Ethnicity, Nativity and the Health of American Blacks

Abstract

Few national studies have empirically examined ethnic differences in health within the American Black population. We utilized logistic regression to examine the relationships among ethnicity, nativity, depressive symptoms, and physical health in the two largest ethnic groups of American Blacks, African Americans and Caribbean Blacks. The data were from the National Survey of American Life, an in-person national household survey representative of the non-institutionalized U.S. Black population. We found that African Americans, U.S.-born Caribbean Blacks, and Caribbean-born Blacks had significantly different self-ratings of their health and self-reports of being diagnosed with a chronic physical health condition. Whether assessed by self-rated health or the presence of at least one physician diagnosed chronic health condition, Caribbean-born Blacks had the best health outcomes and U.S.-born Caribbean Blacks had the worst. This finding remained significant even after considering self-reported depressive symptoms. This study highlights the importance of considering ethnic diversity, nativity and immigration as independent sources of variation in health status within the American Black population.

Aggregating all American Blacks into a single racial category and comparing them to the non-Hispanic White population provides important data on racial disparities in health.¹ Examining the ethnic heterogeneity among American Blacks, however, facilitates investigating how the social contexts within which different groups of Black individuals live influences their health and disease independent of racial category.^2-4 More than twenty years ago, the U.S. Department of Health and Human Services Secretary's Task Force Report on Black and Minority Health argued that the racial categories were too broad to reflect accurately the disease profiles and prevalence of risk factors among subgroups of American Blacks. Yet, consideration of the implications of ethnic heterogeneity among Blacks in the U.S. has generally been neglected in health research.²

Ethnic groups consist of people assumed to have common cultural and often similar physical traits that distinguish them from other ethnic groups, including primary language, nativity, history, traditions, values, and dietary habits.⁵ Within national boundaries ethnic groups are subcultures maintaining certain patterns of behaviors, beliefs and values that distinguish them from other cultural groups.⁶

The two largest ethnic groups of American Blacks are African Americans and Caribbean Blacks.⁷ The vast majority of American Blacks include those born in, or with ancestral roots linked to, the U.S., Canada, South America, the Caribbean, and Africa. This paper examines the relationships among ethnicity, nativity, depressive symptoms, and physical health for African Americans and Caribbean Blacks. Illuminating the social and cultural differences between African Americans and Caribbean Blacks may aid in identifying the pathways through which ethnic health disparities are created and maintained.^8-10

First generation immigrant groups tend to have better health profiles compared to US-born groups.^11-12 This advantage may be due to healthier lifestyles in the countries of origin^13-14, selective migration of healthy immigrants¹⁵, stronger support systems in their home countries¹⁶ or fewer experiences of racialized stress and discrimination.^{12, 17-18} The longer they are in the US, however, immigrants typically lose their health advantage perhaps as a result of adopting unhealthy American health behaviors (e.g. poor diets and lack of exercise) and losing family support and protective cultural resources.^{17, 19-21}

African Americans and Caribbean Blacks differ on key economic, educational, and social dimensions that may be associated with differential health outcomes. ^22-25 Caribbean Blacks tend to have higher incomes and higher levels of education, especially college attendance, than African Americans.^22-25 Some have suggested that Caribbean Blacks who come to the U.S. in comparison to both Caribbean Blacks who remain in their native countries and African Americans tend to be more skilled, better educated, more ambitious, and more highly motivated.²⁵ In fact, Caribbean Blacks are often portrayed as a model of Black achievement^26-27 and are frequently stereotyped as hard workers.^{25, 28-29} In addition, while some Caribbean Black immigrants are more likely than immigrants from other ethnic groups to have low socioeconomic status once in the U.S.,^30-31 English-speaking Caribbean Black immigrants notably have had more economic success than African Americans.^{25-26, 32}

In addition to social and economic differences, African Americans and Caribbean Blacks differ in self-rated health. In the U.S., Caribbean Blacks have a longer life expectancy and better self-rated health than African Americans.³² African American men have shorter life expectancies than Caribbean Black men, and African American women have shorter life expectancies than Caribbean Black women.³³ The health advantages of immigrants, however, tend to diminish the longer immigrants live in the U.S.^{17, 34-36}

People living in the Caribbean have a slightly longer average life expectancy (73.5 years) than African Americans (72.3 years).³³ Over 80% of nations in the Caribbean have an average life expectancy over 70 years. For example, the average life expectancy of Jamaicans is 76.3 years, four years higher than African Americans.³³ Nazroo and colleagues compared African Americans with Caribbean Blacks who live in the U.S. and England.³² They found that African Americans reported worse self-rated health than Caribbean Blacks living in the U.S. and England. African Americans’ health outcomes also were considerably worse than Whites in the U.S. or Great Britain and Caribbean Blacks in England, the Caribbean, or the U.S.³² Caribbean Blacks in the U.S. had a similar economic and health profile to White Americans, while African Americans’ health was comparable to Blacks in England.

