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Eliminating Explicit and Implicit Biases in Health Care: Evidence and Research Needs
Open accessAbstract
Health care providers hold negative explicit and implicit biases against marginalized groups of people such as racial and ethnic minoritized populations. These biases permeate the health care system and affect patients via patient–clinician communication, clinical decision making, and institutionalized practices. Addressing bias remains a fundamental professional responsibility of those accountable for the health and wellness of our populations. Current interventions include instruction on the existence and harmful role of bias in perpetuating health disparities, as well as skills training for the management of bias. These interventions can raise awareness of provider bias and engage health care providers in establishing egalitarian goals for care delivery, but these changes are not sustained, and the interventions have not demonstrated change in behavior in the clinical or learning environment. Unfortunately, the efficacy of these interventions may be hampered by health care providers’ work and learning environments, which are rife with discriminatory practices that sustain the very biases US health care professions are seeking to diminish. We offer a conceptual model demonstrating that provider-level implicit bias interventions should be accompanied by interventions that systemically change structures inside and outside the health care system if the country is to succeed in influencing biases and reducing health inequities.
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“By simulating scenarios that mirror real-life clinical decision-making processes, and through reading the multi-agent conversations, clinicians can be made aware of potential cognitive biases and how to correct them. This facilitates learning in a controlled, educational environment [25,26].”
From Mitigating cognitive biases in clinical decision-making through multi-agent conversations using large language models: simulation study (2024) · cites this paper as [26]
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Health Disparities, Substance-Use Disorders, and Primary-Care
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How to Fix a Broken Health Care System: Pathways to Maximize Health and Well-being for All
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Predictors of program interest in a digital health pilot study for heart health
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“As such, questions about race and ethnicity cannot be fully addressed with the present analyses but should be explored in future work, particularly given evidence for lower rates of digital health utilization for racial and ethnic minorities [13] and evidence of lower healthcare utilization and mistrust of medical pro…”
BackgroundIdentifying and Characterizing Bias at Scale in Clinical Notes Using Large Language ModelsPreprint
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The Bleeding Disorders Research Collaborative
Valentino, L. A., Santaella, M. E. E., Witkop, M., Stanhope, R. W., Valadez, S., Carlson, S. A., Benasutti, H., DiMichele, D., & Recht, M. (2025) · Blood Vessels Thrombosis & Hemostasis · doi:10.1016/j.bvth.2025.100099 · Cited by 5
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Ethnic and Gender Disparities in Access to Deep Brain Stimulation Surgery for Parkinson's Disease
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Bleeding Disorders Research Collaborative: an opportunity for impact
Santaella, M. E. E., Valadez, S., Vázquez, E., Benasutti, H., Carlson, S. A., DiMichele, D., Norris, K. L., Robinson, F., Valentino, L. A., Witkop, M., et al. (2026) · Expert Review of Hematology · doi:10.1080/17474086.2026.2688871 · Cited by 4
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Self-citationBakunda, L., Crooks, R., Johnson, N. A., Osei-Tutu, K. B., Bharwani, A. M., Gye, E., Okoro, D., Hinz, H., Nearing, S., Peer, L., et al. (2024) · MedEdPublish · doi:10.12688/mep.20489.1 · Cited by 4
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“Within healthcare research, the need to prioritise minoritised voices is especially urgent given persistent health disparities and systemic barriers to care (Kerr et al., 2024; Macias-Konstantopoulos et al., 2023; Vela et al., 2022).”
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Ethnicity, Skin Tones, and Cultural Considerations in Wound Care
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“Clinician behavior is fundamental, and the literature shows that health-care professionals hold implicit and explicit biases regarding patients and trial participation (16) that can be addressed through cultural competency and bias training (17,18).”
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Schiavo, R. (2024) · Journal of Communications In Healthcare · doi:10.1080/17538068.2024.2432170 · Cited by 4
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Latine Immigrant Perspectives on Trust of Clinical Research
Tzelios, C., Velasco, M., & Saadi, A. (2024) · Hispanic Health Care International · doi:10.1177/15404153241286745 · Cited by 3
“…the research workforce and addressing structural inequities outside the healthcare system, like barriers to healthcare access, under-and unemployment, and/or low educational attainment to facilitate improved understanding of, and ability to participate in, clinical research (Vela et al., 2022).”
