Mental health disparities research: The impact of within and between group analyses on tests of social stress hypotheses
Introduction
A core aim of the United States Department of Health and Human Services as described in Healthy People 2010 (U.S. Department of Health and Human Services, 2000) is to reduce health disparities by race/ethnicity, gender, and sexual orientation. For example, explaining health disparities between African–Americans and Whites on life expectancy and almost every other indicator of physical health has become a focus of considerable epidemiologic theorizing and research (Mays et al., 2007, Williams and Earl, 2007).
The concept of social disadvantage serves as a starting point for much of this work (Dressler, Oths, & Gravlee, 2005). There are many pathways through which social disadvantage can translate into health disparities, including exposure to deleterious physical and social environments and limited access to adequate health care. Recently, the social stress model has gained predominance as an explanatory frame (Dressler et al., 2005). Social stressors, particularly those related to prejudice and discrimination, have been invoked to explain disparities in diverse mental and physical health outcomes (Clark, Anderson, Clark, & Williams, 1999). The stress model therefore plays a central role in research on the reduction of health disparities (Dressler et al., 2005, Williams and Mohammed, 2009).
The social stress model has long been the predominant paradigm in research on the relationship between social factors and mental health (Horwitz, 1999). Mental health seemed the most obvious and direct health outcome that would be impacted by social stress and the majority of articles from within this frame focus on mental health outcomes (Williams & Mohammad, 2009). Researchers using social stress theory hypothesize that disadvantaged position in the social structure leads to an increase in mental disorders, resulting in health disparities (Thoits, 1999, Wheaton, 1999). The theory is that those of lower social standing—we refer to this as disadvantaged social status—are exposed to more stressful conditions and fewer resources to cope with these conditions than those of higher social standing (Pearlin, 1989). In turn, this added stress causes mental health problems (Dohrenwend, 2000). For example, studies showing high disorder prevalence for those of lower socio-economic and gender status (i.e., the poor and women) were used to support this position (Aneshensel, 1999, Aneshensel and Phelan, 1999, Pearlin, 1989).
In the context of mental health, researchers hypothesize that in addition to other stressors, stressors associated with prejudice and discrimination—both those directly experienced and recognized by individuals as related to prejudice and those that have a more generic ambient effect—add a unique source of stress that may explain how disadvantaged social statuses produce mental health problems (Clark, 2004, Kessler et al., 1999, Meyer, 2003a, Meyer, 2003b, Taylor and Turner, 2002, Williams and Harris-Reid, 1999, Williams et al., 1997). In this paper, we examine the extent to which social stress theories are supported for mental health outcomes. We suggest that this literature has suffered from some conceptual and methodological problems that threaten our ability to draw conclusions about social stress theory. Although we propose no new theory or methodology, we offer a fresh critique, pointing out disconcerting inconsistencies in research findings that have not been sufficiently considered by researchers in the field.
As we illustrate in Fig. 1a, social stress theory implies a mediational model (Clark et al., 1999, Williams and Mohammed, 2009). Prejudice-related stressors are hypothesized as important, although not sole, mediators of the relationship between disadvantaged social status and mental health problems. Based on established practices for assessing mediation, empirical support for this theory requires three steps: (a) evidence of a main effect, i.e., evidence for high disorder prevalence for disadvantaged social groups (represented in Fig. 1a as the total effects of the paths a, b and c); (b) an association between the exposure (disadvantaged social status) and the mediator (prejudice-related stressors) (Fig. 1a, path b); and (c) an association between the mediator and the outcome (mental health problems) (Fig. 1a, path c) (Baron and Kenny, 1986, Judd and Kenny, 1981, MacKinnon et al., 2007). Mediation would be supported if these relationships were substantial and if control for the mediational pathway substantially reduced the main effect.
Despite the interest in health disparities research and in prejudice and discrimination as stressors, and the relevance of this research to national health priorities, researchers rarely test these three required steps. For example, only five (3%) of the one hundred and forty eight studies on mental health problems cited in a recent review conducted mediational analyses (Paradies, 2006; the five studies were Kessler et al., 1999, Roberts et al., 2004, Schulz et al., 2000, Taylor and Turner, 2002, Williams et al., 1997).
Typically, researchers focus on the relationship between stressors and mental health problems (the solid line in Fig. 1b) among members of disadvantaged groups. Note that in such analyses, the stressors are the independent exposure variables but they are mediators in the full conceptual model (Fig. 1a). The other components of the mediational model are typically not tested. In such analyses, the full conceptual model is left unexamined. It is our contention that by de-contextualizing the impact of stress processes (the association between prejudice-related stressors and the mental health outcomes) from the total effect under study (the relationship between disadvantaged social status and mental health outcomes), researchers misrepresent social stress theory and can arrive at flawed inferences about the role of stress in mental health.
Section snippets
The premises of social stress theory
Our argument is based on the following premises of social stress theory: first, our focus is the application of social stress theory to explaining mental health disparities, not all mental health differences. Not all differences are disparities (Herbert, Sisk, & Howell, 2008). For example, finding higher rates of cancer for older individuals is a health difference but not a disparity (Braveman, 2006). A disparity implies an “inequality in health due to social factors or allocation of resources”
Empirical findings in studies of social stress
In what follows, we examine evidence about the effect of disadvantaged group status and prejudice-related stressors on mental health problems. For illustrative purposes we limit our discussion to research on three disadvantaged social groups: lesbians, gay men, and bisexuals (LGB); women; and African–Americans. These groups have very different characteristics but they share a disadvantaged social status and are important for sociological analysis in current American society.
The total effect of
Divergence in sources of evidence
In the remainder of this paper, we consider differences between within-group and between-groups analyses in terms of what each type of analysis tells us about our causal inquiry. We evaluate the implications of these types of analyses for the causal contrast, measurement of the stress construct, impact of sampling bias, and the outcome measures used.
Discussion: inference for social stress as a cause of mental disorders
The ultimate purpose of both the within- and between-groups comparisons in mental health disparities research is to assess whether or not social stress is a cause of mental health problems and, if so, to explain the processes through which it works. To fully describe social stress as a cause, researchers would need to demonstrate that disadvantaged status is related to higher incidence of mental disorders or higher mean levels of mental health problems (using the between-groups analyses) and
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