How Healthcare Disparities Impact Health and Healthcare in Minority Patients and Communities?
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1374 | Health Serv Res. 2019;54:1374–1388.
Health Services Research
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1 | INTRODUC TION
Racial and ethnic differences in health, in which socially disadvantaged racial populations have worse health than whites, are large, pervasive across a broad range of outcomes, and persistent over time.1 They exist for the onset of disease, as well as the severity and course of illness. Socioeconomic status (SES)—whether measured by income, education, occupational status, or wealth—is a strong predictor of vari‐ ations in health and has often been viewed as the driver of racial ineq‐ uities in health. Research finds that although SES predicts variations in
health status within each racial group, racial disparities persist at every level of SES.2 There is a large and growing body of empirical evidence indicating self‐reports of discrimination are race‐related aspects of so‐ cial experience that can have negative effects on health. This paper provides an overview of research on self‐reported discrimination and health, as well as health care utilization. It begins by situating research on racial discrimination and health within the larger context of re‐ search on racism and health. Importantly, self‐reported experiences of discrimination are one mechanism by which racism affects health, and these exposures can be best understood and effectively addressed
DOI: 10.1111/1475‐6773.13222
S P E C I A L I S S U E : E X P E R I E N C E S O F D I S C R I M I N A T I O N I N A M E R I C A
Understanding how discrimination can affect health
David R. Williams PhD, MPH1,2 | Jourdyn A. Lawrence MPH1 | Brigette A. Davis MPH1 | Cecilia Vu MPH1
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. © 2019 The Authors. Health Services Research published by Wiley Periodicals, Inc. on behalf of Health Research and Educational Trust
1Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts 2Department of African and African American Studies, Department of Sociology, Harvard University, Cambridge, Massachusetts
Correspondence David R. Williams, PhD, MPH, Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA. Email: [email protected]
Funding information W.K. Kellogg Foundation, Grant/Award Number: P0131281
Abstract Background: To provide an overview of the empirical research linking self‐reports of racial discrimination to health status and health service utilization. Methods: A review of literature reviews and meta‐analyses published from January 2013 to 2019 was conducted using PubMed, PsycINFO, Sociological Abstracts, and Web of Science. Articles were considered for inclusion using the Preferred Reporting Items for Systematic Review and Meta‐Analyses (PRISMA) framework. Results: Twenty‐nine studies met the criteria for review. Both domestic and interna‐ tional studies find that experiences of discrimination reported by adults are adversely related to mental health and indicators of physical health, including preclinical in‐ dicators of disease, health behaviors, utilization of care, and adherence to medical regimens. Emerging evidence also suggests that discrimination can affect the health of children and adolescents and that at least some of its adverse effects may be ame‐ liorated by the presence of psychosocial resources. Conclusions: Increasing evidence indicates that racial discrimination is an emerging risk factor for disease and a contributor to racial disparities in health. Attention is needed to strengthen research gaps and to advance our understanding of the optimal interventions that can reduce the negative effects of discrimination.
K E Y W O R D S
discrimination, health, health disparities, mental health, racism
| 1375 Health Services Research
WILLIAMS et AL.
within the context of the role of racism in health. The paper then high‐ lights key findings in this burgeoning literature.
2 | BACKGROUND AND THEORETIC AL FR AME WORK
Figure 1 illustrates the multiple components of racism and the ways in which these components can affect health. Racism is viewed as a dynamic societal system that is shaped by and reshapes other so‐ cial institutions such as the political, legal, and economic systems.3‐6 Central to racism, in the US context, is a hierarchical ideology that the dominant white group uses to categorize and rank social groups into races with whites being superior compared to other races. There are three major pathways that link racism to inequities in society and health. The first pathway by which racism operates is cultural racism.6 This refers to the embedding of the inferiority of blacks and other nonwhites into the belief systems, images, and norms of the larger culture that leads to widespread negative beliefs (stereotypes) and attitudes (prejudice) that devalue, marginalize, and subordinate nonwhite racial populations. Cultural racism creates a larger ideo‐ logical environment within which the system of racism can flourish. It initiates and sustains racial prejudice and negative racial stereo‐ types that can lessen support for egalitarian policies, trigger health‐ damaging psychological responses in stigmatized persons such as internalized racism and stereotype threat, and facilitate explicit and implicit biases that restrict access to desirable resources, including medical care.6
The second pathway is institutional or structural racism. We use these terms interchangeably to refer to societal structures and policies that reduce access of the socially stigmatized to desirable opportunities and resources in society.5 The system of racism devel‐ ops and sustains policies and structures that empower the dominant group to differentially allocate desirable societal opportunities and resources to racial groups regarded as inferior. Residential segre‐ gation is one example of an institutional mechanism of racism that adversely affects health in multiple ways.7,8 The forced removal and relocation of American Indians to reservations is another example of institutionalized isolation of a marginalized racial population. Segregation is a critical determinant of SES, as it reduces access to quality elementary and high school education, preparation for higher education, and access to employment opportunities. One na‐ tional study found that the elimination of segregation would erase black‐white differences in income, education, and unemployment, and reduce racial differences in single motherhood by two‐thirds.9 SES, in turn, is a strong predictor of variation in health and risk fac‐ tors that affect health. Segregation can also lead to increased expo‐ sure to multiple psychosocial, physical, and chemical stressors linked to neighborhood and housing conditions, including crime, violence, and air pollution. It can also affect access to and the quality of local services, ranging from medical care to municipal services.
The third pathway through which racism operates is through in‐ dividual‐level discrimination. Stigmatized racial groups experience
differential treatment (discrimination) directed at them by both social institutions and individuals. Considerable scientific evidence docu‐ ments the persistence of objectively assessed individual discrim‐ ination in contemporary society. A review of audit studies—those in which researchers carefully select, match, and train individuals to be equally qualified in every respect but to differ only in race— provide striking examples of contemporary racial discrimination.10 Discrimination has been documented in renting apartments, purchas‐ ing homes and cars, obtaining mortgages and medical care, applying for insurance, and hailing taxis. Such incidents of discrimination can lead to reduced access to a broad range of societal resources and opportunities. Figure 1 indicates that the persistence of stark racial inequities in multiple domains of society can confirm racial stereo‐ types and stigma, and thus serve to reinforce the system of racism. Moreover, the pathways by which racism affect are interrelated and mutually reinforcing.11
The lower panel of Figure 1 serves to further unpack how indi‐ vidual‐level discrimination can affect health. The focus here is on a subset of incidents of individual discrimination that is perceived by the individual. According to social stress theory, perceived discrim‐ ination is a type of stressor that, like other psychosocial stressors, is adversely related to a broad range of physical and mental health outcomes.12,13 A recent study, for example, documented that self‐re‐ ported experiences of discrimination are associated with neural func‐ tioning in ways that mirror patterns observed for other psychosocial stressors (eg, greater spontaneous amygdala activity and greater connectivity between the amygdala and other regions of the brain including the thalamus).14 The lower panel of Figure 1 delineates how discriminatory incidents of which the individual is aware can trigger appraisal and affective reactions that can be experienced as stressful life exposures, and they have a cascade of negative effects on health.15 They can lead to negative emotions that can adversely affect psychological well‐being, leading to symptoms of distress and increasing the risk of discrete psychiatric disorders. These negative emotions can also lead to biological dysregulation that can contrib‐ ute to indicators of subclinical disease and chronic physical illness.15 Coping with negative emotional states can also lead to increases in risky health behaviors, including declines in the utilization of and en‐ gagement with health care services. Figure 1 also acknowledges that in the face of exposure to discrimination, individuals and groups can respond in ways that can neutralize at least some of the negative effects of discrimination.
