racism and hypertension

AMERICAN JOURNAL OF HYPERTENSION 1

STATE OF THE ARTnature publishing group

Racial disparities in hypertension (HTN) continue to be a pressing problem in the United States. There is consistent evidence that black Americans are more likely than white Americans to develop HTN. Prevalence rates for black adults range from 30.6 to 40.5%; whereas the rates for white range from 24.4 to 29%.1–5 There is also evidence of racial dispari-ties in blood pressure (BP) control (control rates: blacks 44.1–65.2%; whites 55.6–86.3%),5–9 although not all studies have found race differences.10,11

These disparities exist despite the fact that black Americans are more likely to be aware of their HTN12 and in some cases are more likely to receive treatment for HTN than are white Americans.7,8 Even when black Americans are as or more adherent to antihypertensive treatment than are whites6,13 disparities in BP control are manifest. To address the high prevalence of HTN among black Americans, it may be useful to identify other variables, including different psychosocial

stressors, that might serve as potential individual-level and environmental risk factors that disproportionately affect black Americans, and to understand the ways in which these vari-ables may operate to increase HTN prevalence.

Racism has been hypothesized to serve as a psychosocial stressor contributing to the excess rates of HTN among black Americans.14–18 The goal of this review is to provide a detailed evaluation of the evidence linking individual/interpersonal, internalized, and institutional racism to HTN and to known risk factors for HTN, including obesity, fitness, and alcohol use, as well as psychosocial stress. We hope to provide an evi-dence base that can inform further examination of the role of racism in the development and course of HTN.

We specifically investigate the effects of racism on black Americans, because the majority of published research on the relation of racism to HTN has focused on black Americans. It is important to note, though, there are also significant dispari-ties for other ethnic groups.3,6,19,20

ConstruCts and definitionsMost broadly, racism has been defined as “the beliefs, attitudes, institutional arrangements, and acts that tend to denigrate indi-viduals or groups because of phenotypic characteristics or ethnic group affiliation.”16 Racism or ethnic discrimination can be

Racism and Hypertension: A Review of the Empirical Evidence and Implications for Clinical PracticeElizabeth Brondolo1, Erica E. Love2, Melissa Pencille1, Antoinette Schoenthaler3 and Gbenga Ogedegbe3

1Department of Psychology, St Johns University, Jamaica, New York, USA; 2Department of Clinical Trials, NYU School of Medicine, New York, New York, USA; 3Center for Healthful Behavior Change, Division of General Internal Medicine, Department of Medicine, NYU School of Medicine, New York, New York, USA. Correspondence: E. Brondolo ([email protected])

Received 14 June 2010; first decision 16 July 2010; accepted 25 December 2010

© 2011 American Journal of Hypertension, Ltd.

BaCkgroundDespite improved hypertension (HTN) awareness and treatment, racial disparities in HTN prevalence persist. An understanding of the biopsychosocial determinants of HTN is necessary to address racial disparities in the prevalence of HTN. This review examines the evidence directly and indirectly linking multiple levels of racism to HTN.

MethodsPublished empirical research in EBSCO databases investigating the relationships of three levels of racism (individual/interpersonal, internalized, and institutional racism) to HTN was reviewed.

resultsDirect evidence linking individual/interpersonal racism to HTN diagnosis is weak. However, the relationship of individual/interpersonal racism to ambulatory blood pressure (ABP) is more consistent, with all published studies reporting a positive relationship of interpersonal racism to ABP. There is no direct evidence linking

internalized racism to BP. Population-based studies provide some evidence linking institutional racism, in the forms of residential racial segregation (RRS) and incarceration, to HTN incidence. Racism shows associations to stress exposure and reactivity as well as associations to established HTN-related risk factors including obesity, low levels of physical activity and alcohol use. The effects vary by level of racism.

ConClusionsOverall the findings suggest that racism may increase risk for HTN; these effects emerge more clearly for institutional racism than for individual level racism. All levels of racism may influence the prevalence of HTN via stress exposure and reactivity and by fostering conditions that undermine health behaviors, raising the barriers to lifestyle change.

Keywords: ambulatory blood pressure; blood pressure; hypertension; racial discrimination; racism

American Journal of Hypertension, advance online publication 17 February 2011; doi:10.1038/ajh.2011.9

http://www.nature.com/doifinder/10.1038/ajh.2011.9

mailto:[email protected]

Race, Racism, and HypertensionSTATE OF THE ART

2 AMERICAN JOURNAL OF HYPERTENSION

tab

le 1

| in

terp

erso

nal

, in

tern

aliz

ed, a

nd

inst

itu

tion

al ra

cism

an

d b

lood

pre

ssu

re

Aut

hor

Sam

ple

Rac

ism

mea

sure

Blo

od p

ress

ure

mea

sure

Pote

ntia

l cov

aria

tes

Fin

din

gs

Inte

rper

sona

l rac

ism

Ba

rksd

ale

et a

l.5021

1 Bl

ack

men

and

w

omen

, con

veni

ence

sa

mpl

e

PRS27

Mea

n SB

PN

one

used

in th

e an

alys

isN

o re

latio

n

Br

oman

5631

2 A

fric

an A

mer

ican

ad

ults

rand

omly

se

lect

ed

Que

stio

nnai

re a

sses

sing

“exp

erie

nces

of

disc

rimin

atio

n or

bei

ng p

reve

nted

from

doi

ng

som

ethi

ng, h

ave

been

has

sled

or m

ade

to fe

el

infe

rior b

ecau

se y

ou a

re B

lack

” in

any

of fi

ve

situ

atio

ns. A

ny p

ositi

ve re

spon

se in

dica

ted

disc

rimin

atio

n

Self-

repo

rted

hy

pert

ensi

onAg

e, se

x, e

duca

tion,

fa

mily

inco

me,

em

ploy

men

t sta

tus

No

rela

tion

Co

zier

et a

l.5859

,000

Bla

ck w

omen

, ta

rget

ed sa

mpl

ing,

sn

owba

ll re

crui

t

Que

stio

nnai

re a

sses

sing

self-

repo

rted

exp

osur

e to

ty

pes o

f per

sona

lly m

edia

ted

raci

sm (i

.e., r

ecei

ved

poor

er se

rvic

e, tr

eate

d as

not

inte

llige

nt, p

eopl

e ac

t af

raid

, tre

ated

as d

isho

nest

, peo

ple

act a

s if t

hey

are

bett

er th

an) a

nd “i

nstit

utio

nal r

acis

m” (

i.e., u

nfai

r tr

eatm

ent o

n th

e jo

b, in

hou

sing

, and

by

polic

e)

Self-

repo

rted

an

tihyp

erte

nsiv

e us

e or

hy

pert

ensi

ve st

atus

with

us

e of

a d

iure

tic

Age,

BM

I, bi

rthp

lace

, ty

pe o

f nei

ghbo

rhoo

d,

educ

atio

n

Posi

tive

rela

tion

for

wom

en b

orn

outs

ide

the

Uni

ted

Stat

es a

nd

born

in p

redo

min

atel

y w

hite

nei

ghbo

rhoo

ds

only

D

in-D

ziet

ham

et a

l.5735

6 Bl

ack

adul

ts,

popu

latio

n-ba

sed

sam

ple

Auth

or d

evel

oped

mea

sure

. Que

stio

ns in

clud

e “w

heth

er th

e pa

rtic

ipan

ts h

ad p

erso

nally

ex

perie

nced

any

raci

st o

r dis

crim

inat

ory

enco

unte

rs

in g

ener

al, w

ork

and

med

ical

sett

ings

Nur

se m

easu

red

SBP

and

DBP

and

self-

repo

rted

ph

ysic

ian-

diag

nose

d hi

gh

bloo

d pr

essu

re a

t tw

o or

m

ore

visi

ts

Age;

mar

ital s

tatu

s SES

; BM

I; co

ping

, abi

litie

sN

o re

latio

n

D

ress

ler52

186

Blac

k, ra

ndom

se

lect

ion,

4

com

mun

ities

Four

item

s ass

essi

ng th

e de

gree

to w

hich

pa

rtic

ipan

ts p

erce

ived

that

pay

rais

es a

nd o

ther

w

ork-

rela

ted

issu

es w

ere

base

d on

race

BP m

easu

rem

ents

take

n at

hom

e w

ith a

nero

id

sphy

gmom

anom

eter

BMI,

age,

sex,

skin

col

orN

o re

latio

n

Ja

mes

et a

l.5513

2 Bl

ack

men

, pr

obab

ility

sam

ple,

1

com

mun

ity

Thre

e qu

estio

ns a

bout

race

as a

hin

dran

ce o

r hel

p to

job

Two

mea

sure

s of r

estin

g BP

take

n du

ring

inte

rvie

wAg

e, e

duca

tion,

que

tlet

inde

x, #

cig

aret

tes,

time

of d

ay

No

dire

ct re

latio

nshi

p

Ja

mes

et a

l.4989

Min

ority

adu

lts

(18.

