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, 2020b). For example, the Centers for Disease Control and Prevention reports that during the period 2007-2016, 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 Indian, Alaska Native, and black women are two to three times more likely to die of pregnancy-related causes than white women. 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: does a provider's IB influence their decision not to make a referral because they believe that patient to be non-compliant, or when to refer a pregnant woman considered high risk?
In 2003, the Institute of Medicine'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 (2018) 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." 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 black oncology patients and their physicians that "patients perceived providers high in IB as less supportive of and spent less time with their patients than providers low in implicit bias. In turn, black patients recognized those attitudes and viewed high-implicit-bias physicians 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).
With the shift towards diversity and equity, there come barriers to inclusion. Such barriers may include attitudinal barriers, physical barriers, a lack of or inappropriate education, organization, and policy barriers.
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 societal emotions tend to assume individuals with disabilities have a poor quality of life. A disability should not be considered a deficit (CDC, 2020a). 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 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, 2020a).
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).
Policy can implement change. Unfortunately, it can also act as a barrier to inclusivity; this is due to a lack of awareness of laws and regulations, a lack of the ability to enforce laws and regulations, or a lack of ability to make change. Policy barriers can also include a lack of funding (CDC, 2020a).
The social constructs of race, ethnicity, and culture affect identity in many ways. Cultural identity is a term that encompasses the distinctiveness of individuals in a community with shared identities and characteristics (Karjalainen, 2020). Self-perception and self-conception are significant components of cultural identity tied to ethnicity, race, religion, and many other factors.
Unfortunately, with identity comes discrimination for the differences that set us apart. Racial bias, microaggressions, and identity-relevant stressors can, unfortunately, be a part of cultural identity. For many, the formation and modification of identity exist within realms of prejudice and racism. Ethnic and racial discrimination is broadcasted as consistent and unfair treatment within institutions and social structures. Because cultural identity is tied to our very existence, such as school, work, and access to healthcare, the impacts of racism are immeasurable. Racism and discrimination can result in inferiority and a marginalized status, resulting in negative health and quality of life (Yip, 2018).
