- Email: [email protected]
The differential impact of discrimination on health among Black and White women
Accepted Manuscript The differential impact of discrimination on health among Black and White women H. Shellae Versey, PhD, Nicola Curtin, PhD PII:
S0049-089X(16)00011-9
DOI:
10.1016/j.ssresearch.2015.12.012
Reference:
YSSRE 1870
To appear in:
Social Science Research
Received Date: 30 April 2014 Revised Date:
23 November 2015
Accepted Date: 31 December 2015
Please cite this article as: Versey, H.S., Curtin, N., The differential impact of discrimination on health among Black and White women, Social Science Research (2016), doi: 10.1016/ j.ssresearch.2015.12.012. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 1
RI PT
RUNNING HEAD: DISCRIMINATION, HEALTH AND MEDIATING PATHS
Corresponding Author:
TE D
H. Shellae Versey, PhD Wesleyan University Department of Psychology 207 High Street Middletown, CT 06459-0408 (860) 685-2868 Email: [email protected]
M AN U
SC
The differential impact of discrimination on health among Black and White women
AC C
EP
Co-author: Nicola Curtin, PhD Clark University Hiatt School of Psychology 950 Main Street Worcester, MA 01610 (508)793-8862 Email: [email protected]
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 1 Abstract Despite a large body of research examining the impact of discrimination on health, the ways in which perceived discrimination may lead to disparate health outcomes through a sense
RI PT
of self and system consciousness is less understood. The current paper is concerned with both mental and physical health consequences of discrimination, as well as mediating pathways
among African American and White women. Indirect effects analyses examine mediating paths
SC
from discrimination to health outcomes via structural awareness and self-esteem, using data from the Women’s Life Path Study (N = 237). Our findings suggest that discrimination is both directly
M AN U
and indirectly associated with health outcomes for both Black and White women, mediated by individual (self-esteem) and group-level (structural awareness) processes. Evidence from this study indicates that discrimination is associated with heightened structural awareness, as well as lower self-esteem – both of which are related to poorer health. Discrimination negatively
TE D
affected health across three domains, although the mechanisms varied somewhat for Black and White women. Broad implications of this research for interdisciplinary scholarship on the effects
EP
of discrimination on health and health disparities are discussed.
AC C
KEYWORDS: Perceived discrimination, health, self-esteem, structural awareness, mediation
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 2 In a contemporary climate where the effects of violence and racism claim front-page headlines across the nation, the question of whether racism and sexism makes us sick seems to hold an obvious answer (Silverstein, 2013). Valenti (2014) notes a body of evidence - both
RI PT
experimental and observational - that concludes that even the threat of racism is sufficient to “trigger a stress response.”
Indeed, research spanning three decades supports the notion that systems of oppression
SC
(e.g., racism, sexism) and differential treatment (discrimination) create an added burden that leads to poorer health for marginalized populations and individuals (Williams & Mohammed,
M AN U
2013). While an extensive review of this literature is beyond the scope of this paper, our intent is to situate the current study within this research tradition by expanding the focus on mental health outcomes as well as mediating processes.
A multilevel framework positions fundamental causes of racism as being rooted in an
TE D
organized system that separates racial groups into ranked categories by which members of lowerranked groups are devalued, disempowered and generally regarded as inferior. Resulting pathways indicate that race and other social status groups, such as age, gender and SES, are
EP
linked to health through a variety of intervening mechanisms (Williams, 1997). One means by which perceived discrimination negatively affects health is through psychological and stress
AC C
responses that affect self-esteem and group identity. Specifically, we draw on social psychological theory to argue that discrimination threatens two “basic” psychological needs that shape how individuals relate to the social world: communion and agency (Bakan, 1966; Swann & Bosson, 2010). The need for communion is strongly tied to self-esteem, and the need for agency is tied to the belief that one can achieve personal goals. We propose that discrimination threatens both needs, and ultimately compromises health. Because communion and agentic
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 3 orientations have been related to several psychological processes, including social status evaluations and self-concept, we use this theoretical framing to explore the effects of discrimination on health as mediated by threats to one’s self and group identity. As we argue
RI PT
below, one way to understand the deleterious effect of discrimination is to consider how it threatens aspects of the self, as well as one’s group identity. We test two paths from
discrimination to negative health outcomes. Further, given the lack of research on older women,
SC
and an increasing interest in intersectional approaches to thinking about important social and
middle-aged Black and White women. Perceived discrimination and health
M AN U
psychological issues, we examine how these pathways may be similar or different for older
We define discrimination as part of a manifestation of racism, sexism and other types of oppression that can be experienced both systemically (e.g., through organizations, institutions,
TE D
geography, policies and practices) and interpersonally (e.g., personal and social interactions). Or put simply, the expression and institutionalization of social relationships through dominance and oppression (Krieger, 2000). Perceived discrimination refers to the perceived negative attitudes
EP
or treatment resulting from this expression based upon group membership (Williams, Spencer, & Jackson, 1999). While the measurement of the construct has been subject to some debate
AC C
(Williams & Mohammed, 2009), we maintain, as have others, that experiences of perceived discrimination constitute a form of stress (Clark et al., 1999; Mays & Cochran, 2001; Pascoe & Smart Richman, 2009; Smedley, 2012). We also note that distinctions can be made regarding terminology – perceived discrimination, self-reported discrimination and discrimination. However, because we believe that these terms collectively refer to a general underlying process, they will be used interchangeably throughout.
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 4 The negative impact of discrimination on health has been documented extensively (Banks, Kohn-Wood, & Spender, 2006; Klonoff, Landrine, & Campbell, 2000; Mays, Cochran & Barnes, 2007; Pascoe & Smart Richman, 2009; Williams & Mohammed, 2009). Generally,
RI PT
perceived discrimination is considered a stressor that compromises both mental and physical health through psychological and biophysical arousal of the stress-response system (Barnes et al., 2004; Pascoe & Smart Richman, 2009). Such responses can contribute to acute and long-term
SC
consequences including chronic hyperactivity of emotional regulation systems and allostatic load. Reviews of the literature find that chronic exposure to everyday discrimination activates a
M AN U
stress-arousal pathway that may facilitate adverse cardiovascular outcomes as indicated by clinical biomarker research (Paradies et al., 2015). In an early study of this effect among middleaged African American women, Lewis and colleagues (2006) find that chronic exposure to discrimination is significantly associated with the presence of coronary artery calcification and
TE D
other cardiovascular risk factors. This and other research suggest a likelihood that chronic stress related to discrimination may involve inflammation processes, thereby promoting metabolic, immune and cardiovascular dysfunction (Lewis et al., 2010)
EP
Although reviews emphasize the importance of identifying specific pathways by which discrimination is likely to contribute to health, almost no attention is given to specific processes
AC C
that might clarify how the process unfolds. After considerable research, the extent to which exposure to perceived discrimination differentially triggers attributions that may result in stressful reactions is unknown. It is this process that the current paper aims to understand better by examining self and group-based identity mediators between self-reported discrimination and health outcomes.
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 5 Because perceived discrimination is a potential stressor, emotional responses to discriminatory treatment are partially a function of the cognitive appraisal of such events as a stressful experience (Lazarus, 1999; King, 2005). Lazarus and Folkman (1984) define a stressor
RI PT
as an event in which the “relationship between the individual and the environment is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being” (p. 19). While the majority of health research focuses on proximal biophysiological stress
SC
responses that result from discrimination, there may be considerable variability in the degree to which discriminatory stressors are perceived and subsequently appraised (Folkman, Lazarus,
M AN U
Gruen, & DeLongis, 1986). Cognitive appraisal describes the process that determines whether an event or transaction is stressful (Folkman & Lazarus, 1984). In many ways, how perceived discrimination relates to feelings of self-worth, in-group/out-group and between-group attitudes is at the core of the mechanism that links discrimination to a negative cascade of biological
TE D
sequelae (Major, Quinton, & McCoy, 2002; Soto et al., 2012). According to some researchers, this point of analysis is critical understanding discrimination-mediated stress (Harrell, 2000). Therefore, the present study builds upon this prior work and provides a mediational framework
EP
whereby discriminatory experiences may reshape views of one’s self, sense of self-worth and heighten sensitivities about larger group-differences and system inequalities (Gurin, 1985;
AC C
Major, Kaiser, O'Brien, & McCoy, 2007; Lazarus & Folkman, 1984; Taylor, 1983). We examined the impact of perceived discrimination on self-esteem and intergroup attitudes, as well as on three indicators of health – depression, emotional functioning and physical functioning. Discrimination, Self-Esteem, and Structural Awareness We argue that the relationship between discrimination and health may be better understood by considering the mediating role of beliefs both about the self and one’s social
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 6 group. The literature suggests several different mediating processes (Harrell et al., 2011); however, we focus on two separate paths that examine the interaction between targets of attribution and the social world. On an individual level, we expect that perceived discrimination
RI PT
compromises health through lower self-esteem. On a macro-level, discrimination may also
thwart worldviews, which impacts health as well (Cooper, Hill & Powe, 2002; Tilburt, 2010). One pathway, based on the effects on personal self-worth, posits that self-evaluation is
SC
critical to health (Mann, Hosman, Schaalma, & de Vries, 2004; Thoits, 2003). When
discrimination threatens self-esteem, health should decline as well. The second pathway, based
M AN U
on discrimination’s effects on beliefs about the origins of group-based inequality, hypothesizes that discrimination has a negative effect on health through increased awareness of structural inequalities (what we call structural awareness). Drawing from social psychologists and feminist ideology, we examine the notion that everyday experiences, particularly those associated with
TE D
multiple marginalized group identities such as African American women, facilitate a “multiple consciousness”, defined as the awareness of multiple systems and how those systems work together to structure power and privilege (Baca Zinn & Thornton Dill, 1996; King, 1988).
EP
Below we discuss the theoretical underpinnings of each proposed pathway, as well as current research related to the relationships between discrimination, self-esteem, and health, as well as
AC C
discrimination, structural awareness, and health. In essence, a central aim of this paper is to examine how two known psychological outcomes of perceived discrimination, decreased selfesteem and increased structural awareness, may help explain the etiologic relationship between discrimination and health.
Discrimination, self-esteem, and health. Social psychologists generally agree that individuals have a basic need for communion, or a need to feel as though they belong (see
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 7 Baumeister & Leary, 1995; Doyal & Gough, 1991; Swan & Bosson, 2010). When that need goes unfulfilled, self-esteem may be challenged (Marmot, 2003). Schieman (2002) and Thoits (2003) report that high self-esteem predicts subjective health. Low self-esteem, in contrast, is
RI PT
associated with negative health outcomes, such as depression (Cheng & Furnham, 2003).
Experiences of rejection, including discrimination, threaten the basic need of communion and negatively impacts self-esteem (Baumeister & Leary 1995; Smart Richman & Leary, 2009).
SC
Given this, it is not surprising that high self-esteem is associated with well-being, happiness, life satisfaction and better coping skills, functioning as a buffer for physical and mental health
M AN U
(Baumeister et al., 2003; DuBois & Flay, 2004; Mann et al., 2004).
While research is clear that self-esteem is important for health, evidence supporting the effects of discrimination on self-esteem remains mixed (Crocker & Major, 1989; Eccleston & Major, 2006; Porter & Washington, 1993). For instance, Branscombe and colleagues (1999)
TE D
contend that targets of discrimination internalize discriminatory acts resulting in poorer selfesteem. Indeed, studies find that members of disadvantaged groups (e.g., racial-ethnic minorities, sexual minorities and women) who also believe that they or members of their group are treated
EP
unfairly, are more likely to have poorer self-esteem and lower psychological well-being (Diaz, Ayala, Bein, Henne, & Marin, 2001; Mays & Cochran, 2001; Swim, Hyers, Cohen, & Ferguson,
AC C
2001). However, other research finds higher levels of self-esteem among groups that have been targets of chronic discrimination, compared to other groups. Further, discrimination can have a positive effect on self-esteem if it permits external attribution, rather than self-blame (Eccleston & Major, 2006). For example, Major and colleagues (2003) found a positive relationship between perceived discrimination and self-esteem, particularly when negative events were attributed to the discrimination and not the self. Other research has shown that the effects of
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 8 discrimination depend on several factors including social evaluations, social inclusion (Leary, 1990), and one’s core assumptions about the world (Major et al., 2007). Major and colleagues (2007) found that experiences of discrimination were associated with decreased self-esteem
RI PT
among people who were higher on meritocracy beliefs (more on these findings below). Several other studies report no direct relationship between perceptions of discrimination and self-esteem (Brown, 2001; Mendoza-Denton, Downey, Purdie, Davis, & Pietrzak, 2002), emphasizing the
SC
need to further understand this relationship and in a larger sense, understand how either personal or group-level attributions may function as a mediator linking discrimination to health.
M AN U
Discrimination, structural awareness, and health. Researchers seeking to understand the nature of how systemic racism and discrimination impact health have consistently emphasized the need to conceptualize and measure the effects of discrimination as a social phenomenon with structural roots (Feagin & Bennefield, 2014). Therefore, drawing on past
TE D
theorizing, we recognize structural awareness as the degree to which people place the responsibility for inequalities on social institutions and structures, as opposed to individuals or groups themselves (i.e., the degree to which they see systemic reasons for individual inability to
EP
be successful or competent within a particular domain). Structural awareness is a rejection of the idea that inequalities between different social groups are due to individual differences or
AC C
qualities about members of a certain group, instead framing them as institutional-level phenomena that perpetuate group inequalities (Gurin, Miller, & Gurin, 1980; Lopez, Gurin, & Nagda, 1998). We posit that such an awareness may trigger a stressful response, as a separate, but related body of literature on stressor controllability suggests that exposure to aversive events which cannot be controlled produces cognitive restructuring, impaired functioning, a weakened immune system and poorer physical and mental health outcomes (Cox et al., 2012; Henderson et
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 9 al., 2012; Kwan et al., 2014; Maier & Watkins, 2005). Using a social psychological lens, we understand the multiple channels that racism and thereby discrimination, operate through and reproduce socially could be interpreted differently depending on the level of consciousness
RI PT
individuals have about these processes.
From a psychological perspective, Swann and Bosson (2010) argue that the “need for agency motivates a desire for self-competence.” (p. 606). In order to understand how
SC
discrimination might negatively impact this need, we draw on social identity theory (SIT; Tajfel &Turner, 1979; 1986) and relative deprivation theory (Crosby, 1976) to frame the link between
M AN U
discrimination and individual and group-level consciousness. Both theories argue that, because of intergroup competition, some individuals will encounter experiences of discrimination based on group membership, that indicate to the individual that there are outside limits imposed to how much they can individually achieve (i.e., their group membership affects their ability to be
TE D
agentic). These experiences can lead to a critique of the existing social hierarchy, which the individual views as impeding their ability to gain resources (we note that both theories allow for other outcomes also, such as a desire to change groups, or even a sense of resignation to one’s
EP
place in the social hierarchy, but those are not of interest to us here). We argue that this critique itself is a manifestation of the thwarting of desires for agency and will negatively affect health.
AC C
We call this knowledge that one’s personal agency is limited as a result of one’s group membership, structural awareness. Just as the relationship between self-esteem and discrimination is complex, so too is that
between discrimination and structural awareness. Some researchers argue that experiences of discrimination increase structural awareness (Cross, 1971; Downing & Roush, 1985; Taylor & McKiman, 1984; Worrell, Cross, & Vandiver, 2001), while others argue that structural
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 10 awareness itself moderates the relationship between perceived discrimination and other important outcomes, such as self-esteem (Foster, Sloto, & Ruby, 2006; Major et al. 2007). The conceptual framework tying discrimination to structural awareness primarily builds
RI PT
from two previous theoretical approaches. The first is taken from the social-psychological
literature and argues that important life experiences, such as discrimination, shape how people view the world and their place in that world (e.g., Janoff-Bullman, 1989; Cross, 1971; Downing
SC
& Roush, 1985; Taylor & McKiman, 1984; Worrell et al., 2001). Theories of group
consciousness, such as Cross’ (1971; Worrell et al., 2001) model of Black identity development
M AN U
and Downing & Roush’s (1985) feminist identity posit that discrimination experiences serve as “encounters” that raise individuals’ awareness of group-level inequalities. For example, Essed (1990, 1991) interviewed women in both the Netherlands and the United States about their personal experiences with discrimination, and found that they connected these experiences to
TE D
larger social inequalities between Black and White people. In a series of studies on the effects of discrimination on well-being, Foster and colleagues (Foster et al., 2006; Foster & Tsarfati, 2005) used these developmental models, as well as the theory of assumptive worlds (Janoff-Bullman,
EP
1989) to argue that experiences of discrimination can negatively affect one’s beliefs about the world by “shattering” (Foster et al., 2006, p. 404) their assumptions about a just world (i.e.,
AC C
raising their structural awareness).
Second, we conceptualize structural awareness as a consequence of discrimination that
heightens knowledge sensitivities and consciousness, much like what has been described in the distrust literature regarding medical research and the inclusion of marginalized groups (e.g., Tuskegee Syphilis experiment) (Shavers, Lynch, & Burmeister, 2002; Wendler, 2006). In other words, experiencing discrimination can make one aware that there are larger power imbalances
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 11 between groups that lead to personal encounters of discriminatory treatment. Indeed, system distrust is related to poorer self-rated health, after adjusting for other explanatory factors such as education, SES, education and neighborhood (Armstrong et al., 2006; Yang et al., 2011). It may
RI PT
be the case that a stronger structural awareness precedes this cascade. In fact, Chen and Yang (2014) found a positive association between discrimination and distrust, and that levels of distrust were higher among women and those of middle-income groups.
SC
The question remains, however, whether increased structural awareness is beneficial or detrimental for health. In other words, does knowing about system and group-based inequalities
M AN U
help individuals manage perceived discrimination more effectively, or does this knowledge contribute to worse health? Because prior research finds that experiencing negative events (such as discrimination) without the ability to control those events leads to increased stress, depression and overall worse health, we hypothesize that increased structural awareness will have similar
TE D
negative effects. While this process has been studied in other contexts [e.g., cognition-emotion relationship and coping styles, stressor controllability, shifting worldviews and health promoting behavior (Cox et al., 2012; Henderson et al., 2012; Kagee & Dixon, 2000; Klassen, Smith,
EP
Shariff-Marco, & Juon, 2008; Lazarus & Smith, 1988; Maier & Watkins, 2005), as well as research that has highlighted relationships between lower just world beliefs and increased
AC C
physiological stress (Tomaka & Blascovich, 1994), and studies linking increased just world beliefs (what we might call low structural awareness) to increased subjective well-being (see Jost & Hunyady, 2005; Jost & Thompson, 2000)], its specific application to discrimination and the stress response is relatively novel. Therefore, we hypothesize that perceived discrimination will lead to increased structural awareness and poorer health outcomes through a mediation pathway. The Current Project
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 12 The significance of the current project is twofold. First, probing potential pathways between perceived discrimination and mediating variables is important to understand the etiology of how perceptions of discrimination trigger stressful reactions. Second, existing studies
RI PT
of perceived discrimination traditionally focus either on racial discrimination (among primarily ethnic minority samples; see for example Clark, 2003; Clark, Anderson, Clark, & Williams, 1999; Mays, Cochran, & Barnes, 2007) or sexist discrimination (among mostly White college
SC
women; see for example, Corning, 2002) separately. This separation of gender and race is problematic, as it often ignores the intersection of the two, and the ways in which such
M AN U
intersections result in unique experiences for women of color (see Berdahl & Moore, 2006; Bowleg, 2008; Purdie-Vaughns & Eibach, 2008; Reid & Comas-Diaz, 1990). Inconsistent findings in the literature about the effects of discriminatory experiences suggest the presence of intragroup variation, in that not all women or all African Americans universally make
TE D
attributions about perceived discrimination in the same way (Clark, 2004; Clark & Gochett, 2006; Cokley, Hall-Clark, & Hicks, 2011; Cozier et al., 2006; Keith, Lincoln, Taylor, & Jackson, 2010; Matthews, Salomen, Kenyon, & Zhou, 2005; Paradies, 2006; Williams & Mohammed,
EP
2009).
Research in psychology and other social sciences is just beginning to understand how
AC C
social categories of identity, difference and disadvantage are separately and jointly associated with important life outcomes (Cole, 2009; Smedley, 2012). Intersectionality is a framework that empirically and conceptually considers the meaning of multiple categories of social group membership (Crenshaw, 1989). This paper interrogates the heterogeneity among older women’s experiences with discrimination and related consequences. We examine the effects of discrimination on both Black and White women in an attempt to disentangle how the effects of
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 13 perceived discrimination may differ among women from different racial backgrounds. In doing so, we attempt to extend the literature in both areas to consider how perceived discrimination may have differential and lingering effects.
RI PT
It is unclear as to what extent the intersection of identities (e.g., race and gender) has salience for interpreting discriminatory experiences (Barnes et al., 2004; Clark, Anderson, Clark, & Williams, 1999). There is limited knowledge regarding which specific aspects of
SC
discrimination are detrimental and for whom (Bratter & Gorman, 2011). For example, gender differences have been noted in relation to frequency and type of discrimination experienced by
M AN U
ethnic-minority individuals (Chavous et al., 2008; Cunningham, 1999), and racial differences in experiences of perceived unfair treatment differ among women (Brown, Matthews, Bromberger, & Chang, 2006). Yet there has been virtually no attention paid to how structural awareness or consciousness about social identities may impede health. Some theories (e.g., double
TE D
disadvantage; double jeopardy hypothesis) suggest that holding more than one disadvantaged status leads to poorer health, due in part to increased exposure to discrimination, as well as a heightened awareness about systems of inequality (Grollman, 2014; King, 1988, Harnois, 2015).
