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A systematic review of studies examining the relationship between
reported racism and health and wellbeing for children and young
people
Naomi Priest
a
,
*
, Yin Paradies
b
, Brigid Trenerry
a
, Mandy Truong
a
, Saffron Karlsen
c
,
Yvonne Kelly
d
a
The McCaughey Centre, Melbourne School of Population Health, University of Melbourne, Level 5, 207 Bouverie St., Carlton 3053, Australia
b
Centre for Citizenship and Globalization, Faculty of Arts and Education, Deakin University, Australia
c
Epidemiology & Public Health, Div of Population Health, University College London, UK
d
Institute for Social & Economic Research, University of Essex, UK
article info
Article history:
Available online 19 December 2012
Keywords:
Prejudice
Racism
Racial discrimination
Child
Youth
Systematic review
Wellbeing
Health outcomes
abstract
Racial discrimination is increasingly recognised as a determinant of racial and ethnic health inequalities,
with growing evidence of strong associations between racial discrimination and adult health outcomes.
There is a growing body of literature that considers the effects of racial discrimination on child and youth
health. The aim of this paper is to provide a systematic review of studies that examine relationships
between reported racial discrimination and child and youth health. We describe the characteristics of
121 studies identied by a comprehensive search strategy, including denitions and measurements of
racial discrimination and the nature of reported associations. Most studies were published in the last
seven years, used cross-sectional designs and were conducted in the United States with young people
aged 12e18 years. African American, Latino/a, and Asian populations were most frequently included in
these studies. Of the 461 associations examined in these studies, mental health outcomes (e.g. depres-
sion, anxiety) were most commonly reported, with statistically signicant associations with racial
discrimination found in 76% of outcomes examined. Statistically signicant associations were also found
for over 50% of associations between racial discrimination and positive mental health (e.g. self esteem,
resilience), behaviour problems, wellbeing, and pregnancy/birth outcomes. The eld is currently limited
by a lack of longitudinal studies, limited psychometrically validated exposure instruments and poor
conceptualisation and denition of racial discrimination. There is also a need to investigate the complex
and varying pathways by which reported racial discrimination affect child and youth health. Ensuring
study quality in this eld will allow future research to reveal the complex role that racial discrimination
plays as a determinant of child and youth health.
Ó2012 Elsevier Ltd. All rights reserved.
Introduction
The importance of social determinants of health (including
historical, cultural, environmental, and political factors) as key to
understanding and addressing health inequalities is now well
established (Commission on Social Determinants of Health, 2008;
Wilkinson & Marmot, 2003). It is widely accepted that a range of
social factors are implicated in ill-health and the persistence of
health inequalities in societies, with considerable evidence of links
between existing forms of social stratication and health inequal-
ities in numerous contexts (Marmot, 2005).
Expanding the social determinants agenda to include a more
explicit emphasis on social determinants of child health across the
life course has been identied as a priority (Li, Mattes, Stanley,
McMurray, & Hertzman, 2009). This includes greater recognition
of the importance of early life conditions to later health, education
and social outcomes in adulthood as well as the ways in which
skills, capabilities and resilience across individual, family, neigh-
bourhood and socio-political contexts inuence accumulation of
advantage and disadvantage throughout life (Maggi, Irwin, Siddiqi,
& Hertzman, 2010). Moreover, the Eurocentric focus of social
determinants of health inequalities research has also been critiqued
(Bonnefoy, Morgan, Kelly, Butt, & Bergman, 2007), with recognition
of the need for research on child health inequalities to consider
a broader range of cultural and geographical contexts (Maggi et al.,
2010). In particular, exploration of developmental processes for
*Corresponding author. Tel.: þ61 3 8344 0926; fax: þ61 3 9348 2832.
E-mail address: npriest@unimelb.edu.au (N. Priest).
Contents lists available at SciVerse ScienceDirect
Social Science & Medicine
journal homepage: www.elsevier.com/locate/socscimed
0277-9536/$ esee front matter Ó2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.socscimed.2012.11.031
Social Science & Medicine 95 (2013) 115e127
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children from indigenous (Priest, Mackean, Davis, Waters, & Briggs,
2012) and minority racial and ethnic groups (Quintana et al., 2006)
is currently underdeveloped.
Racial and ethnic inequalities in child health and wellbeing have
been described across population groups and contexts, particularly
in developed nations such as the United Kingdom, the United
States, Canada, Australia and New Zealand (Quintana et al., 2006).
The bulk of existing scholarship on racial/ethnic disparities inves-
tigates the relative contribution of genetics, health behaviours,
cultural practices and beliefs and socioeconomic position (Dressler,
Oths, & Gravlee, 2005).
However, racism and racial discrimination are increasingly
receiving attention as determinants of racial/ethnic inequalities in
health (Braveman, Egerter, & Williams, 2011). Dened as
a phenomena that results in avoidable and unfair inequalities in
power, resources and opportunities across racial or ethnic groups;
racism can be expressed through beliefs (e.g. negative and inac-
curate stereotypes), emotions (e.g. fear/hatred) or behaviours/
practices (e.g. unfair treatment), ranging from open threats and
insults (including physical violence) to phenomena deeply
embedded in social systems and structures. The behavioural or
practice-based forms of racism are commonly known as racial or
race-based discrimination. Racism can occur at three levels:
internalised (i.e. the incorporation of racist attitudes, beliefs or
ideologies into ones worldview), interpersonal (interactions
between individuals) and systemic racism (production, control and
access to labour, material and symbolic resources within a society)
(Berman & Paradies, 2010;Paradies, 2006a).
Within the literature, the terms racism and racial discrimination
are at times used interchangeably (Giscombe & Lobel, 2005) and
often poorly dened (Paradies, 2006b). In this review we use the
term racial discriminationfor consistency and brevity, and in
recognition that discrimination as unfair treatment is generally the
most common form of racism to be perceived and reported. In using
the term racial discrimination, we include discrimination due to
race, ethnicity, culture and religion, acknowledging the overlapping
nature of these categories within popular and academic discourse,
rather than as an endorsement of raceas an essentialist biological
category. While the inclusion of religion in such denitions is
debated, we do so in recognition that religion is often conated
with ethnicity and culture in popular culture (Hartmann,
Winchester, Edgell, & Gerteis, 2011). Scholars are also increasingly
describing the racialised nature of religious identity, noting that
many markers used to discriminate against racial/ethnic groups are
identical to those applied to religious groups; thus making it
difcult to disentangle these forms of discrimination (Dunn,
Klocker, & Salabay, 2007;Hartmann et al., 2011).
Experiences of racial discrimination can be subtle, unintentional,
unwitting and even unconscious. Events caused by other factors
may be misconstrued as racial discrimination while racist events
may go unnoticed. However, research suggests that respondents are
more likely to under than over report experiences of racial
discrimination (Kaiser & Major, 2006). Moreover, given that
internalised racism is, by its very nature, unrecognised by those
suffering from it while systemic racism is often so pervasive that it is
invisible and/or taken for granted, these forms of racial discrimi-
nation are particularly difcult to perceive. As such, it is important
to note that the studies included in this review are unlikely to
capture the full extent to which racial discrimination and racism
impact on health and wellbeing for children and young people.
