Multiple Reasons for Perceived Everyday Discrimination and All-Cause Mortality Risk Among Older Black Adults

Abstract

Background

This study assessed whether reporting multiple reasons for perceived everyday discrimination was associated with an increased risk for all-cause mortality risk among older Black adults.

Methods

This study utilized data from a subsample of older Black adults from the Health and Retirement Study (HRS), a nationally representative panel study of older adults in the United States. Our measure of multiple reasons for perceived everyday discrimination was based on self-reports from the 2006/2008 HRS waves. Respondents’ vital status was obtained from the National Death Index and reports from key household informants (spanning 2006–2019). Cox proportional hazard models, which accounted for covariates linked to mortality, were used to estimate the risk of all-cause mortality.

Results

During the observation period, 563 deaths occurred. Twenty percent of Black adults attributed perceived everyday discrimination to 3 or more sources. In demographic adjusted models, attributing perceived everyday discrimination to 3 or more sources was a statistically significant predictor of all-cause mortality risk (hazard ratio = 1.45; 95% confidence interval = 1.12–1.87). The association remained significant (hazard ratio = 1.49; 95% confidence interval = 1.15–1.93) after further adjustments for health, behavioral, and economic characteristics.

Conclusions

Examining how multiple reasons for perceived everyday discrimination relate to all-cause mortality risk has considerable utility in clarifying the unique contributions of perceived discrimination to mortality risk among older Black adults. Our findings suggest that multiple reasons for perceived everyday discrimination are a particularly salient risk factor for mortality among older Black adults.

Research on the association between perceived discrimination or unfair treatment and health among older Black adults continues to receive a great deal of scholarly attention (1–4). Though this body of research is not without limitations, prior studies provide consistent evidence that a higher frequency of perceived everyday discrimination (eg, day-to-day forms of interpersonal mistreatment) is an important risk factor for hypertension (5), chronic inflammation (6), cumulative biological risk (7), psychiatric disorders (8), depressive symptoms (9), and other health outcomes among older Black adults (10). Given that perceived everyday discrimination is a risk factor for a range of physical health outcomes among older Black adults, it is plausible that perceived everyday discrimination may also predict all-cause mortality among older Black adults.

The idea that perceived discrimination is a risk factor for all-cause mortality risk is consistent with minority stress theory (11,12). Minority stress theory proposes that Black adults are exposed to unique stressors due to their membership in at least one minority group (13). Heightened exposure to stress has physiological consequences, causing the body to release cortisol and overcompensate to achieve homeostasis. Over time, this repeated overactivation of physiological regulatory systems depletes access to resources (14) and increases one’s risk for health conditions (15). Though scientists agree that premature mortality is the ultimate cumulative effect of perceived discrimination (16,17), studies on the link between perceived everyday discrimination and all-cause mortality risk among Black adults are rare and inconclusive. On the one hand, evidence from Barnes et al.’s (18) study of perceived everyday discrimination and all-cause mortality risk reported that a higher frequency of perceived everyday discrimination was associated with a higher relative risk of death among older Black adults across a 5-year period. On the other hand, Dunlay et al. (19) found that a higher frequency of perceived everyday discrimination was negatively associated with all-cause mortality risk among African Americans in the Jackson Heart Study.

At the same time, there is a growing interest in the health-related consequences of multiple reasons for perceived discrimination among Black adults. As noted earlier, advocates of minority stress theory emphasize the collective nature of minority stress (12) and argue that members of disadvantaged social groups experience multiple forms of perceived discrimination. Though Albert et al. (20) found that perceived everyday discrimination attributed to one’s race was unrelated to all-cause mortality risk among respondents from the Black Women’s Health Study, we are not aware of any study that examines how multiple reasons for perceived everyday discrimination relate to all-cause mortality risk among older Black adults.

Our study addresses this gap in scientific knowledge on the psychosocial determinants of health in late life by examining how multiple reasons for perceived everyday discrimination relate to all-cause mortality risk among older Black adults. Based on prior research (21,22), we hypothesize that multiple reasons for perceived everyday discrimination will be a particularly salient risk factor for all-cause mortality risk among older Black adults. To examine this claim, we drew on data from a subsample of older Black adults from a nationally representative sample of adults older than 50 to assess how multiple reasons for perceived everyday mistreatment relate to all-cause mortality.

Data and Sample

Participants were drawn from the Health and Retirement Study (HRS), an ongoing longitudinal panel study representative of US adults aged 50 years and older designed to monitor age-related changes in health and labor force transitions among older adults in the United States. Data collection for HRS commenced in 1992. In 2006, a rotating random half sample of core panel respondents received a self-administered Psychosocial and Lifestyle Questionnaire that included detailed items reflecting psychosocial stressors to complete and return to the University of Michigan. The remaining half sample received the self-administered Psychosocial and Lifestyle Questionnaire in 2008 (23). For the current study, we used a pooled sample of 1 700 non-Latinx Black adults from the HRS that completed either the 2006 or 2008 Leave-Behind Questionnaire and provided complete data on all psychosocial, demographic, health, and socioeconomic measures to examine the relationship between multiple reasons for perceived everyday discrimination and all-cause mortality risk among older Black Americans.