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Gender Fairness of Machine Learning Algorithms for Pain Detection
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Cardiogenic Shock and Equity: Uncovering Mechanisms, Addressing Disparities, and Advancing Care
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Implicit Racial Bias in Evaluation of Neonatal Opioid Withdrawal Syndrome
Nyman, K., Okolie, F., Davis, N. L., Hager, E. R., & El‐Metwally, D. (2023) · Journal of Racial and Ethnic Health Disparities · doi:10.1007/s40615-023-01887-w · Cited by 3
“Bias can be either implicit or explicit; implicit bias is where the individual is unaware of their own preferences, attitudes, or tendencies whereas explicit bias is where an individual holds conscious beliefs and preferences over certain attributes [4, 5].”
Urban, M. M., Sullivan, K. A., & Purser, K. (2024) · Psychiatry Psychology and Law · doi:10.1080/13218719.2024.2330046 · Cited by 3
“While there are some mixed findings (Ariyo et al., 2022), it is now widely accepted that age-bias is present in healthcare systems, healthcare professionals are not immune, and such bias detrimentally affects patient care (FitzGerald & Hurst, 2017; Vela et al., 2022).”
Challenging Misconceptions about Race in Undergraduate Genetics
Ball, E. M., Costello, R. A., Ballen, C. J., Graze, R. M., & Burkholder, E. W. (2024) · CBE—Life Sciences Education · doi:10.1187/cbe.23-12-0228 · Cited by 3
“…and Banaji, 2022), implicit biases, like color-evasive ideologies (Bonilla-Silva 2018; King et al. , 2023), have been growing throughout the socioeconomic and governmental infrastructure of the United States (Vela et al. , 2022) and are even perpetuated by biology instructors (King et al. , 2023).”
InfluentialMoucheraud, C., Wollum, A., Awan, M. A., Dow, W. H., Friedman, W., Koulidiati, J., Sabasaba, A. N., Shah, M., & Wagner, Z. (2024) · Contraception and Reproductive Medicine · doi:10.1186/s40834-024-00296-6 · Cited by 4
“Health workers’ attitudes may be an important determinant of the services they provide: if health workers hold biased attitudes toward a certain group, they may provide different care to this group [1, 2].”
BackgroundCummings, P., & Lawson, A. K. (2024) · Reproduction · doi:10.1530/rep-24-0041 · Cited by 3
Sullivan, D., Frazer, C., Lopez, L., & Frazer, E. A. (2025) · Journal of Pediatric Surgical Nursing · doi:10.1177/23320249251314112 · Cited by 3
“According to Vela et al. (2022), implicit bias can manifest in various ways: (1) Clinical decision-making : Nurses may unknowingly make assumptions about a patient ’ s health status, lifestyle choices, or adherence to treatment based on their race, ethnicity, or socioeconomic status, leading to…”
Disparities in Aortic Aneurysm Mortality Trends: Revealing Sex and Racial Inequalities
Azuma, M., Ramirez, A., Moser, G. W., Oh, K. J., Kashem, M. A., Toyoda, Y., & Mokashi, S. A. (2025) · Vascular and Endovascular Surgery · doi:10.1177/15385744251321621 · Cited by 3
“24”
Strategies to Prevent and Effectively Respond to Compassion Fatigue and Burnout
Reinken, D. N., & Rizek, J. (2025) · Journal of Emergency Nursing · doi:10.1016/j.jen.2024.10.004 · Cited by 3
Senkyire, E. K., Senkyire, G., Asiedua, E., Tawose-Adebayo, V., & Ohaja, M. (2025) · AJOG Global Reports · doi:10.1016/j.xagr.2025.100505 · Cited by 4
White, K. M., Barber, L. E., Shipman-Lacewell, J. R., Azeez, O., Collop, N. A., & Johnson, D. A. (2025) · Current Sleep Medicine Reports · doi:10.1007/s40675-025-00339-7 · Cited by 4
Wasmuth, S., Bravata, D. M., & Miech, E. J. (2025) · American Journal of Occupational Therapy · doi:10.5014/ajot.2025.051085 · Cited by 3
“Implicit provider biases perpetuate health disparities and poor health care decision making (Davis et al., 2022; Vela et al., 2022), thus making bias a key factor to address if health care eq-uity is to be advanced (Mateo and Williams, 2020).”
