Zaine Akuhata-Huntington, formerly of the Kōhatu Centre for Hauora Māori, University of Otago for his expert consultation on cultural knowledge and stereotyping; Dr Lis Heath, Stuart Chambers, Department of Medicine, University of Otago and Dr Chris Lin, Department of Psychological Medicine, University of Otago, for their helpful input in preparing the grant application Positionality statements Mindful that our identities can influence our approach to science, the authors wish to provide the reader with information of our backgrounds. With respect to gender, when the manuscript was drafted, authors self-identified as male and female. With respect to race, authors self-identified as East Asian and New Zealand Māori References Allen, T. J., Sherman, J. 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The limits of narrative: medical student resistance to confronting inequality and oppression in literature and beyond. Medical Education, 39 (10), 1056–1065. https://10.1111/j.1365-2929.2005.02270.x Additional Declarations No competing interests reported. Supplementary Files CBMSinterviewprotocolandquestions.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5596294","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":395562937,"identity":"4ec2e068-1406-4df2-b122-e9aa4d9eb3c7","order_by":0,"name":"Che-Wei Hsu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8klEQVRIiWNgGAWjYBACxgYwdYCBgb2BZC08BxiJ1QTTIpFApBbm9t5nn3kY7tgb3Hx8/MGPXzYM/O0H2B7+wOewnuPGs3kYniVuuJ2W2Njbl8YgcSaB3UACn5YZaczMPAyHEwxu5xg28PYcZmC4wcAmYYBPy/xnYC1Ah50xbPwL1CIP0pKA1xY2sBbGDTd4DJt5fhxmMABpOYDXL2nMjHMMDifOPJOWOFu2IY3H8Exim2QDHi2G7ceYGd5UHLbnO374wMc3f2zk5I4fPiaJL8QMgeYx8cB8y9jGwAOPXlxAHqQQYeYfvIpHwSgYBaNghAIAd1hN5aKvKq0AAAAASUVORK5CYII=","orcid":"","institution":"The University of Otago","correspondingAuthor":true,"prefix":"","firstName":"Che-Wei","middleName":"","lastName":"Hsu","suffix":""},{"id":395562938,"identity":"e3a3bda3-8aa8-4bcc-9b8f-f93bc34177fd","order_by":1,"name":"Alex Robbins","email":"","orcid":"","institution":"The University of Otago","correspondingAuthor":false,"prefix":"","firstName":"Alex","middleName":"","lastName":"Robbins","suffix":""},{"id":395562939,"identity":"9d5d021f-0ab8-4628-b90f-2fb3abbb66c3","order_by":2,"name":"Tiana Cartwright","email":"","orcid":"","institution":"The University of Otago","correspondingAuthor":false,"prefix":"","firstName":"Tiana","middleName":"","lastName":"Cartwright","suffix":""}],"badges":[],"createdAt":"2024-12-06 23:38:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5596294/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5596294/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":72674529,"identity":"617cb8ec-107c-4a18-8acb-9abebdd044c3","added_by":"auto","created_at":"2024-12-31 05:59:33","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":145265,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eAn Example CBM-S Training Item\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNote. \u003c/em\u003eSurvey elements, Copyright Qualtrics, LLC. Used With Permission\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5596294/v1/a98df5cafce7447e4cb70840.png"},{"id":72674531,"identity":"93b34080-c5c3-43f6-b83c-5698c2216a88","added_by":"auto","created_at":"2024-12-31 05:59:33","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":128854,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eConceptual Relation Between Themes and Sub-themes\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5596294/v1/4e1a603b42ca2a05ac8497a4.png"},{"id":73056736,"identity":"b1c433a0-2339-4145-97bc-588fc066a150","added_by":"auto","created_at":"2025-01-06 10:19:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1018905,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5596294/v1/579c190e-0dbc-48e8-a62d-f062ac5cbb11.pdf"},{"id":72673100,"identity":"0a98e400-2866-4bcb-92cf-9e95467aaadb","added_by":"auto","created_at":"2024-12-31 05:35:33","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":30440,"visible":true,"origin":"","legend":"","description":"","filename":"CBMSinterviewprotocolandquestions.docx","url":"https://assets-eu.researchsquare.com/files/rs-5596294/v1/40da4388448af3c9e21853b0.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Qualitative Study: New Zealand Medical Students’ Experience of Cognitive Bias Modification-Stereotype (CBM-S)—A Self-Run Digital Implicit Bias Training","fulltext":[{"header":"Introduction","content":"\u003cp\u003eImplicit bias consists of mental processes that occur outside of our conscious awareness, which, in part, contributes to health disparities, particularly for marginalized social groups such as Indigenous communities, the elderly, individuals with disabilities, and members of the Rainbow community, among many others. In this context, health inequity can manifest as limited opportunities and unequal access to healthcare, resulting in poorer health outcomes (Baah et al., 2019). Researchers have introduced a novel, self-guided digital training suite known as cognitive bias modification for stereotypes (CBM-S; Hsu, 2023). CBM-S is a digital training designed to reduce biased interpretations of common clinical situations that involve medical students and Māori patients\u0026mdash;an indigenous population of Aotearoa New Zealand (NZ).\u0026nbsp;The training aims to promote helpful interpretations of clinical situations without requiring students to explicitly engage in critical self-reflections of existing beliefs or biases, which is a common method used in extant bias training (Lai et al., 2014). Empirical data have shown promising bias modification effects of CBM-S (Hsu \u0026amp; Akuhata-Huntington, 2024a); in the present qualitative study, we conducted focus group interviews to gather NZ medical students\u0026rsquo; thoughts of CBM-S as an implicit stereotype bias training tool. Gathering rich feedback from students\u0026rsquo; experience and acceptability of CBM-S would help improve the training\u0026rsquo;s application in medical education.\u003c/p\u003e\n\u003cp\u003eExisting bias training initiatives tend to focus on people\u0026rsquo;s inherent stereotype beliefs toward marginalized groups. This is achieved through various means, including increasing people\u0026rsquo;s knowledge about the target marginalized group or providing counterstereotypical exemplars that refute preconceived beliefs and evaluations of that group (Macrae et al., 1994). Despite being common training methods, researchers have shown that these techniques have yielded small and transient effects in modifying beliefs (FitzGerald et al., 2019), likely due to the intrinsic nature of those beliefs (Kelly et al., 2005). Additionally, concentrating solely on beliefs in training could unintentionally undermine efforts to change the way individuals interpret contextual information. More specifically, it is known that stereotype beliefs and biased processes of contextual information may be qualitatively different (Allen et al., 2009; Hsu, 2023; von Hippel et al., 1995). For instance, a common (and unhelpful) stereotype belief about Māori patients is poor health habits, such as smoking or having a poor diet. Having this belief, however, does not always translate to biased processing of information that aligns with the belief. Information processing bias may occur only under specific conditions, such as when a person\u0026rsquo;s goals, task requirements, and the demands and ambiguity of the situation, align in a way that activate thoughts and behaviors that are consistent with beliefs (Allen et al., 2009; Ecker \u0026amp; Bar-Anan, 2019; Jones et al., 2009).\u0026nbsp;Simply put, biased processing occurs when facts, evaluation, and goals align for a person to interpret a given situation in a way that makes sense, which does not solely depend on stereotype beliefs. In the above example, when working with a Māori patient with hypertension who presents in the clinic coughing; one doctor may hold a general belief that Māori has poor health habits and interpret the patient\u0026rsquo;s coughing as a result of long-term smoking;\u0026nbsp;another doctor may hold the same belief about Māori health habits but instead, may attribute the coughing to a virus given the recent COVID-19 pandemic. On the basis of this fundamental difference between beliefs and processing bias, some researchers have explored trainings that target biased information processing.\u003c/p\u003e\n\u003cp\u003eCognitive Bias Modification-Stereotype (CBM-S) is a self-guided digital training that targets information procession bias (Hsu, 2023; Hsu \u0026amp; Akuhata-Huntington, 2024a). It is adapted from a class of evidence-based mental health intervention\u0026mdash;Interpretation Bias Modification\u0026mdash;designed to reduce negative interpretation bias commonly observed in people with mental health issues (Cristea et al., 2015). Hsu and Akuhata-Huntington (2024b) outlined this adaptation process, which involved a co-facilitation approach with inputs from medical students, Māori, and researchers, to co-develop CBM-S training scenarios using transcripts of people\u0026rsquo;s real-life experiences. Scenarios are ambiguous and aimed at eliciting multiple interpretations from the same event, including an interpretation that captures common stereotyping of Māori in clinical settings. The theoretical basis of CBM-S is that individuals with implicit biases toward a social group tend to interpret ambiguous social situations in a way that aligns with their biases (Birtel \u0026amp; Crisp, 2015; Hsu, 2023; Sagar \u0026amp; Schofield, 1980). Scenarios omit the final word of each scenario (e.g., \u003cem\u003eYou wait for a ride outside the hospital. You see a Māori patient, Nikau smoking cigarette. You think unhealthy behaviours in Māori are\u0026hellip;\u003c/em\u003e) to create ambiguity. The biased interpretation in this instance might be \u0026ldquo;\u003cem\u003eYou think unhealthy behaviours in Māori are common\u003c/em\u003e\u0026rdquo;.