3 | METHODS
3.1 | Search strategy
Reviews were identified through a search of PubMed, PsycINFO, Sociological Abstracts, and Web of Science. Reviews were eligi‐ ble for inclusion if they were focused reviews or meta‐analyses, in English, published from January 2013 to the present, extend‐ ing the systematic review and meta‐analysis published by Paradies and colleagues.16 The following keywords were used: (racism* OR
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erm s and C
onditions (https://onlinelibrary.w iley.com
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iley O nline L
ibrary for rules of use; O A
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1376 | Health Services Research
WILLIAMS et AL.
social discrimination*) OR (race* OR racial*) AND discriminat*)) AND (systematic*[sb] OR systematic*[ti] OR review*[ti] OR review*[sb] OR meta‐analysis*[ti]). The bibliographies of included studies were manually examined to identify additional reviews and meta‐analyses.
3.2 | Inclusion criteria
Two of us (JAL, CV) reviewed titles and abstracts of the traced articles followed by a full‐text review to check inclusion criteria using the Covidence systematic review software.17 A third author (DRW) acted as a tiebreaker regarding study selection and inclu‐ sion. A review was eligible for inclusion if it satisfies the following criteria: (a) evaluated studies examining self‐reported racial/eth‐ nic discrimination or studies that examined perceived discrimina‐ tion broadly, and (b) examined health or health‐related outcomes. This is consistent with the finding that adverse health effects of
discrimination are generally evident, irrespective of whether an incident is linked to a general perception of bias or unfair treat‐ ment or to discriminatory experiences attributed to race/ethnicity or other stigmatized social statuses.18,19 The outcomes were men‐ tal health, including positive psychological well‐being, indicators of physical health and risk factors, health behaviors, and health service utilization.
4 | RESULTS
Of 1189 articles screened, based on the criteria for inclusion, two authors (JAL, CV) completed title and abstract screening for 922 unique studies, identifying 32 for full‐text review. An additional study was identified for inclusion (n = 33) from a review of bibliog‐ raphies. A total of 29 reviews were extracted for analysis (Table 1).
F I G U R E 1 The House that Racism Built
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ine Sm ith - Saint T
hom as U
niversity , W iley O
nline L ibrary on [01/07/2024]. See the T
erm s and C
onditions (https://onlinelibrary.w iley.com
/term s-and-conditions) on W
iley O nline L
ibrary for rules of use; O A
articles are governed by the applicable C reative C
om m
ons L icense
| 1377 Health Services Research
WILLIAMS et AL.
TA B
LE 1
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nloaded from https://onlinelibrary.w
iley.com /doi/10.1111/1475-6773.13222 by Jasm
ine Sm ith - Saint T
hom as U
niversity , W iley O
nline L ibrary on [01/07/2024]. See the T
erm s and C
onditions (https://onlinelibrary.w iley.com
/term s-and-conditions) on W
iley O nline L
ibrary for rules of use; O A
articles are governed by the applicable C reative C
om m
ons L icense
1378 | Health Services Research
WILLIAMS et AL.
D is
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T. , e
t a l
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Tr ia
na , M
C .,
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l (2
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M en
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V in
es , A
I., e
t a l (
20 17
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en ta
l h ea
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C ro
ss ‐s
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TS D
, de
pr es
si on
. m ed
ia to
rs /
co nf
ou nd
er s:
a gg
re ss
io n,
co
pi ng
& p
er so
na lit
y, in
te rn
al iz
ed p
sy ch
re sp
on se
(e g,
se
lf‐ es
te em
), ex
te rn
al s
up po
rt iv
e bu
ff er
s
C on
di tio
na l/m
ix ed
: n o
pe rc
en ta
ge b
re ak
‐ do
w n
of tr
en ds
Ph ys
ic al
h ea
lth
Be rn
ar do
, C D
., et
a l
(2 01
7) A
di po
si ty
10 Lo
ng itu
di na
l: 10
0% W
ei gh
t c ha
ng e;
w ai
st c
irc um
fe re
nc e
ch an
ge ; B
M I
ch an
ge ; b
ec om
e ob
es e;
re m
ai n
ob es
e W
ei gh
t c ha
ng e:
p os
iti ve
W ai
st c
irc um
fe re
nc e
ch an
ge : 1
p os
iti ve
, 3
nu ll
BM I c
ha ng
e: 2
p os
iti ve
, 2 n
ul l
Be co
m e
ob es
e: p
os iti
ve Re
m ai
n ob
es e:
n ul
l
TA B
LE 1
(C
on tin
ue d)
(C on
tin ue
s)
14756773, 2019, S2, D ow
nloaded from https://onlinelibrary.w
iley.com /doi/10.1111/1475-6773.13222 by Jasm
ine Sm ith - Saint T
hom as U
niversity , W iley O
nline L ibrary on [01/07/2024]. See the T
erm s and C
onditions (https://onlinelibrary.w iley.com
/term s-and-conditions) on W
iley O nline L
ibrary for rules of use; O A
articles are governed by the applicable C reative C
om m
ons L icense
| 1379 Health Services Research
WILLIAMS et AL.
D is
cr im
in at
io n
st ud
y Fo
cu s
N o.
p ap
er s
in cl
ud ed
St ud
y de
si gn
H ea
lth o
ut co
m es
Fi nd
in gs
Bl ac
k, L
L. , e
t a l (
20 15
) Ph
ys ic
al h
ea lth
19 C
ro ss
‐s ec
tio na
l Lo
ng itu
di na
l* H
ea rt
d is
ea se
ri sk
fa ct
or s
(ie , C
RP (C
‐r ea
ct iv
e pr
ot ei
n) ;
co ro
na ry
c al
ci um
p os
iti ve
s ta
tu s;
IM T
(c ar
ot id
in
tim a‐
m ed
ia th
ic kn
es s)
; a rt
er ia
l p la
qu e;
c or
on ar
y ar
te ry
c al
ci fic
at io
n) ; b
lo od
p re
ss ur
e (a
nd in
ci de
nc e
of
hy pe
rt en
si on
); ad
ve rs
e bi
rt h
ou tc
om es
; c an
ce r/
tu m
or
in ci
de nc
e; w
ei gh
t c ha
ng e
(a nd
b od
y fa
t d is
tr ib
u‐ tio
n) ; o
th er
o ut
co m
es (i
e, a
ll‐ ca
us e
m or
ta lit
y (A
C M
); Ep
st ei
n‐ Ba
rr v
iru s
re ac
tiv at
io n
(E BV
); fr
eq ue
nc y
of
co m
m on
c ol
ds /p
hy si
ca l i
lln es
se s
(c ol
d) )
H ea
rt d
is ea
se ri
sk fa
ct or
s: n
ul l (
3/ 3)
Bl oo
d pr
es su
re : n
ul l (
3/ 3)
A dv
er se
b irt
h ou
tc om
es : n
ul l (
1/ 6)
; p os
iti ve
(5
/6 )
C an
ce r/
tu m
or in
ci de
nc e:
c on
di tio
na l o
n co
nt ex
t o f d
is cr
im in
at io
n (1
/2 );
po si
tiv e
(1 /2
) W
ei gh
t c ha
ng e:
p os
iti ve
(1 /2
); ne
ga tiv
e (1
/2 )
O th
er h
ea lth
o ut
co m
es : A
C M
: n ul
l ( 1/
1) ;
EB V:
p os
iti ve
(1 /1
); C
ol d:
p os
iti ve
(1 /1
)
Bu ss
e, D
., et
a l (
20 17
) St
re ss
27 Ex
pe rim
en ta
l: 37
% (n
= 1
0) Lo
ng itu
di na
l: 7%
(n =
2 )
C ro
ss ‐s
ec tio
na l:
56 %
(n =
1 5)
H yp
ot ha
la m
ic ‐p
itu ita
ry ‐a
dr en
al (H
PA ) a
xi s:
s al
iv ar
y an
d aw
ak en
in g
co rt
is ol
; d eh
yd ro
ep ia
nd ro
st er
on e
(D H
EA );
co rt
ic ot
ro pi
n‐ re
le as
in g
ho rm
on e
Sa liv
ar y
co rt
is ol
: 1 /2
p os
iti ve
; 1 /2
n eg
at iv
e C
or tis
ol a
w ak
en in
g re
sp on
se : 1
/1 p
os iti
ve N
ul l:
co rt
ic ot
ro pi
n‐ re
le as
in g
ho rm
on e;
af
te rn
oo n
D H
EA
D ol
ez sa
r, C
M .,
et a
l (2
01 4)
H yp
er te
ns io
n 44
C ro
ss ‐s
ec tio
na l,
lo ng
itu di
na l,
ex pe
rim en
ta l d
es ig
ns *
H yp
er te
ns iv
e st
at us
; b lo
od p
re ss
ur e
Po si
tiv e:
h yp
er te
ns iv
e st
at us
(z =
0 .0
5;
95 %
C I:
0. 01
, 0 .0
9) , n
ig ht
tim e
am bu
la to
ry
bl oo
d pr
es su
re (z
= 0
.1 5;
9 5%
C I:
0. 04
, 0.
