بدبینی بهداشت و سلامتی در میان بزرگسالان سیاه و سفید: نقش بدرفتاری فردی و سازمانی

Abstract Using data from the 1995 Detroit Area Study (N=1106) this paper finds that black adults report significantly worse self-rated health when compared to whites with similar levels of self-reported morbidity. This relationship, called health pessimism, persists despite statistical controls for age, gender, socioeconomic status, health care access, and health related behaviors. Interpersonal maltreatment is found to be positively associated with health pessimism and more importantly, when comparing adults who perceive similar levels of maltreatment, white and black adults do not differ with respect to health pessimism. This suggests that the increased risk of health pessimism among black adults is due in part to race differences in the perception of interpersonal maltreatment.

Introduction Health pessimism can be described as a characteristic among otherwise healthy individuals who perceive their health to be relatively poor (Ferraro, 1993; Idler, Hudson, & Leventhal, 1999; Van Doorn, 1999). In other words, among health pessimists there is a notable mismatch between subjective (i.e., self-rated health) and objective (i.e., self-reported morbidity or physician assessed health) health status. Previous research has described the social antecedents of health pessimism such as socioeconomic status (Idler et al., 1999) and gender (Idler, Russell, & Davis, 2000) but few researchers have specifically examined the way in which race factors into an individual's global assessment of his or her current health status. Black adults are two times more likely than whites to report that their health is “fair” or “poor” (NCHS, 2000) but physical health differences among blacks and whites do not account for this difference (Ferraro, 1993; Ferraro, Farmer, & Wybraniec, 1997; Maddox, 1962). To date, however, no existing research has investigated or identified the source of race differentials in the risk of health pessimism. This paper examines the role of interpersonal and institutional maltreatment as an important determinant of an individual's assessment of his or her global health status paying particular attention to the notion that the perception of unfair treatment is an important mechanism through which health pessimism rates among black and white adults diverge. In doing so, this paper draws an important connection between work that focuses on the meaning that individuals attach to self-rated health items (Krause & Jay, 1994) with research on the perception of rude or discriminatory actions from others as an independent contributor to population health differences (Finch, Kolody, & Vega, 2000; Krieger and Sidney (1990) and Krieger 1 (2000); Krieger and Sidney, 1996; Williams, Yu, Jackson, & Anderson (1997) and Williams, Yu, Jackson, & Anderson (1997)).

