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Implicit Bias and Cultural Competency in Healthcare Nursing CE Course

2.0 ANCC Contact Hours

About this course:

This 2-hour course reviews the current and historical context of health disparities, racism, and implicit bias. More specifically, the consequences of implicit bias in healthcare are discussed with examples of how various groups (i.e., racial, ethnic, gender, maternal, and infant, among others) have experienced health inequities. Finally, strategies to mitigate implicit bias are discussed, including individual, educational, and organizational; community engagement; inclusive communication; and cultural competency.

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Notice for nurses licensed in Michigan state: This course is not currently able to be used to fulfill the Michigan Implicit Bias CE requirement as it is not an interactive/live module.


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This 2-hour course reviews the current and historical context of health disparities, racism, and implicit bias. More specifically, the consequences of implicit bias in healthcare are discussed with examples of how various groups (i.e., racial, ethnic, gender, maternal, and infant, among others) have experienced health inequities. Finally, strategies to mitigate implicit bias are discussed, including individual, educational, and organizational; community engagement; inclusive communication; and cultural competency. 

After this activity, learners will be prepared to:

  • Discuss the current and historical context of health disparities, racism, and implicit bias
  • Describe the importance of culture and culturally competent care
  • Discuss several examples of how implicit bias impacts health outcomes of various groups, including racial, ethnic, gender, sexual identity, and disability 
  • Discuss how implicit bias has impacted maternal and infant health outcomes, including the role of reproductive justice 
  • Describe strategies to mitigate implicit bias, including individual, educational, and organizational, as well as inclusive communication
  • Discuss the importance of community engagement in mitigating implicit bias

Healthcare providers (HCPs) are responsible for offering high-quality, evidence-based care to optimize patient outcomes. This care should be delivered fairly and equitably to all patients regardless of age, gender, race, ethnicity, religious or cultural background, sexual identity, or physical disability. In 2003, the Institute of Medicine (IOM) produced two seminal reports entitled Crossing the Quality Chasm and Unequal Treatment, catalyzing a movement to address healthcare disparities across all healthcare organizations. In Crossing the Quality Chasm, the IOM identified six pillars for high-quality healthcare, including efficiency, effectiveness, safety, timeliness, patient-centeredness, and equitable care. In the Unequal Treatment report, the IOM highlighted existing healthcare disparities. For example, the IOM reported that People of Color often receive lower-quality healthcare than their white counterparts, even with the same insurance, socioeconomic status, and comorbidities. Since the Crossing the Quality Chasm report, healthcare has made meaningful progress in 5 of the six pillars. However, despite increased recognition and efforts to address healthcare disparities, many inequities persist within the healthcare system (Bryant, 2021; The Joint Commission [TJC], 2016; Wyatt et al., 2016). 

For HCPs to understand the impact of healthcare disparities and strategies to mitigate the barriers to equitable and culturally competent care, they must be familiar with the following definitions.

  • Implicit bias refers to the attitudes or stereotypes that unconsciously affect our actions, understanding, and decisions. These biases can include favorable and unfavorable assessments of another person. Implicit biases are activated involuntarily without individual awareness or intentional control (TJC, 2016).
  • A disability is any condition of the mind or body that creates difficulties in performing activities or interacting with the world (Centers for Disease Control and Prevention [CDC], 2020).
  • Faith is a strong belief in something or an unseen higher power (Potter et al., 2017).
  • A health disparity is any difference (unjust or not) in health outcomes between populations. It is influenced by sex, sexual identity, ethnicity, age, disability, socioeconomic status, and geographic location (US Department of Health and Human Services [HHS] Office of Disease Prevention and Health Promotion [ODPHP], 2020). 
  • Health inequity refers to differences in health outcomes that are systematic, avoidable, and unjust (Wyatt et al., 2016). 
  • A health-disparity population is any specific population with a significant disparity in overall disease prevalence, incidence, morbidity, or mortality rates compared to the general population. Within the US, Hispanic/Latino people, Native American/Alaska Natives, African Americans, Native Hawaiians and Pacific Islanders, Asian Americans, underserved rural populations, socioeconomically disadvantaged populations, and underrepresented sexual and gender groups are all health-disparity populations (Bryant, 2021). 
  • LGBTQIA+ is a term that stands for lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other sexual and gender identities (National LGBTQIA+ Health and Education Center, 2020).
  • Social determinants of health (SDOH) are conditions in the places where people are born, live, work, learn, and play that impact health risks and outcomes (CDC, 2021a). 
  • Religion is a system of beliefs practiced to express spirituality (Potter et al., 2017).
  • Spirituality refers to connectedness within oneself and with others, the environment, and an unseen higher power (Potter et al., 2017).
  • Culture is "the integrated pattern of human knowledge, belief, and behavior that depends upon the capacity for learning and transmitting knowledge to succeeding generations" (Merriam-Webster, 2020). Potter and colleagues (2017) highlight norms, values, and traditions passed down from generation to generation in their definition of culture. 
  • Cultural competence means the provider understands and addresses the entire cultural context of each client within the domain of care. Culturally competent care consists of providing medical care in a way that considers each patient's values, beliefs, and practices (Georgetown University Health Policy Institute, n.d.). Similarly, the National Institutes of Health (NIH) defines cultural respect as the delivery of healthcare services respectful of and responsive to diverse patients' health beliefs, practices, and cultural and linguistic needs (2016). 
  • Culturally sensitive care means the provider is aware and knowledgeable of different cultures and their prevalence in the local community (Potter et al., 2017).
  • Culturally appropriate care means the provider applies their knowledge of a client's culture to their care delivery (Potter et al., 2017).
  • Culturally congruent care is customized to an individual's culture, health-illness context, needs, values, and beliefs (Leininger, 1999). 
  • Transcultural nursing means providing healthcare to patients based on their culture, values, health-illness context, and beliefs (Leininger, 1999).
  • Cultural humility is the practice of self-reflection on how one's background and the background of others impact various interactions such as learning, healthcare, engagement, leadership, and teaching. In addition, the practice of cultural humility means committing to work individually and with others to end inequity and power imbalances (University of Oregon, n.d.). 

