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

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Linking perceived discrimination during adolescence to health during midadulthood: Self-esteem and risk-behavior mechanisms Tse-Chuan Yanga,∗, I-Chien Chenb, Seung-won Choib, Aysenur Kurtulusa a Department of Sociology, Center for Social and Demographic Analysis, University at Albany, State University of New York, 1400 Washington Avenue, Arts and Sciences 351, Albany, NY 12222, USA b Department of Sociology, Michigan State University, 509 East Circle Drive, 317 Berkey Hall, East Lansing, MI 48824, USA

A R T I C LE I N FO

A B S T R A C T

Keywords: Perceived discrimination Health Risk behaviors Self-esteem Life course

Rationale: The literature on the effect of perceived discrimination on health has three gaps. First, the long-term relationship between perceived discrimination and health is underexplored. Second, the mechanisms through which perceived discrimination affects health remain unclear. Third, most studies focus on racial/ethnic discrimination, and other aspects of discrimination are overlooked. Objective: This study aims to fill these gaps by testing a research framework that links the discriminatory experience during adolescence to an individual's health during mid-adulthood via self-esteem and risk behaviors at early adulthood. Method: Structural equation modeling is applied to the National Longitudinal Survey of Youth, 1979 Cohort (N = 6478). Results: The discriminatory experience during adolescence imposes an adverse impact on health during midadulthood even after accounting for other potential covariates, a detrimental effect lasting for over 30 years. In addition, while perceived discrimination reduces self-esteem at early adulthood, it affects only mental health during mid-adulthood, rather than general health. Finally, the discriminatory experience promotes risk behaviors at early adulthood and the risk behaviors subsequently compromise health during mid-adulthood. Conclusions: Using a life course perspective, we find that the effect of perceived discrimination is more profound than the literature suggested and that risk behaviors may account for approximately 17% of the total effect of perceived discrimination on health. Our findings highlight the importance of early interventions in coping with perceived discrimination during adolescence.

1. Introduction Perceived discrimination refers to an individual's experience of receiving unfair treatment due to his/her personal characteristics, such as age, nationality, sex, and race/ethnicity. In the past decade, perceived discrimination has been found to be adversely related to mental and physical health outcomes (Mays et al., 2007; Williams and Mohammed, 2009; Williams et al., 2003). However, little attention has been paid to investigating the mechanisms through which perceived discrimination affects health, and even less is focused on exploring the discriminationhealth relationship from a life course perspective. Should the discriminatory experience serve as a life event, the questions of whether and how this event affects health later in life have been underexplored. The lack of answers to these questions could be largely attributed to the following three knowledge gaps. First, little research has used longitudinal data to examine the potential

∗

long-term impacts of perceived discrimination on health. Applying a metaanalysis to 134 published studies, Pascoe and Richman (2009) concluded that “few studies to date have been able to draw causal conclusions about the relationship between perceived discrimination and physical or mental health because of the cross-sectional designs of most of the research in this area” (p. 545). Recently, Paradies et al. (2015) found that the research on the long-term impact of discrimination on health is scarce and deserves greater attention. Their conclusions not only highlight the need for more research on exploring the causal relationship between perceived discrimination and health but also imply that the effect of perceived discrimination on health may be longlasting. It is critical to understand whether the effect of perceived discrimination on health is enduring for two reasons. The first is that without considering when the discriminatory experience occurred, the discrimination-health association drawn from cross-sectional studies may be mainly driven by the acute stress reactions induced by

Corresponding author. E-mail address: [email protected] (T.-C. Yang).

https://doi.org/10.1016/j.socscimed.2018.06.012 Received 27 November 2017; Received in revised form 6 June 2018; Accepted 17 June 2018 0277-9536/ © 2018 Elsevier Ltd. All rights reserved.

Please cite this article as: Yang, T.-C., Social Science & Medicine (2018), https://doi.org/10.1016/j.socscimed.2018.06.012

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decades (Miller et al., 2009). The other perspective indicates that social adversities undermine an individual's ability to seek resources when s/ he is in need, which is similar to a wound leaving a permanent scar (Turner et al., 2016). Applying these perspectives to this study, experiencing discrimination during adolescence should have a long-term effect on health in later life. Though several studies report that the impact of perceived discrimination on health lasts over time (Brown et al., 2000; Schulz et al., 2006), the time period was relatively short (e.g., less than 10 years). To our knowledge, no study has investigated whether discriminatory experience during adolescence affects an individual's health at or beyond mid-adulthood. If the finding supports this direct pathway, it will manifest in the severity of discriminatory experience at an earlier stage of life than previously documented.

