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HPQ20910.1177/1359105313510336Journal of Health PsychologyBrener et al.
Article
The impact of pluralistic ignorance on the provision of health care for people who inject drugs
Journal of Health Psychology 2015, Vol. 20(9) 1240–1249 © The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1359105313510336 hpq.sagepub.com
Loren Brener1, Courtney von Hippel2, Robyn Horwitz1 and Jade Hamwood2
Abstract Health workers who work with people who inject drugs may believe that their colleagues hold less favorable attitudes toward health services for people who inject drugs than themselves—a phenomenon termed pluralistic ignorance. This research explores whether the presumed attitudes of their colleagues, rather than their own attitudes, predict the behavioral intentions of health workers toward people who inject drugs. A total of 57 hospital-based health workers were surveyed to assess their attitudes toward harm reduction services for people who inject drugs and their perceptions of colleagues’ attitudes. They then responded to a scenario assessing their likelihood of prescribing opiate-based medication to people who inject drugs. Data illustrate that participants support harm reduction services for people who inject drugs more than they believe their colleagues do, demonstrating pluralistic ignorance. Interestingly, participants’ prescription of opiate-based pain medication was predicted by beliefs about their colleagues’ support for services for people who inject drugs, rather than their own beliefs.
Keywords discrimination, health-care workers, health services, people who inject drugs, pluralistic ignorance, stigma
Introduction The relationship between private attitudes, social norms, and behavior is an area that has long received widespread interest. A person’s beliefs about the attitudes of others can influence his or her own attitudes and behavior (Ajzen and Fishbein, 1980; Miller and McFarland, 1991; Perkins and Wechsler, 1996; Turner, 1991). Pluralistic ignorance (Katz and Allport, 1931) occurs when group members erroneously believe that their privately held attitudes differ from the majority of their peers. For example, a recent study among
correctional officers demonstrates pluralistic ignorance whereby correctional officers believe their colleagues are more punitive and less accepting of prisoners than they are (Cook 1University 2University
of New South Wales, Australia of Queensland, Australia
Corresponding author: Loren Brener, National Centre in HIV Social Research, University of New South Wales, Sydney, NSW 2052, Australia. Email: [email protected]
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Brener et al. and Lane, 2013). Erroneous beliefs about the attitudes of others can be important, as these presumed beliefs have been shown to impact behavior in a variety of situations. For example, binge drinking, drug taking, gambling, political correctness, and condom use have been shown to be influenced by the presumed attitudes and beliefs of one’s peer group. It seems individuals feel an internal pressure to adopt an attitude or behavior that they believe is consistent with their peer group even though it deviates from their privately held stance (Bertholet et al., 2011; Borsari and Carey, 2001; Carey et al., 2011; Makela, 1997; Mattern and Neighbors, 2004; Miller and Morrison, 2009; Neighbors et al., 2007; Perkins and Craig, 2006; Perkins et al., 2005; Prentice and Miller, 1993; Van Boven, 2002). As a consequence, people can behave in ways that endorse public opinion, even though it may be contrary to their own attitudes and beliefs (Miller and McFarland, 1987). Hence, pluralistic ignorance can lead to the perpetuation of particular social norms, despite these norms being erroneous and lacking private support (Latkin et al., 2002). For example, in a study at Princeton University, Prentice and Miller (1993) found students’ believed they were more uncomfortable with drinking practices on campus than the average student. They also found an internalizing of the social norm with students showing a shifting of private attitudes on comfort levels and increased alcohol consumption toward the perceived norm over time. It is generally assumed that the attitudes of others are more conservative than one’s own, and a person may be afraid to act in accordance with their own more liberal opinions (Bicchieri and Fukui, 1999; Kauffman, 1981; Wheeler, 1961). An example from the health services arena can be seen in the discrepancy around support for harm reduction services. Harm reduction services are designed to reduce the harmful consequences associated with injecting drug use (Marlatt, 2002; Wodak, 1995). For example, needle and syringe
programs (NSPs) aim to reduce the health risks involved in the sharing of needles and injecting equipment, to provide information on reducing drug-related harms, as well as to ensure safe disposal facilities for injecting equipment (Black et al., 2004). Yet these types of services are often shut down due to lack of support and perceived negative attitudes within the community (Korner and Treloar, 2003; Southgate et al., 2000; Treloar and Fraser, 2007). However, despite adverse media reports and political opposition, research tends to show that community support for harm reduction is largely positive (Lenton and Phillips, 1997; Schwartzkoff et al., 1990; Treloar and Fraser, 2007). In this instance, it may be that people are afraid to publicly show support for harm reduction services in order to avoid appearing different from their peers. There is growing evidence that