EP
Regardless of race, personal experiences with multiple forms of discrimination are associated with the a multiple consciousness (Harnois 2015). Thus, determining whether this is
AC C
relevant in terms of discrimination and health; if Black or White women, for example, have different or similar levels of structural awareness following discrimination and whether this awareness leads to health effects is important in order to understand how discrimination affects different groups. Using an inclusion-centered approach (Choo & Ferree, 2010), we examine the effects of discrimination in a racially diverse sample of women to explore the central hypothesis that the relationship between discrimination, despression and physical and emotional functioning
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 14 is mediated by increased structural awareness and decreased self-esteem. At the same time, we consider the moderating role of race. We expect there to be some variation in the extent to which discrimination is correlated with depression, emotional functioning and physical health
RI PT
functioning for Black and White women.
Prior studies have found that historical events can have differential effects on both health and worldviews depending on birth cohort and social context. The women in the current study
SC
were part of a longitudinal panel study that began in the late 1960s, of female college graduates. Now in their early 60s, these women experienced young adulthood during a time of intense
M AN U
social change (e.g., Women’s Rights Movement, Civil Rights Movement); many of them were involved in, or followed closely the women’s movement and/or the civil rights movements of the 1960s and 70s. They are, therefore, a uniquely interesting sample in which to examine experiences of discrimination, beliefs about social inequalities and health. The aim of the current
TE D
study is to interrogate two mediational pathways linking discrimination to three health outcomes. Specifically, this study is concerned with 1) the direct effect of discrimination on health; 2) the indirect impact of discrimination on health via its relationship to (increased) intersectional
EP
awareness and (decreased) self-esteem (see Figure 1). Our hypotheses are as follows: 1. Hypothesis 1: There is a direct and negative impact of perceived discrimination
AC C
on health outcomes, measured by physical functioning, depression, and emotional functioning. Further, discrimination has an indirect impact on health through lower self-esteem and higher structural awareness. Specifically, (H1a) perceived discrimination is related to low self-esteem, and (H1b) low self-esteem is associated with poor health.
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 15 2. Hypothesis 2: A second mediation pathway proposes that discrimination has an indirect impact on health through structural awareness. Specifically, (H2a) perceived discrimination is positively related to high structural awareness, and
Method Participants and procedure
RI PT
(H2b) high structural awareness is associated with poor health.
SC
The Women’s Life Paths Study is a longitudinal project following a group of women who graduated from the University of Michigan between 1967 and 1973 (see Tangri & Jenkins, 1993
M AN U
and Cole & Stewart, 1996 for a more detailed description of the sample). In the fall of 2008, 244 women participated in the most recent wave of the data collection. Sixty-five percent of the sample identified as White, 33% as Black, and 2% as “other,” and 2 women did not disclose their race. However, only the 237 women who identified as Black (n = 79; 33% of the remaining
TE D
sample) or White (n = 156; 67% of the remaining sample) were included in the current analyses, and all results will be based on this sample. The mean age was 61 years old (SD = 3.65). Most of the sample (88%) had earned a post-graduate degree and over half (61%) had an annual
EP
household income between $50,000 and $150,000; with 14% having an income below $50,000 and 25% having an income over $200,000. Almost all (95%) of the sample were heterosexual,
AC C
with the remaining 5% identifying as lesbian, bisexual, or “other”. There were no differences, by race, on either the rates at which women earned a post-graduate degree, annual household income, or whether the women identified as lesbian or bisexual. However, Black women in the sample were significantly younger on average (60 years old), compared to white women (62 years old); t(233) = 5.09, p < .001). Outcome Variables
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 16 All outcome measures were derived from the modified version of the Medical Outcomes Survey (SF-36; Stewart, Sherbourne, & Hays, 1992; Stewart & Ware, 1992; Turner-Bowker, Bartley, & Ware, 2002). Structurally, the SF-36 contains 36 items used to create eight different
RI PT
domains of health and well-being (McHorney, Ware & Raczek, 1993). The subscales are
designed to measure functioning and well-being, with each representing a different dimension of health. The Physical Functioning subscale is used to assess physical functioning, the Mental
SC
Health inventory subscale to measure mental health symptomology (e.g., depression), and the Role Emotional SF subscale to assess emotional functioning. Although these different measures
M AN U
are correlated, they are also independent as they assess different components of health – mental, emotional and physical and so were treated as three separate outcomes in this paper. Physical Functioning. The physical functioning subscale was used to assess current limitations in activities during the course of a typical day, a measure of the extent to which
TE D
physical health is compromised. Participants were asked to respond whether their physical health prevented them from engaging in regular activities during the 4 weeks before they took the survey. Sample items included, “Did your health cut down on the amount of time you spent on
EP
work or other activities?” and “Did your health present difficulty in performing your work or other activities (e.g., it took extra effort)?” Participants responded to four “yes” (1)/”no” (0)
AC C
items assessing their physical health limitations. Responses to these items were reverse coded, summed, and a total score was created for each participant, with higher scores indicating a lower level of physical health impairment (or better physical health). A maximum score of 4, for example, implies very little physical limitation. The sample mean was 3.22 (SD = 1.35). There was no significant difference between Black (M = 3.40, SD = 1.21) and white (M = 3.13, SD = 1.41) women, t(167.75) = -1.52, p = .13. The SF-36 scale and scoring procedure have been
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 17 validated among African American adults (Wolinsky, Miller, Andresen, Malmstrom, & Miller, 2004) as well as older African Americans (Jang, Chiriboga, Borenstein, Small, & Mortimer, 2009; Utsey, Payne, Jackson, Jones, 2002).
RI PT
Depression. Depressive symptoms were measured according to an eight-item rating from the Mental Health Inventory (MHI) by Ware and Sherbourne (1992) measuring
characteristic attitudes and symptoms of depression. The MHI has been established as a simple
SC
and valid tool for detecting depressive symptoms in the general population and includes the questions: Over the last 4 weeks, how often: (i) ‘Have you felt so down in the dumps that
M AN U
nothing could cheer you up?’, (ii) ‘Have you felt downhearted and blue?’, (iii) ‘Have you been a happy person?’, (iv) ‘Have you been a very nervous person?’ and (v) ‘Have you felt calm and peaceful?’. Each item has six possible responses ranging from “All the time” (6) to ‘none of the time’ (1 points). Appropriate items were reverse scored so that higher scores corresponded to
TE D
higher depressive symptoms. The answers of the third and fifth question need to be reversed. The sample mean for depressive symptoms is 2.38 (SD = .75; α = 0.88). There was no significant difference in levels of depressive symptoms between Black (M = 2.31, SD = .75) and white (M =
EP
2.41, SD = .75) women; t(230) = .96, p = .34.
Emotional Functioning. The emotional functioning subscale was used to assess
AC C
interferences in daily living due to emotional health. The extent to which involvement in typical daily roles and activities is limited by emotional health was measured by a series of items asking, “During the past 4 weeks, have you had any problems with your work or other regular daily activities as a result of any emotional problems?” Participants responded to three “yes” (1)/”no” (0) items assessing emotional health limitations during the previous month. Responses to these items were reverse coded, summed and a total score was created for each participant, such that
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 18 higher scores indicated better emotional health (M = 2.57, SD = .89). There was no significant difference between Black (M = 2.51, SD = .96) and white (M = 2.60, SD = .85) women on reports of emotional functioning; t(230) = .79, p = .43.
RI PT
Predictor and Mediating Variables
Experiences of discrimination. Based on the original construct of everyday
discrimination (Williams, Yu, Jackson, & Anderson, 1997), ten items reflecting general
SC
mistreatment, without specific reference to race, ethnicity, or gender were used. The frequency of each type of mistreatment was assessed with a 4-point scale (1= never; 4 = often. Sample
M AN U
items: “You are treated with less courtesy than other people,” “You receive poorer service than other people at restaurants or stores,”). The measure tapped participants’ experiences of everyday discrimination over the previous 12 months. Participants who responded either “sometimes” or “often” to at least one of the 10 items were asked to respond to an additional prompt inquiring
TE D
about the reason(s) for their experience(s). Response categories included race/ethnicity, gender, age, income level, language, physical appearance, sexual orientation and other. Items were summed and a score was created for each participant (α =.88). The sample
EP
mean was 16.53 (SD = 4.90). Black women reported significantly more experiences of discrimination (M = 19.81, SD = 4.93), compared to White women (M = 14.92, SD = 4.02);
AC C
t(232) = -8.09, p < .001.
Self-esteem and structural awareness. Two mediator variables were included, self-
esteem and structural awareness. Self-esteem was assessed using the 10-item Rosenberg (1965) self-esteem scale. All
items were on a 6-point scale (“strongly disagree” to “strongly agree”); sample item: “I feel that I’m a person of worth, at least on an equal plane with others.” The average for the sample was
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 19 5.35 (SD = .67; α =.86). Black women scored significantly higher on self-esteem (M = 5.48; SD = .69) compared to White women (M = 5.29; SD = .66); t(229) = -2.02, p < .05. Structural awareness was assessed using a composite of 25 items adapted from two
RI PT
measures. All items were asked on a 6-point scale (1 = strongly disagree; 6 = strongly agree). These items were based on Gurin’s (1985; Gurin et al., 1980) rejection of legitimacy measure; seven asked about gender (sample item: “If women don’t advance in their jobs, it is because
SC
there are barriers which keep them from getting ahead.”) and eight addressed race-based
rejection of legitimacy (sample item: “If Blacks don’t advance in their jobs, it is because they
M AN U
aren’t interested enough in getting ahead.”). Ten items assessing Intersectional Awareness scale (IA; Curtin, Stewart, & Cole, under review; sample item: “All oppressions are tied together) were also included (see also Cole, Case, Rios, & Curtin, 2011).
The sample mean for structural awareness was 4.37 (SD = .59; α =.86). There was no
TE D
difference between White (M = 4.37; SD = .64) and Black (M = 4.38; SD = .46) women on this measure; t(194.77) = -.25, p =.81. Control Variables
EP
To determine which variables to include was controls, we examined the associations between education and age and all variables of interest (see Table 1). Given that education was
AC C
unrelated to any variables of interest, it was not included as a control in our analyses. Age was associated with one of our outcomes of interest, physical health, as well as discrimination. Therefore, we included it as a control in all analyses. Plan of Analyses
Hypotheses were tested through a regression analysis of conditional indirect effects. Three such models were run, one for each of the three outcomes of interest: physical health,
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 20 depression, and emotional health. The general model included experiences of discrimination as the independent variable, structural awareness and self-esteem as mediators, race as a moderator, and the health outcomes as the dependent variables.
RI PT
Analyses were performed using Hayes’ (2013) PROCESS macro for SPSS 20. Hayes’ macro automatically estimates co-efficient and standard errors, using bootstrapped samples (we asked for 5,000, which is recommended; Hayes, 2012) and uses mean centered variables (see
SC
Aiken & West, 1991) for all interaction terms. Bootstrapping involves repeated resampling of a subset of the original dataset (n-1), which allowed us to estimate a statistic’s sample distribution
M AN U
and then used that to create significance confidence intervals. The purpose is to more closely approximate the population from which the study sample is taken, without having to sample the entire population. Further, bootstrapping is preferred to other methods for estimating indirect effects, as it does not assume a normally distributed ab (or mediated) path (Hayes, 2012; 2013).
TE D
An effect is considered significant if 0 does not fall between the confidence intervals (CI). Note that the program produces unstandardized coefficients. In order to produce standardized coefficients, we calculated z-scored versions of all the variables of interest for use in these
Table 1.
EP
analyses (see Hayes, 2013). The simple correlations of all variables included in the models are in
AC C
All analyses controlled age. In each set of regression equations, the interaction of race
with each of the predictor variables was assessed. Therefore, we examined the interaction of race and discrimination on structural awareness and self-esteem, as well as each health outcome. We also tested whether race moderated the effects of both structural awareness and self-esteem on each of the health outcomes. Because there was no significant relationship between structural awareness and emotional functioning (see Table 1), we only tested self-esteem as a mediator for
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 21 that outcome (there can be no indirect effect pathway of discrimination to emotional health via structural awareness if structural awareness is not related to emotional health). Results
RI PT
Confirming our hypotheses, experiences of discrimination predicted both structural awareness and self-esteem; the more discrimination women experienced, the higher their
structural awareness and the lower their self-esteem (H1a, H2a). Race did not moderate the
SC
relationship between discrimination and structural awareness or discrimination and self-esteem. Physical Functioning. Confirming our direct-effect hypotheses (see Figure 2),
M AN U
experiences of discrimination had a negative effect on physical health; those who reported more discrimination had lower physical health score, or reported more functional limitations. However this relationship was moderated by race (conditional direct effects analyses showed that it was only significant for white women, see Table 2). Self-esteem, as expected, had a significant
TE D
positive effect on physical health; the interaction of race by self-esteem (on physical health) was not significant. Structural awareness also had a significant direct effect on physical health (the more structurally aware these women were, the greater their physical functional limitations
EP
(counter-intuitively reflected in a lower score); H2b). The interaction of race by structural awareness was not significant. Conditional indirect effects analyses were run to examine whether
AC C
the indirect effects of discrimination on physical functional limitations (via self-esteem and structural awareness) were different for White and Black women. These results indicated that, the negative indirect effect of discrimination on physical health for self-esteem was only significant for White women; meaning that self-esteem did not mediate the relationship between discrimination and physical health among Black women (see Table 2). Further, contrary to our
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 22 hypothesis, discrimination did not exert significant indirect effects on physical health via structural awareness, for either Black or White women (see Table 2). Depression. Contrary to our hypothesis, discrimination did not exert significant direct
RI PT
effects on depression either in the overall regression model (see Figure 3), or when we ran the conditional direct effects test, which examined Black and White women separately (see Table 2). However, both self-esteem and structural awareness had direct and significant effects on
SC
depression; women who were high on self-esteem reported lower levels of depression and
women who were high on structural awareness reported more depression. Race did not moderate
M AN U
any of the relationships between our variables of interest in the model predicting depression (see Figure 2). Examining the indirect effects of discrimination on depression via self-esteem, the effect was only significant for White women. That is, among White women only, discrimination was associated with increased depression, via self-esteem. In examining the conditional indirect
TE D
effects, for both White and Black women, structural awareness mediated the relationship between discrimination and depression. The relationship was positive, indicating that higher levels of discrimination were associated with higher levels of depression, via increased structural
EP
awareness.
Emotional Functioning. Contrary to our hypothesis, discrimination did not exert
AC C
significant direct effects on emotional health either in the overall regression (see Figure 4), or when we ran the conditional direct effects test examining Black and White women separately (see Table 2). However, self-esteem significantly, and positively, affected emotional health. Although there were no significant direct effects of discrimination on emotional health, it did exert significant indirect effects. However, these indirect effects were only significant for White
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 23 women. Among White women, discrimination exerted significant negative effects on emotional health, via self-esteem. Discussion
RI PT
This study examined two mediating pathways between discrimination and health focused on 1) individual attitudes about larger systems of inequality and 2) conceptions of self-worth. We hypothesized a direct effect of discrimination on physical and emotional functioning and
SC
depression, and an indirect effect of discrimination on physical functioning and depression
through (decreased) self-esteem and (increased) structural awareness. Our findings confirm that
M AN U
discrimination negatively affected health across three domains, and that the mechanisms varied somewhat for Black and White women. Across all three health outcomes, self-esteem mediated the relationship between health and discrimination for White women only. Although discrimination was associated with decreased self-esteem for Black women, this relationship did
TE D
not help explain an association between discrimination and health, as it did for White women. Structural awareness mediated the relationship between discrimination and health for all women when predicting depression, though there was no mediation of structural awareness for physical
EP
functioning.
Interestingly, there was no direct relationship between discrimination and depression or
AC C
discrimination and emotional functioning in this sample; even though we did find indirect effects. We believe this observation strengthens the case for exploring mediating paths between discrimination and health. Further, given adaptive processes to manage experiences of unfair treatment across the life course and the potential for proactive coping and participants’ late midlife developmental stage, direct effects are likely heavily mediated (Aspinwall et al., 2005).
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 24 Self-esteem mediates the relationship between discrimination and health for White women only. This finding supports the notion that discrimination impacts self-esteem, particularly for individuals who may have relatively less lifetime exposure of discrimination or
RI PT
for groups who are disadvantaged on a singular axis (e.g., gender). Broadly, beliefs about system legitimizing ideologies are often ubiquitous throughout society and can remain intact if not challenged. Any experience of discriminatory treatment has the potential to challenge such
SC
beliefs, and may lead one to question individual self-worth, particularly if such challenges are not regularly encountered. The mediating effect supports the hypothesis that discrimination is a
M AN U
threat to communion, at least for white women in this sample, which operates in ways that adversely impact health.
Black women may be less likely to devalue self as a consequence of unfair treatment, due to possible repeated lifetime exposure to discrimination on the basis of both race and gender. It
TE D
may also be the case that Black women attribute discrimination to greater system imbalances or barriers, rather than a function of one’s membership in a socially devalued group (e.g., Crocker & Major, 1989; Major, Quinton, & McCoy, 2002). Indeed in a study conducted by Harnois
EP
(2015), data from a large scale survey of Western-European respondents indicates that the likelihood of perceiving multiple forms of discrimination, as opposed to no discrimination, is
AC C
higher among individuals with multiple minority statuses. Women and men who held no other minority statuses were among the least likely to perceive experiencing multiple discrimination, while religious minority women, ethnic minority women, and women with disabilities were among the most likely to have experienced multiple discrimination events (as opposed to no discrimination) in the past year. In addition, analyses from the same study showed that individuals holding multiple minority statuses and who perceive multiple forms of
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 25 discrimination, are more likely than others to perceive multiple discrimination as being widespread (an indication of what we have referred to as structural awareness). Taken together, these findings support a theory of consciousness raising that is associated with multiple
RI PT
experiences of discrimination.
The lack of a mediating relationship between discrimination, self-esteem and health for Black women is also consistent with theories of attribution that frame prejudiced attitudes
SC
against one’s social identity as protective for members of marginalized groups. Research has shown that marginalized groups use a variety of skills in order to counter discrimination,
M AN U
including proactive coping (Mallet & Swim, 2005). Proactive coping, used prior to or during a stressful event, is an opportunity to anticipate discrimination and reduce the stressful impact (Mallett & Swim, 2009). Generally, members of socially devalued groups may learn to anticipate and prepare for injustice, thereby potentially mitigating the effect (Sellers & Shelton, 2003).
TE D
Black women in our study reported more instances of perceived discrimination compared to White women; therefore, it is likely that Black women have adapted proactive coping mechanisms to protect health (Sellers & Shelton, 2003).
EP
Although experiences of discrimination may not impact health through self-esteem for Black women in this study, it does not preclude harm altogether. Indeed, the finding that
AC C
structural awareness mediates the relationship between discrimination and depression for all women aligns with the notion that knowing about power imbalances, and not being able to do anything about them, can in fact be stressful. This relationship may be best understood in a context of stressor controllability. Early experimental studies have shown that behavior and physiological consequences result from stressors that are uncontrollable, relative to controllable stressors (Maier & Watkins, 1998; Weiss, 1968). In fact, experiments with uncontrollable
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 26 stressors in animal models have produced mental health outcomes that have also been associated with discrimination-related stress, notably depression and anxiety (see Maier & Watkins, 1998 for review). This implies that knowing about inequality and determining that one has little
RI PT
control over those inequalities (or how to change them) can be detrimental. Researchers should examine the framework of stressor controllability in future investigations regarding discrimination, structural awareness and health.
SC
The current study integrates a broad and diverse literature on the impact of perceived discrimination on health by proposing a model mediated by psychological processes. These
M AN U
findings provide evidence for such a framework and suggest that further research is warranted in understanding how differential attributions may influence appraisal and subsequent health effects of discriminatory behavior. For example, experiencing discrimination and knowing that there are structural differences between groups negatively impacts mental health. While this finding is
TE D
consistent with research suggesting that the ways in which individuals make sense of the social world have important implications for shaping how discriminatory acts are perceived, understanding how reshaping cognitions influence health behaviors is largely unexplored.
EP
Furthermore, such realizations may be particularly burdensome for Black women, and operate through indirect channels (e.g., distrust) that influences health behaviors and interactions with
AC C
the health-care system and mental health professionals (Chen and Yang, 2014; Wendler, 2006; Tilburt, 2010). Although speculative, it is possible that Black women manage emotional challenges stemming from unfair treatment in various ways that may be protective (e.g., proactive coping, spirituality) given cultural scripts and norms regarding stress and coping (Lekan, 2009; Woods-Giscombe, 2010).
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 27 Taken together, these findings raise several points regarding the significance of evaluating psychological mediators in studying the relationship between discrimination and health. The association between discrimination, heightened structural awareness and depression
RI PT
is novel. Worldviews should be considered in future research linking discrimination and health as it represents a more comprehensive way of capturing the cumulative and interactive effects of discrimination and systemic racism. For all women in our study, increased structural awareness
SC
about group-based inequalities was negatively related to health in three separate domains. This study provides at least one example of how structural bias (perceived discrimination) operates
M AN U
through institutional and structural levels as well as at individual levels.