In addition to the differences in physical health outcomes among American Blacks, African Americans and Caribbean Blacks have different patterns of mental health. These differences, however, do not follow the same pattern as the physical health outcomes. For example, Caribbean Black men have higher rates of mood and anxiety disorders than African American men.⁴ However, Caribbean Black women had lower rates of anxiety and substance disorders than African American women.⁴ Williams and colleagues found that although 12-month estimates of major depressive disorder did not differ for African Americans and Caribbean Blacks, lifetime prevalence was higher for Caribbean Blacks than African Americans (12.9% vs. 10.4%).³⁷

There are significant differences between African Americans and Caribbean Blacks in physical and mental health that have not been addressed adequately. Psychosocial stressors are presumed to influence mental and physical health through the same physiologic pathways.^38-45 In spite of their interrelationship, depressive symptoms and other aspects of poor mental health have been under-studied as possible risk factors or mediators of physical health statuses.^46-47 Various stressors, however, have been associated with increased metabolic abnormalities and related risk factors (i.e., elevated blood pressure, waist circumference) among Black-American, Afro-Caribbean, and African women.^48-50 Depressive symptoms (e.g., feelings of sadness or hopelessness, trouble sleeping, low energy or fatigue, feeling worthless or guilty for no reason, significant weight change) may have particular implications for physical health and self-rated health. Stress may lead people to engage in behaviors (e.g., eating high-fat food, drinking alcohol, using tobacco and other drugs) that may reduce depressed mood and irritability but may increase physical health problems.⁴⁰

It also is important to note that previous studies have rarely considered the effects of nativity, in this case whether or not Caribbean Blacks were born in the Caribbean or the U.S. and ethnicity within the black racial grouping.³² Isolating meaningful variation can be difficult in studying domestic-born populations but comparisons to immigrant samples, especially of racially similar groupings, may assist in illuminating the affects of stressors and environmental factors.¹² The fact that higher socioeconomic position for Caribbean Blacks translates to better physical health, but not better mental health than African Americans, highlights the need to examine patterns of physical and mental health statuses in an integrative framework. While the majority of studies examine mental and physical health conditions separately, we believe there are benefits to considering the intersection of these outcomes in the same analysis.⁴⁰

Thus, this paper examines how ethnicity, nativity, and current depressive symptoms influence the physical health statuses of American Blacks assessed by self-rated health and self-reported physician diagnosed chronic health conditions. Three research questions guide the analyses. First, do African Americans have worse physical health (self-rated physical health and self-reported physician diagnosed chronic medical conditions) than Caribbean Blacks? Second, do U.S.- born Caribbean Blacks have significantly worse self-rated physical health and self-reported physician diagnosed chronic medical conditions than Caribbean-born Blacks? And, three, do depressive symptoms (CES-D) mediate the relationship between ethnicity and both self-rated physical health and self-reported physician diagnosed chronic medical conditions.

In sum, this study considers how ethnic and nativity heterogeneity among American Blacks differentially affect physical health statuses. This analysis is significant because examining ethnicity, nativity, and race may illuminate pathways through which social and cultural factors influence health more generally.

Methods

Participants

The National Survey of American Life (NSAL) is part of a National Institute of Mental Health Collaborative Psychiatric Epidemiology Surveys initiative that included three national surveys: the NSAL, the National Comorbidity Survey Replication (NCS-R), and the National Latino and Asian American Study. The NSAL adult sample was an integrated national household probability sample of 3,570 African Americans, 891 non-Hispanic Whites, and 1,621 Blacks of Caribbean descent (Caribbean Blacks), for a total sample of 6,082 individuals 18 years and older. The African American sample, the core sample of the NSAL, is a nationally representative sample of households located in the 48 contiguous states with at least one Black adult 18 years old or older. In this paper we focus the analysis only on African American and the Caribbean Black NSAL subsamples.

