The role of work in gender identity, stress and health in low-income, middle-aged African-American men

Summary

Although progress has been made in reducing disparities in life expectancy, addressing the persistence of health inequities by race remains a high priority for public health professionals. The purpose of this research was to refine a minority stress model (MSM) by identifying previously unrecognized factors contributing to stress and chronic disease health disparities among low-income middle-aged African-American men. Using a Community-Based Participatory Research approach, we conducted semi-structured individual health interviews with 42 low-income middle-aged African-American men in a mid-size New England city. The interviews focused on the participants’ perceptions of the causes of health disparities. Four major themes emerged from the analysis: the positive aspects of work, both financial and symbolic; and the negative repercussions of not working, both financial and symbolic in terms of a sense of self-respect. On an instrumental level, working men can support their family, be physically active and find social support. Symbolically, work provides a positive sense of identity as a man; it offers both social- and self-respect; it provides discipline and a sense of gratitude. Conversely, the lack of work is a significant source of stress, stemming both from the inability to support one’s family and from having nothing to do, which lead to depression, low self-esteem, suicidal ideation and anger. With no perceived viable routes to socially approved roles, many low-income men of color succumb to internalizing a negative identity. This research demonstrates a clear link between structural problems with the US economy and harms to sense of identity among low-income, middle-aged African-American men.

INTRODUCTION

Although measurable progress has been made in reducing disparities in life expectancy in the USA, addressing the persistence of significant health inequities by race remains a high priority for public health professionals (Baciu et al., 2017). With funding from the US National Institute of Minority Health and Health Disparities, the Men of Color Health Awareness (MOCHA) project uses a community-based participatory research process to achieve three aims: (i) to refine a minority stress model (MSM) by identifying previously unrecognized factors that contribute to stress and chronic disease health disparities among low-income middle-aged African-American men; (ii) to evaluate the effects of the MOCHA program in reducing stress and the associated secondary health status indicators of hypertension and body mass index in a randomized controlled trial (RCT); and (iii) to determine the relative weight and significance of the various factors incorporated into MOCHA’s MSM in predicting health outcomes.

In seeking to refine and further elaborate an evolving MSM, the research described here lies at the intersection of two major debates in the literature: in public health, issues pertaining to the relationship between the social determinants of health and individual health behaviors (Wilkinson and Marmot, 2003); and in political science, the debate between liberal and conservative positions on matters of personal versus social responsibility (Scheffler, 1992). There is considerable evidence pertaining to the effect of the social determinants of health on bio-physiological measures of stress hormones such as cortisol. Less well understood are the mechanisms mediating the link between social structural factors and biological responses, specifically, the relative significance of different pathways linking social and psychological perceptions of social structural factors to the release of stress hormone (Buchanan, 2003, 2008). This issue, of course, reflects long standing debates about the Macro-Micro link (see, e.g. among many possibilities, Knorr-Cetina and Cicourel, 2015). There is also a robust debate between political liberal and conservative positions on the nature of justice, especially around the issue of individual agency, responsibility, merit and desert (Rawls, 1971; Scheffler, 1992; Kekes, 2006; Steele, 2020). Toward the goal of clarifying and advancing these debates, this paper presents the results of our investigation into the relationship between the social structural factor of economic disadvantage and the socio-cultural and individual-level processes of identity formation, with a specific focus on the role of work, socialization into gender identity, and health. We should point out that all of this research was conducted in the USA, but we hope that it might still stimulate thinking in other parts of the world with high levels of unemployment among people of color, such as, e.g. South Africa and Brazil.

Following Norris (2016, pp. 16–17), we define identity as the ‘set of meanings one holds for oneself as an occupant of a particular role … group or category … or as a unique individual’. Gender identity, more specifically, has been defined as ‘a complex set of characteristics and behaviors prescribed for a particular sex by society and learned through the socialization process’ (Edwards, 2015, p. 1). Many factors, such as demographic characteristics and social and occupational roles, influence the development of a person’s sense of identity. Sociologists currently assert that people do not have one ‘true’ identity fixed and stable throughout life; rather, identities are seen to be dynamic, fluid and corrigible, and a product of interactions at the intersection of different characteristics and roles, such as age, income, race, occupation and other attributes (Bowleg, 2008, 2012, Griffith et al., 2013). Regarding gender identities, current conceptualizations emphasize their social construction and multiplicity of masculinities and femininities, over an essentialist binary structure (Connell and Messerschmidt, 2005). In the analysis that follows, we were interested in the effects of work (or lack thereof) on the participant’s sense of identity at the intersection of being male, low-income, middle-aged African-American.