Although this study contributes to the literature on discrimination and health, it is not without some limitations. First, the data are cross-sectional; therefore, the link between discrimination and health may be obscured by this approach. We also cannot claim to determine
TE D
causality or endogeneity between variables. While this is a longitudinal sample, this is the first wave to include a measure of perceived discrimination; therefore, it is difficult to assess whether discrimination precedes structural awareness or vice versa. We acknowledge this is a primary
EP
limitation, as it is not possible to statistically disentangle the causal order of our variables. Further, we acknowledge that it may well be the case that individuals with greater structural
AC C
awareness are more attuned to instances of discrimination. In fact, it is likely that for some people, experiences of discrimination may help foster increased structural awareness, but for others they may develop increased structural awareness via other experiences (such as education, for example), and then become more inclined to perceive discrimination in their everyday lives. Tests of the conditions under which these differences emerge are beyond the scope of this paper, but point to the potentially complex set of relationships between the variables of interest here.
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 28 Secondly, the ways in which discrimination impacts health is a complex process that likely unfolds over time, and therefore, our study is not exhaustive in accounting for the dynamic interplay that likely exists between discrimination, self-esteem, structural awareness and health.
RI PT
For example, the sample that we rely upon for this analysis consists of older, educated women of higher class standing who lived through several important social movements. We cannot be sure whether sensitivities related to discrimination or structural awareness become more salient at a
SC
certain age, or whether these processes generalize to other groups. However, Gee and colleagues (2007) do note that reporting of discrimination varies as women move across the adult life
M AN U
course. For example, women in their early to mid-20s generally report discrimination more frequently, than during early midlife (early to mid-30s). Rates of reporting then rise again as women transition into their 40s and peak in the 50s, before declining somewhat when women get closer to retirement.
TE D
In terms of selectivity by social class, our study included relatively high-income, collegeeducated women who may have different life experiences and ways of viewing the world from both Black and White women of lower class position (Lott, 2012; Miner-Rubino, Winter, &
EP
Stewart, 2004; Smedley, 2012). These potential differences may be central in interpreting encounters of discrimination and subsequent health consequences. We also cannot be certain that
AC C
the mediating processes in this study are not specific to this select sample of women, because other studies have not yet explored these questions. However, public health research has found that worldviews are important for health decisions in younger women (Klassen et al., 2008) and older populations in general (Buck, Baldwin & Schwartz, 2005). Several studies also report that minority groups of higher incomes and education (both women and African Americans) report more racist treatment than their working-class counterparts (Kessler et al. 1999; Moody-Ayers et
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 29 al. 2005; Ren et al. 1999). While this may reflect a reporting bias rather than true frequency, it also alludes to what others have suggested that racial prejudice does not cease as a function of social mobility (James, 1994). Among whites, research focused on racial stigma, poverty and
RI PT
whiteness also shows a greater health burden on poorer whites who report unfair treatment, a relationship that is enhanced for individuals with a high sense of racial awareness (Bratter & Gorman, 2011). Fully unpacking this relationship is difficult as there is little comparative data
SC
for discrimination among older, white middle-class samples, yet the selective nature of our sample should be underscored in the interpretation of our results.
M AN U
Finally, we have to acknowledge the limitations of some of our measures. For example, our measure of structural awareness, although a combination of two widely-used measures, is not a standard measure. We note that studies interested in attitudes towards group inequalities use different measures, and the two used here have been used elsewhere to successfully measure
TE D
beliefs about group-based inequalities (see for example, Cole & Stewart, 1996; Cole et al., 2011; Greenwood, 2008, and Lopez et al., 1998). Therefore, we feel confident that we assessed structural awareness, while acknowledging that there may be other measures one could use (for
EP
example, Altemeyer’s (1996) Right Wing Authoritarianism or Just World Beliefs (Jost & Hunyady, 2005). In addition, the measure of discrimination limits responses to indicating one
AC C
status of discrimination (e.g., race or gender), versus multiple forms at the same time (e.g., Black woman). Therefore, it is unknown whether women in this study experienced multiple forms of discrimination simultaneously (e.g., gendered racism; St. Jean & Feagin, 1998). This investigation also relies on self-reported measures of health, which are subject to bias. We acknowledge this important limitation, though we note that they are all well-established health outcome measures. More ideal would be to have objective outcome measures, including
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 30 indicators of physiological stress response, cardiovascular outcomes, weathering and allostatic load (Geronimus, 2006; Lewis et al., 2010; McEwen, 1998 Sapolsky, 2005). In spite of these limitations, the present study offers some insight into the complex
RI PT
relationship between discrimination and health for women. Beyond the main effect, this study focuses on developmental period (late midlife) to examine the potential chronic burdens
associated with perceived discrimination. Inasmuch as understanding the workings of the world
SC
is a life-course pursuit, the current study is ideally suited to explore reactions to discrimination and protective or risk factors that extend beyond immediate effects. Our findings suggest that
M AN U
examining perceived discrimination without accounting for structural worldview may skew interpretations of discrimination-related health effects. This study extends research on discrimination effects and challenges the notion that there is a universal impact of discrimination that operates in the same way for all groups. We believe our findings also make room for
TE D
exploring how effects of discrimination vary across age demographics. Mature women who have experienced a variety of life events and transitions may be more or less reactive to unfair treatment; yet there is little research about how older groups interpret and make sense of these
EP
events (Almeida & Horn, 2004; Gayman & Barragan, 2013; Stuber et al., 2003). Fundamentally, age, social position or class standing may not completely insulate any one group from the
AC C
negative effects of discrimination. Instead, we speculate that among other factors, exposure to and interpretation of unfair treatment may shift appraisals and have relevance for chronic health burdens. Given the potential for women in our sample to have some existing baseline of structural awareness because of their historical cohort, our findings seem even more relevant for contemporary disparities research. In other words, even women who were exposed to fairly
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 31 liberal worldviews during their formative years don’t react to discrimination in the same way, nor do their reactions hold identical meanings for health. Calls for advancing research focused on social processes and health must draw upon an
RI PT
intersectional approach (Carbado, Crenshaw, Mays & Tomlinson, 2013; Kelly, 2009; Smedley, 2012). A benefit of employing an intersectional analysis is highlighting and emphasizing
structural complexities. We therefore resist a monistic approach in our interpretation of how
SC
experiences of discrimination affect either White women or African Americans only, recognizing that social identity is complicated and there may be other distinctions among this group that
M AN U
contribute to our results. Instead we focus on one primary intersection; the ways in which discrimination may be experienced similarly or differently for older women of different racial backgrounds. It is this framing that should lead future research in this area focused on
AC C
EP
TE D
quantifying discrimination as both a social phenomenon and a risk factor for health.
ACCEPTED MANUSCRIPT
DISCRIMINATION, HEALTH AND MEDIATING PATHS 32 Table 1. Intercorrelations for all variables
5. Self-esteem 6. Structural Awareness 7. Level of Education 8. Age
--.43*** .34*** -.18** .31***
--.56***
--
.19**
-.19**
-.60***
.26***
-.15*
.14*
-.10
.12
.00
.06
-.13*
-.02
.01
AC C
Note. * p < .05. ** p < .01. *** p < .001.
6
7
8
--
SC
4. Discrimination
5
M AN U
3. Emotional Health
4
-.13*
.21***
--
.04
--
.03
-.03
.11
--
-.16*
-.09
-.07
-.10
TE D
2. Depression
3
EP
1. Physical health
2
RI PT
1
--
ACCEPTED MANUSCRIPT
DISCRIMINATION, HEALTH AND MEDIATING PATHS 33
M AN U
SC
Structural Awareness
RI PT
Figure 1. Proposed relationships between discrimination, structural awareness, self-esteem, and health outcomes
Discrimination
AC C
EP
TE D
Self-Esteem
Health Outcome
ACCEPTED MANUSCRIPT
DISCRIMINATION, HEALTH AND MEDIATING PATHS 34
RI PT
Figure 2. Standardized coefficients and standard error terms for moderated (by race) mediation analyses with discrimination, structural awareness, and self-esteem, predicting physical health
Race
-.09 (.07) Structural Awareness
M AN U
.26*** (.07)
Discrimination
Physical Health
TE D EP
.12 (.07)
.24*** (.07)
Self-Esteem
AC C
Race
-.06 (.08)
-.21** (.08) -.26*** (.07)
.11 (.07)
-.15* (.07)
SC
Race
.02 (.06) Race
Note. F = 5.24***, R2 = .16. Race referent group = White women. * p < .05. ** p < .01. *** p < .001.
ACCEPTED MANUSCRIPT
DISCRIMINATION, HEALTH AND MEDIATING PATHS 35
RI PT
Figure 3. Standardized coefficients and standard error terms for moderated (by race) mediation analyses with discrimination, structural awareness, and self-esteem, predicting depression Race
-.09 (.07) Structural Awareness
M AN U
.26*** (.07)
Discrimination
TE D
.12 (.07)
Self-Esteem
EP
(
AC C
Race
.11 (.07)
Depression
.11 (.06) -.26*** (.07)
-.06 (.06)
.18** (.06)
SC
Race
-.59*** (.06) -.02 (.05) Race
Note. F = 18.55***, R2 = .41. Race referent group = White women. * p < .05. ** p < .01. *** p < .001.
ACCEPTED MANUSCRIPT
DISCRIMINATION, HEALTH AND MEDIATING PATHS 36
M AN U
-.05 (.07)
-.15 (.08)
SC
Discrimination
RI PT
Figure 4. Standardized coefficients and standard error terms for moderated (by race) mediation analyses with discrimination and selfesteem predicting emotional health
-.26*** (.07)
.23*** (.07)
Self-Esteem
.12 (.07)
TE D
Race
.00 (.06) Race
AC C
EP
Note. F = 3.54**, R2 = .09. Race referent group = White women. * p < .05. ** p < .01. *** p < .001.
Emotional Health
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 37 Table 2. Conditional effects models predicting health outcomes
SC
RI PT
Outcome: Physical Health Conditional Direct effect of Discrimination on Physical Health Effect SE p 95% CI White women -0.26 0.10 0.01 -0.456, -0.064 Black women -0.09 0.11 0.43 -0.310, 0.131 Conditional Indirect effect of Discrimination on Physical Health via Self-Esteem Boot effect Boot SE Boot 95% CI White women -0.080 0.040 -0.182, -0.022 Black women -0.024 0.026 -0.091, 0.015 Conditional Indirect effect of Discrimination on Physical Health via Structural Awareness Boot effect Boot SE Boot 95% CI White women -0.037 0.028 -0.106, 0.005 Black women -0.033 0.031 -0.135, 0.002
TE D
M AN U
Outcome: Depression Conditional Direct effect of Discrimination on Depression Effect SE P 95% CI White women 0.153 0.084 0.07 -0.013, 0.320 Black women 0.023 0.095 0.81 -0.164, 0.210 Conditional Indirect effect of Discrimination on Depression via Self-Esteem Boot effect Boot SE Boot 95% CI White women 0.200 0.062 0.094, 0.341 Black women 0.053 0.049 -0.029, 0.168 Conditional Indirect effect of Discrimination on Depression via Structural Awareness Boot effect Boot SE Boot 95% CI White women 0.035 0.024 0.001, 0.098 Black women 0.048 0.031 0.004, 0.140
AC C
EP
Outcome: Emotional Health Conditional Direct effect of Discrimination on Emotional Health Effect SE P 95% CI White women -0.114 0.097 0.24 -0.306, 0.077 Black women -0.213 0.111 0.06 -0.432, 0.006 Conditional Indirect effect of Discrimination on Emotional Health via Self-esteem Boot effect Boot SE Boot 95% CI White women -0.080 0.043 -0.191, -0.018 Black women -0.019 0.021 -0.080, 0.010
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 38 Appendix A – Dependent Variables Physical Functioning
RI PT
During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health? 1. Cut down on the amount of time you spent on work or other activities. 2. Accomplished less than you would like. 3. Were limited in the kind of work or other activities. 4. Had difficulty performing the work or other activities (e.g., it took extra effort).
SC
Emotional Functioning
M AN U
During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (e.g. depressed or anxious)? 1. Cut down on the amount of time you spent on work or other activities. 2. Accomplished less than you would like. 3. Didn’t do work or other activities as carefully as usual.
TE D
Depressive Symptoms
These questions are about how you have felt during the past 4 weeks. Please give the one answer that is closest to the way you have been feeling for each item. Did you feel full of life?
AC C
Have you felt calm and peaceful?
EP
Have you felt so down in the dumps that nothing could cheer you up?
Did you have a lot of energy?
Have you felt downhearted and blue? Did you feel worn out?
Have you been a happy person? Did you feel tired?
None of the time
A little of the time
Some of the time
A good bit Most of of the time the time
All of the time
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 39 APPENDIX B – Independent Variable Discriminatory Hassles
Response Scale:
“Never” (1) to “Often” (4)
RI PT
In your day-to-day life how often have you had the following experiences? (Never, Rarely, Sometimes, Often). If you indicated “often” or “sometimes,” what do you think is/are the MAIN REASON(s) for the experience? Check all that you think are the MAIN REASON(s). (Reasons could include race/ethnicity, gender, physical appearance, income level, age, sexual orientation, other).
AC C
EP
TE D
M AN U
SC
1. You are treated with less courtesy than other people. 2. You are treated with less respect than other people. 3. You receive poorer service than other people at restaurants or stores. 4. People act as if they think you are not smart. 5. People act as if they are afraid of you. 6. People act as if they think you are dishonest. 7. People act as if they're better than you are. 8. You or your family members are called names or insulted. 9. You are threatened or harassed. 10. People ignore you or act as if you are not there.
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 40 APPENDIX C – Mediator Variables Structural Awareness Many qualified women can’t get good jobs. Men with the same skills have less trouble. In general, men are more qualified than women for jobs that have great responsibility. Our schools teach women to want the less important jobs. If women don’t advance in their jobs, it is because there are barriers which keep them from getting ahead. 5. By nature women are happiest when they are making a home and caring for children. 6. Men have more of the top jobs because our society discriminates against women. 7. Men have more of the top jobs because they are born with more drive to be ambitious and successful than women. 8. If blacks don’t get a good education or job, they have no one to blame but themselves. If Blacks don’t advance in their jobs, it is because they aren’t interested in getting ahead. 9. If Black Americans don’t go to college, it is because the schools don’t prepare them well. 10. If Blacks don’t advance in their jobs, it is because there are barriers which keep them from getting ahead. 11. In this country, if Blacks don’t get a good education or job, it is because they haven’t had the same opportunities as others. 12. If Blacks can’t find work, it is because there aren’t enough jobs for everybody. 13. If Blacks can’t find work, it is because they don’t look hard enough. 14. If Blacks don’t go to college, it is because they think education is not important. 15. Understanding the experiences of women from different ethnic groups is important. 16. We must understand racism as well as sexism. 17. Homophobia and heterosexism affect the lives of heterosexual people as well as gay men, lesbians and bisexuals. 18. Sex and race are inseparable issues in the lives of women. 19. All oppressions are tied together. 20. While there are important differences in how different kinds of oppression work; there are also important similarities. 21. Women of color are often forgotten when people talk about gender. 22. Racism impacts the lives of white women as well as women of color.
AC C
EP
TE D
M AN U
SC
RI PT
1. 2. 3. 4.
Self-Esteem
1. On the whole, I am satisfied with myself. 2. At times, I think I am no good at all. 3. I feel that I have a number of good qualities. 4. I am able to do things as well as most other people. 5. I feel I do not have much to be proud of. 6. I certainly feel useless at times. 7. I feel that I’m a person of worth, at least on an equal plane with others. 8. I wish I could have more respect for myself. 9. All in all, I am inclined to feel that I am a failure. 10. I take a positive attitude toward myself.
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 41
APPENDIX D
SC
American Indian Asian American Black/African-American Latin American/Latina Mexican American/Chicana Puerto Rican White Other Mixed racial-ethnic background
M AN U
1. 2. 3. 4. 5. 6. 7. 8. 9.
RI PT
Race
Self-reported perceived health
TE D
1. In general, would you say your health is: 2. I am as healthy as anybody I know.
Poor (1) to Excellent (5) Strongly Disagree (1) to Strongly Agree (5)
Socioeconomic position
EP
Mother Occupation Father Occupation Mother Education Father Education
AC C
1. 2. 3. 4.
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 42 References Aiken, L. S., & West, S. G. (1991). Multiple regression: Testing and interpreting interactions. Newbury Park, CA: Sage.
RI PT
Almeida, D. M., & Horn, M. C. (2004). Is daily life more stressful during middle adulthood? In O. G. Brim, C. D. Ryff, & R. C. Kessler (Eds.), How healthy are we? A national study of well-being at midlife (pp. 425–451). Chicago: University of Chicago Press.
SC
Altemeyer, B. (1996). The authoritarian specter. Cambridge, MA: Harvard University Press. Armstrong, K., Rose, A., Peters, N., Long, J. A., McMurphy, S., & Shea, J. A. (2006). Distrust
M AN U
of the health care system and self-reported health in the United States. Journal of General Internal Medicine, 21(4), 292-297. doi: 10.1111/j.1525-1497.2006.00396.x. Aspinwall, L. G., Sechrist, G. B., & Jones, P. (2005). Expect the best and prepare for the worst: Anticipatory coping and preparations for Y2K. Motivation and Emotion, 29, 357-388.
TE D
Bakan, D. (1966). The duality of human existence: Isolation and communion in Western man. Chicago: Rand McNally.
Banks, K. H., Kohn-Wood, L. P., & Spender, M. (2006). An examination of the African
EP
American experience of everyday discrimination and symptoms of psychological distress. Community Mental Health Journal, 42, 555–570.
AC C
Barnes, L. L., de Leon, C. F. M., Wilson, R. S., Bienias, J. L., Bennett, D. A., & Evans, D. A. (2004). Racial differences in perceived discrimination in a community population of older Blacks and Whites. Journal of Aging and Health, 16, 315–337.
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 43 Baumeister, R. F., Campbell, J. D., Krueger, J. I., & Vohs, K. D. (2003). Does high self-esteem cause better performance, interpersonal success, happiness, or healthier lifestyles? Psychological Science in the Public Interest, 4, 1–44.
RI PT
Baumeister, R. F., & Leary, M. R. (1995). The need to belong: desire for interpersonal
attachments as a fundamental human motivation. Psychological Bulletin, 117(3), 497. Berdahl, J. L., Moore, C. (2006). Workplace harassment: Double jeopardy for minority women.
SC
Journal of Applied Psychology, 91(2), 426-436. doi: 10.1037/0021-9010.91.2.426. Bowleg, L. (2008). When Black + Woman + Lesbian? ≠ Black Lesbian Woman: The
M AN U
methodological challenges of qualitative and quantitative intersectionality research. Sex Roles, 59(5-6), 312-325.
Bratter, J. L., & Gorman, B. K. (2011). Is discrimination an equal opportunity risk? Racial experiences, socioeconomic status, and health status among Black and White adults.
TE D
Journal of Health and Social Behavior, 52(3), 365-382.
Branscombe, N. R., Schmitt, M. T., & Harvey, R. D. (1999). Perceiving pervasive discrimination among African Americans: Implications for group identification and well-
EP
being. Journal of Personality and Social Psychology, 77, 135-149. Brown, T. N. (2001). Measuring self-perceived racial and ethnic discrimination in social
AC C
surveys. Sociological Spectrum, 21, 377-392.
Brown, C., Matthews, K. A., Bromberger, J. T., & Chang, Y. (2006). The relation between perceived unfair treatment and blood pressure in a racially/ethnically diverse sample of women. American Journal of Epidemiology, 164(3), 257-262. doi: 10.1093/aje/kwj196
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 44 Buck, T., Baldwin, C. M., Schwartz, G. E. (2005). Influence of worldview on health care choices among persons with chronic pain. Journal of Alternative and Complementary Medicine,11, 561–568.
RI PT
Carbado, D. W., Crenshaw, K. W., Mays, V. M., & Tomlinson, B. (2013). Intersectionality: Mapping the movements of a theory. DuBois Review, 10(2), 303-312.
Chavous, T., Rivas, D., Smalls, C., Griffin, T., & Cogburn, C. D. (2008). Gender matters,
SC
too: The influences of school racial discrimination and racial identity on academic
Psychology, 44(3), 637–654.
M AN U
engagement outcomes among African American adolescents. Developmental
Chen, D., & Yang, T. (2014). The pathways from perceived discrimination to self-rated health: An investigation of the roles of distrust, social capital, and health behaviors. Social Science and Medicine, 104, 64-73. doi:10.1016/j.socscimed.2013.12.021.
TE D
Cheng, H., & Furnham, A. (2003). Personality, self-esteem and demographic predictions of happiness and depression. Journal of Personality and Individual Differences, 34, 921-42. Choo, H. Y., & Ferree, M. M. (2010). Practicing intersectionality in sociological research: A
EP
critical analysis of inclusion, interactions, and institutions in the study of inequalities. Sociological Theory, 28(2), 129-149.
AC C
Clark, R. (2003). Self-reported racism and social support predict blood pressure reactivity in Blacks. Annals of Behavioral Medicine, 25(2), 127-136.
Clark, R. (2004). Interethnic group and intraethnic group racism: Perceptions and coping in Black university students. Journal of Black Psychology, 30, 506–526.
Clark, R., Anderson, N. B., Clark, V. R., & Williams, D. R. (1999). Racism as a stressor for African Americans: A biopsychosocial model. American Psychologist, 54(10), 805-816.
