1. EXTENDING THE “FUNDAMENTAL CAUSE” THEORY TO EXPERIENCES OF RACISM AMONG AMERICAN AND CARIBBEAN PEOPLE OF AFRICAN DESCENT Arthur L Whaley, PhD, DrPH Jackson State University Paper presented at the 3 rd Annual Health Disparities Institute of the Caribbean Exploratory NCMHD Research Center, St. Thomas, VI, October 21-22, 2010

2. Overview  Review the fundamental cause theory  Discuss the dynamics of race and social class in health and mental health outcomes  Present the perspective of, and the evidence for, racism as a fundamental cause of health disparities  Describe and use the National Survey of American Life (NSAL) to test hypothesis that racism is a fundamental cause of racial disparities in health  Conclusion and implications

3. Fundamental-Cause Theory (FCT)  Background  SES differences in health or mental health outcomes persist or increase with improvements in the health care delivery system  Basic Tenets  Resources (money, power, knowledge, prestige) can be used to minimize risk and avoid emergent diseases  Fundamental causes linked to multiple disease outcomes through multiple mechanisms  The association between fundamental cause and disease is reproduced over time via replacement of intervening mechanisms  Implications  Fundamental causes cannot be eradicated through targeting individual-level risk factors Link, B.G., & Phelan, J. (1995), Social condition as a fundamental cause of disease. Journal of Health and Social Behavior, Extra Issue, 80-94.

4. Research Support for Fundamental- Cause Theory  National Longitudinal Mortality Study data revealed that preventable causes of mortality more strongly associated with SES than less preventable causes (Phelan et al., 2004)  The data from the Wisconsin Longitudinal Study and Health and Retirement Study were used to show that SES variables are associated with health disparities even when controlling for IQ (Link et al., 2008)

5. Limitations of the Fundamental Cause Theory  Theory fails to consider cultural context in which social conditions manifest.  FCT cannot explain why ethnicity/race is considered an individual-level risk factor.  The theory also assumes a main effect for the SES-disease relationship.  FCT does not account for the dynamics of the relationship for SES and race.

6. Dynamics of Race and Social Class in Health and Mental Health  Race differences often remain when SES is controlled in health studies (Jackson et al., 2004; Whaley, 2003).  Poverty concentration differs by race and may underlie some of the main effects for race in health studies (see Schulz et al., 2000; Wilson, 1987).  It may be more accurate to consider the interaction between race and SES, instead of simply the main effects (Kessler & Neighbors, 1986)  The interaction may result from differential exposures to racism as an environmental toxin (Whaley, 2003)

7. Perspective on Racism as a Fundamental Cause of Health Disparities  White privilege contributes to better health outcomes for European Americans with similar resources as African Americans (Institute of Medicine, 2002).  Racial disparities in health exist over time and place, despite changes in intervening mechanisms (Whaley, 1998).  Racism creates disparate effects on multiple health and mental health outcomes (Institute of Medicine, 2002; Neighbors et al., 2002).  Racism operates through multiple mechanisms to create disparities in health and mental health

8. Evidence for Racism as a Fundamental Cause of Health Disparities  Research indicates that Black Americans are more concerned than White Americans about their self- presentation to ensure that they receive good health care (Malat, van Ryn, & Purcell, 2006).  Studies show that racial differences in various health and mental health outcomes across the nation have been persistent over decades.  Racial differences in health and mental health outcomes are manifestations of different mechanisms— e.g., physician attitudes and behaviors (individual) and residential segregation (structural).

9. Black-White Rate Ratios, Ages 25-44, for U.S. All-Cause Mortality Adjusted for Income, 1978-1985 Sorlie, P., & Rogot, E. (1992). Black-white mortality differences by family income. Lancet, 340(8815), 346-350.

10. Perceived Discrimination, Economic Resources and Health Outcomes among African-Descended Individuals  Qualitative and quantitative reviews of the literature indicates that perceived discrimination adversely affects mental and physical health (Williams, Neighbors, & Jackson, 2003; Pascoe & Richman, 2009).  Perceived discrimination is associated with an increase in self-reported symptoms in African American women (Keith et al., 2010; Schulz et al., 2005).  Economic resources do not protect African Americans from the effects of discrimination on health and mental health (e.g., Schulz et al., 2005; Siefert et al., 2007)

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

12. National Survey of American Life: Overview  National Survey of American Life is a comprehensive and detailed study of mental disorders and the mental health of Americans of African descent.  Complex sampling produced a representative sample of 3,570 African Americans, 1,623 Caribbean Blacks, and 1,006 non-Hispanic Whites  The questionnaire contains 1,535 items covering 17 domains and takes, on average, 2 hours and 20 minutes to complete

13. National Survey of American Life: Use to Test Fundamental-Cause Theory Independent Variables: Demographic variables (sex, age, education, marital status, employment status, household income), neighborhood quality, psychological variables (self-esteem, perceived lack of control, and perceived discrimination) Dependent Variables: Global self-reports of physical health and mental health. Hypothesis: Perceived discrimination will be positively associated with ratings of poor physical and mental health for persons of African descent

14. National Survey of American Life: Description of Continuous Variables VariableItemsValuesMeanAlpha Sample Item Physical Health Rating 11-52.59-- How would you rate your physical health? Mental Health Rating 11-52.17-- How would you rate your mental health? Neighborhood Quality 81-82.00.81 There is a medical clinic in your neighborhood. Self-Esteem101-4.77 I feel that I am a person of worth. Perceived Lack of Control 101-103.38.77 What happens in my life depends on me. Perceived Discrimination 101-104.70.89 Frequently treated with less respect than others.

15. National Survey of American Life: Results General Linear Model – Physical and mental health ratings regressed on demographic variables only, and then second model adding psychological variables. Separate models of African Caribbeans, African Americans and European Americans Variables of Interest: Education, Income, Neighborhood Quality, and Perceived Discrimination

16. Demographic and Psychosocial Predictors of Global Self-Reported Physical Health by Ethnic/Racial Group Variables African American Wald F African Caribbean Wald F European American Wald F Years of Education 3.113*7.731**3.781* Marital Status 1.4843.327.107 Work Status 19.239**7.704**3.259 Sex16.153**8.208**1.718 Age37.460**8.855**1.847 Household Income 1.8321.51521.262** Rosenberg Self Esteem Scale 30.387**2.55211.159** Perceived Lack of Control 18.833**13.454**17.236** Positive Neighborhood Characteristics.956.89819.270** Perceived Discrimination 4.839*1.3312.576 * p<.05 ** p<.01

17. Demographic and Psychosocial Predictors of Global Self-Reported Mental Health by Ethnic/Racial Group Variables African American Wald F African Caribbean Wald F European American Wald F Years of Education 1.105.671.712 Marital Status.5711.9173.112 Work Status 5.226**3.123.473 Sex12.657**2.1315.892** Age13.201**.9313.673 Household Income.004.257.041 Rosenberg Self Esteem Scale 64.473**17.406**45.344** Perceived Lack of Control 40.121**4.214*14.609** Positive Neighborhood Characteristics 1.441.4651.083 Perceived Discrimination 19.548**2.059.062 * p<.05 ** p<.01

18. Conclusions and Implications  Perceived discrimination was significantly associated with both physical and mental health ratings of African Americans but not African Caribbean or European American respondents.  Interventions to increase patients’ self-advocacy skills and reduce physicians’ bias need to be implemented, especially for African Americans.  Policies and legislation must address racial disparities along with economic inequality to eradicate fundamental causes of health and mental health disparities.