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American Journal of Public Health | February 2003, Vol 93, No. 2200 | Racial/Ethnic Bias and Health | Peer Reviewed | Williams et al.
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Racial/Ethnic Discrimination and Health: Findings From Community Studies
| David R. Williams, PhD, MPH, Harold W. Neighbors, PhD, and James S. Jackson, PhDThe authors review the avail- able empirical evidence from population-based studies of the association between per- ceptions of racial/ethnic dis- crimination and health. This research indicates that dis- crimination is associated with multiple indicators of poorer physical and, especially, men- tal health status.
However, the extant re- search does not adequately address whether and how ex- posure to discrimination leads to increased risk of disease. Gaps in the literature include limitations linked to measure- ment of discrimination, re- search designs, and inatten- tion to the way in which the association between discrimi- nation and health unfolds over the life course.
Research on stress points to important directions for the future assessment of discrim- ination and the testing of the underlying processes and mechanisms by which dis- crimination can lead to changes in health. (Am J Pub- lic Health. 2003;93:200–208)
THERE IS GROWING SCIENTIFIC interest in examining the extent to which perceptions of racial/ ethnic discrimination are a type of stressful life experience that can adversely affect health.1–5
The stress induced by personal experiences of racial bias is viewed as one mechanism by which racism in the larger soci- ety can affect health.6–8 Here we review the evidence for an asso- ciation between discrimination and health in population-based studies. Gaps in the literature are identified, along with critical next steps for advancing research in this area.
RACIAL BIAS AND HEALTH: THE EVIDENCE
A 1999 review of the litera- ture on discrimination and health identified 15 studies of racial/eth- nic discrimination,1 and a 2000 review of studies restricted to mental health identified 13 stud- ies.2 Our goal here is to update these earlier reviews. We used the key word prejudice to search the MEDLINE database from 1998 to the present and the key- words discrimination, race dis- crimination, ethnic discrimination, social discrimination, and racism to search the PSYCHINFO and SOCIOFILE databases for the same period. We limited our search to population-based empir- ical studies that examined the as- sociation between perceptions of racial/ethnic discrimination and a particular indicator of health. We excluded studies involving college student samples9–11 and studies in
which the outcome measured was an aspect of medical care12,13
or stress.14 We identified a total of 53 studies, 24 of them published between 2000 and the present, reflecting the increasing number of studies in this area.
Table 1 lists the included stud- ies and characterizes the associa- tion between perceived discrimi- nation and health status. A positive association indicates that higher levels of discrimination were associated with higher lev- els of illness/health risk in a mul- tivariate model that included ad- justment for demographic and socioeconomic factors (if avail- able). A negative association indi- cates that higher levels of dis- crimination were associated with lower levels of illness/health risk. A conditional association indi- cates the presence of a positive association but only under cer- tain conditions. No association in- dicates that discrimination was unrelated to health status. We ac- knowledge that, by focusing on published articles, we may over- state the strength of the evi- dence. Multiple articles published as part of a single study, such as the Detroit Area Study,15–18 the National Study of Black Ameri- cans,19–22 and the National Sur- vey of Ethnic Minorities in the United Kingdom,23,24 sometimes focus on different outcomes but involve overlapping health status measures in certain instances.
MENTAL HEALTH
Mental health status was the most common outcome exam-
ined. Of the 53 studies reviewed, 32 included at least one measure of mental health. Scales of non- specific distress were the most common mental health indicators used. Of the 25 associations ex- amined for psychological distress, 20 studies reported a positive as- sociation between discrimination and distress,15,18,20,21,25–39,41 3 re- ported a conditional associa- tion,42–44 and 2 reported no as- sociation.19,40 Six studies examined measures of psycho- logical well-being such as happiness and life satisfac- tion,15,18,20,35,42,45 5 examined self-esteem,25,40,45–47 and 3 fo- cused on perceptions of mastery or control.27,45,48 In the case of each of these mental health indi- cators, all but one study45 re- ported a positive association with discrimination.
Four studies21,23,34,49 examined the relationship between per- ceived discrimination and a diag- nosis of major depression, and 3 revealed a positive association. Other studies focusing on mental health examined generalized anxiety disorder,34 early initia- tion of substance use,50 psy- chosis,23 and anger,50 and all re- ported a positive association with discrimination. None of the men- tal health studies showed a nega- tive association.