Racial discrimination can affect health and wellbeing through
several pathways: (1) restricted access to social resources such
as employment, housing and education and/or increased expo-
sure to risk factors (such as unnecessary contact with the
criminal justice system); (2) negative affective/cognitive and
other patho-psychological processes; (3) allostatic load and other
patho-physiological processes; (4) reduced uptake of healthy
behaviours (e.g. exercise) and/or increased adoption of unhealthy
behaviours (e.g. substance misuse) either directly as stress-coping
or indirectly via reduced self-regulation; (5) direct physical injury
caused by racist violence (Brondolo, Brady, Libby, & Pencille,
2011;Brondolo, Hausmann, et al., 2011;Gee, Ro, Shariff-Marco,
& Chae, 2009;Harrell et al., 2011;Paradies, 2006b;Pascoe &
Smart Richman, 2009).
A growing body of epidemiological evidence shows strong asso-
ciations between self-reported racial discrimination and poor adult
health outcomes across diverse minority groups in developed coun-
tries (Brondolo, Brady, et al., 2011;Brondolo, Hausmann, et al., 2011;
Harrell et al., 2011;Lee & Ahn, 2011,2012;Paradies, 2006b;Pascoe &
Smart Richman, 2009;Williams & Mohammed, 2009). There is also
emerging research examining the impact of racial discrimination on
the health and wellbeing of children and young people who are
considered particularly vulnerable to its harmful effects (Pachter &
Garcia Coll, 2009;Paradies, 2006b;Sanders-Phillips, 2009;
Williams & Mohammed, 2009). Childhood exposure to either direct
(Coker et al., 2009;Nyborg & Curry, 2003;Simons et al., 2002;
Szalacha et al., 2003) and/or vicarious racial discrimination (Kelly,
Becares, & Nazroo, in press;Priest, Paradies, Stevens, & Bailie, 2010)
has been linked to poor child health, wellbeing and development.
Experiences of racial discrimination due to structural racism also
impact on childrens wellbeing through access to resources needed
for optimal health (Sanders-Phillips, 2009) and internalised racism
has been associated with poor child health outcomes (Chambers
et al., 2004). Racial discrimination has the potential to negatively
affect thedevelopment and adjustment of children andyoung people,
with potential consequences throughout the life course. In addition,
children of parents affected by racial discrimination (i.e. children
experiencing vicarious racial discrimination) are at increased risk of
developing emotional and behavioural problems through less
supportive parenting and/or changes in racial socialisation (Mays,
Cochran, & Barnes, 2007;Sanders-Phillips, 2009).
Experiences of racial discrimination have been negatively
associated with outcomes as diverse as birth weight and gestation
(Collins, David, Handler, Wall, & Andes, 2004), socio-emotional
wellbeing (Coker et al., 2009;Kelly et al., in press), childhood
illnesses (Priest et al., 2010), cognitive development (Kelly et al., in
press) and indicators of metabolic disease (Chambers et al., 2004).
Previous reviews suggest that research to date has largely focused
on African American adolescents in the United States to the
exclusion of other age groups, populations and national contexts
(Pachter & Garcia Coll, 2009;Sanders-Phillips, 2009).
Understanding of pathways and processes by which racial
discrimination impacts on health and wellbeing outcomes for chil-
dren and young people, and indeed for adult populations, is highly
complex and at present relatively under-developed (Brondolo,
Hausmann et al., 2011;Williams & Mohammed, 2009). While
pathways by which direct, vicarious and group experiences of racial
discrimination inuence health and wellbeing outcomes for chil-
dren and young people are all likely to differ, there may also be
commonalities. It is also suggested that such processes may not only
differ by the target or perceiver of racial discrimination, but may also
vary within and betweenpopulation groups, different ages, and type
and duration of exposure to racial discrimination (Sanders-Phillips,
Settles-Reaves, Walker, & Brownlow, 2009). Given the lack of
current evidence regarding these processes, in this present review
we have considered a diverse range of child and youth health
wellbeing outcomes associated with exposure to racial discrimina-
tion of children and young people themselves, as well as vicariously
by their parents and caregivers. While this unavoidably covers
a range of aetiological pathways by which racial discrimination
N. Priest et al. / Social Science & Medicine 95 (2013) 115e127116
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inuences health and wellbeing, this is consistent with approaches
taken by others in this eld (Pachter & Garcia Coll, 2009;Paradies,
2006b;Pascoe & Smart Richman, 2009;Williams & Mohammed,
2009). Such a life course approach is also advocated to understand
the inuence of racial discrimination on children and young people
across the lifespan regardless of the source of exposure (Gee,
Walsemann, & Brondolo, 2012).
A key gap in this emergent eld is the lack of a high quality
systematic review of empirical studies examining relationships
between reported racial discrimination and health and wellbeing
specically for children and young people. While such reviews exist
among adults (Paradies, 2006b;Pascoe & Smart Richman, 2009;
Williams & Mohammed, 2009) the applicability of the ndings of
these reviews to the unique developmental needs and contexts of
children and young people requires further examination. One non-
systematic review published in 2009 identied 40 articles on
racism and child health, 70% of which considered African American
populations (Pachter & Garcia Coll, 2009). However, as demon-
strated below, this review included only a little over half of the
studies published at that time. Furthermore, almost as many
studies have been published since this time.
This present review provides the rst international systematic
review of epidemiological studies on reported racial discrimination
and health and wellbeing for children and young people. It aims to
describe 1) the nature and characteristics of epidemiological
research on reported racial discrimination and health and wellbeing
for children and young people; 2) denitions and measurement of
reported racial discrimination used in this research, including
method of administration, content and timeframes of exposure; and
3) nature of associations found between reported racial discrimi-
nation and health and wellbeing for children and young people.
Methods
Inclusion criteria
The inclusion criteria for studies were as follows:
1) Empirical studies using quantitative methods including cross-
sectional; prospective and retrospective cohort; caseecontrol;
and intervention designs. Peer-reviewed journal articles (pub-
lished or under-review), and dissertations/theses were included.
2) Reported racial discrimination as the exposure measure, based
on racial, ethnic, cultural and/or religious background. As
described in the introduction, while the inclusion of religion in
such denitions has been debated, this review included reli-
gion in recognition that it is often conated with ethnicity and
culture in popular culture (Hartmann et al., 2011) and the
racialised nature of religious identity (Dunn et al., 2007). This
denition also included racial discrimination based on intern-
alised, interpersonal and/or institutional racism reported by
carers, by children and young people, as well as proxy reports
(e.g. carer report of child experiences).
3) Associations between reported racial discrimination and health
and wellbeing outcomes reported for participants aged 0e18
years old. Health and wellbeing were dened holistically,
including measures of illness and ill-health as well as positive
health outcomes across physical, mental and behavioural
domains (World Health Organization, 1946).
Search strategy and data extraction
The following databases and electronic journal collections were
searched using a detailed and comprehensive search strategy from
the earliest time available to November 2011: Medline (1950e),
PsychInfo (1897e), Sociological Abstracts (1962e), ERIC (1910e),
CINAHL (1982e) and ProQuest (1861e) (for dissertation/theses).
Reference lists of articles selected for full text review were hand-
searched for relevant studies. In addition, Google and key website
searches wereconducted and experts in the eld werecontacted. Key
experts provided details of relevant studies both published and
under-review. Searches were conducted in English only. Medline
search strategy and selection of studies is provided in Appendices 1
and 2 respectively.
