Racial discrimination, mood disorders, and cardiovascular disease among black americans

Racial/Ethnic Discrimination and Cardiometabolic Diseases: A Systematic Review

INTRODUCTION

Racial discrimination has been identified as a risk factor for cardiometabolic diseases, the leading cause of morbidity and mortality among racial/ethnic minority groups; however, there is no synthesis of current knowledge on the association between discrimination and cardiometabolic diseases. The objective of this systematic review was to summarize evidence linking racial/ethnic discrimination and cardiometabolic diseases.

METHODS

The review was conducted based on studies identified via electronic searches of 5 databases (PubMed, Google Scholar, WorldWideScience.org, ResearchGate and Microsoft Academic) using terms related to discrimination and cardiometabolic disease.

RESULTS

Of the 123 eligible studies included in the review, 87 were cross-sectional, 25 longitudinal, 8 quasi-experimental, 2 randomized controlled trials and 1 case-control. Cardiometabolic disease outcomes discussed were hypertension (n = 46), cardiovascular disease (n = 40), obesity (n = 12), diabetes (n = 11), metabolic syndrome (n = 9), and chronic kidney disease (n = 5). Although a variety of discrimination measures was employed across the studies, the Everyday Discrimination Scale was used most often (32.5%). African Americans/Blacks were the most frequently studied racial/ethnic group (53.1%), and American Indians the least (0.02%). Significant associations between racial/ethnic discrimination and cardiometabolic disease were found in 73.2% of the studies.

DISCUSSION

Racial/ethnic discrimination is positively associated with increased risk of cardiometabolic disease and higher levels of cardiometabolic biomarkers. Identifying racial/ethnic discrimination as a potential key contributor to the health inequities associated with cardiometabolic diseases is important for addressing the significant burden borne by racial/ethnic minorities.

Perceived Interpersonal Racism in Relation to Incident Coronary Heart Disease Among Black Women

BACKGROUND

Racism is highly prevalent in the United States. Few data exist about whether perceived interpersonal racism is associated with risk of coronary heart disease (CHD).

METHODS

We followed 48 305 participants in the Black Women's Health Study through biennial mailed and Internet-based health questionnaires from 1997, when they provided information on perceived interpersonal racism and were free of cardiovascular disease and cancer, until the end of 2019. We averaged participant responses to 5 validated questions about perceived interpersonal racism in everyday activities, such as "people act as if they think you are dishonest." We summed the positive responses to 3 questions about perceived racism in interactions that involved jobs, housing, and police; scores ranged from 0 (no to all) to 3 (yes to all). CHD cases were defined as nonfatal myocardial infarctions confirmed through medical records, fatal cases identified through the National Death Index, and self-reported revascularization events. We used Cox proportional hazard models adjusting for major confounders to estimate hazard ratios (HRs).

RESULTS

During 22 years of follow-up, we identified 1947 incident CHD cases. For women who reported experiences of racism in employment, housing, or involving the police relative to women who reported no such experiences, the age-adjusted HR for CHD was 1.35 (95% CI, 1.13-1.61; Ptrend=0.006), and the multivariable HR for CHD was 1.26 (95% CI, 1.05-1.51; Ptrend=0.05). For women in the highest quartile of perceived interpersonal racism in daily life relative to women in the lowest quartile, the age-adjusted HR for CHD was 1.25 (95% CI, 1.07-1.46; Ptrend=0.006). After multivariable adjustment, the HR was attenuated and no longer statistically significant.

CONCLUSIONS

Perceived experiences of interpersonal racism in employment, in housing, and with the police were associated with higher incidence of CHD among Black women, whereas perceived racism in everyday life was not associated with higher risk.

Exploring barriers to living donor kidney transplant for African, Caribbean and Black communities in the Greater Toronto Area, Ontario: a qualitative study protocol

INTRODUCTION

Living donor (LD) kidney transplant (KT) is the best treatment option for many patients with kidney failure as it improves quality of life and survival compared with dialysis and deceased donor KT. Unfortunately, LDKT is underused, especially among groups marginalised by race and ethnicity. African, Caribbean and Black (ACB) patients are 60%-70% less likely to receive LDKT in Canada compared with white patients. Research from the USA and the UK suggests that mistrust, cultural and generational norms, access, and affordability may contribute to inequities. To date, no Canadian studies have explored the beliefs and behaviours related to LDKT in ACB communities. Research approaches that use a critical, community-based approach can help illuminate broader structural factors that may shape individual beliefs and behaviours. In this qualitative study, we will investigate barriers to accessing LDKT in ACB communities in the Greater Toronto Area, to enhance our understanding of the perspectives and experiences of ACB community members, both with and without lived experience of chronic kidney disease (CKD).

METHODS AND ANALYSIS

Hospital-based and community-based recruitment strategies will be used to recruit participants for focus groups and individual interviews. Participants will include self-identified ACB individuals with and without experiences of CKD and nephrology professionals. Collaboration with ACB community partners will facilitate a community-based research approach. Data will be analysed using reflexive thematic analysis and critical race theory. Findings will be revised based on feedback from ACB community partners.

ETHICS AND DISSEMINATION

This study has been approved by the University Health Network Research Ethics Board UHN REB file #15-9775. Study findings will contribute to the codevelopment of culturally safe and responsive educational materials to raise awareness about CKD and its treatments and to improve equitable access to high-quality kidney care, including LDKT, for ACB patients.

