The role of implicit biases on healthcare outcomes has become a concern as some cite that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This webinar will explore definitions of implicit and explicit bias, the nature and dynamics of implicit biases, and how they can affect health outcomes. Because implicit biases are unconscious, strategies will be reviewed to assist in raising professionals' awareness of and interventions to reduce them.
This course is designed for the interprofessional healthcare team and professions working in all practice settings in Michigan.
The purpose of this course is to provide healthcare professionals with an overview of the impact of implicit biases on clinical interactions and decision making.
Upon completion of this course, you should be able to:
- Define implicit and explicit biases and related terminology.
- Evaluate the strengths and limitations of the Implicit Association Test.
- Describe how different theories explain the nature of implicit biases, and outline the consequences of implicit biases.
- Discuss best practices for providing culturally competent care to various patient populations.
- Discuss strategies to raise awareness of and mitigate or eliminate one's implicit biases.
Alice Yick Flanagan, PhD, MSW, received her Master’s in Social Work from Columbia University, School of Social Work. She has clinical experience in mental health in correctional settings, psychiatric hospitals, and community health centers. In 1997, she received her PhD from UCLA, School of Public Policy and Social Research. Dr. Yick Flanagan completed a year-long post-doctoral fellowship at Hunter College, School of Social Work in 1999. In that year she taught the course Research Methods and Violence Against Women to Masters degree students, as well as conducting qualitative research studies on death and dying in Chinese American families.
Previously acting as a faculty member at Capella University and Northcentral University, Dr. Yick Flanagan is currently a contributing faculty member at Walden University, School of Social Work, and a dissertation chair at Grand Canyon University, College of Doctoral Studies, working with Industrial Organizational Psychology doctoral students. She also serves as a consultant/subject matter expert for the New York City Board of Education and publishing companies for online curriculum development, developing practice MCAT questions in the area of psychology and sociology. Her research focus is on the area of culture and mental health in ethnic minority communities.
Contributing faculty, Alice Yick Flanagan, PhD, MSW, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.
John M. Leonard, MD
Jane C. Norman, RN, MSN, CNE, PhD
James Trent, PhD
Randall L. Allen, PharmD
The division planners have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.
Sarah Campbell
The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.
The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.
Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.
It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.
Supported browsers for Windows include Microsoft Internet Explorer 9.0 and up, Mozilla Firefox 3.0 and up, Opera 9.0 and up, and Google Chrome. Supported browsers for Macintosh include Safari, Mozilla Firefox 3.0 and up, Opera 9.0 and up, and Google Chrome. Other operating systems and browsers that include complete implementations of ECMAScript edition 3 and CSS 2.0 may work, but are not supported. Supported browsers must utilize the TLS encryption protocol v1.1 or v1.2 in order to connect to pages that require a secured HTTPS connection. TLS v1.0 is not supported.
The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.
Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.
#97440: Implicit Bias: The Michigan Requirement
The role of implicit biases on healthcare outcomes has become a concern as some cite that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This webinar will explore definitions of implicit and explicit bias, the nature and dynamics of implicit biases, and how they can affect health outcomes. Because implicit biases are unconscious, strategies will be reviewed to assist in raising professionals' awareness of and interventions to reduce them.
Learners should engage with the archived webinar, below, and the provided resources to explore the topics covered in this course. Addressing implicit bias requires that each professional honestly examine their own biases and those that influence the systems in which they work.
The following webinar, produced by NetCE, provides an in-depth discussion of implicit bias and the provision of culturally sensitive and responsive care.
A transcript of the webinar may be accessed here.
Implicit bias and culturally responsive health care are complex subjects. The following resources are provided in the event that you are interested in further exploring the topic, or even trying some of the approaches discussed in this webinar.
| Project Implicit |
| https://implicit.harvard.edu/implicit |
| Think Out Loud Podcast |
| https://www.opb.org/article/2020/10/30/young-black-people-share-their-experiences-growing-up-in-portland |
| George Takei: Growing Up Asian-American |
| https://www.pbs.org/wnet/pioneers-of-television/video/george-takei-growing-up-asian-american |
| Seattle Public Library LGBTQ Staff Picks |
| https://www.spl.org/programs-and-services/social-justice/lgbtq/lgbt-staff-picks |
| American Bar Association Diversity and Inclusion Center |
| Toolkits and Projects |
| https://www.americanbar.org/groups/diversity/resources/toolkits |
| National Implicit Bias Network |
| https://implicitbias.net/resources/resources-by-category |
| The Ohio State University |
| The Women's Place: Implicit Bias Resources |
| https://womensplace.osu.edu/resources/implicit-bias-resources |
| The Ohio State University |
| Kirwan Institute for the Study of Race and Ethnicity |
| http://kirwaninstitute.osu.edu |
| University of California, Los Angeles |
| Equity, Diversity, and Inclusion: Implicit Bias |
| https://equity.ucla.edu/know/implicit-bias |
| University of California, San Francisco, Office of Diversity and Outreach |
| Unconscious Bias Resources |
| https://diversity.ucsf.edu/resources/unconscious-bias-resources |
| Unconscious Bias Project |
| https://unconsciousbiasproject.org |
| University of California, San Diego Center for Mindfulness |
| https://medschool.ucsd.edu/som/fmph/research/mindfulness |
| University of California, Los Angeles Guided Meditations |
| https://www.uclahealth.org/marc/mindful-meditations |
| Mindful: Mindfulness for Healthcare Professionals |
| https://www.mindful.org/mindfulhome-mindfulness-for-healthcare-workers-during-covid |
| Norfolk and Suffolk NHS Foundation Trust |
| The STOPP Technique |
| https://www.youtube.com/watch?v=tStXi7f7Vgk |
1. Institute of Medicine Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, Smedley BD, Stith AY, Nelson AR (eds). Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. Washington, DC: National Academies Press; 2003.
