Ren XS, Amick BC, Williams DR.
Racial/ethnic disparities in health: the interplay between discrimination and socioeconomic status.
Ethn Dis 1999;9(2):151-65.

This study evaluated the association between discrimination and self-perceived health status. It had two main objectives: to examine the pattern of discrimination and the extent to which exposure to discrimination is influenced by SES and to examine the relationship between race discrimination and SES discrimination, as well as the effect of these two factors on black-white differences in self-perceived health status.

Participants were recruited from the 1990 General Social Survey (GSS), a nationally representative sample of English-speaking persons at least 18 years old living in non-institutional settings in the United States (which sampled 2,474 respondents for 1995 National Survey of Functional Health). A survey questionnaire was mailed to all GSS participants, with a response rate of 76% (77% for whites and 64% for African Americans). Psychological distress (CESD), general health perceptions (SF-36) and mental health perceptions (SF-36) were used to measure self-perceived health status. SES was measured by education (less than high school, high school, and some college) and income (less than $25000, $25-45000, and more than $45000). Racial discrimination was measured by asking "having you ever experienced unfair treatment, been prevented from doing something, or been made to feel inferior because of race in 7 different situations: at school, getting a job, at work, getting medical care, getting housing, from the police or in the courts, and on the street or in a public setting?". SES discrimination was measured by asking another set of questions about the unfair treatment they experienced due to their low SES.

In this study, African Americans (N=134) had lower educational attainment, lower annual household income, and were less likely to be married than whites (N=1,525), but racial groups were similar with regard to age patterns and employment status. Overall, 57.5% of African Americans reported at least one of the seven experiences of race discrimination versus only 10.2% of whites; 52.4% of African Americans reported at least one experience of SES discrimination versus only 23.6% of whites. Race discrimination was associated with educational attainment for African Americans but not for whites; SES discrimination was associated with educational attainment for whites but not for African Americans. For African Americans, persons with more education were more likely to experience race discrimination. For whites, persons with more education were less likely to experience SES discrimination. (The authors offer several explanations for the finding that African Americans with more education are more likely to experience discrimination, including: the more educated African Americans may become more sensitive to the way they are treated as they move out of poverty; the more educated African Americans may be better able to articulate, rather than internalize, experiences of discrimination; and the less educated African Americans may be more hurt by economic plight than experiences of discrimination.)

With regard to self perceived general health status, African Americans were less likely than whites to perceive their general health as better, even after adjusting for other demographic characteristics (older age, lower education and income, and unemployment were also negatively associated with self-perceived general health). Once the models adjusted for experiences of discrimination, the effect of race diminished, suggesting that race differences in perceived health can be partly explained by African Americans being more likely to experience race/SES.

African Americans were also less likely to report good mental health status than whites (although the racial difference was not statistically significant); however, after adjusting for other demographic characteristics, African Americans were more likely to report good mental health status than whites. (Older age, female gender, little education, being formerly married, and having a low income were associated with poorer self-perceived mental health status.) Adding measures of discrimination to the model slightly reduced the positive effect of black race. Respondents who had any experience of discrimination were less likely to report good mental health than those who had no such experiences.

Racial group was not associated with CESD psychological distress scores until adding other demographic characteristics to the model. After adjusting for education, marital status, income, and employment, African Americans had lower psychological distress ratings than whites. Once discrimination was included in the models, the effect of race was even stronger, suggesting that, if it weren't for experiences of race and SES discrimination, African Americans would have much lower psychological distress scores (better health) than whites. (The authors offered two explanations for the finding that African Americans were less likely than whites to have poor self-perceived mental health: African Americans could be more accustomed to coping with stress or have greater access to coping resources than whites due to more frequent exposure, and the scales used in this study many be measuring different underlying constructs for African Americans and whites.)

For all three measures of self-perceived health status, discrimination due to race and SES (both) tended to have a stronger adverse influence on the health of African Americans than that of whites.

The authors conclude that this study supports the hypothesis that racial differences in health status can be explained partially by the discrimination that African Americans have experienced due to their racial identity or low SES. They add that, in light of the higher rates of reported discrimination among African Americans but lower rate of poor self-perceived mental health, future research should examine (longitudinally) the cumulative effects of discrimination on the mental health status of African Americans, and ascertain the extent to which variation in the social distribution of coping resources might explain disparities in the mental health status between whites and African Americans. Further, efforts should be directed to examining the potential racial differences in psychometric properties of health status measures.