Exposure to anti-Black Lives Matter movement and obesity of the Black population

RATIONALE

Black Lives Matter (BLM) is a social movement against systematic injustice and police violence toward Black people whose goal is to ensure their safety and the expression of their culture. As BLM gained momentum, counter-movements emerged, such as All Lives Matter (ALM), White Lives Matter (WLM), and Blue Lives Matter (BlueLM). Because they undermine support for Black people's safety and culture, exposure to stances against BLM can be a race-related stressor. Although the perception of racial discrimination has been associated with negative health outcomes in Black people, it is not clear whether exposure to negative stances on a race-related social issue is associated with worse health outcomes.

OBJECTIVE

We investigated whether living in areas of the United States with a high prevalence of negative stances on BLM is associated with worse health outcomes, such as higher body mass index (BMI) and prevalence of obesity.

METHODS

We scraped geo-coded tweets (N = 51,020) that contained #BLM, #ALM, #WLM, and #BlueLM from 2014 to 2016. We determined the stances of the tweets on BLM using machine learning algorithms and aggregated stances at the metropolitan or micropolitan statistical area (MMSA) levels. Participants' BMI and obesity status were derived from the 2017 BRFSS SMART data in 76 MMSAs, as compiled by the Centers for Disease Control and Prevention (N = 20,530).

RESULTS

After controlling for individual- and regional-level covariates, regional measures of racism and police brutality rate, and baseline BMI in 2014 aggregated on MMSA level, Black people had a higher BMI and prevalence of obesity in areas that showed higher negative stances on BLM. Stances against BLM were positively associated with implicit racism against Black people and can be an acute race-related stressor associated with negative downstream health outcomes.

CONCLUSION

Negative societal sentiments around race-related issues may be detrimental to the health outcomes of minority populations.

Racism and Older Black Americans' Health: a Systematic Review

We reviewed research that examines racism as an independent variable and one or more health outcomes as dependent variables in Black American adults aged 50 years and older in the USA. Of the 43 studies we reviewed, most measured perceived interpersonal racism, perceived institutional racism, or residential segregation. The only two measures of structural racism were birth and residence in a "Jim Crow state." Fourteen studies found associations between racism and mental health outcomes, five with cardiovascular outcomes, seven with cognition, two with physical function, two with telomere length, and five with general health/other health outcomes. Ten studies found no significant associations in older Black adults. All but six of the studies were cross-sectional. Research to understand the extent of structural and multilevel racism as a social determinant of health and the impact on older adults specifically is needed. Improved measurement tools could help address this gap in science.

Psychosocial stress and neuroendocrine biomarker concentrations among women living with or without HIV

OBJECTIVE

Women living with HIV (WLWH) experience psychosocial stress related to social-structural vulnerabilities. To investigate neuroendocrine pathways linking stress and increased cardiovascular disease risk among WLWH, we evaluated associations between psychosocial stress (i.e., perceived stress, posttraumatic stress, and experiences of race- and gender-based harassment) and a composite neuroendocrine biomarker index among WLWH and women without HIV.

METHODS

In 2019-2020, Women's Interagency HIV Study participants in Washington, DC completed a questionnaire and provided blood and 12-hour overnight urine samples for testing of serum dehydroepiandrosterone sulfate (DHEA-S) and urinary free cortisol, epinephrine, and norepinephrine. Psychosocial stress was measured using the Perceived Stress Scale, PTSD Checklist-Civilian Version, and Racialized Sexual Harassment Scale. Latent profile analysis was used to classify participants into low (38%), moderate (44%), and high (18%) stress groups. Composite biomarker index scores between 0-4 were assigned based on participants' number of neuroendocrine biomarkers in high-risk quartiles (≥75th percentile for cortisol, epinephrine, and norepinephrine and ≤25th percentile for DHEA-S). We evaluated associations between latent profile and composite biomarker index values using multivariable linear regression, adjusting for socio-demographic, behavioral, metabolic, and HIV-related factors.

RESULTS

Among 90 women, 62% were WLWH, 53% were non-Hispanic Black, and median age was 55 years. In full multivariable models, there was no statistically significant association between psychosocial stress and composite biomarker index values among all women independent of HIV status. High (vs. low) psychosocial stress was positively associated with higher mean composite biomarker index values among all monoracial Black women (adjusted β = 1.32; 95% CI: 0.20-2.43), Black WLWH (adjusted β = 1.93; 95% CI: 0.02-3.83) and Black HIV-negative women (adjusted β = 2.54; 95% CI: 0.41-4.67).

CONCLUSIONS

Despite a null association in the overall sample, greater psychosocial stress was positively associated with higher neuroendocrine biomarker concentrations among Black women, highlighting a plausible mechanism by which psychosocial stress could contribute to cardiovascular disease risk.

Do trait psychological characteristics moderate sympathetic arousal to racial discrimination exposure in a natural setting?

Personality and psychological traits are known to influence how individuals react to and cope with stress, and thus, have downstream health and aging consequences. However, research considering psychological health traits as individual-level difference factors moderating the links been racism-related stress and health for racial and ethnic minorities in the United States is rare. Using intensive daily diaries and a wearable sensor that continuously recorded sympathetic nervous system arousal in a sample of racial and ethnic minority college students (80% African American, first-generation Black, or African; 20% Latinx), we linked arousal to racism-related experiences dynamically throughout the day as participants naturally went about their lives. Findings suggest that multiple traits are associated with increased arousal in real time when interpersonal discrimination is perceived, but that only anger and anxiety also predicted increased arousal during moments of rumination and reflection on race-related inequities. Vicarious discrimination exposure moments were also linked to suppressed arousal in general, but particularly for more anxious individuals. We use a stress appraisal and coping framework to elucidate the ways in which individual psychological differences may inform physiological responses to race-related stress. The biopsychosocial pathways by which cognitive appraisal and interpersonal race-related stress contribute to racial health disparities are also discussed.

