{"id":7783,"date":"2020-08-17T09:28:59","date_gmt":"2020-08-17T16:28:59","guid":{"rendered":"https:\/\/www.qualityhealth.org\/wpsc\/?p=7783"},"modified":"2020-10-26T16:13:07","modified_gmt":"2020-10-26T23:13:07","slug":"stigma-bias-in-healthcare-the-obstacles-consequences-and-changes-needed","status":"publish","type":"post","link":"https:\/\/www.qualityhealth.org\/wpsc\/2020\/08\/17\/stigma-bias-in-healthcare-the-obstacles-consequences-and-changes-needed\/","title":{"rendered":"Stigma & Bias in Healthcare: The Obstacles, Consequences and Changes Needed"},"content":{"rendered":"

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by: Anita Sulaiman<\/strong> | Principal Consultant and Executive Coach at IBEX Consulting<\/span><\/p>\n

What does every one of us need \u2013 regardless of age, race, gender, religion or nationality? Healthcare. One of the biggest and most enduring challenges in healthcare is the issue of provider stigma and bias, and their impact on patient outcomes. We all need healthcare, but we do not all have the same access to quality care.<\/span><\/span><\/p>\n

Stigma (defined as a powerful social process that is characterized by labeling, stereotyping and separation, leading to status loss and discrimination, in a context of power) drives morbidity and mortality1,2<\/sup>. An individual labeled or stereotyped is devalued. The resulting bias contributes to discrimination. It is a fundamental cause of population health inequalities.<\/span><\/p>\n

Merriam-Webster defines stigma as a mark of shame or discredit. This mark is a distinguishing characteristic, such as mental illness, that is viewed negatively. Shame associated with it creates significant obstacles to equitable care. The shame that stigmatized individuals are subjected to is a power dynamic. To combat stigma, health interventions must address this social factor as well as the immanent power play.<\/span> Failure to fully appreciate its importance undermines their efficacy.<\/span><\/p>\n

Stigmatized statuses and the relationship of bias to education<\/strong><\/span><\/h3>\n

Examples of stigmatized statuses include minority\/proscribed sexual orientation*, minority race\/ethnicity, obesity, disability, substance abuse disorder (SUD), HIV\/AIDS, diabetes and now COVID-19. * Did you know that 16 states in the US still have sodomy laws?<\/span><\/p>\n

Consider obesity: according to the Centers for Disease Control and Prevention, 42.4% of adults 20 years and older are obese (2017 \u2013 2018). A 2015 review of the empirical literature on weight bias in healthcare concluded that many healthcare providers held strong negative attitudes and stereotypes about people with obesity. Such attitudes influence person-perceptions, judgment, interpersonal behavior and decision-making. One finding is that physicians tend to spend less time in appointments with patients who are overweight3<\/sup>.<\/span><\/p>\n

How educational institutions prepare physicians play a part. Education on obesity in undergraduate and graduate medical education is inadequate; even more so on weight bias and stigma and its impact on the health of individuals who struggle with obesity4<\/sup>.<\/span><\/p>\n

Two recent studies indicated that weight bias among medical professionals dated back to their undergraduate years3<\/sup>. Study authors concluded, \u201cThese results suggest that interventions targeting weight bias among students and healthcare trainees may be warranted\u201d. Medical programs can better equip physicians by closing this gap. With 4 out of 10 Americans qualifying as obese, improvements in the efficacy of public health programs focused on obesity prevention and reduction have the potential to benefit well over a third of Americans. The same logic applies to other stigmatized statuses.<\/span><\/p>\n

Additionally, there is also a \u201chidden curriculum\u201d that is learned early on in training \u2013 a socialization process outside of formal lessons. Hidden curriculum messages abound, such as accepting being overworked and that seeking help for mental health struggles is not okay.<\/span> Schools and facilities need to be deliberate about addressing this aspect of the learning environment for medical students and trainees. The biggest challenge is it is hidden; the first step, therefore, is to expose it. \u00a0<\/span><\/p>\n

Dennis Rosen, MD, a pediatric pulmonologist at Boston Children\u2019s Hospital and Assistant Professor of Pediatrics at Harvard Medical School explained that physicians, like everybody else, use heuristics \u2013 decision-making shortcuts. The problem is some heuristics guiding clinical decision-making are based on personal bias. They predispose us to certain behaviors and choices.<\/span><\/p>\n

Implicit bias, which practitioners are unaware of, and explicit bias, which they are aware of, can influence the choice of treatments offered to patients.<\/span> Bias can ultimately lead to the provision of substandard care to some patients compared with others with the same clinical presentation5<\/sup>. Because heuristics are unconscious and reinforced by repetition, they can be difficult to overcome once they are ingrained.<\/span><\/p>\n

