Perceived Racial Discrimination and Adoption of Health Behaviors … … · he rates of morbidity...

Perceived Racial Discrimination and Adoption of Health Behaviorsin Hypertensive Black Americans: The CAATCH Trial

Jessica M. Forsyth, Antoinette Schoenthaler, Gbenga Ogedegbe, Joseph Ravenell

Journal of Health Care for the Poor and Underserved, Volume 25, Number1, February 2014, pp. 276-291 (Article)

Published by The Johns Hopkins University PressDOI: 10.1353/hpu.2014.0053

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© Meharry Medical College Journal of Health Care for the Poor and Underserved 25 (2014): 276–291.

Perceived Racial Discrimination and Adoption of Health Behaviors in Hypertensive

Black Americans: Th e CAATCH Trial

Jessica M. Forsyth, PhDAntoinette Schoenthaler, EdDGbenga Ogedegbe, MD, MS

Joseph Ravenell, MD, MS

Abstract: Background. Few studies examine psychosocial factors infl uencing the adoption of healthy behaviors among hypertensive patients. Th e eff ect of discrimination on health be haviors remains untested. Purpose. To examine the infl uence of discrimination on adop-tion of healthy behaviors among low- income Black hypertensive patients. Methods. Black patients (N = 930) in community- based primary care practices enrolled in the CAATCH trial. Mixed eff ects regressions examined associations between perceived discrimination and change in medication adherence, diet, and physical activity from baseline to 12 months, controlling for intervention, gender, age, income, and education. Results. Patients were low- income, high- school- educated, with a mean age of 57 years. Greater discrimination was associated with worse diet and lower medication adherence at baseline. Discrimina-tion was associated with greater improvement in healthy eating behaviors over the course of the 12-month trial. Conclusions. Prior exposure to discrimination was associated with unhealthy behaviors at baseline, but did not negatively infl uence the adoption of health behaviors over time.

Key words: Discrimination, hypertension, Blacks, physical activity, diet, medication adherence.

The rates of morbidity and mortality related to cardiovascular disease are dispro-portionately high among Black Americans compared with non- Hispanic Whites.1

A large proportion of this disparity can be attributed to the rates of hypertension among Blacks.1 Despite improvements in the rates of blood pressure control among all hypertensive Americans, the rate of blood pressure control among Blacks remains signifi cantly lower than that among Whites.2,3 Adverse health behaviors such as sed-entary lifestyle, lower potassium intake, lower consumption of fruits and vegetables, and poor adherence to antihypertensive medication are prevalent among Blacks,4– 6 and

ORIGINAL PAPER

Th e authors are affi liated with the Center for Healthful Behavior Change, NYU School of Medicine. Please address correspondence to Jessica Forsyth, PhD; Center for Healthful Behavior Change; Division of General Internal Medicine; New York University School of Medicine; 227 East 30th Street, Room 630F; New York, NY 10016; (646) 501-2602; jessica.forsyth@nyumc .org.

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277Forsyth, Schoenthaler, Ogedegbe, and Ravenell

may play a role in the lower blood pressure control rate among hypertensive Blacks compared with that of the general population.

Clinical trials support the effi cacy of interventions targeting therapeutic lifestyle change, including increased consumption of fruits and vegetables, reduced consumption of fat and sodium, increased physical activity, and medication adherence in controlling hypertension.7– 10 However, few studies have examined psychosocial factors that may interfere with the adoption of lifestyle change among low- income Black hypertensive patients, a population that is at particularly high- risk for cardiovascular disease.