people who inject drugs (PWID) often face stigma and discrimination from health-care workers (Butt, 2008; Day et al., 2003; Fontana and Kronfol, 2004; Treloar and Hopwood, 2004). The attitudes of health-care workers toward PWID may reflect societal views of drug users as morally reprehensible and criminal (Ahern et al., 2007; Elliott and Chapman, 2000; Fife and Wright, 2000; Paterson et al., 2007). Negative attitudes of health-care staff toward PWID can impact the quality of health care provided (Brener et al., 2007; Humphreys et al., 1996; Rintamaki et al., 2007), client treatment access (Anti-Discrimination Board of New South Wales, 2001), and even treatment retention (Brener et al., 2010). The literature suggests that these negative attitudes manifest into discriminatory practices by health-care workers ranging from subtle to overt forms of discrimination (AntiDiscrimination Board of New South Wales, 2001; Brener et al., 2007; Crofts et al., 1997; Day et al., 2003. Research indicates that standards of patient care are not being properly adhered to, with inconsistent use of standard precautions (Frazer et al., 2011; Temple-Smith et al., 2006) and breaches of patient
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confidentiality (Anti-Discrimination Board of New South Wales, 2001) more commonplace among clients who are known to be injecting drug users. Discriminatory behavior on the part of health-care workers toward PWID is particularly evident in relation to the administration of opiate-based medication for pain relief, where research suggests that there is a reluctance to prescribe such medication to PWID (Gardner-Nix, 2003; Scanlon and Chugh, 2004; Schnoll and Weaver, 2003; Simpson, 2004). This reluctance may stem from health-care workers’ concerns about patients’ addiction and possible abuse of medication (Bhamb et al., 2006; Ponte and Johnson-Tribino, 2005). The documented unwillingness of some health-care workers to prescribe adequate pain relief to PWID may ultimately be influenced not only by the way they perceive PWID but also by the way they think their colleagues feel about PWID. For example, health-care workers may worry that providing opiate-based pain medication would be perceived by their colleagues as naive because their PWID clients are taking advantage of them. No research has yet examined how pluralistic ignorance may relate to individual’s treatment of others in a meaningful context such as the provision of health care. This research will explore whether health-care workers show pluralistic ignorance with regard to harm reduction services. That is, will health-care workers indicate that they are relatively supportive of healthcare services for PWID, while believing that their colleagues are less supportive of such services? In turn, pluralistic ignorance may then manifest itself in a reduced willingness to prescribe pain medication for their clients who inject drugs, as health-care workers will rely on the presumed attitudes of their colleagues to determine whether opiate-based pain medication should be provided. In sum, this research assesses whether an erroneous belief about colleagues’ attitudes will lead health-care workers to treat their PWID clients in a manner that fits neither their own preferences nor the preferences of their colleagues.
Methods Procedure Participants selected for the study were medical staff (doctors and nurses) working in the emergency department of two different public hospitals in metropolitan Brisbane, Australia, during the summer of 2010. These hospitals were chosen as they cater to a number of PWID. Contact was made with department directors, and approval was obtained for the study. Doctors and nurses working in the emergency department were told about the study by the directors. They were also given a summary of the study, which outlined the research and invited them to participate during their tea break or when there was a lull in activity. Non-probability purposive and convenience sampling was used in which any nurse or doctor working in the emergency department was eligible for the study. Potential participants were notified that the researcher would be available at the hospital on particular days to conduct the survey. A private space was set up in each hospital for participants to complete the survey with refreshments provided by the researchers (no other incentive was provided). Participants were given an information sheet explaining that the survey was about people who use drugs and that they were chosen to participate as they work in a hospital that caters to a number of PWID. The survey was self-administered and took less than 15 minutes to complete. A researcher was present during survey completion to answer questions and to ensure participants did not communicate with each other. The study had ethics approval from the University of Queensland and from the University of New South Wales Human Research Ethics Committee.
Instrument Pluralistic ignorance and harm reduction services. In order to establish whether pluralistic ignorance exists around the provision of harm reduction services for PWID, participants answered questions about their support for six different harm reduction services (Hopwood
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Brener et al. et al., 2010), followed by questions assessing their perceptions of colleagues’ support for these same services. A sample pair of items is as follows: How do you feel about needle and syringe programs (NSP)? By your estimation, what percentage of people in your profession would support a needle and syringe program (NSP)?