19 )
N ul
l: bl
oo d
pr es
su re
(s ys
to lic
: z =
0 .0
1; 9
5%
C I:
−0 .0
1, 0
.0 3)
(d ia
st ol
ic : z
= 0
.2 ; 9
5% C
I: −0
.0 1,
0 .0
3)
Ko ro
us , K
M .,
et a
l (2
01 7)
C or
tis ol
16 Ex
pe rim
en ta
l: 25
% (n
= 4
) N
on ex
pe rim
en ta
l: 75
%
(n =
1 2)
C ur
re nt
c or
tis ol
, d iu
rn al
c or
tis ol
, c or
tis ol
re ac
tiv ity
, av
er ag
e co
rt is
ol Po
si tiv
e (r
= .0
40 ; 9
5% C
I: 0.
03 8‐
0. 11
7)
Le w
is , T
T. , e
t a l
(2 01
4) C
ar di
ov as
cu la
r he
al th
38 26
c ro
ss ‐s
ec tio
na l
12 lo
ng itu
di na
l/c oh
or t o
r un
sp ec
ifi ed
Li fe
st yl
e fa
ct or
s (e
g, s
m ok
in g,
p hy
si ca
l a ct
iv ity
, a lc
oh ol
in
ta ke
); hy
pe rt
en si
on a
nd b
lo od
p re
ss ur
e; b
io m
ea s‐
ur es
(e g,
o be
si ty
, C ‐r
ea ct
iv e
pr ot
ei n,
c or
on ar
y ar
te ry
oc
cl us
io n)
C on
di tio
na l:
lif es
ty le
fa ct
or s;
re st
in g
bl oo
d pr
es su
re /h
yp er
te ns
io n;
b io
m ea
su re
s Po
si tiv
e: a
m bu
la to
ry b
lo od
p re
ss ur
e
Lo ck
w oo
d, K
G .,
et a
l (2
01 8)
C ar
di ov
as cu
la r
he al
th 21
C ro
ss ‐s
ec tio
na l,
lo ng
itu di
na l,
ex pe
rim en
ta l d
es ig
ns *
C ar
di ov
as cu
la r r
ea ct
iv ity
(i e,
b lo
od p
re ss
ur e,
h ea
rt
ra te
, h ea
rt ra
te v
ar ia
bi lit
y, to
ta l p
er ip
he ra
l r es
is ta
nc e,
pr
ee je
ct io
n pe
rio d,
c ar
di ac
o ut
pu t);
H PA
a xi
s (ie
, di
ur na
l c or
tis ol
s lo
pe );
im m
un e
(ie , C
‐r ea
ct iv
e pr
ot ei
n,
in te
rle uk
in , m
on oc
yt e
ch em
oa tt
ra ct
an t p
ro te
in ,
tu m
or n
ec ro
si s
fa ct
or , i
nt er
fe ro
n) , n
eu ra
l a ct
iv ity
G en
er al
ly p
os iti
ve a
ss oc
ia tio
ns fo
r C V
D
re ac
tiv ity
, f la
tt er
d iu
rn al
c or
tis ol
s lo
pe s,
sy
st em
ic in
fla m
m at
io n,
a nd
n eu
ra l a
ct iv
ity
in th
e br
ai n
re gi
on s
co ns
is te
nt w
ith e
xp o‐
su re
to p
sy ch
os oc
ia l s
tr es
s
TA B
LE 1
(C
on tin
ue d)
(C on
tin ue
s)
14756773, 2019, S2, D ow
nloaded from https://onlinelibrary.w
iley.com /doi/10.1111/1475-6773.13222 by Jasm
ine Sm ith - Saint T
hom as U
niversity , W iley O
nline L ibrary on [01/07/2024]. See the T
erm s and C
onditions (https://onlinelibrary.w iley.com
/term s-and-conditions) on W
iley O nline L
ibrary for rules of use; O A
articles are governed by the applicable C reative C
om m
ons L icense
1380 | Health Services Research
WILLIAMS et AL.
D is
cr im
in at
io n
st ud
y Fo
cu s
N o.
p ap
er s
in cl
ud ed
St ud
y de
si gn
H ea
lth o
ut co
m es
Fi nd
in gs
H ea
lth b
eh av
io rs
D es
al u,
J M
., et
a l
(2 01
9) A
lc oh
ol u
se 27
C ro
ss ‐s
ec tio
na l:
85 %
Lo ng
itu di
na l:
15 %
C on
su m
pt io
n; b
in ge
/h ea
vy d
rin ki
ng ; a
t‐ ris
k dr
in k‐
in g;
a lc
oh ol
u se
d is
or de
rs (A
U D
); ne
ga tiv
e dr
in ki
ng
co ns
eq ue
nc es
Po si
tiv e:
c on
su m
pt io
n (r
= .1
2; 9
5% C
I: 0.
08 , 0
.1 7)
; b in
ge d
rin ki
ng (r
= .0
6; 9
5%
C I:
0. 02
, 0 .1
0) ; a
t‐ ris
k dr
in ki
ng (r
= .1
4;
95 %
C I:
0. 06
, 0 .2
3) ; n
eg at
iv e
dr in
ki ng
co
ns eq
ue nc
es (r
= .2
5; 9
5% C
I: 0.
09 , 0
.4 2)
N ul
l: AU
D (r
= .1
0; 9
5% C
I: −0
.0 1,
0 .2
0)
G ilb
er t,
PA .,
et a
l (2
01 6)
A lc
oh ol
u se
97 C
ro ss
‐s ec
tio na
l: 80
% Lo
ng itu
di na
l: 18
% Ex
pe rim
en ta
l: 2%
A lc
oh ol
‐r el
at ed
o ut
co m
es (n
um be
r o f d
rin ks
p er
m
on th
, p as
t 2 w
ee ks
o f b
in ge
d rin
ki ng
, p as
t w ee
k/
30 d
ay s/
y ea
r o f a
lc oh
ol u
se , p
as t 2
m on
th s
of
w ee
ke nd
d rin
ki ng
, d rin
ki ng
‐r el
at ed
p ro
bl em
s, p
as t‐
ye ar
a lc
oh ol
u se
, p as
t 3 0/
90 d
ay s
of b
in ge
d rin
ki ng
, dr
in ki
ng d
eb ut
, a lc
oh ol
u se
d is
or de
r, lif
et im
e al
co ho
l us
e, h
az ar
do us
d rin
ki ng
, c ur
re nt
a lc
oh ol
u se
, a lc
oh ol
us
e di
so rd
er )
Po si
tiv e:
4 5%
(n =
1 4)
N ul
l: 32
% (n
= 1
0) C
on di
tio na
l: 23
% (n
= 7
)
Sl op
en , N
., et
a l
(2 01
6) Sl
ee p
17 Lo
ng itu
di na
l: 29
% (n
= 5
[1
da ily
d ia
ry ])
C ro
ss ‐s
ec tio
na l:
71 %
(n =
1 2)
Po or
s le
ep o
ut co
m es
(i e,
d ur
at io
n, e
ff ic
ie nc
y, s
le ep
la ‐
te nc
y, w
ak e
af te
r s le
ep o
ns et
, R EM
s le
ep , l
ig ht
s le
ep ,
st ag
e 3
an d
4 sl
ee p)
Po si
tiv e:
s le
ep d
iff ic
ul tie
s or
in so
m ni
a (1
6/ 16
; 1 00
% );
po or
s le
ep q
ua lit
y (7
/7 ;
10 0%
)
H ea
lth c
ar e
ut ili
za tio
n
Be n,
J .,
et a
l ( 20
17 )
H ea
lth c
ar e
ut ili
za tio
n Re
vi ew
: 8 3
M et
a‐ an
al ‐
ys is
: 5 9
C ro
ss ‐s
ec tio
na l:
96 .4
% Lo
ng itu
di na
l: 3.
