_____________________________________________________________ Cultural Competence: An Overview
PREJUDICE Prejudice is a generally negative feeling, attitude, or stereotype against members of a group [13]. It is important not to equate prejudice and racism, although the two concepts are related. All humans have prejudices, but not all individuals are racist. The popular definition is that “prejudice plus power equals racism” [13]. Prejudice stems from the process of ascribing every member of a group with the same attributes [14]. RACISM Racism is the “systematic subordination of members of tar- geted racial groups who have relatively little social power…by members of the agent racial group who have relatively more social power” [15]. Racism is perpetuated and reinforced by social values, norms, and institutions. There is some controversy regarding whether unconscious (implicit) racism exists. Experts assert that images embedded in our unconscious are the result of socialization and personal observations, and negative attributes may be unconsciously applied to racial minority groups [16]. These implicit attributes affect individuals’ thoughts and behaviors without a conscious awareness. Structural racism refers to the laws, policies, and institutional norms and ideologies that systematically reinforce inequities, resulting in differential access to services such as health care, education, employment, and housing for racial and ethnic minorities [17; 18]. BIAS: IMPLICIT AND EXPLICIT 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 [19]. 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 [20]. The term “implicit bias” refers to the unconscious atti- tudes and evaluations held by individuals. These individuals do not necessarily endorse the bias, but the embedded beliefs/ attitudes can negatively affect their behaviors [21; 22; 23; 24]. Some have asserted that the cognitive processes that dictate implicit and explicit biases are separate and independent [24].
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 [25]. 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 [26]. According to Georgetown University’s National Center on Cultural Competency, social characteristics that can trigger implicit biases include [27]: • Age • Disability • Education • English language proficiency and fluency • Ethnicity • Health status • Disease/diagnosis (e.g., human immunodeficiency virus [HIV]) • 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 [20; 28]. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals’ implicit biases can further exacerbate these existing disadvantages [28]. 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 [21]. Specific conditions or environmental risk factors have been associated with an increased risk for certain implicit biases, including [104; 105]: • Stressful emotional states (e.g., anger, frustration) • Uncertainty • Low-effort cognitive processing • Time pressure
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