Examining links between daily stressor appraisals and C-reactive protein levels in Black and White women: The National Growth and Health Study

Abstract

Background

Racial disparities in health have reached a critical juncture, particularly between Black and White individuals. Inflammation and daily stress have been proposed as biopsychological pathways. However, studies examining links between inflammation and individuals' appraisals of daily stressors—which are modifiable and could be intervention targets—have been limited in diverse populations. This study investigated these associations in a sample of Black and White women.

Methods

Midlife women (159 Black, 163 White) were part of a prospective cohort study in which they completed daily evening diaries assessing appraisals of daily stressor demands and coping efficacy (feeling in control, efficacious, resourceful). Participants also provided a fasting blood sample which was assessed for high-sensitivity C-reactive protein (hs-CRP), a systemic inflammatory marker. Multiple linear regression models examined associations between race, daily stressor appraisals, and interactions with hs-CRP, controlling for education, income, and body mass index. Race-stratified models were also examined.

Results

The interaction between race and coping efficacy, but not stressor demands, was significantly associated with hs-CRP. Specifically, more positive appraisal of coping efficacy was linked with lower hs-CRP levels in White women (Beta = −0.147, p = .024), but not in Black women (Beta = 0.078, p = .226).

Discussion

For White women, greater perceived coping efficacy with daily stressors may buffer stress-related inflammation, providing a promising intervention target. Given the scarcity of daily stress research with diverse samples, we need to better measure and understand these relationships in Black samples and other racial and ethnic groups.

Highlights

• •Racial health disparities between Black and White individuals persist.
• •Inflammation and daily stress are potential mechanisms for these disparities.
• •Daily stressor appraisals and inflammation in Black and White women were examined.
• •Greater coping efficacy buffered inflammation in White women, but not Black women.
• •More research is needed to understand these links in Black women and other groups.

1. Introduction

Racial disparities in health have reached a critical juncture, particularly between Black and White individuals, with Black individuals experiencing elevated mortality across the lifespan (Williams and Mohammed, 2009). Stress is a determinant of health disparities due to chronic stressors such as discrimination and racism, leading to wear and tear on the body and dysregulating multiple biological systems, including the immune system. However, limited research has examined the role of stressor appraisals in daily life and their relationship to inflammation in Black and White women.

Inflammation is a crucial link between stress and stress-related diseases (Liu et al., 2017). Chronic stress can trigger prolonged, systemic inflammation, causing tissue damage and potentially leading to pathologies (Furman et al., 2019). One marker of systemic inflammation is C-reactive protein (CRP), an acute phase protein, which tends to be higher in Black individuals compared to White individuals due to social determinants of health such as socioeconomic status (SES) and racial and ethnic identities that are minoritized (Stepanikova et al., 2017). Many studies have examined stress perceptions and inflammation, typically assessing global perceived stress over the past month, and have been limited to mostly White samples (Barbosa-Leiker et al., 2014; McDade et al., 2006).

Few studies of stress and inflammation have specifically examined individuals' appraisals of daily stressors, and even fewer have included sufficient samples of Black participants. Stressor appraisals involve appraisals of stressor demands (evaluation of what is at stake during a stressful situation) and coping efficacy (evaluation of the available coping resources in response to the stressor) (Lazarus and Folkman, 1984). However, our understanding of how race, which is associated with different experiences of chronic stress, affects the links between daily stressor appraisals and CRP levels is limited. Further, few studies have examined these associations in social groups that hold intersecting identities with race and gender. Not only are Black women exposed to more cumulative stressors, but they also appraise and cope with stressors differently, which might have differential effects on inflammation. One example of a coping mechanism at the intersection of race and gender is the Superwoman Schema, which describes a response by Black women to racialized and gendered oppression through socialization to be strong, suppress their emotions, resist vulnerability, succeed despite limited resources, and help others at their own expense (Perez et al., 2023). Such coping responses may represent a mechanism that could contribute to differences in health outcomes for Black women.