perceived discrimination; this may be seen in reactions such as a rapid increase in cortisol levels and the dysregulation of biological systems (Brondolo et al., 2008). Using longitudinal data allows us to more thoroughly understand the potential impact of perceived discrimination on health. In contrast, it is plausible that unhealthy people tend to be more sensitive to the behaviors/treatments they receive than their healthy counterparts (Pascoe and Richman, 2009), which leads them to report more perceived discrimination. A life course perspective or at least a longitudinal research design is required to explicitly test the causal relationship between perceived discrimination and health. Second, the mechanisms linking perceived discrimination and health over time have been underexplored. There is a growing interest in investigating the mechanisms between perceived discrimination and health (Williams and Mohammed, 2009). For example, several scholars reported that social capital and health care system distrust mediate the effect of perceived discrimination on health (Chen and Yang, 2014; Yang and Chen, 2018); yet, their studies were cross-sectional, and the longitudinal mechanisms remain unclear. Moreover, despite the finding that women's functional limitations were affected by discriminatory experiences reported seven to nine years prior, Pavalko et al. (2003) neglected to consider whether respondents adopted any behaviors or attitudes in response. They did not fully take advantage of their longitudinal data by exploring the mechanisms through which perceived discrimination affects functional limitations. Third, extant longitudinal studies have targeted specific sociodemographic groups, and few findings can be generalized to the entire population. Most of the studies implementing longitudinal research designs have focused on exclusive sociodemographic groups, such as women (Pavalko et al., 2003) and racial/ethnic minority groups, particularly non-Hispanic Blacks (Brown et al., 2000; Schulz et al., 2006). Previous research has tended to explore racial/ethnic discrimination given the complicated context of US history, which leaves other types of discrimination (e.g., nationality) largely overlooked. As the demographic structure has continued to change rapidly over the past four decades, it has become important to study how perceived discrimination, broadly defined, affects health over time. This study aims to fill these gaps by proposing a research framework that investigates two mechanisms linking discrimination in the midteens to health in mid-adulthood and testing these mechanisms with data from the National Longitudinal Survey of Youth, 1979 Cohort (NLSY79), a nationally representative survey that has been administered by the Bureau of Labor Statistics since 1979.

1.3. Self-esteem as a temporal mechanism Without appropriate and timely intervention, perceived discrimination may become a chronic stressor. It will inevitably have an enduring adverse impact on health given the numerous associated biological reactions, such as elevated blood pressure and an increased cortisol level that have damaging effects on health. A heightened stress response is one pathway that mediates the adverse impact of perceived discrimination on health. Discriminatory experience may limit positive emotion and increase negative emotion (Pascoe and Richman, 2009); we argue that during adolescence, experiencing discriminatory events has a strong and negative impact on self-esteem, which in turn undermines health. Self-esteem refers to an individual's overall assessment of his/her value to others and to society at large and is a sociometer that reflects the sum of interpersonal dynamics and social life experience (Leary and Baumeister, 2000; Rosenberg, 1965). Self-esteem has been connected to a range of outcomes. Low self-esteem, for example, has been found to compromise health and limit life chances, and high selfesteem could improve romantic relationships, work performance, and educational achievement (Donnellan et al., 2005; Orth et al., 2012). As perceived discrimination often, if not always, causes one to feel unworthy, incompetent, and incapable, these negative emotional states contribute to the lowering of self-esteem. That is, individuals who experienced discriminatory events are more likely to devaluate themselves and report low self-esteem. More importantly, several studies have suggested that self-esteem is largely determined during adolescence, after which it becomes fairly stable through an individual's life course (Longmore et al., 2004; Trzesniewski et al., 2003). Specific to this study, we anticipate that self-esteem developed during adolescence is strongly related to that reported in young adulthood (the sequential mediating pathway shown in Fig. 1). While self-esteem is related to negative emotional states, it is not a necessary component of poor mental health. Research has reported that self-esteem is a construct distinct from mental health (Rosenberg et al., 1989; Sowislo and Orth, 2013). Self-esteem is merely related to many behavioral and mental problems (e.g., learning disorders and suicidal ideation) rather than being part of these problems (Erol and Orth, 2011). That being said, self-esteem is, at best, a determinant of other mental health issues. Just as it is related to mental health, self-esteem has many implications for physical health. Though most current studies have focused on how self-esteem is associated with various mental health outcomes, some previous research has found that self-esteem has a significant effect on chronic health conditions, functional status, and self-rated health as measured at a later life stage (House et al., 1994; Vingilis et al., 1998). Strong evidence was further reported in longitudinal studies. Trzesniewski et al. (2006), for instance, found that adolescents with low self-esteem are at higher risks of having cardiorespiratory health problems, high waist to hip ratios, and/or poor selfperceived health during adulthood. The plausible explanation for this long-term effect of self-esteem on health is two-fold. One possibility is that in contrast to their counterparts with low self-esteem, adolescents with high self-esteem demonstrate stronger confidence and belief that

1.1. Theoretical framework and hypotheses Pascoe and Richman (2009) suggested that the overall impact of perceived discrimination on health can be partially mediated by heightened stress response and risk behaviors. The former refers to the psychological responses, particularly negative emotion and self-devaluation; the latter is the engagement in risk behaviors (e.g., substance abuse) as a way to cope with perceived discrimination. Extending their suggestion to the aforementioned literature gaps, we propose a research framework that (1) directly links the discriminatory experience during adolescence (i.e., age 16 to 22) to health outcomes during mid-adulthood (i.e., ages in the forties and fifties); and (2) indirectly transmits the effect of perceived discrimination via two mechanisms: self-esteem and risk behaviors in early adulthood (see Fig. 1). We explain the research framework as follows. 1.2. The direct effect of perceived discrimination on health We argue that the exposure to discriminatory behaviors during adolescence is a life event that is as important as other social adversities based on two theoretical perspectives. The biological embedding process suggests that experiencing social adversities in early life alters biological systems by increasing one's vulnerability to diseases over 2

