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. Author manuscript; available in PMC: 2022 Dec 1.
Published in final edited form as: J Health Psychol. 2020 Jun 4;26(14):2688–2698. doi: 10.1177/1359105320931185

The impact of world assumptions on the association between discrimination and internalizing and substance use outcomes

Angela M Haeny 1, Jacqueline Woerner 2, Manik Ahuja 3, Terrell A Hicks 4, Cassie Overstreet 1,4,5, Ananda Amstadter 4, Carolyn E Sartor 1
PMCID: PMC7714705  NIHMSID: NIHMS1606723  PMID: 32498568

Abstract

This study investigated whether core beliefs about the world being safe and predictable (i.e. world assumptions) mediated the association between discrimination and internalizing and substance use problems among individuals from marginalized groups. Path analyses tested mediating effects of four types of world assumptions on the association between discrimination (race-, gender-, and sexual orientation-based) and anxiety, depression, alcohol and cannabis problems in college students (N = 1,181, agemean = 19.50, SD = 1.67). Limited support for mediation by world assumptions was found: among Asian students, race-based discrimination indirectly impacted anxiety symptoms through low perceived controllability of events. Direct effects across groups and discrimination types were also found.

Keywords: alcohol problems, cannabis problems, discrimination, internalizing symptoms, world assumptions

Introduction

It has been well-established that discrimination – unjust differential treatment due to social identity – is associated with poor mental health and substance use outcomes among marginalized groups (e.g. female, sexual minority, and racially/ethnically diverse individuals) (Gilbert and Zemore, 2016; Pascoe and Richman, 2009; Williams and Mohammed, 2009). Minority stress models suggest that having a marginalized identity is associated with excessive stress (Brooks, 1981; Clark et al., 1999; Harrell, 2000; Meyer, 2003), and discrimination has been identified as one such stressor. In fact, discrimination has been identified as one core social mechanism that partially explains health disparities among minoritized groups (Bailey et al., 2017; Jones, 2000; Marmot et al., 2008).

Discrimination has been linked with increased substance use among women (e.g. Otiniano Verissimo et al., 2014), sexual minority (e.g. Evans-Polce et al., 2019), Latinx (e.g. Unger et al., 2016), Asian (e.g. Iwamoto et al., 2016), and Black populations (e.g. Desalu et al., 2019) in the U.S. The harmful effects of discrimination have also been implicated in internalizing symptoms (e.g. anxiety and depression) among individuals from these marginalized groups (Clark, 2014; McLaughlin et al., 2010; Pilver et al., 2011; Schmitt and Branscombe, 2014). Given the significant associations between these constructs, identifying the mechanisms that link discrimination to mental health and substance use problems is critical to reducing harms associated with discrimination.

One potential mechanism linking discrimination to internalizing and substance use outcomes that has yet to be explored includes global beliefs about the world, also referred to as world assumptions (Janoff-Bulman, 1989). World assumptions theory (Janoff-Bulman, 1989) suggests that traumatic life events may modify people’s views of the world (i.e. about the world being a safe, benevolent, and a generally predictable place). According to this theory, when an individual’s assumptions about the world as safe and meaningful are shattered by a stressful or traumatic event, this can result in pathology (Janoff-Bulman, 1992, 2010). For example, negative world assumptions have been found to mediate the relation between trauma exposure and posttraumatic stress disorder symptoms (Shahar et al., 2013), alcohol-related consequences (Thompson et al., 2010), and symptoms of depression (Lilly et al., 2011). Research suggests that interpersonal (e.g. sexual or physical assault) forms of trauma may more negatively impact world assumptions than non-interpersonal (e.g. natural disaster, motor vehicle accident) forms of trauma (Lilly et al., 2011; Ullman, 1997; Wagner et al., 2009). Given that discrimination is a type of interpersonal stressor that can be experienced as traumatic (Anderson and Stevenson, 2019; Carter, 2007; Carter et al., 2013), discrimination may similarly impact world assumptions. Prior research has found world views moderate the association between discrimination and mental health outcomes (e.g. Kim and Park, 2018; Major et al., 2007). However, the potential effect of chronic experiences of discrimination on world views (e.g. viewing the world as less safe), which subsequently impacts internalizing and substance use problems, has not been systematically tested.

