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The Journals of Gerontology Series B: Psychological Sciences and Social Sciences logoLink to The Journals of Gerontology Series B: Psychological Sciences and Social Sciences
. 2022 May 4;77(11):1990–2005. doi: 10.1093/geronb/gbac068

Discrimination, Racial Identity, and Hypertension Among Black Americans Across Young, Middle, and Older Adulthood

Courtney S Thomas Tobin 1, Ángela Gutiérrez 2,3,✉, Keith C Norris 4, Roland J Thorpe Jr 5
Editor: Jessica Kelley
PMCID: PMC9683505  PMID: 35512278

Abstract

Objectives

Substantial evidence documents the protective role of racial identity—or the meaning and significance that individuals attribute to race—among Black Americans, yet the impact of racial identity on physical health outcomes beyond young adulthood is unclear. To clarify the extent to which racial identity remains influential for physical health across the life course, this study investigated (a) the direct associations between discrimination, racial identity, and hypertension, (b) whether racial identity buffered the negative effects of discrimination, and (c) the extent to which these patterns varied among young (21–35), middle-aged (36–49), and older (>50) Black adults.

Methods

Data from the Nashville Stress and Health Study (N = 627) were used to examine two identity dimensions: “racial centrality” (i.e., importance of Black identity to one’s sense of self) and “closeness to other Black people” (COBP). Modified Poisson models estimated relationships between racial identity, discrimination, and hypertension. Interactions determined whether racial identity moderated the discrimination–hypertension association within and across age groups.

Results

High centrality and moderate COBP were directly linked to elevated hypertension odds among young adults, but lower odds among older adults; racial identity was not directly associated with hypertension among middle-aged adults. Results also indicated that racial identity conditioned the discrimination–hypertension relationship in distinct ways across age groups.

Discussion

Findings underscore the significance of racial identity as sources of both psychosocial vulnerability and resilience for minority aging. Clinicians and public health professionals should consider racial identity beyond young adulthood to promote healthy aging via hypertension management among Black Americans.

Keywords: Closeness to other Black people, Discrimination, Hypertension, Racial centrality, Racial identity

Hypertension contributes to substantial racial disparities in cardiovascular disease and mortality (Howard et al., 2018). Black Americans experience a greater prevalence and earlier onset of uncontrolled hypertension than White Americans across the life course (Cutler et al., 2008; Howard et al., 2018; Thorpe et al., 2014). Consequently, reducing hypertension is critical for reducing premature morbidity and mortality among Black Americans. While research has linked low socioeconomic status (SES) and heightened exposure to social stressors (e.g., discrimination) to Black Americans’ high rates of hypertension (Spruill et al., 2019; Williams et al., 2016), fewer studies have assessed protective factors that may reduce this risk (Bell et al., 2012; Cozier et al., 2018; Levin & Vanderpool, 1989). To ameliorate disparities and promote healthy aging, evaluating the risk and protective processes contributing to hypertension among Black Americans across stages of adulthood is needed.

Discrimination and Hypertension

Prior research identifies discrimination as a psychosocial risk factor contributing to heightened hypertension risk among Black Americans. Racial discrimination encompasses perceived unfair treatment due to racial bias and has been evaluated within a stress and coping framework (Brondolo et al., 2009). The biopsychosocial model of Clark et al. (1999) emphasizes discrimination as a stressor that triggers a host of psychological and physiological stress responses, including hypertension, among Black Americans.

Although research demonstrates a significant association between discrimination and blood pressure among this population, findings are mixed (Krieger, 1990; Lebrón et al., 2020; Lewis et al., 2009; Taylor et al., 2017). Studies found that discrimination contributed to elevated blood pressure among Black Americans (Din-Dzietham et al., 2004). Others observed elevated blood pressure among Black Americans who reported no discrimination or those who reported substantial instances of discrimination (Krieger, 1990; Krieger & Sidney, 1996). By contrast, some showed that discrimination was significantly associated with increasing systolic but not diastolic blood pressure (Lewis et al., 2009; Ryan et al., 2006), while other scholars reported null findings (Barksdale et al., 2009; Peters, 2004; Taylor et al., 2017). More recently, some observed that the association between discrimination and ambulatory blood pressure was amplified among older Black Americans (Beatty Moody et al., 2016), but others reported no significant link between discrimination and hypertension among older Black adults (Nguyen et al., 2021). Such mixed study findings underscore the need to clarify the impact of discrimination on hypertension across adulthood.

Prior research on discrimination and hypertension or blood pressure has primarily focused on adolescents or young to middle-aged adults, while others simply controlled for age (Clark, 2006; Krieger, 1990; Roberts et al., 2008; Ryan et al., 2006). To the best of our knowledge, only one study has investigated the discrimination–blood pressure association among older Black Americans (Lewis et al., 2009), and none have assessed the discrimination–hypertension association across age groups. Because hypertension risk increases with age, simply controlling for age or omitting studies among older adults may obscure the discrimination–hypertension relationship across the life course. This points to the need to evaluate the role of psychosocial coping processes that may mitigate this relationship (Cuffee et al., 2012; Michaels et al., 2019).

Black Racial Identity

The degree to which stressors trigger a physiological stress response varies with individuals’ coping responses (Clark et al., 1999; Turner, 2013). Yet, consideration of coping processes that diminish the adverse health consequences of discrimination has been relatively limited. The biopsychosocial model of Clark et al. (1999) emphasizes the critical role of racism-specific coping responses in shaping the impact of discrimination on health. More recently, Brondolo et al. (2009) highlighted the ways that racial identity may serve as a coping strategy for Black Americans to cope with discrimination.