Racism and Electronic Health Records (EHRs): Perspectives for research and practice
Emani, S., Rodriguez, J. A., & Bates, D. W. (2023) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocad023 · Cited by 3
Ely, E. (2023) · Journal of Education for Library and Information Science · doi:10.3138/jelis-2022-0059 · Cited by 3
“I don't want to be the squeaky wheel”: Addressing bias as a leader in emergency medicine
Suri, A., Yang, D. H., Sun, W. W., Fofana, M., Binstadt, E. S., Weygandt, P. L., Moll, J. L., Strout, T. D., Gipson, K. A., Norman, M. S., et al. (2024) · Academic Emergency Medicine · doi:10.1111/acem.14869 · Cited by 3
“8,17 For instance, while in agreement regarding individual susceptibility to bias, leaders described discomfort arising from not knowing how to respond to instances of bias and expressed uncertainty around how to define bias and prioritize its mitigation.”
BackgroundImpact of Urinary Tract and Vaginal Infections on the Physical and Emotional Well-being of Women
Ojha, S., Vishwakarma, P. K., Mishra, S. K., & Tripathi, S. M. (2024) · Infectious Disorders - Drug Targets · doi:10.2174/0118715265286164240508064714 · Cited by 3
Vigneswaran, J., Ogunnowo, S., Millis, J. M., Roggin, K. K., Posner, M. C., Matthews, J. B., & Dorsey, C. A. (2024) · The American Journal of Surgery · doi:10.1016/j.amjsurg.2024.115834 · Cited by 3
Understanding Implicit Bias and Its Impact in Veterinary Medicine
Tan, J., & Fogelberg, K. (2024) · Veterinary Clinics of North America Small Animal Practice · doi:10.1016/j.cvsm.2024.06.005 · Cited by 3
Championing Civility in the Clinical Learning Environment: Evaluation of a Novel Training Program
Shofer, S. L., Gagliardi, J. P., Bryant, S., Khedagi, A. M., Mohottige, D., Gregory, A., Zaas, A. K., Truong, T., & Staples, B. B. (2024) · Academic Medicine · doi:10.1097/acm.0000000000005866 · Cited by 3
Post-Traumatic Stress Across Color Lines: A History of Anti-Black Exclusion & PTSD
Miola, R. E., Morgan, M., Green, M. N., & Ross, R. N. (2025) · Community Mental Health Journal · doi:10.1007/s10597-025-01450-3 · Cited by 3
“In a systematic review of interventions focused on providers across the healthcare spectrum, Vela et al. (2022), found that though these interventions increased awareness and interest in reducing biases, none of the studies reviewed were able to achieve sustained reduction of biases.”
Do difficult encounters affect pain treatment outcomes? A prospective cohort study
Liu, W. L., van Gelderen, E., Mawalkar, R., Wang, E. J., Treisman, G. J., & Cohen, S. P. (2025) · Pain Medicine · doi:10.1093/pm/pnaf027 · Cited by 3
Srinivasan, S., & Vallipriya, R. (2025) · IGI Global eBooks · doi:10.4018/979-8-3693-3683-0.ch002 · Cited by 3
Clifford, D. E., Laing, E. M., Harris, C., Slagel, N., Levinson, J. A., Squires, N. D., & Hunger, J. M. (2025) · Journal of Nutrition Education and Behavior · doi:10.1016/j.jneb.2025.03.011 · Cited by 3
Artificial Intelligence in medicine
Sonawane, U., & Komorowski, M. (2023) · AI critique · doi:10.1515/9783839467664-009 · Cited by 3
Beyond the Question: Reexamining a Parent’s Unusual Request
Callahan, K. P., Narva, A. M., Stoller, J. Z., & Fiester, A. M. (2024) · PEDIATRICS · doi:10.1542/peds.2023-064954 · Cited by 2
Grant, S. J., Jean‐Baptiste, M., Mills, J. A., & Mihas, P. (2024) · Journal of Racial and Ethnic Health Disparities · doi:10.1007/s40615-024-02205-8 · Cited by 2
“Implicit bias trainings have also been shown to help health care professionals recognize and mitigate subconscious biases, allowing for more equitable interactions with patients and across the health care system that build trust [44].”