To address this, we examined the links between race, daily stressor appraisals, and CRP in a sample of Black and White midlife women. Based on prior literature, we hypothesized that daily stressor appraisals of greater demands and lower coping efficacy will be associated with higher CRP. We also tested whether these associations were stronger in Black women or White women. However, given the lack of prior research in Black individuals, we considered these analyses exploratory. Our study recruited an equal number of Black and White women, allowing us to test associations within each racial group.

2. Methods and materials

2.1. NGHS overview, participants, and procedures

The National Heart, Lung, and Blood Growth & Health Study (NGHS) is a prospective cohort study that recruited Black and White girls at age 9–10 from Richmond (CA), Cincinnati (OH), and Washington (D.C.). A total of 2379 girls (1209 Black, 1166 White) were enrolled in the study in 1987 and followed through 10 years of annual data collection (for an overview of the NGHS, see Morrison, 1992).

Starting in 2015, a follow-up study re-recruited 624 (307 Black, 317 White) of the original 887 participants (459 Black, 428 White) from the Richmond site at age 36–43 (73.8 % retention rate among eligible women). Eligibility criteria were 1) an original NGHS participant from the Richmond site, 2) not pregnant at the time of recruitment, and had not experienced a pregnancy, miscarriage, or abortion within the last three months, and 3) not living abroad, incarcerated, or otherwise institutionalized. Eligible participants provided written informed consent and participated in a three-part protocol, which consisted of 1) a baseline survey 2) a home or clinic visit, and 3) post-visit daily diary and biospecimen collection (hs-CRP). All study procedures were conducted in compliance with relevant laws and institutional guidelines. This study was approved by the University of California, Berkeley Institutional Review Board (most recent approval date 01-09-2020; reference number 2013-11-5774; for an overview of the NGHS follow-up study, see Laraia et al., 2023). Informed consent was obtained from participants prior to conducting study procedures and the privacy of participants was protected. Analyses for the current study included participants with available data on hs-CRP and daily stress diaries (n = 322; 159 Black, 163 White).

2.2. Measures

Daily Stressor Appraisals. We used daily stress diaries to minimize recall bias. Daily evening diaries (3 days) asked participants “What was the most stressful event that happened today?” and to rate their psychological responses on a 5-point scale using items adapted from prior studies (Almeida et al., 2002). Appraisal of stressor demands was assessed with the following two items: “How stressful was this situation for you, today, at its peak?” and “How demanding was it to deal with this situation?”. Items were averaged across the three days, as done previously (Fuligni et al., 2009) (daily Cronbach alphas for stressor demands items >0.80). Appraisal of coping efficacy was assessed with the following three items: “Did you feel that you had control over the stressful situation (not your reaction to it, but the actual situation)?“, “To what extent did you have the resources (emotional, social, or cognitive) to deal with this situation?“, and “To what extent did you feel you were able to effectively handle this situation?“. Items were again averaged across the three days (daily Cronbach alphas for coping efficacy items >0.75). Higher scores indicated higher daily appraisals of stressor demands and coping efficacy.

High-Sensitivity C-Reactive Protein (hs-CRP). The hs-CRP assay was performed by LabCorp (test 120,766, CPT 86141). LabCorp has a strictly followed standardized automated protocol, certified by Clinical Laboratory Improvement Amendments (CLIA), using a standard clinically used immunochemiluminometric assay. Participants provided a fasting blood draw in the morning after a 10-h fast. Blood was collected into a green-top (heparin) tube and assayed at the nearest LabCorp clinic. Because recent infections can impact CRP, we ensured that women had no signs of infection the day before the blood draw. Higher CRP levels indicated higher inflammation.

Sociodemographics. The baseline survey assessed sociodemographic information, including participant race, age, marital status, highest level of education, and annual household income.

