Introduction

Americans are a multi-ethnic society and becoming increasingly diverse. The 2000 U.S. Census indicated that 34.6 million Americans identified as Black/African-American, 10.2 million people as Asian/Asian-American, and 35.3 million people as Hispanic or Latino of any race (U.S. Census Bureau 2008).Footnote 1 By 2050, demographers estimate that 14.6% of Americans will be Black, 8% will be Asian, and almost one in four (24.4%) will be Latino(a) (Passel and Cohn 2008). Moreover, at present, immigrants and their descendents across all ethnic groups are expected to account for most population growth in the coming decades, further increasing the heterogeneity of the US population both across and within ethnic groups (Pew Hispanic Center 2008).

Substantial research demonstrates that health outcomes are distributed unequally among these diverse ethnic groups. For example, rates of hypertension and related complications are significantly higher in Blacks than in non-Hispanic Whites or Asians (American Heart Association 2008). Even within broad groupings, there is substantial heterogeneity in health outcomes. Among Latino(a)s, Puerto Ricans demonstrate particularly poor health (e.g., relatively high rates of premature mortality) whereas Cubans show better health when compared to other Latino(a) subgroups (National Center for Health Statistics 2008). Across ethnic groups, immigrants often evidence better health than their US-born counterparts (Jasso et al. 2004; Singh and Siahpush 2002).

Such disparities run counter to the idea of America as a land of equality, justice, and opportunity for all. Eliminating these inequities is a major goal of the US national health agenda set by Congress in “Healthy People 2010” (U.S. Department of Health and Human Services 2000) and is likely to remain a key objective of Healthy People 2020 (http://www.healthypeople.gov/HP2020/). Despite the increasing public health and research attention focused on health disparities, investigators have yet to fully specify the factors that create and maintain disparities in health status and health care. Consequently, clinicians and researchers have faced limitations in their ability to develop interventions that will effectively target the pathways underlying disparities or offset their effects on health outcomes in affected groups.

In attempting to explain the negative health outcomes experienced by racial and ethnic minorities, researchers have increasingly turned their attention to racial and ethnic discrimination (Mays et al. 2007; Shavers and Shavers 2006). Racism is a potent psychosocial stressor that is characterized by both social ostracism and blocked economic opportunity. Research from a range of disciplines has clearly demonstrated the harm engendered by all types of social ostracism and isolation (Baumeister et al. 2005; Inzlicht et al. 2006). Racism also has led to inequitable access to social, educational, and material resources. These are resources that have both direct effects on health status (i.e., through access to healthy diets and appropriate medical care) and indirect effects on health status, through their influence on stress, psychosocial resources, and positive and negative emotions (Adler and Snibbe 2003; Adler and Rehkopf 2008; Gallo and Matthews 2003).

Despite the clear theoretical rationale for hypothesizing that racism and ethnic discrimination affect health, empirical demonstrations of these effects are still in their early stages. Further work is needed to understand the mechanisms through which racism and ethnic discrimination relate to health. In addition, research is needed to understand how to intervene to reduce the deleterious impact of racism and discrimination.

Fortunately, the field is expanding rapidly. A quick literature search using the terms racism or racial discrimination and health indicates an exponential growth in the research investment in this area. From 1997 to 2002, there were 47 published peer reviewed papers focused on racism or racial discrimination and health indexed in Academic Review, Medline, and PsychInfo. In the next 5 years, ending in 2007, 284 papers were published. Similarly, from 1997 to 2001 87 papers were published examining cultural diversity and health, but in the 5 years ending in 2007, 317 papers were published.

The purpose of this special section is to review key research areas relevant to elucidating the health consequences of ethnic and racial discrimination and its potential contribution to health disparities. The momentum for this special section developed initially out of discussions between special section editors Elizabeth Brondolo and Hector Myers, during the 2005 meeting of the Society of Behavioral Medicine, following a panel discussion on ethnicity and health. The panel highlighted the continued need for rigorous and inter-disciplinary research to investigate the causes of racial disparities in health and interventions to eliminate them. Subsequently, in 2007, Drs. Brondolo and Gallo were introduced when they served as reviewers for a National Institutes of Health study section considering proposals on stress and health. Their discussions pointed to the need for a synthesis of empirical research that could guide the development of future interventions. These conversations culminated in the idea of a special section for the Journal of Behavioral Medicine. With the support of Editor Chris France, and contributions from some of the leading experts in the field, the special section came to fruition.

