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Health Disparities due to Diminished Return among Black Americans: Public Policy Solutions

January 2018
Social Issues and Policy Review 12(1):112-145

DOI:10.1111/sipr.12042

Authors:

Charles R. Drew University of Medicine and Science

There are persistent and pervasive disparities in the health of Black people compared to non-Hispanic Whites in the United States. There are many reasons for this gap; this article explores the role of “Blacks’ diminished gain” as a mechanism behind racial health disparities. Diminished gain is a phenomenon wherein the health effects of certain socioeconomic resources and psychological assets are systematically smaller for Blacks compared to Whites. These patterns are robust, with similar findings across different resources, assets, outcomes, settings, cohorts, and age groups. However, the role of diminished gain as a main contributing mechanism to racial health disparities has been historically overlooked. This article reviews the research literature on diminished gain and discusses possible causes for it, such as the societal barriers created by structural racism. Policy solutions that may reduce Blacks’ diminished gain are discussed.

Differential Effects of Psychosocial Factors on Health of Blacks than Whites

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Social Issues and Policy Review, Vol. 12, No. 1, 2018, pp. 112--145

Health Disparities due to Diminished Return among

Black Americans: Public Policy Solutions

Shervin Assari∗

University of Michigan

There are persistent and pervasive disparities in the health of Black people com-

pared to non-Hispanic Whites in the United States. There are many reasons for

this gap; this article explores the role of “Blacks’ diminished gain” as a mecha-

nism behind racial health disparities. Diminished gain is a phenomenon wherein

the health effects of certain socioeconomic resources and psychological assets

are systematically smaller for Blacks compared to Whites. These patterns are ro-

bust, with similar findings across different resources, assets, outcomes, settings,

cohorts, and age groups. However, the role of diminished gain as a main contribut-

ing mechanism to racial health disparities has been historically overlooked. This

article reviews the research literature on diminished gain and discusses possible

causes for it, such as the societal barriers created by structural racism. Policy

solutions that may reduce Blacks’ diminished gain are discussed.

Introduction

Across almost all domains, people who self-identify as Black or African

American experience worse health compared to people who self-identify as White

(Williams & Collins, 1995; Williams, Priest, & Anderson, 2016). Racial health

disparities start even before birth (Lu & Halfon, 2003) and extend throughout

childhood (Caprio et al., 2008), adulthood (McClellan et al., 2006), and older

adulthood (Pappas, Queen, Hadden, & Fisher, 1993). Some well-documented

examples are greater infant mortality rate (MacDorman, 2011), greater incidence

∗Correspondence concerning this article should be addressed to Shervin Assari, Department

of Psychiatry, University of Michigan, 4250 Plymouth Rd., Ann Arbor, MI 48109-2700 [e-mail:

assari@umich.edu].

Author would like to thank Stephanie Vidaillet Gelderloos, Brianna Preiser, Mohammed Saqib,

and Maeva Adoumie for their contribution to the drafts of this article. Shervin Assari is supported by

the Heinz C. Prechter Bipolar Research Fund and the Richard Tam Foundation at the University of

Michigan Depression Center.

112

2018 The Society for the Psychological Study of Social Issues

Health Disparities due to Diminished Return among Black Americans 113

of childhood chronic disease (Miller, 2000), and higher mortality and morbidity

of Blacks later in life (McClellan et al., 2006; Murray et al., 2006). Although

the overall health of all Americans has improved over the past several decades,

the racial health gap has remained relatively constant (National Center for Health

Statistics, 2015). In the past, economic, social, and health policies and programs

that have addressed these health disparities have been largely unsuccessful in

narrowing the disparities in morbidity and mortality between Black and White

Americans (Griffith, Evans, & Bor, 2017; Artiga, Damico, & Garfield, 2015).

(Similar health disparities impact other minority groups including Hispanics and

Native Americans but for reasons of length will not be discussed in this article.)

There are multiple interactive reasons for the continued health gap between

Blacks as a minority group and Whites as the majority group members, and no

single model or cause can fully explain the complex biosocial mechanisms. Of

course, the possibility exists that there are population-level genetic differences that

result in differential incidence rates for some diseases, as well as differences in the

way certain diseases develop and progress. Such differences as causes of health

disparities merit examination, but it is highly doubtful that they can fully explain

the racial/ethnic differences in health status. Other likely causes of health status

disparities concern inequities in the quality of health care received by different

social groups (Nelson, Stith, & Smedley, 2002) as well as cultural differences of

patients receiving health care (Caprio et al., 2008). This article almost exclusively

focuses on racial health disparities due to the structural racism embedded in the

U.S. social structure, meaning the system of socioeconomic stratification (e.g.,

the class structure), social institutions, or other patterned relations between large

social groups (Krieger, 2012; Williams & Mohammed, 2013). The core thesis

is that due to the current American social structure, economic resources (i.e.,

material and symbolic goods, which can be accessed and used in social actions)

and psychological assets (i.e., personal attributes and traits such as optimism,

coping, and mood) systemically generate larger health gains for White Americans

than they do for Black Americans.

This article reviews research literature showing that first, health is largely

shaped by societal factors outside the health sector, and second, social resources

and psychological assets are essential for health (Link & Phelan, 1995). The next

section summarizes research that shows Blacks experience diminished gains from

certain socioeconomic resources and psychological assets. After discussion of the

meaning of these findings, we propose potential mechanisms that may explain

such differential effects. Implications for theory, research, and policy are then

addressed.

The primary sources for the data presented in this article are secondary anal-

yses conducted by the author’s research team. These studies are based on the

following national surveys or cohorts: (1) the Americans’ Changing Lives (ACL)

study, a 25-year cohort of 3,600+adults (1986–2011), (2) the Midlife in the

114 Assari

United States (MIDUS) study, a 10-year cohort of 7,100+adults (1995–2004),

(3) the Religion, Aging, and Health Survey (RAHS), a 3-year cohort of 1,500 older

adults (2001–2004), (4) Health and Retirement Study (HRS), an ongoing cohort

of 37,000+older adults (1992–current), and (5) the National Survey of American

Life (NSAL), a survey of 6,000+adults and 1,100+adolescents (2001–2003).

These studies have mostly recruited representative samples of children, adoles-

cents, adults, and older adults living in the United States. As a result, the results are

generalizable to the U.S. population. Although these studies have included several

different racial/ethnic groups, most of these findings are relevant to health gaps

between Black and Whites, as they are typically the largest and most extensively

studied.

Economic and Social Resources, Personal Assets, and Health

The World Health Organization (WHO) Commission on Social Determinants

of Health (2008) and many public health researchers (e.g., Marmot, Allen, Bell, &

Goldblatt, 2012) have argued that people’s health and illness are initially shaped

by factors outside the health sector. That is, exposure to enduring social ills such as

poverty, poor education, and unemployment are strong contributors to racial health

disparities. Thus, many health problems have origins that may predate exposure to

disparities in the quality of the health care Black patients receive. This view does

not challenge the importance of health care disparities in health status disparity

(Nelson, Stith, & Smedley, 2002) but instead argues that such disparities do not

fully explain the large gaps in the health of Blacks and Whites.

Differential Effects versus Differential Exposures

Our model of health disparities argues that there are two related but distinct

processes that cause the Black–White health gap in United States. The first is

“differential exposure,” in which Blacks are less likely to have access to certain

resources (e.g., quality education, well-paying employment, etc.) and more likely

to be exposed to certain risk factors (e.g., discrimination). The second process

is “diminished gain” or “differential effects,” in which Blacks are less likely to

experience benefits, or positive consequences, from resources in their environment

they do receive and assets they do possess. Both “differential exposure” and

“differential effects” contribute to the development of racial health disparities

across the life course.

Economic and social resources are essential for maintaining health and avoid-

ing illness (Link & Phelan, 1995). Mirowsky and Ross (2003) have described the

health effects of socioeconomic resources, such as education, as enduring, con-

sistent, and growing. Social determinants of health (SDH; i.e., the conditions in

which people are born, grow, live, work, and age) and Socioeconomic Status

Health Disparities due to Diminished Return among Black Americans 115

(SES) (i.e., individual’s or family’s economic and social position in relation to

others, based on income, education, and occupation) provide access to material

and human resources. These resources collectively minimize the risk of exposure

to, and subsequent negative consequences of, illness (Phelan, Link, & Tehranifar,

2010). Multiple cross-sectional and longitudinal studies such as HRS (Bowen &

Gonz´

alez, 2010), the Panel Study of Income Dynamics (McDonough, Williams,

House, & Duncan, 1999), the Survey of Health, Aging and Retirement in Europe

(SHARE) (Leopold & Engelhardt, 2013), and the ACL (Herd, Goesling, & House,

2007), find that education, employment, and income are among the most impor-

tant social resources that reduce risk of premature morbidity (Gueorguieva et al.,

2009) and mortality (Hummer & Hernandez, 2013).

However, Everson-Rose and Lewis (2005) assert that, at least some of the

health effects of economic and social resources and SDH are mitigated by certain

psychological or personal assets or resources. For example, mastery, sense of

agency, and self-efficacy (i.e., beliefs about one’s ability to meaningfully affect

one’s environment) all mediate the effects of economic adversities on physical

and mental health outcomes (Everson-Rose, House, & Mero, 2004). Subsequent

research by Surtees et al. (2010) and Turiano, Chapman, Agrigoroaei, Infurna,

and Lachman (2014) have further supported the importance of personal assets in

the maintenance of individuals’ health.

One of the primary foci of the recent research by our team has been to use

national data sets to determine the relative impact of exposure to social, economic,

and psychological resources and the mitigating effects of certain personal assets

or strengths on the health of Blacks and Whites. Table 1 summarizes the results

of more than 20 papers by my colleagues and I documenting the “differential

effects” of social resources and psychological assets on the health of Whites and

Blacks. As previously suggested, these studies have consistently found smaller

health benefits from access to social resources and possession of certain assets for

Blacks compared to Whites. These findings seem to hold across developmental

phases, as they are observed among young people (Assari, Thomas, Cadlwell, &

Mincy, 2017), adults (Assari & Lankarani, 2016a), and older adults (Assari &

Lankarani, 2016b).

For example, a 25-year follow-up of more than 3,000 adults showed that

educational attainment (Assari & Lankarani, 2016a) and employment (Assari,

2017a) have stronger protective effects on the life expectancy of Whites compared

to Blacks. In another study, having access to a higher number of social contacts

(i.e., being a member of a larger social network) increased life expectancy of

Whites but not Blacks in a sample of adults over 25 years of age (Assari, 2017b).

Similarly, higher levels of self-efficacy (Assari, 2017c) and sense of control over

life (Assari, 2017d) may better reduce the risk of premature mortality for Whites

than for Blacks over time. Holmes and Zajacova (2014) reported similar findings.

