Perceptions of race/ethnicity-based discrimination: a review of measures and evaluation of their usefulness for the health care setting

Associations between racial discrimination, limited English proficiency, and health-related quality of life among 6 Asian ethnic groups in California

OBJECTIVES

We examined the association of racial discrimination and limited English proficiency with health-related quality of life among Asian Americans in California.

METHODS

We studied Chinese (n = 2576), Filipino (n = 1426), Japanese (n = 833), Korean (n = 1128), South Asian (n = 822), and Vietnamese (n = 938) respondents to the California Health Interview Survey in 2003 and 2005. We assessed health-related quality of life with the Centers for Disease Control and Prevention's measures of self-rated health, activity limitation days, and unhealthy days.

RESULTS

Overall, Asians who reported racial discrimination or who had limited English proficiency were more likely to have poor quality of life, after adjustment for demographic characteristics. South Asian participants who reported discrimination had an estimated 14.4 more activity limitation days annually than South Asians who did not report discrimination. Results were similar among other groups. We observed similar but less consistent associations for limited English proficiency.

CONCLUSIONS

Racial discrimination, and to a lesser extent limited English proficiency, appear to be key correlates of quality of life among Asian ethnic groups.

Racial/ethnic differences in self-reported racism and its association with cancer-related health behaviors

OBJECTIVES

We used population-based survey data to estimate the prevalence of self-reported racism across racial/ethnic groups and to evaluate the association between self-reported racism and cancer-related health behaviors.

METHODS

We used cross-sectional data from the 2003 California Health Interview Survey. Questions measured self-reported racism in general and in health care. The cancer risk behaviors we assessed were smoking, binge drinking, not walking, being overweight or obese, and not being up to date with screenings for breast, cervical, colorectal, and prostate cancers. Analyses included descriptive analyses and logistic regression.

RESULTS

Prevalences of self-reported racism varied between and within aggregate racial/ethnic groups. In adjusted analyses, general racism was associated with smoking, binge drinking, and being overweight or obese; health care racism was associated with not being up to date with screening for prostate cancer. Associations varied across racial/ethnic groups.

CONCLUSIONS

Associations between general racism and lifestyle behaviors suggest that racism is a potential stressor that may shape cancer-related health behaviors, and its impact may vary by race/ethnicity.

Racial discrimination and health: a systematic review of scales with a focus on their psychometric properties

The literature addressing the use of the race variable to study causes of racial inequities in health is characterized by a dense discussion on the pitfalls in interpreting statistical associations as causal relationships. In contrast, fewer studies have addressed the use of racial discrimination scales to estimate discrimination effects on health, and none of them provided a thorough assessment of the scales' psychometric properties. Our aim was to systematically review self-reported racial discrimination scales to describe their development processes and to provide a synthesis of their psychometric properties. A computer-based search in PubMed, LILACS, PsycInfo, Scielo, Scopus and Web of Science was conducted without any type of restriction, using search queries containing free and controlled vocabulary. After initially identifying 3060 references, 24 scales were included in the review. Despite the fact that discrimination stands as topic of international relevance, 23 (96%) scales were developed within the United States. Most studies (67%, N = 16) were published in the last 12 years, documenting initial attempts at scale development, with a dearth of investigations on scale refinements or cross-cultural adaptations. Psychometric properties were acceptable; sixteen of all scales presented reliability scores above 0.7, 19 out of 20 instruments confirmed at least 75% of all previously stated hypotheses regarding the constructs under consideration, and conceptual dimensional structure was supported by means of any type of factor analysis in 17 of 21 scales. However, independent researchers, apart from the original scale developers, have rarely examined such scales. The use of racial terminology and how it may influence self-reported experiences of discrimination has not yet been thoroughly examined. The need to consider other types of unfair treatment as concurrently important health-damaging exposures, and the idea of a universal instrument which would permit cross-cultural adaptations, should be discussed among researchers in this emerging field of inquiry.

Perceptions of Racism in Children and Youth (PRaCY): properties of a self-report instrument for research on children's health and development

Experiences of racial discrimination have been demonstrated to be related to racial and ethnic disparities in mental and physical health and healthcare. There has been little study, however, of the relationship between racism and health in children, and few psychometrically valid and reliable instruments to measure Perceptions of Racism in Children and Youth (PRaCY) exist. This paper reports on the development and testing of such an instrument, the PRaCY. Development of the instrument began with open-ended qualitative interviews, from which a proto-questionnaire was created. The questionnaire gathered information on the prevalence, attribution, emotional responses, and coping responses to 23 situations identified by participants in the qualitative phase. The proto-questionnaire was administered to 277 children between the ages of 8 and 18 years (38% Latino/a, 31% African-American, 19% multiracial/multicultural, 7% West Indian/Caribbean, and 5% Other). Item analysis resulted in two developmentally appropriate 10-item instruments (one for ages 7-13, another for ages 14-18). Internal consistency reliability was strong (alpha = 0.78 for both versions of the instrument). Confirmatory factor analysis demonstrated good fit for both versions (younger-Comparative Fit Index (CFI): 0.967, Root Mean Square Error of Approximation (RMSEA): 0.047; older-CFI: 0.934, RMSEA: 0.056). Differential item functioning analyses demonstrated no group-specific biases in item response. PRaCY scores were appropriately associated with higher depressive symptom scores and elevated anxiety scores in the younger sample. Results indicate that the PRaCY is a valid and reliable instrument that measures perceptions of racism and discrimination in children and youth aged 8-18 from diverse racial/ethnic backgrounds.