The objective of the current study was to investigate whether core beliefs about safety, control over events, and trustworthiness and predictability of people mediate the association between discrimination and internalizing and substance use problems in members of marginalized groups. Specifically, we examined associations of racial discrimination among Black, Latinx, and Asian individuals, gender-based discrimination among women, and sexual orientation-based discrimination among sexual minority individuals with anxiety, depression, and problem use of alcohol and cannabis in a college sample. We hypothesized that discrimination would be associated with elevated rates of depression, anxiety, and alcohol and cannabis problems and, consistent with findings from the trauma literature (Lilly et al., 2011; Shahar et al., 2013; Thompson et al., 2010), that this association would be mediated by negative world assumptions.

Methods

Participants

The sample was drawn from a study of 1,313 students from a mid-Atlantic university in the United States who completed an online survey of stress, personality, substance use, and mental health between 2015 and 2017. For the purposes of this study, the sample was limited to those who identified as Black (25%), Latinx (13%), Asian (18%), or White (45%) (N = 1,181) due to low endorsement of other race categories (“Native American” [<.01%], “Multiracial” [2%] and “Other” [5%]). Approximately 75 percent of the sample was female and 90 percent identified as heterosexual. The mean age was 19.50 (SD=1.67) years. Participants were recruited from undergraduate psychology courses using the Sona research management system and were compensated with research credit. Eligibility criteria were a minimum age of 18 years and ability to complete an online survey in English. This study was approved by the university’s Institutional Review Board, and all participants provided electronic informed consent to participate in this study.

Measures

Demographics

All participants self-reported their demographic information, including age, sex, sexual orientation, and race. In terms of race, anyone who endorsed Hispanic/Latino was categorized as Latinx, and non-Latinx Black, Asian, and White students were categorized as Black, Asian, and White, respectively (consistent with the National Epidemiologic Survey on Alcohol-Related Conditions approach to creating a single variable reflecting race and ethnicity). There was low endorsement of “Native American,” “Pacific Islander,” “multiracial,” and “other” categories so (as noted above) these groups were not included in the present study. Biological sex was assessed with “female” and “male” as the options. Gender identity was not explicitly assessed. The options for sexual orientation were: homosexual, bisexual, and heterosexual. Individuals who identified as homosexual or bisexual were combined into a “sexual minority” group due to low endorsement of each.

Perceived discrimination

Discrimination experiences were assessed using the Everyday Discrimination Scale (EDS; Williams et al., 1997), in which nine different experiences are presented (e.g. you are treated with less respect than other people are; you are threatened or harassed). For each experience, participants are asked the frequency they have occurred (1 = almost every day, 5 = less than once a year) and the main reasons (due to their ancestry, race, sexual orientation, religion, education/income, and/or gender). In the current study, we created race- (α = .85), sexual orientation- (α = .81), and gender-specific discrimination scores (α = .78), by including only those items in which race, sexual orientation, or gender, respectively, was identified as a main reason. The scale was reverse coded so that higher scores indicate more frequent discrimination experiences.

World assumptions

The World Assumptions Questionnaire (WAQ; Kaler, 2009) is a 22-item measure assessing beliefs about the world. The WAQ consists of four subscales: controllability of events (CE; α = .68) (e.g. “I don’t feel in control of events that happen to me”), comprehensibility and predictability of people (CPP; α = .76) (e.g. “people often behave in unpredictable ways”), trustworthiness and goodness of people (TGP; α = .72) (e.g. “most people can be trusted”), and safety and vulnerability (SV; α = .62) (“terrible things might happen to me”). The response options vary from 1 = strongly agree to 6 = strongly disagree. The subscales were coded such that higher scores indicate more positive world assumptions.