116 Assari

Tab le 1 . Differential Effects of Psychosocial Factors on Health of Blacks than Whites

Data set Panel

Follow-up

(years) Predictor Outcome Author

ACL +25 Education Mortality Assari and Lankarani (2016a)

ACL +25 Employment Mortality Assari (2017a)

ACL +25 Neighborhood

safety

Mortality Assari (2016a)

ACL +25 Social contacts Mortality Assari (2017b)

ACL +25 Self-rated health Mortality Assari, Lankarani, and

Burgard (2016)

ACL +25 Depression Mortality Assari et al., 2016)

ACL +25 Anger and

hostility

Mortality Assari (2016b)

ACL +25 Self-efficacy Mortality Assari (2016c)

RAHS +3 Sense of control Mortality Assari (2017d)

ACL +25 Depression Mortality Assari and Burgard (2015)

NSAL −−Depression Obesity Assari (2014)

FFCWS +15 Family

socioeconomic

status

Obesity Assari, Thomas, Cadlwell,

and Mincy (2017)

ACL +25 Depression Chronic disease Assari, Burgard and Zivin,

2015)

ACL +25 Restless sleep Chronic disease Assari, Sonnega, Leggett, and

Pepin (2017)

FFCWS +15 Family

socioeconomic

status

Self-rated health Assari, Caldwell, and Mincey

(2017)

HRS +6 Education Sleep, body mass

index, exercise

Assari et al., 2016)

RAHS −−Life purpose Body mass index Assari (2016c)

NSAL −−Education Suicidal ideation Assari (2015)

RAHS −−Education Alcohol use Assari and Lankarani (2016d)

NSAL −−Stress Depression Assari and Lankarani (2016c)

NSAL −−Income Depression Assari and Caldwell (2017e)

ACL +25 Education Depression Assari (2017b)

ACL +15 Depressive

symptoms

Depression Moazen-Zadeh and Assari

(2016)

ACL +25 Neuroticism Depression Assari (2017f)

NSAL −−Obesity Intention to

reduce weight

Assari and Lankarani (2015)

ACL, Americans’ Changing Lives; HRS, Health and Retirement Study; RAHS, Religion, Aging, and

Health Survey; FFCWS, Fragile Families and Child Well-Being Study; NSAL, National Survey of

American Life.

Thus, not all racial/ethnic health disparities are simply due to lower SES

(LaVeist, 2005), higher stress (Lantz, House, Mero, & Williams, 2005), higher

levels of discrimination (Williams, Neighbors, & Jackson, 2003), and the inferior

health care (Nelson, Stith, & Smedley, 2002) that Blacks and other minority groups

are disproportionately exposed to. It is also the relative gain or loss of such factors

that affects a person’s health.

Health Disparities due to Diminished Return among Black Americans 117

These findings suggest that there are multiple related causes of health dis-

parities. That is, some people have argued that it is one’s social class, rather than

one’s race, that contributes to their health status. Such arguments ignore the strong

covariation between race, social class, and where one lives in the United States

(“place”). Thus, others have persuasively argued that it is both race and the risk

factors that covary with race that are responsible for the poor health of Blacks rel-

ative to Whites (Navarro, 1990). Some researchers (e.g., LaVeist, 2005) have tried

to disentangle the effects of race and place from SES, with the assumption that

SES, place, and other risk factors fully explain racial health disparities (LaVeist,

Pollack, Thorpe, Fesahazion, & Gaskin, 2011).

Probably the most important contribution of this article is to present convinc-

ing evidence that suggests not all of the health disparities are due to the differential

exposure of Blacks and Whites to risk and protective factors. Instead, the same

protective and risk factors result in various levels of health across racial groups.

Our findings suggest that hypothesizing SES differences, place differences, or the

additional exposure of Blacks to stress (e.g., discrimination) as the only causes of

health disparities is oversimplistic. If that were true, equalizing SES, eliminating

segregation, or eliminating discrimination would eliminate the Black–White gap

in health. We argue that the picture is more complex: that part of these disparities

will persist even if racial groups become equal in SES, place, and stress, because

SES generates less health gains for Blacks than Whites.

In other words, we should not assume that there might be a third factor, or a

set of third factors, that would simply explain (i.e., mediate) the effect of race on

health. Therefore, it is not either race or SES but race and SES that generate the

lower health status of Blacks compared to Whites. Supporting our results, Navarro

(1990) has argued that it is “race and class” not “race or class” that explain health

disparities. This is in contrast to the traditional view that third factors such as

SES, place, or stress that covary with race and health may fully explain the

effects of race on health (Lantz et al., 2005; Miller & Taylor, 2012). Although

“differential exposure” also plays a major role in shaping health disparities, the role

of “differential effects” should not be overlooked. We argue that racial differences

are not solely due to additional exposure to low SES or stress; rather at least some

of them are due to the “diminished gain” experienced by Black people in the

United States, as well as other disadvantaged groups.

The protective health effects of psychosocial resources (e.g., education, em-

ployment, and neighborhood) and psychological assets are unequal between the

socially privileged and the economically disadvantaged groups. The ability of a

group to take advantage of any additional resource is conditional on other protec-

tive factors that are available to them. The effects of social and economic resources

are diminished for Blacks due to structural factors, such as poverty, segregation,

racism, and discrimination, that hinder their ability to navigate the system and take

advantage of new resources that become available to them (Krieger, 2012; Gee &

118 Assari

Ford, 2011; Williams & Mohammed, 2013; Agency for Healthcare Research &

Quality, 2015).

A Paradoxical Effect

An interesting implication of the greater health gains from certain resources

among Whites compared to Blacks is that, following this logic, Whites would

experience greater health loss than Blacks when economic resources are reduced

or eliminated. Data from national surveys on the impact of SES on health confirm

this. That is, Whites gain more from a higher SES and lose more from a lower

SES. Whites may also do worse than Blacks under conditions of adversity such as

economic depression. For example, low education (Assari & Lankarani, 2016a)

and living in poor neighborhoods (Assari, 2016a) reduce the life expectancy of

Whites more than they do for Blacks. Unemployment is associated with the largest

decline in life expectancy among White men, while Black men lose minimum life

expectancy due to unemployment (Assari, 2017a).

One method of examining the relative impact of certain protective and risk

factors on health is to study the slopes when health is regressed onto these fac-

tors. Greater slopes can be interpreted as an indicator of relative advantage, but

they reflect vulnerability (DiAngelo, 2011). As most social risk and protective

factors show greater slopes for Whites than for Blacks, Whites’ health seems to

be more dependent upon presence of SDH and SES than Blacks. Stressful life

events can also have larger effects on depression in Whites as compared to Blacks

(Assari & Lankarani, 2016d). For example, Whites have shorter life expectan-

cies than Blacks when they have few positive emotions (Assari, Moazen-Zadeh,

Lankarani, & Micol-Foster, 2016), poorer anger control (Assari, 2016b), lower

self-efficacy (Assari, 2017c), and lower sense of agency (Assari, 2017d). Also,

poor sleep (Assari, Sonnega, Leggett, & Pepin, 2016) and negative emotions (As-

sari & Lankarani, 2016c) have larger effects on the incidence of chronic disease

for Whites compared to Blacks. These papers collectively suggest that health costs

associated with fewer psychological assets are greater for Whites than Blacks.

Malat, Mayorga-Gallo, and Williams (2017) propose that Whites’ greater

vulnerability to risk factors relative to Blacks may be due to their higher social

status and greater privilege. That is, they may be less prepared than Blacks to

respond to social and economic adversity. Thus, the Black–White difference in

resilience in the face of unexpected difficulties is due to social rather than biological

processes. Vulnerability can be conceptualized as a cost of social privilege to

Whites, and resilience can be thought of as a gift of adversity. In this view,

vulnerability is secondary to the lack of preparedness of Whites to cope with

adversity, given their social privilege overall. Compared to Blacks who have dealt

with a wide range of economic and social stressors for centuries, Whites are less

resilient to adversity (Keyes, 2009). An example of this lack of preparedness

Health Disparities due to Diminished Return among Black Americans 119

is the recent increase in deaths of despair (i.e., death due to suicide, overdose,

and substance use) in White Americans documented by Case and Deaton (2015).

They found that low SES Whites, particularly low SES White men, have recently

experienced an increase in mortality due to high-risk behaviors. Research by

Geronimus et al. (2015) also showed that adversity is associated with the shortening

of telomeres in Whites but not Blacks.

In contrast, many Blacks have found ways to manage their harsh environment,

which may have helped them to develop a systematic resilience (Keyes, 2009),

a phenomenon also called “Blacks’ flourishing” (Keyes, 2009; Ryff, Keyes, &

Hughes, 2003). This hypothesis about Blacks’ resilience is in line with an extensive

theoretical and empirical body of work regarding resilience (Lyons, Parker, Katz,

& Schatzberg, 2009), defined as succeeding in the face of adversity (Zimmerman,

Ramirez-Valles, & Maton, 1999). In this view, the social group that experiences

adversities gradually becomes more efficient in mobilizing their available assets

and resources to protect the individual and mitigate the impact of risk factors. As a

result, despite several social and economic risk factors, Blacks maintain their sense

of well-being. This is also consistent with recent studies showing that Blacks with

depression maintain higher levels of hope (Assari & Lankarani, 2016e), positive

emotions (Lankarani & Assari, 2017), and mastery (Assari & Lankarani, 2017f)

compared to Whites.

Thus, at a minimum, we can conclude that some health disparities are shaped

outside of the healthcare system. The U.S. social structure continually generates

gaps between social groups. We argue that there are significant parts of health

disparities caused by the very nature of American social structure and how it

functions. Unless this social structure is altered, racial health disparities will

continue to grow. According to this explanation, disparities develop even before

health care is needed. This suggests a needed shift in attention from a medical

to a sociological model of health disparities. In the absence of any change, the

U.S. social system will continue to generate smaller health gains from the same

resources and assets for Blacks compared to Whites. While the gain is conditional

on race, it is difficult to close racial gaps in health, without altering the operation

and functionality of the macrolevel system. In its current form, American society,

even with equitable access to resources across social groups, results in reliable

health disparities between the socially privileged and disadvantaged groups.

It is not wise for policy makers, evaluators, and others to assume that socioe-

conomic resources and assets will equally influence the health of all social groups,

as risk and protective factors interact with sociodemographic characteristics on

health (Mehta & Preston, 2016). As a result, there is a need to systematically test

all potential interactions between race, ethnicity, and SES indicators on health

outcomes (Williams & Collins, 1995; Kessler & Neighbors, 1986). Disparities

seem to be larger at the highest levels of SES, suggesting that diminished gain

may be greater at higher SES levels (Farmer & Ferraro, 2005). However, due to

120 Assari

the substantial covariation between race and SES, and also due to residual and

unmeasured confounding variables (i.e., epidemiologic terms that indicate biases

due to an inability to cancel the effects of all potential covariates/confounders),

it is exceedingly challenging to decompose the effects of race and SES on health

(Kaufman, Cooper, & McGee, 1997). Residual and unmeasured confounding vari-

ables are a common threat to the validity of research on the effects of race and

health (Fewell, Davey Smith, & Sterne, 2007). In many studies where the individ-

ual level, but not community level SES is measured, higher level SES may be an

unmeasured confounder.

The Impact of Economic Inequalities of the Racial Health Gap

The racial gap in health may widen in the future as has happened before.