Accelerated aging: A marker for social factors resulting in cardiovascular events?

BACKGROUND

Medicine and public health are shifting away from a purely "personal responsibility" model of cardiovascular disease (CVD) prevention towards a societal view targeting social and environmental conditions and how these result in disease. Given the strong association between social conditions and CVD outcomes, we hypothesize that accelerated aging, measuring earlier health decline associated with chronological aging through a combination of biomarkers, may be a marker for the association between social conditions and CVD.

METHODS

We used data from the Coronary Artery Risk Development in Young Adults study (CARDIA). Accelerated aging was defined as the difference between biological and chronological age. Biological age was derived as a combination of 7 biomarkers (total cholesterol, HDL, glucose, BMI, CRP, FEV1/h2, MAP), representing the physiological effect of "wear and tear" usually associated with chronological aging. We studied accelerated aging measured in 2005-06 as a mediator of the association between social factors measured in 2000-01 and 1) any incident CVD event; 2) stroke; and 3) all-cause mortality occurring from 2007 through 18.

RESULTS

Among 2978 middle-aged participants, mean (SD) accelerated aging was 3.6 (11.6) years, i.e., the CARDIA cohort appeared to be, on average, 3 years older than its chronological age. Accelerated aging partially mediated the association between social factors and CVD (N=219), stroke (N=36), and mortality (N=59). Accelerated aging mediated 41% of the total effects of racial discrimination on stroke after adjustment for covariates. Accelerated aging also mediated other relationships but to lesser degrees.

CONCLUSION

We provide new evidence that accelerated aging based on easily measurable biomarkers may be a viable marker to partially explain how social factors can lead to cardiovascular outcomes and death.

Everyday Discrimination, Depressive Symptoms, and Suicide Ideation Among African American Men

Suicide has remained a leading cause of death among African American males, yet empirical investigations that focus on the experiences of this group are limited. Therefore, we aim to interrogate the impact of everyday discrimination as a risk factor for depressive symptoms and suicide ideation among African American men. Data were drawn from the African American male subsample of the National Survey of American Life (n = 1,271). Path analysis and tests for indirect effects were used to examine relationships between everyday discrimination, depressive symptoms, and suicide ideation. Three sources of everyday discrimination were examined (any everyday discrimination, race-based everyday discrimination, and other everyday discrimination). Study findings revealed that race-based everyday discrimination was the only type of discrimination that was significantly associated with both increased rates of depressive symptoms and suicide ideation. Further, the indirect effect from race-based everyday discrimination to suicide ideation via depressive symptoms was also statistically significant. Thus, the impact of daily encounters with discrimination extends beyond depressive symptoms and is related to higher rates of suicide ideation. Moreover, experiences with discrimination do not have to be overt to be harmful toward African American men's mental health. Culturally relevant suicide prevention interventions are needed to account for the role of discrimination in the lives of African American men.

Discrimination as a social determinant of stress and health among New York City taxi drivers

Discrimination is associated with poorer mental and physical health outcomes. Taxi drivers have a higher risk of exposure to discrimination and higher rates of chronic conditions. A cross-sectional needs assessment was conducted with a multilingual group of 535 male taxi drivers in New York City. Drivers reporting higher discrimination were more likely to have higher perceived stress and were more likely to have anxiety/depression and chronic pain, adjusting for confounders. Workplace-based interventions designed to help drivers cope with discrimination, stress, and chronic health conditions, interventions to educate the taxi-riding public, and greater attention to these issues from administrative agencies are warranted.

The Effects of Hopelessness on Chronic Disease Among African Americans and Caribbean Blacks: Findings from the National Survey of American Life (NSAL)

This paper examines the relationship between hopelessness on chronic disease in a national sample of African Americans (3570) and Caribbean Blacks (1438) Using the National Survey of American Life. A multivariate negative binomial regression examined whether chronic disease is associated with hopelessness, controlling for sociodemographic characteristics. Overall, 13.14% of the sample reported they were highly hopeless, and 31.5% indicated they were moderately hopeless. About 19% of respondents experienced chronic disease. Bivariate associations showed that those who have ever had chronic disease significantly differed from those who did not in regard to age, gender and spirituality. Multivariate results showed that respondents who ever have had chronic disease reported significantly higher hopelessness scores than those with no chronic disease. The study findings contribute to the current body of literature by supporting findings from smaller studies on the relationship between depression and hopelessness in African Americans and Caribbean Blacks.

Effects of sexual/gender minority- and race-based enacted stigma on mental health and substance use in female assigned at birth sexual minority youth

OBJECTIVE

People of color who are also sexual and gender minorities (SGM) experience forms of enacted stigma based on both their racial/ethnic identity and their SGM status. We set out to test the effects of enacted stigma specific to race/ethnicity and SGM identity on mental health and substance use problems among female assigned at birth (FAB) SGM of color.

METHOD

Data come from a community-based sample of FAB SGM who also identified as racial/ethnic minorities (N = 352). The effects of racial discrimination, SGM victimization, and sexual orientation microaggressions on depression symptoms, anxiety symptoms, alcohol-related problems, and marijuana-related problems were tested using linear regression and negative binomial models.

RESULTS

Enacted stigma based on both race/ethnicity and SGM status were significant predictors of mental health outcomes and alcohol-related problems within the same model, which suggested that both uniquely contributed to poorer health. There was little support for interactive effects between the multiple forms of enacted stigma. Marijuana-related problems were best explained by enacted stigma based on race/ethnicity only.

