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Implicit provider bias in cardiovascular disease care of Black women: the lives of Black women with heart disease matter

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Implicit provider bias in cardiovascular disease care of Black women: the lives of Black women with heart disease matter

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Content Running head: PROJECT HEARTWISE 1
Implicit Provider Bias in Cardiovascular Disease Care of Black Women:
The Lives of Black Women with Heart Disease Matter
Dr. Andra D. Johnson, DSW
Capstone Project
In Partial Fulfillment of the Requirements for the Degree
Doctor of Social Work
Suzanne Dworak-Peck School of Social Work
University of Southern California
Dr. Jennifer Lewis, PhD
Date: July 23, 2020
August 2020
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Table of Contents
Area 1: Executive Summary………………………………………………………………….5
Project Description……………………………………………………….…………..6
The Problem………………………………………………………………………….6
Project Methodology…………………………………………………………………6
Landscape Implications………………………………………………………………………8
Area 2: Conceptual Framework
Description of Social Problem …………………………………………………….…9
Prevalence and Impact…………………………………………………………...…...10
Relative Concepts…………………………………………………………………….11
Literature Review…………………………………………………………………….12
Social Significance………………………………………………………………...…15
Knowledge Gap……………………………………………………………………....16
Conceptual Framework and Theory of Change………………………………………16
Area 3: Problems of Practice and Innovative Solutions
Program Description………………………………………………………………….18
Logic Model…………………………………………………………………………..19
Proposed Innovation and the Effects on the Grand Challenge……………………….19
Innovation Defense…………………………………………………………………...20
Feedback from Multiple Stakeholders………………………………………….…….21
History, Policy, and Public Knowledge………………………………………………22
Opportunities for Innovation…………………………………………………………23
Facilitators……………………………………………………………………………24
Political, Organizational, and Community Obstacles………………………………...25
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Area 4: Project Structure, Methodology, and Action
Prototype……………………………………………………………………………...25
Market Analysis………………………………………………………………………25
EPIS Framework………………………………………………….…………………..26
Internal Context………………………………………………….……………………27
External Context……………………………………………………………………....28
Barriers………………………………………………………………………………..28
Facilitators…………………………………………………………………………….29
Feasibility and Fidelity………………………………………………………….…….29
Implementation Phase…………………………………………………………………29
Sustainability……………………………………………….…………………………30
Data Collection………………………………………………………………………..30
Measures………………………………………………………………………………31
Monitoring and Evaluation……………………………………………………………32
Budget…………………………………………………………………………………33
Structural Considerations and Plans…………………………………………….…….33
Stakeholder Involvement Plan………………………………………………………...33
Community Strategies…………………………………………………………………34
Dissemination Plan and Technology………………………………………….……….34
Ethical concerns……………………………………………………………………….35
Area 5: Conclusion, Action, and Implications
Summary………………………………………………………………………………35
Opportunities………………………………………………………………………….36
Social Work and Medicine……………………………………………………………37
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Risks and Limitations…………………………………………………………………38
Conclusion…………………………………………………………………………….38
Next Steps……………………………………………………………………………. 38
References………………………………………………………………………….....40

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Project HeartWise
Area One: Executive Summary
Cardiovascular disease is the number one killer of Black women who are dying at rates of
50,000 deaths each year, and 69 times higher than all social groups in the United States. Boston
Scientific, 2018). Across the country, Black women are experiencing the adverse impact of
cardiovascular disease as they lack consistent heart screening, testing, diagnosis, prevention, or
detection measures due to implicit provider bias. When presenting to the emergency room with cardiac
symptoms, many providers misdiagnose and turn away Black women from emergency care without
cardiac intervention despite having heart disease risks and symptoms. As a result, Black women
experience permanent damage to their hearts due to the systemic problem of implicit provider bias.
There is a need to address implicit provider bias as a systemic problem in cardiovascular
disease care of Black women. Most research in this area focuses on how implicit provider bias impacts
decision making, service delivery, and heart outcomes with Black women. Still, the study is limited
about disrupting the problem of systemic racism in health care. The education is also deficient in the
area of explicitly evaluating and fixing the systematic harm caused to Black women who experience
implicit provider bias in cardiovascular disease care. Therefore, the need to address this health
disparity is clear, which aligns with the Social Work Grand Challenge of Reducing the Health Gap. An
innovative solution that addresses social determinants of health, implicit provider bias, inconsistent
screening, and referral to cardiology and aggressive cardiac intervention is necessary for improving
health equity with this population. Provider bias in the cardiovascular disease care of Black women
affects clinical decision-making and service delivery to this group, and in effect, is linked to poor heart
health outcomes for this population.