The term African American is used to refer to people who self-identified as Black but did not identify ancestral ties to the Caribbean. Caribbean Blacks are people who self-identified as Black and indicated (a) that they were of West Indian or Caribbean descent, (b) that they were from a country included on a list of Caribbean countries presented by the interviewers, or (c) that their parents or grandparents were born in a Caribbean country. The Caribbean Black sample was selected from the core sampling areas of the NSAL (n=265) and from additional metropolitan segments (n=1,356) that were sampled based on the concentration of Blacks of Caribbean descent. The White American sample was a stratified, disproportionate sample of White American adults residing in households located in census tracts and blocks that have a 10% or greater African American population. Although not a focus on this analysis, White Americans in the NSAL represent 14% of the White population in the United States.

Most interviews (86%) were completed face-to-face using a computer-assisted instrument and lasted an average of 2 hours and 20 minutes. The remaining interviews were either partially or entirely conducted by telephone. All the interviews were performed in English, but the Caribbean sample included persons from English-, French-, Spanish-, and Dutch-speaking Caribbean countries. Data collection was completed between February 2, 2001 and June 30, 2003. The final response rate was 72.3% overall: 70.7% for African Americans, 77.7% for Caribbean Blacks, and 69.7% for non-Hispanic whites. For all three racial/ethnic samples, the NSAL weights were designed to correct for disproportionate sampling, non-response, and population representation across various socio-demographic characteristics.

Measures

Ethnicity and nativity

Ethnicity and nativity were modeled using a three-level variable. Item categories were African American (coded 1), U.S.-born Caribbean Blacks (coded 2), and Caribbean-born Blacks (coded 3).

Physical health

The NSAL survey included a variety of physical and mental health measures. This analysis used two outcome measures of physical health, self-rated physical health status, and self-reported physician diagnosed chronic medical conditions. Self-rated physical health was measured by asking respondents, “How would you rate your overall physical health at the present time? Would you say it is excellent, very good, or good [all coded 0], or fair or poor [coded 1]?” Self-report of chronic medical conditions was measured by asking respondents “whether a doctor or a health professional had ever told you that you had the health problem listed below, arthritis or rheumatism, ulcers, cancer, hypertension, diabetes, a liver problem, a kidney problem, stroke, asthma, chronic lung disease, a blood circulation problem, sickle cell disease, heart trouble, HIV/AIDS, glaucoma, tuberculosis, fertility problems and osteoporosis.” The count of physical health problems is the sum of yes responses to those 18 health problems. Responses to this question ranged from 0 to 13 chronic medical conditions reported with a mean of 1.3. Self-report of chronic medical conditions was coded 1 for those reporting one or more physical health problems and 0 for those who reported no physical health conditions.

Depressive symptoms

Depressive symptoms were measure by a 12-item version of Center for Epidemiologic Studies Depression (CESD) scale. Each item employed a four-point scale (ranging from “less than 1 day” to “5-7 days”) where respondents were asked, “During the past week, how often did you feel this way?” Symptoms included, for example, “I was not as good as other people; I had trouble keeping my mind on what I was doing; I felt depressed ...” Cronbach's alpha coefficient for the 12-item CESD was .77. The CESD was included in our analysis as a continuous variable to test whether any of the direct effects of ethnicity and nativity on health statuses were mediated by depressive symptoms.

Data analysis

Logistic regression for complex survey data sets was conducting using SAS software, Version 9.1 of the SAS system for Windows (Copyright © 2004. SAS Institute Inc. SAS and all other SAS Institute Inc. product or service names are registered trademarks or trademarks of SAS Institute Inc., Cary, NC, USA). Logistic regression models were adjusted for several covariates, including gender, age, education, employment, and marital status. Income, measured on a continuous scale of U.S. dollars was also included as a covariate. Because self reports of annual household income typically have extreme ranges, we divided each respondent household income by a constant $5,000 to better normalize the income distributions.

Two regression models were used to test the associations. Model 1 tested the crude association between ethnicity, nativity, and physical health statuses. Model 2 tested the association between ethnicity, nativity, and physical health status, adjusted for depressive symptoms and gender, age, education, work status, income, and marital status correlates. Differences in physical health across ethnicity were examined by comparing self-rated physical heath and chronic health conditions of US- born Caribbean Blacks and Caribbean- born Blacks to African Americans (Table 2). The effect of nativity on physical health was examined by comparing the self-rated physical health and chronic health conditions of Caribbean- born Blacks to US- born Caribbean Blacks (Table 3). In further analyzing results from logistic regression models, we interpreted the analysis of effects for the null hypothesis of no difference in self-rated physical health and chronic medical conditions between African Americans, U.S.-born Caribbean Blacks, and Caribbean-born Blacks.

