Differential Effects of Personal-Level vs Group-Level Racial Discrimination on Health among Black Americans

Discrimination and Tobacco Use Outcomes Among US Adults: Effect Modification by Race/Ethnicity

INTRODUCTION

Racial/ethnic discrimination (hereafter, discrimination) is associated with tobacco use. However, little is known about the relationship between discrimination and dual/polytobacco use and tobacco use disorder (TUD), including how these relationships vary by race/ethnicity.

METHODS

Data on adults 18 and older come from the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III (n = 35,881). Past-year discrimination was measured using the Experiences of Discrimination scale. Past 30-day exclusive, dual, and polytobacco use was measured as the mutually exclusive use of any combination of four types of tobacco products: cigarettes, electronic nicotine delivery systems, other combustibles (i.e., cigars and pipe), and smokeless tobacco. Past-year TUD was defined according to DSM-5 criteria. Associations between discrimination and exclusive, dual, and polytobacco use and discrimination and TUD were estimated using multinomial logistic regression and logistic regression, respectively. Models were stratified by race/ethnicity (i.e., Hispanic, non-Hispanic (NH) White, NH Black, another race/ethnicity) to assess effect modification.

RESULTS

Adults who used tobacco and who had TUD was 24.2% and 19.2%, respectively. More discrimination was associated with higher odds of exclusive, dual, and polytobacco use as well as TUD. Models stratified by race/ethnicity suggest that discrimination was associated with dual/polytobacco use among NH Black adults (OR: 1.05, 95% CI: 1.002-1.11) and NH White adults (OR: 1.18, 95% CI: 1.13-1.22). While more discrimination was associated with TUD among all racial/ethnic groups, the relationship was the strongest for NH White adults.

CONCLUSIONS

Discrimination was associated with more severe tobacco use outcomes among multiple racial/ethnic groups, but associations were the strongest for NH White adults.

Racial disparities in cancer genetic counseling encounters: study protocol for investigating patient-genetic counselor communication in the naturalistic clinical setting using a convergent mixed methods design

BACKGROUND

Despite decades of effort to reduce racial cancer disparities, Black people continue to die at higher rates from cancer than any other U.S. racial group. Because prevention is a key to the cost-effective and long-term control of cancer, the potential for cancer genetic counseling to play a central role in reducing racial cancer disparities is high. However, the benefits of genetic counseling are not equitable across race. Only 2% of genetic counselors self-identify as Black/African American, so most genetic counseling encounters with Black patients are racially discordant. Patients in racially discordant medical interactions tend to have poorer quality patient-provider communication and receive suboptimal clinical recommendations. One major factor that contributes to these healthcare disparities is racial bias. Drawing on findings from prior research, we hypothesize that genetic counselor providers' implicit racial prejudice will be associated negatively with the quality of patient-provider communication, while providers' explicit negative racial stereotypes will be associated negatively with the comprehensiveness of clinical discussions of cancer risk and genetic testing for Black (vs. White) patients.

METHODS

Using a convergent mixed methods research design, we will collect data from at least 15 genetic counseling providers, from two different institutions, and their 220 patients (approximately equal number of Black and White patients per provider) whose appointments are for a hereditary cancer condition. The data sources will include two provider surveys, two patient surveys, video- and/or audio-recordings of genetic counseling encounters, and medical chart reviews. The recorded cancer genetic counseling in-person and telehealth encounters will be analyzed both qualitatively and quantitatively to assess the quality of patient-provider communication and the comprehensiveness of clinical discussion. Those data will be linked to pre- and post-encounter survey data and data from medical chart reviews to test our hypotheses.

DISCUSSION

Findings from this multi-site study will highlight specific aspects of cancer genetic counseling encounters (patient-provider communication and clinical recommendations) that are directly associated with patient-centered outcomes (e.g., satisfaction, trust, genetic testing completion). Patient-provider communication and clinical recommendations are modifiable factors that can be integrated into current genetic counseling training curricula and thus can have immediate impact on genetic counseling training and practice.

Personal- vs. Group-Level Discrimination and Physical and Mental Health Outcomes Among Black Adolescents

BACKGROUND

The negative health consequences of personal experiences of racial discrimination (personal-level discrimination) has been well-documented across developmental stages, including adolescence, in Black individuals. There is also some evidence suggesting perceiving other Black individuals experiencing racial discrimination (group-level discrimination) can protect one's health in Black adults.