1% B

lack

) co

nven

ienc

e sa

mpl

e of

em

ploy

ees

Org

aniz

atio

nal P

reju

dice

-Dis

crim

inat

ion

Scal

e49M

ean

SBP

and

DBP

Self-

este

em; c

olle

ctiv

e es

teem

; val

ue d

iffer

ence

s w

ith p

eers

& su

perv

isor

s;

expr

essi

vene

ss

Posi

tive

rela

tion

Kr

iege

r5910

1 Bl

ack

and

whi

te

wom

en, r

ando

m

sam

ple

Inte

rvie

w q

uest

ions

: Hav

e yo

u ev

er e

xper

ienc

ed

disc

rimin

atio

n, b

een

kept

from

doi

ng so

met

hing

, or

been

has

sled

or m

ade

to fe

el in

ferio

r (at

scho

ol, a

t w

ork,

get

ting

a jo

b, a

t hom

e, g

ettin

g m

edic

al c

are)

be

caus

e of

you

r rac

e?

Mea

n SB

P an

d D

BPAg

eN

egat

ive

rela

tion,

no

t sig

nific

ant w

hen

adju

sted

for a

ge

Kr

iege

r and

Sid

ney48

4,08

6 Bl

ack

and

whi

te,

targ

eted

recr

uitm

ent

Self-

adm

inis

tere

d qu

estio

nnai

re: f

ive

sets

of

ques

tions

whi

ch a

ddre

ssed

whe

ther

they

had

eve

r ex

perie

nced

dis

crim

inat

ion,

bee

n pr

even

ted

from

do

ing

som

ethi

ng o

r bee

n ha

ssle

d or

mad

e to

feel

in

ferio

r in

seve

ral s

ituat

ions

bas

ed o

n ra

ce o

r col

or

(at s

choo

l, ge

ttin

g a

job,

at w

ork,

get

ting

hous

ing,

ge

ttin

g m

edic

al c

are,

on

the

stre

et o

r in

a pu

blic

se

ttin

g an

d fr

om th

e po

lice

or in

the

cour

ts)

Mea

n SB

P an

d D

BPAg

e; so

cial

cla

ss; a

nnua

l fa

mily

inco

me,

edu

catio

n,

mar

ital s

tatu

s

U-s

hape

d re

latio

n,

effe

cts v

ary

by g

ende

r an

d so

cial

cla

ss

tab

le 1

| Con

tin

ued

on

nex

t pag

e

Race, Racism, and Hypertension STATE OF THE ART


tab

le 1

| Con

tin

ued

Aut

hor

Sam

ple

Inte

rper

son

al ra

cism

mea

sure

Blo

od p

ress

ure

mea

sure

Pote

ntia

l cov

aria

tes

Fin

din

gs

Pe

ters

5416

2 Bl

ack

adul

ts,

conv

enie

nce

sam

ple

RaLE

S;26

,125

KRD

Q59

Mea

n SB

P an

d D

BPAg

e, tr

ait a

nger

, tra

it an

xiet

y, a

nger

exp

ress

ion

No

rela

tion

Po

ston

et a

l.4722

1 Bl

ack

med

ical

pr

ofes

sion

als,

born

in

Uni

ted

Stat

es o

r Afr

ica

PRS27

Mea

n SB

PBi

rthp

lace

, BM

I, ag

eN

o re

latio

n

Ry

an e

t al.51

666

Blac

k or

Lat

ino(

a)

adul

ts (1

90 B

lack

), sn

owba

ll sa

mpl

ing

BRFS

S re

actio

ns to

race

mod

ule—

thre

e qu

estio

ns

“How

oft

en d

o yo

u fe

el d

isco

mfo

rt, o

r ang

er b

y th

e w

ays o

ther

s tre

at y

ou in

you

r eve

ryda

y lif

e be

caus

e of

you

r rac

e? d

o yo

u fe

el th

at “r

acia

l dis

crim

inat

ion

dim

inis

hes y

our a

bilit

y to

ach

ieve

you

r goa

ls fu

lly?”

“Y

ou h

ave

been

rece

ivin

g le

ss th

an th

e be

st h

ealth

ca

re b

ecau

se o

f you

r rac

e?”

Mea

n BP

Ethn

icity

, age

, gen

der,

toba

cco

use,

exe

rcis

e,

BP m

eds,

BMI,

inco

me,

ed

ucat

ion,

em

ploy

men

t, in

sura

nce

U-s

hape

d re

latio

n—bo

th th

e lo

wes

t and

hi

ghes

t lev

els o

f ex

posu

re h

ad h

ighe

r BP

than

indi

vidu

als

with

mod

erat

e ex

posu

re

Br

ondo

lo e

t al.62

357

Blac

k an

d La

tino

adul

ts, 2

45 w

ith

nigh

ttim

e re

adin

gs,

conv

enie

nce

sam

ple

Perc

eive

d Et

hnic

Dis

crim

inat

ion

Que

stio

nnai

re-

Com

mun

ity V

ersi

on24

ABP

-day

and

nig

htAg

e, ra

ce, g

ende

r, BM

I, cy

nici

sm/h

ostil

ity,

indi

vidu

al-le

vel m

easu

res

of S

ES, a

lso

obse

rvat

ion

leve

l mea

sure

s of c

affe

ine

and

alco

hol,

post

ure,

sm

okin

g

PR p

ositi

vely

as

soci

ated

with

ni

ghtt

ime

SBP

and

DBP

, inv

erse

ly re

late

d to

BP

dipp

ing

H

ill e

t al.66

40 B

lack

stud

ents

, co

nven

ienc

e sa

mpl

ePR

S,27

raci

sm in

aca

dem

ic se

ttin

gs, p

ublic

sett

ing,

ra

cist

stat

emen

tsA

BP-d

ay a

nd n

ight

Gen

der,

BMI

PR in

aca

dem

ic se

ttin

g po

sitiv

ely

asso

ciat

ed

with

day

time

DBP

and

ni

ghtt

ime

DBP

. No

effe

cts f

or S

BP

Sm

art R

ichm

an

et a

l.6561

Bla

ck a

nd w

hite

adu

lts,

conv

enie

nce

sam

ple

Ever

yday

unf

air t

reat

men

t (di

scrim

inat

ion)

(n

o qu

estio

ns o

n at

trib

utio

n to

race

)A

BP-d

ay a

nd n

ight

Sex,

age

, rac

e, S

ES, B

MI,

host

ility

, neu

rotic

ism

, an

d ob

serv

atio

nal l

evel

va

riatio

ns in

pos

ture

UT/

D p

ositi

ve re

latio

n to

ove

rall

DBP

. Tim

e tr

end:

for h

igh

UT/

D

(vs.

low

) inc

reas

e ov

er th

e da

y, sh

allo

w

decr

easi

ng sl

ope

durin

g ni

ght

Si

ngle

ton

et a

l.6352

Bla

ck a

dults

, co

nven

ienc

e sa

mpl

ePR

S,27

ove

rall,

exp

osur

e in

pub

lic p

lace

s, ra

cist

st

atem

ents

ABP

-day

and

nig

htN

o in

form

atio

nRa

cism

in p

ublic

se

ttin

gs p

ositi

vely

re

late

d to

nig

httim

e SB

P an

d D

BP. N

o ef

fect

s for

day

time

BP

To

mfo

hr e

t al.64

91 B

lack

and

whi

te a

dults

, co

nven

ienc

e sa

mpl

eEv

eryd

ay u

nfai

r tre

atm

ent (

disc

rimin

atio

n), n

o qu

estio

ns o

n at

trib

utio

n to

race

68A

BP-t

wo

days

and

two

nigh

tsAg

e, g

ende

r, ra

ce,

BMI,

defe

nsiv

enes

s/so

cial

des

irabi

lity

SES,

an

d av

erag

e BP

, hos

tility

, m

arita

l sta

tus,

wee

kly

cons

umpt

ion

of a

lcoh

olic

be

vera

ges,

and

smok

ing.

UT/

D is

ass

ocia

ted

with

less

nig

httim

e di

ppin

g of

SBP

and

D

BP. N

o in

tera

ctio

ns

with

race

. UT/

D

med

iate

s rac

e di

ffere

nces

in d

ippi

ng.

tab

le 1

| Con

tin

ued

on

nex

t pag

e



tab

le 1

| Con

tin

ued

Aut

hor

Sam

ple

Rac

ism

mea

sure

HTN

mea

sure

Pote

ntia

l cov

aria

tes

Fin

din

gs

Inte

rnal

ized

raci

sm

Tu

ll et

al.89

Age

and

body

mas

s m

atch

ed sa

mpl

es o

f A

fric

an-C

arib

bean

, no

ndia

betic

wom

en a

ged

25–6

0. Tw

enty

-sev

en

with

hig

h in

tern

aliz

ed

raci

sm a

nd tw

enty

-six

w

ith lo

w in

tern

aliz

ed

raci

sm

Nad

anol

itiza

tion

scal

e31M

ean

SBP

and

DBP

or

pres

ence

of

hype

rten

sion

Perc

eive

d st

ress

sc

ore,

def

eate

d co

ping

st

yle

No

rela

tion

Aut

hor

Sam

ple

Rac

ism

mea

sure

HTN

mea

sure

Pote

ntia

l cov

aria

tes

Fin

din

gs

Inst

itutio

nal r

acis

m

Fa

ng e

t al.96

All

resi

dent

s of N

YC

draw

n fr

om c

ensu

s 199

0 an

d de

ath

regi

stra

tions

fr

om 1

988

to 1

994

Cont

rast

bet

wee

n la

rgel

y bl

ack

and

larg

ely

whi

te

area

s (la

rgel

y bl

ack

≤75%

bla

ck, l

arge

ly w

hite

≤75

%

whi

te),

plus

Har

lem

Dea

th re

gist

ratio

n in

form

atio

n fr

om N

YC

DO

H, c

ause

of d

eath

is

repo

rted

by

a ph

ysic

ian

(ICD

- 9.