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Project Description
The proposed innovation, aptly named Project HeartWise, is a unique, innovative best practice
model in cardiovascular disease care that addresses the heart disparity experienced by Black women
due to implicit and explicit provider bias (herein referred to as "provider bias"). Using Kurt Lewin's
theory of change, intervention on the systemic barrier of implicit provider bias occurs in three steps: 1)
assess, 2) educate, and 3) behavior change (Hussain et al. (2016). Overall, the proposed innovation is a
coherent, well-organized, and informative strategy with recommended interventions to close the health
gap in cardiovascular disease care. It creates heart equity for Black women with heart disease.
The Problem
Black women with heart disease, who are dying at rates of 50,000 deaths per year and at rates
69 times higher than all groups in the United States, lack access to heart screening and aggressive and
life-saving cardiovascular disease care due to the systemic problem of provider bias. The proposed
innovation will help to decrease or eliminate the heart disparity experienced by Black women, increase
the number of positive heart outcomes that will save the lives of Black women with heart disease, and
promote heart equity for Black women with heart disease. The proposed innovation has several
implementation goals related to the program's outcomes and impact. The program seeks to decrease or
eliminate provider bias in cardiovascular disease care of Black women by improving processes in the
healthcare system, (including an automatic heart screening) explicitly requiring a seamless referral
process to cardiology that removes the implications of bias. The proposed innovation, called Project
HeartWise, will increase the cardiovascular utilization rate of Black women while decreasing the
number of Black women who are misdiagnosed and turned away from cardiovascular care.
Project Methodology
The proposed innovation uses Lewin's three-stage change process to eliminate provider bias in
cardiovascular disease care of Black women is designed to raise provider awareness, educate, and
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demonstrate provider behavior change. In step one, confidential evaluation of provider attitude and
beliefs about Black women will be completed by providers to raise their awareness about their own
bias. The goal of this step is to unfreeze the negative stereotypes and beliefs held by providers who are
unaware of their bias toward Black women, and that prepares them for the second step. The pretest
given at the start of participation in the program and providers will complete the posttest survey not
later than at the end of the first year so that they can evaluate if there have been any changes in their
attitudes and beliefs about Black women.
In step two, providers will receive education about bias in health care. As an incentive to
participate in the program, providers will be offered a free, one-hour webinar offering continuing
medical education unit (CME) presented by a physician on the topic of "Provider Bias and Health
Disparities Related to Black Women," which will increase provider awareness of bias in healthcare
affecting Black women with heart disease. The one-hour presentation places emphasis on cultural
competence, cultural proficiency, cultural humility, characteristics, and skills that help providers work
effectively cross-culturally. Leveraging technology and the partnership with the University of
Wisconsin Collaborative Center for Health Equity, the free CME webinar will be accessible to
providers who use a login I.D. that can be accessed by computer, cell phone, and tablet. Webinar
attendance and completed course evaluations collected via a login I.D.; at the end of the webinar,
providers will evaluate the content of the webinar training, which must be submitted to receive a
certificate of completion.
In step three, provider behavior change will be observed and evaluated on two levels. During
the first level, providers in OB/GYN and primary care clinics will complete automatic heart screenings
and automatic seamless referrals to cardiology. These providers will complete and submit monthly
performance measures indicating the number of automatic heart screenings completed and the number
of automatic referrals made to cardiology. Behavior change indicators for providers in OB/GYN and
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primary care include 1) the number of Black women, both new and established patients who receive
heart screenings, and 2) the number of Black women, both new and established patients who are
automatically seamlessly referred to cardiology.
During the second level, behavior change is further indicated by cardiologists who receive
automatic referrals from the OB/GYN and primary care clinics. To align with best practices in
cardiovascular disease care, cardiologists will complete comprehensive, diagnostic testing and provide
an aggressive cardiac intervention with Black women. Cardiologists will complete and submit monthly
performance measures that demonstrate behavior change in the cardiovascular disease care process.
Behavior change indicators are connected to service delivery which includes types of clinical decisions
made, the use of patient-centered care during encounters, the number of comprehensive evaluations,
the number of diagnostic testings given, and aggressive interventions such as cardiac catheterization,
stents, angioplasty, medication management, the number of follow-ups for cardiac care, and heart
outcomes with Black women.
Landscape Implications
The proposed innovation is committed to eradicating the norms that uphold systemic racism in
cardiovascular disease care. The proposed change confronts the Theory of Structural Violence in
healthcare that is driven by the influence of social determinants of health on implicit provider bias. As
a best practice model, the proposed innovation enhances the cardiovascular screening and referral
process for Black women with heart disease risks and symptoms on an automatic basis. Provider
behavior change will focus on behavior metrics and performance measures to evaluate the
effectiveness of the proposed innovation.
The likelihood of the proposed innovation's success is real; its impact will resonate in the field
of cardiovascular disease care with Black women and will resonate with the Grand Challenge itself.
Also, the proposed innovation has the potential for scalability within the next five years. The impact
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will occur in four areas in the cardiovascular disease care of Black women. For example, there will be
an increase in the number of positive heart outcomes, including the reduction in deaths and disability.
There will be an increase in the number of Black women of all ages whose lives are saved by
detection, prevention, and aggressive cardiac intervention. As exhibited in the proposed innovation's
best practice model storyboard, the proposed innovation is scalable to other cardiovascular disease
centers in the United States and worldwide that serve Black women with heart disease within the
United States and worldwide.
Area Two: Conceptual Framework
Description of Social Problem
Health disparities, health care disparities, and health inequities adversely affect the health and
wellness of many Americans, including Black women with heart disease. Disparities in health refer to
the systemic differences in the availability and quality of care delivered to socially, economically, and
environmentally disadvantaged communities (Healthy People 2020, 2020). Despite the enactment of
the Affordable Care 2010, millions of Americans continue to be adversely impacted by disparities and
inequalities in the healthcare system/
After the passage of the Affordable Care Act 2010, millions of Americans are still adversely
affected by the gaps in both health and health care services (Spencer et al. 2016). Disparities in health
and health care impact marginalized groups in unprecedented numbers and illustrate the level of health
inequity in the American healthcare system. Health inequity is based solely along racial and ethnic
lines not related to issues of access to care, clinical preferences, or type of intervention. According to
the report "Unequal Treatment," the Institute of Medicine (2003) controlled for access to care barriers,
insurance, education, and income, racial and ethnic minorities receive worse health care than non-
minorities, and that both explicit and implicit provider bias play a potential role (Institute of Medicine,
2003). From this standpoint, the Grand Challenge Close the Health Gap in Social Work must be
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addressed from a systemic level to find solutions that might work to promote heart equity for Black
women (Spencer et al., 2016).
Prevalence and Impact
Black women are affected by heart disparity in cardiovascular disease. This population has a
higher prevalence of diabetes, hypertension, high cholesterol, high blood pressure, and lower rates of
physical inactivity, and possibly genetic predisposition to heart disease, they experience barriers to
cardiovascular disease care due to systemic implicit provider bias. The systemic wall of implicit
provider bias in cardiovascular disease care creates a specific structural injury to Black women as heart
disease. It is the number one killer of Black women.
The adverse impacts on Black women's cardiac health illustrate how implicit provider bias
disadvantages Black women's cardiovascular care. For example, Black women do not receive adequate
time with providers during encounters. Examining the correlation between the lack of patient-centered
care and race, Brewer et al. (2013) found that Black women with heart disease receive less time with
their providers during appointments than their White counterparts. Feeling ignored by providers
during visits suggests that Black women with heart disease feel unsupported by their providers. During
interviews with Black women about their experiences with providers, they report feeling invisible,
ignored, and not heard by providers during medical encounters (Johnson, 2019). Even more
concerning, Black women who present at emergency rooms with heart attack symptoms are being
misdiagnosed or turned away from receiving any cardiac screening or intervention. Braveman et al.
(2014) argue that implicit provider bias in cardiovascular disease care is a systemic barrier for Black
women who, even when having higher education and health insurance coverage, cannot gain access to
life-saving cardiac interventions.

