Association of race consciousness with the patient-physician relationship, medication adherence, and blood pressure in urban primary care patients.

Blacks are disproportionately affected by hypertension, having the highest prevalence in the United States and one of the highest rates worldwide.1,2 Compared with whites, blacks are more likely to have hypertension and be treated with antihypertensive medications but are less likely to have controlled blood pressure (BP).3,4 Furthermore, blacks report lower rates of antihypertensive medication adherence.5,6 Perceived discrimination4,7–9 and impaired patient–physician relationships10,11 are 2 potential mechanisms for racial disparities in adherence and hypertension control. It has been suggested that blacks who face discrimination on a day-to-day basis may “ready themselves” to cope with overt and covert forms of racism through adoption of survival strategies.7,12,13 Clark and colleagues14 conceptualize racism as an environmental stressor that, depending on how it is perceived, activates an individual’s coping responses, resulting in a cascade of psychological and physiological responses (allostatic load) that then contribute to health outcomes. The resultant elevation of environmental vigilance and anticipatory threat may contribute to racial disparities in health generally7,8,15 and specifically to risk of hypertension among blacks.7 Furthermore, psychological distress among blacks has been independently predictive of the development of hypertension;16 thus the constant psychological vigil and heightened physiological response associated with racial discrimination among blacks may increase their risk of hypertension.7 Although perceived discrimination and individual reactions to it may have a direct impact on BP, there is also ample support for an indirect influence on BP through effects of perceived discrimination on patient adherence8 and the patient–physician relationship.10,17,18 The existing body of literature does not comprehensively examine the associations between reactions to discrimination and adherence to antihypertensive regimens, patient–provider relationships, and BP among persons with hypertension. Therefore, further investigation is necessary to elucidate these potential mechanisms for racial disparities. Race consciousness is a novel measure of racial climate at the individual level, originally described by Jones as one potential mechanism to characterize and assess the impact of multiple dimensions of racial discrimination on health disparities.19 Among blacks, race consciousness is postulated as a heightened awareness of one’s stigmatized status, resulting in heightened vigilance and anticipatory stress toward the threat of discrimination, which could contribute to elevated rates of hypertension and other cardiovascular health issues.7,8 Indeed, recent work links anticipation of or perseveration on possible discrimination (termed “racism-related vigilance”) to disparities in sleep difficulty between blacks and whites20 and hypertension prevalence and large arterial elasticity among blacks.21,22 There is less knowledge about the meaning of race consciousness and its potential effects among whites. The experience may differ from that for blacks; however, both racial groups may experience psychological stress as a result, leading to poor health. One theory suggests that a strong white racial identity has both progressive and defensive components; thus, race consciousness could have varied meaning and reflect polarized reactions to the social environment among whites of different backgrounds.23 Given the socially dominant status of whites in the United States, higher levels of race consciousness could reflect greater awareness of white privilege.24 Another explanation, particularly among whites who reside in areas with a high black population, is that race consciousness represents heightened fear of victimization, an anxiety-provoking stressor.25 Scholars of critical race theory are still debating whether race consciousness enhances or adversely affects the health of whites.26 The clinical relevance of race consciousness and its contribution to racial disparities in hypertension is relatively unexplored. Most studies use indirect measures such as perceived racial discrimination or racial identity.27 We sought to explore race consciousness and its effect on the patient–physician relationship, medication adherence, and BP control among urban primary care patients. We hypothesized that race consciousness is a measure of vigilance and anticipatory stress among blacks and anxiety-provoked stress among whites, both of which are associated with poorer ratings of the patient–physician relationship, lower medication adherence, and higher BP.