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 45 Clark, R., & Gochett, P. (2006). Interactive effects of perceived racism and coping responses predict a school-based assessment of blood pressure in Black youth. Annals of Behavioral Medicine, 32, 1–9.
RI PT
Cokley, K., Hall-Clark, B., & Hicks, D. (2011). Ethnic minority-majority status and mental health: the mediating role of perceived discrimination. Journal of Mental Health Counseling, 33, 243-263.
SC
Cole, E. R. (2009). Intersectionality and research in psychology. American Psychologist, 64, 170-180.
M AN U
Cole, E. R., Case, K. A., Rios, D., & Curtin, N. (2011). Understanding what students bring to the classroom: Moderators of the effects of diversity courses on student attitudes. Cultural Diversity and Ethnic Minority Psychology, 17(4), 397 - 405.
Cole, E.R., & Stewart, A. J. (1996). Meanings of political participation among black and white
TE D
women: Political identity and social responsibility. Journal of Personality and Social Psychology, 71(1), 130-140.
Cooper, L. A., Hill, M. N., & Powe, N. R. (2002). Designing and evaluating interventions to
EP
eliminate racial and ethnic disparities in health care. Journal of General Internal Medicine, 17(6), 477-486. doi: 10.1046/j.1525-1497.2002.10633.x.
AC C
Corning, A. F. (2002). Self-esteem as a moderator between perceived discrimination and psychological distress among women. Journal of Counseling Psychology, 49(1), 117126.
Cozier, Y., Palmer, J. R., Horton, N. J., Fredman, L., Wise, L. A., & Rosenberg, L. (2006). Racial discrimination and the incidence of hypertension in U. S. Black women. Annals of Epidemiology, 16(9), 681-687. doi: 10.1016/j.annepidem.2009.01.008.
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 46 Crenshaw, K. (1991). Mapping the margins: intersectionality, identity politics, and violence against women of color. Stanford Law Review, 43(6), 1241-1299.
stigma. Psychological review, 96, 608-630.
RI PT
Crocker, J. & Major, B. (1989). Social stigma and self-esteem: the self-protective properties of
Crosby, F. (1976). A model of egoistical relative deprivation. Psychological Review, 83(2), 85113.
SC
Cross, W. E., Jr. (1971). The Negro-to-Black conversion experience. Black World, 20 (9), 13–27. Cunningham, M. (1999). African American adolescent males’ perceptions of their community
27(5), 569–589.
M AN U
resources and constraints: A longitudinal analysis. Journal of Community Psychology,
Curtin, N., Stewart, A. J., & Cole, E. R. (under review). Challenging the status quo: The role of intersectional awareness in activism for social change and pro-social intergroup attitudes.
TE D
Psychology of Women Quarterly.
Diaz, R. M., Ayala, G., Bein, E., Henne, J., & Marin, B. V. (2001). The impact of homophobia, poverty, and racism on the mental health of gay and bisexual Latino men: Findings from
EP
3 US cities. American Journal of Public Health, 91(6), 927-932. Downing, N. E., & Roush, K. L. (1985). From Passive Acceptance to Active Commitment A
AC C
Model of Feminist Identity Development for Women. The Counseling Psychologist, 13(4), 695-709.
Doyal, L., & Gough, I. (1991). A theory of human need. Basingstoke: Macmillan. DuBois, D. L., & Flay, B. R. (2004). The healthy pursuit of self-esteem: Comment on and alternative to the Crocker and Park (2004) formulation. Psychological Bulletin, 130(3), 415-420.
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 47 Eccleston, C. P., & Major, B. N. (2006). Attributions to discrimination and self-esteem: The role of group identification and appraisals. Group Processes & Intergroup Relations, 9(2), 14-162.
RI PT
Essed, P. (1990). Everyday racism: Reports from women of two cultures. Claremont, CA: Hunter House.
Essed, P. (1991). Understanding everyday racism: An interdisciplinary theory. Newbury Park,
SC
CA: Sage.
Feagin, J., & Bennefield, Z. (2014). Systemic racism and U. S. health care. Social Science and
M AN U
Medicine, 103, 7-14. doi: 10.1016/j.socscimed.2013.09.006.
Foster, M. D., Sloto, L., & Ruby, R. (2006). Responding to discrimination as a function of meritocracy beliefs and personal experiences: Testing the model of shattered assumptions. Group Processes & Intergroup Relations, 9(3), 401-411.
TE D
Foster, M. D. & Tsarfati, E. M. (2005). The motivational quality of shattered assumptions when responding to an acute experience of gender discrimination. Personality and Social Psychology Bulletin, 31, 1730-1738.
EP
Gayman, M. D., & Barragan, J. (2013). Multiple perceived reasons for major discrimination and depression. Society and Mental Health, 3(3), 203-220.
AC C
Gee, G. C., Pavalko, E. K., & Long, J. S. (2007). Age, cohort and perceived age discrimination: Using the life course to assess self-reported age discrimination. Social Forces, 86(10),
265-290.
Geronimus, A. T., Hicken, M., Keene, D., & Bound, J. (2006). “Weathering” and age patterns of allostatic load scores among Blacks and Whites in the United States. American Journal of Public Health, 96(5), 826-833.
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 48 Greenwood, R. (2008). Intersectional political consciousness: Appreciation for intragroup differences and solidarity in diverse groups. Psychology of Women Quarterly, 32(1), 3647. doi:10.1111/j.1471-6402.2007.00405.x
RI PT
Grollman, E. A. (2014). Multiple disadvantaged statuses and health: The role of multiple dimensions of discrimination. Journal of Health and Social Behavior, 55, 3-19.
Gurin, P. (1985). Women's gender consciousness. Public Opinion Quarterly, 49, 143-163.
SC
Gurin, P., Miller, A. H., & Gurin, G. (1980). Stratum identification and consciousness. Social Psychology Quarterly, 43, 30-47.
M AN U
Harrell, C. J. P., Burford, T. I., Cage, B. N., Nelson, T. M., Shearon, S., Thompson, A., & Green, S. (2011). Multiple pathways linking racism to health outcomes. Du Bois Review, 8, 143– 157.
Hayes, A. F. (2012). PROCESS: A versatile computational tool for observed variable mediation,
TE D
moderation, and conditional process modeling [White paper]. Retrieved from http://www.afhayes.com/ public/process2012.pdf Hayes, A. F. (2013). Introduction to mediation, moderation, and conditional process analysis.
EP
New York: The Guilford Press
Henderson, R. K., Snyder, H. R., Gupta, T., & Banich, M. T. (2012). When does stress help or
AC C
harm? The effects of stress controllability and subjective stress response on stroop performance. Frontiers in Psychology, 3(179), 1-51.
James, S. A. (1994). John Henryism and the health of African-Americans. Culture, Medicine and Psychiatry, 18, 163-182
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 49 Jang, Y., Chiriboga, D. A., Borenstein, A. R., Small, B. J., & Mortimer, J. A. (2009). Healthrelated quality of life in community-dwelling older Whites and African Americans. Journal of Aging and Health, 21(2), 336-349.
of the schema construct. Social Cognition, 7, 113– 136.
RI PT
Janoff-Bulman, R. (1989). Assumptive worlds and the stress of traumatic events: Applications
Jost, J., & Hunyady, O. (2005). The psychology of system justification and the palliative
SC
function of ideology. European Review of Social Psychology, 13(1), 111-153. doi:10.1080/10463280240000046
M AN U
Jost, J.T., & Thompson, E.P. (2000). Group-based dominance and opposition to equality as independent predictors of self-esteem, ethnocentrism, and social policy attitudes among African Americans and European Americans. Journal of Experimental Social Psychology, 36, 209–232.
TE D
Kagee, A., & Dixon, D. N. (2000). Worldview and health promoting behavior: A causal model. Journal of Behavioral Medicine, 23(2), 163-179. Keith, V. M., Lincoln, K. D., Taylor, J. R., & Jackson, J. S. (2010). Discriminatory experiences
EP
and depressive symptoms among African American Women: Do skin tone and mastery matter? Sex Roles, 62(1-2), 48–59. doi:10.1007/s11199-009-9706-5.
AC C
Kelly, U. A. (2009). Integrating intersectionality and biomedicine research. Advances in Nursing Science, 32(2), E42-E56.
Klassen, A. C., Smith, K. C., Shariff-Marco, S., & Juon, H. S. (2008). A healthy mistrust: How worldview relates to attitudes about breast cancer screening in a cross-sectional survey of low-income women. International Journal of Equity in Health, 7(5), 1-19.
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 50 Klonoff, E. A., Landrine, H., & Campbell, R. (2000). Sexist discrimination may account for well-known gender differences in psychiatric symptoms. Psychology of Women Quarterly, 24, 93–99.
RI PT
Landrine, H., & Klonoff, E.A. (2000). Racial discrimination and smoking among Blacks. Ethnicity and Disease, 10(2), 195-202.
Lazarus, R. S. (1999). Stress and emotion: A new synthesis. New York: Springer.
SC
Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer. Leary, M. R. (1990). Responses to social exclusion: Social anxiety, jealousy, loneliness,
M AN U
depression, and low self-esteem. Journal of Social and Clinical Psychology, 9, 221–229. Lekan, D. (2009). Sojourner syndrome and health disparities in African American women. ANS Advances in Nursing Science, 32(4): 307-321. Lopez, G. E., Gurin, P., & Nagda, B. A. (1998). Education and understanding structural causes for group inequalities. Political
TE D
Psychology, 19(2), 305-329. doi:10.1111/0162-895X.00106
Lewis, T. T., Aiello, A. E., Leurgans, S., Kelly, J., & Barnes, L. L. (2010). Self-reported experiences of everyday discrimination are associated with elevated C-reactive protein
EP
levels in older African–American adults. Brain, Behavior, and Immunity, 24, 438–443. doi:10.1016/j.bbi.2009.11.011
AC C
Lott, B. (2012). The social psychology of class and classism. American Psychologist, 67(8), 650658.
Maier, S. F., & Watkins, L. R. (2005). Stressor controllability and learned helplessness: The role of the dorsal raphe nucleus, serotonin, and corticotripin-releasing factor. Neuroscience & Biobehavioral Reviews, 29(4-5), 829-841.
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 51 Major, B., Kaiser, C. R., O'Brien, L. T., & McCoy, S. K. (2007). Perceived discrimination as worldview threat or worldview confirmation: Implications for self-esteem. Journal of Personality and Social Psychology, 92(6), 1068-1086. doi: 10.1037/0022-
RI PT
3514.92.6.1068.
Major, B., Quinton, W. J., & McCoy, S. K. (2002). Antecedents and consequences of attributions to discrimination: Theoretical and empirical advances. In M. P. Zanna (Ed.), Advances in
SC
Experimental Social Psychology (Vol. 34, pp. 251-330). US: Academic Press.
Major, B., Quinton, W. J., & Schmader, T. (2003). Attributions to discrimination and self-
M AN U
esteem: Impact of group identification and situational ambiguity. Journal of Experimental Social Psychology, 39, 220–231.
Mallett, R. K., & Swim, J. K. (2005). Bring it on: Proactive coping with discrimination. Motivation and Emotion, 29, 407–437. doi:10.1007/s11031-006-9014-0
TE D
Mallet, R. K., & Swim, J. K. (2009). Making the best of a bad situation: Proactive coping with racial discrimination. Basic and Applied Social Psychology, 31, 4, 304-316. Mann, M., Hosman, C. M. H., Schaalma, H. P., & de Vries, N. K. (2004). Self-esteem in a broad
372.
EP
spectrum approach for mental health promotion. Health Education Research, 19(4), 357-
AC C
Marmot, M. (2003). Self esteem and health: Autonomy, self esteem, and health are linked together. British Medical Journal, 13(327), 574-575.
Matthews, K. A., Salomon, K., Kenyon, K., & Zhou, F. (2005). Unfair treatment, discrimination, and ambulatory blood pressure in black and white adolescents. Health Psychology, 24(3), 258-265.
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 52 Mays, V. M., Cochran, S. D., & Barnes, N. W. (2007). Race, race-based discrimination, and health outcomes among African Americans. Annual Review of Psychology, 58, 201-225.
RI PT
Mays, V. M., & Cochran, S. D. (2001). Mental health correlates of perceived discrimination among lesbian, gay and bisexual adults in the United States. American Journal of Public Health, 91(11), 1869–1876.
Journal of Medicine, 338, 171–179.
SC
McEwen, B. S. (1998). Protective and damaging effects of stress mediators. New England
M AN U
Mendoza-Denton, R., Downey, G., Purdie, V., Davis, A., & Pietrzak, J. (2002). Sensitivity to status-based rejection: Implications for African-American students' college experience. Journal of Personality and Social Psychology, 83, 896-918.
Miner-Rubino, K., Winter, D. G., & Stewart, A. J. (2004). Gender, social class, and the
TE D
subjective experience of aging: Self-perceived personality change from early adulthood to late midlife. Personality and Social Psychology Bulletin, 30, 1599-1610. Paradies, Y. (2006). A systematic review of empirical research on self-reported racism and
EP
health. International Journal of Epidemiology, 35, 888–901. Pascoe, E. A., & Smart Richman, L. (2009). Perceived discrimination and health: A meta-
AC C
analytic review. Psychological Bulletin, 135(4): 531-554.
Porter, J. R., & Washington, R. E. (1993). Minority identity and self-esteem. Annual Review of Sociology, 19, 139-161.
Purdie-Vaughns, V., & Eibach, R. P. (2008). Intersectional invisibility: The distinctive advantages and disadvantages of multiple subordinate-group identities. Sex Roles, 59, 377-391. doi: 10.1007/s11199-008-9424-4.
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 53 Reid, P. T., & Comas-Diaz, L. (1990). Gender and ethnicity: Perspectives on dual status. Sex Roles, 22, 397–408. Rosenberg, M. (1965). Society and the adolescent self-image. Princeton, NJ: Princeton
RI PT
University Press.
Sapolsky, R. M. (2005). The influence of social hierarchy on primate health. Science, 308(5722), 648-652.
SC
Schieman, S. (2002). Socioeconomic status, job conditions, and well-being. Sociological Quarterly, 43, 627-646.
San Francisco, CA: Jossey-Bass
M AN U
Schultz, A., & Mullings, L. (2006). Gender, race, class and health: Intersectional approaches.
Sellers, R. M. & Shelton, J. N. (2003). The role of racial identity in perceived racial discrimination. Journal of Personality and Social Psychology, 84, 1079-1092.
TE D
Shavers, V. L., Lynch, C. F., & Burmeister, L. F. (2000). Knowledge of the Tuskegee study and its impact on the willingness to participate in medical research studies. Journal of the National Medical Association, 92(12), 563-572.
EP
Silverstein, J. (2013, March 12). How racism is bad for our bodies. The Atlantic. Retrieved from http://www.theatlantic.com/health/archive/2013/03/how-racism-is-bad-for-our-
AC C
bodies/273911/.
Smart Richman, L., & Leary, M. R. (2009). Reactions to discrimination, stigmatization, ostracism, and other forms of interpersonal rejection: a multimotive model. Psychological Review, 116(2), 365.
Smedley, B. D. (2012). The lived experience of race and its health consequences. American Journal of Public Health, 102(5), 933-935.
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 54 Soto, J. A., Armenta, B. E., Perez, C. R., Zamboanga, B. L., Umaña-Taylor, A. J., Lee, R. M., Schwartz, S. J., Park, I. J. K., Huynh, Q. L., Whitmourne, S. K., Le, T. N., & Ham, L. S. (2012). Strength in numbers? Cognitive reappraisal tendencies and psychological
Minority Psychology, 18, 384–394. doi: 10.1037/a0029781
RI PT
functioning among Latinos in the context of oppression. Cultural Diversity and Ethnic
SC
St. Jean, Y., & Joe Feagin, J. (1998). Double burden: Black Women and everyday racism. Armonk, NY: M. E. Sharpe.
M AN U
Stewart, A. L., Sherbourne, C., Hays, R. D., et al. Summary and Discussion of MOS Measures. (1992). In A. L. Stewart & J. E. Ware (Eds.), Measuring Functioning and Well-Being: The Medical Outcome Study Approach (pp. 345-371). Durham, NC: Duke University Press.
TE D
Stewart, A.L., & Ware, J.E. (1992). Measuring Functioning and Well-Being: The Medical Outcomes Study Approach. Durham, NC: Duke University Press. Stuber, J., Meyer, I., & Link, B. (2008). Stigma, prejudice, discrimination and health. Social
EP
Science and Medicine, 67(3), 351-357.
Swann, W. B., Jr., & Bosson, J. (2010). Self and identity. In S. T. Fiske, D. T. Gilbert, & G.
AC C
Lindzey (Eds.), Handbook of social psychology (5th ed., pp. 589 – 628). New York, NY: McGraw-Hill.
Swim, J. K., Hyers, L. L., Cohen, L. L., & Ferguson, M. J. (2001). Everyday sexism: Evidence for its incidence, nature, and psychological impact from three daily diary studies. Journal of Social Issues, 57, 31–53.
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 55 Tajfel, H., & Turner, J. C. (1979). An integrative theory of intergroup conflict. In W. G. Austin & S. Worchel (Eds.), Psychology of Intergroup Relations (pp. 33-47). Monterey, CA: Brooks/Cole.
RI PT
Tajfel, H., & Turner, J. C. (1986). The social identity theory of intergroup behavior. In S.
Worchel & W. G. Austin (Eds.), The psychology of intergroup relations (pp. 7–24). Chicago: Nelson-Hall.
SC
Tangri, S. S., & Jenkins, S. (1993). The University of Michigan class of 1967: The Women's Life Paths Study. In K. Hulbert, D. Schuster, K. Hulbert, D. Schuster (Eds.), Women's lives
Francisco, CA US: Jossey-Bass.
M AN U
through time: Educated American women of the twentieth century (pp. 259-281). San
Taylor, D. M., & McKirnan, D. J. (1984). Theoretical contributions: A five-stage model of intergroup relations. British Journal of Social Psychology, 23(4), 291-300.
TE D
Taylor, S. E. (1983). Adjustment to threatening events: A theory of cognitive adaptation. American Psychologist, 38, 1161–1173.
Thoits, P. A. (2003). Personal agency in the accumulation of multiple role-identities. In P. J.
EP
Burke, T. J. Owens, R. T. Serpe, & P. A. Thoits (Eds.), Advances in identity theory and research (pp. 179–194). New York, NY: Kluwer Academic/Plenum Publishers.
AC C
Tilburt, J. C. (2010). The role of worldviews in health disparities education. Journal of General Internal Medicine, 25(2), 178-181.
Tomaka, J., & Blascovich, J. (1994). Effects of justice beliefs on cognitive appraisal of and subjective physiological, and behavioral responses to potential stress. Journal of Personality and Social Psychology, 67(4), 732-740. Turner-Bowker, D.M., Bartley, P.J., & Ware, J.E., Jr. (2002). SF-36® Health Survey &
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 56 “SF” Bibliography: Third Edition (1988-2000). Lincoln, RI: QualityMetric Incorporated. Valenti, J (2015, January 26). Sexism is making women sick. The Guardian. Retrieved from
RI PT
http://www.theguardian.com/commentisfree/2015/jan/26/sexism-is-making-women-sick. Wendler, D., Kington, R., Madans, J., Van Wye, G., Christ-Schmidt, H., Pratt, L. A., Brawley, O. W., Gross, C. P., & Emanuel, E. (2006). Are racial and ethnic minorities less willing
SC
to participate in health research? PLoS Medicine, 3(2), 0201-0210.
Williams, D. R., Yu, Y., Jackson, J., & Anderson, N. (1997). Racial differences in physical and
Psychology, 2(3), 335–351.
M AN U
mental health: Socioeconomic status, stress, and discrimination. Journal of Health
Williams, D. R., & Mohammed, S. A. (2009). Discrimination and racial disparities in health: evidence and needed research. Journal of Behavioral Medicine, 32(1), 20-47.
TE D
doi:10.1007/s10865-008-9185-0.
Williams, D. R., Neighbors, H. W., & Jackson, J. S. (2008). Racial/ethnic discrimination and health: Findings from community studies. American Journal of Public Health, 98(1),
EP
S29-S37.
Williams, D. R., Spencer, M. S., & Jackson, J. S. (1999). Race, stress and physical health: The
AC C
role of group identity. In R. J. Contrada & R. D. Ashmore (Eds.) Self and Identity:
Fundamental Issues (pp. 71-100). New York: Oxford University Press.
Woods-Giscombé, C. L. (2010). Superwoman Schema: African American women’s views on stress, strength and health. Qualitative Health Research, 20(5), 668-683.
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 57 Worrell, F. C., Cross, W. E., & Vandiver, B. J. (2001). Nigrescence theory: Current status and challenges for the future. Journal of Multicultural Counseling and Development, 29(3), 201-213.
RI PT
Yang, T. C., Matthews, S. A., & Shoff, C. (2011). Individual health care system distrust and neighborhood social environment: how are they jointly associated with self-rated health?
AC C
EP
TE D
M AN U
SC
Journal of Urban Health, 88, 945–958.
ACCEPTED MANUSCRIPT
Research highlights We examine depression, physical and emotional health as consequences of discrimination.
•
Models test the mediating role of self-esteem and increased structural awareness.
•
Using an intersectional approach, these models are tested among Black and White women.
•
Discrimination impacts health outcomes for both Black and White women in variant ways.
•
Indirect effects and within-group heterogeneity are discussed.