Measures

All-cause mortality

Two methods were used to determine respondents’ vital status. First, study records from the HRS were matched to the National Death Index through 2011. Second, reports of vital status from a household proxy were utilized through 2019. Survival time was computed from birth month to either month of last interview or death month. To gauge the accuracy of our specification of mortality, we compared calculated life expectancy estimates from our mortality file to life expectancy estimates from the National Center of Health Statistics (NCHS). Estimates from our mortality file were remarkably close to those provided to the NCHS. This coincides with past research, which indicates “that mortality ascertainment in the HRS is effectively complete” (24).

Perceived discrimination

HRS respondents completed the abbreviated version of the perceived everyday discrimination scale, which consists of 5 items assessing the frequency of respondents’ experiences of perceived everyday discrimination on a scale ranging from 1 (never) to 6 (almost everyday). Items include the following: (a) “You are treated with less courtesy or respect than other people,” (b) “You receive poorer service than other people at restaurants or stores,” (c) “People act as if they think you are not smart,” (d) “People act as if they are afraid of you,” and (e) “You are threatened or harassed.” This version of the perceived everyday discrimination scale has demonstrated good reliability and validity and is used in studies on health among older Black adults (25,26). Following prior works (25), we reverse-coded the response items, rescaled to zero, and averaged over the number of items to produce a continuous perceived everyday discrimination scale ranging from 0 to 5 (Cronbach’s alpha = 0.80). Higher scores are indicative of more frequent perceived everyday discrimination.

Reasons for perceived everyday discrimination

The HRS allows respondents to attribute perceived everyday discrimination to the following 9 reasons: age, ancestry, appearance, physical disability, race, sex, sexual orientation, weight, and other factors. HRS respondents could endorse as few or as many attributions as they believed were appropriate to their experience(s). For a more detailed breakdown of the sources of discrimination please see the Supplementary Materials. We created a count of the number of attributions HRS respondents offered for experiencing perceived everyday discrimination (range: 0–9). To assess whether all-cause mortality risk varies by multiple reasons for perceived everyday discrimination, we followed past research (21,22) and specified a categorical measure to differentiate Black respondents reporting: (a) no more than one attributed reason for perceived everyday discrimination (reference group), (b) 2 attributed reasons for perceived everyday discrimination, and (c) 3 or more attributed reasons for perceived everyday discrimination. We analyzed additional specifications of this measure, such as a count of the number of reasons for perceived everyday discrimination, and these specifications provided substantively similar results.

Covariates

We account for covariates potentially associated with the multiple reasons for perceived everyday discrimination and all-cause mortality risk. Demographic variables included for the analyses: chronological age, gender (1 = women, 0 = men), region (1 = southern residence, 0 = non-southern residence in the United States), nativity status (1 = born in the United States, 0 = all else), and marital status (1 = currently married, 0 = all else) at baseline. Health conditions were measured using a summary indicator for whether respondents reported a professional diagnosis with any of the following conditions since the last interview (ie, the 2004 or 2006 wave): heart problems, cancer, diabetes, stroke, or lung problems at baseline. Health behaviors include the number of days per week the respondent consumed alcoholic beverages and smoking status (ie, never smoked [reference group], former smoker, and current smoker) at baseline. Economics includes years of education and the log of wealth (ie, total assets–total liabilities) at baseline to reduce the skewness of its distribution.

Statistical Analysis

Given that the proportional hazards assumption was met, Cox proportional hazard models were run to calculate the hazard ratios (HRs) and 95% confidence interval (CI) of all-cause mortality risk among older Black adults in the HRS. Our study implements the following modeling strategy. To estimate mortality risk, we fit models on mortality risk and multiple reasons for perceived everyday discrimination, perceived everyday discrimination, and demographic characteristics (Model 1). Model 2 builds on Model 1 by controlling for health conditions and behaviors. Model 3 builds on Model 2 by controlling for economics. Sampling weights were applied to account for the complex sample design of the HRS. All analyses were estimated using Stata 16 (StataCorp LLC, College Station, TX).