The initial search generated 5693 results that were screened for
inclusion. All titles and abstracts were screened independently by
two authors using Endnote X4. Any queries about a study to be
included in the review were discussed with a third author. When
required, full text papers were obtained in order to assess inclusion.
Some papers with abstracts in English and full text in other
languages were identied, and these were translated into English
when possible. After screening, 121 studies were identied as
meeting the inclusion criteria.
The quality of included studies was appraised using the Health
Evidence Bulletin Wales critical appraisal tool adapted from the
Critical Appraisal Skills Programme (CASP) (http://hebw.cf.ac.uk/
projectmethod/appendix5.htm#top). This tool assesses key
domains of study quality, including clarity of aims, appropriateness
and rigour of design and analysis, including risk of bias, and relevance
of results. Only studies of medium or high quality were included.
Data from studies meeting the inclusion criteria were entered by
all authors into an Excel spreadsheet. Data extraction of a random
10% sample of included studies was conducted independently by
a second author in order to ensure data quality. Extracted data was
analysed using basic descriptive statistics in Excel 2011 for
Macintosh. A formal meta-analysis was not conducted due to the
heterogeneity of studies in terms of design, study populations,
exposure and outcome measures.
Results
From the 5693 titles generated by the search, 153 papers repre-
senting 121 studies met the inclusion criteria. We were unable to
obtain the full texts of three articles with abstracts that initially met
the inclusion criteria (Borges et al., 2011;Murrell, 1996;Sedmak,
2003). Of the 153 papers, 122 were published journal articles and
reports and 31 were unpublished theses/dissertations. Main reasons
for exclusion were samples not being within age range, studies
utilising poor methodological quality or papers with inadequate
reporting of methods or not reporting health outcomes for children
and young people. A number of studies were also excluded that
utilised measures of general discrimination that did not specify
discrimination due to racial, ethnic,cultural or religious background.
On occasion, multiple papers were published from the same study.
As a consequence, the unit of analysis for this review is study rather
than publication. Studies reporting more than one sample were
considered as one study with multiple associations. (Note: some
percentages may not add to 100% due to i) some categories not re-
ported by all studies and ii) some categories are not mutually
exclusive to the unit of analysis i.e. studies.)
Description of the studies
Table 1 provides details of the key characteristics of included
studies. Details of all associated publications representing included
studies are set out in Appendix 3.
The majority of studies included in this review were published
in the last seven years (66% n¼80) and in English (99% n¼120),
with one study published in Spanish (Castro, 2005). Most of the
studies used a cross-sectional study design (78% n¼94). Of these,
N. Priest et al. / Social Science & Medicine 95 (2013) 115e127 117
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12 were cross-sectional analyses from a longitudinal study
although longitudinal analysis was not reported. The majority of
studies used convenience (i.e. non-representative) samples (83%
n¼100), with a majority of studies including samples of 100e1000
children, young people or carers (77% n¼94). Most of the studies
were conducted in the US (71% n¼86) and in urban areas (77%
n¼93). The majority of studies (85% n¼103) reported outcomes
for young people aged 12e18 years. A total of 46 studies (38%) re-
ported outcomes for children aged 6e11 years, ve studies (4%) for
children 3e5 years, and 13 studies (11%) were reported outcomes
for newborns/infants 0e2 years. The three most common ethnic/
racial groups represented in the studies were African American
(40% n¼49), Latino/a (29% n¼35) and Asian, including East Asian,
South Asian and other Asian (25% n¼30).
Dening racial discrimination
Only one third of studies (38 of 121) in this review provided
adenition of racial discrimination. The majority of denitions
recognised both interpersonal and systemic forms of racial
discrimination. However, interpersonal racial discrimination was
mentioned more frequently than systemic racial discrimination. A
majority of denitions also dened racial discrimination as differ-
ential treatment by race or ethnicity. These denitions were general
in nature and did not specify for which racial groups this treatment
was positive or negative. Several denitions included the detri-
mental effects of racial discrimination (i.e. for minority or non-
dominant groups) with some of these also highlighting the privi-
leges accrued through racial discrimination for dominant groups
such as White people. Racial discrimination was dened as an
ideology of inferiority or superiority in only a small number of
studies and generally not attributed to both.
Exposure measurement
For the 121 studies in this review, a total of 123 different
instruments/scales assessed reported racial discrimination. Across
the instruments, there was considerable variation in exposure
measurement and scale length. Of the 123 measures, 69 were
between 1 and 9 items in length (with 8 consisting of only a single
item) and 51 were between 10 and 44 items in length. One study
did not report the number of items used (Dominguez, Dunkel-
Schetter, Glynn, Hobel, & Sandman, 2008).
A number of different instruments were used as exposure
measures. The two most common instruments used (in ve studies
each) were the Everyday Discrimination Scale (EDS) (Clark,
Coleman, & Novak, 2004;Williams, Yu, Jackson, & Anderson,
1997) and the Experiences of Discrimination (EOD) scale (Krieger,
1990;Krieger, Smith, Naishadham, Hartman, & Barbeau, 2005).
The next most commonly used scales were the Adolescent
Discrimination Distress Index (ADDI) (Fisher, Wallace, & Fenton,
2000), and the Racism and Life Experiences Scale (RaLES)
(Harrell, Merchant, & Young, 1997), each used four times. The
Schedule of Racist Events (SRE) (Landrine & Klonoff, 1996) was used
in three studies. The EDS and EOD have shown good internal reli-
ability and construct validity (Bastos, Celeste, Faerstein, & Barros,
2010) while the EDS has also performed well in cognitive testing
(Reeve et al., 2011). The ADDI has shown poor internal consistency
and efforts towards content validation have not been reported,
while psychometric testing on the RaLES has not been published in
a peer-reviewed journal (Bastos et al., 2010). According to Bastos
et al. (2010) other utilised exposure measures that have been
psychometrically validated include the Asian American Racism-
Related Stress Inventory (AARSI) (Liang, Li, & Kim, 2004), the
Index of Race-Related Stress (IRRS) (Utsey, 1999) and the Perceived
Table 1
Characteristics of 121 empirical quantitative studies of reported racial discrimina-
tion and child and youth health.
Number of studies % of total studies
First year of publication
1990e1994 2 2
1995e1999 8 7
2000e2004 30 25
2005e2009 53 44
2011e28 23
Study design
Case-control 3 2
Cross-sectional 94 78
Longitudinal 24 20
Sampling procedure
Convenience 100 83
Population/representative 21 17
Sample size
n<100 4 3
100 n<200 32 26
200 n1000 62 51
n1000 23 19
Region of study
a
Australia/New Zealand 5 4
South America 2 2
Canada 7 6
Europe/UK 22 18
Israel 2 2
US 86 71
Study population characteristics
Age group
2
Newborns/infants (0e2 years) 13 11
Preschool (3e5 years) 5 4
Primary school (6e11 years) 46 38
High school (12e18 years) 103 85
Ethnic/racial group
2b
White 28 23
Latino/a 35 29
African American 49 40
Asian
c
30 25
Indigenous 11 9
African 11 9
Bi/multiracial 16 13
Other 13 11
Refugee/immigrant status
Refugees 3 3
Immigrants 46 38
Religion
1
Christian 7 6
Muslim 4 3
Other
d
54
Place of residence
2
Urban 93 77
Rural 20 17
Remote 8 7
Exposure time frame
1
None 78 64
Past year or less 25 21
>1year 5 years 1 1
Lifetime 9 7
Type of discrimination
2
Direct 117 97
Group 18 15
Vicarious 10 8
Informant group
2
Carer self report 21 17
Child/Youth self report 104 86
No. of items in measure
9 items 69 57
10 items 51 42
NR 1 1
Percentages may not add to 100% due to rounding.
