My appreciation to the SNOHD Workgroup - Kati Knight, Kiarri Kershaw, Briana Mezuk, Sha Juan
Colbert, Darrell Hudson, and Jane Rafferty, for the analyses and charts and the “State of the Dream
2004” and “State of the Dream 2005” reports, United for a Fair Economy, 37 Temple Place, 2nd
Floor Boston, MA 02111, for some of the slides in this presentation. I also thank the entire PRBA
group for their assistance. Supported by grants from the National Institute of Mental Health,
National Institute on Drug Abuse, Office of Behavioral and Social Science Research, National
Institute on Aging ,and National Center for Minority Health Disparities Research.
Š
Dr. James Jackson presented “A Life-Course
Perspective on Physical and Mental Health
Disparities” as the UIC Institute for Health Research
and Policy Distinguished Lecture at the School of
Public Health auditorium in Chicago on Dec. 3,
2008. For more information, visit www.ihrp.uic.edu.
18
15
12
Black American
White
9
6
5.1
3
3.1
0
ECA
Source: ECA, Epidemiologic Catchment Area Study, Psychiatric Disorders in America, 1991.
*ECA does not distinguish between African American respondents and Caribbean respondents.
ƒ Vice-President Dan Quayle*
*date lost in antiquity on misquote of United Negro College
Fund banner “A Mind is a Terrible Thing to Waste”
ƒ Stephanie Plum – bail bond enforcer who is always
having her life threatened, her cars torched or blown
up, and her apartment broken into, is constantly
eating doughnuts, cakes, pizza and similar comfort
foods.
ƒ “The ability to eat Cheez Doodles and Krispy
Kremes and never get fat” (Janet Evanovich’s one
superpower wish)
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
Social Determinants of Poor Health
Law of Small Effects and Race Disparities
Race & Race Differences in Opportunities
Poor Structured Conditions of Living by Race
Constant Environmental Stressors and Stress
Environmental Affordances for Unhealthy Coping
Strategies
Chronic Activation of Stress Network (HPA Axis)
Poor Health Behaviors to Cope with Stress
Ensuing Physical Health Disorders
Protection from Mental Health Disorders
Figure 1: Differences, Disparities, and Discrimination
Minority
Difference
Non-Minority
Quality of Health Care/Health
Clinical Appropriateness
and Need
Patient Preferences
The Operation of Healthcare
Systems and the Legal and
Regulatory Climate
Discrimination: Biases and
Prejudice, Stereotyping, and
Uncertainty
UNKNOWN
Populations with Equal Access to Health Care
Disparity
RELATIVE POSITION AND HEALTH
HOW DOES IT OPERATE?
ƒ
POWER
ƒ SOCIAL PARTICIPATION
ƒ SOCIAL ENVIRONMENT
ƒ BEHAVIOUR
ƒ EARLY LIFE
Material
Factors
Social
Structure
Work
Social
Environment
Psychological
Brain
NeuroEndocrine and
Immune
Health
Behaviours
Patho-physiological
Changes
Organ impairment
Early
Life
Genes
Culture
Marmot, 2004
Well-being
Mortality
Morbidity
Mortality by Grade of Employment
Whitehall Men 25 yr Follow-up
Relative rate
Admin
2
1.9
1.8
1.7
1.6
1.5
1.4
1.3
1.2
1.1
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Prof/Exec
Clerical
Other
40-64yrs
64-69yrs
Marmot and Shipley, 1996
70-89yrs
30
3.04
odds ratio
35
3
25
2.21
2
1.34
20
1.59
15
1
10
1
>70,000
50,001-
30,001-
20,001-
15,000-
<15,000
5
proportion %
3.89
4
0
0
AVERAGE HOUSEHOLD INCOME 1993
ADJ
ADJ + Education
PROPORTION
ADJ for age, sex, race, family size, period Mcdonough et al AJPH 1997
Servant keeping classes
Middle working class
Highest working class
Poorest
Deaths per 1,000
born per annum
300
247
240
173
180
120
60
Rowntree (1901)
94
184
10.0
8.1
7.6
8.0
5.9
5.4
6.0
3.7
4.0
5.0
3.6
2.0
0.0
I
IIINM
Father's Social Class
Health Statistics Quarterly 2001
IV
Sole
Registration
Social class I
Social class V
85
79.2
77.7
77
80
75
83.4
73.9
72
68.2
66.5
70
65
60
1972-76
1992-96
MALES
Health Statistics Quarterly, 1999
1972-76
1992-96
FEMALES
Ross et al; BMJ 2000
ƒ
Even if we don’t know what “IT” is
77.4
71.62
71.7
64.11
1968
2000
White
Black
Years to Parity: 71
Parity Year: 2071
Source: National Center for Health Statistics, National Vital Statistics Reports, Dec. 19, 2002, Table 11.