6% H
ea lth
s er
vi ce
e xp
er ie
nc es
[H SE
] ( ie
, c om
m un
ic at
io n;
sa
tis fa
ct io
n/ pe
rc ei
ve d
qu al
ity o
f c ar
e; tr
us t;
so m
e co
m bi
na tio
n of
th es
e) H
ea lth
s er
vi ce
u til
iz at
io n
[H SU
] ( ie
, h av
in g
ex am
in a‐
tio ns
, s cr
ee ni
ng s,
c he
ck s,
e tc
; u pt
ak e
of tr
ea tm
en ts
, m
ed ic
at io
ns , v
ac ci
na tio
ns ; h
os pi
ta l v
is its
a nd
a dm
is ‐
si on
s to
E Rs
; d el
ay in
g he
al th
c ar
e; in
su ra
nc e
co ve
r‐ ag
e; s
om e
co m
bi na
tio n
of th
es e)
H SE
: n eg
at iv
e H
SU : c
on di
tio na
l o n
ou tc
om e,
n eg
at iv
el y
as so
ci at
ed w
ith u
pt ak
e of
tr ea
tm en
ts a
nd
se ek
in g
he al
th c
ar e;
n o
as so
ci at
io n
fo r t
he
ot he
r m ea
su re
s
G as
to n,
G B.
, e t a
l (2
01 3)
H IV
tr ea
tm en
t ad
he re
nc e
16 Q
ua lit
at iv
e A
nt ire
tr ov
ira l m
ed ic
at io
n or
m ed
ic al
s el
f‐ ca
re
ad he
re nc
e D
is cr
im in
at io
n se
rv es
a s
a ba
rr ie
r t o
m ed
i‐ ca
l c ar
e, p
oo re
r s el
f‐ ra
te d
he al
th , l
ow er
se
lf‐ ca
re a
dh er
en ce
, l es
s sa
tis fa
ct io
n w
ith
ca re
, g re
at er
d ep
re ss
iv e
sy m
pt om
s
TA B
LE 1
(C
on tin
ue d)
(C on
tin ue
s)
14756773, 2019, S2, D ow
nloaded from https://onlinelibrary.w
iley.com /doi/10.1111/1475-6773.13222 by Jasm
ine Sm ith - Saint T
hom as U
niversity , W iley O
nline L ibrary on [01/07/2024]. See the T
erm s and C
onditions (https://onlinelibrary.w iley.com
/term s-and-conditions) on W
iley O nline L
ibrary for rules of use; O A
articles are governed by the applicable C reative C
om m
ons L icense
| 1381 Health Services Research
WILLIAMS et AL.
D is
cr im
in at
io n
st ud
y Fo
cu s
N o.
p ap
er s
in cl
ud ed
St ud
y de
si gn
H ea
lth o
ut co
m es
Fi nd
in gs
C hi
ld re
n an
d ad
ol es
ce nt
s
A lh
us en
, J L.
, e t a
l (2
01 6)
M at
er na
l a nd
c hi
ld
he al
th 15
Q ua
lit at
iv e:
2 7%
(n =
4 )
Q ua
nt ita
tiv e:
7 3%
(n =
1 1)
Pr et
er m
b irt
h; lo
w b
irt h
w ei
gh t;
sm al
l‐f or
‐g es
ta tio
na l‐
ag e
ne w
bo rn
; a cc
es s
to a
nd q
ua lit
y of
p re
na ta
l c ar
e Pr
et er
m b
irt h
(q ua
nt s
tu di
es : 5
): 3/
5 nu
ll;
2/ 5
po si
tiv e
Lo w
b irt
h w
ei gh
t ( qu
an t s
tu di
es : 3
): 2/
3 po
si tiv
e; 1
/3 n
ul l
Sm al
l‐f or
‐g es
ta tio
na l‐a
ge : p
os iti
ve In
iti at
io n
of p
re na
ta l c
ar e
(q ua
nt s
tu di
es :1
): nu
ll
Be nn
er A
D . e
t a l
(2 01
8) So
ci oe
m ot
io na
l, ac
ad em
ic , a
nd
be ha
vi or
al h
ea lth
21 4
C ro
ss ‐s
ec tio
na l
Lo ng
itu di
na l*
So ci
oe m
ot io
na l w
el l‐b
ei ng
(d ep
re ss
io n,
in te
rn al
iz in
g sy
m pt
om s,
p os
iti ve
w el
l‐b ei
ng , s
el f‐
es te
em );
ac a‐
de m
ic (a
ch ie
ve m
en t,
sc ho
ol e
ng ag
em en
t, m
ot iv
at io
n) ;
be ha
vi or
al (e
xt er
na liz
in g
be ha
vi or
s, ri
sk y
se x
be ha
v‐ io
rs , s
ub st
an ce
u se
, d ev
ia nt
p ee
r a ff
ili at
io ns
)
Ra ci
al d
is cr
im in
at io
n w
as p
os iti
ve ly
a s‐
so ci
at ed
w ith
d ep
re ss
io n,
in te
rn al
iz in
g sy
m pt
om s,
e xt
er na
liz in
g be
ha vi
or s,
ri sk
y se
x be
ha vi
or s,
s ub
st an
ce u
se , d
ev ia
nt
pe er
a ff
ili at
io ns
a nd
n eg
at iv
el y
as so
ci at
ed
w ith
s el
f‐ es
te em
, a ca
de m
ic a
ch ie
ve m
en t,
sc ho
ol e
ng ag
em en
t, ac
ad em
ic m
ot iv
at io
n
H ea
rd G
ar ris
N J
et a
l (2
01 8)
C hi
ld h
ea lth
(i nf
an t
he al
th o
ut co
m es
, m
en ta
l h ea
lth ,
so ci
oe m
ot io
na l
he al
th , h
ea lth
c ar
e ut
ili za
tio n,
p hy
si ca
l he
al th
, c og
ni tiv
e de
ve lo
pm en
t, an
d yo
ut h
he al
th )
30 C
as e‐
co nt
ro l (
10 %
), cr
os s‐
se c‐
tio na
l ( 27
% ),
an d
lo ng
itu di
na l
(5 3%
)
In fa
nt h
ea lth
o ut
co m
es (p
re te
rm b
irt h,
c or
tis ol
re ac
tiv ‐
ity , b
irt hw
ei gh
t); m
en ta
l h ea
lth (d
ep re
ss iv
e sy
m p‐
to m
s, a
nx ie
ty , s
ub st
an ce
u se
, w el
l‐b ei
ng , a
nx ie
ty );
so ci
oe m
ot io
na l h
ea lth
(e xt
er na
liz in
g an
d in
te rn
al iz
in g
be ha
vi or
, s oc
io em
ot io
na l d
iff ic
ul tie
s, s
el f‐
es te
em ,
po si
tiv e
be ha
vi or
); he
al th
c ar
e ut
ili za
tio n
(fr eq
ue nc
y of
s ic
k ch
ild v
is its
); ph
ys ic
al h
ea lth
(B M
I, ge
ne ra
l c hi
ld
ill ne
ss , w
ei gh
t f or
a ge
); co
gn iti
ve d
ev el
op m
en t (
sp at
ia l
ab ili
ty );
yo ut
h he
al th
o ut
co m
es (d
ep re
ss iv
e)
C ar
eg iv
er ra
ci al
d is
cr im
in at
io n
is a
ss oc
ia te
d w
ith p
re te
rm b
irt h
in 4
/7 s
tu di
es , c
or tis
ol
re ac
tiv ity
in 1
/1 s
tu dy
, a nd
b irt
hw ei
gh t
in 6
/9 s
tu di
es o
bs er
vi ng
c hi
ld o
ut co
m es
. W
ith in
p os
tb irt
h, c
ar eg
iv er
p at
hw ay
: c ar
‐ eg
iv er
ra ci
al d
is cr
im in
at io
n is
a ss
oc ia
te d