Substance use outcomes

Alcohol problems

Problematic alcohol use over the past year was assessed using the Alcohol Use Disorders Identification Test (AUDIT; Saunders et al., 1993). The AUDIT consists of 10 items, 3 items assessing quantity and frequency of use, 3 items assessing disordered use, and 4 items assessing negative consequences associated with use. AUDIT scores range from 0 to 40, with higher scores indicating more problems (α = .86). An AUDIT score of 8 or higher suggests harmful use.

Cannabis problems

Problematic cannabis use over the past 6 months was assessed using the Cannabis Use Disorders Identification Test (CUDIT; Adamson and Sellman, 2003). Similar to the AUDIT, the CUDIT consists of 10 items, 3 items assessing quantity and frequency of use, 3 items assessing disordered use, and 4 items assessing negative consequences as a result of use. CUDIT scores also range from 0 to 40, with higher scores indicating more problems (α = .88). A CUDIT score of 8 or higher suggests harmful use.

Internalizing outcomes

Anxiety

The 7-item Generalized Anxiety Disorder scale (GAD-7; Spitzer et al., 2006) was used to assess symptoms of anxiety (e.g. Feeling nervous, anxious or on edge). Respondents are asked how frequently they have experienced each symptom (1 = not at all to 4 = nearly every day) over the past 2 weeks. The responses are summed with higher scores indicating higher anxiety (α = .91).

Depression

The 9-item Patient Health Questionnaire (PHQ-9; Kroenke et al., 2001) was used to assess depression. Respondents are asked how frequently they experience each symptom (e.g. Little interest or pleasure in doing things) using the same response options as the GAD-7. The responses are summed, with higher scores indicating greater severity of depression (α = .90).

Analytic approach

Path analysis was used to test direct effects of discrimination and indirect effects of world assumptions on internalizing and substance use problems in MPlus (Muthén and Muthén, 2018). Figure 1 provides the conceptual model of the mediation effects tested herein. The effect of race-based discrimination was assessed in Black, Latinx, and Asian students, the effect of gender-based discrimination was assessed in women, and the effect of sexual orientation-based discrimination was assessed in sexual minority students. The race-based discrimination models adjusted for age, sex, and sexual orientation, the gender-based discrimination model adjusted for age, race, and sexual orientation, and the sexual orientation-based discrimination model adjusted for age, sex, and race. Bivariate correlations for each subgroup are in Supplemental Table 1. Family-wise error was adjusted for using the Bonferroni-Holm method (Holm, 1979).

Figure 1.

Figure 1.

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Conceptual model of world assumptions mediating the association between discrimination and internalizing and substance use problems.

Results

Descriptive information on discrimination, world assumptions, and internalizing and substance use problems is reported in Supplemental Table 1. Table 1 provides the standardized regression coefficients and standard errors for direct and indirect effects of discrimination, world assumptions, and internalizing and substance use problems for the three race-based discrimination models (Black, Latinx, and Asian students) the gender-based discrimination model, and the sexual orientation-based discrimination model. Effects that remained significant after adjustment for family-wise error are indicated with an asterisk.

Table 1.

Standardized regression coefficients and standard errors for direct and indirect effects of discrimination, world assumptions, substance use, and internalizing problems among women, Black, Latinx, Asian, and sexual minority individuals.