Research has shown that chronic stress is associated with reduced participation in positive health behaviors, such as maintaining a healthy diet and engaging in regular physical activity, and is implicated in increased negative health behaviors, such as drinking alcohol, smoking, and consuming high fat and high sugar foods.11– 15 Th ere is evidence that reliance on negative health behaviors to cope with chronic stressors is even greater among Blacks than it is among Whites, and that negative health behaviors may provide a protective mental health function for Blacks in particular.11, 12

One chronic source of stress that specifi cally impacts Black Americans is racial discrimination. Decades of research has provided evidence that racial discrimination is a unique stressor for Blacks that has a deleterious impact on a variety of mental and physical health outcomes,16, 17 including cardiovascular reactivity and ambulatory blood pressure.18 One proposed pathway by which discrimination infl uences health is that the stress of discrimination leads to the use of negative health behaviors as cop-ing strategies and depletes the self- regulatory resources necessary to maintain positive health behaviors.11,16 Th ere is evidence that perceived discrimination is signifi cantly associated with a variety of health behaviors including reduced health screening,19– 21 delays in seeking treatment, tests or prescriptions,22– 24 less frequent provider visits to treat serious illness,19 and reduced participation in secondary preventive care for hypertension, diabetes, and heart disease.22 Perceived discrimination has also been associated with lower adherence to antiretroviral medications,25 and use of alternative rather than conventional medications.26

Studies have found consistent associations between perceived discrimination and negative health behaviors related to hypertension risk among Blacks, including smoking

and alcohol consumption.27– 30 However, few studies have examined the relationship of discrimination to lifestyle behaviors specifi cally associated with increased blood pressure control such as adherence to antihypertensive medications, diet, and physical activ-ity. Th e only existing study that directly examined the relationship between perceived discrimination and dietary behaviors found a signifi cant negative association between perceived discrimination and eff orts to avoid unhealthy food.31 Of only two studies conducted, neither found a signifi cant association between perceived discrimination and physical activity among Blacks.32, 33

Most of the studies that have examined the infl uence of perceived discrimination on health behaviors have been cross- sectional analyses of large population- based sur-veys. To date, no study has examined the infl uence of discrimination on therapeutic lifestyle behaviors among hypertensive patients. Low- income Blacks with hypertension are at particularly high risk for poor medication adherence34 and are more likely to experience complications associated with uncontrolled blood pressure.35 Th us, the aim


278 Racial discrimination and health behaviors

of the current study is to examine, in a longitudinal study, the infl uence of perceived discrimination on the adoption of healthy lifestyle behaviors among Black hypertensive patients in treatment at community- based primary care practices.

Methods

Th is study was conducted as part of a two- arm cluster- randomized controlled trial, Counseling African Americans To Control Hypertension (CAATCH). Th e objective of the CAATCH trial was to evaluate the eff ectiveness of a multilevel intervention targeted at physicians and patients compared to usual care in improving blood pressure control in hypertensive Blacks receiving care in 30 underserved community health centers (CHC) in the metropolitan New York City area from 2004 to 2008. Patients were eligible for the CAATCH trial if they, a) self- identifi ed as African American/ Black; b) were receiv-ing care in CHC site; c) had been diagnosed with hypertension (ICD diagnosis code: 401– 401.9); c) were taking at least one antihypertensive medication; but d) still had uncontrolled blood pressure based on mean measurements using an automated blood pressure device (BPTru); e) were 18 years of age or older; and f) were fl uent in English.

Over the course of the study, clinic sites were randomized upon recruitment to either the intervention or the usual care arm, with 15 clinics randomized to each condition. Th e intervention consisted of computerized interactive patient education designed to increase hypertension knowledge, home blood pressure monitoring, and group behav-ioral counseling sessions focused on adoption of therapeutic lifestyle recommendations including dietary change, reducing intake of sodium, increasing physical activity, and improving adherence to antihypertensive medication regimens. Patients in the usual care condition received print publications of the National Heart, Lung and Blood Institute on lowering blood pressure and the DASH eating plan. Additional details regarding the CAATCH trial are reported elsewhere.36

A total of 1,056 patients were enrolled in the CAATCH trial. Patients completed face- to-face interviews with and had their blood pressure measured (using an automated blood pressure monitor) by trained research assistants at their CHC at baseline, six and 12 months. Th e current study reports on secondary analysis of data from 930 patients enrolled in the CAATCH trial who had complete data on each of the six covariate variables (age, comorbidity, education, gender, income, marital status) included in the current analysis. All study procedures were approved by the Institutional Review Board at New York University School of Medicine and at all study sites.