METHODS

This study examined the role of personal- and group-level discrimination in Black adolescent health. The study was a secondary analysis of survey data collected from 186 Black adolescents that included reports of discrimination, physical function, anxiety, and depression.

RESULTS

Black adolescents who reported greater, as opposed to lower, personal-level discrimination were more likely to experience poorer physical and mental health outcomes. While group-level discrimination was also associated with physical health outcomes, it was not directly associated with mental health outcomes. Importantly, across all three health outcomes, awareness of group-level discrimination mitigated the negative health consequences of personal-level discrimination. Among adolescents who reported low levels of group-level discrimination, personal-level discrimination was associated negatively with physical function and positively with anxiety and depressive symptoms. Among adolescents who reported high levels of group-level discrimination, there was no association between personal-level discrimination and any of the health outcomes.

DISCUSSION

Consistent with prior research with Black adults, awareness of high group-level discrimination may protect Black adolescents from the negative health consequences of personal-level discrimination. The pattern of the results is also consistent with the literature of the personal-group discrimination discrepancy (PGDD) and psychological wellbeing. Future research should investigate the psychological mechanisms implicated in PGDD (e.g., external attribution of discrimination and intragroup comparison) as potential coping strategies for Black adolescents against the negative health consequences of personal-level discrimination.

Eating to cope: Advancing our understanding of the effects of exposure to racial discrimination on maladaptive eating behaviors

OBJECTIVE

Racial discrimination is a stressor for young Black women that leads to poor health outcomes, including maladaptive eating. This study presents findings on racial discrimination and maladaptive eating behaviors (overeating, LOC eating) using ecological momentary assessment (EMA).

METHODS

Black emerging adult women (N = 27) with overweight or obesity participated in a 14-day EMA study examining exposure to racial discrimination, eating behaviors, and racial identity. Frequencies and chi-square tests were used to characterize the type of racial discrimination experienced and frequency of overeating. Mixed effect ordinal logistic regression models were used to assess the relation between racial discrimination and maladaptive eating. Moderation analysis was conducted by creating interaction terms for discrimination and racial identity variables.

RESULTS

81.5% of participants reported experiencing racial discrimination. Young Black women reporting exposure to racial discrimination were more likely to endorse higher levels of both overeating and LOC eating compared to times when discrimination was not experienced (p < .0001). Racial identity moderated the link between racial discrimination and maladaptive eating (overeating, LOC) such that reporting greater levels of private regard buffered the deleterious effect of racial discrimination. Higher levels of public regard exacerbated the association between racial discrimination and both overeating, and LOC. Higher centrality worsened the relation between racial discrimination and LOC.

CONCLUSION

Young Black women might use maladaptive eating to cope with exposure to racial discrimination, which underscores the importance of examining the link between racism and disordered eating, particularly among Black women submerged in a society that continuously exposes them to racial discrimination.

PUBLIC SIGNIFICANCE

Emerging adult Black women are exposed to racial discrimination daily. In theory, exposure to racial discrimination could contribute to overeating and loss of control eating in this population. Using ecological momentary assessment, to capture experiences and eating behaviors in the moment they occur, this project quantified the magnitude of racial discrimination and how it was associated with maladaptive eating behaviors. Further, it examined ways in which racial identity was linked to this association.

Does Conduct, Oppositional Defiant, and Panic Disorder Symptoms Associate with Suicidal Ideations Among African American Adolescents?

Previous studies suggest that mental illness symptoms among adolescents, such as conduct disorder, oppositional defiant disorder, and panic disorder symptoms often associate with suicidal ideations. Despite this, few studies have examined whether these mental illness symptoms associate with suicidal ideations among African American adolescents. To address these limitations, the current study examined whether conduct disorder, oppositional defiant disorder, and panic disorder symptoms associated with suicidal ideations (N = 261). Using binominal logistic regression, results suggest that conduct disorder symptoms were associated with a higher likelihood of endorsing suicidal ideations than oppositional defiant disorder symptoms. Finally, panic disorder symptoms and gender differences were not associated with suicidal ideations. Preventive efforts and psychotherapy implications are discussed.