During the planning stages, a series of conference calls and email exchanges among the special section authors centered on the many methodological and conceptual difficulties involved in the study of racism and its health correlates. The discussions underscored the value of examining and integrating existing empirical research on the environmental, social, and intrapersonal processes that subserve the health impact of racism. The section editors and authors represent diverse ethnic and personal backgrounds, theoretical perspectives, and disciplines, permitting many alternate viewpoints and ideas to be discussed during these planning conversations. This type of collaborative and cross-disciplinary communication is critical to build the knowledge base that will guide clinicians and policy-makers.

Despite the growth in the number and quality of papers addressing racism or discrimination and health, the research area remains difficult and complex. The overarching goal of this special section is to examine the state-of-the-science and to articulate an agenda that can help guide future research. The papers address the difficulties in developing integrative models that consider the effects of racism in light of other stressors (Myers 2009), examine the relationship of racism to health (Williams and Mohammed 2009) and health care (Klonoff 2009), consider the empirical research on the effectiveness of strategies for coping with racism (Brondolo et al. 2009), and propose models that better integrate ethnic and cultural factors in the development of interventions to improve health in targeted groups (Castro et al. 2009). Although by no means an exhaustive representation of the area, in aggregate, the papers explore several fundamental questions that require further attention if we are to advance the field. We outline these questions and then briefly describe the five papers in the following sections.

What is the state-of-the-science regarding health disparities and the role of racism in relation to health status?

Eliminating health disparities was established as a central public health priority nearly a decade ago; however, a mid-course review for Healthy People 2010 suggested few systematic changes in the levels of ethnicity or socioeconomic-driven health disparities (http://www.healthypeople.gov/Data/midcourse/). Thus, documenting and tracking disparities and progress toward reducing them remains an important research goal. But early studies of disparities tended to focus exclusively on between ethnic and race group differences. New research has highlighted the importance of examining variations within groups to understand how factors such as racism may disproportionately affect the group and also account for variations in health within the group. These within-group studies have yielded important information on the relationship of racial discrimination to health (Williams and Mohammed 2009). Still needed are studies that combine the best of both between-group and within-group approaches. These studies can examine ethnicity as a moderating factor in the relationship of psychosocial stressors, such as racism, to health outcomes, enabling investigators to identify the specific types of stressors that contribute to between-group variations in health outcomes.

How can we conceptualize and measure racism?

One of the most challenging issues in the study of racism has been its conceptualization and measurement (Brondolo et al. 2009; Landrine et al. 2006; Williams 1996; Williams and Mohammed 2009). A highly cited definition from Clark and colleagues’ seminal 1999 paper (Clark et al. 1999) defined racism as “the beliefs, attitudes, institutional arrangements, and acts that tend to denigrate individuals or groups because of phenotypic characteristics or ethnic group affiliation” (p. 805). Contrada has used the more general term of ethnic discrimination and defined it as unfair treatment received because of one’s ethnicity, where “ethnicity” refers to various groupings of individuals based on race or culture of origin (Contrada et al. 2000, 2001).

To provide a structure to guide the study of race-related maltreatment, several authors have articulated models of the different levels and types of racism (Harrell 2000; Krieger 1999; Taylor et al. 1996). Harrell and others have emphasized that racism occurs on multiple levels—cultural, institutional, interpersonal—and that it is expressed in a variety of contexts via both explicit and implicit communication. Racism can take the form of cultural communications (e.g., advertisements or movies that depict members of ethnic minority groups in derogatory or stereotype-confirming ways), institutional policies that restrict access to opportunities or resources, and interpersonal behaviors that either subtly or blatantly convey a message that the members of the targeted group should be excluded and/or rejected and do not deserve the opportunities or protections against dangerous and unfair treatment that others receive. All forms of racism can have individual as well as population level effects.