CONCLUSIONS

Racially diverse FAB SGM are at unique risk of experiencing multiple forms of discrimination and aggression based on their minority identities that each contribute negatively to their wellbeing. Consideration of the multiple forms of enacted stigma they face is necessary for understanding health disparities in these populations. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Interactive Relations Across Dimensions of Interpersonal-Level Discrimination and Depressive Symptoms to Carotid Intimal-Medial Thickening in African Americans

OBJECTIVE

This study aimed to examine within-race interactions of multiple dimensions of self-reported discrimination with depressive symptoms in relation to carotid intimal-medial thickness (IMT), a subclinical marker of atherosclerosis prospectively implicated in stroke incidence, in middle-aged to older African American and white adults.

METHODS

Participants were a socioeconomically diverse group of 1941 African Americans (56.5%) and whites from the Healthy Aging in Neighborhoods of Diversity across the Life Span study (30-64 years old, 47% men, 45.2% with household income <125% federal poverty threshold) who underwent carotid IMT measurement. Discrimination was assessed across four dimensions (everyday, frequency across various social statuses, racial, and lifetime burden). The Center for Epidemiologic Studies Depression scale was used to assess depressive symptoms.

RESULTS

In cross-sectional hierarchical regression analyses, two interactions were observed in African Americans: more frequent discrimination across various social statuses (b < 0.001, p = .006) and a higher lifetime discrimination burden (b < 0.001, p = .02) were each related to thicker carotid IMT in those with greater depressive symptoms. No significant findings were observed within whites.

CONCLUSIONS

Among African Americans, those reporting high levels of discrimination and depressive symptoms have increased carotid atherosclerosis and may be at greater risk for clinical end points compared with those reporting one or neither of these risk factors. Findings suggest that assessment of interactive relationships among social and psychological factors may elucidate novel pathways for cardiovascular disease, including stroke, among African Americans.

Racial Discrimination, Disease Activity, and Organ Damage: The Black Women's Experiences Living With Lupus (BeWELL) Study

Black women are disproportionately affected by systemic lupus erythematosus (SLE), a chronic, potentially debilitating autoimmune disease, and they also experience more rapid progression and worse outcomes compared with other groups. We examined if racial discrimination is associated with disease outcomes among 427 black women with a validated diagnosis of SLE, who live in the Atlanta, Georgia, metropolitan area, and were recruited to the Black Women's Experiences Living with Lupus Study (2015-2017). Frequency of self-reported experiences of racial discrimination in domains such as employment, housing, and medical settings was assessed using the Experiences of Discrimination measure. SLE activity in the previous 3 months, including symptoms of fatigue, fever, skin rashes, and ulcers, was measured using the Systemic Lupus Activity Questionnaire; irreversible damage to an organ or system was measured using the Brief Index of Lupus Damage. Results of multivariable linear regression analyses examining the Systemic Lupus Activity Questionnaire and log-transformed Brief Index of Lupus Damage scores indicated that increasing frequency of racial discrimination was associated with greater SLE activity (b = 2.00, 95% confidence interval: 1.32, 2.68) and organ damage (b = 0.08, 95% confidence interval: 0.02, 0.13). Comprehensive efforts to address disparities in SLE severity should include policies that address issues of racial discrimination.

Links between discrimination and cardiovascular health among socially stigmatized groups: A systematic review

BACKGROUND

There is a high prevalence of cardiovascular disease across diverse groups in the U.S. population, and increasing research has identified stigma as a potential barrier to cardiovascular disease prevention and treatment. This systematic review examines evidence linking discrimination and cardiovascular health among socially stigmatized groups.

STUDY DESIGN

Six databases were systematically reviewed from inception through February 2018 for studies with adult subjects, focusing on cardiovascular health indicators among social groups stigmatized because of their gender, race/ethnicity, age, body weight/obesity, or sexual orientation. The Newcastle-Ottawa Scale was used to evaluate the methodological quality and risk of bias for nonrandomized studies, and the Cochrane Collaboration 7-item domain for randomized controlled and experimental trials.

RESULTS

The search identified 84 eligible studies published between 1984 and 2017. Studies retrieved were categorized according to demonstrated links between stigma and cardiovascular disease risk factors including blood pressure (n = 45), heart rate variability (n = 6), blood/saliva cardiovascular biomarkers (n = 18), as well as other indicators of cardiovascular health (n = 15). Based on the findings from included studies, 86% concluded that there was a significant relationship among stigma or discrimination and cardiovascular health indicators among socially stigmatized groups. However, there were varying degrees of evidence supporting these relationships, depending on the type of discrimination and cardiovascular health indicator. The current evidence implies an association between perceived discrimination and cardiovascular health. However, a majority of these studies are cross-sectional (73%) and focus on racial discrimination (79%), while using a wide variety of measurements to assess social discrimination and cardiovascular health.

CONCLUSIONS

Future research should include longitudinal and randomized controlled trial designs, with larger and more diverse samples of individuals with stigmatized identities, using consistent measurement approaches to assess social discrimination and its relationship with cardiovascular health.