PHYSICAL HEALTH
General self-report measures were the most commonly used indicators of physical health sta- tus. Six studies15–17,23,24,51 in- cluded a global self-rated health
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TABLE 1—Studies of Perceived Discrimination and Health
Positive Negative Conditional No Associationa Associationb Associationc Associationd Total
Mental health studies
Well-being 15, 18, 20, 35, 42 45 6
Self-esteem 25, 40, 46, 47 45 5
Control/mastery 27, 48 45 3
Psychological distress 15, 18, 20, 21, 25–39, 41 42–44 19, 40 25
Major depression 23, 34, 49 21 4
Anxiety disorder 34 1
Other mental disorder 23, 50 2
Anger 50 1
Total 38 0 3 6 47
Physical health studies
Self-rated health 15–17, 23, 24, 51 6
Other self-report 15, 16, 20, 23, 37, 51 19, 52 23, 24, 33 11
Blood pressure 52, 55, 56 23, 24, 57, 58, 59 55, 60, 61 11
Other cardiovascular 62 24, 61 3
Mortality 22 1
Very low birthweight 63 64 2
Total 16 0 9 9 34
Health behavior studies
Smoking 26, 65, 66 3
Alcohol 67, 68 2
Total 5 0 0 0 5
Overall total 59 0 12 15 86
Note. Italicized numbers represent the relevant article’s location in the reference list. Totals are the sums of the numbers of articles reporting various types of empirical associations between perceived discrimination and indicators of health status/health risk. Many of the articles reviewed examined multiple outcomes, so the number of associations summarized (86) exceeded the number of articles examined (53). aDefined as more perceived discrimination associated with higher levels of illness/health risk. bDefined as more perceived discrimination associated with lower levels of illness/health risk. cDefined as a positive association but only under some conditions. dDiscrimination unrelated to health status/health risk.
item as an outcome variable, and all reported that discrimination was associated with poorer health status. Eleven studies examined other self-report indicators of health status, including chronic conditions, indicators of disability, and other global ratings of health. Six of these studies revealed a positive relationship with discrim- ination,15,16,20,23,37,51 2 reported a positive association only under some conditions,19,52 and 3 re- ported no association.23,24,33
There has also been consider- able interest in the relationship
between perceptions of discrimi- nation and blood pressure and in the potential for discrimination to account, at least in part, for the elevated prevalence of hyperten- sion among African Ameri- cans.53,54 Eleven studies exam- ined this association, and the findings were complex. A positive association between discrimina- tion and blood pressure was found in 3 studies52,55,56; in an additional 5 studies, the effect was dependent on coping style,57,58 sex or social class,59 or ethnicity.23,24 In 2 studies, reports
of no previous exposure to dis- crimination were associated with elevated blood pressure among at least some respondents,58,59 and 3 studies showed that discrimina- tion was unrelated to blood pres- sure or hypertension.55,60,61
Some studies have also exam- ined other cardiovascular out- comes. One study revealed a pos- itive association between chronic everyday discrimination and the development of atherosclerotic disease (intima-media thickness) in the carotid artery among Black women but not among
White women,62 but in 2 studies discrimination was unrelated to self-reported heart disease.24,61
A range of other outcomes have also been examined. One study reported a positive associa- tion between perceived discrimi- nation and low birthweight only among women with high scores on other risk factors63; in another study, however, these 2 variables were unrelated.64 Results from a national sample showed that dis- crimination was related to ele- vated mortality risks over a 13- year follow-up period among African Americans who had self- blaming as opposed to external attributional orientations.22
Recognizing that health be- haviors may be the pathway through which perceptions of discrimination can affect health, several recent studies have ex- amined cigarette smoking and al- cohol use. Three studies re- vealed a positive association between discrimination and ciga- rette smoking,26,65,66 and 2 oth- ers reported similar associations for alcohol use.67,68 Two studies examined the contributions of discrimination to explaining ra- cial disparities in health. Both showed that, after consideration of socioeconomic status, percep- tions of discrimination made an incremental contribution in ac- counting for Black–White differ- ences in self-reported physical health.15,37
GAPS IN KNOWLEDGE
Generally, discrimination is associated with poor health sta- tus, and the association is strongest in the case of mental health. Although most studies have involved probability sam- ples, there is considerable varia- tion in methodological quality, with virtually every study hav-
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ing at least one serious method- ological limitation such as a small sample size, a limited number of statistical analyses, inadequate controls for potential confounders, inadequate assess- ment of discrimination or health status (or both), and reliance on cross-sectional data (only 3 of the studies included involved prospective data). Nonetheless, the consistency of the finding that discrimination is associated with higher rates of disease is quite robust. However, we do not know the extent to which exposure to perceived discrimi- nation leads to increased risk of disease, the conditions under which this might occur, or the mechanisms and processes that might be involved.