1
Categories in this section are not complete.
2
Categories are not mutually exclusive in relation to the unit of analysis (i.e. studies).
a
Regions in only one study: Barbados and Turkey.
b
Racial/ethnic backgrounds included in <10 studies: Caribbean/West Indies (9),
Turkish (8), Eastern European (8), Arab/Middle Eastern (5), Greek/Italian (3), and Pacic(3).
c
Includes South Asian, East Asian and other Asian.
d
Other: Mormon, Protestant, Native American Church, Buddhist, Jewish, Atheist.
N. Priest et al. / Social Science & Medicine 95 (2013) 115e127118
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Racism Scale (McNeilly, Anderson, Armstead, et al., 1996,McNeilly,
Anderson, Robinson, et al., 1996).
In 79 studies, scales were developed specically for the study, or
inclusion of items from other studies that did not appear to be
standard scales, was reported. Where standard scales were used,
these were modied in 14 studies. Almost two-thirds of studies
(61% n¼74) included in this review reported the internal consis-
tency of the racial discrimination exposure scale developed
specically for the study, 67 (55%) of which were 0.70, though far
fewer studies (8% n¼10) described use of factor analysis to
examine measure structure.
Studies in this review predominantly examined reported expe-
riences of interpersonal racial discrimination with only a handful of
studies (4% n¼5) specically indicating that they were measuring
racial discrimination due to systemic racism. One study explicitly
examined internalised racism (Chambers et al., 2004). Studies
examined interpersonal racism in schools, at work and in
employment processes, in the neighbourhood or community, in
shops and shopping centres, in restaurants, in housing, in dealings
with police and the criminal justice system, in businesses and
banks, on public transport and in public. However, insufcient and
inconsistent reporting of settings limits detailed synthesis of this
information. Similarly, limited data was reported regarding
perpetrators of racial discrimination, although where reported this
included adults and peers, teachers, medical staff, police, commu-
nity members, security guards, restaurant staff, shop owners and
general members of the public.
Most studies included measures examining direct experiences
of racial discrimination (97% n¼117) while 18 studies (15%)
included measures that specically assessed reported racial
discrimination for a respondents entire ethnic/racial group and 10
studies (8%) included measures of vicarious racial discrimination
(i.e. reports on othersexperiences of racial discrimination).
Studies predominantly utilised child/youth self-reports of racial
discrimination (86% n¼104), with fewer including carer reports
of racial discrimination (17% n¼21). No studies included carer
proxy reports specically for children or young people (i.e. carer
assessment of vicarious racial discrimination). Of the 21 studies
reporting child/youth health outcomes associated with carer
reports of racial discrimination, 16 were carer report only, 4 both
carer and child/youth self report, and one both primary carer and
main householder reported racial discrimination. Of the carer
report measures, 15 captured carer direct experience of racial
discrimination only (11 of which were with pregnant women and
examining effects of racial discrimination on birth outcomes), two
measured carer direct and vicarious racial discrimination
combined (i.e. for you and your family/household) while two
others used separate items for carer direct experience and carer
vicarious report for a member of your family (Gibbons, Gerrard,
Cleveland, Wills, & Brody, 2004) or other African Americans
(Caughy, OCampo, & Muntaner, 2004). In Stevens, Vollebergh,
Pels, and Crijnen (2005) the carer measure was report of group
experience only (do you feel Moroccans are discriminated
against?) while Kelly et al. (in press) included carer direct and
report of racial discrimination in residential area. Six studies re-
ported child/youth health outcomes associated with exposure
measures that included discrimination due to religion, ve of
which included religion in the same item as discrimination due to
race, ethnicity or culture. Four used general terms (e.g. discrimi-
nation because of your ethnicity, religion or colour?) and one used
aspecic combination of religion, ethnicity and acculturation
strategy (e.g. discrimination due to being Muslim, Somali, and
maintaining Somali culture). One study reported associations with
discrimination due to religion, but did not report participant
religious background.
Only 43 studies (36%) included a timeframe associated with
exposure measurement. Of these, 25 studies measured exposure in
the past year, one study measured exposure in the last ve years
and nine studies measured reported racial discrimination over
a lifetime. Other timeframes for exposure included during school
years, immigration or pregnancy.
Associations between reported racial discrimination and child
health-related outcomes
Table 2 shows the associations found between reported racial
discrimination and child health-related outcomes in the 121
studies included in this review. These outcomes are grouped in
broad categories and are shown alongside information on the
nature of the associations between these outcomes and self-
reported racial discrimination.
Overall, the 121 included studies included 461 reported health-
related outcomes. Of these, 46% of examined outcomes were
negatively associated with reported racial discrimination, 18% were
positive, and 3% were conditional. Mental health outcomes were the
most commonly reported health-related outcome, with 51% of all
health-related outcomes related to mental health. The most
consistent association between reported racial discrimination and
health was for negative mental health outcomes (e.g. anxiety,
depression and negative self esteem), for which 76% of examined
outcomes were signicantly associated with reported racial
discrimination in a positive direction (i.e. reported racial discrimi-
nation associated with worse mental health outcomes). For positive
mental health outcomes (e.g. resilience, self-worth, self-esteem,
psychological adaption, psychological adjustment, social and adap-
tive functioning) 62% of examined outcomes were signicantly
associated with reported racial discrimination in a negative direc-
tion. Behaviour problems/delinquent behaviours (e.g. aggression,
internalising, externalising and conduct problems) were also
commonly studied, with statistically signicant positive associa-
tions found in 69% of examined outcomes and no association found
in the remaining examined outcomes. Health-related behaviours
(i.e. alcohol use, drug use and smoking) were examined in 74
outcomes, of which 51% found a signicant positive associationwith
reported racial discrimination. Wellbeing/life satisfaction/quality of
life outcomes were also examined across 22 outcomes, with 45%
negatively associated with reported racial discrimination and 50%
unrelated. About 79% of negative pregnancy/birth outcomes exam-
ined were positively associated with reported racial discrimination.
Fifteen of examined outcomes were related to physical health (e.g.
blood pressure, childhood illnesses), of which 67% showed no
signicant association with reported racial discrimination.
