STATE OF THE ART
nature publishing group
Racism and Hypertension: A Review of the Empirical
Evidence and Implications for Clinical Practice
Elizabeth Brondolo1, Erica E. Love2, Melissa Pencille1, Antoinette Schoenthaler3 and Gbenga Ogedegbe3
Background
Despite improved hypertension (HTN) awareness and treatment,
racial disparities in HTN prevalence persist. An understanding of
the biopsychosocial determinants of HTN is necessary to address
racial disparities in the prevalence of HTN. This review examines the
evidence directly and indirectly linking multiple levels of racism
to HTN.
Methods
Published empirical research in EBSCO databases investigating the
relationships of three levels of racism (individual/interpersonal,
internalized, and institutional racism) to HTN was reviewed.
Results
Direct evidence linking individual/interpersonal racism to HTN
diagnosis is weak. However, the relationship of individual/
interpersonal racism to ambulatory blood pressure (ABP) is more
consistent, with all published studies reporting a positive relationship
of interpersonal racism to ABP. There is no direct evidence linking
Racial disparities in hypertension (HTN) continue to be a
pressing problem in the United States. There is consistent
evidence that black Americans are more likely than white
Americans to develop HTN. Prevalence rates for black adults
range from 30.6 to 40.5%; whereas the rates for white range
from 24.4 to 29%.1–5 There is also evidence of racial disparities in blood pressure (BP) control (control rates: blacks 44.1–
65.2%; whites 55.6–86.3%),5–9 although not all studies have
found race differences.10,11
These disparities exist despite the fact that black Americans
are more likely to be aware of their HTN12 and in some cases
are more likely to receive treatment for HTN than are white
Americans.7,8 Even when black Americans are as or more
adherent to antihypertensive treatment than are whites6,13
disparities in BP control are manifest. To address the high
prevalence of HTN among black Americans, it may be useful
to identify other variables, including different psychosocial
internalized racism to BP. Population-based studies provide some
evidence linking institutional racism, in the forms of residential racial
segregation (RRS) and incarceration, to HTN incidence. Racism shows
associations to stress exposure and reactivity as well as associations
to established HTN-related risk factors including obesity, low levels of
physical activity and alcohol use. The effects vary by level of racism.
Conclusions
Overall the findings suggest that racism may increase risk for HTN;
these effects emerge more clearly for institutional racism than
for individual level racism. All levels of racism may influence the
prevalence of HTN via stress exposure and reactivity and by fostering
conditions that undermine health behaviors, raising the barriers to
lifestyle change.
Keywords: ambulatory blood pressure; blood pressure; hypertension;
racial discrimination; racism
American Journal of Hypertension, advance online publication 17 February 2011;
doi:10.1038/ajh.2011.9
stressors, that might serve as potential individual-level and
environmental risk factors that disproportionately affect black
Americans, and to understand the ways in which these variables may operate to increase HTN prevalence.
Racism has been hypothesized to serve as a psychosocial
stressor contributing to the excess rates of HTN among black
Americans.14–18 The goal of this review is to provide a detailed
evaluation of the evidence linking individual/interpersonal,
internalized, and institutional racism to HTN and to known
risk factors for HTN, including obesity, fitness, and alcohol
use, as well as psychosocial stress. We hope to provide an evidence base that can inform further examination of the role of
racism in the development and course of HTN.
We specifically investigate the effects of racism on black
Americans, because the majority of published research on the
relation of racism to HTN has focused on black Americans. It
is important to note, though, there are also significant disparities for other ethnic groups.3,6,19,20
1Department of Psychology, St Johns University, Jamaica, New York, USA;
2Department of Clinical Trials, NYU School of Medicine, New York, New York, USA;
3Center for Healthful Behavior Change, Division of General Internal Medicine,
Department of Medicine, NYU School of Medicine, New York, New York, USA.
Correspondence: E. Brondolo ([email protected])
Received 14 June 2010; first decision 16 July 2010; accepted 25 December 2010
© 2011 American Journal of Hypertension, Ltd.
