CHAPTER 2
The Impact of Bias in Healthcare

Habib Naqvi

Director, NHS Race and Health Observatory, UK

OVERVIEW

• Bias can take different forms and negatively impact people’s mental and physical health.
• Bias built into healthcare policies and processes can place patients at risk and harm them.
• Debiasing medical research and policy can benefit everyone.
• It is not always easy to unlearn biases, but it is important to do so for the betterment of society.
• Common, helpful actions can be taken to identify and help unlearn biases – such as learning about other cultures, ethnicities and identities.

Definitions

Often, we recognise bias as a natural inclination for or against an idea, object, group or individual. However, it is also learnt and is highly dependent on variables such as a person’s religious beliefs, race, ethnicity, sex and educational background. At the individual level, bias can negatively affect someone’s health and personal and professional relationships; at a societal level, it can lead to unfair treatment of a group or community. Examples of this in history include apartheid and slavery (Box 2.1).

Box 2.1 Examples of social justice and bias issues facing the world.

Slavery – you would think that slavery was a non-issue in current culture. However, it is still a social injustice issue found around the world.

Racial segregation – a famous historical example was the segregation of Black Americans in the US via Jim Crow laws. Another example of segregation was apartheid in South Africa.

Ageism – the elderly are discriminated against, creating negative stereotypes of the elderly as being weak, feeble or unable to change. A few examples include being denied work or being seen as a societal burden.

Pay gap – when it comes to pay in the workplace, there is a noticeable differentiation by, for example, gender and ethnicity.

LGBTQ+ – individuals of the Lesbian, Gay, Bisexual, Transsexual and Queer (LGBTQ) community face several forms of social injustice and oppression. For example, same-sex marriages are outlawed in some states in the USA and countries.

Poverty – when you think of poverty, you might think of having little food or living in a homeless shelter. However, the sad truth is that many individuals do not have access to food, clean water, schooling, healthcare or even sanitation.

Indeed, some biases can be positive and helpful, like choosing to eat foods that are considered healthy or making a conscious decision not to buy products from a company that has knowingly caused harm to others. However, biases are often based on stereotypes rather than on any actual evidence base associated with an individual or circumstance. Whether positive or negative, such cognitive shortcuts can result in prejudgements that can lead to rash decision making or discriminatory practices.

The Equality Act 2010 applies to everyone in Britain. It aims to protect people from discrimination, harassment and victimisation based on age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex and sexual orientation.

Thus, what is the relationship between bias and discrimination? Discrimination is the unjust treatment of people based on the groups or classes they belong to. It is an action that stems from an attitudinal bias: when we misunderstand someone different from us, we treat them differently. This misunderstanding can be caused by implicit or explicit bias.

Understanding bias

Bias arises from our tendency to sort people into groups while also paying attention to what kinds of people are most likely to have power and resources in a society. Noticing that specific kinds of characteristics, for example, age, race and gender, are associated with having more or less status, power, resources or respect from others can lead to judgements about people or groups. This way of attaching social value to particular characteristics is what leads to bias: a disproportionate preference for (or, on the other hand, an aversion to) an idea or a group of people, usually in a way that is closed-minded or unfair. This, in turn, can create discriminatory behaviours, practices and institutional policies.

Implicit bias

Implicit bias is often viewed as an unconscious or immediate thought process that may go directly against our conscious beliefs. Bias comes from natural tendencies coupled with what we learn and observe, starting at a very young age. We are often biased in favour of people or groups we see as familiar, making us think of them as being ‘safe’, and biased against groups we have learned to see as distinct or ‘unsafe’. These associations, whether conscious or unconscious, can shape our attitudes and comfort levels around people we perceive as different and can, in turn, affect how we treat them (Box 2.2).

Examples of implicit bias include:

• preferring to socialise with people who only look like you or have similar identities to yours, without noticing that you tend to do this
• reflexively feeling discomfort when you are around individuals or groups with certain characteristics (based on, for example, race, sexual orientation or gender), even though you do not know anything about them as people
• automatically changing how you speak with or about other people who identify differently from you
• regularly showing more respect or giving preferential treatment to certain people based solely on particular characteristics
• having a negative opinion about someone, e.g. assuming someone is unhealthy or unintelligent, based on their race, age, gender or other characteristics, without any personal knowledge of them as an individual.

Box 2.2 Implicit bias.

Abdullah Mufti is a postdoctorate Fellow who, having completed his PhD in cancer research, is hoping to further his career by seeking a lectureship position whilst continuing his research. Having had multiple research articles accepted for high-impact journals, he has struggled to find an academic research post. Having written to various institutes, he has either not heard back from them or they have declined to consider his experience within their laboratories. Out of frustration at his lack of progress and curiosity regarding his lack of responses, he changed his name to Duncan Smith. He had prompt replies and was offered several opportunities to pursue with the same institutions that had previously rejected his applications.

Evidence shows that implicit attitudes are widespread amongst populations globally, influencing everyday behaviours. For instance, one widely cited study by Rooth [1] found that simply changing names from White-sounding ones to Black-sounding ones on CVs had a negative effect on shortlisting for interviews. Implicit bias was suspected to be the culprit, and replication of the study in Sweden, using Arab-sounding names instead of Swedish-sounding names, found a correlation between the HR professionals who preferred the CVs with Swedish-sounding names and a higher level of implicit bias towards Arabs.

Explicit bias

Explicit bias is the conscious process by which we evaluate another person or persons, deem them ‘acceptable’ or ‘unacceptable’, and then treat them according to how we see them. Unlike implicit bias, which is often unconscious or automatic, explicit bias is making a clear and conscious judgement about groups of people based on their identity.

Examples of explicit bias include:

• consciously using language that is derogatory, disrespectful, a slur or othering when speaking about people with different identities
• reacting angrily or disrespectfully to someone speaking another language (or speaking with a specific accent) or wearing clothing that is significant to their culture, religion or ethnicity because of negative personal feelings about what it means to be part of that culture, religion or ethnicity (Box 2.3)
• treating a person or group of people as unintelligent or immature, or being overtly condescending because of the characteristics of those people (based on, for example, race, sexual orientation or gender)
• bullying or discriminating against people because they are different, either because of your own biases or because you want to belong to the ‘in group’.

Box 2.3 Explicit bias.

A female Muslim medical student, Salma Shafiq, is on a paediatric placement. She wears the hijab. During this placement, the students receive group teaching about Paediatric Life Support (PLS) from a paediatric consultant.

This teaching session covers the ABCDE assessment of unwell children. The Resuscitation Council UK algorithm advises an assessment of breathing by doing the following:

• Look for chest movements.
• Listen at the child’s nose and mouth for breath sounds.
• Feel for air movement on your cheek.

All the students were given an opportunity to practise the algorithm whilst being observed by their peers and the consultant.

After a few students, it is Salma’s turn to be observed. Whilst Salma is undertaking the assessment, the consultant stops her and asks how she feels for the breath. She states that she is feeling it on her cheek. The consultant then shouts at her, ‘You are supposed to be feeling for it on your ears...