401–

404)

Age,

edu

catio

n,

unem

ploy

men

t, bi

rth

in

Sout

h of

US

No

rela

tion

G

rady

and

Ram

irez92

91,7

48 R

ecor

ds o

f bla

ck

and

whi

te m

othe

rs d

raw

n fr

om N

YC D

epar

tmen

t of

Hea

lth V

ital

reco

rds

Loca

l spa

tial s

egre

gatio

n in

dex

Pres

ence

of c

hron

ic H

TN

or p

regn

ancy

-rel

ated

HTN

Age,

mar

ital s

tatu

s, pl

ace

of b

irth,

edu

catio

n,

Med

icai

d us

e, p

over

ty

Posi

tive

rela

tions

hip:

hi

gher

segr

egat

ion,

gr

eate

r ris

k of

ch

roni

c an

d pr

egna

ncy

HTN

M

oble

y et

al.10

9Sa

mpl

e of

200

1–20

02

data

of 2

,692

wom

en

enro

lled

in th

e W

ISEW

OM

AN

pro

gram

of

the

Cent

ers o

f Dis

ease

Co

ntro

l and

Pre

vent

ion

The

degr

ee to

whi

ch m

embe

rs o

f eac

h ra

ce/e

thni

c gr

oup

are

expo

sed

mor

e to

one

ano

ther

than

to

mem

bers

of o

ther

raci

al/e

thni

c gr

oups

10-y

ear C

HD

risk

ca

lcul

ated

by

an

algo

rithm

usi

ng g

ende

r, ag

e, to

tal a

nd h

igh

dens

ity li

popr

otei

n (H

DL)

, ch

oles

tero

l, SB

P, Sm

okin

g st

atus

, dia

bete

ssta

tus

Indi

vidu

al c

hara

cter

istic

s:

age,

smok

ing

stat

us,

educ

atio

n, ra

ce/e

thni

city

Bu

ilt E

nviro

nmen

t ch

arac

teris

tics:

land

use

m

ix, p

er 1

,000

resi

dent

s—nu

mbe

r of f

itnes

s fa

cilit

ies,

full

size

gro

cery

st

ores

, fas

t foo

d pl

aces

, re

stau

rant

s, m

inim

arts

. So

cioe

colo

gica

l ch

arac

teris

tics:

robb

ery

arre

sts p

er 1

,000

resi

dent

s

Neg

ativ

e re

latio

n

tab

le 1

| Con

tin

ued

on

nex

t pag

e



considered as a form of social ostracism. Phenotypic or cultural characteristics are used to render individuals outcasts, making them targets of social exclusion, unfair treatment, and harass-ment; and consequently, either directly or indirectly, depriving them of social and economic opportunities and threatening per-sonal safety.21 Detailed reviews concerning the conceptualiza-tion and measurement of racism are available elsewhere.16,18,22

Racism can occur on multiple levels: individual/inter-personal, internalized, and institutional.22,23 Individual-level racism includes episodes of race-based maltreatment that are perpetrated by individuals and targeted at other individuals.17,22 In the context of an interpersonal exchange, these exchanges are considered interpersonal racism, which has been defined as “directly perceived discriminatory inter-actions between individuals whether in their institutional roles or as public and private individuals.”22 Individual-level racism is typically assessed with self-report surveys inquiring about exposure to acts perceived as discriminatory, unfair, or disrespectful (i.e., refs. 24–27). Self-report surveys assess the subset of experiences of ethnicity-related maltreatment that are directly perceived by the target and are generally labeled perceived racism or ethnic discrimination.

Internalized racism is defined as “the acceptance, by mar-ginalized racial populations, of the negative societal beliefs and stereotypes about themselves.”28 The internalization of negative stereotypes about ones’ own group may develop in response to repeated exposure to ethnicity-based maltreat-ment, as a function of cultural communications of attitudes toward stigmatized groups, and from familial or other sociali-zation processes, as well as other mechanisms.29,30 In studies of BP among black individuals, internalized racism has been assessed with a self-report scale (i.e., Nadanolitization scale)31 that measure the degree of agreement with typical stereotypes about the black individuals.

Institutional racism refers to specific policies and/or pro-cedures of institutions (i.e., government, business, schools, churches, etc.) which consistently result in unequal treatment or outcomes for particular groups, even though other non-race-related factors may also be associated with the disparate outcomes.32,33 Policies resulting in unequal treatment can be considered as a form of racism, despite the absence of evidence of deliberate racial prejudice on the part of the policy-makers. This is the case when majority-group policy-makers are less aware of or responsive to the consequences of these policies for minority stakeholders.34 In general, research on the rela-tionship of institutional racism to HTN has focused on the relationship of BP to the tangible outcomes of these policies, including access to education or health care, residential seg-regation, incarceration, among other outcomes.35,36 Two out-comes that have been specifically studied in relation to HTN include residential racial segregation (RRS) and incarceration.ta

ble

1 | C

onti

nu

ed

Aut

hor

Sam

ple

RRS/

inst

itut

ion

al ra

cism

mea

sure

HTN

mea

sure

Pote

ntia

l cov

aria

tes

Fin

din

gs

M

oren

off e

t al.94

Prob

abili

ty sa

mpl

e of

3,

105

part

icip

ants

age

d 18

and

ove

r fro

m v

ario

us

citie

s in

Chic

ago

2000

Cen

sus—

neig

hbor

hood

com

posi

tion,

per

cent

H

ispa

nic,

per

cent

imm

igra

nt, p

erce

nt n

on-b

lack

in

cens

us tr

act

Mea

n SB

P an

d D

BPSe

x, a

ge, r

ace/

ethn

icity

, ed

ucat

ion,

inco

me,

m

arita

l sta

tus,

pres

ence

of

chi

ldre

n, B

MI,

heal

th

insu

ranc

e st

atus

, reg

ular

m

edic

al c

are

stat

us,

imm

igra

tion

stat

us,

exer

cise

freq

uenc

y

No

rela

tion

Sc

hlun

dt e

t al.93

3,01

4 Te

leph

one

surv

eys

done

usi

ng a

sam

ple

of

men

and

wom

en in

Nor

th

Nas

hvill

e an

d N

ashv

ille/

Dav

idso

n, T

N

2000

Cen

sus—

perc

ent o

f bla

cks i

n ce

nsus

trac

tSe

lf-re

port

ed d

iagn

osed

hy

pert

ensi

onN

one

used

in a

naly

sis

Posi

tive

rela

tion

W

ang

et a

l.97H

isto

ry o

f inc

arce

ratio

nIn

cide

nt h

yper

tens

ion

Dem

ogra

phic

s, cl

inic

al

risk

fact

ors,

beha

vior

al ri

sk

fact

ors,

SES

Posi

tive

rela

tion

ABP

, am

bula

tory

BP;

BM

I, bod

y m

ass i

ndex

; BP,

bloo

d pr

essu

re; B

RFSS

, Beh

avio

r Ris

k Fa

ctor

Sur

veill

ance

Sys

tem

; CH

D, c

hron

ic h

eart

dis

ease

; DBP

, dia

stol

ic B

P; H

TN, h

yper

tens

ion;

KRD

Q, K

riege

r Rac

ial D

iscr

imin

atio

n Q

uest

ionn

aire

; PR

S, P

erce

ived

Rac

ism

Sca

le; R

aLES

, Rac

ism

and

Life

Exp

erie

nces

Sca

le; R

RS, r

esid

entia

l rac

ial s

egre

gatio

n; S

BP, s

ysto

lic B

P; S

ES, s

ocio

econ

omic

stat

us.