People draw on various resources—material, relational, and ideational—to shape their identity (Givens et al., 2016). Ideational resources refer to the ideas available in one’s cultural milieu about who one is supposed to be, how one is supposed to act, and what behaviors are valued in a given setting. Stereotypes are an ideational resource that people often use to make sense of a situation and discern meanings about the significance of each other’s actions (Givens et al., 2016). Stereotypes of men may be positive (e.g. breadwinner, protector) or negative (e.g. sexually aggressive, prone to violence). Although the proposition that people inherently seek coherence and integrity over the course of their lifetime has been challenged (Norris, 2016), studies suggest that people’s self-understandings tend to come in sets, or ‘identity constellations’, where one aspect of a person’s identity (e.g. gender) has implications for other aspects (e.g. occupational role; Givens et al., 2016).

Norms prescribing gender-appropriate behaviors are instilled from an early age. Male and female gender roles are frequently normalized by presenting them as a product of biological facts and part of the natural order (Edwards, 2015). Although many men deviate from common stereotypes, pressure to live up to certain expectations nonetheless remains powerful. Generally, because people are taught by society to understand how to conform to certain role expectations, the majority of people tend to accept, often subconsciously, mainstream society’s views about the proper behaviors for each gender (Norris, 2016). Socialization processes result in men experiencing social pressures to uphold gender role norms. The dominant form of masculinity in Western societies includes expressions of independence, competitiveness and stoicism, avoidance of feminine behaviors, provision for one’s family and displays of authority and control (David and Brannon, 1976; Courtenay, 2000; Hong, 2000). The high prevalence of unhealthy behaviors among men has been found to be partially explained by patterns of male gender socialization (Courtenay, 2000; Griffith et al., 2011a). Similarly, differences in learned gender-specific behaviors are thought to be major contributors to many of the health disparities found between men and women (Griffith et al., 2011b, 2012; Griffith, 2015; Hooker et al., 2012).

Coming at these same issues from a different angle, Katerndahl and Parchman (2002) identify two types of ‘identity mismatches’, which have been linked to mental health harms such as declines in self-esteem (Marcussen, 2006). The first mismatch, an ‘aspiration discrepancy’, refers to the difference between who one would like to be and who one actually is. The second mismatch, an ‘obligation discrepancy’, concerns the difference between who one believes one should be and who one actually is. Mismatches between low-income African-American men’s aspirational and obligational senses of identity can generate significant stresses at the sociocultural level.

Based on MOCHA’s evolving MSM, we hypothesized that low-income, middle-aged African-American men draw on distinct socially constructed definitions of black masculinities, which may then generate stresses associated with identity mismatches, which in turn affect their health behaviors and health. Drawing on the above frameworks, we set out to examine how the various social and institutional contexts in which men find themselves ‘elicit different demonstrations of health beliefs and behaviors, and provide different opportunities’ to perform gender in particular ways, including health behaviors (Courtenay, 2000, p. 1388). We wanted to explore the relationship between work and health to identify potential mediating constructs that might serve to flesh out and better explain the relationship between the social determinants of health and health behaviors. We were particularly interested in how (un)employment affects perceptions of gender role identity in low-income, middle-aged African-American men have available to them. In addition to the instrumental consequences of insufficient funds to obtain adequate food, shelter, clothing etc., the analysis that follows examines how lack of employment may also have symbolic implications for the sociocultural processes associated with healthy identity development, i.e. experiencing well-being, high positive self-esteem, and not getting overtaken by self-destructive behaviors (Moody-Adams, 1992–1993).