Table 2.

Association between ethnicity and physical health as measured by self-rated health status and self-report of chronic medical conditions.

	Self-Rated Physical Health Status, OR(95%CI)		Self-Report Chronic Medical Conditions, OR(95%CI)
	Model 1	Model 2	Model 1	Model 2
Ethnic group
African American	1.00	1.00	1.00	1.00
US- born Caribbean Blacks	1.10 (0.70,1.74)	1.61 (1.07,2.41)	0.92 (0.56,1.54)	1.47 (0.88,2.46)
Caribbean- born Blacks	0.66 (0.51,0.85)	0.86 (0.64,1.14)	0.69 (0.52,0.93)	0.68 (0.49,0.96)
Test of Main Effect of 3-level ethnic group variable = 0, (p-values)	0.01	0.04	0.03	0.04
CESD	--	1.10 (1.08,1.12)	--	1.04 (1.02,1.06)
Gender
Male	--	1.00	--	1.00
Female		1.08 (0.87,1.34)	--	1.43 (1.21,1.68)
Age
≤ 29	--	1.00	--	1.00
30-44	--	1.67 (1.22,2.29)	--	2.12 (1.77,2.53)
45-59	--	2.70 (2.09,3.50)	--	5.95 (4.56,7.76)
≥ 60	--	2.41 (1.75,3.33)	--	13.30 (9.03,19.59)
Education
≤11 yrs	--	1.00	--	1.00
12 yrs	--	0.78 (0.63,0.98)	--	0.62 (0.51,0.76)
13-15 yrs	--	0.74 (0.54,1.01)	--	0.69 (0.55,0.87)
≥ 16 yrs	--	0.53 (0.39,0.72)	--	0.59 (0.41,0.84)
Work Status
Employed	--	1.00	--	1.00
Unemployed	--	1.34 (0.92,1.94)	--	1.05 (0.79,1.42)
Not in labor force	--	2.87 (2.15,3.83)	--	1.83 (1.42,2.36)
Income	--	0.96 (0.92,1.00)	--	1.00 (0.98,1.01)
Marital Category
Married/Partner	--	1.00	--	1.00
Separated/Divorced/Widowed	--	1.19 (0.90,1.58)	--	0.86 (0.70,1.07)
Never Married	--	0.95 (0.72,1.25)	--	0.79 (0.62,1.00)

Table 3.

Association between nativity and physical health as measured by self-rated health status and self-report of chronic medical conditions.

	Self-Rated Physical Health Status, OR(95%CI)		Self-Report Chronic Medical Conditions, OR(95%CI)
	Model 1	Model 2	Model 1	Model 2
Ethnic groups
US-born Caribbean Blacks	1.00	1.00	1.00	1.00
Caribbean- born Blacks	0.60 (0.35, 1.02)	0.48 (0.26, 0.87)	0.75 (0.39, 1.43)	0.45 (0.23, 0.88)

Additional regression analyses examined the significance of depressive symptoms as a mediator of the association between ethnicity, nativity and physical health statuses (Table 2). The significance of depressive symptoms as a mediator was assessed through a series of regressions using SAS software, Version 9.1. First, self-rated physical health and chronic health conditions were regresses separately on the predictor variables, ethnicity and nativity. The hypothesized mediator, depressive symptoms was then regressed on the predictor variables, ethnicity and nativity. Finally, the main outcome variables of self-rated physical health and chronic health conditions were regressed separately on ethnicity and nativity, and the potential mediator, depressive symptoms. As noted later, no evidence of a mediating role of depressive symptoms in self-reported health or chronic medical conditions was found.

Results

Table 1 shows mean scores for variables used in the analysis. The mean score of depressive symptoms (range 0-33) was 6.68. A total of 42% of the sample reported no chronic medical conditions and 58% reported having been diagnosed with one or more medical conditions. Twenty-percent of study participants reported their self-rated health as poor or fair. Respondents were well distributed across the education and age categories (Table 1). In general, participants were more likely to be married and employed (Table 1). Approximately 65% of Caribbean Blacks were born in the Caribbean while 35% were born in the U.S.

Table 1.

