EXTENDING THE “FUNDAMENTAL CAUSE” EXTENDING THE “FUNDAMENTAL CAUSE” THEORY TO EXPERIENCES OF RACISM THEORY TO EXPERIENCES OF RACISM AMONG AMERICAN AND CARIBBEAN AMONG AMERICAN AND CARIBBEAN PEOPLE OF AFRICAN DESCENTPEOPLE OF AFRICAN DESCENT

Arthur L Whaley, PhD, DrPHArthur L Whaley, PhD, DrPHJackson State UniversityJackson State University

Paper presented at the 3Paper presented at the 3rdrd Annual Health Disparities Institute of the Caribbean Annual Health Disparities Institute of the Caribbean Exploratory NCMHD Research Center, St. Thomas, VI, October 21-22, 2010Exploratory NCMHD Research Center, St. Thomas, VI, October 21-22, 2010

OverviewOverview Review the fundamental cause theoryReview the fundamental cause theory Discuss the dynamics of race and social class in Discuss the dynamics of race and social class in

health and mental health outcomeshealth and mental health outcomes Present the perspective of, and the evidence for, Present the perspective of, and the evidence for,

racism as a fundamental cause of health disparitiesracism as a fundamental cause of health disparities Describe and use the National Survey of American Describe and use the National Survey of American

Life (NSAL) to test hypothesis that racism is a Life (NSAL) to test hypothesis that racism is a fundamental cause of racial disparities in healthfundamental cause of racial disparities in health

Conclusion and implicationsConclusion and implications

Fundamental-Cause Theory (FCT)Fundamental-Cause Theory (FCT) BackgroundBackground

SES differences in health or mental health outcomes persist or SES differences in health or mental health outcomes persist or increase with improvements in the health care delivery systemincrease with improvements in the health care delivery system

Basic TenetsBasic Tenets Resources (money, power, knowledge, prestige) can be used to Resources (money, power, knowledge, prestige) can be used to

minimize risk and avoid emergent diseasesminimize risk and avoid emergent diseases Fundamental causes linked to multiple disease outcomes through Fundamental causes linked to multiple disease outcomes through

multiple mechanismsmultiple mechanisms The association between fundamental cause and disease is The association between fundamental cause and disease is

reproduced over time via replacement of intervening mechanismsreproduced over time via replacement of intervening mechanisms

ImplicationsImplications Fundamental causes cannot be eradicated through targeting Fundamental causes cannot be eradicated through targeting

individual-level risk factorsindividual-level risk factorsLink, B.G., & Phelan, J. (1995), Social condition as a fundamental cause of disease. Journal of Health and Social Behavior, Extra Issue, 80-94.

Research Support for Fundamental-Research Support for Fundamental-Cause Theory Cause Theory National Longitudinal Mortality Study data revealed National Longitudinal Mortality Study data revealed

that preventable causes of mortality more strongly that preventable causes of mortality more strongly associated with SES than less preventable causes associated with SES than less preventable causes (Phelan et al., 2004)(Phelan et al., 2004)

The data from the Wisconsin Longitudinal Study and The data from the Wisconsin Longitudinal Study and Health and Retirement Study were used to show that Health and Retirement Study were used to show that SES variables are associated with health disparities SES variables are associated with health disparities even when controlling for IQ (Link et al., 2008)even when controlling for IQ (Link et al., 2008)

Limitations of the Fundamental Limitations of the Fundamental Cause TheoryCause Theory

Theory fails to consider cultural context in which Theory fails to consider cultural context in which social conditions manifest.social conditions manifest.

FCT cannot explain why ethnicity/race is FCT cannot explain why ethnicity/race is considered an individual-level risk factor.considered an individual-level risk factor.

The theory also assumes a main effect for the The theory also assumes a main effect for the SES-disease relationship.SES-disease relationship.

FCT does not account for the dynamics of the FCT does not account for the dynamics of the relationship for SES and race.relationship for SES and race.