Racial identity refers to a sense of collective identity based on the perception of sharing a common racial heritage with a particular group; it often serves as an underlying set of schemas that help individuals make sense of and respond to experiences as members of their racial group (Helms, 1990; Brondolo et al., 2009). Two distinct dimensions of racial identity linked to health include “racial centrality” and “closeness to other Blacks” (hereafter referred to as closeness to other Black people [COBP]).” While racial centrality refers to a normative self-definition in terms of race or the importance of Black identity to one’s sense of self (Bediako et al., 2007), COBP refers to the degree to which individuals feel connected to, understood by, or share common experiences and/or ideologies with other Black people (Ida & Mizell, 2012).

One’s racial identity may vary in the extent to which they identify with or feel connected to their ascribed ethnic group (Phinney, 1996), and its significance often increases with age (Broman et al., 1988; Demo & Hughes, 1990). Racial identity also varies based on social, psychological, and environmental factors (Seaton et al., 2012; Spencer, 2005). Experiencing racial discrimination may be particularly influential in shaping racial identity, as these situations may prompt individuals to reflect on the significance and meaning of race in their lives (Seaton et al., 2012; Sellers & Shelton, 2003). Racial identity may also influence individuals’ perceptions of and experiences with discrimination, as identity provides a worldview by which to interpret and respond to diverse experiences, including racial discrimination (Sellers & Shelton, 2003). Nevertheless, racial identity scholarship has typically focused on young adult populations (Yip et al., 2006), with less consideration of racial identity (Demo & Hughes, 1990; Smith & Thornton, 1993; Thornton et al., 1997) and its health implications among older individuals (Hughes et al., 2015; Thomas Tobin et al., 2021; Thompson et al., 2002). As such, our understanding of racial identity among middle-aged and older Black Americans remains limited.

Racial Identity and Health

In addition to the biopsychosocial model of Clark et al. (1999), the stress process model (Pearlin et al., 1981) provides strong theoretical grounds to investigate the role of racial identity in the discrimination–hypertension relationship. A central tenet of the stress process model is that health disparities arise from differences in exposure to social stressors like discrimination. It also specifies the pathways through which psychosocial resources, like racial identity, may both mediate and moderate the stress–health association (Turner, 2013). Research has documented the direct and indirect effects of racial identity on mental health (Caldwell et al., 2002; Donovan et al., 2013; Durkee & Williams, 2015). However, few studies have assessed the mechanisms linking racial identity to physical health (Dagadu & Christie-Mizell, 2014; Hughes et al., 2015; Neblett & Carter, 2012; Williams et al., 1999).

Among these, some studies suggest a direct association between racial identity and physical health. For instance, COBP was associated with a greater probability of heart trouble among Black Americans (Dagadu & Christie-Mizell, 2014), and those who held negative beliefs about Black people had a greater risk of cardiovascular disease (Chae et al., 2010). Another study found that Black adults, whose racial identity was characterized by an intense focus on Black Americans as a group and a general rejection of White culture, experienced elevated blood pressure (Thompson et al., 2002). Thus, findings on the racial identity–physical health relationship are mixed.

Some suggest that Black racial identity may be psychologically taxing and directly undermine physical health by triggering the body’s stress response (Dagadu & Christie-Mizell, 2014). Contrarily, the limited research assessing the indirect effects of racial identity on physical health suggests that racial identity may also be protective, through racial identity’s buffering role against discrimination (Neblett & Carter, 2012; Williams et al., 1999). When encountering discrimination, individuals with a racial identity characterized by positive Black American views had the lowest blood pressure (Neblett & Carter, 2012). Moreover, Williams et al. (1999) found that racial identity buffered the effect of discrimination on chronic health problems (Williams et al., 1999). These findings underscore the ways that racial identity shapes physical health. Yet, because racial identity is often overlooked in research, especially among older Black Americans, its potential as a buffer against the impact of discrimination on hypertension beyond young adulthood remains poorly understood.

The Present Study

The purpose of this study was to clarify the relationships between discrimination, racial identity, and hypertension among Black Americans across young, middle, and older adulthood. Guided by our conceptual model in Figure 1, we assess:

Figure 1.

Figure 1.

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Conceptual model of the pathways linking discrimination, racial identity, and hypertension among Black Americans across adulthood.

Notes: (A), (B), and (C) refer to the relationships considered in the present study. Specifically, path (A) refers to the direct association between discrimination and hypertension; path (B) examines the direct linkages between racial identity and hypertension; and path (C) assesses whether racial identity moderates or conditions the discrimination–hypertension association. Although prior studies suggest there is a significant direct association between discrimination and racial identity and that racial identity may mediate the relationship between discrimination and hypertension, these linkages were not examined in the present analysis.

  1. Age patterns in discrimination and two dimensions of Black identity: racial centrality and COBP.

  2. The direct and indirect associations between discrimination, racial identity, and hypertension among Black Americans.

  3. Whether the direct and interactive associations between discrimination, racial identity, and hypertension vary significantly by age.