Characterizing Discrimination Experiences by Race among Homeless Adults

Objectives: Among domiciled samples, racial discrimination is a known stressor linked with poorer quality of life. However, homeless adults may be particularly vulnerable to discrimination due to multiple factors beyond race. In this study, we characterized perceived discrimination and its reported impact on quality of life in a sample of adults who were homeless. Methods: Homeless adults recruited from Oklahoma City self-reported their socio-demographics, past discrimination experiences, and their impact on quality of life via the MacArthur Major Experiences of Discrimination Questionnaire. Descriptive statistics and frequencies were used to characterize perceived discrimination experiences and impact. Racial differences were examined using ANO- VAs/Kruskal-Wallis tests and chi-square tests. Results: Discrimination experiences attributed to homelessness were common and consistent between the races. Black adults perceived significantly more lifetime discrimination experiences than white adults, and attributed the majority to race. Relative to Whites and American Indians, black adults were more likely to endorse links between discrimination and having a harder life. Conclusions: Results suggest that black homeless adults may represent the most vulnerable racial subgroup for hardships in life as a conse- quence of perceived discrimination among homeless adults.

Racial discrimination, educational attainment, and biological dysregulation among midlife African American women

OBJECTIVE

To examine the association between self-reported racial discrimination and allostatic load, and whether the association differs by socioeconomic position.

METHODS

We recruited a purposive cross-section of midlife (ages 30-50) African American women residing in four San Francisco Bay area counties (n = 208). Racial discrimination was measured using the Experience of Discrimination scale. Allostatic load was measured as a composite of 15 biomarkers assessing cardiometabolic, neuroendocrine, and inflammatory activity. We calculated four composite measures of allostatic load and three system-specific measures of biological dysregulation. Multivariable regression was used to examine associations, while adjusting for relevant confounders.

RESULTS

In the high education group, reporting low (b = -1.09, P = .02, 95% CI = -1.99, -0.18) and very high (b = -1.88, P = .003, 95% CI = -3.11, -0.65) discrimination was associated with lower allostatic load (reference=moderate). Among those with lower education, reporting low (b = 2.05, P = .008, 95% CI = 0.55,3.56) discrimination was associated with higher allostatic load. Similar but less consistent associations were found for poverty status. Associations were similar for cardiometabolic functioning, but not for neuroendocrine or inflammatory activity.

CONCLUSIONS

Racial discrimination may be an important predictor of cumulative physiologic dysregulation. Factors associated with educational attainment may mitigate this association for African American women and other groups experiencing chronic social stress.

Discrimination and Chronic Kidney Disease among Caribbean Blacks: The Effects of Immigration and Social Status

This study examined the association between discrimination and chronic kidney disease (CKD) among Caribbean blacks and how this association varies by marital status, educational attainment, and length of U.S. residency within the frameworks for the stress buffering hypothesis and stress process model. The analysis was based on the Caribbean black subsample of the National Survey of American Life (N = 1551). Logistic regression models were conducted to test the aims of this study. The findings indicate that the association between discrimination and CKD varied by length of U.S. residency, marital status, and education. Overall, the findings demonstrate the importance of considering immigration and sociodemographic context when investigating the relation between discrimination and CKD in immigrant populations.

Weathering the storm; a review of pre-pregnancy stress and risk of spontaneous abortion

The Weathering Effect is a theory that links stress exposure, over the life-course, with racial disparities in reproductive outcomes, through the effects of social adversity on a woman's body. The concept of maternal "weathering" captures cumulative somatic and psychological adversities that can exacerbate the effects of aging. Much of the evidence for weathering comes from observational studies linking self-report measures with reproductive outcomes. The purpose of this review is to explore biological mechanisms that underlie these observations. We focus on spontaneous abortion because this event is understudied despite evidence of racial disparities in this outcome. Spontaneous abortion is the most common pregnancy failure, and it happens early in pregnancy. Early pregnancy is a time most susceptible to the harmful effects of immune dysregulation that may, in part, result from adversities experienced before pregnancy begins. In exploring these mechanisms, we draw on well-defined signaling processes observed in the stressor-depression relationship. Pro-inflammatory dysregulation, for example, has particular relevance to immunological control occurring early in pregnancy. Early pregnancy immunologic changes affect the trajectories of pregnancy via control of trophoblastic invasion. Within the first few weeks of pregnancy, uterine derived cytokines operate within cytokine networks and play a critical role in this invasion. Programming for pro-inflammatory dysregulation can occur before conception. This dysregulation, brought into early pregnancy, has implications for viability and success of the index pregnancy. These patterns suggest early pregnancy health is susceptible to stress processing pathways that influence this immunologic control in the first six to eight weeks of pregnancy. In this review, we discuss the known mediating role of immune factors in the stressor-depression relationship. We also discuss how adversity experienced before the index pregnancy, or "pre-pregnancy" may influence these pathways, and subsequently influence early pregnancy health. There is a need to understand adversity, experienced before pregnancy, and mechanisms driving the effects of these experiences on pregnancy outcomes. This approach is a useful entry point for understanding racial inequities in pregnancy health through an understanding of differences in exposures to adversity. We hypothesize that spontaneous abortion involves cyclical changes within a woman's reproductive tract in response to stressors that are established well before a woman enters into pregnancy. Furthermore, we propose mechanisms that potentially drive weathering processes relevant to reproductive disparities. We also examine what is known about pre-pregnancy stress exposures associated with race, inequity, and adversity, and their potential impact on neuroendocrine and immune changes affecting early pregnancy risk.

Discrimination and Health Among Taxi Drivers in New York and Toronto

Immigrant taxi drivers in metropolitan cities are exposed to experiences of discrimination and occupation-based health risks. Given the structural differences in health care systems in the United States and Canada, we investigated the differences in reports of discrimination, health conditions and concern about health conditions between taxi drivers in New York City and Toronto, Ontario. Participants were recruited for a taxi driver Needs Assessment Survey as part of a Taxi Network needs assessment project using a street side convenience sampling technique in New York City and Toronto. The matched sample contained 33 drivers from Toronto and 33 drivers from NYC. All Toronto drivers in our sample reported having health insurance while over a quarter of NYC drivers did not have health insurance. Toronto drivers reported greater everyday and workplace discrimination. Drivers in both cities experienced higher rates than average, and reported concern about, major health conditions. We also found preliminary evidence suggesting a relationship between experiencing discrimination and reporting chronic pain. Our findings suggest the need for future research to more closely examine the associations between discrimination and health among the taxi driver population.

