Elsevier

Social Science & Medicine

Volume 104, March 2014, Pages 64-73
Social Science & Medicine

The pathways from perceived discrimination to self-rated health: An investigation of the roles of distrust, social capital, and health behaviors

https://doi.org/10.1016/j.socscimed.2013.12.021Get rights and content

Highlights

  • We test three pathways linking perceived discrimination to self-rated health (SRH).

  • Discrimination is associated with enhanced distrust in the health care system.

  • Discrimination decreases neighborhood social capital, which further hinders SRH.

  • Discrimination induces risky behaviors that affect health conditions and SRH.

  • Net of the two pathways above, discrimination is negatively related to SRH.

Abstract

Although there has been extensive research on the adverse impacts of perceived discrimination on health, it remains unclear how perceived discrimination gets under the skin. This paper develops a comprehensive structural equation model (SEM) by incorporating both the direct effects of perceived discrimination on self-rated health (SRH), a powerful predictor for many health outcomes, and the indirect effects of perceived discrimination on SRH through health care system distrust, neighborhood social capital, and health behaviors and health conditions. Applying SEM to 9880 adults (aged between 18 and 100) in the 2008 Southeastern Pennsylvania Household Health Survey, we not only confirmed the positive and direct association between discrimination and poor or fair SRH, but also verified two underlying mechanisms: 1) perceived discrimination is associated with lower neighborhood social capital, which further contributes to poor or fair SRH; and 2) perceived discrimination is related to risky behaviors (e.g., reduced physical activity and sleep quality, and intensified smoking) that lead to worse health conditions, and then result in poor or fair SRH. Moreover, we found that perceived discrimination is negatively associated with health care system distrust, but did not find a significant relationship between distrust and poor or fair SRH.

Introduction

Racial discrimination can occur in all aspects of life and could be generally classified into two types: interpersonal and institutional discrimination (National Research Council, 2004). The former refers to an individual's discriminatory behaviors against people of minority groups, which can be directly perceived (e.g., verbal abuse or physical attack). The latter indicates the discriminatory actions embedded in social structures and may not be visible, such as policies, norms, and practices that lead to either unintended or intended unequal access to resources and power across racial groups. Wellman (2007) suggested that racial discrimination could be regarded as a process where Whites accumulate resources at the expense of other minorities, and is related to the superior White race framing (Feagin, 2009). Although in the past few decades, interpersonal discrimination in the United States has been declined, the white-oriented norms or decision-making embedded in social organizations or institutions may pass on the so-called "white privilege" (Flagg, 1993, Wellman, 2007). That is, despite the Civil Rights Act of 1964, racism/discrimination has not disappeared. Instead, racial discrimination has been hidden or transformed into other subtle existence (Quillian, 2006).

Following the transformation in racial discrimination, it is difficult to precisely detect and/or measure discrimination. Audit studies have been argued to be the most appropriate approach to measure discrimination (Bertrand & Mullainathan, 2004). However, the audit method has its limitations (Heckman & Siegelman, 1993) and may not be applicable particularly when collecting observational data (Quillian, 2006). In this study, we do not attempt to fully capture or measure the discrimination behaviors that an individual may encounter. Instead, we endeavor to understand if the subjective discriminatory experience has negative implications for an individual's health. The underlying assumption of this study is that an individual's well-being is subject to his/her life experience.

Our assumption above follows recent research that focused on an individual's experience with discriminatory actions (i.e., perceived discrimination) (Acevedo-Garcia et al., 2013, Karlsen and Nazroo, 2002, Larson et al., 2007). The negative consequences of perceived discrimination have been identified in the housing market (Pager & Shepherd, 2008), and health care (Griffith et al., 2007). Lately, the focus has shifted to the exploration of how perceived racial discrimination affects individual health outcomes. For example, it has been found that people who experienced racial discrimination are more likely to engage in risky behaviors (Pascoe & Richman, 2009) and to have more depressive symptoms (Schulz et al., 2006) and higher blood pressure (Karlsen & Nazroo, 2002) in contrast to their counterparts without perceived discrimination. The relationships between perceived discrimination and a range of health measures hold even after controlling for individual sociodemographic features (Harris et al., 2006). Extending from these recent studies, this study aims to investigate the association between perceived discrimination and self-rated health (SRH), a powerful predictor for future mortality and/or occurrence of diseases (Idler and Benyamini, 1997, Jylhä, 2009).

Almost a decade ago, several scholars strongly encouraged the studies that explicitly examine the association between SRH and racial discrimination (Boardman, 2004, Williams et al., 2003). Many research projects, since then, have reported that poor or fair SRH is associated with perceived racial discrimination (Borrell et al., 2006, Chae and Walters, 2009, Larson et al., 2007, Schulz et al., 2006) with few exceptions (Krieger, Kosheleva, Waterman, Chen, & Koenen, 2011). Although these studies generally established the relationship between perceived discrimination and SRH, the etiologic mechanisms through which perceived discrimination affects SRH remains underexplored (Borrell et al., 2006). The goal of this study is to fill this gap by proposing and examining a conceptual framework that explains how racial discrimination is related to SRH.