Race and Ethnicity and Cardiometabolic Risk Profile: Disparities Across Income and Health Insurance in a National Sample of US Adults

CONTEXT

Income and health insurance are important social determinants of cardiovascular disease (CVD) and may explain much racial/ethnic variation in CVD burden. However, racial/ethnic disparities in cumulative cardiometabolic (CMB) risk profile by insurance type and income level have not been studied on a national scale.

OBJECTIVES

To test the hypothesis that racial/ethnic minorities experience greater CMB burden at each income level and insurance type than non-Hispanic Whites (NHW).

SETTING

This study used nationally representative data from the National Health Interview Survey (NHIS).

DESIGN

Observational (cross-sectional).

PARTICIPANTS

In total, 134661 (weighted N = 197780611) adults, 18 years or older, from the 2013-2017 NHIS.

PRIMARY OUTCOME

CMB risk profile.

INTERVENTION/ANALYSIS

Age-adjusted prevalence of optimal, average, and poor CMB risk profile-defined respectively as self-report of 0, 1-2, and 3 or more risk factors of diabetes, hypertension, obesity, or hypercholesterolemia-was examined for NHW, non-Hispanic Blacks (NHB), and Hispanics. Multivariable ordinal logistic regression models were used to test the association between race and ethnicity and CMB profile overall and separately by household income level and insurance type.

RESULTS

Overall, 15% of NHB and 11% of Hispanics experienced poor CMB risk profile, compared with 9% for NHW. In fully adjusted models, NHB and Hispanics, respectively had nearly 25%-90% and 10%-30% increased odds of poor CMB profile across insurance types and 45%-60% and 15%-30% increased odds of poor CMB profile across income levels, relative to NHW. The observed disparities were widest for the Medicare group (NHB: OR = 1.90; Hispanics: OR = 1.31) and highest-income level (NHB: OR = 1.62).

CONCLUSIONS

Racial/ethnic minorities experience poor CMB profile at each level of income and insurance. These findings point to the need for greater investigation of unmeasured determinants of minority cardiovascular (CV) health, including structural racism and implicit bias in CV care.

Assessing Perceived Discrimination as Reported by Black and White Women Diagnosed with Breast Cancer

OBJECTIVE

Although a number of factors contribute to racial disparities in breast cancer outcomes, perceived discrimination in healthcare may be a key factor that hinders positive interactions and negatively impacts patient outcomes. The goals of our study were to (1) assess the prevalence of perceived discrimination as reported by breast cancer patients and (2) identify factors related to discrimination in women overall as well as by race.

DESIGN

This study is a secondary analysis of a larger study, "Narrowing the Gaps in Adjuvant Therapy," where a convenience sample of 359 women completed one telephone survey assessing sociodemographics, and attitudes and beliefs concerning breast cancer treatments and care. Chi-square analysis was used to assess the relationship of categorical variables with perceived discrimination, while the F-test was employed for continuous variables. Logistic regression determined predictors of perceived discrimination, a dichotomous variable (none vs. any).

RESULTS

A majority of women were Black (58%), privately insured (85%), and had at least a Bachelor's degree (48%). Discrimination was reported by 32.4% of women, with significantly more Black women reporting discrimination than White women. Insurance status, attitudes toward treatment, and distress factors were significantly related to perceived discrimination. In the logistic model, women who were less trusting of their providers (OR = 0.863 [0.751, 0.993], p = .021) and Black women (OR = 7.241 [0.751, 0.993], p = .039) were more likely to report incidences of discrimination.

CONCLUSIONS

Our findings suggest a need to understand Black survivor's experiences with healthcare. Similarly, future work must focus on identifying ways to improve provider trust amongst breast cancer survivors.

Discrimination and Health: The Mediating Effect of Acculturative Stress

There is not much evidence on the effects of south–south migration and its consequences on physical and mental health. Our objective was to examine the mediating role of Acculturative Stress in the association between ethnic discrimination and racial discrimination with physical and mental health. This research is a non-experimental, analytical, cross-sectional study. A total of 976 adult Colombian migrants living in Chile were interviewed. We used the Everyday Discrimination Scale, the acculturative stress scale, and the Medical Outcomes Study Short Form (SF-12) for health status; we found that racial and ethnic discrimination had a negative effect on physical and mental health. In the simultaneous presence of both types of discrimination, racial discrimination was completely absorbed by ethnic discrimination, the latter becoming a total mediator of the effect of racial discrimination on mental and physical health. Our findings are consistent with the literature, which suggests that there are various types of discrimination which, individually or in their intersectionality, can have negative effects on health.