518
Constructs and Definitions
Most broadly, racism has been defined as “the beliefs, attitudes,
institutional arrangements, and acts that tend to denigrate individuals or groups because of phenotypic characteristics or ­ethnic
group affiliation.”16 Racism or ethnic discrimination can be
maY 2011 | VOLUME 24 NUMBER 5 | 518-529 | AMERICAN JOURNAL OF HYPERTENSION
AMERICAN JOURNAL OF HYPERTENSION | VOLUME 24 NUMBER 5 | may 2011
132 Black men,
probability sample,
1 community
89 Minority adults
(18.1% Black)
convenience sample
of employees
101 Black and white
women, random
sample
4,086 Black and white,
targeted recruitment
James et al.55
James et al.49
Krieger59
Krieger and Sidney48
Self-administered questionnaire: five sets of
questions which addressed whether they had ever
experienced discrimination, been prevented from
doing something or been hassled or made to feel
inferior in several situations based on race or color
(at school, getting a job, at work, getting housing,
getting medical care, on the street or in a public
setting and from the police or in the courts)
Age, BMI, birthplace,
type of neighborhood,
education
Age, sex, education,
family income,
employment status
BMI, age, sex, skin color
Mean SBP and DBP
Mean SBP and DBP
No direct relationship
No relation
No relation
Positive relation for
women born outside
the United States and
born in predominately
white neighborhoods
only
No relation
Negative relation,
not significant when
adjusted for age
Table 1 | Continued on next page
U-shaped relation,
Age; social class; annual
family income, education, effects vary by gender
and social class
marital status
Age
Positive relation
Self-esteem; collective
esteem; value differences
with peers & supervisors;
expressiveness
Two measures of resting Age, education, quetlet
BP taken during interview index, # cigarettes, time
of day
BP measurements taken
at home with aneroid
sphygmomanometer
Findings
None used in the analysis No relation
Potential covariates
Nurse measured SBP and Age; marital status SES;
BMI; coping, abilities
DBP and self-reported
physician-diagnosed high
blood pressure at two or
more visits
Self-reported
antihypertensive use or
hypertensive status with
use of a diuretic
Self-reported
hypertension
Mean SBP
Blood pressure measure
Mean SBP and DBP
Interview questions: Have you ever experienced
discrimination, been kept from doing something, or
been hassled or made to feel inferior (at school, at
work, getting a job, at home, getting medical care)
because of your race?
Organizational Prejudice-Discrimination Scale49
Three questions about race as a hindrance or help
to job
Four items assessing the degree to which
participants perceived that pay raises and other
work-related issues were based on race
186 Black, random
selection,
4 communities
Questionnaire assessing self-reported exposure to
types of personally mediated racism (i.e., received
poorer service, treated as not intelligent, people act
afraid, treated as dishonest, people act as if they are
better than) and “institutional racism” (i.e., unfair
treatment on the job, in housing, and by police)
Dressler52
59,000 Black women,
targeted sampling,
snowball recruit
Cozier et al.58
Questionnaire assessing “experiences of
discrimination or being prevented from doing
something, have been hassled or made to feel
inferior because you are Black” in any of five
situations. Any positive response indicated
discrimination
Author developed measure. Questions include
“whether the participants had personally
experienced any racist or discriminatory encounters
in general, work and medical settings
312 African American
adults randomly
selected
Broman56
PRS27
Racism measure
Din-Dzietham et al.57 356 Black adults,
population-based
sample
211 Black men and
women, convenience
sample
Sample
Barksdale et al.50
Interpersonal racism
Author
Table 1 | Interpersonal, internalized, and institutional racism and blood pressure
Race, Racism, and Hypertension
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519
520
666 Black or Latino(a)
adults (190 Black),
snowball sampling
357 Black and Latino
adults, 245 with
nighttime readings,
convenience sample
40 Black students,
convenience sample
Poston et al.47
Ryan et al.51
Brondolo et al.62
Hill et al.66
Interpersonal racism measure
PRS,27 racism in academic settings, public setting,
racist statements
Perceived Ethnic Discrimination QuestionnaireCommunity Version24
BRFSS reactions to race module—three questions
“How often do you feel discomfort, or anger by the
ways others treat you in your everyday life because
of your race? do you feel that “racial discrimination
diminishes your ability to achieve your goals fully?”
“You have been receiving less than the best health
care because of your race?”
PRS27
RaLES;26,125 KRDQ59
91 Black and white adults, Everyday unfair treatment (discrimination), no
convenience sample
questions on attribution to race68
Tomfohr et al.64
PRS,27 overall, exposure in public places, racist
statements
52 Black adults,
convenience sample
Singleton et al.63
61 Black and white adults, Everyday unfair treatment (discrimination)
convenience sample
(no questions on attribution to race)
221 Black medical
professionals, born in
United States or Africa
Peters54
Smart Richman
et al.65
Sample
162 Black adults,
convenience sample
Author
Table 1 | Continued
ABP-two days and two
nights
ABP-day and night
ABP-day and night
ABP-day and night
ABP-day and night
Mean BP
Mean SBP
Mean SBP and DBP
Blood pressure measure
Findings
UT/D is associated
with less nighttime
dipping of SBP and
DBP. No interactions
with race. UT/D
mediates race
differences in dipping.
