Eliminating Stigma Toolbox

Implicit bias and stigma are potential factors in perpetuating healthcare disparities and have a negative impact on the patients who experience them. Organizations committed to advancing health equity will make it a priority to acknowledge and mitigate these forms of discrimination. Each manifests differently and requires a different approach to address.

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What is implicit bias?

Implicit bias is the unconscious collection of stereotypes and attitudes that are developed toward certain groups of people or situations that affect understanding, actions, and decision-making.¹ All humans have a natural tendency to make assessments based on characteristics such as race, ethnicity, age, gender, sexual orientation, and disability status. These assessments, which can be favorable and unfavorable, are triggered involuntarily in as little as a tenth of a second.^2,3  While this process saves cognitive resources, it also allows bias to influence how we register the information without our awareness.  This makes implicit bias difficult to control and fix.  

Implicit biases often do not reflect our declared core values and beliefs. As a result, our decisions and actions will contradict our stated intentions, no matter how strongly we are committed to them.⁵ What we say about ourselves, to ourselves and to others, is not consistent with what is happening internally. This universal phenomenon can lead to discriminatory behaviors or actions that perpetuate healthcare disparities.   

What is Stigma or Explicit Bias?

Stigma or explicit bias includes attitudes, stereotypical beliefs, and/or feelings about people or a group that can motivate one to consciously discriminate and marginalize.  Positive or negative preferences result in people drawing boundaries to distinguish themselves from others or to identify with a favored group.6 Health-related stigma is disqualification of individuals and groups of people who live with certain health conditions.  People with those conditions may have a lived experience characterized by exclusion, blame, and/or devaluation. When one is on the receiving end of stigma, the shame, distrust, and rejection can influence their decision to seek care.⁷ They may avoid care altogether or have an undesirable response to treatment. This, in turn, leads to poorer health outcomes and disparities in care.

Implicit Bias & Stigma in Healthcare

There is a growing body of literature about the effects of implicit bias and stigma on the delivery of quality healthcare and achieving optimal health outcomes. For groups that are already vulnerable, implicit bias and stigma further disadvantage them.

• Reducing Stigma Education Tools (ReSET)
  • The aim of this free training is to help healthcare providers confidently identify and address stigma surrounding opioid use disorder (OUD), to ensure the delivery of equitable and compassionate healthcare for all patients living with opioid addiction. While there is a focus on OUD, anyone interested in learning more about stigma will find this training helpful.
• Implicit Bias Module Series
  • This course will introduce you to insights about how our minds operate and help you understand the origins of implicit associations. You will also uncover some of your own biases and learn strategies for addressing them. Each of the four modules is divided into a short series of lessons, many taking less than 10 minutes to complete. You can complete the lessons and modules at your convenience.
• Unconscious Bias Training that Works
  • This article outlines the reasons why traditional unconscious bias (UB) training is ineffective.  Increasing awareness isn’t enough. UB training that gets results teaches attendees to manage their biases, practice new behaviors and track the progress. The authors describe the components of UB training programs that work.
• Implicit Bias Video Series
  • Have you heard the term implicit bias but are not totally sure what it means?  This series of seven short videos provides an overview of implicit bias with a focus on key terms and definitions.
• Preventing and Reducing Stigma
  • This customizable slide deck can be used to describe why addressing stigma within healthcare is important, discuss the potential impacts of stigma, and explore strategies for engaging providers in the prevention and reduction of stigma.  A two-page resource is also provided.
• Are You Aware of Your Implicit Bias?
  • This webinar recording addresses the role of implicit bias and how it impacts individuals who seek substance use treatment and other behavioral health services to mitigate adverse behavioral health outcomes. Methods and tactics to reduce implicit bias are explored to eliminate the stigma associated with those who require substance use treatments or other behavioral health services.

Stigma Assessment

• Stigma Survey
  • This is a short survey to assess an individual’s level of stigma
• Stigma-Free Tool
  • This Stigma-Free Tool is a simple and engaging way to privately assess your attitudes around stigma, and see where you may want to improve your actions and thoughts around the topic of stigma. It also provides a percentage at the end of the activity, suggests further ways to examine your perceptions and directs you to our page on how to take ACTION. Includes a stigma-free pledge.
• Implicit Association Test
  • The Implicit Association Test (IAT) measures attitudes and beliefs that people may be unwilling or unable to report. The IAT may be especially interesting if it shows that you have an implicit attitude that you did not know about.  It measures the strength of associations between concepts (e.g., black people, gay people) and evaluations (e.g., good, bad) or stereotypes (e.g., athletic, clumsy).