Participants. Th e sample consisted of 930 patients (482 in the intervention group and 448 in the usual care condition) from 30 community health clinics with a mean age of 57 years. As shown in Table 1, 72% were female; 72% had an income of $20,000 or less; 69% had a high school education or less; 65% were unemployed; and 52% were on Medicaid. At baseline the mean blood pressure for the sample was 149/ 90 mm Hg, and the mean number of hypertensive medications per patient was 1.88.

Measures. Medication adherence was assessed with the Morisky Medication Adher-ence Measure,37 a 4-item self- report measure of medication- taking behavior with a yes/ no response format (e.g., “Have you ever forgotten to take your blood pressure medication?” “When you feel badly due to the medicine, do you skip it?”). Yes responses



Table 1.PATIENT SAMPLE CHARACTERISTICS

Baseline Overall % or Mean (SD)

N = 930 6 Months Mean

(SD) N = 930

12 Months Mean (SD)

N = 930

Intervention Group 51.8%n = 482

— —

Demographic Age 57 (12.2) — — Female 71.8% — — Born in US 71.4% — — Marital Status Single 28.9% — — Married 25.7% — — Divorced/ Separated 17.2% — — Widowed 15.1% — — Education < High School 37.1% — — High School 32.6% — — Some College 17.6% — — Unemployed 64.9% — — Insurance None 9.1% — — Private 13.9% — — Medicare 26.2% — — Medicaid 52.4% — — Health Maintenance Organization

15.5% — —

Income <10,000 46.2% — — 10,000– 20,000 26.1% — — >20,000 27.7% — —Discrimination (18– 106 higher) Lifetime 35.8 (18.3) — — Past Year 28.5 (14.2) — — Stress 37.3 (21.3) — —Poor Medication Adherence(0– 4 higher) 1.06 (1.2) .90 (1.1) .81 (1.1)Poor Diet (12– 69 higher) 45.4 (9.8) 43.0 (9.5) 42.7 (9.6)Physical Activity (kcal/ week) 823.4 (1652.1) 1033.4 (1652.3) 1001.1 (1927.7)Blood Pressure Systolic, mm Hg 149 (20) 131 (30) 133 (27) Diastolic, mm Hg 90 (13) 80 (18) 80 (16)



are summed with higher scores indicating greater nonadherence to prescribed hyper-tensive medications. Th e Morisky scale has demonstrated strong reliability (α = .90) in previous research with low- income urban samples 38 and it has been highly correlated with objective measures of adherence including pharmacy fi ll and blood pressure control rates.39, 40 Cronbach’s alpha reliabilities of the scale for the current sample were α = .83 at baseline, and α = .81 at six and 12 months.

Healthy diet was assessed with the diet items of the Rapid Eating and Activity Assessment for Patients (REAP). Th e REAP is a 31-item dietary and physical activ-ity assessment measure which was developed to be administered by physicians dur-ing medical history interviews and physical examinations.41 Th e 27 diet items assess patient- reported intake of fruits and vegetables, whole grains, sodium, fat, saturated fat, cholesterol, calcium- rich foods, and sugary foods and drinks. Item responses are in three- point Likert format (1 = oft en to 3 = rarely/ never) with higher scores indicat-ing less healthy eating habits. Th e REAP has strong test- retest reliability (r = .86), and validity was demonstrated through signifi cant correlations between the REAP and nutrients from the Food Frequency Questionnaire.41 Only the diet items of the scale were used in the current analyses in order to create a diet variable that is distinct from the physical activity variable. Cronbach’s alpha reliabilities for the 27 REAP diet items for the current sample was α = .83 at baseline, and α = .82 at six and 12 months.