Racism in public
settings positively
related to nighttime
SBP and DBP. No
effects for daytime BP
UT/D positive relation
to overall DBP. Time
trend: for high UT/D
(vs. low) increase
over the day, shallow
decreasing slope
during night
PR in academic setting
positively associated
with daytime DBP and
nighttime DBP. No
effects for SBP
PR positively
associated with
nighttime SBP and
DBP, inversely related
to BP dipping
U-shaped relation—
both the lowest and
highest levels of
exposure had higher
BP than individuals
with moderate
exposure
No relation
Table 1 | Continued on next page
Age, gender, race,
BMI, defensiveness/
social desirability SES,
and average BP, hostility,
marital status, weekly
consumption of alcoholic
beverages, and smoking.
No information
Sex, age, race, SES, BMI,
hostility, neuroticism,
and observational level
variations in posture
Gender, BMI
Age, race, gender, BMI,
cynicism/hostility,
individual-level measures
of SES, also observation
level measures of caffeine
and alcohol, posture,
smoking
Ethnicity, age, gender,
tobacco use, exercise,
BP meds, BMI, income,
education, employment,
insurance
Birthplace, BMI, age
Age, trait anger, trait
No relation
anxiety, anger expression
Potential covariates
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Race, Racism, and Hypertension
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HTN measure
Mean SBP and DBP or
presence of
hypertension
HTN measure
91,748 Records of black Local spatial segregation index
and white mothers drawn
from NYC Department
of Health Vital
records
The degree to which members of each race/ethnic
Sample of 2001–2002
group are exposed more to one another than to
data of 2,692 women
members of other racial/ethnic groups
enrolled in the
WISEWOMAN program
of the Centers of Disease
Control and Prevention
Grady and Ramirez92
AMERICAN JOURNAL OF HYPERTENSION | VOLUME 24 NUMBER 5 | may 2011
Mobley et al.109
Age, education,
unemployment, birth in
South of US
Potential covariates
Perceived stress
score, defeated coping
style
Potential covariates
10-year CHD risk
calculated by an
algorithm using gender,
age, total and high
density lipoprotein (HDL),
cholesterol, SBP, Smoking
status, diabetesstatus
Positive relationship:
higher segregation,
greater risk of
chronic and
pregnancy HTN
No relation
Findings
No relation
Findings
Table 1 | Continued on next page
Individual characteristics: Negative relation
age, smoking status,
education, race/ethnicity
Built Environment
characteristics: land use
mix, per 1,000 residents—
number of fitness
facilities, full size grocery
stores, fast food places,
restaurants, minimarts.
Socioecological
characteristics: robbery
arrests per 1,000 residents
Presence of chronic HTN Age, marital status, place
or pregnancy-related HTN of birth, education,
Medicaid use, poverty
Death registration
Contrast between largely black and largely white
areas (largely black ≤75% black, largely white ≤75% information from NYC
DOH, cause of death is
white), plus Harlem
reported by a physician
(ICD - 9.401–404)
All residents of NYC
drawn from census 1990
and death registrations
from 1988 to 1994
Fang et al.96
Institutional racism
Racism measure
Sample
Author
Racism measure
Nadanolitization scale31
Age and body mass
matched samples of
African-Caribbean,
nondiabetic women aged
25–60. Twenty-seven
with high internalized
racism and twenty-six
with low internalized
racism
Sample
Tull et al.89
Internalized racism
Author
Table 1 | Continued
Race, Racism, and Hypertension
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521
ABP, ambulatory BP; BMI, body mass index; BP, blood pressure; BRFSS, Behavior Risk Factor Surveillance System; CHD, chronic heart disease; DBP, diastolic BP; HTN, hypertension; KRDQ, Krieger Racial Discrimination Questionnaire;
PRS, Perceived Racism Scale; RaLES, Racism and Life Experiences Scale; RRS, residential racial segregation; SBP, systolic BP; SES, socioeconomic status.