Associations between study/exposure characteristics and
health-related outcomes
The statistical signicance (at the p<0.05 level) of associations
between reported racial discrimination and health outcomes also
varied by exposure characteristics (Table 3). The highest proportion
of signicant associations occurred in studies published between
2000 and 2004, located in rural areas or including Latino/a, Eastern
European or Turkish participants. Studies with exposure instru-
ments of 10 or more items had slightly more signicant associa-
tions (67%) than studies with exposure instruments with 9 or less
items (62%). Of studies measuring racial discrimination within rural
locations, 68% of associations examined were signicant, compared
with 60% for remote locations and 66% for urban locations. Studies
examining reported racial discrimination among only preschool-
aged children reported 37% signicant associations, compared
with between 60% and 65% for newborns, primary and high school
N. Priest et al. / Social Science & Medicine 95 (2013) 115e127 119
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Table 2
Findings of 121 empirical quantitative studies of reported racial discrimination and health (P<0.05 unless otherwise indicated).
a
Positive Negative Conditional Unrelated Total
Negative mental health 96 76% 4 3% 27 21% 127
Anxiety 7 64% 4 36% 11
Depression 57 79% 4 6% 11 15% 72
Depression/anxiety 1 100% 1
Distress 3 60% 2 40% 5
Hopelessness 3 60% 2 40% 5
Loneliness 2 100% 2
Mental health problems 2 100% 2
Negative self esteem 1 100% 1
Post-traumatic stress 1 100% 1
Psychological distress 1 100% 1
Social and emotional difculties 7 64% 4 36% 11
Somatic symptoms 1 100% 1
Stress 7 100% 7
Suicide 4 57% 3 43% 7
Positive mental health 2 2% 67 62% 7 6% 32 30% 108
Emotional adjustment 1 100% 1
Psychological adaptation 1 100% 1
Psychological adjustment 1 100% 1
Resilience 1 50% 1 50% 2
Self esteem 2 2% 58 62% 7 8% 26 28% 93
Self-worth 2 50% 2 50% 4
Social and adaptive Functioning 4 67% 2 33% 6
Physical health 3 20% 2 13% 10 67% 15
Blood pressure 2 40% 3 60% 5
Childhood illnesses 1 100% 1
Common childhood illnesses 1 100% 1
Insulin resistance 1 100% 1
Obesity 5 100% 5
Physical symptoms 1 50% 1 50% 2
General health 2 100% 2
Health problems 2 100% 2
Negative general health 3 100% 3
Feeling unhappy 1 100% 1
Feeling unhealthy 1 100% 1
Health problems 1 100% 1
Positive general health 1 100% 1
Self-rated health 1 100% 1
Wellbeing/life satis/QoL
1
10 45% 1 5% 11 50% 22
General health and wellbeing 1 100% 1
HrQoL
2
1 100% 1
Life satisfaction 3 38% 1 13% 4 50% 8
Wellbeing 5 42% 7 58% 12
Negative pregnancy/birth 11 79% 3 21% 14
LBW
3
4 80% 1 20% 5
Preterm birth 6 86% 1 14% 7
Preterm birth/LBW 1 100% 1
VLBW
4
1 100% 1
Positive pregnancy/birth 2 33% 4 67% 6
Birth Weight 2 67% 1 33% 3
Gestational age 2 100% 2
Weight for gestational age 1 100% 1
Behaviour problems/delinquent behaviour 58 69% 26 31% 84
ADHD
5
1 100% 1
Aggression 5 83% 1 17% 6
Behaviour problems 15 94% 1 6% 16
Conduct problems 3 100% 3
Delinquent behaviour 4 67% 2 33% 6
Deviance 1 100% 1
Emotional and behavioural problems 1 100% 1
Emotional problems 1 100% 1
Externalising 8 62% 5 38% 13
Internalising 20 57% 15 43% 35
Problem behaviour 1 100% 1
Health related behaviours 38 51% 3 4% 1 1% 32 43% 74
Alcohol 9 60% 6 40% 15
Drug use 20 49% 1 2% 20 49% 41
Smoking 9 50% 2 11% 1 6% 6 33% 18
Healthcare utilisation 1 20% 1 20% 3 60% 5
Access and cost of healthcare 2 100% 2
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aged children. Relatively consistent patterns of associations were
identied between reported racial discrimination and health-
related outcomes across age groups (Table 4). However, a higher
proportion of negative mental health associations were non-
signicant among preschoolers compared to older children and
young people while a greater proportion of physical health asso-
ciations were signicant for newborns compared to older children.
Mediation of the associations between reported racial
discrimination and health-related outcomes
A number of mediators were also identied. While many
mediators identied in the included studies could also plausibly be
moderators, we have retained the terminology used by study
authors. The association between youth reported racial discrimi-
nation and substance use was mediated by anger (Gibbons et al.,
Table 2 (continued )
Positive Negative Conditional Unrelated Total
Dissatisfaction with healthcare 1 100% 1
Healthcare utilisation and compliance 1 100% 1
Patient satisfaction 1 100% 1
Total 212 46% 84 18% 15 3% 150 33% 461
1
QoL ¼Quality of Life.
2
HrQoL ¼Health-related Quality of Life.
3
LBW ¼Low Birth Weight.
4
VLBW ¼Very Low Birth Weight.
5
ADHD ¼Attention Decit Hyperactivity Disorder.
a
% of associations between that health outcome and measures of reported racial discrimination in a particular direction.
Table 3
Signicance of associations examined in 121 empirical quantitative studies of re-
ported racial discrimination and child and youth health (P<0.05).
Total number
signicant
associations
Total number
associations
examined
% of total
associations
signicant
Year
1990e1994 3 5 60%
1995e1999 24 33 73%
2000e2004 78 103 76%
2005e2009 124 198 63%
2011e67 122 55%
Study design
Cross sectional 216 340 64%
Longitudinal 76 115 66%
Sample size
9 items 142 230 62%
10 items 153 230 67%
NR 1 1 100%
Sample size
n<100 5 12 42%
100 n<200 70 118 59%
200 n<1000 163 245 67%
n1000 58 86 67%
Sampling procedure
Convenience 249 385 65%
Population/representative 47 76 62%
Location
Remote 31 52 60%
Rural 62 91 68%
Urban 245 371 66%
Region of study
USA 225 345 65%
Other 71 116 61%
Age
Newborns 14 23 61%
Preschool 7 19 37%
Primary 122 202 60%
High 268 413 65%
Racial/ethnic BACKGROUND
African 21 42 50%
African American 138 225 61%
Arab/Middle East 9 17 53%
Asian
1
65 118 55%
Bi/multiracial 31 50 62%
Caribbean/West Indies 39 77 51%
Eastern European 14 20 70%
Greek/Italian 13 27 48%
Indigenous 41 65 63%
Latino/a 93 132 70%
Pacic 10 21 48%
Turkey 17 21 81%
White 67 110 61%
Other 269 412 65%
1
Includes South Asian, East Asian and other Asian.
Table 4
Findings of 121 empirical quantitative studies of reported racial discrimination and
health by age group (P<0.05 unless otherwise indicated).