2. Amodio DM. The social neuroscience of intergroup relations. Eur Rev Soc Psychol. 2008;19(1):1-54.
3. The Joint Commission, Division of Health Care Improvement. Quick Safety 23: Implicit Bias in Health Care. Available at https://www.jointcommission.org/-/media/tjc/documents/newsletters/quick-safety-issue-23-apr-2016-final-rev.pdf. Last accessed May 23, 2023.
4. Edgoose J, Quiogue M, Sidhar K. How to identify, understand, and unlearn implicit bias in patient care. Fam Pract Manag. 2019;26(4):29-33.
5. Georgetown University National Center for Cultural Competence. Conscious and Unconscious Biases in Health Care. Available at https://nccc.georgetown.edu/bias. Last accessed May 23, 2023.
6. FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics. 2017;18(1):19.
7. Blair IV, Steiner JF, Havranek EP. Unconscious (implicit) bias and health disparities: where do we go from here? Perm J. 2011;15(2): 71-78.
8. Hall WJ, Chapman MV, Lee KM, et al. Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review. Am J Public Health. 2015;105(12):e60-e76.
9. Matthew DB. Toward a structural theory of implicit racial and ethnic bias in health care. Health Matrix. 2015;5(1):61-85.
10. Baron AS, Banaji MR. The development of implicit attitudes: evidence of race evaluations from ages 6 and 10 and adulthood. Psychol Sci. 2006;17(1):53-58.
11. Ogungbe O, Mitra AK, Roberts JK. A systematic review of implicit bias in health care: a call for intersectionality. IMC Journal of Medical Science. 2019;13(1):1-16.
12. Georgetown University National Center for Cultural Competence. What the Literature Is Telling Us. Available at https://nccc.georgetown.edu/bias/module-2/2.php. Last accessed May 23, 2023.
13. FitzGerald C, Martin A, Berner D, Hurst S. Interventions designed to reduce implicit prejudices and implicit stereotypes in real world contexts: a systematic review. BMC Psychol. 2019;7(1):29.
14. DeAngeles T. In Search of Cultural Competence. Available at https://www.apa.org/monitor/2015/03/cultural-competence. Last accessed May 23, 2023.
15. Lekas H-M, Pahl K, Lewis CF. Rethinking cultural competence: shifting to cultural humility. Health Services Insights. 2020;13:1178632920970580.
16. Velott D, Sprow FK. Toward health equity: mindfulness and cultural humility as adult education. New Directions for Adult & Continuing Education. 2019;161:57-66.
19. Essed P. Everyday Racism: Reports for Women of Two Cultures. Dutch ed. Claremont, CA: Hunter House; 1990.
20. Lum D. Culturally Competent Practice: A Framework for Understanding Diverse Groups and Justice Issues. 4th ed. Belmont, CA: Cengage; 2010.
21. Baker DL, Schmaling K, Fountain KC, Blume AW, Boose R. Defining diversity: a mixed-method analysis of terminology in faculty applications. The Social Science Journal. 2016;53(1):60-66.
22. Crenshaw K. Mapping the margins: intersectionality, identity politics, and violence against women of color. Stanford Law Rev. 1991;43(6):1241-1299.
23. Diller JV. Cultural Diversity: A Primer for the Human Services. 5th ed. Stamford, CT: Cenage Learning; 2014.
24. Gasner B, McGuigan W. Racial prejudice in college students: a cross-sectional examination. College Student Journal. 2014;48(2):249-256.
26. Harawa NT, Ford CL. The foundation of modern racial categories and implications for research on Black/White disparities in health. Ethn Dis. 2009;19(2):209-217.
27. Ross JP. The indeterminacy of race: the dilemma of difference in medicine and health care. Soc Theory Health. 2016;15(1):1-24.
28. Okazaki S, Saw A. Culture in Asian American community psychology: beyond the East-West binary. Am J Community Psychol. 2011;47(1-2):144-156.
29. Wijeyesinghe CL, Griffin P, Love B. Racism-curriculum design. In: Adams M, Bell LA, Griffin P (eds). Teaching for Diversity and Social Justice. 2nd ed. New York, NY: Routlege; 2007: 123-144.
31. Gee G, Ford C. Structural racism and health inequities: old issues, new directions. Du Bois Review: Social Science Research on Race. 2011;8(1):115-132.
32. Johnson TJ. Intersection of bias, structural racism, and social determinants with health care inequities. Pediatrics. 2020;146(2):e2020003657.
33. Greenwald AG, McGhee DE, Schwartz JLK. Measuring individual differences in implicit cognition: the Implicit Association Test. Journal of Personality and Social Psychology. 1998;74(6):1464-1480.