UNEMPLOYMENT AND AFRICAN-AMERICAN MEN

Precise estimates of the percentage of African-American men who are unemployed are surprisingly difficult to track down. In one of the most extensive studies to date, the political economist Eberstadt (2016, p. 9) notes, ‘the questions are more difficult to answer today than at any time in living memory … because fundamental indicators of our country’s economic outlook are far out of alignment with one another’. It is well recognized among researchers that there are multiple measures of unemployment used in the USA; the most well-known is the Bureau of Labor Statistics ‘U-3’ measure. The U-3 measure is defined as the number of unemployed persons divided by the civilian labor force, but it excludes persons ‘not in the labor force’, defined as ‘those who have been out of work for 27 weeks or more, those who are not looking for work’ and ‘institutionalized’ persons (in prison or school). The official U-3 unemployment rate in the USA in 2018 was 4.3% for the general population, while it was 9.5% for African-American men. Less frequently cited in the press, the ‘U-6’ rate is a wider measure of unemployment, which includes discouraged and ‘marginally attached’ workers (e.g. part-time seasonal workers). Based on the analyses of Eberstadt (2017, p. 3), when one includes discouraged and institutionalized men, ‘By 2015, nearly 22% of US men between the ages of 20 and 65 were not engaged in paid work of any kind’ (Other analysts using different methods have derived roughly similar estimates. Yarrow (2018), e.g. finds, ‘One out of six (16.66%) prime-working-age adult males in the USA is now temporarily unemployed, or “between jobs”, or “looking for work”’.). Eberstadt goes on to state that this is an estimate for the population as a whole, noting that rates of joblessness are significantly higher among the less educated (e.g. men without a high school diploma are twice as likely to be out of work as men who graduated high school), African-Americans, and people with criminal records. Eberstadt concludes, ‘America is now home to an immense army of jobless men no longer even looking for work—more than 7 million alone between the ages of 25 and 55, the traditional prime of working life’ (p. 3). Eberstadt’s conclusions are consistent with William Julius Wilson’s earlier 1996 study, where he found, ‘For the first time in the 20th century most adults in many inner-city ghetto neighborhoods are not working in a typical week’ (p. xiii). As rates of joblessness are compounded by low levels of education, race and criminal records, and as people with these characteristics tend to become segregated into certain urban neighborhoods, people living in such areas routinely observe that a majority of men of color are not engaged in paid wage labor of any kind.

Baker (2016) has assembled an array of evidence that shows how these trends are the result of an economic policy that has redistributed income to top earners over the last four decades, which not only affects unemployment, but also the wages available to the rest of the population. These policies include trade agreements that have eroded the US manufacturing base and sustained attacks on union membership, which have had a significant impact on wages and other kinds of social provision. A macroeconomic policy aimed at securing full employment was the prevailing view from 1944 to 1980, when Coretta Scott King and other civil rights activists championed the cause of full employment (Stein, 2017). In 1978, the goal of full employment was codified in the Humphrey–Hawkins Full Employment Act. Starting in the early 1980s, however, the national policy goal of full employment was gradually abandoned and replaced by the Federal Reserve’s current goal of keeping inflation low, which has had an immense impact on unemployment levels and the prospects for finding decent work. Poor and working-class black men have borne the brunt of these economic redistribution policies. To identify potential sources of stress on minority men’s health, we examined the interaction between structural factors related to the economy and cultural factors pertaining to positive self-esteem and healthy identity development.

In short, the purpose of the research presented here was to uncover and explicate factors mediating the relationships and pathways between the social structure and individual biological responses in order to elaborate and refine an evolving MSM: How does unemployment result in health disparities between low-income African-American men and the dominant white majority? Prior research has provided scant data to flesh out a comprehensive account of potential mediating factors and lingering debates remain on the relative weight of social structural factors versus individual health behaviors. To address these gaps in the literature, we used a Community-Based Participatory Research process to uncover the perceptions of low-income, middle-aged African-American men regarding the causes of health disparities.

METHODS

The MOCHA Moving Forward project is a National Institute of Minority Health and Health Disparities-funded Community-Based Participatory Research investigation. The research is divided into two phases: an 18-month exploratory research phase, and a 3.5-year RCT. The exploratory research phase was designed to flesh out our evolving MSM, by seeking to identify and refine new constructs to further elaborate the distinct components of the model (the significance and potential pathways of the different factors introduced in the model will be tested in the RCT phase of the research). In the exploratory phase, we collected data using three formative research methods: oral histories, digital storytelling and semi-structured individual health interviews. Here we report on the analysis of the individual health interviews.

MOCHA was initiated by community members concerned about glaring health disparities in a mid-sized New England city prior to their collaboration with academic researchers. At MOCHA’s invitation, university researchers were asked to conduct a rigorous evaluation of the MOCHA program to assess its impact on community health. To maintain continuity with its grassroots community-driven origins, we collectively decided to use a Community-Based Participatory Research process to achieve the specific aims listed earlier. This approach has proven to be highly advantageous both for the recruitment of participants and for the purposes of data analysis. Although a more detailed description of the methods of recruitment has been described elsewhere (Graham et al., 2018), in brief, MOCHA has been successful in recruiting participants due to the strong social networks that members of the MOCHA Steering Committee have built over a lifetime of residence and reputation in the community. MOCHA uses both direct and indirect methods for recruitment purposes. Directly, MOCHA men table at large community events (e.g. the Stone Soul Picnic, the Jazz Festival etc.) and at high traffic locations, such as community health centers and social service agencies. Indirectly, MOCHA has a weekly time spot on a popular local radio program, mounted billboards in select neighborhoods and posted flyers at community centers, barber shops and restaurants catering to African-American clientele.

