Becoming competent about cultural differences means a healthcare provider has integrated cultural knowledge into their practice. As mentioned earlier, this requires an ongoing self-examination of one’s own cultural and professional background. In this way, providers can become aware of prejudices and stereotypes that can affect their behavior when interacting with someone from a different culture (Gradellini et al., 2021).

Cultural competence training provides facts about patient cultures and can include interventions such as intercultural communication skills training and exploration of potential barriers to care (UW, 2020). Successful training programs can help healthcare workers work more effectively, in an understanding and reflexive manner, not only with regard to ethnicity and cultural background, but also gender, age, lifestyles, personal choices (Constantinou et al., 2022).

Despite its effectiveness, integration of cultural competence training in the healthcare setting has been inconsistent. The concept has been criticized for either being too broad, impossible to operationalize and measure, or linked largely with ethnicity and cultural background, triggering more stereotypes than it intended to overcome (Constantinou et al., 2022).

In recent years, there have been improvements, although problems remain. There is a lack of consensus on what should be taught, limited and inconsistent formal evaluation of interventions, and a lack of standard references (Gradellini et al., 2021)

5.1 Tackling Implicit Bias, Explicit Bias, and Perception Bias

Implicit bias is an attitude or internalized stereotype that affects a person’s perception, action, or decision-making in an unconscious manner. It can contribute to unequal treatment based on characteristics such as race, ethnicity, nationality, gender, gender identity, sexual orientation, religion, socioeconomic status, age, or disability (FitzGerald et al., 2019).

Implicit racism is a form of power and oppression that has a profound impact on how patients experience healthcare. Black and Indigenous peoples and other minority groups are more likely to experience poorer health outcomes, be given less-effective treatments, and have a lower quality of care than white Americans.

Implicit biases occur below the level of consciousness, using information developed from our life experiences and habits. Although biases can help us to make sense of the world, allowing us to classify individuals into categories quickly and automatically, they have caused considerable harm to people who are the target, leading to discrimination and lack of access to the benefits available to members of society who do not experience these biases.

Implicit bias is widespread, even among individuals who explicitly reject prejudice. It persists through structural and historical inequalities that have been slow to change (Payne et al., 2019). Decades of research have demonstrated that discrimination, driven by implicit bias, impacts healthcare access, trust in clinicians, care quality, and patient outcomes (Dirks et al, 2022).

Explicit or conscious bias, unlike implicit bias, occurs when we are aware of our prejudices and attitudes toward certain groups. This can lead to positive or negative preferences for a particular group.

Explicit forms of bias include preferences, beliefs, and attitudes of which people are generally consciously aware, personally endorse, and can identify and communicate (Vela et al., 2022). Explicit bias can lead to unequal treatment, lack of access to care, and influence differential diagnostic and treatment decisions.

Over time, expressions of explicit bias have declined, but implicit bias has remained unrelenting. Implicit bias permeates the healthcare system and affects communication, clinical decision making, and institutionalized practices. A complex system of discrimination and bias contributes to devastating health inequities that persist despite a growing understanding of its root causes (Vela et al., 2022).

Perception bias is a type of implicit bias that occurs when a perception is skewed based on inaccurate and overly simplistic assumptions about a group a person “belongs” to. This can include biases or stereotypes about age, gender, ethnicity, and appearance.

Providers may feel they can overcome biases through sheer willpower. They may feel that bias does not occur among professionals and experts, or they may believe that they are impartial and immune to bias. They may perceive bias as only associated with corrupt or malicious people or with “bad apples” rather than systemic issues. Although research has shown this to be incorrect, they often feel that bias is eliminated by technology, instrumentation, automation, or artificial intelligence (Dror, 2020).

Strategies to reduce bias and discrimination in healthcare include (Greenwald et al., 2022):

• Make identification of disparities a standard organizational practice. Studies have shown that identifying disparities can reduce bias.
• Increase the development of strategies intended to reduce bias.
• Use caution regarding remedies described as “training.” There is considerable variety in training offerings, which often lack licensing or certification.
• Understand how each organization structures diversity, equity, and inclusion efforts.

5.2 Diagnostic and Treatment Bias

The use of racial terms to describe epidemiologic data perpetuates the belief that race itself puts patients at risk for disease, and this belief is the basis for race-based diagnostic bias. Rather than presenting race as correlated with social factors that shape disease or acknowledging race as an imperfect proxy for ancestry or family history that may predispose one to disease, the educators we observed portrayed race itself as an essential—biologic—causal mechanism.

Amutah, et al., 2021
New England Journal of Medicine

Patient-provider interactions, treatment decisions, patient adherence to recommendations, and patient health outcomes can be influenced by bias. This can lead to an unintentional form of discrimination that affects decision-making structurally and systematically and is hard to identify and uncover (Nápoles et al., 2022).

Studies have shown that implicit racial bias profoundly influences clinical decision-making. It affects nonverbal behaviors such as eye contact and posture and has been shown to influence the quality of physicians’ interpersonal communication with Black patients and, in turn, patients’ trust and perceptions of their physicians (van Ryn et al., 2015).

5.3 Mental Health Care

Cultural differences can affect the rates of diagnosis of certain mental disorders. For example, diagnosis of attention deficit hyperactivity disorder varies widely across countries. These variations reflect the influence of culture on the tolerability of certain behaviors in children, and the perception and acceptance of the diagnosis (Ogundare, 2020).

Current diagnostic classifications of mental illness rely mostly on Western worldviews of what constitutes abnormal behaviors. In reality, however, there are many cultural variations in how people perceive and experience the world. These variations affect the reliability and validity of the diagnostic instruments that are used to diagnosis mental illness (Ogundare, 2020).

The DSM-IV (to some extent) and DSM-V (to a larger extent) have recognized the importance of cultural considerations in the manifestation of illness, diagnosis, and treatment of mental disorders. The DSM-V includes a cultural formulation chapter that aims to help clinicians evaluate cultural aspects of the diagnostic procedure and added a Cultural Formulation Interview to aid the implementation (Ogundare, 2020).

Clinical diagnosis of a mental disorder requires clinicians to fit patient information into existing diagnostic categories, and the weaker the fit between the available information about the patient and the diagnostic criteria, the greater the uncertainty regarding clinical diagnosis. Failure to consider a patient’s cultural context leads to misinterpretation of the patient’s behaviors and leads to diagnostic inaccuracies. Conversely, cultural sensitivity and knowledge of the cultural context provides a more contextualized perspective, improves diagnostic accuracy, and helps identify a patient’s severity and ongoing vulnerability (Ogundare, 2020).