The six forms of harm reduction services participants were asked about include NSPs (example above), methadone maintenance program, Medically Supervised Injecting Centre, the trialing of prescribed heroin to PWID, pharmacies supplying sterile injecting equipment to PWID, and government-funded illicit drug user (peer based) organizations. Participants’ attitudes toward one of these harm reduction services were assessed first, followed by their estimation of how others in their profession support that same harm reduction service. This pattern was repeated for each of the six harm reduction services. Items assessing participant’s personal attitudes toward each harm reduction service were scored on a 5-point Likert scale from 1 (strongly oppose) to 5 (strongly support). Participants estimate of what percentage of others in their profession they believe support these services was indicated by circling the number that corresponds to their estimation on a scale that rose in 10 percent increments from 0 to 100 percent. In order to examine the relationship between participants’ attitudes and their estimation of others’ attitudes (i.e. the degree of pluralistic ignorance), the 6 items measuring participants’ attitudes toward harm reduction services (Cronbach’s alpha = .77) were coded as 0 (not supportive) or 1 (supportive). Items measuring estimations of others’ attitudes toward harm reduction services (Cronbach’s alpha = .79) were divided by 100 to convert it from a percentage to a scale with 0 (none of my colleagues support this service) and 1 (all of my colleagues support this service) as the endpoints.
Likelihood of providing opiate-based pain relief. The survey instrument provided a scenario in which participants indicated the likelihood that they would provide pain relief to a PWID. Participants read the following scenario and then responded on a 5-point scale with 1 (definitely not) and 5 (definitely would) as the endpoints: You are treating a patient who you know has a history of injecting drug use who also suffers from a painful medical condition. The patient insists on pain relief but you are not sure whether it is warranted at this time. How likely would you be to prescribe pain medication for this patient?
Demographics. At the end of the survey, participants answered questions to assess their age, gender, professional title (doctor or nurse), and percentage of hours spent working directly with PWID in the past week. All analyses were performed using SPSS V18.
Results Participants The sample included 57 medical staff (19 doctors and 37 nurses). The mean age of respondents was 39, one person did not respond to this question and one-third of the sample was male. Almost all (95%) of the participants reported spending 20 percent or less of their hours in the last week working with injecting drug users, indicating that the vast majority of the sample had a small degree of contact with PWID in comparison to their total patient load.
Pluralistic ignorance toward harm reduction services Scales measuring participants’ attitudes toward harm reduction services and the way they felt others in their profession thought of these services indicate that participants support harm reduction services more than they believe others support these services. Analysis of variance (ANOVA) results revealed that participants’ support for harm reduction services (mean (M) = .57,
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Journal of Health Psychology 20(9) prescribing pain medication. In contrast, Figure 2(b) shows that perceptions of colleagues’ attitudes toward harm reduction services predict whether pain medication will be provided. When the demographic variables (e.g. age and gender) are included in the primary analyses, the relationships described remain unchanged.
Discussion Figure 1. Results indicating that participants support harm reduction services more than they believe others support these services.
standard deviation (SD) = .32, standard error (SE) = .04, 95% confidence interval (CI) = [.48, .65]) was significantly greater than their estimation of others’ support (M = .48, SD = .15, SE = .02, 95% CI = [.44, .52]), demonstrating pluralistic ignorance, F(1, 53) = 5.47, p < .05. This pattern of results can be seen in Figure 1. Participants indicated that they were fairly likely to provide pain relief to a PWID client (M = 3.39; SD = 1.24). The likelihood of providing pain relief did not differ between men (M = 3.28; SD = 1.18) and women (M = 3.44, SD = 1.28), F(1, 53) = .22, p > .64. Importantly, pluralistic ignorance impacted participants’ behavioral intentions to provide pain relief. Specifically, regression analysis revealed that participants’ beliefs about their colleagues’ attitudes impacted whether they would prescribe pain medication to a PWID. Those who perceived their colleagues as supportive of harm reduction services (Beta = .35, p < .05) were more likely to prescribe medication in the pain relief scenario. In contrast, participants’ own support for harm reduction services had no impact on their likelihood of prescribing pain relief (Beta = −.18, not significant [NS]). These relationships are depicted in Figures 2(a) and (b) in which scatter plots of participants’ responses are provided along with the regression lines. Figure 2(a) demonstrates that participants’ attitudes toward harm reduction services do not predict their likelihood of
Findings from this study show evidence of differences between private support for harm reduction services and perceptions of the support for such services by colleagues. Specifically, health-care workers reported more positive attitudes toward harm reduction services than they perceived their colleagues to hold, thereby demonstrating pluralistic ignorance. Furthermore, the results of this exploratory study illustrate that the discriminatory behaviors of health-care workers may be influenced not by the way they feel, but by the way they think their colleagues feel. Specifically, medical staff who felt their colleagues were less supportive of harm reduction services for PWID were also less likely to prescribe opiate-based pain medication to a client who injects drugs, irrespective of their own support for harm reduction services. Indeed, participants’ own attitudes toward harm reduction services had no bearing on whether pain relief would be provided. Hence, this research shows that the perceptions of colleagues’ negative attitudes impact health workers’ own behavioral intent to prescribe opiate-based pain relief to PWID. There are a variety of possible implications of these findings. First, they highlight the link between pluralistic ignorance and discriminatory behavior and provide a rationale for the reported inadequate provision of pain relief to PWID despite health-care staff holding positive attitudes toward health services for PWID (Gardner-Nix, 2003; Scanlon and Chugh, 2004; Schnoll and Weaver, 2003; Simpson, 2004). Second, these findings may have important implications for the training of health-care staff who work with stigmatized groups such as PWID. The current emphasis on reducing stigma
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Par cipant’s support for harm reduc on services
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Figure 2. (a) Relationship between participant’s willingness to prescribe pain medication and participant’s support for harm reduction services; (b) relationship between participant’s willingness to prescribe pain medication and participant’s perception of others’ support for harm reducing services.