Results

Descriptive statistics for study measures are depicted in the full sample and by mortality status in Table 1. Sixty-one percent of respondents attributed perceived everyday discrimination to no more than one source. Eighteen percent of respondents attributed perceived everyday discrimination to 2 sources, while 20% of respondents attributed perceived everyday discrimination to 3 or more sources. The mean perceived everyday discrimination score was 0.87 (standard deviation [SD]: 0.91). The average age is 65.61 (SD = 9.77). Forty-one percent of older Black adults were men. Ninety-five percent of older Black adults were born in the United States, 60% resided in the South, and 47% were currently married at the time of interview. Older Black adults report an average of 0.55 recent chronic conditions (SD = 0.76). On average, older Black adults reported 11.73 years of education (SD = 3.31), and the mean household wealth (logged) was 9.94 (SD = 1.57) at the baseline interview. Of the 2006/2008 sample of respondents, 563 died.

Table 1.

Descriptive Statistics by Vital Status Among Older Black Adults, 2006/2008 Health and Retirement Study

	Full Sample (N = 1 700)		Alive (N = 1 137)		Deceased (N = 563)
	Mean/%	SD	Mean/%	SD	Mean/%	SD
Perceived discrimination
Multiple reasons for perceived everyday discrimination
No more than one attribution	0.61		0.62		0.60
Two attributed reasons	0.18		0.19		0.18
Three or more attributed reasons	0.20		0.20		0.22
Everyday discrimination (range: 0–5)	0.87	0.91	0.90	0.91	0.79	0.89
Demographics
Age (range: 52–99 years)	65.61	9.77	62.7*	7.6	71.8	1.9
Men	0.41		0.39*		0.46
Women	0.58		0.60*		0.54
Born in the United States	0.95		0.95*		0.97
Southern region of residence	0.60		0.59*		0.62
Currently married	0.47		0.49*		0.42
Health conditions
Number of recent health conditions (range: 0–5)	0.55	0.76	0.44*	1.42	0.76	0.84
Health behaviors
Number of alcoholic beverages consumed per day (range: 0–7)	0.61	1.40	0.68*	0.70	0.47	1.33
Never smoked (reference)	0.41		0.44*		0.35
Former smoker	0.39		0.37*		0.42
Current smoker	0.20		0.19*		0.23
Economics
Years of education (range: 0–17)	11.73	3.31	12.30*	2.95	11.50	3.70
Household wealth (logged; range: 0–13.56)	9.94	1.57	11.01*	1.18	9.65	1.09

*Alive and deceased respondents significantly differ at p < .05.

Differences between alive and deceased respondents are also given in Table 1. Compared to living respondents, on average, decedents were older and more likely to be male, foreign-born, living in the South, and not married. With respect to health and health behaviors, decedents had more chronic conditions and higher smoking rates. Economically speaking, living respondents had more years of education and household wealth compared to deceased respondents.

Table 2 presents HRs from Cox proportional hazard models predicting all-cause mortality among older Black adults. In Model 1, we found that, compared to respondents that reported no more than one attribution for perceived everyday discrimination, attributing perceived everyday discrimination to 3 or more reasons increased the hazard of mortality (HR: 1.45, 95% CI: 1.12–1.87). Models 2 and 3 adjusted for other specific groups of covariates that are often linked to perceived discrimination and/or mortality to assess the robustness of attributing perceived everyday discrimination to 3 or more sources and all-cause mortality risk association. Model 2 added newly diagnosed chronic conditions and health behaviors; however, the substantive results were similar to Model 1. Attributing perceived everyday discrimination to 3 or more reasons was significantly associated with increased mortality risk (HR: 1.46, 95% CI: 1.13–1.89). Economic measures were added in Model 3. Once again, attributing perceived everyday discrimination to 3 or more reasons was significantly associated with an increased hazard of mortality (HR: 1.49, 95% CI: 1.15–1.93).

Table 2.

Results of the Proportional Hazards Regression Analysis of the Association Between Mortality Risk and Multiple Reasons for Perceived Everyday Discrimination Among Older Black Adults in the Health and Retirement Study (n = 1 700)

	Model 1	Model 2	Model 3
Perceived discrimination
Multiple reasons for perceived everyday discrimination
Two attributed reasons for perceived everyday discrimination	1.18 (0.90–1.53)	1.16 (0.89–1.51)	1.21 (0.92–1.59)
Three or more attributed reasons for perceived everyday discrimination	1.45 (1.12–1.87)	1.46 (1.13–1.89)	1.49 (1.15–1.93)
Everyday discrimination	0.94 (0.83–1.07)	0.94 (0.82–1.07)	0.94 (0.82–1.07)
Demographics
Age	0.79 (0.75–0.82)	0.79 (0.75–0.82)	0.78 (0.75–0.82)
Female	0.64 (0.52–0.79)	0.73 (0.60–0.91)	0.74 (0.60–0.92)
Born in the United States	1.32 (0.90–1.94)	1.19 (0.79–1.79)	1.18 (0.78–1.78)
Southern residence	1.23 (1.03–1.48)	1.24 (1.03–1.50)	1.18 (0.98–1.43)
Currently married	0.84 (0.68–1.03)	0.85 (0.69–1.06)	0.90 (0.73–1.12)
Health conditions/statuses
Number of recent chronic conditions		1.43 (1.28–1.59)	1.41 (1.26–1.57)
Health behaviors
Number of alcoholic beverages consumed per day		0.94 (0.86–1.02)	0.95 (0.87–1.03)
Former smoker		1.18 (0.95–1.46)	1.17 (0.95–1.46)
Current smoker		2.23 (1.69–2.95)	2.14 (1.61–2.84)
Economics
Years of education			0.93 (0.87–0.99)
Household wealth (logged)			0.98 (0.95–1.00)