Results Table 2 presents morbidity rates for serious and chronic illnesses among black and white adults in the Detroit Area Study. Of the thirteen illnesses, blacks report higher rates on five outcomes, however only one (high blood pressure) is statistically significant. Whites report significantly higher rates of high cholesterol and cancer compared to blacks but apart from these differences there are no observed differences in serious or chronic illnesses among whites and blacks. Blacks do report slightly elevated rates of functional limitations compared to whites, but, this difference is only modestly significant (p<0.09). Therefore, according to these measures of objective health status we might expect whites to report similar (or worse) self-rated health compared to blacks. Instead, 23.34% of black respondents compared to only 12.82% of whites report relatively poor self-rated health (χ2=17.38, p<0.001). As with previous work in this area ( Ferraro, 1993; Ferraro & Farmer, 1999; Maddox, 1962) the two-fold increase in the percentage of respondents reporting their health to be “fair” or “poor” compared to the moderate to negligible differences in physical morbidity provides initial support for Hypothesis 1 (blacks are more likely than whites to be health pessimists). Table 2. Race differentials in physical morbidity, functional health, and self-rated health Non-Hispanic white (n=520) Non-Hispanic black (n=586) Pr |W−B|=0 Self-reported morbidity High blood pressure 24.78 31.31 0.032 Stroke 3.26 2.34 0.452 Heart attack 13.79 11.09 0.251 Diabetes 6.62 9.23 0.153 Cancer 6.06 2.60 0.032 Arthritis 19.22 22.70 0.215 Ulcer 8.45 9.30 0.677 Asthma 8.95 9.62 0.748 Liver problem 3.12 2.31 0.494 Kidney problem 7.29 7.12 0.921 Bronchitis 7.61 5.15 0.171 Blood circulation problem 7.20 8.45 0.506 High cholesterol 22.54 15.15 0.012 Functional health status Activity limitations −0.04 0.04 0.088 (0.69) (0.85) Self-rated health (good, very good, excellent) Fair or poor 12.82 23.34 0.001 Source: 1995 Detroit Area Study (N=1106); all data have been weighted. Note: Cell entries represent percentages for categorical variables and means (standard deviation) for continuous variables. Table options The estimates presented in Table 3 are obtained from two multivariate logistic regression models in which the dependent variable is coded 1 if respondents reported “Fair” or “Poor” health and 0 if otherwise. Model 1 controls for race, age, sex, socioeconomic status, self-reported morbidity, functional health status, health care access, and health related behaviors. According to these results more educated adults are less likely to be health pessimists compared to those with lower levels of education. Smoking status is strongly associated with elevated risk of health pessimism such that current and former smokers are almost twice as likely as those who have never smoked to be health pessimistic. And physically inactive adults face a 75% increase in the relative odds of health pessimism compared to those who exercised recently. Likewise, as expected, when comparing person's with similar health levels, those who wanted to see a physician in the past year but were unable to report worse self-rated health status compared to those who were able to see a doctor. Nevertheless, despite this extensive array of statistical controls, blacks continue to be more than twice as likely as whites to be health pessimists (OR=2.20). Not only is the magnitude of the effect large but this effect is highly significant (p<0.01). As with descriptive statistics presented in Table 2, these findings provide further support for Hypothesis 1. Table 3. Logistic regression estimates: are perceptions of maltreatment associated with poor/fair self-rated health? Model 1 Model 2 Sociodemographic characteristics Race (non-Hispanic white) Non-Hispanic black 2.20∗∗ 1.57 Age (Years) 1.01 1.02 Female 1.09 1.19 Socioeconomic status Education (years) 0.92∗ 0.91∗ Income to needs ratio (percent of poverty) 0.93 0.94 Physical health status Self-reported morbidity High blood pressure 3.17∗∗∗ 3.27∗∗∗ Stroke 1.65 1.73 Heart attack 1.14 1.14 Diabetes 1.84∗ 1.71∗ Cancer 1.85 1.75 Arthritis 1.16 1.09 Ulcer 1.22 1.18 Asthma 1.19 1.09 Liver problems 0.57 0.53 Kidney problems 3.11∗∗ 3.21∗∗ Bronchitis 0.92 0.98 Blood circulation problems 1.94∗ 1.89∗ High cholesterol 0.91 0.91 Activity limitations 1.69∗∗∗ 1.68∗∗∗ Health care access Marginalization from health care provider 1.25∗ 1.02 Regular doctor 1.20 1.27 Last visited the doctor over a year ago 0.65 0.61 Health risks Smoking status (never smoked) Former smoker 1.89∗ 1.88∗ Current smoker 1.95∗ 1.90∗ Physically inactive 1.75∗ 1.85∗ Obese 0.81 0.86 Perceived maltreatment Interpersonal 1.34∗∗∗ Institutional 1.26 −2Log likelihood 533.68 519.68 Likelihood-ratio 14.00∗∗∗ Degrees of freedom 2 Source: 1995 Detroit Area Study (N=1106); All data have been weighted. Note: Cell entries represent odds-ratios. ∗∗∗ p<0.001. ∗∗ p<0.01. ∗ p<0.05. Table options Hypothesis 2 and 3 are examined in the Model of Table 3. First, results indicate that those who perceive maltreatment from others in their day-to-day activities are significantly more likely (OR=1.34, p<0.001) to be health pessimists compared to those who report relatively low levels of maltreatment (support for Hypothesis 2). The relationship between perceptions of institutional-based maltreatment and health pessimism, while operating in the expected direction, is not significantly different from zero. The inclusion of these two variables significantly improves the model fit as indicated by the likelihood ratio test (χ2=14.00, d.f.=2, p<0.001) and more importantly, the coefficient for non-Hispanic black in Model 1 (OR=2.20, p<0.01) is significantly reduced in Model 2 (OR=1.57, p<0.25) and becomes statistically indistinguishable from zero. These findings indicate that the perception of maltreatment mediates the relationship between race and health pessimism observed elsewhere ( Ferraro, 1993) and supports Hypothesis 3. It is also worth noting that Model 1 reports a 25% increase in the relative odds of reporting health pessimism among those who were marginalized from health care providers but this effect is eliminated after controlling for perceived unfair treatment suggesting that those who perceive elevated levels of unfair treatment may also perceive relative difficulties in accessing important health care resources. Two important dimensions of this relationship were also considered. First, as discussed elsewhere (see Krieger, 2000 for a review), people may perceive that they are being treated unfairly for a number of reasons including but not limited to their racial or ethnic identity. The analyses presented here do not differentiate between unfair treatment because of respondents’ race, age, gender, sexual orientation, or disability. Rather, perceptions of unfair treatment are considered to be more globally understood. It is also important to consider the possibility that the specific reason individuals understand themselves to be treated unfairly could have important consequences with respect to health outcomes. For example Krieger and Sidney, (1997) find that the elevated rates of perceived maltreatment among gay and lesbian men and women were moderated in important ways by gender and race. More importantly, Cochran and Mays (1994) find that mental health outcomes are more strongly affected by perceptions of discrimination and maltreatment when the reason for the maltreatment is made explicit (e.g., race related or gender specific). For each aspect of perceived maltreatment from institutions and in a summary fashion for all aspects of perceived individual maltreatment, the Detroit Area Study asked respondents to report “the main reason for these experiences” including ethnicity, gender, race, age, religion, physical appearance, sexual orientation, and class. To examine these relationships empirically, a number of ancillary analyses (results not shown) were performed but in all cases the inclusion of controls for the source of perceived maltreatment did not change the substantive findings presented above. Second, two important papers (Saldago de Snyder, 1987; Finch et al., 2000) find elevated rates of depression among adults who perceive that they are being treated unfairly or discriminated against. Because depression has been linked to changes in self-rated health status, independent of changes in physical health status (Han, 2002) additional analyses were performed (results not shown) in which statistical controls for depressive symptoms were included in the multivariate models presented in Table 3 however this control did not change the substantive findings above.