Residential segregation refers to “the degree to which groups of people categorized on a variety of scales (race, eth-nicity, income) occupy different space within urban areas.”37 We focus on race-based residential segregation (RRS), which is likely to be a function of a number of both historical and current actions on the part of institutions (i.e., real estate developers, lending organizations, employers) as well as the actions of individuals within neighborhoods.37 RRS also serves as a proxy for the extent to which black individuals are ostra-cized by other groups.38 Across all income groups, blacks tend to live in more racially segregated areas than do whites, but RRS is most pronounced among individuals with low levels of income and education.35 Strategies for conceptualizing and quantifying RRS have been well reviewed elsewhere.37,39,40 Examples of measures include the index of dissimilarity and the proportion of black residents in a given area, a measure used in most studies of HTN despite some limitations to its interpretability.37,41

Rates of incarceration in the criminal justice system can also be regarded as an index of institutional racism.42,43 In compar-ison to whites, most evidence suggests that black Americans are more likely to be incarcerated, even when controlling for a wide range of case and jurisdiction-related variable.42 These differences have developed in part, because of stereotypes about the propensity of black Americans to be violent, as well as legal and policing policies and practices.42,43

This review extends our prior work and examines studies of adults linking each level of racism to HTN diagnosis or to BP levels (with BP levels serving as a proxy for a documented diag-nosis of HTN).14,44 To obtain all relevant studies, we searched all EBSCO-host-related databases, including MEDLINE and Psych Info using the terms: racism, racial discrimination, eth-nic discrimination, institutional racism, internalized racism, self-stereotyping, residential segregation, racial segregation, racial residential segregation, and incarceration combined with BP, cardiovascular response, reactivity, HTN, and health. All papers were searched for any additional relevant refer-ences. Papers available through August 2010 were included. Table 1 includes the details of all reviewed studies for each level of racism.

To further understand the mechanisms through which rac-ism may affect HTN, we also investigate the relationship of racism to obesity, low levels of fitness, and excess alcohol con-sumption. Each has been documented to be associated with increased HTN prevalence.20,45 Reductions in these risk fac-tors have been associated with improvements in BP, and they are frequent targets of physician recommendations.45

We include data on psychosocial stress as a risk factor, although the relationship is not as well documented or accepted as lifestyle-related risk factors. Events and conditions are perceived as stressful when they are appraised as salient and

threatening, and present demands for coping that are perceived to exceed the individual’s resources.46 Both systematic and conceptual reviews suggest that chronic, but not acute stres-sors are more likely to be associated with increased risk for HTN.47,48

All levels of racism can result in acute stress exposure, but racism is widely regarded as a chronic stressor.16,21,49 Interpersonal racism takes the form of discrete events, includ-ing both overt and covert episodes of race-related maltreat-ment. These acute events can become chronic stressors if they occur frequently and/or if the experience has persistent negative effects. For example, the acute effects of race-related maltreatment may be maintained if the targeted individual experiences constraints on his or her ability to resolve the situation or cope with its aftermath.21,46 Institutional racism is associated with conditions (e.g., residential segregation, incarceration) that present additional obstacles or sustained demands that can act as chronic stressors.

raCisM and htn: exaMining the assoCiations of interpersonal, internalized, and institution‑alized raCisM to htn diagnosis or Bp levels and htn‑related risk faCtorsindividual/interpersonal racismThe bulk of the research on racism and HTN has investigated the effects of individual-level or interpersonal racism.15,17 Most studies employed within-group designs to investigate the degree to which the intensity of exposure to racism affects risk for HTN within black individuals. In our prior review,14 we indicated limited direct relationships of racism to HTN diag-nosis. The subsequent publications support this conclusion.

To date there have been 12 observational studies (described in 13 papers) which included black adults and which examined the relationship between self-reported exposure to interpersonal racism and resting BP level (e.g., a mean of two or three read-ings taken under standardized conditions)47–55 or self-reported or physician-diagnosed hypertensive status.48,56–58 Seven stud-ies did not find a direct relationship between perceived rac-ism and BP when the investigators examined the sample as a whole.47,50,52–54,56,57 Two studies have found a negative relation-ship either among older participants54 or among the participant group as a whole.59 There are two studies that report a U-shaped relationship of racism to HTN, in which, depending on partici-pants’ race, gender, and social class, there were elevated BP lev-els in those experiencing high levels of racism or no racism vs. moderate levels of racism.48,51 There are only two studies that reported a positive relationship between self-reported racism and either BP level or self-reported diagnosis of HTN either in the group overall49 or in one subgroup (i.e., non-US born women).58 However, one of these studies included a small sam-ple (n = 89), only 18% of whom were black.49



In contrast, the data from ambulatory BP (ABP) monitoring studies are more consistent. ABP, and in particular nocturnal ABP, is regarded as a more reliable predictor of target organ damage than are clinic measures.60 Ambulatory monitoring also captures BP reactivity to daily events. The six studies of adults all reported positive relationships between perceived racism/discrimination and either daytime ABP,61 nighttime ABP or BP dipping,62–65 or both.66

There are substantial variations in the quality of these stud-ies of HTN diagnosis, clinic BP or ABP. Only four of the studies employed population-based or randomly selected samples.55–57,59 As shown in Table 1, some studies employed measures with a small number of items inquiring about dis-crimination in general or experiences of discrimination in spe-cific venues (i.e., such as work or medical care),48,52,55,56,59 and very little psychometric information was provided about these measures. Others studies included measures that have been subjected to extensive psychometric testing (e.g., Perceived Racism Scale, Everyday Discrimination, or the Perceived Ethnic Discrimination Questionnaire-Community Version).47,49,50,54 The studies of ABP (vs. those of BP level or HTN diagnosis) were more likely to include measures with known and good psychometric properties. However, it is important to note that neither the more limited scales, nor those with good psycho-metric properties yielded positive effects in studies of clinic BP or HTN status. In contrast, the same scales (i.e., the Perceived Racism Scale, Everyday Discrimination/Unfair treatment) were associated with ABP, even in studies with much smaller samples.61–66

As is the case with all self-report measures, scores on meas-ures of perceived racism may contain some error. The scales measuring perceived racism cannot distinguish between the target’s perceptions of racial bias in cases in which these per-ceptions are accurate (i.e., the perpetrators’ actions were moti-vated by racial bias) vs. those in which the target’s perceptions are a function of misperceptions or misattributions to discrimi-nation. To attempt to control for intrapersonal factors such as hostility or neuroticism that might influence the percep-tions of racism (and potentially HTN), but may develop from nonracism- related factors (e.g., temperament, family function-ing, etc.), some investigators have included measures of per-sonality characteristics as covariates.62,65 Three ABP studies in which measures of negative-affect related traits (e.g., hostility or neuroticism) were included as covariates find that the effects of perceived racism on ABP remain robust and significant.62,64,65

Measures of perceived racism which inquire about dis-crimination in a variety of venues could elicit answers reflect-ing perceptions of institutional racism (i.e., perceptions of being mistreated as a function of institutional policies) rather than experiences of interpersonal maltreatment. Racism may also affect an individual’s access to economic and social

resources, and in turn affect HTN risk through deprivation. Consequently, most investigators included measures of indi-vidual level or neighborhood socioeconomic status (SES) as a partial control for the effects of these environmental or insti-tutional variables. In studies in which the effects of SES were explicitly evaluated,67 the inclusion of SES as a control variable did not eliminate the effects of perceived racism/discrimina-tion on ABP.62 However, some studies suggest that SES mod-erates the effects of racism on BP, although the direction of effects is not consistent and additional work is needed.48,55,57

Individual-level racism may also have health effects in cir-cumstances in which the targeted individual is unaware of the exposure.68,69 Some investigators have advocated the use of measures of unfair treatment or discriminatory behavior (e.g., the Everyday Unfair Treatment Scale68,69) which assess exposure to interpersonal experiences that are likely to be a function of racial discrimination, without requiring participants to attribute the maltreatment to racial bias. These scales can be considered as a measure of the construct “ everyday unfair treat-ment” rather than racial discrimination per se, because individ-uals can perceive themselves as targeted for unfair treatment for many reasons (i.e., including their social class or gender). Some investigators have included additional questions about the attri-butions for the maltreatment; however, none of the studies of HTN or ABP in adults included these items.

All studies of HTN and clinic BP employed measures directly referring to race. All ABP studies included measures assessing experiences of unfair or discriminatory treatment in everyday life (i.e., Everyday Unfair Treatment, Perceived Racism Scale, and Perceived Ethnic Discrimination Questionnaire-Community Version). Four of these studies included meas-ures which explicitly refer to race as a cause for the unfair treatment (i.e., Perceived Racism Scale and Perceived Ethnic Discrimination Questionnaire-Community Version),61–63,66 whereas two other studies included measures of unfair treat-ment that did not explicitly refer to race.64,65 Associations of unfair treatment/discrimination to ABP among blacks were found using either type of measure of unfair treatment.