Physical activity was assessed with the Paff enbarger Physical Activity and Exercise Index, a self- report measure of the number of kilocalories expended per week.42 It assesses the type and intensity of three types of activities including walking, stair climb-ing, and sports and recreational activities (divided into three categories: low intensity, moderate intensity, and heavy intensity). Each type of activity is assigned a kilocalorie score (e.g., walking has a value of 8 kcal/ minute; heavy intensity activities have a value of 10 kcal/ minute). Scores on the measure are total kilocalories expended per week, with higher scores indicating greater physical activity. Validity of the Paff enbarger Index has been demonstrated through signifi cant associations between Index scores and a test of physical fi tness (maximal treadmill performance),43 as well as a 64% increase in risk for heart attack among low scorers compared with high scorers.42 Physical activity was measured at baseline, six months, and 12 months.

Perceived racial discrimination was assessed with the lifetime, past year, and stress scales of the Schedule of Racist Events questionnaire.44 Th e SRE is an 18-item self- report measure that assesses exposure to discriminatory experiences across a variety of domains including service settings, schools, the workplace, and public places. Each item is responded to three times on a six- point Likert scale to indicate frequency of exposure to discrimination in the past year, over the lifetime (1 = never; 3 = sometimes; 6 = almost all of the time), and appraisal of the experiences as stressful (1 = not at all; 6 = extremely). Scores are summed to yield three subscale scores: lifetime, past year, and stress, with higher scores indicating more frequent exposure to perceived discrimination (range = 18– 108). Previous research has demonstrated high reliabilities (α ≥ .90) for each of the scales, and the scale has been correlated with a number of health outcomes. Cronbach’s alpha reliabilities for the current sample were Past Year (α = .93), Lifetime (α = .94), Stress (α = .94). In order to provide a multidimensional but parsimonious racial



discrimination variable for the current study, a unit- weighted composite perceived discrimination score was created by summing z- scores for the three scales of the SRE and calculating an average composite discrimination score. Perceived discrimination was only measured at baseline in the current study.

Demographic variables assessed included age, gender, household income, education level, marital status, employment status, and health insurance status.

Analyses. Th e objective of the study was to examine whether perceived discrimi-nation infl uences the adoption of health behaviors associated with hypertension from baseline to 12 months. Th e distribution of physical activity was positively skewed, so the data for this variable were log transformed prior to analysis. In order to provide a multidimensional but parsimonious perceived discrimination variable, a unit- weighted composite perceived discrimination score was created by summing z- scores for all three scales (past year, lifetime, and stress) and calculating an average discrimination score.

Of the 930 participants who had complete data on the four covariates, only 774 had complete data on the discrimination measure. A Little Missing Completely At Random test indicated that missing values on the discrimination measure did not occur at random. In order to minimize bias due to missing data on the independent variable, missing scores on discrimination were imputed via maximum likelihood estimation (using the Expectation- Maximization algorithm). All subsequent analyses were run using both the imputed discrimination scores and the original discrimination scores. No signifi cant diff erences in the results were observed. Th e results for the imputed discrimination scores are reported.

Mixed eff ects regressions were estimated to allow us to look at the change in outcome variables at the level of individual participants over time, which can then be aggregated to an overall estimate of change across all individuals. Mixed eff ects regressions allow the estimation of change for all subjects, including those who may be missing data at some of the time points. Th e dependent variables were change in medication adherence, diet, and physical activity over study time (i.e., the course of the study, from baseline to 12 months). Each of the variables was measured at three time points over the course of the study: baseline, six months, and 12 months.