We are only beginning to understand the ways in which varying levels and types of racism confer health risks (Brondolo et al. in press). However, the strategies to reduce exposure and mitigate the health impact of racism are likely to be specific to the type of maltreatment experienced. Therefore, studies contrasting the prevalence and health effects of different categories of racism/ethnic discrimination are also needed, and this will require alterations in approaches to conceptualizing and measuring racism.

How does the impact of racism unfold over time across generations and across the lifespan?

We view racism as a substantial public health threat. From this perspective, individual, institutional, or cultural exposures to ethnicity-based maltreatment serve as precipitating events that initiate a series of acute and enduring changes in cognition, affect, behavior, and psychophysiological responses. These changes affect everyone, both the targets of discrimination and those who observe or enact the discriminatory behavior. The existence of racism influences the way other people think and feel about and act towards members of the targeted group, and the way targets think and feel about themselves and others. Such alterations in affect and cognition are likely to contribute to racial disparities in health status, both directly and indirectly (Brondolo et al. in press, 2008). When these changes affect the targeted individual, they may contribute to variations in behavioral and psychophysiological responses to stress, changing the individual’s interactions with others and increasing the risk for stress-related disorders over time. When these changes affect the perspectives of others, they may contribute to the development of institutional policies or outcomes (e.g., residential segregation or race-related differences in medical care) that have substantial effects not only on the individual, but on the community as a whole. Further, a growing body of evidence from Holocaust survivors and other trauma victims suggests that exposure to high intensity or life-threatening events may have effects on subsequent generations through behavioral and possibly psychobiological processes (Kassai and Motta 2006). Studies are needed that examine the ways in which individuals adapt not only to acute episodes of discrimination, but also to the intergenerational history of discrimination and the possibility of on-going exposure.

Can we develop a comprehensive biospsychosocial model that permits us to evaluate the unique effects of racism on health as well as its joint effects in consideration with other psychosocial stressors?

Given the complex and wide-ranging effects of racism, conceptualizing and assessing its impact independent of other stressors faced by ethnic minority individuals is extremely difficult. For example, many minority groups, including African-Americans and Latinos, experience marked socioeconomic disadvantages, such as poverty and poor educational opportunities, relative to non-Hispanic Whites (National Center for Health Statistics 2008). Furthermore, institutionalized and other forms of racism are likely to contribute directly to the socioeconomic disadvantages sustained by ethnic minority groups (Karlsen and Nazroo 2002; Shavers and Shavers 2006). Some individuals targeted for discrimination because of their cultural characteristics (e.g., language or dress) may also face immigration and acculturation stressors. Individuals who experience ethnic discrimination also may be disproportionately susceptible to other types of stressors, such as chronic stress (e.g., work-related stress due to low occupational status, environmental stress due to living in unsafe neighborhoods or crowded settings), and daily hassles. Given these relationships and the potential for synergistic effects among these various stressors, attempts to separate racism from the broader social–cultural context in which it occurs can potentially undermine efforts to establish its true health impact (for discussion, see Myers 2009). Integrative theoretical perspectives are needed to better capture the complex association between racism and health. New analytic and sampling approaches are required. Studies that sample individuals of different ethnicities from a broad range of individual and neighborhood-level SES are needed, as are studies that promote an understanding of the daily experiences associated with exposure to racism and different levels of socioeconomic status.

What are the specific pathways through which racism affects health?

The pathways leading from racism to health are certain to be complex and multi-dimensional. Much of the research on racism and health has examined the effects of racism on physiological systems, testing hypotheses about close linkages between exposure and biological outcomes. For example, both laboratory and ambulatory monitoring studies have documented the relationship between racism and psychophysiological reactivity, including cortisol, blood pressure, and heart rate responses (Brondolo et al. in press, 2008; Clark 2000; Fang and Myers 2001; Guyll et al. 2001; Harrell et al. 2003; McNeilly et al. 1995; Richman et al. 2007; Tull et al. 2005). These patterns of reactivity have been linked to the development of stress-related disorders, such as hypertension and other cardiovascular diseases (Matthews et al. 2004; Treiber et al. 2003). These alterations in the degree or frequency of physiological stress responses may represent one pathway through which racism ultimately affects health outcomes.

