Implicit Bias in Health Care ___________________________________________________________________
• Sexual orientation, gender identity, or gender expression • Skin tone • Substance use
DEFINITIONS OF IMPLICIT BIAS AND OTHER TERMINOLOGIES
IMPLICIT VS. EXPLICIT BIAS In a sociocultural context, biases are generally defined as nega- tive 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 [5; 101]. These individuals are generally uninterested in changing their biases [102]. 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. The individual’s ideas may then be reflected in his/her work as a manager. FitzGerald and Hurst assert that there are cases in which implicit cognitive processes are involved in biases and con- scious availability, controllability, and mental resources are not [6]. The term “implicit bias” refers to the unconscious attitudes and evaluations held by individuals. These individu- als do not necessarily endorse the bias, but the embedded beliefs/attitudes can negatively affect their behaviors [2; 7; 8; 9; 102]. They are automatically activated, and an individual may not even be aware that these biases affect their behaviors and communication patterns [101]. Some have asserted that the cognitive processes that dictate implicit and explicit biases are separate and independent [9]. 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 necessar- ily change in accordance to these outward expressions [10]. Because implicit biases occur on the subconscious or uncon- scious level, particular social attributes (e.g., skin color) can quietly and insidiously affect perceptions and behaviors [11]. According to Georgetown University’s National Center on Cultural Competency, social characteristics that can trigger implicit biases include [12]: • Age
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. 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,
• Disability • Education • English language proficiency and fluency • Ethnicity • Health status • Disease/diagnosis (e.g., HIV/AIDS) • Insurance • Obesity • Race • Socioeconomic status
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