Cross-Sectional Association between Perceived Discrimination and
Hypertension in African-American Men and Women
The Pitt County Study
Calpurnyia B. Roberts1, Anissa I. Vines1, Jay S. Kaufman1, and Sherman A. James2
1Department of Epidemiology, School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC.
2Terry Sanford Institute of Public Policy, Duke University, Durham, NC.
Received for publication February 12, 2007; accepted for publication October 23, 2007.
Few studies have examined the impact of the frequency of discrimination on hypertension risk. The authors
assessed the cross-sectional associations between frequency of perceived racial and nonracial discrimination and
hypertension among 1,110 middle-aged African-American men (n ¼ 393) and women (n ¼ 717) participating in the
2001 follow-up of the Pitt County Study (Pitt County, North Carolina). Odds ratios were estimated using gender-
specific unconditional weighted logistic regression with adjustment for relevant confounders and the frequency of
discrimination. More than half of the men (57%) and women (55%) were hypertensive. The prevalences of per-
ceived racial discrimination, nonracial discrimination, and no discrimination were 57%, 29%, and 13%, respec-
tively, in men and 42%, 43%, and 15%, respectively, in women. Women recounting frequent nonracial
discrimination versus those reporting no exposure to discrimination had the highest odds of hypertension (adjusted
odds ratio ¼ 2.34, 95% confidence interval: 1.09, 5.02). A nonsignificant inverse odds ratio was evident in men who
perceived frequent exposure to racial or nonracial discrimination in comparison with no exposure. A similar
association was observed for women reporting perceived racial discrimination. These results indicate that the type
and frequency of discrimination perceived by African-American men and women may differentially affect their risk
African continental ancestry group; discrimination (psychology); hypertension; prejudice; sex factors; stress
Abbreviations: CI, confidence interval; OR, odds ratio.
In the United States, the prevalence of hypertension con-
tinues to rise, especially among Blacks, despite moderate
improvements in the treatment and control of hypertension
(1, 2). For example, from 1988–1994 to 1999–2002, in na-
tionally representative samples of Blacks and Whites aged
20 years or older, the prevalence of hypertension increased
from 33.9 percent to 38.6 percent in Black men and from
37.6 percent to 44.0 percent in Black women (3). In com-
parison with Blacks, the increases among White men (from
24.4 percent to 26.6 percent) and women (from 24.2 percent
to 29.6 percent) remained significantly lower in both time
periods (3). While obesity (4, 5), physical inactivity (6, 7),
socioeconomic status (3), and access to quality health care
(8–10) undoubtedly explain some of the residual differences
in Black Americans’ elevated risk of hypertension, there is
a growing interest in elucidating the potentially causal role
of less traditional risk factors, particularly discrimination
Jones describes discrimination as the ‘‘behavioral enact-
ment of prejudice, which can be defined as a negative
attitude towards a person or group based on social
comparisons’’ (13, p. 288). Negative attitudes attributed to
Correspondence to Calpurnyia B. Roberts, CB #8050, School of Public Health, University of North Carolina at Chapel Hill, Bank of America Bldg.,
Suite 306, 137 East Franklin Street, Chapel Hill, NC 27514 (e-mail: email@example.com).
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discrimination have been linked to adverse physiologic re-
actions involving blood pressure. Several studies have dem-
onstrated that in African Americans, short-term exposure to
racist stimuli via a speech task (14), film excerpts (15, 16),
and imagery tasks (17, 18) resulted in increases in diastolic
blood pressure (14–16), systolic blood pressure (15, 16), and
heart rate (17, 18) reactivity, respectively. Researchers have
hypothesized that the chronic triggering of these cardiovas-
cular reactions due to discrimination could lead to the de-
velopment of hypertension (19). Thus, reducing stress
caused by discrimination could alleviate the excess burden
of hypertension and other health inequalities experienced by
African-American men and women.