Separate regressions were run for each of the three continuous outcome variables. Th e independent variable for all analyses was perceived discrimination. Th e independent variable was mean centered by creating deviation scores by subtracting the mean of the distribution from each score. Centering is conducted to reduce multicollinearity. Study time was naturally coded as months (0, 6, and 12) when data was collected. Th e critical analysis was the assessment of the discrimination by study- time interaction, which if signifi cant would suggest that change in the outcome over the course of the study was diff erent as a function of perceived discrimination. Th e interaction was represented by the partialed product of perceived discrimination and study time. Th e degree of nesting w/ in provider and practice levels was small (ICC = < .03), thus these levels were not included in the analyses as nested factors. For each regression a simple model adjusting only for the intervention was tested fi rst, followed by a second model adjusting for the intervention and the four covariates: gender, age, education, and income.



Results

Th e results of the fi rst mixed eff ects regression for medication adherence were signifi cant for the simple model adjusting only for the eff ect of the intervention, indicating that there was a signifi cant main eff ect for perceived discrimination on medication adherence at baseline (F = 20.982; p < .001; Est = .201; Standard Error = .044). Perceived discrimina-tion reported retrospectively at baseline was associated with decreased adherence at baseline. Th ere was a signifi cant main eff ect for study time on medication adherence (F = 29.497; p < .001; Est = – .040; SE = .007), with medication adherence improving over the course of the study from baseline to 12 months. Th ere was no interaction between discrimination and study time on medication adherence (F = .197; p > .05; Est = – .004; SE = .009), indicating that perceived exposure to racial discrimination did not infl uence the change in medication adherence over the course of the study. Th e main eff ect for perceived discrimination on medication adherence remained signifi cant in the second model adjusting for gender, age, education, and income (F = 8.847; p < .01; Est = .138; SE = .044). See Table 2.

As depicted in Figure 1, the results of the second mixed eff ects regression for diet were signifi cant for the simple model indicating a main eff ect for perceived discrimination on diet at baseline (F = 25.980; p < .001; Est = 1.897; SE = .372), with greater perceived discrimination associated with less healthy diet. Th ere was also a signifi cant interaction between perceived discrimination and study time on diet (F = 7.197; p < .01; Est = – .189;

Table 2.MIXED EFFECTS REGRESSIONS PREDICTING MEDICATION ADHERENCEa

Model Variables Estimate SE 95% CI p

1 Discrimination .201 .044 .115 .287 .000Months – .040 .007 – .055 – .026 .000Discrimination x Study Time – .004 .009 – .021 .013 .657Intervention – .291 .063 – .415 – .168 .000

2 Discrimination .131 .044 .045 .218 .003Months – .040 .007 – .055 – .026 .000Discrimination x Study Time – .003 .009 – .020 .014 .712Intervention – .305 .062 – .427 – .184 .000Gender .051 .069 – .084 .187 .455Age – .022 .003 – .027 – .017 .000Education – .005 .019 – .042 .032 .790Income .018 .031 – .043 .079 .553

aDependent variable: Medication AdherenceCI = Confi dence Intervals



SE = .070) such that the change in diet from baseline to 12 months was signifi cantly greater for those with high exposure to perceived discrimination compared with those with low perceived exposure. Greater exposure to perceived discrimination was associ-ated with greater improvement in diet over the course of the study. Th e main eff ect for discrimination (F = 13.600; p < .01; Est = 1.372; SE = .372) and the interaction between discrimination and study time (F = 7.239; p < .05; Est = – .189; SE = .070) remained signifi cant in the second model adjusting for gender, age, education, and income (see Table 3). In order to determine whether the eff ect of the interaction was due solely to regression to the mean over time, we tested a third model adjusting for baseline diet and found that the interaction of discrimination and study time remained signifi cant (F = 6.127; p < .05; Est = – .183; SE = .074).