Williams and Collins (1995) have provided a historical review regarding the

widening of the racial gap in mortality and other health outcomes as a func-

tion of changes in economic conditions. They showed how a decline in Blacks’

economic well-being and an increase in Black–White economic inequalities re-

sults in a widening of the Black–White health gap across a number of health

indicators. For example, between 1980 and 1991, the racial life expectancy gap

grew from 6.9 to 8.3 years. Black men and women’s life expectancy significantly

declined from 1984 to 1989 (National Center for Health Statistics, 1994; Williams

& Collins, 1995). The age-adjusted Black to White death ratio increased from

1980 to 1991, with the annual excess of deaths increasing by 6,000 in Blacks com-

pared to Whites. During the same period, the age-adjusted death rate decreased

more rapidly for American Whites than for American Blacks (Williams & Collins,

1995). Freeman (1993) used mortality data over a 20-year period from 1960 to

1980 in Harlem, New York, and Blacks and Whites on the national level. Although

there was a steady decline in national mortality rate; there was no considerable

gain in life expectancy for Blacks who lived in Harlem, New York, over the same

period. There were also differences in the incidence of certain diseases. For exam-

ple, the decline in the incidence of heart disease was smaller for Blacks compared

to Whites, which likely resulted in a widening of the racial gap in life expectancy

(Kochanek, Maurer, & Rosenberg, 1994). The racial health gap widens when the

racial economic gap widens. In the 1980s, the ratio of Blacks earnings to White

earnings was smaller, relative to the ratio of earnings in the 1970s. In concert with

the widening of the economic gap, racial health disparities also widened for a

range of health indicators (Williams & Collins, 1995). From 1984 to 1989, while

the life expectancy of Whites showed a consistent increase, the life expectancy of

Blacks declined (Williams & Collins, 1995).

Between 1960 and 1984, the protective effect of education against the risk of

mortality increased substantially for White but not Black men (Feldman, Makuc,

Kleinman, & Cornoni-Huntley, 1989). The gap in rate of mortality among groups

Health Disparities due to Diminished Return among Black Americans 121

of differing levels of SES increased from 1960 to 1986 (Pappas, Queen, Hadden,

& Fisher, 1993). From 1969 to 1989, breast cancer mortality declined for high

SES women, however, the mortality rate increased for low SES women during the

same period (Wagener & Schatzkin, 1994). From 1980 to 1991, preterm delivery

and low birth weight increased among Black women, while the same statistics

remained unchanged for White women. This resulted in a widening of the racial

gap in infant mortality rates during this period (Rowley et al., 1993). There was

also a widening of the racial gap in the rates of sexually transmitted diseases from

1980 to 1991 (Castro, 1993).

These are all historical examples of the racial health gap widening as a direct

result of economic factors. Widening of the racial gap is not limited by or specific

to a single health outcome, as it has occurred across domains, and spillover effects

may impact multiple health domains. In the absence of political and public policy

changes working to address higher level societal and structural factors such as

residential segregation and institutional racism, Blacks are unlikely to gain from

resources at the same level as Whites (Assari, 2017e).

Possible Mechanisms behind Differential Effects

The following section discusses five potential mechanisms behind the “di-

minished gain” or “differential effects” experienced by Blacks. These mecha-

nisms include: (1) labor market preferences and practices, (2) income and wealth

generation and purchasing power, (3) interpersonal, institutional, and structural

discrimination, (4) cumulative gain due to initial advantage, and (5) extra cost

associated with upward social mobility among Blacks. These mechanisms operate

across levels and range from public policies to individual characteristics. While

some of these explanatory mechanisms are related to the social structure and oper-

ate at the macrolevel, some others may predominantly exert their effects through

group or individual levels. They are interconnected as the labor market may result

in racial gap in income, and racial differences in purchasing power may cause

upward social mobility of Blacks to be more costly. Additionally, these mech-

anisms are not mutually exclusive, and some may be more relevant than others

depending on the resource and asset, age group, cohort, and outcome. For instance,

differential life expectancy gain from education and employment are mostly due

to racial differences in education quality and labor market practices. Interpersonal

discrimination, however, may offer a better explanation for why high SES may

not protect Black men against depression (Assari, 2017g).

Labor Market Preferences and Practices

At least some of Blacks’ diminished health return of SES is due to the

smaller effect of education on employment and income for Blacks compared

122 Assari

to Whites, which is due to racism in the labor market. From 1954 until 2013,

Black unemployment rate has been consistently double that of Whites (Desilver,

2013). When Blacks do find employment, due to the existing racial gap in pay,

they earn less than Whites (Jencks & Mayer, 1990). They also enter different

types of occupations from Whites, as Blacks more commonly enter occupations

that increase their exposure to environmental risk factors (U.S. Department of

Labor, Bureau of Labor Statistics, 2011). Blacks must often take minimum wage,

repetitive jobs that increase their risk for poor mental health, substance abuse,

and health problems (O’Campo & Rojas-Smith, 1998). As a result, an increase in

education and employment results in more tangible health gains for Whites than

Blacks (Monnat, 2014).

The labor market is one of many American institutions that suffer from

structural and institutional racism (Huffman & Cohen, 2004). Compared to White

counterparts, college-educated Blacks are much less likely to be employed, which

reduces any health gain from education (Wilhelm, 1987). The income gap is larger

at higher levels of education. In 2006, among men with a master’s degree, Blacks

earned $27,000 less than Whites (IWPR, 2010). Despite a similar job experience

and education, employed Blacks are more commonly exposed to occupational

hazards and carcinogens than their White counterparts (Williams & Collins, 1995).

These differences all serve to explain why education and employment result in

smaller health gains for Blacks.

Income and Wealth Generation and Purchasing Power

Income (i.e., the flow of economic resources to the household or family)

and wealth (i.e., the reserve of economic resources) are both lower in Blacks

than Whites. In fact, higher wealth of Whites may explain why the same income

results in smaller health gains for Blacks than Whites. Across the same levels

of income, Black households have less wealth, which has enormous direct and

indirect implications for health across generations (Oliver & Shapiro, 2006). In

the Fragile Families and Child Well-Being Study (FFCWS), family SES at birth

better protected White youth against poor self-rated health (SRH) and high body

mass index (BMI) than it did Black youth. That is, an increase in family SES at

birth was a better promoter of future health for White youth than Black youth

(Assari, Thomas, Cadlwell, & Mincy, 2017; Assari, 2018c). These papers suggest

that diminished gain starts early in life, and includes multigenerational aspects

(i.e., parental SES on offspring health).

Lower accumulation of wealth in Black families is cited as the result of a

long history of racism and discrimination (Oliver & Shapiro, 2006). As houses

are major assets, and location is the major determinant of housing value (Shapiro,

2006), residential segregation has played a major role in shaping the racial gap

in wealth (Oliver & Shapiro, 2006). In addition to wealth differences, enormous

Health Disparities due to Diminished Return among Black Americans 123

racial differences also exist in income generation. Compared to Whites, Black

households have a higher tendency to rely on multiple earners who collectively

contribute to the total household income (Dressler, 1993). Among middle-class

families, Blacks are, compared to Whites, more recent and less established in their

social class, which diminishes their health gains from social class (Collins, 1983).

As argued by Marmot (2015), how social groups can expend their available

resources may be even more important than their SES resources. At any given

income or wealth level, Blacks have lower purchasing power than Whites. Due to

residential segregation, food deserts, and limited access to high-quality resources

in inner cities, Blacks pay a higher price than Whites for the same goods and

services (Williams, Priest, & Anderson, 2016).

Discrimination

One mechanism that offers an explanation for the diminished health gain

of Blacks from SES resources is discrimination (Hudson et al., 2012). Discrim-

ination negatively impacts a wide range of health outcomes (Mays, Cochran, &

Barnes, 2007). Chronic exposure to discrimination increases risk of psychiatric

disorders (Hope, Assari, Cole-Lewis, & Caldwell, 2017). Additionally, experi-

encing discrimination carries consequences for physical health including higher

rates of heart disease (Lewis, Williams, Tamene, & Clark, 2014), hypertension

(Mezuk, Kershaw, Hudson, Lim, & Ratliff, 2011), obesity (Hickson et al., 2012),

and mortality (Barnes, et al., 2008). Discrimination also influences biological

markers such as cortisol levels, which reflect stress responses (Lee et al., 2017),

oxidative stress, which reflects inflammation (Szanton et al., 2012), and telomere

length, which reflects aging (Chae et al., 2014). Given the recent trends in the

racist rhetoric and public presence of White supremacy, discrimination may have

a growing impact in American society in the coming years. Events such as those

in Charlottesville and Ferguson suggest that racism and discrimination are still

present in the United States.

Discrimination also minimizes the health gains from SES resources (Hudson

et al., 2012). Hudson et al. (2012) also found the protective effects of SES among

Black adults are smaller in the presence of discrimination. Assari and Caldwell

(2018c) also used a national sample of Black youth and found that discrimination

has a stronger effect on Major Depressive Disorder (MDD) of Black boys with

higher levels of SES compared to low levels of SES. This finding is supported by

other research that has shown that discrimination is more consequential for Black

males than Black females (Assari et al., 2017). The Black men most vulnerable to

MDD as a result of discrimination also hold high hegemonic masculinity beliefs

(Caldwell, Antonakos, Tsuchiya, Assari, & De Loney, 2013).

Discrimination is not limited to between individuals. Blacks are systematically

discriminated against in educational and correctional settings. Historically, race

124 Assari

has had an effect on education in the United States (Grogger, 1996; Steele, 1992),

with Blacks typically attending lower quality schools (Card & Krueger, 1992).

Both individual level race and racial composition of schools are major determi-

nants of educational resources and schooling quality (Roscigno, & Ainsworth-

Darnell, 1999). Exclusionary disciplines are disproportionately applied to Black

children (Fenning & Rose, 2007). The result is huge Black–White gaps in school

performance (Jencks & Phillips, 2011). Due to an increased risk of discrimination

by their teachers (Noguera, 2009), Black boys are at an exceptionally high risk

of school dropout (Rumberger, 1983), which contributes to the school to prison

pipeline (Wald & Losen, 2003). Seaton and Douglass (2014) showed that Black

youth report a daily average of 2.5 discriminatory events that increase their de-

pressive symptoms on the following day. Another institution that systematically

discriminates against Blacks is the banking system (Ross & Yinger, 2002). Black

families often pay much higher interest rates on their mortgages than do White

families. According to the Home Mortgage Disclosure Act (HMDA) data, even

high-income Blacks pay more subprime (high) mortgage rates than comparable

high-income Whites (Bocian, Ernst, & Li, 2008). Mortgage discrimination directly

results in Black–White differences in foreclosure rates (Bocian, Li, & Ernst, 2010).

Cumulative Disparities due to Initial Advantage

Gains are typically larger for the “Haves” (i.e., the majority and the social

advantaged groups) than the “Have-Nots” (i.e., the minority and marginalized

groups that are at economically disadvantage conditions) (Ceci & Papierno,

2005). As a result, policy makers, program planners, and evaluators should

be aware that many interventions that increase overall access of the society to

resources may not reduce disparities between groups. This is possibly because

socially and economically privileged groups are better equipped to capitalize on

new programs that become available to them, compared to marginalized groups.

