Racial and Socioeconomic
Health Disparities:
Policy-Driven Inequities
and Chronic Stress
Holly Avey, PhD, MPH
Academy Health Annual Research Meeting
June 28, 2009
Research Objectives
1. To investigate the a priori theory
that exposure to the chronic stress
of structural (policy-driven) inequity
affects the psychological appraisal process,
creating or exacerbating stress-related illness
From Policy-Driven Inequity
to Disparities
Mechanisms for Stress to Translate into Illness
Immediate health effects
Fight-or-flight response
Interim health effects
Chronic illness
Allostatic load
Increased blood pressure
High blood pressure
Heart disease
Increased heart rate
Irregular heart beat
Stroke
Fats released into blood
High cholesterol
Increased blood clotting
Circulation diverted to
major muscle groups
Circulation of fats
Visceral obesity
restricted
Blood diverted away from
Low birth weight
fetus
Sugars released into
blood
Breathing rate increases
Glucose intolerance
Diabetes
Hyperventilation
Shortness of breath
Asthma
Respiratory disease
Immune system
increases, followed by
suppressed immune
function
Colds
Flu
Pneumonia
Dental cavities
Cancer
Contract HIV (if exposed)
HIV / AIDS
Mind becomes more
alert, followed by
suppressed mental
function
Lethargy
Nervousness
Depression
Anxiety
Mechanisms for Stress to Translate into Illness
Immediate health effects
Fight-or-flight response
Interim health effects
Chronic illness
Allostatic load
Increased blood pressure
High blood pressure*
Heart disease*
Increased heart rate
Irregular heart beat
Stroke*
Fats released into blood
High cholesterol
Increased blood clotting
Circulation diverted to
major muscle groups
Circulation of fats
Visceral obesity*
restricted
Blood diverted away from
Low birth weight*
fetus
Sugars released into
blood
Breathing rate increases
Glucose intolerance
Diabetes*
Hyperventilation
Shortness of breath
Asthma*
Respiratory disease*
Immune system
increases, followed by
suppressed immune
function
Colds
Flu*
Pneumonia*
Dental cavities*
Cancer*
Contract HIV* (if
exposed)
HIV / AIDS*
Mind becomes more
alert, followed by
suppressed mental
function
Lethargy
Nervousness
Depression*
Anxiety*
* = illness for which there is a racial and/or socioeconomic health disparity (U.S. Department of Health and Human Services, 2000)
Research Objectives
2. To illuminate underlying mechanisms
of race and class discrimination, such as social
closure and relative deprivation
Underlying Mechanisms
of Race and Class Discrimination:
Social Closure
• When social and economic opportunities are
restricted for certain groups
• Includes restriction of access to:
– Employment
– Housing
– Education
– Transportation
– Healthcare
– Legal representation
Underlying Mechanisms
of Race and Class Discrimination:
Relative Deprivation
• When certain groups perceive they are
deprived of resources compared to others
• Includes:
– Corporate welfare – Media and consumerism
– Wealth gap
– Property taxes
Study Design:
• Surveys were administered to a convenience
sample of 310 low- and middle-SES Blacks
and low- and middle-SES Whites recruited
from doctor’s offices in a large metropolitan
area of the Southeast
• A sub-set of each population used the
photovoice technique and participated in
focus groups
Quantitative Data
Demographic
Variables
Age
Gender
Education
Independent
Variables
Race
• Self-report
• Proxy for
institutionalized
racial
discrimination
Qualitative Data
Dependent
Variables
Stress measures
• Life Events
• Daily Hassles
• Traumatic Events
• Perceived Stress
Focus Group
Questions
Things that cause
you stress
• Photovoice and
focus group data
• Pile-sorted into
groups
• Top 3 stressors
Control over stressor
Stress-Related Illness Relative importance
SES
• High blood pressure
• Self-report,
of stressor
• High cholesterol
poverty threshold • Heart disease
Resources to deal
& wealth items
• Stroke
with stressor
•
Obesity
• Proxy for
Stressors for
•
Diabetes
institutionalized
alternate racial and
• Asthma
socioeconomic
• Cancer
income groups
discrimination
• HIV/AIDS
• Depression
• Anxiety
Analysis
• Quantitative data was analyzed using multiple
regression
• Qualitative photovoice data was analyzed by
participants according to photovoice guidelines
1) select pictures
2) contextualize pictures
3) codify pictures
• Qualitative focus group data was analyzed using pile
sorting and inductive analysis
• Quantitative and qualitative data were then
triangulated
Quantitative Data
Stress Scales