These objectives extend prior research. Specifically, few studies have assessed discrimination, as only two examined discrimination and physical health outcomes among older Black Americans and none considered hypertension (Lewis, 2009, 2010). Moreover, most studies among older Black Americans assess only one dimension of discrimination (Lewis, 2010). Similarly, there are few studies on racial identity among older adults (Demo & Hughes, 1990; Smith & Thornton, 1993; Thornton et al., 1997) and fewer that focus on racial identity across stages of adulthood (Yip et al., 2006). Given that societal factors (e.g., the Civil Rights Movement, federal policies) influence identity development, however, it is critical to assess age patterns in racial identity. By evaluating exposure to both major and everyday discrimination and considering two distinct dimensions of racial identity (i.e., racial centrality and COBP) among young, middle-aged, and older adults, this study aims to clarify the ways that racially relevant experiences contribute to disparities in physical health across the life course, while assessing the buffering role of racial identity in the discrimination–hypertension association. Given their substantial burden of high hypertension, identifying the psychosocial risks and resources shaping hypertension among middle-aged and older Black Americans is a public health priority.

Method

Sample

The Nashville Stress and Health Study (NSAHS) is a population-based sample of Black and White adults ages 22–69 from Nashville and surrounding areas within Davidson County, Tennessee. A random sample was obtained using a multistage, stratified sampling approach. Black households were oversampled; sampling weights allowed for generalizability to the county population. Between 2011 and 2014, 1,252 respondents provided information about their personal and family backgrounds, stress and coping experiences, and health histories during 3-hour computer-assisted interviews with race-concordant interviewers. Clinicians visited respondents’ homes the following day to collect 12-hour urine samples and blood samples, blood pressure, anthropometric measurements, and document prescription medication usage. Less than 1% of the total sample was missing sociodemographic or biological data due to difficulty in drawing sufficient blood, specimen contamination, or clinician visit refusal. The NSAHS and all study procedures were approved by the Vanderbilt University Institutional Review Board (Brown et al., 2006). The present analyses included all 627 Black Americans in the sample.

Measures

Hypertension

Hypertension was based on the report of physician diagnosis. A binary variable was created to identify whether the participants reported physician-diagnosed hypertension (1 = yes, 0 = no).

Discrimination

Two dimensions of discrimination were considered. Major discrimination (Williams et al., 1997) was a count assessing lifetime exposure to seven major events of unfair treatment across domains such as employment, housing, education, and financial institutions (e.g., “been unfairly fired or denied a promotion,” “for unfair reasons, not been hired for a job”). Everyday discrimination (Williams et al., 1997; Cronbach’s alpha = 0.84) measured exposure to chronic, day-to-day experiences of unfair treatment (e.g., “treated with less courtesy than other people” or “people act as if they are afraid of you). Responses ranged from 0 (never) to 4 (almost always); scores were generated from the sum of the items. We created a discrimination index to examine the collective impact of these dimensions, based on the standardized average of both discrimination scores. Higher scores indicate greater exposure to discrimination stress.

Racial identity

Consistent with previous studies (Thomas Tobin et al., 2021), racial centrality was measured with four items (α = 0.75), including “You have a strong sense of yourself as a member of your racial/ethnic group.” COBP was measured with six items (α = 0.78) that included, “Your values, attitudes, and behaviors are shared by most members of your racial/ethnic group.” Responses for these dimensions ranged from 1 (strongly disagree) to 7 (strongly agree). Items were summed; higher values indicate a greater sense of a central Black identity and feelings of COBP, respectively.

Covariates

To assess differences across stages of adulthood, respondents’ age was categorized: (0) young adults (22–35 years old); (1) middle-aged adults (36–49 years old); (2) older adults (>50 years old). Gender was dichotomized: (0) men and (1) women. Marital status was coded as (0) married, (1) never married, and (2) other (e.g., widowed, separated, or divorced). Respondents’ SES was measured using a standardized index of years of completed education, annual household income, and level of occupational prestige determined by the 2000 Nam–Powers–Boyd occupational scores (Nam & Boyd, 2004). SES scores were calculated by standardizing and summing the three dimensions, then dividing by the number of dimensions on which data were available (Erving & Thomas, 2018; Thomas Tobin & Moody, 2021). Given its documented associations with discrimination and racial identity (Sellers & Shelton, 2003), we also assessed past-month depressive symptoms using the 20-item Center for Epidemiologic Studies Depression (CES-D) scale (Radloff, 1977; Cronbach’s alpha = 0.89). Items included, “could not shake off the blues” and “had crying spells.” Response options ranged from (0) not at all to (3) almost all the time. Items were summed; higher values indicate greater depressive symptomatology.

Analytic Strategy

We estimated weighted means and frequency distributions for the full sample and separately by age; t tests and X2 tests determined significant differences across adulthood. Because the prevalence of hypertension was greater than 10%, modified Poisson regression models were specified to examine the associations between discrimination, racial identity, and hypertension (McNutt et al., 2003; Thorpe et al., 2017; Zou, 2004). Racial identity dimensions were examined in separate models because they were highly correlated (r = 0.52); racial centrality models are presented in Table 2 and COBP models in Table 3. We utilized the following modeling strategy: Model 1 assessed the impact of age and discrimination on hypertension; racial identity was added in Model 2, and Model 3 included the interaction between discrimination and age. Model 4 tested the interaction between racial identity and age, while an interaction term between discrimination and racial identity was included in Model 5. Model 6 tested a three-way interaction between discrimination, racial identity, and age. Wald tests assessed overall significance of each interaction term. Significant interactions were graphed and depicted in Figure 2. All models controlled for covariates described previously. p Values less than .05 were considered statistically significant. All analyses were performed using STATA 17.0.