Dynamics of Race and Social Class in Dynamics of Race and Social Class in Health and Mental HealthHealth and Mental Health

Race differences often remain when SES is controlled in Race differences often remain when SES is controlled in health studies (Jackson et al., 2004; Whaley, 2003).health studies (Jackson et al., 2004; Whaley, 2003).

Poverty concentration differs by race and may underlie Poverty concentration differs by race and may underlie some of the main effects for race in health studies (see some of the main effects for race in health studies (see Schulz et al., 2000; Wilson, 1987).Schulz et al., 2000; Wilson, 1987).

It may be more accurate to consider the interaction It may be more accurate to consider the interaction between race and SES, instead of simply the main effects between race and SES, instead of simply the main effects (Kessler & Neighbors, 1986)(Kessler & Neighbors, 1986)

The interaction may result from differential exposures to The interaction may result from differential exposures to racism as an environmental toxin (Whaley, 2003)racism as an environmental toxin (Whaley, 2003)

Perspective on Racism as a Fundamental Perspective on Racism as a Fundamental Cause of Health DisparitiesCause of Health Disparities White privilege contributes to better health outcomes White privilege contributes to better health outcomes

for European Americans with similar resources as for European Americans with similar resources as African Americans (Institute of Medicine, 2002).African Americans (Institute of Medicine, 2002).

Racial disparities in health exist over time and place, Racial disparities in health exist over time and place, despite changes in intervening mechanisms (Whaley, despite changes in intervening mechanisms (Whaley, 1998).1998).

Racism creates disparate effects on multiple health Racism creates disparate effects on multiple health and mental health outcomes (Institute of Medicine, and mental health outcomes (Institute of Medicine, 2002; Neighbors et al., 2002).2002; Neighbors et al., 2002).

Racism operates through multiple mechanisms to Racism operates through multiple mechanisms to create disparities in health and mental health create disparities in health and mental health

Evidence for Racism as a Fundamental Evidence for Racism as a Fundamental Cause of Health DisparitiesCause of Health Disparities Research indicates that Black Americans are more Research indicates that Black Americans are more

concerned than White Americans about their self-concerned than White Americans about their self-presentation to ensure that they receive good health presentation to ensure that they receive good health care (Malat, van Ryn, & Purcell, 2006).care (Malat, van Ryn, & Purcell, 2006).

Studies show that racial differences in various health Studies show that racial differences in various health and mental health outcomes across the nation have and mental health outcomes across the nation have been persistent over decades.been persistent over decades.

Racial differences in health and mental health Racial differences in health and mental health outcomes are manifestations of different mechanismsoutcomes are manifestations of different mechanisms—e.g., physician attitudes and behaviors (individual) —e.g., physician attitudes and behaviors (individual) and residential segregation (structural).and residential segregation (structural).

Black-White Rate Ratios, Ages 25-44, for U.S. Black-White Rate Ratios, Ages 25-44, for U.S. All-Cause Mortality Adjusted for Income, All-Cause Mortality Adjusted for Income, 1978-19851978-1985

0

0.5

1

1.5

2

2.5

Male Female

Unadjusted

Adjusted

Sorlie, P., & Rogot, E. (1992). Black-white mortality differences by family income.  Lancet, 340(8815), 346-350. 

Perceived Discrimination, Economic Perceived Discrimination, Economic Resources and Health Outcomes among Resources and Health Outcomes among African-Descended IndividualsAfrican-Descended Individuals

Qualitative and quantitative reviews of the literature Qualitative and quantitative reviews of the literature indicates that perceived discrimination adversely affects indicates that perceived discrimination adversely affects mental and physical health (Williams, Neighbors, & mental and physical health (Williams, Neighbors, & Jackson, 2003; Pascoe & Richman, 2009).Jackson, 2003; Pascoe & Richman, 2009).