• Words Matter: How Language Choice Can Reduce Stigma
  • This resource examines the role of language in perpetuating substance use disorder stigma, offers tips to assess how and when we may be using stigmatizing language, and steps to ensure that we use language that is positive, productive, and inclusive.
• Associated Press (AP): AP Stylebook, 55^th Edition
  • Published in 2020, the 55th edition of The Associated Press Stylebook and Briefing on Media Law includes more than 200 new or revised entries including addiction and drug-related terms. The AP dropped certain words in favor of language that recognizes that addiction is not a moral failing but a disease. This is a valuable tool for journalists or anyone interesting in using non-stigmatizing language in their writing.
• People Matter, Words Matter
  • The AHA, together with behavioral health and language experts from member hospitals and partner organizations, offers a series of downloadable posters to help your employees adopt patient-centered, respectful language. Please consider downloading, printing and sharing each poster with team members and encourage them to use this language both in front of patients and when talking to colleagues. 
• Getting the Story Right: Journalists and the Language of Addiction
  • This one-hour training is designed to introduce the AP Guidelines and writing about substance use in a humane and non-stigmatizing fashion. This training is targeted to journalists and individuals who write about substance use. There may be an associated cost for this training.
• Words Matter: Language, Stigma, and Discrimination Against People with Substance Use Disorders
  • This in-depth training (2-3 hours) provides an introduction to stigma for clinicians, healthcare workers, and community organizations working with people who use drugs. There may be an associated cost for this training.
• Unconscious Bias Resources for Health Professionals
  • The Association of American Medical Colleges offers resources to assist healthcare professionals at academic medical centers meet their goals around addressing unconscious biases.
• How to Identify, Understand, and Unlearn Implicit Bias in Patient Care
  • This resource offers ways to take steps to recognize and correct unconscious assumptions toward groups to promote health equity. (Posted with permission from AAFP).
• Reducing Stigma (COVID-19)
  • This website offers information about stigma around COVID-19 and tips for community leaders and public health officials on preventing stigma.
• Addressing Bias & Driving Equity
  • This is an online learning and resource center designed to support clinical and non-clinical health professionals build skills and knowledge about implicit bias to drive health equity.
• Beyond Labels: Do Your Part to Reduce Stigma
  • This award-winning, interactive website, designed for people who work in healthcare fields, offers ways to help reduce stigma among all moms and babies so they can get the support and care they need.
• How to Reduce Implicit Bias
  • As more health care organizations work toward achieving health equity, it is not enough to focus on intentional discrimination. This blog post provides insights on why organizations must also acknowledge implicit bias and how address it.
• Implicit Bias in Health Care
  • This document addresses implicit bias and its effects on health care. It discusses safety actions to consider to ensure the best outcomes and zero harm for all patients.
• The EveryONE Project: Implicit Bias Resources
  • This website offers a variety of resources on implicit bias, including training, an implicit bias reading list, and customizable PowerPoint presentations. Access to the resources requires an AAFP membership.
• Addressing Implicit Bias, Racial Anxiety, and Stereotype Threat in Education and Healthcare
  • Perception Institute is a consortium of researchers, advocates, and strategists who translate cutting-edge mind science research on race, gender, ethnic, and other identities into solutions that reduce bias and discrimination, and promote belonging. They work in sectors where bias has the most profound impact—education, healthcare, media, workplace, law enforcement, and civil justice.

References

1. Edgoose J, Quiogue M, Sidhar, K. (2019) How to Identify, Understand, and Unlearn Implicit Bias in Patient Care. American Academy of Family Physicians Fam Pract Manag. Jul-Aug;26(4):29-33.
2. American Bar Association Commission on Disability Rights. Implicit Biases & People with Disabilities. Implicit Bias Guide. Accessed October 2 2021 at https://www.americanbar.org/groups/diversity/disabilityrights/resources/implicit_bias/.
3. Marcelin JR, Siraj DS, Victor R, Kotadia S, & Maldonado YA (September 2019). The Impact of Unconscious Bias in Healthcare: How to Recognize and Mitigate It, The Journal of Infectious Diseases, Volume 220, Issue Supplement_2, Pages S62–S73, https://doi.org/10.1093/infdis/jiz214.
4. Psychology Today. Heuristics. Accessed October 15 2021 at https://www.psychologytoday.com/us/basics/heuristics.
5. Perception Institute. Explicit Bias. Accessed September 20 2021 at https://perception.org/research/explicit-bias/.
6. U.S. Department of Justice. Police-Community Relations Toolkit: Understanding Bias: A Resource Guide. Accessed September 20 2021 at https://www.justice.gov/crs/file/836431/download#:~:text=Explicit%20bias%20is%20the%20traditional,are%20examples%20of%20explicit%20biases
7. Weiss MG, Ramakrishna J, Somma D. (Aug 2006). Health-related stigma: rethinking concepts and interventions. Psychol Health Med.;11(3):277-87. doi: 10.1080/13548500600595053. PMID: 17150065.