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What is implicit bias and how might it affect patient outcomes in hearing healthcare? Yovina Khiroya provides insight into the terminology and the effect on people and service delivery.

As much as possible within healthcare, we try to reduce implicit bias. Implicit bias is defined as when we have “an attitude towards people or associate stereotypes with them without our conscious knowledge” [1]. This includes people of a different race, the LGBTQ+ community or anyone who is inherently different from yourself. Implicit bias in healthcare professionals is linked to poorer patient-provider interactions, lower levels of treatment adherence and worse patient health outcomes [2]. A recent study even found that maternal mortality was 50% more likely for black women than white women in the United States - a sign of implicit bias [3].

There are many studies, reviews and articles across various medical journals detailing different ways that we can address and eradicate implicit bias in healthcare. Some recommend training programmes to educate providers on how to communicate with people from ethnic minority backgrounds, others advise on strategies to be aware of our own implicit bias to that we can dispel them [4,5]. Being able to effectively communicate and counsel people from different cultures can lead to better patient safety, improved shared decision-making, and enhanced patient empowerment [6]. However, can this be taken one step further than improved patient communication?



Achieving health equality is one of the founding principles of the NHS. It focuses on the idea that all people should have fair and equal access to healthcare [7]. This means that everyone is treated the same. In theory, this sounds like a fantastic concept free of implicit bias. However, in practicality it is not. How can everyone be treated the same when everyone is different?

Otitis media is highly prevalent (more than 90%) in Aboriginal and Torres Strait Islander children in certain areas of Australia [8]. Health equality would determine that all children across Australia should be screened for otitis media. However, population-based screening has not been found to reduce the prevalence of ear health problems in Indigenous children. Otitis media in Indigenous children typically first occurs within the first few weeks of birth and can persist into adolescence, compared to the occurrence in non-Indigenous children, which is typically transitory in nature [9]. Hence, otitis media in Indigenous children requires a different approach. This would be health equity.

“By ignoring aspects of people’s sociocultural identity, we risk developing a ‘monocultural view’ and overlooking potential causes and complexities that determine our health”

Health equity is defined as giving everyone the opportunity to “attain their full health potential” [10]. It is based upon people’s specific needs. To put it into simpler terms, “equality is giving everyone the same pair of shoes. Equity is giving everyone a pair of shoes that fits” [11].

When we think about implicit bias in healthcare, we tend to think about differences in culture, gender, religion, or sexuality and how we should avoid taking these into consideration for our treatment plans. By ignoring aspects of people’s sociocultural identity, we risk developing a ‘monocultural view’ and overlooking potential causes and complexities that determine our health [12]. Health equity advises that we should think about these aspects when treating our patients, not in a discriminatory sense, but in a way that truly accepts the entire patient. Health equity is the true definition of patient-centred care.

So how can we encourage this in our everyday practice? The first step to cultural humility and reducing implicit bias is awareness and education. We cannot be expected to become woke and enlightened beings overnight. Afterall, as much as we may dislike it, we all have our own unconscious bias within us. The key is to be aware of these thoughts and feelings so that we can keep them in check. Once this is achieved, we can communicate with our patients in a way that truly accepts them for who they are. This encourages open, honest conversation with true empathy for our patients [13].

“Afterall, as much as we may dislike it, we all have our own unconscious bias within us. The key is to be aware of these thoughts and feelings so that we can keep them in check”

The audiology sector in England is fairly limited on treatment options for hearing loss. Within the NHS you have the option of hearing aids, bone-anchored hearing aids or cochlear implants depending on your patient’s type of hearing loss and your NHS Trust. Within the private sector you’re limited to just hearing aids most of the time. The fact that 6.7 million people in the UK could benefit from hearing aids, but only two million people use them, indicates that the current approach of health equality is not working for those with hearing loss [14]. Limiting the option of technology to hearing aids for most patients certainly does not consider their inherent differences. For example, what about people in the Deaf community, or cultures that are not accepting of hearing aids?

Audiology as a profession first began to help people with hearing loss. However, many of us have become pigeonholed into only helping those who are open to hearing aids. To truly offer health equity within audiology we must expand our range of treatment options. For example, lipreading, communication training, non-verbal communication training, speech recognition systems, plus many more, are all options that patients can utilise to help manage their hearing loss.

In closing, the healthcare industry is making a change towards reducing implicit bias in the way we communicate and counsel patients. However, to move towards a truly effective patient-centred way of treating patients, we must adopt a health equity model of healthcare. In short, we must begin to offer ‘a shoe that fits’.



1. Perception Institute. Implicit bias. 2022.

2. 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):e60-76.
3. Saluja B. How implicit bias contributes to racial disparities in maternal morbidity and mortality in the United States. J Womens Health (Larchmt) 2021;30(2):270-3.
4. Gopal DP, Chetty U, O’Donnell P, et al. Implicit bias in healthcare: clinical practice, research and decision making. Future Healthc J 2021;8(1)40-8.
5. Hagiwara N, Lafata JE, Mezuk B, et al. Detecting implicit racial bias in provider communication behaviors to reduce disparities in healthcare: Challenges, solutions, and future directions for provider communication training. Patient Educ Couns 2019;102(9):1738-43.
6. Pérez-Stable EJ, El-Toukhy S. Communicating with diverse patients: How patient and clinician factors affect disparities. Patient Educ Couns 2018;101(12):2186-94.
7. NHS England. NHS quality and Diversity Council. 2022

8. Morris PS, Leach AJ, Silberberg P, et al. Otitis media in young Aboriginal children from remote communities in Northern and Central Australia: a cross-sectional survey. BMC Paediatr 2005;5:27.
9. Closing the Gap Clearinghouse. Ear disease in Aboriginal and Torres Strait Islander children. Australian Government: Australian Institute of Health and Welfare. 2014

10. National Center for Chronic Disease Prevention and Health Promotion. Health equity. Centers for Disease Control and Prevention. 2022.

11. RISE Activity: Visualizing equality vs. equity. 2022.

12. Kagawa-Singer M, Dressler WW, George SM, Elwood WN. The cultural framework for health: An integrative approach for research and program design and evaluation. 2015.

13. English K. Counseling cannot be colorblind. 2021.

14. British Academy of Audiology. Hearing loss and deafness. British Academy of Audiology. 2022

All links last accessed December 2022.

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YovinaKhiroya-Morjaria Khiroya-Morjaria

Pindrop Hearing, London, UK.

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