Positive relation
Demographics, clinical
risk factors, behavioral risk
factors, SES
Incident hypertension
History of incarceration
Wang et al.97
Positive relation
None used in analysis
3,014 Telephone surveys 2000 Census—percent of blacks in census tract
done using a sample of
men and women in North
Nashville and Nashville/
Davidson, TN
Schlundt et al.93
Self-reported diagnosed
hypertension
2000 Census—neighborhood composition, percent Mean SBP and DBP
Probability sample of
3,105 participants aged Hispanic, percent immigrant, percent non-black in
18 and over from various census tract
cities in Chicago
Sex, age, race/ethnicity,
education, income,
marital status, presence
of children, BMI, health
insurance status, regular
medical care status,
immigration status,
exercise frequency
Findings
RRS/institutional racism measure
HTN measure
Sample
Morenoff et al.94
Potential covariates
Race, Racism, and Hypertension
Author
Table 1 | Continued
522
No relation
STATE OF THE ART
c­ onsidered as a form of social ostracism. Phenotypic or cultural
characteristics are used to render individuals outcasts, making
them targets of social exclusion, unfair treatment, and harassment; and consequently, either directly or indirectly, depriving
them of social and economic opportunities and threatening personal safety.21 Detailed reviews concerning the conceptualization and measurement of racism are available elsewhere.16,18,22
Racism can occur on multiple levels: individual/interpersonal, internalized, and institutional.22,23 Individuallevel racism includes episodes of race-based maltreatment
that are perpetrated by individuals and targeted at other
individuals.17,22 In the context of an interpersonal exchange,
these exchanges are considered interpersonal racism, which
has been defined as “directly perceived discriminatory interactions between individuals whether in their institutional
roles or as public and private individuals.”22 Individual-level
racism is typically assessed with self-report surveys inquiring
about exposure to acts perceived as discriminatory, unfair, or
disrespectful (i.e., refs. 24–27). Self-report surveys assess the
subset of experiences of ethnicity-related maltreatment that
are directly perceived by the target and are generally labeled
­perceived ­racism or ethnic discrimination.
Internalized racism is defined as “the acceptance, by marginalized racial populations, of the negative societal beliefs
and stereotypes about themselves.”28 The internalization of
negative stereotypes about ones’ own group may develop in
response to repeated exposure to ethnicity-based maltreatment, as a function of cultural communications of attitudes
toward stigmatized groups, and from familial or other socialization processes, as well as other mechanisms.29,30 In studies
of BP among black individuals, internalized racism has been
assessed with a self-report scale (i.e., Nadanolitization scale)31
that measure the degree of agreement with typical stereotypes
about the black individuals.
Institutional racism refers to specific policies and/or procedures of institutions (i.e., government, business, schools,
churches, etc.) which consistently result in unequal treatment
or outcomes for particular groups, even though other nonrace-related factors may also be associated with the disparate
outcomes.32,33 Policies resulting in unequal treatment can be
considered as a form of racism, despite the absence of evidence
of deliberate racial prejudice on the part of the policy-makers.
This is the case when majority-group policy-makers are less
aware of or responsive to the consequences of these policies
for minority stakeholders.34 In general, research on the relationship of institutional racism to HTN has focused on the
relationship of BP to the tangible outcomes of these policies,
including access to education or health care, residential segregation, incarceration, among other outcomes.35,36 Two outcomes that have been specifically studied in relation to HTN
include residential racial segregation (RRS) and incarceration.
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Residential segregation refers to “the degree to which
groups of people categorized on a variety of scales (race, ethnicity, income) occupy different space within urban areas.”37
We focus on race-based residential segregation (RRS), which
is likely to be a function of a number of both historical and
current actions on the part of institutions (i.e., real estate
­developers, lending organizations, employers) as well as the
actions of individuals within neighborhoods.37 RRS also serves
as a proxy for the extent to which black individuals are ostracized by other groups.38 Across all income groups, blacks tend
to live in more racially segregated areas than do whites, but
RRS is most pronounced among individuals with low ­levels
of income and education.35 Strategies for conceptualizing and
quantifying RRS have been well reviewed elsewhere.37,39,40
Examples of measures include the index of dissimilarity and
the proportion of black residents in a given area, a measure
used in most ­studies of HTN despite some limitations to its
interpretability.37,41
Rates of incarceration in the criminal justice system can also
be regarded as an index of institutional racism.42,43 In comparison to whites, most evidence suggests that black Americans
are more likely to be incarcerated, even when controlling for
a wide range of case and jurisdiction-related variable.42 These
differences have developed in part, because of stereotypes
about the propensity of black Americans to be violent, as well
as legal and policing policies and practices.42,43
This review extends our prior work and examines studies of
adults linking each level of racism to HTN diagnosis or to BP
levels (with BP levels serving as a proxy for a documented diagnosis of HTN).14,44 To obtain all relevant studies, we searched
all EBSCO-host-related databases, including MEDLINE and
Psych Info using the terms: racism, racial discrimination, ethnic discrimination, institutional racism, internalized racism,
self-stereotyping, residential segregation, racial segregation,
racial residential segregation, and incarceration combined
with BP, cardiovascular response, reactivity, HTN, and health.
All papers were searched for any additional relevant references. Papers available through August 2010 were included.
Table 1 includes the details of all reviewed studies for each
level of racism.