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Relevant Concepts
It is essential to understand concepts related to the discussion of the problem. Health disparity,
heart disparity, health care disparity, social determinants of health, and implicit provider bias, health
equity, and heart equity will be defined to give clarity about how these concepts relate to the
discussion. For example, a health disparity is the type of health difference linked with social,
economic, and environmental disadvantages experienced. In contrast, health care disparity involves
systemic factors that lead to differences in quality of care delivered, such as, for example, the
differences between public and private hospitals (Healthy People 2020, 2020). Heart disparity refers to
the disproportionate or higher prevalence and rates of cardiovascular disease, new disability relative to
other groups in the country (Association of Black Cardiologists, 2018). For example, the heart
disparity experienced by Black women refers to the differences between this population and other
groups regarding health insurance coverage, access to and use of cardiovascular disease care, and
quality of that care (Association of Black Cardiologists, 2018; Williams, 2009).
Health equity is the attainment of the highest level of health for all people in a society that
values everyone equally (Healthy People 2020). One example of health equity is heart equity for Black
women, which ensures that Black women with heart disease who need cardiovascular disease care are
perceived and treated as equals by society. That community is willing to address historical and
contemporary health care inequalities experienced by this group.
Another concept relative to the discussion is the social determinants of health. Marmot (2009)
describes the social determinants of health as the socio-economic conditions that determine the
distribution of health wealth. The social determinants of health decide who gets health care, what kind
of health care, and the quality of health care received based on race, ethnicity, and gender, and other
socio-economic factors. The social determinants of health are the root cause of health disparities and
health inequity that are harmful to Black women with heart disease (Marmot, 2009).
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The concept relative to the problem is implicit provider bias. Grounded in the theory of
aversive racism, the provider who has implicit bias is emotional and involves the automatic,
unconscious attitudes, negative association, and evaluation of a person based on irrelevant
characteristics such as race or gender (DeAngelis, 2019). Bias, found in attitudes and beliefs related to
stereotypes about another group, generates from social determinants of health rooted in the historical
context of Black women within the American healthcare system that dates to slavery, and the
provider's upbringing related to family and community values. Implicit provider bias exists in the
spaces of 1) racism, 2) discrimination, 3) prejudiced attitudes, negative stereotypes, and reduced
perceptions of Black women, 4) stigma about Black women, 5) misdiagnosis and turning Black women
away from cardiac screening and care, and 6) misalignment with the use of patient-centered care with
this population. As a result, implicit provider bias adversely impacts clinical decision-making, service
delivery, and reduced heart outcomes for Black women with heart disease (Washington, 2006).
Literature Review
The literature review confirms the existence of the heart disparity experienced by Black
women. It is a public health issue that has potential implications on national security and workforce
diversity, the Black community, and Black families, many of which are headed by Black women
(Association of Black Cardiologists, Boston Scientific, 2018, Williams, 2009, Washington, 2006). -
Current research focuses on the prevalence and intervention strategies needed by this population.
Additional research supports the need for a comprehensive evaluation and early aggressive
cardiovascular disease intervention with Black women. A proponent of this approach, Williams (2009)
emphasizes the need to complete a thorough assessment, and to initiate early aggressive cardiac
intervention with this population. Completing a comprehensive cardiac history of Black women is
necessary for compliance with care. Worrall et al. (2012) argue that to get Black women's respect for
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managing their cardiovascular disease, ask Black women about their heart health history, including
their specific heart disease symptoms such as shortness of breath, chest pain, and other warning signs.
The high prevalence of the cardiovascular disease among Black women is devasting to this
population. Boggs (2017) asserts that the high rates of death and disability among Black women with
cardiovascular disease are indicative of the heart disparity experienced by Black women. Additionally,
there is a sound argument about raising the awareness of providers about the history of bias in
healthcare, including how the medical community, in the name of medical advancements, used
enslaved Black women in their treatments and experiments that caused emotional and physical trauma
to the health, wellness, and the lives of Black women. Additionally, Washington (2006) argues that it
is essential to understand contextually the link between systemic racism, Black women's health
disparities, and the disparities in health care experienced by Black women.
Providers have discretion about how much intervention and care they decide to give to patients.
Cooper (2014) studied the effects of racism on cardiovascular disease care. The researcher concluded
that race is a gradient used to determine who has access to cardiovascular disease care. However, the
researcher acknowledges that more research on this topic is needed. Implicit provider bias interferes
with the providers' ability to listen to the meaning of stress in the lives of Black patients. Brewer et al.
(2018) interviewed 4,383 Black adults who acknowledged that providers could gain patient trust by
simply recognizing stress in patients and talking about the stressors with their patients shows a sign of
genuine concern from providers. They conclude that developing a space where the patient's stress
level takes into consideration in cardiovascular disease care helps to build a real race-patient-physician
relationship.
Implicit provider bias affects service delivery to Black women with heart disease. Pezzin et al.
(2007) studied the existence of disparities in cardiovascular disease service delivery and found that
race and gender discrimination exist for Black women who have heart disease. The researchers
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gathered data from the U.S. National Hospital Ambulatory Health Care Surveys of Emergency
Departments experienced by Black women and found that Black women were less likely than all
groups to receive initial cardiac screening, testing, and monitoring when they present to emergency
rooms with heart symptoms (Pezzin et al., 2007).
Research suggests that at least one-third of cardiologists are unaware of the racial and ethnic
disparities in cardiovascular disease care that affects decision-making in cardiovascular disease care.
As a result, not only are Black women not receiving life-saving cardiovascular interventions, but they
lack the necessary education and awareness needed about their cardiac risks and symptoms. For
example, Mody et al. (2012) report that Black women do not receive adequate cardiovascular disease
education and therapy, including aggressive interventions such as cardiac catheterization for neither
acute coronary nor myocardial infarctions.
Negative stereotypes and stigma adversely affect the clinical relationship between providers
and patients who are Black women. Ahmed (2017) contends that negative stereotypes about Black
women can lead to both unconscious and conscious bias against these patients. The researcher
concludes that providers can benefit from understanding the relationship between health and
discrimination by paying more attention to the underlying social determinants of health that link to
discrimination in health care.
A review of articles gives evidence of bias in health care. FitzGerald (2017) reviewed 42 health
care articles containing vignettes, patient characteristics, and provider self-bias testing. The research
reveals that healthcare professionals have biases that are comparable to that of the general population
and that Black patients receive less rapport-building with their providers and less patient-centered care.
The phenomenon of less rapport-building and less patient-centered care with Black patients aligns with
the research. Phelan et al. (2019) believe that stereotype threat in the patient experience due to implicit
provider bias is detrimental to the relationship between provider and patient. They assert that when
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Black patients perceive a racially and other stereotypical threat from providers, the race-patient-
provider dynamic is adversely affected, resulting in the overall health care experience of Black
patients.
Discrepancies in cardiovascular disease care with Black women reflect how the healthcare
system has systematically failed Black women. Stallings (2018) emphasizes that Black women are not
getting treatment options due to provider bias. The author concludes that as a result of this systemic
failure, the risk for death and disability among Black women with heart disease increases (Stallings,
2018).
Engaging providers in studies that measure bias is challenging but is required to make progress
toward health care equality. According to van Ryn et al. (2015), although implicit provider bias is not
easy to capture or fix, it warrants continued investigation because of its implications for patient
treatment. Additionally, the current measurement of implicit bias is limited. According to a study
found by DeAngelis (2019), Implicit Association Tests taken by physicians used to measure their bias
found that physicians have higher anti-Black biases than all other test-takers, except for Black male
and female physicians. When sharing their reactions to their scores on the Implicit Association Test
(IAT), physicians were surprised at the strength of their biases (DeAngelis, 2019). Unfortunately, there
is new criticism about the poor test-retest reliability and validity implications of the Implicit
Association Test and the belief that higher test scores do not predict biased behavior (DeAngelo,
2019).
Social Significance
The systemic problem of implicit provider bias in the cardiovascular disease care of Black
women is both socially significant and vital to real people. The social significance illustrates the
imprint of Black women in spaces such as public health, workplace diversity, national security, the
Black community, and Black families. The adverse impact of implicit provider bias towards Black
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women is also socially significant regarding clinical decision-making, service delivery, and heart
outcomes which can be passed on to other marginalized, low income, communities of color affected by
health disparities and health inequity.
Without intervention into the systemic problem of implicit provider bias in cardiovascular
disease care of Black women, these women continue to be at risk for structural harm. The Theory of
Structural Violence refers to a form of systematic ways that social structures harm disadvantaged
groups (Matthew, 2015). The Theory of Structural Violence, a conceptual framework that emphasizes
how social structures that systematically puts people in harm's \way have neither a face nor an
individual who can be held accountable for the injury. When applied to cardiovascular disease care of
Black women, structural violence prevents Black women from meeting their basic cardiovascular care
needs, and it prevents Black women with heart disease from experiencing the quality of life (Matthew,
2015).
Knowledge Gap
The systemic barrier of implicit provider bias in cardiovascular disease care creates a specific
structural injury to Black women that has not been adequately addressed in the research. Despite the