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Fig. 1. Research framework and hypotheses linking perceived discrimination during adolescence to health during middle adulthood.

counterparts without such experience. Focusing on Hispanic adolescents over a three-year time span, Unger et al. (2014) not only supported the adverse impact of discrimination on smoking but also reported that perceived discrimination was positively correlated to alcohol consumption. Arguably, the research on the effect of perceived discrimination on substance abuse yields the strongest evidence. For example, Brody et al. (2012) found that the discriminatory experience elevates the probability of substance abuse among young males but not young females. Similar findings related to substance abuse were reported elsewhere (Basáñez et al., 2013; Hurd et al., 2014). Following the literature, we can expect that individuals who report perceived discrimination are more likely to engage in risk behaviors, such as smoking, drinking, and substance abuse. In addition to the linkage from perceived discrimination to risk behaviors, our mechanism suggests that risk behaviors at young adulthood impose a negative impact on health during mid-adulthood. Indeed, it is well documented that smoking is closely related to different forms of cancer, cardiovascular diseases, and strokes (CDC, 2015; Tucker et al., 2005). Similarly, excessive alcohol consumption was the third leading lifestyle-related cause of death, having both short-term and long-term detrimental impacts on health, such as unintentional injuries, poisoning, and high blood pressure, among other negative health outcomes (CDC, 2016; Miller et al., 2007). With respect to substance abuse, the majority of the literature supports the detrimental effect of such activities on health (Arseneault et al., 2002; Fergusson et al., 2002, 2003; McGee et al., 2000; Tucker et al., 2005). Explicitly, those who engaged in risk behaviors during young adulthood, particularly smoking, drinking, and substance abuse, will have worse health outcomes at mid-adulthood than those who did not. Drawing from the research framework and discussion above (Fig. 1), we propose three research hypotheses:

they are capable of pursuing a healthy lifestyle, creating a mindset of confidence and principle that can be further translated into healthy living attitudes, life choices, and ultimately good health (Melnyk et al., 2006). The other explanation is that high self-esteem empowers individuals to have more control over their ability and mentality to cope with serious chronic diseases than low self-esteem. High self-esteem improves physical health, especially after major surgeries such as the procedural response to stroke (Chang and Mackenzie, 1998). 1.4. Risk behaviors as a mechanism According to Pascoe and Richman (2009), the engagement in risk behaviors during early adulthood serves as a mechanism through which perceived discrimination during adolescence affects health outcomes at mid-adulthood. Specifically, as a life event, perceived discrimination increases the likelihood of an individual participating in risk behaviors that can eventually undermine his/her health at mid-adulthood. Researchers have identified the belief held by some individuals who feel that the negative outcomes precipitated by discrimination, such as stress, shame, or confusion, can be escaped or avoided by engaging in unhealthy behaviors (e.g., smoking, alcohol use, substance abuse, or delinquency) (Bennett et al., 2005; Okamoto et al., 2009). Others suggested that discriminatory experience increases certain externalizing reactions such as anger and hostility, which can promote risk-taking behaviors, especially in the form of substance abuse (Gibbons et al., 2010). Several cross-sectional studies showed that perceived discrimination encourages risk behaviors, such as smoking, drinking alcohol, and using marijuana (Purnell et al., 2012; Sanders-Phillips et al., 2014). More closely related to this current study, several scholars analyzing longitudinal data offered stronger evidence for the relationship between discrimination and risk behaviors. Specifically, Wiehe et al. (2010) found that the prevalence of smoking was higher among teenagers who experienced discrimination seven years ago than among their

(H1). Discriminatory experience during adolescence imposes an adverse impact on health during mid-adulthood, even after taking the

3

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1980. The other mechanism is through risk behaviors. Specifically, in 1998, the NLSY79 respondents were asked if they have participated in the following four behaviors that may negatively affect health: smoking, marijuana use, cocaine use, and the use of other sedatives. We created a composite score ranging from zero to four, with the number indicating how many behaviors of these four a respondent reported. Risk behaviors have been hypothesized to be positively associated with discriminatory experience (Gibbons et al., 2007; Whitbeck et al., 2001), which then affects health in mid-adulthood. Control variables. Beyond the key variables above, we consider the following control variables in our analysis to better examine the mechanisms proposed in this study. A respondent's baseline (1979) demographics and family background were first considered, including respondent's gender (females coded one, males zero), race/ethnicity (non-Hispanic white as the reference group, non-Hispanic black, and Hispanics), and both paternal and maternal years of education. In addition, at different survey years, we further included a range of timevarying individual socioeconomic and demographic variables, such as respondents' educational attainment (treated an ordinal variable ranging from one [less than high school] to four [above college]), family income (natural logarithm transformed), and marital status at different waves (married coded one, otherwise zero).

two mechanisms and other individual characteristics into account. (H2). Net of other factors, the perception of discrimination during adolescence reduces self-esteem during adolescence and early adulthood, which in turn undermines health during mid-adulthood. (H3). Discriminatory experience promotes risk behaviors in early adulthood, which eventually act to compromise health during midadulthood.