Based on the Specific Aims detailed in the original grant proposal, we planned to interview 40 individuals equally divided into healthy and unhealthy men for the semi-structured individual interviews during the exploratory phase of the research. The sample size was driven by a theoretical sampling strategy aimed at eliciting the respective perceptions of healthy and unhealthy participants to determine if there were any differences between them; a sample size of 20 participants per group was determined as the minimal number of participants recommended as a rule of thumb in qualitative research (Creswell, 2012), within the constraints of funding allocated by the NIH.

In the event, we enrolled 42 low-income African-American men between the ages of 35–65 (mean = 49.4 years old) for face-to-face, semi-structured individual health interviews. The interview protocol focused on the respondents’ perceptions of the causes of health disparities, using a set of five broad open-ended questions. The interview protocol and informed consent procedures were approved by the University of Massachusetts, Amherst, Institutional Review Board prior to initiating data collection.

We used a recursive process to analyze the interviews. Typically, the field interviewers completed two to three interviews each week. After the interviews were transcribed, the MOCHA research team, consisting of two MOCHA Steering Committee members, two faculties and two graduate research assistants, met once a week to review the transcripts, during the open coding stage. Discussions were wide-ranging, from the specifics of a particular phrase by a particular respondent, to reflections on the ‘big picture’ challenges facing the community; thus, we used an iterative method moving back and forth to situate the details in individual responses in the broader context of life for these men in contemporary American society (Miles et al., 2013). As new codes and themes emerged, we re-examined previously reviewed transcripts to look for similar themes and nuanced variations on a theme. Graduate student research assistants helped codify, systematize and re-code the interview transcripts using an emergent coding manual created in NVivo 11; initial raw codes were categorized into different nodes and the tree node function was used to identify interactions between nodes. To corroborate the credibility of identified themes (Denzin and Lincoln, 2000; Patton, 2001), we sought out member-checking feedback from the 10-member MOCHA Steering Committee, and we presented the preliminary results to a group of eight interview participants. The following presents the key themes pertaining to the relationship between unemployment and self-respect/healthy identity development.

RESULTS

To provide a sketch of the participants whose responses are presented below, the interviews were conducted with 42 low-income middle-aged (ages 35–70) African-American men recruited largely from four contiguous neighborhoods with high concentrations of African-American residents. Based on the personal histories of the MOCHA Steering Committee members, special efforts were made to conduct outreach to homeless shelters, halfway houses and men in after-incarceration programs. Consistent with data presented in the Introduction, roughly half of the men interviewed were currently out of work. Almost all of the interviewees had experienced prolonged bouts of unemployment; none had attended college. The results that follow are organized into four themes: the positive aspects of work, both financial and symbolic; and the negative repercussions of not working, both financial (or instrumental) and symbolic in terms of the subjects’ sense of identity and self-respect.

Positive aspects of work

All of the men interviewed appreciated the benefits of a regular full-time job. They also perceived that work is valuable not only financially, as the instrumental means for simple survival, but also symbolically, in terms of their perceived social status, role in the community, self-respect and sense of masculine identity.

Financial/instrumental

Work enables men to fulfill their traditional role as breadwinner for the family: [In working, I am] ‘doing what I need to do to support my family. It’s a job in order for me to be able to supply my family with what they need’. The interviewees also appreciated the instrumental benefits of work for their own health: ‘I do a lot more walking now that I’m working. I walk to and from work’. Another stated:

A manual labor job forces you to walk or work around a warehouse that’s like a mile long, so by the end of your eight-hour shift, you’ve walked at least five to ten miles. Because I’ve had a job like that, where you were walking back and forth, lifting this, lifting that, you’re forced to have some physical activity’. Work is also a major source of social support, which has been strongly associated with positive health benefits: “If I ain’t pulling somebody else up to come to work, then they’re pulling me up. It’s like a buddy-buddy system.

The data show that the significance of working extends beyond this instrumental financial support to affect one’s sense of identity too. One participant noted:

For me, it does both. Basically, it relieves stress when I know I’m doing my job and paying the bills. [But] It also makes me feel on top of things. It makes me feel important. It makes me feel I’m an idol again and all that type of stuff.