poor heart health outcomes for Black women, there is limited research on how to eradicate implicit
provider bias in cardiovascular disease care of Black women.
Conceptual Framework and Theory of Change
The heart disparity that Black women experience due to implicit provider bias is a compelling
disparity to eradicate. The innovative step forward includes holding providers accountable for
recognizing their bias and its implications on cardiovascular disease care of Black women, aligning
with their Hippocratic Oath. Creating a unique innovation that disrupts the systemic problem of
provider bias in cardiovascular disease care aligns with the ideology that health equity is a fundamental
human right rooted in social justice.
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Additionally, the proposed innovation posits that health care for everyone should be at the
highest standard of care and not based on the social determinants of health (Marmot, 2017). Both
premises align with the belief that the lives of Black women with heart disease matter. Fixing the
problem requires a solution that is innovative, purposeful, viable, sustainable, and scalable. Scalability
suggests that the proposed innovation must have 1) evidence of effectiveness, 2) the potential to
expand its reach beyond its locality, be embraced by its target groups, and 3) deliverables that are at an
acceptable cost (Milat et al. (2013).
The heart disparity that Black women experience due to implicit provider bias is not only a
compelling disparity to eradicate, but it also allows for the leveraging of best practices and the
Hippocratic Oath in cardiovascular disease care with Black women. The innovation is a step forward in
closing the health gap in cardiovascular disease care for Black women. Disrupting the systemic
problem of implicit provider bias will be discussed in more detail using the Theory of Change Model
identified in the Seamless Referral Process flow chart. (Appendix O)
The purpose of the innovation is to intervene on the systemic problem of provider bias in
cardiovascular disease care of Black women. It disrupts the norms associated with this problem by
holding providers professionally and ethically accountable for recognizing and addressing their bias
related to the cardiovascular care of Black women. Designed to create automatic processes in the heart
screening and seamless referral using providers who work in OB/GYN and primary care, the
innovation also uses cardiologists to complete comprehensive evaluations, diagnostic testing,
interventions, and follow up care in a hospital setting.
The innovation offers a three-step intervention process that includes 1) raising provider
awareness of bias using self-administered pre- and post-testing, 2) educating providers about bias in
health care using a free one-hour webinar taught by a provider about bias in health care, and 3)
provider behavior change that will be tracked provider behavior change by the number of heart
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screening, seamless referrals to cardiology, and use of aggressive cardiovascular interventions using a
patient-centered care approach that is documented and tracked on monthly performance measures.
Area Three: Problems of Practice and Solutions
Program Description
The proposed innovation is a best practice model in cardiovascular disease care of Black
women due to systemic implicit provider bias. It is designed to intervene by testing for implicit
provider bias, creating automatic heart screening for new and existing Black women who present to
OB/GYN and primary care clinics. It evokes an automatic seamless referral process from OB/GYN
and primary care to cardiology clinics so that Black women with heart disease risks and symptoms
receive a comprehensive cardiac evaluation, diagnostic testing, and aggressive cardiac interventions
and follow-up services.
The program requires that participating providers identify and measure their own bias toward
Black women, their engagement and performance with Black women with heart disease risks and
symptoms, and to monitor the heart outcomes of this population based on their cardiac interventions.
These performance measures and heart outcomes are crucial for providers to align with best practices
in cardiovascular disease care of Black women, and the Hippocratic Oath.
The proposed innovation has an intense focus on implicit provider bias intervention and
strategies that disrupt the norms associated with implicit provider bias in cardiovascular disease care of
Black women. The proposed innovation will 1) decrease or eradicate the heart disparity that Black
women experience due to provider bias, 2) decrease poor heart outcomes among this population, 3)
increase Black women's access to aggressive cardiovascular care, 4) minimize the impact of the social
determinants of health on this population, and 5) increase the number of lives saved for Black women
with heart disease. Project HeartWise's core values center on emotional safety promises to both the
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participant doctors and Black women with heart disease, and it has the support and appreciation from
the program's staff and partners.
Logic Model
The proposed innovation connects well with the logic model and theory of change. To help
explain the change process, activities associated with the Logic Model show how the intervention
works by outlining the activities in preparation for program implementation. The logic model shows
the theory of change by identifying strategic inputs, activities, outputs, outcomes, and impact that will
make for a successful launch. The innovation's inputs are resources that are needed, such as a Project
Director, social worker, health advocate, data entry specialist, secretary, nurse, gynecologists, primary
care doctors, and cardiologists. The proposed innovation will change the course of cardiovascular
disease care of Black women in the United States and worldwide. It can serve as a model for other
marginalized groups who need cardiovascular disease care.
Proposed Innovation and the Effects on the Grand Challenge
Eliminating systemic implicit bias in cardiovascular disease care of Black women is a Grand
Challenge. The proposed innovation is a unique best practice model in cardiovascular disease care
designed to intervene in the systemic problem of implicit provider bias in the cardiovascular disease
care of Black women. The proposed innovation, called Project HeartWise, leverages the Hippocratic
Oath and technology to eliminate bias to eliminate health disparities in order to close the gap in
cardiovascular disease care experienced by Black women. The proposed innovation, implemented in a
large or small hospital setting, targets OB/GYN and primary care providers, and cardiologist directly
addresses the systemic implicit provider bias in an innovative way that disrupts the norms associated
with this problem. It helps to increase heart equity for Black women.
The proposed innovation helps to improve the Grand Challenge Close the Health Gap in Social
Work by leveraging social work values attending to health disparities, empathy, compassion,
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relatedness, and social justice. Also, the proposed innovation provides social workers with the
opportunity to make both immediate and positive impact on the lives of Black women with heart
disease while helping these women to navigate the healthcare system successfully. The proposed
innovation contributes to the medical field, as well, by eliminating the systemic barrier of implicit
providers that preclude Black women with heart disease to close the health gap. The proposed
innovation is a best practice model that leverages the Hippocratic Oath, and technology in
cardiovascular care with Black women.
The proposed innovation addresses issues related to the patient-race-provider dynamic ensuring
the patient gets adequate time and feels seen and heard during encounters, to feel seen and heard, to be
evaluated comprehensibly, to be educated about heart disease risks, symptoms, and to learns ways to
effectively manage one's own cardiovascular disease. management. provided a cardiac intervention
plan, to be treated respectfully, and to ensure Black women have a partner in the management of their
cardiovascular disease. Fourth, the proposed innovation decreases the number of premature deaths and
disability from heart disease experienced by Black women due to implicit provider bias. Also, the
proposed innovation creates heart equity for Black women with heart disease.
Innovation Defense
What is being done about provider bias in the cardiovascular disease care of Black women? At
this time, community-based efforts comprised of local and community clinics, medical group practices,
and community partnerships with stakeholders show their investment and commitment to increasing
the capacity for advocacy and prevention work with Black women with heart disease. The community-
based approach to cardiovascular disease care with Black women with heart disease has strengths and
weaknesses. Strengths highlighted by this approach is its focus on high-risk communities, prevention,
raising awareness of heart disease, and intervening on lifestyle and personal choices. Limitations of the
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community-based approach are the possible lack of interest by the target population who may perceive
the approach as irrelevant, intrusive, inapplicable, and unsustainable in its design.
Feedback from Multiple Stakeholders
The proposed innovation incorporates feedback from stakeholders. Stakeholders are allies,
collaborators, and partners of the proposed innovation who make up the Advisory Board. The
Advisory Board members are champions who align with the proposed innovation's core mission,
vision, and core values (Appendix M). These members come from various backgrounds, including
academic scholars, centers for health disparity, clinical and medical social workers, medical providers,
an epidemiologist, a cultural competence expert, clergy, community leaders, and Black women with
heart disease. Together, these stakeholders are committed to eradicating systemic racism in
cardiovascular disease care by championing the fundamental belief that heart equity is a basic human
right rooted in social justice.
Stakeholder feedback is valuable to the overall functioning and gives confirmation and
direction to the proposed program. Key takeaways from multiple stakeholders demonstrate their
thoughtful analysis about the systemic racism in cardiovascular disease care of Black women.
Healthcare is a business that is the genocide of Black people's health, and the belief that heart disease
is a byproduct primarily related to the stress from racism and discrimination, among other risk factors
that include the social and psychological impact of racism. Additionally, stakeholders believe that
medical intervention for Black women needs to include PTSD related to racial isolation and health
disparities.
The proposed innovation's stakeholders offer solutions to the systemic problem of implicit
provider bias in cardiovascular disease care of Black women. Each stakeholder completed a telephone
or Zoom virtual meeting. During these individual interviews, all felt that Black women with heart
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cardiac risks and symptoms are treated differently from their White counterparts with the same cardiac
risk factors and symptoms. They agree that proper attention, better screening and intervention, and set
priorities by the healthcare industry. Consistently, stakeholders assert that Black women need to be
informed about both general and personal heart disease risks and symptoms. One of the cardiologists
suggests that improved approaches are required for the treatment of cardiovascular disease in Black
women because the current ones available are not working. That race should have no role in saving the
lives of Black women with cardiovascular disease. This cardiologist states that the solution must
incorporate an institutional component to break through the systemic barriers in cardiovascular disease.
History, Policy, and Public Knowledge
There is a growing awareness about the role and impact of health disparities, health inequity,
and social determinants of health on the cardiovascular disease care of Black women.