a,b,c
Positive Negative Conditional Unrelated Total
Negative mental health
Preschool (3e5 years) 3 43% 4 57% 7
Primary (6e11 years) 30 70% 2 5% 11 26% 43
High (12e18 years) 87 76% 4 4% 23 20% 114
Positive mental health
Primary (6e11 years) 2 4% 27 53% 4 8% 18 35% 51
High (12e18 years) 2 2% 66 63% 7 7% 30 29% 105
Physical health
Newborns/infants (0e2 years) 1 50% 1 50% 2
Preschool (3e5 years) 1 14% 6 86% 7
Primary (6e11 years) 1 20% 2 40% 2 40% 5
High (12e18 years) 2 25% 2 25% 4 50% 8
General health
Primary (6e11 years) 2 100% 2
High (12e18 years) 2 100% 2
Negative general health
Primary (6e11 years) 3 100% 3
High (12e18 years) 3 100% 3
Positive general health
High (12e18 years) 1 100% 1
Wellbeing/life satis/QoL
Primary (6e11 years) 5 45% 6 55% 11
High (12e18 years) 10 45% 1 5% 11 50% 22
Negative pregnancy/birth
Newborns/infants (0e2 years) 11 79% 3 21% 14
positive pregnancy/birth
Newborns/infants (0e2 years) 2 33% 4 67% 6
Behaviour problems/delinquent behaviour
Preschool (3e5 years) 1 100% 1
Primary (6e11 years) 37 69% 17 31% 54
High (12e18 years) 54 68% 26 33% 80
Health related behaviours
Primary (6e11 years) 15 52% 14 48% 29
High (12e18 years) 38 51% 3 4% 1 1% 32 43% 74
Healthcare utilisation
Newborns/infants (0e2 years) 1 100% 1
Preschool (3e5 years) 1 25% 1 25% 2 50% 4
Primary (6e11 years) 1 25% 1 25% 2 50% 4
High (12e18 years) 1 25% 1 25% 2 50% 4
a
% of associations between that health outcome and measures of reported
discrimination in a particular direction.
b
Not all outcomes were explored in all age groups.
c
Refer to Table 2 for total associations across all age levels.
N. Priest et al. / Social Science & Medicine 95 (2013) 115e127 121
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2010) by anger and delinquent behaviour (Whitbeck, Hoyt,
McMorris, Chen, & Stubben, 2001) and by anger and delinquent
peers (Cheadle & Whitbeck, 2011). Distress, friendssubstance use
and young peoples risk cognitions (including willingness to try
drugs) were also found to mediate the association between racial
discrimination and substance use while supportive parenting was
an attenuating mediator, associated with less willingness and
intention to use substances (Gibbons et al., 2010,2004,2007). Post-
traumatic stress was also found to mediate the relationship
between racial discrimination and alcohol use (Flores, Tschann,
Dimas, Pasch, & de Groat, 2010).
The relationship between racial discrimination and depression
was mediated via intergroup competence (Phinney, Madden, &
Santos, 1998). Mediators of the relationship between racial
discrimination and self-esteem were ethnic identity (Castro, 2005;
Romero & Roberts, 2003), ethnic afrmation and exploration
(Romero & Roberts, 2003), internalising problems (Smokowski &
Bacallao, 2007;Smokowski, Bacallao, & Buchanan, 2009,
Smokowski, Rose, & Bacallao, 2010), stress (DuBois, Burk-Braxton,
Swenson, Tevendale, & Hardesty, 2002) interethnic contact and
attitudes (Castro, 2005) as well as familism and prosocial friends for
those with ethnic identity and biculturalism (Smokowski &
Bacallao, 2007). Liebkind, Jasinskaja-Lahti, and Solheim (2004)
found the effect of racial discrimination on self-esteem was medi-
ated by reduced ethnic identity and that such identity was associ-
ated with increased sense of mastery that in turn increased self-
esteem. Cassidy, OConnor, Howe, and Warden (2004) reported
self-esteem (personal and ethnic self esteem, or how individuals
evaluate the ethnic group with which they identify) as a mediator
between racial discrimination and anxiety and that ethnic self-
esteem mediated the relationship between racial discrimination
and depression. Ethnic self esteem also mediated the relationship
between racial discrimination and global self worth in other
research (Verkuyten, 2003;Verkuyten & Thijs, 2006). Self-esteem
also mediated the relationship between racial discrimination and
psychological adjustment (Jasinskaja-Lahti & Liebkind, 2001). The
relationship between racial discrimination and depression was
mediated by discriminatory victimisation and cultural orientation
(Deng, Kim, Vaughan, & Li, 2010;Kim-Bae, 2000) and by perceived
threat (Hunter, Durkin, Heim, Howe, & Bergin, 2010) while
perceived social support mediated the association between racial
discrimination and externalising symptoms (Nair, 2008).
Carer related factors were also identied as mediators, with
carer negative affect and carer drug problems mediating relation-
ships between carer reported racial discrimination and common
childhood illnesses (Priest et al., 2010), while parental distress
mediated between parent reported racial discrimination and
substance use in 12e13 year olds (Gibbons et al., 2004). Parente
adolescent conict mediated the association between reported
racial discrimination and internalising problems (Smokowski &
Bacallao, 2007;Smokowski et al., 2009,2010).
Effect modication of the association between reported racial
discrimination and health-related outcomes
The associations between reported racial discrimination and
health-related outcomes examined in this review were modied by
a number of factors, which either intensied or attenuated the
association between reported racial discrimination and health.
Details of signicant interaction terms and the relationships they
modied are provided in Table 5. Moderators included: individual
level factors such as age, gender, cognitive development; coping
responses to racial discrimination such as anger, talking to
someone, accepting it; social support such as friends, community
support; parenting quality and frequency and type of racial
socialisation messages; and ethnic group orientation and cultural
identication factors. In addition, ethnicity was reported as
a signicant interaction term in several studies with associations
between racial discrimination and health varying in magnitude for
different ethnic and racial groups (Di Cosmo et al., 2011;Greene,
Way, & Pahl, 2006;Verkuyten, 2003).
Discussion
This review reveals a growing body of literature on the rela-
tionship between reported racial discrimination and the health and
wellbeing of children and young people, with well over half of
included studies published in the last seven years. It provides
compelling evidence for acknowledging and addressing racial
discrimination as a key determinant of health for children and
young people by documenting strong and consistent relationships
between reported racial discrimination and a range of detrimental
health outcomes across various age groups, racial/ethnic back-
grounds and settings.
Patterns of association between racial discrimination and child and
youth health
The patterns in the relationship between racial discrimination
and health for children and young people parallel ndings from the
broader racial discrimination and health literature (Paradies, 2006b;
Pascoe & Smart Richman, 2009;Williams & Mohammed, 2009). This
review reveals a strongand consistent positive relationship between
racial discrimination and negative mental health outcomes such as
anxiety, depression and psychological distress, and birth-related
outcomes such as preterm birth and low birth weight, as well as
a strong and consistent negative relationship between racial
discrimination and positive mental health outcomes, such as self-
esteem, self-worth and psychological adaptation and adjustment.
Weaker relationships existed for physical health outcomes together
with mixed or relatively weak associations for other examined
outcomes. A novel nding emerging from this review was an asso-
ciation between racial discrimination and behaviour problems
including delinquent behaviours, that was as strong and consistent
as the association with negative mental health outcomes. The
varying strength of associations between racial discrimination and
physical and mental health and problem behaviours may reect
different causal pathways and processes, with psychological and
behavioural outcomes likely to be more proximally related to racial
discrimination than physical health. In particular, weaker associa-
tions between racial discrimination and physical health outcomes
for children and young people likely reect delayed onset between
racial discrimination exposure and outcomes such as blood pressure,
obesity and other chronic illnesses, which often become evident
long after damaging exposure occurs (Barker, Eriksson, Forsén, &
Osmond, 2002;Ben-Schlomo & Kuh, 2002;Williams &
Mohammed, 2009;Worthman & Panter-Brick, 2008). Use of more
sensitive measures suchas biomarkers of allostatic load and chronic
disease in childhood and adolescence (e.g. salivary cortisol, inam-
matory markers) is recommended to explore further these effects
across the life-course (Sanders-Phillips et al., 2009;Worthman &
Panter-Brick, 2008). Similarly, problem behaviours such as alcohol
and drug use are uncommon in adolescents under16 years and there
is likely to be considerable time lag between racial discrimination
exposure in childhood and the onset of such behaviours. Thus, the
negative effects of racial discrimination in younger children on
problem behaviours may be underestimated in current studies due
to inadequate length of follow up, although further investigation is
required as insufcient evidence is currently available to reject or
support this hypothesis. Understanding the complex causal
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Table 5
Signicant effect modiers of associations between reported racism (i.e. racial discrimination) and child and youth health outcomes.