Interpersonal racism and risk factors for HTN. Although two recent studies reported no concurrent relationship of racism to body mass index,70,71 another prospective investigation reported that increases in interpersonal racism were positively associated with weight gain over a period of 8 years.72 To our knowledge there have been no studies of the relationship of indi-vidual-level racism and the intake of specific nutrients such as sodium or potassium. Perceived racism has been associated with greater risk for any level of alcohol use (but not binge or heavy drinking) among black Americans.73 Prospective studies also indicate a relationship of perceived discrimination to increases in alcohol use, partially mediated by discrimination-related



changes in psychological distress.74 The one study specifically examining physical activity in a large population-based sample, did not find a relationship with racism.75

In contrast, there is substantial, clear and consistent evidence that individual-level racism is associated with indices of psycho-logical distress (e.g., negative affect, anger, depression, and anx-iety), as well as personality characteristics (e.g., hostility, trait negative mood) that increase the experience of distress.15,17,76,77 Racism may also influence cardiovascular responses to stress exposure. BP reactivity to stress has been identified as an inde-pendent predictor of the development of HTN.78,79 Several studies report that perceived individual-level racism predicts the magnitude of BP reactivity to laboratory-induced stres-sors.80–85 However, others studies found no direct relation-ship of individual-level racism to BP reactivity or recovery, and report that the effects of racism emerged only when moderated by other characteristics (e.g., support or hostility).80,82,86

Interpersonal racism is more consistently related to perceived stress and negative emotions than to lifestyle-related factors, including physical activity or obesity. It is worth noting that some,50,57 although not all,54 studies of racism and HTN found that stress reactions to racism were associated with HTN diag-nosis or BP level, even when exposure to race-based maltreat-ment was not. However, there are still very limited data.

internalized racismTo our knowledge, there is only one study directly assessing the effects of internalized racism, assessed with a modified ver-sion of the Nadanolitization scale on BP in Afro-Caribbean women. The authors did not find a direct relationship of inter-nalized racism to resting BP.87

The measure of internalized racism (i.e., the Nadanolitization scale) assesses the belief that members of one’s group have characteristics that correspond to common stereotypes about the group. This may or may not be related to self- stereotyping (i.e., the degree to which the individual has incorporated these stereotypes into his or her self-concept). New research is employing methods from cognitive psychology, including variations on the Implicit Association Test, to assess noncon-scious self-stereotyping.88

Internalized racism and HTN risk factors. Internalized racism does not show a relationship with body mass index,87 but is more closely associated with abdominal obesity, with three of four studies reporting a significant positive relationship.89–91 One study suggests that internalized racism is associated with perceived stress among black women.87

institutional racismThe data linking racial residential segregation to HTN is mixed. RRS has been associated with greater risk for HTN

among both black and white mothers, such that mothers living in more racially segregated areas (e.g., areas in which there were high percentages of black individuals and in which residents were less likely to interact with others who were not black) were more likely to report having chronic HTN and to be at risk for pregnancy-related HTN, controlling for neigh-borhood poverty and other factors.92 Another study reported that the percentage of black individuals living in an area was correlated with the percentage of individuals with HTN, but did not control for other facets of the neighborhood in which black individuals predominate, including higher density and lower cost of housing, variables independently associated with HTN.93

In contrast, two population-based studies of black adults did not find any relationship of the proportion of blacks living in the neighborhood to prevalence of HTN among black adults94 controlling for other neighborhood risks.95 Fang et al. reports that for black adults, there was no effect of residential area on HTN-related mortality.96 Finally, a large population-based study of black women from communities varying in size, seg-regation, and other factors found that racial segregation, as assessed by an index evaluating the likelihood that individu-als would interact with others of another ethnicity or race, was negatively associated with a measure of 10-year risk for coronary heart disease in which HTN was one factor used to comprise the measure.64

To our knowledge, there is only one study specifically exam-ining the link between incarceration and HTN.97 The inves-tigators report that a history of incarceration was associated with HTN prevalence and new incidences of HTN because incarceration across both black and white adults drawn from a national sample of young adults drawn from the Coronary Artery Risk Development in Young Adults (CARDIA) study. The effects were strongest for black men, the group most likely to have been incarcerated, but interactions of race and incar-ceration were not significant.

There is substantial evidence that black Americans live in more disadvantaged communities than other groups.34 The limited available evidence suggests that neighborhood disad-vantage may mediate the relationship of RRS to HTN.40 Low levels of neighborhood economic resources, including hous-ing quality and affluence have been associated with increased prevalence of HTN,98,99 as have perceptions of social stress in the community, including crime, perceptions of safety, marital instability, and crowding.100–103 There may also be additional environmental factors influencing racial disparities in HTN, given the wide geographic disparities in rates of HTN among both blacks Americans.104 Efforts to intervene to reduce HTN will require an understanding of the specific circumstances or deprivations that are most closely associated with HTN and which mediate the effects of RRS on HTN.40



Institutional racism and HTN risk factors. Data from most,105–

108 but not all109 studies suggest that living in neighborhoods with higher levels of RRS is associated with a higher prevalence of obesity. The data on the association of neighborhood afflu-ence to obesity is clear: rates of obesity are higher in neighbor-hoods with low vs. high SES.37,110

To our knowledge, there is no direct evidence that RRS is independently linked to higher rates of alcohol abuse or dependence. However, there is evidence that economically disadvantaged neighborhoods and those with higher levels of neighborhood stress are associated with a higher rate of alco-holism.111–113 The available data on RRS suggest that indi-viduals living in more segregated communities are less likely to be physically active.114 RRS has been associated with both objective indices of stress (e.g., crime),115 subjective reports of neighborhood stress,116 and fewer community resources for stress reduction (e.g., parks, recreational facilities, etc.).117

A portion of these neighborhood effects on HTN risk fac-tors may be a function of the barriers to obtaining healthy foods and accessing recreational facilities, combined with greater access to liquor stores.110,118–121 In one experimental study in which very low income individuals from low income neighborhoods were randomly assigned to live in new, higher income neighborhoods revealed decreases in obesity (but not HTN) over a 5-year period.122 Similarly, in the Yonkers project, low income minority families who were randomly assigned to be able to move to middle class neighborhoods reported less alcohol abuse than did families unable to move.123

suMMaryBlack individuals remain at higher risk for the development of HTN than do white individuals, despite improvements in awareness and treatment. There is evidence that racism appears to affect risk for HTN, but the effects are complex. Among black Americans, interpersonal racism is associated with ABP,61–

63,66,124 and in particular nocturnal BP, although it does not appear to be reliably associated with resting measures of BP or HTN diagnosis.47,50,52–54,56,57,59 There is mixed evidence link-ing RRS, an index of institutional racism, to HTN prevalence and BP levels,92,93 and emerging evidence that prison incarcer-ation is associated with HTN prevalence.97 It is not clear if the effects of RRS are attributable to the degree of racial isolation or the degree of deprivation associated with the neighborhood, as neighborhood SES is inversely associated with HTN inci-dence.98,99 There is no evidence directly linking internalized racism to BP, but there have been very few studies.

Racism may influence the incidence of HTN by increasing the incidence of HTN-related risk factors. There is limited evidence that interpersonal racism is associated with the development of obesity.72 RRS is associated with higher levels of obesity93 and lower levels of fitness.114 Both interpersonal

racism and neighborhood deprivation and stress have been linked to alcohol use, but more data are needed on the effects of internalized racism and RRS. All levels of racism are associ-ated with perceived stress, and individual-level racism, in par-ticular, is associated with distress21 and stress reactivity.125

ConClusionsTaken together, the evidence suggests that institutional and interpersonal racism are likely to contribute to the develop-ment of HTN, although multiple mechanisms and trajectories may be involved. Individual-level racism, and potentially inter-nalized racism, may act in part by increasing the frequency, magnitude, duration, and psychophysiological effects of stress exposure. The harsh or impoverished environments that are a function of institutional racism may add additional stress and raise barriers to achieving a healthy lifestyle.

The relationship of perceived racism to BP emerges more clearly, when the measures inquire about episodes of interper-sonal maltreatment vs. global judgments of exposure to dis-crimination. This may reflect problems with the reliability of global discrimination measures or the strategies for measur-ing BP. However, it is also possible that the findings reflect the aspects of individual-level racism (i.e., stressful interpersonal maltreatment) that are most closely associated with BP.

Exposure to race-related maltreatment has been shown to be positively related to increased rates of negative interpersonal interactions in general.73,77 If the effects of perceived racism on BP are mediated through exposure to daily interpersonal maltreatment, the effects of racism on BP may not be apparent during brief conditions involving rest (or neutral or positive interactions with medical personnel). Instead, the effects of racism may be more likely to emerge when BP is assessed dur-ing everyday events, including episodes of interpersonal con-flict. This is consistent with the finding that perceived racism/discrimination is more closely related to ABP than to resting clinic BP. The importance of ongoing interpersonal conflict to BP is underscored by our recent report that the level of daily interpersonal harassment predicted masked HTN (i.e., clinic normotension plus elevated ABP) in a sample of black and Latino(a) adults.126 Further study of the effects of racism on psychobiological responses to interpersonal relationships is needed, as is research on coping strategies that might moder-ate or buffer these effects.