An initial advantage, characterized by the availability of SES resources and

psychological assets (coping, affect, self efficacy, and mastery), disproportion-

ately advances the majority group, explaining why Whites gain more than Blacks

from any additional resources later in life (Ceci & Papierno, 2005). Over time, this

disparity accumulates, widening preexisting gaps between social groups and their

ability to gain from available resources and assets. As stated in the Cumulative

Advantage Theory, having an initial advantage results in further cumulative ad-

vantage, and an initial disadvantage is accentuated over time (Shaywitz, Shaywitz,

Pugh, & Constable, 1995).

Nonequivalence of childhood SES has been used to explain why high SES dur-

ing adulthood is less protective for Blacks than Whites (Warner & Hayward, 2006;

Colen, 2011). Holmes and Zajacova (2014), for example, attributed differential

health effects of SES resources across races to racial differences in childhood SES.

Health Disparities due to Diminished Return among Black Americans 125

There are, however, studies whose findings do not support such an explanation

(Brown, O’Rand, & Adkins, 2012). Overall, it has not been determined whether

or not racial gap in childhood SES is exclusively responsible for the differential

health effects of adulthood SES.

Cost of Upward Social Mobility

To climb the social ladder, Blacks have a tendency to use effortful coping

(Sellers & Neighbors, 1999). Blacks report high levels of goal-striving stress

(Sellers & Neighbors, 2008) defined as the “discrepancy between aspiration for

and achievement of a better way of life, weighted by the subjective probability of

success, and the level of disappointment experienced if those life goals were not

realized” (Neighbors, Sellers, Zhang, & Jackson, 2011, p. 51). One example is John

Henryism, a well-studied, effortful coping strategy that is commonly exercised by

Black men to deal with discrimination in their daily life and aid in upward social

mobility. John Henryism is, however, not the only form of coping that Blacks use

for upward social mobility. Blacks and Whites employ different coping strategies

to deal with stress (Conway, 1986). For instance, compared to Whites, Blacks have

a higher tendency to rely on social support and religion to cope with adversities

(Reevy & Maslach, 2001).

Effortful coping strategies come with psychological and physiological costs

(Bennett et al., 2004; James, 1994; Sellers & Neighbors, 2008). Although most of

the literature has focused on the undesired mental health effects of John Henryism

(Hudson et al., 2016), the health risk associated with John Henryism goes beyond

merely a psychological cost (James, Strogatz, Wing, & Ramsey, 1987). Whether

John Henryism promotes health or impairs health seems to depend on one’s

access to other resources such as SES and social support (Hudson et al., 2016).

John Henryism may function as a resource or as a health hazard (Mujahid, James,

Kaplan, & Salonen, 2017). John Henryism is most damaging when it covaries with

low access to SES resources and social support (James, 1994). John Henryism

increases cardiovascular risk (Mujahid, James, Kaplan, & Salonen, 2017). As

a result, John Henryism may have a unique role is shaping health disparities,

particularly in higher SES levels. These processes could explain the smaller health

gain due to educational achievement for Blacks compared to Whites (Fuller-

Rowell, Doan, & Eccles, 2012).

Policy Implications

This section discusses potentially relevant social and economic policies

based on the findings discussed above. Unlike other resources discussed, income

has similar effects on mortality among Blacks and Whites (Assari & Lankarani,

2016a; Fedewa, McClellan, Judd, Guti´

errez, & Crews, 2014). Thus, we believe

126 Assari

that income redistribution policies should be regarded as a central policy strategy

to reduce Blacks’ diminished gain. Second, it is necessary to distance ourselves

from any policy or program that stimulates or supports widening of the racial

health gap. Simultaneously, there is a need to enforce policies that reduce

tolerance for discrimination at all levels against Blacks and other minority groups.

As equal access generates differential impact across populations, policy solutions

should go beyond simply equalizing access and address barriers in the life of

Blacks. These policy solutions should be at multiple levels (e.g., individual,

organizational, and institutional levels). Finally, we argue that religion and social

support should be leveraged as they show particularly beneficial effects among

Blacks.

Income Redistribution Policies

As just noted, income is one of the few exceptions to the Blacks’ dimin-

ished health return (Assari & Lankarani, 2016a; Fedewa et al., 2014). While many

SES indicators and/or psychological assets better protect Whites than Blacks

(Table 1), each unit increase in income shows the same increase in life expectancy

for Whites and Blacks (Assari & Lankarani, 2016a). The observation that all

groups similarly gain health from income is very promising and argues for income

redistribution policies as a main solution to close the racial gap in health. For exam-

ple, policy solutions may include (1) increasing the minimum wage for jobs often

occupied by Blacks, (2) reducing the racial wage gap in the U.S. labor market,

and (3) tax policies that help low income families to accumulate more wealth over

time. Helping Blacks achieve higher incomes may be one of the most effective so-

lutions to health disparities, given income is one of the fewest economic resources

that similarly translates to health gain, regardless of race (Assari & Lankarani,

2016a). This is particularly important as Blacks are overrepresented in low paying

jobs. Policies providing temporary financial incentives and cash assistance may

also have a role in addressing needs of people in deep poverty (Bitler & Hoynes,

2016). There is empirical evidence suggesting that income redistribution predicts

well-being (Cheung, 2017). Countries where income is distributed evenly have a

higher level of health status (Kawachi & Kennedy, 1997).

Avoiding Policies that May Widen the Health Gap

A critical step to reduce the health gap is avoiding policies or programs

that disproportionately improve the health of the socially advantaged majority

group. Policy analysts who evaluate the impact of social policies should consider

the differential effects of the same policies on Whites and Blacks, in addition to

evaluating the overall effects on the total population. There is also a particular need

to identify policies that minimize Blacks’ diminished return (Lorenc et al., 2013).

Health Disparities due to Diminished Return among Black Americans 127

It is important to identify subpopulation differences in factors that alter the uptake

and impact of the interventions across population subgroups. Some of the factors

that impact service provision or access of interventions across subgroups include

differential intervention efficacy, population variation in trust and acceptability of

the program, as well as variation in compliance (Lorenc et al., 2013). Low trust,

poor participation rate, and low adherence of Blacks can be traced to historical

factors such as formal racist laws and informal racist social customs (Kennedy,

Mathis, & Woods, 2007). To regain Blacks’ trust, there is a need for considerable

efforts and investments at all levels in the healthcare system and other institutions.

Zero Discrimination at All Levels

More legislation is required to reduce discrimination. Additionally, stronger

enforcement of existing antidiscrimination policies should be in place. To reduce

the ongoing structural discrimination in education quality (Roscigno & Ainsworth-

Darnell, 1999), we must invest more in the schooling and education in urban Black

communities (Card & Krueger, 1992). Such investments may help schools reduce

discrimination against Black children, and specifically address school dropout

rates among Black boys (Rumberger, 1983). A particularly supportive policy

would be the education of teachers and principals of predominantly Black schools

to reduce disproportionate disciplinary actions against Black boys (Fenning &

Rose, 2007). Teachers who work at majority Black schools, in particular, should

receive training to minimize discrimination and bias, particularly against Black

boys (Noguera, 2009). Federal and state level policies should minimize disparities

in availability of educational resources across social groups (Jencks & Phillips,

2011). Systematic evaluations of educational systems are necessary to monitor how

these policies reduce the existing gaps in school performance between the majority

and the minority populations. Policies and programs that increase education quality

in majority Black schools, particularly those that are least resourced (Grogger,

1996), may increase protecting effects of education on health of Blacks. Such

investments may produce returns in community growth due to the salient role

of education quality in the economic growth and human capital development

(Hanushek & W¨

oßmann, 2007).

Similar to the educational system, we must abnegate discrimination in other

sectors such as banking, housing, the correctional system, and policing. Federal

enforcement agencies have the responsibility to more stringently enforce the ex-

isting antidiscriminatory laws, such as fair lending laws. Such careful monitoring

may reduce discrimination across systems (White, 2009).

Going Beyond Equalizing Access

As equal resources and assets result in unequal gain (Assari, 2017e), social,

public, and economic policies that merely equalize distribution of populations to

128 Assari

resources and assets, but ignore the barriers not equally distributed across social

groups, may unintentionally exacerbate existing racial health inequities. Despite

good intentions, such universal policies do little to reduce, and even have the

potential to aggravate, the racial health gap in the United States. Policies should

go beyond universal investments. Any policy that overemphasizes equal access

without considering the structural barriers that maintain the relative disadvantages

of Blacks should be regarded as a policy that risks widening the racial health

gap. Given the greater likelihood of Whites to derive benefits from any additional

resource, programs should include racial comparisons in their evaluations and

ensure that no social group is left behind in translating new resources and programs

to tangible and measurable health gains.

One solution is to consider more tailored interventions and programs that

address the specific needs of Blacks and other marginalized groups. Policies

should specifically target the structural barriers and constraints that limit Blacks’

ability to convert their available economic resources and psychological assets into

health outcomes. Policies should address societal barriers prevalent in the life of

Blacks who live in urban communities with limited resources. Simultaneously

targeting barriers and providing additional resources may increase the efficacy

and return of any social or economic policy, which would, cumulatively, reduce

racial health disparities.

With specific regard to employment and education policies, significant atten-

tion should be given to the quality of education, type of occupation, and income

generated by such resources. Education and employment initiatives that disregard

the deeply rooted structural and societal inequalities that Blacks face will not be

sufficiently impactful.

In addition, there is a need for purposeful policies to reduce the racial residen-

tial segregation that still exists in the United States. Such segregation operates as

structural and contextual barriers in the lives of many Blacks today. A majority of

Black neighborhoods are distant from high paying jobs and high-quality education

(Lewis, James, Hancock, & Hill-Jackson, 2008). In addition, the disproportionate

number of fast food restaurants and liquor stores in Black neighborhoods are re-

sponsible for increasing the risks of obesity and chronic diseases such as stroke,

hypertension, and diabetes for Blacks (Morgenstern et al., 2009). Black neighbor-

hoods are also poor in resources for health care. Finally, social disorder, crime,

and gang violence limit the ability of Blacks in urban areas to thrive (Thomas,

Caldwell, Assari, Jagers, & Flay, 2016).

Discriminatory lending practices still continue. The existing antidiscrimina-

tion laws in lending practices must be imposed more dependably. To minimize

discriminatory lending practices we may not require new legislation, but simply

a better implementation and enforcement of the existing laws. Equitable eco-

nomic policies have a unique importance in preventing health disparities across

social groups. Discriminatory mortgage and loan practices that exist should be

Health Disparities due to Diminished Return among Black Americans 129

prohibited. If needed, new policies should prohibit higher bars and more restricted

thresholds that Blacks must meet to qualify for loans. Policies should also enforce

equal interest rates and mortgage down payments for Blacks and Whites (Pager &

Shepherd, 2008).

As already established, without extra help, Blacks will have difficulty com-

peting with Whites to secure high paying jobs and educational opportunities. Our

findings expand on the past research and conclude that comparable resources con-

sistently generate less positive impact on the lives of Blacks compared to Whites.