Sample weighted characteristics for African Americans and Caribbean Blacks

	Full Sample	African American	U.S.-born Caribbean Blacks	Caribbean-born Blacks
Unweighted Sample No.	5176	3570	440	1166
Gender
Male	44.50% (0.81%)	44.03% (0.83%)	50.83% (7.66%)	51.08% (3.62%)
Female	55.50% (0.81%)	55.97% (0.83%)	49.17% (7.66%)	48.92% (3.62%)
Self-Rated Physical Health Status
Excellent/Very good/good	79.96% (0.72%)	79.72% (0.76%)	78.09% (3.93%)	85.68% (1.53%)
Poor/Fair	20.04% (0.72%)	20.28% (0.76%)	21.91% (3.93%)	14.32% (1.53%)
Self-Report Chronic Medical Conditions
0 conditions	41.56% (0.96%)	41.07% (1.01%)	43.00% (6.28%)	50.21% (3.61%)
1+ conditions	58.44% (0.96%)	58.93% (1.01%)	57.00% (6.28%)	49.79% (3.61%)
Center for Epidemiologic Studies Depression Scale, (CESD)*	6.68 (0.17)	6.70 (0.19)	7.45 (0.86)	5.81 (0.33)
Age
≤ 29	24.84% (1.03%)	24.37% (1.11%)	47.79% (3.37%)	22.17% (1.78%)
30-44	35.37% (0.85%)	35.44% (0.91%)	29.58% (2.50%)	36.67% (2.62%)
45-59	23.48% (0.81%)	23.79% (0.86%)	11.07% (1.80%)	23.99% (3.50%)
≥ 60	16.31% (0.81%)	16.40% (0.85%)	11.56% (4.41%)	17.17% (2.61%)
Age*	42.18 (0.49)	42.33 (0.52)	35.06 (1.43)	43.14 (0.89)
Education
≤11 yrs	23.99% (1.13%)	24.19% (1.20%)	21.93% (6.26%)	20.36% (2.31%)
12 yrs	37.28% (1.01%)	37.86% (1.09%)	24.03% (2.83%)	32.69% (2.04%)
13-15 yrs	23.98% (0.93%)	23.83% (0.97%)	30.40% (5.83%)	23.91% (2.69%)
≥ 16 yrs	14.74% (1.06%)	14.12% (1.13%)	23.65% (4.65%)	23.05% (2.04%)
Work Status
Employed	67.42% (0.98%)	66.83% (1.05%)	72.87% (3.22%)	76.17% (3.23%)
Unemployed	9.99% (0.66%)	10.07% (0.71%)	9.64% (3.24%)	8.51% (1.83%)
Not in labor force	22.60% (0.90%)	23.10% (0.96%)	17.49% (1.69%)	15.32% (2.20%)
Income*	$37,545 ($1,403.43)	$36,833 ($1,487.96)	$52,768 ($6,947.50)	$43,943 ($2,762.67)
Marital Category
Married/Partner	42.25% (0.99%)	41.65% (1.03%)	37.10% (4.68%)	57.54% (2.94%)
Separated/Divorced/Widowed	26.22% (0.72%)	26.77% (0.75%)	15.49% (3.75%)	20.43 (3.30%)
Never Married	31.53% (1.22%)	31.57% (1.31%)	47.42% (3.64%)	22.03% (1.70%)

^*Reported sample means and SE for all categories

Self-rated health

There were significant differences in the report of self-rated health as poor or fair when comparing African Americans, U.S.-born Caribbean Blacks, and Caribbean-born Blacks in Model 1 (p-value = 0.01) and Model 2 (p-value = 0.04). However, a closer examination of within-group differences between the self-rated health of African Americans, U.S.-born Caribbean Blacks, and Caribbean-born Blacks revealed different patterns of significance between Models 1 and 2. In Model 1, there was not a significant difference between African Americans’ and U.S.-born Caribbean Blacks’ self-rated health; however, when covariates and depressive symptoms were added in Model 2, U.S.-born Caribbean Blacks were significantly more likely than African Americans to rate their health as fair or poor (Model 2, Table 2. OR: 1.61, 95%CI: (1.07, 2.41)). Caribbean-born Blacks were significantly less likely than African Americans to rate their health as fair or poor in the Model 1 (Table 2. OR: 0.66, 95%CI: (0.51, 0.85)); however, when covariates and depressive symptoms were considered in Model 2, there was no difference between Caribbean-born Blacks and African Americans in self-rated health (Model 2, Table 2. OR: 0.86, 95%CI: (0.64, 1.14)). In addition to comparing the two groups of Caribbean Blacks to African Americans, we also examined the effects of nativity by comparing U.S.-born Caribbean Blacks with Caribbean-born Blacks (Table 3). In these analyses, U.S.-born Caribbean Blacks were significantly more likely than Caribbean-born Blacks to rate their health as fair or poor in Model 2 (Table 3, p = .01). Overall, Caribbean-born Blacks were least likely to rate their health as fair or poor and U.S.-born Caribbean Blacks reported having the worst self-rated health.