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe way CBM-S works is that medical students are presented with a set of scenarios, one at a time, to elicit their pre-existing biased interpretations pertaining to each scenario. To modify students\u0026rsquo; interpretation bias, CBM-S presents students with a fragment of the final word, similar to a CAPTCHA (Completely Automated Public Turing test to tell Computers and Humans Apart) mechanism, for the students to solve. The resolution of the final word completes the scenarios and clarifies the ambiguity of the scenarios in a benign, non-stereotypical manner [e.g.,\u0026nbsp;\u003cem\u003eYou wait for a ride outside the hospital. You see a Māori patient, Nikau smoking cigarette. You think unhealthy behaviours in Māori are ov-rg-ner-lised\u003c/em\u003e (overgeneralised)]. Finally, a Yes/No question is asked to reinforce the non-stereotype interpretation (e.g., \u0026ldquo;Do all Māori smoke? Answer: No). See Fig. 1 for another example of a CBM-S training item.\u003c/p\u003e\n\u003cp\u003eCBM-S offers numerous benefits compared to extant bias training methods. It is self-guided, does not require specialized expertise, is cost-effective, and can be easily accessed and implemented across different learning and professional environments. Additionally, the digitalized delivery may be especially helpful for medical students who fear negative judgment due to their personal beliefs or emotions, thereby impacting their willingness to participate fully and openly in training (Gonzalez et al., 2014, 2019; Hernandez et al., 2013). CBM-S, given its self-guided format, may also overcome the barrier of understaffing in the field of education, particularly where cultural experts are required. Unlike other implicit bias training methods, such as metacognition, fact provision, and group discussions, the method in which CBM-S addresses biases is in a more nuanced and indirect manner, which requires little effort to complete (Hirsch et al., 2018; Hsu \u0026amp; Akuhata-Huntington, 2024a). Furthermore, given the flexibility of CBM-S, training modules could expand to other marginalized communities, such as other ethnicity groups, the Rainbow community, older persons, and people with disability, to name a few (Hsu, 2023). Finally, CBM-S has been shown to have moderate to large effects in modifying students\u0026rsquo; interpretation bias of clinically-relevant scenarios involving Māori patients. In a randomized control trial of a single session CBM-S training using\u0026nbsp;a pre-post test study design\u0026nbsp;(Hsu \u0026amp; Akuhata-Huntington, 2024b), 59 NZ medical students ranging from 1\u003csup\u003est\u003c/sup\u003e\u0026ndash;5\u003csup\u003eth\u003c/sup\u003e year in medicine were randomized to either the training or the control group. A battery of measures was administered, including assessments for interpretation bias, implicit and explicit bias, and stereotype beliefs. Results revealed that students\u0026rsquo; interpretation bias scores reduced over time and at post-test in the training condition, but not the control group.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo enhance the implementation and dissemination of CBM-S in medical education, it is crucial to examine medical students\u0026apos; subjective experience with CBM-S (Kilgour et al., 2016; Schneider \u0026amp; Preckel, 2017). In a previous study, we have gathered quantitative data on the acceptability and usability of CBM-S (Hsu \u0026amp; Akuhata-Huntington, 2024b). In that study, students rated the CBM-S training on acceptability and usability using a 7-point Likert scale. Results indicated that CBM-S is generally perceived by NZ medical students as a clear and easy to use training for targeting implicit bias. In the present study, we aim to gather a richer understanding of NZ medical students\u0026rsquo; experience of CBM-S by collating feedback of their experience and acceptability of CBM-S. This study complements the previous CBM-S randomized controlled trial (i.e., Hsu \u0026amp; Akuhata-Huntington, 2024a).\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eParticipant\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUniversity medical students (N = 17) were recruited from on campus flyers and a NZ student job search website. Inclusion criteria to participate in the study were fluent English literacy and currently enrolled in medicine at a NZ medical school (University of Auckland or University of Otago). This included students who were enrolled in Early Learning in Medicine (Year 2 and Year 3 of medicine, which is pre-clinical training) and Advance Learning in Medicine (Year 4 to Year 6, where students rotate through various clinical placements). We did not consider Year 1 students for our study as the medical program in NZ offers Year 1 students more generalized papers related to health science rather than in medicine per se and not all Year 1 students enter medical school (officially, they are first year health science students). The range of demographic variations of participating students were unintentionally selected and based on students\u0026rsquo; availability for attending group interviews (see Table 1 for students\u0026rsquo; characteristics). Noteworthy is that the study captured a diverse sample of student backgrounds and characteristics, particularly with including students from different year groups and universities across NZ.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u0026nbsp;\u003c/strong\u003e\u003cem\u003eDemographic Characteristics of Students\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 70.1299%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudent Characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.8701%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of Students\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 70.1299%;\"\u003e\n \u003cp\u003eYear in Medicine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.8701%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 70.1299%;\"\u003e\n \u003cp\u003eEarly Learning in Medicine (Year 2 and Year 3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.8701%;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 70.1299%;\"\u003e\n \u003cp\u003eAdvance Learning in Medicine (Year 4\u0026ndash;Year 6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.8701%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 70.1299%;\"\u003e\n \u003cp\u003eEthnicity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.8701%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 70.1299%;\"\u003e\n \u003cp\u003eMāori\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.8701%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 70.1299%;\"\u003e\n \u003cp\u003eNZ European\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.8701%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 70.1299%;\"\u003e\n \u003cp\u003eAsian\u003c/p\u003e\n \u003cp\u003ePasifika\u003c/p\u003e\n \u003cp\u003eOther (Latin American, Iraqi, Australian, European, African)\u003c/p\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.8701%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 70.1299%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.8701%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 70.1299%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.8701%;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 70.1299%;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.8701%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 70.1299%;\"\u003e\n \u003cp\u003eUniversity Program\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.8701%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 70.1299%;\"\u003e\n \u003cp\u003eUniversity of Otago\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.8701%;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 70.1299%;\"\u003e\n \u003cp\u003eUniversity of Auckland\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.8701%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNote.\u0026nbsp;\u003c/em\u003eSome students identified with more than one ethnicity group; there are only two medical training programs in New Zealand\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProcedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA qualitative descriptive study designed was used in the present study. Students were invited to participate in group interviews. About a week prior to the interview, students completed a 16-item CBM-S training session to provide them with an overview of the training so that they could provide feedback on it. One researcher (CWH) conducted all the interviews online via Microsoft Teams with six independent groups consisting of 3\u0026ndash;5 students. We followed a semi-structured interview format consisting of 10 primary questions (see Supplementary file). Interview questions were derived from two sources: 1) questions from the feedback survey on CBM-S\u0026nbsp;reported in Hsu and Akuhata-Huntington (2024b) and 2) the interview guide from Leung et al.\u0026rsquo;s (2019) study\u0026mdash;a qualitative clinical study on bias modification for paranoid patients. The questions covered\u0026nbsp;students\u0026rsquo; overall experience of CBM-S, their thoughts on the training content, delivery and structure of CBM-S, what they found helpful and not so helpful, and a comparison of CBM-S to existing bias training programs. Invitation and open-ended questions were used to reduce researcher bias. To optimize data saturation, interviews were concluded once\u0026nbsp;students indicated that they had no additional information to provide for each question and at the end of the interview.