w ith
d ep
re ss
iv e
sy m
pt om
s in
1 /7
s tu
di es
, an
xi et
y in
1 /3
, s ub
st an
ce u
se in
1 /2
, w
el l‐b
ei ng
in 1
/1 , d
ep re
ss iv
e sy
m pt
om s
in 1
/7 , e
xt er
na liz
in g
in 7
/1 0,
in te
rn al
iz in
g be
ha vi
or in
4 /7
, s oc
io em
ot io
na l d
iff ic
ul ‐
tie s
in 2
/2 , s
el f‐
es te
em in
1 /1
, p os
iti ve
b e‐
ha vi
or in
1 /4
, f re
qu en
cy o
f s ic
k ch
ild v
is its
in
1 /2
, B M
I i n
1/ 1,
g en
er al
c hi
ld il
ln es
s in
1 /2
, w ei
gh t f
or a
ge in
1 /1
, a nd
s pa
tia l
co gn
iti ve
a bi
lit y
in 1
/1 in
c hi
ld o
ut co
m es
; w
ith in
p os
tb irt
h, o
th er
p at
hw ay
: c ar
eg iv
er
ra ci
al d
is cr
im in
at io
n w
as a
ss oc
ia te
d w
ith
de pr
es si
ve s
ym pt
om s
in 1
/2 s
tu di
es in
ch
ild o
ut co
m es
TA B
LE 1
(C
on tin
ue d)
(C on
tin ue
s)
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nloaded from https://onlinelibrary.w
iley.com /doi/10.1111/1475-6773.13222 by Jasm
ine Sm ith - Saint T
hom as U
niversity , W iley O
nline L ibrary on [01/07/2024]. See the T
erm s and C
onditions (https://onlinelibrary.w iley.com
/term s-and-conditions) on W
iley O nline L
ibrary for rules of use; O A
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om m
ons L icense
1382 | Health Services Research
WILLIAMS et AL.
D is
cr im
in at
io n
st ud
y Fo
cu s
N o.
p ap
er s
in cl
ud ed
St ud
y de
si gn
H ea
lth o
ut co
m es
Fi nd
in gs
Pr ie
st N
. e t a
l ( 20
13 )
M en
ta l a
nd p
hy si
ca l
he al
th (n
eg a‐
tiv e
an d
po si
tiv e
m en
ta l h
ea lth
, ne
ga tiv
e an
d po
si ‐
tiv e
ge ne
ra l h
ea lth
, ph
ys ic
al h
ea lth
, ne
ga tiv
e an
d po
si ‐
tiv e
pr eg
na nc
y,
be ha
vi or
p ro
bl em
s,
w el
l‐b ei
ng , h
ea lth
‐ re
la te
d be
ha v‐
io rs
, h ea
lth c
ar e
ut ili
za tio
n)
12 1
2% C
as e‐
co nt
ro l,
78 %
C
ro ss
‐s ec
tio na
l, an
d 20
%
lo ng
itu di
na l
N eg
at iv
e m
en ta
l h ea
lth (a
nx ie
ty , d
ep re
ss io
n, d
is tr
es s,
ho
pe le
ss ne
ss , l
on el
in es
s, n
eg at
iv e
se lf‐
es te
em ,
po st
tr au
m at
ic s
tr es
s, p
sy ch
ol og
ic al
d is
tr es
s, s
oc ia
l an
d em
ot io
na l d
iff ic
ul tie
s, s
om at
ic s
ym pt
om s,
s tr
es s,
su
ic id
e, m
en ta
l h ea
lth p
ro bl
em s)
; p os
iti ve
m en
ta l
he al
th (e
m ot
io na
l a dj
us tm
en t,
ps yc
ho lo
gi ca
l a dj
us t‐
m en
t, ps
yc ho
lo gi
ca l a
da pt
io n,
re si
lie nc
e, s
el f‐
es te
em ,
se lf‐
w or
th , s
oc ia
l a nd
a da
pt iv
e fu
nc tio
ni ng
); ph
ys ic
al
he al
th (b
lo od
p re
ss ur
e, c
hi ld
ho od
il ln
es se
s, c
om ‐
m on
c hi
ld ho
od il
ln es
se s,
in su
lin re
si st
an ce
, o be
si ty
, ph
ys ic
al s
ym pt
om s)
; g en
er al
h ea
lth ; n
eg at
iv e
ge ne
ra l
he al
th (f
ee lin
g un
ha pp
y, fe
el in
g un
he al
th y,
h ea
lth
pr ob
le m
s) ; p
os iti
ve g
en er
al h
ea lth
(s el
f‐ ra
te d
he al
th );
w el
l‐b ei
ng (g
en er
al h
ea lth
, H rQ
oL , l
ife s
at is
fa ct
io n,
w
el l‐b
ei ng
); ne
ga tiv
e pr
eg na
nc y
(L BW
, p re
te rm
b irt
h,
V LB
W );
po si
tiv e
pr eg
na nc
y (b
irt h
w ei
gh t,
ge st
at io
na l
ag e)
; b eh
av io
r p ro
bl em
s (A
D H
D , a
gg re
ss io
n, b
eh av
io r
pr ob
le m
s, c
on du
ct p
ro bl
em s,
d el
in qu
en t b
eh av
‐ io
r, de
vi an
ce , e
m ot
io na
l a nd
b eh
av io
ra l p
ro bl
em s,
ex
te rn
al iz
in g,
in te
rn al
iz in
g, p
ro bl
em b
eh av
io r;
he al
th ‐
re la
te d
be ha
vi or
(a lc
oh ol
, d ru
g us
e, s
m ok
in g)
; h ea
lth
ca re
u til
iz at
io n
(a cc
es s
an d
co st
)
O f t
he 1
21 s
tu di
es a
nd 4
61 a
ss oc
ia tio
ns ,
46 %
o f a
ss oc
ia tio
ns w
er e
ne ga
tiv el
y as
so ci
at ed
w ith
re po
rt ed
ra ci
al d
is cr
im i‐
na tio
n, 1
8% w
er e
po si
tiv e
an d
3% w
er e
co nd
iti on
al . 7
6% o
f t he
a ss
oc ia
tio ns
b e‐
tw ee
n ra
ci al
d is
cr im
in at
io n
an d
ne ga
tiv e
m en
ta l h
ea lth
o ut
co m
es w
er e
po si
tiv e.
62
% o
f t he
a ss
oc ia
tio ns
b et
w ee
n ra
ci al
di
sc rim
in at
io n
an d
ne ga
tiv e
m en
ta l h
ea lth
ou
tc om
es w
er e
ne ga
tiv e.
6 9%
o f t
he a
ss o‐
ci at
io ns
b et
w ee
n ra
ci al
d is
cr im
in at
io n
an d
be ha
vi or
p ro
bl em
s/ de
lin qu
en t b
eh av
io rs
w
er e
po si
tiv e.
5 1%
o f t
he a
ss oc
ia tio
ns b
e‐ tw
ee n
ra ci
al d
is cr
im in
at io
n an
d he
al th
‐r e‐
la te
d be
ha vi
or s
w er
e po
si tiv
e. 4
5% o
f t he
as
so ci
at io
ns b
et w
ee n
ra ci
al d
is cr
im in
at io
n an
d w
el l‐b
ei ng
/l ife
s at
is fa
ct io
n/ qu
al ity
o f
lif e
ou tc
om es
w er
e ne
ga tiv
e an
d 50
% w
as
un re
la te
d. 7
9% o
f t he
a ss
oc ia
tio ns
b e‐
tw ee
n ra
ci al
d is
cr im
in at
io n
an d
ne ga
tiv e
pr eg
na nc
y/ bi
rt h
ou tc
om es
w er
e po
si tiv
e.