It is also not clear whether there is a dose–response rela- tionship between discrimination and changes in health status. As noted, some studies have re- vealed nonlinear patterns in the association between perceived discrimination and blood pres- sure.1,58,59,69 At present, we do not know the threshold for expo- sure to, appraisal of, or response to the stress of discrimination that is necessary to alter disease processes. It is also not clear whether persistent exposure to perceived discrimination accen- tuates the impact of exposure to the stressor or leads to patterns of habituation, such that the ef- fect of perceived discrimination is minimized.
The coverage of population groups has also been selective. Only 6 studies have focused on children or adolescents,25,41,46,47,50,66
while the vast majority have fo- cused on adults. Most have been based in the United States, but recent studies have included im- migrant groups in Canada,32,44
England,23,24 Ireland,41 the
Netherlands,45,47 and Finland.29
Most US research has focused on the experience of African Ameri- cans, but there has been increas- ing attention to other racial/eth- nic groups. Most of the studies comparing 2 racial groups have been limited to Blacks and Whites.
A RESEARCH AGENDA
Clearly, research on discrimi- nation and health is in its in- fancy. However, the available ev- idence suggests that perceived discrimination is an important though understudied race-related stressor that may adversely affect health. Because perceived dis- crimination represents a type of stressful life experience, there is much that can be learned from the larger stress literature that can inform and structure future research in this area. We con- sider insights related both to measurement of discrimination and to mechanisms and proc- esses by which it can affect health.
MEASURING DISCRIMINATION
One of the critically important issues for future research is to improve the assessment of dis- crimination in health studies.1,53
There is not a consensus in the literature as to the optimal mea- sures to capture exposure to dis- crimination. We found wide vari- ability in how discrimination is assessed, with no approach clearly standing out as superior to others. The extant measures vary considerably in both their length and content. Only a few studies employed scales with multiple items, although some in- cluded elaborate and lengthy scales. Some measures seek to
capture acute experiences of dis- crimination, others capture only chronic experiences, some cap- ture both, and many make no distinction between acute and chronic indicators.
In most studies, participants’ exposure to discrimination is measured at one point in time. In some studies, respondents have been asked to provide a retro- spective report regarding expo- sure to perceived discrimination over their life course, while other studies have involved a 30-day, 1-year, or 3-year time frame.
Comprehensive Coverage: Acute and Chronic Discrimination
The literature on assessment of stress offers important lessons for the study of discriminatory experiences. As is the case with other stressful experiences, dis- crimination is multidimensional, and its assessment should pro- vide comprehensive coverage of all relevant domains. The most commonly assessed types of stressful experiences are life events, chronic stress, and daily hassles, and they all have their analogues among existing mea- sures of discrimination. Life events are discrete, observable stressors. Chronic stressors are ongoing problems that are often role related. “Daily hassles” re- fers to chronic or episodic irrita- tions that are minor.
Major acute experiences of ra- cial bias are the most commonly assessed type of discriminatory experience. We found that few studies have provided psycho- metric data regarding the mea- sures of discrimination used. Many of the studies involving multiple-item scales reported Cronbach α coefficients, but only 6 attempted some type of scale validation such as test–
retest convergence/stability or factor analysis.26,29,39,46,60,65
Many of these studies focused on the 18-item Schedule of Rac- ist Events.26 Psychometric prop- erties have also been reported for other measures.70,71
However, not all psychometric data are necessary for all mea- sures of exposure to discrimina- tion. While a measure of internal reliability is relevant for indices that assess chronic exposure to discrimination, it is not an appro- priate statistic for a checklist of acute experiences of discrimina- tion. As has been argued in the literature on stressful life events, the items included in inventories measuring acute stressful experi- ences are not intended as alterna- tive indicators of a single under- lying construct.72,73 Because the experience of one of these events does not necessarily increase the likelihood of another, internal re- liability should not be expected for such a checklist, and evidence of high internal reliability may suggest that there are problems involving item redundancy.72
The preceding also under- scores the importance of compre- hensive assessment of acute ex- periences of discrimination. Because these experiences are largely independent of each other, failure to include relevant events understates exposure to discrimination and thus underes- timates the association between acute discrimination and health. At the same time, test–retest reli- ability—not for the total checklist of acute experiences of discrimi- nation but for the specific stress- ors themselves—is appropriate in the evaluation of acute measures of perceived discrimination.