and discrimination within the health-care sector has been fueled largely by an acknowledgement of the impact that stigma and discrimination can have on client health and well-being (Butt, 2008; Fortenberry et al., 2002; Pascoe and Smart Richman, 2009), health-care access, drug treatment uptake, and treatment retention (Bodenlos et al., 2007; Brener et al., 2010). Programs developed to reduce negative attitudes among health-care workers largely focus on working with and attempting to change the attitudes of the individual health-care worker (Roche and Freeman, 2004). Findings from this research,
however, indicate that beliefs about coworkers’ attitudes are also important to address. Indeed, pluralistic ignorance may help explain a reported lack of support for health services for PWID within the community more generally. For example, the media has been known to report that community support for harm reduction services for PWID is low or even absent, despite research showing that this is not the case (Lenton and Phillips, 1997; Schwartzkoff et al., 1990; Treloar and Fraser, 2007). The findings of this exploratory study suggest that health-care education for those working
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with PWID should address the perceptions workers have about the beliefs of their colleagues. This may require a change in the focus of health education to emphasize not only the individuals’ own attitudes but also their thoughts and feelings about the attitudes of colleagues. Such health education can be developed using paradigms informed by social norms theory—which challenges pluralistic ignorance by presenting evidence depicting the true attitudes of the majority (Berkowitz, 2005). This theory works on the assumption that in order for a person to be receptive to the accurate norm, he or she must first be made aware of the discrepancy between his or her beliefs about the norm and the real norm (Glassman and Braun, 2010; Johnson, 2012).
Limitations and future research There are several limitations to the current study that should be noted. First, the sample was small, self-selected (i.e. doctors and nurses chose to participate during their break), and restricted to two hospitals in one capital city in Australia. As a consequence, it is not clear whether these results are widely generalizable. Second, the finding that pluralistic ignorance influences behavior was evident only in relation to the prescription of pain relief to PWID. While the data from this study illustrate the relevance of pluralistic ignorance in determining discriminatory behavior in an important healthcare context, future research with a larger health-care worker sample addressing a wider range of health-care attitudes and behaviors is required to provide further support for the relationship between pluralistic ignorance and behavioral outcomes. It would also be worthwhile to include a range of health-care workers who have greater or different types of contact with PWID (e.g. through drug treatment programs or at harm reduction services). It is noteworthy that the majority of our sample had little recent contact with PWID. Research suggests that effects of contact with PWID on the attitudes of health-care workers is not clear-cut and
may depend on the type of contact, context of contact, and type of attitude measured (Brener et al., 2007; Von Hippel et al., 2008). These issues would be interesting to explore further with reference to pluralistic ignorance. Finally, it is possible that social desirability caused participants to report more support for harm reduction than they actually felt. Although this possibility could account for the pluralistic ignorance found with regard to support for harm reduction services, it does not explain why perceptions of others’ support, and not participants’ own attitudes, predicted the likelihood of prescribing pain medication. As a consequence, it seems unlikely that social desirability is driving these results. Research on social norms theory suggests that highlighting the real attitudes of health-care workers’ colleagues in an intervention setting may help close the gap between health-care workers beliefs about their colleagues’ attitudes compared to their own attitudes. Dispelling such a myth of difference may, in effect, ensure that people act in accordance with their own beliefs when working with PWID, through an understanding that their beliefs are actually similar to those of their colleagues. It may also serve to lessen or prevent discriminatory actions based on erroneous beliefs about the attitudes of others. As noted, additional research should build on this finding by engaging with a larger and more diverse sample and addressing a number of meaningful behavioral outcomes. Such research would inform the design of an appropriate intervention to reduce discrimination and ensure that PWID are afforded good quality health care including adequate pain medication if required. The current research provides support for the significance of pluralistic ignorance in influencing behavior and ultimately in shaping discriminatory practices among health-care workers who work with stigmatized populations. Funding This research received no specific grant from any funding agency in the public, commercial, or not-forprofit sectors.