Discussion

Over the past 2 decades, an increasing amount of research has focused on the relationship between perceived discrimination and physical health among Black adults in the United States (1,27,28). Not surprisingly, research on this topic tends to suggest that greater exposure to perceived everyday discrimination is an important risk factor for poorer physical health among older Black adults. Though important, studies on the relationships between perceived everyday discrimination and all-cause mortality risk are both rare and inconclusive (18–20). Additionally, while we are aware of one study that examines how perceived everyday discrimination attributed to one’s race relates to all-cause mortality risk among Black women (20), the question of whether multiple attributions of perceived everyday discrimination influence mortality risk among older Black adults remains unanswered. This study addresses this gap in research on the psychosocial risk factors related to all-cause mortality among older Black adults. Our study suggests that multiple reasons for perceived everyday discrimination are a critical risk factor for all-cause mortality among older Black adults.

Our primary objective was to assess the relationship between the multiple reasons for perceived everyday discrimination and all-cause mortality risk among older Black adults. Reports of multiple reasons for perceived everyday discrimination are critical to assess for this cohort of Black adults, as they belong to at least one socially disadvantaged group and came of age during de facto segregation in the United States (29). Our initial results found support for the claim that multiple reasons for perceived everyday discrimination are a risk factor for all-cause mortality risk among older Black adults, as attributing perceived everyday discrimination to 3 or more reasons was significantly associated with greater mortality risk among older Black adults in demographic adjusted models. Moreover, the HR demonstrating the association between 3 or more attributed reasons for perceived everyday discrimination and all-cause mortality remained essentially unchanged by introducing the number of new chronic conditions, health behaviors, and economics to the models. This suggests that the underlying mechanism linking multiple reasons for perceived everyday discrimination to mortality risk does not operate through health (eg, chronic condition onset) and health behaviors (eg, smoking).

The current study presents 2 main limitations that future research on perceived discrimination and health among Black Americans should address. Primarily, we draw on data from the HRS’s 2006/2008 psychosocial supplement linked to information on vital status for older Black adults. Yet, we do not know how reports of multiple reasons for perceived everyday discrimination vary across the life course. Second, studies on multiple attributed reasons for perceived discrimination and health tend to focus on younger and/or middle-aged adults (30). Though this study underscores the benefits of using an attributional approach to operationalizing perceived discrimination in a way that recognizes the multiple sources of perceived discrimination among older Black adults, future work should assess whether possible variations in multiple reasons for perceived everyday discrimination are differentially associated with all-cause mortality risk among older Black adults. That is, certain combinations may be more deleterious for mortality risk than others. For example, given research linking attributing everyday discrimination to one’s ancestry, physical disability, and weight, these combinations may be especially deadly (31).

At the same time, this study also contributes to ongoing conversations on the health implications of perceived discrimination among older Black adults. To date, prior research on Black adults has overwhelmingly focused on the frequency of perceived everyday discrimination and perceived everyday discrimination based solely on racial self-identification (1). This study draws on minority stress theory to demonstrate how multiple attributions for perceived everyday discrimination influence mortality risk among older Black adults. These findings are consistent with arguments put forth elsewhere regarding the health implications of other “isms” in the lives of Black children and adults (1,22). Moreover, the mixed findings of past research regarding perceived everyday discrimination and all-cause mortality among older Black adults may be due to the lack of explicit attention to the multiple reasons for perceived everyday discrimination (32).

This study demonstrates that attributing perceived everyday discrimination to 3 or more sources is a risk factor for all-cause mortality among older Black adults. Prospective data collection efforts are needed to capture the timing, stressfulness, and multiple attributions for everyday discrimination among Blacks across the life course. Public health and social work practitioners must consider strategies to address the detrimental effects that this measure of stress exposure has on the health of older Black adults.

Funding

This work was supported by Georgia Clinical and Translational Science Alliance (UL1TR002378); Michigan Center for Urban African American Aging Research; SC/UCLA Center on Biodemography and Population Health (P30 AG017625).

Conflict of Interest

None declared.