2. Methods The NLSY79 serves as the major data source for this study. First administered in 1979, it targeted the population aged 14 to 22 (Bureau of Labor Statistics, 2012). The respondents were followed annually through 1994 and have been tracked biennially since then. The NLSY79 has maintained a very high response rate in each wave and had considerable sample retention for such a long-term follow-up period. This study uses the following waves: 1979, 1980, 1987, 1998, and 2010; 1979 and 1980 measurements are defined as adolescent, and those in 1987 and 1998 are defined as early adulthood. When observed in 2010, the NLSY79 participants were between the ages of 45 and 53 with all having already taken the 40-year-old health module where a range of health outcomes were measured. The 40-year-old health module was administered to participants at the first interview after they turned age 40 and was only re-administered to those who skipped these questions. That is, respondents answered the health-related questions only once in their 40s.

2.2. Analytic approach Given the nature of the longitudinal data and our research hypotheses, we examined the framework in Fig. 1 with the structural equation modeling (SEM) approach to simultaneously estimate the relationships among these concepts/factors and examine the two mechanisms. To implement the SEM models, we used MPlus 7.0 (Muthén and Muthén, 2012) and the full information maximum likelihood estimation method that takes missing values into account. The strategy began with a descriptive statistical analysis to provide a better understanding of our data. We then followed the two-stage approach (Anderson and Gerbing, 1988) to implement a model where the two pathways were not considered, the purpose being to establish the auxiliary relationship between perceived discrimination and health. The second model further took into account all covariates and the two proposed mechanisms to investigate whether the effect of perceived discrimination on health could be mediated. Not only did we summarize the standardized coefficients into tables, but we also conducted decomposition analysis to calculate the proportion of changes in health through both direct and indirect pathways (Hayes, 2013; Muthén and Muthén, 2012). With respect to model fit diagnostics, since there is not agreement on which index performs best, a range of model fit indices were used to understand whether the proposed research framework fits the NLSY79 data well, with such measures as the comparative fit index (CFI), root mean square error of approximation (RMSEA), and standardized root mean square residual (SRMR). According to our research framework, the SEM model aims to simultaneously test five pathways: (1) the direct effect of perceived discrimination on health; (2) the indirect effect of perceived discrimination on health through self-esteem in 1980; (3) the indirect effect of perceived discrimination on health through self-esteem in 1987; (4) the sequential indirect effect of perceived discrimination on health through self-esteem in 1980 and 1987; and (5) the indirect effect of perceived discrimination on health via risk behaviors.

2.1. Measures Dependent variable. We measured an individual's health during mid-adulthood with the short-form 12-question (SF-12 hereafter) summary scores in the 40-year-old health module to assess the overall physical and psychological health. The NLSY79 40-year-old health module adopted the method developed by Ware et al. (1995) to calculate the SF-12 physical component and SF-12 mental component summary scores. The SF-12 is a generic measure that does not target any specific age or disease group. The physical and mental component scores range from zero (lowest level of health) to 100 (highest level of health), and, in general, a respondent with a score over 50 has better health than a typical person in the population (Bureau of Labor Statistics, 2012). We treated the concept of health as a latent variable, and the physical and mental component scores were the observed indicators for health in our analysis. Key independent variable. In 1979, respondents were asked whether they perceived discrimination when seeking a job due to any of following five factors: race/ethnicity, nationality, sex, age, and language. Those who answered “yes” to this question were coded one, otherwise zero. It should be noted that while the measure of perceived discrimination is relatively rough, its scope goes beyond race/ethnicity and has been used in federal level surveys, such as the Behavioral Risk Factor Surveillance System by the Centers for Disease Control and Prevention. As the survey question was focused on the job market, we further limited our samples to those aged 16 to 22. Mediating variables. To examine our hypotheses, respondents' selfesteem scores in 1980 and 1987 were considered in the analysis. The NLSY79 adopted Rosenberg's self-esteem scale (Rosenberg, 1989), which has been commonly used in the literature (Schmitt and Allik, 2005). Following the previous discussion, we expect that discriminatory experience is negatively related to self-esteem (Link et al., 2001), and low self-esteem negatively affects health (Trzesniewski et al., 2006). As self-esteem has been found to be consistent over time (Longmore et al., 2004; Trzesniewski et al., 2003), we applied the sequential mediation mechanism to the 1980 and 1987 self-esteem scores, effectively presuming self-esteem in 1987 can be predicted by that in

3. Results and discussion Descriptive statistics of the variables used in the analysis appear in Table 1, along with comparisons between those with and without perceived discrimination. We summarize several key findings as follows. First, in contrast to those without discriminatory experience during adolescence, respondents reporting perceived discrimination were less healthy as their SF-12 physical and psychological health 4

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Table 1 Descriptive statistics of variables in this study by discriminatory experience. Overall