Culture comprises a group of people who share beliefs, faith systems, values, ways of thinking, and actions. Culture provides a framework in which illness is defined, as people tend to react differently to disease based on their cultural perspective. Patients vary widely in their cultural and spiritual backgrounds and belief systems. Culture includes multiple attributes such as communication style, language, customs, norms, traditions, religion, art, musi


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c, dress, health beliefs, and health practices. Since culture influences health beliefs and practices, HCPs must examine and address their preconceptions before providing optimal culture and spiritual care to their patients (Potter et al., 2017). 

Additionally, ethnicity, race, gender, sexual orientation, and immigration status are essential considerations in the expanding view of culture. Nurse theorist Madeleine Leininger (1999) explained transcultural nursing as a comparative study of cultures to understand their similarities and differences. In essence, the goal of transcultural nursing is to provide culturally congruent care that is meaningful and compatible with each patient's values. For example, rather than advising all patients to take medications at one time during the day, a nurse can provide culturally congruent care by learning about each patient's lifestyle and customizing their recommendations to fit this lifestyle. In addition, HCPs can focus on offering personalized care through culturally competent care (Leininger, 1999). In other words, culturally competent care is a process by which HCPs provide individualized care, which is crucial for reducing healthcare disparities (Albougami et al., 2016).

Background

Mahzarin Banaji and Anthony Greenwald first coined the term implicit bias in 1995, arguing that unconscious associations and judgments primarily influence social behavior. These researchers theorized that for every conscious decision made, there are many more decisions made unconsciously based on previously learned information. The human brain begins learning from the moment of birth. People use feedback from loved ones, friends, caretakers, teachers, and the media to alter behavior and shape beliefs early in life. With large amounts of data to process, we categorize and assign judgments (good or bad) to the data. Therefore, inherent biases are formed through exposure to, responses to, and feedback from various sources. For example, people exhibit biases when they exhibit a preference for or an aversion to a group of people. These biases are the foundation for stereotypes, prejudice, and discrimination. Once learned, these stereotypes and prejudices are resistant to change, even when evidence disproves them. Research has shown that implicit bias, specifically pro-white bias, occurs in children as young as 3 to 5 years old (Glas & Faloye, 2020; Narayan, 2019; Perception Institute, n.d.; TJC, 2016).

Some biases may be exhibited with awareness and intention, known as intentional or explicit biases. However, implicit biases reside deep in the subconscious and are not accessible through introspection (e.g., examining one's mental and emotional processes). Since most actions occur without conscious thought, implicit biases will often predict how people respond more accurately than conscious values. For example, HCPs can value and intend to provide equitable care to all patients; however, research shows that implicit bias creates health disparities and inequities. Thus, HCPs will use these unconscious attitudes, perceptions, or judgments when making clinical decisions. In addition, stressful situations can compound implicit bias since acting from these unconscious, initial perceptions requires less time and energy. Therefore, HCPs may exhibit attitudes or behaviors that do not align with their commitment to equitable care (Glas & Faloye, 2020; Narayan, 2019; Perception Institute, n.d.).