AC C
EP
TE D
M AN U
SC
RI PT
•
S0049-089X(16)00011-9
DOI:
10.1016/j.ssresearch.2015.12.012
Reference:
YSSRE 1870
To appear in:
Social Science Research
Received Date: 30 April 2014 Revised Date:
23 November 2015
Accepted Date: 31 December 2015
Please cite this article as: Versey, H.S., Curtin, N., The differential impact of discrimination on health among Black and White women, Social Science Research (2016), doi: 10.1016/ j.ssresearch.2015.12.012. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 1
RI PT
RUNNING HEAD: DISCRIMINATION, HEALTH AND MEDIATING PATHS
Corresponding Author:
TE D
H. Shellae Versey, PhD Wesleyan University Department of Psychology 207 High Street Middletown, CT 06459-0408 (860) 685-2868 Email: [email protected]
M AN U
SC
The differential impact of discrimination on health among Black and White women
AC C
EP
Co-author: Nicola Curtin, PhD Clark University Hiatt School of Psychology 950 Main Street Worcester, MA 01610 (508)793-8862 Email: [email protected]
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 1 Abstract Despite a large body of research examining the impact of discrimination on health, the ways in which perceived discrimination may lead to disparate health outcomes through a sense
RI PT
of self and system consciousness is less understood. The current paper is concerned with both mental and physical health consequences of discrimination, as well as mediating pathways
among African American and White women. Indirect effects analyses examine mediating paths
SC
from discrimination to health outcomes via structural awareness and self-esteem, using data from the Women’s Life Path Study (N = 237). Our findings suggest that discrimination is both directly
M AN U
and indirectly associated with health outcomes for both Black and White women, mediated by individual (self-esteem) and group-level (structural awareness) processes. Evidence from this study indicates that discrimination is associated with heightened structural awareness, as well as lower self-esteem – both of which are related to poorer health. Discrimination negatively
TE D
affected health across three domains, although the mechanisms varied somewhat for Black and White women. Broad implications of this research for interdisciplinary scholarship on the effects
EP
of discrimination on health and health disparities are discussed.
AC C
KEYWORDS: Perceived discrimination, health, self-esteem, structural awareness, mediation
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 2 In a contemporary climate where the effects of violence and racism claim front-page headlines across the nation, the question of whether racism and sexism makes us sick seems to hold an obvious answer (Silverstein, 2013). Valenti (2014) notes a body of evidence - both
RI PT
experimental and observational - that concludes that even the threat of racism is sufficient to “trigger a stress response.”
Indeed, research spanning three decades supports the notion that systems of oppression
SC
(e.g., racism, sexism) and differential treatment (discrimination) create an added burden that leads to poorer health for marginalized populations and individuals (Williams & Mohammed,
M AN U
2013). While an extensive review of this literature is beyond the scope of this paper, our intent is to situate the current study within this research tradition by expanding the focus on mental health outcomes as well as mediating processes.
A multilevel framework positions fundamental causes of racism as being rooted in an
TE D
organized system that separates racial groups into ranked categories by which members of lowerranked groups are devalued, disempowered and generally regarded as inferior. Resulting pathways indicate that race and other social status groups, such as age, gender and SES, are
EP
linked to health through a variety of intervening mechanisms (Williams, 1997). One means by which perceived discrimination negatively affects health is through psychological and stress
AC C
responses that affect self-esteem and group identity. Specifically, we draw on social psychological theory to argue that discrimination threatens two “basic” psychological needs that shape how individuals relate to the social world: communion and agency (Bakan, 1966; Swann & Bosson, 2010). The need for communion is strongly tied to self-esteem, and the need for agency is tied to the belief that one can achieve personal goals. We propose that discrimination threatens both needs, and ultimately compromises health. Because communion and agentic
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 3 orientations have been related to several psychological processes, including social status evaluations and self-concept, we use this theoretical framing to explore the effects of discrimination on health as mediated by threats to one’s self and group identity. As we argue
RI PT
below, one way to understand the deleterious effect of discrimination is to consider how it threatens aspects of the self, as well as one’s group identity. We test two paths from
discrimination to negative health outcomes. Further, given the lack of research on older women,
SC
and an increasing interest in intersectional approaches to thinking about important social and
middle-aged Black and White women. Perceived discrimination and health
M AN U
psychological issues, we examine how these pathways may be similar or different for older
We define discrimination as part of a manifestation of racism, sexism and other types of oppression that can be experienced both systemically (e.g., through organizations, institutions,
TE D
geography, policies and practices) and interpersonally (e.g., personal and social interactions). Or put simply, the expression and institutionalization of social relationships through dominance and oppression (Krieger, 2000). Perceived discrimination refers to the perceived negative attitudes
EP
or treatment resulting from this expression based upon group membership (Williams, Spencer, & Jackson, 1999). While the measurement of the construct has been subject to some debate
AC C
(Williams & Mohammed, 2009), we maintain, as have others, that experiences of perceived discrimination constitute a form of stress (Clark et al., 1999; Mays & Cochran, 2001; Pascoe & Smart Richman, 2009; Smedley, 2012). We also note that distinctions can be made regarding terminology – perceived discrimination, self-reported discrimination and discrimination. However, because we believe that these terms collectively refer to a general underlying process, they will be used interchangeably throughout.
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 4 The negative impact of discrimination on health has been documented extensively (Banks, Kohn-Wood, & Spender, 2006; Klonoff, Landrine, & Campbell, 2000; Mays, Cochran & Barnes, 2007; Pascoe & Smart Richman, 2009; Williams & Mohammed, 2009). Generally,
RI PT
perceived discrimination is considered a stressor that compromises both mental and physical health through psychological and biophysical arousal of the stress-response system (Barnes et al., 2004; Pascoe & Smart Richman, 2009). Such responses can contribute to acute and long-term
SC
consequences including chronic hyperactivity of emotional regulation systems and allostatic load. Reviews of the literature find that chronic exposure to everyday discrimination activates a
M AN U
stress-arousal pathway that may facilitate adverse cardiovascular outcomes as indicated by clinical biomarker research (Paradies et al., 2015). In an early study of this effect among middleaged African American women, Lewis and colleagues (2006) find that chronic exposure to discrimination is significantly associated with the presence of coronary artery calcification and
TE D
other cardiovascular risk factors. This and other research suggest a likelihood that chronic stress related to discrimination may involve inflammation processes, thereby promoting metabolic, immune and cardiovascular dysfunction (Lewis et al., 2010)
EP
Although reviews emphasize the importance of identifying specific pathways by which discrimination is likely to contribute to health, almost no attention is given to specific processes
AC C
that might clarify how the process unfolds. After considerable research, the extent to which exposure to perceived discrimination differentially triggers attributions that may result in stressful reactions is unknown. It is this process that the current paper aims to understand better by examining self and group-based identity mediators between self-reported discrimination and health outcomes.
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 5 Because perceived discrimination is a potential stressor, emotional responses to discriminatory treatment are partially a function of the cognitive appraisal of such events as a stressful experience (Lazarus, 1999; King, 2005). Lazarus and Folkman (1984) define a stressor
RI PT
as an event in which the “relationship between the individual and the environment is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being” (p. 19). While the majority of health research focuses on proximal biophysiological stress
SC
responses that result from discrimination, there may be considerable variability in the degree to which discriminatory stressors are perceived and subsequently appraised (Folkman, Lazarus,
M AN U
Gruen, & DeLongis, 1986). Cognitive appraisal describes the process that determines whether an event or transaction is stressful (Folkman & Lazarus, 1984). In many ways, how perceived discrimination relates to feelings of self-worth, in-group/out-group and between-group attitudes is at the core of the mechanism that links discrimination to a negative cascade of biological
TE D
sequelae (Major, Quinton, & McCoy, 2002; Soto et al., 2012). According to some researchers, this point of analysis is critical understanding discrimination-mediated stress (Harrell, 2000). Therefore, the present study builds upon this prior work and provides a mediational framework
EP
whereby discriminatory experiences may reshape views of one’s self, sense of self-worth and heighten sensitivities about larger group-differences and system inequalities (Gurin, 1985;
AC C
Major, Kaiser, O'Brien, & McCoy, 2007; Lazarus & Folkman, 1984; Taylor, 1983). We examined the impact of perceived discrimination on self-esteem and intergroup attitudes, as well as on three indicators of health – depression, emotional functioning and physical functioning. Discrimination, Self-Esteem, and Structural Awareness We argue that the relationship between discrimination and health may be better understood by considering the mediating role of beliefs both about the self and one’s social
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 6 group. The literature suggests several different mediating processes (Harrell et al., 2011); however, we focus on two separate paths that examine the interaction between targets of attribution and the social world. On an individual level, we expect that perceived discrimination
RI PT
compromises health through lower self-esteem. On a macro-level, discrimination may also
thwart worldviews, which impacts health as well (Cooper, Hill & Powe, 2002; Tilburt, 2010). One pathway, based on the effects on personal self-worth, posits that self-evaluation is
SC
critical to health (Mann, Hosman, Schaalma, & de Vries, 2004; Thoits, 2003). When
discrimination threatens self-esteem, health should decline as well. The second pathway, based
M AN U
on discrimination’s effects on beliefs about the origins of group-based inequality, hypothesizes that discrimination has a negative effect on health through increased awareness of structural inequalities (what we call structural awareness). Drawing from social psychologists and feminist ideology, we examine the notion that everyday experiences, particularly those associated with
TE D
multiple marginalized group identities such as African American women, facilitate a “multiple consciousness”, defined as the awareness of multiple systems and how those systems work together to structure power and privilege (Baca Zinn & Thornton Dill, 1996; King, 1988).
EP
Below we discuss the theoretical underpinnings of each proposed pathway, as well as current research related to the relationships between discrimination, self-esteem, and health, as well as
AC C
discrimination, structural awareness, and health. In essence, a central aim of this paper is to examine how two known psychological outcomes of perceived discrimination, decreased selfesteem and increased structural awareness, may help explain the etiologic relationship between discrimination and health.
Discrimination, self-esteem, and health. Social psychologists generally agree that individuals have a basic need for communion, or a need to feel as though they belong (see
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 7 Baumeister & Leary, 1995; Doyal & Gough, 1991; Swan & Bosson, 2010). When that need goes unfulfilled, self-esteem may be challenged (Marmot, 2003). Schieman (2002) and Thoits (2003) report that high self-esteem predicts subjective health. Low self-esteem, in contrast, is
RI PT
associated with negative health outcomes, such as depression (Cheng & Furnham, 2003).
Experiences of rejection, including discrimination, threaten the basic need of communion and negatively impacts self-esteem (Baumeister & Leary 1995; Smart Richman & Leary, 2009).
SC
Given this, it is not surprising that high self-esteem is associated with well-being, happiness, life satisfaction and better coping skills, functioning as a buffer for physical and mental health
M AN U
(Baumeister et al., 2003; DuBois & Flay, 2004; Mann et al., 2004).
While research is clear that self-esteem is important for health, evidence supporting the effects of discrimination on self-esteem remains mixed (Crocker & Major, 1989; Eccleston & Major, 2006; Porter & Washington, 1993). For instance, Branscombe and colleagues (1999)
TE D
contend that targets of discrimination internalize discriminatory acts resulting in poorer selfesteem. Indeed, studies find that members of disadvantaged groups (e.g., racial-ethnic minorities, sexual minorities and women) who also believe that they or members of their group are treated
EP
unfairly, are more likely to have poorer self-esteem and lower psychological well-being (Diaz, Ayala, Bein, Henne, & Marin, 2001; Mays & Cochran, 2001; Swim, Hyers, Cohen, & Ferguson,
AC C
2001). However, other research finds higher levels of self-esteem among groups that have been targets of chronic discrimination, compared to other groups. Further, discrimination can have a positive effect on self-esteem if it permits external attribution, rather than self-blame (Eccleston & Major, 2006). For example, Major and colleagues (2003) found a positive relationship between perceived discrimination and self-esteem, particularly when negative events were attributed to the discrimination and not the self. Other research has shown that the effects of
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 8 discrimination depend on several factors including social evaluations, social inclusion (Leary, 1990), and one’s core assumptions about the world (Major et al., 2007). Major and colleagues (2007) found that experiences of discrimination were associated with decreased self-esteem
RI PT
among people who were higher on meritocracy beliefs (more on these findings below). Several other studies report no direct relationship between perceptions of discrimination and self-esteem (Brown, 2001; Mendoza-Denton, Downey, Purdie, Davis, & Pietrzak, 2002), emphasizing the
SC
need to further understand this relationship and in a larger sense, understand how either personal or group-level attributions may function as a mediator linking discrimination to health.
M AN U
Discrimination, structural awareness, and health. Researchers seeking to understand the nature of how systemic racism and discrimination impact health have consistently emphasized the need to conceptualize and measure the effects of discrimination as a social phenomenon with structural roots (Feagin & Bennefield, 2014). Therefore, drawing on past
TE D
theorizing, we recognize structural awareness as the degree to which people place the responsibility for inequalities on social institutions and structures, as opposed to individuals or groups themselves (i.e., the degree to which they see systemic reasons for individual inability to
EP
be successful or competent within a particular domain). Structural awareness is a rejection of the idea that inequalities between different social groups are due to individual differences or
AC C
qualities about members of a certain group, instead framing them as institutional-level phenomena that perpetuate group inequalities (Gurin, Miller, & Gurin, 1980; Lopez, Gurin, & Nagda, 1998). We posit that such an awareness may trigger a stressful response, as a separate, but related body of literature on stressor controllability suggests that exposure to aversive events which cannot be controlled produces cognitive restructuring, impaired functioning, a weakened immune system and poorer physical and mental health outcomes (Cox et al., 2012; Henderson et
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 9 al., 2012; Kwan et al., 2014; Maier & Watkins, 2005). Using a social psychological lens, we understand the multiple channels that racism and thereby discrimination, operate through and reproduce socially could be interpreted differently depending on the level of consciousness
RI PT
individuals have about these processes.
From a psychological perspective, Swann and Bosson (2010) argue that the “need for agency motivates a desire for self-competence.” (p. 606). In order to understand how
SC
discrimination might negatively impact this need, we draw on social identity theory (SIT; Tajfel &Turner, 1979; 1986) and relative deprivation theory (Crosby, 1976) to frame the link between
M AN U
discrimination and individual and group-level consciousness. Both theories argue that, because of intergroup competition, some individuals will encounter experiences of discrimination based on group membership, that indicate to the individual that there are outside limits imposed to how much they can individually achieve (i.e., their group membership affects their ability to be
TE D
agentic). These experiences can lead to a critique of the existing social hierarchy, which the individual views as impeding their ability to gain resources (we note that both theories allow for other outcomes also, such as a desire to change groups, or even a sense of resignation to one’s
EP
place in the social hierarchy, but those are not of interest to us here). We argue that this critique itself is a manifestation of the thwarting of desires for agency and will negatively affect health.
AC C
We call this knowledge that one’s personal agency is limited as a result of one’s group membership, structural awareness. Just as the relationship between self-esteem and discrimination is complex, so too is that
between discrimination and structural awareness. Some researchers argue that experiences of discrimination increase structural awareness (Cross, 1971; Downing & Roush, 1985; Taylor & McKiman, 1984; Worrell, Cross, & Vandiver, 2001), while others argue that structural
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 10 awareness itself moderates the relationship between perceived discrimination and other important outcomes, such as self-esteem (Foster, Sloto, & Ruby, 2006; Major et al. 2007). The conceptual framework tying discrimination to structural awareness primarily builds
RI PT
from two previous theoretical approaches. The first is taken from the social-psychological
literature and argues that important life experiences, such as discrimination, shape how people view the world and their place in that world (e.g., Janoff-Bullman, 1989; Cross, 1971; Downing
SC
& Roush, 1985; Taylor & McKiman, 1984; Worrell et al., 2001). Theories of group
consciousness, such as Cross’ (1971; Worrell et al., 2001) model of Black identity development
M AN U
and Downing & Roush’s (1985) feminist identity posit that discrimination experiences serve as “encounters” that raise individuals’ awareness of group-level inequalities. For example, Essed (1990, 1991) interviewed women in both the Netherlands and the United States about their personal experiences with discrimination, and found that they connected these experiences to
TE D
larger social inequalities between Black and White people. In a series of studies on the effects of discrimination on well-being, Foster and colleagues (Foster et al., 2006; Foster & Tsarfati, 2005) used these developmental models, as well as the theory of assumptive worlds (Janoff-Bullman,
EP
1989) to argue that experiences of discrimination can negatively affect one’s beliefs about the world by “shattering” (Foster et al., 2006, p. 404) their assumptions about a just world (i.e.,
AC C
raising their structural awareness).
Second, we conceptualize structural awareness as a consequence of discrimination that
heightens knowledge sensitivities and consciousness, much like what has been described in the distrust literature regarding medical research and the inclusion of marginalized groups (e.g., Tuskegee Syphilis experiment) (Shavers, Lynch, & Burmeister, 2002; Wendler, 2006). In other words, experiencing discrimination can make one aware that there are larger power imbalances
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 11 between groups that lead to personal encounters of discriminatory treatment. Indeed, system distrust is related to poorer self-rated health, after adjusting for other explanatory factors such as education, SES, education and neighborhood (Armstrong et al., 2006; Yang et al., 2011). It may
RI PT
be the case that a stronger structural awareness precedes this cascade. In fact, Chen and Yang (2014) found a positive association between discrimination and distrust, and that levels of distrust were higher among women and those of middle-income groups.
SC
The question remains, however, whether increased structural awareness is beneficial or detrimental for health. In other words, does knowing about system and group-based inequalities
M AN U
help individuals manage perceived discrimination more effectively, or does this knowledge contribute to worse health? Because prior research finds that experiencing negative events (such as discrimination) without the ability to control those events leads to increased stress, depression and overall worse health, we hypothesize that increased structural awareness will have similar
TE D
negative effects. While this process has been studied in other contexts [e.g., cognition-emotion relationship and coping styles, stressor controllability, shifting worldviews and health promoting behavior (Cox et al., 2012; Henderson et al., 2012; Kagee & Dixon, 2000; Klassen, Smith,
EP
Shariff-Marco, & Juon, 2008; Lazarus & Smith, 1988; Maier & Watkins, 2005), as well as research that has highlighted relationships between lower just world beliefs and increased
AC C
physiological stress (Tomaka & Blascovich, 1994), and studies linking increased just world beliefs (what we might call low structural awareness) to increased subjective well-being (see Jost & Hunyady, 2005; Jost & Thompson, 2000)], its specific application to discrimination and the stress response is relatively novel. Therefore, we hypothesize that perceived discrimination will lead to increased structural awareness and poorer health outcomes through a mediation pathway. The Current Project
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 12 The significance of the current project is twofold. First, probing potential pathways between perceived discrimination and mediating variables is important to understand the etiology of how perceptions of discrimination trigger stressful reactions. Second, existing studies
RI PT
of perceived discrimination traditionally focus either on racial discrimination (among primarily ethnic minority samples; see for example Clark, 2003; Clark, Anderson, Clark, & Williams, 1999; Mays, Cochran, & Barnes, 2007) or sexist discrimination (among mostly White college
SC
women; see for example, Corning, 2002) separately. This separation of gender and race is problematic, as it often ignores the intersection of the two, and the ways in which such
M AN U
intersections result in unique experiences for women of color (see Berdahl & Moore, 2006; Bowleg, 2008; Purdie-Vaughns & Eibach, 2008; Reid & Comas-Diaz, 1990). Inconsistent findings in the literature about the effects of discriminatory experiences suggest the presence of intragroup variation, in that not all women or all African Americans universally make
TE D
attributions about perceived discrimination in the same way (Clark, 2004; Clark & Gochett, 2006; Cokley, Hall-Clark, & Hicks, 2011; Cozier et al., 2006; Keith, Lincoln, Taylor, & Jackson, 2010; Matthews, Salomen, Kenyon, & Zhou, 2005; Paradies, 2006; Williams & Mohammed,
EP
2009).
Research in psychology and other social sciences is just beginning to understand how
AC C
social categories of identity, difference and disadvantage are separately and jointly associated with important life outcomes (Cole, 2009; Smedley, 2012). Intersectionality is a framework that empirically and conceptually considers the meaning of multiple categories of social group membership (Crenshaw, 1989). This paper interrogates the heterogeneity among older women’s experiences with discrimination and related consequences. We examine the effects of discrimination on both Black and White women in an attempt to disentangle how the effects of
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 13 perceived discrimination may differ among women from different racial backgrounds. In doing so, we attempt to extend the literature in both areas to consider how perceived discrimination may have differential and lingering effects.
RI PT
It is unclear as to what extent the intersection of identities (e.g., race and gender) has salience for interpreting discriminatory experiences (Barnes et al., 2004; Clark, Anderson, Clark, & Williams, 1999). There is limited knowledge regarding which specific aspects of
SC
discrimination are detrimental and for whom (Bratter & Gorman, 2011). For example, gender differences have been noted in relation to frequency and type of discrimination experienced by
M AN U
ethnic-minority individuals (Chavous et al., 2008; Cunningham, 1999), and racial differences in experiences of perceived unfair treatment differ among women (Brown, Matthews, Bromberger, & Chang, 2006). Yet there has been virtually no attention paid to how structural awareness or consciousness about social identities may impede health. Some theories (e.g., double
TE D
disadvantage; double jeopardy hypothesis) suggest that holding more than one disadvantaged status leads to poorer health, due in part to increased exposure to discrimination, as well as a heightened awareness about systems of inequality (Grollman, 2014; King, 1988, Harnois, 2015).