Symbol of esteem

According to these men, work ‘makes you feel good as a man’. Another stated, ‘I just wanted to go to work to maintain my family, because that was more important to me’ [emphasis added]. One participant captured the relationship between work and respect well:

Today, I’m a trusted employee that is looked up to and respected on many different levels. I have a beautiful relationship with my boss. What I do, I help people move on their way.

Work helps to build a positive sense of identity and self-esteem by providing access to a number of social benefits, such as discipline, a desire to give back to the community and a feeling of gratitude. One man explicitly noted that the significance of work goes beyond financial support, by providing discipline, which has its own rewards:

Going to work every day takes a lot of discipline, it takes a lot of focus, and you don’t necessarily get paid finances at the end of the day, of course, like you want. But the reward is more in the fact of knowing that you went out, you didn’t break any laws, you didn’t hurt anyone (or yourself), that you went out and you put forth a good day’s work. You might not necessarily get paid at the end of the day, but you get paid just like everybody else, either at the end of the week or either weekly or biweekly.

Work also enables one to contribute to a greater good, and with that, the capacity to rise above personal misfortunes, however temporarily, and do something positive:

Now I am able to make commitments and work for the community. That helps my self-esteem and makes me get out of myself. Getting out of myself is a plus because when I’m into myself, I’m thinking negative things. When I get out of myself and get into the community—the community is doing positive things, therefore, I do positive things. It helps my self-esteem.

Work gives men a sense of gratitude:

I’m grateful that I got this job, I’m grateful for the work I do. I’m able to give back, so I take care of myself carefully and I’m grateful for my health.

To be sure, the participants were well aware that work is not an unqualified good. They perceived its downsides, in particular in terms of stress and confrontations with racism:

It’s to the point where sometimes you could work so hard that you lose yourself in your work and you’re not really there for your family as much. That’s where the stress levels come from, because sometimes you want to be there for your family, but you’re working so hard.

Even when you have a job, people are looking to put you down or get you fired or get you away from doing what you need to do to raise whoever that you need to do. If it happened to be yourself alone, if you get fired or lose your job, then you can’t take care of yourself. It’s a lot of promotions and things that we are denied just because of the color of our skin.

Although work was perceived to be a common source of stress for many, it was the loss or lack of work that carried much greater significance for these men, again, both instrumentally and as a social status indicator.

Negative aspects of absence of work

Instrumental

At the instrumental level, being out of work was the most commonly cited source of stress for these men, leading to depression, a loss of hope, suicidal ideation and anger. The lack of work makes a man feel bad about himself in failing to fulfill his role as a man:

Basically, it’s because everybody’s—they got people, like, seriously depressed because they have desire to do things: ‘I have the desire to take care of my kid, but I can’t take care of my kid because I can’t get a job’. That’s a depressing thing.

I think one of the main points [is] when you see a man that’s sitting at home and not able to do anything—not being able to go to work—nothing—just sit at home, that’s stressful.

The lack of work leads to a loss of hope:

Oh, man, I can’t get a job. Oh, I can’t get that. It’s stressful, but when somebody comes on it, give you, or educate you about [finding work], then they say, “Okay, now I got hope for myself.” But when you can’t find work and don’t have hope, then your life is—it ain’t good.

These men felt stressed about paying bills on an almost daily basis when not working:

We don’t have enough money for our gas, so how am I going to get to work, honey? How am I going to get you to work, get me to work, and get the kids to daycare?

Another man remarked:

What I’m saying is stress, like when you wake up and your car won’t work. Now you’ve got to find a way for your son to get to school every day.

As a result, being out of work damages one’s sense of self-esteem:

They have all kinds of projects and programs that I can get into, right. But it starts with my self-esteem. With no self-esteem, I don’t have initiative to do any of that.

As a final observation, the stress, depression and loss of hope from being out of work leads some to contemplate suicide, or to take out their frustration on others:

Then, the next thing you know, it lead to either suicide, or going home and beating your girl when you know she’s home there, try to provide for you and your kids.

Symbolic harms to sense of identity

In addition to its direct effects on one’s physical and mental health, the absence of work carries symbolic consequences for masculine identity. ‘That [lack of work] makes people feel bad about everything, especially a man. If he’s any type of a man, if he can’t provide for his child in some way, it’s going to hurt him really bad’. The perceived failure to find and hold a job generates the kinds of stresses associated with identity mismatches, discrepancies between both who one wants to be or who one thinks he should be, and who one actually is. Almost every single respondent commented on their desire and perceived obligation to fulfill their role as provider for their family.