To date, published research on the association between
perceived exposure to racial discrimination and blood pres-
sure in Black Americans has produced mixed findings (12),
with several studies reporting either a positive association
(20) or an inverse association (21) and others reporting null
associations (22–25). Important associations between blood
pressure and racial discrimination have been observed in
persons born outside of the United States (22), persons of
higher socioeconomic status (23), working-class persons
(24), and older persons (25). Interstudy differences in sam-
ple selection, sample characteristics, and the measurement
of perceived discrimination could account for these mixed
results (19, 26). In addition, hypertension was self-reported
in half of these studies (20–22), which may have caused
Further, there are several unresolved methodological
issues in the literature on discrimination and health (11, 12,
19). These include (but are not limited to) ascertaining the
relative influence of the frequency of perceived discrimina-
tion versus the intensity of perceived discrimination and the
effect (e.g., dose-response or threshold) that these qualita-
tive measures may exert on health outcomes (12, 19). It is
also pertinent to consider the impact of perceived nonracial
forms of discrimination as well as racial forms by gender,
since Black women and men may experience and react dif-
ferently to discrimination, which may differentially affect
their blood pressure (19, 21, 24).
Our goals in this study were to obtain additional insight
into the potential impact of discrimination on the risk of
hypertension in African Americans by addressing the fol-
lowing three research questions: 1) Compared with persons
reporting never perceiving racial discrimination, does per-
ceiving racial or nonracial (e.g., ageism, sexism) discrimi-
nation increase the odds of hypertension? 2) Does the
frequency of perceived racial or nonracial discrimination
modify the observed associations in a dose-response man-
ner? 3) Do these associations differ by gender?
MATERIALS AND METHODS
Data for this study came from the 2001 follow-up survey
of African Americans in the Pitt County Study, carried out
in Pitt County, North Carolina. The Pitt County Study was
initiated in 1988 for the purpose of identifying social, eco-
nomic, and behavioral precursors of hypertension and re-
lated disorders among African Americans aged 25–50 years
at baseline. Neighborhoods containing middle-class African-
American households were oversampled in order to
achieve an economically diverse study population. Of the
2,225 race- and age-eligible persons, 1,773 (80 percent; 661
men and 1,112 women) were interviewed (27). In 2001,
household interviews were sought with all cohort members
believed to be alive, noninstitutionalized, and residing
within a 100-mile (160-km) radius of Greenville, North
Carolina, the county’s principal city. Of the 1,540 persons
(543 men and 997 women) meeting these criteria, 1,221 (79
percent; 428 men and 793 women) were reinterviewed. Of
these, 43 were excluded because of significant discrepancies
in birth year (?2 years) or height (?2 inches (?5 cm))
between the 1988 and 2001 surveys (28). Observations with
missing values for the outcome, main exposure, and poten-
tial confounders were also excluded (n ¼ 68). The final
study population included 1,110 participants (393 men
and 717 women), 63 percent of the original baseline cohort.
Measurement of perceived exposure to discrimination
In the 2001 follow-up survey, the Everyday Discrimina-
tion Scale designed by Williams et al. (29) was used to
measure exposure to unfair treatment due to race or other
factors. Seven of the original nine scale items were used in
the 2001 follow-up survey. For parsimony, two of the
items—‘‘people act as though they are better than
you’’ and ‘‘[people] think you are dishonest’’—were not
included, and two other items—‘‘being treated with less
courtesy’’ and ‘‘being treated with less respect’’—were
combined, for a total of six items. The participants were
asked whether 1) ‘‘you are treated with less courtesy or
respect than other people’’; 2) ‘‘you receive poorer service
than other people at restaurants or stores’’; 3) ‘‘people act as
if they think that you are not smart’’; 4) ‘‘people act as
though they are afraid of you’’; 5) ‘‘you are called names
or insulted’’; and 6) ‘‘you are threatened or harassed.’’ The
potential responses to each item focused on the frequency of
exposure: almost every day (score ¼ 5), at least once a week
(score ¼ 4), a few times a month (score ¼ 3), a few times
a year (score ¼ 2), less than once a year (score ¼ 1), or never
(score ¼ 0). Subsequently, respondents were asked to
choose the single most important reason for the reported
discrimination; the options included race, gender, age,
height or weight, shade of skin color, or other.
To answer the first research question, we created three
mutually exclusive exposure categories to represent the pri-
mary type of discrimination perceived by the participants.
The first category, perceived racial discrimination, consisted
of persons who attributed discrimination to their race or skin
color. The second category, perceived nonracial discrimina-
tion, was composed of persons who considered their expo-
sure to discrimination as deriving from factors other than
race or skin color. The third category, no perceived discrim-
ination, consisted of persons who answered ‘‘never’’ to all
six questions on the Everyday Discrimination Scale.