EP
Regardless of race, personal experiences with multiple forms of discrimination are associated with the a multiple consciousness (Harnois 2015). Thus, determining whether this is
AC C
relevant in terms of discrimination and health; if Black or White women, for example, have different or similar levels of structural awareness following discrimination and whether this awareness leads to health effects is important in order to understand how discrimination affects different groups. Using an inclusion-centered approach (Choo & Ferree, 2010), we examine the effects of discrimination in a racially diverse sample of women to explore the central hypothesis that the relationship between discrimination, despression and physical and emotional functioning
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 14 is mediated by increased structural awareness and decreased self-esteem. At the same time, we consider the moderating role of race. We expect there to be some variation in the extent to which discrimination is correlated with depression, emotional functioning and physical health
RI PT
functioning for Black and White women.
Prior studies have found that historical events can have differential effects on both health and worldviews depending on birth cohort and social context. The women in the current study
SC
were part of a longitudinal panel study that began in the late 1960s, of female college graduates. Now in their early 60s, these women experienced young adulthood during a time of intense
M AN U
social change (e.g., Women’s Rights Movement, Civil Rights Movement); many of them were involved in, or followed closely the women’s movement and/or the civil rights movements of the 1960s and 70s. They are, therefore, a uniquely interesting sample in which to examine experiences of discrimination, beliefs about social inequalities and health. The aim of the current
TE D
study is to interrogate two mediational pathways linking discrimination to three health outcomes. Specifically, this study is concerned with 1) the direct effect of discrimination on health; 2) the indirect impact of discrimination on health via its relationship to (increased) intersectional
EP
awareness and (decreased) self-esteem (see Figure 1). Our hypotheses are as follows: 1. Hypothesis 1: There is a direct and negative impact of perceived discrimination
AC C
on health outcomes, measured by physical functioning, depression, and emotional functioning. Further, discrimination has an indirect impact on health through lower self-esteem and higher structural awareness. Specifically, (H1a) perceived discrimination is related to low self-esteem, and (H1b) low self-esteem is associated with poor health.
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 15 2. Hypothesis 2: A second mediation pathway proposes that discrimination has an indirect impact on health through structural awareness. Specifically, (H2a) perceived discrimination is positively related to high structural awareness, and
Method Participants and procedure
RI PT
(H2b) high structural awareness is associated with poor health.
SC
The Women’s Life Paths Study is a longitudinal project following a group of women who graduated from the University of Michigan between 1967 and 1973 (see Tangri & Jenkins, 1993
M AN U
and Cole & Stewart, 1996 for a more detailed description of the sample). In the fall of 2008, 244 women participated in the most recent wave of the data collection. Sixty-five percent of the sample identified as White, 33% as Black, and 2% as “other,” and 2 women did not disclose their race. However, only the 237 women who identified as Black (n = 79; 33% of the remaining
TE D
sample) or White (n = 156; 67% of the remaining sample) were included in the current analyses, and all results will be based on this sample. The mean age was 61 years old (SD = 3.65). Most of the sample (88%) had earned a post-graduate degree and over half (61%) had an annual
EP
household income between $50,000 and $150,000; with 14% having an income below $50,000 and 25% having an income over $200,000. Almost all (95%) of the sample were heterosexual,
AC C
with the remaining 5% identifying as lesbian, bisexual, or “other”. There were no differences, by race, on either the rates at which women earned a post-graduate degree, annual household income, or whether the women identified as lesbian or bisexual. However, Black women in the sample were significantly younger on average (60 years old), compared to white women (62 years old); t(233) = 5.09, p < .001). Outcome Variables
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 16 All outcome measures were derived from the modified version of the Medical Outcomes Survey (SF-36; Stewart, Sherbourne, & Hays, 1992; Stewart & Ware, 1992; Turner-Bowker, Bartley, & Ware, 2002). Structurally, the SF-36 contains 36 items used to create eight different
RI PT
domains of health and well-being (McHorney, Ware & Raczek, 1993). The subscales are
designed to measure functioning and well-being, with each representing a different dimension of health. The Physical Functioning subscale is used to assess physical functioning, the Mental
SC
Health inventory subscale to measure mental health symptomology (e.g., depression), and the Role Emotional SF subscale to assess emotional functioning. Although these different measures
M AN U
are correlated, they are also independent as they assess different components of health – mental, emotional and physical and so were treated as three separate outcomes in this paper. Physical Functioning. The physical functioning subscale was used to assess current limitations in activities during the course of a typical day, a measure of the extent to which
TE D
physical health is compromised. Participants were asked to respond whether their physical health prevented them from engaging in regular activities during the 4 weeks before they took the survey. Sample items included, “Did your health cut down on the amount of time you spent on
EP
work or other activities?” and “Did your health present difficulty in performing your work or other activities (e.g., it took extra effort)?” Participants responded to four “yes” (1)/”no” (0)
AC C
items assessing their physical health limitations. Responses to these items were reverse coded, summed, and a total score was created for each participant, with higher scores indicating a lower level of physical health impairment (or better physical health). A maximum score of 4, for example, implies very little physical limitation. The sample mean was 3.22 (SD = 1.35). There was no significant difference between Black (M = 3.40, SD = 1.21) and white (M = 3.13, SD = 1.41) women, t(167.75) = -1.52, p = .13. The SF-36 scale and scoring procedure have been
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 17 validated among African American adults (Wolinsky, Miller, Andresen, Malmstrom, & Miller, 2004) as well as older African Americans (Jang, Chiriboga, Borenstein, Small, & Mortimer, 2009; Utsey, Payne, Jackson, Jones, 2002).
RI PT
Depression. Depressive symptoms were measured according to an eight-item rating from the Mental Health Inventory (MHI) by Ware and Sherbourne (1992) measuring
characteristic attitudes and symptoms of depression. The MHI has been established as a simple
SC
and valid tool for detecting depressive symptoms in the general population and includes the questions: Over the last 4 weeks, how often: (i) ‘Have you felt so down in the dumps that
M AN U
nothing could cheer you up?’, (ii) ‘Have you felt downhearted and blue?’, (iii) ‘Have you been a happy person?’, (iv) ‘Have you been a very nervous person?’ and (v) ‘Have you felt calm and peaceful?’. Each item has six possible responses ranging from “All the time” (6) to ‘none of the time’ (1 points). Appropriate items were reverse scored so that higher scores corresponded to
TE D
higher depressive symptoms. The answers of the third and fifth question need to be reversed. The sample mean for depressive symptoms is 2.38 (SD = .75; α = 0.88). There was no significant difference in levels of depressive symptoms between Black (M = 2.31, SD = .75) and white (M =
EP
2.41, SD = .75) women; t(230) = .96, p = .34.
Emotional Functioning. The emotional functioning subscale was used to assess
AC C
interferences in daily living due to emotional health. The extent to which involvement in typical daily roles and activities is limited by emotional health was measured by a series of items asking, “During the past 4 weeks, have you had any problems with your work or other regular daily activities as a result of any emotional problems?” Participants responded to three “yes” (1)/”no” (0) items assessing emotional health limitations during the previous month. Responses to these items were reverse coded, summed and a total score was created for each participant, such that
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 18 higher scores indicated better emotional health (M = 2.57, SD = .89). There was no significant difference between Black (M = 2.51, SD = .96) and white (M = 2.60, SD = .85) women on reports of emotional functioning; t(230) = .79, p = .43.
RI PT
Predictor and Mediating Variables
Experiences of discrimination. Based on the original construct of everyday
discrimination (Williams, Yu, Jackson, & Anderson, 1997), ten items reflecting general
SC
mistreatment, without specific reference to race, ethnicity, or gender were used. The frequency of each type of mistreatment was assessed with a 4-point scale (1= never; 4 = often. Sample
M AN U
items: “You are treated with less courtesy than other people,” “You receive poorer service than other people at restaurants or stores,”). The measure tapped participants’ experiences of everyday discrimination over the previous 12 months. Participants who responded either “sometimes” or “often” to at least one of the 10 items were asked to respond to an additional prompt inquiring
TE D
about the reason(s) for their experience(s). Response categories included race/ethnicity, gender, age, income level, language, physical appearance, sexual orientation and other. Items were summed and a score was created for each participant (α =.88). The sample
EP
mean was 16.53 (SD = 4.90). Black women reported significantly more experiences of discrimination (M = 19.81, SD = 4.93), compared to White women (M = 14.92, SD = 4.02);
AC C
t(232) = -8.09, p < .001.
Self-esteem and structural awareness. Two mediator variables were included, self-
esteem and structural awareness. Self-esteem was assessed using the 10-item Rosenberg (1965) self-esteem scale. All
items were on a 6-point scale (“strongly disagree” to “strongly agree”); sample item: “I feel that I’m a person of worth, at least on an equal plane with others.” The average for the sample was
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 19 5.35 (SD = .67; α =.86). Black women scored significantly higher on self-esteem (M = 5.48; SD = .69) compared to White women (M = 5.29; SD = .66); t(229) = -2.02, p < .05. Structural awareness was assessed using a composite of 25 items adapted from two
RI PT
measures. All items were asked on a 6-point scale (1 = strongly disagree; 6 = strongly agree). These items were based on Gurin’s (1985; Gurin et al., 1980) rejection of legitimacy measure; seven asked about gender (sample item: “If women don’t advance in their jobs, it is because
SC
there are barriers which keep them from getting ahead.”) and eight addressed race-based
rejection of legitimacy (sample item: “If Blacks don’t advance in their jobs, it is because they
M AN U
aren’t interested enough in getting ahead.”). Ten items assessing Intersectional Awareness scale (IA; Curtin, Stewart, & Cole, under review; sample item: “All oppressions are tied together) were also included (see also Cole, Case, Rios, & Curtin, 2011).
The sample mean for structural awareness was 4.37 (SD = .59; α =.86). There was no
TE D
difference between White (M = 4.37; SD = .64) and Black (M = 4.38; SD = .46) women on this measure; t(194.77) = -.25, p =.81. Control Variables
EP
To determine which variables to include was controls, we examined the associations between education and age and all variables of interest (see Table 1). Given that education was
AC C
unrelated to any variables of interest, it was not included as a control in our analyses. Age was associated with one of our outcomes of interest, physical health, as well as discrimination. Therefore, we included it as a control in all analyses. Plan of Analyses
Hypotheses were tested through a regression analysis of conditional indirect effects. Three such models were run, one for each of the three outcomes of interest: physical health,
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 20 depression, and emotional health. The general model included experiences of discrimination as the independent variable, structural awareness and self-esteem as mediators, race as a moderator, and the health outcomes as the dependent variables.
RI PT
Analyses were performed using Hayes’ (2013) PROCESS macro for SPSS 20. Hayes’ macro automatically estimates co-efficient and standard errors, using bootstrapped samples (we asked for 5,000, which is recommended; Hayes, 2012) and uses mean centered variables (see
SC
Aiken & West, 1991) for all interaction terms. Bootstrapping involves repeated resampling of a subset of the original dataset (n-1), which allowed us to estimate a statistic’s sample distribution
M AN U
and then used that to create significance confidence intervals. The purpose is to more closely approximate the population from which the study sample is taken, without having to sample the entire population. Further, bootstrapping is preferred to other methods for estimating indirect effects, as it does not assume a normally distributed ab (or mediated) path (Hayes, 2012; 2013).
TE D
An effect is considered significant if 0 does not fall between the confidence intervals (CI). Note that the program produces unstandardized coefficients. In order to produce standardized coefficients, we calculated z-scored versions of all the variables of interest for use in these
Table 1.
EP
analyses (see Hayes, 2013). The simple correlations of all variables included in the models are in
AC C
All analyses controlled age. In each set of regression equations, the interaction of race
with each of the predictor variables was assessed. Therefore, we examined the interaction of race and discrimination on structural awareness and self-esteem, as well as each health outcome. We also tested whether race moderated the effects of both structural awareness and self-esteem on each of the health outcomes. Because there was no significant relationship between structural awareness and emotional functioning (see Table 1), we only tested self-esteem as a mediator for
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 21 that outcome (there can be no indirect effect pathway of discrimination to emotional health via structural awareness if structural awareness is not related to emotional health). Results
RI PT
Confirming our hypotheses, experiences of discrimination predicted both structural awareness and self-esteem; the more discrimination women experienced, the higher their
structural awareness and the lower their self-esteem (H1a, H2a). Race did not moderate the
SC
relationship between discrimination and structural awareness or discrimination and self-esteem. Physical Functioning. Confirming our direct-effect hypotheses (see Figure 2),
M AN U
experiences of discrimination had a negative effect on physical health; those who reported more discrimination had lower physical health score, or reported more functional limitations. However this relationship was moderated by race (conditional direct effects analyses showed that it was only significant for white women, see Table 2). Self-esteem, as expected, had a significant
TE D
positive effect on physical health; the interaction of race by self-esteem (on physical health) was not significant. Structural awareness also had a significant direct effect on physical health (the more structurally aware these women were, the greater their physical functional limitations
EP
(counter-intuitively reflected in a lower score); H2b). The interaction of race by structural awareness was not significant. Conditional indirect effects analyses were run to examine whether
AC C
the indirect effects of discrimination on physical functional limitations (via self-esteem and structural awareness) were different for White and Black women. These results indicated that, the negative indirect effect of discrimination on physical health for self-esteem was only significant for White women; meaning that self-esteem did not mediate the relationship between discrimination and physical health among Black women (see Table 2). Further, contrary to our
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 22 hypothesis, discrimination did not exert significant indirect effects on physical health via structural awareness, for either Black or White women (see Table 2). Depression. Contrary to our hypothesis, discrimination did not exert significant direct
RI PT
effects on depression either in the overall regression model (see Figure 3), or when we ran the conditional direct effects test, which examined Black and White women separately (see Table 2). However, both self-esteem and structural awareness had direct and significant effects on
SC
depression; women who were high on self-esteem reported lower levels of depression and
women who were high on structural awareness reported more depression. Race did not moderate
M AN U
any of the relationships between our variables of interest in the model predicting depression (see Figure 2). Examining the indirect effects of discrimination on depression via self-esteem, the effect was only significant for White women. That is, among White women only, discrimination was associated with increased depression, via self-esteem. In examining the conditional indirect
TE D
effects, for both White and Black women, structural awareness mediated the relationship between discrimination and depression. The relationship was positive, indicating that higher levels of discrimination were associated with higher levels of depression, via increased structural
EP
awareness.
Emotional Functioning. Contrary to our hypothesis, discrimination did not exert
AC C
significant direct effects on emotional health either in the overall regression (see Figure 4), or when we ran the conditional direct effects test examining Black and White women separately (see Table 2). However, self-esteem significantly, and positively, affected emotional health. Although there were no significant direct effects of discrimination on emotional health, it did exert significant indirect effects. However, these indirect effects were only significant for White
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 23 women. Among White women, discrimination exerted significant negative effects on emotional health, via self-esteem. Discussion
RI PT
This study examined two mediating pathways between discrimination and health focused on 1) individual attitudes about larger systems of inequality and 2) conceptions of self-worth. We hypothesized a direct effect of discrimination on physical and emotional functioning and
SC
depression, and an indirect effect of discrimination on physical functioning and depression
through (decreased) self-esteem and (increased) structural awareness. Our findings confirm that
M AN U
discrimination negatively affected health across three domains, and that the mechanisms varied somewhat for Black and White women. Across all three health outcomes, self-esteem mediated the relationship between health and discrimination for White women only. Although discrimination was associated with decreased self-esteem for Black women, this relationship did
TE D
not help explain an association between discrimination and health, as it did for White women. Structural awareness mediated the relationship between discrimination and health for all women when predicting depression, though there was no mediation of structural awareness for physical
EP
functioning.
Interestingly, there was no direct relationship between discrimination and depression or
AC C
discrimination and emotional functioning in this sample; even though we did find indirect effects. We believe this observation strengthens the case for exploring mediating paths between discrimination and health. Further, given adaptive processes to manage experiences of unfair treatment across the life course and the potential for proactive coping and participants’ late midlife developmental stage, direct effects are likely heavily mediated (Aspinwall et al., 2005).
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 24 Self-esteem mediates the relationship between discrimination and health for White women only. This finding supports the notion that discrimination impacts self-esteem, particularly for individuals who may have relatively less lifetime exposure of discrimination or
RI PT
for groups who are disadvantaged on a singular axis (e.g., gender). Broadly, beliefs about system legitimizing ideologies are often ubiquitous throughout society and can remain intact if not challenged. Any experience of discriminatory treatment has the potential to challenge such
SC
beliefs, and may lead one to question individual self-worth, particularly if such challenges are not regularly encountered. The mediating effect supports the hypothesis that discrimination is a
M AN U
threat to communion, at least for white women in this sample, which operates in ways that adversely impact health.
Black women may be less likely to devalue self as a consequence of unfair treatment, due to possible repeated lifetime exposure to discrimination on the basis of both race and gender. It
TE D
may also be the case that Black women attribute discrimination to greater system imbalances or barriers, rather than a function of one’s membership in a socially devalued group (e.g., Crocker & Major, 1989; Major, Quinton, & McCoy, 2002). Indeed in a study conducted by Harnois
EP
(2015), data from a large scale survey of Western-European respondents indicates that the likelihood of perceiving multiple forms of discrimination, as opposed to no discrimination, is
AC C
higher among individuals with multiple minority statuses. Women and men who held no other minority statuses were among the least likely to perceive experiencing multiple discrimination, while religious minority women, ethnic minority women, and women with disabilities were among the most likely to have experienced multiple discrimination events (as opposed to no discrimination) in the past year. In addition, analyses from the same study showed that individuals holding multiple minority statuses and who perceive multiple forms of
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 25 discrimination, are more likely than others to perceive multiple discrimination as being widespread (an indication of what we have referred to as structural awareness). Taken together, these findings support a theory of consciousness raising that is associated with multiple
RI PT
experiences of discrimination.
The lack of a mediating relationship between discrimination, self-esteem and health for Black women is also consistent with theories of attribution that frame prejudiced attitudes
SC
against one’s social identity as protective for members of marginalized groups. Research has shown that marginalized groups use a variety of skills in order to counter discrimination,
M AN U
including proactive coping (Mallet & Swim, 2005). Proactive coping, used prior to or during a stressful event, is an opportunity to anticipate discrimination and reduce the stressful impact (Mallett & Swim, 2009). Generally, members of socially devalued groups may learn to anticipate and prepare for injustice, thereby potentially mitigating the effect (Sellers & Shelton, 2003).
TE D
Black women in our study reported more instances of perceived discrimination compared to White women; therefore, it is likely that Black women have adapted proactive coping mechanisms to protect health (Sellers & Shelton, 2003).
EP
Although experiences of discrimination may not impact health through self-esteem for Black women in this study, it does not preclude harm altogether. Indeed, the finding that
AC C
structural awareness mediates the relationship between discrimination and depression for all women aligns with the notion that knowing about power imbalances, and not being able to do anything about them, can in fact be stressful. This relationship may be best understood in a context of stressor controllability. Early experimental studies have shown that behavior and physiological consequences result from stressors that are uncontrollable, relative to controllable stressors (Maier & Watkins, 1998; Weiss, 1968). In fact, experiments with uncontrollable
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 26 stressors in animal models have produced mental health outcomes that have also been associated with discrimination-related stress, notably depression and anxiety (see Maier & Watkins, 1998 for review). This implies that knowing about inequality and determining that one has little
RI PT
control over those inequalities (or how to change them) can be detrimental. Researchers should examine the framework of stressor controllability in future investigations regarding discrimination, structural awareness and health.
SC
The current study integrates a broad and diverse literature on the impact of perceived discrimination on health by proposing a model mediated by psychological processes. These
M AN U
findings provide evidence for such a framework and suggest that further research is warranted in understanding how differential attributions may influence appraisal and subsequent health effects of discriminatory behavior. For example, experiencing discrimination and knowing that there are structural differences between groups negatively impacts mental health. While this finding is
TE D
consistent with research suggesting that the ways in which individuals make sense of the social world have important implications for shaping how discriminatory acts are perceived, understanding how reshaping cognitions influence health behaviors is largely unexplored.
EP
Furthermore, such realizations may be particularly burdensome for Black women, and operate through indirect channels (e.g., distrust) that influences health behaviors and interactions with
AC C
the health-care system and mental health professionals (Chen and Yang, 2014; Wendler, 2006; Tilburt, 2010). Although speculative, it is possible that Black women manage emotional challenges stemming from unfair treatment in various ways that may be protective (e.g., proactive coping, spirituality) given cultural scripts and norms regarding stress and coping (Lekan, 2009; Woods-Giscombe, 2010).
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 27 Taken together, these findings raise several points regarding the significance of evaluating psychological mediators in studying the relationship between discrimination and health. The association between discrimination, heightened structural awareness and depression
RI PT
is novel. Worldviews should be considered in future research linking discrimination and health as it represents a more comprehensive way of capturing the cumulative and interactive effects of discrimination and systemic racism. For all women in our study, increased structural awareness
SC
about group-based inequalities was negatively related to health in three separate domains. This study provides at least one example of how structural bias (perceived discrimination) operates
M AN U
through institutional and structural levels as well as at individual levels.
