Recognizing Implicit Bias Can Reduce Inequities in Children’s Health

"Recognizing that implicit bias affects all of us, regardless of our conscious intention, gives us a better chance of addressing that bias and breaking cycles of inequity," says NICHQ Chief Health Officer, Elizabeth Coté, MD, MPA.

In his second year of clinical practice, Joseph R. Betancourt, MD, MPH, was tasked to prescribe flu vaccinations for a largely Latino population—an assignment he felt prepared for being a native Spanish speaker whose family was from Puerto Rico.

“My first patient was a 72-year-old Latina woman,” recalls Betancourt. “She was a perfect candidate for the flu shot. I wanted to ensure that she was engaged, educated and knowledgeable because I had always been taught that was what mattered most. I spent ten minutes going through all the information with her in Spanish—I reviewed the pros, the cons, went through all the details—before asking if she wanted to receive one. ‘No, no la quiero,’ she said. 'No, no I do not want it.'”

This first patient was followed up by a Latino man, another patient for whom the vaccination was strongly indicated. Again, Betancourt reviewed the information; again, the patient declined the treatment. Over the next four months, this pattern continued, with over 90 percent of Betancourt’s Latino patients declining the vaccination. Eventually, Betancourt began assuming the patients would not want the shot. His delivery changed. He spoke faster and with a more abrupt tone. The informative speech that had originally taken ten minutes to deliver was cut in half.

“I fell into the trap of stereotyping,” says Betancourt. “Instead of asking questions to find out why my patients kept declining the shot, I found myself believing that this population, as a whole, was unlikely to want the vaccine. I recognized a pattern and I reacted to it, letting it inform my actions for any patients that fit the pattern.”

Betancourt calls this story his epiphany. Even though he genuinely wanted what was best for his patients, he let a stereotype based on a perceived pattern influence the quality of care he provided. For Betancourt, who cared about these patients and spoke their language, this experience confirmed that implicit bias is pervasive and unavoidable.

Implicit bias is the unconscious stereotypes that influence our actions and decisions.

Betancourt—a nationally and internationally recognized expert in healthcare disparities, cross-cultural health and cross-cultural communication—recently told this story to the improvement teams working on the National Action Partnership to Promote Safe Sleep Improvement and Innovation Network (NAPPSS-IIN), which seeks to make infant safe sleep and breastfeeding the national norm. Five hospital-based teams involved in the project are testing and developing strategies to ensure that families and caregivers in multiple care settings receive consistent advice on evidence-based infant safe sleep and breastfeeding best practices. By recognizing and confronting implicit bias, the participating teams are better equipped to address the significant racial and ethnic disparities in safe sleep and breastfeeding behaviors.

“We’re not only trying to understand how implicit bias might feed those inequities,” says NICHQ Chief Health Officer, Elizabeth Coté, MD, MPA. “We’re also trying to understand how that bias might inform the processes and resources we’re developing now. Recognizing that implicit bias affects all of us, regardless of our conscious intention, gives us a better chance of addressing that bias and breaking cycles of inequity.”

Interested in learning how to address implicit bias in your work? Keep reading to find out what Betancourt recommends health professionals and improvement teams do to better identify bias and prevent it from affecting their behaviors and decisions.

First, accept that implicit bias happens and understand why.   

“No one is immune,” says Betancourt. “Our environment—the things we see in the media; the experiences that generate positive and negative emotions—influences our subconscious learning and create subconscious biases. This is unavoidable.”

Because of how our brains are wired, these biases influence our actions. Our brains are always looking for patterns, shortcuts to help us understand and navigate the world around us. When we recognize patterns based on subconscious bias, they cause us to react and make biased decisions.

Next, identify your own conditioning.

“It can be difficult to believe we ever act differently based on an implicit bias, especially since we are not aware of it,” says Betancourt. “But we can’t address the behavior until we accept its existence. Think about your own experiences and find your own epiphany, a time when you made an assumption that caused you to treat someone differently.” 

Betancourt also recommends taking the Implicit Association Test (IAT), an established tool for measuring biases that people may not be aware they have. 

Once you identify your own conditioning, start double checking your decision-making processes. For every decision you make, ask yourself, ‘Am I falling into patterns?’ and ‘What might be swaying my decisions?’ Making this additional effort to practice self-reflection and understand what’s driving a family’s actions can keep you from stereotyping.

Then, change your approach to avoid reinforcing stereotypes.

When Betancourt offered flu shots to that same Latino community the following year, he changed his approach. Instead of opening with an informative speech, he asked each patient, “Is there any reason you may not want the flu shot?” His patients then shared their concerns and Betancourt was able to respond with relevant advice and information. The number of patients receiving the shot rose significantly, and the stereotype that Latino patients did not want the shot was debunked.

Betancourt also advises that it is important to acknowledge possible mistrust from families who may believe you are going to treat them differently because of structural mistrust based on historical bias.

“We need to put mistrust on the table,” says Betancourt, “and let families know that we are committed to giving them the best support possible. When families don’t trust us, they may be less likely to listen to our requests or to share their own concerns. And as a result, we may misunderstand their actions and fall into stereotyping.”

These communication and conversation tactics can go a long way toward addressing implicit bias and improving health equity. Interested in learning more? This recent article offers conversational tactics to build trust among families and address safe sleep disparities. Or consider reading Blindspot, an exploration of the hidden biases all people carry.