67 %
o f t
he a
ss oc
ia tio
ns b
et w
ee n
ra ci
al
di sc
rim in
at io
n an
d ph
ys ic
al h
ea lth
h ad
no
s ig
ni fic
an t a
ss oc
ia tio
ns . A
dd iti
on al
ly ,
m en
ta l h
ea lth
w as
th e
m os
t s tu
di ed
a s‐
so ci
at io
n am
on g
th e
12 1
st ud
ie s
an d
46 1
re la
tio ns
hi ps
(5 1%
o f a
ss oc
ia tio
ns w
er e
m en
ta l h
ea lth
‐r el
at ed
)
*S tu
dy ty
pe b
re ak
do w
n w
as n
ot s
pe ci
fie d.
TA B
LE 1
(C
on tin
ue d)
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nloaded from https://onlinelibrary.w
iley.com /doi/10.1111/1475-6773.13222 by Jasm
ine Sm ith - Saint T
hom as U
niversity , W iley O
nline L ibrary on [01/07/2024]. See the T
erm s and C
onditions (https://onlinelibrary.w iley.com
/term s-and-conditions) on W
iley O nline L
ibrary for rules of use; O A
articles are governed by the applicable C reative C
om m
ons L icense
| 1383 Health Services Research
WILLIAMS et AL.
4.1 | Discrimination and mental health
A 2015 meta‐analysis by Paradies and colleagues16 found over 300 articles on racial discrimination and health published through 2013, with the association between discrimination and mental health stronger than for physical health. Although 8 out of every 10 stud‐ ies came from the United States, there were publications from 19 other countries. Discrimination was significantly associated with poorer mental health outcomes (eg, depression, anxiety, psycho‐ logical stress, r = −.23) and positive mental health outcomes (eg, self‐esteem, life satisfaction, control, well‐being, r = −.13). The meta‐ analysis found that the effect sizes for the association between perceived discrimination and mental health were stronger in cross‐ sectional studies than in longitudinal ones and in nonrepresentative samples than in representative ones.
A meta‐analysis of 51 studies in Europe highlights growing in‐ ternational evidence. Across diverse ethnic populations, positive associations were found between ethnic discrimination and emo‐ tional distress, as well as inverse associations with positive markers of well‐being, such as self‐esteem and self‐efficacy.20 Several recent reviews continue to document an inverse association between dis‐ crimination and good mental health.21‐27 For example, a 2014 review reported the results of two meta‐analyses focused on the association between discrimination and well‐being.28 Discrimination, in the first meta‐analysis, was associated with poorer well‐being (self‐esteem, depressive and anxiety symptoms, psychological distress, and life satisfaction), with the association being somewhat weaker for posi‐ tive outcomes than negative ones. The observed associations (effect sizes) were larger for disadvantaged groups compared to advantaged groups (eg, women vs men) and for children than for adults. They were also evident in both cross‐sectional and longitudinal analyses. In the second meta‐analysis, the researchers examined experimental data for studies relating the manipulation of discrimination to indi‐ cators of well‐being. The study found a significant negative effect (d = −0.25) of multiple exposures to discrimination on well‐being. A single event of discrimination was not adversely related to well‐ being. Research also indicates that exposure to discrimination can ad‐ versely affect the personality characteristics of adults. Longitudinal analyses in two national studies, the Health and Retirement Survey and the Midlife in the United States Study (MIDUS), found that in‐ cident discrimination was associated with increases in neuroticism (negative emotions) and declines in agreeableness (trusting) and in conscientiousness (organization and discipline).29
One review documented that in addition to discrimination being positively associated with measures of depression, anxiety symp‐ toms, and psychological distress, it is also associated with increased risk of defined psychiatric disorders.18 For example, in the National Study of American Life (NSAL), among African American and Caribbean Black adults 55 years and older, both racial and nonra‐ cial chronic Everyday Discrimination was positively associated with increased risk of any lifetime (LT) disorder, as well as LT mood and anxiety disorders.30 It was also associated with an increased risk of depressive symptoms and serious psychological distress. Similarly,
in the National Latino and Asian American Study (NLAAS), Everyday Discrimination was associated with an increased risk of psychiatric disorders, but the association was stronger among Mexicans than for Puerto Ricans.31 In the same study, Everyday Discrimination was associated, in multivariate models, with increased odds of any DSM‐ IV disorder (odds ratio [OR] = 1.90), depressive disorder (OR = 1.72), and anxiety disorder (OR = 2.24) among Asian Americans.32 Another review documented a positive association between discrimination and PTSD or other indicators of trauma in 70 percent of the associ‐ ations examined.33
Research also reveals that the accumulation of experiences of discrimination over time is associated with an increased risk of men‐ tal health problems. For example, in the Study of Women Across the Nation (SWAN), the levels of Everyday Discrimination were assessed six times over 10 years.34 It found that women who experienced the highest accumulation of experiences of discrimination over time, domains, and attributes (race/ethnicity, sex, or other) reported the highest levels of depressive symptoms. This pattern was evident for all women (black, Chinese, Hispanic, and white), regardless of their race or ethnic group. Similarly, a study in the United Kingdom ex‐ amined the cumulative, longitudinal effects of racial discrimination on mental health of ethnic minorities.35 The study found evidence of a dose‐response relationship between the cumulative discrimi‐ nation measure (number of experiences and number of time points exposed) and a scale of nonspecific psychological distress.
Most of the early studies of discrimination were cross‐sectional. In addition, the extent to which observed associations between dis‐ crimination and mental health outcomes were due to unmeasured psychological factors remained unclear. These concerns have been addressed in recent research.18 Although the majority of studies of discrimination and health are still cross‐sectional, there are a grow‐ ing number of prospective studies that link changes over time in discrimination to increases in symptoms of distress and depression. One review of 25 daily diary, longitudinal studies found that over 90 percent of the time, discriminatory events on a given day were as‐ sociated with increased symptoms of distress.36 A few studies have also documented that the association between discrimination and mental health remains robust after adjustment for potential psycho‐ logical confounders such as neuroticism, social desirability, hostility, and negative affect.18
4.2 | Discrimination and physical health
In the Paradies meta‐analysis model, racial discrimination was sig‐ nificantly associated with poorer general health (r = −.13) and poorer physical health (r = −.09).16 Research also reveals that discrimina‐ tion is associated with multiple indicators of adverse cardiovascular disease (CVD) outcomes and risk factors of CVD. A 2014 paper37 reviewed the research on self‐reported discrimination and CVD published between 2011 and 2013. It found that most studies fo‐ cused on hypertension, smoking, and other health behaviors, with few studies on cardiovascular endpoints. However, one study docu‐ mented that self‐reported discrimination was associated with more
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nloaded from https://onlinelibrary.w
iley.com /doi/10.1111/1475-6773.13222 by Jasm
ine Sm ith - Saint T
hom as U
niversity , W iley O
nline L ibrary on [01/07/2024]. See the T
erm s and C
onditions (https://onlinelibrary.w iley.com
/term s-and-conditions) on W
iley O nline L
ibrary for rules of use; O A
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1384 | Health Services Research
WILLIAMS et AL.
severe coronary artery obstruction among veterans undergoing car‐ diac catherization, for blacks but not whites.38 A review of discrimi‐ nation and physical health among black women found few significant associations for indicators of CVD, highlighting the need to better understand the conditions under which the stress of discrimination has adverse health effects.39
A 2017 review of 10 longitudinal studies found evidence of a consistent association between self‐reported discrimination and body mass index (BMI), waist circumference, and incidence of obesity.40 The associations between experiences of discrimination and adiposity were predominantly linear, and racial discrimination was also significantly associated with changes in BMI and waist circumference among women, but not men. Nonetheless, racial discrimination was significantly associated with the incidence of obesity overall.