Chronic conditions

There were significant differences in self-reports of physician diagnosed chronic medical conditions when comparing African Americans, U.S.-born Caribbean Blacks and Caribbean-born Blacks in the crude Model 1 (p-value = .03) and Model 2 (p-value= .04). In Model 1, Caribbean-born Blacks were significantly less likely to report one or more chronic medical conditions compared to African Americans (Model 1, Table 2. OR: 0.69, 95%CI: (0.52, 0.93)). Model 2 shows that U.S.-born Caribbean Blacks and African Americans did not differ in their report of chronic conditions; however, Caribbean-born Blacks remained less likely than African Americans to report one or more chronic medical conditions (Model 2, Table 2 OR: 0.68, 95%CI: (0.49, 0.96)). Overall, Caribbean-born Blacks were least likely to report one or more chronic medical conditions, and U.S.-born Caribbean Blacks were most likely to report being diagnosed with one or more chronic conditions.

For both self-rated health and chronic conditions, an increase in depressive symptoms was associated with a decrease in health status. This was the case adjusting for ethnicity and all covariates: Model 2 for self-rated physical health (Table 2. OR: 1.10, 95%CI: (1.08, 1.12)) and chronic medical conditions (Table 2. OR: 1.04, 95%CI: (1.02, 1.06)). Overall, increased depressive symptoms remained significantly associated with worse physical health. However, as noted earlier, depressive symptoms was not a significant mediator of the association between ethnicity, nativity and physical health outcomes.

Several covariates were significantly associated with both self-rated health and physician diagnosed chronic medical conditions. In Model 2, American Blacks 45-59 years old had the highest odds of poor or fair physical health. Those 60 years old and older were most likely to report having been diagnosed with one or more chronic medical conditions. Significant differences in health were also found between the employed and unemployed. The unemployed were significantly more likely to rate their health as fair or poor and to report more chronic medical conditions. Gender was a significant predictor of chronic conditions but not self-rated health; females were more likely to report chronic conditions in Model 2 (Table 2, OR: 1.43, 95%CI: (1.21, 1.68). Education was a significant predictor of worse physical health for both self-rated health and chronic medical conditions. In general, education of any amount greater than 11 years (compared with 11 or less years) yielded decreased odds of reporting worse physical health.

Discussion

This paper examined the relationships among ethnicity, nativity, and the physical health status of American Blacks. We found that African Americans, U.S.-born Caribbean Blacks, and Caribbean-born Blacks had significantly different self-ratings of health and reports of being diagnosed with a chronic medical condition. Whether physical health was measured by self-rated health or presence of at least one chronic health condition, Caribbean-born Blacks had the best health outcomes and U.S.-born Caribbean Blacks had the worst. This finding remained significant after controlling for current self-reported depressive symptoms. U.S.-born Caribbean Blacks were significantly more likely than African Americans to rate their health as fair or poor, and both groups were more likely than Caribbean-born Blacks to state that their health was fair or poor. African Americans were more likely than both Caribbean Black groups to report having been diagnosed with chronic medical conditions.

Previous research by Nazroo and colleagues examined the health outcomes of African Americans and Caribbean Blacks but did not examine nativity.³² The current study builds on the study by Nazroo and colleagues³² by examining nativity among Caribbean Blacks, in addition to comparing Caribbean Blacks with African Americans. While Caribbean Blacks have generally been found to have better health outcomes than African Americans,³³ disaggregating the group into U.S.-born and Caribbean-born provides a different picture. U.S.-born Caribbean Blacks were more likely to report poorer self-rated health though they did not differ on the likelihood of being diagnosed with a chronic medical condition. Nativity among Caribbean Blacks was also significant. Consistent with the literature describing the “immigrant health paradox” in Latinos and other groups,^{17, 34-35} we found that the health profiles of African Americans and U.S.-born Caribbean Blacks were not significantly different from each other but both African Americans’ and U.S.-born Caribbean Blacks’ health were significantly worse than Caribbean-born Blacks.

