In order to gain a better understanding of how racial discrimination influences health it is important to understand how discrimination is related to other well-known social determinants of health such as SEP. Our investigation into the associations between perceived racial discrimination and individual- and neighborhood-level SEP has revealed complex relationships between these factors. In race-specific unadjusted analyses, both individual-level and neighborhood-level SEP were significantly associated with perceived racial discrimination for African-American women (women in higher levels of disadvantage were less likely to report discrimination). One explanation for these findings may be underreporting by persons of low SEP, as also reported by others (Ruggiero and Taylor 1995
, Krieger 2000
). While it is not entirely clear why persons of low SEP are less likely to report experiences of racial discrimination, Krieger has suggested that persons of lower social position, especially those subject to multiple forms of subordination or deprivation, may internalize oppression, resulting in underreporting of perceived racial discrimination by individuals of lower SEP (Krieger and Sidney 1996
, Krieger 2000
). Underlying explanations include: denial (Crosby 1984
), keeping quiet about unfair treatment (Krieger 1990
), or the endorsement of racial ideology (the acceptance of beliefs about race and racial inequality), low levels of racial identification, or the internalization of racial prejudice (expression of negative feelings toward members of your racial group) (Brown et al. 2000
, Jackson et al. 2003
, Sellers and Shelton 2003
). The sensitive nature of the topic, social desirability, or feeling uncomfortable reporting discrimination to a person of a different racial background may also contribute to underreporting (Barnes et al. 2008
, Moorman et al. 1999
). Although we were unable to race match our interviewers to study participants, our interviews were conducted by telephone, possibly ameliorating some of these barriers.
There are additional possible explanations for the observed inverse relationship between perceived racial discrimination and neighborhood disadvantage for African-American women, beyond adjustment for individual-level SEP. Because this association was in part explained by adjusting for racial composition of the neighborhood, it may be that African-American women living in more disadvantaged neighborhoods (as well as more racially segregated neighborhoods) do not experience as much interpersonal racial discrimination because of less interaction with persons of different races. Members of minority groups living in a majority community may be made more aware of belonging to a low status minority group (Pickett and Wilkinson 2008
). Other explanations for this finding may include potential buffering effects due to social cohesion and social support in more homogenous communities, or that racial discrimination is such a common and shared experience that it is not perceived of as extraordinary, and thus not reported. If reports of discrimination differ systematically by SEP, for reasons other than genuine differences in exposure, then how studies of discrimination and health are conceptualized, undertaken, and interpreted may need to be reconsidered.
It is clear that SEP had a significant effect on whether African-American women reported racial discrimination, whereas for White women, we did not observe SEP effects at the individual or neighborhood level. This was apparent both in our initial total population models in which we observed a significant interaction between race and the neighborhood SEP Index (data not shown) and in the race-specific models. For African-American women, once we controlled for racial composition of the neighborhood, the effect of neighborhood SEP was further attenuated. Thus, racial/ethnic composition may play an important role in the experience of discrimination for members of minority groups and should be appropriately accounted for in disparities research. Further research is needed to better understand how racial composition is related to neighborhood social cohesion (and whether it is particularly salient for disadvantaged populations), or if reporting less discrimination among African-American women in disadvantaged neighborhoods is simply due to less interaction with Whites. These racial/ethnic differences in results also underscore the underlying concept that perceived discrimination likely has very different context and meaning for individuals of minority races/ethnicities than individuals of majority races/ethnicities.
A strength of this study, in addition to the collection of detailed multilevel SEP information, is the multi-dimensionality of the perceived discrimination measure, by which we measured experiences that occurred in seven possible situations over the lifetime. While we were unable to separately examine each situation in which discrimination was experienced in multivariable models, the multi-dimensionality of the measure has been shown to be important in validity and reliability compared to other measures that use single-item responses (Krieger et al. 2005
). Notwithstanding the many advantages of the measure of discrimination used here, other relevant measures of discrimination that assess additional dimensions, minor ‘everyday’ discrimination versus major events, acute versus chronic exposures, and frequency of exposure, may also be important in evaluating the relationships between neighborhood characteristics and perceived discrimination. Kressin et al. (2008)
recently reviewed the discrimination literature and concluded that additional measures are needed to adequately assess perceived discrimination in the health care setting. Some studies have shown that chronic exposure to discrimination is a stronger predictor of health outcomes than acute or recent exposures (Williams et al. 1997
, Bird and Bogart 2001
, Lewis et al. 2006
). Thus, examining how other measures of discrimination are related to neighborhood characteristics and subsequent health outcomes is an area for future research.
A limitation that many multilevel studies share is the use of administrative census data as a proxy for neighborhood. It is unlikely that census boundaries directly coincide with a meaningful definition of ‘neighborhood’ as defined by residents. However, there are several advantages to using census data, such as the systematic collection of data for the entire population and its accessibility. While 1990 census information was chosen for reasons of temporal sequencing, we cannot rule out changes in neighborhood characteristics between the 1990 census and the timing of individual interviews. However, as neighborhoods generally do not change significantly over short time periods (Geronimus and Bound 1998
), this is unlikely to have had a significant impact on reported findings.
Since these analyses involve cross-sectional associations, there is a potential concern about causality. However, if the individuals who perceived racial discrimination self-selected into predominantly same-race neighborhoods, one might observe a spurious association between perceived racial discrimination and neighborhood-level SEP. Because of the high correlation between neighborhood racial composition and neighborhood-level SEP (high percentage non-White and low SEP), in this scenario, perceived racial discrimination would appear to be associated with low neighborhood-level SEP in African-Americans, whereas it would be associated with higher neighborhood-level SEP in White women. Given the opposite direction of our findings, as well as the adjustment for racial composition of the neighborhoods, we can safely rule out this potential bias.
While these data were collected for the purpose of examining race differences in the screening mammography process, the sampling strategies were designed to reflect the general population of African-American and White women of screening age (i.e., healthy women, age 40–79). As the Connecticut African-American population is largely urban (US Census Bureau n.d. b), by identifying the major mammography facilities that serve this population (Jones et al. 2001
) (but still serve predominantly White women), it is likely that this sample of African-American and White women is reasonably representative of the adult female population (in this age group) in the general Conneticut population. However, if women who were lost to follow-up or never presented for a mammogram (not assessed in this study) were more likely to have lived in even more disadvantaged neighborhoods than those represented in the study sample, it is possible that we underestimated the effect of neighborhood-level SEP on perceived racial discrimination. Connecticut, like many parts of the USA, can be characterized by significant socioeconomic gaps and residential racial segregation (University of Michigan Population Studies Center 2000
), and while replication of these results in other populations is necessary, our findings may have broad implications for understanding the interplay between neighborhood disadvantage, residential segregation, and how racial discrimination is perceived and reported in African-Americans and Whites in the USA.