Institutional racism is associated with conditions includ-ing neighborhood poverty, segregation, and incarceration that provide limited access to health promoting resources and constraints on the development and/or deployment of health promoting coping strategies.110 This suggests that resources and coping may mediate the relationship of institu-tional racism to HTN. Yet, experimental data suggest that the ways in which these variables act as mediators is complex. For



example, moving to a less impoverished area was associated with decreases in obesity and alcohol abuse, but was not asso-ciated with changes in hypertensive status.122,123

Research is needed to understand the specific community-level variables that affect HTN incidence. It is possible that multiple environmental factors (e.g., high levels of stress expo-sure plus limited access to healthy foods) must be present to trigger the onset of HTN. Alternatively, environmental vari-ables may exert an effect on risk for HTN only in the presence of genetic vulnerability. Different levels of racism may inter-act to compound risk by impairing coping. For example, the negative mood states that are a persistent effect of exposure to interpersonal racism may undermine the motivation needed to overcome the effects of institutional racism, including environ-ments with few resources for healthy living.62 Risk factors may operate differently over the course of development. The early life effects of racism, including the well-documented effects of racism on birth weight,127,128 may set the stage for increased vulnerability to the additional challenges presented by chronic interpersonal maltreatment or neighborhood poverty.

Despite progress, research on racism and HTN is still in its early stages. To more fully understand the relationship of rac-ism to HTN, it will be important to identify the ways each level of racism acts as a stressor or as a barrier to health promotion. These continued efforts will be necessary to identify targets for prevention and intervention.

Acknowledgments: This publication was made possible by prior support to E.B. from grant R01HL68590 and ongoing support to G.O. from the following grants: P60MD003421; R01HL087301; and R01HL078566. The contents of this work are solely the responsibility of the authors and do not represent the official views of NIH.

Disclosure: The authors declared no conflict of interest.

1. Borrell LN, Crawford ND, Barrington DS, Maglo KN. Black/white disparity in self-reported hypertension: the role of nativity status. J Health Care Poor Underserved 2008; 19:1148–1162.

2. Fiscella K, Holt K. Racial disparity in hypertension control: tallying the death toll. Ann Fam Med 2008; 6:497–502.

3. Glover MJ, Greenlund KJ, Ayala C. Racial/ethnic disparities in prevalence, treatment, and control of hypertension-United States, 1999-2002. MMWR 2002; 53:7–9.

4. Glover MJ, Greenlund KJ, Ayala C, Croft JB. Racial/ethnic disparities in prevalence, treatment, and control of hypertension-United States, 1999–2002. MMWR 2005; 54:7–9.

5. Hajjar I, Kotchen TA. Trends in prevalence, awareness, treatment, and control of hypertension in the United States, 1988-2000. JAMA 2003; 290:199–206.

6. Angell SY, Garg RK, Gwynn RC, Bash L, Thorpe LE, Frieden TR. Prevalence, awareness, treatment, and predictors of control of hypertension in New York City. Circ Cardiovasc Qual Outcomes 2008; 1:46–53.

7. Hertz RP, Unger AN, Cornell JA, Saunders E. Racial disparities in hypertension prevalence, awareness, and management. Arch Intern Med 2005; 165: 2098–2104.

8. Victor RG, Leonard D, Hess P, Bhat DG, Jones J, Vaeth PA, Ravenell J, Freeman A, Wilson RP, Haley RW. Factors associated with hypertension awareness, treatment, and control in Dallas County, Texas. Arch Intern Med 2008; 168:1285–1293.

9. Chobanian AV. The Hypertension Paradox -- More uncontrolled disease despite improved therapy. New England J Med 2009; 361:10.

10. Cutler JA, Sorlie PD, Wolz M, Thom T, Fields LE, Roccella EJ. Trends in hypertension prevalence, awareness, treatment, and control rates in United States adults between 1988-1994 and 1999-2004. Hypertension 2008; 52:818–827.

11. Wyatt SB, Akylbekova EL, Wofford MR, Coady SA, Walker ER, Andrew ME, Keahey WJ, Taylor HA, Jones DW. Prevalence, awareness, treatment, and control of hypertension in the Jackson Heart Study. Hypertension 2008; 51:650–656.

12. U.S. Department of Agriculture, Agricultural Research Service, Beltsville Human Nutrition Research Center, Food Surveys Research Group (M. Beltsville, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics (M. Hyattsville. What We Eat in America, NHANES 2003–2004). <www.cdc.gov/nchs/data/nhanes/nhanes_03_04/general_data_release_doc_03-04.pdf> (2010).

13. Sarafidis PA, Li S, Chen SC, Collins AJ, Brown WW, Klag MJ, Bakris GL. Hypertension awareness, treatment, and control in chronic kidney disease. Am J Med 2008; 121:332–340.

14. Brondolo E, Rieppi R, Kelly KP, Gerin W. Perceived racism and blood pressure: a review of the literature and conceptual and methodological critique. Ann Behav Med 2003; 25:55–65.

15. Pascoe EA, Smart Richman L. Perceived discrimination and health: a meta-analytic review. Psychol Bull 2009; 135:531–554.

16. Clark R, Anderson NB, Clark VR, Williams DR. Racism as a stressor for African Americans. A biopsychosocial model. Am Psychol 1999; 54:805–816.

17. Paradies Y. A systematic review of empirical research on self-reported racism and health. Int J Epidemiol 2006; 35:888–901.

18. Williams DR, Collins C. US socioeconomic and racial differences in health: Patterns and explanations. Annu Rev Sociol 1995; 21:349–386.

19. Bell CN, Thorpe RJ Jr, Laveist TA. Race/Ethnicity and hypertension: the role of social support. Am J Hypertens 2010; 23:534–540.

20. Rosamond W, Flegal K, Furie K, Go A, Greenlund K, Haase N, Hailpern SM, Ho M, Howard V, Kissela B, Kissela B, Kittner S, Lloyd-Jones D, McDermott M, Meigs J, Moy C, Nichol G, O’Donnell C, Roger V, Sorlie P, Steinberger J, Thom T, Wilson M, Hong Y; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics–2008 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2008; 117:e25–146.

21. Brondolo E, Brady N, Libby DJ, Pencille M. Racism as a psychosocial stressor. In: Baum A, Contrada RJ (eds). The Handbook of Stress Science: Psychology, Medicine and Health. New York, Springer, in press.

22. Krieger N. Embodying inequality: a review of concepts, measures, and methods for studying health consequences of discrimination. Int J Health Serv 1999; 29:295–352.

23. Harrell SP. A multidimensional conceptualization of racism-related stress: implications for the well-being of people of color. Am J Orthopsychiatry 2000; 70:42–57.

24. Brondolo E, Kelly KP, Coakley V, Gordon T, Thompson S, Levy E, Gordon A, Tobin JN, Sweeney M, Contrada RJ. The Perceived Ethnic Discrimination Questionnaire: Development and preliminary validation of a community version. J Appl Soc Psychol 2005; 35: 335–365.

25. Landrine H, Klonoff EA. The Schedule of Racist Events: A measure of racial discrimination and a study of its negative physical and mental health consequences. J Black Psychol 1996; 22:144–168.

26. Harrell SP, Merchant MA, Young SA. Psychometric properties of the Racism and Life Experience Scales (RaLES). Unpublished manuscript. 1997.

27. McNeilly MD, Anderson NB, Armstead CA, Clark R, Corbett M, Robinson EL, Pieper CF, Lepisto EM. The perceived racism scale: a multidimensional assessment of the experience of white racism among African Americans. Ethn Dis 1996; 6:154–166.

28. Williams DR, Williams-Morris R. Racism and mental health: the African American experience. Ethn Health 2000; 5:243–268.

29. Burkley M, Blanton H. Endorsing a negative in-group stereotype as a self-protective strategy: Sacrificing the group to save the self. J Exp Soc Psychol 2008; 44:37–49.

30. Sinclair S, Hardin CD, Lowery BS. Self-stereotyping in the context of multiple social identities. J Pers Soc Psychol 2006; 90:529–542.

31. Taylor J, Grundy C. Measuring black internalization of white stereotypes about African Americans: The Nadanolitization scale. In: Jones RL (ed). The Handbook of Tests and Measurements for Black Populations. Cobb & Henry: Hampton, VA, 1996. pp. 217–226.



32. Gee G, Walsemann K. Does health predict the reporting of racial discrimination or do reports of discrimination predict health? Findings from the National Longitudinal Study of Youth. Soc Sci Med 2009; 68:1676–1684.

33. Better S. Institutional Racism: A Primer on Theory and Strategies for Social Change. Rowman & Littlefield: Chicago, 2002.

34. Williams DR, Jackson PB. Social sources of racial disparities in health. Health Aff (Millwood) 2005; 24:325–334.

35. Williams DR, Collins C. Racial residential segregation: a fundamental cause of racial disparities in health. Public Health Rep 2001; 116:404–416.

36. Myers HF. Ethnicity- and socio-economic status-related stresses in context: an integrative review and conceptual model. J Behav Med 2009; 32:9–19.

37. Kramer MR, Hogue CR. Is segregation bad for your health? Epidemiol Rev 2009; 31:178–194.

38. Emerson MO, Yancey G, Chai KJ. Does race matter in residential segregation? Exploring the preferences of White Americans. Am Social Rev 2001; 66:922–935.

39. Massey D, Denton N. American Apartheid: Segregation and the Making of the Underclass. Harvard University Press: Cambridge, MA, 1994.