The stressors of being young and Black: Cardiovascular health and Black young adults

OBJECTIVE

To examine the impact of stressors relevant to the lives of Black young adults including racial, financial, occupational, and general stress and psychological distress on cardiovascular disease (CVD) risk. Specifically, this study examined the relationship between multiple psychosocial stressors and two CVD risk indicators (i.e. obesity and blood pressure).

DESIGN

This study used a quantitative design which included surveys, the collection of anthropometric and blood pressure (BP) measures. Participants were 124 Black college students aged 18 to 27 years old.

MAIN OUTCOME MEASURES

Participants completed measures to assess psychological distress, general, occupational, financial and racial stress. Measures of body mass index (BMI), waist-to-hip ratio (WHR) and BP were collected to assess CVD risk.

RESULTS

Findings indicated a significant effect of internalised racism on BMI and a significant effect of individual racial stress on diastolic BP. Also, depression was significantly associated with systolic BP. There were no significant results for WHR.

CONCLUSION

Findings suggested that the relationship among racial stress, psychological distress and CVD be further explored.

Racial discrimination, socioeconomic position, and illicit drug use among US Blacks

PURPOSE

We assessed the relationship of self-reported racial discrimination with illicit drug use among US Blacks, and whether this differed by socioeconomic position (SEP).

METHODS

Among 6587 Black participants in Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (2004-2005), we used multiple logistic regression models to test the association between racial discrimination (measured on the 6-item Experiences of Discrimination scale) and past-year illicit drug use, and whether this differed by SEP.

RESULTS

Racial discrimination was associated with past-year drug use [adjusted odds ratio (aOR) 2.32; 95 % confidence interval (CI) 1.70, 3.16] and with frequent drug use (aOR 1.91; 95 % CI 1.22, 2.99). For frequent illicit drug use, this relationship was stronger among higher SEP participants (aOR 3.55; 95 % CI 2.09, 6.02; p interaction < 0.01).

CONCLUSIONS

The stronger association between racial discrimination and frequent illicit drug use among higher SEP Blacks suggests a complex interplay between disadvantaged and privileged statuses that merits further investigation. The finding of a significant difference by SEP highlights the importance of considering differences within heterogeneous race/ethnic groups when investigating health disparities.

Discrimination and excessive weight gain during pregnancy among Black and Latina young women

RATIONALE

Excessive weight gain during pregnancy is a major determinant of later life obesity among both Black and Latina women and their offspring. However, psychosocial determinants of this risk, including everyday discrimination, and potential moderators of such effects remain unexplored.

OBJECTIVE

We examined the influence of discrimination, a culturally relevant stressor, on odds of gaining weight beyond Institute of Medicine recommendations during pregnancy. Whether the effect was moderated by race/ethnicity, age, or depressive symptoms was also examined.

METHOD

Participants were 413 Black and Latina pregnant young women, ages 14-21 years. Experience with discrimination and all moderators were assessed in the second trimester. Last weight recorded in the third trimester was abstracted from medical records and used to determine excessive weight gain.

RESULTS

Ever experiencing discrimination was associated with a 71% increase in the odds of excessive weight gain. The effect of discrimination was primarily present among women who attributed this treatment to membership in a historically oppressed group (e.g., ethnic minority, female) or to membership in other stigmatized groups (e.g., overweight). The effect of ever experiencing discrimination was not moderated by race/ethnicity or age but was moderated by depressive symptoms. Supporting the perspective of the environmental affordances model, discrimination strongly predicted excessive weight gain when women were low in depressive symptoms but had no effect when women were high in depressive symptoms. The moderating role of depressive symptoms was equivalent for Black and Latina women.

CONCLUSION

Results highlight the role of discrimination in perpetuating weight-related health disparities and suggest opportunities for improving health outcomes among young pregnant women.

Racial Discrimination and HIV-related Risk Behaviors in Southeast Louisiana

OBJECTIVES

We examined the relationship between cumulative experiences of racial discrimination and HIV-related risk taking, and whether these relationships are mediated through alcohol use among African Americans in semi-rural southeast Louisiana.

METHODS

Participants (N = 214) reported on experiences of discrimination, HIV sexual risk-taking, history of sexually transmitted infection (STI), and health behaviors including alcohol use in the previous 90 days. Experiences of discrimination (scaled both by frequency of occurrence and situational counts) as a predictor of a sexual risk composite score as well as a history of STI was assessed using multivariate linear and logistic regression, respectively, including tests for mediation by alcohol use.

RESULTS

Discrimination was common in this cohort, with respondents confirming their experience on average 7 of the 9 potential situations and on more than 34 separate occasions. After adjustment, discrimination was significantly associated with increasing sexual risk-taking and lifetime history of STI when measured either by frequency of occurrence or number of situations, although there was no evidence that these relationships were mediated through alcohol use.

CONCLUSIONS

Cumulative experiences of discrimination may play a significant role in sexual risk behavior and consequently increase vulnerability to HIV and other STIs.