In the general literature on stress, chronic stressors are stronger predictors of onset and course of illness than are acute
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life events74; they are challeng- ing to measure, however, and few studies have comprehen- sively assessed them and exam- ined their effects on health, and even fewer have focused on objective health outcomes.75
Conceptually, persistent and re- peated experiences of discrimi- nation are especially relevant in identifying the contribution of discrimination to health condi- tions in which onset and progres- sion are characterized by long periods of time. To date, assess- ment of chronic discrimination has focused on the domains of work and education.71 There is a need to focus beyond the inter- personal conflicts and tensions associated with these contexts and assess chronic stressors, such as persistent noise, air pol- lution, or crowding, that can also be consequences of institutional discrimination.76 In addition, as is the case with the larger litera- ture on chronic stressors, mea- sures of chronic exposure to discrimination need to devote more attention on directly as- sessing duration and frequency of exposure.75
Comprehensive Coverage: Traumas, Nonevents, and Macrostressors
Traumas, nonevents, and macrostressors are other distinc- tive types of stressors77 that point to promising areas of expansion for comprehensively assessing discrimination. Traumas are acute or chronic stressors, such as sexual assault or natural disas- ters, that are very serious, over- whelming in impact, and usually regarded as outside of the typical range of human experience. Al- though some experiences of dis- crimination that receive high- profile media coverage are clearly traumatic, we know little
about their prevalence in the general population, and current assessment strategies do not gather the contextual information necessary to identify traumatic experiences.
Macrostressors are large-scale, systems-related stressors such as economic recessions. Highly pub- licized race-related traumatic events may also be macrostres- sors. Such experiences can lead to vicarious discrimination, and the effects of historical trauma in- volving an individual’s racial/eth- nic group may be transmitted across generations.78 Some of the items included in the Cultural Racism and Collective Racism subscales of the Index of Race- Related Stress appear to capture macrostressors.79
Nonevents are desired and ex- pected experiences that fail to occur. Nonevents appear to be especially appropriate to the study of racial bias, because one key characteristic of racism is its ability to produce blocked oppor- tunity.80(p99–128) Some types of nonevents, such as being denied a promotion, are captured by ex- isting measures of acute experi- ences of discrimination, but the literature has yet to characterize exposure to this stressor in a sys- tematic way.
The stress literature indicates that the various types of stress have independent effects on health, such that an evaluation of the full impact of stress re- quires inclusion of all relevant classes of stressors.77,81 It is thus likely that, as a result of the liter- ature’s failure to consider the distinct and cumulative impact of multiple dimensions of perceived discrimination, current assess- ments of the strength of the as- sociation between perceived dis- crimination and health represent underestimates.
Comprehensive Coverage: Content
The stress literature has indi- cated that it is crucial for mea- sures of stressors to provide ade- quate representation of all of the stressful experiences occurring in individuals’ lives.74,82 This issue is relevant to the measures of perceived discrimination that have been used to date, espe- cially among population sub- groups such as children, adoles- cents, and the elderly. One strategy that has been used to identify additional stressors is the use of follow-up probes that seek to elicit important stressors that may not have been captured by standard questions.72 A similar approach should be used in stud- ies of acute and chronic mea- sures of discrimination. The data obtained could enable us to iden- tify the extent to which there are experiences of discrimination that are not included in our exist- ing measures.
At the same time, the stress lit- erature also indicates that more items do not necessarily translate into a better measure, because not all stressful experiences are equally likely to affect health. All stressors are not equivalent, with as many as half of the items on inventories of life events having little or no association with health status for most individu- als.72,73 A judicious selection of 30 to 50 events is regarded as adequate to capture exposure to acute stressful experiences.72
Thus, research is needed to iden- tify the specific indicators of dis- crimination that are associated with health status.