Without Discrimination

With Discrimination

Mean

SD

Mean

SD

Mean

SD

Physical health during mid-adulthood Psychological health during mid-adulthood Age in 1979 Self-esteem in 1980 Self-esteem in 1987 Counts of risk behavior in 1998 Educational status in 1980 Educational status in 1987 Educational status in 1998 Educational status when turning 40 year old Marital status in 1987 Marital status in 1998 Marital status when turning 40 year old Family income in 1987 (Ln) Family income in 1998 (Ln) Family income in 2006 (Ln) Father's education (years) Mother's education (years)

52.395 52.948 19.631 23.715 23.764 1.894 1.894 2.369 2.497 2.443 0.480 0.590 0.649 10.018 10.635 10.937 11.808 11.593

(7.767) (8.134) (1.787) (4.112) (4.102) (.894) (.754) (.774) (.801) (.795) (.500) (.492) (.477) (.823) (.933) (.995) (3.612) (2.805)

53.088 53.342 19.934 23.902 23.956 1.825 1.974 2.404 2.515 2.461 0.501 0.615 0.669 10.078 10.699 10.972 11.928 11.714

(6.785) (7.763) (1.779) (4.083) (4.076) (.861) (.737) (.765) (.794) (.790) (.500) (.487) (.471) (.796) (.881) (1.002) (3.607) (2.693)

51.695 52.577 19.359 23.572 23.616 1.954 1.824 2.340 2.485 2.428 0.462 0.572 0.629 9.965 10.573 10.905 11.682 11.476

(8.600) (8.469) (1.738) (4.128) (4.111) (.914) (.763) (.779) (.806) (.798) (.494) (.500) (.483) (.839) (.980) (.985) (3.603) (2.896)

Female Non-Hispanic Whites Non-Hispanic Blacks Hispanics

49.398% 79.500% 14.094% 6.406%

46.584% 83.103% 12.016% 4.813%

52.096% 76.105% 16.000% 7.898%

N

6478

2971

3507

t-test significance level

*** *** *** *** *** *** *** ***

*** *** *** *** *** ** ** *** *** *** ** **

Note. Sample means are weighted. ***p < 0.001, **p < 0.01, *p < 0.05, for two-tailed t-test. Statistical significance indicates a group difference within each variable.

foremost, the SEM results indicate that perceived discrimination during adolescence has a long-lasting impact on health during mid-adulthood, even after controlling for the two mediating pathways and other covariates. Model 1 provides the auxiliary evidence that perceived discrimination matters (β=-0.551), and Model 2 offers further support for this argument and confirms that the effect of perceived discrimination could be partially mediated by self-esteem and risk behaviors in early adulthood (β=-0.373). Situating the analytic results into the NLSY79 data, we found that the respondents who experienced discrimination when they were 16–22 years old were less healthy at ages 47 to 53 in contrast to those who did not report any discriminatory experience during adolescence. This relationship holds even after taking into account other sociodemographic characteristics. This finding suggests that the detrimental effect of perceived discrimination on health lasts for more than 30 years and to our knowledge, no study reported an effect of perceived discrimination on health that is longer than two decades. This finding sheds new light on discrimination and health literature. Second, while self-esteem seems to play a role in transmitting the effect of perceived discrimination during adolescence on individual health during mid-adulthood, the results shown in Fig. 2 reveal a complicated relationship. Explicitly, the SEM results indicate that experiencing discrimination in 1979 decreased a respondent's self-esteem in 1980 (β =-0.386) but was not related to self-esteem in 1987. Selfesteem in 1980 subsequently and positively affected self-esteem in 1987 (β=0.403) and was found to be associated with health during midadulthood (β=0.070). However, self-esteem in 1987 was not related to health during mid-adulthood, despite the direction of the estimated coefficient following our expectation (β=0.046). We also note that, while self-esteem in 1980 was a strong predictor for self-esteem in 1987, respondents' education and family income in 1987 were both positively related to self-esteem in the same year. Third, in comparison to the self-esteem mechanism, the evidence for the risk behaviors pathway was stronger. Individuals who experienced discrimination in 1979 engaged in more risk behaviors (β=0.174) in 1998 (i.e., early adulthood) than those who did not have any

scores are significantly lower. To illustrate, the average SF-12 physical health score was over 53 among those without perceived discrimination but it was below 52 for the respondents with discriminatory experience. Second, on average, individuals who perceived discrimination during adolescence reported lower self-esteem (23.572) than did their counterparts without such experience (23.902). This gap (23.572–23.902 = −0.33) barely changed in 1987 (23.616–23.956 = −0.34), which echoes the literature that self-esteem remains stable after adolescence (Longmore et al., 2004; Trzesniewski et al., 2003). Third, the average count of risk behaviors was higher among those who reported discrimination experience than those who did not report. While the difference in tallied risk behaviors was relatively small, the relatively large standard deviations and a t-test indicated that the gap was statistically significant. In addition to the differences in the dependent variables, mediators, and key independent variable, Table 1 suggests that there was a difference in respondents' educational attainment before 1987, which may be explained by respondents' age that ranges between 16 and 22 in the data. Some may already complete their education, while others may still be in school. Moreover, the descriptive findings indicated that the family backgrounds of the respondents with perceived discrimination were slightly worse than those of the respondents without perceived discrimination. For example, both father's and mother's education levels (in years) were lower among individuals reporting discrimination. Finally, the racial/ethnic composition varied by discrimination experience. Specifically, there were more Hispanics and non-Hispanic Blacks in the group with perceived discrimination. Though there were also more females reporting discrimination than males, the difference was not significant. The bivariate correlations among variables and a brief discussion are available online. The SEM results (standardized coefficients) are shown in Table 2. Following our analytic strategy, we first implemented a model without any mediating mechanisms (i.e., Model 1 in Table 2) and then included all pathways in the analysis (Model 2). To more concisely summarize our findings, we put the estimated coefficients into the analytic framework (see Fig. 2) and discussed the key findings below. First and 5

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Table 2 Structural equation modeling results (health as a latent factor).

