Stereotyping: The link between theory and practice

Patient Education Elsevier Scientific

and Counseling, 8 (1986) Publishers Ireland Ltd.

17

17-25

Original Articles STEREOTYPING:

THE

SUSAN

and BRENDA

J. BLALOCK*

LINK

Department of Health Education, Chapel Hill, NC (U.S.A.) (Received (Revision (Accepted

BETWEEN MCEVOY

School

THEORY

AND

PRACTICE

DEVELLIS

of Public

Health,

University

of North

Carolina,

July 12th, 1985) received August 27th, 1985) September IOth, 1985)

ABSTRACT

Patient educators have long acknowledged the importance of individualizing educational interventions to the specific needs of individual patients. In this paper, we discuss ways in which stereotyping can interfere with this process. First, we examine stereotyping from the more general perspective of information processing. Biases introduced by stereotyping that affect the way individuals process information are discussed and the concepts of cognitive schemas and behavioral confirmation are described. We then briefly review selected studies that demonstrate stereotyping of patients by health care providers. The paper concludes with a discussion of the implications of stereotyping for patient education and the presentation of four strategies patient educators might employ either to decrease the occurrence of stereotyping or to avoid some of its detrimental effects. Key words: Stereotyping Behavioral science

-

Patient

education

-

Health

care providers

-

INTRODUCTION

Quality patient education requires that patient educators be aware of and respond to individual differences among patients, evaluate information about them in an objective, unbiased manner, and develop relationships that promote open and honest two-way communication. Stereotyping, however, may jeopardize the ability of educators to provide quality, individualized *To whom all correspondence should be sent at: Department of Health Education, School of Public Health, 319C Rosenau Hall - 201H, University of North Carolina, Chapel Hill, NC 27514, U.S.A. 0738-3991/86/$03.50 Printed and Published

@ 1986 in Ireland

Elsevier

Scientific

Publishers

Ireland

Ltd.

18

patient education by introducing a bias into the way educators evaluate information about patients. As a result of this bias, educators’ interactions with patients may be negatively influenced. Therefore, it’is important that patient educators understand how stereotyping occurs and how some of its detrimental effects might be avoided. To accomplish this, we first outline the theoretical framework that underlies the study of stereotyping, we then review selected studies that document the occurrence of stereotyping in health care settings, and conclude with a discussion of the implications of stereotyping for those involved in patient education. THEORETICAL BACKGROUND A stereotype, quite simply, is a set of beliefs about the personal attributes of a group of people [l]. Stereotypes of people grouped together on the basis of characteristics such as sex, age, race, ethnic origin, and occupation are prevalent in our society. However, we usually think of stereotyping as something done by a relatively few, unenlightened, prejudiced people. Although we probably all know of others who stereotype, few of us would openly admit that we engage in the process ourselves. Yet, recent work in the area of social cognition suggests that, to some extent, we all engage in stereotyping. Stereotyping is now believed to be an almost inevitable result of the way the human mind processes information. Cognitive schemas by a tremenOver the course of a single day an individual is confronted dous amount of information. Much of this information goes unnoticed and only a small fraction becomes stored in the individual’s memory. Further, even the information stored in memory tends to fade quickly over time. The process through which an individual extracts certain information from the environment, interprets it, stores it in memory, and then remembers it at a later time is called information processing. To explain why certain types of information are processed more easily than others, researchers have turned to the concept of cognitive schemas. According to this concept much of the information in one’s memory is stored, not as separate pieces, but as clusters of associated thoughts, i.e. cognitive schemas [2]. Therefore, when one piece of information within a cluster becomes salient, others from that same cluster also come to mind. Stereotypes are a special kind of schema in which the central concept is a group of people identified by some characteristic that they share. For example, a stereotypic schema about people who are ill may consist of beliefs that sick people are dependent, demanding and not much fun to be around. Thus when one thinks of a -person who is ill, these other thoughts may also come to mind. Obviously, it is possible to stereotype any person on the basis of a wide variety of characteristics (e.g. sex, race, occupation, age). In general, research has demonstrated that we are more likely to stereotype an individual on

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the basis of a particular characteristic when: (1) situational factors cause that characteristic to be salient, (2) we have preexisting expectations of what people with the characteristic are like, and (3) the individual behaves in a way that is consistent with our stereotype of people with that characteristic