The Weight of Racial Discrimination: Examining the Association Between Racial Discrimination and Change in Adiposity Among Emerging Adult Women Enrolled in a Behavioral Weight Loss Program

BACKGROUND

Non-Hispanic Black (NHB) emerging adult (EA) women are at disproportionate risk for obesity but experience limited benefit from behavioral weight loss (BWL) programs. Race-related stress could play a role; the goal of this study was to examine the association between racial discrimination (RD) and early (3 months) changes in adiposity, and to explore potential protective factors, among EA in an adapted BWL program.

METHODS

This is an ancillary study of non-Hispanic White (NHW) and NHB EA women enrolled in an adapted BWL trial (N = 49; 55.1% NHB; Age 21.2 (2.1); BMI = 33.0 + 4.3 kg/m²). At baseline, group- and personal-level RD (RD-group and RD-personal), racial identity (NHB women only), vigilant coping, and social support were assessed via validated questionnaires. Weight and waist circumference were measured objectively at 0 and 3 months.

RESULTS

NHW women manifested greater reductions in waist circumference relative to NHB women (p = .004). RD-personal did not predict change in waist circumference at 3 months (p = .402); however, the association between RD-group and change in waist circumference was statistically significant (p = .015), such that reporting greater group-level discrimination predicted a smaller decrease in waist circumference; the model explained 22% of the variance. Social support and vigilant coping were not statistically significant in the model. Among NHB women only, higher racial identity-centrality predicted greater reduction in waist circumference (p = .019).

CONCLUSION

Findings suggest racial discrimination could contribute to greater cardiometabolic risk during this developmental period. Future research should examine how experiences of racial discrimination unfold in the daily lives of NHB women to inform mechanistic interventions to enhance health and well-being.

TRIAL REGISTRATION

NCT02736981. Low Intensity Weight Loss for Young Adults.

Racial Difference in the Relationship Between Health and Happiness in the United States

Background

Although health is a prerequisite for happiness, the salience of health for maintaining happiness may be diminished for Blacks when compared to Whites, a phenomenon which can be explained by the Black-White mental health paradox and minorities’ diminished returns.

Aim

To understand if Black and White adult Americans differ in the effects of self-rated health (SRH) on happiness.

Methods

This cross-sectional study used data from the General Social Survey (GSS; 1972–2018), a nationally representative survey in the US. Our analytical sample included 42,201 Black and White adults. The independent variable was SRH. Happiness was the dependent variable. Sociodemographic factors were covariates. Race was the moderator. Logistic regression was used to analyze the data without and with interaction terms between race and SRH.

Results

Overall, good SRH was positively associated with happiness, however, there was a significant interaction between race/ethnicity and good SRH on the outcome (i.e. happiness) . This finding suggested that the boosting effect of good SRH on happiness is weaker for Black than White people.

Conclusion

In the United States, due to a weaker concordance between good health and happiness, Blacks who have poor SRH are more likely to report happiness. At the same time, Whites who are healthy report happiness, however, Blacks who are healthy do not necessarily report happiness. Disjointed link between health and happiness may be due to different racial, ethnic, and cultural perceptions of physical health and happiness as well as salience of physical health as a component of happiness. This may be an adaptive response of Blacks to sociopolitical as well as health-related adversities over centuries as a result of the combination of oppression, injustice, and poverty.

Social Determinants of Health Improve Predictive Accuracy of Clinical Risk Models for Cardiovascular Hospitalization, Annual Cost, and Death

BACKGROUND

Risk models in the private insurance setting may systematically underpredict in the socially disadvantaged. In this study, we sought to determine whether US minority Medicare beneficiaries had disproportionately low costs compared with their clinical outcomes and whether adding social determinants of health (SDOH) into risk prediction models improves prediction accuracy.

