Maternal Health Disparities ___________________________________________________________________
Implicit bias has been linked to a variety of health dispari- ties [23]. Health disparities are differences in health status or disease that systematically and adversely affect less advantaged groups [24]. These inequities are often linked to historical and current unequal distribution of resources due to poverty, structural inequities, insufficient access to health care, and/ or environmental barriers and threats [25]. As illustrated, health disparities have been clearly documented in maternal and perinatal care among racial/ethnic groups. In an ideal situation, health professionals would be explicitly and implicitly objective, and clinical decisions would be com- pletely free of bias. However, healthcare providers have implicit (and explicit) biases at a rate comparable to that of the general population [22; 26]. It is possible that these implicit biases shape healthcare professionals’ behaviors, communications, and interactions, which may produce differences in help seek- ing, diagnoses, and ultimately treatments and interventions [26]. They may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients’ trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up [15]. POWER DYNAMICS Power dynamics are inevitable in many situations, including throughout the healthcare system, when two or more individu- als are attempting to balance the power among themselves. These dynamics may look different in various situations. Seven types of power dynamics have been identified: coercive, expert, reward, informational, formal, referent, and connection [27]. When power is exerted differently between the parties, inequity can result. In practice, healthcare professionals may use power to protect their autonomy and exert their expertise. This can lead to problems in interprofessional collaboration and in a failure to focus on the patient’s role in making healthcare deci- sions, advocating for their needs and preferences, and being an empowered member of the care team. Communication, competence, and role perceptions are common factors that influence power dynamics [28]. ORGANIZATIONAL FACTORS Larger organizational, institutional, societal, and cultural forces contribute, perpetuate, and reinforce implicit and explicit biases, racism, and discrimination. Psychological and neuro- scientific approaches ultimately decontextualize racism [17; 29]. Sources of bias in organizations include internal politics, culture, leadership, organizational history, and team-specific structures. Organizational bias reaches far beyond individuals themselves; the language used or tasks identified influence how the organization functions daily [30]. Bias within an organiza- tion can detour patients from visiting if they feel they are being viewed or cared for as a “lesser” patient. One of the primary roles and responsibilities of health professionals is to analyze how institutional and organizational factors promote racism and implicit bias and how these factors contribute to health disparities. This analysis should extend to include one’s own position in this structure.
EXPLICIT AND IMPLICIT BIAS Bias plays a pivotal role in health care, especially patient care. Therefore, it is important to define the term. In a sociocultural context, biases are generally defined as negative evaluations of a particular social group relative to another group. Explicit biases are conscious, whereby an individual is fully aware of his/her attitudes and there may be intentional behaviors related to these attitudes [13]. For example, an individual may openly endorse a belief that women are weak, and men are strong. This bias is fully conscious and is made explicitly known. Implicit bias refers to the unconscious attitudes and evaluations held by individuals. These individuals do not necessarily endorse the bias, but the embedded beliefs/attitudes can negatively affect their behaviors [14; 15; 16; 17]. Some have asserted that the cognitive processes that dictate implicit and explicit biases are separate and independent [17]. Implicit biases can start as early as 3 years of age. As children age, they may begin to become more egalitarian in what they explicitly endorse, but their implicit biases may not neces- sarily change in accordance with these outward expressions [18]. Because implicit biases occur on the subconscious or unconscious level, particular social attributes (e.g., skin color) can quietly and insidiously affect perceptions and behaviors [19]. According to Georgetown University’s National Center on Cultural Competency, social characteristics that can trigger implicit biases include [20]: • 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
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 disadvan- taged or produces inequities [21; 22]. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals’ implicit biases can further exacerbate these existing disadvantages [21].
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MDNJ1525
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