Perceived discrimination is associated with an increase Perceived discrimination is associated with an increase in self-reported symptoms in African American women in self-reported symptoms in African American women (Keith et al., 2010; Schulz et al., 2005).(Keith et al., 2010; Schulz et al., 2005).

Economic resources do not protect African Americans Economic resources do not protect African Americans from the effects of discrimination on health and mental from the effects of discrimination on health and mental health (e.g., Schulz et al., 2005; Siefert et al., 2007)health (e.g., Schulz et al., 2005; Siefert et al., 2007)

Physicians’ Recommendation of Coronary Physicians’ Recommendation of Coronary Artery Bypass Graft Surgery by Patients’ Artery Bypass Graft Surgery by Patients’ Race-Gender GroupRace-Gender Group

0

5

10

15

20

25

30

35

40

Male Female

Black

White

van Ryn, M., Burgess, D., Malat, J., & Griffin, J. (2006). Physicians' Perceptions of Patients' Social and Behavioral Characteristics and Race Disparities in Treatment Recommendations for Men With Coronary Artery Disease. American Journal of Public Health, 96(2), 351-357.

National Survey of American Life: National Survey of American Life: OverviewOverview National Survey of American Life is a National Survey of American Life is a

comprehensive and detailed study of mental comprehensive and detailed study of mental disorders and the mental health of Americans of disorders and the mental health of Americans of African descent.African descent.

Complex sampling produced a representative Complex sampling produced a representative sample of 3,570 African Americans, 1,623 sample of 3,570 African Americans, 1,623 Caribbean Blacks, and 1,006 non-Hispanic WhitesCaribbean Blacks, and 1,006 non-Hispanic Whites

The questionnaire contains 1,535 items covering 17 The questionnaire contains 1,535 items covering 17 domains and takes, on average, 2 hours and 20 domains and takes, on average, 2 hours and 20 minutes to completeminutes to complete

National Survey of American Life: Use to National Survey of American Life: Use to Test Fundamental-Cause TheoryTest Fundamental-Cause Theory

Independent Variables: Demographic variables (sex, Independent Variables: Demographic variables (sex, age, education, marital status, employment status, age, education, marital status, employment status, household income), neighborhood quality, household income), neighborhood quality, psychological variables (self-esteem, perceived psychological variables (self-esteem, perceived lack of control, and perceived discrimination)lack of control, and perceived discrimination)

Dependent Variables: Global self-reports of physical Dependent Variables: Global self-reports of physical health and mental health.health and mental health.

Hypothesis: Perceived discrimination will be Hypothesis: Perceived discrimination will be positively associated with ratings of poor physical positively associated with ratings of poor physical and mental health for persons of African descentand mental health for persons of African descent

National Survey of American Life: National Survey of American Life: Description of Continuous VariablesDescription of Continuous Variables

VariableVariable ItemsItems ValuesValues MeanMean AlphaAlpha Sample ItemSample Item

Physical Health RatingPhysical Health Rating 11 1-51-5 2.592.59 ---- How would you rate your How would you rate your physical health?physical health?

Mental Health RatingMental Health Rating 11 1-51-5 2.172.17 ---- How would you rate your How would you rate your mental health?mental health?

Neighborhood QualityNeighborhood Quality 88 1-81-8 2.002.00 .81.81 There is a medical clinic in There is a medical clinic in your neighborhood.your neighborhood.

Self-EsteemSelf-Esteem 1010 1-41-4 .77.77 I feel that I am a person of I feel that I am a person of worth.worth.

Perceived Lack of Perceived Lack of ControlControl

1010 1-101-10 3.383.38 .77.77 What happens in my life What happens in my life depends on me.depends on me.

Perceived Perceived DiscriminationDiscrimination

1010 1-101-10 4.704.70 .89.89 Frequently treated with less Frequently treated with less respect than others.respect than others.