[31. Categorizing people into groups allows us to deal efficiently with a greater amount of information at one time than would otherwise be possible [2]. To the extent that these categories reflect reality and are not overgeneralized, they can be useful in directing our initial behavior when we meet people for the first time. As long as our initial expectations can be modified as we acquire additional information, categorization may have many beneficial effects. However, our expectations that certain characteristics are associated with certain kinds of people can bias the way we process information, making it unlikely that new information will be evaluated fairly. Hamilton notes three types of biases [2]. First, stereotypes focus attention on those aspects of a person’s behavior that are consistent with the stereotype. Second, they influence the way an individual’s behavior is interpreted. For example, if a person who is expected to be demanding makes a request, it is much more likely to be interpreted as a demand than if the same request were made by someone not expected to be demanding. Third, we are more likely to remember behaviors that support our stereotypes than we are to remember behaviors that contradict or disconfirm them. Together, these biases provide us with a great deal of information that appears to support our stereotypes. They make it likely that we will be convinced that our stereotypes are accurate even in cases where the objective information is lacking or contradictory, Although normally we do not attempt to evaluate the accuracy of our stereotypes on a conscious level, investigators have asked subjects to do so in order to study the processes involved [4]. Even when subjects deliberately try to challenge the accuracy of a stereotype, they primarily take into account only the first of the following four types of information that should be considered: (1) stereotyped individuals who possess the stereotyped characteristic, (2) stereotyped individuals who do not possess the characteristic, (3) non-stereotyped individuals who possess the characteristic and (4) non-stereotyped individuals wo do not possess the characteristic [ 41. Thus, the observation of any stereotyped individual with the characteristic in question is often taken as confirmation of the stereotype’s accuracy. We fail to recognize that the stereotype was not fairly evaluated, because 75% of the relevant information was ignored and much of the other 25% was biased in favor of stereotype confirmation. Behavioral confirmation In addition to the cognitive processes discussed above which bias the way we process information about stereotyped individuals, a behavioral process, i.e behavioral confirmation, results in our actually creating information that supports our stereotypes. Behavioral confirmation involves a type of chain

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reaction set in motion by the stereotyped beliefs an individual holds about a group of people [ 51. For example, if a physician expects female patients to be extremely demanding, that physician may respond slowly or begrudingly to requests from a female patient. In response, the patient may become increasingly adamant about her requests. In effect the demanding patient the physician originally expected to encounter has been created. The chain is complete if the patient, assuming that the only way to have her needs met is by being demanding, is then demanding with other physicians or health care providers. At this point, the stereotype has truly created its own reality [ 51. As with the cognitive biases, behavioral confirmation does not necessarily take place at a conscious level. We do not intentionally constrain the behavior of individuals in efforts to prove that our stereotypes are correct. In fact, we may be totally unaware of the ways in which our behavior influences the behavior of others. However, the subtlety of the mechanisms involved makes it even more likely that when behavioral confirmation occurs it will provide impressive evidence in support of the original stereotype. STEREOTYPING

WITHIN

THE HEALTH

CARE

SYSTEM

The health care system encourages the development and perpetuation of stereotypes by categorizing individuals first as ‘patients’ and by then subcategorizing them through the diagnostic process (e.g. ‘cancer patients’, ‘alcoholic patients’). Patients may also be subcategorized on the basis of obvious physical characteristics or on the basis of personal information available to health care providers such as income or mental health history

[61. Basic research on stereotyping has identified a number of other factors that foster stereotyping [3,7,8]. Four factors particularly relevant to health care settings are: status differences between health care providers and patients, the superficiality and limited focus of patient-provider interactions, the emotionally charged atmosphere surrounding medical care, and highly visible cues that differentiate patients from providers (e.g. uniforms, medical jargon) [3,7]. Medical care settings also may inhibit many patients from disclosing personal information that would help practitioners see their unique attributes. Not surprisingly research from a variety of sources has documented the occurrence of stereotyping in health care settings. Provider attitudes and beliefs Studies have found that medical and nursing textbooks and professional journals often present a stereotypic view of patients in general and of certain patient subgroups in particular [e.g. 9,101. For example, sex stereotypes are fostered by textbooks that link female patients with mental and emotional disorders. Such materials may result in common stereotypes coming to be shared by many members of a profession and being passed from one generation to the next.