State of the Dream 2004 Report
32.6
17.8
14
5.7
1968
2002
White
Black
The Black-White Gap in
Infant Mortality is
increasing.
Source: National Center for Health Statistics, National Vital Statistics Reports, Sept. 18, 2003, Table 3l.
State of the Dream 2004 Report
10
9
8
7
6
5
4
3
2
1
0
25
20
15
10
5
0
Still in
School
<High
School
High School
Black/White Ratio
per 100,000 live births
30
High
School+
Joanne G. Hogan, Ph.D., Bao-Ping Zhu, MD, MS. Division of Epidemiology Services, Community Health Agency, Michigan
Department of Community Health.
White
Black
Ratio
% probability of survival
80
70
60
50
40
30
20
US White Poor White US Black Poor Black
Males
Males
Males
Males
Geronimus et al, NEJM 1996
ƒ
ƒ
Self–reported (or other reported) race/ethnicity most
often used categorization in both biological and
social research
Why should we observe such large and both
consistent (African Americans), and inconsistent
(Caribbeans, Latinos, Asians, etc), disparities
among race/ethnic groups
Figure 2: Self and Other Race Perceptions
Self
Yes
Black
Other
Not
Black
Yes Black
Not Black
African
American
Asian
Hispanic
Afro Caribbean
Asian
Hispanic
Afro Caribbean
Non-Hispanic
White
ƒ
ƒ
ƒ
Discrimination and perceived racism as a class of
stressors have been shown to have health and mental
health effects among racial and ethnic minorities
Discrimination operates in the context of social, political,
economic, and cultural influences over the individual and
group life-course
Discrimination and perceived racism, as well as other
non-race-related stressors tied to poor structural life
conditions probably play a role in health and mental
health processes, but the role is complex
ƒ
ƒ
There is no one single factor that produces
observed physical health disparities among
race/ethnic groups in U.S.
Group of small differences which may
accumulate over the life-course to produce
observed differences in adulthood and older ages
among different race/ethnic groups
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
Gene/gene and gene/environment interactions
Discrimination and perceived racism (stress
process)
Accumulated stress (weathering, allostatic load,
etc.)
Life course selection
Cultural factors
Behavioral differences
SES and institutional arrangement
ƒ
ƒ
ƒ
Accumulated Treatment Differences (e.g. Weathering –
Geronimous, Allostatic Load – McEwen, etc.)
Social & Psychological Factors (e.g. John Henyrism, Selfefficacy, mastery, etc).
Culturally & Environmentally Mediated Behavioral Coping
Strategies
We cannot easily parse these potential effects into their
constituent parts and assign individual contributions
ƒ
Blacks disproportionately in comparison to NonHispanic Whites remain materially disadvantaged
and geographically segregated, especially in poor,
core urban areas
Entire U.S. Population
Asia n
4%
Highest-Income Fifth
Native &
Asian other
Latino 5%
1%
6%
Black
6%
Na tive & othe r
1%
La tino
10 %
Lowest-Income Fifth
Latino
13%
Native &
Asian other
3%
2%
Bla c k
12 %
Black
20%
White
73%
White
82%
Source: U.S. Census Bureau, Current Population Survey 2004 Supplement – Vertical Income Distribution.
White
62%
10.8%
10.4%
5.2%
5.1%
1972
2003
White
Black
The Black-White Gap
in Unemployment
Rates has increased
since 1972.
Source: Bureau of Labor Statistics, Employment Situation Historical Table A-2 (1972 is the first year with unemployment
data for African Americans). State of the Dream 2004 Report
$121,000
$97,800
$5,300
$19,000
1989
2001
Years to Parity: 98
White
Black
Parity Year: 2099
Source: Arthur B. Kennickell, “A Rolling Tide: Changes in the Distribution of Wealth in the U.S., 1989-2001,” Levy
Economics Institute, Nov. 2003. Note: 1989 is the first year for available methodologically consistent data.
State of the Dream 2004 Report
Figure 3. Official Poverty Rate, Persons Age 18-64, 1974-2004
35
30
% Adults Poor
25
22.6
20.3
20
15
10
5.9
8.3
5
0
1974
1979
1984
1989
Year
White Non-Hispanic
Danziger, 2006
1994
African American
1999
2004
ƒ There are Large Disparities in Living Arrangements
favoring non-Hispanic Whites
ƒ
ƒ
Neighborhood Segregation & Health (Roux, et al,
2002)
Differentially Stressful (e.g. Roux et al, 2001; 2002;
Geronimous & Thompson, 2004; Massey, 2004)
ENVIRONMENT
(neighborhood effects,
noise, poverty, urban
areas, etc.)