Th e results of the third mixed eff ects regression was signifi cant for the simple model adjusting only for the eff ect of the intervention. Th ere was a signifi cant main eff ect for perceived discrimination on physical activity at baseline (F = 5.180; p < .05; Est = 1.406; SE = .618), indicating that perceived discrimination was associated with increased physical activity. Th ere was a signifi cant main eff ect for study time on physical activity (F = 14.825; p < .001; Est = .470; SE = .122), indicating that physical activity improved over the course of the study from baseline to 12 months. Th ere was no interaction between perceived discrimination and study time on physical activity (F = .590; p > .05; Est = .108; SE = .141), indicating that perceived exposure to racial discrimination did not infl uence the change in physical activity over the course of the study. In the second model adjusting for gender, age, education, and income the main eff ect for discrimination on physical activity was no longer signifi cant (F = .963; p > .05; Est = .618; SE = .630). See Table 4.

Figure 1. Changes in diet from baseline to 12 months, by discrimination.



Table 3.MIXED EFFECTS REGRESSIONS PREDICTING DIETa

Model Variables Estimate SE 95% CI p

1 Discrimination 1.897 .372 1.166 2.627 .000Months – .434 .061 – .553 – .315 .000Discrimination x Study Time – .189 .070 – .327 – .050 .007Intervention – .727 .569 – 1.845 .390 .202

2 Discrimination 1.372 .372 .642 2.102 .000Months – .433 .060 – .551 – .314 .000Discrimination x Study Time – .189 .070 – .327 – .051 .007Intervention – 1.199 .560 – 2.298 – .099 .033Gender – 1.968 .621 – 3.187 – .748 .002Age – .176 .024 – .223 – .128 .000Education – .385 .171 – .721 – .049 .025Income – .254 .279 – .803 .295 .363

aDependent variable: DietCI = Confi dence Intervals

Table 4.MIXED EFFECTS REGRESSIONS PREDICTING PHYSICAL ACTIVITYa

Model Parameter Estimate SE 95% CI p

1 Discrimination 1.406 .618 .194 2.618 .023Months .470 .122 .230 .710 .000Discrimination x Study Time .108 .141 – .168 .385 .442Intervention – 1.947 .888 – 3.690 – .204 .029

2 Discrimination .618 .630 – .618 1.854 .327Months .479 .122 .240 .719 .000Discrimination x Study Time .116 .141 – .160 .393 .409Intervention – 2.019 .890 – 3.765 – .273 .024Gender – 2.597 .989 – 4.537 – .656 .009Age – .152 .038 – .226 – .077 .000Education .472 .271 – .060 1.003 .082Income .124 .447 – .753 1.000 .782

aDependent variable: Physical ActivityCI = Confi dence Intervals



Discussion

A fairly large body of research has provided evidence of the relationship between discrimination and health outcomes, but relatively few studies have examined the mechanisms to explain this relationship. Two primary pathways have been proposed to explain the infl uence of discrimination on health. In the fi rst, chronic exposure to racial discrimination is hypothesized to cause physiological stress reactions that have a detrimental impact on downstream health outcomes. In the second pathway discrimi-nation is hypothesized to infl uence health by increasing reliance on the use of negative health behaviors as coping strategies, while reducing the ability to adopt and maintain positive health behaviors, thereby resulting in negative health outcomes. Th is study contributes to the limited literature examining the perceived discrimination- health behavior pathway.

Our results indicated that, among low- income Black patients being treated for hyper-tension, greater perceived racial discrimination was associated with signifi cantly worse diet and lower medication adherence at baseline. Although the relationship between perceived discrimination and physical activity was initially signifi cant and positive, the relationship became non- signifi cant aft er adjusting for gender, age, education and income, suggesting that gender and age may have accounted for this relationship. Th ese results are consistent with the two existing studies that have examined the relationship between discrimination and physical activity, which did not fi nd a signifi cant association. In a study of well- educated, middle- class African American men, no relationship was found between perceived discrimination and exercise, measured using a single item.32 Similarly, no association was found between perceived discrimination and physical activity measured using pedometers in a study of Black and Latino low- income hous-ing residents.33 It is possible that, particularly among low- income urban populations, the impact of chronic experiences of discrimination on intentional physical activity engaged in as a health- promoting behavior is obscured by increased use of walking as the primary means of transportation and/or physical activity associated with work. Additionally, it is possible that institutional, rather than interpersonal, discrimination may have a greater impact on physical activity.