Unfortunately, race as a determinant of health continues to be the underlying issue dominating the
public discourse on health care. Washington (2006) writes about the health care injustices experienced
by Blacks that date back to slavery. This phenomenon is clearly illustrated when reviewing the
historical context of slavery and noting the role of the medical community's use of enslaved Black
women to advance medicine. It addresses issues related to the patient-race-provider dynamic, ensuring
the patient gets adequate time and feels seen and heard during encounters. Another plan to eliminate
reliance on social determinants of health focuses on an education and training approach that also works
in collaboration with medical personnel; as noted by Marmot (2017), health equity is both a just and
morally right thing for any nation to do (Marmot, 2017).
Both sides of the political aisle have philosophical differences in healthcare and how to solve
the health gap. The national debate about health focuses on policy disagreements between the political
parties that differ in their thoughtful approach to health care. The current strategy has erroneously
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centered on health care access rather than on the underlying root causes for the health gap, which
include addressing racism and the social determinants of health (Marmot, 2017).
Steeped in an economic model, healthcare in the United States uses a business model that
emphasizes the cost of health care, and that gives the nod to the notion of privilege. Girod (2018)
estimates that in 2018, the federal government spent $1.1 trillion on health care, $225 billion in income
tax expenditures for health care, over $60 billion related to health disparities, and notes that a family of
four spent an average of more than $28,000 on health care (Girod, 2018). Gabow (2016) asserts that
the current strategy that focuses on the profit model versus the social justice model is not effectively
closing the health gap, while Marmot (2017) emphasizes the importance of education and training,
working in collaboration with medical professionals, and observing the patients from a broader
perspective as practical strategies to eliminate reliance on social determinants of health.
Politically, the proposed innovation aligns with liberals who are leading the discourse that
healthcare is a fundamental human right for everyone and one that is rooted in social justice. Believing
this paradigm shift is on the right side of the healthcare debate is evidenced by their accomplishments
in passing the 1965 Medicare (1965), the 1997 Children's Health Insurance Plan, and the 2010
Affordable Care Act (Democratic Party Platform, 2019). Liberal Democrats believe the trend toward
health equity is worth fighting for, and they vow to continue moving the country toward sustainable
health equity for all (Democratic Party Platform, 2019).
Opportunities for Innovation
There are opportunities for the creation of innovation in cardiovascular disease care that will fix
the problem of systemic implicit provider bias in cardiovascular disease care of Black women. The
proposed innovation uses the alignment between the norms and deviants associated with implicit
provider bias and heart disparity. Gaining traction is the shift away from conservative support for a
cost-driven business model in health care to the liberal assertion that health care is a fundamental
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human right and a social justice issue. This shift in public debate rests on the belief that health equity is
just and the morally right thing for any nation to do (Marmot, 2017). The shift in the national health
care debate comes at a time when Americans experience over three million positive coronavirus tests
with over 150,000 deaths in the United States due to COVID-19. The proposed innovation represents a
paradigm shift about health equity that also changes the debate about how to solve the gap in
cardiovascular disease that adversely impacts Black women. COVID-19 is yet another health disparity
experienced by Blacks and other communities of color. Kochanek et al. (2017) state Americans are
experiencing chronic health issues and health disparities; unrealized loss of financial impact on
families due to the high rates of deaths of Black women with heart disease underscores this point.
Facilitators
Partners and allies are essential to the proposed innovation's mission, vision, and core
values. Successful engagement requires drawing on each partner and ally's unique assets that ensure
the broadest representation of participants possible. Partners and allies are the proposed innovation's
champions who promote the fundamental belief that health care is a basic human right and social
justice. One of these champions is the University of Wisconsin Collaborative Center for Health Equity.
The Collaborative Center for Health Equity is assisting the proposed innovation by addressing
disparities in health and health outcomes in diverse communities of Wisconsin.
Another champion is the Director of Ball State University, and Director of MA Degree
Programs in Adult & Community Education., who assists the proposed innovation by linking it to local
and statewide community health that includes the Indiana Minority Health Coalition, Allen County
Health Disparities Coalition, and the Health Visions Midwest Coalition. Additional Champions linked
with the proposed innovation are social workers, mental health providers, and clergy field located in
Georgia, Ohio, and Wisconsin. Each plays a vital role in providing feedback, encouragement, and
identifying funding and cultural competence resources that might be useful to the proposed innovation.
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Political, organizational, and community obstacles
There may be adversaries who might want to stop the implementation of the proposed
innovation (Oberlander, 2007; Woolf et al., 2011). According to Graham et al., (2011), another
adversarial relationship might occur when Black women who have heart disease do not trust the doctor
who is not engaged in patient-centered care. Graham (2011) notes that an additional problem to
consider is when beneficiaries do not have many options in choosing their cardiologist based on their
health plan or lack thereof. Another obstacle discovered is the inability to a partnership or collaborate
with women’s and minority health organizations in Madison, Wisconsin, and in Cleveland, Ohio. The
directors of both organizations did not respond to outreach efforts to discuss the proposed innovation.
Analysis of these failed efforts concluded that the organizations were not interested in developing a
partnership or collaboration with the proposed innovation or prioritize the request to partner or
collaborate.
Area 4: Project Structure, Methodology and Action Components
Prototype
The proposed innovation is a best practice model that disrupts the systemic barrier of implicit
provider bias in cardiovascular disease care of Black women. The prototype is a website that delivers
an essential message to society about how the problem of systemic implicit provider bias adversely
impacts the lives of Black women with heart disease. The website links implicit provider bias, clinical
decision-making, service delivery, and reduced heart outcomes for Black women. The site uses
vibrant images of Black women and providers to tell the overall story of the linkage between implicit
provider bias in cardiovascular disease care of Black women and reduced heart outcomes.
Market Analysis
Efforts to address Black women and cardiovascular disease have focused primarily on lifestyle
issues, personal choices, and on raising awareness about one's risks and symptoms. For example, the
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American Heart Association's The Heart Truth campaign is a national awareness campaign sponsored
by the federal government and the first national campaign about women and heart disease to target
health care providers (Pregler et al., 2009). The campaign is grounded in well-informed research using
focus groups and partnerships to raise increase awareness of heart disease as women's number one
killer, and to help women begin to take action to manage their risks and symptoms (Long, et al. (2007,
The Heart Truth Campaign, 2020). Although The Heart Truth campaign reports, it has taken steps to
engage Black women, its effectiveness with this population remains to be seen, as efficacy is difficult
to evaluate with this population.
EPIS Framework
The proposed innovation will use the Exploration, Preparation, Implementation, Sustainment
(EPIS) framework as a strategic approach to implementing the proposed innovation. During the
implementation phase, the recruitment, selection, hire, and start dates are to be completed between the
period of December 2020 through June 2021. Flyers will be posted in OB/GYN, primary care, and
cardiology clinics to recruit providers. Selected providers will review and sign an informed consent
with attached program goals, roles and responsibility, and clinics will take a pretest for bias within 30
days of selection.
The EPIS Framework aligns with the priorities and implementation strategies of the proposed
innovation. The EPIS framework focuses on the exploration, inner and external contexts, networking,
facilitators, and barriers involved in the programs' implementation steps. In the Exploration phase, two
activities took place. First, one-hour telephone individual interviews with Black women with heart
disease provided qualitative research confirming the existence of the implicit provider bias in their
cardiovascular disease care. They shared their recommendations about specific observable behaviors
that biased providers need to change that considered racist, disrespectful, apathetic, and unprofessional
to work effectively with Black women with heart disease (Johnson, 2019).
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During the exploration phase of EPIS, a Design Lab group activity was held in a classroom
where classmates agreed to participate in discussing whether there is a need to address implicit
provider bias when working with Black women with heart disease risks and symptoms, and to explore
whether OB/GYN providers should be one of the lists of providers selected to participate in the
proposed intervention. The participants watch two short videos totaling approximately 3 minutes. The
first short video was presented by a Black cardiologist who warned that heart disease is worst for
Black women. The second short video showed two Black women explaining what it is like living with
heart disease. Participants received a copy of the proposed innovation's best practice storyboard to help
visualize and learn about the proposed innovation, the problem, and the solution. At least three critical
takeaways from the Design Lab activity resulted. First, participants suggested that hiring a nurse would
benefit innovation's heart screening process. However, participants assigned to respond to the vignette
seemed to avoid identifying or share their initial reactions to a Black woman becoming loud and angry
about perceived racism. Instead, this group provided feedback about heart disease educational
materials that might be helpful to patients.
Internal Context:
During the exploration stage, engagement with hospital leadership to develop a partnership is
crucial to the implementation of the proposed innovation to determine interest and the readiness for
implementation of the program, securing funding for the providers with the goal of creating a
memorandum of agreement between the hospital and the proposed innovation that supports covering
the salaries and wages of providers in their existing job descriptions, and in-kind resources for space,
equipment, furniture, technical and research support that will be necessary to implement the strategies.
Additional internal partnerships with providers and departments across the hospital are needed to assist
with the implementation of the proposed innovation. It is necessary to gain support and buy-in from
providers who are selected to participate and from the hospital's compliance office, which can ensure
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that providers can access the one-hour webinar on their platform, complete the course evaluation, and
provide the CME certificate.
