___________________________________________________________________ Implicit Bias in Health Care
Cultural Competence Cultural competence is broadly defined as practitioners’ knowledge of and ability to apply cultural information and appreciation of a different group’s cultural and belief systems to their work [14]. It has also been defined as a process between the patient and practitioner based on how patients identify and respond to their experiences based on their worldviews and cultural values when they seek help and then receive care [104]. The acquisition of cultural competence is a dynamic process, meaning that there is no endpoint to the journey to becoming culturally aware, sensitive, and competent. Some have argued that cultural curiosity is a vital aspect of this approach. Cultural Humility Cultural humility refers to an attitude of humbleness, acknowl- edging one’s limitations in the cultural knowledge of groups. Practitioners who apply cultural humility readily concede that they are not experts in others’ cultures and that there are aspects of culture and social experiences that they do not know. From this perspective, patients are considered teachers of the cultural norms, beliefs, and value systems of their group, while practitioners are the learners [15]. Cultural humility is a lifelong process involving reflexivity, self-evaluation, and self- critique [16]. Experts have identified five attributes of cultural humility: openness, self-awareness, egoless, supportive interac- tion, and self-reflection and critique [105]. Discrimination Discrimination has traditionally been viewed as the outcome of prejudice [17]. It encompasses overt or hidden actions, behaviors, or practices of members in a dominant group against members of a subordinate group [18; 106]. Discrimination has also been further categorized as lifetime discrimination, which consists of major discreet discriminatory events, or everyday discrimination, which is subtle, continual, and part of day- to-day life and can have a cumulate effect on individuals [19]. Diversity Diversity “encompasses differences in and among societal groups based on race, ethnicity, gender, age, physical/mental abilities, religion, sexual orientation, and other distinguishing characteristics” [20]. Diversity is often conceptualized into singular dimensions as opposed to multiple and intersecting diversity factors [21]. Intersectionality Intersectionality is a term to describe the multiple facets of identity, including race, gender, sexual orientation, religion, sex, and age. These facets are not mutually exclusive, and the meanings that are ascribed to these identities are inter-related and interact to create a whole [22].
• Age • Disability • Education • English language proficiency and fluency • Ethnicity • Health status • Disease/diagnosis (e.g., HIV/AIDS) • Insurance • Obesity • Race • Socioeconomic status • Sexual orientation, gender identity, or gender expression • Skin tone • Substance use
For example, studies have shown that implicit biases regarding pain experiences of Black patients and treatment adherence by patients with obesity continue to exist in health care. In one study, health professionals demonstrated less respect for patients with higher body mass index (BMI) [102]. These implicit biases affect how clinicians interact with patients, manage conditions, structure treatment protocols, and express empathy [103]. An alternative way of conceptualizing implicit bias is that an unconscious evaluation is only negative if it has further adverse consequences on a group that is already disadvantaged or pro- duces inequities [6; 13]. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals’ implicit biases can further exacerbate these existing disadvantages [13]. When the concept of implicit bias was introduced in the 1990s, it was thought that implicit biases could be directly linked to behavior. Despite the decades of empirical research, many questions, controversies, and debates remain about the dynamics and pathways of implicit biases [2]. OTHER COMMON TERMINOLOGIES In addition to understanding implicit and explicit bias, there is additional terminology related to these concepts that requires specific definition.
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