More disturbingly, when there are no perceived viable routes to socially approved respectable roles, many low-income men of color at high risk for ill health gradually succumb to assimilating a negative identity, simultaneously drawing on social stereotypes while also serving as a sign of protest against the treatment of African-Americans in the USA today:

Years that I’ve seen, very few black men are working, and that stresses you out. Most black men over there are hustling and call their self, ‘pimp daddy’, and all this.

Now, when you don’t have a job, you sit around, and you gather a lot. If you start to gather a lot, then there’s enough people that’s going to do something. Usually, they’re going to do something to satisfy themselves, or maybe the group got together and said, ‘We really need some money. I don’t have any money. My family can’t eat and whatever’. Now, what do they do? They go look to crime or drugs because they can’t cope. Then, they go get in trouble with crime.

We had to hustle. We had to do what we got to do to make bread. That’s the reason why we get caught up being in jail, because we’re trying to make it, when we should be going to school … We have to hustle on the street and do wrong things.

Over time, chronic unemployment channels, constrains and delimits the social roles available to these men (e.g. provider, breadwinner), generating stresses as their aspirational identity butts up against time-worn social stereotypes. There is a widespread popular belief in America that anyone can find work if they look for it. And therefore, if one is not working, the most plausible explanation must be that he is just not trying hard enough, which is to say, they must be lazy. Even while bearing the brunt of an economy that intentionally uses unemployment to control inflation, these low-income middle-aged African-American men could not escape the stereotype, as they implore other men living in the neighborhood, ‘You can’t just be a lazy person and sit at home’. Some attribute it to a generational shift, although few explicitly tied it to transformations in the modern post-industrial economy:

People are afraid to start from the bottom. They just want something handed to them. They got too uppity in America. They refuse certain jobs, so that’s why you see the Spanish doing all the restaurant jobs and all that, because they’re not afraid to work. They’ll work 16 hours a day. A black man, “I’m not doing that. I’m too good for that. I’d rather hang out all day and bum money.” Friends of mine are not willing to work that 16-hour shift because it’s a whole different generation now. They’re freaking lazy. When our parents grew up, they worked 16 hours a day, man, every day. It was normal. Our generation is different now. Somewhere along the line, we lost track.

As many teenagers get exposed to street gangs and the lure of ‘easy money’, they get habituated to a life of hustling and the idea of seeking socially approved button-down nine-to-five jobs loses its appeal.

That’s because they don’t want to work. They don’t want to get up and work. They’re just relying on the streets always. That’s what they got comfortable with when they were young.

They end up becoming drug dealers to get the fast money because they don’t want to work. They want it here and now.

Now, you’ve got some people that just don’t want to work. They don’t want to do nothing, because they think it should be easy. If they don’t get taught in a household because they don’t want to teach them that is because it starts with the parents or whatever they live in.

A lot of black men – looking at women as the mother, the girlfriend, as the mother – don’t want to work.

Rather than attribute a potential lack of motivation to seek work to inherent racial disposition, a more plausible explanation may lie in the high levels of chronic stress, which is emotionally exhausting, to which these men are exposed, an account that is supported by the universal desire to have a decent job expressed by the participants in this research. Based on the interviews with these 42 low-income, middle-aged African-American men, unemployment evidently affects not only their instrumental/financial capacity to purchase basic essentials, but it also disfigures a positive sense of masculine identity. The ‘identity mismatch’ generates additional stresses, which have been associated with depression in other research.

DISCUSSION

The results presented here show a clear link between problems with the structure of the US economy and deep-seated harms to one’s sense of identity among low-income, middle-aged African-American men. Based on these interview data, it appears that the impacts of the structural factor of unemployment extend well beyond the daily stresses of not being able to pay bills, to the deeper dimensions of corroding one’s sense of self-respect, self-esteem and identity. In the participants’ words, ‘If he’s any type of a man, if he can’t provide for his child in some way, it’s going to hurt him really bad” and “They have all kinds of projects and programs that I can get into, right. But, it starts with my self-esteem. With no self-esteem, I don’t have initiative to do any of that’. The evidence presented here suggests that the sources of stress associated with health disparities among low-income African-American men are complex, operating on mutually reinforcing levels.