STRESSORS
(job, family,
financial,
relationships)
Figure 4a: Hypothesized Interrelationships Among
Environment, Stressors, and Physical Health Disorders
PHYSICAL
HEALTH
DISORDERS
(diabetes, cancer, organ
damage, etc)
ƒ
ƒ
Afford Differential Opportunities, e.g. food,
services, jobs (e.g. Morland, et al, 2001; 2002; Wing
et al, 2002)
Afford Differential Coping Resources (e.g. Fast
Food Outlets, Liquor Stores, Illegal Drug
Distributors, etc. Roux, 2002)
ENVIRONMENT
(neighborhood effects,
noise, poverty, urban
areas, etc.)
POOR HEALTH
BEHAVIORS
(smoking, drinking, using
alcohol and drugs, overeating)
STRESSORS
(job, family,
financial,
relationships)
PHYSICAL
HEALTH
DISORDERS
(diabetes, cancer, organ
damage, etc)
Figure 4b: Hypothesized Interrelationships Among
Environment, Stressors, Negative Health Behaviors and Physical
Health Disorders
ƒ
ƒ
ƒ
Large disparities in all cause and specific cause
death rates exist among ethnic and racial
groups – these differences are not due in any
simple way to socioeconomic status
Infant mortality rates have declined but large
difference exist between African Americans
and whites
There are large disparities in health care
utilization between African Americans and
whites
30
Diabetes Prevalence in Females (%)
25
20
Black
15
White
10
5
0
18-24 Years
25-44 Years
45-64 Years
65-74 Years
75-84 Years
85+ Years
Prevalence of Selected Chronic Conditions by Age, Sex, and Race/Ethnicity: United States,
1997-2005. National Health Interview Survey (NHIC05)
30
Diabetes Prevalence in Males (%)
25
20
Black
15
White
10
5
0
18-24 Years
25-44 Years
45-64 Years
65-74 Years
75-84 Years
85+ Years
Prevalence of Selected Chronic Conditions by Age, Sex, and Race/Ethnicity: United States,
1997-2005. National Health Interview Survey (NHIC05)
70
Hypertension Prevalence in Females (%)
60
50
40
Black
White
30
20
10
0
18-24 Years
25-44 Years
45-64 Years
65-74 Years
75-84 Years
85+ Years
Prevalence of Selected Chronic Conditions by Age, Sex, and Race/Ethnicity: United States,
1997-2005. National Health Interview Survey (NHIC05)
70
Hypertension Prevalence in Males (%)
60
50
40
Black
White
30
20
10
0
18-24 Years
25-44 Years
45-64 Years
65-74 Years
75-84 Years
85+ Years
Prevalence of Selected Chronic Conditions by Age, Sex, and Race/Ethnicity: United States,
1997-2005. National Health Interview Survey (NHIC05)
300
250
200
White
Black
Am. Indian
Hispanic
Asian/PI
150
100
50
0
1980
1985
1990
1995
ƒ There are links from childhood (infancy, neonatal,
pregnancy, etc.) social conditions to race/ethnic
disparities in adulthood and older age (e.g. Warner &
Hayward, 2003)
ƒ Over the life course blacks more than any other group
live the fewest years and a high proportion of these
years is in poor health (e.g. Hayward & Heron, 2002)
ƒ Health, race, ethnicity and mobility (SES) are linked in
complex ways across childhood, adolescence,
adulthood, and old age (e.g. Hayward et al, 2003;
Whitfield & Hayward, 2003; Crimmins et al, 2000;
Crimmins & Saito, 2001)
Pregnancy to Death
Blacks May be More Highly Selected for Positive
Health Than Whites Early in Life and Late in Life
16
14
Mortality Rates
12
10
8
Black mother
White mother
6
4
2
Pe
ri n
at
al
fe
ta
l
La
te
Fe
ta
l
Po
st
ne
on
at
al
eo
na
ta
l
N
ne
on
at
al
Ea
rl y
In
fa
nt
0
Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System: Hoyert DL,
Heron M, Murphy SL, Kung HC. Deaths: Final data for 2003. National vital statistics reports. Vol 54. Hyattsville, Maryland.
National Center for Health Statistics. 2006; and unpublished numbers.
Stressors
3
2.5
Black:White Ratio
2
Females
1.5
Poly. (Females)
1
0.5
0
< 1 Year 1-4 Years 5-9 Years
10-14
Years
15-19
Years
20-24
Years
25-34
Years
35-44
Years
45-54
Years
55-64
Years
65-74
Years
75-84
Years
85+
Years
Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed Mortality File
1999-2004. CDC WONDER On-line Database, compiled from Compressed Mortality File 1999-2004 Series 20
No. 2J, 2007.