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HPQ20910.1177/1359105313510336Journal of Health PsychologyBrener et al.
Article
The impact of pluralistic ignorance on the provision of health care for people who inject drugs
Journal of Health Psychology 2015, Vol. 20(9) 1240–1249 © The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1359105313510336 hpq.sagepub.com
Loren Brener1, Courtney von Hippel2, Robyn Horwitz1 and Jade Hamwood2
Abstract Health workers who work with people who inject drugs may believe that their colleagues hold less favorable attitudes toward health services for people who inject drugs than themselves—a phenomenon termed pluralistic ignorance. This research explores whether the presumed attitudes of their colleagues, rather than their own attitudes, predict the behavioral intentions of health workers toward people who inject drugs. A total of 57 hospital-based health workers were surveyed to assess their attitudes toward harm reduction services for people who inject drugs and their perceptions of colleagues’ attitudes. They then responded to a scenario assessing their likelihood of prescribing opiate-based medication to people who inject drugs. Data illustrate that participants support harm reduction services for people who inject drugs more than they believe their colleagues do, demonstrating pluralistic ignorance. Interestingly, participants’ prescription of opiate-based pain medication was predicted by beliefs about their colleagues’ support for services for people who inject drugs, rather than their own beliefs.
Keywords discrimination, health-care workers, health services, people who inject drugs, pluralistic ignorance, stigma
Introduction The relationship between private attitudes, social norms, and behavior is an area that has long received widespread interest. A person’s beliefs about the attitudes of others can influence his or her own attitudes and behavior (Ajzen and Fishbein, 1980; Miller and McFarland, 1991; Perkins and Wechsler, 1996; Turner, 1991). Pluralistic ignorance (Katz and Allport, 1931) occurs when group members erroneously believe that their privately held attitudes differ from the majority of their peers. For example, a recent study among
correctional officers demonstrates pluralistic ignorance whereby correctional officers believe their colleagues are more punitive and less accepting of prisoners than they are (Cook 1University 2University
of New South Wales, Australia of Queensland, Australia
Corresponding author: Loren Brener, National Centre in HIV Social Research, University of New South Wales, Sydney, NSW 2052, Australia. Email: [email protected]
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Brener et al. and Lane, 2013). Erroneous beliefs about the attitudes of others can be important, as these presumed beliefs have been shown to impact behavior in a variety of situations. For example, binge drinking, drug taking, gambling, political correctness, and condom use have been shown to be influenced by the presumed attitudes and beliefs of one’s peer group. It seems individuals feel an internal pressure to adopt an attitude or behavior that they believe is consistent with their peer group even though it deviates from their privately held stance (Bertholet et al., 2011; Borsari and Carey, 2001; Carey et al., 2011; Makela, 1997; Mattern and Neighbors, 2004; Miller and Morrison, 2009; Neighbors et al., 2007; Perkins and Craig, 2006; Perkins et al., 2005; Prentice and Miller, 1993; Van Boven, 2002). As a consequence, people can behave in ways that endorse public opinion, even though it may be contrary to their own attitudes and beliefs (Miller and McFarland, 1987). Hence, pluralistic ignorance can lead to the perpetuation of particular social norms, despite these norms being erroneous and lacking private support (Latkin et al., 2002). For example, in a study at Princeton University, Prentice and Miller (1993) found students’ believed they were more uncomfortable with drinking practices on campus than the average student. They also found an internalizing of the social norm with students showing a shifting of private attitudes on comfort levels and increased alcohol consumption toward the perceived norm over time. It is generally assumed that the attitudes of others are more conservative than one’s own, and a person may be afraid to act in accordance with their own more liberal opinions (Bicchieri and Fukui, 1999; Kauffman, 1981; Wheeler, 1961). An example from the health services arena can be seen in the discrepancy around support for harm reduction services. Harm reduction services are designed to reduce the harmful consequences associated with injecting drug use (Marlatt, 2002; Wodak, 1995). For example, needle and syringe
programs (NSPs) aim to reduce the health risks involved in the sharing of needles and injecting equipment, to provide information on reducing drug-related harms, as well as to ensure safe disposal facilities for injecting equipment (Black et al., 2004). Yet these types of services are often shut down due to lack of support and perceived negative attitudes within the community (Korner and Treloar, 2003; Southgate et al., 2000; Treloar and Fraser, 2007). However, despite adverse media reports and political opposition, research tends to show that community support for harm reduction is largely positive (Lenton and Phillips, 1997; Schwartzkoff et al., 1990; Treloar and Fraser, 2007). In this instance, it may be that people are afraid to publicly show support for harm reduction services in order to avoid appearing different from their peers. There is growing evidence that