To further understand the mechanisms through which racism may affect HTN, we also investigate the relationship of
racism to obesity, low levels of fitness, and excess alcohol consumption. Each has been documented to be associated with
increased HTN prevalence.20,45 Reductions in these risk factors have been associated with improvements in BP, and they
are frequent targets of physician recommendations.45
We include data on psychosocial stress as a risk ­factor,
although the relationship is not as well documented or
accepted as lifestyle-related risk factors. Events and conditions
are perceived as stressful when they are appraised as ­salient and
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STATE OF THE ART
threatening, and present demands for coping that are ­perceived
to exceed the individual’s resources.46 Both ­systematic and
conceptual reviews suggest that chronic, but not acute stressors are more likely to be associated with increased risk for
HTN.47,48
All levels of racism can result in acute stress exposure,
but racism is widely regarded as a chronic stressor.16,21,49
Interpersonal racism takes the form of discrete events, including both overt and covert episodes of race-related maltreatment. These acute events can become chronic stressors if
they occur frequently and/or if the experience has persistent
negative effects. For example, the acute effects of race-related
maltreatment may be maintained if the targeted individual
experiences constraints on his or her ability to resolve the
situation or cope with its aftermath.21,46 Institutional racism
is associated with conditions (e.g., residential segregation,
incarceration) that present additional obstacles or sustained
demands that can act as chronic stressors.
Racism and Htn: Examining the Associations
of Interpersonal, Internalized, and Institution‑
alized Racism To Htn Diagnosis Or Bp Levels and
Htn‑Related Risk Factors
Individual/interpersonal racism
The bulk of the research on racism and HTN has investigated
the effects of individual-level or interpersonal racism.15,17
Most studies employed within-group designs to investigate the
degree to which the intensity of exposure to racism affects risk
for HTN within black individuals. In our prior review,14 we
indicated limited direct relationships of racism to HTN diagnosis. The subsequent publications support this conclusion.
To date there have been 12 observational studies (described in
13 papers) which included black adults and which examined the
relationship between self-reported exposure to interpersonal
racism and resting BP level (e.g., a mean of two or three readings taken under standardized conditions)47–55 or self-reported
or physician-diagnosed hypertensive status.48,56–58 Seven studies did not find a direct relationship between perceived racism and BP when the investigators examined the sample as a
whole.47,50,52–54,56,57 Two studies have found a negative relationship either among older participants54 or among the participant
group as a whole.59 There are two ­studies that report a U-shaped
relationship of racism to HTN, in which, depending on participants’ race, gender, and social class, there were elevated BP levels in those experiencing high levels of racism or no racism vs.
moderate levels of racism.48,51 There are only two studies that
reported a positive relationship between self-reported racism
and either BP level or self-reported diagnosis of HTN either
in the group overall49 or in one subgroup (i.e., non-US born
women).58 However, one of these ­studies included a small sample (n = 89), only 18% of whom were black.49
523
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In contrast, the data from ambulatory BP (ABP) monitoring
studies are more consistent. ABP, and in particular nocturnal
ABP, is regarded as a more reliable predictor of target organ
damage than are clinic measures.60 Ambulatory monitoring
also captures BP reactivity to daily events. The six studies of
adults all reported positive relationships between perceived
racism/discrimination and either daytime ABP,61 nighttime
ABP or BP dipping,62–65 or both.66
There are substantial variations in the quality of these studies of HTN diagnosis, clinic BP or ABP. Only four of the
studies employed population-based or randomly selected
samples.55–57,59 As shown in Table 1, some studies employed
measures with a small number of items inquiring about discrimination in general or experiences of discrimination in specific venues (i.e., such as work or medical care),48,52,55,56,59 and
very little psychometric information was provided about these
measures. Others studies included measures that have been
subjected to extensive psychometric testing (e.g., Perceived
Racism Scale, Everyday Discrimination, or the Perceived Ethnic
Discrimination Questionnaire-Community Version).47,49,50,54
The studies of ABP (vs. those of BP level or HTN diagnosis)
were more likely to include measures with known and good
psychometric properties. However, it is important to note that
neither the more limited scales, nor those with good psychometric properties yielded positive effects in studies of clinic BP
or HTN status. In contrast, the same scales (i.e., the Perceived
Racism Scale, Everyday Discrimination/Unfair treatment)
were associated with ABP, even in studies with much smaller
samples.61–66
As is the case with all self-report measures, scores on measures of perceived racism may contain some error. The scales
measuring perceived racism cannot distinguish between the
target’s perceptions of racial bias in cases in which these perceptions are accurate (i.e., the perpetrators’ actions were motivated by racial bias) vs. those in which the target’s perceptions
are a function of misperceptions or misattributions to discrimination. To attempt to control for intrapersonal factors such
as hostility or neuroticism that might influence the perceptions of racism (and potentially HTN), but may develop from
nonracism-­related factors (e.g., temperament, family functioning, etc.), some investigators have included measures of personality characteristics as covariates.62,65 Three ABP studies in
which measures of negative-affect related traits (e.g., hostility or
neuroticism) were included as covariates find that the effects of
perceived racism on ABP remain robust and significant.62,64,65
Measures of perceived racism which inquire about discrimination in a variety of venues could elicit answers reflecting perceptions of institutional racism (i.e., perceptions of
being mistreated as a function of institutional policies) rather
than experiences of interpersonal maltreatment. Racism
may also affect an individual’s access to economic and social
524
Race, Racism, and Hypertension
resources, and in turn affect HTN risk through deprivation.