Unemployment is unquestionably perceived to be the most significant source of stress in the lives of the men interviewed for this research (to recall, the best estimates available suggest that more than half of the men in neighborhoods where MOCHA is working are out of work; Wilson, 1987; Eberstadt, 2016). As our results show, the inability to find a job often gets expressed in terms of blaming the unemployed for being lazy, rather than pointing to lack of decent jobs produced by a capitalist market economy. In response to these findings, we have introduced two new modules into the MOCHA curriculum on the social determinants of health to help the men see and better understand why it is so difficult for African-American men to find work. Rather than being lazy or it being simply a matter of not trying hard enough, we think a more plausible explanation for the perceived lack of motivation lies in the sense of exhaustion caused by the multitude of chronic stressors to which these men are exposed. As the participants themselves say, however, for many people, accepting personal responsibility is often the first step in changing deleterious patterns of behavior (Steele, 2020). Consistent with the principles of CBPR, we would urge caution in suggesting that the researchers have a ‘true’ and better understanding of the participants’ interests and self-understanding than the subjects themselves.

The issue of getting a decent job in today’s economy is made more difficult by the deprivations of being raised in poverty, starting in early childhood, where young African-American children are being severely disadvantaged, and not provided with the support they need to fully develop the skills and capabilities necessary for gaining decent jobs in a post-industrial economy. As generations of African-Americans have been robbed of whatever prosperity they may have accumulated and would otherwise pass along to their heirs (Coates, 2014), the chronic cumulative impact of unemployment and poverty has generated intense stresses on these men’s sense of identity as men and their perceived role in society. As decent jobs in manufacturing with unionized factory labor have shipped overseas, the wages and benefits of jobs that remain are inadequate and many of the jobs available in central cities today generally require capacities and credentials not possessed by many of the currently unemployed (Solow, 1998). Thus, these results belie the adequacy of a Rawlsian sense of social justice based on providing fair and equal opportunity tout court, raising critical questions about the distribution of capabilities.

Over the past two decades, there has been growing attention to a theory of justice called the capabilities approach. The capabilities approach is most closely associated with the work of Sen (1992, 1999a,b, 2009) and Nussbaum (1990, 1993, 2011). In laying out this approach, Sen has mounted trenchant critiques of the Rawlsian principle of fair equality of opportunity, arguing that such opportunities are cruel fictions when many options are foreclosed or delimited by the effects of poverty, inferior education, racism, disproportionate exposure to environmental toxins and other similar accidents of birth. Instead, Sen argues that the principal concern of justice should be what people are actually able to achieve, a position Sen (2009) calls ‘substantive freedom’. According to Sen (1992, p. 30), capabilities are defined as ‘a person’s ability to do valuable acts and reach valuable states of being’. If people’s abilities are so stunted by existing social conditions that the range of opportunities that they can actually realize is severely restricted, then that society cannot be considered just, no matter how much people may believe that everyone has a fair and equal opportunity to assume any social position.

In the capabilities framework, the most serious concern for justice follows from the fact that the social position into which people are now born provides markedly different levels of support for developing one’s capabilities to participate meaningfully in all aspects of economic, political and social life. The capabilities acquired to achieve socially valued projects, activities and relationships vary dramatically by social position, due to factors well beyond the individual’s control. Thus, the most serious injustice facing the country today is disregard for the deprivations that perpetuate deficits in people’s capabilities. In this view, injustice can be assessed by the extent to which the current policies and practices of the major social institutions in modern society enable certain socially identifiable groups to develop the capabilities that make it possible for them to earn a decent living, to find work to support a family (or other living arrangements), and to engage in socially valuable activities, projects and relationships, whereas others are left without the ability to make something of their lives, which diminishes their self-respect and their ability to garner the respect of their fellow citizens. There is strong evidence that differences in capabilities are manifest by the time children start pre-school, e.g. in significant discrepancies in vocabulary levels (Farkas and Beron, 2004), which brings us to our final point.

On an ethical level, Shelby (2015, 2016) has analyzed and refutes the ethical justification for implementing interventions designed to change individual behaviors in marginalized, low-income African-American communities (through, e.g. workshops on interview skills, job-training programs, writing resumes). He makes a compelling case that the paternalistic imposition of such programs would cause irreparable damage to the self-respect of people so targeted, by implicating them as the locus of blame for the problem. On the contrary, the root cause of black male unemployment is structural: the need for policies that create jobs for all at livable wages.

Limitations

There are a number of important limitations about which we need to caution readers. First, the study was conducted in an urban center located in New England, where people in rural and other parts of the country may have significantly different experiences. Second, there may be significant self-selection biases, both with regards to particular city where the research was conducted and for the individual participants, where the program was initiated by community members themselves and participants volunteer to enroll, suggesting a predisposition to want to change. Third, the study was conducted in the USA, which may limit its replicability and generalizability in other international locations. Finally, with respect to the limits to the generalizability of our study results, we note that this small study is part of a larger research endeavor. We are currently testing the constructs identified here in a larger RCT, where if we find positive results, we plan to seek future funding to replicate and test the intervention in multiple locations.