Variations in role occupancy can also affect variations in expo- sure to stress, especially in the case of assessment of role-related stressors.72 Among the most prevalent forms of chronic role-
related discrimination is discrimi- nation at work. One measure- ment solution in the area of role- related workplace discrimination and other forms of role-related discrimination is to establish the number of roles occupied by an individual and adjust for role oc- cupancy in assessing the effects of role-related stressors on health status.72
Identifying Relevant Characteristics of Stressors, Appraisals, and Situations
Research reveals that the as- sociation between a stressor and health varies when specific char- acteristics of the stressful experi- ence are taken into account.73
Key aspects of stressful life expe- riences include the domain in which the event occurs, the magnitude of the event, the tem- poral characteristics of the event, and the nature of the re- lationship between the stressor in question and other race- related and non-race-related stressors.74 Thus, more informa- tion about discrimination and its particular context is necessary for determining its impact. Some measures of discrimination at- tempt to assess severity by hav- ing respondents rate their expe- riences according to their stressfulness.26,35 However, this approach has been rejected in the larger stress literature be- cause it fails to separate mea- sures of exposure from mea- sures of reactions to stressors.73
Also, inadequate attention has been given to the temporal char- acteristics and course of particu- lar stressors in general74 and measures of discrimination in particular. Stressors can be char- acterized according to the dura- tion of exposure to the event, du- ration of the appraised threat or demand, and duration of behav-
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ioral, emotional, or physiological responses to the stressor.83 Other temporal characteristics, such as the continuousness or repetitive- ness of the stressor, may also be important.74,84
Certain individual and con- textual factors may increase one’s vulnerability to stressful experiences by accentuating ap- praisal of the stress.74 However, we do not know the characteris- tics of individuals or situations that modify the effects of per- ceived discrimination on health. Beliefs about oneself and the environment are individual fac- tors that might affect appraisals of stress. The salience of racial consciousness and identity might function in this way for race-related stressors.10,11,16,24,85
Similarly, resources such as so- cial support and feelings of con- trol could enhance an individ- ual’s capacity to cope and respond to stressful experiences. Attention should also be given to the long-term consequences of moderating variables. For ex- ample, factors such as disposi- tional optimism could enhance adaptive capacities, while cop- ing styles such as denial, repres- sion, and neuroticism might pro- vide short-term relief but have longer term negative effects on health.
Assessments of characteris- tics of discriminatory experi- ences should include character- istics of the perpetrator. One study of African Americans showed that experiences of dis- crimination were more strongly related to psychological distress when the perpetrator was also Black than when the perpetra- tor was White.38 However, a laboratory-based study revealed that the race of the perpetrator had little impact on partici- pants’ responses.86
Assessing Discrimination Over the Life Course
An important challenge for fu- ture research is to capture expo- sure to experiences of discrimi- nation over the life course. At present, it is not clear whether the effects of exposure to dis- crimination are cumulative. Ex- isting longitudinal analyses have failed to characterize exposure to perceived discrimination throughout the follow-up period. For example, the National Study of Black Americans captured ex- posure to discrimination within the previous 30 days at baseline and used the same window of exposure in subsequent waves.19,22
An important barrier to long- term retrospective reports of dis- crimination is substantial error due to forgetting. Some evidence suggests that the falloff in report- ing stressors occurs at a rate of 5% per month.87 Recent re- search on the structure of autobi- ographical memory reveals that event history calendars can facili- tate reconstruction of past events more completely and accurately and lead to better quality retro- spective reports than traditional questionnaires.88,89 These ap- proaches should be used to cap- ture exposure to discrimination over the life course.
Subjective Nature of Reports Many researchers are con-
cerned about the shared re- sponse biases that can occur when both the measure of stress and measures of health status are based on self-reports. This is es- pecially important in mental health studies in which there is concern about confounding be- tween reports of discrimination and health based on selective re- call as a function of current men- tal health status.73 However, the
available evidence suggests that these fears may not be war- ranted.53 For example, a national longitudinal study of African Americans revealed no associa- tion between baseline measures of major depression or psycho- logical distress and subsequent reports of racial discrimination.21
Several strategies that have been used to improve individu- als’ accuracy in reporting stress- ors should be applied to the study of discrimination as well. These strategies include using cues to memory such as visual representations and reminders of personally salient events, word- ing questions in ways that clearly define the domain of the experi- ence being captured, and using a life events calendar, which helps to identify the onset and resolu- tion of stressful experiences. These efforts have been shown to substantially increase the relia- bility of reports of stressful expe- riences.90 Establishing the accu- racy of reports of perceptions of discrimination is important in correctly estimating the associa- tion between discrimination and health outcomes.