Although this study contributes to the literature on discrimination and health, it is not without some limitations. First, the data are cross-sectional; therefore, the link between discrimination and health may be obscured by this approach. We also cannot claim to determine
TE D
causality or endogeneity between variables. While this is a longitudinal sample, this is the first wave to include a measure of perceived discrimination; therefore, it is difficult to assess whether discrimination precedes structural awareness or vice versa. We acknowledge this is a primary
EP
limitation, as it is not possible to statistically disentangle the causal order of our variables. Further, we acknowledge that it may well be the case that individuals with greater structural
AC C
awareness are more attuned to instances of discrimination. In fact, it is likely that for some people, experiences of discrimination may help foster increased structural awareness, but for others they may develop increased structural awareness via other experiences (such as education, for example), and then become more inclined to perceive discrimination in their everyday lives. Tests of the conditions under which these differences emerge are beyond the scope of this paper, but point to the potentially complex set of relationships between the variables of interest here.
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 28 Secondly, the ways in which discrimination impacts health is a complex process that likely unfolds over time, and therefore, our study is not exhaustive in accounting for the dynamic interplay that likely exists between discrimination, self-esteem, structural awareness and health.
RI PT
For example, the sample that we rely upon for this analysis consists of older, educated women of higher class standing who lived through several important social movements. We cannot be sure whether sensitivities related to discrimination or structural awareness become more salient at a
SC
certain age, or whether these processes generalize to other groups. However, Gee and colleagues (2007) do note that reporting of discrimination varies as women move across the adult life
M AN U
course. For example, women in their early to mid-20s generally report discrimination more frequently, than during early midlife (early to mid-30s). Rates of reporting then rise again as women transition into their 40s and peak in the 50s, before declining somewhat when women get closer to retirement.
TE D
In terms of selectivity by social class, our study included relatively high-income, collegeeducated women who may have different life experiences and ways of viewing the world from both Black and White women of lower class position (Lott, 2012; Miner-Rubino, Winter, &
EP
Stewart, 2004; Smedley, 2012). These potential differences may be central in interpreting encounters of discrimination and subsequent health consequences. We also cannot be certain that
AC C
the mediating processes in this study are not specific to this select sample of women, because other studies have not yet explored these questions. However, public health research has found that worldviews are important for health decisions in younger women (Klassen et al., 2008) and older populations in general (Buck, Baldwin & Schwartz, 2005). Several studies also report that minority groups of higher incomes and education (both women and African Americans) report more racist treatment than their working-class counterparts (Kessler et al. 1999; Moody-Ayers et
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 29 al. 2005; Ren et al. 1999). While this may reflect a reporting bias rather than true frequency, it also alludes to what others have suggested that racial prejudice does not cease as a function of social mobility (James, 1994). Among whites, research focused on racial stigma, poverty and
RI PT
whiteness also shows a greater health burden on poorer whites who report unfair treatment, a relationship that is enhanced for individuals with a high sense of racial awareness (Bratter & Gorman, 2011). Fully unpacking this relationship is difficult as there is little comparative data
SC
for discrimination among older, white middle-class samples, yet the selective nature of our sample should be underscored in the interpretation of our results.
M AN U
Finally, we have to acknowledge the limitations of some of our measures. For example, our measure of structural awareness, although a combination of two widely-used measures, is not a standard measure. We note that studies interested in attitudes towards group inequalities use different measures, and the two used here have been used elsewhere to successfully measure
TE D
beliefs about group-based inequalities (see for example, Cole & Stewart, 1996; Cole et al., 2011; Greenwood, 2008, and Lopez et al., 1998). Therefore, we feel confident that we assessed structural awareness, while acknowledging that there may be other measures one could use (for
EP
example, Altemeyer’s (1996) Right Wing Authoritarianism or Just World Beliefs (Jost & Hunyady, 2005). In addition, the measure of discrimination limits responses to indicating one
AC C
status of discrimination (e.g., race or gender), versus multiple forms at the same time (e.g., Black woman). Therefore, it is unknown whether women in this study experienced multiple forms of discrimination simultaneously (e.g., gendered racism; St. Jean & Feagin, 1998). This investigation also relies on self-reported measures of health, which are subject to bias. We acknowledge this important limitation, though we note that they are all well-established health outcome measures. More ideal would be to have objective outcome measures, including
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 30 indicators of physiological stress response, cardiovascular outcomes, weathering and allostatic load (Geronimus, 2006; Lewis et al., 2010; McEwen, 1998 Sapolsky, 2005). In spite of these limitations, the present study offers some insight into the complex
RI PT
relationship between discrimination and health for women. Beyond the main effect, this study focuses on developmental period (late midlife) to examine the potential chronic burdens
associated with perceived discrimination. Inasmuch as understanding the workings of the world
SC
is a life-course pursuit, the current study is ideally suited to explore reactions to discrimination and protective or risk factors that extend beyond immediate effects. Our findings suggest that
M AN U
examining perceived discrimination without accounting for structural worldview may skew interpretations of discrimination-related health effects. This study extends research on discrimination effects and challenges the notion that there is a universal impact of discrimination that operates in the same way for all groups. We believe our findings also make room for
TE D
exploring how effects of discrimination vary across age demographics. Mature women who have experienced a variety of life events and transitions may be more or less reactive to unfair treatment; yet there is little research about how older groups interpret and make sense of these
EP
events (Almeida & Horn, 2004; Gayman & Barragan, 2013; Stuber et al., 2003). Fundamentally, age, social position or class standing may not completely insulate any one group from the
AC C
negative effects of discrimination. Instead, we speculate that among other factors, exposure to and interpretation of unfair treatment may shift appraisals and have relevance for chronic health burdens. Given the potential for women in our sample to have some existing baseline of structural awareness because of their historical cohort, our findings seem even more relevant for contemporary disparities research. In other words, even women who were exposed to fairly
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 31 liberal worldviews during their formative years don’t react to discrimination in the same way, nor do their reactions hold identical meanings for health. Calls for advancing research focused on social processes and health must draw upon an
RI PT
intersectional approach (Carbado, Crenshaw, Mays & Tomlinson, 2013; Kelly, 2009; Smedley, 2012). A benefit of employing an intersectional analysis is highlighting and emphasizing
structural complexities. We therefore resist a monistic approach in our interpretation of how
SC
experiences of discrimination affect either White women or African Americans only, recognizing that social identity is complicated and there may be other distinctions among this group that
M AN U
contribute to our results. Instead we focus on one primary intersection; the ways in which discrimination may be experienced similarly or differently for older women of different racial backgrounds. It is this framing that should lead future research in this area focused on
AC C
EP
TE D
quantifying discrimination as both a social phenomenon and a risk factor for health.
ACCEPTED MANUSCRIPT
DISCRIMINATION, HEALTH AND MEDIATING PATHS 32 Table 1. Intercorrelations for all variables
5. Self-esteem 6. Structural Awareness 7. Level of Education 8. Age
--.43*** .34*** -.18** .31***
--.56***
--
.19**
-.19**
-.60***
.26***
-.15*
.14*
-.10
.12
.00
.06
-.13*
-.02
.01
AC C
Note. * p < .05. ** p < .01. *** p < .001.
6
7
8
--
SC
4. Discrimination
5
M AN U
3. Emotional Health
4
-.13*
.21***
--
.04
--
.03
-.03
.11
--
-.16*
-.09
-.07
-.10
TE D
2. Depression
3
EP
1. Physical health
2
RI PT
1
--
ACCEPTED MANUSCRIPT
DISCRIMINATION, HEALTH AND MEDIATING PATHS 33
M AN U
SC
Structural Awareness
RI PT
Figure 1. Proposed relationships between discrimination, structural awareness, self-esteem, and health outcomes
Discrimination
AC C
EP
TE D
Self-Esteem
Health Outcome
ACCEPTED MANUSCRIPT
DISCRIMINATION, HEALTH AND MEDIATING PATHS 34
RI PT
Figure 2. Standardized coefficients and standard error terms for moderated (by race) mediation analyses with discrimination, structural awareness, and self-esteem, predicting physical health
Race
-.09 (.07) Structural Awareness
M AN U
.26*** (.07)
Discrimination
Physical Health
TE D EP
.12 (.07)
.24*** (.07)
Self-Esteem
AC C
Race
-.06 (.08)
-.21** (.08) -.26*** (.07)
.11 (.07)
-.15* (.07)
SC
Race
.02 (.06) Race
Note. F = 5.24***, R2 = .16. Race referent group = White women. * p < .05. ** p < .01. *** p < .001.
ACCEPTED MANUSCRIPT
DISCRIMINATION, HEALTH AND MEDIATING PATHS 35
RI PT
Figure 3. Standardized coefficients and standard error terms for moderated (by race) mediation analyses with discrimination, structural awareness, and self-esteem, predicting depression Race
-.09 (.07) Structural Awareness
M AN U
.26*** (.07)
Discrimination
TE D
.12 (.07)
Self-Esteem
EP
(
AC C
Race
.11 (.07)
Depression
.11 (.06) -.26*** (.07)
-.06 (.06)
.18** (.06)
SC
Race
-.59*** (.06) -.02 (.05) Race
Note. F = 18.55***, R2 = .41. Race referent group = White women. * p < .05. ** p < .01. *** p < .001.
ACCEPTED MANUSCRIPT
DISCRIMINATION, HEALTH AND MEDIATING PATHS 36
M AN U
-.05 (.07)
-.15 (.08)
SC
Discrimination
RI PT
Figure 4. Standardized coefficients and standard error terms for moderated (by race) mediation analyses with discrimination and selfesteem predicting emotional health
-.26*** (.07)
.23*** (.07)
Self-Esteem
.12 (.07)
TE D
Race
.00 (.06) Race
AC C
EP
Note. F = 3.54**, R2 = .09. Race referent group = White women. * p < .05. ** p < .01. *** p < .001.
Emotional Health
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 37 Table 2. Conditional effects models predicting health outcomes
SC
RI PT
Outcome: Physical Health Conditional Direct effect of Discrimination on Physical Health Effect SE p 95% CI White women -0.26 0.10 0.01 -0.456, -0.064 Black women -0.09 0.11 0.43 -0.310, 0.131 Conditional Indirect effect of Discrimination on Physical Health via Self-Esteem Boot effect Boot SE Boot 95% CI White women -0.080 0.040 -0.182, -0.022 Black women -0.024 0.026 -0.091, 0.015 Conditional Indirect effect of Discrimination on Physical Health via Structural Awareness Boot effect Boot SE Boot 95% CI White women -0.037 0.028 -0.106, 0.005 Black women -0.033 0.031 -0.135, 0.002
TE D
M AN U
Outcome: Depression Conditional Direct effect of Discrimination on Depression Effect SE P 95% CI White women 0.153 0.084 0.07 -0.013, 0.320 Black women 0.023 0.095 0.81 -0.164, 0.210 Conditional Indirect effect of Discrimination on Depression via Self-Esteem Boot effect Boot SE Boot 95% CI White women 0.200 0.062 0.094, 0.341 Black women 0.053 0.049 -0.029, 0.168 Conditional Indirect effect of Discrimination on Depression via Structural Awareness Boot effect Boot SE Boot 95% CI White women 0.035 0.024 0.001, 0.098 Black women 0.048 0.031 0.004, 0.140
AC C
EP
Outcome: Emotional Health Conditional Direct effect of Discrimination on Emotional Health Effect SE P 95% CI White women -0.114 0.097 0.24 -0.306, 0.077 Black women -0.213 0.111 0.06 -0.432, 0.006 Conditional Indirect effect of Discrimination on Emotional Health via Self-esteem Boot effect Boot SE Boot 95% CI White women -0.080 0.043 -0.191, -0.018 Black women -0.019 0.021 -0.080, 0.010
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 38 Appendix A – Dependent Variables Physical Functioning
RI PT
During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health? 1. Cut down on the amount of time you spent on work or other activities. 2. Accomplished less than you would like. 3. Were limited in the kind of work or other activities. 4. Had difficulty performing the work or other activities (e.g., it took extra effort).
SC
Emotional Functioning
M AN U
During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (e.g. depressed or anxious)? 1. Cut down on the amount of time you spent on work or other activities. 2. Accomplished less than you would like. 3. Didn’t do work or other activities as carefully as usual.
TE D
Depressive Symptoms
These questions are about how you have felt during the past 4 weeks. Please give the one answer that is closest to the way you have been feeling for each item. Did you feel full of life?
AC C
Have you felt calm and peaceful?
EP
Have you felt so down in the dumps that nothing could cheer you up?
Did you have a lot of energy?
Have you felt downhearted and blue? Did you feel worn out?
Have you been a happy person? Did you feel tired?
None of the time
A little of the time
Some of the time
A good bit Most of of the time the time
All of the time
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 39 APPENDIX B – Independent Variable Discriminatory Hassles
Response Scale:
“Never” (1) to “Often” (4)
RI PT
In your day-to-day life how often have you had the following experiences? (Never, Rarely, Sometimes, Often). If you indicated “often” or “sometimes,” what do you think is/are the MAIN REASON(s) for the experience? Check all that you think are the MAIN REASON(s). (Reasons could include race/ethnicity, gender, physical appearance, income level, age, sexual orientation, other).
AC C
EP
TE D
M AN U
SC
1. You are treated with less courtesy than other people. 2. You are treated with less respect than other people. 3. You receive poorer service than other people at restaurants or stores. 4. People act as if they think you are not smart. 5. People act as if they are afraid of you. 6. People act as if they think you are dishonest. 7. People act as if they're better than you are. 8. You or your family members are called names or insulted. 9. You are threatened or harassed. 10. People ignore you or act as if you are not there.
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 40 APPENDIX C – Mediator Variables Structural Awareness Many qualified women can’t get good jobs. Men with the same skills have less trouble. In general, men are more qualified than women for jobs that have great responsibility. Our schools teach women to want the less important jobs. If women don’t advance in their jobs, it is because there are barriers which keep them from getting ahead. 5. By nature women are happiest when they are making a home and caring for children. 6. Men have more of the top jobs because our society discriminates against women. 7. Men have more of the top jobs because they are born with more drive to be ambitious and successful than women. 8. If blacks don’t get a good education or job, they have no one to blame but themselves. If Blacks don’t advance in their jobs, it is because they aren’t interested in getting ahead. 9. If Black Americans don’t go to college, it is because the schools don’t prepare them well. 10. If Blacks don’t advance in their jobs, it is because there are barriers which keep them from getting ahead. 11. In this country, if Blacks don’t get a good education or job, it is because they haven’t had the same opportunities as others. 12. If Blacks can’t find work, it is because there aren’t enough jobs for everybody. 13. If Blacks can’t find work, it is because they don’t look hard enough. 14. If Blacks don’t go to college, it is because they think education is not important. 15. Understanding the experiences of women from different ethnic groups is important. 16. We must understand racism as well as sexism. 17. Homophobia and heterosexism affect the lives of heterosexual people as well as gay men, lesbians and bisexuals. 18. Sex and race are inseparable issues in the lives of women. 19. All oppressions are tied together. 20. While there are important differences in how different kinds of oppression work; there are also important similarities. 21. Women of color are often forgotten when people talk about gender. 22. Racism impacts the lives of white women as well as women of color.
AC C
EP
TE D
M AN U
SC
RI PT
1. 2. 3. 4.
Self-Esteem
1. On the whole, I am satisfied with myself. 2. At times, I think I am no good at all. 3. I feel that I have a number of good qualities. 4. I am able to do things as well as most other people. 5. I feel I do not have much to be proud of. 6. I certainly feel useless at times. 7. I feel that I’m a person of worth, at least on an equal plane with others. 8. I wish I could have more respect for myself. 9. All in all, I am inclined to feel that I am a failure. 10. I take a positive attitude toward myself.
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 41
APPENDIX D
SC
American Indian Asian American Black/African-American Latin American/Latina Mexican American/Chicana Puerto Rican White Other Mixed racial-ethnic background
M AN U
1. 2. 3. 4. 5. 6. 7. 8. 9.
RI PT
Race
Self-reported perceived health
TE D
1. In general, would you say your health is: 2. I am as healthy as anybody I know.
Poor (1) to Excellent (5) Strongly Disagree (1) to Strongly Agree (5)
Socioeconomic position
EP
Mother Occupation Father Occupation Mother Education Father Education
AC C
1. 2. 3. 4.
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 42 References Aiken, L. S., & West, S. G. (1991). Multiple regression: Testing and interpreting interactions. Newbury Park, CA: Sage.
RI PT
Almeida, D. M., & Horn, M. C. (2004). Is daily life more stressful during middle adulthood? In O. G. Brim, C. D. Ryff, & R. C. Kessler (Eds.), How healthy are we? A national study of well-being at midlife (pp. 425–451). Chicago: University of Chicago Press.
SC
Altemeyer, B. (1996). The authoritarian specter. Cambridge, MA: Harvard University Press. Armstrong, K., Rose, A., Peters, N., Long, J. A., McMurphy, S., & Shea, J. A. (2006). Distrust
M AN U
of the health care system and self-reported health in the United States. Journal of General Internal Medicine, 21(4), 292-297. doi: 10.1111/j.1525-1497.2006.00396.x. Aspinwall, L. G., Sechrist, G. B., & Jones, P. (2005). Expect the best and prepare for the worst: Anticipatory coping and preparations for Y2K. Motivation and Emotion, 29, 357-388.
TE D
Bakan, D. (1966). The duality of human existence: Isolation and communion in Western man. Chicago: Rand McNally.
Banks, K. H., Kohn-Wood, L. P., & Spender, M. (2006). An examination of the African
EP
American experience of everyday discrimination and symptoms of psychological distress. Community Mental Health Journal, 42, 555–570.
AC C
Barnes, L. L., de Leon, C. F. M., Wilson, R. S., Bienias, J. L., Bennett, D. A., & Evans, D. A. (2004). Racial differences in perceived discrimination in a community population of older Blacks and Whites. Journal of Aging and Health, 16, 315–337.
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 43 Baumeister, R. F., Campbell, J. D., Krueger, J. I., & Vohs, K. D. (2003). Does high self-esteem cause better performance, interpersonal success, happiness, or healthier lifestyles? Psychological Science in the Public Interest, 4, 1–44.
RI PT
Baumeister, R. F., & Leary, M. R. (1995). The need to belong: desire for interpersonal
attachments as a fundamental human motivation. Psychological Bulletin, 117(3), 497. Berdahl, J. L., Moore, C. (2006). Workplace harassment: Double jeopardy for minority women.
SC
Journal of Applied Psychology, 91(2), 426-436. doi: 10.1037/0021-9010.91.2.426. Bowleg, L. (2008). When Black + Woman + Lesbian? ≠ Black Lesbian Woman: The
M AN U
methodological challenges of qualitative and quantitative intersectionality research. Sex Roles, 59(5-6), 312-325.
Bratter, J. L., & Gorman, B. K. (2011). Is discrimination an equal opportunity risk? Racial experiences, socioeconomic status, and health status among Black and White adults.
TE D
Journal of Health and Social Behavior, 52(3), 365-382.
Branscombe, N. R., Schmitt, M. T., & Harvey, R. D. (1999). Perceiving pervasive discrimination among African Americans: Implications for group identification and well-
EP
being. Journal of Personality and Social Psychology, 77, 135-149. Brown, T. N. (2001). Measuring self-perceived racial and ethnic discrimination in social
AC C
surveys. Sociological Spectrum, 21, 377-392.
Brown, C., Matthews, K. A., Bromberger, J. T., & Chang, Y. (2006). The relation between perceived unfair treatment and blood pressure in a racially/ethnically diverse sample of women. American Journal of Epidemiology, 164(3), 257-262. doi: 10.1093/aje/kwj196
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 44 Buck, T., Baldwin, C. M., Schwartz, G. E. (2005). Influence of worldview on health care choices among persons with chronic pain. Journal of Alternative and Complementary Medicine,11, 561–568.
RI PT
Carbado, D. W., Crenshaw, K. W., Mays, V. M., & Tomlinson, B. (2013). Intersectionality: Mapping the movements of a theory. DuBois Review, 10(2), 303-312.
Chavous, T., Rivas, D., Smalls, C., Griffin, T., & Cogburn, C. D. (2008). Gender matters,
SC
too: The influences of school racial discrimination and racial identity on academic
Psychology, 44(3), 637–654.
M AN U
engagement outcomes among African American adolescents. Developmental
Chen, D., & Yang, T. (2014). The pathways from perceived discrimination to self-rated health: An investigation of the roles of distrust, social capital, and health behaviors. Social Science and Medicine, 104, 64-73. doi:10.1016/j.socscimed.2013.12.021.
TE D
Cheng, H., & Furnham, A. (2003). Personality, self-esteem and demographic predictions of happiness and depression. Journal of Personality and Individual Differences, 34, 921-42. Choo, H. Y., & Ferree, M. M. (2010). Practicing intersectionality in sociological research: A
EP
critical analysis of inclusion, interactions, and institutions in the study of inequalities. Sociological Theory, 28(2), 129-149.
AC C
Clark, R. (2003). Self-reported racism and social support predict blood pressure reactivity in Blacks. Annals of Behavioral Medicine, 25(2), 127-136.
Clark, R. (2004). Interethnic group and intraethnic group racism: Perceptions and coping in Black university students. Journal of Black Psychology, 30, 506–526.
Clark, R., Anderson, N. B., Clark, V. R., & Williams, D. R. (1999). Racism as a stressor for African Americans: A biopsychosocial model. American Psychologist, 54(10), 805-816.
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 45 Clark, R., & Gochett, P. (2006). Interactive effects of perceived racism and coping responses predict a school-based assessment of blood pressure in Black youth. Annals of Behavioral Medicine, 32, 1–9.
