Effects of Perceived Racial Discrimination on Health Status and Health Behavior: A Differential Mediation Hypothesis

Significant differences in health status between African Americans (Blacks) and European Americans (Whites) exist in the U.S., even when controlling for a variety of economic, environmental, and physiological factors (Dressler, Oths, & Gravlee, 2005). These differences have led a number of researchers to recommend that future studies pay more attention to psychosocial factors as contributors to health disparities in the U.S. and in other countries; primary among these factors is perceived racial discrimination (Mays, Cochran, & Barnes, 2007; Williams & Mohammed, 2009). There have been three reviews of this expanding literature in the past 10 years (Paradies, 2006; Pascoe & Richman, 2009; Williams, Neighbors, & Jackson, 2003), and all of them have reached similar conclusions: Discrimination is associated with worse mental and physical health. These reviews provide the background for the current study, which examines the relations between discrimination and physical health status versus health-impairing behavior (i.e., problematic drinking). Discrimination and Physical Health The relation between discrimination and mental health is straightforward: Discrimination leads to an increase in negative affect, which can produce a decline in mental health. Self-reports of discrimination have been associated with elevated anxiety and depression (referred to here, collectively, as distress) (Bynum et al., 2007), as well as anger and hostility (Simons et al., 2006; Whitbeck, Hoyt, McMorris, Chen, & Stuben, 2001). Pascoe and Richman’s meta-analysis identified 105 studies that included measures of discrimination and mental health status. They produced a weighted average correlation of -.20 between discrimination and mental health outcomes. Almost all of these studies were cross-sectional; however, Schulz et al. (2006) found that increases in self-reported discrimination predicted increases in depression and decreases in perceived overall general health. Pascoe and Richman also identified 36 studies reporting a relation (almost all synchronous) between discrimination and indicators of physical health (e.g., self-reports of overall health status). The average correlation in these studies was -.13. Although the correlations between discrimination and mental vs. physical health were not significantly different, Pascoe and Richman suggest that the relation with mental health may be somewhat stronger. Others have reached the same conclusion, pointing out that the effect of discrimination on physical health may be robust, but it takes longer for discrimination to produce physical health problems than either distress or hostility (Paradies, 2006). The primary reason is that the former relation is mediated by the latter (discrimination → distress → morbidity), and, therefore, may not appear in cross-sectional analyses (Gee & Walsemann, 2009). In fact, both the first and second paths of the discrimination → distress → health problems linkage have been shown repeatedly, but almost always in separate studies. Discrimination and Substance Use Discrimination also affects health status through its effects on health-impairing behaviors. Pascoe and Richman identified 13 studies that linked discrimination with unhealthy behaviors, such as substance use, and found an average correlation of .18. Several of these studies included prospective data. Gibbons et al. (2004) found that discrimination assessed at age 10/11 predicted substance use five years later in a panel of Black adolescents in the Family and Community Health Study (FACHS). A similar relation between discrimination and problematic substance use was also found among the parents of these Black children. In fact, discrimination was the strongest predictor of problematic use of all of the factors that were assessed with the parents, including multiple types of stressors (social, financial, familial) and contextual factors (e.g., substance availability, neighborhood crime). In addition, analyses with both the parents and the adolescents found that the relation between discrimination and use was mediated by change in distress; in other words, discrimination at T1 predicted an increase in anxiety and depression from T1 to T2 (two years later), and this increase in distress was associated with an increase in self-reported use. Mediation of the Relations between Discrimination and Substance Use Anger vs. distress A subsequent series of studies with the FACHS sample, using both survey and experimental methods (Gibbons et al., 2010), suggested that the discrimination → use relation may be more complex than originally thought. When anger (with the adolescents) and hostility (with the parents) were added to the models as mediators, discrimination predicted changes in both distress and anger, as expected. However, the path from distress to use was no longer significant; in essence, it was replaced by the path from hostility to use. More specifically, for the parents, discrimination at T1 was associated with an increase in hostility at T2, and this change predicted an increase in problematic use three years later. The same pattern appeared with the adolescents: T1 discrimination was associated with elevated anger and distress, but only anger predicted use five years later; there was no (apparent) effect of distress. Experimental evidence In a follow-up lab study (Gibbons et al., 2010, Study 2), a subsample of the FACHS adolescents (M age = 19 years) was asked to envision one of the following: a discriminatory experience, a stressful nondiscriminatory experience, or a neutral experience, and then their mood states and willingness to use drugs were assessed. Relative to the two nondiscriminatory scenarios, discrimination was associated with an elevation in both anger and depression, as well as drug willingness. However, anger, but not depression, was associated with drug willingness; consequently, only anger mediated the impact of discrimination on willingness. Similar results were reported by Stock, Gibbons, Peterson, and Gerrard (in press) who used the “Cyberball” paradigm as a way to manipulate perceived discrimination. In this case, Black young adults (M age = 21.5) who thought they had been excluded by Whites in the Cyberball game reported more perceived discrimination (cf. Goodwin, Williams, & Carter-Sowell, 2010) and more willingness to use substances, and the relation between the two of them was mediated by anger (and not depression). Differential Mediation: Internalizing vs. Externalizing Reactions There is precedent in the literature for the differential mediation hypothesis, i.e., anger / hostility is more strongly related to substance use, whereas distress is more strongly related to health problems, but the evidence is mostly indirect. First, distress is often associated with avoidance of risky behaviors (Maner & Schmidt, 2006; Mitte, 2007). In contrast, anger / externalizing behavior has generally been associated with risk-taking (Rydell et al., 2008), including substance use (Aklin, Moolchan, Luckenbaugh, & Ernst, 2009). Whitbeck et al. (2001) measured discrimination and affect among American Indian adolescents, and found that discrimination was associated with both internalizing and externalizing symptoms, but only the latter were related to substance use. Bardone et al. (1998) found that conduct disorder (externalizing) predicted health-risk behavior, including risky sex and alcohol and drug use, but not health problems. In contrast, anxiety predicted medical problems, but not substance use (Laukkanen et al., 2002, found similar results). Overview Most reviews of the discrimination / health literature have included a call for additional prospective studies of the relations among discrimination, negative affect, and health outcomes in order to determine why discrimination has pronounced effects on both physical and mental health. Literature reviews have also recommended examination of additional affective reactions as mediators of the relation between stress and physical health problems (Lerner et al., 2007; Miller, Chen, & Parker, 2011). The current research examined these relations in a panel of Black women across four waves of data, spanning eight years. Analyses examined cumulative discrimination as a predictor of both health status and health-impairing behavior (problematic alcohol use), controlling for other types of stress (e.g., negative life events, financial hardship). The following differential mediation hypothesis was made: Perceived discrimination is associated with increases in both physical health problems and problematic substance use; however, the former relation is mediated by change in internalizing reactions (depression and anxiety), whereas the latter relation is mediated by change in externalizing reactions (hostility).