Another strategy for address- ing the potential of bias in obser- vational studies is to include sta- tistical adjustment for potentially confounding factors. Such adjust- ment strengthens the analytic de- sign and increases the likelihood that observed associations be- tween perceived discrimination and health outcomes might re- flect a causal relationship. Most of the studies reviewed included controls for sociodemographic variables, and some controlled for other stressors; however, few adjusted for additional psycho- logical variables. A clear consen- sus has yet to emerge regarding the potential confounding vari- ables that should be included in
such studies. Personality disposi- tions such as neuroticism, social desirability, and negative affect are promising candidates.91
Measurement: Framing the Question
One debate that has emerged in the literature is the extent to which race should be made salient in assessments of discrimi- nation. Williams and col- leagues15–18,34 have adopted an approach that downplays the sa- lience of race and frames expo- sure to discrimination in terms of “unfair treatment.” Once a partic- ular unfair treatment experience has been endorsed, the respon- dent is asked to indicate the source of this unfair treatment and is allowed to select from multiple social status categories, including race and ethnicity. It has been suggested by some that this approach may not truly cap- ture racial discrimination,92 but the current evidence in support of such a view is weak.53
At the same time, approaches to the assessment of discrimina- tion that involve long lists of questions in which a respondent is repeatedly asked whether a particular event occurred “be- cause of your race” can produce demand characteristics that lead to either overreports or underre- ports of exposure. One study of college students showed that the use of discrimination terminology in the wording of questions leads to higher self-reports of both ra- cial and sex discrimination.93
Complex Relationships Among Stressors
Another important issue in the literature is that of gaining an un- derstanding of how multiple types of discrimination relate to each other as well as to other types of stressors. Chronic stress is linked to exacerbation of the
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effects of acute life events, espe- cially when the life domains af- fected by these events are the same as those affected by chronic stress.73 Experience of a particular acute stressor may also change the meaning of other on- going chronic stressors, generate new stressors, or exacerbate ex- isting ongoing strains.72,94
Losing one’s job because of one’s race (acute discrimination) can trigger a chronic stressor such as financial strain, which in turn can exacerbate marital con- flict. This example illustrates that chronic or acute experiences of discrimination may magnify the impact of other non-race-related stressors. Turner and Avison95 at- tempted to address this complex relationship among multiple types of stressors by obtaining detailed information about each reported event in terms of both when it began and when it ended. More generally, research on discrimination needs to con- sider the joint effects of acute and chronic stressors, especially within the same domain.
Studying Individual Events Future research should focus
on studying individual experi- ences of discrimination to pro- vide an understanding of both the causal processes by which these stressors might affect health and the pathways through which they operate, as well as the coping challenges, resources, and vulnerabilities that can play a role in these processes.73 The study of individual events might also enhance our understanding of the specific aspects of discrimi- nation that would affect the strength of its association with health status.
One approach to obtaining rich contextual data on discrimi- nation is use of the Life Events
and Difficulties Schedule,96 a semistructured intensive personal interview that allows for detailed qualitative probes to identify the contextual threat of events, severity levels, and the timing of events in relationship to the onset of health problems. Some evidence suggests that such in- tense interviewing methods are effective in terms of dating events.97 However, this approach is not without its problems.73 It is labor intensive and requires highly trained interviewers, and, more important, the contextual rating of the stressful experience often incorporates important in- formation about stress modifiers into the stress severity rating.
Nonetheless, this approach might yield useful foundational data for future research on dis- crimination. It can shed light on many of our unanswered ques- tions, facilitating identification of traumatic experiences of discrim- ination, the key characteristics of perceived discrimination that are related to changes in health sta- tus, the range of coping re- sponses to discrimination, and the complex ways in which expe- riences of discrimination are re- lated to other stressors.
FROM ASSOCIATIONS TO UNDERLYING PROCESSES
A major challenge in future re- search is to think more carefully about the models by which per- ceived discrimination might ad- versely affect health status, in- cluding focusing more explicit attention on the plausible path- ways by which these effects might occur. One of the most critical needs is for more careful research attention to the specific mechanisms by which percep- tions of discrimination might ad- versely affect health. The litera-
ture on stress and health indi- cates that stressors influence physical illness primarily through causing negative emotional states such as anxiety and depression, which in turn can have direct ef- fects on biological processes or patterns of behavior that affect disease risk.74
It is instructive that mental health has been the most fre- quently studied outcome in the research literature on discrimina- tion and health and that, consis- tently, perceptions of discrimina- tion tend to be associated with poorer mental health status. Re- searchers studying the associa- tion between perceptions of dis- crimination and health can view measures of mental health status as intermediary mechanisms by which perceptions of discrimina- tion might ultimately affect physi- cal disease processes.