Consequently, most investigators included measures of individual level or neighborhood socioeconomic status (SES) as a
partial control for the effects of these environmental or institutional variables. In studies in which the effects of SES were
explicitly evaluated,67 the inclusion of SES as a control variable
did not eliminate the effects of perceived racism/discrimination on ABP.62 However, some studies suggest that SES moderates the effects of racism on BP, although the direction of
effects is not consistent and additional work is needed.48,55,57
Individual-level racism may also have health effects in circumstances in which the targeted individual is unaware of
the exposure.68,69 Some investigators have advocated the use
of measures of unfair treatment or discriminatory behavior
(e.g., the Everyday Unfair Treatment Scale68,69) which assess
exposure to interpersonal experiences that are likely to be a
function of racial discrimination, without requiring participants
to attribute the maltreatment to racial bias. These scales can be
considered as a measure of the construct “­everyday unfair treatment” rather than racial discrimination per se, because individuals can perceive themselves as targeted for unfair treatment for
many reasons (i.e., including their social class or ­gender). Some
investigators have included additional questions about the attributions for the maltreatment; however, none of the studies of
HTN or ABP in adults included these items.
All studies of HTN and clinic BP employed measures directly
referring to race. All ABP studies included measures assessing
experiences of unfair or discriminatory treatment in ­everyday
life (i.e., Everyday Unfair Treatment, Perceived Racism
Scale, and Perceived Ethnic Discrimination QuestionnaireCommunity Version). Four of these studies included measures which explicitly refer to race as a cause for the unfair
treatment (i.e., Perceived Racism Scale and Perceived Ethnic
Discrimination Questionnaire-Community Version),61–63,66
whereas two other studies included measures of unfair treatment that did not explicitly refer to race.64,65 Associations of
unfair treatment/discrimination to ABP among blacks were
found using either type of measure of unfair treatment.
Interpersonal racism and risk factors for HTN. Although two
recent studies reported no concurrent relationship of racism
to body mass index,70,71 another prospective investigation
reported that increases in interpersonal racism were positively
associated with weight gain over a period of 8 years.72 To our
knowledge there have been no studies of the relationship of individual-level racism and the intake of specific nutrients such as
sodium or potassium. Perceived racism has been associated with
greater risk for any level of alcohol use (but not binge or heavy
drinking) among black Americans.73 Prospective studies also
indicate a relationship of perceived discrimination to increases
in alcohol use, partially mediated by ­discrimination-related
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changes in psychological distress.74 The one study specifically
examining physical activity in a large population-based sample,
did not find a relationship with racism.75
In contrast, there is substantial, clear and consistent evidence
that individual-level racism is associated with indices of psychological distress (e.g., negative affect, anger, depression, and anxiety), as well as personality characteristics (e.g., ­hostility, trait
negative mood) that increase the experience of distress.15,17,76,77
Racism may also influence cardiovascular responses to stress
exposure. BP reactivity to stress has been identified as an independent predictor of the development of HTN.78,79 Several
studies report that perceived individual-level racism predicts
the magnitude of BP reactivity to laboratory-induced stressors.80–85 However, others studies found no direct relationship of individual-level racism to BP reactivity or recovery, and
report that the effects of racism emerged only when moderated
by other characteristics (e.g., support or hostility).80,82,86
Interpersonal racism is more consistently related to perceived
stress and negative emotions than to lifestyle-related factors,
including physical activity or obesity. It is worth noting that
some,50,57 although not all,54 studies of racism and HTN found
that stress reactions to racism were associated with HTN diagnosis or BP level, even when exposure to race-based maltreatment was not. However, there are still very limited data.