Body Mass Index (BMI). Weight and height measurements were collected to calculate BMI (kg/m²). Each anthropometric measure was taken three times and values were averaged.

Chronic Inflammatory Diseases and Anti-Inflammatory Medications. The presence of chronic inflammatory diseases was assessed. Primary chronic inflammatory diseases included asthma, rheumatoid arthritis, and chronic obstructive pulmonary disease (COPD). Anti-inflammatory medication use was also assessed.

2.3. Statistical analysis

All analyses were conducted with IBM SPSS Statistics Version 27. Hs-CRP was natural log (ln) transformed, which improved skewness (Statistic = 0.10, SE = 0.14) and kurtosis (Statistic = −0.45, SE = 0.27). Pearson correlations, t-tests and chi-square statistics were used to examine relationships between sociodemographic and daily stressor appraisal variables, as well as hs-CRP. Multiple linear regression models were used to examine associations between race, daily stressor appraisals (separate models for appraisals of stressor demands and coping efficacy), and hs-CRP levels, controlling for covariates that were significantly associated with hs-CRP (education, income, BMI). Chronic inflammatory diseases, such as asthma, rheumatoid arthritis, and COPD, were not significantly associated with ln hs-CRP (all ps > .05). Anti-inflammatory medication use was significantly associated with ln hs-CRP (p < .01), but controlling for this variable did not change the main findings. Continuous variables were mean-centered and dichotomous variables were dummy coded. Race-stratified analyses were also performed to examine associations within each racial group.

3. Results

3.1. Descriptives

Descriptive statistics are shown in Table 1. Participants were on average 39 years old with a narrow age range (37–42), due to the cohort design. A large proportion of participants were from a lower SES background (59 % had less than a college degree; 46 % had an annual household income < $60,000). Black participants reported lower SES compared to White participants. However, unlike other studies that are often characterized by structural confounding of race and SES, a unique strength of the current sample is that there was a sufficient representation of higher SES Black women (27 % college degree or higher; 36 % household income of ≥ $60,000) and lower SES White women (45 % less than college degree; 29 % household income < $60,000). Participants had an average hs-CRP of 4.10 mg/L, indicating moderate elevation. 11 % of participants had an hs-CRP above 10.0 mg/L, indicating exaggerated elevation, but main results were robust to the exclusion of these individuals, so they were included. Black participants had higher BMI and hs-CRP, and lower appraisals of stressor demands, relative to White participants.

Table 1.

Descriptive statistics for sociodemographic and study variables.

Variable	Entire Sample (n = 322) Mean (SD) or No. (%)	Black Participants (n = 159) Mean (SD) or No. (%)	White Participants (n = 163) Mean (SD) or No. (%)
Age, years	39.14 (1.09)	39.16 (1.05)	39.12 (1.13)
Marital status, No. (%) married	189 (59 %)a	67 (42 %)	122 (75 %)
Education, No. (%) less than college degree	189 (59 %)a	116 (73 %)	73 (45 %)
Annual household income, No. (%) < $60,000	142 (46 %)a	96 (64 %)	46 (29 %)
Body Mass Index (BMI)	32.15 (9.78)a	34.85 (10.48)	29.52 (8.26)
Appraisal of stressor demands	2.77 (0.88)a	2.65 (0.96)	2.89 (0.77)
Appraisal of coping efficacy	3.27 (0.88)	3.25 (1.00)	3.30 (0.76)
High-sensitivity C-reactive protein (hs-CRP), mg/L	4.10 (6.09)a	4.74 (5.92)	3.48 (6.21)

^aIndicates significant race differences (p < .05).