Research needs to assess the extent to which reports of dis- crimination and the negative emotional states created by them might lead to health behaviors, such as impaired sleep patterns, decreased physical activity, in- creased substance use, and overeating, that may ultimately affect disease risk. Use of tobacco and alcohol and poor diets have been established as risk factors for multiple chronic illnesses. As noted, some studies have shown that exposure to discrimination is associated with problem drink- ing67,68 and cigarette smoking.65
Experiences of discrimination and the negative affect created by them may also lead to lower levels of compliance with med- ical recommendations.74 This lat- ter mechanism has not yet been explored in the literature.
In studying how individuals confront and adapt to discrimina- tion, it is also important to focus on the potential positive, as well
as negative, consequences. Some stressful life experiences can change people’s perspectives in ways that can improve and en- hance their coping capacity and make them better able to deal with future stressful experiences. A growing literature on trauma- related growth documents that some individuals experience pos- itive changes in their lives as a result of adaptation to traumatic experiences.98
At this early stage of the re- search, we do not understand how exposure to discrimination leads to changes in particular bi- ological responses and health be- haviors. Future research needs to identify the conditions under which particular types of expo- sure affect health. A broad range of health-related outcomes should be used to examine the specificity of underlying proc- esses. Research also needs to identify the specific physiological systems (cardiovascular, neuroen- docrine, immune) that are af- fected by discrimination.
In addition, we are largely un- aware of what may be the cru- cial psychological or biological vulnerability factors and the ex- tent to which the same race- related stressor can produce dif- ferent responses in different individuals. We are equally un- aware of the individual factors, both genetic and psychological, that result in some organ sys- tems being especially vulnerable to the health effects of discrimi- nation. Some evidence suggests, for example, that greater genetic vulnerability to depression is as- sociated with an increased im- pact of stressful life experiences on major depression.73
The model of underlying processes should also guide se- lection of the measure of discrim- ination most appropriate for a
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particular study. The target popu- lation and its characteristics, as well as the research questions used, should guide the selection of the most appropriate measure of discrimination. The optimal measure of a stressor depends on understanding the disease and its course, especially the particular stage of the disease that is under investigation.74
For example, the appropriate measure of discrimination for studying a disease, such as ather- osclerosis, that develops over dec- ades would be different from the measure used to study a new episode of major depression. The relevant measure might differ for research questions focused on un- derstanding onset of disease and research questions seeking to cap- ture progression or course of dis- ease. Thus, the choice of instru- ment and research design should be linked to the particular re- search context. Depending on the question, there may be a need to capture lifetime exposures to stressful experiences as well as the timing of such exposures.
CONCLUSIONS
Race plays a significant role as a determinant of health in the United States. Racial disparities in all-cause and infant mortality are larger now than they were in 1950.99 The persistence of racial inequalities in health must be understood in light of the persistence of racialized social structures that affect health sta- tus in multiple ways.8,100 The re- search reviewed here suggests that the subjective experience of racial bias may be a neglected determinant of health and a contributor to racial disparities in health.
Perceptions of discrimination appear to induce physiological
and psychological arousal, and, as is the case with other psycho- social stressors, systematic expo- sure to experiences of discrimina- tion may have long-term consequences for health. These experiences are part of the social and psychological context in which disease risk emerges and within which effective interven- tions to improve health must be embedded. Although the rigor- ous scientific research that would allow us to evaluate causal direc- tionality in the discrimination– health association is still in the future, the available evidence suggests that there is likely to be a high payoff in pursuing this line of research.
Despite the many inadequa- cies noted in assessment of dis- crimination and the limitations of earlier research, there is sub- stantial consistency of results, especially among the method- ologically strongest studies. Findings are consistent as well with the larger literature on stress and the mechanisms by which potential stressors can af- fect health. It is impressive that perceptions of discrimination tend to be associated with poorer health across a broad range of outcomes and across socially disadvantaged groups in different societies. Nonetheless, virtually all of the studies con- ducted in this field have in- volved limitations with respect to comprehensively assessing discrimination and identifying accumulation of exposures over the life course. The promise of the research findings in this area and the research directions out- lined here suggest an urgent need to systematically assess the extent to which exposure and adaptation to racial/ethnic bias affect the health of various pop- ulation groups.
About the Authors The authors are with the Institute for So- cial Research, University of Michigan, Ann Arbor.
Requests for reprints should be sent to David R. Williams, PhD, MPH, Institute for Social Research, University of Michi- gan, PO Box 1248, Ann Arbor, MI 48106-1248 (e-mail: wildavid@umich. edu).