Alcohol problems Cannabis problems Anxiety Depression
Race-based discrimination
Black participants (n = 291)
Direct effects
 Race-based discrimination .12 (.06) .12 (.06) .10 (.06) .14 (.06)
Indirect effects
 Controllability of events <.01 (.001) −.001 (.01) −.001 (.01) −.001 (.01)
 Controllability and predictability of people −.002 (.004) −.003 (.01) −.001 (.003) <.01 (.003)
 Safety and vulnerability −.004 (.01) −.02 (.02) −.001 (.01) −.01 (.01)
 Trustworthiness and goodness of people .10 (.06) .004 (.01) .02 (.01) .02 (.01)
Latinx participants (n = 152)
Direct effects
 Race-based discrimination −.03 (.08) .10 (.08) .06 (.08) .11 (.08)
Indirect effects
 Controllability of events <.01 (.002) −.002 (.004) −.01 (.02) −.01 (.02)
 Controllability and predictability of people −.001 (.01) .001 (.004) .01 (.02) .004 (.01)
 Safety and vulnerability <.01 (.002) .001 (.003) .001 (.003) .003 (.01)
 Trustworthiness and goodness of people −.001 (.004) −.002 (.001) −.10 (.02) −.01 (.01)
Asian participants (n = 207)
Direct effects
 Race-based discrimination −.01 (.07) .03 (.08) .07 (.07) −.01 (.07)
Indirect effects
 Controllability of events .01 (.01) −.002 (.01) .03 (.02) .04 (.02)
 Controllability and predictability of people <.01 (.01) <.01 (.01) <.01 (.001) <.01 (.001)
 Safety and vulnerability .002 (.02) .001 (.01) <.01 (.001) <.01 (.01)
 Trustworthiness and goodness of people .01 (.10) .02 (.01) .03 (.07) .03 (.02)
Gender-based discrimination
Women (n = 879)
Direct effects
 Gender-based discrimination .14 (.03) * .17 (.04) * .12 (.03) * .15 (.03) *
Indirect effects
 Controllability of events <.01 (.001) <.01 (.001) .003 (.01) .004 (.01)
 Controllability and predictability of people <.01 (.001) <.01 (.001) <.01 (.001) <.01 (.001)
 Safety and vulnerability −.001 (.001) −.001 (.001) .002 (.003) .002 (.002)
 Trustworthiness and goodness of people .002 (.03) .004 (.003) .10 (.01) .01 (.01)
Sexual orientation-based discrimination
Sexual minority participants (n = 114)
Direct effects
 Sexual orientation-based discrimination .07 (.10) .08 (.10) .13 (.09) .18 (.08)
Indirect effects
 Controllability of events <.01 (.01) .004 (.009) .02 (.02) .02 (.02)
 Controllability and predictability of people .001 (.02) <.01 (.01) −.004 (.01) −.10 (.01)
 Safety and vulnerability .01 (.02) −.004 (.01) .001 (.003) <.01 (.003)
 Trustworthiness and goodness of people .03 (.10) .03 (.10) .05 (.04) .04 (.08)
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Note. Bold indicates raw p < .05.

*

= adjusted for family-wise error p < .05. The Black, Latinx, and Asian models adjusted for age, sex, and sexual orientation. The female model adjusted for age, race, and sexual orientation. The sexual minority model adjusted for age, sex, and race.

Race-based discrimination

Black participants

Race-based discrimination was associated with increased alcohol problems and symptoms of depression. However, these effects did not remain after adjusting for family-wise error. No indirect effects were found for WAQ subscales on race-based discrimination and internalizing or substance use problems.

Latinx participants

No direct effects of race-based discrimination were found with internalizing or substance use problems. Similarly, no indirect effects were found for WAQ subscales on race-based discrimination and internalizing or substance use problems.

Asian participants

No direct effects of race-based discrimination were found with internalizing or substance use problems. An indirect effect was found such that Asians who endorsed race-based discrimination had lower controllability of event scores, which in turn was associated with experiencing more symptoms of depression. However, this effect did not remain after adjusting for family-wise error.

Gender-based discrimination

Examining women only, gender-based discrimination was associated with increased alcohol and cannabis problems and more symptoms of anxiety and depression. These effects remained significant after adjusting for family-wise error. No indirect effects were found for WAQ subscales on gender-based discrimination and internalizing or substance use problems.

Sexual orientation-based discrimination

Among sexual minority students, sexual orientation-based discrimination was not associated with internalizing or substance use problems. No indirect effects were found for WAQ subscales on sexual orientation-based discrimination and internalizing or substance use problems.

