Elsevier

Social Science & Medicine

Volume 63, Issue 6, September 2006, Pages 1415-1427
Social Science & Medicine

Self-reported health, perceived racial discrimination, and skin color in African Americans in the CARDIA study

https://doi.org/10.1016/j.socscimed.2006.04.008Get rights and content

Abstract

This study investigates the association between self-reported physical and mental health and both perceived racial discrimination and skin color in African American men and women. We used data from the longitudinal coronary artery risk development in young adults study (CARDIA) in African American men and women (n=1722) in the USA. We assessed self-reported mental and physical health status and depressive symptoms at the Year 15 (2000–2001) follow-up examination using the Medical Outcomes Study Short Form (SF-12) and the Center for Epidemiologic Studies Depression scale. Skin color was measured at the Year 7 examination (1992–1993). To assess racial discrimination, we used a summary score (range 0–21) for 7 questions on experiencing racial discrimination: at school, getting a job, getting housing, at work, at home, getting medical care, on the street or in a public setting. Self-reported racial discrimination was more common in men than in women (78.1% versus 73.0%, p<0.05) and in those with higher educational attainment, independent of gender. Discrimination was statistically significantly associated with worse physical and mental health in both men and women, before and after adjustment for age, education, income, and skin color. For example, mental health (0–100 scale) decreased an average of 0.29 units per unit increase in racial discrimination score in men; this became 0.32 units after adjustment. There was no association between self-reported physical and mental health and skin color. Further studies of the health consequences of discrimination will require investigation of both the upstream determinants of discrimination and the downstream mechanisms by which perceived discrimination affects health outcomes.

Introduction

Disparities in heath status between blacks (or African Americans) and whites are large, pervasive and persistent over time (Danzinger & Gottschalk, 1993; Lenfant, 1996; “National Institutes of Health”, October 6, 2000; US Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. 2nd ed., 2000; Williams, 2005). There are large socioeconomic status (SES) differences between these two racial groups and they account for a substantial portion of the racial differences in health. However, the persistence of racial differences in health, even when SES is considered, has stimulated scientific interest in identifying other race-related factors that are adversely affecting the health of African Americans. Discrimination has recently emerged as an important risk factor for health that is differentially distributed across race and may contribute to elevated health risks for African Americans (Krieger, 1999; Williams, 1999; Williams & Collins, 1995; Williams, Neighbors, & Jackson, 2003; Williams, Yu, Jackson, & Anderson, 1997).

Recent research reveals that a substantial proportion of African Americans experience discrimination and there is evidence that discrimination is adversely related to multiple indicators of health status. For example, discrimination has been found to be associated with multiple indicators of mental and physical health (Harrell, Hall, & Taliaferro, 2003; Krieger, 1999; Krieger & Sidney, 1996; Schulz et al. (2000), Schulz et al. (2000); Schulz et al. (2000), Schulz et al. (2000); Williams et al., 2003). In sum, these studies have found that African Americans reporting experiencing racial discrimination are more likely to exhibit negative health outcomes than their counterparts experiencing no discrimination.

The shade of skin color (or skin tone), another potential risk factor for the health of African Americans, has received inadequate research scrutiny. In many cultures the color black is associated with negative attributes (Brown, Ward, Lightbourn, & Jackson, 1999; Franklin, 1968; Williams, 1997) and the African American population is no an exception (Brown et al., 1999). Research has long indicated that skin tone is a maker of social status and an important predictor of access to opportunity and resources within the black population in the United States (Drake & Clayton, 1945; Frazier, 1957). Since the days of slavery, when lighter skin tone reflected family ties to whites, lighter skinned blacks were more likely to obtain freedom and had greater access than others to education, property and employment opportunities (Frazier, 1957). More recent studies indicate the persistence of skin tone in affecting the quality of life of African Americans. For example, the National Study of Black Americans conducted in 1979–1980, found that compared to their darker complexioned peers, lighter-skinned blacks had higher levels of education, occupational prestige, personal and family income and were more likely to have spouses with more education and higher occupational prestige (Hughes & Hertel, 1990; Keith & Herring, 1991). Moreover, these associations were stronger for women than for men.