people who inject drugs (PWID) often face stigma and discrimination from health-care workers (Butt, 2008; Day et al., 2003; Fontana and Kronfol, 2004; Treloar and Hopwood, 2004). The attitudes of health-care workers toward PWID may reflect societal views of drug users as morally reprehensible and criminal (Ahern et al., 2007; Elliott and Chapman, 2000; Fife and Wright, 2000; Paterson et al., 2007). Negative attitudes of health-care staff toward PWID can impact the quality of health care provided (Brener et al., 2007; Humphreys et al., 1996; Rintamaki et al., 2007), client treatment access (Anti-Discrimination Board of New South Wales, 2001), and even treatment retention (Brener et al., 2010). The literature suggests that these negative attitudes manifest into discriminatory practices by health-care workers ranging from subtle to overt forms of discrimination (AntiDiscrimination Board of New South Wales, 2001; Brener et al., 2007; Crofts et al., 1997; Day et al., 2003. Research indicates that standards of patient care are not being properly adhered to, with inconsistent use of standard precautions (Frazer et al., 2011; Temple-Smith et al., 2006) and breaches of patient
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confidentiality (Anti-Discrimination Board of New South Wales, 2001) more commonplace among clients who are known to be injecting drug users. Discriminatory behavior on the part of health-care workers toward PWID is particularly evident in relation to the administration of opiate-based medication for pain relief, where research suggests that there is a reluctance to prescribe such medication to PWID (Gardner-Nix, 2003; Scanlon and Chugh, 2004; Schnoll and Weaver, 2003; Simpson, 2004). This reluctance may stem from health-care workers’ concerns about patients’ addiction and possible abuse of medication (Bhamb et al., 2006; Ponte and Johnson-Tribino, 2005). The documented unwillingness of some health-care workers to prescribe adequate pain relief to PWID may ultimately be influenced not only by the way they perceive PWID but also by the way they think their colleagues feel about PWID. For example, health-care workers may worry that providing opiate-based pain medication would be perceived by their colleagues as naive because their PWID clients are taking advantage of them. No research has yet examined how pluralistic ignorance may relate to individual’s treatment of others in a meaningful context such as the provision of health care. This research will explore whether health-care workers show pluralistic ignorance with regard to harm reduction services. That is, will health-care workers indicate that they are relatively supportive of healthcare services for PWID, while believing that their colleagues are less supportive of such services? In turn, pluralistic ignorance may then manifest itself in a reduced willingness to prescribe pain medication for their clients who inject drugs, as health-care workers will rely on the presumed attitudes of their colleagues to determine whether opiate-based pain medication should be provided. In sum, this research assesses whether an erroneous belief about colleagues’ attitudes will lead health-care workers to treat their PWID clients in a manner that fits neither their own preferences nor the preferences of their colleagues.
Methods Procedure Participants selected for the study were medical staff (doctors and nurses) working in the emergency department of two different public hospitals in metropolitan Brisbane, Australia, during the summer of 2010. These hospitals were chosen as they cater to a number of PWID. Contact was made with department directors, and approval was obtained for the study. Doctors and nurses working in the emergency department were told about the study by the directors. They were also given a summary of the study, which outlined the research and invited them to participate during their tea break or when there was a lull in activity. Non-probability purposive and convenience sampling was used in which any nurse or doctor working in the emergency department was eligible for the study. Potential participants were notified that the researcher would be available at the hospital on particular days to conduct the survey. A private space was set up in each hospital for participants to complete the survey with refreshments provided by the researchers (no other incentive was provided). Participants were given an information sheet explaining that the survey was about people who use drugs and that they were chosen to participate as they work in a hospital that caters to a number of PWID. The survey was self-administered and took less than 15 minutes to complete. A researcher was present during survey completion to answer questions and to ensure participants did not communicate with each other. The study had ethics approval from the University of Queensland and from the University of New South Wales Human Research Ethics Committee.
Instrument Pluralistic ignorance and harm reduction services. In order to establish whether pluralistic ignorance exists around the provision of harm reduction services for PWID, participants answered questions about their support for six different harm reduction services (Hopwood
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Brener et al. et al., 2010), followed by questions assessing their perceptions of colleagues’ support for these same services. A sample pair of items is as follows: How do you feel about needle and syringe programs (NSP)? By your estimation, what percentage of people in your profession would support a needle and syringe program (NSP)?