Table 2.

Associations Between Age, Discrimination, Racial Centrality, and Hypertension Among Black Americans Nashville Stress and Health Study (2011–2014; N = 627)

Model 1 Model 2 Model 3 Model 4 Model 5 Model 6
OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)
Age
 22–35 years old (Ref.) 1.00 1.00 1.00 1.00 1.00 1.00
 36–49 years old 1.19 (0.77, 1.85) 1.15 (0.74, 1.78) 1.24 (0.76, 2.01) 2.47 (0.83, 7.32) 1.17 (0.75, 1.82) 7.41** (1.58, 34.80)
 50–69 years old 1.97*** (1.71, 2.75) 1.93*** (1.39, 2.68) 2.25*** (1.56, 3.23) 3.58** (1.27, 10.11) 1.95*** (1.41, 2.71) 10.55*** (2.54, 43.81)
Discrimination 1.06* (1.01, 1.11) 1.05* (1.01, 1.11) 1.21*** (1.11, 1.32) 1.05 (0.99, 1.11) 0.97 (0.78, 1.20) 1.95*** (1.35, 2.82)
Racial centrality
 Low centrality (Ref.) 1.00 1.00 1.00 1.00 1.00
 Moderate centrality 1.30 (0.65, 2.60) 1.30 (0.67, 2.53) 2.13 (0.50, 9.09) 1.26 (0.70, 2.27) 6.00* (1.07, 33.51)
 High centrality 1.41 (0.79, 2.51) 1.37 (0.83, 2.28) 3.00 (0.71, 12.60) 1.30 (0.82, 2.07) 6.71* (1.26, 35.75)
Discrimination × Age
 Discrimination × 22–35 years old (Ref.) 1.00
 Discrimination × 36–49 years old 0.95 (0.85, 1.06)
 Discrimination × 50–69 years old 0.80*** (0.72, 0.88)
Racial centrality × Age
 Low centrality × 22–35 years old (Ref.) 1.00
 Moderate centrality × 36–49 years old 0.37 (0.10, 1.33)
 Moderate centrality × 50–69 years old 0.64 (0.21, 1.99)
 High centrality × 36–49 years old 0.39 (0.10, 1.51)
 High centrality × 50–69 years old 0.39 (0.12, 1.24)
Discrimination × Racial centrality
 Discrimination × Low centrality (Ref.) 1.00
 Discrimination × Moderate centrality 1.03 (0.81, 1.30)
 Discrimination × High centrality 1.13 (0.92, 1.39)
Discrimination × Racial centrality × Age
 Discrimination × Low centrality × 22–35 years old (Ref.) 1.00
 Discrimination × Moderate centrality × 36–49 years old 2.90** (1.42, 5.88)
 Discrimination × Moderate centrality × 50–69 years old 2.31** (1.30, 4.10)
 Discrimination × High centrality × 36–49 years old 2.80** (1.40, 5.59)
 Discrimination × High centrality × 50–69 years old 1.78* (1.03, 3.06)
Intercept 0.26*** (0.18, 0.39) 0.20*** (0.10, 0.43) 0.19*** (0.09, 0.38) 0.12** (0.03, 0.47) 0.21*** (0.11, 0.41) 0.04*** (0.01, 0.25)
Wald Testa F(2, 256) = 9.27*** F(4, 254) = 5.36*** F(2, 256) = 3.19* F(4, 254) = 4.16**
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Notes: Odds ratios (ORs) and 95% confidence intervals (CIs) from Modified Poission models are presented. Gender, marital status, socioeconomic status, and depressive symptoms are included as covariates in all models. Ref. = reference category.

aWald tests were used to indicate the overall significance of each interaction term.

*p < .05; **p < .01; ***p < .001 (two-tailed tests).

Table 3.

Associations Between Age, Discrimination, Closeness to Other Black People, and Hypertension Among Black Americans Nashville Stress and Health Study (2011–2014; N = 627)