Internalized racism
To our knowledge, there is only one study directly assessing
the effects of internalized racism, assessed with a modified version of the Nadanolitization scale on BP in Afro-Caribbean
women. The authors did not find a direct relationship of internalized racism to resting BP.87
The measure of internalized racism (i.e., the Nadanolitization
scale) assesses the belief that members of one’s group have
characteristics that correspond to common stereotypes about
the group. This may or may not be related to self-­stereotyping
(i.e., the degree to which the individual has incorporated
these stereotypes into his or her self-concept). New research
is employing methods from cognitive psychology, including
variations on the Implicit Association Test, to assess nonconscious self-stereotyping.88
Internalized racism and HTN risk factors. Internalized racism
does not show a relationship with body mass index,87 but is
more closely associated with abdominal obesity, with three of
four studies reporting a significant positive relationship.89–91
One study suggests that internalized racism is associated with
perceived stress among black women.87
Institutional racism
The data linking racial residential segregation to HTN is
mixed. RRS has been associated with greater risk for HTN
AMERICAN JOURNAL OF HYPERTENSION | VOLUME 24 NUMBER 5 | may 2011
STATE OF THE ART
among both black and white mothers, such that mothers
­living in more racially segregated areas (e.g., areas in which
there were high percentages of black individuals and in which
residents were less likely to interact with others who were not
black) were more likely to report having chronic HTN and to
be at risk for pregnancy-related HTN, controlling for neighborhood poverty and other factors.92 Another study reported
that the percentage of black individuals living in an area was
correlated with the percentage of individuals with HTN, but
did not control for other facets of the neighborhood in which
black individuals predominate, including higher density and
lower cost of housing, variables independently associated
with HTN.93
In contrast, two population-based studies of black adults did
not find any relationship of the proportion of blacks ­living in
the neighborhood to prevalence of HTN among black adults94
controlling for other neighborhood risks.95 Fang et al. reports
that for black adults, there was no effect of residential area on
HTN-related mortality.96 Finally, a large population-based
study of black women from communities varying in size, segregation, and other factors found that racial segregation, as
assessed by an index evaluating the likelihood that individuals would interact with others of another ethnicity or race,
was negatively associated with a measure of 10-year risk for
coronary heart disease in which HTN was one factor used to
­comprise the measure.64
To our knowledge, there is only one study specifically examining the link between incarceration and HTN.97 The investigators report that a history of incarceration was associated
with HTN prevalence and new incidences of HTN because
incarceration across both black and white adults drawn from
a national sample of young adults drawn from the Coronary
Artery Risk Development in Young Adults (CARDIA) study.
The effects were strongest for black men, the group most likely
to have been incarcerated, but interactions of race and incarceration were not significant.
There is substantial evidence that black Americans live in
more disadvantaged communities than other groups.34 The
limited available evidence suggests that neighborhood disadvantage may mediate the relationship of RRS to HTN.40 Low
levels of neighborhood economic resources, including housing quality and affluence have been associated with increased
prevalence of HTN,98,99 as have perceptions of social stress in
the community, including crime, perceptions of safety, marital
instability, and crowding.100–103 There may also be additional
environmental factors influencing racial disparities in HTN,
given the wide geographic disparities in rates of HTN among
both blacks Americans.104 Efforts to intervene to reduce HTN
will require an understanding of the specific circumstances or
deprivations that are most closely associated with HTN and
which mediate the effects of RRS on HTN.40
525
STATE OF THE ART
Institutional racism and HTN risk factors. Data from most,105–
but not all109 studies suggest that living in neighborhoods
with higher levels of RRS is associated with a higher prevalence
of obesity. The data on the association of neighborhood affluence to obesity is clear: rates of obesity are higher in neighborhoods with low vs. high SES.37,110
To our knowledge, there is no direct evidence that RRS
is independently linked to higher rates of alcohol abuse or
dependence. However, there is evidence that economically
disadvantaged neighborhoods and those with higher ­levels of
neighborhood stress are associated with a higher rate of alcoholism.111–113 The available data on RRS suggest that individuals living in more segregated communities are less likely
to be physically active.114 RRS has been associated with both
objective indices of stress (e.g., crime),115 subjective reports of
neighborhood stress,116 and fewer community resources for
stress reduction (e.g., parks, recreational ­facilities, etc.).117
A portion of these neighborhood effects on HTN risk factors may be a function of the barriers to obtaining healthy
foods and accessing recreational facilities, combined with
greater access to liquor stores.110,118–121 In one experimental
study in which very low income individuals from low income
neighborhoods were randomly assigned to live in new, higher
income neighborhoods revealed decreases in obesity (but not
HTN) over a 5-year period.122 Similarly, in the Yonkers project,
low income minority families who were randomly assigned to
be able to move to middle class neighborhoods reported less
alcohol abuse than did families unable to move.123
108
Summary
Black individuals remain at higher risk for the development
of HTN than do white individuals, despite improvements in
awareness and treatment. There is evidence that racism appears
to affect risk for HTN, but the effects are complex. Among black
Americans, interpersonal racism is associated with ABP,61–
63,66,124 and in particular nocturnal BP, although it does not
appear to be reliably associated with resting measures of BP or
HTN diagnosis.47,50,52–54,56,57,59 There is mixed evidence linking RRS, an index of institutional racism, to HTN prevalence
and BP levels,92,93 and emerging evidence that prison incarceration is associated with HTN prevalence.97 It is not clear if the
effects of RRS are attributable to the degree of racial isolation
or the degree of deprivation associated with the neighborhood,
as neighborhood SES is inversely associated with HTN incidence.98,99 There is no evidence directly linking internalized
racism to BP, but there have been very few studies.