Self-esteem in 1980 Perceived discrimination in 1979 Female (=1) Non-Hispanic Blacks Hispanics Mother's education Father's education Educational status in 1980 Age at 1979 Self-esteem in 1987 Perceived discrimination in 1979 Self-esteem in 1980 Mother's education Father's education Educational status in 1987 Family income in 1987 (Ln) Marital status in 1987 Risk behaviors in 1998 Perceived discrimination in 1979 Female (=1) Non-Hispanic Blacks Hispanics Mother's education Father's education Educational status in 1998 Family income in 1998 (Ln) Marital status in 1998 (1 = married) Health Perceived discrimination in 1979 Risk behaviors in 1998 Self-esteem in 1980 Self-esteem in 1987 Female (=1) Non-Hispanic Blacks Hispanics Educational status when turning 40 years old Family income in 2006 (Ln) Marital status when turning 40 years old (1 = married) CFI RMSEA SRMR

Model 1 (Standardized)

Model 2 (Standardized)

Estimate

Estimate

se

−0.386 −0.619 0.465 0.785 0.215 0.051 1.089 −0.013

(.186) (.183) (.211) (.272) (.043) (.033) (.164) (.066)

0.029 0.403 0.063 0.034 0.563 0.522 0.217

(.171) (.023) (.040) (.033) (.128) (.115) (.183)

0.174 −0.042 −0.078 −0.084 0.001 0.033 −0.126 −0.053 −0.170

(.047) (.047) (.065) (.065) (.012) (.009) (.034) (.034) (.062)

−0.373 −0.500 0.070 0.046 −0.883 0.443 0.250 0.041 0.784 0.495

(.188) (.215) (.034) (.032) (.395) (.271) (.221) (.126) (.330) (.293)

se

−0.551

(.162)

***

−0.690 0.364 0.330 0.293 0.622 0.288

(.210) (.161) (.178) (.104) (.164) (.156)

*** * + ** *** +

0.897 0.043 0.020

* *** * ** *** ***

***

*** ***

***

*** *** ** * * * *

*

0.872 0.032 0.020

***p < 0.001, **p < 0.01, *p < 0.05, +p < 0.10. Note. CFI = comparative fit index, RMSEA = root mean square error of approximation, SRMR = standardized root mean residual.

results by all possible pathways in our research framework. The following findings drawn from Table 3 are notable. The direct effect of perceived discrimination during adolescence on health during midadulthood was confirmed. There was also evidence to support the risk behaviors pathway (0.174 × -0.500 = −0.087), which suggests that, ceteris paribus, the latent health score during mid-adulthood (measured by the SF-12 physical and psychological health scales) was reduced by 0.087 points for those who perceived discrimination in 1979 due to risk behaviors in early adulthood. While this number, −0.087, does not seem large, it accounts for more than 17% of the total effect of perceived discrimination on health (−0.087/-0.493 = 0.176) or 72.5% of the total indirect effect (−0.087/-0.120 = 0.725). The decomposition results did not yield any support for the selfesteem mechanism. Based on the research framework (Fig. 1), there are three possible pathways from perceived discrimination in 1979 to an individual's health during mid-adulthood via the two self-esteem measures. The first two go through self-esteem recorded in 1980 and in 1987, respectively; the third is the sequential pathway connecting selfesteem in 1980 to self-esteem in 1987, which ultimately affects health. As shown in Table 3, the formal tests for the three indirect effects did not support the argument that self-esteem partially mediates the effect of perceived discrimination on health. We would like to note that the

discriminatory experience. These risk behaviors, in turn, compromised this group's health during mid-adulthood (β=-0.500). In addition to perceived discrimination, the number of risk behaviors during early adulthood was found to be negatively associated with a respondent's education and marital status in the same survey year. With respect to the diagnostic indices in Table 2, the CFIs were fairly close to the conventional cutoff threshold of 0.9 (Bentler and Bonett, 1980), and both RMSEA and SRMR were well below the criterion of 0.05. A recent study (Lai and Green, 2016) suggests that it is not uncommon that these diagnostic indices disagree with each other because they evaluate the model fit from different perspectives. As the cutoff values are arbitrary, it is not necessary to “disregard the model just because an index fails to meet the cutoff” (p. 234) as substantive contributions should outweigh the diagnostics (Lai and Green, 2016). The results in Table 2 demonstrate the estimated effect of each segment in a pathway. As suggested by recent literature (Hayes, 2013; Muthén and Muthén, 2012), it is necessary to conduct a statistical test for the product of each estimated effect in order to obtain robust evidence for the proposed mechanism. Following this suggestion, we further decomposed the total effect of perceived discrimination on health into direct and indirect effects and formally tested their statistical significance (Muthén and Muthén, 2012). Table 3 shows the analytic 6