These results advocate for the implementation of affirmative action policies. How-

ever, affirmative action is one of the most controversial public policies that focuses

on redistribution of resources and opportunities (Katz & Taylor, 2013). In the view

of many Whites, affirmative action is reverse discrimination (Dansby, 1996), and

not every group views it as fair and just (Peterson, 1994). These counter concerns

make affirmative action politically charged (Crosby, 2004), particularly in the

current political climate. As a result of this resistance, it is very difficult to get

bipartisan political support for affirmation action policies. Still, there is a need

for reevaluation of the actual effects of affirmative action policies (Rabinowitz,

Sears, Sidanius, & Krosnick, 2009) and its impact on groups not targeted by affir-

mative action policies and practices. Affirmative action would still seem to offer

one powerful remedy to the differential exposure and differential gain typically

experienced by Black people in the United States.

Policy analysts should investigate the gap-widening potential of interventions

and policies that only increase the access of populations to resources. Given that

the system prefers Whites to Blacks overall, and given the current political climate,

interventions may elevate the economically advantaged populations to a greater

degree than their less advantaged counterparts. It is the responsibility of researchers

to study in which conditions a policy can inadvertently widen the existing racial gap

(Ceci & Papierno, 2005). Lorenc et al. (2013) reviewed public health interventions

aimed to promote the overall health of the population, but are at risk for increasing

inequalities. They called such programs Interventions-Generating Inequalities.

Although media campaigns and workplace smoking bans have the potential to

generate inequalities, provision of resources; fiscal interventions (e.g., tobacco

pricing), and structural workplace interventions are likely to reduce the racial gap.

Graham and Kelly (2004) have provided conceptual and theoretical frameworks

that help to identify interventions-generating inequalities. Lorenc et al. (2013)

also distinguish the “upstream” interventions that focus on social or policy-level

determinants such as reducing price barriers from “downstream” interventions

that focus on individual factors such as education. Overall, Lorenc et al. (2013)

argue that downstream interventions do not appear to reduce inequalities, and may

increase them. They propose that upstream resource provision interventions may

effectively reduce disparities.

130 Assari

Policy Responses Should be Multilevel

Given that we attribute most of the findings we have reported as due to

various kinds of racism, we suggest that the solution should be multilevel and

target all aspects of racism that hinder Blacks’ lives. This section reviews how

Williams and Mohammed (2013), Bailey et al. (2017), Reskin (2012), and Gee &

Ford (2011) conceptualized Black–White health disparities as the byproduct of the

structure and function of American society. Williams and Mohammed (2013) have

argued that racial disparity is a product of multilevel processes. They theorize a

wide range of procedures by which racism adversely impacts the health of Blacks.

Institutional racism systematically reduces Blacks’ access to safe and high-quality

housing, neighborhood, schooling, employment, and other desirable material and

human resources in society (Williams & Mohammed, 2013). Bailey et al. (2017)

define structural racism as “the totality of ways in which societies foster [racial]

discrimination, via mutually reinforcing [inequitable] systems..(e.g., in housing,

education, employment, earnings, benefits, credit, media, health care, criminal

justice, etc.) that in turn reinforce discriminatory beliefs, values, and distribution of

resources,” (p. 1455) reflected in history, culture, and interconnected institutions.

Building on a systems perspective, Reskin (2012) defined racism as a dis-

crimination system that constantly generates racial disparities across several life

domains including but not limited to schooling, housing, residential location, em-

ployment, health, credit, banking, lending, and justice. Gee and Ford (2011) also

argue that racial health disparities have structural, rather than individual, causes.

Societal and structural factors such as social segregation and economic policies

that operate through intergenerational mechanisms are responsible for health in-

equalities. As a result, policy solutions should attack a wide range of dimensions

of the social structure as they collectively result in health disparities (Gee & Ford,

2011). Reskin (2012) argues that an appropriate response should include poli-

cies and interventions that operate simultaneously across subsystems, and directly

challenge all the processes of racism across the subsystems in which racism op-

erates. Thus, to eliminate health disparities, policy solutions should consider the

reciprocal interrelations between the components of the integrated system that is

generating the health disparities. All these require better representation of Blacks

in high-level policy making, which itself depends on an increase in political par-

ticipation (e.g., voting) of Blacks and other minority populations (Hamilton &

Ture, 2011).

Geronimus et al. (2016) introduced the “Jedi Public Health (JPH)” as one

solution to the effects of racism. This framework, “...focuses on changing

features of settings in everyday life, rather than individuals, to promote popu-

lation health equity, a high priority, yet, elusive national public health objective”

(p. 105). Geronimus et al. (2016) have argued that there is a need for expansion as

well as a reorientation of efforts to eliminate population health inequities. In the

Health Disparities due to Diminished Return among Black Americans 131

JPH framework, policies and interventions should remove all the discrediting cues

in daily life of Blacks and other minority groups. Such Jedi Public Health policies

will disrupt the continuously harmful physiological and psychological processes

that fuel racial health inequities.

The appropriate policy response would include a wide range of multilevel

policies that operate across various subsystems. Policies that target societal as

well as individual level discrimination are needed. There is a need for policies

that improve neighborhood safety as well as those that increase availability of ed-

ucational resources at majority Black schools. Policies should increase access and

improve the quality of medical care for Blacks. These policies, and others, would

help Blacks take control of their lives, which has implications for improving their

health (Williams & Mohammed, 2013). In a seminal article published recently in

the journal Lancet, Bailey et al. (2017) argue that efforts to dismantle structural

racism have historically encountered serious resistance from institutions, com-

munities, and individuals seeking to preserve their racial privilege. They argued,

however, that a focus on structural racism would be a concrete, feasible, and

promising approach toward advancing health equity in United States.

Leveraging Religion and Social Support in Communities

Although Blacks gain less than Whites from several economic resources and

psychological assets, religion and social support are exceptions to this general

rule. Increases in religious involvement and social support provide larger health

gains for Blacks compared to Whites. Several studies have documented Blacks’

advantage in gaining health from religion and social support (Lincoln, Chatters, &

Taylor, 2003). To give an example, church attendance is associated with thirteen

and seven extra years in life expectancy for Blacks and Whites, respectively

(Hummer, Ellison, Rogers, Moulton, & Romero, 2004). In a national sample,

church-based social support fully mediated the effect of religious involvement on

the well-being of Blacks but not Whites (Assari, 2013). Each unit of increase

in positive social relations had a larger protective effect against depression for

Blacks than Whites (Lincoln, Chatters, & Taylor, 2003). Church has become a

source for forgiveness, resilience, and very strong relation with God, which all

protect the health of Blacks. In addition to a place of worship, the church has

traditionally been a social institution that provides goods and tangible services for

Black families, regardless of social status (Krause, 2002).

Social relations are also more extended in Blacks than Whites as they include

supportive relations from fictive kin relations (defined as social ties that are based

on neither consanguineal [blood ties] nor affinal [“by marriage”] ties [Ebaugh &

Curry, 2000]), friends, and community members (Taylor & Chatters, 1991). Thus,

social support and religion might have operated historically as cultural refuges by

Black communities to cope with oppression and economic adversity. Although

132 Assari

it is plausible to argue that Blacks have mastered their ability to mobilize their

social support, research is still needed on whether social support and religion can

mitigate Blacks’ diminished return or not. However, these findings advocate for

allocating additional resources for promotion of positive family relations, extended

social relations, and faith-based programs in Black communities. Although it is

not easy to draw a causal inference between religious involvement and health,

and reverse causality is always a concern (healthier individuals may attend church

more frequently), the association between various aspects of religion and health

are stronger for Blacks than Whites.

All this said, we recognize that given the current political climate, there

are enormous barriers to the implementation of the policies discussed. It is al-

ways easier to describe than solve the problem. However, as stated by David

Williams (2012) as a society, we need to demand and challenge the current po-

litical system for appropriate alleviative policies that are needed for an equitable

society.

Theoretical Implications

This review shows that although Blacks suffer worse physical health out-

comes, their minority status per se does not reflect greater physical or psycho-

logical vulnerability (Dowd & Bengtson, 1978). As explained in this article, it

is Whites not Blacks for whom economic and psychological risk factors have

systematically stronger effects. This pattern is indicative of Blacks’ resilience

rather than vulnerability. This is important given that in discussing some health

disparities, scholars often use the terms vulnerable and minority populations in-

terchangeably (Hutchinson et al., 2007). For instance, Double Jeopardy (Dowd &

Bengtson, 1978), Triple Jeopardy (Bowleg, Huang, Brooks, Black, & Burkholder,

2003), and Multiple Jeopardy (King, 1988) and Multiple Disadvantage (Groll-

man, 2014) hypotheses have traditionally conceptualized minority populations as

vulnerable groups that are more susceptible to the effects of any additional risk

factor (King, 1988). Most of these frameworks conceptualize synergistic effects

of racial minority status and additional risk factors. The results reviewed in this

article, however, suggest that in most cases, race, per se, does not have synergis-

tic effects with additional risk factors. In contrast to all these theories, this line

of research has methodically documented Blacks’ systemic resilience instead of

their vulnerability. The reason Blacks suffer worse health outcomes is not because

they are vulnerable, but because they are disproportionately exposed to a large

number of economic and social adversities, and have less access to economic and

social buffers. Ironically, exposure and vulnerability move in opposite directions.

The social group that experiences more exposures to risk factors at the same time

shows a lower level of vulnerability.

Health Disparities due to Diminished Return among Black Americans 133

As a social group, Blacks suffer poor health outcomes despite their consis-

tent resilience to each individual risk factor. This phenomenon can be understood

by the law of small effects (Brown et al., 2014). According to this law, health

disparities are not a consequence of a few large factors, but rather are shaped

by multiple sets of small factors. Jackson, Govia, and Sellers (2010) have used

the term “rule of small effects” to describe social origins of racial health dis-

parities. Findings by our research team show that each risk factor results in a

smaller health decline for Blacks than Whites. While the term “rule of small

effects” is still true, the phrase “rule of smaller effects” may be more accu-

rate, as most of the effects are systematically smaller for Blacks, compared to

Whites.

Research Implications

Further research is needed on population variations and mechanisms behind

such variations in the effects of SDH and SES and the resulting health disparities

due to such diminished gain. For instance, additional research is needed on differ-

ential social, psychological, and biological costs of upward social mobility among

Blacks, particularly Black men (Fuller-Rowell & Doan, 2010). More research is

needed on relative contribution of the education system, labor market, correc-

tional system, and segregation in shaping differential effects based on race. This

is very important given the historic emphasis on the role of different distribution

of SES and SDH as causes of health disparity (Marmot, Allen, Bell, Bloomer, &

Goldblatt, 2012).

We also need to ascertain the most effective economic and social policies that

enable diverse populations to equally gain from their available resources. Overall,

we know very little about programs and policies that can undo “diminished return”

or “differential effects” (Assari & Caldwell, 2017a) among Blacks. In addition,

there is a need to identify and flag the interventions that have the potential to

improve the health of the population overall but may widen the health inequalities

and the gaps across population groups (Ceci & Papierno, 2005; Lorenc et al.,

2013). SES and SDH historically play a role in the causes of health disparity, thus

in the interest of alleviating this health disparity, it is important to identify causes

of this disparity across racial groups and to be able to identify and change social

and economic policies that disproportionately favor the initially advantaged as

opposed to the initially disadvantaged.