Discussion

Extensive evidence indicates discrimination is associated with internalizing and substance use problems among individuals with marginalized identities including women, Black, Latinx, Asian, and sexual minority individuals (e.g. Desalu et al., 2019; Evans-Polce et al., 2019; Iwamoto et al., 2016; Schmitt and Branscombe, 2014; Unger et al., 2016); however, the mechanisms underlying these associations are not well understood. This study investigated world assumptions as one possible mechanism. We found very limited support for this hypothesized pathway: the association between race-based discrimination and anxiety was explained by low perceived controllability of events among Asian students, though this effect fell out of the range of significance after adjusting for multiple tests. Although these findings should be treated as only suggestive, the hypothesis that among Asian students, race-based discrimination experiences can lead to a decreased sense of control, which increases feelings of anxiety, may warrant additional investigation. Though not universally observed (Chou et al., 2012; Woo, 2018), many studies have found an association between race-based discrimination and anxiety among Asian individuals (e.g. Gee et al., 2007; Hwang and Goto, 2008; Juang and Alvarez, 2010; Pernice and Brook, 1996), though this is the first study to identify world assumptions as a potential mechanism linking the two. Prior research indicates that increased peer support and positive ethnic identity can have buffering effects on the association of discrimination and poor mental health outcomes among Asian people (Iwamoto and Liu, 2010; Juang et al., 2016), and thus may represent worthwhile treatment targets.

We were surprised that the evidence for mediation effects of world assumptions between discrimination and internalizing and substance use outcomes was limited given the evidence for mediation effects for trauma (Lilly et al., 2011; Shahar et al., 2013; Thompson et al., 2010) and the fact that some forms of discrimination may be experienced as traumatic (Anderson and Stevenson, 2019; Carter, 2007; Carter et al., 2013). One potential reason that we did not find parallel associations to what has been observed with trauma is that our measure of discrimination was based on experiences that can happen on a daily basis, some of which may not be acutely distressing. The theory behind world assumptions is that stressful, traumatic events result in shattering world assumptions (Janoff-Bulman, 1989; Kaler, 2009). We hypothesized that everyday forms of discrimination would have a cumulative effect that may also result in altering world assumptions and lead to internalizing and substance use problems; however, our findings provide limited support for this theory. If everyday discrimination shifts world assumptions in a gradual way, the current sample may have been too young for the impact of everyday discrimination to alter world assumptions to such an extent that they influence mental health. Discrimination experienced in relation to major life events (e.g. impacting housing or employment) may be more relevant to the hypothesized mediation model.

Although we found limited support for our hypotheses, there are several other notable findings. By considering different forms of discrimination in multiple marginalized groups and numerous mental health outcomes, this study provides a broad perspective of the relation between discrimination and poor mental health and substance use outcomes. Our findings replicated prior work indicating race-based and gender-based discrimination are associated with increased internalizing and substance use problems among Black people and women, respectively (Desalu et al., 2019; Otiniano Verissimo et al., 2014; Schmitt and Branscombe, 2014). Sexual orientation-based discrimination was not associated with any of the outcomes in the current study, which is inconsistent with prior research (Evans-Polce et al., 2019; Schmitt and Branscombe, 2014), but potentially due to limited statistical power.

We were intentional about investigating the association of race-based discrimination with internalizing and substance use outcomes among Black, Latinx, and Asian students in separate models as opposed to combining all people of color into one group. Modeling these groups separately allowed us to identify distinctions in these associations by race. Our findings are consistent with prior findings linking race-based discrimination to symptoms of depression and problem alcohol use among Black individuals (Desalu et al., 2019; Schmitt and Branscombe, 2014). However, race-based discrimination was not associated with internalizing or substance use problems among Asian or Latinx individuals. Our findings are consistent with one study that did not find associations between race-based discrimination and alcohol or cannabis use among Asian college students (Chia-Chen Chen et al., 2014). However, our results are inconsistent with other studies suggesting that race-based discrimination is associated with increased alcohol use among Asian people using national epidemiological data (Chae et al., 2008) and a community sample of Asian American adults in Arizona (Yoo et al., 2010) and internalizing symptoms among Asian college students using the same discrimination, anxiety, and depression measures as our study (Chia-Chen Chen et al., 2014). Consistencies in the findings from the current study with prior research (Chia-Chen Chen et al., 2014) suggests race-based discrimination may not impact the development of cannabis problems among Asian college students.