Stressors
2.5
Black:White Ratio
2
1.5
Males
Poly. (Males)
1
0.5
0
< 1 Year
1-4 Years
5-9 Years
10-14
Years
15-19
Years
20-24
Years
25-34
Years
35-44
Years
45-54
Years
55-64
Years
65-74
Years
75-84
Years
85+ Years
Centers for Disease Control and Prevention, National Center for Health Statistics.
Compressed Mortality File 1999-2004. CDC WONDER On-line Database, compiled
from Compressed Mortality File 1999-2004 Series 20 No. 2J, 2007.
2.5
Female
Male
2
Black:White Ratio
1.5
1
0.5
0
<1 Yr
1-4 Yrs 5-9 Yrs 10-14 Yrs15-19 Yrs20-24 Yrs25-34 Yrs35-44 Yrs45-54 Yrs55-64 Yrs65-74 Yrs75-84 Yrs 85+ Yrs
ƒ Poor health behaviors parallel the race/ethnic
disparities found in health status
30
Percent current smokers (%)
25
20
Black
15
White
10
5
0
8th Graders
10th
Graders
12th
Graders
18-24 Years 25-34 Years 35-44 Years 45-64 Years
65 Years
and over
National Center for Health Statistics Health, United States, 2006 With Chartbook on Trends in the Health
of Americans. Hyattsville, MD: 2006, Charts 63 and 67
35
30
Percent current smokers (%)
25
20
Black
White
15
10
5
0
8th Graders
10th
Graders
12th
Graders
18-24 Years 25-34 Years 35-44 Years 45-64 Years
65 Years
and over
National Center for Health Statistics Health, United States, 2006
2006 With Chartbook on Trends in the Health of
Americans. Hyattsville, MD: 2006, Charts 63 and 67
40
35
Obesity Prevalence (%)
30
25
Black
20
White
15
10
5
0
2-5 Years
6-11 Years
12-19 Years
20-39 Years
40-59 Years
≥ 60 Years
Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight
and obesity in the United States, 1999-2004. JAMA 295:1549-1555. 2006.
70
60
Obesity Prevalence (%)
50
40
Black
White
30
20
10
0
2-5 Years
6-11 Years
12-19 Years
20-39 Years
40-59 Years
≥ 60 Years
Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight
and obesity in the United States, 1999-2004. JAMA 295:1549-1555. 2006.
60
50
40
White
Black
Hispanic
30
20
10
0
12- 18- 26- 31- 36- 41- 46- 51- 56- 61- 66+
17 25 30 35 40 45 50 55 60 65
Source: NHSDA; National Household Study on Drug Abuse, 1997.
60
50
40
White
Black
Hispanic
30
20
10
0
12- 18- 26- 31- 36- 41- 46- 51- 56- 61- 66+
17 25 30 35 40 45 50 55 60 65
Source: NHSDA; National Household Study on Drug Abuse, 1997.
60
50
40
White
Black
Hispanic
30
20
10
0
12- 18- 26- 31- 36- 41- 46- 51- 56- 61- 66+
17 25 30 35 40 45 50 55 60 65
Source: NHSDA; National Household Study on Drug Abuse, 1997.
80
Met recommendations for vigorous physical activity
70
60
50
Black
White
40
30
20
10
0
14
15
16
17
18-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79
Years Years Years Years Years Years Years Years Years Years Years Years Years Years Years Years
80+
Centers for Disease Control and Prevention (CDC). Youth Risk Behavior Surveillance System Survey
Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control
and Prevention, 2005
Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey
Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control
and Prevention, 2005
90
Met recommendations for vigorous activity (%)
80
70
60
50
Black
White
40
30
20
10
0
14
15
16
17
18-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79
Years Years Years Years Years Years Years Years Years Years Years Years Years Years Years Years
80+
Centers for Disease Control and Prevention (CDC). Youth Risk Behavior Surveillance System Survey
Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control
and Prevention, 2005
Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey
Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control
and Prevention, 2005
35
30
25
White
Black
Hispanic
20
15
10
5
0
12- 1817 25
2630
31- 3635 40
4145
46- 5150 55
5660
61- 66+
65
NOTE: Heavy alcohol use is defined as drinking five or more drinks per occasion on 3 or more days in the
past 30 days.
40
35
30
25
White
Black
Hispanic
20
15
10
5
0
12- 1817 25
2630
31- 3635 40
4145
46- 5150 55
5660
NOTE: Drug use is defined as the use of any illicit drug in the past year.
61- 66+
65
20
15
White
Black
Hispanic
10
5
0
12- 1817 25
2630
31- 3635 40
4145
46- 5150 55
5660
61- 66+
65
NOTE: Marijuana use is defined as the use of marijuana in the past 30 days.