As the mechanisms that cause this health disparity across racial groups are

complex and multifaceted, research into its many sides and their intersections,

particularly research on the intersection of policy, social psychology, economics,

sociology, and public health, is required. We still do not know to what extent these

differential effects are due to culture and what proportion of them are due to social

structure (i.e., higher level policies and procedures that are in place as a part of

134 Assari

social structure and how the society functions as a system) (Krieger, 2012; Gee &

Ford, 2011).

There is also a need to study how culture and individual behaviors explain

the effect of poverty and economic disadvantage on health. Culture and social

norms may be particularly important in explaining Black–White differences in

diet, obesity, and diabetes (Carter & Assari, 2017). Racial and ethnic groups use

different coping behaviors that are learned from their culture (LaVeist, Thorpe,

Pierre, Mance, & Williams, 2014). For instance, Black women may have a higher

tolerance toward larger body sizes and obesity, as a cultural adaptation to economic

adversity and neighborhood danger (Pope, Corona, & Belgrave, 2014). As a result,

larger body size is not perceived as obesity and may not initiate weight control

behaviors in Black women, which has implications for high prevalence of obesity,

even at high SES levels (Assari & Lankarani, 2015). While Black women may have

a higher tendency to turn to comfort food to cope with stress, Black men may have

a higher tendency to turn to substances, particularly alcohol (Jackson, Knight, &

Rafferty, 2010). These patterns may explain why high SES may fail to protect Black

women against obesity (Assari, Nikahd, Malekahmadi, Lankarani, & Zamanian,

2016). For example, Black men and Black women show different associations

between obesity and depression (Assari, 2014). Surprisingly, depression reduces

rather than increases the risk of obesity for Black men; this is not true for Black

women (Assari, 2014). These findings speak to the complex and multiplicative

effects of race, gender, SES, culture, and individual behaviors on health (Assari,

2014).

Because of this complexity, future research should consider an intersectional-

ity framework to study the nonlinear and multiplicative effects of race, gender, and

class on health. The concept that it is not simply race but the intersection of race,

gender, and class that shapes access to opportunity structure and the impact of

stress is a cornerstone of the intersectionality framework (Bauer, 2014). According

to this theory, it is not an individual identity, but the intersections of multiple iden-

tities that determines exposures and vulnerabilities to risk and protective factors

(Collins, 2015; Hancock, 2007). This is supported by the considerable theoretical

and empirical work on cultural moderation hypothesis (Markus and Kitayama,

1991). Based on this hypothesis, cultural groups differ in the associations between

SES, emotions, and health outcomes. For instance, the associations between SES,

affect, inflammation, and health outcomes are also stronger for Whites than Asians

(Kitayama & Park, 2010). Among Blacks, men and women differ in the type of

health outcomes that follow their exposure to stress (Assari & Lankarani, 2017;

Assari, Smith, Caldwell, & Zimmerman, 2015).

Health Disparities due to Diminished Return among Black Americans 135

Summary

Refuting the arguments that racial disparities are due to biologically inherent

deficits in Blacks (e.g., Herrnstein & Murray, 2010), this article demonstrates

that racial differences in health are due to social rather than biological processes.

In contrast to the argument by Herrnstein & Murray (2010) who conceptualize

racial differences in assets due to biological (i.e., fixed and unmodifiable) factors,

the current article provides evidence that Black–White differences are primarily

due to society’s hindrance of Blacks’ potential to achieve tangible gains from the

resources in their environment. Blacks’ diminished health gain does not indicate

an inability to use the resources available to them nor a mismanagement of assets.

Rather, Blacks’ diminished gain should be viewed as a consequence of American

society’s historical mistreatment of Blacks. Similarly, the larger effects of risk

factors for Whites should not be interpreted as Whites’ fragility (i.e., due to

biology). The finding that Whites exhibit a greater health decline in response to a

decline in resources should be attributed to their historical social dominance and

privileged life.

Neither Whites nor Blacks should be blamed for the differential effects dis-

cussed here. Such differential effects are not innate but due to American social

structure. Such differential effects will continue until structural racism in U.S.

institutions is eliminated. Unless a drastic change is made, Blacks and Whites will

not similarly benefit from the same social and economic resources. In the absence

of such changes, upward social mobility will be always associated with extra

social, psychological, and physiological costs for Blacks compared to Whites.

Of course, these findings should not encourage redirection of investments from

Blacks to Whites, with the excuse that such reforms would have larger returns for

Whites.

In closing, we must acknowledge that most of the findings cited in this

article are correlational. Thus, causality can be only suggested, but not proven.

Many of these findings derived from longitudinal studies come with measurement

biases, residual confounding variables, selection bias due to differential attrition,

and lower sample size of Blacks. These all threaten the validity of any causal

conclusions. However, we do not believe these findings can be easily explained

by methodological shortcomings, as they are robust across settings, predictors,

outcomes, cohorts, and age groups. Further, the causal inferences made in this

article seem to be the most reasonable and parsimonious interpretations of the

differential associations we have reported.

It seems quite unlikely that ethical experimental studies in which, for example,

resources are systematically provided to one group and not to another can ever be

conducted. Perhaps, however, more sophisticated analytical methods may permit

stronger causal inferences. Such methods and further research on differential

136 Assari

exposure and differential gain may provide us with more insight into the causes

of racial disparities in health and lead to new policies to address these disparities.

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at University of Michigan, Ann Arbor. He holds affiliate faculty appointments

at the Center for Research on Ethnicity, Culture, and Health (CRECH), Poverty

Solutions, and the Institute for Healthcare Policy and Innovation (IHPI). He studies

the differential effects of social risk and protective factors by race, gender, class,

and place. Instead of main and universal effects, his research has focused on how

the intersections of race, ethnicity, gender, class, and place alter the social processes

behind illness and health. With more than 15 years of post-graduate research

experience, he has authored more than 200 peer-reviewed papers. He is an elected

fellow of the New York Academy of Medicine (NYAM), Society of Behavioral

Medicine (SBM), and the American Academy of Health Behavior (AAHB). He has

chaired committees and councils for American College of Epidemiology (ACE)

and AAHB, and is currently the president of the Scientific Association for Public

Health in Iran (SAPHIR).

Structural Racism, Healthcare Policy, and Their Impact on Health Disparities Among Underserved Populations in the United States

Article

Full-text available

Mar 2025

Olu Mbanugo

ABSTRACT: Structural racism is a deeply embedded determinant of health disparities in the United States, disproportionately affecting underserved populations, including racial minorities and low-income communities. Historical and systemic inequities in housing, employment, education, and environmental exposure contribute to adverse health outcomes, perpetuating disparities in disease prevalence, life expectancy, and access to quality healthcare. Healthcare policy plays a pivotal role in either mitigating or exacerbating these disparities, with legislative frameworks, insurance coverage, and institutional practices shaping healthcare accessibility and quality. Despite reforms such as the Affordable Care Act (ACA), racial and socioeconomic gaps in healthcare persist due to structural barriers, including discriminatory provider practices, limited healthcare infrastructure in marginalized communities, and socioeconomic constraints preventing equitable access to preventive care and treatment. Policies that fail to account for the disproportionate burden of chronic diseases, mental health issues, and maternal health crises among marginalized groups further entrench disparities. Additionally, underfunding of healthcare facilities serving predominantly minority populations exacerbates inequities, limiting access to specialized care and advanced medical technologies. Addressing structural racism in healthcare requires policy interventions that promote equity-driven resource allocation, culturally competent care, and accountability measures for discriminatory practices. AI-driven healthcare solutions, telemedicine expansion, and public-private partnerships offer promising avenues for reducing disparities by improving accessibility and affordability. However, ethical considerations, data biases, and regulatory challenges must be addressed to ensure these innovations serve all populations equitably. This study examines the intersection of structural racism and healthcare policy, evaluating their collective impact on health disparities and proposing evidence-based strategies for equitable healthcare reform.

Digital Conversations about Severe Depression Symptoms Across Different Ethnic and Racial Groups: A Big-data, Machine Learning Analysis

Article

Mar 2025

Background: Although studies have explored the use of technology and social media to help minorities suffering from depression, prior research has not thoroughly analyzed the racial and ethnic variation in the digital conversations related to symptoms of severe depression across racial/ethnic groups in the United States (U.S.). Method: Machine-learning methods were used to extract open-source online conversations in the US from February 1, 2019, to November 1, 2020. The information included self-identified racial/ethnic groups: Hispanics, Non-Hispanic whites (NHw), African Americans and Asian Americans. Symptoms of Severe Depression were defined by the term “depression” and included at least two of the pre-determined severity adjectives described by the users in the conversation. Analyses were conducted for four domains: 1) Topics Generated, 2) Sentiments, 3) Mindset, and 4) Path to Treatment. Results: A total of 1.3 million unique conversations referring to symptoms of severe depression posted during the selected period were analyzed. Conversations were most frequent among NHw 54%, Hispanics 21%, African Americans 20%, and 6% Asian Americans. Conversations were different across racial and ethnic groups: NHw talked more about diagnosis, making their conversations along the path to treatment more balanced out between the stages. They were more proactive than any other racial/ethnic groups. Depression was perceived as a more social phenomenon among African Americans. Asian Americans had the highest percentage of positive sentiment oriented toward the world and the future. Hispanics were less proactive, more negative, symptomatic, and less involved in treatment when compared with the conversations of other individuals of other racial/ethnic groups. Conclusions: In conclusion, we have shown that conversations referring to symptoms of depression differs by race/ethnicity, and that these results highlight opportunities for culturally competent approaches to address areas amenable to change that could impact the ability of people to seek and receive mental health support. Future studies identifying ethnic/racial variations in severe depression symptoms may help to improve equity in mental health care.

Intersecting race/ethnicity and gender in physiological dysregulation profiles and associations with socioeconomic status among older adults in the United States

Article

Apr 2025

Reported Racial Discrimination in Healthcare Settings and Impacts on Health Outcomes in a Racially Diverse Sample in the United States: Findings from the Behavioral Risk Factor Surveillance System

Article

Apr 2025

Healthcare racial discrimination remains a barrier to optimal health outcomes. While organizations have implemented initiatives to reduce discrimination in healthcare systems, it’s unclear whether these efforts have improved health outcomes. This study examines the association between healthcare racial discrimination and health outcomes among Black non-Hispanic, Hispanic, and White non-Hispanic participants. Using 2014 Behavioral Risk Factor Surveillance System data (n = 22,610), we conducted logistic regression models to examine the associations between healthcare discrimination and health outcomes, adjusting for sociodemographic factors. We then stratified models by race/ethnicity to assess differential effects for each race or ethnic group. In adjusted models, Black and Hispanic participants were more likely to experience physical (Black-adjusted odds ratio [aOR]=2.18; 95% confidence interval [CI]= 2.15-2.21), (Hispanic-aOR=1.36; 95% CI=1.22-1.25), emotional symptoms (Black-aOR=3.04; 95% CI=3.01-3.07), (Hispanic-aOR=1.39; 95% CI=1.37-1.40) and fair or poor health status (Black-aOR=1.15; 95% CI=1.14-1.16), (Hispanic-aOR=1.10; 95% CI=1.09-1.10) than White participants. In stratified analyses, reports of healthcare discrimination were associated with a greater likelihood of negative health outcomes. Healthcare Discrimination had the strongest effect on physical symptoms among White participants (aOR = 8.15, 95% CI = 8.01–8.29), emotional symptoms among Hispanic participants (aOR = 7.30, 95% CI = 7.16–7.44) and fair/poor health among Black participants (aOR = 2.31, 95% CI = 2.26–2.53). Healthcare discrimination is a significant predictor of poor health, with varying impacts across racial groups. Addressing these inequities requires eliminating provider bias, improving racial concordance in care, and expanding data collection on healthcare discrimination to assess the effectiveness of health equity initiatives.