However, racism may also exert effects on health through other pathways. Additional literature demonstrates a consistent relationships between racism and engagement in risky health behaviors such as smoking and substance use (Borrell et al. 2007; Choi et al. 2006; Landrine and Klonoff 2000), less use of preventive services including cholesterol testing or mammography (Hausmann et al. 2008; Trivedi and Ayanian 2006), and nonadherence to prescribed medical regimens (Casagrande et al. 2007; Thrasher et al. 2008). There may be dynamic relationships among these pathways (e.g., negative mood may influence both autonomic function and smoking). Studies examining the varying contributions of both stress reactivity and health behavior to health disparities are needed, as are studies that consider ethnic/racial differences in these effects.

Racism may also affect health through its impact on health care (Smedley et al. 2003). There are well documented racial disparities in health care as well as health status. A growing literature examines the effects of racism on the patient–provider relationship, a key element of the health care process (Benkert and Peters 2005; Peters 2004). Moreover, there is evidence that physicians make differential estimates of risk for diseases, and spend less time planning and collaborating with individuals from some ethnic/racial groups (Benkert and Peters 2005). These impairments in the patient–provider relationship may also indirectly undermine efforts to promote healthy behavior. Further studies on the effects of racism on the health care process are needed to understand the potential points of intervention. (For discussion, see Klonoff 2009).

How can targeted individuals cope with racism? How can we intervene to diminish the health risks?

Regardless of the quantity and quality of research examining the association between racism and health and underlying mechanisms, we cannot make progress toward eliminating health disparities unless we begin to develop effective interventions. But the investigation of strategies to intervene to reduce the health effects of racism raises some thorny questions. Are we accepting the inevitability of racism if we try to treat its effects? Should we focus all of our efforts on eliminating racism? If we work to identify and develop effective and individual level coping strategies are we teaching people that they can tolerate unfair treatment?

Despite these concerns, intervention on an individual level may be one part of an effective response to racism. However, notwithstanding the wide-spread recognition that racism is a serious stressor, very limited consensus exists on the strategies individuals can use to mitigate the health effects of exposure (see Brondolo et al. 2009). The type of coping strategies that will be effective may vary by the context (i.e., at work, in public, etc.) in which the race-related maltreatment occurs. Similarly, different strategies may be needed to cope with an acute episode of maltreatment versus the on-going distress that may be a function of the continued threat of exposure. Additional research is needed to identify the specific types of strategies that are most effective in addressing race-related maltreatment as it occurs and ameliorating associated pain and suffering.

An urgent need exists for new intervention methods to reduce the psychological and physiological effects of racism. Several promising approaches integrate social–cognitive theories with skills building to expand the range of coping strategies available to decrease the adverse consequences of internalizing racist attitudes (Oyserman et al. 2007; Steele 1997). Improved psychoeducational efforts aimed at disseminating knowledge about the ways in which racism affects cognitive, affective, and psychophysiological processes may contribute to targeted individuals’ ability to self-regulate in the face of discrimination. More effective coping on an individual level may lead to greater commitment and energy to work on the community or national level.

Research is also needed to understand the effects of efforts to restrain discriminatory behavior. For example, despite widespread use of diversity training to decrease exposure to racism, particularly in the workplace, there has been very limited empirical evaluation of its effectiveness. New efforts are needed to systematically understand ways of improving inter-group communication that promote an appreciation of differences, while at the same time recognizing that race/ethnicity is only one salient characteristic of each individual.