The six forms of harm reduction services participants were asked about include NSPs (example above), methadone maintenance program, Medically Supervised Injecting Centre, the trialing of prescribed heroin to PWID, pharmacies supplying sterile injecting equipment to PWID, and government-funded illicit drug user (peer based) organizations. Participants’ attitudes toward one of these harm reduction services were assessed first, followed by their estimation of how others in their profession support that same harm reduction service. This pattern was repeated for each of the six harm reduction services. Items assessing participant’s personal attitudes toward each harm reduction service were scored on a 5-point Likert scale from 1 (strongly oppose) to 5 (strongly support). Participants estimate of what percentage of others in their profession they believe support these services was indicated by circling the number that corresponds to their estimation on a scale that rose in 10 percent increments from 0 to 100 percent. In order to examine the relationship between participants’ attitudes and their estimation of others’ attitudes (i.e. the degree of pluralistic ignorance), the 6 items measuring participants’ attitudes toward harm reduction services (Cronbach’s alpha = .77) were coded as 0 (not supportive) or 1 (supportive). Items measuring estimations of others’ attitudes toward harm reduction services (Cronbach’s alpha = .79) were divided by 100 to convert it from a percentage to a scale with 0 (none of my colleagues support this service) and 1 (all of my colleagues support this service) as the endpoints.
Likelihood of providing opiate-based pain relief. The survey instrument provided a scenario in which participants indicated the likelihood that they would provide pain relief to a PWID. Participants read the following scenario and then responded on a 5-point scale with 1 (definitely not) and 5 (definitely would) as the endpoints: You are treating a patient who you know has a history of injecting drug use who also suffers from a painful medical condition. The patient insists on pain relief but you are not sure whether it is warranted at this time. How likely would you be to prescribe pain medication for this patient?
Demographics. At the end of the survey, participants answered questions to assess their age, gender, professional title (doctor or nurse), and percentage of hours spent working directly with PWID in the past week. All analyses were performed using SPSS V18.
Results Participants The sample included 57 medical staff (19 doctors and 37 nurses). The mean age of respondents was 39, one person did not respond to this question and one-third of the sample was male. Almost all (95%) of the participants reported spending 20 percent or less of their hours in the last week working with injecting drug users, indicating that the vast majority of the sample had a small degree of contact with PWID in comparison to their total patient load.
Pluralistic ignorance toward harm reduction services Scales measuring participants’ attitudes toward harm reduction services and the way they felt others in their profession thought of these services indicate that participants support harm reduction services more than they believe others support these services. Analysis of variance (ANOVA) results revealed that participants’ support for harm reduction services (mean (M) = .57,
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Journal of Health Psychology 20(9) prescribing pain medication. In contrast, Figure 2(b) shows that perceptions of colleagues’ attitudes toward harm reduction services predict whether pain medication will be provided. When the demographic variables (e.g. age and gender) are included in the primary analyses, the relationships described remain unchanged.
Discussion Figure 1. Results indicating that participants support harm reduction services more than they believe others support these services.
standard deviation (SD) = .32, standard error (SE) = .04, 95% confidence interval (CI) = [.48, .65]) was significantly greater than their estimation of others’ support (M = .48, SD = .15, SE = .02, 95% CI = [.44, .52]), demonstrating pluralistic ignorance, F(1, 53) = 5.47, p < .05. This pattern of results can be seen in Figure 1. Participants indicated that they were fairly likely to provide pain relief to a PWID client (M = 3.39; SD = 1.24). The likelihood of providing pain relief did not differ between men (M = 3.28; SD = 1.18) and women (M = 3.44, SD = 1.28), F(1, 53) = .22, p > .64. Importantly, pluralistic ignorance impacted participants’ behavioral intentions to provide pain relief. Specifically, regression analysis revealed that participants’ beliefs about their colleagues’ attitudes impacted whether they would prescribe pain medication to a PWID. Those who perceived their colleagues as supportive of harm reduction services (Beta = .35, p < .05) were more likely to prescribe medication in the pain relief scenario. In contrast, participants’ own support for harm reduction services had no impact on their likelihood of prescribing pain relief (Beta = −.18, not significant [NS]). These relationships are depicted in Figures 2(a) and (b) in which scatter plots of participants’ responses are provided along with the regression lines. Figure 2(a) demonstrates that participants’ attitudes toward harm reduction services do not predict their likelihood of
Findings from this study show evidence of differences between private support for harm reduction services and perceptions of the support for such services by colleagues. Specifically, health-care workers reported more positive attitudes toward harm reduction services than they perceived their colleagues to hold, thereby demonstrating pluralistic ignorance. Furthermore, the results of this exploratory study illustrate that the discriminatory behaviors of health-care workers may be influenced not by the way they feel, but by the way they think their colleagues feel. Specifically, medical staff who felt their colleagues were less supportive of harm reduction services for PWID were also less likely to prescribe opiate-based pain medication to a client who injects drugs, irrespective of their own support for harm reduction services. Indeed, participants’ own attitudes toward harm reduction services had no bearing on whether pain relief would be provided. Hence, this research shows that the perceptions of colleagues’ negative attitudes impact health workers’ own behavioral intent to prescribe opiate-based pain relief to PWID. There are a variety of possible implications of these findings. First, they highlight the link between pluralistic ignorance and discriminatory behavior and provide a rationale for the reported inadequate provision of pain relief to PWID despite health-care staff holding positive attitudes toward health services for PWID (Gardner-Nix, 2003; Scanlon and Chugh, 2004; Schnoll and Weaver, 2003; Simpson, 2004). Second, these findings may have important implications for the training of health-care staff who work with stigmatized groups such as PWID. The current emphasis on reducing stigma
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Par cipant’s support for harm reduc on services
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Figure 2. (a) Relationship between participant’s willingness to prescribe pain medication and participant’s support for harm reduction services; (b) relationship between participant’s willingness to prescribe pain medication and participant’s perception of others’ support for harm reducing services.