Wilson, N. A., Ruffolo, L. I., Juviler, P. G., Fabiano, T., Kelly, W. F., Lillvis, D. F., Edwards, M., Vu, N., Chiou, R., Wallenstein, K., et al. (2025) · The Journal of Trauma: Injury, Infection, and Critical Care · doi:10.1097/ta.0000000000004560 · Cited by 2
Challenges in colorectal cancer post-surgical surveillance: A critical evaluation and path forward
Krishnan, A., & Mukherjee, D. (2025) · World Journal of Gastrointestinal Surgery · doi:10.4240/wjgs.v17.i6.106965 · Cited by 2
Morales, C., Ruelas, M., Daluz, T., Analco, E., Vera, N., Rivera, J., Covington, M., & Hawes, S. M. (2025) · Frontiers in Veterinary Science · doi:10.3389/fvets.2025.1539811 · Cited by 2
Langevin, R., Mohanraj, D., Shah, L., Sabin, J., Wood, B. R., Pratt, W., Weibel, N., & Hartzler, A. L. (2025) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocaf143 · Cited by 2
The culturally diverse experience of persons with aphasia with healthcare providers
Brown, W. E., & Azios, J. H. (2025) · Aphasiology · doi:10.1080/02687038.2025.2586712 · Cited by 2
Harkins, S., Thomas, C. D., Hulchafo, I. I., Topaz, M., Landau, R., & Barcelona, V. (2025) · International Journal of Obstetric Anesthesia · doi:10.1016/j.ijoa.2025.104824 · Cited by 2
Examining Japanese laypeople’s nationality preferences for physicians: a nationwide study
Fujikawa, H., Mori, H., Nishizaki, Y., Yano, Y., & Naito, T. (2025) · Scientific Reports · doi:10.1038/s41598-025-29740-6 · Cited by 2
“Second, laypeople in Japan may also be susceptible to implicit bias, defined as unconscious attitudes or stereotypes that potentially lead to unfavorable evaluation of an individual based on their characteristics (e.g., gender, nationality, race) 48 .”
Barrier, K. M., & Ramos, M. D. (2025) · Teaching and learning in nursing · doi:10.1016/j.teln.2025.11.021 · Cited by 2
Fariman, S., Ahmadi, A., Trogdon, J. G., Coombs, L. A., & Lafata, J. E. (2025) · Journal of General Internal Medicine · doi:10.1007/s11606-025-10052-4 · Cited by 3
Wang, F., Gao, J., Yao, Z.-Y., Fung, K. P.-L., Jia, C.-X., Cheng, S., & Wong, J. P. (2025) · International Journal of Mental Health Promotion · doi:10.32604/ijmhp.2025.069458 · Cited by 3
“This finding aligns with evidence from studies on healthcare providers demonstrating that targeted training can produce persistent shifts in attitudes post-intervention [51,52].”
Addressing genetic discrimination and its stigmatizing effects through human rights
Rud, A., Porter, E., Joly, Y., & Uberoi, D. (2026) · Journal of Community Genetics · doi:10.1007/s12687-025-00853-9 · Cited by 2
“(Vela et al. 2022 ) Without a formal definition of GD, unaddressed ambiguity makes it harder to identify when discrimination has occurred and harder still to seek redress.”
The Language of Bias: Labeling and Its Impact on Emergency Department Patients
Vega, L. E. C., & Feliciano, V. E. F. (2026) · Journal of Emergency Nursing · doi:10.1016/j.jen.2025.12.004 · Cited by 2
Discrimination in Health Care Against Children With Medical Complexity and Caregiver Mental Health.
