A multi-group path analysis of the relationship between perceived racial discrimination and self-rated stress: how does it vary across racial/ethnic groups?

A systematic review of how social connectedness influences associations between racism and discrimination on health outcomes

Racial discrimination is a well-known risk factor of racial disparities in health. Although progress has been made in identifying multiple levels through which racism and racial discrimination influences health, less is known about social factors that may buffer racism's associations with health. We conducted a systematic review of the literature with a specific focus on social connectedness, racism, and health, retrieving studies conducted in the United States and published between January 1, 2012, and July 30, 2022, in peer-reviewed journals. Of the 787 articles screened, 32 were selected for full-text synthesis. Most studies (72%) were at the individual level, cross-sectional, and among community/neighborhood, school, or university samples. Studies had good methodological rigor and low risk of bias. Measures of racism and racial discrimination varied. Discrimination scales included unfair treatment because of race, schedule of racist events, experiences of lifetime discrimination, and everyday discrimination. Measures of social connectedness (or disconnectedness) varied. Social-connectedness constructs included social isolation, loneliness, and social support. Mental health was the most frequently examined outcome (75%). Effect modification was used in 56% of studies and mediation in 34% of studies. In 81% of studies, at least 1 aspect of social connectedness significantly buffered or mediated the associations between racism and health. Negative health associations were often weaker among people with higher social connectedness. Social connectedness is an important buffering mechanism to mitigate the associations between racial discrimination and health. In future studies, harmonizing metrics of social connectedness and racial discrimination can strengthen causal claims to inform interventions.

A Critical Race Theory Analysis of Mental Health Disparities Research

Health disparities and the impact of racism on the mental and physical health of people of color has been well-documented. However, health research has historically approached race as a genetic and biological attribute to explain differences in health outcomes. Although more recent policies and research have begun to move toward conceptualizing race as a socially constructed category that can be thought of as a proxy for racism, the ways in which race and racism are conceptualized in mental health disparities research needs deeper analysis. Using critical race theory (CRT) and content analysis, we investigate how mental health research has examined race, racism, and mental health in PubMed articles published between 2012 and 2022. Findings suggest a need for more complex conceptualizations of race, particularly related to essentialized, monoracial framings that rarely explore how race is defined and employed. Much of the research analyzed did not position racism, discrimination, or oppression as central to contextualizing racial mental health disparities. Additionally, the role of voice was often missing, limiting understandings of racialized experiences. Results of this analysis illuminate areas the need for more racism conscious approaches to understanding racial disparities in mental health and identifying opportunities to promote health equity.

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.

Association between race/color and incidence of hypertension in the ELSA-Brasil population: investigating the mediation of racial discrimination and socioeconomic position

OBJECTIVE

To investigate the mediation effect of socioeconomic position and racial discrimination in the association between race/color and incidence of hypertension in 4-years follow up.

METHODS

We included 8,370 participants of the Longitudinal Study of Adult Health (ELSA-Brasil). A latent variable was constructed to represent socioeconomic position (SEP). The perception of discrimination was measured through an adaptation of the Lifetime Major Events Scale; and hypertension was defined using standard criteria. We investigated Body Mass Index (BMI) due to its role in proximal risk for hypertension. To investigate the mediating role of SEP and racial discrimination, we used structural equation modeling.

RESULTS

SEP had a direct and negative effect on HT incidence (HT incidence increased in worse SEP categories), while the effect of BMI on HT was direct and positive. We did not find significant direct effects of race/color and racial discrimination on HT. As for indirect effects, we observed associations between race/color and HT only through SEP mediation.

CONCLUSION

According to our results, race/color is indirectly related to HT incidence, mediated by SEP. Racial discrimination was not a mediator in the relationship between race/color and HT in the follow-up period.

An examination of ACEs, the internalization of the Superwoman Schema, and mental health outcomes among Black adult women

Despite the growing literature on the mental health implications of adverse childhood events (ACEs), little empirical evidence considers the role of sociocultural scripts in Black women's experiences of trauma and mental health. Emerging scholarship suggests that gendered racial stereotypes, such as the Superwoman Schema, might worsen the impact of ACEs on the mental health outcomes of Black women in the U.S. To address this gap, we sought to examine relationships among Black women's exposure to ACEs, endorsement of the Superwoman Schema, and mental health outcomes. The current sample included 447 Black women (20-35 years old) who completed measures of adverse childhood events, Superwoman Schema endorsement, and mental health (stress, anxiety, and depression). ACEs and endorsement of the Superwoman Schema were associated with higher stress, anxiety, and depressive symptomology. Additionally, Black women who experienced more ACEs and felt a stronger obligation to present an image of strength indicated more stress. Black women who experienced more ACEs and had a stronger determination to succeed reported higher anxiety. These results offer further evidence of the role of the Superwoman Schema on Black women's mental health. The authors discuss future research directions and clinical implications regarding the interconnections among sociocultural scripts of Black womanhood and trauma experiences.