Race, wealth and health: The role of reparations

Article

Mar 2025
SOC SCI MED

State Minimum Wage and Food Insecurity Among US Households With Children

Article

Mar 2025

Importance Food insecurity among households with children and economic hardship is a persistent US challenge. Federal food assistance programs have been unable to fully address food insecurity, leading to interest in the role other labor and economic policies could play. One relevant state-level policy that has received limited attention is the state minimum wage. Objective To assess whether state minimum wage generosity was associated with change in food insecurity among households with children and explore differential policy impacts across sociodemographic groups. Design, Setting, and Participants This cross-sectional study of a national sample of US households from the Current Population Survey used a 2-way fixed effects modeling approach to test whether increases in state minimum wage from 2005 to 2022 were associated with improvements in food insecurity controlling for household- and state-level time-varying covariates. Working households with children who were most likely to be affected by policy changes (ie, limited educational attainment) were included. Analyses were conducted in July through September 2024. Exposure The 2022 inflation-adjusted effective minimum wage for each state in December which was derived from legal sources. Main Outcomes and Measures Past-month household food insecurity assessed in December 2022. Results The sample of 97 944 working households with children and limited educational attainment were mostly female headed (54 077 [55.2%]) with a mean (SD) 1.8 (1.1) children in the home; 22 130 households (22.6%) reported Hispanic identity, 10 545 non-Hispanic Black (10.8%), and 59 500 non-Hispanic White (60.8%). Inflation-adjusted state minimum wage ranged from

7.15 to

16.85 over the 18-year study period. We observed that a 10% increase in the state minimum wage was significantly associated with a 0.39 percentage point reduction (95% CI, −0.74 to −0.04 percentage points; P = .03) in food insecurity. There was limited evidence of differences in the association across race and ethnicity, participation in the US Supplemental Nutrition Assistance Program, or household composition. Conclusions and Relevance In this pooled cross-sectional study, findings suggest that state legislatures that elected to increase their state minimum wage may have also improved state food security rates among households with children at risk for economic hardship. Findings provide policymakers with actionable evidence to consider in setting minimum wages that could reduce the burden of food insecurity among US children and families.

How Intersectional Identity and Discrimination Contribute to Depressive Symptoms and Hair Cortisol Concentrations among Low-Income, Racially and Sexual Diverse Adults

Article

Mar 2025
PSYCHONEUROENDOCRINO

Academic Aspirations of 12th Grade Students in the United States: Place-Based Diminished Returns of Parental Education in Rural Areas

Article

Mar 2025

Background The Motivational Theory of Life-Span Development suggests that individual aspirations are shaped by both internal and external resources. Parental education is a key determinant of educational aspirations, yet its effects may vary by geographic location, demonstrating spatial patterns of Minorities’ Diminished Returns (MDRs). Objectives This study examines the association between parental education and aspirations for graduate or professional education among non-Latino White adolescents, with a specific focus on urban-suburban versus rural differences. Methods Using data from the 12th-grade cohort of the Monitoring the Future (MTF) 2024 survey, we conducted multivariate analyses to assess the relationship between parental education and aspirations for graduate or professional education. We further examined whether this association was moderated by geographic location (urban-suburban vs. rural) to identify place-based MDRs. Results Higher parental education was associated with greater aspirations for advanced education; however, this effect was weaker in rural areas compared to urban and suburban settings. These findings highlight that even among non-Latino White adolescents, rural residence diminishes the benefits of socioeconomic resources, providing evidence of place-based MDRs. Conclusion Rural residents face a dual disadvantage—both lower socioeconomic status and weaker returns on those resources—necessitating targeted interventions beyond resource allocation. To address disparities in educational aspirations in rural areas, policymakers should focus on improving equitable access to educational opportunities and ensuring that these resources translate into comparable outcomes across different social and geographic contexts.

Demographics and Trends in Outpatient Surgery for Laryngeal Cancer: 2016-2021

Article

Mar 2025
OTOLARYNG HEAD NECK

Objective: To analyze the utilization patterns of outpatient laryngoscopic excision procedures for laryngeal cancer in the United States, examining procedural costs and patient demographics to identify disparities in healthcare access. Study design: Retrospective cohort study. Setting: National Ambulatory Surgery Sample database of major ambulatory surgeries in the United States, 2016-2021. Methods: Encounters for endoscopic resection of laryngeal cancers were identified focusing on patient demographics and procedural costs. Analysis was performed regarding trends over time. Results: Of 11,371 encounters in 2016-2021, patients were mostly male (82.6%), White (75.3%), and living in metropolitan areas with greater than 1 million residents (54.1%), with an even distribution between income quartiles. Predictors of utilization at urban teaching hospitals progressively decreased in patients residing in smaller metropolitan areas (250-999,000 residents (odds ratio [OR] = 0.451, P ≤ .0001) and 50-249,000 residents (OR = 0.193, P ≤ .0001). Higher utilization was found in non-White patients (Black [OR = 1.673, P = .0075], Hispanic [OR = 1.752, P = .0118]), and those with patients with higher income (2nd quartile [OR = 1.411, P = .0058], 3rd quartile [OR = 2.017, P ≤ .0001], and 4th quartile [OR = 4.422, P < .0001]). These findings were consistent on multivariate analysis, however belonging to a racial minority lost significance (Black patients [P = .0508], Hispanic [P = .3008]). Conclusion: There are existing disparities in endoscopic resection of laryngeal cancers. Our findings add to the literature underscoring the importance of expanding access to minimally invasive laryngeal preserving surgical treatment.

Black-White Differences Related to Ageism and Health: Evidence from the Experiences of Aging in Society Project

Article

Mar 2025

Age-based stereotypes, prejudices, and discrimination (ageism) are implicated in poor health, yet it is unclear if all groups of older adults experience the same amounts, types, and outcomes of ageism. This exploratory study investigated differences in ageism and health among Black and White USA adults ages 50 + who participated in the Experiences of Aging in Society project (2021–2023) (N = 131; 78% female, 46% Black, mean age 70). We compared amounts and types of self-reported ageism by race using three measures: Everyday Ageism Scale, Expectations Regarding Aging Survey, and Everyday Discrimination Scale when attributed to age. We identified racial differences in associations between ageism and the number of chronic health conditions participants had using z-tests of racially-stratified regression parameters. Black and White older adults generally reported comparable amounts of ageism across measures. Everyday ageism was associated with more chronic conditions at comparable levels by race, though findings suggested race-specific patterns in the most influential types: Black adults-age discrimination and White adults-internalized ageism. Positive expectations of aging and everyday discrimination attributed to age were associated with the health of White but not Black adults; only the former demonstrated significant race differences. While Black and White older adults may report comparable exposure to ageism, race may contribute to divergent mechanisms of risk and health consequences. Findings endorse the Everyday Ageism Scale for ageism-health research including Black adults and all measures for exclusively White samples. Interventions promoting older adult health may benefit from attending to similarities and differences at the intersection of ageism and race.

Unequal Gain of Equal Resources across Racial Groups

Article

Full-text available

Jan 2018
IJHPM

Shervin Assari

The health effects of economic resources (eg, education, employment, and living place) and psychological assets (eg, self-efficacy, perceived control over life, anger control, and emotions) are well-known. This article summarizes the results of a growing body of evidence documenting Blacks’ diminished return, defined as a systematically smaller health gain from economic resources and psychological assets for Blacks in comparison to Whites. Due to structural barriers that Blacks face in their daily lives, the very same resources and assets generate smaller health gain for Blacks compared to Whites. Even in the presence of equal access resources and assets, such unequal health gain constantly generates a racial health gap between Blacks and Whites in the United States. In this paper, a number of public policies are recommended based on these findings. First and foremost, public policies should not merely focus on equalizing access to resources and assets, but also reduce the societal and structural barriers that hinder Blacks. Policy solutions should aim to reduce various manifestations of structural racism including but not limited to differential pay, residential segregation, lower quality of education, and crime in Black and urban communities. As income was not found to follow the same pattern demonstrated for other resources and assets (ie, income generated similar decline in risk of mortality for Whites and Blacks), policies that enforce equal income and increase minimum wage for marginalized populations are essential. Improving quality of education of youth and employability of young adults will enable Blacks to compete for high paying jobs. Policies that reduce racism and discrimination in the labor market are also needed. Without such policies, it will be very difficult, if not impossible, to eliminate the sustained racial health gap in the United States.

Blacks’ Diminished Health Return of Family Structure and Socioeconomic Status; 15 Years of Follow-up of a National Urban Sample of Youth

Article

Full-text available

Dec 2017

The protective effect of family structure and socioeconomic status (SES) on physical and mental health is well established. There are reports, however, documenting a smaller return of SES among Blacks compared to Whites, also known as Blacks’ diminished return. Using a national sample, this study investigated race by gender differences in the effects of family structure and family SES on subsequent body mass index (BMI) over a 15-year period. This 15-year longitudinal study used data from the Fragile Families and Child Wellbeing Study (FFCWS), in-home survey. This study followed 1781 youth from birth to age 15. The sample was composed of White males (n = 241, 13.5%), White females (n = 224, 12.6%), Black males (n = 667, 37.5%), and Black females (n = 649, 36.4%). Family structure and family SES (maternal education and income to need ratio) at birth were the independent variables. BMI at age 15 was the outcome. Race and gender were the moderators. Linear regression models were run in the pooled sample, in addition to race by gender groups. In the pooled sample, married parents, more maternal education, and income to need ratio were all protective against high BMI of youth at 15 years of age. Race interacted with family structure, maternal education, and income to need ratio on BMI, indicating smaller effects for Blacks compared to Whites. Gender did not interact with SES indicators on BMI. Race by gender stratified regressions showed the most consistent associations between family SES and future BMI for White females followed by White males. Family structure, maternal education, and income to need ratio were not associated with lower BMI in Black males or females. The health gain received from family economic resources over time is smaller for male and female Black youth than for male and female White youth. Equalizing access to economic resources may not be enough to eliminate health disparities in obesity. Policies should address qualitative differences in the lives of Whites and Blacks which result in diminished health returns with similar SES resources. Policies should address structural and societal barriers that hold Blacks against translation of their SES resources to health outcomes.