CONCLUSION

The results of this research show that it is not just material deprivation alone that causes stress, which in turn explains the presence of health disparities, but also how poverty and unemployment buttress social stereotypes that lead to lasting damage in the development of a healthy sense of identity. Previous research has shown that health disparities between Black and white populations persist after controlling for levels of income and education, providing suggestive evidence of the independent effect of racism; our research offers insights into potential pathways that may explain the significant independent effect of racism on health outcomes. In seeking to refine and further elaborate a MSM, the analysis presented here provides further insight into the pathways linking the Social Determinants of Health, social status and health outcomes. A key insight from Marmot and his colleagues shows how, even among the gainfully employed, social status matters. It is not a uniquely black American male problem.

Considerable attention has been paid to Case and Deaton’s (2020) recent book on Deaths of Despair (2020), which focuses on the increases in premature death rates among white middle-aged men to explain the unprecedented decline in overall life expectancy rates in the USA. Although their research raises important questions about macroeconomic policies concerning ‘free trade’, it focuses on the sequelae associated with the 2008 global recession in one particular population cohort, while our research examines the experiences of a distinct population, namely, poor and working class black American men. The findings presented here are representative the effects of prior retrenchments in public sector provision of jobs and services, which has resulted in chronic long-term (often multi-generational) exposure to stress, on the health of the African-American population—effects which are further compounded by the persistence of racism—to account for health disparities. The social structural effects of unemployment are aggravated by social processes of denigration (and at times, open hostility) aimed at the African-American population in the USA, which has gradually become assimilated into deep-seated character traits that define self-identity. Our results indicate that, while full employment and guaranteed family income will go a long ways to alleviating health disparities, concerns about justice, especially those raised by Sen’s capabilities approach, suggest that full employment may not be sufficient. In the dominant white population, wealth accumulates over generations as property and other assets are passed down from one generation to the next. To compensate for past injustices, it is time to open candid and frank discussions about the need for enforcement of anti-discrimination laws, and universal recognition of worker’s rights and the provision of social welfare programs.

Shelby’s critique of individually focused remedial programs, which could be said of the vast bulk of health promotion efforts in the USA, points to the need and significance of grassroots advocacy programs like MOCHA. MOCHA started from within the community and conscientiously strives to respond to voiced community needs. Programs at the local level are well-positioned to work with youth, families and the larger community to increase, strengthen and expand individual-level skills and capabilities, but, as every public health professional knows, it is difficult, if not impossible, to alleviate joblessness at the local level. The challenge then is going from such local individual-level interventions to harnessing the political wherewithal to succeed in changing macro-economic policy. There are a small number of CBPR projects that have succeeded in addressing structural determinants, but they have largely been successful by capitalizing on social policy changes initiated independently of their specific program aims (de Sayu and Sparks, 2017). More broadly, there are significant practical, political and economic constraints that make it virtually impossible to conduct rigorous RCTs that might provide convincing scientific evidence of the health benefits of macroeconomic full employment policies or guaranteed family income (Buchanan and Allegrante, 2007). Mobilizing from within to advocate for programs designed to impart the skills now in demand in the modern economy is essential to foster self-respect in neighborhoods and communities with high levels of unemployment. But there also needs to be concerted, coordinated efforts to link local efforts nationwide in mobilizing communities of color to join with national coalitions, challenge the American myth of free and equal opportunity, and demand macroeconomic policy that benefits those now shut out by the callous disregard for unconscionable levels of unemployment and poverty. One important piece of future research would be to conduct a rigorous evaluation of the effects of guaranteed family income programs on closing the gap in life expectancy and quality of life generated by stress-related chronic disease risk in African-Americans. As a society, we deny true freedom to low-income black men, and the capacity to pursue a healthy life unimpaired by unnecessary and preventable socially generated stressors, when we fail to recognize the fundamental need for jobs at livable wages. This research has shown how broad changes in macroeconomic policy affect the process of individual black male identity formulation, as these policies aggravate the underlying socialization expectations about the role of males as ‘bread winners’ responsible for the sole protection and support of their families and themselves. Our research indicates that broad changes in macroeconomic policy deform processes of individual black male identity formulation, with consequent impacts on health inequities.

FUNDING

The research described in this report was supported by the National Institute of Minority Health and Health Disparities (NIMHD) of the National Institutes of Health under award number 5R01MD010618. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.