Self-reported experiences of discrimination in older black adults are associated with insula functional connectivity

Self-reported experiences of discrimination are associated with a number of negative health outcomes. However, the neurobiological correlates of discrimination remain elusive. Recent neuroimaging work suggests that the amygdala is sensitive to forms of social adversity and the insula is involved in assessments of trust. We hypothesized that functional connectivity (FC) of these brain regions may be associated with discrimination in older Black adults. One-hundred and twenty-four nondemented older Black adults participating in the Minority Aging Research Study or the Clinical Core study of the Rush Alzheimer's Disease Center completed a measure of self-reported experiences of discrimination and a 3T MRI brain scan including structural T1 and resting-state fMRI EPIBOLD sequences. The right and left amygdala and insula regions were anatomically delineated as ROIs according to the Harvard-Oxford Brain Atlas and whole-brain voxelwise FC analyses were conducted using default parameters in the CONN toolbox. In regression analyses controlling for demographics and global cognition, self-reported experiences of discrimination were associated with greater FC between the left insula and the bilateral intracalcarine cortex, weaker FC between the left insula and the left dorsolateral prefrontal cortex, and weaker FC between the right insula and the left supplementary motor area. Amygdala analyses yielded no significant findings. Greater self-reported experiences of discrimination are associated with differential insula functional connectivity in older adults. More specifically, results suggest that discrimination is associated with differential connectivity of a key region (the insula) involved in trust perception.

Pathways to Well-being among LGBT adults: Sociopolitical Involvement, Family Support, Outness, and Community Connectedness with Race/Ethnicity as a Moderator

People who identify as lesbian, gay, bisexual, and/or transgender (LGBT) experience disparate levels of psychological distress due to marginalization, yet there are also opportunities for community connectedness and sociopolitical involvement in identify-specific issues and organizations, which may improve psychological well-being. This study contributes to intersectional research on LGBT psychological well-being by locating LGBT community connectedness as a mediator of the associations between well-being and (a) LGBT sociopolitical involvement and (b) being out as LGBT among a sample of predominately LGBT-identified adults in the United States and Puerto Rico (n = 4940) across four racial/ethnic identity groups: non-Hispanic Black, Latinx/Hispanic, non-Hispanic White, and other races/ethnicities. Analyses revealed that separate models were operating across racial/ethnic identity groups. Path analysis further showed that LGBT community connectedness mediated (either partially or fully) the effects of both LGBT sociopolitical involvement and outness on well-being. Direct effects on well-being were also found for family support across all groups and for outness only among the non-Hispanic White and other races/ethnicities groups. Community leaders and practitioners should seek to create opportunities for LGBT sociopolitical involvement and other activities that may facilitate feeling connected to LGBT community as part of efforts to promote LGBT well-being.

Veterans' perceptions of racial bias in VA mental healthcare and their impacts on patient engagement and patient-provider communication

OBJECTIVES

Drawing from social identity threat theory, which posits that stigmatized groups are attuned to situational cues that signal racial bias, we examined how African-American veterans evaluate verbal and non-verbal cues in their mental health encounters. We also explored how their evaluations of perceived racial bias might influence their healthcare engagement behaviors and communication.

METHODS

We interviewed 85 African-American veterans who were receiving mental health services from the US Department of Veterans Affairs (VA), examining their views and experiences of race in healthcare. We analyzed the data using a constructivist grounded theory approach.

RESULTS

Participants identified several identity threatening cues that include lack of racial diversity representation in healthcare settings, and perceptions of providers' fears of Black patients. We describe how participants evaluated situational cues as identity threats, and how these cues affected their engagement behaviors and healthcare communication.

CONCLUSION

Our findings revealed situational cues within clinical encounters that create for Black veterans, fear of being negatively judged based on stereotypes that have characterized African-Americans.

PRACTICE IMPLICATIONS

We discuss the implications of these findings and provide suggestions on how to create identity safe environments for minority patients that include delivery of person-centered care, and organizational structures that reduce providers' burnout.

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.

Linking perceived discrimination during adolescence to health during mid-adulthood: Self-esteem and risk-behavior mechanisms

RATIONALE

The literature on the effect of perceived discrimination on health has three gaps. First, the long-term relationship between perceived discrimination and health is underexplored. Second, the mechanisms through which perceived discrimination affects health remain unclear. Third, most studies focus on racial/ethnic discrimination, and other aspects of discrimination are overlooked.

OBJECTIVE

This study aims to fill these gaps by testing a research framework that links the discriminatory experience during adolescence to an individual's health during mid-adulthood via self-esteem and risk behaviors at early adulthood.

METHOD

Structural equation modeling is applied to the National Longitudinal Survey of Youth, 1979 Cohort (N = 6478).

RESULTS

The discriminatory experience during adolescence imposes an adverse impact on health during mid-adulthood even after accounting for other potential covariates, a detrimental effect lasting for over 30 years. In addition, while perceived discrimination reduces self-esteem at early adulthood, it affects only mental health during mid-adulthood, rather than general health. Finally, the discriminatory experience promotes risk behaviors at early adulthood and the risk behaviors subsequently compromise health during mid-adulthood.

CONCLUSIONS

Using a life course perspective, we find that the effect of perceived discrimination is more profound than the literature suggested and that risk behaviors may account for approximately 17% of the total effect of perceived discrimination on health. Our findings highlight the importance of early interventions in coping with perceived discrimination during adolescence.