40. Acevedo-Garcia D, Lochner KA, Osypuk TL, Subramanian SV. Future directions in residential segregation and health research: a multilevel approach. Am J Public Health 2003; 93:215–221.

41. White K. Evaluating the mechanisms of racial and ethnic residential segregation: Self-reported hypertension among Blacks in New York City. Diss Abstr Int: Section B: The Sci and Eng 2009; 69.

42. Doerner JK, Demuth S. The independent and joint effects of race/ethnicity, gender and age on sentencing outcomes in U.S. Federal Courts. Justice Quarterly 2010; 27:1–27.

43. Trusts TPC. One in 100: Behind Bars in America 2008. The Pew Charitable Trusts: Washington, DC, 2008.

44. Brondolo E, Lackey S, Love E. Race, racism & health: Evaluating racial disparities in hypertension to understand the links between racism and health status. In: Revenson TA, Baum A (eds.). Handbook of Health Psychology, in press.

45. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, Jones DW, Materson BJ, Oparil S, Wright JT Jr, Roccella EJ. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003; 289:2560–2572.

46. Brondolo E, Brady Ver Halen N, Pencille M, Beatty D, Contrada RJ. Coping with racism: a selective review of the literature and a theoretical and methodological critique. J Behav Med 2009; 32:64–88.

47. Poston WS, Pavlik VN, Hyman DJ, Ogbonnaya K, Hanis CL, Haddock CK, Hyder ML, Foreyt JP. Genetic bottlenecks, perceived racism, and hypertension risk among African Americans and first-generation African immigrants. J Hum Hypertens 2001; 15:341–351.

48. Krieger N, Sidney S. Racial discrimination and blood pressure: the CARDIA Study of young black and white adults. Am J Public Health 1996; 86:1370–1378.

49. James K, Lovato C, Khoo G. Social identity correlates of minority workers’ health. Acad Manage J 1994; 37:383–396.

50. Barksdale DJ, Farrug ER, Harkness K. Racial discrimination and blood pressure: perceptions, emotions, and behaviors of black American adults. Issues Ment Health Nurs 2009; 30:104–111.

51. Ryan AM, Gee GC, Laflamme DF. The Association between self-reported discrimination, physical health and blood pressure: findings from African Americans, Black immigrants, and Latino immigrants in New Hampshire. J Health Care Poor Underserved 2006; 17:116–132.

52. Dressler WW. Social identity and arterial blood pressure in the African-American community. Ethn Dis 1996; 6:176–189.

53. Peters RM. The relationship of racism, chronic stress emotions, and blood pressure. J Nurs Scholarsh 2006; 38:234–240.

54. Peters RM. Racism and hypertension among African Americans. West J Nurs Res 2004; 26:612–631.

55. James SA, LaCroix AZ, Kleinbaum DG, Strogatz DS. John Henryism and blood pressure differences among black men. II. The role of occupational stressors. J Behav Med 1984; 7:259–275.

56. Broman CL. The health consequences of racial discrimination: a study of African Americans. Ethn Dis 1996; 6:148–153.

57. Din-Dzietham R, Nembhard WN, Collins R, Davis SK. Perceived stress following race-based discrimination at work is associated with hypertension in African-Americans. The metro Atlanta heart disease study, 1999-2001. Soc Sci Med 2004; 58:449–461.

58. Cozier Y, Palmer JR, Horton NJ, Fredman L, Wise LA, Rosenberg L. Racial discrimination and the incidence of hypertension in US black women. Ann Epidemiol 2006; 16:681–687.

59. Krieger N. Racial and gender discrimination: risk factors for high blood pressure? Soc Sci Med 1990; 30:1273–1281.

60. Pickering TG, Hall JE, Appel LJ, Falkner BE, Graves J, Hill MN, Jones DW, Kurtz T, Sheps SG, Roccella EJ. Recommendations for blood pressure measurement in humans and experimental animals: Part 1: blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research. Hypertension 2005; 45:142–161.

61. Steffen PR, McNeilly M, Anderson N, Sherwood A. Effects of perceived racism and anger inhibition on ambulatory blood pressure in African Americans. Psychosom Med 2003; 65:746–750.

62. Brondolo E, Libby DJ, Denton EG, Thompson S, Beatty DL, Schwartz J, Sweeney M, Tobin JN, Cassells A, Pickering TG, Gerin W. Racism and ambulatory blood pressure in a community sample. Psychosom Med 2008; 70:49–56.

63. Singleton JG, Robertson J, Robinson JC, Austin C, Edochie V. Perceived racism and coping: Joint predictors of blood pressure in Black Americans. Negro Educ Rev 2008; 59:93–113.

64. Tomfohr L, Cooper DC, Mills PJ, Nelesen RA, Dimsdale JE. Everyday discrimination and nocturnal blood pressure dipping in black and white Americans. Psychosom Med 2010; 72:266–272.

65. Smart Richman L, Pek J, Pascoe E, Bauer DJ. The effects of perceived discrimination on ambulatory blood pressure and affective responses to interpersonal stress modeled over 24 hours. Health Psychol 2010; 29:403–411.

66. Hill LK, Kobayashi I, Hughes JW. Perceived racism and ambulatory blood pressure in African American college students. J Black Psychol 2007; 33:404–421.

67. Brondolo E, Beatty DL, Cubbin C, Weinstein M, Saegert S, Wellington RL, Tobin JN, Cassells A, Schwartz JE. Sociodemographic variations in self-reported racism in a community sample of blacks and latino(a)s. J Appl Soc Psychol 2009; 39:407–429.

68. Williams DR, Yu Y, Jackson JS, Anderson NB. Racial differences in physical and mental health: Socioeconomic status, stress and discrimination. J Health Psychol 1997; 2:335–351.

69. Forman TA, Williams D, Jackson JS. Race, place, and discrimination. Perspectives on Social Problems 1997; 9:231–261.

70. Hunte HE, Williams DR. The association between perceived discrimination and obesity in a population-based multiracial and multiethnic adult sample. Am J Public Health 2009; 99:1285–1292.

71. Shelton RC, Puleo E, Bennett GG, McNeill LH, Sorensen G, Emmons KM. The association between racial and gender discrimination and body mass index among residents living in lower-income housing. Ethn Dis 2009; 19: 251–257.

72. Cozier YC, Wise LA, Palmer JR, Rosenberg L. Perceived racism in relation to weight change in the Black Women’s Health Study. Ann Epidemiol 2009; 19:379–387.

73. Borrell LN, Jacobs DR, Jr., Williams DR, Pletcher MJ, Houston TK, Kiefe CI. Self-reported racial discrimination and substance use in the coronary artery risk development in adults study. American J Epidemiol 2007; 20:1–12.

74. Gibbons FX, Gerrard M, Cleveland MJ, Wills TA, Brody G. Perceived discrimination and substance use in African American parents and their children: a panel study. J Pers Soc Psychol 2004; 86:517–529.

75. Shelton RC, Puleo E, Bennett GG, McNeill LH, Goldman RE, Emmons KM. Racial discrimination and physical activity among low-income-housing residents. Am J Prev Med 2009; 37:541–545.

76. Brondolo E, Brady N, Thompson S, Tobin JN, Cassells A, Sweeney M, McFarlane D, Contrada RJ. Perceived racism and negative affect: analyses of trait and state measures of affect in a community sample. J Soc Clin Psychol 2008; 27:150–173.

77. Broudy R, Brondolo E, Coakley V, Brady N, Cassells A, Tobin JN, Sweeney M. Perceived ethnic discrimination in relation to daily moods and negative social interactions. J Behav Med 2007; 30:31–43.

78. Matthews KA, Katholi CR, McCreath H, Whooley MA, Williams DR, Zhu S, Markovitz JH. Blood pressure reactivity to psychological stress predicts hypertension in the CARDIA study. Circulation 2004; 110:74–78.

79. Treiber FA, Kamarck T, Schneiderman N, Sheffield D, Kapuku G, Taylor T. Cardiovascular reactivity and development of preclinical and clinical disease states. Psychosom Med 2003; 65:46–62.

80. Clark R. Self-reported racism and social support predict blood pressure reactivity in Blacks. Ann Behav Med 2003; 25:127–136.



81. Clark R. Perceptions of interethnic group racism predict increased vascular reactivity to a laboratory challenge in college women. Ann Behav Med 2000; 22:214–222.

82. Clark R, Adams JH. Moderating effects of perceived racism on John Henryism and blood pressure reactivity in Black female college students. Ann Behav Med 2004; 28:126–131.

83. Clark R. Perceived racism and vascular reactivity in black college women: moderating effects of seeking social support. Health Psychol 2006; 25:20–25.

84. Kamala S, Thomas MS, Nelesen RA, Malcarne VL, Ziegler MG, Dimsdale JE. Ethnicity, perceived discrimination, and vascular reactivity to phenylephrine. Psychosom Med 2006; 68:692–697.

85. Guyll M, Matthews KA, Bromberger JT. Discrimination and unfair treatment: relationship to cardiovascular reactivity among African American and European American women. Health Psychol 2001; 20:315–325.