External Context:
External partnerships with local academic resources will benefit the implementation and the
fidelity of the program, including the University of Wisconsin Collaborative Center for Health Equity,
WomenHeart, the American Heart Association, and the Association of Black Cardiologists, which will
provide academic advocacy, and research support. Further networking opportunities with inter-
organizational resources that generate allies build partnerships and collaborations with donors,
colleagues, local and state health coalitions, and professional organizations like the National
Association of Social Workers (NASW), the National Association of Black Social Worker (NABSW).
Barriers:
There are challenges in the implementation of the proposed innovation. Implementation
barriers include the inability to locate a medical facility in which to implement due to the lack of
interest, readiness, or funding. Another obstacle is the lack of provider interest or participation, and the
lack of adequate numbers of Black women seen during visits in the OB/GYN, primary care, and
cardiology clinics that could impact the scalability of the program. Some providers might be reluctant
to confront their bias toward Black women out of fear of being labeled racist. Others may believe they
have no bias toward this population and may conclude the innovation does not apply to them.
Providers might inconsistently initiate and participate in heart screening, seamless referral process, and
aggressive cardiovascular disease interventions. A medical facility may not want to allocate a
percentage of providers' workload to fund the salaries and benefits of doctors participating in this
program. Despite estimated surplus projections in both Start-Up and First Full Year Operation
summary budgets, finding the providers' salaries and benefits will be challenging and may require a
contingency plan.
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Facilitators
It is essential to have buy-in from facilitators that help the implementation process. These include the
hospital, primary care, and specialty clinics OB/GYN and cardiology. For example, collaborating with
the University of Wisconsin Collaborative Center for Health Equity will ensure access to the webinar
platform, the course evaluation, and CME certificate, as well as locating a physician to provide the
one-hour webinar training to ensure buy-in from the medical community.
Feasibility and Fidelity
To consider feasibility issues, the activities must adhere to the intention of the intervention.
That is why it is necessary to use existing providers who have proven experience to deliver the
intervention. Hiring a licensed medical social worker and cardiac nurse will also ensure responsiveness
to patient concerns and needs during the selection of program components. To help measure, monitor,
and analyze fidelity issues, other strategies such as the e use of documentation, collecting data from
provider bias pre-post-test and provider performance measure logs, patient satisfaction surveys of their
race-patient-provider relationship after visits, the number of referral rates to cardiology, number of
aggressive cardiac interventions, and type of heart outcomes, and feedback from Black women who
complete the patient-race-provider survey to evaluation completed at the end of each visit to assess
their relationship from their perspective.
Implementation Phase:
During the implementation phase, the recruitment, selection, hire, and start dates will be
completed between the period of December 2020 through June 2021. Providers selected from the
OB/GYN, primary care, and cardiology clinics will take the pretest for bias within 20 days of
selection. The program's staff will be hired and given opportunities for professional development to
maintain their credentials throughout the program. One week before the program's start date is June
2021, providers will also be reminded by email of the importance of their roles and informed of the
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program's short, intermediate, and long-term goals to improve cardiovascular disease care of Black
women, and the possibility to scale the program. The participants will have the opportunity to address
their questions or concerns in writing by email, phone, or virtual meeting any time during their
participation in the proposed innovation.
Sustainability
During the sustainability phase of the implementation process, it is crucial to measure the
effectiveness of what constitutes a good outcome. Methods used to gather information are essential
because of the focus on what should be sustained, for example, program-specific activities, training,
networking, approach and strategies, integration with other programs, funding, media campaign,
partnerships, and positive outcomes Palinkas, 2019).
Data Collection:
Data will be collected about the effectiveness of the proposed innovation, the responses on the
provider pre-and posttests, the responses about the one-hour webinar using course evaluations, and the
effectiveness of the implementation of the program. Also, the program's statistician will receive data
obtained from monthly performance measures submitted by providers that analyze and track practice
behavior. The statistician will synthesize the monthly results and create a quarterly report presented to
the Program Director; the Program Director will share the results with the staff and Advisory Board.
Data collected from interviews with key personnel, partners, and collaborators encountered during the
process of implementation. Semi-structured interviews with key staff will focus on themes such as
program and hospital support, ongoing funding, community support, and buy-in, coalitions and
collaborations, and current program issues.
Additionally, a web-based survey of stakeholders and other networks that serve Black women
with heart disease will be collected, with the results being disseminated internally to review and
analyze. Open-ended questions to partners and allies about their experiences with implementation and
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sustainment, facilitators, and barriers will help. The data will be analyzed for themes and subthemes
such as funding, consistency with organizational culture, favorable outcomes, evaluation, planning,
staff and other program infrastructure, and institutionalization, and then compared the proposed
innovation's implementation process.
Measures
Within thirty days of the start of the program in June 2021, providers will complete a
confidential, online pre- and posttest bias survey to evaluate their beliefs, attitudes, and behaviors
using a bias instrument related explicitly to Black women. (Appendix D) After completing the pretest
for bias, providers will be asked to maintain a journal of their thoughts about bias toward Black
women, and about what they learned from the webinar training and course valuation responses at the
end of each. A one-hour webinar training offered by the program will be used to identify changes in
personal responses to bias indicators, and any differences in their responses concerning their increased
or decreased learning about bias in health care presented by a physician.
To measure the impact of the proposed innovation on their practice with Black women,
providers will complete a confidential pre-and posttest questionnaire that focuses on attitudes, beliefs,
and behavior toward Black women six months after starting the program, and again at twelve months,
and again at least 30 days before their last day of operation with the proposed innovation. (Appendix
D). These patients will complete a confidential survey about their race-patient-provider-race-patient
evaluation survey to evaluate their perspective of the race-patient-provider relationship at the end of
encounters; this can be done with the assistance of the social worker if needed. These completed
surveys are submitted in a non-descript box located near the medical social worker's office to ensure
compliance and confidentiality with the process, and the survey responses can be mailed back to the
program in a self-addressed envelope to ensure delivery.
Monitoring and Evaluation:
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The establishment of the evaluation plan must be clear for asking the right questions and
getting the correct answers about the proposed innovation. The evaluation plan helps key program staff
decide about data collection, and data that track the critical matrices outlined in the logic model.
Palinkas (2019) purports a successful implementation, practical outcomes, and significant
improvement. Therefore, feedback about innovation gaps or lapses in program delivery is needed to
assess for success, quality assurance, and improvement issues.
There are implementation outcomes observed in the proposed innovation. For example,
observable implementation outcomes desired are 1) changes in provider behavior when providing
cardiovascular disease care to Black women, 2) the notation of increased awareness of provider bias,
and 3) professional commitment to reduce or eliminate provider bias in the cardiovascular disease care
of Black women. There will also be an increased alignment with best practices in cardiovascular
disease care of Black women that aligns with the Hippocratic Oath. The difference in bias and other
fundamental matrices tracked are the number of 1) providers who complete the bias pre- and posttest,
2) providers who complete webinar attendance, and course evaluation forms. Additional vital metrics
that tracked include 1) the number of Black women screened for heart disease, 2) the number of Black
women automatically and seamlessly referred to cardiology, 3) the number of Black women who
receive comprehensive diagnostic testing and evaluation labs that include stress tests, blood pressure
tests, and EKGs, and 4) the number of Black women who are recommended and receive aggressive
cardiovascular interventions such as cardiac catheterization, stents, angioplasty, and coronary artery
bypass graft surgery. Also evaluated is the number of hospitalizations for heart disease and follow up
cardiac care.
Process evaluation, outcome evaluation, and impact evaluation help to identify the strengths
and limitations of the proposed innovation so that adjustments are made as necessary. The program
benefits from process evaluation because of its focus on whether the proposed innovation was carried
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out as planned. Also, outcomes evaluation is appropriate in measuring change for program impact.
Lastly, the impact evaluation, which takes place at the end of the program's implementation, will
determine whether the program has brought about a change to the attitudes, believes, and behaviors of
providers to Black women with cardiovascular disease.
Budget
The costs associated with implementing the proposed innovation in a hospital setting is high.
The total revenue for the Start-Up budget is $2,550,000,00, and the First Full Year Operation budget
decreases to $2,3000.00; both budgets identify a surplus at the end of the respective year. The bulk of
personnel expenses will need to cover the following providers:
Structural Considerations and Plans
If the proposed innovation is implemented in a hospital setting, it will fall under the auspices of
the hospital's structure. Generally, hospitals are non-profit 501c3 entities that are governed by its Board
of Directors. Therefore, if the proposed innovation is successfully implemented under that structure,
the hospital has the final authority over the proposed innovation's financial auspices. The expected
source for the significant personnel is the medical facility willing to implement the proposed project.
The hospital's willingness to incorporate the proposed innovation into the providers' existing job
descriptions will cover the costs associated with providers' salaries and benefits. However, if the
medical facility is unable or unwilling to incorporate the proposed innovation into the existing job
descriptions of the provider to cover the cost of the provider's personnel expenses, the contingency
plan will be implemented under the auspices of Four Rivers & Associates LLC, a practice that
provides professional consulting services until a hospital setting is identified.
Stakeholder Involvement Plan