Exposure Modier Outcome
Attenuated Intensied
Youth reported racism
from peers in school
Adolescent low Anglo orientation for boys
Maternal high Anglo orientation and
high familism for girls
Externalising behaviour
(Delgado et al., 2011)
Youth reported racism
from peers in school
Adolescent low Anglo orientation for boys Problem behaviours
Youth reported racism Performing well academically Conduct problems (Brody et al., 2006)
Depression (Brody et al., 2006)
Youth reported racism Low in trait anger Systolic BP & Diastolic BP (Clark, 2006)
Youth reported racism Accepting itBP status (Clark & Gochett, 2006)
Youth reported racism Talking to SomeoneBP status (Clark & Gochett, 2006)
Youth reported racism High religious coping Externalising problems (Ahmed, 2007)
Youth reported racism High majority cultural identication for boys
High American Indian identication for girls
Delinquent behaviours
Drug use problems (Jones, 2009)
Youth reported racism High ethnic identity Externalising problems
Youth reported racism Males Conduct problems (Brody et al., 2006)
Youth reported racism Males Drug use
Self esteem (Zubrick et al., 2005)
Youth reported racism High gender discrimination Depression (Cogburn et al., 2011)
Youth reported racism Nurturant parenting Conduct problems
Depression (Brody et al., 2006)
Youth reported racism Supportive parenting Substance use (Gibbons 2010)
Youth reported racism Supportive parenting Violent Delinquency (Simons et al., 2006)
Youth reported racism High public regard Depressive symptoms/perceived
stress (Sellers et al., 2006)
Youth reported racism High positive racial socialisation messages Depression and problem behaviour
(Neblett et al., 2008)
Youth reported racism Moderate negative racial socialisation Problem behaviour (Neblett et al., 2008)
Youth reported racism Absence of preparation for bias Self esteem (Harris-Britt et al., 2007)
Youth reported racism Presence of race pride socialisation Self esteem (Harris-Britt et al., 2007)
Youth reported racism High family support Externalising problems (Ahmed, 2007)
Youth reported racism Low community support for rst
generation youth
Internalising problems (Ahmed, 2007)
Youth reported racism Prosocial friends Conduct problems
Depression (Brody et al., 2006)
Youth reported racism Genetic status (carrying one or two
copies of the short
allele variant of 5-HTTLPR compared with those
carrying two copies of the long allele variant)
Conduct problems
Gender (Brody et al., 2011)
Youth reported racism Family conict Loneliness
Anxiety (Juang & Alvarez, 2010)
Youth reported racism Family cohesion Loneliness
Anxiety (Juang & Alvarez, 2010)
Youth reported peer
discrimination
High maladaptive coping Self esteem (Chatman, 2007)
Youth reported individual
level racism
Being alienated (low racial centrality, low private
regard and low public regard)
Depressive symptoms
(E. K. Seaton, 2009)
Youth reported
discrimination distress
High in communalistic coping Anxiety (Gaylord-Harden
& Cunningham, 2009)
Youth reported
collective/institutional
racism
Pre-formal reasoning Self esteem (Seaton 2010)
Youth reported
collective/institutional
racism
Low school/neighbourhood diversity Life satisfaction (Eleanor
K. Seaton & Yip, 2009)
Youth perceived racism Low white American identication Substance use (Galliher et al., 2011)
Youth perceived racism Multiracial youth compared to Asian or
African Americans
Substance use (Choi et al., 2006)
Youth perceived racism Increased connection to ethnic group Problem behaviour (Wong et al., 2003)
Maternal report of racism John HeNRyism Preterm delivery (Mustillo, 2002)
Maternal report of racism Perceived adequate social networks Low birth weight (Mustillo, 2002)
Maternal report of lifetime
and past year racism
Getting violent Preterm/LBW (Rankin et al., 2011)
Maternal report of lifetime
and past year racism
Active coping Preterm/LBW (Rankin et al., 2011)
Maternal perceived racism No more than 12 years education Preterm birth (Rosenberg et al., 2002)
Lifetime experiences
of racism
Stress and prenatal depression Preterm birth risk (Misra et al., 2010)
Fathersreports of
workplace racism
Less acculturated family context Depression (Crouter et al., 2006)
The reference citations in Table 5 are listed in Supplementary data.
N. Priest et al. / Social Science & Medicine 95 (2013) 115e127 123
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pathways between racial discrimination and health outcomes is also
important in this context, given evidence that stress and poor
mental health can lead to poor physical health outcomes and
problem health behaviours such as alcohol and drug use, and vice
versa (Sanders-Phillips, 2009;Sanders-Phillips et al., 2009). It is also
plausible that poor physical/mental health and behavioural dif-
culties inuence experiences and perceptions of racial discrimina-
tion. This further reinforces the need for longitudinal studies to
determine direction of associationsand causality, although evidence
from longitudinal studies in adult populations suggests that racial
discrimination does precede ill-health (Paradies, 2006a,2006b;
Pascoe & Smart Richman, 2009;Williams & Mohammed, 2009).
While most studies included in this review show racial
discrimination negatively impacts mental and physical health
outcomes, some report ndings in the opposite direction. The most
plausible explanation for these results is some form of study bias,
whether related to measurement error, selection bias, unmeasured
or unaccounted for confounders, moderators or mediators, and/or
analytic errors (Kirkwood & Sterne, 2003).
A range of mediators of the association between racial
discrimination and various health-outcomes were also docu-
mented in this review, including: emotions such as anger, perceived
threat, negative affect and (di)stress; individual factors related to
cognition and behaviour as well as identity, cultural orientation,
competence and self-esteem; and interpersonal factors relating to
conict, social support, peer and interethnic relations. These
mediating factors are broadly similar to those noted in studies
examining racial discrimination and health among adults.
A similar diversity of constructs was noted as effect modiers in
this review. Supporting the conceptual model developed by
Sanders-Phillips (2009),ndings relating to moderation indicate
that positive parenting and socialisation as well as social support
and ethnic attachment may be effective in ameliorating the detri-
mental effects of racial discrimination. Conversely, some forms of
cultural orientation, identication and acculturation appear to
intensify the ill-effects of racial discrimination.
The proportion of statistically signicant associations between
reported racial discrimination and health-related outcomes varied
considerably between racial/ethnic groups but no clear patterns
emerged. As noted in a previous review, the consistency of asso-
ciations between racial discrimination and health for White
participants is comparable with other ethnic/racial groups
(Paradies, 2006b). However, this review conrms the over-
whelming evidence that minority groups report more racial
discrimination than White people.