The recipients of the discriminatory behavior, on the other hand, are typically fully aware of the unconscious attitudes of these biases. In many cases, two or more stigmatized statuses intersect (e.g. race-related and substance use stigma), increasing the likelihood of discrimination and compounding the burden on the individual.<\/span> A common complaint among members of stigmatized groups is that they are not taken seriously or are made to feel uncomfortable. When a person feels disrespected or experiences discomfort, they lose trust and disengage. Trust once lost is difficult to regain.<\/span><\/p>\n

Stigma Complex<\/strong><\/span><\/h3>\n

Various factors contribute to stigma, including negative attitudes or beliefs, fear and lack of awareness. Providers may fear infection, mortality or behavior associated with a condition or group. Institutional policies and practices (e.g. having a separate window at a facility\u2019s pharmacy for HIV patients to pick up medication) can also be drivers, at the organizational level. When some groups receive unequal treatment, this drives disparities.<\/span><\/p>\n

The Washington State Diversity and Equity Project – a study released in October 2019 – showed higher rates of smoking, disability and poorer mental health among LGBTQ individuals than their heterosexual counterparts. The first of its kind to examine LGBTQ people of all ages across the state, it included a supplementary community-based survey focused on economic and social inequities, which revealed significant rates of discrimination, trauma and barriers to healthcare and other services among the approximately 1,800 adults surveyed6<\/sup>.<\/span><\/p>\n

Overall, the data showed greater challenges for transgender, bisexual and queer people and racial\/ethnic minorities. The implications are wide. These findings help highlight vulnerable populations that public health interventions need to pay special attention to.<\/span><\/p>\n

Stigma is complex, occurring on many levels. There are three main inter-related types of stigma: structural, public and self-stigma, plus courtesy stigma (directed towards family and friends) and label avoidance7<\/sup>.<\/span><\/p>\n

    \n
  • Structural stigma:<\/strong> societal conditions, cultural norms and institutional practices that constrain the opportunities, resources and well-being for stigmatized populations.<\/span><\/li>\n
  • Public stigma:<\/strong> negative attitudes, beliefs and behaviors held within a community for the larger cultural context that comprises negative social norms.<\/span><\/li>\n
  • Self-stigma<\/strong>: the internalization of public stigma by a person with a condition, disorder or minority status.<\/span><\/li>\n<\/ul>\n

    All of the above influence the decision to seek help and impact health outcomes. Understanding this concept of what researchers term a \u201cstigma complex\u201d i.e. stigma as a multi-level, multi-dimensional phenomenon is key. It enables the identification of specific targets for change at each level. Sustainable change would require effective strategies at all levels where stigma can touch populations most at risk.<\/span><\/p>\n

    Stigma in a healthcare setting is particularly egregious <\/strong><\/span><\/h3>\n

    Everyone has a right, without distinction of any kind, to not be discriminated against. So important is this right that it is enshrined in Article 2 of the Universal Declaration of Human Rights. Being refused service at a restaurant does not have the same implications as not being able to get medical attention when you are sick, especially if you are in need of life-saving medical intervention. It could mean life or death. That is why stigma and bias matter in healthcare and is rightfully garnering increased attention.<\/span><\/p>\n

    Any health facility employee who has patient contact can stigmatize.<\/span> For this reason, education and other stigma reduction efforts need to reach all employees. Often, however, they do not. It is important that interventions involve all cadres of healthcare workers. Every possible point of encounter with patients, or what I call (to borrow from Marketing) Moment of Truth, must be taken into account to ensure a seamless, effective, culturally appropriate delivery.<\/span><\/p>\n

    I emphasize seamless because most patient appointments involve more than one area of a facility. A positive patient experience means the patient\u2019s needs are met in every part of the entire encounter.<\/span> For health facilities, this means addressing stigma and bias at the system level. I would advocate for a culture of zero tolerance toward stigma. Imagine a healthcare world without stigma and bias. That is the goal.<\/span><\/p>\n

    Looming mental health crisis<\/strong><\/span><\/h3>\n

    Stigma disempowers. In a health system, provider stigma compromises access to diagnosis, treatment and successful health outcomes. Just as concerning is its impact on healthcare workers living with stigmatized conditions. Like patients, they too may conceal their own health status. Fearing discrimination, they may be reluctant to access needed care8<\/sup>.<\/span><\/p>\n

    On July 11, The New York Times published the harrowing story of Dr Lorna M Breen, in an article titled, \u201cI couldn\u2019t do anything: The virus and an E.R. Doctor\u2019s Suicide\u201d. A \u201cconsummate overachiever\u201d, Dr Breen, 49, who studied both emergency and internal medicine, was managing the busy emergency department at New York-Presbyterian Allen Hospital in Upper Manhattan while also in a dual degree master\u2019s program at Cornell University. Brilliant and full of zest, she was known to be unflappable.<\/em><\/span><\/p>\n