3.2. Associations of race and daily stressor appraisals on hs-CRP

There were no main effects of race or stressor appraisals on hs-CRP (see Supplemental Table 1). Models examining race-by-stressor appraisal interactions are presented in Table 2. Results showed that the interaction between race and appraisal of stressor demands was not significantly linked with hs-CRP (p = .574; Table 2, Model 1). However, the interaction between race and stressor appraisal of coping efficacy was significantly associated with hs-CRP (Beta = 0.163, p = .026; Table 2, Model 2; see Supplemental Fig. 1). Race-stratified models (see Supplemental Table 2) showed that more positive appraisal of coping efficacy was linked with lower hs-CRP concentrations in White women (Beta = −0.147, p = .024), but not in Black women (Beta = 0.078, p = .226).

Table 2.

Multiple linear regression models examining daily stressor appraisals, race, and interactions with high-sensitivity C-reactive protein.

Interaction Models	Variable	Unstandardized Coefficients		Standardized Coefficients	t	p	r2part
		B	Std. Error	Beta
Model 1	Constant	0.674	0.10		6.82	<.001
	Education	0.088	0.13	0.036	0.69	0.491	0.001
	Annual household income	−0.001	0.01	−0.004	−0.07	0.946	0.00001
	BMI	0.083	0.01	0.661	13.83	<.001	0.371
	Race	−0.119	0.12	−0.049	−0.99	0.325	0.002
	Appraisal of stressor demands	0.074	0.10	0.053	0.76	0.450	0.001
	Interaction of race-by-appraisal of stressor demands	−0.071	0.13	−0.039	−0.56	0.574	0.001
	Model fit	R = 0.642; R2 = 0.412; F(6, 303) = 35.42; p < .001
Model 2	Constant	0.681	0.10		6.95	<.001
	Education	0.088	0.13	0.036	0.69	0.493	0.001
	Annual household income	0.002	0.01	0.006	0.11	0.912	0.00002
	BMI	0.081	0.01	0.648	13.60	<.001	0.353
	Race	−0.116	0.12	−0.047	−0.97	0.335	0.002
	Appraisal of coping efficacy	−0.210	0.10	−0.151	−2.08	.038	0.008
	Interaction of race-by-appraisal of coping efficacy	0.286	0.13	0.163	2.25	.026	0.010
	Model fit	R = 0.649; R2 = 0.421; F(6, 303) = 36.76; p < .001

Outcome: High-sensitivity C-reactive protein (hs-CRP; natural log transformed).

Note: Education coded as 0 = less than college degree, 1 = college degree or higher; BMI = Body-Mass-Index; Race coded as 0 = White, 1 = Black.

4. Discussion

This study examined whether daily stressor appraisals were associated with systemic inflammation and for which stressor appraisals—stressor demands or coping efficacy—this relationship existed. Furthermore, given that Black and White women are differentially exposed to discrimination and racism stress, we tested whether these relationships differed by race. Our main finding was that greater perceived coping efficacy with daily stressors—feeling more in control, efficacious, and resourceful in managing everyday situations—was associated with lower CRP in White, but not in Black women.

Our hypothesis that greater coping efficacy with daily stressors is associated with CRP levels was supported, but only in White women. This suggests that coping efficacy is relevant to stress-related health outcomes, such as inflammation, for this group. Indeed, previous research has demonstrated that perceived self-efficacy to control stressors results in enhanced immune function in majority White samples (Wiedenfeld et al., 1990). Perceptions of coping efficacy may be an important intervention target to mitigate the effects of stress on stress-related diseases, particularly in White women since they do not encounter as many race-related stressors, although they may face other types of discrimination, such as sexism. However, contrary to our expectation, there was no relationship between perceived stressor demands and CRP levels, neither in the overall sample, nor in White women specifically. This contrasts with prior research, which has shown that the perception of daily stressors is associated with elevated CRP levels in primarily White samples (Barbosa-Leiker et al., 2014). It is possible that the previous study was conducted in a higher SES sample, while our sample was primarily of a lower SES.