Providing more culturally responsive healthcare is also a potential means of intervening with racial disparities on a structural level (Klonoff 2009). In recognition of the increasing diversity of our society, medical education has begun to place a greater emphasis on training professionals to provide more culturally responsive and effective quality care. New Jersey and Washington State have made physician cultural competency training a condition of licensure; California requires inclusion of cultural competency in all continuing medical education activities. Seven other states have pending legislation addressing the provision of continuing education in multicultural health by each professional health regulatory authority (http://www.washingtonvotes.org/2006-SB-6194). As a group, health care providers are motivated and accountable, and they may therefore be open to specific interventions to increase equity in healthcare quality. Further research is needed to identify the specific educational strategies and personal characteristics that foster effective patient–provider relations.

Another approach to addressing health disparities that is receiving considerable attention involves tailoring interventions to better address specific needs of ethnic or cultural groups (Castro et al. 2009). In some cases, tailored interventions differ in the language or aesthetics of the intervention materials; in other cases the changes consider the day-to-day experiences and beliefs of the cultural groups. Ethnicity and race are complex variables, affecting beliefs, behaviors and access to resources. Thus, it has proven difficult to evaluate the effectiveness of cultural competency interventions or efforts to tailor health promotion interventions to the needs of diverse patient groups. New models and analytic strategies are needed to help researchers understand the complex ways in which ethnicity affects health outcomes. Ethnicity may influence risk exposure, health behaviors, and coping resources. Different aspects of ethnicity-related variables (e.g., cultural beliefs, dietary habits, family structures) may exert effects at every point in the chain from stress exposure to health.

The special section papers

The special section begins with Hector Myers’ discussion of the evidence concerning existing health disparities, emphasizing major areas of importance, including cardiovascular disease, diabetes, HIV/AIDS, and birth outcomes, as well as access to care. He presents a comprehensive theoretical model that considers the ways in which racism, poverty and other major stressors interact to affect health via the inter-related mechanisms of stress, resources, cognition and emotion, and bio-behavioral pathways over the lifespan to contribute to cumulative vulnerabilities. By facilitating theoretically-driven predictions concerning relationships across multiple levels of the individual and social–cultural context, this model can significantly enhance future research efforts.

Next, David Williams and Selina Mohammed provide an overview of recent research concerning ethnic health disparities and systematically review the ways in which racism has been documented to affect health outcomes. They address some of the key issues involved in conceptualizing and measuring racism, and consider the multiple dimensions of racism that can affect health on an individual and population level. The authors examine the deeply-embedded nature of institutionalized racism and its effects, such as the pronounced residential segregation that has shaped access to resources and opportunities of African-Americans and Native Americans’ for generations. This not only affects their own health over the lifespan, but can potentially contribute to health impairments in their offspring.

Elizabeth Klonoff then offers a review and update of the literature concerning ethnicity-related disparities in healthcare, and considers a number of factors that may contribute to these disparities. She identifies the ways in which cultural racism may indirectly affect the attitudes of health care providers, leading to experiences of interpersonal racism in the consulting room and more systemic or institutional racism when targeted groups receive different diagnoses and treatment options.

Elizabeth Brondolo and colleagues consider how racism can be conceptualized as a stressor, drawing attention to theoretical models of stress and coping that may shed light on the possible link between racism and health, and providing a selective review of the ways in which racial identity, anger coping, and social support can moderate the health consequences of racism. They discuss the need for new measurement strategies to assess the coping strategies individuals can use in confronting different types and levels of racism, highlighting the importance of examining both the acute effects of specific episodes of ethnicity-related maltreatment as well as the longer term effects associated with anticipating maltreatment over the lifespan.

In the final paper, Felipe Castro considers culturally-tailored interventions from a systematic, theoretical perspective. An ecodevelopmental model is presented as a framework that can capture the multiple levels on which sociocultural influence on health and health behavior, using diabetes as an example. A number of corollary issues involved in designing culturally appropriate interventions are considered to guide investigators in thinking about the roles of race, ethnicity, and culture in health care interventions.

Conclusions

Through this special section, we seek to provide a framework for generating new knowledge to guide future efforts to reduce racial and ethnic disparities in health. However, in the end, we find that we raise more questions than we answer. In this overview we have highlighted some of the key areas addressed by the existing literature. We close by expressing the hope that we have encouraged readers to engage in the investigations needed to resolve the important outstanding questions that emerge throughout the papers from this special section.