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Further evidence of stereotyping within health care settings comes from investigations that have directly assessed the attitudes and beliefs of practitioners toward patients or specific patient subgroups. In these studies, practitioners are given only minimal information about a person (e.g. ‘a typical female patient’). Practitioners’ attitudes and beliefs are then measured, usually using bipolar adjective pairs (e.g. Intelligent-Stupid; Dependent-Independent). Using this methodology, Westbrook [ 111 found that subjects from several different health professions (e.g. medicine, nursing, occupational therapy) attributed fewer socially desirable traits (e.g. ability to adapt, sincerity) to sick persons than to healthy persons. Other studies have found that nurses tend to view all patients as dependent [ 10,121. Investigators also have studied the impact of certain diagnostic labels on the evaluation of patients by health professionals. Goodyear [ 131 demonstrated that rehabilitation counselors have more positive attitudes toward patients described as physically disabled than toward those described as intellectually impaired, emotionally disturbed or socially deviant. Likewise, Wallston and his colleagues have demonstrated that nurses’ attitudes toward patients vary as a function of certain diagnostic classifications [14,15]. Researchers also have focused on a variety of personal characteristics upon which patients may be categorized (e.g. sex, age). Again findings indicate that health professionals do associate certain traits with different groups of patients [ 10,16-221. For example, Broverman [ 161 found that mental health clinicians viewed women as less independent, less objective and more submissive than men. The extent to which group stereotypes such as these are applied to individual patients has been investigated using a methodology similar to that described above. However, rather than asking subjects to respond to a very brief patient description, subjects are presented with much more in-depth information (i.e. individuating information) about a specific hypothetical patient. The aim is to determine if subjects use this individuating information in their judgements of individual patients and, as a result, respond to specific patients in a less stereotypic manner. Using this methodology, investigators have found that practitioners’ stereotypes can influence their attitudes toward specific patients [15,23]. However, other studies have demonstrated that, at least under certain conditions, individuatmg information decreases practitioners’ stereotyping of individuals [ 14,21,24]. Research is now needed to understand the conditions under which specific information about individual patients is likely to be incorporated into providers’ attitudes toward those patients. Provider behavior toward patients If the effects of stereotyping were limited to our beliefs and attitudes they might well be of little concern to practitioners. However, as suggested above, stereotypes can influence behavior as well as attitudes. For example, studies of the prescribing practices of physicians indicate that among patients with

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emotional complaints, female patients are more likely to be prescribed tranquilizers than are male patients [25,26]. Wallen, Waitzkin and Stoeckle [27] went a step further and examined actual patient and physician behavior during the medical interview. They found that the sex of the patient did affect patient-provider communication. Men received fewer, but more complete explanations than women. Further, in response to direct questions, physicians frequently gave female patients less information than was requested. This was not true of their responses to questions raised by male patients. However, because this study was limited to male physicians, the findings may not apply to female physicians. A limitation of all the studies cited above is their correlational nature which makes it difficult to infer cause and effect relationships. However, in addition to these correlational studies, DeVellis, Adams and DeVellis [ 241, using an experimental research design, demonstrated that stereotypes can affect the quality of patient-provider communication. In this study, nursing students responded to concerns raised by negatively stereotyped patients (i.e. the voluntarily childless) with less empathy than to concerns raised by other patients. IMPLICATIONS FOR PATIENT’EDUCATION

The studies reviewed above demonstrate the range of research that has been done relevant to stereotyping within health care settings. Together, they provide convincing evidence that health professionals do engage in stereotyping of patients. They also suggest that these stereotypes can influence the way clinicians behave toward individual members of stereotyped groups. This potential negative impact of stereotyping on the care received by patients makes stereotyping a phenomenon with which health care providers must be concerned. Stereotyping may have even more serious implications for patient education than for other aspects of health care. The primary role of most patient educators is to develop and implement educational interventions that promote the voluntary adoption of healthful behaviors. This role requires that educators assess patients’ unique educational needs. If these assessments are based on stereotypic expectations, rather than on objective information, programs are likely to be ineffective and may even alienate those they intend to serve. Unfortunately, there is no easy resolution to this dilemma. Past research has been much more successful at demonstrating the existence of stereotypes than at developing interventions to counteract them. However, it is possible to make some suggestions. First, we should be attentive to cultural factors that reinforce existing stereotypes. For example, it is likely that the same types of biases evident in medical texts and journals are present in patient education materials as well. When selecting materials, patient educators should be sensitive to evidence of stereotyping such as: Overgeneralizations about characteristics shared by members of a group (e.g. ulcer patients are