Health Disparity and Inequity

Despite increased awareness among patients and providers, disparities in health and healthcare remain pervasive. Health inequities appear in health outcomes and healthcare, arising from educational, environmental, and socioeconomic factors. Health results from a complex interplay of factors, including individual (e.g., genetics, lifestyle), population group (e.g., sex, sexual orientation, race and ethnicity, immigration status), and SDOH. There is a strong link between social determinants and healthcare disparity. Social attributes such as income/wealth, education, access to healthcare, family and household structure, social support, occupation, neighborhood conditions, and social institutions are examples of SDOH (Potter et al., 2017). For example, children living in poverty are more likely to experience obesity. Studies have also reported that Black people are more likely to die of cardiovascular disease than their white counterparts. In addition, transgender men are less likely to have adequate pap screening than cisgender (a person whose personal identity and gender corresponds with their birth sex) women. Anyone can experience a health disparity based on race, ethnicity, age, sex, gender, sexual identity, religion, immigration status, socioeconomic status, or other differentiating characteristics. While social, environmental, and economic disadvantages can impact the degree of health and disease risk factors, they do not account for all gaps in health outcomes among various populations (Bryant, 2021; CDC, 2021c; ODPHP, n.d.). 

Although progress has been made in narrowing the gap in health outcomes, eliminating health disparities has not occurred. For example, African American women have the highest percentage of preterm births (11%), and rates of low-birth-weight infants have increased for African American and Hispanic infants. Native Americans and Alaska Natives have some of the highest infant mortality rates (i.e., 60% higher than their white counterparts). Obesity is another condition that affects underrepresented racial and ethnic groups at a disproportional rate. Hispanic children and adolescents (ages 2 to 19) have the highest prevalence of obesity in the US (21.9%). Heart disease is a leading cause of death and disability, disproportionately affecting people across races, ethnicities, and genders. For example, African Americans are 30% more likely to die prematurely from heart disease than their white counterparts. In addition, African American men are twice as likely to die prematurely from a stroke than their white peers. Although the health disparity gap for most outcomes has decreased over time, the gap has increased for some. For example, the African American-white disparity gap for acquired immunodeficiency syndrome (AIDS) has grown substantially in diagnoses and mortality (Baciu et al., 2017; ODPHP, n.d.). 

Furthermore, approximately 61 million US adults are affected by a disability, which translates to 26% of the US population. Disabled individuals face many health disparities, such as higher rates of obesity, smoking, and inactivity; fewer preventive screenings; and higher rates of death from breast and lung cancers (CDC, 2020). Research also suggests that some LGBTQIA+ people have more chronic conditions with a higher prevalence and an earlier onset of disabilities than individuals who do not identify as LGBTQIA+ (National LGBTQIA+ Health and Education Center, 2020). In the US, the identified LGBTQIA+ population has increased to 4.5%, highlighting the need for additional cultural competence to reduce healthcare disparities for this community in particular (Gallup, 2018).

Healthcare disparities result in poor health outcomes for specific populations and a significant financial burden. The excess disease burden from healthcare disparities leads to increased costs for health systems, patients and families, insurers, and employers (through lower work productivity and higher absenteeism). In 2009, the total cost of racial/ethnic disparities was approximately $82 billion, with $60 billion in excess healthcare costs and $22 billion in lost productivity. If these disparities persist, the estimated economic burden in the US will increase to $353 billion by 2050. A disproportionate share of healthcare costs in the US is related to patients with complex health needs. Because individuals with lower socioeconomic status and underrepresented racial/ethnic groups often have more chronic health conditions, their cost for care is significantly higher. In addition, these racial/ethnic groups are more likely to experience adverse events, longer hospitalizations, and more readmissions and undergo inappropriate and costly tests. These health disparities and inequities primarily occur due to ineffective communication processes, a limited ability to understand different cultures, and implicit biases (Wyatt et al., 2016). 

Racism

Interpersonal and structural racism are fundamental causes of health disparities and health inequities. According to the Office of Minority Health and Health Equity (OMHHE), 2010 statistics show that the US population has become increasingly diverse, with approximately 36% of the population being People of Color. However, racism can negatively affect a person's physical and mental health, preventing them from attaining optimal health. Across the country, People of Color experience higher rates of poor health than their white counterparts. These individuals are more likely to be diagnosed with diabetes, hypertension, obesity, asthma, and heart disease. In addition, Black Americans have a 4-year lower life expectancy than white Americans. Recent data have also shown that Black American, Hispanic/Latino, Native American, and Alaska Native populations experience higher rates of hospitalization and death from COVID-19. These health disparities exist even when accounting for other socioeconomic factors. Both current and historical experiences of racism and discrimination have often led to mistrust of the healthcare system by People of Color. Forced sterilization of women and the Tuskegee Syphilis Study are examples of medical abuse contributing to distrust of the healthcare system for affected racial communities. This mistrust has carried forward to the COVID-19 pandemic, fueling suspicion of vaccines, vaccination providers, and institutions making recommendations regarding the use of vaccines (Bryant, 2021; CDC, 2021c; OMHHE, 2021a, 2021b).

Interpersonal racism refers to biased responses when individuals interact with others of a different race. For example, interpersonal racism has been evident throughout the COVID-19 pandemic, with various attacks on Asian and Asian American communities. Microaggressions (i.e., verbal, behavioral, or environmental discriminatory actions, whether intentional or unintentional, against members of a particular group) are forms of interpersonal racism (OMHHE, 2021a, 2021b; Vanderbilt University, n.d.). According to the National Institute on Minority Health and Health Disparities (NIMHD; 2021), structural racism and discrimination (SRD) refer to the macro-level conditions, such as institutional policies or residential segregation, that impact individuals and populations. SRD can limit opportunities and resources that negatively impact access to healthcare and the well-being of affected individuals or populations based on race, ethnicity, gender, religion, immigration status, physical characteristics or health conditions, sexual identity, social class, or another differentiating status. For example, neighborhood segregation has been shown to impact racial disparities directly in health outcomes (NIMHD, 2021). 

In the 19th and 20th centuries, racism fueled the segregation of Black and white people, with segregated hospitals delivering separate and unequal healthcare. The Civil Rights Act of 1964 was the first step toward desegregating hospitals; however, many of these institutions refused to desegregate until the Medicaid and Medicare program in 1966 threatened to withhold federal funding. Many local, state, and national organizations have attempted to address health and healthcare inequities in the last few decades. In 1985, the US Department of Health and Human Services Office of Minority Health released the Heckler Report, which addressed racial and minority health. It recommended a nationwide approach for improving minority health. In 2003, the IOM released the Unequal Treatment report discussed above that included recommendations for addressing disparities in practice and research. Finally, in 2010, the National Center on Minority Health and Health Disparities (NCMHD) became part of the NIH in response to the Affordable Care Act (ACA) becoming law. The NCMHD was tasked with eliminating inequities in health and healthcare. However, despite efforts at the local, state, organizational, and national levels, health and healthcare inequities remain due to structural racism (Ortega & Roby, 2021). 

The ACA was designed to address health inequities by expanding access to healthcare for more populations (i.e., those who are experiencing economic inequality and are uninsured). However, even with the expansion of Medicaid and the insurance marketplace, health insurance inequities persist. Another component of the ACA was the shift from fee-for-service to value-based programs to reduce spending and increase the value of care. In addition, incentives were given to institutions that engaged in care coordination and penalized poor-performing hospitals. However, safety-net hospitals (e.g., those serving low-income populations) are less likely to have the resources to engage in value-based models and, therefore, are more likely to be penalized. In addition, lower payment rates from Medicaid and Medicare result in fewer providers accepting patients with these types of insurance. Finally, although numerous studies have demonstrated the continued inequities in health and healthcare, many researchers fail to connect systemic and structural racism as the likely driver of these inequities. These studies highlight that the problem of health inequity persists, but research has failed to explain how racism and discrimination can impact the poor quality of care. Without citing racism as a primary driver of health or healthcare inequities, researchers and organizations can propose or imply harmful conclusions to explain the data, such as blaming health inequities on the populations affected by them. These examples demonstrate that structural racism persists and contributes to ongoing health inequities experienced by Populations of Color (Ortega & Roby, 2021). 

Implicit Bias in Healthcare

Implicit bias affects everyone: every individual makes unconscious judgments or stereotypes about other people or experiences the biases of others based on a differentiating status. Implicit bias involves activity throughout the brain, including the frontal cortex (i.e., reasoning, first impressions, and empathy), amygdala (i.e., automatic responses to stimuli and fear-flight-freeze response), and temporal lobes (i.e., storage of basic information about individuals and social stereotypes). In some situations, implicit bias can be helpful. For example, a person can quickly assess and instinctually respond based on learned behavior when faced with a dangerous situation. However, implicit bias is usually manifested when automatic responses combined with social conditioning result in bias against another individual based on a differentiating status such as race, disability, immigration status, or sexual identity (American Academy of Family Physicians [AAFP], 2019). 

The Implicit Association Test (IAT) is a computerized measurement of implicit preferences that bypasses conscious processing. The University of Virginia, the University of Washington, and Harvard University collaborated to form Project Implicit, utilizing the IAT to examine the thoughts and feelings outside conscious awareness or control. As a result, more than 4.5 million IAT tests were completed between 1998 and 2006, demonstrating that (a) implicit bias is pervasive, (b) individuals are often unaware of their implicit bias, (c) implicit biases can predict behavior, and (d) individuals have different levels of implicit bias (TJC, 2016). Many healthcare organizations have begun administering the IAT to HCPs, highlighting that implicit bias exists among HCPs at the same rates as the general population. For example, when the IAT was administered at an obesity conference, the results showed that participants associated obese individuals with stereotypes such as being lazy and worthless (Institute for Healthcare Improvement [IHI], 2017; TJC, 2016). Gopal and colleagues (2021) conducted a systematic review and found that the IAT was commonly used throughout the literature. However, other researchers have questioned whether the IAT can accurately predict discrimination. Due to the conflicting information in the literature, Gopal and colleagues recommend that the IAT only be used as a tool for self-reflection and learning and not for punitive reasons (2021). 

Research has shown that HCP implicit bias can negatively impact the patient-provider relationship. In addition, implicit bias can influence treatment decisions, treatment adherence, clinical decision-making, and patient health outcomes. These biases, though unintentional, can have severe consequences for health and healthcare. Not only can implicit bias perpetuate healthcare disparities, but it can also negatively impact patient-centered care, communication, trust, and interpersonal treatment. HCPs may not be aware of their implicit bias, but their patients likely are. When a patient experiences implicit bias, they are more likely to rate their experience poorly and less likely to engage meaningfully in their care. Therefore, implicit bias can impact whether patients seek services at a particular organization. Whether explicitly or implicitly, HCPs can make assumptions about patients that can negatively impact the care given. For example, some HCPs may limit shared decision-making or explanations of medical concepts because they assume a patient has a low health literacy. Similarly, HCPs may limit treatment options because they assume that patients cannot afford them (Heath, 2020; IHI, 2017; TJC, 2016). Other examples of how implicit bias has impacted healthcare include the following (Baciu et al., 2017; Chopik & Giasson, 2017; IHI, 2017; TJC, 2016):

  • Black women are more likely to die after a breast cancer diagnosis.
  • People of Color are more likely to be labeled as too passive about their healthcare.
  • Black men are less likely to receive chemotherapy or radiation therapy for prostate cancer.
  • Women are three times less likely to receive a knee arthroplasty than men when clinically appropriate. An underlying bias in this situation is that men are more stoic and more inclined to participate in strenuous activity.
  • Black and Latino patients experience longer wait times for medical care. In addition, white HCPs often spend less time with Patients of Color. 
  • Black men are more likely to have testicle(s) removed for testicular cancer.
  • Non-white patients are less likely to have pain medication (i.e., narcotic or non-narcotic) prescribed. One reason for this variation in treatment was the false belief that Black individuals have tougher skin than white individuals. 
  • Non-white patients receive fewer renal transplants than white patients.
  • Non-white patients receive fewer cardiovascular interventions than white patients.
  • Black patients are more likely to die in the ICU, receiving life-sustaining interventions rather than transitioning to hospice care. 
  • Pediatric non-white patients are less likely to be accurately diagnosed with cystic fibrosis because it is considered a "white disease."
  • Veterans have a higher risk of suicide, PTSD, depression, and substance abuse than the general population. 
  • Negative attitudes or stereotyping about older age are associated with memory impairments, slower recovery from disability, and poor health behavior and physical functioning for aging patients. 

Power Dynamics

The patient-provider relationship can foster patient engagement in their care and establish trust. However, a power dynamic can potentially influence this relationship (i.e., how power affects a relationship between 2 or more people). HCPs are well-educated individuals tasked with providing high-quality, equitable care to patients across various races, ethnicities, gender identities, and other differentiating statuses. Unfortunately, HCPs can display implicit bias during patient-provider interactions, resulting in a negative experience and mistrust. When patients experience implicit bias from providers, they may interpret care recommendations as a form of control or dominance in the relationship. Therefore, HCPs must be acutely aware of their communication patterns, particularly their verbiage. According to social psychology theories, people in powerful positions can use first-person plural pronouns (i.e., "we," "ours," or "us") to maintain control over others with perceived lesser power. For example, HCPs with higher implicit bias scores are more likely to use language like, "We will lose weight, right?" This type of language can perpetuate the power dynamic within a patient-provider relationship (DeAngelis, 2019). 

Health Disparities in Obstetric and Gynecologic Health

Approximately 700 women in the US die each year during pregnancy or the year after. Another 50,000 women experience severe pregnancy-related complications. Implicit bias in reproductive healthcare can lead to disparities in health outcomes and access to care for underserved racial and ethnic populations. Multiple factors contribute to health disparities, including underlying chronic conditions, variations in the quality of care, structural racism, and SDOH. Racial disparities are well documented in obstetrics and gynecology care. For example, non-Hispanic Black women have higher preterm birth rates than their white counterparts (Bryant, 2021; CDC, 2021f). Some additional examples of racial disparities in obstetric and gynecologic care include: 

  • Maternal death in the US is more prevalent in non-Hispanic Black women than in other groups. According to data from the CDC Pregnancy Mortality Surveillance System (PMSS), Black and Native American/Alaska Native women are 2 to 3 times more likely to die from pregnancy-related causes than white women (CDC, 2021f; Petersen et al., 2019). 
  • Severe maternal morbidity (SMM) refers to a life-threatening event during pregnancy, delivery, or postpartum. Numerous studies have found that Women of Color were more likely to experience SMM than white women. For example, Black women had a 115% higher risk of SMM than white women. Similar findings were reported for all other racial and ethnic minority groups compared to non-Hispanic white women. In a cross-sectional analysis of a large nationwide database, Aziz and colleagues (2019) evaluated over 11.3 million births between 2012 and 2014. The researchers found that non-Hispanic Black women were approximately 80% more likely to be readmitted postpartum and 16% more likely to experience an SMM during readmission than non-Hispanic white women (Aziz et al., 2019; Bryant, 2021).
  • Impact on postpartum hemorrhage: Gyamfi-Bannerman and colleagues (2019) conducted a retrospective cohort study of 360,000 women who experienced postpartum hemorrhage. After adjusting for comorbidity, non-Hispanic Black women who experienced postpartum hemorrhage had a higher risk of severe morbidity and death than non-Hispanic white women. 
  • Cancer mortality: Black and Hispanic women have higher cervical cancer rates and associated mortality than non-Hispanic white women. Similarly, non-Hispanic Black women have higher mortality rates for ovarian cancer than white women. In addition, Black women have a 55% higher mortality risk for endometrial cancer than White women. One reason for these disparities is that Black women are more likely to be diagnosed later due to care that varies from recommended guidelines. Finally, Black women have a higher mortality rate for breast cancer, even though they have a lower incidence of the disease than white women (Bryant, 2021; Huang et al., 2020). 
  • Infant mortality is defined as the death of an infant before their first birthday, while the infant mortality rate is the number of deaths for every 1,000 live births. In 2019, the infant mortality rate in the US was 5.6 deaths per 1,000 live births. The five leading causes of infant mortality include preterm birth and low birth weight, injuries, sudden infant death syndrome (SIDS), congenital disabilities, and maternal pregnancy complications. In addition, racial and ethnic disparities exist for maternal pregnancy complications and preterm birth, contributing to disparities in infant mortality rates. In 2018, the infant mortality rates were: non-Hispanic Blacks 10.8, Native Hawaiian or other Pacific Islander 9.4, Native American or Alaska Native 8.2, Hispanic 4.9, non-Hispanic white 4.6, and Asian 3.6 per 1,000 live births (CDC, 2021b).
  • Other outcomes: Racial and ethnic disparities exist across other health outcomes. For example, Latino women have had the highest increase in gestational diabetes compared to other racial/ethnic groups. Asian women have double the risk of severe obstetric perineal laceration compared with other racial/ethnic groups. Black women are more likely than white women to undergo open surgery and experience surgical complications when undergoing a hysterectomy for benign indications (Bryant, 2021). 

These examples highlight the health disparities and inequities among racial and ethnically diverse populations related to obstetrical and gynecological health outcomes. These differences may be partially attributed to patient-level variables such as biological factors or genetics. However, many of these differences persisted even after researchers controlled for many of those characteristics. Research has also highlighted numerous differences in the healthcare that women of diverse racial/ethnic populations receive (i.e., health screening, type of care, and level of care). Biological or genetic factors cannot explain these differences, highlighting systemic and structural barriers to care equity (Bryant, 2021). 

Some examples of these healthcare disparities include (Bryant, 2021; White et al., 2017):

  • Health screening: The United States National Health Interview Survey (NHIS) data shows that non-Hispanic Black women have higher mammography screening rates than other groups. However, Native American/Alaska Native and Asian women are least likely to be up to date with recommended cervical and breast cancer screenings. 
  • Hysterectomy: Black women, Hispanic women, and women with public insurance are less likely to receive minimally invasive techniques (i.e., laparoscopic, robotic, or vaginal) for hysterectomy than white women.  
  • Ectopic pregnancy: Like hysterectomy procedures, Black and Hispanic women were less likely to receive tube-conserving surgery (i.e., salpingostomy) for an ectopic pregnancy than white women. 
  • Contraception: Black and Hispanic women are less likely to use highly or moderately effective contraception than white women.

Determining the factors that impact the disparities in healthcare provided to women of different races and ethnicities can be challenging. These factors can include the patient, clinician, healthcare system, and sociocultural levels. First, patient-related factors may play some role in the disparities in health outcomes or care received. For example, women may advocate for varying degrees of quality care based on their education level or health literacy. Next, implicit bias among clinicians is another factor that can result in different levels of care provided to women of different racial/ethnic groups. In addition to implicit bias, clinician-patient communication may be suboptimal and culturally insensitive. Next, the healthcare system creates a broader structure for health and care disparities. For example, Women of Color in the US are more likely to experience financial and insurance constraints, limiting treatment options. Finally, SDOH plays an important role in women's health outcomes. For example, women may be labeled as nonadherent to recommended treatments or medications when, in fact, barriers such as stable housing, transportation, or lack of food are significantly impacting health choices (Bryant, 2021; CDC, 2021f; Ricks et al., 2021). 

According to the SisterSong Women of Color Reproductive Justice Collective, reproductive justice is a person’s "right to maintain bodily autonomy, have children, not have children, and parent the children they have in safer and sustainable communities (SisterSong, n.d.)." This organization was founded in 1997 by 16 Women of Color representing Native American, Latin American, African American, and Asian American communities. The reproductive justice movement differs from the reproductive rights movement of the 1970s, which many people felt only focused on the abortion debate. Instead, the reproductive justice movement focuses more broadly on how factors such as race, ethnicity, social class, disability, and sexual identity can limit patient freedom. In addition, the reproductive justice movement focuses on limiting oppressive circumstances related to informed choices about pregnancy and access to affordable, equitable care and education (i.e., contraception, prevention, and care for sexually transmitted infections [STIs], alternative birth options, domestic violence assistance, safe homes, adequate wages, and comprehensive prenatal and pregnancy care; SisterSong, n.d.). 

Strategies to Reduce Healthcare Disparities

For HCPs committed to providing high-quality, safe, and equitable care, the realization that we all have some implicit bias can be challenging to understand. For healthcare organizations to deliver equitable care for all patients, strategies must focus on intentional (i.e., explicit discrimination) and implicit bias. When HCPs understand that stereotyping and implicit bias are typical aspects of human cognition, they can be more receptive to learning strategies to mitigate their biases. Various techniques have been suggested in the literature to mitigate implicit bias in healthcare and healthcare organizations (Bryant, 2021; IHI, 2017). 

Clinician Preparation

Since HCPs are often unaware of their implicit bias, mitigation strategies can be challenging. Many interventions to reduce implicit bias have been implemented in education and criminal justice. However, there have been limited published strategies for healthcare. Researchers have proposed three conditions necessary to minimize implicit bias: the intention to change existing biases, attention to one's stereotypes, and time to practice strategies to break learned associations. HCPs are encouraged to complete a self-assessment of their bias to establish an intention to change existing biases. Once HCPs have identified their implicit biases, strategies can be employed to lessen their effects (Bryant, 2021; IHI, 2017). 

Some suggested strategies found in the literature are as follows (AAFP, 2019; Bryant, 2021; IHI 2017): 

  • Stereotype replacement occurs when an individual recognizes responses to an individual or a scenario that elicits stereotypes. Then, the individual intentionally replaces the biased response with an unbiased response. 
  • Counter-stereotypic imaging occurs when individuals recognize their stereotypical responses to another person from a particular background. Then, they visualize interactions with other people from the same background who disprove the stereotype. 
  • Individuating occurs when an individual’s specific details (e.g., background, family, likes, dislikes, work) are evaluated to make better judgments based on the individual instead of group-based assumptions. 
  • Perspective-taking occurs when an individual actively considers the perspective of the person experiencing a stereotype. Reflecting on what a person may experience because of a stereotype helps identify the impact of implicit bias. 
  • Increasing opportunities for positive contact occurs when an individual actively seeks opportunities to interact with and experience positive examples of stereotyped groups. These opportunities can include expanding one's network of friends or colleagues where people of other races, ethnicities, gender identities, etc., are present. 
  • Partnership building occurs when a patient-provider relationship shifts away from a power dynamic of a high-status person and a low-status person. Instead, the relationship reflects collaborating equals. 
  • Building empathy for others can help to minimize implicit bias. Empathy can bring the HCP and patient together within the context of shared experiences. This strategy can help protect patients from stereotypes and shift the power dynamic. 
  • Practicing mindfulness can help incorporate self-awareness and assessment while regulating emotions and behaviors. As discussed previously, stress and cognitive overload can increase the likelihood of automatization during interactions, leading to implicit bias. Patient care can be stressful, with the potential for emergent and stressful situations. For HCPs, incorporating mindfulness techniques into their daily practice can help increase attention on present experiences and reduce implicit bias in clinical decision-making. 

Educational Preparation

Mitigation strategies for HCPs are essential to reduce implicit bias. However, universities and other educational institutions play a pivotal role in mitigating implicit biases among medical and nursing students. The need for these early intervention strategies is highlighted because underrepresented groups account for 30% of the US population, but only 9% of medical doctors are from such underrepresented groups. Researchers have recommended that learners engage in self-awareness to confront their biases and establish mechanisms to regulate them. Like other clinical skill education, students should have opportunities to practice strategies to reduce bias. Some effective strategies can include writing reflection and group discussion exercises, which can evoke and counter stereotypes in a controlled, simulated setting. In addition, case presentations, actual patient exposures, and intentional immersion experiences can also allow learners to engage in critical dialogue regarding biases (Bryant, 2021). 

Organizational or Systemic Changes

Healthcare organizations can employ various system-wide strategies to reduce health disparities and implicit bias. For example, care bundles within various subspecialties in an organization can promote safe and equitable care. However, creating these bundles alone is not enough; hospital organizations need to leverage data to review quality and safety metrics, ensuring safe and equitable care is delivered. For example, the Council on Patient Safety in Women's Health Care developed the "Reduction of Peripartum Racial/Ethnic Disparities" bundle to promote safe care for women. In addition to standardized care practices, this bundle also recommended that every health system provide staff-wide education on implicit bias. Staff-wide education is a recommended strategy for all healthcare organizations. All healthcare staff and employees should participate in implicit bias training. Standard educational approaches should also be coupled with simulation training or case-based training. These active learning strategies are most effective in reducing implicit bias. Healthcare organizations should also complete a comprehensive evaluation of their hiring and disciplinary practices to ensure fairness and equity. Increasing the diversity of the healthcare workforce has been shown to improve disparities in health outcomes (Britt, 2020; Bryant, 2021; National Council of Patient Safety in Women's Health Care, 2016). 

The IHI white paper entitled "Achieving Health Equity: A Guide for Health Care Organizations" highlights that access to care is insufficient to reduce health disparities. Organizations committed to improving health equity must be prepared to change the current system fundamentally and make health equity a system-level priority. The IHI provides a framework with five core components to guide organizations in making health equity system-level changes (IHI, 2016; see Table 1). 

Table 1

IHI Framework for Healthcare Organizations to Achieve Health Equity

(OMH, 2018) 

Inclusive Communication 

To reduce health disparities and implicit bias within healthcare, organizations must emphasize the importance of inclusive communication (i.e., addressing all people inclusively and respectfully). Therefore, the CDC has created resources for healthcare organizations to help ensure their communication products and strategies adapt to each population's specific cultural, environmental, linguistic, and historical contexts. These resources are continually adapted as cultural and language norms continue to change. The CDC also highlights that these resources are not prescriptive or exhaustive but rather a guide to provide resources and suggestions for an inclusive approach to various topics (CDC, 2021d). The CDC highlights five communication principles for healthcare organizations to build inclusive communication (see Table 3).  

Table 3 

Health Equity Guiding Principles for Inclusive Communication   

(CDC, 2021d)

Community Engagement

Community engagement is a crucial component of promoting equitable health and access to healthcare services. Employers, healthcare systems, public health agencies, policymakers, and community- and faith-based organizations can help reduce implicit bias and health disparities. These groups can join efforts to ensure communities access the resources needed to maintain and manage physical and mental health. Shared cultural, family, and faith-based values are familiar sources of support for community members. These entities can powerfully influence communities by highlighting health disparities and inequities among various groups and finding solutions to mitigate implicit biases. For example, community- and faith-based organizations can model healthy lifestyle choices and help connect community members to needed services such as housing, food, and healthcare. They can help establish trust between HCPs and community members. In addition, when individuals engage in community- and faith-based organizations, there are increased opportunities for positive contact with others from stereotyped groups. Public health agencies can promote equitable access to care by ensuring information and services are culturally and linguistically appropriate for the community members. These agencies can build partnerships with community leaders to provide resources and education and reduce health disparities (CDC, 2021e). 


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