Conscious and Unconscious Biases in Health Care

Establishing Common Ground

Definitions Related to Disparate Treatment, Health Status, and Health Care

DefinitionsThe following are terms commonly found in the literature that are used to delineate differential or disparate treatment between and among racial, ethnic, social, or other cultural groups. It is helpful that there is a shared understanding of how these terms are used in the course. While there are many definitions of such terms, these were selected because they underpin the constructs and best represent the progressive thinking in those who study the intersection of health and health care disparities and bias.

  • Disparity as used within the context of health care reflects more than numbers-not just differences in prevalence rates or morbidity and mortality rates. A disparity can be thought of as “A chain of events signified by a difference in: the environment, access to, utilization of, and quality of care, health status, or a particular health outcome that deserves scrutiny.”3
  • Health disparity represents a type of systemic difference in the prevalence, morbidity, disease burden, mortality of a disease or illness of one social group as compared with another as a function of underlying social advantage or disadvantage.4 A health disparity is also defined as a particular type of health difference that is closely linked with social or economic disadvantage. Such disparities adversely affect groups of people who have systematically experienced greater social or economic obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; mental health; cognitive, sensory, or physical disability; sexual orientation; geographic location; or other characteristics historically linked to discrimination or exclusion.3
  • Disparities in health care are the types of differences between groups in which health care treatment, services, or outcomes vary in a way that is unjustified by the underlying need or preference of the patient who is associated with membership in a social group. The measure of the differences is usually by comparison with the dominant population group or the population as a whole. The differences may be quantified by differences in race, ethnicity, language spoken, socioeconomic status, disability, national origin, sexual orientation, or other social attribute marginalized by society. These differences are reflected in service system attributes.5,6 Disparities in health care are reflected in discrimination in care and care settings and differences in insurance, access, quality, and services provided.1
  • Group categorization is the practice of acting toward a person based in part on his or her social group.5
  • Discrimination is differential behavior or conduct of one person or group toward another person or group that is based on individual prejudice or societal norms that have institutionalized prejudicial attitudes.7,8
  • Bias is the cognitive tendency among humans to make systematic decisions in certain circumstances based on cognitive factors rather than evidence.9 Bias becomes a concern when it interferes with how we make fair decisions.
  • A stereotype is a cognitive structure that contains the perceiver’s knowledge, beliefs, and expectations about a human group.10 Stereotypes are reflected in the preconceptions that one person has about another based on group membership. Stereotypes are normal strategies that humans use to process and store information in an efficient manner.10 A stereotype is “a widely held image of a group of people through which individuals are perceived or the application of an attitude set based on the group or class to which the person belongs.”11(p814)
  • Prejudice is an explicit, known, conscious, and usually pejorative judgment or attitude toward a group. Prejudice is beliefs and attitudes that people know they hold and can control deliberately and strategically.12 Such biases can result in prejudice. However, people have conscious access to their explicit biases and are able to monitor and control them to mitigate their impact on their behavior.10
  • Unconscious or implicit bias is the unintentional activation of prejudicial attitudes toward a group based on stereotypes that have receded from consciousness overtime and have become invisible to the holder.5 These attitudes represent “overlearned associations with a strong affective basis that are difficult to completely overwrite with recent experiences or acquired values.”12(p948) Such biases result in an automatic and unconscious reaction and/or behavior.13(p138)