Skin tone may also be related to health, at least under certain conditions. Early studies of African Americans examined the association between skin color and health status with skin tone as a proxy for genetic admixture, with darker skinned blacks presumed to be of purer African ancestry (Boyle, 1970; Gillum, 1979; Harburg, Gleibermann, Roeper, Schork, & Schull, 1978). These initial studies found a positive association between darker skin color and hypertension (Boyle, 1970; Gillum, 1979; Harburg et al., 1978). Subsequent studies revealed that this association was reduced to non-significance when adjusted for SES, confirming the importance of skin tone as a marker of social status (Keil, Sandifer, Loadholt, & Boyle, 1981; Keil, Tyroler, Sandifer, & Boyle, 1977). However, one study documented that the association between skin color, SES and health may be complex (Klag, Whelton, Coresh, Grim, & Kuller, 1991). These researchers found that darker skin color was associated with higher levels of blood pressure only among low SES African Americans. Apparently, the occupancy of two low status positions (low SES and dark skin color) was especially deleterious to health.

Prior research has shown that skin tone is also a marker for discrimination, with darker skinned blacks reporting higher levels of discrimination than their lighter skinned peers (Keith & Herring, 1991; Klonoff & Landrine, 2000). Because dark skinned African Americans experienced more discrimination than their light skin peers, skin color may interact with discrimination to affect health. However, prior research has not examined potential interactions between skin color and discrimination on health outcomes. Moreover, women, both African-American and white, are more likely to report gender discrimination. However, African American women are less likely to report racial discrimination than African American men (Keith & Herring, 1991; Klonoff & Landrine, 2000; Krieger, Sidney, & Coakley, 1998) but more likely to be educated and be in executives and professional occupations. Finally, because women tend to have lighter skin than men, it is possible that the association between skin color and health outcomes vary with gender. Therefore, skin color, discrimination and SES could be related to health in complex ways. These associations could also vary by gender, due to differences in levels and sources of discrimination experienced by men and women. However, at the present time, we do not have a clear understanding of how discrimination, skin color, and SES relate to each other and combine to affect the health risks of contemporary African American men and women. Some evidence suggests that the significance of skin color within the African American population may be declining in the post-1960s black consciousness era (Brown et al., 1999), while other evidence indicates that the shade of one's skin continues to matter for Blacks (Herring, Keith, & Horton, 2004).

The availability of data from CARDIA, a 15-year longitudinal study of the evolution of cardiovascular risk among young adults, affords the opportunity to investigate the association of self-reported physical and mental health status with perception of racial discrimination and also with skin color, before and after adjusting for selected covariates, including indicators of socioeconomic position (SEP), in African American men and women. We hypothesized that racial discrimination and darker skin color would each be associated with worse mental and physical health in African American men and women. We further hypothesized that the potential associations between skin color and health outcomes might be mediated by racial discrimination (skin color causing discrimination that causes poor health outcomes). Alternatively, skin color, as a marker of genetic admixture, might be confounding associations between discrimination and health outcomes (genetic effects on phenotypes associated both with discrimination and health outcomes). We also hypothesized that these complex associations of racial discrimination and skin color with health would differ by gender and by socioeconomic indicators.

Section snippets

Methods

CARDIA is a prospective study of cardiovascular risk factors in 5115 persons aged 18–30 years at the baseline examination (1985–1986), recruited primarily through telephone contact from community lists in three cities (Birmingham, AL; Chicago, IL; and Minneapolis, MN) and from the membership roster of a large prepaid health plan (Oakland, CA) (Cutter et al., 1991; Friedman et al., 1988). The goal of the recruitment was to obtain at each of the four centers nearly equal numbers of African

Results

On average, African American men were more likely to be married, less educated and more likely to be in the higher income categories than African American women (Table 1). Women reported significantly worse mental (mean MCS 48.6 versus 51.5) and physical health (mean PCS 50.1 versus 51.3) than men. The same pattern held for the CES-D score (11.2 for women versus 9.5 for men). Men were more likely to report any experience of discrimination than women (78.1% versus 73%). This pattern is present

Discussion

In our cohort of 33–45 year old African-Americans from four urban areas in the US, self-reported racial discrimination was reported in 75% of participants, but was somewhat more common in men than in women and in those with higher educational attainment independent of gender. We confirmed our initial hypotheses that perceived racial discrimination is associated with worse physical and mental health in both men and women, a finding that persisted after adjustment for age, education and income.

Acknowledgments

This work was supported by the National Institute Dental and Craniofacial Research Grant K22DE15317 and the Robert Wood Johnson Health and Society Scholars Program (to LNB). The CARDIA Study was supported by National Heart Lung Blood Institute contracts N01-HC-48047, N01-HC-48048, N01-HC-48049, N01-HC-48050 and N01-HC-95095. In addition, this work was supported by the MacArthur Network on Socioeconomic Factors and Health and the Columbia Center for the Health of Urban Minorities (CHUMS) (To

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