National Survey of American Life: National Survey of American Life: ResultsResults

General Linear Model – Physical and mental health General Linear Model – Physical and mental health ratings regressed on demographic variables only, ratings regressed on demographic variables only, and then second model adding psychological and then second model adding psychological variables. Separate models of African variables. Separate models of African Caribbeans, African Americans and European Caribbeans, African Americans and European AmericansAmericans

Variables of Interest: Education, Income, Variables of Interest: Education, Income, Neighborhood Quality, and Perceived Neighborhood Quality, and Perceived DiscriminationDiscrimination

Demographic and Psychosocial Predictors of Global Self-Reported Demographic and Psychosocial Predictors of Global Self-Reported Physical Health by Ethnic/Racial GroupPhysical Health by Ethnic/Racial Group

VariablesVariables African AmericanAfrican AmericanWald FWald F

African CaribbeanAfrican CaribbeanWald FWald F

European American European American Wald FWald F

Years of EducationYears of Education 3.113*3.113* 7.731**7.731** 3.781*3.781*

Marital StatusMarital Status 1.4841.484 3.3273.327 .107.107

Work StatusWork Status 19.239**19.239** 7.704**7.704** 3.2593.259

Sex Sex 16.153**16.153** 8.208**8.208** 1.7181.718

AgeAge 37.460**37.460** 8.855**8.855** 1.8471.847

Household IncomeHousehold Income 1.8321.832 1.5151.515 21.262**21.262**

Rosenberg Self Esteem ScaleRosenberg Self Esteem Scale 30.387**30.387** 2.5522.552 11.159**11.159**

Perceived Lack of ControlPerceived Lack of Control 18.833**18.833** 13.454**13.454** 17.236**17.236**

Positive Neighborhood Positive Neighborhood CharacteristicsCharacteristics

.956.956 .898.898 19.270**19.270**

Perceived DiscriminationPerceived Discrimination 4.839*4.839* 1.3311.331 2.5762.576

* p<.05** p<.01

Demographic and Psychosocial Predictors of Global Self-Reported Demographic and Psychosocial Predictors of Global Self-Reported Mental Health by Ethnic/Racial GroupMental Health by Ethnic/Racial Group

VariablesVariables African AmericanAfrican AmericanWald FWald F

African CaribbeanAfrican CaribbeanWald FWald F

European American European American Wald FWald F

Years of EducationYears of Education 1.1051.105 .671.671 .712.712

Marital StatusMarital Status .571.571 1.9171.917 3.1123.112

Work StatusWork Status 5.226**5.226** 3.1233.123 .473.473

Sex Sex 12.657**12.657** 2.1312.131 5.892**5.892**

AgeAge 13.201**13.201** .931.931 3.6733.673

Household IncomeHousehold Income .004.004 .257.257 .041.041

Rosenberg Self Esteem ScaleRosenberg Self Esteem Scale 64.473**64.473** 17.406**17.406** 45.344**45.344**

Perceived Lack of ControlPerceived Lack of Control 40.121**40.121** 4.214*4.214* 14.609**14.609**

Positive Neighborhood Positive Neighborhood CharacteristicsCharacteristics

1.4411.441 .465.465 1.0831.083

Perceived DiscriminationPerceived Discrimination 19.548**19.548** 2.0592.059 .062.062

* p<.05** p<.01

Conclusions and ImplicationsConclusions and Implications Perceived discrimination was significantly Perceived discrimination was significantly

associated with both physical and mental health associated with both physical and mental health ratings of African Americans but not African ratings of African Americans but not African Caribbean or European American respondents.Caribbean or European American respondents.

Interventions to increase patients’ self-advocacy Interventions to increase patients’ self-advocacy skills and reduce physicians’ bias need to be skills and reduce physicians’ bias need to be implemented, especially for African Americans.implemented, especially for African Americans.

Policies and legislation must address racial Policies and legislation must address racial disparities along with economic inequality to disparities along with economic inequality to eradicate fundamental causes of health and eradicate fundamental causes of health and mental health disparities.mental health disparities.