Regarding Latinx individuals, our findings are counter to national epidemiological data indicating race-based discrimination is associated with greater odds of major depressive disorder, generalized anxiety disorder, and drug use disorder (but not alcohol use disorder) among Latinx adults (McLaughlin et al., 2010) and longitudinal data from Latinx youth indicating discrimination is associated with risk of alcohol and marijuana use (Unger et al., 2016). The lack of consistency of our findings with results from these prior studies may be attributable to differences in sample characteristics, discrimination measures, or operationalization of internalizing and substance use outcomes. The current study was based on college students, who may represent more affluent Latinx people. In addition, the current study used a measure of discrimination due to race whereas prior studies assessed discrimination specifically based on Latinx heritage (McLaughlin et al., 2010) or used a general measure of discrimination (Unger et al., 2016).

Limitations

Although the assessment time frames were lifetime for discrimination and current for world assumptions, internalizing and substance use problems, this was a cross-sectional study, so we cannot be certain that discrimination experiences preceded the development of world assumptions and that world assumptions preceded internalizing and substance use problems. Further, conclusions cannot be drawn regarding the association of discrimination with the constructs investigated in the current study in individuals who do not identify as Latinx, Asian, Black, or White or those on the sexual minority spectrum who do not identify as lesbian, gay or bisexual. Although we were intentional about investigating each racial/ethnic group separately, these subgroups still represent heterogenous groups and potentially important within group variation was not examined. In addition, as previously noted, given the small percentage of sexual minority participants in the sample, analyses of sexual orientation-based discrimination may have been underpowered to detect associations. Finally, our study was based a sample of college students, so our findings may not generalize to populations that differ in terms of social class, geographical location, age, or cognitive abilities.

Future directions

Future research on the role of world assumptions in relation to mental health outcomes should include measures of discrimination that assess impact on major life events, such as obtaining employment, housing, or a bank loan. Similarly, the potential mediating effects of world assumptions on the relation between race-, gender-, and sexual orientation-related trauma and internalizing and substance misuse should be formally tested. To understand the mechanisms impacting the association between discrimination and internalizing and substance misuse, additional research using prospective data is needed. Further, future research should be intentional about recruiting larger samples of individuals who identify as sexual minority, so these effects can be investigated by subgroup. Given research linking coping styles to the development of internalizing problems (Alloy et al., 1990; Webb et al., 2012) and substance misuse (Cooper et al., 1992; Windle and Windle, 2015), the potential role of coping styles in the pathway from discrimination to shattered world assumptions and internalizing and substance use problems merits exploration. Subjective deprivation has been found to contribute to maintaining poor mental health symptoms (Beshai et al., 2016) and may also be worth investigating as a moderator of the hypothesized association. Similarly, perceived injustice is associated with increased alcohol use (Howard and Cordes, 2010) and may impact the association between discrimination and internalizing and substance use problems. Finally, research has found self-stigma is more strongly associated with internalizing symptoms than substance misuse in women with PTSD and SUD (Melchior et al., 2019). Future research could investigate whether self-stigma differentially impacts the association between discrimination and internalizing and substance use problems.

Supplementary Material

Supplemental table

Acknowledgments

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The present study was supported by the National Institutes of Health (R01 AA023549, T32 DA15035, F31 DA048559, R25 DA035163, and T32 DA019426).

Footnotes

Supplemental material

Supplemental material for this article is available online.

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Supplemental table
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