Research has also focused on some of the specific pathways that may link exposure to discrimination to changes in health status. A meta‐analysis of discrimination and cortisol output found a small positive association.41 Another review of 21 studies of discrimina‐ tion and the HPA axis found that discrimination has both positive and negative associations with salivary cortisol.42 An additional review of 21 studies focused on multisystem responses to discrimination and found strong consistent associations between discrimination and CVD and HPA axis reactivity, but less consistent associations for immune responses.43
Another subclinical indicator of heart disease that has been ex‐ amined in relationship to discrimination is intima‐media thickness (IMT). An early study found that discrimination was positively as‐ sociated with IMT.44 Recent analyses of data from the SWAN study assessed everyday discrimination six times over 10 years and as‐ sessed its relationship with intima‐media thickness.45 It found that the average levels of discrimination in years 0, 1, 2, 3, 7, and 10 were associated with higher IMT levels at year 12. The association was significant only for white women and not for black, Hispanic, and Chinese women, even though black and Chinese women reported higher levels of discrimination than whites. There is a need to better understand which indicators of discrimination will be predictive of specific health outcomes, for particular population subgroups.
From the earliest studies of discrimination, there has been an increasing interest in the association between discrimination and blood pressure. A recent comprehensive review and meta‐analysis of the association between self‐reported discrimination and hyper‐ tension identified 44 studies.46 It found a small, significant associ‐ ation between perceived discrimination and hypertension. Larger effect sizes observed were between perceived discrimination and nighttime ambulatory systolic (SBP) and diastolic blood pressure (DBP), especially among blacks. Prior research had found that African Americans are more likely than whites to manifest a blunted blood pressure decline during sleep, a pattern that is predictive of an increased risk for cardiovascular mortality and other outcomes. This review indicated that exposure to discrimination contributes to the decrease in blood pressure dipping during sleep, which results in ele‐ vated levels of nighttime blood pressure among blacks. It is currently
not clear if the association between discrimination and SBP and DBP is independent of its association with obesity. In the SWAN study, exposure to Everyday Discrimination predicted increases in SBP and DBP over 10 years of follow‐up, even after adjusting for known sociodemographic, behavioral, and medical risk factors. However, consistent across multiple racial groups, when a measure of adipos‐ ity (either waist circumference or BMI) was added to the model, the association was no longer significant.47
Several recent studies have examined the association between discrimination and inflammation. Among African Americans in the MIDUS study, experiences of discrimination were associated with increased emotional dysregulation (venting and denial) and with in‐ creased biological dysregulation, as measured by increases in three indicators of inflammation (interleukin‐6, e‐selectin, and c‐reactive protein).48 Another recent study found that lifetime discrimination but not chronic everyday discrimination was associated with in‐ creased risk of four markers of inflammation in multivariate mod‐ els.49 Another recent article on discrimination and inflammation found that the associations varied by gender and the indicator of inflammation.50
These findings highlight the need to better understand how the different types of discrimination combine to affect health.
Recent analyses have also examined discrimination in relation‐ ship to other indicators of biological functioning. Allostatic load (AL) is a measure of multisystem dysregulation. In the MIDUS study, this index sums 24 indicators of risk scores across seven physiological systems.51 Analyses of data from African Americans in the MIDUS study found that after adjusting for demographic factors, SES, med‐ ication use, cigarette smoking, alcohol use, and mental health symp‐ toms, Everyday Discrimination was associated with higher AL scores. Also, attributions of Everyday Discrimination to race were not more strongly linked to AL than attributions linked to other social statuses. Another recent study has shed light on the pathways that might link discrimination to AL.52 In this study, African Americans had higher levels of allostatic load (11 indicators of physiological functioning) and discrimination than their white peers. Discrimination was as‐ sociated with elevated AL scores. However, this association was fully mediated by measures of anger and poor sleep. Another re‐ cent study using national data from the HRS linked higher levels of Everyday Discrimination with lower telomere length for blacks but not whites.53
4.3 | Discrimination and health behaviors
Recent reviews indicate that there is a behavioral pathway linking experiences of discrimination to health, with exposure to discrimina‐ tion predictive of engaging in more high‐risk behaviors and fewer health‐promoting activities. For example, a 2016 systematic review found 97 studies published between 1980 and 2015 that examined the association between discrimination and alcohol use.54 Most studies focused on African Americans and most found positive as‐ sociations between increased experiences of discrimination, alco‐ hol consumption, and other drinking‐related problems. The review
14756773, 2019, S2, D ow
nloaded from https://onlinelibrary.w
iley.com /doi/10.1111/1475-6773.13222 by Jasm
ine Sm ith - Saint T
hom as U
niversity , W iley O
nline L ibrary on [01/07/2024]. See the T
erm s and C
onditions (https://onlinelibrary.w iley.com
/term s-and-conditions) on W
iley O nline L
ibrary for rules of use; O A
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om m
ons L icense
| 1385 Health Services Research
WILLIAMS et AL.
noted that there was considerable variation in quality across the studies and the need for more longitudinal data collection and the use of representative samples. Similarly, a 2019 meta‐analytic re‐ view of 27 studies of African Americans found a positive association between discrimination and alcohol consumption, binge drinking, at‐risk drinking, and negative consequences.55 Discrimination was unrelated to alcohol use disorder. Earlier reviews found that experi‐ ences of discrimination were associated with increased risk of ciga‐ rette smoking and drug use.19,56
A 2016 review found 17 studies that examined the association between discrimination and sleep (sleep duration and quality), and every study found at least one positive association between expo‐ sure to discrimination and poor sleep.57 Most studies were cross‐ sectional in design (12 of 17); however, three were prospective studies, one was a natural experiment, and one utilized a nine‐day diary component.
4.4 | Discrimination and health care
Another pathway linking discrimination to poor health status is the potential of experiences of discrimination to lead to reduced health care‐seeking behaviors and adherence to medical regimens. A re‐ cent review and meta‐analysis of studies of racism and health ser‐ vice utilization identified 83 papers for review and 59 papers for meta‐analysis.58 Major findings included that persons reporting ex‐ periences of racial discrimination had two to three times the odds of being less trusting of health care workers and systems, perceiv‐ ing lower quality of and satisfaction with care, and expressing less satisfaction with patient‐provider communication and relationships. Experiencing racism was also associated with delays in seeking health care and reduced adherence to medical recommendations, although these outcomes were not frequently assessed. Findings related to the use of health services were mixed and mostly not sta‐ tistically significant. The review also noted important methodologi‐ cal limitations in the research. Many of the measures used to assess discrimination were brief (<25 percent of papers used measures with nine or more items) and over 50 percent of the measures used did not specify a timeframe regarding exposure to racism. A review of 16 qualitative studies examined the role of discrimination in adherence to treatment among persons with HIV.59 It was found that exposure to discrimination was associated with less adherence to antiretrovi‐ ral medication, less self‐care, and lower levels of satisfaction with care.