Leveraging support from a legislator is vital to the credibility of the proposed innovation. Key
takeaways from a recent interview with Indiana Senator Todd Young's office to discuss the proposed
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innovation found that the senator's work on advocacy for social justice in Black maternal health is in
alignment with the mission for heart equity as described in the proposed innovation. The senator's
office provided contact information for other state legislators who might also be interested in the area
of cardiovascular disease and Black women and who might become an ally to the proposed innovation.
The Indiana Minority Coalition is a focal point and a unified voice for local coalitions who
have concerns about health disparities in the state of Indiana. It is an effective platform to address and
solve the problem of systemic racism in cardiovascular disease care of Black women and to
disseminate information about the proposed innovation as an opportunity to solve it. Another
stakeholder involvement that includes relevant constituencies is the University of Wisconsin
Collaborative Center for Health Disparities. Outreach efforts have been made to inquire about the
Center's ability to provide specific education resources required in stage two of the proposed
innovation. These specific education resources include the learning platform needed to disseminate and
present the webinar, the identification of possible medical providers who can discuss the topic of bias
in health care, and provide the CME certificate given to providers who attend the webinar and who
also complete a course evaluation to measure their learning.

Communication Strategies

An effective strategic communication plan is needed to engage audiences in the proposed
innovation successfully. The Heart Equity for Black Women campaign is sponsored by the proposed
innovation to create an opportunity for heart equity for Black that disrupts implicit provider bias
through provider awareness, education, and provider behavior change
Dissemination plan and technology
The dissemination plan consists of using The Heart Equity for Black Women campaign to
become a brand that leverages its message through a short video platform format. The campaign
delivers an essential message about the critical role of provider bias as a systemic barrier in
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cardiovascular disease care of Black women and how implicit provider bias adversely impacts the lives
of Black women with heart disease. The short video points viewers towards the link
https://www.projectheartwise.org for more information about the implementation strategy taken by the
proposed innovation to eradicate the systemic problem of implicit provider bias in cardiovascular
disease care of Black women, and how to partner with the proposed innovation to action to advocate
for heart health equity for Black women with heart disease
Ethical concerns