86. Richman LS, Kohn-Wood LP, Williams DR. The role of discrimination and racial identity for mental health service utilization. J Soc & Clin Psychol 2007; 26:960–981.

87. Tull ES, Sheu YT, Butler C, Cornelious K. Relationships between perceived stress, coping behavior and cortisol secretion in women with high and low levels of internalized racism. J Natl Med Assoc 2005; 97:206–212.

88. Oyserman D, Fryberg SA, Yoder N. Identity-based motivation and health. J Pers Soc Psychol 2007; 93:1011–1027.

89. Tull SE, Wickramasuriya T, Taylor J, Smith-Burns V, Brown M, Champagnie G, Daye K, Donaldson K, Solomon N, Walker S, Fraser H, Jordan OW. Relationship of internalized racism to abdominal obesity and blood pressure in Afro-Caribbean women. J Natl Med Assoc 1999; 91:447–452.

90. Butler C, Tull ES, Chambers EC, Taylor J. Internalized racism, body fat distribution, and abnormal fasting glucose among African-Caribbean women in Dominica, West Indies. J Natl Med Assoc 2002; 94:143–148.

91. Chambers EC, Tull ES, Fraser HS, Mutunhu NR, Sobers N, Niles E. The relationship of internalized racism to body fat distribution and insulin resistance among African adolescent youth. J Natl Med Assoc 2004; 96:1594–1598.

92. Grady SC, Ramírez IJ. Mediating medical risk factors in the residential segregation and low birthweight relationship by race in New York City. Health Place 2008; 14:661–677.

93. Schlundt DG, Hargreaves MK, McClellan L. Geographic clustering of obesity, diabetes, and hypertension in Nashville, Tennessee. J Ambul Care Manage 2006; 29:125–132.

94. Morenoff JD, House JS, Hansen BB, Williams DR, Kaplan GA, Hunte HE. Understanding social disparities in hypertension prevalence, awareness, treatment, and control: the role of neighborhood context. Soc Sci Med 2007; 65:1853–1866.

95. McGrath JJ, Matthews KA, Brady SS. Individual versus neighborhood socioeconomic status and race as predictors of adolescent ambulatory blood pressure and heart rate. Soc Sci Med 2006; 63:1442–1453.

96. Fang J, Madhavan S, Bosworth W, Alderman MH. Residential segregation and mortality in New York City. Soc Sci Med 1998; 47:469–476.

97. Wang EA, Pletcher M, Lin F, Vittinghoff E, Kertesz SG, Kiefe CI, Bibbins-Domingo K. Incarceration, incident hypertension, and access to health care: findings from the coronary artery risk development in young adults (CARDIA) study. Arch Intern Med 2009; 169:687–693.

98. Diez-Roux AV, Nieto FJ, Muntaner C, Tyroler HA, Comstock GW, Shahar E, Cooper LS, Watson RL, Szklo M. Neighborhood environments and coronary heart disease: a multilevel analysis. Am J Epidemiol 1997; 146:48–63.

99. Cozier YC, Palmer JR, Horton NJ, Fredman L, Wise LA, Rosenberg L. Relation between neighborhood median housing value and hypertension risk among black women in the United States. Am J Public Health 2007; 97:718–724.

100. Gary TL, Safford MM, Gerzoff RB, Ettner SL, Karter AJ, Beckles GL, Brown AF. Perception of neighborhood problems, health behaviors, and diabetes outcomes among adults with diabetes in managed care: the Translating Research Into Action for Diabetes (TRIAD) study. Diabetes Care 2008; 31:273–278.

101. Wilson DK, Kliewer W, Sica DA. The relationship between exposure to violence and blood pressure mechanisms. Curr Hypertens Rep 2004; 6:321–326.

102. Mujahid MS, Diez Roux AV, Shen M, Gowda D, Sánchez B, Shea S, Jacobs DR Jr, Jackson SA. Relation between neighborhood environments and obesity in the Multi-Ethnic Study of Atherosclerosis. Am J Epidemiol 2008; 167:1349–1357.

103. Harburg E, Erfurt JC, Hauenstein LS, Chape C, Schull WJ, Schork MA. Socio-ecological stress, suppressed hostility, skin color, and Black-White male blood pressure: Detroit. Psychosom Med 1973; 35:276–296.

104. Kershaw KN, Diez Roux AV, Carnethon M, Darwin C, Goff DC Jr, Post W, Schreiner PJ, Watson K. Geographic variation in hypertension prevalence among blacks and whites: the multi-ethnic study of atherosclerosis. Am J Hypertens 2010; 23:46–53.

105. Diez-Roux AV, Northridge ME, Morabia A, Bassett MT, Shea S. Prevalence and social correlates of cardiovascular disease risk factors in Harlem. Am J Public Health 1999; 89:302–307.

106. Robert SA, Reither EN. A multilevel analysis of race, community disadvantage, and body mass index among adults in the US. Soc Sci Med 2004; 59:2421–2434.

107. Popkin BM, Duffey K, Gordon-Larsen P. Environmental influences on food choice, physical activity and energy balance. Physiol Behav 2005; 86:603–613.

108. Chang VW. Racial residential segregation and weight status among US adults. Soc Sci Med 2006; 63:1289–1303.

109. Mobley LR, Root ED, Finkelstein EA, Khavjou O, Farris RP, Will JC. Environment, obesity, and cardiovascular disease risk in low-income women. Am J Prev Med 2006; 30:327–332.

110. Kwate NOA. Fried chicken and fresh apples: Racial segregation as a fundamental cause of fast food density in black neighborhoods. Health & Place 2008; 14:32–44.

111. Blomgren J, Martikainen P, Mäkelä P, Valkonen T. The effects of regional characteristics on alcohol-related mortality-a register-based multilevel analysis of 1.1 million men. Soc Sci Med 2004; 58:2523–2535.

112. Buu A, Mansour M, Wang J, Refior SK, Fitzgerald HE, Zucker RA. Alcoholism effects on social migration and neighborhood effects on alcoholism over the course of 12 years. Alcohol Clin Exp Res 2007; 31:1545–1551.

113. Boardman JD, Finch BK, Ellison CG, Williams DR, Jackson JS. Neighborhood disadvantage, stress, and drug use among adults. J Health Soc Behav 2001; 42:151–165.

114. Lopez R. Black-white residential segregation and physical activity. Ethn Dis 2006; 16:495–502.

115. Cohen LE, Felson M. Social change and crime rate trends: A routine activity approach. Am Sociol Rev 1979; 44:588–608.

116. Schulz AJ, Zenk SN, Israel BA, Mentz G, Stokes C, Galea S. Do neighborhood economic characteristics, racial composition, and residential stability predict perceptions of stress associated with the physical and social environment? Findings from a multilevel analysis in Detroit. J Urban Health 2008; 85:642–661.

117. Gee GC, Payne-Sturges DC. Environmental health disparities: a framework integrating psychosocial and environmental concepts. Environ Health Perspect 2004; 112:1645–1653.

118. Morland K, Wing S, Diez Roux A. The contextual effect of the local food environment on residents’ diets: the atherosclerosis risk in communities study. Am J Public Health 2002; 92:1761–1767.

119. Gorman DM, Speer PW. The concentration of liquor outlets in an economically disadvantaged city in the northeastern United States. Subst Use Misuse 1997; 32:2033–2046.

120. LaVeist TA, Wallace JM Jr. Health risk and inequitable distribution of liquor stores in African American neighborhood. Soc Sci Med 2000; 51:613–617.

121. Romley JA, Cohen D, Ringel J, Sturm R. Alcohol and environmental justice: the density of liquor stores and bars in urban neighborhoods in the United States. J Stud Alcohol Drugs 2007; 68:48–55.

122. Kling JR, Liebman JB, Katz LF. Experimental analysis of neighborhood effects. Econometrica 2007; 75:83–119.

123. Fauth RC, Leventhal T, Brooks-Gunn J. Short-term effects of moving from public housing in poor to middle-class neighborhoods on low-income, minority adults’ outcomes. Soc Sci Med 2004; 59:2271–2284.

124. Beatty DL, Matthews KA. Unfair treatment and trait anger in relation to nighttime ambulatory blood pressure in African American and white adolescents. Psychosom Med 2009; 71:813–820.

125. Harrell JP, Hall S, Taliaferro J. Physiological responses to racism and discrimination: an assessment of the evidence. Am J Public Health 2003; 93:243–248.

126. Schoenthaler AM, Schwartz J, Cassells A, Tobin JN, Brondolo E. Daily interpersonal conflict predicts masked hypertension in an urban sample. Am J Hypertens 2010; 23:1082–1088.

127. Giscombé CL, Lobel M. Explaining disproportionately high rates of adverse birth outcomes among African Americans: the impact of stress, racism, and related factors in pregnancy. Psychol Bull 2005; 131:662–683.

128. Collins JW Jr, David RJ, Handler A, Wall S, Andes S. Very low birthweight in African American infants: the role of maternal exposure to interpersonal racial discrimination. Am J Public Health 2004; 94:2132–2138.

racism and hypertension

Documents