This article was accepted October 21, 2002.
Contributors All of the authors contributed to the conceptualization of this article. D. R. Williams and H. W. Neighbors analyzed the data, and all of the authors con- tributed to the writing of the article.
Acknowledgments Preparation of this commentary was supported by grant MH 59575 from the National Institute of Mental Health and by the John D. and Catherine T. MacArthur Foundation Research Net- work on Socioeconomic Status and Health.
We wish to thank Scott Wyatt, Carl Hill, Rashid Njai, and Car Nosel for as- sistance with research and manuscript preparation.
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665. Esme Fuller-Thomson, A. Nuru-Jeter, Meredith Minkler, Jack M. Guralnik. 2009. Black—White Disparities in Disability Among Older Americans. Journal of Aging and Health 21:5, 677-698. [Crossref]
666. Haslyn E. R. Hunte, David R. Williams. 2009. The Association Between Perceived Discrimination and Obesity in a Population- Based Multiracial and Multiethnic Adult Sample. American Journal of Public Health 99:7, 1285-1292. [Abstract] [Full Text] [PDF] [PDF Plus]
667. Elliot M. Friedman, David R. Williams, Burton H. Singer, Carol D. Ryff. 2009. Chronic discrimination predicts higher circulating levels of E-selectin in a national sample: The MIDUS study. Brain, Behavior, and Immunity 23:5, 684-692. [Crossref]
668. D. C. Cooper, P. J. Mills, W. A. Bardwell, M. G. Ziegler, J. E. Dimsdale. 2009. The Effects of Ethnic Discrimination and Socioeconomic Status on Endothelin-1 Among Blacks and Whites. American Journal of Hypertension 22:7, 698-704. [Crossref]
669. Kathy Sanders-Phillips. 2009. Racial Discrimination: A Continuum of Violence Exposure for Children of Color. Clinical Child and Family Psychology Review 12:2, 174-195. [Crossref]
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673. Leland K. Ackerson, K. Viswanath. 2009. The Social Context of Interpersonal Communication and Health. Journal of Health Communication 14:sup1, 5-17. [Crossref]
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678. M. Robin DiMatteo, Carolyn B. Murray, Summer L. Williams. 2009. Gender Disparities in Physician-Patient Communication Among African American Patients in Primary Care. Journal of Black Psychology 35:2, 204-227. [Crossref]
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693. Luisa N. Borrell. 2009. Race, Ethnicity, and Self-Reported Hypertension: Analysis of Data From the National Health Interview Survey, 1997–2005. American Journal of Public Health 99:2, 313-319. [Abstract] [Full Text] [PDF] [PDF Plus]
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698. Hyung Chol Yoo, Gilbert C. Gee, David Takeuchi. 2009. Discrimination and health among Asian American immigrants: Disentangling racial from language discrimination. Social Science & Medicine 68:4, 726-732. [Crossref]
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717. Saffron Karlsen. 2008. A Race Equality Foundation Briefing Paper Better Health Briefing 3 Ethnic inequalities in health: the impact of racism. Ethnicity and Inequalities in Health and Social Care 1:2, 58-66. [Crossref]
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735. Lisa B. Spanierman, Euna Oh, V. Paul Poteat, Anita R. Hund, Vetisha L. McClair, Amanda M. Beer, Alexis M. Clarke. 2008. White University Students' Responses to Societal Racism. The Counseling Psychologist 36:6, 839-870. [Crossref]
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742. Tamara A. Baker, Nicole T. Buchanan, Nicole Corson. 2008. Factors Influencing Chronic Pain Intensity in Older Black Women: Examining Depression, Locus of Control, and Physical Health. Journal of Women's Health 17:5, 869-878. [Crossref]
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745. Debra Joy Pérez, Lisa Fortuna, Margarita Alegría. 2008. Prevalence and correlates of everyday discrimination among U.S. Latinos. Journal of Community Psychology 36:4, 421-433. [Crossref]
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751. Rob Whitley, Steve Green. 2008. Psychosocial Stressors and Buffers Affecting Black Women in Montreal. Canadian Journal of Community Mental Health 27:1, 37-48. [Crossref]
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756. Maury Nation. 2008. Concentrated disadvantage in urban neighborhoods: psychopolitical validity as a framework for developing psychology-related solutions. Journal of Community Psychology 36:2, 187-198. [Crossref]
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