4.5 | Discrimination in children and adolescents
Although much of the early research on discrimination and health focused on adult populations, there has been an increasing atten‐ tion in recent years to the role of discrimination in health outcomes for children and adolescents. A 2013 review identified 121 studies (with 461 outcomes) that examined the association between dis‐ crimination and health among persons 0‐18 years old.60 Indicators of mental health status were the most frequently assessed. Exposure
to discrimination was positively associated with symptoms of anxi‐ ety and depression, aggression, internalizing behavior, externalizing behavior, and conduct problems. Discrimination was also inversely associated with indicators of positive mental health, such as life satisfaction, resilience, self‐esteem, and quality of life. Consistent with the literature on adults, a positive association was found be‐ tween discrimination and poor health practices (alcohol use, drug use, and smoking) in 51 percent of 74 tests. Discrimination was also positively related to poor pregnancy or birth‐related outcomes, such as low birth weight and preterm birth. Research also indicates that adolescents experience discrimination in online contexts. One study, for example, found that after adjustment for age, gender, ethnicity, other adolescent stress, and offline discrimination, online discrimi‐ nation was positively related to depressive symptoms and anxiety symptoms among 14‐ to 18‐year olds.61
A 2018 meta‐analysis of 214 studies examined racial/ethnic dis‐ crimination and adolescent outcomes.62 It found that there were moderate positive associations between discrimination and multi‐ ple indicators of socioemotional distress (eg, depressive symptoms or effects) and internalizing symptoms (eg, anxiety, loneliness, and somatic symptoms). Discrimination was also inversely related to in‐ dicators of positive well‐being (eg, life satisfaction, prosocial behav‐ iors, and self‐control), as well as general self‐esteem and self‐worth. The review also included 73 studies that examined the association between discrimination and academic performance. Small‐to‐mod‐ erate inverse associations were evident between discrimination and school engagement (eg, attendance), motivation (eg, academic efficacy), and achievement (eg, GPA). This review also documented behavioral pathways among adolescents. There were 71 studies assessing the association between discrimination and risky health behaviors. Small‐to‐moderate positive associations were evident for discrimination with substance abuse, externalizing behaviors (eg, delinquency and anger), affiliation with deviant peers, and risky sex‐ ual behaviors (eg, unprotected sex). The analysis also found that for socioemotional distress, associations were stronger for Asian and Latino adolescents compared to African Americans. Another signifi‐ cant moderating effect observed was for the developmental period. Associations with socioemotional distress were stronger in early ad‐ olescence (age 10‐13) than late adolescence, and for academics, they were stronger in mid‐adolescence than early adolescence.
A recent study of Latino adolescents illustrates the complex pathways between discrimination and mental health. Using three waves of data, it found that racial/ethnic discrimination predicted increases in symptoms of depression and anxiety.63 It also found that outward anger expression was a significant mediator, with greater racial/ethnic discrimination associated with more frequent outward anger expression. Anger expression, in turn, was associated with higher levels of anxiety and depression. This study suggests the pos‐ sibility that prevention and intervention efforts around managing anger could reduce at least some of the negative effects of racial discrimination on Latino youths' mental health.
A few studies have also reported that adverse effects of discrimi‐ nation experienced as an adolescent are predictive of physical health
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outcomes in early adulthood. For example, a study of 331 black ad‐ olescents from nine rural counties in Georgia found that youth with high and stable perceived racial discrimination at age 16, 17, and 18 had higher levels of multisystem biological dysregulation as mea‐ sured by stress hormones (cortisol, epinephrine, and norepineph‐ rine), systolic and diastolic blood pressure, inflammation, and weight by age 20.64 A recent review of 30 longitudinal studies found that vicarious discrimination (ie, experiences of discrimination that occur in the life of adults in a child's social network or others with whom the child identify) can adversely affect the health of the target child both prenatally and postbirth.65
4.6 | Discrimination and disparities in health
Most studies of discrimination and health have not examined the contribution that these exposures make to account for racial dispari‐ ties in health. However, a few studies in the United States and in‐ ternationally have documented that perceived discrimination makes an incremental contribution over SES in accounting for racial/ethnic inequities in mental health and self‐reported measures of physical health. This pattern has been evident in community and national studies in the United States, New Zealand, Australia, and South Africa.56
Recent studies provide further evidence of the role of discrimi‐ nation in contributing to racial inequities. One study examined SES trajectories over a 33‐year period and their relationship to discrimi‐ nation and self‐rated health.66 It found that increased SES for whites is associated with lower reported discrimination. In contrast, for blacks and Hispanics, upward mobility is associated with increased exposure to discrimination compared to their socioeconomically stable peers. Importantly, exposure to discrimination explained a large part of the black/white gap in self‐rated health (but not the Hispanic/white gap). A study in the United Kingdom also assessed the role of discrimination in ethnic inequalities in mental health.35 In cross‐sectional and longitudinal analyses, they found that adjusting for socioeconomic disadvantage and racial discrimination eliminated ethnic inequalities in mental health for some ethnic groups in the United Kingdom but not for others.
4.7 | Individual and collective protective and resilient responses
Figure 1 also indicates that targets of discrimination are not passive actors but can respond in individual and collective ways to minimize the negative effects of racism. Lewis and colleagues18 have reviewed the limited evidence pointing to a number of resources that have been shown to cushion at least some of the negative effects of expo‐ sure to discrimination on health. For example, prospective analyses in national studies have shown that religious beliefs and behavior can reduce some of the negative effects of discrimination on health. Other evidence reviewed revealed that there is limited evidence that mindfulness (ie, nonjudgmental attention and awareness) can also reduce the negative effects of discrimination on mental health
problems, as measured by depressive symptoms. Finally, research also finds emotional support from family, friends, and supportive professionals can also buffer the adverse impacts of exposure to dis‐ crimination on health.
There is still much to be learned about the full range of protective factors that can ameliorate the negative effects of discrimination on health and the conditions that maximize the health‐protective ef‐ fects of such resources. Relatedly, we need a serious and sustained program of research that would guide us in identifying the interven‐ tions that enhance civility and respect for stigmatized groups in our society. There is also a serious need for societal interventions to be developed and implemented to reduce and ultimately eliminate so‐ cietal prejudice and discrimination. Such research is currently in its infancy.67 We also need more systematic attention to the extent to which efforts that seek to comprehensively address the social de‐ terminants of health can reduce exposure to racism and its negative consequences.68
5 | DISCUSSION
This review of research on discrimination and health points to many areas that would benefit from further investigation. Prior reviews indicate that methodological limitations that need to be addressed include the overreliance on cross‐sectional studies and refining the measurement approaches to maximize comprehensiveness and ac‐ curacy in the assessment of discrimination.56 This would require greater attention to capturing the critical stressful dimensions of discriminatory experiences, including the severity, chronicity, and duration of these experiences. There is a need to expand assessment to capture discrimination in multiple domains (eg, race, sex, gender, sexual orientation, stigmatized religious status, and SES), and to extend analyses to assess how exposure in more than one domain relate to each other and combine to affect the adverse impact of discrimination on physical and mental health.5 Emerging evidence suggests that utilizing an intersectionality framework that examines associations between discrimination and health, with the simultane‐ ous consideration of multiple social categories, leads to larger as‐ sociations than when only a single social category is considered.69 Given the increasing evidence of the adverse impacts of discrimi‐ nation early in life, there is also growing awareness of the need to better understand how discriminatory experiences emerge and ac‐ cumulate over the life course and combine with other stressful expe‐ riences to affect physical and mental health.70
6 | CONCLUSION
This article has provided a glimpse of the growing empirical evi‐ dence linking self‐reported experiences of discrimination to health. This area of study is only about three decades old. While there is much that we need to learn and important limitations that need to be addressed, the range of health outcomes associated with
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discrimination is impressive, and the incidence of multiple popu‐ lations being affected by discrimination, both domestically and globally, is striking. It is now clear that discrimination is a newly emerging risk factor for a broad range of health outcomes that may make an important contribution to understanding racial and ethnic variations in health and health care utilization. This body of research is a reminder that a broad range of psychosocial factors in homes, neighborhoods, workplaces, and schools can be critical determinants of health, and that improving health and reducing inequities in health will likely require interventions outside of the traditional domains of health policy.
ACKNOWLEDG MENTS
Joint Acknowledgment/Disclosure Statement: Sandra Krumholz for assistance with preparation of the manuscript. Preparation of this manuscript was supported in part by the W.K. Kellogg Foundation.
ORCID
David R. Williams https://orcid.org/0000‐0002‐8654‐6228
Jourdyn A. Lawrence https://orcid.org/0000‐0003‐4162‐9860
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SUPPORTING INFORMATION
Additional supporting information may be found online in the Supporting Information section.
How to cite this article: Williams DR, Lawrence JA, Davis BA, Vu C. Understanding how discrimination can affect health. Health Serv Res. 2019;54:1374–1388. https ://doi. org/10.1111/1475‐6773.13222
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