    Then the pandemic hit and the structure that held her life together crumbled. She started working long days that bled from one into another, at both the Allen and the main Columbia medical campus. Even after contracting COVID-19 herself, she pushed on as much as was humanly possible. Their already over-burdened facility was inundated by constant streams of severely sick people and the bodies kept piling up. \u201cI\u2019m drowning right now.\u201d Those were her words to her Bible study group that she was actively involved with. Still, she soldiered on. Used to toughing it out, she kept doing her best to keep up with the overwhelming demands and relentless schedule. <\/em><\/span><\/p>\n

    When she finally called her sister for help on April 9, Dr Breen was not herself. Her eyes had dulled and she did not speak unless questioned, giving only one or two-word answers. When asked if she wanted to hurt herself, she indicated yes. She was terribly embarrassed because \u201cshe had suffered a breakdown when the city was desperate for heroes. And she was certain her career would not survive it\u201d.<\/em><\/span><\/p>\n

    Dr Breen was admitted for 11 days into the psychiatric ward. Upon discharge, her condition seemed to have improved and family members were optimistic enough that they talked about getting her back to New York. But on April 26, less than three weeks from the day she reached out, Dr Breen killed herself. \u00a0<\/em><\/span><\/p>\n

    This tragedy shined a spotlight on the pressures that can be crippling to doctors and an unspoken truth among them, particularly emergency physicians. \u201cIf Dr Breen is lionized along the legions of other health care workers who gave so much \u2013 maybe too much \u2013 of themselves, then her shattered family also wants her to be saluted for exposing something more difficult to acknowledge: the culture within the medical community that makes suffering easy to overlook or hide; the trauma that doctors comfortably diagnose, but are reluctant to personally reveal, for fear of ruining their careers.\u201d9<\/sup><\/em><\/span><\/p>\n

    Dr Breen may be alive today had the culture been different. In the age of the novel coronavirus, her untimely demise underscores the urgency of the need for change. As the pandemic drags on, the survival of the people society has conferred hero status on will increasingly depend on the health system\u2019s ability to create an ecosystem more supportive of provider health.<\/em><\/span>\u00a0<\/em><\/span><\/span><\/p>\n

    Mental illness is a condition that afflicts millions of Americans every year. If you are suffering from it, you are not alone. 1 in 5 adults experience mental illness. 1 in 25 adults experience serious mental illness. Among youths (aged 6 to 17), 1 in 6 experience a mental health disorder. Suicide is the 2nd<\/sup> leading cause of death among people aged 10 to 3410<\/sup>.<\/span><\/p>\n

    Despite its prevalence and the pressing need, the stigma attached to mental health is pervasive and firmly entrenched. Public attitudes are slowly shifting. However, mental illness remains a barrier to full participation in society and those with the condition continue to struggle with how they and their illness are perceived, not just by their providers but also by society.<\/span><\/p>\n

    In implementing change, language, although seemingly innocuous, makes a difference. Language reflects attitudes. Fortunately, healthcare facilities are beginning to understand its role in perpetuating stigma and how it can help transform an organization\u2019s culture \u2013 from discriminatory to inclusive.<\/span><\/p>\n

    More and more, for example, are favoring \u201cfirst person\u201d language, moving from terms like \u201cdrug abuser\u201d, which implies that the person is the problem to \u201cperson with substance abuse disorder\u201d, which recognizes \u2013 appropriately – that the person has a problem that can be addressed.<\/span> Another example is using \u201cperson with\/being treated for schizophrenia\u201d versus \u201cschizophrenic\u201d. Stigmatizing language looks at the person as a condition, when the condition is only a part of the person; it does not define them.<\/span><\/p>\n

    Psychological fallout of the pandemic<\/strong><\/span><\/h3>\n

    The issue of stigma is a weighty one, particularly in light of the current pandemic. Since the first U.S. reported case of the coronavirus, SARS-coV-2, in January, it has spread like wildfire across the country, infecting over 5.4 million and killing over 170,000 people to date. According to CDC Director, Robert Redfield, in a piece in the Washington Post on June 25, 2020 titled, \u201cCDC Chief says coronavirus cases may be 10 times higher than reported\u201d, for every case confirmed, 10 more cases are unreported. The United States makes up about 26% of all cases worldwide. It is the biggest health threat of our time.<\/span><\/p>\n

    As part of their strategy to mitigate the risks and curb the spread, local and federal authorities issued public health and safety directives, which, while necessary, are having short and long term behavioral health consequences as people\u2019s well-being are increasingly affected by extended stay-at-home orders and social distancing.<\/span><\/p>\n

    In May, Mental Health America conducted an online mental health screening on over 211,000 participants11<\/sup>. Results were staggering. Among other things, it revealed, since the start of the pandemic:<\/span><\/p>\n