\u0026nbsp;All interviews were recorded and transcribed verbatim. Students received a NZ$30 gift card for their participation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Coding and Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQualitative analyses were used to directly capture and report the experiences and opinions of students to minimize researcher bias and avoid over-analyzing the data or imposing external interpretations. We adopted two qualitative analytical approaches: framework analysis (Gale et al., 2013) and thematic analyses (Braun \u0026amp; Clarke, 2006). First, framework analysis was used to identify themes and sub-themes that aligned with elements of people\u0026rsquo;s experiences with the CBM training, as found in previous studies (Hsu \u0026amp; Akuhata-Huntington, 2024b; Leung et al., 2019). Independently, each researcher (CWH, AR, TC) reviewed the interview transcripts to become familiar with the content and extract key ideas. From this, each researcher identified initial codes that aligned with the research questions to develop a coding framework. The interview data were then organized into themes and sub-themes according to these relevant codes.\u003c/p\u003e\n\u003cp\u003eNext, we used thematic analysis to focus and identify data that did not fit into the initial framework. This process involved independently reviewing the data again, generating new codes, identifying emerging themes and sub-themes, and revisiting the transcripts to ensure that codes accurately reflected the content. The final step involved synthesizing all the themes and sub-themes, highlighting examples of students\u0026rsquo; verbatim responses under each sub-theme, and validating and optimizing the accuracy of the analyses through cross-referencing among researchers.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eIn our qualitative analyses, we found that some themes and subthemes were initially identified during framework analysis; thematic analysis revealed additional, unforeseen codes and themes. All-in-all, six major thematic categories emerged\u0026ndash; \u003cem\u003eEngagement; Understanding of CBM-S; Perceived impact of CBM-S; Application of CBM-S; Barriers and facilitators; Initial expectations of training\u003c/em\u003e. A number of nested sub-themes were identified with each overarching theme. Fig. 2 depicts the conceptual relation between the themes (circles) and sub-themes (boxes).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme\u0026nbsp;1: Engagement and Acceptability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis theme depicted students\u0026rsquo; overall experience of CBM-S training and their level of engagement while completing the training. It included students\u0026rsquo; perception toward the delivery\u0026nbsp;and\u0026nbsp;structure\u0026nbsp;of\u0026nbsp;the\u0026nbsp;training,\u0026nbsp;how easy or difficult they found the training to complete, and their level of enjoyment and interest in completing the training. Overall, students had a positive view of CBM-S and found the training both acceptable and engaging to use.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTraining\u0026nbsp;Delivery\u0026nbsp;and Structure\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSpecific sub-themes regarding training delivery and structure that emerged from the interviews were: the delivery device (laptop or phone), delivery method (self-run or facilitated), delivery content (simple or detailed), and delivery frequency and duration (single session or multiple sessions).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDelivery Device\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn general, most students did not notice much difference between using a laptop or phone to complete the training. A few students, however, appreciated the ease of using a laptop to complete the missing-letter word task and associated laptops with learning.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eI did mine on the laptop, so it was pretty easy as well. I\u0026rsquo;m not sure how it would\u0026nbsp;\u003c/em\u003e\u003cem\u003ework on a phone, but I think the laptop just makes the software easier to use.\u003c/em\u003e\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo; just did it on my phone and it was quite easy to move on..\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026apos;t think it would have made a difference, but I don\u0026apos;t know. I kind of feel like when I use my phone to do, like, an activity like this, it\u0026apos;s almost like I, like, more rushed through it and I don\u0026apos;t take as much in, whereas I put more effort into something if it\u0026apos;s, like, on my iPad or my laptop, I don\u0026apos;t know. I just associate that more with, like, learning and stuff.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDelivery Method\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost students expressed a preference for the self-guided format. They reported feeling more comfortable completing the training in their own space and valued the flexibility of controlling the pace.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eYou\u0026rsquo;d feel like less, like if you were someone that had a lot of those\u0026nbsp;\u003c/em\u003e\u003cem\u003eunconscious biases at first, you might feel bad about that if you were in front of\u0026nbsp;\u003c/em\u003e\u003cem\u003eother people, but if you were alone in your room, you\u0026rsquo;d be like, oh, maybe I\u0026nbsp;\u003c/em\u003e\u003cem\u003eshould check that.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think it\u0026apos;s nice to have the freedom of, like, just doing it whenever, especially\u0026nbsp;\u003c/em\u003e\u003cem\u003ebecause, like, you have so many little things to do throughout the day or week\u0026nbsp;\u003c/em\u003e\u003cem\u003eor whatever. It\u0026apos;s nice to be like, okay, I\u0026apos;ve got half an hour break here. I\u0026apos;ll do it\u0026nbsp;\u003c/em\u003e\u003cem\u003ehere. As opposed to, like, you know, having it less flexible.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think it\u0026rsquo;s good because you can just think about, think about it yourself, like it\u0026rsquo;s all stemming from you. Whereas if you\u0026rsquo;re doing it with other people or something, they can just say something and you can just say, oh, yea, true.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOne student, however, noted that a disadvantage of this type of independent learning is maintaining adherence to the training.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Yeah. I think the disadvantage of doing it on your own is I think adherence.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDelivery Content\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost students found the simplicity of CBM-S beneficial for engagement. Somes students, however, noted that this simplicity could hinder the effectiveness of the training, as users may skip the scenarios and directly guess the missing letter in the word task.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eI liked how you didn\u0026apos;t have to, I don\u0026apos;t know, use as much, like, mental power, I guess. Like it didn\u0026apos;t take a lot of motivation to get through the quiz, which I like, so I think it\u0026apos;ll be much easier for people to do it.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;yeah, just the simplicity of it, really, like just being able to go through and how simple it was to read the stems and sort of. Yeah, I think the simplicity of it was quite good.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Some of the scenarios is quite obvious as to what the word was without even reading this scenario because only one letter was missing. I wasn\u0026apos;t sure if that was intentional to make it easy, but I think that could make some people just skip reading the scenario and just get on with the next question.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDelivery Frequency and Duration\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll students indicated a preference for multiple but shorter training sessions.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;But I think if you overload people, people can start to find things tedious, yeah.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think we\u0026apos;ll need the warning for the 59 items, but I\u0026apos;m thinking, like, if it\u0026apos;s 59, because you are kind of tired at the end, so it might be easier for the trainee to pick up bias because you are just not thinking\u0026hellip;\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I\u0026rsquo;m not really sure about the number of questions. Maybe, you know, yeah, it\u0026rsquo;s a good experience. But then at near the end it just started becoming like a pattern recognition thing rather than realising my own biases.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEase of Use; Enjoyment and Interest\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBy and large, students found the training easy to use, with clear presentation of the content. Some students praised the layout, mentioning that it was neatly organized with no overlapping buttons. Additionally, students appreciated the opportunity to actively engage in the training\u0026mdash;as opposed to passively receiving information like in a lecture or workshop.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003cem\u003eIt was pretty straight to the point\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;\u003c/em\u003e\u003cem\u003eusually sometimes there\u0026apos;s overlaps between buttons and it\u0026apos;s hard to press, but I don\u0026apos;t have a problem with that.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003cem\u003eThink this is more sort of, like, practical, like, what you guys are saying about the other learning being passive. Like, what we\u0026apos;ve done, like, workshops and discuss things, I think you can sort of still sit back and just, like, take it all in, just listen to what they say. Like, yeah, whatever. I\u0026apos;ll try not to be biased. I\u0026apos;ll do my best. But then to go and have to do this training yourself and, you know, you actively have to go through and read all the scenarios and do it, I think you\u0026apos;re sort of more prompted to put more in than you are in, like, a workshop or a lecture where you just sort of sit through and let it wash over you.