34. Blair IV, Steiner FJ, Fairclough DL, et. al. Clinicians implicit ethnic/racial bias and perceptions of care among Black and Latino patients. Ann Fam Med. 2013;11(1):43-52.
35. Dehon E, Weiss N, Jones J, Faulconer W, Hinton E, Sterling S. A systematic review of the impact of physician implicit racial bias on clinical decision making. Acad Emerg Med. 2017;24(8):895-904.
36. Lai CK, Wilson ME. Measuring implicit intergroup biases. Soc Personal Psychol Compass. 2020;15(1).
38. Forscher PS, Lai CK, Axt JR, et al. A meta-analysis of procedures to change implicit measures. J Per Soc Psychol. 2019;117(3):522-559.
39. Nosek BA, Smyth FL, Hansen JJ, Devos T, Lindner NM, Ranganath KA. Pervasiveness and correlates of implicit attitudes and stereotypes. Eur Rev Soc Psychol. 2007;18:36-88.
40. Morin R. Exploring Racial Bias Among Biracial and Single-Race Adults: The IAT. Available at https://www.pewresearch.org/social-trends/2015/08/19/exploring-racial-bias-among-biracial-and-single-race-adults-the-iat. Last accessed May 23, 2023.
41. Bertrand M, Mullainathan S. Are Emily and Greg more employable than Lakisha and Jamal? A field experiment on labor market discrimination. Am Econ Rev. 2004;94:991-1013.
42. Hansen M, Schoonover A, Skarica B, Harrod T, Bahr N, Guise J-M. Implicit gender bias among U.S. resident physicians. BMC Med Educ. 2019;19(1):396.
43. Phelan SM, Dovidio JF, Puhl RM, et al. Implicit and explicit weight bias in a national sample of 4,732 medical students: the medical student changes study. Obesity (Silver Spring). 2014;22(4):1201-1208.
44. Johnson TJ, Hickey RW, Switzer GE, et al. The impact of cognitive stressors in the emergency department on physician implicit racial bias. Acad Emerg Med. 2016;23(3):297-305.
45. National Center for States Courts. Strategies to Reduce the Influence of Implicit Bias. Available at https://horsley.yale.edu/sites/default/files/files/IB_Strategies_033012.pdf. Last accessed May 23, 2023.
46. Greenwald AG, Banaji MR. Implicit social cognition: attitudes, self-esteem, and stereotypes. Psychological Review. 1995;102(1):4-27.
47. Lucas HD, Creery JD, Hu X, Paller KA. Grappling with implicit social bias: a perspective from memory research. Neuroscience. 2019;406:684-697.
48. Gawronski B. Six lessons for a cogent science of implicit bias and its criticism. Perspect Psychol Sci. 2019;14(4):574-595.
49. Aronson E. Social cognition. In: Aronson E (ed). Social Animal. New York, NY: Worth Publishers; 2008: 117-180.
50. Roche JM, Arnold HS, Ferguson AM. Social judgments of digitally manipulated stuttered speech: cognitive heuristics drive implicit and explicit bias. J Speech, Lang Hear Res. 2020;63(10):3443-3452.
51. Kempf A. If we are going to talk about implicit race bias, we need to talk about structural racism: moving beyond ubiquity inevitability in teaching and learning about race. The Journal of Culture and Education. 2020;19(2):50.
52. De Houwer J. Implicit bias is behavior: a functional-cognitive perspective on implicit bias. Perspect Psychol Sci. 2019;14(5):835-840.
53. De Houwer J. What is Implicit Bias? Available at https://www.psychologytoday.com/us/blog/spontaneous-thoughts/201910/what-is-implicit-bias. Last accessed May 23, 2023.
54. Staats C. State of the Science: Implicit Bias Review, 2014. Available at https://kirwaninstitute.osu.edu/research/2014-state-science-implicit-bias-review. Last accessed May 23, 2023.
55. Reihl KM, Hurley RA, Taber KH. Neurobiology of implicit and explicit bias: implications for clinicians. J Neuropsychiatry Clin Neurosci. 2015;27(4):248-253.
57. Penner LA, Hagiwara N, Eggly S, Gaertner SL, Albrecht TL, Dovidio JF. Racial healthcare disparities: a social psychological analysis. Eur Rev Soc Psychol. 2013;24(1):70-122.
58. Wong Y-LR, Vinsky J. Beyond implicit bias: embodied cognition, mindfulness, and critical reflective practice in social work. Australian Social Work. 2021;74(2):186-197.
59. Castillo EG, Isom J, DeBonis KL, Jordan A, Braslow JT, Rohrbaugh R. Reconsidering systems-based practice: advancing structural competency, health equity, and social responsibility in graduate medical education. Acad Med. 2020;95(12):1817-1822.
60. Dehlendorf C, Bryant AS, Huddleston HG, Jacoby VL, Fujimoto VY. Health disparities: definitions and measurements. Am J Obstet Gynecol. 2010;202(3):212-213.
61. Centers for Disease Control and Prevention. Health Disparities Among Youth. Available at https://www.cdc.gov/healthyyouth/disparities/index.htm. Last accessed May 23, 2023.
62. Healthy People 2030. Questions and Answers. Available at https://health.gov/our-work/national-health-initiatives/healthy-people/healthy-people-2030/questions-answers#q9. Last accessed May 23, 2023.