The proposed innovations have a mission, vision, and core values that are available for review.
(Appendix N) Conscious decisions informed by ethical decision-making, moral awareness, and moral
decision-making using the NASW Ethical Principles to avoid unintentional and intentional injury to
participating providers. Vigilance regarding issues of nonmaleficence. To prevent potential ethical
violations, providers must receive and sign an informed consent form detailing the costs and benefits
of their involvement before starting the program. Also, in the event of HIPAA and confidentiality
violations, conflict of interest, program transparency, or other ethical concerns or dilemmas,
consultation with the NASW Office of Professional Review Board will be made (NASW, 2017).
Additionally, in the event of provider misconduct or suspected violations affecting patients seen in the
program, the peer review body at the hospital, or the local and state medical societies, or the state
licensing board will be notified (American Medical Association, 2020).
Area 5: Conclusion, Actions & Implications
Summary

Implicit provider bias is a systemic barrier in the cardiovascular disease care of Black women.
Heart disease is the number one cause of death for Black women in the United States, and many
women are unaware of their risks and symptoms. Also, heart disease causes disability in women living
with the disease as it interferes with daily activities such as taking a walk or climbing stairs. Compared
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with other groups, Black women have higher rates of heart disease risk factors and are less likely to be
aware of the threat posed by the condition.
Black women with heart disease do not receive heart screening, comprehensive evaluation,
diagnostic testing, diagnosis, aggressive intervention, medication, referral, or follow up cardiovascular
disease care on parity with Whites due to provider bias. Implicit provider bias in the cardiovascular
disease care of Black women affects clinical decision-making, service delivery, and reduced heart
outcomes for group, and in effect, is linked to the cardiovascular disease health disparity experienced
by Black women. The root causes of heart inequity for Black women are systemic and embedded in
implicit provider bias and the social determinants of health. These inequalities in health care
exacerbate the health gap, causing increases in the health gap between the rich and the poor (Brewer et
al., 2014; Johnson, 2017; Marmot, 2017.
Designing a best practice model in health care that disrupts the norms associated with systemic
implicit provider bias in cardiovascular disease care of Black women is innovative. It is an opportunity
to close the health gap and give voice to a marginalized group who has systematically been impacted
by health disparities, health care disparities, and health inequities. To leverage the Hippocratic Oath
and technology gives accountability to the change process in the design. The proposed innovation
shifts the national debate about cardiovascular disease care, implicit provider bias, and the role of
social determinants of health.
Opportunities
There are many opportunities to disseminate the prototype. The website can immediately be
shared on the internet to raise awareness about bias in health care. The website is a platform to spread
the word about the problem of implicit bias in cardiovascular disease care of Black women, and it
provides action steps to eliminate provider bias in health care. The public can answer the call to join as
a partner, collaborator, ally to advocate for health equity and heart equity for Black women because of
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their lives matter. A two-minute short video and an infographic are also available for immediate
dissemination on YouTube and LinkedIn about the adverse impact of implicit provider bias on clinical
decision-making, service delivery, and reduced heart outcomes with Black women, that provide
contact information if they want to get involved.
Social Work and Medicine
The proposed innovation is unique compared with other programs aimed to address Black
women's heart disease. Most attempts to assist Black women with cardiovascular disease are given
information about awareness, prevention, lifestyle, personal choices to help them with managing their
risks and symptoms. While many of those programs have success stories, they do not get to the
underlying causes of the health gap in cardiovascular disease care of Black women.
The proposed innovation is a best practice model in cardiovascular disease care of Black
women explicitly designed to intervene on the system of health care inequity on implicit using a three-
step change model to disrupt implicit provider bias to save the lives of Black women with heart
disease: 1) awareness, 2) education and 3) behavior change. The model attempts to hold providers
accountable for best practices in cardiovascular disease care by leveraging the Hippocratic Oath and
technology. Raising provider awareness of bias using pre-post-tests, educating them about the history
of bias in health care can help set the stage for behavior change in cardiovascular disease care that is
actionable and measurable.
The proposed innovation and impactful in a meaningful way. The proposed innovation uses a
Patient Questionnaire to give voice to Black women, allowing them to evaluate the services they
receive from providers and feel heard. who can speak about the patient-race-provider relationship
from her viewpoint, thus making her feel less invisible. The opportunity to be heard by the health care
system that has treated her with invisibility.
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Implications
There is a need for both systemic and policy changes that promote healthcare as a fundamental
human right, and that changes from a business model to a social model that supports that health care is
a fundamental human right and social justice issue. Without significant changes to the internal
structures that uphold racism in health care, Black women will continue to die from the systematic
barrier that prevents this population from obtaining life-saving cardiovascular disease care.
Risks and Limitations
Despite the benefits and of both the internal and external contexts, several barriers to
implementation exist. Challenges such as funding, finding a hospital setting to implement the program,
COVID-19, the lack of hospital and provider acceptance of the program implementation process and
outcomes must be sustainable, have fidelity, and be monitored and measured for quality assurance and
success.
Conclusion
Sustainability issues are so crucial in the implementation process and outcomes. Sustainability
issues in the Start-Up and First Full Year Operation remain a concern as it relates to the provider
personnel expense. Ethical concerns are addressed in the innovation through social work and medicine
through linkages to professional organizations that have oversight when reporting violations that
threaten the lives of the patients and that threaten the integrity of the program.
Next Steps

The next step is in the implementation phase is to continue to cultivate the proposed
innovation's implementation strategies. The innovator designer will continue to leverage technology to
disseminate its message using the www using social media platforms, including the website, the two-
minute short video, and using the infographic to promote the three-step change process. Collaboration
with the University of Wisconsin Collaborative Center for Health Disparities to access and coordinate
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resources for the one-hour webinar platform, course evaluation, and CME certificate. Opportunities to
partner and collaborate with new and established stakeholders to find a hospital setting for the
proposed innovation. If the contingency plan implements, it will provide consultation services that will
be the vehicle from which to provide consultation and training services about the model until a medical
facility is identified for implementation. At that time, the innovation will transition to a non-profit
entity under the auspice of the recognized medical facility

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Asset Metadata

Creator Johnson, Andra D. (author)

Core Title Implicit provider bias in cardiovascular disease care of Black women: the lives of Black women with heart disease matter

School Suzanne Dworak-Peck School of Social Work

Degree Doctor of Social Work

Degree Program Social Work

Publication Date 04/15/2021

Defense Date 07/24/2020

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag access,behavior change,black women,cardiovascular disease,clinical-decision-making,education,health disparities,health equity,heart disease,heart-health outcomes,implicit provider bias,OAI-PMH Harvest,service delivery,social determinants of health,systemic barrier,systemic racism in health care,theory of change

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Lewis, Jennifer (committee chair), Bremond, Diandra (committee member), Kay-Wicker, Robin C. (committee member)

Creator Email andrajoh@usc.edu,riversja2001@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-444263

Unique identifier UC11668249

Identifier etd-JohnsonAnd-9472.pdf (filename),usctheses-c89-444263 (legacy record id)

Legacy Identifier etd-JohnsonAnd-9472.pdf

Dmrecord 444263

Document Type Capstone project

Rights Johnson, Andra D.

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA