Health Equity

It is sometimes easy to forget when surrounded by our own comfortable environment that our languages, culture, ethnicity, etc., can be unfamiliar to someone else and pose a barrier. For example, imagine you are in Norway hiking on a trail. You get separated from your friends and find yourself lost on this difficult trail. While looking for the way to the main parking area, you trip over a log and injure your ankle. Because of this injury, you are unable to walk. During the fall, you break your phone, rendering it useless. Finally, you see people in the distance and start yelling and waving frantically. You begin explaining your situation when you realize no one can understand you. They start speaking to you in a different language and point to your ankle. Though they may understand you are hurt, you cannot be sure. This situation is nerve-wracking, and it is evident that there is a language barrier. At times, our patients may feel exactly like this.

There are seven billion individuals in this world and over 6,00 languages. It is easy to see how quickly language can become a barrier. The population is increasing and becoming more mobile, blurring traditional language, racial, and ethnic lines. Nearly one-third of the United States (US) population has been identified as an ethnic or racial minority. More than 50 countries report that more than 15% of their population is comprised of immigrants (Kaljee & Stanton, 2011). It is important to be cognizant of the many different cultures and backgrounds of our patients and coworkers.

Culture, bias, age, gender, background, sexuality, and much more help to define our identity and beliefs. We are all unique and deserve appreciation and respect for who we are. Healthcare facilities are responsible for employing staff that reflect their service area and the people they serve. They are also responsible for ensuring staff are educated on cultural issues relevant to their service area and beyond.

Every patient deserves an equal opportunity to be healthy, regardless of any factors or circumstances. Obstacles to health include discrimination, bias, poverty, and a lack of access to equitable healthcare (Gómez et al., 2021). Health equity encompasses and requires fundamental awareness and action in culture and organizational structure. This course will focus on culture and individual variables that are important aspects of health equity.

Before defining culture and cultural competency, important concepts of health equity, it is important to provide definitions for common words used when discussing culture.

Race- this is a social construct and term that has been used to group or classify individuals. These classifications have been used to identify and often marginalize people across the globe. Our physical appearance, cultural backgrounds, and social factors help classify our race (National Human Genome Research Institute, 2024). According to the US Census Bureau (2022), there are five major races, and they include:

• White- those with origins in Europe, North Africa, or the Middle East.
• Black or African American- those with origins in Africa.
• American Indian or Alaskan Native- those with origins in North, Central, and South America with community attachment and/or tribal affiliation.
• Asian- those with origins in the Far East, Southeast Asia, and the Indian Continent, including China, Japan, India, Cambodia, Korea, Vietnam, Pakistan, Thailand, and the Philippines.
• Native Hawaiian or Other Pacific Islander- those with origins in the Pacific Islands, such as Hawaii, Guam, and Samoa. 

Unfortunately, prejudice and racism are often tied in with racial identity (Charmaraman & Grossman, 2010).

Ethnicity- this refers to the social group that an individual identifies with or belongs to and is often made up of factors that include a proper name that expresses the community, common ancestry, shared memories that are often historical, elements of a common culture, including language and religion, a sense of solidarity, and a link to a homeland (Hutchinson & Smith, 1996).

Both race and ethnicity are social constructs tied to an individual's self-concept and lived experience (Charmaraman & Grossman, 2010).

Diversity- this term encompasses the inclusion of individuals from various races, ethnic and social backgrounds, sexual orientations, genders, ages, experiences, opinions, etc. (Oxford University Press, n.d.; Servaes et al., 2022). It is often used to describe or encompass individual and unique differences (The George Washington University, n.d.).

Equity- this refers to justice and fairness. Equity, different from equality, means acknowledging and adjusting to imbalances (National Association of Colleges and Employers [NACE], n.d.). With equity, resources and opportunities are made available to promote equality. Differences and divergences are included and should be celebrated (Jurado de Los Santos et al., 2020).

Inclusion- this describes an active intent to engage with diversity (The George Washington University, n.d.).

Social determinants of health- non-medical factors that can influence health. Factors include conditions surrounding where individuals are born, where they live, work, and their age (Centers for Disease Control and Prevention [CDC], 2024c). Other factors include climate change, racism, social policies, and political systems (CDC, 2024d).

When thinking of culture, many equate it to race and ethnicity only. Culture also encompasses shared values, how individuals come to understand their history, and similar behaviors and worldviews. Specific components of culture that may be shared include religious and socioeconomic backgrounds and sexual orientations. There can even be cultures within occupations, such as the nursing culture or military culture. Individuals sharing a cultural belief are often organized into groups and identified by age, gender, and common interests.

Cultural competency- Many definitions of cultural competency exist, and it has evolved over the years. Generally, it means a set of values, behaviors, attitudes, and beliefs allowing effective cross-cultural communication. It represents the ability to:

• Value similarities and differences
• Have an awareness of differences and respond appropriately to them
• Conduct a cultural self-assessment
• Institutionalize cultural knowledge
• Adapt to cultural diversity

Cultural competency is defined as the healthcare provider's ability to understand the values and beliefs of various racial, ethnic, social, and religious groups. Understanding these values and beliefs is pertinent to practicing healthcare in a culturally competent manner. Health-related cultural beliefs should and can be integrated into the care we provide our patients (Kaljee & Stanton, 2011). Cultural competency has been defined as the capacity and ability of organizations, healthcare systems, and healthcare providers to provide high-quality care to diverse populations that is safe, family- and patient-centered, equitable, and evidence-based (National Quality Forum, 2009).

Cultural humility- this is a tool that can be used to embrace self-reflection and learn about one's internal beliefs and thoughts that may influence cultural identity. Cultural humility also involves self-awareness and self-critique (Yeager & Bauer-Wu, 2013).

When discussing culture, it is important to highlight and define types of bias, as many people often see, feel, or experience it.

Implicit bias (IB)- the human tendency to make decisions outside of conscious awareness and based on inherent factors rather than evidence, may influence the provided health care. Also known as unconscious bias, IB establishes itself through attitudes or behaviors developed early in life that are prejudiced against or in favor of one person or group compared to another (FitzGerald & Hurst, 2017). As identified in the literature across professional health disciplines, IB is associated with negative health disparities, health inequities, and substandard care among diverse populations. Likewise, IB may affect all persons' health by unconsciously influencing how providers perceive and act toward clients and, conversely, how clients may view provider interactions (National Center for Cultural Competency [NCCC], 2021; Institute of Medicine [IOM], 2003).

Facts and Bias

IB is unintentional and attributed to the reflexive neurological system that drives the brain's automatic processing function. As such, an individual's feelings, attitudes, and decisions are involuntary, and their subsequent actions may conflict with their stated views (NCC, 2021). Consequently, the effects of IB can be difficult to identify and measure, and actions resulting from it often are challenging to recognize and control. Healthcare literature describes ongoing IB mitigation efforts, including the promotion of provider awareness, participation in continuing education, advancement of policy development, legislation, and institutional changes, and the contribution of research (FitzGerald & Hurst, 2017; NCCC, 2021; Brecher et al., 2019; The Joint Commission, 2020). Learning about IB (later in the course) and how it differs from explicit bias, recognizing types of IB and how provider-client interactions are affected, and embracing strategies to address its impact on practice are approaches toward reducing barriers to equitable care, closing the gap in health disparities between diverse populations, and achieving patient-centered care.

IB presents challenges in health care when it manifests itself inappropriately and unconsciously contributes to health disparities. Health disparities are the differences in the burden of illness, injury, disability, or mortality outcomes between groups distinguished by characteristics such as age, gender, race, and ethnicity, leading to unfair and avoidable differences in health outcomes and are considered preventable (CDC, 2023a). For example, the CDC reports that from 2007 to 2016, nearly 700 women died in the US annually from pregnancy-related complications (Petersen et al., 2019). Maternal mortality in the US is alarming, as are its significant racial and ethnic disparities. American Indians, Alaska Natives, and African Americans are two to three times more likely to die of pregnancy-related causes than Caucasians. It is understood that social determinants of health have historically prevented many people from diverse minority groups from "accessing fair opportunities for economic, physical, and emotional health, factors understood to impact health equity" (Howell, 2018). Although targeted efforts to isolate causes and develop successful mitigation strategies to combat US maternal mortality are ongoing, further innovative research and creative strategies are warranted. Suggestions for provider-targeted IB research on this topic may include providers' IB influencing their decision not to refer a patient because they believe that patient to be non-compliant.

In 2003, the IOM's formative report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, laid a foundation for exploration into healthcare disparities in the US, including bias toward patients of diverse racial, ethnic, or cultural populations. The report concluded that "bias, stereotyping, prejudice, and clinical uncertainty on the part of health care providers may contribute to racial and ethnic disparities in health care" (IOM, 2003). More recently, FitzGerald and Hurst's (2017) systematic review of 42 articles discussed robust documentation of IB among nurses and physicians and reinforced the negative effects of professional caregivers' IB on vulnerable populations, including "minority ethnic populations, immigrants, socioeconomically challenged individuals, persons with low health literacy, sexual minorities, children, women, elderly, mentally ill, overweight and the disabled." These reports and studies contribute to the evolving body of knowledge about IB in health care through research and provoke thoughts about the effects of IB on health outcomes.

Multidisciplinary health literature indicates that many factors contribute to health disparities, including "quality of healthcare, underlying chronic conditions, structural racism, and IB" (Petersen et al., 2019). Narayan (2019) cites literature that indicates health care providers' IB is associated with "inequitable care and negative effects on patient care including inadequate patient assessments, inappropriate diagnoses and treatment decisions, less time involved in patient care, and patient discharges with insufficient follow-up." Additionally, Saluja and Bryant (2021), suggest that IB can affect provider-patient communication among people of color. The effects may include "subtle racial biases expressed by providers, such as approaching patients with a condescending tone that decreases the likelihood that patients will feel heard and valued by their providers" (Saluja and Bryant, 2021). Variations in therapy options may also occur based on assumptions about clients' treatment adherence capabilities or presumed health issues.

Additionally, IB may negatively impact clinical outcomes and violate patient trust. Penner et al. (2016) found in a study of oncology patients who were African American and their physicians that patients perceived providers high in IB as less supportive and spent less time with their patients than providers low in IB. In turn, patients recognized those attitudes and viewed physicians with high IP as less patient-centered than physicians low in this bias. "The patients also had more difficulty remembering what their physicians told them, had less confidence in their treatment plans, and thought it would be more difficult to follow recommended treatments." These findings on providers' implicit racial bias underscore patients' perceptions of their experiences with providers' IB. However, its overall effects on healthcare quality and health outcomes for diverse populations invite further exploration (Penner et al., 2016).

A cultural assessment is an important part of a patient visit that can bring forth pertinent knowledge and prevent IB. To care for all patients, including culturally diverse patients, providers should increase their assessment skills and provide thoughtful interventions. Making assumptions about a culture or depending on standard knowledge is inappropriate and may create barriers. An inadequate cultural assessment may result from noncompliance and poor health outcomes, ultimately eroding the patient's trust in the healthcare provider (Kaljee & Stanton, 2011).

Culture

Providers should ensure they are evaluating cultural information that is relevant to the patient's care. The provider should ask open-ended questions to allow the patient to express the situation. The provider should also ask about the patient's thoughts on the illness/injury and how it will impact their lives/quality of life; answers to these questions may reveal important cultural perceptions. The situation's outcome will be enhanced by forming a partnership with the patient and alleviating their fears.

Besides a cultural assessment, healthcare providers should participate in IB testing. Surprising to many providers, the level of IB demonstrated by healthcare professionals is understood to be comparable to the general population (FitzGerald & Hurst, 2017). Given the unconscious nature of IB, directly asking providers about their IB through a self-report survey is not recommended. However, two common methods used to assess IB are Implicit Association Testing (IAT) and Assumption Method (AM).

IAT is a computer-generated online testing method that "measures implicit associations between participants' concepts and attitudes across a wide range of domains: race and ethnicity, disability, sexuality, age, gender, religion, and weight." For over 20 years, web-based IAT data has been collected through Project Implicit, a consortium of researchers from Harvard University, the University of Virginia, and the University of Washington to study and promote the understanding of attitudes, stereotypes, and other hidden biases that influence perception, judgment, and action (Project Implicit, n.d.).

AM is a clinical vignette-based testing method that measures differences across participants' responses. The vignettes are designed to be the same except for one variable, such as gender. Inferences are made based on statistically significant responses correlated with the selected feature, such as the patient's gender. An inference is made that "the response is partly due to the result of implicit processes in the subject's decision-making" (FitzGerald & Hurst, 2017).

Priming is another way to measure reactions related to inherent and subconscious attitudes. The Priming Test is designed to measure the strength of the association between two stimuli, or targets and particular attributes, or primes. The targets are comparable categories, and the primes are associated with those categories. The Semantic Priming Test uses words, and the Visual Priming Test uses images. These tests produce a prime (word or image) on a screen for a specific period before the target is shown. The participant is told to focus on separating the targets. The participant will react faster if the target is more associated with the prime (Ocejo, 2024).

Affect Misattribution Procedure (AMP) is another test used to measure and evaluate IB. The AMP presents multiple images that are assigned to two categories. Examples of categories include products, ethnic groups, or people. The second category may be neutral, such as a gray image. Then, an icon is displayed with a character, judged as positive or negative. According to the measurement logic, the effect associated with the image is transferred to the character (Payne et al., 2005).

These are just some examples of common tests used to measure and evaluate IB. There are others; however, they may not be commonly used, and their validity has not been verified.

Because culture, cultural competency, racism, and IB are evident in care, most facilities use a standard tool or model of care to help provide equitable care to all. Madeleine Leininger's theory of cultural care has resulted in the creation of many tools. The foundation of Leininger's theory is based on the idea that each group has important customs and cultural heritage. Leininger's Cultural Care Diversity and Universality Theory and the Sunrise Model arose from this theory. They started the movement of defining cultural care and incorporating concepts of culture within nursing assessment. The Sunrise Model specifically uses components that focus on caring for a patient in a global and multifaceted environment, including characteristics of culture that create an interdependent relationship (Leininger, 2002).

To preserve the cultural atmosphere within the nursing environment, it is crucial that healthcare providers understand these important characteristics and care for each patient individually. From this, transcultural patient care has been created, and several models of transcultural care are used today.

There are six data collection areas within Giger and Davidhizar's Transcultural Assessment Model (2013). This model focuses on the idea that though each culture has different characteristics, they are shared fundamental factors such as (Giger, 2013): 

• Communication- What language does the patient use? Notice the pronunciation of words. Is silence a part of language? What do the nonverbal forms of communication indicate?
• Space- Pay careful attention to body movements. What defines personal space?
• Social organization- Review geography, socioeconomic status, ethnicity, age, religion and spirituality, sexual orientation, gender, and life cycle status.
• Time- What is the importance of time? How is time used? Is there a focus on the past, present, or future?
• Environmental controls- How does the patient define health and illness? What are the patient's current health practices?
• Biological variations- Social support and coping, genetic susceptibility to various diseases, physical dimensions, and nutritional status/preferences.
• Cultural uniqueness- Birthplace, race, and length of time in the country.

Many areas of care, such as primary, secondary, and tertiary care, utilize the Purnell Model for Cultural Competence. This model is rooted in concepts such as nutrition, social support, communication, development within families, biology, economics, sociology, and anthropology (Purnell, 2002). These many disciplines are conceptualized in this model as a circle; society is depicted as the outer ring, the second ring is community, family represents the third ring, and the inner ring is the person. The twelve domains of the Purnell Model are used as assessment guides and include the following (Purnell, 2002):

1. Heritage includes education, occupation, residence, origin, economics, and topography.
2. Communication includes body language, volume, tone, eye contact, distancing, dialects, facial expressions, and time.
3. Family roles and organization include social status, roles of each person, structure, child-rearing, and structure.
4. The workforce includes dominant and secondary cultures, barriers, and autonomy.
5. Biocultural ecology includes both biological and physical characteristics.
6. High-risk behaviors involve safety and drug and alcohol use.
7. Nutrition involves health promotion, common foods, limitations, and rituals.
8. Pregnancy and child-rearing include birthing, postpartum, child-rearing, and fertility practices.
9. Death includes various rituals and bereavement.
10. Spirituality involves religion, prayer, the meaning of life, and spirituality.
11. Healthcare practices include the beliefs and barriers surrounding health, traditions, self-medication, rehabilitation, and the responsibility for health.
12. Healthcare practitioners include perceptions, folk practices, and gender healthcare status.

This model assumes that healthcare providers all need the same information. The assessment looks at four variables of the individual's functioning, including personal practice, family, health practices, and global society. The model's assumptions include the concept that all cultures have similar core components, but some variations fluctuate with time. This model also assumes that healthcare providers grasp the importance of culture and assess culture while caring for patients.

Another model frequently used is The Process of Cultural Competence in the Delivery of Healthcare Services by Campinha-Bacote (2002). There are five assumptions with this model, including the following:

1. Cultural competence is not a singular event but an ongoing process.
2. There are five constructs related to cultural competence- cultural awareness, knowledge, desire, skill, and encounters.
3. Intra-ethnic variation exists.
4. Healthcare providers' competence levels and their ability to provide care to ethnically and culturally diverse individuals are directly related.
5. Cultural competence is essential when effectively caring for patients.

Our multicultural world is continuously evolving, and this model encompasses the ever-changing and multidirectional roles of culture in our everyday society.

Now that culture has been defined, it is time to review specific cultural and personal variables that may be important to patients.

Religion

Religion denotes shared beliefs and practices. Spirituality encompasses the connection someone feels to something bigger than themselves. It is important to note that individuals with the same religion may possess different practices and beliefs.

It is important to recognize the many different religions that are practiced today. The following list is not all-encompassing, as many other religions and practices exist.

Buddhism- originating in South Asia, this is one of the world's largest religions. In Buddhism, individuals believe that life cycles through a period of suffering and rebirth. The goal is to achieve a state of nirvana, or total enlightenment. Buddhists do not believe in a god or type of deity but believe in supernatural beings that can aid or hinder them on their paths to nirvana (National Geographic Society, 2023). Buddhists also believe in four noble truths, which include the following (Aich, 2013):

1. Life is full of suffering (Duhkha)- examples of suffering include disease, death, old age, sorrow, and despair.
2. The cause of suffering (Duhkha-samudaya)- attachment is the cause of suffering. Attachment, derived from the word trishna, is associated with or translated from craving, thirst, clinging, desire, and lust. Attachment is also associated with dvesha, or hate and avoidance, as well as avidya, or ignorance.
3. Stopping suffering (Duhkha-nirodha)- this is where nirvana comes in; working through life without attachment can help Buddhists achieve nirvana.
4. Extinguishing suffering (Duhkha-nirodha-marga)- this represents another path, often referred to as marga, that Buddha called the Eightfold Path to liberation. This path can allow a Buddhist to be misery-free.

Christianity- with over two billion practicing this faith, it is the most widely practiced religion. This religion's center is Jesus Christ and His birth, death, and resurrection. Christians, followers of Christianity, are considered monotheistic, believing in only one God. Christians who believe God sent Jesus to save the world also believe Jesus will return for the Second Coming. This religion is outlined in the Holy Bible (History, 2024a).

The three elements of God include the following:

1. The Father
2. The Son
3. The Holy Spirit

These three exist as one God and are termed the Holy or Blessed Trinity (Stanford Encyclopedia of Philosophy, 2020).

Hinduism- this has been identified as the oldest religion and is sometimes referred to as Sanatana Dharma. Hinduism, considered a natural religion, is practiced by Hindus. It is a natural and indigenous religion with diverse traditions and philosophies. All beings, including organisms, are Divine manifestations and have equal worth. The Divine can do the following:

1. Manifest in different ways
2. Be worshipped in many ways
3. Speak and relate to individuals in different ways

Hindus also believe in pluralism, which allows for diversity. Those both alike and unlike can connect through unique and varying characteristics with the Divine and on their own. Pluralism allows for increased religious and social freedom (Hindu American Foundation, n.d.).

Islam is the second-largest religion. Like Christianity, it is considered a monotheistic faith, believing in only one God, Allah. Followers of Islam, also known as Muslims, try to live in complete submission to Allah. Muslims follow the Koran, believing there will be a judgment day and that life exists after death (History, 2024b).

There are five pillars to the Islam faith, and they include the following:

1. Shahada- this means the profession of faith.
2. Salat- this means prayer, which occurs five times throughout the day and is performed while facing Mecca. Prayer is often performed in a certain way, such as on a rug or mat.
3. Zakat- this involves the donation of income to those who are in need.
4. Sawm- this centers around fasting. During Ramadan, the ninth month of the Islamic calendar, Muslims fast during daylight hours.
5. Hajj- this means pilgrimage. If Muslims are able to travel to Saudi Arabia, which depends on their financial and health status, they should travel to the holy city at least once (Canby, 2019).

Jehovah's Witness- this religion is newer, starting in the 19th century. Jehovah's Witnesses do not believe in the Trinity; they believe Jesus is a separate entity and that the Holy Spirit refers to the power of God. Kingdom Halls serve as a gathering center for Jehovah's Witnesses (Schmalz, 2023). While some of their beliefs are similar to those of Christians, such as living morally by the Bible and aiming to live honestly, they hold unique beliefs and perspectives. For example, Jehovah's Witnesses do not celebrate Christmas or non-religious holidays like birthdays. Jehovah's Witnesses' beliefs also prevent them from receiving blood transfusions (Pavlikova & van Dijk, 2021).

Judaism- this is another older religion that follows monotheism, believing only one God exists. Abraham is the founder of Judaism. Followers of Judaism are referred to as Jews. Jews and rabbis (their spiritual leaders) worship in places called synagogues. Followers of Judaism also follow the sacred text called the Tanakh. The Torah, the first five books of the Tanakh, is more well-known and provides a guideline for Jews to follow (History, 2024c).

Age

There tend to be groups or clusters of people within a cultural group with personal beliefs or characteristics others may not possess. These groups of people share the same cultural beliefs as the group, but each has individual differences, for example, age. Significant differences in physique and development exist between infants, children, adolescents, adults, and aging adults.

Children are impacted by the group's belief about the role of children, with limited communication and cognition. Also, the caregiver's race, ethnicity, and religion may impact the child. The family unit may differ significantly, and culture helps determine the family dynamic's design, roles, and functions (Committee on Family Caregiving for Older Adults et al., 2016).

The aging adult, at times with cognitive limitations and disabilities, must endure the added complications of the group's beliefs about individuals who are aging. The aging adult who is considered a minority will often have poorer health, such as an increase in chronic disease and higher rates of premature death (National Academies of Sciences, Engineering, and Medicine et al., 2017). This subset of the population faces barriers such as ageism, which is prejudice, bias, stereotyping, and discrimination based solely on someone's age (WHO, 2021). Stereotypes include older adults being frail, dependent on others, or unable to contribute to society (Stubbe, 2021).

Disability

Individuals with disabilities have additional experiences and beliefs surrounding their disability, with added complications from the disability, including limitations in cognition, functional abilities, and communication. (Van Herwaarden et al., 2020). Individuals diagnosed with a mental illness will have varying experiences and beliefs about that illness (Snodgrass et al., 2017). Because of the stigma of mental illness, acceptance of treatment may be an obstacle to effective care planning.

With the shift towards diversity and equity, there come barriers to inclusion. Such barriers that patients with disabilities experience include attitudinal barriers, physical barriers, a lack of education, inappropriate education, or organizational and policy barriers.

Attitudinal- Attitudinal barriers are a common and basic type of barrier that can contribute to and lead to the formation of other barriers. Common attitudinal barriers include stereotyping, stigma, discrimination, and prejudice. For example, many individuals tend to assume those with disabilities have a poor quality of life. A disability should not be considered a deficit (CDC, 2024a). Attitudinal barriers further stigma and discrimination and deny others dignity and equal opportunity. Negative attitudes foster a disabling environment and intensify discrimination and other barriers to inclusion.

Physical- Physical barriers also pose a challenge to inclusion, including environmental and structural barriers that prevent access and mobility. Examples of physical barriers include not having a wheelchair ramp or accessible walkways (CDC, 2024a).

Communication- Communication barriers exist for many, including those with disabilities. Disabilities involving reading, writing, hearing, and speaking are more likely to experience communication barriers. Examples of barriers include the following (CDC, 2024a):

• No Braille or large print material available for those with vision impairments.
• Individuals with audio impairments may face communication barriers without closed captioning on videos.
• No interpreter or someone fluent in American Sign Language is available.
• If someone has a cognitive impairment, using technical and over-medicalized language will result in a communication barrier. 

Financial- Financial barriers exist for disabled and non-disabled individuals. Financial barriers include a lack of insurance coverage, gaps in insurance coverage that may not cover rehabilitation services, lower income for those who are disabled, confusion, or a lack of information surrounding costs, payments, and insurance coverage. Not only is a lack of transportation a barrier, but so is the cost of transportation (Soltani et al., 2019).

Education can serve as a barrier to inclusion. If education is not inclusive, does not provide information on resources, or introduces bias, it is a barrier to inclusion.

Organizational barriers to inclusion encompass a variety of barriers on administrative, programmatic, and architectural levels. Examples include microaggressions, emotional barriers, jargon, and insensitive behaviors (Abbott & McConkey, 2006).

A policy can implement change. Unfortunately, it can also act as a barrier to inclusivity due to a lack of awareness of laws and regulations, a lack of the ability to enforce them, or a lack of ability to make change. Policy barriers can also include a lack of funding (CDC, 2024a).

Social barriers, often related to social determinants of health, are more likely in those who are disabled. The following are statistics related to social barriers for those who are disabled (CDC, 2024a):

• Those with disabilities are less likely to be employed.
• Those with disabilities are less likely to have completed high school.
• Children with disabilities are more likely to experience violence.

Healthcare barriers exist that can make it more difficult for those with disabilities to get the care they deserve. These barriers include a lack of communication, inconvenient scheduling, insufficient time to care for the patient or explain necessary information, and poor attitudes of providers and staff (CDC, 2024a).

Military

Members of the military often have various beliefs related to the training they had and their warrior status. Examples of beliefs and traits may include hyper-masculine qualities such as stoicism, toughness, assertiveness/aggression, and holding values like self-sacrifice (Shields et al., 2017).

Unfortunately, healthcare is often under-utilized by veterans because they believe that non-military healthcare members are unable to meet their needs due to a lack of understanding of the military experience.

There are many health conditions that military members and veterans are at greater risk of experiencing, such as suicide, infectious diseases, exposure to harmful chemicals, hearing loss, and traumatic brain injuries. They are also at an increased risk of experiencing mental illness, such as anxiety, depression, and post-traumatic stress disorder.

It is pertinent that healthcare providers aim to understand the various branches of the military and what they are likely to experience and move beyond seeing just the physical injuries but the emotional and psychological toll as well (National Academies of Sciences, Engineering, and Medicine et al., 2017).

Mental illness

Culture also influences aspects of mental health and illness. When there is a difference in culture and a healthcare provider does not possess knowledge or awareness of the differing culture, differences become obstacles, and the healthcare provider is less likely to meet the patient's needs (Nair & Adetayo, 2019). Members of racial and ethnic minorities who have a mental illness are:

• More likely to receive inadequate care.
• Less likely to have access to and receive needed mental health services.

Cultural barriers for patients with mental illness include the following (Fountain House, 2022; Stubbe, 2021):

• Mistrust of healthcare providers/care they receive
• Lack of diverse healthcare members
• Alternative idea of health and illness

Cultural Groups

There are often sub-cultural groups within each culture. For example, there are pockets of health-conscious communities that are vigilant against vaccinations worldwide. Immunizations are often viewed with distrust. It is important to note that individuals within cultures may have differing beliefs due to unique experiences.

Previous nontraditional cultural groups are now increasing in popularity. For example, former nontraditional groups, such as street youth and gay and lesbian youth, are now being recognized as cultural groups. Because of the shared values among these groups, healthcare decisions are sometimes made similarly. Health outcomes may be negatively impacted if healthcare providers do not recognize the patient's identification with these groups (Kaljee & Stanton, 2011).

A safe environment created by healthcare providers is necessary for patients to feel comfortable expressing detailed information about their medical history. Medical records that allow patients to safely identify their sexuality, such as lesbian, gay, bisexual, transgender, queer, and/or questioning (LGBTQ+), can bring awareness to the provider on the potential needs of the patient. The healthcare provider's cultural competency can ameliorate the quality of patient interactions.

Unfortunately, the LGBTQ+ community continues to have negative experiences, especially related to homophobia and unequal healthcare treatment.

The Joint Commission and the IOM have supported the inclusion of gender identity and sexual orientation in electronic medical records (Office of Disease Prevention and Health Promotion, 2022; The Joint Commission, 2011). This information assists with tracking and analyzing health disparities in the LGBTQ+ community.

To help bridge the gap in healthcare disparities that affect the LGBTQ+ community, education on providing culturally competent care is pertinent. Many feel it is necessary and support the inclusion of competencies in curricula that address issues on gender, sexuality, and many other important topics.

Continuing education for all forms of healthcare providers on pertinent LGBTQ+ issues is necessary due to the sparsity of education and literature on issues in this community.

The Healthcare Equality Index (HEI), established in 2007, has been used to designate US healthcare facilities as leaders in LGBTQ+ healthcare equality (Human Rights Campaign, n.d.). Though there is an increased need for diversity in a culturally competent workforce, there is also a lack of resources and abilities to train providers in cultural competence. Cultural competency is a fundamental issue that is necessary to provide appropriate healthcare. It is crucial that healthcare providers champion as patient advocates (Human Rights Campaign, n.d.).

Patients may view healthcare interventions differently based on cultural differences. In 1932, the Tuskegee experiment began under the direction of the Public Health Service and the Tuskegee Institute. The goal of the experiment was to examine the history of syphilis in hopes of justifying interventions among black patients (CDC, 2023b).

Six hundred black men were enrolled in the study without any informed consent being obtained. Patients were being told they needed to be treated for a "bad blood" condition. The study, which was supposed to last six months, lasted 40 years. Even though penicillin was chosen for this disease, the patients enrolled in the Tuskegee experiment did not receive adequate treatment. The Assistant Secretary for Health and Scientific Affairs appointed a panel to review the study in 1972 (CDC, 2023b).

The panel concluded that the study was ethically unjustified and the knowledge gained was not worth the risks the participants were exposed to. The panel review resulted in a class-action lawsuit with an out-of-court settlement. To provide healthcare benefits to the remaining participants and their widows and children, the government created a program for which the CDC eventually became responsible. This unjust experiment led to the creation of the National Research Act, which was signed into law in 1974. Then, the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research was created, which also led to the development of the National Bioethics Advisory Commission in 1995 (CDC, 2023b).

The evil and inexcusable Tuskegee experiment had many negative outcomes. For example, African American patients often chose to avoid any preventative healthcare, especially when healthcare was supported by the federal government. However, with the advancing diverse healthcare workforce, some attitudes among minority groups are changing. However, a lot of work is still necessary. Because of the Tuskegee experiment, new laws on ethics within research have been established, heightening cultural competency awareness.

Medicine and healthcare have shifted from a paternalistic view to one where patients actively participate in their care. Healthcare providers should aim to provide services that align with patient values. Previously, discussing a patient's culture was considered to be taboo. Now, with the evolution of patient care, identifying patients within a cultural group and discussing this has been associated with improved health outcomes and patient trust.

Becoming culturally competent is one of the main strategies used to eliminate healthcare disparities. Cultural competence, known to enhance healthcare practices, is a key aspect of practice and policy. The first step in providing culturally competent care is possessing self-awareness. This awareness starts when one recognizes their own values and beliefs and understands the values and beliefs of healthcare providers. Self-awareness can be very helpful when understanding and assessing patients' cultural beliefs. Healthcare providers should be aware of their own attitudes and biases, allowing for sensitivity and appreciation of the needs of others. Introspection and reflecting on personal attitudes toward various ethnic backgrounds can help healthcare providers identify if any of these beliefs can impede providing effective care. Therefore, it is essential to develop skills to provide culturally competent care.

Different cultures perceive the role of healthcare providers differently. Some view the healthcare provider as a trusted confidant who can provide valuable and necessary advice. Other cultures view the healthcare provider's advice as an intrusion. Healthcare providers must adjust their approach to care based on the patient's background and expectations.

Empathy, a pivotal component of culturally competent care, enables healthcare providers to perceive, respond to, and appreciate a patient's nonverbal and verbal cues. Many studies have shown that the providers' nonverbal communication best predicts patient satisfaction.

The Agency for Healthcare Research and Quality and the Office of Minority Health of the US Department of Health and Human Services (n.d.) created the National Standards on Culturally Linguistically Appropriate Services (CLAS). These standards are recommendations, mandates, and guidelines for eliminating racial and ethnic health disparities. The idea behind CLAS is that improved communication specific to various racial, social, and ethnic groups would improve health status.

Principal Standard

• Provide equitable, understandable, effective, and respectful care and services that are responsive to diverse cultural practices and beliefs, including language, communication, and health literacy.

Governance, Leadership, and Workforce

• Sustain and advance organizational leadership and governance, promoting CLAS and health equity with practices, resources, and policies.
• Promote, support, and recruit culturally and linguistically diverse workforce, leadership, and governance that is responsive to the area's population.
• Educate and train the workforce, leadership, and governance on linguistically and culturally appropriate practices and policies.
• Provide free language assistance and other communication needs to those with limited English proficiency, promoting timely access to care.
• Inform patients of the availability of services for language assistance in their preferred language, both verbally and in writing.
• Ensure that those providing language assistance are competent in their services; minors and untrained individuals should not be used as interpreters.
• Provide easy-to-understand multimedia, signage, and print materials in languages commonly used by the population(s) in the service area.

Engagement, Continuous Improvement, and Accountability

• Create linguistically and culturally appropriate policies, goals, and management accountability, infusing them throughout the planning and operations of an organization.
• Conduct continual assessments of CLAS-related activities within the organization, ensuring the integration of these measures into quality improvement activities.
• Collect and maintain reliable and accurate demographic data to monitor and evaluate CLAS's impact on health equity and patient outcomes.
• Conduct regular assessments of the community's health assets and needs and use the results to plan and implement patient services.
• Create a partnership with the community to design, implement, and evaluate various practices, policies, and services to ensure linguistic and cultural appropriateness.
• Create culturally and linguistically appropriate resolution processes for conflicts and grievances to identify, prevent, and resolve them.
• Communicate the organization's progress in sustaining and implementing CLAS to the general public, constituents, and stakeholders.

Standards 4-7 must be maintained in health organizations that receive federal funding. Many states now follow this guidance by enacting cultural competency legislation.

Now that we have covered the steps to promote effective communication and appropriate services and learned the definition of IB, it is time to discuss how to mitigate IB while promoting culturally competent care.

Healthcare professionals typically intend to provide optimal patient care, but IB may negatively impact their aim. Strategies to disrupt IB, such as promoting self-awareness and participation in formal training, suggest that biases learned earlier in life may be mitigated (FitzGerald et al., 2019). Efforts to define consistent, evidence-based bias reduction strategies are advancing, and evaluation is ongoing. Meanwhile, learning about types of IB and how they may affect health care remains important. Likewise, supporting institutional changes is necessary to sustain meaningful, ongoing mitigation efforts. The literature is rich with resources to mitigate IB, including but not limited to the following topics:

1. Awareness of common types of IB
2. Legislation to institutionalize IB training across health professions and healthcare systems

Scenario/situation/patient description

A 66-year-old Hispanic male resides in a rural community. He contacted his primary care provider's office with the following complaints: temperature of 100.2 degrees for three days, headache, body ache, fatigue, and nasal congestion with a runny nose. They underwent a COVID-19 polymerase chain reaction (PCR) test at their local pharmacy yesterday, received their positive test result today, and are anxious to speak to their healthcare provider about treatment.

Intervention/strategies

A telehealth appointment is conducted with their healthcare provider. The patient's condition warrants community-based treatment, and strategies are discussed. The patient specifically asks about medication to cure Covid-19. They had heard about it from a friend and believed many people get it through their local livestock supply store. Their healthcare provider responds that they understand from speaking with other local healthcare professionals that some recommend Ivermectin therapy, which is also available for livestock. The healthcare provider proceeds to write that prescription to be filled at the pharmacy.

Discussion of outcomes

The CDC reports that the US Food and Drug Administration has not authorized using Ivermectin to prevent or treat COVID-19 (CDC, 2021). Likewise, Ivermectin has not been recommended by the National Institutes of Health's COVID-19 Treatment Guidelines Panel for treating COVID-19. The healthcare provider's decision to prescribe this medication appears to be influenced by their IB to conform with their patient's request and some colleagues' anecdotal treatment recommendations. It is not an evidence-based treatment decision. Rather, the treatment decision is consistent with conformity bias, a type of IB.

Strengths and weaknesses of the approach used in the case

Typically, healthcare professionals intend to provide optimal care to all patients, but IB may negatively impact their aim. Conformity bias is an IB associated with the tendency to be influenced by other people's views (Brecher et al., 2019).

Our nation is a vessel for many ethnic nationalities, with many subcultures and healthcare ideas. Healthcare professionals are the caregivers responsible for caring for many patients, including those of different backgrounds and cultures. Cultural competence, a continual process of understanding, learning, and advocating, is essential in healthcare. It is important to identify conflicts and awareness of internal ideas and beliefs. Healthcare providers should seek ways and resources to understand ways to care for a diverse population.

IB is the unconscious and, therefore, the unintentional human tendency to make decisions based on inherent factors rather than evidence. No one is immune, not even healthcare professionals. Recognizing common types of IB by building self-awareness and participating in voluntary or mandatory training are steps health professionals may take to minimize its impact on care. Likewise, state governments' mandates specific to IB in healthcare are embedding training across health professions and care settings into law. More research is needed to measure how IB training may change health providers' short- and long-term beliefs, practices, and patients' perceptions. Ultimately, these steps are intended to minimize IB among healthcare providers, reduce barriers to equitable care, close the gap in health disparities between diverse populations, and meet patients' needs. Minimizing IB and promoting cultural competence will increase health equity for all.

• Abbott, S., & McConkey, R. (2006). The barriers to social inclusion as perceived by people with intellectual disabilities. Journal of Intellectual Disabilities: JOID, 10(3), 275–287. Visit Source.
• Administration for Community Living. (2023). Older Americans Act. Administration for Community Living. Visit Source.
• Aich, T. K. (2013). Buddha philosophy and western psychology. Indian Journal of Psychiatry, 55(Suppl 2), S165–S170. Visit Source.
• American Cancer Society (ACS). (2020). Health Equity Principles. American Cancer Society. Visit Source.
• Aririguzoh, S. (2022). Communication competencies, culture and SDGs: effective processes to cross-cultural communication. Humanities and Social Sciences Communications, 9(96). Visit Source.
• Brandt, A. M. (1978). Racism and research: the case of the Tuskegee Syphilis Study. The Hastings Center Report, 8(6), 21–29.
• Brecher, L., Hartman, S., McNeil S., Westby, A., & Spicer, A. (2019). Implicit bias training facilitator guide. American Academy of Family Physicians. Visit Source.
• Campinha-Bacote, J. (2002). The process of cultural competence in the delivery of healthcare services: A model of care. Journal of Transcultural Nursing: Official Journal of the Transcultural Nursing Society, 13(3), 181–201. Visit Source.
• Canby, S. (2019). The Five Pillars of Islam. The Metropolitan Museum of Art. Visit Source.
• Centers for Disease Control and Prevention (CDC). (2024a). Common barriers to participation experienced by people with disabilities. Centers for Disease Control and Prevention. Visit Source.
• Centers for Disease Control and Prevention (CDC). (2023a). Health disparities. Centers for Disease Control and Prevention. Visit Source.
• Centers for Disease Control and Prevention (CDC). (2021). Rapid increase in Ivermectin prescriptions and reports of severe illness associated with use of products containing Ivermectin to prevent or treat COVID-19. Centers for Disease Control and Prevention. Visit Source.
• Centers for Disease Control and Prevention (CDC). (2024b). What is health equity?. Centers for Disease Control and Prevention. Visit Source.
• Centers for Disease Control and Prevention (CDC). (2024c). Social determinants of health. Centers for Disease Control and Prevention. Visit Source.
• Center for Disease Control and Prevention (CDC). (2023b). The U.S. Public Health Service untreated Syphilis study at Tuskegee. Center for Disease Control and Prevention. Visit Source.
• Centers for Disease Control and Prevention (CDC). (2024d). NCHHSTP Social Determinants of Health. Centers for Disease Control and Prevention. Visit Source.
• Charmaraman, L., & Grossman, J. M. (2010). Importance of race and ethnicity: an exploration of Asian, Black, Latino, and multiracial adolescent identity. Cultural diversity & ethnic minority psychology, 16(2), 144–151. Visit Source.
• Committee on Family Caregiving for Older Adults; Board on Health Care Services; Health and Medicine Division; National Academies of Sciences, Engineering, and Medicine; Schulz R, Eden J, editors. (2016). Families Caring for an Aging America. National Academies Press (US). Visit Source.
• Ettner, R., Monstrey, S., & Coleman, E. (2016). Principles of transgender medicine and surgery. In Routledge eBooks. Visit Source.
• FitzGerald, C., & Hurst, S. (2017). Implicit bias in healthcare professionals: A systematic review. BMC Medical Ethics, 18(1), 19. Visit Source.
• FitzGerald, C., Martin, A., Berner, D., & Hurst, S. (2019). Interventions designed to reduce implicit prejudices and implicit stereotypes in real world contexts: a systematic review. BMC psychology, 7(1), 29. Visit Source.
• Fountain House. (2022). Why is cultural competence important in mental health care? Fountain House. Visit Source.
• Giger, J. N. (2013). Transcultural nursing: Assessment & intervention. Mosby.
• Gómez, C. A., Kleinman, D. V., Pronk, N., Wrenn Gordon, G. L., Ochiai, E., Blakey, C., Johnson, A., & Brewer, K. H. (2021). Addressing health equity and social determinants of health through healthy people 2030. Journal of Public Health Management and Practice: JPHMP, 27(Suppl 6), S249–S257. Visit Source.
• Governor Gretchen Whitmer. (2021). Governor Gretchen Whitmer and LARA announce adopted training requirement to improve equity across Michigan's Health Care System. Governor Gretchen Whitmer. Visit Source.
• Haghighi, A. S., (2021). Biases in healthcare: An overview. Medical News Today. Visit Source.
• Hegazi, A., & Pakianathan, M. (2018). LGBT sexual health. Medicine, 46(5), 300–303. Visit Source.
• Herschthal, E. (2022). Slavery, health, and healing now: The state of the field. Journal of the History of Medicine and Allied Sciences, 77(1), 1–23. Visit Source.
• Hindu American Foundation. (n.d.). Oneness and pluralism: Hinduism's essence. Hindu American Foundation. Visit Source.
• History. (2024a). Christianity. History. Visit Source.
• History. (2024b). Isam. History. Visit Source.
• History. (2024c). Judaism. History. Visit Source.
• Howell, E. A. (2018). Reducing disparities in severe maternal morbidity and mortality. Clinical Obstetrics and Gynecology, 61(2), 387–399. Visit Source.
• Human Rights Campaign. (n.d.). Healthcare equality index 2024. Human Rights Campaign. Visit Source.
• Human Rights Campaign. (2023). Glossary of Terms. Human Rights Campaign. Visit Source.
• Hutchinson, J., & Smith, A. D. (1996). Introduction. In Ethnicity. pp. 1–14. Oxford University Press, Oxford and New York.
• Illinois General Assembly. (2022). Public Act 102-0604. Illinois General Assembly. Visit Source.
• Institute of Medicine (IOM). (2003). Unequal treatment: Confronting racial and ethnic disparities in health care. Washington (DC): National Academies Press (US). Visit Source.
• The Joint Commission (TJC). (2011). Advancing effective communication, cultural competence, and patient- and family-centered care for the lesbian, gay, bisexual, and transgender (LGBT) community. The Joint Commission. Visit Source.
• The Joint Commission. (2020). Quick safety 23: Implicit bias in health care. The Joint Commission. Visit Source.
• Jordan, G. (2018). Understanding implicit bias in health care. National Athletic Trainer Association. Visit Source.
• Jurado de Los Santos, P., Moreno-Guerrero, A. J., Marín-Marín, J. A., & Soler Costa, R. (2020). The term equity in education: A literature review with scientific mapping in web of science. International Journal of Environmental Research and Public Health, 17(10), 3526. Visit Source.
• Kaljee, L., & Stanton, B. (2011). Cultural Issues in Pediatric Care. Elsevier EBooks, 13-13, e22.
• Karjalainen, H. (2020). Cultural identity and its impact on today's multicultural organizations. International Journal of Cross Cultural Management, 20(2), 249–262. Visit Source.
• Ladha, T., Zubairi, M., Hunter, A., Audcent, T., & Johnstone, J. (2018). Cross-cultural communication: Tools for working with families and children. Paediatrics & child health, 23(1), 66–69. Visit Source.
• Leininger, M. (2002). Culture care theory: A major contribution to advance transcultural nursing knowledge and practices. Journal of Transcultural Nursing: Official Journal of the Transcultural Nursing Society, 13(3), 189–201. Visit Source.
• Nair, L., & Adetayo, O. A. (2019). Cultural competence and ethnic diversity in healthcare. Plastic and Reconstructive Surgery-Global Open, 7(5), e2219. Visit Source.
• Narayan, M. C. (2019). CE: Addressing implicit bias in nursing: A review. The American Journal of Nursing, 119(7), 36–43. Visit Source.
• National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on Community-Based Solutions to Promote Health Equity in the United States; Baciu A, Negussie Y, Geller A, et al., editors. (2017). Communities in Action: Pathways to Health Equity. Washington (DC): National Academies Press (US). The State of Health Disparities in the United States. Visit Source.
• National Association of Colleges and Employers (NACE). (n.d.). Equity. National Association of Colleges and Employers. Visit Source.
• National Center for Cultural Competence (NCCC). (2021). Conscious & Unconscious Biases in Health Care. National Center for Cultural Competence. Visit Source.
• National Geographic Society. (2023). Buddhism. National Geographic Society. Visit Source.
• National Health Law Program. (n.d.). Equity stance. National Health Law Program. Visit Source.
• National Human Genome Research Institute. (2024). Race. National Human Genome Research Institute. Visit Source.
• National Institute on Minority Health and Health Disparities. (2024). What Is Health Equity?. National Institute on Minority Health and Health Disparities. Visit Source.
• National Quality Forum. (2009). Endorsing a framework and preferred practices for measuring and reporting culturally competent care quality. National Quality Forum. Visit Source.
• Ocejo, C. & López, M. (2024). IAT and priming tests explained. Bitbrain. Visit Source.
• Office of Disease Prevention and Health Promotion. (2022). Lesbian, gay, bisexual, and transgender health. Healthy People. Visit Source.
• Office of Minority Health. (n.d.). National culturally and linguistically appropriate service standards. U.S. Department of Health & Human Services. Visit Source.
• Onwuachi-Saunders, C., Dang, Q. P., & Murray, J. (2019). Reproductive rights, reproductive justice: Redefining challenges to create optimal health for all women. Journal of Healthcare, Science and the Humanities, 9(1), 19–31.
• Oxford University Press. (n.d.). Diversity. Oxford English Dictionary. Visit Source.
• Pakianathan, M., Daley, N., & Hegazi, A. (2016). Gay, bisexual, and other men who have sex with men: Time to end the fixation with HIV. BMJ, 354, i4739. Visit Source.
• Pavlikova, B., & van Dijk, J. P. (2021). Jehovah's Witnesses and their compliance with regulations on smoking and blood treatment. International Journal of Environmental Research and Public Health, 19(1), 387. Visit Source.
• Payne, B. K., Cheng, C. M., Govorun, O. & Stewart, B. D. (2005). An Inkblot for Attitudes: Affect Misattribution as Implicit Measurement. Journal of Personality and Social Psychology, 89(3), 277-293. Visit Source.
• Penner, L. A., Dovidio, J. F., Gonzalez, R., Albrecht, T. L., Chapman, R., Foster, T., Harper, F. W. K., Hagiwara, N., Hamel, L. M., Shields, A. F., Gadgeel, S., Simon, M. S., Griggs, J. J., & Eggly, S. (2016). The effects of oncologist implicit racial bias in racially discordant oncology interactions. Journal of Clinical Oncology, 34(24), 2874–2880. Visit Source.
• Petersen, E. E., Davis, N. L., Goodman, D., Cox, S., Syverson, C., Seed, K., Shapiro-Mendoza, C., Callaghan, W. M., & Barfield, W. (2019). Racial/Ethnic Disparities in Pregnancy-Related Deaths - United States, 2007-2016. MMWR. Morbidity and Mortality Weekly Report, 68(35), 762–765. Visit Source.
• Project Implicit. (n.d.). What is implicit bias? Project Implicit. Visit Source.
• ‌Purnell, L. (2002). The Purnell model for cultural competence. Journal of Transcultural Nursing, 13(3), 193–196. Visit Source.
• Saluja, B., & Bryant, Z. (2021). How implicit bias contributes to racial disparities in maternal morbidity and mortality in the United States. Journal of Women's Health, 30(2), 270–273. Visit Source.
• Schmalz, M. (2023). Who are Jehovah’s Witnesses? A religion scholar explains the history of the often misunderstood group. The Conversation. Visit Source.
• Servaes, S., Choudhury, P., & Parikh, A. K. (2022). What is diversity?. Pediatric Radiology, 52(9), 1708–1710. Visit Source.
• Shields, D. M., Kuhl, D., & Westwood, M. J. (2017). Abject masculinity and the military: Articulating a fulcrum of struggle and change. Psychology of Men & Masculinity, 18(3), 215–225. Visit Source.
• Snodgrass, J. G., Lacy, M. G., & Upadhyay, C. (2017). "Developing culturally sensitive affect scales for global mental health research and practice: Emotional balance, not named syndromes, in Indian Adivasi subjective well-being". Social science & medicine (1982), 187, 174–183. Visit Source.
• Soltani, S., Takian, A., Akbari Sari, A., Majdzadeh, R., & Kamali, M. (2019). Financial Barriers to Access to Health Services for Adult People with Disability in Iran: The Challenges for Universal Health Coverage. Iranian journal of public health, 48(3), 508–515.
• Stanford Encyclopedia of Philosophy. (2020). Trinity. Stanford Encyclopedia of Philosophy. Visit Source.
• State of California Department of Justice. (2021). Attorney General Bonta ensures California perinatal healthcare facilities are compliant with the law mandating anti-implicit bias training for healthcare providers. Office of the Attorney General. Visit Source.
• State of New Jersey. (2021). Governor Murphy signs legislation requiring maternal health care professionals to undergo explicit and implicit bias training. State of New Jersey. Visit Source.
• Stubbe, D. E. (2021). Check Your Ageism at the Door: Implicit Bias in the Care of Older Patients. Focus (American Psychiatric Publishing), 19(3), 322–324. Visit Source.
• The George Washington University. (n.d.). Diversity and inclusion defined. Office for Diversity, Equity & Community Engagement. Visit Source.
• Tilghman, B. (2013). What is the Elder Justice Act? Kindred Hospitals. Visit Source.
• U.S. Department of Health and Human Services. (n.d.). Healthy people 2030 framework. Office of Disease Prevention and Health Promotion. Visit Source.
• United States Census Bureau. (2022). About the topic of race. United States Census Bureau. Visit Source.
• van Herwaarden, A., Rommes, E. W. M., & Peters-Scheffer, N. C. (2020). Providers' perspectives on factors complicating the culturally sensitive care of individuals with intellectual disabilities. Research in Developmental Disabilities, 96, 103543. Visit Source.
• World Health Organization (WHO). (n.d.). Sexual Health. World Health Organization. Visit Source.
• World Health Organization (WHO). (2021). Ageing: Ageism. World Health Organization. Visit Source.
• Yeager, K. A., & Bauer-Wu, S. (2013). Cultural humility: Essential foundation for clinical researchers. Applied Nursing Research: ANR, 26(4), 251–256. Visit Source.
• Yearby, R., Clark, B., & Figueroa, J. F. (2022). Structural racism in historical and modern US Health Care Policy. Health Affairs (Project Hope), 41(2), 187–194. Visit Source.
• Yip, T. (2018). Ethnic/Racial Identity-A double-edged sword? Associations with discrimination and psychological outcomes. Current Directions in Psychological Science, 27(3), 170–175. Visit Source.