Model 1 Model 2 Model 3 Model 4 Model 5 Model 6
OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)
Age
22–35 years old (Ref.) 1.00 1.00 1.00 1.00 1.00 1.00
36–49 years old 1.19 (0.77, 1.85) 1.17 (0.75, 1.82) 1.25 (0.76, 2.07) 1.57 (0.79, 3.10) 1.17 (0.75, 1.83) 2.50* (1.08, 5.75)
50–69 years old 1.97*** (1.41, 2.75) 1.90** (1.28, 2.83) 2.21*** (1.44, 3.37) 3.82*** (1.77, 8.26) 1.90** (1.28, 2.83) 0.59** (0.39, 0.89)
Discrimination 1.06* (1.01, 1.11) 1.05 (0.99, 1.11) 1.21*** (1.11, 1.32) 1.05 (0.99, 1.11) 1.04 (0.94, 1.16) 1.65** (1.10, 2.47)
Closeness to other Black people (COBP)
 Low COBP (Ref.) 1.00 1.00 1.00 1.00 1.00
 Moderate COBP 1.23 (0.89, 1.71) 1.22 (0.88, 1.70) 2.87* (1.10, 7.50) 1.23 (0.89, 1.69) 4.08** (1.37, 12.16)
 High COBP 1.20 (0.83, 1.75) 1.22 (0.84, 1.76) 0.98 (0.24, 4.01) 1.20 (0.84, 1.71) 1.38 (0.31, 6.10)
Discrimination × Age
Discrimination × 22–35 years old (Ref.) 1.00
Discrimination × 36–49 years old 0.95 (0.83, 1.08)
Discrimination × 50–69 years old 0.79*** (0.71, 0.88)
COBP × Age
 Low COBP × 22–35 years old (Ref.) 1.00
 Moderate COBP × 36–49 years old 0.49 (0.19, 1.28)
 Moderate COBP × 50–69 years old 0.24* (0.06, 0.86)
 High COBP × 36–49 years old 1.57 (0.38, 6.38)
 High COBP × 50–69 years old 0.96 (0.23, 4.01)
Discrimination × COBP
 Discrimination × Low COBP (Ref.) 1.00
 Discrimination × Moderate COBP 1.01 (0.91, 1.12)
 Discrimination × High COBP 1.01 (0.87, 1.17)
Discrimination × COBP × Age
Discrimination × Low COBP × 22–35 years old (Ref.) 1.00
Discrimination × Moderate COBP × 36–49 years old 0.47 (0.81, 2.68)
Discrimination × Moderate COBP × 50–69 years old 1.28 (0.82, 1.98)
Discrimination × High COBP × 36–49 years old 3.56*** (1.77, 7.16)
Discrimination × High COBP × 50–69 years old 3.04** (1.47, 6.30)
Intercept 0.26*** (0.18, 0.39) 0.23*** (0.16, 0.34) 0.21*** (0.014, 0.32) 0.15*** (0.07, 0.33) 0.23*** (0.16, 0.34) 0.09*** (0.04, 0.23)
Wald Testa F(2, 256) = 9.42*** F(4, 254) = 1.97 F(2, 256) = 0.02 F(4, 254) = 3.44**
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Notes: Odds ratios (ORs) and 95% confidence intervals (CIs) from Modified Poission models are presented. Gender, marital status, socioeconomic status, and depressive symptoms are included as covariates in all models. Ref. = reference category.

aWald tests were used to indicate the overall significance of each interaction term.

*p < .05; **p < .01; ***p < .001 (two-tailed tests).

Figure 2.

Figure 2.

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The moderating role of racial identity in the association between discrimination and varies significantly among young, middle-aged, and older Black Americans.

Notes: Nashville Stress and Health Study (N = 627); results from significant (p < .05) three-way interactions between discrimination, racial, identity dimensions, gender, marital status, socioeconomic status, and depressive symptoms were also included as covariates in all models.

Results

Sample characteristics are shown in Table 1. Of the 627 respondents, nearly half had hypertension. Most reported relatively low exposure to discrimination (mean [M] = 0.50, standard deviation [SD] = 2.38) and endorsed high racial centrality (50.25%) and moderate COBP (37.47%).

Table 1.

Sample Characteristics of Black Americans by Age, Nashville Stress and Health Study (2011–2014)

All (ages 22–69; N = 627) Young adults (ages 22–35; n = 146) Middle-aged adults (ages 36–49; n = 208) Older adults (ages 50–69; n = 273) p Valuea
M or % (SD) (Range) M or % (SD) M or % (SD) M or % (SD)
Hypertension 47.13 31.68 39.27 67.83 <.01
Discriminationb 0.50 (2.38) (−2.76–7.12) 0.69 (1.86) 0.47 (2.28) 0.35 (2.89) .27
Racial centrality
 Low centrality (Ref.) 19.46 24.06 15.60 18.84 <.01
 Moderate centrality 30.28 41.87 26.69 23.24
 High centrality 50.25 34.07 57.72 57.92
Closeness to other Black people (COBP)
 Low COBP (Ref.) 36.68 46.92 36.18 28.07 <.01
 Moderate COBP 37.47 38.37 42.46 32.33
 High COBP 25.85 14.71 21.36 39.71
Gender
 Men (Ref.) 45.10 42.16 48.38 44.76 .67
 Women 54.90 57.84 51.62 55.24
Socioeconomic status (SES)b −0.47 (0.97) (−2.93–1.68) −0.30 (0.78) −0.53 (1.02) −0.58 (1.05) <.001
Marital status
 Married (Ref.) 35.29 26.98 39.29 39.06 <.001
 Never married 39.18 67.83 37.30 15.59
 Other 25.54 5.19 23.41 45.46
Depressive symptoms 14.33 (12.58) (0–47) 16.55 (10.16) 14.47 (13.67) 12.24 (12.89) <.001
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Notes: Weighted means, standard deviations (SD), and ranges are presented for continuous variables; weighted percentages are presented for categorical variables. Ref. = reference category.

a“Young Adults” is the reference category.

bStandardized variable.

Examining characteristics by age groups revealed that middle-aged (39.27%) and older adults (67.83%) were more likely to have hypertension than young adults (31.68%, p < .01). Exposure to discrimination was similar across age groups. Racial identity varied significantly with age. More middle-aged (57.72%) and older adults (57.92%) endorsed high racial centrality than young adults (34.07%, p < .01). More young adults (46.92%) indicated low COBP, relative to middle-aged and older adults, who were more likely to endorse moderate COBP (42.46%) and high COBP (32.71%), respectively.

Middle-aged and older adults reported significantly lower SES (p < .001) and depressive symptoms scores (p < .001) and were more likely to be married (p < .001) relative to young adults.