63. National Center for Health Statistics. Health, United States, 2015: With Special Feature on Racial and Ethnic Health Disparities. Available at https://www.cdc.gov/nchs/data/hus/hus15.pdf. Last accessed May 23, 2023.
64. National Center for Health Statistics. Life Expectancy. Available at https://www.cdc.gov/nchs/fastats/life-expectancy.htm. Last accessed May 23, 2023.
65. Roth LM, Henley MM. Unequal motherhood: racial-ethnic and socioeconomic disparities in cesarean sections in the United States. Social Problems. 2012;59(2):207-227.
66. Sagynbekov K. Gender-Based Health Disparities: A State-Level Study of the American Adult Population. Available at https://milkeninstitute.org/sites/default/files/reports-pdf/103017-Gender-BasedHealthDisparities.pdf. Last accessed May 23, 2023 .
67. Pharr JR, Kachen A, Cross C. Health disparities among sexual gender minority women in the United States: a population-based study. Journal of Community Health. 2019;44(4):721-728.
68. Haines KL, Zens T, Beems M, Rauh R, Jung HS, Agarwal S. Socioeconomic disparities in the thoracic trauma population. J Surg Res. 2018;224:160-165.
69. Chapman EN, Kaatz A, Carnes M. Physicians and implicit bias: how doctors may unwittingly perpetuate health care disparities.J Gen Intern Med. 2013;28(11):1504-1510.
70. Green AR, Carney DR, Pallin DJ, et al. Implicit bias among physicians and its prediction of thrombolysis decisions for Black and White patients. J Gen Intern Med. 2007;22(9):1231-1238.
71. Hagiwara N, Penner LA, Gonzalez R, et. al. Racial attitudes, physician-patient talk time ratio, and adherence in racially discordant medical interactions. Soc Sci Med. 2013;87:123-131.
72. Cooper LA, Roter DL, Carson KA, et al. The associations of clinicians' implicit attitudes about race with medical visit communication and patient ratings of interpersonal care. Am J Public Health. 2012;102(5):979-987.
73. Gonzalez CM, Deno ML, Kintzer E, Marantz PR, Lypson ML, McKee MD. Patient perspectives on racial and ethnic implicit bias in clinical encounters: implications for curriculum development. Patient Education & Counseling. 2018;101(9):1669-1675.
74. Teal CR, Gill AC, Green AR, Crandall S. Helping medical learners recognize and manage unconscious bias toward certain patient groups. Med Educ. 2012;46(1):80-88.
75. Bennett MJ. A developmental approach to training for intercultural sensitivity. Int J Intercult Relat. 1986;10(2):179-196.
76. Lain EC. Racialized interactions in the law school classroom: pedagogical approaches to creating a safe learning environment. J Legal Educ. 2018;67(3):780-801.
77. Sukhera J, Watling CA. A framework for integrating implicit bias recognition into health professions education. Acad Med. 2018;93(1):35-40.
78. Bennett CJ, Dielmann KM. Weaving the threat of implicit bias through health administration curricula to overcome gender disparities in the workforce. J Health Adm Educ. 2017:34(2): 277-294.
79. Sukhera J, Wodzinski M, Rehman M, Gonzalez CM. The Implicit Association Test in health professions education: a meta-narrative review.Perspect Med Educ. 2019;8(5):267-275.
80. Johnson R, Richard-Eaglin A. Combining SOAP notes with guided reflection to address implicit bias in health care. J Nurs Educ. 2020;59(1):59-59.
81. Zestcott CA, Blair IV, Stone J. Examining the presence, consequences, and reduction of implicit bias in health care: a narrative review. Group Process Intergroup Relat. 2016;19(4):528-542.
82. Devine PG, Forscher PS, Austin AJ, Cox WT. Long-term reduction in implicit race bias: a prejudice habit-breaking intervention.J Exp Soc Psychol. 2012;48(6):267-1278.
83. Todd AR, Bodenhausen GV, Richeson JA, Galinsky AD. Perspective taking combats automatic expressions of racial bias. J Pers Soc Psychol. 2011;100(6):1027-1042.
84. Drwecki BB, Moore CF, Ward SE, Prkachin KM. Reducing racial disparities in pain treatment: the role of empathy and perspective-taking. Pain. 2011;152(5):1001-1006.
85. Whitford DK, Emerson AM. Empathy intervention to reduce implicit bias in pre-service teachers. Psychol Rep. 2019;122(2):670-688.
86. Mayo Clinic. Consumer Health: Mindfulness Exercises. Available at https://www.mayoclinic.org/healthy-lifestyle/consumer-health/in-depth/mindfulness-exercises/art-20046356. Last accessed May 23, 2023.
87. Narayan MC. Addressing implicit bias in nursing: a review. American Journal of Nursing. 2019;119(7):36-43.
88. Goldstein E. The STOP Practice for Stress. Available at https://www.mindful.org/the-s-t-o-p-practice-for-stress. Last accessed May 23, 2023.
89. Burgess DJ, Beach MC, Saha S. Mindfulness practice: a promising approach to reducing the effects of clinician implicit bias on patients. Patient Educ Couns. 2017;100(2):372-376.