METHODS AND RESULTS

Retrospective observational cohort study of 2016 to 2017 Medicare Current Beneficiary Survey data (n=3614) linked to Medicare fee-for-service claims. Logistic and linear regressions were used to determine the relationship between race/ethnicity and annual costs of care, all-cause hospitalization, cardiovascular hospitalization, and death. We calculated the observed-to-expected (O:E) ratios for all outcomes under 4 risk models: (1) age+sex, (2) model 1+clinical comorbidity adjustment, (3) model 2+SDOH, and (4) SDOH alone. Our sample was 44% male and 11% black or Hispanic. Among minorities, adverse clinical outcomes were inversely related to cost. After multivariable adjustment, blacks/Hispanics had higher rates of cardiovascular hospitalization (incidence rate ratio, 1.78; P=0.012) but similar annual costs ($-336, P=0.77) compared with whites. Among whites, models 1 to 4 all showed similar O:E ratios, suggesting high accuracy in risk prediction using current models. Among minorities, adjustment for age, sex, and comorbidities underpredicted all-cause hospitalization by 20% (O:E, 1.20) and cardiovascular hospitalization by 70% (O:E, 1.70) and overpredicted death by 21% (O:E, 0.79); adding SDOH brought O:E near 1 for all outcomes. Among both groups, the SDOH risk model alone performed with equal or superior accuracy to the model based on clinical comorbidities.

CONCLUSIONS

A paradoxical relationship was observed between clinical outcomes and costs among racial and ethnic minorities. Because of systematic differences in access to care, cost may not be an appropriate surrogate for predicting clinical risk among vulnerable populations. Adjustment for SDOH improves the accuracy of risk models among racial and ethnic minorities and could guide use of prevention strategies.

Investigation of the Predictors of Self-rated Health of Economically Disadvantaged African American Men and Women: Evidence for Sponge Hypothesis

Background and aims

According to the sponge hypothesis, compared to men's self-rated health (SRH), women's SRH is more likely to reflect conditions other than chronic medical conditions (CMCs) such as psychiatric disorders (PDs). As a result, poor SRH is a weaker predictive factor for mortality risk for women than men. Most of this literature, however, is done in samples that are predominantly middleclass White. To test the sponge hypothesis among economically disadvantaged African Americans (AAs), this study compared low-income AA men and women for the effects of the number of PDs and CMCs on SRH.

Materials and Methods

This cross-sectional study recruited a non-random sample (n = 150) of economically disadvantaged AA adults with PD(s). Structured face-to-face interviews were used to collect data. SRH was measured using a single-item measure. PDs and CMCs were also self-reported. We applied linear regression models to test the interactions between SRH and the number of PDs and CMC as well as gender.

Results

The number of PDs and CMCs were associated with SRH in the pooled sample of low-income AA adults with PD(s). However, we found a significant interaction between the number of PDs and gender. This interaction suggested a stronger association between PDs and SRH for AA women than AA men. Gender did not alter the association between the number of CMCs and SRH.

Conclusion

The number of PDs is a determinant of SRH for low-income AA women but not AA men, supporting the sponge hypothesis.

Vicarious Racism Stress and Disease Activity: the Black Women's Experiences Living with Lupus (BeWELL) Study

BACKGROUND

Indirect or vicarious exposure to racism (e.g., hearing about or observing acts of racism or discrimination) is a salient source of stress for African Americans. Emerging research suggests that these "secondhand" experiences of racism may contribute to racial health inequities through stress-mediated pathways. Systemic lupus erythematosus (SLE) is an inflammatory autoimmune disease that disproportionately impacts African American women and is characterized by racial disparities in severity. Health outcomes in this population may be susceptible to vicarious racism given that SLE is shown to be sensitive to psychosocial stress.

METHODS

Data are from 431 African American women with SLE living in Atlanta, Georgia in the Black Women's Experiences Living with Lupus (BeWELL) Study (2015-2017). Vicarious racism stress was measured with four items assessing distress from (1) hearing about racism in the news; (2) experiences of racism among friends or family; (3) witnessing racism in public; and (4) racism depicted in movies and television shows. Multivariable linear regression was used to examine associations with disease activity measured using the Systemic Lupus Activity Questionnaire.

RESULTS

Adjusting for sociodemographic and health-related covariates, vicarious racism stress was associated with greater disease activity (b = 2.15; 95% CI = 1.04-3.27). This association persisted even after adjustment for personal experiences of racial discrimination (b = 1.80; 95% CI = 0.67-2.92).