Discrimination, Racial Centrality, and Hypertension

The associations between discrimination, racial centrality, and hypertension are presented in Table 2. Model 1 shows a significant positive relationship between discrimination and hypertension, controlling for age (odds ratio [OR] = 1.06, 95% confidence interval [CI] = 1.01–1.11, p < .05). There was no direct association between racial centrality and hypertension in Model 2. In Model 3, there was a significant interaction between discrimination and age (F = 9.27, p < .001), indicating that the impact of discrimination on hypertension varied across age groups. Specifically, increased exposure to discrimination was associated with greater odds of hypertension for young and middle-aged adults; there was no significant link between discrimination and hypertension for older adults. Model 4 shows a significant interaction between racial centrality and age (F = 5.36, p < .001), such that high centrality was associated with elevated odds of hypertension for young adults but diminished hypertension odds for older adults. Older adults endorsing moderate centrality had the highest odds of hypertension; racial centrality was unrelated to hypertension for middle-aged adults.

Whether racial centrality buffered the impact of discrimination on hypertension for all ages was considered in Model 5. A significant interaction term (F = 3.19, p < .05) indicated that the odds of hypertension increased with greater exposure to discrimination for individuals with high racial centrality. However, additional nuances were revealed in Model 6, which showed a significant three-way interaction between discrimination, racial centrality, and age (F = 4.16, p < .05). Figure 2 illustrates these patterns, showing that racial centrality moderates the discrimination-hypertension association in distinct ways across age groups. Among young adults (Figure 2A), greater discrimination exposure confers significantly greater odds of hypertension among individuals endorsing low centrality relative to those endorsing moderate or high centrality. Among middle-aged adults (Figure 2B), individuals with low racial centrality experience elevated hypertension odds at baseline, but diminished odds as discrimination exposure increases. In contrast, middle-aged adults with moderate or high racial centrality had lower hypertension odds at baseline with increased odds of hypertension at higher levels of discrimination exposure. Among older adults (Figure 2C), there were no significant differences in the impact of discrimination on hypertension, as discrimination was unrelated to hypertension regardless of racial centrality levels for this group.

Discrimination, COBP, and Hypertension

Table 3 shows the relationships between discrimination, COBP, and hypertension. There was a significant association between discrimination and hypertension (Model 1, p < .05) that also varied by age (Model 3; F = 9.42, p < .001). While there was no direct COBP–hypertension link in Model 2, Model 4 indicates that this association varies significantly across age groups. Specifically, COBP has a distinct impact among older adults (OR = 0.24, 95% CI = 0.06–0.86, p < .05), such that older adults with moderate COBP experienced significantly lower odds of hypertension than their young adult counterparts; COBP was unrelated to hypertension for middle-aged adults.

While Model 5 suggests that COBP did not moderate the impact of discrimination on hypertension, Model 6, which tested a three-way interaction between discrimination, COBP, and age, indicates that this buffering effect in fact varied across age groups (F = 3.44, p < .01). As shown in Figure 2A, the odds of hypertension increased significantly in the face of greater discrimination exposure among young adults with low and moderate COBP. Young adults with high COBP experienced significantly lower odds of hypertension in comparison. By contrast, there were no significant differences in the discrimination–hypertension associations among middle-aged or older adults, indicating that COBP did not buffer the impact of discrimination among these groups.

Discussion

The disproportionately high prevalence of hypertension among Black Americans across adulthood underscores the need to identify psychosocial risk and protective factors hypertension. Given limited research on racial identity beyond young adulthood, as well as its role in shaping physical health, this study investigated the pathways linking discrimination, racial identity, and hypertension among young, middle-aged, and older Black adults. We found racial identity shapes hypertension both directly and indirectly; these associations are age-specific and vary across racial identity dimensions. We advance prior research by demonstrating the complex ways that psychosocial risk and protective factors work both independently and synergistically to shape physical health for Black Americans across adulthood. We discuss several notable findings below.

Age Patterns in Discrimination and Racial Identity

Given the significance of discrimination as a psychosocial stressor commonly faced by Black Americans, and its potential contribution to elevated hypertension rates among this group, we first assessed the distribution of discrimination exposure across stages of adulthood. Findings revealed similar exposure levels across age groups, which is surprising considering the distinct structural and interpersonal experiences of young, middle-aged, and older Black Americans. For instance, the Civil Rights Movement, when federal and corporate policies explicitly normalized structural discrimination (Churchwell et al., 2020), influenced the social context and shaped the experiences faced by Black Americans who lived during this period, in ways that were quite different than that experienced by middle-aged and younger peers (Thomas Tobin et al., 2020). Nevertheless, inequitable social structures support the production and perpetuation of racism across the life course, even while racism-related experiences change over time (Breheny et al., 2021). Thus, while the quantity of reported discrimination exposures is consistent across these groups, the qualitative nature of these exposures may vary.

The distinct influence of discrimination in the lives of Black Americans across adulthood may contribute to observed age patterns in racial identity, the development of which has been linked to individuals’ experiences of racial discrimination (Seaton et al., 2012; Sellers & Shelton, 2003). While previous studies have primarily assessed racial identity among young adults, our findings indicate higher levels of both racial identity dimensions among middle-aged and older adults, relative to young adults, extends prior research that racial identity increases with age (Broman et al., 1988; Demo & Hughes, 1990).