Mental Health Disparities
ƒ In comparison to health statuses,
mortality, and poor health behaviors,
prevalence rates for major psychiatric
disorders reveal very few, if any,
black/white disparities favoring whites,
and for most lower prevalence rates for
African Americans
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
Weissman & Myer (1978) - Community
Somervall et al (1989) - ECA
Kessler et al (1994; 2003) NCS/NCS-R
Breslau et al (2003) NCS-R
Jackson et al (2003) NSAL
Riolo et al (2004) – NHANES III
At the same time these and other studies have
shown higher rates of dysthymic disorder and
psychological distress among blacks in comparison
to whites
18
16
14
12
10
8
6
4
2
NHW
AA
From Robins Psychiatric Disorders in America (1991) [ECA], Blazer American Journal of Psychiatry
(1994) [NCS], Breslau Psychological Med (2006) [NCS-R] , Has in Arch Gen Psychiatry (2005)
[NESARC], Williams Arch Gen Psychiatry (2007) [NSAL], and Jonas ,Social Psychiatry, Psychiatric
Epidemiology (2003) [NHANES]. *Lifetime MDE not MDD
1.4
1.2
1
Affective
Anxiety
Substance
Any Disorder
0.8
0.6
0.4
0.2
0
B/W Ratio H/W Ratio
40
31.5
35
30
25
20.8
22.6
African American
Caribbean
White *
20
15
10
5
0
NSAL
Source: NSAL, National Survey of American Life, 2004.
Note: Adjusted for age.
*NSAL Whites living in areas with Black population of 10% or more.
**Includes 7 disorders asked of all races: Major Depression, Dysthymia, Mania, Panic Disorder, Social Phobia, Generalized Anxiety Disorder,
and Agoraphobia
20
15.5
13.9
16
11.9
12
African American
Caribbean
White *
8
4
0
NSAL
Source: NSAL, National Survey of American Life, 2004.
Note: Adjusted for age.
*NSAL Whites living in areas with Black population of 10% or more.
**Includes 7 disorders asked of all races: Major Depression, Dysthymia, Mania, Panic Disorder, Social Phobia, Generalized Anxiety Disorder,
and Agoraphobia
30
25
20
White
Black
Hispanic
15
10
5
66
+
61
-6
5
56
-6
0
51
-5
5
46
-5
0
41
-4
5
36
-4
0
31
-3
5
26
-3
0
18
-2
5
12
-1
7*
*
0
*NHSDA 1997, National Household Survey on Drug Abuse
**Data not available for respondents aged 12-17 years old
30
25
20
White
Black
Hispanic
15
10
5
66
+
61
-6
5
56
-6
0
51
-5
5
46
-5
0
41
-4
5
36
-4
0
31
-3
5
26
-3
0
18
-2
5
12
-1
7*
*
0
*NHSDA 1997, National Household Survey on Drug Abuse
**Data not available for respondents aged 12-17 years old
ENVIRONMENT
(neighborhood effects,
noise, poverty, urban
areas, etc.)
POOR HEALTH
BEHAVIORS
(smoking, drinking, using
alcohol and drugs, overeating)
STRESSORS
(job, family,
financial,
relationships)
Figure 4c: Hypothesized Interrelationships Among
Environment, Stressors, Negative Health Behaviors and
Psychiatric Health Disorders
PSYCHIATRIC
HEALTH
DISORDERS
(major depression,
anxiety, PTSD)
ƒ
ƒ
ƒ
ƒ
Structural life inequalities are hypothesized to “cause”
both health and mental health disparities
Structural life inequalities in income, wealth,
employment and educational opportunities are large
and unfavorable for African Americans and other
minorities
Physical health disparities are large and unfavorable
for African Americans and other minorities
Mental health disparities in comparison to whites are
small and often favorable for African Americans, but
variable for other groups
ENVIRONMENT
(neighborhood effects,
noise, poverty, urban
areas, etc.)
STRESSORS
(job, family,
financial,
relationships)
PHYSICAL
HEALTH
DISORDERS
(diabetes, cancer, organ
damage, etc)
PSYCHIATRIC
HEALTH
DISORDERS (major
depression, anxiety, PTSD)
Figure 4d: Hypothesized Interrelationships Among
Environment, Stressors, and Physical and Mental Health
Disorders
ENVIRONMENT
(neighborhood effects,
noise, poverty, urban
areas, etc.)