90. Kang Y, Gray JR, Dovidio JF. The nondiscriminating heart: lovingkindness meditation training decreases implicit intergroup bias.J Exp Psychol Gen. 2014;143(3):1306-1313.
91. 91.Tang Y-Y, Hölzel BK, Posner MI. The neuroscience of mindfulness meditation. Nat Rev Neurosci. 2015;16(4):213-225.
92. Blair IV, Ma JE, Lenton AP. Imagining stereotypes away: the moderation of implicit stereotypes through mental imagery. J Pers Soc Psychol. 2001;81(5):828-841.
93. Dasgupta N, Asgari, S. Seeing is Believing: exposure to counterstereotypic women leaders and its effect on the malleability of automatic gender stereotyping. J Exp Soc Psychol. 2004;40(5):642–658.
94. National Center for States Courts. Addressing Implicit Bias in the Courts. Available at https://www.nccourts.gov/assets/inline-files/public-trust-12-15-15-IB_Summary_033012.pdf?q_DMMIVv0v_eDJUa1ADxtw59Zt_svPgl. Last accessed May 23, 2023.
95. Applebaum B. Remediating campus climate: implicit bias training is not enough. Studies in Philosophy & Education. 2019;38(2): 129-141.
96. Byrne A, Tanesini A. Instilling new habits: addressing implicit bias in healthcare professionals. Adv Health Sci Educ Theory Pract. 2015;20(5):1255-1262.
97. D'Amour D, Oandasan I. Interprofessionality as the field of interprofessional practice and interprofessional education: an emerging concept. J Interprof Care. 2005;(Suppl 1):8-20.
99. Lam AHY, Wong JTL, Ho ECM, Choi RYY, Fung MST. A concept analysis of interdisciplinary collaboration in mental healthcare.COJ Nurse Healthcare. 2017;1(2).
100. Cahn PS. How interprofessional collaborative practice can help dismantle systemic racism. J Interprof Care. 2020;34(4):431-434.
101. Healthy People 2030. Social Determinants of Health. Available at https://health.gov/healthypeople/priority-areas/social-determinants-health. Last accessed May 23, 2023.
102. Substance Abuse and Mental Health Services Administration. Improving Cultural Competence: Quick Guide for Clinicians. Available at https://store.samhsa.gov/sites/default/files/d7/priv/sma16-4931.pdf. Last accessed May 23, 2023.
103. Agency for Healthcare Quality and Research. Health Literacy Universal Precautions Toolkit, 2nd Edition. Available at https://www.ahrq.gov/health-literacy/improve/precautions/index.html. Last accessed May 23, 2023.
104. U.S. Census Bureau. About the Topic of Race Available at https://www.census.gov/topics/population/race/about.html. Last accessed at May 23, 2023.
105. U.S. Census Bureau. National Black (African American) History Month: February 2023. Available at https://www.census.gov/newsroom/facts-for-features/2023/black-history-month.html. Last accessed May 23, 2023.
106. U.S. Census Bureau. National African-American (Black) History Month: February 2018. Available at https://www.census.gov/newsroom/facts-for-features/2018/black-history-month.html. Last accessed May 23, 2023.
107. Tamir C. The Growing Diversity of Black America: 46.8 Million People in the U.S. Identify as Black. Available at https://www.pewresearch.org/social-trends/2021/03/25/the-growing-diversity-of-black-america. Last accessed May 23, 2023.
108. American Psychiatric Association. Working with African American/Black Patients. Available at https://www.psychiatry.org/psychiatrists/cultural-competency/education/best-practice-highlights/best-practice-highlights-for-working-with-african-american-patients. Last accessed May 23, 2023.
109. U.S. Census Bureau. Asian American, Native Hawaiian and Pacific Islander Heritage Month: May 2023. Available at https://www.census.gov/newsroom/facts-for-features/2021/asian-american-pacific-islander.html. Last accessed May 23, 2023.
110. Budiman A, Ruiz NG. Asian Americans are the Fastest-Growing Racial or Ethnic Group in the U.S. Available at https://www.pewresearch.org/fact-tank/2021/04/09/asian-americans-are-the-fastest-growing-racial-or-ethnic-group-in-the-u-s. Last accessed May 23, 2023.
111. Pew Research Center. U.S. Hispanic Population Growth has Leveled Off. Available at https://www.pewresearch.org/fact-tank/2017/08/03/u-s-hispanic-population-growth-has-leveled-off. Last accessed May 23, 2023.
112. Pew Research Center. Demographics of Asian Americans. Available at https://www.pewresearch.org/social-trends/2013/04/04/asian-groups-in-the-u-s. Last accessed May 23, 2023.
113. Ong P, Ong E. The Future of Asian America in 2040 Asian American Electorate to Double. Available at https://luskin.ucla.edu/sites/default/files/AA2040_report.pdf. Last accessed May 23, 2023.
114. Lee E. Asian American families: an overview. In: McGoldrick M, Giordano J, Pearce JK (eds). Ethnicity and Family Therapy. 2nd ed. New York, NY: The Guilford Press; 1996: 227-248.
115. U.S. Census Bureau. We the People: Asians in the United States: Census 2000 Special Reports. Available at http://www.u.arizona.edu/~jag/Census-Asians-2000Rpt.pdf. Last accessed May 23, 2023.