Associations Between Discrimination, Racial Identity, and Hypertension

Our findings reinforce important nuances of the direct and indirect associations between discrimination, racial identity, and hypertension across adulthood.

Young adults

Although younger individuals tend to face lower hypertension risk relative to older individuals, findings highlight several key risk and protective factors among this group. For example, discrimination and both racial identity dimensions were directly linked to hypertension among young adults, bolstering prior research showing that discrimination undermines physical health (Williams et al., 1999) and contributes to increased hypertension risk among young Black adults. However, we found young adults who felt being Black was a highly central part of their self-concept faced an increased risk of hypertension, while young adults who reported feeling only moderately close to other Black people were also more likely to be hypertensive compared to those reporting either low and high COBP.

Though consistent with some previous studies (e.g., Dagadu & Christie-Mizell, 2014), these patterns were somewhat unexpected because prior research has often emphasized the positive influence of racial identity (Brondolo et al., 2009; Clark et al., 1999). Our findings support the notion that, at times, Black racial identity may be psychologically and physiologically taxing due to individuals’ awareness of their membership in and connectedness to individuals within a marginalized social group (Dagadu & Christie-Mizell, 2014; Ida & Mizell, 2012). Research suggests that while racial centrality may heighten individuals’ awareness of race and their potential exposure to racial bias in ways that protect them from its negative effects, such awareness may also be exhausting, elicit distress and anger, and erode social relationships (Brondolo et al., 2009). Though COBP may provide meaningful connections to other Black people whose shared experiences may diminish feelings of social rejection (due to racism), such connections may also vicariously expose individuals to additional stressors (Brondolo et al., 2009; Hughes et al., 2015). This may be especially relevant for young adults, whose racial identities and other coping strategies are developing. Scholars also note that transitions in racial identity may trigger elevated blood pressure by heightening perceptions of racial bias and conflict (Thompson et al., 2002).

Despite these negative direct associations, results demonstrate the protectiveness of racial centrality and COBP among young adults. When exposed to discrimination, young adults with low centrality and moderate COBP faced significantly higher odds of hypertension compared to individuals who endorsed moderate/high levels of racial centrality and low or high COBP. This is an important nuance. While these racial identity dimensions may generally contribute to elevated hypertension risk among young adults, results suggest they also confer physical health benefits in the face of racism-related stress. Although research has examined the health significance of racial identity among Black young adults, few studies have considered its physiological implications (Dagadu & Christie-Mizell, 2014; Thompson et al., 2002). To the best of our knowledge, only one study has investigated the links between racial identity and blood pressure among college students (Neblett & Carter, 2012). Therefore, our findings advance this research by highlighting the distinct direct and indirect pathways through which racial centrality and COBP contribute to hypertension risk among young Black adults.

Middle-aged adults

As with young adults, discrimination was also significantly linked to greater odds of hypertension among middle-aged adults. Yet, neither racial centrality nor COBP were directly linked to hypertension among this group, an unsurprising pattern, given the mixed findings of prior research (Chae et al., 2010; Dagadu & Christie-Mizell, 2014). One potential explanation for this finding is that while these aspects of identity may generally produce positive feelings (Sellers et al., 1998), they may not be sufficient to directly influence hypertension risk (Brondolo et al., 2009), particularly during this stage of the life course. Midlife often represents a period focused on managing competing social roles and responsibilities (e.g., employment and caregiving), and middle-aged Black Americans face the added burden of discrimination and other racism-related exposures (Thomas Tobin et al., 2020). While this group endorses relatively high levels of racial identity, other social identities (e.g., breadwinner and caregiver) may be at the forefront during this stage of adulthood, limiting the direct impact of racial identity on hypertension.

Results indicate that racial centrality conditions the impact of discrimination on hypertension among middle-aged Black Americans, such that low centrality was protective against discrimination. Interestingly, middle-aged individuals endorsing low racial centrality experienced the highest hypertension risk at low levels of discrimination, and their hypertension risk diminished as discrimination exposure increased. Somewhat counterintuitive, these results suggest that middle-aged Black Americans facing frequent discrimination may gain greater physical health benefits from a decentralized Black identity. While individuals with moderate/high centrality faced lower hypertension risk with low discrimination exposure, their health risk increased significantly when encountering more discrimination. As previously noted, these individuals may experience heightened awareness of racism that, at times, may be psychologically beneficial, but may also lead to adverse physical health consequences with greater discrimination exposures (Brondolo et al., 2009). By contrast, while they would not experience the benefits associated with a central Black identity, middle-aged individuals endorsing low centrality might be in a better position to psychologically disconnect when experiencing discrimination. Our finding that COBP did not moderate the discrimination–hypertension association among this group suggests that middle-aged adults may draw on other identity-related resources beyond racial identity. Given the early onset of hypertension among Black Americans (Cutler et al., 2008; Ford, 2011), future studies should identify the distinct processes through which racial identity shapes physical health among middle-aged adults.

Older adults

Despite reporting comparable discrimination exposure relative to younger individuals, discrimination was not significantly associated with hypertension among older Black Americans. Research suggests that the null effects of discrimination on hypertension may be due to habituation, which occurs when the adverse impact of stressors diminish over time (Assari & Lankarani, 2016). Many older Black Americans have experienced countless discrimination events throughout their lives (Barnes et al., 2004). Thus, it is possible that individuals may deem subsequent exposures as less stressful or they may become more adept at coping with discriminatory experiences (Brondolo et al., 2009). Because so few studies have examined the relationship between discrimination and hypertension among older adults (Beatty Moody et al., 2016; Nguyen et al., 2021), additional research is needed to clarify this linkage.