POOR HEALTH
BEHAVIORS
(smoking, drinking, using
alcohol and drugs, overeating)
STRESSORS
(job, family,
financial,
relationships)
PHYSICAL
HEALTH
DISORDERS
(diabetes, cancer, organ
damage, etc)
PSYCHIATRIC
HEALTH
DISORDERS (major
depression, anxiety, PTSD)
Figure 4e: Hypothesized Interrelationships Among
Environment, Stressors, Negative Health Behaviors and Physical
and Mental Health Disorders
ƒ
ƒ
ƒ
ƒ
ƒ
Coping strategies in the face of non-race, and race
specific, stressors may themselves be harmful to health
(Jackson, 2002; Jackson & Knight, 2006)
Stress-related precursors of serious mental health
problems are more available to consciousness than are
those of physical health problems
This psychological awareness motivates individuals to
action
For example, Dallman et al (2003) suggested that
people eat comfort food to reduce activity in the
chronic stress-response network (Cannetti, et al, 2002)
It is proposed that other behaviors, e.g. smoking,
alcohol and drug use have similar, immediate, effects
to reduce activation of the stress-response network
ENVIRONMENT
(neighborhood effects,
noise, poverty, urban
areas, etc.)
POOR HEALTH
BEHAVIORS
(smoking, drinking, using
alcohol and drugs, overeating)
STRESSORS
(job, family,
financial,
relationships)
CHRONIC ACTIVATION
OF HPA* AXIS
(downregulation of immune
system, outcomes associated
with negative health behaviors)
PHYSICAL
HEALTH
DISORDERS
(diabetes, cancer, organ
damage, etc)
PSYCHIATRIC
HEALTH
DISORDERS (major
depression, anxiety, PTSD)
Figure 4f: Possible Interrelationships Among Environment,
Stressors, Negative Health Behaviors and Physical and Mental
Health Disorders (Jackson & Knight, 2006; Jackson, et al, under
review) *hypothalamic-pituitary-adrenal
ƒ
ƒ
ƒ
Complex interactions between endocrine and
neurological systems (Sapolsky)
Under chronic stress negative feedback breakdown
and there is continued release of CRF and cortisol
Long term chronic activation of HPA axis may be
related to etiology of some mental disorders
(Barden, 2004; McEwen, 1989; Young et al, 2004a;
2004b)
Figure 3: “Adaptation?” (Dallman, 2003)
Increasing Intensity/duration
Stressor (s)
Central Stress Response Network (CRF, NE)
Behavior
Autonomic
Neuroendocrine
Immune
1. Stress response rapidly abolishes the stressor
- transient activation of the stress response network
2. Stress response slowly removes the stressor
- prolonged activation of the central response network
3. Stress response cannot remove the stressor
- consistently activated central response network
ƒ
ƒ
ƒ
Comfort Foods (high in fats and carbohydrates) may
aid in shutdown of stress response by inhibiting
release of CRF (e.g. Dallman et al)
Alcohol, nicotine, and drug use stimulate release of
dopamine and beta-endorphins aiding in shutdown
of stress response and leading to feelings of
relaxation and calm (e.g. Akil & Cicero; Piazza &
LeMoal; Marinelli & Piazza).
Paradoxically these drugs may also further
activation of the HPA axis – thus individuals may
be psychologically released from stress, but they are
not physically released from the effects of stress
(Dallman, 2003)
ƒ“In other words, when we are under stress, it's important
whether we reach for the bag of potato chips or go for a
swim or a jog. Eating a rich diet and drinking alcohol feed
into the allostatic load -- they increase the levels of these
stress mediators and, thus, make hypertension and insulin
resistance, among other consequences, more likely
(McEwen & Krahn, 1999)”
ƒ
Weak: Poor health behaviors mask the stress
response cascade of neural and hormonal events that
have long-term effects on the development of
mental disorders. Individuals are not able to report
on stress-related symptoms that are ameliorated by
poor health behaviors, though the physical cascade
continues.
ƒ
Strong: Poor health behaviors through their actions
on the HPA axis and other brain hormones actually
interfere with the cascade of neural and hormonal
events that ordinarily would lead over time to
mental disorders.
ƒ
ƒ
Negative Structural Conditions and Controls (Wave
I)
Gender, Age, Region, Education, Occupational and
Employment Status, Family Income, Poverty
Negative Stressful Events (count) (Wave I)
Serious illness, moved, lost job, robbed, anything else bad
ƒ
ƒ
ƒ
Poor Health Behaviors (count) (Wave I)
Currently smoke, ever smoke, drink, BMI
Poor Self-Reported Health (Wave II)
ƒ
Poor Chronic Health (count) (Wave II)
Arthritis, lung disease, hypertension, diabetes, etc.