116. Lee E. Working with Asian Americans: A Guide for Clinicians. New York, NY: The Guilford Press; 1997.
117. U.S. Census Bureau. Hispanic Heritage Month 2022. Available at https://www.census.gov/newsroom/facts-for-features/2022/hispanic-heritage-month.html. Last accessed May 23, 2023.
118. Pew Research Center. 2015, Hispanic Population in the United States Statistical Portrait. Available at https://www.pewresearch.org/hispanic/2017/09/18/2015-statistical-information-on-hispanics-in-united-states-trend-data. Last accessed May 23, 2023.
119. Pew Hispanic Center. Hispanic Origin Profiles, 2010. Available at https://www.pewresearch.org/hispanic/2012/06/27/country-of-origin-profiles. Last accessed May 23, 2023.
120. Kagawa Singer M, Dressler W, George S. Culture: the missing link in health research. Soc Sci Med. 2016;170:237-246.
121. .Krogstad JM. Hispanics Have Accounted for More than Half of Total U.S. Population Growth Since 2010. Available at https://www.pewresearch.org/fact-tank/2020/07/10/hispanics-have-accounted-for-more-than-half-of-total-u-s-population-growth-since-2010. Last accessed May 23, 2023.
122. U.S. Census Bureau. We the People: American Indians and Alaska Natives in the United States. Available at https://www.census.gov/library/publications/2006/dec/censr-28.html. Last accessed May 23, 2023.
123. U.S. Census Bureau. Facts for Features: American Indian and Alaska Native Heritage Month: November 2022. Available at https://www.census.gov/newsroom/facts-for-features/2022/aian-month.html. Last accessed May 23, 2023.
124. U.S. Census Bureau. American Indian and Alaska Native Heritage Month: November 2017. Available at https://www.census.gov/newsroom/facts-for-features/2017/aian-month.html. Last accessed May 23, 2023.
125. Center for Disease Control and Prevention. Health of American Indian or Alaska Native Population. Available at https://www.cdc.gov/nchs/fastats/american-indian-health.htm. Last accessed May 23, 2023.
126. U.S. Census Bureau. QuickFacts: United States. Available at https://www.census.gov/quickfacts/fact/table/US/PST045221. Last accessed May 23, 2023.
127. Butler M, McCreedy E, Schwer N, et al. Improving Cultural Competence to Reduce Health Disparities. Rockville, MD: Agency for Healthcare Research and Quality; 2016.
128. U.S. Census Bureau. American Community Survey: B04006 People Reporting Ancestry. Available at https://data.census.gov/cedsci/table?q=ancestry&tid=ACSDT1Y2019.B04006. Last accessed May 23, 2023.
129. Bruine de Bruin W, Parker AM, Strough J. Age differences in reported social networks and well-being. Psychology Aging. 2020;35(2):159-168.
130. Braun FK, Fine ES, Greif DC, Devenny JM. Guidelines for multicultural assessment: an Asian Indian American case study. J Multicult Couns Devel. 2010;38(3):130-141.
131. Agaronnik N, Campbell EG, Ressalam J, Iezzoni LI. Exploring issues relating to disability cultural competence among practicing physicians. Disabil Health J. 2019;12(3):403-410.
132. Okun BF, Fried J, Okun ML. Understanding Diversity: A Learning-As-Practice Primer. Pacific Grove, CA: Brooks/Cole Publishing Co.; 1999.
133. Lynch EW, Hanson MJ (eds). Developing Cross-Cultural Competence: A Guide for Working with Children and Their Families. 4th ed. Baltimore, MD: Paul H. Brookes Publishing, Co.; 2011.
134. Ayonrinde O. Importance of cultural sensitivity in therapeutic transactions: considerations for healthcare providers. Disease Management & Health Outcomes. 2003;11(4):233-248.
135. Singh NN, Mckay JD, Singh AN. Culture and mental health: nonverbal communication. J Child Fam Stud. 1998;7(4):403-409.
136. Manrai LA, Manrai AK, Lascu D, Friedeborn S. Determinants and effects of cultural context: a review, conceptual model, and propositions. Journal of Global Marketing. 2019;32(2):67-82.
138. Chang H, Chen L. Commonalities as an alternative approach to analyzing Asian Pacific communication. Journal of Asian Pacific Communication. 2015;25(1):1-21.
139. Herring RD. Nonverbal communication: a necessary component of cross-cultural counseling. J Multicult Couns Devel. 1990;18(4):172-179.
140. le Roux J. Effective educators are culturally competent communicators. Intercultural Education. 2002;13(1):37-48.
141. Akechi H, Senju A, Uibo H, et al. Attention to eye contact in the West and East: autonomic responses and evaluative ratings. PLoS One. 2013;8(3):e59312.
142. Chung DK. Asian cultural commonalities: a comparison with mainstream culture. In: Furuto S, Biswas R, Chung DK, Murase K, Ross-Sheriff F (eds). Social Work Practice with Asian Americans. Newbury Park, CA: Sage Publications; 1992: 27-44.
143. Castillo RJ. Culture and Mental Illness: A Client-Centered Approach. Pacific Groves, CA: Brooks/Cole Publishing Company; 1997.