Racism may influence the incidence of HTN by ­increasing
the incidence of HTN-related risk factors. There is limited
­evidence that interpersonal racism is associated with the
development of obesity.72 RRS is associated with higher levels
of obesity93 and lower levels of fitness.114 Both interpersonal
526
Race, Racism, and Hypertension
racism and neighborhood deprivation and stress have been
linked to alcohol use, but more data are needed on the effects
of internalized racism and RRS. All levels of racism are associated with perceived stress, and individual-level racism, in particular, is associated with distress21 and stress reactivity.125
Conclusions
Taken together, the evidence suggests that institutional and
interpersonal racism are likely to contribute to the development of HTN, although multiple mechanisms and trajectories
may be involved. Individual-level racism, and potentially internalized racism, may act in part by increasing the frequency,
magnitude, duration, and psychophysiological effects of stress
exposure. The harsh or impoverished environments that are a
function of institutional racism may add additional stress and
raise barriers to achieving a healthy lifestyle.
The relationship of perceived racism to BP emerges more
clearly, when the measures inquire about episodes of interpersonal maltreatment vs. global judgments of exposure to discrimination. This may reflect problems with the reliability of
global discrimination measures or the strategies for measuring BP. However, it is also possible that the findings reflect the
aspects of individual-level racism (i.e., stressful interpersonal
maltreatment) that are most closely associated with BP.
Exposure to race-related maltreatment has been shown to be
positively related to increased rates of negative interpersonal
interactions in general.73,77 If the effects of perceived racism
on BP are mediated through exposure to daily interpersonal
maltreatment, the effects of racism on BP may not be apparent
during brief conditions involving rest (or neutral or positive
interactions with medical personnel). Instead, the effects of
racism may be more likely to emerge when BP is assessed during everyday events, including episodes of interpersonal conflict. This is consistent with the finding that perceived racism/
discrimination is more closely related to ABP than to resting
clinic BP. The importance of ongoing interpersonal conflict to
BP is underscored by our recent report that the level of daily
interpersonal harassment predicted masked HTN (i.e., clinic
normotension plus elevated ABP) in a sample of black and
Latino(a) adults.126 Further study of the effects of racism on
psychobiological responses to interpersonal relationships is
needed, as is research on coping strategies that might moderate or buffer these effects.
Institutional racism is associated with conditions including neighborhood poverty, segregation, and incarceration
that provide limited access to health promoting resources
and ­constraints on the development and/or deployment of
health promoting coping strategies.110 This suggests that
resources and coping may mediate the relationship of institutional ­racism to HTN. Yet, experimental data suggest that the
ways in which these variables act as mediators is complex. For
MAY 2011 | VOLUME 24 NUMBER 5 | AMERICAN JOURNAL OF HYPERTENSION
Race, Racism, and Hypertension
e­ xample, ­moving to a less impoverished area was associated
with decreases in obesity and alcohol abuse, but was not associated with changes in hypertensive status.122,123
Research is needed to understand the specific communitylevel variables that affect HTN incidence. It is possible that
multiple environmental factors (e.g., high levels of stress exposure plus limited access to healthy foods) must be present to
trigger the onset of HTN. Alternatively, environmental variables may exert an effect on risk for HTN only in the presence
of genetic vulnerability. Different levels of racism may interact to compound risk by impairing coping. For example, the
negative mood states that are a persistent effect of exposure to
interpersonal racism may undermine the motivation needed to
overcome the effects of institutional racism, including environments with few resources for healthy living.62 Risk factors may
operate differently over the course of development. The early
life effects of racism, including the well-documented effects of
racism on birth weight,127,128 may set the stage for increased
vulnerability to the additional challenges presented by chronic
interpersonal maltreatment or neighborhood poverty.
Despite progress, research on racism and HTN is still in its
early stages. To more fully understand the relationship of racism to HTN, it will be important to identify the ways each level
of racism acts as a stressor or as a barrier to health promotion.
These continued efforts will be necessary to identify targets for
prevention and intervention.
Acknowledgments: This publication was made possible by prior support to
E.B. from grant R01HL68590 and ongoing support to G.O. from the following
grants: P60MD003421; R01HL087301; and R01HL078566. The contents of
this work are solely the responsibility of the authors and do not represent
the official views of NIH.
Disclosure: The authors declared no conflict of interest.
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