CONCLUSIONS

Vicarious racism may result in heightened disease activity and contribute to racial disparities in SLE. Our findings suggest that acts of racism committed against members of one's racial group may have distinct health consequences beyond the immediate victim or target.

Personal Versus Group Experiences of Racism and Risk of Delivering a Small-for-Gestational Age Infant in African American Women: a Life Course Perspective

The majority of studies investigating the relationship between racism/racial discrimination and birth outcomes have focused on perceived experiences of racism/racial discrimination directed at oneself (personal racism). However, evidence suggests individuals report with greater frequency racism/racial discrimination directed at friends, family members, or other members of their racial/ethnic group (group racism). We examined how much African American (AA) women report lifetime experiences of perceived racism or racial discrimination, both personal and group, varied by maternal age. We also investigated whether reports of personal and group racism/racial discrimination were associated with the risk of delivering a small-for-gestational age (SGA) infant and how much maternal age in relation to developmental life stages (adolescence [≤ 18 years], emerging adulthood [19-24 years], and adulthood [≥ 25 years]) moderated the relationship. Data stem from the Baltimore Preterm Birth Study, a hybrid prospective/retrospective cohort study that enrolled 872 women between March 2000 and July 2004 (analyzed in 2016-2017). Spline regression analyses demonstrated a statistically significant (p value for overall association < 0.001) and non-linear (p value = 0.044) relationship between maternal age and the overall racism index. Stratified analysis showed experiences of racism overall was associated with a higher odds ratio of delivering an SGA infant among AA women aged ≥ 25 years (OR = 1.45, 95% CI 1.02-2.08). The overall racism index was not associated with the SGA infant odds ratio for emerging adults (OR = 0.86, 95% CI 0.69-1.06) or adolescents (OR = 0.92, 95% CI 0.66-1.28). Multiple aspects of racism and the intersection between racism and other contextual factors need to be considered.

Perceived discrimination and physical health-related quality of life: The Hispanic Community Health Study/Study of Latinos (HCHS/SOL) Sociocultural Ancillary Study

RATIONALE

The aim of this study was to examine the direct associations of perceived personal and group discrimination with physical health-related quality of life (HRQoL) among Latinx adults. We also tested whether ethnic identity and depression symptoms sequentially mediate these associations.

METHOD

This population-based study included 5313 Latinx adults, ages 18-74 years, from the Hispanic Community Health Study/Study of Latinos (2008-11) and its Sociocultural Ancillary Study (2010-11). Participants were recruited from the Bronx; NY; Chicago, IL; Miami, FL; and San Diego, CA. Self-reported perceived personal and group discrimination, ethnic identity, depression symptoms, and physical HRQoL were ascertained through interviewer-administered surveys. Survey-weighted path analysis was used to examine direct and indirect effects simultaneously in one analytic model controlling for demographic covariates.

RESULTS

Path analysis indicated that higher perceived personal discrimination was directly associated with poorer physical HRQoL and this association was only mediated by depression symptoms. In contrast, perceived group discrimination was not directly associated with physical HRQoL. However, each of the direct paths linking perceived group discrimination to physical HRQoL were statistically significant: perceived group discrimination was positively associated with ethnic identity, and ethnic identity was negatively associated with depression symptoms, and, in turn, depression symptoms were negatively associated with physical HRQoL. Our model accounted for 18% of the variance of physical HRQoL.

CONCLUSIONS

Perceived personal and group discrimination are differently associated with physical HRQoL. Results highlight the importance of considering self-perceptions of different discrimination forms when evaluating its impact on the physical HRQoL of Latinx adults.

The Association Between Racial Discrimination and Suicidality among African-American Adolescents and Young Adults

This study assessed the association between racial discrimination and suicidality (ideation, plan, or attempt) in African-American adolescents and young adults (n = 806, mean age = 17.9 years). Structured psychiatric phone interviews were conducted in offspring and their mothers in a high-risk alcoholism family study. Logistic regression analyses using offspring's own racial discrimination as a predictor revealed elevated odds of suicidality, even after adjusting for correlated psychiatric conditions (OR = 1.76) but was reduced to non-significance after adjusting for maternal experiences of racial discrimination (OR = 3.19 in males), depression, and problem drinking. Findings support a link between racial discrimination and suicidality in African-American youth that, for males, is partially explained by maternal racial discrimination.