Ames, S. G., Patterson, E., Verdelis, G., Zigler, C., Gerber, D., Houtrow, A., Gatewood, A. K., Wright, S., Meeks, H. D., & Coller, R. (2026) · Hospital Pediatrics · doi:10.1542/hpeds.2025-008876 · Cited by 2
Winkle, L. J. V., Rogers, S., Thornock, B. O., Schwartz, B. D., Horst, A., Fisher, J. A., & Michels, N. (2023) · Frontiers in Medicine · doi:10.3389/fmed.2023.1282199 · Cited by 2
Speer, J. E., & Conley, Q. (2024) · BMC Medical Education · doi:10.1186/s12909-024-05097-8 · Cited by 2
Hunting, G., & Hankivsky, O. (2024) · Sustainable development · doi:10.5772/intechopen.1005543 · Cited by 3
Introduction: understanding prejudice and communication
Nshom, E. (2024) · Edward Elgar Publishing eBooks · doi:10.4337/9781802209662.00007 · Cited by 2
Tierney, K., Wagenfeld‐Heintz, E., Bane, C., Linares, S., Sandberg, M., Moss, D., Duerst, A., Walters, C., Bautista, T., Gumbleton, L., et al. (2024) · Journal of Midwifery & Women s Health · doi:10.1111/jmwh.13700 · Cited by 2
Revisiting the Policy Implications of Implicit Social Cognition
Axt, J. R., Posada, V. P., Roy, E., & To, J. (2025) · Social Issues and Policy Review · doi:10.1111/sipr.70003 · Cited by 2
Vukosavljevic, S., Radovanovic, S. M., Mihaljević, O., Zdravkovic, N. D., Stojić, V., Milojević, S., Radovanovic, J., Stepović, M., Janicijevic, K. M., Folic, N. D., et al. (2025) · Children · doi:10.3390/children12070854 · Cited by 2
“Similarly, but in the area of mental health, boys tend to seek help less than girls due to sociocultural upbringing [25].”
Changing habits of mind: Seven concrete lessons for aspiring community-based researchers
Agner, J. (2025) · Journal of Occupational Science · doi:10.1080/14427591.2025.2501952 · Cited by 2
“They are defined by the national and institutional cultures researchers reside in and are affected by myriad types of implicit and explicit bias (Farias et al., 2016; Vela et al., 2022).”
From education to patient care: the impact of weight stigma in healthcare
D’Arpino, E., & Kardong‐Edgren, S. (2025) · Baylor University Medical Center Proceedings · doi:10.1080/08998280.2025.2528397 · Cited by 4
Trends and Disparities in Poststroke Depression Within 1 Year of Ischemic Stroke
Sanmartin, M. X., Katz, J. M., Ali, M. M., WANG, J. J., Cohn, E. G., Rula, E. Y., Sinvani, L., & Sanelli, P. C. (2025) · Journal of Neuropsychiatry · doi:10.1176/appi.neuropsych.20240247 · Cited by 3
Interventions to Reduce Implicit Bias in High-Stakes Professional Judgements: A Systematic Review
Merla, I., Gabbert, F., & Scott, A. J. (2025) · Behavioral Sciences · doi:10.3390/bs15111592 · Cited by 4
“While numerous interventions have been trialled, most have shown little reliable impact on clinical decisions or behaviour (Vela et al., 2022).”
Metadata
- Authors
- Vela, M. B., Erondu, A. I., Smith, N. A., Peek, M. E., Woodruff, J. N., & Chin, M. H.
- Affiliations
- University of Illinois Chicago (US)
- University of California, Los Angeles (US)
- Hospital of the University of Pennsylvania (US)
- University of Chicago (US)
- ORCID
- Woodruff, James N.
- Venue
- Annual Review of Public Health
- Publisher
- Annual Reviews
- Published
- 2022-04-05
- Volume
- 43
- Issue
- 1
- Pages
- 477-501
- ISSN
- 0163-7525 (ISSN-L)
- 1545-2093
- PMC
- PMC9172268
- OpenAlex
- W4206528627
- Cited by
- 426
- References
- 102
- Citations by year
- 2026: 89 · 2025: 176 · 2024: 97 · 2023: 55 · 2022: 9
- FWCI
- 14.19
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Locations
- Annual Review of Public Health (publishedVersion, cc-by)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion, cc-by)
- Funders
- National Institute of Diabetes and Digestive and Kidney Diseases (P30DK092949)
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Cultural Competency in Health Care
- Social Sciences › Sociology and Political Science › Racial and Ethnic Identity Research
- Social Sciences › Sociology and Political Science › Social and Intergroup Psychology
- Keywords
- implicit bias, explicit bias, healthcare workers, racial and ethnic minorities, health disparities, bias interventions, patient-clinician communication, clinical decision-making, organizational discrimination, structural change, conceptual model
- MeSH terms
- Attitude of Health Personnel, Communication, Health Personnel, Humans, Bias, Healthcare Disparities
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