Number of Depressive Symptoms (Wave II)
ƒ
Psychological Distress (Wave II)
ƒ
DSM IIIR Depression (Wave II)
Early Version of Composite International Diagnostic
Instrument – WHO-CIDI
Structural Life Inequalities
Chronic
Stressors/Stress
Behaviors
Physical Health
Disparities
Structural Life Inequalities
Chronic
Stressors/Stress
Behaviors
Poor Physical
Health
Whites
Blacks
Structural Life Inequalities
Chronic
Stressors/Stress
Behaviors
Poor Physical
Health
Whites
Blacks
Structural Life Inequalities
Chronic
Stressors/Stress
Behaviors
Whites
Blacks
Psychiatric Health Disorders
Structural Life Inequalities
Chronic
Stressors/Stress
Behaviors
Whites
Blacks
Psychiatric Health Disparities
Predicting DSMIII Depression by Stressors at Levels of
Unhealthy Behaviors (UHB): Whites
1
Predicted Probability
0.9
0.8
0.7
UHB-0
0.6
UHB-1
0.5
UHB-2
0.4
UHB-3
0.3
0.2
0.1
0
-2
-1
0
1
2
3
Centered Stress
Jackson, Knight & Rafferty (under review)
4
5
6
Predicted Probability
Predicting DSMIII Depression by Stressors at Levels
of Unhealthy Behaviors (UHB): Blacks
1
0.9
0.8
0.7
0.6
UHB-0
UHB-1
0.5
0.4
0.3
0.2
0.1
0
UHB-2
UHB-3
-2
-1
0
1
2
3
Centered Stress
Jackson, Knight & Rafferty (under review)
4
5
6
Predicting DSMIII Depression by Stressors at Levels of
Unhealthy Behaviors (UHB): Whites
1
Predicted Probability
0.9
0.8
0.7
UHB-0
0.6
UHB-1
0.5
UHB-2
0.4
UHB-3
0.3
0.2
0.1
0
-2
-1
0
1
2
3
Centered Stress
Jackson, Knight & Rafferty (under review)
4
5
6
Predicted Probability
Predicting DSMIII Depression by Stressors at Levels
of Unhealthy Behaviors (UHB): Blacks
1
0.9
0.8
0.7
0.6
UHB-0
UHB-1
0.5
0.4
0.3
0.2
0.1
0
UHB-2
UHB-3
-2
-1
0
1
2
3
Centered Stress
Jackson, Knight & Rafferty (under review)
4
5
6
*Mezuk, Jackson, et al, 2008
ƒ Baltimore Epidemiologic Catchment Area
(ECA) Study
ƒ Population-based multi-stage probability sample
ƒ Baseline N = 3481
ƒ 67% female
ƒ 34% African American
ƒ 18+ years old in 1981
ƒ Four waves – 23 years – of follow-up
Eaton Acta Psychiatrica Scandinavica 2007
Wave 3 (Total N = 1920)
NHW
AA
1214
642
57.6 (17.6)
49.9 (14.3)
Female
59.7%
69.9%
At least some college
28.5%
28.5%
Employed
53.9%
50.9%
7 (5 – 10)
9 (5 – 11)
Lifetime Depression
Syndrome (Wave 3)
14.4%
11.5%
Prevalent CVD
17.7%
15.6%
Prevalent Type 2 Diabetes
7.5%
9.2%
Fair/Poor Self-Rated Health
23.7%
33.5%
N
Age (Mean, SD)
Number of stressful life
events (Median, IQR)
Wave 3 (Total N = 1920)
NHW
AA
Male
Female
Male
Female
489
725
193
449
Current smoker
34.5%
27.3%
48.9%
45.5%
>2 Alcoholic drinks/day
30.9%
12.5%
26.6%
11.8%
Obese (BMI>30)
22.2%
23.1%
16.2%
41.9%
Poorly balanced diet
51.2%
45.8%
61.6%
58.1%
None
24.2%
34.5%
14.0%
14.0%
One
32.3%
35.6%
41.4%
35.3%
Two
28.3%
20.9%
29.0%
36.7%
Three or four
15.3%
9.1%
15.6%
14.0%
N
Number poor health behaviors
Mezuk, et al, 2008
African Americans
Non-Hispanic Whites
Model 1
Odds ratio
Model 2
Odds ratio
Model 1
Odds ratio
Model 2
Odds ratio
Age (yrs)
0.95
0.95
0.99
0.99
Sex (ref Male)
0.84
0.89
3.00*
2.92*
DepSx Wave 3
(ref No DepSx)
11.3*
12.48*
7.77 *
7.82*
Education (yrs)
1.22*
1.26*
1.04
1.04
Employed (Yes=1)
2.71*
2.99*
0.60
0.60
Stressful life events
(Median-centered)
1.00
1.30*
1.05
1.00
Number of PHB
2.22*
3.43*
0.90
0.89
Life events X PHB
N
LRT (1 df)
0.84*
341
341
5.76 (p<0.016)
1.04
601
601
1.50 (p<0.220)
African Americans
Non-Hispanic Whites
Model 1
Odds ratio
Model 2
Odds ratio
Model 1
Odds ratio
Model 2
Odds ratio
Age (yrs)
0.95
0.95
0.99
0.99
Sex (Female=1)
0.83
0.88
3.00*
2.91*
11.6*
13.52*
7.76 *
7.79*
Education (yrs)
1.22*
1.25*
1.04
1.04
Employed (Yes=1)
2.70*
3.01*
0.60
0.60
Stressful life events
(Median-centered)
1.00
1.38*
1.05
1.00
4.56
8.08
16.9
44.0*
0.92
0.82
0.95
0.79
DepSx Wave 3 (Yes=1)
PHB (ref = None or 1)
Two
Three or Four
Life events X PHB
N
LRT (1 df)
0.81*
341
341
6.82 (p<0.009)
1.04
601
601
1.56 (p<0.212)
ƒ
ƒ
ƒ
ƒ
Disparities in physical health and mental health statuses and
services do exist - but we do not know exactly why - Law
of Small Effects
The differences between physical & mental health
disparities by race/ethnicity are not easy to understand
