Implicit attitudes and stigma in healthcare: A conversation with Professor Loren Brener
We spoke with Loren Brener, Professor at the Centre for Social Research in Health (CSRH) and member of the Tackling Stigma team about implicit attitudes, how they differ from explicit beliefs, and why even well-intentioned healthcare workers can act in ways that don’t align with their stated values.
Can you tell us a little bit about implicit attitudes? What are they?
Theorists suggest we have two main types of attitudes. One is explicit attitudes. These are attitudes we’re aware of, that we can identify, talk about, and modify. The other is implicit attitudes. These exist at an unconscious level.
They’re automatic associations we make with people, situations, or events. They can be triggered by seeing a particular person or a stigmatised condition and they happen outside of conscious awareness.
Implicit attitudes aren’t something we can directly modify. They just automatically exist. Importantly, implicit and explicit attitudes can coexist. A person can hold positive explicit attitudes while also having negative implicit associations about the same group, particularly when that group is stigmatised.
Can you share an example of what implicit attitudes may look like in action?
You might see a person experiencing homelessness and consciously think about their difficult life circumstances, feel empathy, and want to help. At the same time, your implicit attitudes might be telling you to move away because the person could be dangerous or behave erratically.
You might find yourself stepping around them or crossing the road, even though that doesn’t align with your expressed beliefs.
Another example: perhaps people who inject drugs are explicitly welcomed into clinical spaces, but then healthcare workers may subtly move their chair back or put their bag under their chair. These behaviours likely reflect implicit concerns that the person might steal or behave unpredictably.
These are examples of how behaviour can be shaped differently by implicit and explicit attitudes.
How do we measure and differentiate between implicit and explicit attitudes?
Explicit attitudes are usually measured using surveys or statements, such as “I think people who inject drugs are good” or “I think they’re bad”. These are attitudes people are aware of and can modify, and they can respond in socially desirable ways.
Implicit attitudes are measured using reaction time tasks. Words and images with positive or negative associations are flashed on a screen, and the speed of responses shows how quickly associations are made.
For example, early race-based Implicit Association Test (IATs) showed that many white participants more quickly associated Black faces with negative words than with positive words. That reaction time difference was taken as a measure of implicit bias. These responses aren’t under conscious control and can’t be easily modified.
You mentioned the Implicit Association Test. Can you give us some background on what it is and how it’s used?
The Implicit Association Test, or IAT, is the most commonly used tool for measuring implicit associations. It works by measuring reaction times, looking at how quickly people make associations between different categories.
It was originally developed by researchers at Harvard to assess racial bias, but it’s since been used much more widely, including to examine gender bias, such as associations between men and mathematical or scientific ability. Early versions of the IAT focused on two categories, like Black and White or male and female.
There is also a version known as the Single Category Implicit Association Test, which allows researchers to focus on one group rather than comparing two. We’ve used this version to examine attitudes towards people who inject drugs, as well as with people who inject drugs themselves, to look at internalised stigma. That can be quite confronting and uncomfortable, but it’s a really interesting measure of internalised stigma.
If we're serious about identifying and addressing implicit attitudes, these kinds of tools are important because identifying bias is the first step towards understanding how it influences behaviour.
What impact can implicit attitudes have?
One key thing is that implicit and explicit attitudes don’t just coexist, they can also predict different behaviours.
Positive explicit attitudes tend to predict certain behaviours, while negative implicit attitudes can predict others, particularly non-verbal behaviours that people aren’t aware of.
For example, in our research we’ve found that people with more negative implicit attitudes towards people who inject drugs are less likely to express a desire to help them, even when they report positive explicit attitudes towards that group.
Why do you think that happens?
I think it’s a combination of things. Some people are trying to respond in socially desirable ways. They’re trying to present themselves well and have good intentions. In other cases, people simply don’t realise they have these negative associations.
For clinicians who hold strong explicit commitments to equity, discovering implicit attitudes can be confronting. How should they understand that disconnect?
The world is complex and we have a lot to process. Implicit attitudes are based on past experiences, things we learned growing up, and messages we’ve absorbed from the media. They’re cognitive shortcuts that allow us to process information quickly.
They’re often negative when they relate to stigmatised conditions because those associations have been learned over time. At the same time, we can express positive explicit attitudes because we’ve had time to reflect and think about them.
Having implicit attitudes isn’t a reflection of someone’s moral compass. We all have them. They’re part of being human. What’s import
What can be done about implicit attitudes?
The first step is acknowledging that we all have implicit biases. If people can reflect on how these biases might show up in non-verbal behaviours, particularly in healthcare settings, then they can think about how to act in line with their explicit, positive attitudes instead of letting implicit associations shape their behaviour.
Is everyone open to doing the work?
No, I don’t think everyone is. It takes bravery to acknowledge that some of our attitudes sit outside our conscious control, especially when we try hard to hold positive views towards stigmatised groups.
It’s brave to step back and reflect on how we think about people and how we might interact in ways that could make someone uncomfortable, even when that’s not our intention.
At a glance
Implicit and explicit attitudes can coexist and predict different behaviours
Implicit attitudes operate outside conscious awareness and are not directly controllable
Reaction-time tests are the most common way to measure implicit attitudes
Negative implicit attitudes can influence non-verbal behaviour, even when explicit attitudes are positive
Implicit attitudes can shape behaviour even when intentions are positive
Acknowledging implicit bias requires reflection and, often, courage
Addressing implicit bias starts with recognition, but must extend to behaviour