and discrimination within the health-care sector has been fueled largely by an acknowledgement of the impact that stigma and discrimination can have on client health and well-being (Butt, 2008; Fortenberry et al., 2002; Pascoe and Smart Richman, 2009), health-care access, drug treatment uptake, and treatment retention (Bodenlos et al., 2007; Brener et al., 2010). Programs developed to reduce negative attitudes among health-care workers largely focus on working with and attempting to change the attitudes of the individual health-care worker (Roche and Freeman, 2004). Findings from this research,
however, indicate that beliefs about coworkers’ attitudes are also important to address. Indeed, pluralistic ignorance may help explain a reported lack of support for health services for PWID within the community more generally. For example, the media has been known to report that community support for harm reduction services for PWID is low or even absent, despite research showing that this is not the case (Lenton and Phillips, 1997; Schwartzkoff et al., 1990; Treloar and Fraser, 2007). The findings of this exploratory study suggest that health-care education for those working
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with PWID should address the perceptions workers have about the beliefs of their colleagues. This may require a change in the focus of health education to emphasize not only the individuals’ own attitudes but also their thoughts and feelings about the attitudes of colleagues. Such health education can be developed using paradigms informed by social norms theory—which challenges pluralistic ignorance by presenting evidence depicting the true attitudes of the majority (Berkowitz, 2005). This theory works on the assumption that in order for a person to be receptive to the accurate norm, he or she must first be made aware of the discrepancy between his or her beliefs about the norm and the real norm (Glassman and Braun, 2010; Johnson, 2012).
Limitations and future research There are several limitations to the current study that should be noted. First, the sample was small, self-selected (i.e. doctors and nurses chose to participate during their break), and restricted to two hospitals in one capital city in Australia. As a consequence, it is not clear whether these results are widely generalizable. Second, the finding that pluralistic ignorance influences behavior was evident only in relation to the prescription of pain relief to PWID. While the data from this study illustrate the relevance of pluralistic ignorance in determining discriminatory behavior in an important healthcare context, future research with a larger health-care worker sample addressing a wider range of health-care attitudes and behaviors is required to provide further support for the relationship between pluralistic ignorance and behavioral outcomes. It would also be worthwhile to include a range of health-care workers who have greater or different types of contact with PWID (e.g. through drug treatment programs or at harm reduction services). It is noteworthy that the majority of our sample had little recent contact with PWID. Research suggests that effects of contact with PWID on the attitudes of health-care workers is not clear-cut and
may depend on the type of contact, context of contact, and type of attitude measured (Brener et al., 2007; Von Hippel et al., 2008). These issues would be interesting to explore further with reference to pluralistic ignorance. Finally, it is possible that social desirability caused participants to report more support for harm reduction than they actually felt. Although this possibility could account for the pluralistic ignorance found with regard to support for harm reduction services, it does not explain why perceptions of others’ support, and not participants’ own attitudes, predicted the likelihood of prescribing pain medication. As a consequence, it seems unlikely that social desirability is driving these results. Research on social norms theory suggests that highlighting the real attitudes of health-care workers’ colleagues in an intervention setting may help close the gap between health-care workers beliefs about their colleagues’ attitudes compared to their own attitudes. Dispelling such a myth of difference may, in effect, ensure that people act in accordance with their own beliefs when working with PWID, through an understanding that their beliefs are actually similar to those of their colleagues. It may also serve to lessen or prevent discriminatory actions based on erroneous beliefs about the attitudes of others. As noted, additional research should build on this finding by engaging with a larger and more diverse sample and addressing a number of meaningful behavioral outcomes. Such research would inform the design of an appropriate intervention to reduce discrimination and ensure that PWID are afforded good quality health care including adequate pain medication if required. The current research provides support for the significance of pluralistic ignorance in influencing behavior and ultimately in shaping discriminatory practices among health-care workers who work with stigmatized populations. Funding This research received no specific grant from any funding agency in the public, commercial, or not-forprofit sectors.
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