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Yeah, it was very much just like, click the buttons, like, go through it and, like, if it was something, like, compulsory, I probably would not have engaged even as much as I did for this, if that makes sense. If you had to type something in that would almost engage you more.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFor some students, the number of sessions may have hindered their engagement.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;So the first sort of five or six questions, it was pretty good. It was good to know that I have some biases and things like that. But then after sort of questions six or seven or eight, from that point onwards, it started just becoming like a pattern recognition thing.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;but it probably just drag on a little bit towards the end.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme\u0026nbsp;2:\u0026nbsp;Understanding CBM-S\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis theme illustrated the clarity and understanding of navigating through the CBM-S training. It highlighted that some students experienced difficulties in identifying the final word in certain scenarios.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003cem\u003eI couldn\u0026apos;t think of the exact word that they were looking for, but that\u0026apos;s just because I had no idea what they were talking about.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003cem\u003eI think I ended up doing random letters to try figure out what it was.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSome students were confused about how the training reduced stereotype interpretation bias and also noted that CBM-S might be better suited for proficient English speakers.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I couldn\u0026apos;t exactly, like, pinpoint, like, how does this relate to the training we\u0026apos;re supposed to do?\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Next thing I come up with is the English thing, but you\u0026apos;re training the doctors in New Zealand, so you don\u0026apos;t really need to think about it.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;like what\u0026rsquo;s the point of the second part of that question? So I noticed sometimes the second part of the questions will be like the same as the first part\u0026hellip;.; It doesn\u0026rsquo;t feel as reinforcing, as if it was kind of slightly different, which makes something different that makes you think a little bit more.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme\u0026nbsp;3:\u0026nbsp;Relevance\u0026nbsp;of\u0026nbsp;CBM-S\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis theme outlined the relevance of the training content and perceived effectiveness of CBM-S as a bias training tool for medical students. Two sub-themes emerged: 1) relevance to a medical setting and 2) capturing common Māori stereotype biases.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eClinical Relevance\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudents reported that the training scenarios portrayed realistic medical situations, though some students noted that\u0026nbsp;the scenarios seemed to assume bias, suggesting that CBM-S may not be effective for individuals who are not biased.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I thought that the clinical scenarios were super relevant and very, like, appropriate. And I sort of found myself, as I read through the scenario, I was thinking back to situations where I\u0026apos;d actually encountered that and things like that. And so I thought that the clinical scenarios were actually really good and sort of simple, but very realistic as well. Things like that could definitely happen in the hospital.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;It almost makes you not really want to buy into it because you\u0026apos;re like, oh, this training is assuming the worst of me when the reality is, I think 95% of the time, we wouldn\u0026apos;t be biased in that situation. So I think, yeah, it would be different if we were putting in a bias response and then it was calling us out, but it almost feels like it\u0026apos;s calling us out when we wouldn\u0026apos;t have been biased in the first place.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I do relate to it quite a lot, especially there\u0026rsquo;s a few scenarios;\u0026hellip;I was actually in my 4\u003csup\u003eth\u003c/sup\u003e year. I was working in a hospital where there\u0026rsquo;s the community is like more than 50% Pasifika patients. So like it\u0026rsquo;s quite common in that scenario.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStereotype Relevance\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudents found that most of the scenarios captured common (unhelpful) stereotypes toward Māori patients.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think the scenarios that were given were, like, pretty most common stereotypes. I would say that we hear about our Māori people, that it was very relevant.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The other scenarios, other than the fact that first one, because that confused me. I thought the scenarios that were given were quite relevant because there\u0026apos;s stuff that I\u0026apos;ve heard and that\u0026apos;s some of it. It\u0026apos;s, like, similar, like, maybe to, like, my pacific culture a little bit, like, with stereotypes that we have down there.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Yeah, I think when you don\u0026apos;t recognize the stereotype, it\u0026apos;s just I\u0026apos;m confused because I think, why are we asking this? Like, I think might have been the first question where they say a group of people come in with, like, red t-shirts and then the question was like, did you expect them to wear something green?\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;There\u0026rsquo;s one question just that stood out to me about like I think it was something like there\u0026rsquo;s a group of family members all wearing the same shirt;\u0026hellip;there would be some health professionals would be thinking, oh, yeah, it\u0026rsquo;s they\u0026rsquo;re part of a gang or something.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOne student pointed out that having previous Māori cultural training helped them better understand the scenarios.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I mean, obviously it\u0026apos;s very targeted towards that one thing. So that without all my other learning on Māori culture might be a little bit confusing, but because I\u0026apos;ve done both, it was very helpful.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme\u0026nbsp;4:\u0026nbsp;Application\u0026nbsp;of\u0026nbsp;CBM-S\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis theme illustrated students\u0026rsquo; perception of using CBM-S as a training tool for medical students to challenge and modify unhelpful Māori stereotypes in a clinical settings. Specifically, students compared CBM-S to other existing Māori cultural training programs, offering their appraisal and feedback on its effectiveness. Overall, most students supported the idea of a simple, self-run training like CBM-S to complement existing cultural training programs; they also found CBM-S effective in modifying stereotypes bias towards Māori.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAppraisals\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eof\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;CBM-S\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudents appreciated CBM-S as a training tool, in particular the inclusion of contextual information presented through various real-life clinical scenarios.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think the big thing was to make us aware of their culture and beliefs and just to give us an understanding so we can use it later on.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We learn about Māori culture, and maybe that\u0026apos;s coming in, like, ALM, maybe in the future for us, but, like, we don\u0026apos;t really apply any of this or, like, in a real-life context, like, with the things we learn.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;A lot of us, we have a lot of unconscious biases from our training based on how we\u0026apos;re trained to do snapshot judgments, but they\u0026apos;re not always the best, especially if they\u0026apos;re judging a person and not their actual condition. And so if it came to removing biases and helping people access health services, then I\u0026apos;m all for it, you know?\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think CBM is really good. Like it\u0026rsquo;s a really easy way for someone to realise their biases and kind of try to help correct that. Like it\u0026rsquo;s not that like there\u0026rsquo;s ways to make the training, you know, very engaging and rather than just being fed information. It\u0026rsquo;s more like a, it\u0026rsquo;s kind of fun to be honest\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEffectiveness of CBM-S\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudents found the training helpful in modifying stereotype bias by offering a more constructive and adaptive alternative interpretation of the scenarios.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think there was a scenario where a group of Māori men came into a hospital and they said they were, like, shouting. And the question was, are they being disruptive? And I immediately thought, well, yeah, because they might have been in a fight or I don\u0026apos;t know, but it said they weren\u0026apos;t. And then it forced me to think they may have been shouting because they\u0026apos;re in pain or they might have been hurt. So, yeah, like, things like that forced me to think of it in another way.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think some of them really got me thinking, like the one I told you about, about the shouting. Some of them were a little like the questions were too obvious, but, yeah, I don\u0026apos;t mind that.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Sometimes it would sort of feel like they want you to think, like, this one thing first, even though that wouldn\u0026apos;t be your first thought initially. Like, the evidence that they perhaps present to you would be presented in a way that you\u0026apos;d think maybe one thing when usually you\u0026apos;d think another.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eComparisons with Existing Bias Training\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudents shared their thoughts on the similarities and differences between CBM-S and other Māori cultural and bias trainings. For the main part, students emphasized that CBM-S was a more targeted and focused training, specifically addressing common Māori stereotypes whereas existing cultural training programs were more about cultural immersion and promoting general cultural competency rather than focusing on stereotypes.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think what\u0026apos;s different is there\u0026apos;s a more emphasis on understanding Māori culture and customs and the way they do things. Like, so the culture itself, whereas this training is more like one, like, stereotypes. And it\u0026apos;s just kind of like, I don\u0026apos;t know, applying it to more, like, real life stuff.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eThey sort of did cultural immersion so that they can prevent us from thinking about stereotypes and having that sort of bias. But because of that, I don\u0026apos;t think we really explored any of the stereotypes that we\u0026apos;ve got today. So that\u0026apos;s probably the main difference between the training, which, because that mainly focuses on the stereotypes only, and that\u0026apos;s something we didn\u0026apos;t cover\u003c/em\u003e.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026apos;t think in the past they covered stereotypes specifically. I think they just wanted to give us a general, overall idea of Māori culture, but they didn\u0026apos;t really go into anything in detail. So this was completely different area, I think\u003c/em\u003e.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026apos;t think there\u0026apos;s many opportunities to specifically look at stereotypes, which I think is very important. So, yeah, it\u0026apos;s good to have a general overall idea, but it\u0026apos;s also, yeah, I liked how it targeted those things that we might miss, but it becomes really important when we actually meet Māori patients.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Yeah, I think the bias modification stuff is quite different to some of the cultural training because all the other stuff that I\u0026rsquo;ve done is always kind of been in like groups. So there\u0026rsquo;s one benefit is that you can kind of do it independently and work through your own like individual biases\u0026hellip;\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme\u0026nbsp;5:\u0026nbsp;Initial Expectations of Training\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis theme was thematic related to the Theme 4, \u0026lsquo;Applications of CBM-S\u0026rsquo;. Students generally had no prior expectations but based their expectations on existing cultural or bias training experiences.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eI personally didn\u0026apos;t really have any expectations of what it would be like. I was surprised when it said that you had to, like, insert the missing letter. Like, I thought it would be more of an active thing. Not that that was a bad thing, but I was just surprised by that.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eI honestly didn\u0026apos;t have many expectations going into it. I feel like I had sort of thoughts, like, hearing about the bias training. I think in the past, I can\u0026apos;t remember what they\u0026apos;re called, but we\u0026apos;ve had to do, like, um, certain activities online. You might know what these are, and you sort of, like, do repetitive things and you choose, like, a certain stereotype. Like, in this case, it was obviously ethnicity, but I remember doing it to see if you had a bias towards, like, overweight people\u003c/em\u003e\u0026rdquo; (this student was likely referring to the Implicit Association Test)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme\u0026nbsp;6:\u0026nbsp;Barriers and Facilitators\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis theme explored the factors that students found either supportive or challenging during their CBM-S training session. Four sub-themes were identified: contextual information, performance feedback, outline of training, and training presentations. This theme is conceptually linked to all the other identified themes and could be seen as influencing or moderating the effects of those themes. In addition to identifying barriers and facilitating factors, students offered valuable suggestions for improving CBM-S as a bias training tool for medical students. These suggestions are summarized in Table 2.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eContextual Information\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudents reported experiencing some difficulties in making sound clinical decisions regarding patient safety due to the limited information provided in the training scenarios.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;There were some cases where it was really too short to get any information from it\u0026hellip;Yeah, it\u0026apos;s just one sentence and you can\u0026apos;t really get much from that. And you can\u0026apos;t really, like, respond appropriately because you don\u0026apos;t have enough information.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;If there were more clues in the scenario about perhaps how the patients interacted with each other in the family or what kind of presentation of injury that they had. Some injuries are more likely to be abusive than others.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFeedback on Performance\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll students agreed that they would have appreciated receiving some kind of feedback on their performance and/or their biases in order to elicit a self-reflective process.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;getting, like, some feedback at the end, like, after you\u0026apos;ve done it\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;you did all these scenarios, but you never really, like, there was no sort of feedback on how you did\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;But I did find something that was missing from the experience was, like, the feedback and discussion aspect, because as much as it was, we told, like, yes or no, you don\u0026apos;t really know why or how.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eOutline of Training\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudents highlighted the need for a summary on how the training works and evidence of the training\u0026rsquo;s effectiveness.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Well, I mean, like, I knew how to do it, but I was kind of like, what are they? What are you trying to achieve from this?\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;If the training is like, you know, evidence based and there\u0026apos;s a, you know, there\u0026apos;s a reason to why it\u0026apos;s passive and why there\u0026apos;s so many, then I\u0026apos;d put that, like, on the front page and be like, yeah, this will take you 15-20 minutes, but it is shown to actually work. And this is why we\u0026apos;re doing it this way, because otherwise, I think you\u0026apos;re not going to get the buy in.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Yeah, I think like maybe an instruction to the students before they start training be like think about the answer in your mind and then after that, they click next and then the word comes up.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTraining Presentation\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudents highlighted several aspects that they found helpful or challenging regarding the presentation of CBM-S.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003cem\u003eA few questions were, like, repetitive. Like, so maybe if you could have different questions, maybe.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I liked how there was a practice at the beginning. If that wasn\u0026apos;t there. I may have been a little confused on what they wanted\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Yeah, like, if I were to think about it, because actually I want to go back and think about that. Like, it would be cool, too, but yeah.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think instead of, like, an underscore, it was a dash. I think it would be more clear if it was like, an underscore.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u0026nbsp;\u003c/strong\u003e\u003cem\u003ePractical Recommendations for the Future Advancement of CBM-S Informed by Student Feedback\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.183%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRecommendations\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50.817%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudents\u0026rsquo; Responses\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCBM-S Training Scenarios\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.183%;\"\u003e\n \u003cp\u003eAssociate CBM-S with related existing medical curriculum and/or bias training modules\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50.817%;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;But if you have it associated with something, so you\u0026apos;re expecting it, I think you\u0026apos;ll get better engagement and you won\u0026apos;t get people hating it like we did with the retain knowledge tests\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;a good way would be doing at the start of each run or each attachment.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.183%;\"\u003e\n \u003cp\u003eHaving relatable scenarios across training items to create more context and better flow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50.817%;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Yeah, yeah. And then it just flows a bit nicer, and it would feel like more like one scenario. You\u0026apos;d learn more about that context.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Maybe the scenarios could be more sort of make it more related to the actual attachment, so then people feel more kid of related. So there\u0026rsquo;s something like surgery, then you make it in like a surgical setting. If it\u0026rsquo;s like a GP, then you make it more like a community setting\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.183%;\"\u003e\n \u003cp\u003eScenarios reflective of personal experiences:\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50.817%;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I think back to the training we\u0026apos;ve had during our clinical years, and often it\u0026apos;s like hearing people\u0026apos;s personal stories. It actually leaves, like, a lasting impact. Like, if I had someone sitting in front of me saying that, yeah, you know, I went into the hospital and I experienced this and this and this, and it was really bad, then that would make me sort of think twice and make me think, okay, these assumptions still happen, whereas, like, sort of quick online training.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.183%;\"\u003e\n \u003cp\u003eIncorporating videos or audio to accompany text-based scenarios to increase the amount peripheral information + engagement\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50.817%;\"\u003e\n \u003cp\u003e\u0026ldquo;\u003cem\u003e\u0026hellip;if you had, like, a little video clip of it, then you could understand a whole lot more of the context.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;when I do a survey, I prefer if it was more visually stimulating\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Maybe having like some pictures or something in it might help break it up a little bit more or kind of make it more like feel less like it\u0026rsquo;s dragging on as much\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTraining Delivery and Structure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.183%;\"\u003e\n \u003cp\u003eShorter but more regular spaced-out sessions. Collated feedback from students suggested a 10-30 training items per training session, with one student noting that ,ore training items may help improve the effectiveness of CBM-S\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50.817%;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Yeah, I reckon 30 would be my. Where I would just tap out after that.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I think, like, maybe 20 a month would work best. Just because. So much to do right now.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Probably 8, maximum 10\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;around 12 or something like that\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;\u003cem\u003eI think if you\u0026apos;re doing something that\u0026apos;s so passive, you probably need the numbers to, like, actually work.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.183%;\"\u003e\n \u003cp\u003eCultural training, in general, should be included earlier in medical training, but also reintroducing similar concepts throughout medical training\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50.817%;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I think pretty early on, like, we do the cultural immersion in ELM, too. So I think either in ELM 2 or 3 might as well start getting exposed to those and being aware of them before you go into hospital.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;if the students are in clinical years, maybe at the start of each of their attachments;\u0026hellip;in Auckland, we usually do like six or seven clinical attachments across the whole year. So maybe like six or seven at the start of each attachment just to kind of like a reset like a refresher kind of thing.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHuman Input and Self-reflections\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.183%;\"\u003e\n \u003cp\u003eSelf-run format of the training facilitated engagement but having someone to discuss the training scenarios with may also be beneficial\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50.817%;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I feel like if it\u0026apos;s more sort of a discussion, collaborative approach rather than just like, yes or no questions on your own, not getting sort of any real feedback after. Yeah, I think there\u0026apos;s a bit more scope for, like, being aware and learning from your bias. There is more like collaboration and that sort of stuff.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.183%;\"\u003e\n \u003cp\u003eOpen box to replace the Yes/No question with an open response to combat the limited information in the brief training scenarios\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50.817%;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Maybe like, an interesting question afterwards would be: what information would you need to make a judgment about this person, about whether this was a case of abuse? What more would you need?\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.183%;\"\u003e\n \u003cp\u003eDiscussion session to debrief after receiving the CBM-S training would be.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50.817%;\"\u003e\n \u003cp\u003e\u0026ldquo;\u003cem\u003eSome people might need to talk about it or debrief afterwards, which you could make it a part of that, or you could make it like a part of an EPE session or a Māori session.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.183%;\"\u003e\n \u003cp\u003eFeedback on their performance and/or their biases in order to elicit a self-refectory process.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50.817%;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;you did all these scenarios, but you never really, like, there was no sort of feedback on how you did\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.183%;\"\u003e\n \u003cp\u003eOpen box to replace the missing letter word task to combat the limited information in the brief training scenarios\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50.817%;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip; just maybe leaving it kind of like a blank\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003espace and, like, saying to the students, this is how many letters are in the word, but not necessarily giving as many words, if that makes sense. Because in a way, it doesn\u0026apos;t skew them to think of, like, absolute protective factors, but also doesn\u0026apos;t completely negate the bias that the activity is trying to minimize\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec34\" class=\"Section2\"\u003e \u003ch2\u003eSummary of Results\u003c/h2\u003e \u003cp\u003eIn the present study, we reported the perspectives of Aotearoa New Zealand medical students\u0026rsquo; experience of Cognitive Bias Modification-Stereotypes (CBM-S)\u0026mdash;a digital training suite designed to reduce implicit stereotyping of an indigenous population of NZ, Māori (Tangata Whenua, people of the land). Several aspects of the training received positive feedback, and helpful suggestions were made for improving the training\u0026rsquo;s quality and delivery. The training received positive feedback on various aspects, including its engagement, clarity, application, and effectiveness and relevance to medical training and stereotyping of Māori patients. By and large, students found the training simple to use with a well-organized user interface, which echoes previous quantitative rating data on CBM-S (Hsu \u0026amp; Akuhata-Huntington, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2024b\u003c/span\u003e). The simplicity of the training, however, was reported with the caveat that the simple design may hinder the training\u0026rsquo;s modification effects because students might complete the training without reading the training scenarios. Students did not express a clear preference for completing the training on a laptop or a phone. However, some students felt that laptops might be easier for completing the word task and associated laptops more closely with learning. In regards to content relevance, students indicated that CBM-S scenarios captured common Māori stereotypes that are often observed in clinical settings, which likely reflects the co-facilitated approach with medical students and Māori participants that researchers adopted in generating training scenarios (Hsu \u0026amp; Akuhata-Huntington, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2024b\u003c/span\u003e). Leung et al. (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), who also adopted a co-facilitated approach to develop CBM training scenarios for biased paranoid thoughts revealed findings that were consistent with the results of the present study. Additionally, unlike existing cultural trainings, which promote understanding of Māori culture and values, students reported that CBM-S targets stereotype bias. Taken together, students consistently agreed that CBM-S can be an effective and applicable educational tool for reducing implicit bias towards Māori patients among medical students.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec35\" class=\"Section2\"\u003e \u003ch2\u003eSelf-guided Training\u003c/h2\u003e \u003cp\u003eStudents expressed appreciation for the self-run format and their active involvement in the training (i.e., completing the word task), reporting a sense of independence, engagement, and feeling in control of the pace of the training. This sense of autonomy and engagement can be explained through a self-determination theory lens, which posits that when individuals experience autonomy, it strengthens their self-efficacy and intrinsic motivation, resulting in greater engagement (Bakker et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Ryan \u0026amp; Deci, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2000\u003c/span\u003e). In Leung et al.'s (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) study on CBM for paranoia, participants expressed a greater sense of autonomy for the self-guided training format compared to the expert-facilitated training.\u003c/p\u003e \u003cp\u003eIn addition to a greater sense of control and independence, students in our study reported that the self-directed format reduced their need for impression management, as they felt less pressure to respond in ways that would be seen favorably by others. Empirical evidence has shown that medical students may resist implicit bias training, especially when discussions focus on emotionally charged topics describing systemic discrimination, institutional racism, and health inequities. For example, Gonzalez et al. (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) found that American medical students expressed resistance to implicit bias training, in part, due to shame and fear of being negatively evaluated by other students in class. Wear and Aultman (\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e2005\u003c/span\u003e) found that many of their Year 4 medical students struggled to engage with topics such as inequality and oppression, suggesting that this difficulty stemmed from students\u0026rsquo; resistance to confronting these issues. These basic findings of students\u0026rsquo; resistance on inequity issues, bias, and racism have been replicated in other medical education studies (Gonzalez et al., 2014; Hernandez et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Teal et al., \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2010\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec36\" class=\"Section3\"\u003e \u003ch2\u003eFacilitator/Peer Interaction\u003c/h2\u003e \u003cp\u003eWhile students value the self-guided and self-paced nature of the training, they have suggested several ways to integrate CBM-S within a structure that includes supportive human interaction, an element that was missing in the original CBM-S approach. For instance, students welcomed the idea of having opportunities for debriefing or discussion sessions with their peers or a facilitator at the end of the training; another suggestion was to receive feedback on their performance during the training to help foster self-awareness and consolidate their learning. These recommendations align with existing literature, which emphasizes that students often appreciate the inclusion of educator and peer support or interaction in digital trainings and that having human input improves engagement (Edelbring et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Henry et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e Students also thought that incorporating a debriefing or discussion session could help address the challenges in balancing competing and complementary decision-making processes as a result of limited contextual information that the training scenarios provided. More specifically, students raised concerns about issues of making sound judgements when confronted with common unhelpful stereotypes about Māori (e.g., child abuse is a Māori issue; Maydell, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) conflicted with potential risk issues (e.g., actual child abuse). Clinical decisions are typically guided by two systems (based on the dual-process theory; Epstein, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e1994\u003c/span\u003e): System 1, which handles intuitive decision-making that uses limited information, while System 2 involves more deliberate and thoughtful analysis taking contextual details into account to make informed choices. System 1 is more susceptible to cognitive biases, so encouraging the use of System 2 in clinical decision-making could help reduce this tendency (Tay et al., \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Offering debriefing or discussion sessions following a self-run CBM-S training may encourage System 2 processing.\u003c/p\u003e \u003cp\u003eIn addition to the debriefing or discussion sessions for balancing competing decision-making processes, students also suggested the following: 1) CBM-S runs in parallel to existing bias or cultural trainings, which likely already has a discussion component; 2) accompany text-based scenarios with videos or audios to provide a richer perspective in the training scenarios; 3) include a prompt to encourage self-reflection (e.g., \u0026ldquo;\u003cem\u003ean instruction to the students before they start training be like think about the answer in your mind\u0026hellip;\u0026rdquo;\u003c/em\u003e); and 4) include an open text box as a part of the follow-up question to allow students to share their thoughts and self-reflect on the scenarios, which is vital for learning and challenging biases (Sabin et al., \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). In previous studies on CBM, participants have recommended the inclusion of a similar self-reflective component (Beard et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Leung et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). An important point to note about CBM-S is that consciously reflecting on one\u0026rsquo;s biases may not be necessary for the training to be effective. CBM-S was not intended to encourage self-reflection in students. Instead, it focuses on the unconscious learning of rules that shapes interpretation, thereby helping to reduce stereotype biases. Nevertheless, we recommend that future updates to CBM-S could at least offer students a platform for debriefing or discussion sessions.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec37\" class=\"Section2\"\u003e \u003ch2\u003eDelivery and Engagement\u003c/h2\u003e \u003cp\u003eGiven the typical heavy study load that medical students face, they expressed a preference for shorter but more frequent training sessions to balance both engagement and effectiveness. Students suggested range of 10\u0026ndash;30 items per session, which was a shorter training session compared to the 40-item session used in Leung et al. (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). To enhance engagement and retain effectiveness, our students also suggested that CBM-S be introduced earlier in medical curriculum, linked to other topics within the medical curriculum or clinical attachments, incorporate unique and relatable scenarios, and include a visual alongside the text-based scenarios. Embedding CBM-S training into existing curriculum may provide a natural integration of debriefing or discussion sessions.\u003c/p\u003e \u003cp\u003eAlthough the feedback was mostly positive, a few students struggled to understand how the training worked and found some items challenging to read and complete. Some students were unsure about how CBM-S modified stereotype bias; other students discussed including more information about the training, such as the evidence supporting CBM-S to explain how the training scenarios work to reduce biases. Interestingly, it has been documented that people hold different ideas about the meaning of \u0026lsquo;evidence-based practice\u0026rsquo;, with many people believing that these interventions are rigid, impersonal, and not tailored to individual needs (Becker et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Carman et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Tanenbaum, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2008\u003c/span\u003e). Future improvements to CBM-S could include additional information of how CBM-S works without explicitly labeling the training as \u0026lsquo;evidence-based\u0026rsquo;.\u003c/p\u003e \u003cdiv id=\"Sec38\" class=\"Section3\"\u003e \u003ch2\u003eStudy Limitations\u003c/h2\u003e \u003cp\u003eThere were some notable improvements that could be made to our study. First, having one interviewer may have hindered the amount of information received with no additional prompts from another interviewer. Furthermore, having a single interviewer may also increase the risk of bias and hinder the rigor of the data. Related to this point is that, since some of the researchers in the current study were also developers of CBM-S, researcher bias may exist. The research team took steps to minimize potential bias by actively seeking refutational data during the analysis. Additionally, the development of themes and sub-themes was an ongoing process, with continuous revisions and adjustments made by three researchers until a final agreement was reached. Taken together, these methodological approaches likely helped minimize researcher bias. Nevertheless, we honor a post-positivist perspective and acknowledge that complete objectivity is unlikely because researchers' perceptions, biases, and assumptions may inevitably influence both the questions posed and the interpretation of the data in this study (Guba \u0026amp; Lincoln, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e1994\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSecond, there is a possibility that students\u0026rsquo; responses were susceptible to social desirability given the overlap between the researcher who conducted the interviews and his role as a lecturer in the medical school (CWH). Of note, it was identified that the lecturer had only taught one of the students involved in the study at the time of the interviews and that 20% of participants were from a different university.\u003c/p\u003e \u003cp\u003eFinally, our findings were collapsed across feedback from students in both ELM and ALM, which may be skewed as ALM students would have had more clinical experience and greater exposure to stereotyping of marginalized communities in a clinical setting. However, the relatively equal number of students in both year groups may have helped to mitigate this potential skew.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe present study explored New Zealand medical students\u0026rsquo; experiences and acceptability of Cognitive Bias Modification-Stereotype (CBM-S), a digital training designed to reduce implicit stereotype bias towards marginalized groups\u0026mdash;specifically Māori, an indigenous population of New Zealand. A previous randomized control trial has shown promising bias modification effects of CBM-S in the same context. Through semi-structured group interviews with 20 medical students, six major themes emerged: \u003cem\u003eEngagement, Understanding, Perceived Impact, Application, Barriers and Facilitators, and Initial Expectations\u003c/em\u003e. Overall, CBM-S was well-received, with students appreciating its self-guided format and relevance to clinical practice. Students also found CBM-S engaging, easy to use, and thought the training materials were relevant to clinical practice and in addressing implicit stereotype bias towards Māori patients. Suggestions for improvement included incorporating debriefing and interactive discussion sessions and ways to enhance the delivery and engagement of CBM-S. These findings offer valuable insights to enhance CBM-S for future medical education and professional development applications.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStatements and Declarations\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCompeting interests:\u003c/strong\u003e \u003cp\u003eThe authors declare that there is no conflict of interest regarding the publication of this manuscript. The authors have no conflict of interest related to the employment or financial and non-financial interests concerning this manuscript.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFunding\u003c/strong\u003e \u003cp\u003eThis study was funded by the Medical Education Research Fund (MERF), Otago Medical School (grant number N/A).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthics approval:\u003c/strong\u003e \u003cp\u003e This study received institutional ethical approval (University of Otago 22/063) and was conducted in accordance with the ethical principles outlined in the 1964 Declaration of Helsinki or its later amendments or comparable ethical standards.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent to participate\u003c/strong\u003e \u003cp\u003e\u003cb\u003eand publish\u003c/b\u003e: Informed consent was obtained from all participants prior to their involvement in the study.\u003c/p\u003e \u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare that there is no conflict of interest regarding the publication of this manuscript. The authors have no conflict of interest related to the employment or financial and non-financial interests concerning this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis study was funded by the Medical Education Research Fund (MERF), Otago Medical School (grant number N/A).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval:\u0026nbsp;\u003c/strong\u003eThis study received institutional ethical approval (University of Otago 22/063) and was conducted in accordance with the ethical principles outlined in the 1964 Declaration of Helsinki or its later amendments or comparable ethical standards.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate and publish:\u003c/strong\u003e Informed consent was obtained from all participants prior to their involvement in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability:\u003c/strong\u003e Qualitative data analysis is available at https://tinyurl.com/CBMSQualdata\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization: C.W. Hsu, Z. Akuhata-Huntington\u0026bull; Methodology: C.W. Hsu, Z. Akuhata-Huntington, A. Robbins, T. Cartwright\u0026bull; Software: C.W. Hsu\u0026bull; Validation: C.W. Hsu\u0026bull; Formal Analysis: C.W. Hsu, A. Robbins, T. Cartwright\u0026bull; Investigation: C.W. Hsu\u0026bull; Resources: C.W. Hsu, Q. Liu\u0026bull; Data Curation: C.W. Hsu, A. Robbins, T. Cartwright\u0026bull; Writing \u0026ndash; Original Draft: C. W. Hsu\u0026bull; Writing \u0026ndash; Review \u0026amp; Editing: C.W. Hsu, A. Robbins, T. Cartwright\u0026bull; Visualization: C. W. Hsu\u0026bull; Supervision: C. W. Hsu\u0026bull; Project Administration: C.W. Hsu\u0026bull; Funding Acquisition: C.W. Hsu, Q. Liu, L. Heath, C. C. Lin, S, Chambers, Z. Akuhata-Huntington\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to acknowledge and express our gratitude to Dr Qian Liu, Higher Education Development Centre, University of Otago for his guidance in developing the interview protocol and questions; Zaine Akuhata-Huntington, formerly of the Kōhatu Centre for Hauora Māori, University of Otago for his expert consultation on cultural knowledge and stereotyping; Dr Lis Heath, Stuart Chambers, Department of Medicine, University of Otago and Dr Chris Lin, Department of Psychological Medicine, University of Otago, for their helpful input in preparing the grant application\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePositionality statements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMindful that our identities can influence our approach to science, the authors wish to provide the reader with information of our backgrounds. With respect to gender, when the manuscript was drafted, authors self-identified as male and female. With respect to race, authors self-identified as East Asian and New Zealand Māori\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAllen, T. J., Sherman, J. W., Conrey, F. R., \u0026amp; Stroessner, S. J. (2009). Stereotype strength and attentional bias: preference for confirming versus disconfirming information depends on processing capacity. \u003cem\u003eJournal of Experimental Social Psychology, 45\u003c/em\u003e(5), 1081\u0026ndash;1087. https://doi.org/10.1016/j.jesp.2009.06.002\u003c/li\u003e\n\u003cli\u003eBaah, F. O., Teitelman, A. M., Riegel, B. (2019). 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The limits of narrative: medical student resistance to confronting inequality and oppression in literature and beyond. \u003cem\u003eMedical Education, 39\u003c/em\u003e(10), 1056\u0026ndash;1065. https://10.1111/j.1365-2929.2005.02270.x\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"cognitive bias modification, implicit bias training, medical education, health inequity, qualitative study, interpretation bias","lastPublishedDoi":"10.21203/rs.3.rs-5596294/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5596294/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIn healthcare, it has been well-documented that marginalized communities face a higher risk of health problems due to inequitable opportunities, with implicit bias contributing a major role to this health inequity. In the present qualitative study, we aimed to complement a previous randomized control trial that examined Cognitive Bias Modification-Stereotype (CBM-S)\u0026mdash;a self-run digital training for medical students targeting their implicit stereotype bias towards Māori, an indigenous population of New Zealand. We gathered feedback from New Zealand medical students\u0026rsquo; experiences and acceptance of CBM-S in order to improve its implementation in medical education. Semi-structured group interviews were conducted with 20 students (in their 1st to 5th year of medicine), with 3\u0026ndash;5 students per interview group. Qualitative analyses using framework and thematic analysis revealed six major thematic categories: \u003cem\u003eEngagement; Understanding of CBM-S; Perceived impact of CBM-S; Application of CBM-S; Barriers and facilitators; Initial expectations of training\u003c/em\u003e, along with several nested sub-themes. By and large, CBM-S was perceived favorably by students on various aspects, including engagement, clarity, application, and effectiveness and relevance to clinical settings and stereotyping of Māori patients. Particularly, students appreciated the self-guided format and active involvement during the training, reporting a sense of independence, engagement, and feeling in control of the pace. Several helpful suggestions were made with including debriefing sessions, interactive discussion session, and ways to improve the delivery and engagement of CBM-S. The rich content that was obtained from the present study open up an avenue for improving CBM-S for future studies and application in medical education.\u003c/p\u003e","manuscriptTitle":"A Qualitative Study: New Zealand Medical Students’ Experience of Cognitive Bias Modification-Stereotype (CBM-S)—A Self-Run Digital Implicit Bias Training","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-31 05:35:28","doi":"10.21203/rs.3.rs-5596294/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7f2acb29-0cae-4bb8-b176-08c412927b07","owner":[],"postedDate":"December 31st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-12-31T05:35:28+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-31 05:35:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5596294","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5596294","identity":"rs-5596294","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}