Discrimination, mental health, and leukocyte telomere length among African American men

African American men in the US experience disparities across multiple health outcomes. A common mechanism underlying premature declines in health may be accelerated biological aging, as reflected by leukocyte telomere length (LTL). Racial discrimination, a qualitatively unique source of social stress reported by African American men, in tandem with poor mental health, may negatively impact LTL in this population. The current study examined cross-sectional associations between LTL, self-reported racial discrimination, and symptoms of depression and anxiety among 92 African American men 30-50 years of age. LTL was measured in kilobase pairs using quantitative polymerase chain reaction assay. Controlling for sociodemographic factors, greater anxiety symptoms were associated with shorter LTL (b=-0.029, standard error [SE]=0.014; p<0.05). There were no main effects of racial discrimination or depressive symptoms on LTL, but we found evidence for a significant interaction between the two (b=0.011, SE=0.005; p<0.05). Racial discrimination was associated with shorter LTL among those with lower levels of depressive symptoms. Findings from this study highlight the role of social stressors and individual-level psychological factors for physiologic deterioration among African American men. Consistent with research on other populations, greater anxiety may reflect elevated stress associated with shorter LTL. Racial discrimination may represent an additional source of social stress among African American men that has detrimental consequences for cellular aging among those with lower levels of depression.

Discrimination and Cumulative Disease Damage Among African American Women With Systemic Lupus Erythematosus

OBJECTIVES

We examined associations between unfair treatment, attributions of unfair treatment to racial discrimination, and cumulative disease damage among African American women with systemic lupus erythematosus (SLE).

METHODS

We used multivariable regression models to examine SLE damage among 578 African American women in metropolitan Atlanta, Georgia, recruited to the Georgians Organized Against Lupus cohort.

RESULTS

When we controlled for demographic, socioeconomic, and health-related covariates, reporting any unfair treatment was associated with greater SLE damage compared with reporting no unfair treatment (b = 0.55; 95% confidence interval = 0.14, 0.97). In general, unfair treatment attributed to nonracial factors was more strongly associated with SLE damage than was unfair treatment attributed to racial discrimination, although the difference was not statistically significant.

CONCLUSIONS

Unfair treatment may contribute to worse disease outcomes among African American women with SLE. Unfair treatment attributed to nonracial causes may have a more pronounced negative effect on SLE damage. Future research may further examine possible differences in the effect of unfair treatment by attribution.

Self-reported experiences of discrimination and health: scientific advances, ongoing controversies, and emerging issues

Over the past two decades, research examining the impact of self-reported experiences of discrimination on mental and physical health has increased dramatically. Studies have found consistent associations between exposure to discrimination and a wide range of Diagnostic and Statistical Manual of Mental Disorders (DSM)-diagnosed mental disorders as well as objective physical health outcomes. Associations are seen in cross-sectional as well as longitudinal studies and persist even after adjustment for confounding variables, including personality characteristics and other threats to validity. However, controversies remain, particularly around the best approach to measuring experiences of discrimination, the significance of racial/ethnic discrimination versus overall mistreatment, the need to account for "intersectionalities," and the importance of comprehensive assessments. These issues are discussed in detail, along with emerging areas of emphasis including cyber discrimination, anticipatory stress or vigilance around discrimination, and interventions with potential to reduce the negative effects of discrimination on health. We also discuss priorities for future research and implications for interventions and policy.

"More than skin deep": stress neurobiology and mental health consequences of racial discrimination

Ethnic minority groups across the world face a complex set of adverse social and psychological challenges linked to their minority status, often involving racial discrimination. Racial discrimination is increasingly recognized as an important contributing factor to health disparities among non-dominant ethnic minorities. A growing body of literature has recognized these health disparities and has investigated the relationship between racial discrimination and poor health outcomes. Chronically elevated cortisol levels and a dysregulated hypothalamic-pituitary-adrenal (HPA) axis appear to mediate effects of racial discrimination on allostatic load and disease. Racial discrimination seems to converge on the anterior cingulate cortex (ACC) and may impair the function of the prefrontal cortex (PFC), hence showing substantial similarities to chronic social stress. This review provides a summary of recent literature on hormonal and neural effects of racial discrimination and a synthesis of potential neurobiological pathways by which discrimination affects mental health.

Pathways between perceived discrimination and health among immigrants: evidence from a large national panel survey in Germany

OBJECTIVE

Discrimination is an important determinant of health, and its experience may contribute to the emergence of health inequalities between immigrants and nonimmigrants. We examine pathways between perceived discrimination and health among immigrants in Germany: (1) whether perceptions of discrimination predict self-reported mental and physical health (SF-12), or (2) whether poor mental and physical health predict perceptions of discrimination, and (3) whether discrimination affects physical health via mental health.

DESIGN

Data on immigrants come from the German Socio-Economic Panel (SOEP) from the years 2002 to 2010 (N = 8,307), a large national panel survey. Random and fixed effects regression models have been estimated.

RESULTS

Perceptions of discrimination affect mental and physical health. The effect of perceived discrimination on physical health is mediated by its effect on mental health. Our analyses do not support the notion that mental and physical health predict the subsequent reporting of discrimination. Different immigrant groups are differentially exposed to perceived discrimination.

CONCLUSION

In spite of anti-discrimination laws, the health of immigrants in Germany is negatively affected by perceived discrimination. Differential exposure to perceived discrimination may be seen as a mechanism contributing to the emergence of health inequalities in Germany.

Experiences of racism and the incidence of adult-onset asthma in the Black Women's Health Study

BACKGROUND

Chronic stress resulting from experiences of racism may increase the incidence of adult-onset asthma through effects on the immune system and the airways. We conducted prospective analyses of the relation of experiences of racism with asthma incidence in the Black Women's Health Study, a prospective cohort of black women in the United States followed since 1995 with mailed biennial questionnaires.