Eliminating Racism: Profiles in Controversy

Book

Full-text available

Jan 1988

The chapters presented here provide the reader with an awareness of the divergent views of what constitutes racism and frameworks for reducing it. This book points out that the dialogue and research on this subject since the mid-1970s have yielded increased contro versy over the theories, foundation, and continued existence of racism. Ironically, what we viewed in the 1954Brown decision and the Civil Rights Act of 1964as the beginning of the end of racism turned out to be the beginning of confusion over the course of action to ensure societal acceptance of political mandates. Hence, the title of this book captures the essence of the emotional core of any forum for examining racism, past and present. One of the most controversial forums has been that ofeducation, beginning with the D.S. Supreme Court's 1954ruling in Brown v. Board oi Education. Behind every event that has spawned controversy is a profile in courage. It was not a simple decision for the players in the scenario of the Brown v. Board oi Education case to step forward and present themselves as evidence of discrimination. Blackparents supported by black organizations viewed this legal action as a chance for equal opportunity. Yet, the 1950s were a time when black communities were pained by the thought that bigotry and institutional racism would forever stand in the way of their achieving equality.

Whites but Not Blacks Gain Life Expectancy from Social Contacts

Article

Full-text available

Oct 2017

Shervin Assari

Background. Recent research suggests that the health gain from economic resources and psychological assets may be systematically larger for Whites than Blacks. Aim. This study aimed to assess whether the life expectancy gain associated with social contacts over a long follow up differs for Blacks and Whites. Methods. Data came from the Americans’ Changing Lives (ACL) Study, 1986–2011. The sample was a nationally representative sample of American adults 25 and older, who were followed for up to 25 years (n = 3361). Outcome was all-cause mortality. The main predictor was social contacts defined as number of regular visits with friends, relatives, and neighbors. Baseline demographics (age and gender), socioeconomic status (education, income, and employment), health behaviors (smoking and drinking), and health (chronic medical conditions, obesity, and depressive symptoms) were controlled. Race was the focal moderator. Cox proportional hazard models were used in the pooled sample and based on race. Results. More social contacts predicted higher life expectancy in the pooled sample. A significant interaction was found between race and social contacts, suggesting that the protective effect of more social contacts is smaller for Blacks than Whites. In stratified models, more social contacts predicted an increased life expectancy for Whites but not Blacks. Conclusion. Social contacts increase life expectancy for White but not Black Americans. This study introduces social contacts as another social resource that differentially affects health of Whites and Blacks.

Psychological pathways from racial discrimination to cortisol in African American males and females

Article

Full-text available

Apr 2018
J BEHAV MED

The association between racial discrimination (discrimination) and stress-related alterations in the neuroendocrine response—namely, cortisol secretion—is well documented in African Americans (AAs). Dysregulation in production of cortisol has been implicated as a contributor to racial health disparities. Guided by Clark et al. (Am Psychol 54(10):805–816, 1999. doi:10.1037/0003-066X.54.10.805) biopsychosocial model of racism and health, the present study examined the psychological pathways that link discrimination to total cortisol concentrations in AA males and females. In a sample of 312 AA emerging adults (45.5% males; ages 21–23), symptoms of anxiety, but not depression, mediated the relation between discrimination and total concentrations of cortisol. In addition, the results did not reveal sex differences in the direct and indirect pathways. These findings advance our understanding of racial health disparities by suggesting that the psychological consequences of discrimination can uniquely promote physiologic dysregulation in AAs.

Neuroticism Predicts Subsequent Risk of Major Depression for Whites but Not Blacks

Article

Full-text available

Sep 2017

Shervin Assari

Cultural and ethnic differences in psychosocial and medical correlates of negative affect are well documented. This study aimed to compare blacks and whites for the predictive role of baseline neuroticism (N) on subsequent risk of major depressive episodes (MDD) 25 years later. Data came from the Americans’ Changing Lives (ACL) Study, 1986–2011. We used data on 1219 individuals (847 whites and 372 blacks) who had data on baseline N in 1986 and future MDD in 2011. The main predictor of interest was baseline N, measured using three items in 1986. The main outcome was 12 months MDD measured using the Composite International Diagnostic Interview (CIDI) at 2011. Covariates included baseline demographics (age and gender), socioeconomics (education and income), depressive symptoms [Center for Epidemiologic Studies Depression Scale (CES-D)], stress, health behaviors (smoking and driking), and physical health [chronic medical conditions, obesity, and self-rated health (SRH)] measured in 1986. Logistic regressions were used to test the predictive role of baseline N on subsequent risk of MDD 25 years later, net of covariates. The models were estimated in the pooled sample, as well as blacks and whites. In the pooled sample, baseline N predicted subsequent risk of MDD 25 years later (OR = 2.23, 95%CI = 1.14–4.34), net of covariates. We also found a marginally significant interaction between race and baseline N on subsequent risk of MDD (OR = 0.37, 95% CI = 0.12–1.12), suggesting a stronger effect for whites compared to blacks. In race-specific models, among whites (OR = 2.55; 95% CI = 1.22–5.32) but not blacks (OR = 0.90; 95% CI = 0.24–3.39), baseline N predicted subsequent risk of MDD. Black-white differences in socioeconomics and physical health could not explain the racial differences in the link between N and MDD. Blacks and whites differ in the salience of baseline N as a psychological determinant of MDD risk over a long period of time. This finding supports the cultural moderation hypothesis and is in line with other previously reported black–white differences in social, psychological, and medical correlates of negative affect and depression.

Racial Discrimination in Health Care Is Associated with Worse Glycemic Control among Black Men but Not Black Women with Type 2 Diabetes

Article

Full-text available

Sep 2017

Background A growing body of research suggests that racial discrimination may affect the health of Black men and Black women differently. Aims This study examined Black patients with diabetes mellitus (DM) in order to test gender differences in (1) levels of perceived racial discrimination in health care and (2) how perceived discrimination relates to glycemic control. Methods A total of 163 Black patients with type 2 DM (78 women and 85 men) provided data on demographics (age and gender), socioeconomic status, perceived racial discrimination in health care, self-rated health, and hemoglobin A1c (HbA1c). Data were analyzed using linear regression. Results Black men reported more racial discrimination in health care than Black women. Although racial discrimination in health care was not significantly associated with HbA1c in the pooled sample (b = 0.20, 95% CI = −0.41 −0.80), gender-stratified analysis indicated an association between perceived discrimination and higher HbA1c levels for Black men (b = 0.86, 95% confidence intervals (CI) = 0.01–1.73) but not Black women (b = −0.31, 95% CI = −1.17 to −0.54). Conclusion Perceived racial discrimination in diabetes care may be more salient for glycemic control of Black men than Black women. Scholars and clinicians should take gender into account when considering the impacts of race-related discrimination experiences on health outcomes. Policies should reduce racial discrimination in the health care.

Income Redistribution Predicts Greater Life Satisfaction Across Individual, National, and Cultural Characteristics

Article

Full-text available

Aug 2017

Felix Cheung

The widening income gap between the rich and the poor has important social implications. Governmental-level income redistribution through tax and welfare policies presents an opportunity to reduce income inequality and its negative consequences. The current longitudinal studies examined whether within-region changes in income redistribution over time relate to life satisfaction. Moreover, I examined potential moderators of this relationship to test the strong versus weak hypotheses of income redistribution. The strong hypothesis posits that income redistribution is beneficial to most. The weak hypothesis posits that income redistribution is beneficial to some and damaging to others. Using a nationally representative sample of 57,932 German respondents from 16 German states across 30 years (Study 1) and a sample of 112,876 respondents from 33 countries across 24 years (Study 2), I found that within-state and within-nation changes in income redistribution over time were associated with life satisfaction. The models predicted that a 10% reduction in Gini through income redistribution in Germany increased life satisfaction to the same extent as an 37% increase in annual income (Study 1), and a 5% reduction in Gini through income redistribution increased life satisfaction to the same extent as a 11% increase in GDP (Study 2). These associations were positive across individual, national, and cultural characteristics. Increases in income redistribution predicted greater satisfaction for tax-payers and welfare-receivers, for liberals and conservatives, and for the poor and the rich. These findings support the strong hypothesis of income redistribution and suggest that redistribution policies may play an important role in societal well-being. (PsycINFO Database Record

Positive and Negative Affect More Concurrent among Blacks than Whites

Article

Full-text available

Aug 2017

Background: While positive and negative affect are inversely linked, people may experience and report both positive and negative emotions simultaneously. However, it is unknown if race alters the magnitude of the association between positive and negative affect. The current study compared Black and White Americans for the association between positive and negative affect. Methods: We used data from MIDUS (Midlife in the United States), a national study of Americans with an age range of 25 to 75. A total number of 7108 individuals were followed for 10 years from 1995 to 2004. Positive and negative affect was measured at baseline (1995) and follow-up (2004). Demographic (age and gender), socioeconomic (education and income) as well as health (self-rated health, chronic medical conditions, and body mass index) factors measured at baseline were covariates. A series of linear regressions were used to test the moderating effect of race on the reciprocal association between positive and negative affect at baseline and over time, net of covariates. Results: In the pooled sample, positive and negative affect showed inverse correlation at baseline and over time, net of covariates. Blacks and Whites differed in the magnitude of the association between positive and negative affect, with weaker inverse associations among Blacks compared to Whites, beyond all covariates. Conclusion: Weaker reciprocal association between positive and negative affect in Blacks compared to Whites has implications for cross-racial measurement of affect and mood, including depression. Depression screening programs should be aware that race alters the concordance between positive and negative affect domains and that Blacks endorse higher levels of positive affect compared to Whites in the presence of high negative affect.

High Risk of Depression in High-Income African American Boys

Article

Aug 2017

Background: Despite the well-established literature on the protective effect of socioeconomic status (SES) on physical and mental health, there are a few reports on poor mental health of blacks with high SES. Using a national sample, this study investigated the association between household income and risk of major depressive disorder (MDD) in black youth based on ethnicity, gender, and their intersection. Methods: One thousand one hundred seventeen black adolescents (810 African Americans and 360 Caribbean blacks) were included in the current study. Household income was the main predictor. MDD (lifetime, 12-month, and 30-day) was the main outcome. Age was the covariate. Ethnicity and gender were the focal moderators. Logistic regressions were used for data analysis. Results: In the pooled sample, household income was not associated with risk of MDD (lifetime, 12-month, or 30-day). We found significant interactions between income and gender on lifetime and 12-month MDD, suggesting a stronger protective effect of income on MDD for females than males. We also found significant interaction between income and ethnicity on 30-day MDD, suggesting stronger protective effect of income against MDD for Caribbean blacks than African Americans. In African American males, high household income was associated with higher risk of lifetime, 12-month, and 30-day MDD. For Caribbean black males and females, high household income was associated with lower odds of 30-day MDD. Conclusion: Findings suggest that ethnicity and gender influence how socioeconomic resources such as income are associated with MDD risk among black youth. Higher household income may be associated with higher risk of MDD for African American males.

Health Disparities due to Diminished Return among Black Americans: Public Policy Solutions

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