Combining explicit and implicit measures of racial discrimination in health research

OBJECTIVES

To improve measurement of discrimination for health research, we sought to address the concern that explicit self-reports of racial discrimination may not capture unconscious cognition.

METHODS

We used 2 assessment tools in our Web-based study: a new application of the Implicit Association Test, a computer-based reaction-time test that measures the strength of association between an individual's self or group and being a victim or perpetrator of racial discrimination, and a validated explicit self-report measure of racial discrimination.

RESULTS

Among the 442 US-born non-Hispanic Black participants, the explicit and implicit measures, as hypothesized, were weakly correlated and tended to be independently associated with risk of hypertension among persons with less than a college degree. Adjustments for both measures eliminated the significantly greater risk for Blacks than for Whites (odds ratio = 1.4), reducing it to 1.1 (95% confidence interval = 0.7, 1.7).

CONCLUSIONS

Our results suggest that the scientific rigor of research on racism and health will be improved by investigating how both unconscious and conscious mental awareness of having experienced discrimination matter for somatic and mental health.

Racial discrimination and health among Asian Americans: evidence, assessment, and directions for future research

Research shows that racial discrimination is related to illness among diverse racial and ethnic populations. Studies of racial discrimination and health among Asian Americans, however, remain underdeveloped. In this paper, the authors review evidence on racial discrimination and health among Asian Americans, identify gaps in the literature, and provide suggestions for future research. They identified 62 empirical articles assessing the relation between discrimination and health among Asian Americans. The majority of articles focused on mental health problems, followed by physical and behavioral problems. Most studies find that discrimination was associated with poorer health, although the most consistent findings were for mental health problems. This review suggests that future studies should continue to investigate the following: 1) the measurement of discrimination among Asian Americans, whose experiences may be qualitatively different from those of other racial minority groups; 2) the heterogeneity among Asian Americans, including those factors that are particularly salient in this population, such as ethnic ancestry and immigration history; and 3) the health implications of discrimination at multiple ecologic levels, ranging from the individual level to the structural level.

Patients' perceptions of discrimination during hospitalization

OBJECTIVE

To identify sources of perceived discrimination during hospitalization and examine the relationship of perceived discrimination to patient and hospital stay characteristics, and to patient ratings of care.

BACKGROUND

Patient experiences of discrimination within the health-care system are associated with delays in care seeking, non-adherence to medical advice and poorer health status. Most research to date has focused on race and ethnicity-based discrimination, and few studies have included hospitalized patients.

METHODS

Questions about patients' experiences of discrimination were added to a regular patient opinion survey conducted at the Geneva University Hospitals. Participants were 1537 adult residents of Switzerland discharged from the hospital between 15 February and 15 March 2007.

RESULTS

A total of 171 (11.1%) respondents reported at least one source of discrimination. Most (93, 54.4%) reported a single cause of discrimination. The most frequent causes of discrimination were language, age, nationality and having a disease that is viewed negatively by others. Fifteen percentage of non-European respondents reported at least one of the following types of discrimination: language, nationality, religion and skin colour. Reporting discrimination from any cause was associated with higher Picker Patient Experience problem scores, and patients who reported discrimination were less likely to describe their care as very good or excellent and less likely to recommend the hospital to others.

CONCLUSIONS

Patient experiences of discrimination during hospitalization are relatively frequent and are associated with lower patient ratings of care. Collection of data on patient experiences of discrimination may contribute to the development of interventions aimed at ensuring respectful, quality care for all patients.

Potential unintended consequences of tobacco-control policies on mothers who smoke: a review of the literature

BACKGROUND

Secondhand smoke poses risks to children, particularly those from low socioeconomic backgrounds. Recently, there has been an increase in tobacco-control policies designed to reduce children's exposure to secondhand smoke, including interventions to change parental smoking behaviors. However, little attention has been paid to understanding potential unintended consequences of such initiatives on mothers who smoke. As such, the objectives of this paper are to explore the potential consequences of tobacco-control policies designed to reduce children's exposure to secondhand smoke on socially disadvantaged mothers who smoke and to provide recommendations for research, policy, and practice.

EVIDENCE ACQUISITION

A theory-guided, qualitative narrative review of the perceived discrimination, stigma, and stress and coping literature was conducted. MEDLINE and PsycINFO were searched to identify relevant articles from 1980 to October 2008 for review.