The lack of associations between perceived stressor demands or coping efficacy and CRP levels in Black women highlights a need for a deeper understanding of the relationship between stress processes, particularly stressor appraisals, and inflammation in this population. Social stressors have a demonstrated influence on dysregulating biological systems, including the immune system, but this occurs through complicated processes. More positive stressor appraisals may not play a buffering role in Black individuals because they are likely to encounter stressors such as chronic racism (Woo, 2018), which might overwhelm and be difficult to manage with individual coping efficacy within a larger culture that perpetuates racism through structural and institutional mechanisms. Black women also encounter gendered racism (Lewis et al., 2017), the simultaneous experience of both racism and sexism, which might be similarly difficult to manage within the individual.

Importantly, however, we found that Black women had lower perceived stressor demands than White women, which runs counter to many models theorizing the role of stress in racial health disparities. It may be that perceived stress does not have the explanatory power that prior theory has assumed, or we may not be using sensitive enough measurement tools to capture stress in a way that is salient to Black women. Black women possess unique perspectives, identities, and experiences, and encounter unique stressors that arise from the intersection of social structures (Everett et al., 2010). Appraisals can also be conceptualized as the relative difference between demands and resources. Positive challenge stress has been defined as lower demands relative to higher resources/coping efficacy, compared to threat which has been defined as higher demands relative to lower resources/coping efficacy (Epel et al., 2018). Using this definition, Black women may be feeling more positive challenge stress on average compared to White women. Further research employing an intersectional approach is necessary to understand the influence of racism and sexism on Black women's health.

4.1. Limitations

This was a cross-sectional study, so no causal inferences can be made. We also did not collect data on the frequency of daily stressors, although a greater frequency of stressors has been associated with greater inflammation (Fuligni et al., 2009), nor did we measure appraisals of upcoming stressors. Additionally, we did not investigate whether daily stressors reported by Black women were specifically social stressors such as sexism, racism, and discrimination.

4.2. Conclusion

Greater perceived coping efficacy with daily stressors—feeling more in control, efficacious, and resourceful in managing everyday situations—may buffer against the harmful impact of daily life stressors on inflammation in White women. Given the scarcity of research with diverse samples, we need to better understand the relationship between daily stressor appraisals and inflammation in groups impacted by the intersection of social structures, such as Black women. In clinical settings, it may be beneficial to identify women with elevated daily stressor exposure. Interventions could target stress management and coping strategies on an individual level, although systems-level interventions are also needed to buffer against the impact of daily stressors on inflammation.

CRediT authorship contribution statement

Sarah E. Ahmadi: Writing – review & editing, Writing – original draft. Joanna Y. Guan: Writing – review & editing. Meital Mashash: Writing – review & editing. Elissa J. Hamlat: Writing – review & editing. Mahasin S. Mujahid: Writing – review & editing. A. Janet Tomiyama: Writing – review & editing. Barbara A. Laraia: Writing – review & editing, Funding acquisition. Elissa S. Epel: Writing – review & editing, Funding acquisition. Stefanie E. Mayer: Writing – review & editing, Formal analysis, Conceptualization.

Research data for this article

Historical NGHS data are publicly available at https://biolincc.nhlbi.nih.gov/. The follow-up NGHS data used for this study are not publicly available, but de-identified data may be available on request, subject to approval by the internal review board and under a formal data use agreement. Please contact BAL (blaraia@berkeley.edu) or ESE (elissa.epel@ucsf.edu).

Funding

This work was supported by the National Institutes of Health grant numbers R01HD073568 and R01AG059677 (to BAL and ESE), R00AG062778 (to SEM), and R24AG048024 (to ESE).

Declaration of competing interest

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:

Stefanie E. Mayer, Barbara A. Laraia, and Elissa S. Epel report financial support that was provided by the National Institutes of Health. Other authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A. Supplementary data

The following is the Supplementary data to this article:

Data availability

Historical NGHS data are publicly available at https://biolincc.nhlbi.nih.gov/. The follow-up NGHS data may be available on request.