METHODS

Among 38,142 participants followed from 1997 to 2011, 1,068 reported incident asthma. An everyday racism score was created based on five questions asked in 1997 and 2009 about the frequency in daily life of experiences of racism (eg, poor service in stores), and a lifetime racism score was based on questions about racism on the job, in housing, and by police. We used Cox regression models to derive multivariable incidence rate ratios (IRRs) and 95% CIs for categories of each racism score in relation to incident asthma.

RESULTS

The IRRs were 1.45 (95% CI, 1.19-1.78) for the highest compared with the lowest quartile of the 1997 everyday racism score (P for trend<.0001) and 1.44 (95% CI, 1.18-1.75) for the highest compared with the lowest category of 1997 lifetime racism. Among women who reported the same levels of racism in 1997 and 2009, the IRRs for the highest categories of everyday and lifetime racism were 2.12 (95% CI, 1.55-2.91) and 1.66 (95% CI, 1.20-2.30), respectively.

CONCLUSIONS

Given the high prevalence of experiences of racism and asthma in black women in the United States, a positive association between racism and asthma is of public health importance.

Discrimination, racial bias, and telomere length in African-American men

BACKGROUND

Leukocyte telomere length (LTL) is an indicator of general systemic aging, with shorter LTL being associated with several chronic diseases of aging and earlier mortality. Identifying factors related to LTL among African Americans may yield insights into mechanisms underlying racial disparities in health.

PURPOSE

To test whether the combination of more frequent reports of racial discrimination and holding a greater implicit anti-black racial bias is associated with shorter LTL among African-American men.

METHODS

Cross-sectional study of a community sample of 92 African-American men aged between 30 and 50 years. Participants were recruited from February to May 2010. Ordinary least squares regressions were used to examine LTL in kilobase pairs in relation to racial discrimination and implicit racial bias. Data analysis was completed in July 2013.

RESULTS

After controlling for chronologic age and socioeconomic and health-related characteristics, the interaction between racial discrimination and implicit racial bias was significantly associated with LTL (b=-0.10, SE=0.04, p=0.02). Those demonstrating a stronger implicit anti-black bias and reporting higher levels of racial discrimination had the shortest LTL. Household income-to-poverty threshold ratio was also associated with LTL (b=0.05, SE=0.02, p<0.01).

CONCLUSIONS

Results suggest that multiple levels of racism, including interpersonal experiences of racial discrimination and the internalization of negative racial bias, operate jointly to accelerate biological aging among African-American men. Societal efforts to address racial discrimination in concert with efforts to promote positive in-group racial attitudes may protect against premature biological aging in this population.

Self-Reported Experiences of Discrimination and Cardiovascular Disease

Researchers have long speculated that exposure to discrimination may increase cardiovascular disease (CVD) risk but compared to other psychosocial risk factors, large-scale epidemiologic and community based studies examining associations between reports of discrimination and CVD risk have only emerged fairly recently. This review summarizes findings from studies of self-reported experiences of discrimination and CVD risk published between 2011-2013. We document the innovative advances in recent work, the notable heterogeneity in these studies, and the considerable need for additional work with objective clinical endpoints other than blood pressure. Implications for the study of racial disparities in CVD and clinical practice are also discussed.

Mediators of discrimination and self-rated health among African Americans

OBJECTIVES

To examine whether stress and depressive symptoms mediated relationships of perceived discrimination and self-rated health among African Americans.

METHODS

A nonparametric bootstrapping procedure was used to assess mediation, controlling for sociodemographic variables, among 1406 cohort study adults (age=45.5±12.6, 25.1% male).

RESULTS

Greater discrimination was associated with poorer self-rated health (β =-.010, SE=.003, p = .001). Stress and depressive symptoms were each significant mediators of this relationship in single and multiple mediator models (ps ≤ 05).

CONCLUSIONS

Perceived discrimination may contribute to poorer self-rated health among African Americans through heightened levels of stress and depression. Interventions addressing these mechanisms might help reduce the impact of discrimination on health. Definitive results await longitudinal study designs to assess causal pathways.

Perceived racial/ethnic discrimination, problem behaviors, and mental health among minority urban youth

OBJECTIVES

We examined perceived frequency and intensity of racial/ethnic discrimination and associations with high-risk behaviors/conditions among adolescents.

DESIGN

With surveys from 2490 racial/ethnic minority adolescents primarily with low socioeconomic status, we used regression analysis to examine associations between racial/ethnic discrimination and behavioral health outcomes (alcohol use, marijuana use, physical aggression, delinquency, victimization, depression, suicidal ideation, and sexual behaviors).

RESULTS

Most adolescents (73%) experienced racial/ethnic discrimination and 42% of experiences were 'somewhat-' or 'very disturbing.' Adolescents reporting frequent and disturbing racial/ethnic discrimination were at increased risk of all measured behaviors, except alcohol and marijuana use. Adolescents who experienced any racial/ethnic discrimination were at increased risk for victimization and depression. Regardless of intensity, adolescents who experienced racial/ethnic discrimination at least occasionally were more likely to report greater physical aggression, delinquency, suicidal ideation, younger age at first oral sex, unprotected sex during last intercourse, and more lifetime sexual partners.

CONCLUSION

Most adolescents had experienced racial/ethnic discrimination due to their race/ethnicity. Even occasional experiences of racial/ethnic discrimination likely contribute to maladaptive behavioral and mental health outcomes among adolescents. Prevention and coping strategies are important targets for intervention.