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Fig. 2. Summary of structural equation modeling results based on the full model where all the control variables are included.

stress) or affects health within a relatively short time period (within a decade or so) (Brown et al., 2000; Schulz et al., 2006). The significant direct effect found in our analysis is among the first to report that the influence of perceived discrimination on health could last for over three decades. The finding drawn from the first hypothesis could be further understood using the “critical moment model” in life course theory (Kuh and Ben-Sholomo, 2005), which posits that a person's health in later life is a function of their experience during critical periods of growth and development in earlier life. As discussed previously, adolescence is a vital period for developing personality and identity (WHO, 2015). The exposure to discriminatory behaviors during adolescence has an enduring and direct impact on health during mid-adulthood. In our second hypothesis, we anticipated that self-esteem at early adulthood should mediate part of the effect of perceived discrimination on health. The findings for this hypothesis did not support our expectation. More specifically, while the SEM results in Table 2 indicated that self-esteem in 1980 may carry some of the total effect of perceived discrimination on health, the decomposition results in Table 3 suggest that self-esteem is not a mechanism through which perceived discrimination affects health. Though the second hypothesis is not confirmed, the analytic findings support the sequential relationship starting from perceived discrimination to self-esteem in 1980 and ultimately leading to self-esteem in 1987. The missing link in the proposed pathway is the longitudinal relationship between self-esteem in 1987 and health during mid-adulthood. One plausible explanation for this finding is that while self-esteem may be more closely related to psychological health, the latent health variable in our analysis failed to reflect this association. Another possible explanation for why the pathway through self-esteem did not receive strong support can be drawn from the recent work by Brondolo et al. (2018). Specifically, they argued that both cognitive control and stress appraisal processes mediate the adverse impact of perceived discrimination on health. Low self-esteem in adolescence, hence, can be regarded as a product of self-devaluation and poor recovery from discrimination. In the long run, adolescents with low selfesteem tend to have impaired social relationships in later life, which

Table 3 Health latent model: Decomposition into direct and indirect effects (using standardized coefficient). Path (Perceived discrimination during adolescence to health during middle adulthood) Direct path: Perceived Discrimination → Mid-adulthood Health Indirect path: Perceived Discrimination → Self-esteem 1980 → Midadulthood Health Perceived Discrimination → Self-esteem 1987 → Midadulthood Health Perceived Discrimination → Self-esteem 1980 → Selfesteem1987 → Mid-adulthood Health Perceived Discrimination → Early Adulthood Risk Behavior → Mid-adulthood Health Total indirect Total

β

se

−0.373*

(.188)

−0.027

(.018)

0.001

(.008)

−0.007

(.006)

−0.087*

(.044)

−0.120* −0.493*

(.056) (.242)

*p < 0.05.

results in Table 2 seem to suggest that part of the effect of perceived discrimination on health could be mediated by self-esteem in 1980, but the product of the two segments (−0.386 × 0.07 = −0.027) was nonsignificant in the formal test. 3.1. Implications of the current findings for the literature on experiencing discrimination We used the findings above to examine the research hypotheses of this study. The first hypothesis states that experiencing discrimination during adolescence has a detrimental effect on health during midadulthood even after other covariates and mechanisms are considered. The direct effect of perceived discrimination on health in Model 2 and Fig. 2 confirms this hypothesis. Furthermore, according to the decomposition results, this direct effect accounts for approximately 75% of the total health effect of perceived discrimination. As discussed previously, the literature largely supports the conclusion that perceived discrimination has an immediate impact on health (as a source of acute 7

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this complex relationship.