But one route by which these differences may be mediated
is through behaviors used by some race/ethnic groups to
cope with the psychological consequences of chronically
stressful life conditions
These behaviors are influenced by gender, culture and
environmental opportunities (affordances)
ƒ
ƒ
Specifically, behavioral coping strategies, in the
face of chronic stressful conditions, that may be
effective in “preserving” African American
mental health, may simultaneously contribute,
along with structural inequalities and stressful
life conditions, to observed physical health
disparities in morbidity and mortality among
some race and ethnic groups (Jackson, 2002;
Jackson & Knight, 2006; Jackson, et al under
review)
And this effect may be mediated by the stress
response network (Dallman et all, 2003)
ƒ
“Habitually attempting to relieve stress-induced
dysphoric effects of the CRF- (corticotropinreleasing factor) driven (neurons) central chronic
stress-response network may make one feel
better, but is likely to be bad for long-term
health” (Dallman et al, 2003; McEwen, 2003)
ƒ
ƒ
ƒ
Blacks have early-learned, environmentally mediated,
effective coping strategies to deal with stressful conditions of
life; these behaviors are not “merely” hedonic but reflect
adaptive responses to maladaptive environments
These behaviors may be effective, perhaps through the
chronic stress-response network, in impeding the biological
cascade to mental disorders, resulting in positive mental
disorder disparities for Blacks in comparison to nonHispanic Whites
These behaviors contribute, however, along with poor living
conditions, lack of resources, and environmentally produced
chronic stress, over the life-course, to negative race
disparities in physical health morbidity and mortality
ƒ
ƒ
Consistent Negative Physical Health Disparities for
Blacks vs. White
Positive Mental Disorder Disparities for Blacks vs.
Whites
ƒ
Major Effects of Chronic Stressors
ƒ
Gender Differences in Poor Health Behaviors
ƒ
Patterns of Change over the Life-Course in Physical
and Mental Health and Poor Health Behaviors
ƒ
ƒ
ƒ
Physical health and psychiatric disorder disparities
are not reducible in any simplistic way to differences
in social and economic statuses among groups
(Report of the Surgeon General, 2001)
Complex, multi-faceted -- racial, ethnic, culturally,
environmentally and life-course, influenced
Succinctly, blacks and other groups in this society
may buy their reduced rates of psychiatric disorders
with higher rates of physical health morbidities and
excess and early mortality
ƒ
Physical health and psychiatric disorder
disparities cannot be understood outside of a
Bioecological model that emphasizes the
interrelationships of history, life-span influences,
period, context, race/ethnicity, and individual
resilience and coping capacities.
Human Agency and Individual
Motivation Must be Considered in
any Theoretical Formulation Related
to “Explaining” Health Disparities
ƒ The health differentials by race/ethnicity are not easy to
understand
ƒ Why should self-reported race be related to physical and
mental health outcomes?
ƒ Pathways for how “self” and “other conceptions of race
affect health outcomes is potentially explicable
ƒ New bio-behavioral studies are needed that take a more
complex view of gene x gene and gene x environment
interactions.
ƒ Greater attention needs to be paid to understanding
“environment” in any evolutionary, genetic, and biobehavioral view of complex human behaviors and
diseases
ƒ We must develop effective strategies for this
society to make social and political changes for
this, and the next, generation of black
Americans -- who after all comprise one of our
oldest groups of American citizens
ƒ This strategy will not only benefit black
Americans but will be of benefit to the growing
ethnic and racial populations in this country,
and, in fact, our society as a whole.
http://rcgd.isr.umich.edu/prba/nsal.htm
http://www.icpsr.umich.edu/sumprog/courses/2007-03-44.html
http://www.icpsr.umich.edu/training/index.html