In addition to the implications of the ethnicity and nativity associations, higher rates of depressive symptoms was a significant predictor of worse physical health statuses. The results of depressive symptoms predicting physical health outcomes highlights the importance of uncovering the role of mental health statuses and processes in research on physical health.⁴⁰ Even when other critical covariates were considered (e.g., income, education, marital status), depressive symptoms remained a significant predictor. While it is common in Western health and medical research to separate mental and physical health, these findings remind us how artificial this separation may be. It is critical for future conceptual models and studies to consider how mental health and physical health are inextricably intertwined.^39-42

Beyond the differences in health, the analysis of covariates yielded important findings that may help to inform future research and interventions. For example, there was a curvilinear relationship between age and physical health. American Blacks age 45-59 reported worse physical health than those 29 or younger, 30-44, and 60 years and over. Regarding gender, women were more likely to report being diagnosed with a chronic health condition than men, but there was no difference in the likelihood of self-reporting fair or poor health. Age, gender, education, and socioeconomic status function differently, and in some cases non-linearly, within each ethnic group; age and gender seem to have particularly important salience for the physical health of American Blacks. Since different age groups and genders have different social roles, strains and stressors, age and gender may be salient factors to consider in developing interventions to reduce health disparities and poor health outcomes experienced by subgroups of American Blacks.^51-52

The finding of no gender differences in self-rated health coupled with women being more likely to report having been diagnosed with a chronic condition is inconsistent with literature on gender differences in health.⁵³ Read and Gorman³⁶ found that women across ethnic groups consistently reported worse self-rated health than men, and that Black women were more likely than Black men to report poorer self-rated health, more functional limitations, and more diagnosed medical conditions. Payne⁵³ suggests that men tend to have more life-threatening conditions than women, but women tend to have more conditions that increase physical limitations and pain. Courtenay⁵⁴ suggests that men may be more likely to report very good or excellent physical health status as a way of concealing vulnerability and increasing perceived invulnerability, which may be protective of how male self images. This may be particularly important for American Black men, who have few other avenues through which to reinforce positive self-images since many economic and social aspects of success in this society are blocked by discrimination.^{53, 55-57}

There are several limitations of the current study. Due to the cross-sectional data, we are unable to test causal relationships among the factors examined. While the analysis highlighted the critical associations of ethnicity, nativity, mental health, and other factors to American Blacks’ physical health statuses, there was unexplained variance that might have been due to unmeasured factors salient to each ethnic group, and other important predictors and covariates that could help explain the association between ethnicity and physical health. For example, factors such as high-effort coping (e.g. John Henryism), goal-striving stress, racial socialization, ethnic identity, racial identity, and perceived and experienced discrimination could play a role. Information collected from the modified CESD, self-rated physical health, and self-reports of chronic conditions and other variables are all gathered by self-reports, and subject to recall bias. While we were able to discuss the self-report of a physician diagnosed chronic health condition, it was beyond the scope of the paper to include measures of severity, duration, or the limitations that the conditions may have imposed. Finally, the short recall period of self-reported depressive symptoms, “over the past week,” employed in the CESD only permits considering the influence of the immediate experience of these symptoms. The CESD also did not include chronicity, duration, or potential debilitating impact of depressive symptoms over time that may be more associated with chronic medical conditions and overall physical health status.

Developing a deeper understanding of the socio-demographic correlates of health among African Americans and Caribbean Blacks provides data relevant to the continued exploration of pathways and mechanisms that may contribute to ethnic health disparities more generally. Future research is needed to examine how these results related to ethnicity and nativity hold across other Black ethnic groups (e.g. African immigrants) in the U.S. Second, it will be critical to disaggregate how residential segregation and other social and environmental factors influence the life chances, stress, and health of ethnic groups of American Blacks.⁵⁸ It also is important to identify which sub-groups of U.S.-born Caribbean Blacks, Caribbean-born Blacks, and African Americans may be most vulnerable to adverse health outcomes. Are there specific combinations of gender, age group, and socioeconomic status that increase risk of morbidity and mortality? Finally, developing and utilizing measures that attempt to integrate physical and mental health statuses would provide important and potentially robust tools for understanding the overall health processes and statuses among American Blacks.