makes it difficult to maintain supportive and health-promoting relationships with others. As a result, adolescents with low self-esteem are more likely to engage in risk behaviors and inappropriate reactions to stress and exposure to distress. Finally, we hypothesized that perceived discrimination increases the number of risk behaviors in early adulthood, which eventually undermines health during mid-adulthood. Unlike the self-esteem pathway, this mechanism received strong support from the SEM analysis and accounted for roughly 17% of the total effect of perceived discrimination on health. This finding confirms the hypothesis that engaging in risk behaviors may serve as a way to cope with the negative emotional states caused by perceived discrimination and can eventually contribute to poor health (Arseneault et al., 2002; Fergusson et al., 2002, 2003; McGee et al., 2000; Tucker et al., 2005). This pathway echoes the accumulation of risk argument (Blane, 2006), indicating that the exposure to a risk factor during one period may lead to the exposure to another risk factor at the next stage of life, ultimately affecting health in the future. In other words, adolescents who experienced discrimination were more likely than others to have cumulative hazards to health in later life by sequentially engaging in smoking, drinking, or substance abuse during early adulthood. As the NLSY79 data are longitudinal and the research design is complex, we conducted three different sensitivity analyses. We first focused on whether using different weights that the Bureau of Labor Statistics provides changes our findings and conclusions. The NLSY website suggests that when using multiple waves of data, it is a conventional practice to use the weights for the year of the dependent variable, so we used that approach in this study. It is also possible to use custom weights and indeed, we found that using custom weights did not alter our findings. The second sensitivity analysis was to consider the potential selection bias (into perceived discrimination) with the Heckman correction (Heckman, 1979). Specifically, we first calculated the probability of perceiving discrimination with a range of variables, such as race/ethnicity, age, and parental education and then corrected the potential self-selection process by including the probability into the analysis. The results and conclusions are largely the same. (The results for these sensitivity analyses are available upon request.) The final sensitivity analysis treated the SF-12 physical and psychological health scores as manifest variables, rather than two indicators of latent health. The results and conclusions remained the same. Beyond the sensitivity analyses, the stark difference in sample size across race/ethnicity groups raises the question of whether the findings above were driven by non-Hispanic whites, the dominant group in our sample. We conducted a series of likelihood ratio tests between nonHispanic whites and non-whites (i.e., non-Hispanic blacks and Hispanics) to investigate whether there is a significant difference in each of the five pathways in Table 3. The likelihood ratio tests indicated that the direct effect of perceived discrimination on health was stronger among non-Hispanic whites than non-whites, but both effects were negatively related to health. Overall, the two-group comparison analyses suggest that our findings and conclusions may not be driven by a certain race/ethnicity group and could be a general pattern of how individuals react to discrimination experience. While our research framework assumes that the two mechanisms are independent, it is likely that the self-esteem pathway (psychological mechanism) triggers risk behaviors (behavioral mechanism). We implemented an analysis (not shown) in which three additional pathways linking self-esteem to risk behavior were considered and found that none was statistically significant (the three pathways were: (a) perceived discrimination → self-esteem1980 → early adulthood risk behavior → mid-adulthood health; (b) perceived discrimination → self-esteem1987 → early adulthood risk behavior → mid-adulthood health; and (c) perceived discrimination → self-esteem1980 → self-esteem1987 → early adulthood risk behavior → mid-adulthood health). Though our results do not support the possible connection between the psychological and behavioral mechanisms, future research should investigate

3.2. Limitations This study is subject to several limitations. First, our measure of risk behaviors was limited to the 1998 survey questions, as the NLSY79 changes questionnaires regularly, and information on risk behaviors at early adulthood was available only in 1998. While our measure covers major risk behaviors such as smoking and substance abuse, it can be further improved by taking other dimensions into account, such as unintended pregnancy, unprotected sexual behaviors (leading to sexually transmitted diseases), and unhealthy dietary behaviors (Brener et al., 2013). Second, though the research framework was drawn from the literature (Pascoe and Richman, 2009), other potential mechanisms between perceived discrimination and health are not tested in this study. That is, while our data show a clear temporal sequence among variables, the analytic findings may not fully reflect the causal relationship between discrimination and health. To fully establish the causal association, alternative mechanisms should be considered. Third, when the data were first collected in 1979, all participants were youths so the information on health status at the baseline was not available. This caveat should be kept in mind when interpreting the results. Finally, this study measured perceived discrimination when seeking a job with five different aspects, namely race/ethnicity, nationality, sex, age, and language. Future research should situate discriminatory experience in other social contexts, such as the health care systems or the housing markets (Gee, 2002; Pager and Shepherd, 2008), to explore different mechanisms. 4. Conclusions This study contributes to the extant literature on perceived discrimination and health from a life course perspective. We find the profound long-term effect of perceived discrimination on heath during mid-adulthood and risk behaviors as a critical mechanism underlying the association. Given that this study's timespan is over three decades, it addresses the gap wherein greater attention is needed to understand the long-term impact of discriminatory experience on health (Paradies et al., 2015). Taking a holistic approach, it is also indispensable that future studies take into account the larger social contexts to better understand the association between perceived discrimination and health. Discrimination can occur in various social settings, such as cultural, institutional, and interpersonal contexts through gender/racial/cultural stereotypes, unfair policies against certain groups, and interactions among individuals (e.g., language) (Brondolo et al., 2010; Gee, 2002; Pager and Shepherd, 2008). These different contexts carry different implications for the effect of discrimination on health. This study provides some policy implications. The long-lasting adverse effect of perceived discrimination on health highlights the importance of providing support to those who experience discriminatory behaviors, such as consultation and resources to overcome the stress caused by discrimination. These interventions should be accompanied with changes in larger social contexts in order to be effective. Moreover, the risk-behavior mechanism suggests that it is critical to help individuals to cope with the negative feelings caused by perceived discrimination. This should be accomplished using supportive actions, such as social support/validation from family and engaging in relaxing and pleasurable activities, instead of harmful actions like risk behaviors. By minimizing risk behaviors, the health disparity during midadulthood may be reduced. Finally, the linkage from perceived discrimination to psychological health during mid-adulthood via self-esteem underscores the need for early intervention for adolescents who have experienced discrimination. As self-esteem becomes stable after adolescence, prioritizing its quick restoration, such as with group therapy, following instances of perceived discrimination may promote health in the long run by shifting attention to a person's positive 8

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characteristics (Brown, 2014; Rigby and Waite, 2007).

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