Future studies should examine the physical health consequences of racial identity among older adults. This study demonstrates significant, direct associations between hypertension and both racial identity dimensions. Older adults who endorsed high racial centrality experienced significantly lower odds of hypertension relative to individuals reporting low/moderate centrality. Interestingly, moderate, rather than low or high COBP, also conferred lower hypertension odds among this age group. This suggests that for older adults, feeling that their Black identity is important for their self-concept while also feeling somewhat connected to other Black people was generally protective against hypertension risk. Interestingly, neither racial identity dimension was a significant moderator of the discrimination–hypertension association among this group. Thus, discrimination was unrelated to hypertension regardless of racial identity among older adults. Collectively, findings demonstrate the continued significance of racial identity for later-life physical health. They also highlight the distinct ways this resource influences health, as the protectiveness of racial identity regardless of discrimination exposure suggests that efforts to enhance these dimensions might be an effective strategy to reduce hypertension rates among high-risk older Black Americans.

Limitations

Results should be considered in light of limitations. We are unable to make conclusions about causality or temporal ordering with cross-sectional data. Additionally, the regional sample of Black Americans in the NSAHS limits our ability to generalize these results to the broader population. Future studies should examine these relationships using nationally representative longitudinal data to clarify the ways that racial identity shapes hypertension risk over time. Relatedly, our study examined racial identity and hypertension among Black adults aged 22–69. Consequently, we are unable to draw conclusions about the impact of racial identity among adults aged 70 years and older. Nevertheless, we identified nuanced patterns across young, middle-aged, and older adult groups Results provide important insights into the ways that aging processes are shaped by psychosocial resources, such as racial identity. Future studies should extend this research to explore the impact of racial identity on blood pressure and other physical health conditions among significantly older samples of Black Americans. Finally, our study assessed two dimensions of Black identity (i.e., racial centrality and COBP), but there are other identity dimensions (e.g., Black group evaluation, public and private regard) that may have important implications for hypertension risk among this population. Therefore, additional research should investigate whether and how other racial identity dimensions may influence hypertension among Black Americans.

Contributions and Conclusions

This study makes several theoretical and public health contributions. First, by applying the stress process model (Pearlin, 1981) to empirically assess the pathways conceptualized in Clark’s (1999) biopsychosocial model, this research elucidates the complex mechanisms through which racial identity buffers the impact of discrimination on physical health of Black adults beyond young adulthood. Furthermore, we extend the discrimination–health research among older Black Americans focusing on depression, cognition, and mortality (Barnes, 2008, 2012; Qin, 2020), by documenting the relation of discrimination, racial identity, and hypertension risk among older Black Americans up to age 69.

Second, we extend research on the physical health significance of racial identity (e.g., Thomas Tobin et al., 2021) by distinguishing between racial centrality and COBP. By focusing on racial identity, this study moves the discourse on racial health disparities beyond biological essentialism (i.e., race is meaningful because it is biological) and advances research recognizing the role of psychosocial factors in shaping physical health (Ford et al., 2019). Thus, racial identity represents a key mechanism through which racial minoritized status becomes embodied to shape health. Third, our within-group approach highlights significant age and identity-based heterogeneity among Black Americans (minority aging vs health disparities research), overcoming common pitfalls in conducting comparisons across racial and ethnic groups (Whitfield et al., 2008), and identifying the unique psychosocial risks and resources contributing to hypertension risk among Black Americans. Finally, results underscore the public health significance of racial identity. As racial centrality and COBP directly shape hypertension risk and are protective against the adverse health consequences of discrimination for some Black Americans, age-based and culturally proficient health promotion programs can be adapted to integrate the significance of racial identity for health improvements among Black Americans.

Contributor Information

Courtney S Thomas Tobin, Department of Community Health Sciences, Jonathan and Karin Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA.

Ángela Gutiérrez, Department of Community Health Sciences, Jonathan and Karin Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA; Department of Social Medicine, Heritage College of Osteopathic Medicine, Ohio University, Athens, OH, USA.

Keith C Norris, Divisions of Nephrology and General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, CA, USA.

Roland J Thorpe, Jr, Program for Research on Men’s Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.

Funding

Data collection for the Nashville Stress and Health Study was supported by a grant (R01-AG034067) from the Office of Behavioral and Social Science Research and the National Institute on Aging to R. Jay Turner. We are grateful to the California Center for Population Research at UCLA (CCPR) for general support. CCPR receives population research infrastructure funding (P2CHD041022) from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). Courtney S. Thomas Tobin, PhD received support from the University of California, Los Angeles (UCLA), Resource Centers for Minority Aging Research Center for Health Improvement of Minority Elderly (RCMAR/CHIME) under NIH/NIA Grant P30-AG021684, and from the UCLA Clinical and Translational Science Institute (CTSI) under NIH/NCATS Grant Number UL1TR001881. This content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Conflict of Interest

The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Author Contributions

C. S. Thomas Tobin planned the study, performed the data analysis, and wrote the article. A. Gutiérrez also wrote the article and helped with revising the article. K. C. Norris supervised the data analysis, oversaw the drafting, and revising of the manuscript. R. J. Thorpe Jr. supervised the data analysis, oversaw the drafting, and revising of the manuscript.

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