The conceptual framework of this study is basically built upon two recent knowledge streams related to discrimination. The first is focused on health care system distrust that is related to institutional discrimination. As discussed previously, discrimination may exist in organizations or institutions. For example, Gee (2002) found that discrimination against Chinese Americans among loan associations negatively affected minority health. A study further showed that the knowledge of institutional discrimination (e.g., Tuskegee Study) increase the distrust of the health care system (Shavers, Lynch, & Burmeister, 2002). A recent report has shown that experiencing discriminatory behaviors was positively related to individual health care system distrust (Armstrong et al., 2013). Based on these findings, we argued that perceived discrimination would further exacerbate distrust.

Furthermore, the literature on the determinants of SRH has suggested that a high level of health care system distrust is related to poor or fair SRH, net of other explanatory covariates such as education, poverty status, and neighborhood social conditions (Armstrong et al., 2006, Mohseni and Lindstrom, 2007, Yang et al., 2011). One explanation is that people with high health care system distrust tend to be less likely to seek medical advice, to adhere to medication, or to utilize preventive health services than those with low levels of distrust (LaVeist et al., 2009, Musa et al., 2009, Yang and Matthews, 2012). The lack of these health behaviors may contribute to the assessment of poor or fair overall health status. Coupled with the fact that discrimination is positively associated with distrust, one proposed mechanism from discrimination to SRH is that perceived discrimination first increases health care system distrust and then leads to a poor or fair SRH.

The second pathway emphasizes the role of social capital that is associated with interpersonal discrimination. As demonstrated in the literature (Finch et al., 2001, Karlsen and Nazroo, 2002, Larson et al., 2007, Schulz et al., 2006), perceived interpersonal discrimination is a major source of depression and a barrier to health. More explicitly, perceived discrimination would not only affect an individual's health but also influence his/her social interactions. Note that the concept of social capital could be operationalized as an ecological factor (Putnam, 2000) or an individual's asset (Lin, 1999). The former has been widely used in health research but relatively little attention has been paid to the latter (Song, Son, & Lin, 2010). In this study, we adopted the individual perspective as perceived discrimination may directly affect an individual's social behaviors. When an individual experiences discriminatory behaviors, s/he may tend to limit her/his social interactions with others to avoid the recurrence of racial discrimination, which may in turn constrain her/his social involvement and lead to reduced social capital. Another potential explanation is that when experiencing racial discrimination, individuals may seek social support from her/his social network to cope with stress, which is a type of taxing resources and may not be recovered (Folkman, Lazarus, Gruen, & DeLongis, 1986). As a result, an individual's social capital may be decreased due to racial discrimination. When one has a reduced social capital, s/he may have insufficient support to maintain a good health status (Fujiwara and Kawachi, 2008, Nieminen et al., 2010). Therefore, we propose that perceived discrimination would sabotage an individual's social capital because of the minimized social interactions or over-taxing of existing resources/social support. Consequently, the reduced social capital may lead an individual to report poor or fair overall self-rated health.

Section snippets

Conceptual framework and hypotheses

Built around the two mechanisms above, the conceptual framework of this study is demonstrated in Fig. 1. In addition to the four major variables discussed previously (i.e., discrimination, health care system distrust, social capital, and SRH), we include an individual's sociodemographic characteristics, health behaviors, and health conditions into the framework. The variables in rectangles indicate manifest variables; whereas those in ovals are latent variables. We further explain why these

Data

This study used the Public Health Management Corporation's (PHMC) 2008 Southeastern Pennsylvania Household Health Survey to test the research hypotheses. The PHMC conducted interviews with 10,007 adults living in five counties of the Philadelphia metropolitan area (PHMC, 2008). Specifically, the study area was stratified into 54 service areas that were developed by PHMC on the basis of ZIP codes. Each service area has approximately 30,000-75,000 adult population (in 2008) and a computerized

Descriptive statistics

Table 1 provides an overall summary of all the manifest variables in the SEM, and the statistical comparisons between those with discrimination experience and their counterparts. More than 9 percent of the respondents indicated that they had experienced discrimination when getting medical care or housing and, on average, they had significantly worse health status than did those without discrimination experience. Particularly, chronic diseases and depression were more prevalent among

Discussions

The literature on racial discrimination and health has mainly focused on the direct relationship between racial discrimination and a range of health outcomes, such as increased allostatic load, depression, and cardiovascular diseases (Mays et al., 2007, Pascoe and Richman, 2009), but the indirect pathways through which racial discrimination operates to affect health outcomes have not been fully investigated. While self-rated health is a powerful predictor for future diseases and mortality (

Acknowledgments

We acknowledge assistance provided by Population Research Institute at Penn State University, which receives core funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (R24-HD041025). We also acknowledge Penn State's Social Science Research Institute and libraries for securing the data license.

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