Th e results of the current study are consistent with the only other published study that has examined the relationship between perceived discrimination and dietary behavior. In an examination of the eff ect of discrimination and dietary beliefs on dietary intake among a probability- based metropolitan sample, Manuel31 found that discrimination was associated with reduced avoidance of unhealthy foods. Th ese studies support the discrimination- health behavior pathway by providing evidence that exposure to dis-crimination may infl uence one’s resolve to maintain a healthy diet despite awareness that certain foods have a negative infl uence on health.

Th e observed relationship between perceived discrimination and baseline medica-tion adherence was largely consistent with the few studies on this topic that have been conducted to date. In a pilot study examining the infl uence of perceived discrimination based on race, sexual orientation, and HIV- status and adherence to HIV treatment among people living with HIV, chronic lifetime and past year racial discrimination predicted lower adherence to antiretroviral medication at baseline and again three



to four months later, while other types of discrimination did not.25 In a second study, perceived racial discrimination was associated with the use of alternative health care to prevent and treat sickness and as a substitute for conventional care among Black and Latino heads of household in urban public housing developments.26 Similarly, qualita-tive research on low- income African American hypertensives found that stressful life conditions and lack of trust in healthcare providers due to perceived racial discrimina-tion were experienced as signifi cant barriers to medication adherence.45 Th ese studies suggest that chronic perceived discrimination may infl uence patients’ willingness or ability to adhere to prescribed medication regimens.

Our fi ndings indicated that the infl uence of experiences of perceived discrimination on the adoption of healthy lifestyle behaviors over the course of a year was fairly com-plex. All participants reported improved medication adherence, physical activity, and diet over the course of 12 months, regardless of whether they were in the intervention or usual care arm of the study. Controlling for the eff ect of the intervention, greater exposure to perceived discrimination was associated with greater improvement in diet over the course of 12 months, but discrimination did not infl uence improvement in medication adherence or physical activity. Th e fi nding that greater perceived discrimina-tion was associated with increased improvement in diet over time is counter- intuitive. Our analysis controlling for baseline diet indicated that the steeper slope observed for the high discrimination group was not an artifact of regression to the mean, suggesting that there was an actual positive infl uence of discrimination on adoption of healthy diet over the course of treatment.

It is possible that participants who reported low exposure to discrimination were underreporting their experiences, thereby infl uencing the outcomes with respect to diet. Research has shown that participants who perceive survey questions as socially unacceptable tend to underreport their experiences, and that the presence of an inter-viewer can infl uence responses to sensitive questions.46 It is also possible that there were other personality characteristics possessed by participants who were willing to honestly report their exposure to discrimination that might have been associated with increased resolve or motivation to make the dietary changes recommended by physi-cians. Increased exposure to discrimination, particularly over the life course, could encourage the development of particular racism- related coping resources or racial identity attitudes that may improve the adoption of particular lifestyle behaviors. For example, research has found that racial identity attitudes characterized by heightened sensitivity to and a nuanced understanding of the complex dynamics of race and racism have been associated with increased reports of perceived discrimination.47 Th ese same racial identity attitudes have also been associated with a number of positive psychoso-cial variables including high internal locus of control48 and high self- esteem,49 which could increase motivation and commitment to make recommended changes in diet.

Th e fact that discrimination was associated with worse diet at baseline, but increased adoption of healthy diet during the course of the study, suggests that the stress of dis-crimination may be associated with unhealthy eating habits even for those who possess positive psychosocial resources. Yet, there may be some part of the act of participating in a study targeting blood pressure reduction among Black patients, or discussing one’s experiences of discrimination during an interview focused on health behaviors, that



served to activate the use of psychosocial resources previously not directed towards healthy eating.