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ambitious, impatient and lonely) and assumptions of differences between members of different groups (e.g. overweight males are motivated to lose weight for health reasons whereas overweight females are motivated for reasons related to appearance). Materials that convey this type of information should be carefully evaluated. Because many stereotypes contain an element of truth and may appear to reflect reality, identifying biased material is not as easy as it might seem. As a general rule, we believe that whenever materials convey information of questionable accuracy, they should not be used. Second, because stereotyping requires the identification of categories of individuals (e.g. patients, providers), we may be able to reduce stereotyping by redefining group boundaries and incorporating the patient into the ‘patient care team’. By blurring the roles of patients and providers and increasing patients’ involvement in their medical care we also may decrease stereotyping. For example, Janz, Becker and Hartman [28] suggest that active involvement of patients in the contracting process may ‘combat the stereotype of the ideal client as a passive recipient of medical care’. Others have also discussed the advantages of increasing patients’ involvement in decisions about their health care [ 291. Third, past research has demonstrated that we are most likely to stereotype individuals when we know little about them as individuals. Therefore, we may be able to attack stereotyping by encouraging appropriate patient self-disclosure, thereby increasing the likelihood that patients will provide us with individuating information about themselves. Factors that promote patient self-disclosure include: The provision of sufficient time for patients and practitioners to interact on more than a superficial basis, practitioner willingness to listen to patients’ concerns, and the use of appropriate selfdisclosure by practitioners (e.g. an example of difficulty the practitioner once had complying with a recommended regimen) [ 301. Finally, we must be particularly attentive to the information patients tell us about themselves. Research has demonstrated that, at least under certain circumstances providers do attend to and incorporate such information into their assessments of individual patients [ 14,21,24]. One way to increase our attentiveness to this type of information may be to adopt a strategy of ‘disconfirmatory hypothesis testing’ [4]. That is, when we encounter patients from negatively stereotyped groups, we might try to think explicitly of those characteristics or behaviors that would be ‘out of character’ for patients in those groups. Then we could look specifically for that type of information. Introducing this conscious bias into our information processing may counterbalance the unconscious biases introduced by stereotyping. Attending to individuating information about specific patients can have two beneficial effects. First, it can result in less stereotyping of the patients involved and, second, it may lead to modification of the stereotype itself. For example, imagine a practitioner whose stereotype of elderly patients included the belief that they prefer not to be involved in making decisions related to their medical care. If an elderly patient made it clear that he/she

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did want to be included in such decisions, the practitioner would be unlikely to allow the stereotype to guide the patient interaction. Although the practitioner’s stereotype of elderly people in general might not change completely, this experience might result in a distinction being made between different types of elderly patients (i.e. those who want to be involved in medical decisionmaking vs. those who prefer not to be involved). As the number of categories used for grouping individuals increases, fewer people are placed into each category. Consequently, each category incorporates more individuating information and beliefs about individual group members rely less upon generalizations. Thus, it becomes increasingly likely that the characteristics associated with members of a group will more accurately reflect group members’ true characteristics. Although stereotyping might still occur, some of its detrimental effects would be short-circuited. In conclusion, we have attempted to convey throughout this paper that stereotyping can, through very subtle mechanisms, jeopardize our ability to provide patient education that is individualized to patients’ unique needs. Stereotyping, we believe, is not a process epgaged in by only a few prejudiced people, but rather it is a process that we all engage in to some extent. We have presented a number of strategies for preventing stereotyping and counteracting their negative effects. We believe these strategies can provide guidance -in the development and implementation of educational interventions by practitioners who are aware of and sensitive to the issues involved. ACKNOWLEDGMENT

We wish to thank Lynda Anderson, Jo Anne Earp, Kenneth McLeroy, Carol Runyan and Victor Strecher for their comments on an earlier draft of this manuscript. REFERENCES 1 Ashmore RD, Del Boca FK: Conceptual approaches to stereotypes and stereotyping. In Hamilton DL (Ed.): Cognitive Processes in Stereotyping and Intergroup Behavior. Hillsdale, NJ: Lawrence Erlbaum Associates, 1981. 2 Hamilton DL: A cognitive-attributional analysis of stereotyping. In Berkowitz L (Ed.): Advances in Experimental Social Psychology (Vol. 12). New York, NY: Academic Press, 1979. 3 Taylor SE: A categorization approach to stereotyping. In Hamilton DL (Ed.): Cognitive Processes in Stereotyping and Intergroup Behavior. Hillsdale, NJ: Lawrence Erlbaum Associates, 1981. 4 Snyder M, Cantor N: Testing hypotheses about other people: The use of historical knowledge. J Exp Sot Psycho1 1979; 15: 330-342. 5 Snyder M: On the self-perpetuating nature of social stereotypes. In Hamilton DL (Ed.): Cognitive Processes in Stereotyping and Intergroup Behavior. Hillsdale, NJ: Lawrence Erlbaum, 1981. 6 DeVellis BM, Wallston BS, Wallston KA: Stereotyping: A threat to individualized patient care. In Miller MH, Flynn B (Eds.): Current Perspectives in Nursing: Social Issues and Trends (Vol. 2). St. Louis, MS: Mosby, 1980.

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