144. Fong R, Furuto S (eds). Culturally Competent Practice: Skills, Interventions, and Evaluations. Needham Heights, MA: Allyn & Bacon; 2001.
145. Panos PT, Panos AJ. A model for a culture-sensitive assessment of patients in health care settings. Soc Work Health Care. 2000;31(1):49-62.
146. Fondacaro KM, Harder VS. Connecting cultures: a training model promoting evidence-based psychological services for refugees. Training & Education in Professional Psychology. 2014;8(4):320-327.
147. Kleinman A. The Illness Narratives: Suffering, Healing and the Human Condition. New York, NY: Basic Books; 1988.
148. Galanti GA. Caring for Patients from Different Cultures. 5th ed. Philadelphia, PA: University of Pennsylvania Press; 2015.
149. Pachter LM. Culture and clinical care: folk illness beliefs and behaviors and their implications for health care delivery. JAMA. 1994;271(9):690-695.
150. Beckerman NL, Corbett L. Immigration and families: treating acculturative stress from a systemic framework. Fam Ther. 2008;35(2): 63-81.
151. Ellis BH, Abdi SM, Winer JP. Psychosocial assessment with refugee and immigrant youth and families. In: Mental Health Practice with Immigrant and Refugee Youth: A Socioecological Framework. Washington, DC: American Psychological Association; 2020: 53-76.
152. Weisman A, Feldman G, Gruman C, et al. Improving mental health services for Latino and Asian immigrant elders. Prof Psychol Res Pr. 2005;36(6):642-648.
153. Committee on Health Care for Underserved Women. Committee Opinion #512: health care for transgender individuals. Obstet Gynecol. 2011;118(6):1454-1458.
154. National LGBT Health Education Center. Affirmative Care for Transgender and Gender Non-Conforming People: Best Practices for Front-line Health Care Staff. Available at https://www.lgbtagingcenter.org/resources/pdfs/13-017_TransBestPracticesforFrontlineStaff_v9_04-30-13.pdf. Last accessed May 23, 2023.
155. Addis M, Mahalik JR. Men, masculinity, and the contexts of help seeking. Am Psychol. 2003;58(1):5-14.
156. Courtenay WH. Key determinants of the health and well-being of men and boys. Internat J Mens Health. 2003;2(1):1-30.
157. Mahalik JR, Lagan HD, Morrison JA. Health behaviors and masculinity in Kenyan and US male college students. Psychol Men Masculin. 2006;7(4):191-202.
158. Mahalik JR, Burns SM, Syzdek M. Masculinity and perceived normative health behaviors as predictors of men's health behaviors. Soc Sci Med. 2007;64(11):2201-2209.
159. Galdas PM, Cheater F, Marshall P. Men and health help-seeking behaviour: literature review. J Adv Nurs. 2005;49(6):616-623.
160. Peerson A, Saunders M. Men's health literacy: advancing evidence and priorities. Crit Pub Health. 2009;19(3&4):441-456.
161. Kutner M, Greenberg E, Jin Y, Paulsen C. The Health Literacy of America's Adults: Results from the 2003 National Assessment of Adult Literacy. Washington, DC: National Center for Education Statistics; 2006.
162. Peak T, Gast J, Ahlstrom D. A needs assessment of Latino men's health concerns. Am J Mens Health. 2010;4(1):22-32.
163. U.S. Department of Veterans Affairs. Spotlight: Gender Differences in Healthcare. Available at https://www.hsrd.research.va.gov/news/feature/gender_differences.cfm. Last accessed May 23, 2023.
164. Sears JT, Williams WL (eds). Overcoming Heterosexism and Homophobia: Strategies That Work. 1st ed. New York, NY: Columbia University Press; 1997.
165. Centers for Disease Control and Prevention. The State of Aging and Health in America 2013. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept. of Health and Human Services; 2013.
166. Williamson IR. Internalized homophobia and health issues affecting lesbians and gay men. Health Education Research. 2000;15(1):97-107.
167. Greenberg JS, Bruess CE, Conklin SC. Sexual orientation. In: Greenberg JS, Bruess CE, Conklin SC. Exploring the Dimensions of Human Sexuality. 4th ed. Sudberry, MA: Jones and Bartlett Publishers; 2011:352-356.
168. Centers for Disease Control and Prevention. Health Considerations for LGBTQ Youth. Available at https://www.cdc.gov/healthyyouth/disparities/health-considerations-lgbtq-youth.htm. Last accessed May 23, 2023.
169. National Center for Transgender Equality. Understanding Transgender People: The Basics. Available at https://transequality.org/issues/resources/understanding-transgender-people-the-basics. Last accessed May 23, 2023.
170. Dean L, Meyer IH, Robinson K, et al. Lesbian, gay, bisexual, and transgender health: findings and concerns. J Gay Lesbian Med Assoc. 2000;4(3):102-151.
171. Meyer IH. Why lesbian, gay, bisexual, and transgender public health? Am J Public Health. 2001;91(6):856-859.
172. Jones BE, Hill MJ. Mental Health Issues in Lesbian, Gay, Bisexual, and Transgender Communities. 1st ed. Washington, DC: American Psychiatric Publishing: 2002.