Th ere are some limitations that should be considered in interpreting the results of this study. Our results provided evidence that discrimination impacts medication adherence, but defi nitive conclusions about the causality of this relationship cannot be drawn because these results were found in cross- sectional analyses. Nonetheless, the retrospective nature of the discrimination measure, which assessed cumulative experiences over the past year and lifetime and the more immediate timeframe for the outcome measures suggest directionality in the relationship. Although the results of our longitudinal analyses suggest that there may not be a causal relationship between dis-crimination and medication adherence or physical activity, these fi ndings are interpreted with caution since all of the participants were participating in a clinical trial in which they were exposed to an intervention or usual care practices that sought to improve the very health behaviors being assessed. Th e fact that our sample is not representa-tive also restricts the ability to generalize our results beyond low- income hypertensive African Americans outpatients. In order to draw more defi nitive conclusions about the causal relationship between discrimination and health behaviors, additional research with more representative samples is warranted.

Our results may also have been infl uenced by measurement error. Discrimination, medication adherence, physical activity and dietary behaviors were all assessed using self- report measures and may therefore be subject to recall bias, social desirability in response patterns, or the infl uence of patient personality traits. All data in our study was collected through face-to-face interviews by racially diverse research assistants. Research suggests that participants are likely to underreport sensitive experiences, such as those with discrimination, under these circumstances.46 It is also possible that cross- race interview dyads further infl uenced already sensitive participants to under-report their experiences with discrimination, thereby underestimating the impact of discrimination on health behaviors. Similarly, K/ cal estimations on the physical activity measure were positively skewed, suggesting that participants may have over- reported physical activity. Future research would benefi t from the use of objective measures of nutrition, physical activity and medication adherence. Additionally, the REAP measure used to assess dietary behaviors was developed for use in clinical settings and may not have provided the best estimate of actual dietary behavior for research purposes. It is important to note that while the diff erences in diet between those with high versus low exposure to discrimination were statistically signifi cant, it is not immediately evident whether the observed diff erence in diet also has clinical signifi cance with respect to its impact on blood pressure control.

Despite these limitations, our fi ndings suggest that perceived discrimination is a psychosocial stressor that infl uences health behavior among Black hypertensive patients. Th e results of the current and previous studies suggest that racial discrimina-tion may have an impact on dietary and medication adherence behaviors, and that the mechanisms underlying this relationship may warrant further examination. Although perceived discrimination did not appear adversely to aff ect the adoption of healthy lifestyle behaviors over the course of treatment, it is possible that other unmeasured variables infl uenced this relationship. Future research should consider how individual



diff erences, such as racial identity and styles of coping with discrimination, may con-tribute to the relationship between exposure to discrimination and health behaviors.

Acknowledgments

Th is work was supported by the National Heart, Lung and Blood Institute and the National Institute for Minority Health and Health Disparities.

Confl ict of Interest Statement: Th e authors have no confl ict of interest to disclose.

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2. National Center for Health Statistics. Health, United States, 2010: with special feature on death and dying. Hyatsville, MD: National Center for Health Statistics, 2011. Available at: http:// www .cdc .gov/ nchs/ data/ hus/ hus10 .pdf.

3. Egan BM, Zhao Y, Axon RN. US trends in prevalence, awareness, treatment, and control of hypertension, 1988– 2008. JAMA. 2010 May 26;303(20):2043– 50. http:// dx.doi .org/ 10.1001/ jama.2010.650; PMid:20501926

4. Bolen JC, Rhodes L, Powell- Griner EE, et al. State- specifi c prevalence of selected health behaviors, by race and ethnicity—Behavioral Risk Factor Surveillance System, 1997. MMWR CDC Surveill Summ. 2000 Mar 24;49(2):1-60.

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