EVIDENCE SYNTHESIS

There is evidence that strategies designed to reduce secondhand smoke have contributed to smoking stigmatization. However, there is little research on the consequences of these initiatives or how they affect low-income mothers who smoke. Stigmatization research suggests that such policies may have unanticipated outcomes for socially disadvantaged mothers who smoke, such as decreased mental health; increased use of cigarettes or alcohol; avoidance or delay in seeking medical care; and poorer treatment by healthcare professionals. Recommendations for researchers, practitioners, and policymakers are presented.

CONCLUSIONS

Further research is needed to understand how initiatives to reduce children's exposure to secondhand smoke, as well as broader tobacco-control initiatives, can be designed to minimize potential harm to mothers who smoke.

Differences in the self-reported racism experiences of US-born and foreign-born Black pregnant women

Differential exposure to minority status stressors may help explain differences in United States (US)-born and foreign-born Black women's birth outcomes. We explored self-reports of racism recorded in a survey of 185 US-born and 114 foreign-born Black pregnant women enrolled in Project Viva, a prospective cohort study of pregnant women in Boston, Massachusetts, USA. Self-reported prevalence of personal racism and group racism was significantly higher among US-born than foreign-born Black pregnant women, with US-born women having 4.1 and 7.8 times the odds, respectively, of childhood exposure. In multivariate analyses, US-born women's personal and group racism exposure also was more pervasive across the eight life domains we queried. Examined by immigrant subgroups, US-born women were more similar in their self-reports of racism to foreign-born women who moved to the US before age 18 than to women who immigrated after age 18. Moreover, US-born women more closely resembled foreign-born women from the Caribbean than those from Africa. Differential exposure to self-reported racism over the life course may be a critically important factor that distinguishes US-born Black women from their foreign-born counterparts.

Discrimination and racial disparities in health: evidence and needed research

This paper provides a review and critique of empirical research on perceived discrimination and health. The patterns of racial disparities in health suggest that there are multiple ways by which racism can affect health. Perceived discrimination is one such pathway and the paper reviews the published research on discrimination and health that appeared in PubMed between 2005 and 2007. This recent research continues to document an inverse association between discrimination and health. This pattern is now evident in a wider range of contexts and for a broader array of outcomes. Advancing our understanding of the relationship between perceived discrimination and health will require more attention to situating discrimination within the context of other health-relevant aspects of racism, measuring it comprehensively and accurately, assessing its stressful dimensions, and identifying the mechanisms that link discrimination to health.

Discrimination and racial disparities in health: evidence and needed research

This paper provides a review and critique of empirical research on perceived discrimination and health. The patterns of racial disparities in health suggest that there are multiple ways by which racism can affect health. Perceived discrimination is one such pathway and the paper reviews the published research on discrimination and health that appeared in PubMed between 2005 and 2007. This recent research continues to document an inverse association between discrimination and health. This pattern is now evident in a wider range of contexts and for a broader array of outcomes. Advancing our understanding of the relationship between perceived discrimination and health will require more attention to situating discrimination within the context of other health-relevant aspects of racism, measuring it comprehensively and accurately, assessing its stressful dimensions, and identifying the mechanisms that link discrimination to health.

A mixed-methods approach to developing a self-reported racial/ethnic discrimination measure for use in multiethnic health surveys

OBJECTIVE

The development of measures of self-reported racial/ethnic discrimination is an active area of research, but few measures have been validated across multiple racial/ethnic and language groups. Our goal is to develop and evaluate a discrimination measure that is appropriate for use in surveys of racially and ethnically diverse populations.

METHODS

To develop our measure, we employ a mixed-methods approach for survey research, drawing from both qualitative and quantitative traditions, including literature review, cognitive testing, psychometric analyses, behavior coding as well as two rounds of field testing using a split-sample design. We tested our new measure using two different approaches to elicit self-reported experiences of racial/ethnic discrimination.

RESULTS

Our new measure captures four dimensions of racial/ethnic discrimination: 1) frequency of encounters with discrimination across several domains (eg, medical care, school, work, street and other public places); 2) timing of exposure (eg recent, lifetime); 3) appraisal of discrimination as stressful; and 4) responses to discrimination.

CONCLUSIONS

Because of the growing interest in measurement of racial/ethnic discrimination in health surveys, we think this report on the methods informing the development and testing of the discrimination module that will be used on the California Health Interview Survey would be useful to other researchers. The application of mixed methods to rigorously test the validity and reliability of our instrument proves to be a good roadmap for measuring racial/ethnic discrimination in multicultural and multilingual populations.

Discrimination and racial disparities in health: evidence and needed research

This paper provides a review and critique of empirical research on perceived discrimination and health. The patterns of racial disparities in health suggest that there are multiple ways by which racism can affect health. Perceived discrimination is one such pathway and the paper reviews the published research on discrimination and health that appeared in PubMed between 2005 and 2007. This recent research continues to document an inverse association between discrimination and health. This pattern is now evident in a wider range of contexts and for a broader array of outcomes. Advancing our understanding of the relationship between perceived discrimination and health will require more attention to situating discrimination within the context of other health-relevant aspects of racism, measuring it comprehensively and accurately, assessing its stressful dimensions, and identifying the mechanisms that link discrimination to health.