173. Perry B. The sociology of hate: theoretical approaches. In: Levin B, Iganski P, Blazak R, Lawrence FM. Hate Crimes. Volumes 1-5. Westport, CT: Greenwood Publishing Group, Inc.; 2009: 56-57.
174. Herek GM. The context of anti-gay violence: notes on cultural and psychological heterosexism. J Interpersonal Violence. 1990;5(3):316-333.
175. American Psychological Association Committee on Lesbian and Gay Concerns. Avoiding Heterosexual Bias in Language. Available at https://www.apa.org/pi/lgbt/resources/language. Last accessed May 23, 2023.
176. Like RC, Steiner RP, Rubel AJ. Society of Teachers of Family Medicine (STFM) Core Curriculum Guidelines: recommended core curriculum guidelines on culturally sensitive and competent health care. Fam Med. 1996;28(4):291-297.
177. Baker K, Beagan B. Making assumptions, making space: an anthropological critique of cultural competency and its relevance to queer patients. Med Anthropol Q. 2014;28(4):578-598.
178. O'Hanlan KA, Cabaj RP, Schatz B, Lock J, Nemrow P. A review of the medical consequences of homophobia with suggestions for resolution. J Gay Lesbian Med Assoc. 1997;1(1):25-39.
179. Kitzinger C. Speaking of oppression: psychology, politics, and the language of power. In: Rothblum ED, Bond LA (eds). Preventing Heterosexism and Homophobia. Thousand Oaks, CA: Sage Publications; 1996.
180. Matthews CR, Adams EM. Using a social justice approach to prevent the mental health consequences of heterosexism. J Prim Prev. 2009;30(1):11-26.
181. Hong JS, Woodford MR, Long LD, Renn KA. Ecological covariates of subtle and blatant heterosexist discrimination among LGBQ college students. J Youth Adolesc. 2016;45(1):117-131.
182. Woodford MR, Kulick A, Sinco BR, Hong JS. Contemporary heterosexism on campus and psychological distress among LGBQ students: the mediating role of self-acceptance. Am J Orthopsychiatry. 2014;84(5):519-529.
183. Misener TR, Sowell RL, Phillips KD, Harris C. Sexual orientation: a cultural diversity issue for nursing. Nurs Outlook. 1997;45(4):178-181.
185. Greene RR, Cohen HL. Social work with older adults and their families: changing practice paradigms. Fam Soc. 2005;86(3):367-374.
186. Koenig T, Spano R. Professional hope in working with older adults. J Sociol Soc Welf. 2006;33(2):25-44.
187. Administration for Community Living. 2021 Profile of Older Americans. Available at https://acl.gov/sites/default/files/Profile%20of%20OA/2021%20Profile%20of%20OA/2021ProfileOlderAmericans_508.pdf. Last accessed May 17, 2023.
188. Pew Research Center. The Return of the Multi-Generational Family Household. Available at https://www.pewresearch.org/social-trends/2010/03/18/the-return-of-the-multi-generational-family-household. Last accessed May 22, 2023.
189. Pew Research Center. A Record 64 Million Americans Live in Multigenerational Households. Available at https://www.pewresearch.org/fact-tank/2018/04/05/a-record-64-million-americans-live-in-multigenerational-households. Last accessed May 22, 2023.
190. U.S. Senate. America's Aging Workforce: Opportunities and Challenges. Available at https://www.aging.senate.gov/imo/media/doc/Aging%20Workforce%20Report%20FINAL.pdf. Last accessed May 23, 2023.
191. Toossi M, Torpey E. Older Workers: Labor Force Trends and Career Options. Available at https://www.bls.gov/careeroutlook/2017/article/older-workers.htm. Last accessed May 23, 2023.
193. Harrar S. It's Time to Throw Out Stereotypes on Aging. Available at https://www.aarp.org/health/healthy-living/info-2022/aging-survey.html. Last accessed May 17, 2023.
194. U.S. Department of Defense. 2021 Demographics Report: Profile of the Military Community. Available at https://download.militaryonesource.mil/12038/MOS/Reports/2021-demographics-report.pdf. Last accessed May 23, 2023.
195. U.S. Department of Veterans Affairs. National Center for Veterans Analysis and Statistics: Veteran Population, Fiscal Year 2020. Available at https://www.va.gov/vetdata/veteran_population.asp. Last accessed May 23, 2023.
196. Kime P. Experts: Docs Should Ask about Patients' Military History. Available at https://www.militarytimes.com/pay-benefits/military-benefits/health-care/2015/02/16/experts-docs-should-ask-about-patients-military-history. Last accessed May 23, 2023.
197. American Academy of Nursing. Have You Ever Served? Available at http://www.haveyoueverserved.com. Last accessed May 23, 2023.
198. National Institutes of Health. Cultural Respect. Available at https://www.nih.gov/institutes-nih/nih-office-director/office-communications-public-liaison/clear-communication/cultural-respect. Last accessed May 23, 2023.
199. Centers for Disease Control and Prevention. Women, Caregiving, and COVID-19. Available at https://www.cdc.gov/women/caregivers-covid-19/index.html. Last accessed May 23, 2023.
200. U.S. Department of Health and Human Services. Office on Women's Health. Mental Health. Available at https://www.womenshealth.gov/mental-health. Last accessed May 23, 2023.
Mention of commercial products does not indicate endorsement.