Qualitative Data
Determine sample
for qualitative
methods
Photovoice
and Focus
Groups
Compare sources of
stress with scale items
Determine if race
and/or SES account
for a significant
portion of variance in
stress scores
Explore relationship
between race, SES and
perceived sources of
stress
Explore context
of stress experience
Principal Quantitative Findings
• Race was not found to have an influence on
stress scores or stress-related illnesses
• Low-socioeconomic status was associated with
• Higher exposure to traumatic events
• Higher total stress exposures
• Higher levels of perceived stress
• Higher perceived stress was associated with
higher stress-related illness burden
• Especially for hypertension, depression, and anxiety
Explanatory Regression Analyses for
Variables Predicting Stress Scale Scores
β
Variable entered
Step 1
Age
Gender
Education
SES
-.06
-.07
-.10
Age
Gender
Education
SES
-.02
.03
-.13*
Age
Gender
Education
SES
.17**
.03
-.20**
Age
Gender
Education
SES
-.14*
-.12*
-.19**
Age
Gender
Education
SES
.07
.01
-.18**
*p < .05 ** p <.01
Step 2
R2
Life Events Stress
.02
-.10
Daily Hassles Stress
.02
-.10
Traumatic Events Stress
.07**
-.17**
Perceived Stress
.07**
-.14*
Total Stress Exposures
.04**
-.16*
Model F
∆R2
1.65
1.83
.01
1.82
1.91
.01
7.88**
7.85**
.02**
7.05**
6.52**
.01*
4.23**
4.82**
.02*
Principal Qualitative Findings
• Differential exposures and stress appraisals
are a result of institutionalized class
discrimination which limits social and
economic resources for low-SES populations
such as:
– Housing
– Transportation
– Legal representation
– Physical and behavioral
health care
Social Closure
Prego (LSW): “A lot of the lower class people that don’t make money
get the focus on them. When there’s…children with rich families
they get abused and their parents do drugs and drink and nobody
says anything because they have money so … it’s all about money
anymore.”
Georgia Girl (LSW): “Working in a small business, the banks will work
with them much quicker and help them, because the former
company I was working with was just bouncing checks like crazy …
$500 and something dollars a month … where if that had been us
they would have … taken us to jail for deposit account fraud.”
Fred (MSW): “Society structure [is] that if you have more money you
can get better help that is going to be more effective for you if you
have the insurance. If you don’t have it is so limited.”
Relative Deprivation
Boom Boom (LSB): “Now us, not having much money … if we get put
out, we’re on the streets … if they lose the big place … they can still
get an apartment. They’re not going to be put on the street.”
Blacky (LSB): “They can get their car fixed with money, even if it breaks
down.”
Boom Boom(LSB): “Ervin Magic Johnson came out and said he had the
AIDS virus, he says he’s clean. I mean he’s over it. How many people
are dying from it? Why because they don’t have the money. They
don’t have the resources to get the medication to pay for it. …
That’s the difference between a lot of money and a little money.”
Nissan (LSB): “Power and control.”
Conclusions
• Results confirmed the a priori theory
that low-SES groups are exposed to more stressors
and have higher levels of perceived stress
and stress-related illness than middle-SES groups
• Results did not confirm the same to be true for Blacks
when compared to Whites
• Historical mechanisms of institutionalized race
discrimination may make SES more relevant as a stressor
for Blacks today
• The policy-driven context of social and economic
resources results in perceptions of social closure and
relative deprivation for low-SES groups
Implications for Policy
• Policies that limit social and economic
resources or result in inequitable
opportunities for low-SES populations can
result in social closure and relative deprivation
• Such policies and the psychological
assessments they trigger may be a root cause
of many SES-related health disparities
Implications for Policy
• Policy egalitarianism*
– Equitable education spending and financial aid
– Less restrictive TANF support
– Support for unions
– Equitable transportation expenditures
– Housing equity – foreclosure policies
Moller S. The state and structural vulnerability: Policy egalitarianism and household income. Research in Social
Stratification and Mobility. 2008; 26 (4): 323-340.
Thank you!
Holly Avey, PhD, MPH
Senior Research Associate
Georgia Health Policy Center
Georgia State University
havey@gsu.edu
404-413-0291