Location and populations of studies
As noted in previous reviews (Pachter & Garcia Coll, 2009;
Sanders-Phillips, 2009), the literature on racial discrimination and
child health is dominated by studies conducted in US urban contexts
with adolescent children. Although previous reviews have noted
a predominance of studies involving African Americans (Pachter &
Garcia Coll, 2009), this systematic review reveals a considerable
proportion of studies also focussing on Latino/a and Asian (including
East Asian, South Asian and other Asian populations).
Denition and measurement of racial discrimination
With only a third of studies explicitly dening racial discrimi-
nation, this review highlights a lack of attention to the con-
ceptualisation of racism and racial discrimination both as
a determinant of health (Paradies, 2006a)and as a more general
phenomenon (Berman & Paradies, 2010). In particular, there was
little recognition of racism and racial discrimination as an ideology
of both inferiority and superiority (including White privilege).
Consistent with discussions in recent literature (Dunn et al., 2007;
Hartmann et al., 2011) in this review where studies did consider
the health effects of discrimination due to religion, they predomi-
nantly did so in the same measure as racial discrimination and
therefore considered them conceptually equivalent. Further
exploration of these concepts and the health effects of religious-
and racial discrimination, as well as other forms of discrimination,
such as gender, age, physical appearance, is an important area for
future work.
Racial discrimination was assessed using a wide variety of
instruments within studies included in this review. Most instru-
ments that were developed were only utilised in one study with the
most popular two scales used in only ve studies each. As a result,
there remains a lack of convergence in relation to racial discrimi-
nation exposure assessment within this body of literature. While
a number of instruments were checked for internal consistency (i.e.
Cronbachs alpha), only a few scales were examined using factor
analysis or cognitive testing, item response theory, extreme groups
comparison, convergent/discriminant validity or testeretest reli-
ability. Furthermore, as many of the instruments were originally
designed for adults, it is unclear how effectively or comprehen-
sively they tap into experiences relevant to children and young
people (Pachter & Garcia Coll, 2009;Pachter, Szalacha, Bernstein, &
Garcia Coll, 2010).
Debate continues regarding the aetiologically relevant time
period for reported racial discrimination as it relates to various
health outcomes. Specifying the timeframes of exposure measure-
ment may help elucidate such aetiology, including consideration of
lag times between exposure to racial discrimination and ill-health
(Williams & Mohammed, 2009). It would also allow time-series
analysis in longitudinal cohort or repeated cross-sectional studies
(Paradies, 2006b;Williams & Mohammed, 2009). However, less
than a third of studies in this review included a timeframe associ-
ated with exposure measurement.
Although assessment of setting-based exposure to interpersonal
racial discrimination was common, comprehensive reporting of
this information was neglected. There was also limited focus on
perpetrators of racial discrimination and insufcient consideration
of vicarious racial discrimination as a determinant of health for
children and young people. Further exploration is needed of the
differential effects of racial discrimination experienced by care-
givers, family and peers, compared to experiences of racial
discrimination by children and young people themselves. Greater
clarity of measurement across levels of racial discrimination is also
required, with institutional racial discrimination explicitly assessed
by few included studies and internalised racial discrimination as
a determinant of health examined by only one (Chambers et al.,
2004). Only a handful of studies explicitly assessed systemic
forms of racial discrimination, despite long-standing recognition of
these phenomena as two of the three levels of racism experienced
(Lipsky, 1978;Williams, 1985).
The scant existing literature on the linearity of the relationship
between racial discrimination and ill-health (i.e. (curvi)linear
doseeresponse relationship) (Paradies, 2006b) warrants further
investigation in relation to child and youth health and wellbeing.
Similarly, inconsistencies in the reporting of racial discrimination in
studies involving adults (Hausmann, Kressin, Hanusa, & Ibrahim,
2010) suggest that further attention to the interplay between
carer proxy-reports and child/youth self-reports of racial discrim-
ination may add to our methodological understanding of racial
discrimination.
There were relatively fewvariations in the associations between
study/exposure characteristics and health-related outcomes. It is
notable that longitudinal studies had the same proportion of
N. Priest et al. / Social Science & Medicine 95 (2013) 115e127124
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statistically signicant associations between racial discrimination
and health as cross-sectional studies, suggesting that racial
discrimination leads to ill-health rather than vice versa. The nd-
ings also indicate that studies with larger sample sizes were much
more likely to demonstrate statistically signicant associations
while the use of convenience sampling does not appear to affect the
proportion of statistically signicant associations.
Supplementary video related to this article can be found at
http://dx.doi.org/10.1016/j.socscimed.2012.11.031.
Child age and study ndings
Although the small number of studies involving preschool
children precludes any rm conclusions, there are a number of
plausible reasons for the much lower proportion of statistically
signicant associations amongst studies involving this age group.
Although strong associations between racial discrimination and
birth-related outcomes were evident, the association between
racial discrimination and mental health in particular may not have
accumulated by this age. It is also possible that carers are able to
effectively buffer children of this age from the detrimental effects of
racial discrimination. Alternatively, these nding may reect
additional challenges involved in valid and reliablemeasurement of
racial discrimination among very young children. Few studies in
this review engaged with the developmental challenges particular
to the study of racial discrimination and health among children.
Such challenges depend on a range of cognitive, situational and
individual variables including classication skills, social compari-
sons and moral reasoning as well as aspects of awareness, identity,
stereotypes and attitudes (Brown & Bigler, 2005).
In addition to the lacunae identied above, the study of racial
discrimination and health among children and young people would
benet from a more explicit and sophisticated consideration of the
contribution of racial discrimination to ethnic/racial disparities in
health. This would require a relatively greater focus on between as
well as within group differences in studies that investigate racial
discrimination in concert with a range of other social factors that
either facilitate or compromise health and wellbeing.
Limitations
Our search strategy included only electronic databases that
mainly contain English language articles. The fact that this review
relies so heavily upon articles written in English, can be considered
as a source of bias. There is also potential for null or negative
ndings to be under-represented due to publication bias, since
researchers and academic journals have traditionally minimised
the importance of these ndings (Quintana & Minami, 2006). The
inclusion of theses and non-peer reviewed sources in this review
sought to minimise this bias. While a meta-analysis was not
possible due to signicant heterogeneity among studies, further
scholarship may be able to utilise meta-analysis to examine the
effects of racial discrimination on a range of specic health and
wellbeing outcomes (e.g. depression) for which greater homoge-
neity is likely.
Conclusions
The data synthesised in this review provides strong evidence for
racial discrimination as a critical determinant of child and youth
health and wellbeing, demonstrating the detrimental effects of
racial discrimination on child and youth health outcomes across age
groups, racial/ethnic groups, study locations and methods. In order
to build understanding of pathways by which racial discrimination
inuences health and wellbeing outcomes and to inform
development of effective evidence based strategies for ameliorating
its harmful effects, there is a need for high-quality longitudinal
research in this eld using robust multidimensional measures of
racial discrimination as well as examination of potential moderators
and mediators.
Acknowledgements
We would like to thank Dr Belinda Burford, Cochrane Health
Review Group, for advice on the review, protocol; Hannah Reich,
Zachary Russell, and Alison Baker for research assistance; and Don
Priest for, support with data analysis. Naomi Priest was supported
by an NHMRC postdoctoral training fellowship, (#628897) and by
the Victorian Health Promotion Foundation during the preparation
of this manuscript.
Appendix A. Supplementary data
Supplementary data related to this article can be found at http://
dx.doi.org/10.1016/j.socscimed.2012.11.031.
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