To test the second research question, we summed numer-
ical scores associated with the responses ‘‘never’’ to ‘‘almost
every day,’’ on a scale of 0 to 5. The total sum of the
scores ranged from 0 to 30 for each participant. Tertiles
Discrimination and Hypertension in African Americans625
Am J Epidemiol 2008;167:624–632
by guest on November 2, 2015
14. Guyll M, Matthews KA, Bromberger JT. Discrimination and
unfair treatment: relationship to cardiovascular reactivity
among African American and European American women.
Health Psychol 2001;20:315–25.
15. Armstead CA, Lawler KA, Gorden G, et al. Relationship of
racial stressors to blood pressure responses and anger expres-
sion in black college students. Health Psychol 1989;8:541–56.
16. Fang CY, Myers HF. The effects of racial stressors and hos-
tility on cardiovascular reactivity in African American and
Caucasian men. Health Psychol 2001;20:64–70.
17. Jones DR, Harrell JP, Morris-Prather CE, et al. Affective and
physiological responses to racism: the roles of Afrocentrism
and mode of presentation. Ethn Dis 1996;6:109–22.
18. Sutherland ME, Harrell JP. Individual differences in physio-
logical responses to fearful, racially noxious, and neutral im-
agery. Imagination Cogn Pers 1986;6:133–50.
19. Krieger N. Discrimination and health. In: Berkman L,
Kawachi I, eds. Social epidemiology. New York, NY: Oxford
University Press, 2000:36–75.
20. James SA, LaCroix AZ, Kleinbaum DG, et al. John Henryism
and blood pressure differences among black men. II. The role
of occupational stressors. J Behav Med 1984;7:259–75.
21. Krieger N. Racial and gender discrimination: risk factors for
high blood pressure? Soc Sci Med 1990;30:1273–81.
22. Cozier Y, Palmer JR, Horton NJ, et al. Racial discrimination
and the incidence of hypertension in US black women. Ann
23. Dressler WW. Lifestyle, stress, and blood pressure in a south-
ern black community. Psychosom Med 1990;52:182–98.
24. KriegerN, SidneyS. Racial discrimination andblood pressure:
the CARDIA Study of young black and white adults. Am J
Public Health 1996;86:1370–8.
25. Peters RM. Racism and hypertension among African Ameri-
cans. West J Nurs Res 2004;26:612–31.
26. Karlsen S, Nazroo JY. Measuring and analyzing ‘‘race,’’ rac-
ism, and racial discrimination. In: Oakes JM, Kaufman JS, eds.
Methods in social epidemiology. San Francisco, CA: Jossey-
27. Strogatz DS, James SA, Haines PS, et al. Alcohol consumption
and blood pressure in black adults: The Pitt County Study. Am
J Epidemiol 1991;133:442–50.
28. James SA, Van Hoewyk J, Belli RF, et al. Life-course socio-
economic position and hypertension in African American
men: The Pitt County Study. Am J Public Health 2006;96:
29. Williams DR, Yu Y, Jackson JS, et al. Racial differences
in physical and mental health: socioeconomic status, stress,
and discrimination. Am J Health Psychol 1997;2:335–51.
30. Chobanian AV, Bakris GL, Black HR, et al. The seventh report
of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure: the JNC 7
report. JAMA 2003;289:2560–72.
31. Centers for Disease Control and Prevention. Defining over-
weight and obesity. Atlanta, GA: Centers for Disease Control
and Prevention, 2006. (http://www.cdc.gov/nccdphp/dnpa/
32. Strogatz DS, Croft JB, James SA, et al. Social support, stress,
and blood pressure in black adults. Epidemiology 1997;8:
33. James SA, Keenan NL, Strogatz DS, et al. Socioeconomic
status, John Henryism, and blood pressure in black adults.
The Pitt County Study. Am J Epidemiol 1992;135:
34. James SA, Hartnett SA, Kalsbeek WD. John Henryism and
blood pressure differences among black men. J Behav Med
35. James SA, Strogatz DS, Wing SB, et al. Socioeconomic status,
John Henryism, and hypertension in blacks and whites. Am J
36. Duijkers TJ, Drijver M, Kromhout D, et al. ‘‘John Henryism’’
and blood pressure in a Dutch population. Psychosom Med
37. Brown C, Matthews KA, Bromberger JT, et al. The relation
between perceived unfair treatment and blood pressure in
a racially/ethnically diverse sample of women. Am J Epide-
632Roberts et al.
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