RI PT
Cokley, K., Hall-Clark, B., & Hicks, D. (2011). Ethnic minority-majority status and mental health: the mediating role of perceived discrimination. Journal of Mental Health Counseling, 33, 243-263.
SC
Cole, E. R. (2009). Intersectionality and research in psychology. American Psychologist, 64, 170-180.
M AN U
Cole, E. R., Case, K. A., Rios, D., & Curtin, N. (2011). Understanding what students bring to the classroom: Moderators of the effects of diversity courses on student attitudes. Cultural Diversity and Ethnic Minority Psychology, 17(4), 397 - 405.
Cole, E.R., & Stewart, A. J. (1996). Meanings of political participation among black and white
TE D
women: Political identity and social responsibility. Journal of Personality and Social Psychology, 71(1), 130-140.
Cooper, L. A., Hill, M. N., & Powe, N. R. (2002). Designing and evaluating interventions to
EP
eliminate racial and ethnic disparities in health care. Journal of General Internal Medicine, 17(6), 477-486. doi: 10.1046/j.1525-1497.2002.10633.x.
AC C
Corning, A. F. (2002). Self-esteem as a moderator between perceived discrimination and psychological distress among women. Journal of Counseling Psychology, 49(1), 117126.
Cozier, Y., Palmer, J. R., Horton, N. J., Fredman, L., Wise, L. A., & Rosenberg, L. (2006). Racial discrimination and the incidence of hypertension in U. S. Black women. Annals of Epidemiology, 16(9), 681-687. doi: 10.1016/j.annepidem.2009.01.008.
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 46 Crenshaw, K. (1991). Mapping the margins: intersectionality, identity politics, and violence against women of color. Stanford Law Review, 43(6), 1241-1299.
stigma. Psychological review, 96, 608-630.
RI PT
Crocker, J. & Major, B. (1989). Social stigma and self-esteem: the self-protective properties of
Crosby, F. (1976). A model of egoistical relative deprivation. Psychological Review, 83(2), 85113.
SC
Cross, W. E., Jr. (1971). The Negro-to-Black conversion experience. Black World, 20 (9), 13–27. Cunningham, M. (1999). African American adolescent males’ perceptions of their community
27(5), 569–589.
M AN U
resources and constraints: A longitudinal analysis. Journal of Community Psychology,
Curtin, N., Stewart, A. J., & Cole, E. R. (under review). Challenging the status quo: The role of intersectional awareness in activism for social change and pro-social intergroup attitudes.
TE D
Psychology of Women Quarterly.
Diaz, R. M., Ayala, G., Bein, E., Henne, J., & Marin, B. V. (2001). The impact of homophobia, poverty, and racism on the mental health of gay and bisexual Latino men: Findings from
EP
3 US cities. American Journal of Public Health, 91(6), 927-932. Downing, N. E., & Roush, K. L. (1985). From Passive Acceptance to Active Commitment A
AC C
Model of Feminist Identity Development for Women. The Counseling Psychologist, 13(4), 695-709.
Doyal, L., & Gough, I. (1991). A theory of human need. Basingstoke: Macmillan. DuBois, D. L., & Flay, B. R. (2004). The healthy pursuit of self-esteem: Comment on and alternative to the Crocker and Park (2004) formulation. Psychological Bulletin, 130(3), 415-420.
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 47 Eccleston, C. P., & Major, B. N. (2006). Attributions to discrimination and self-esteem: The role of group identification and appraisals. Group Processes & Intergroup Relations, 9(2), 14-162.
RI PT
Essed, P. (1990). Everyday racism: Reports from women of two cultures. Claremont, CA: Hunter House.
Essed, P. (1991). Understanding everyday racism: An interdisciplinary theory. Newbury Park,
SC
CA: Sage.
Feagin, J., & Bennefield, Z. (2014). Systemic racism and U. S. health care. Social Science and
M AN U
Medicine, 103, 7-14. doi: 10.1016/j.socscimed.2013.09.006.
Foster, M. D., Sloto, L., & Ruby, R. (2006). Responding to discrimination as a function of meritocracy beliefs and personal experiences: Testing the model of shattered assumptions. Group Processes & Intergroup Relations, 9(3), 401-411.
TE D
Foster, M. D. & Tsarfati, E. M. (2005). The motivational quality of shattered assumptions when responding to an acute experience of gender discrimination. Personality and Social Psychology Bulletin, 31, 1730-1738.
EP
Gayman, M. D., & Barragan, J. (2013). Multiple perceived reasons for major discrimination and depression. Society and Mental Health, 3(3), 203-220.
AC C
Gee, G. C., Pavalko, E. K., & Long, J. S. (2007). Age, cohort and perceived age discrimination: Using the life course to assess self-reported age discrimination. Social Forces, 86(10),
265-290.
Geronimus, A. T., Hicken, M., Keene, D., & Bound, J. (2006). “Weathering” and age patterns of allostatic load scores among Blacks and Whites in the United States. American Journal of Public Health, 96(5), 826-833.
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 48 Greenwood, R. (2008). Intersectional political consciousness: Appreciation for intragroup differences and solidarity in diverse groups. Psychology of Women Quarterly, 32(1), 3647. doi:10.1111/j.1471-6402.2007.00405.x
RI PT
Grollman, E. A. (2014). Multiple disadvantaged statuses and health: The role of multiple dimensions of discrimination. Journal of Health and Social Behavior, 55, 3-19.
Gurin, P. (1985). Women's gender consciousness. Public Opinion Quarterly, 49, 143-163.
SC
Gurin, P., Miller, A. H., & Gurin, G. (1980). Stratum identification and consciousness. Social Psychology Quarterly, 43, 30-47.
M AN U
Harrell, C. J. P., Burford, T. I., Cage, B. N., Nelson, T. M., Shearon, S., Thompson, A., & Green, S. (2011). Multiple pathways linking racism to health outcomes. Du Bois Review, 8, 143– 157.
Hayes, A. F. (2012). PROCESS: A versatile computational tool for observed variable mediation,
TE D
moderation, and conditional process modeling [White paper]. Retrieved from http://www.afhayes.com/ public/process2012.pdf Hayes, A. F. (2013). Introduction to mediation, moderation, and conditional process analysis.
EP
New York: The Guilford Press
Henderson, R. K., Snyder, H. R., Gupta, T., & Banich, M. T. (2012). When does stress help or
AC C
harm? The effects of stress controllability and subjective stress response on stroop performance. Frontiers in Psychology, 3(179), 1-51.
James, S. A. (1994). John Henryism and the health of African-Americans. Culture, Medicine and Psychiatry, 18, 163-182
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 49 Jang, Y., Chiriboga, D. A., Borenstein, A. R., Small, B. J., & Mortimer, J. A. (2009). Healthrelated quality of life in community-dwelling older Whites and African Americans. Journal of Aging and Health, 21(2), 336-349.
of the schema construct. Social Cognition, 7, 113– 136.
RI PT
Janoff-Bulman, R. (1989). Assumptive worlds and the stress of traumatic events: Applications
Jost, J., & Hunyady, O. (2005). The psychology of system justification and the palliative
SC
function of ideology. European Review of Social Psychology, 13(1), 111-153. doi:10.1080/10463280240000046
M AN U
Jost, J.T., & Thompson, E.P. (2000). Group-based dominance and opposition to equality as independent predictors of self-esteem, ethnocentrism, and social policy attitudes among African Americans and European Americans. Journal of Experimental Social Psychology, 36, 209–232.
TE D
Kagee, A., & Dixon, D. N. (2000). Worldview and health promoting behavior: A causal model. Journal of Behavioral Medicine, 23(2), 163-179. Keith, V. M., Lincoln, K. D., Taylor, J. R., & Jackson, J. S. (2010). Discriminatory experiences
EP
and depressive symptoms among African American Women: Do skin tone and mastery matter? Sex Roles, 62(1-2), 48–59. doi:10.1007/s11199-009-9706-5.
AC C
Kelly, U. A. (2009). Integrating intersectionality and biomedicine research. Advances in Nursing Science, 32(2), E42-E56.
Klassen, A. C., Smith, K. C., Shariff-Marco, S., & Juon, H. S. (2008). A healthy mistrust: How worldview relates to attitudes about breast cancer screening in a cross-sectional survey of low-income women. International Journal of Equity in Health, 7(5), 1-19.
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 50 Klonoff, E. A., Landrine, H., & Campbell, R. (2000). Sexist discrimination may account for well-known gender differences in psychiatric symptoms. Psychology of Women Quarterly, 24, 93–99.
RI PT
Landrine, H., & Klonoff, E.A. (2000). Racial discrimination and smoking among Blacks. Ethnicity and Disease, 10(2), 195-202.
Lazarus, R. S. (1999). Stress and emotion: A new synthesis. New York: Springer.
SC
Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer. Leary, M. R. (1990). Responses to social exclusion: Social anxiety, jealousy, loneliness,
M AN U
depression, and low self-esteem. Journal of Social and Clinical Psychology, 9, 221–229. Lekan, D. (2009). Sojourner syndrome and health disparities in African American women. ANS Advances in Nursing Science, 32(4): 307-321. Lopez, G. E., Gurin, P., & Nagda, B. A. (1998). Education and understanding structural causes for group inequalities. Political
TE D
Psychology, 19(2), 305-329. doi:10.1111/0162-895X.00106
Lewis, T. T., Aiello, A. E., Leurgans, S., Kelly, J., & Barnes, L. L. (2010). Self-reported experiences of everyday discrimination are associated with elevated C-reactive protein
EP
levels in older African–American adults. Brain, Behavior, and Immunity, 24, 438–443. doi:10.1016/j.bbi.2009.11.011
AC C
Lott, B. (2012). The social psychology of class and classism. American Psychologist, 67(8), 650658.
Maier, S. F., & Watkins, L. R. (2005). Stressor controllability and learned helplessness: The role of the dorsal raphe nucleus, serotonin, and corticotripin-releasing factor. Neuroscience & Biobehavioral Reviews, 29(4-5), 829-841.
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 51 Major, B., Kaiser, C. R., O'Brien, L. T., & McCoy, S. K. (2007). Perceived discrimination as worldview threat or worldview confirmation: Implications for self-esteem. Journal of Personality and Social Psychology, 92(6), 1068-1086. doi: 10.1037/0022-
RI PT
3514.92.6.1068.
Major, B., Quinton, W. J., & McCoy, S. K. (2002). Antecedents and consequences of attributions to discrimination: Theoretical and empirical advances. In M. P. Zanna (Ed.), Advances in
SC
Experimental Social Psychology (Vol. 34, pp. 251-330). US: Academic Press.
Major, B., Quinton, W. J., & Schmader, T. (2003). Attributions to discrimination and self-
M AN U
esteem: Impact of group identification and situational ambiguity. Journal of Experimental Social Psychology, 39, 220–231.
Mallett, R. K., & Swim, J. K. (2005). Bring it on: Proactive coping with discrimination. Motivation and Emotion, 29, 407–437. doi:10.1007/s11031-006-9014-0
TE D
Mallet, R. K., & Swim, J. K. (2009). Making the best of a bad situation: Proactive coping with racial discrimination. Basic and Applied Social Psychology, 31, 4, 304-316. Mann, M., Hosman, C. M. H., Schaalma, H. P., & de Vries, N. K. (2004). Self-esteem in a broad
372.
EP
spectrum approach for mental health promotion. Health Education Research, 19(4), 357-
AC C
Marmot, M. (2003). Self esteem and health: Autonomy, self esteem, and health are linked together. British Medical Journal, 13(327), 574-575.
Matthews, K. A., Salomon, K., Kenyon, K., & Zhou, F. (2005). Unfair treatment, discrimination, and ambulatory blood pressure in black and white adolescents. Health Psychology, 24(3), 258-265.
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 52 Mays, V. M., Cochran, S. D., & Barnes, N. W. (2007). Race, race-based discrimination, and health outcomes among African Americans. Annual Review of Psychology, 58, 201-225.
RI PT
Mays, V. M., & Cochran, S. D. (2001). Mental health correlates of perceived discrimination among lesbian, gay and bisexual adults in the United States. American Journal of Public Health, 91(11), 1869–1876.
Journal of Medicine, 338, 171–179.
SC
McEwen, B. S. (1998). Protective and damaging effects of stress mediators. New England
M AN U
Mendoza-Denton, R., Downey, G., Purdie, V., Davis, A., & Pietrzak, J. (2002). Sensitivity to status-based rejection: Implications for African-American students' college experience. Journal of Personality and Social Psychology, 83, 896-918.
Miner-Rubino, K., Winter, D. G., & Stewart, A. J. (2004). Gender, social class, and the
TE D
subjective experience of aging: Self-perceived personality change from early adulthood to late midlife. Personality and Social Psychology Bulletin, 30, 1599-1610. Paradies, Y. (2006). A systematic review of empirical research on self-reported racism and
EP
health. International Journal of Epidemiology, 35, 888–901. Pascoe, E. A., & Smart Richman, L. (2009). Perceived discrimination and health: A meta-
AC C
analytic review. Psychological Bulletin, 135(4): 531-554.
Porter, J. R., & Washington, R. E. (1993). Minority identity and self-esteem. Annual Review of Sociology, 19, 139-161.
Purdie-Vaughns, V., & Eibach, R. P. (2008). Intersectional invisibility: The distinctive advantages and disadvantages of multiple subordinate-group identities. Sex Roles, 59, 377-391. doi: 10.1007/s11199-008-9424-4.
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 53 Reid, P. T., & Comas-Diaz, L. (1990). Gender and ethnicity: Perspectives on dual status. Sex Roles, 22, 397–408. Rosenberg, M. (1965). Society and the adolescent self-image. Princeton, NJ: Princeton
RI PT
University Press.
Sapolsky, R. M. (2005). The influence of social hierarchy on primate health. Science, 308(5722), 648-652.
SC
Schieman, S. (2002). Socioeconomic status, job conditions, and well-being. Sociological Quarterly, 43, 627-646.
San Francisco, CA: Jossey-Bass
M AN U
Schultz, A., & Mullings, L. (2006). Gender, race, class and health: Intersectional approaches.
Sellers, R. M. & Shelton, J. N. (2003). The role of racial identity in perceived racial discrimination. Journal of Personality and Social Psychology, 84, 1079-1092.
TE D
Shavers, V. L., Lynch, C. F., & Burmeister, L. F. (2000). Knowledge of the Tuskegee study and its impact on the willingness to participate in medical research studies. Journal of the National Medical Association, 92(12), 563-572.
EP
Silverstein, J. (2013, March 12). How racism is bad for our bodies. The Atlantic. Retrieved from http://www.theatlantic.com/health/archive/2013/03/how-racism-is-bad-for-our-
AC C
bodies/273911/.
Smart Richman, L., & Leary, M. R. (2009). Reactions to discrimination, stigmatization, ostracism, and other forms of interpersonal rejection: a multimotive model. Psychological Review, 116(2), 365.
Smedley, B. D. (2012). The lived experience of race and its health consequences. American Journal of Public Health, 102(5), 933-935.
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 54 Soto, J. A., Armenta, B. E., Perez, C. R., Zamboanga, B. L., Umaña-Taylor, A. J., Lee, R. M., Schwartz, S. J., Park, I. J. K., Huynh, Q. L., Whitmourne, S. K., Le, T. N., & Ham, L. S. (2012). Strength in numbers? Cognitive reappraisal tendencies and psychological
Minority Psychology, 18, 384–394. doi: 10.1037/a0029781
RI PT
functioning among Latinos in the context of oppression. Cultural Diversity and Ethnic
SC
St. Jean, Y., & Joe Feagin, J. (1998). Double burden: Black Women and everyday racism. Armonk, NY: M. E. Sharpe.
M AN U
Stewart, A. L., Sherbourne, C., Hays, R. D., et al. Summary and Discussion of MOS Measures. (1992). In A. L. Stewart & J. E. Ware (Eds.), Measuring Functioning and Well-Being: The Medical Outcome Study Approach (pp. 345-371). Durham, NC: Duke University Press.
TE D
Stewart, A.L., & Ware, J.E. (1992). Measuring Functioning and Well-Being: The Medical Outcomes Study Approach. Durham, NC: Duke University Press. Stuber, J., Meyer, I., & Link, B. (2008). Stigma, prejudice, discrimination and health. Social
EP
Science and Medicine, 67(3), 351-357.
Swann, W. B., Jr., & Bosson, J. (2010). Self and identity. In S. T. Fiske, D. T. Gilbert, & G.
AC C
Lindzey (Eds.), Handbook of social psychology (5th ed., pp. 589 – 628). New York, NY: McGraw-Hill.
Swim, J. K., Hyers, L. L., Cohen, L. L., & Ferguson, M. J. (2001). Everyday sexism: Evidence for its incidence, nature, and psychological impact from three daily diary studies. Journal of Social Issues, 57, 31–53.
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 55 Tajfel, H., & Turner, J. C. (1979). An integrative theory of intergroup conflict. In W. G. Austin & S. Worchel (Eds.), Psychology of Intergroup Relations (pp. 33-47). Monterey, CA: Brooks/Cole.
RI PT
Tajfel, H., & Turner, J. C. (1986). The social identity theory of intergroup behavior. In S.
Worchel & W. G. Austin (Eds.), The psychology of intergroup relations (pp. 7–24). Chicago: Nelson-Hall.
SC
Tangri, S. S., & Jenkins, S. (1993). The University of Michigan class of 1967: The Women's Life Paths Study. In K. Hulbert, D. Schuster, K. Hulbert, D. Schuster (Eds.), Women's lives
Francisco, CA US: Jossey-Bass.
M AN U
through time: Educated American women of the twentieth century (pp. 259-281). San
Taylor, D. M., & McKirnan, D. J. (1984). Theoretical contributions: A five-stage model of intergroup relations. British Journal of Social Psychology, 23(4), 291-300.
TE D
Taylor, S. E. (1983). Adjustment to threatening events: A theory of cognitive adaptation. American Psychologist, 38, 1161–1173.
Thoits, P. A. (2003). Personal agency in the accumulation of multiple role-identities. In P. J.
EP
Burke, T. J. Owens, R. T. Serpe, & P. A. Thoits (Eds.), Advances in identity theory and research (pp. 179–194). New York, NY: Kluwer Academic/Plenum Publishers.
AC C
Tilburt, J. C. (2010). The role of worldviews in health disparities education. Journal of General Internal Medicine, 25(2), 178-181.
Tomaka, J., & Blascovich, J. (1994). Effects of justice beliefs on cognitive appraisal of and subjective physiological, and behavioral responses to potential stress. Journal of Personality and Social Psychology, 67(4), 732-740. Turner-Bowker, D.M., Bartley, P.J., & Ware, J.E., Jr. (2002). SF-36® Health Survey &
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 56 “SF” Bibliography: Third Edition (1988-2000). Lincoln, RI: QualityMetric Incorporated. Valenti, J (2015, January 26). Sexism is making women sick. The Guardian. Retrieved from
RI PT
http://www.theguardian.com/commentisfree/2015/jan/26/sexism-is-making-women-sick. Wendler, D., Kington, R., Madans, J., Van Wye, G., Christ-Schmidt, H., Pratt, L. A., Brawley, O. W., Gross, C. P., & Emanuel, E. (2006). Are racial and ethnic minorities less willing
SC
to participate in health research? PLoS Medicine, 3(2), 0201-0210.
Williams, D. R., Yu, Y., Jackson, J., & Anderson, N. (1997). Racial differences in physical and
Psychology, 2(3), 335–351.
M AN U
mental health: Socioeconomic status, stress, and discrimination. Journal of Health
Williams, D. R., & Mohammed, S. A. (2009). Discrimination and racial disparities in health: evidence and needed research. Journal of Behavioral Medicine, 32(1), 20-47.
TE D
doi:10.1007/s10865-008-9185-0.
Williams, D. R., Neighbors, H. W., & Jackson, J. S. (2008). Racial/ethnic discrimination and health: Findings from community studies. American Journal of Public Health, 98(1),
EP
S29-S37.
Williams, D. R., Spencer, M. S., & Jackson, J. S. (1999). Race, stress and physical health: The
AC C
role of group identity. In R. J. Contrada & R. D. Ashmore (Eds.) Self and Identity:
Fundamental Issues (pp. 71-100). New York: Oxford University Press.
Woods-Giscombé, C. L. (2010). Superwoman Schema: African American women’s views on stress, strength and health. Qualitative Health Research, 20(5), 668-683.
ACCEPTED MANUSCRIPT DISCRIMINATION, HEALTH AND MEDIATING PATHS 57 Worrell, F. C., Cross, W. E., & Vandiver, B. J. (2001). Nigrescence theory: Current status and challenges for the future. Journal of Multicultural Counseling and Development, 29(3), 201-213.
RI PT
Yang, T. C., Matthews, S. A., & Shoff, C. (2011). Individual health care system distrust and neighborhood social environment: how are they jointly associated with self-rated health?
AC C
EP
TE D
M AN U
SC
Journal of Urban Health, 88, 945–958.
ACCEPTED MANUSCRIPT
Research highlights We examine depression, physical and emotional health as consequences of discrimination.
•
Models test the mediating role of self-esteem and increased structural awareness.
•
Using an intersectional approach, these models are tested among Black and White women.
•
Discrimination impacts health outcomes for both Black and White women in variant ways.
•
Indirect effects and within-group heterogeneity are discussed.
AC C
EP
TE D
M AN U
SC
RI PT
•