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DOI: 10.1177/0898264312440322 2012 24: 1018 originally published online 26 March 2012J Aging Health

Angela D. Thrasher, Olivio J. Clay, Chandra L. Ford and Anita L. StewartEthnic Health Disparities Research Among Older Adults

Theory-Guided Selection of Discrimination Measures for Racial/

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1University of North Carolina Gillings School of Global Public Health, NC, USA2University of Alabama at Birmingham, AL, USA3University of California at Los Angeles, CA, USA4Institute for Health & Aging, University of California -San Francisco, San Francisco, CA, USA

Corresponding Author:Angela D. Thrasher, Department of Health Behavior and Health Education, Gillings School ofGlobal Public Health, University of North Carolina at Chapel Hill, 315 Rosenau Hall,CB # 7400, Chapel Hill, NC 27599-7440, USAEmail: [email protected]

Theory-GuidedSelection ofDiscriminationMeasures for Racial/Ethnic HealthDisparities ResearchAmong Older Adults

Angela D. Thrasher, PhD, MPH 1, Olivio J. Clay, PhD 2,Chandra L. Ford, PhD, MPH, MLIS 3,and Anita L. Stewart, PhD 4

AbstractObjectives: Discrimination may contribute to health disparities amongolder adults. Existing measures of perceived discrimination have providedimportant insights but may have limitations when used in studies of older adults.This article illustrates the process of assessing the appropriateness of existingmeasures for theory-based research on perceived discrimination and health.Method: First, we describe three theoretical frameworks that are relevant to

the study of perceived discrimination and health—stress-process models, lifecourse models, and the Public Health Critical Race (PHCR) praxis. We thenreview four widely-used measures of discrimination, comparing their content


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Thrasher et al. 1019

and describing how well they address key aspects of each framework, anddiscussing potential areas of modification. Discussion: Using theory to guidemeasure selection can help improve understanding of how perceived discrimi-nation may contribute to racial/ethnic health disparities among older adults.

Keywordsrace/ethnicity, discrimination, disparities, measurement, theory

Introduction

Discrimination, unfair treatment based on personal characteristics or groupmembership (Williams, Yu, Jackson, & Anderson, 1997), is a potential deter-minant of racial/ethnic health disparities among older adults (Anderson,Bulatao, & Cohen, 2004; Clark, 2004). A recent meta-analysis (Pascoe &Richman, 2009) concluded that perceptions of discrimination 1 produceheightened stress responses and has a significant effect on health. Experiencesof discrimination can be severe events such as being prevented from movinginto a neighborhood, or routine hassles such as receiving poorer service than

other people at restaurants and stores (Williams et al., 1997). Discriminationis an experience shared by most people but more often reported by racial/ethnic minorities (Kessler, Mickelson, & Williams, 1999), including olderadults (Barnes et al., 2004). This may lead to a higher burden of stress amongminorities that, over time, contributes to disparities in health (Pearlin,Schieman, Fazio, & Meersman, 2005; Sternthal, Slopen, & Williams, 2011).

Interest in the relationship between perceived discrimination and health-related outcomes is apparent from several reviews of the literature (Brondolo,

Gallo, & Myers, 2009; Harrell, Hall, & Taliaferro, 2003; Krieger, 1999; Paradies,2006; Pascoe & Richman, 2009; Williams & Mohammed, 2009; Williams, Neighbors, & Jackson, 2003). Studies of older adults are more recent, withresearch finding that perceived discrimination is associated with mental health(Barnes et al., 2004; Boardman, 2004; Jang, Chiriboga, Kim, & Rhew, 2010;Jang, Chiriboga, & Small, 2008; Lewis et al., 2009; Taylor, Kamarck, & Shiffman,2004), physical health (Barnes et al., 2008; Roberts, Vines, Kaufman, & James,2008), biological measures (Albert et al., 2008; Friedman, Williams, Singer, &Ryff, 2009; Lewis, Aiello, Leurgans, Kelly, & Barnes, 2010; Lewis et al., 2009),and preventive service use (Crawley, Ahn, & Winkleby, 2008; Dailey, Kasl,Holford, & Jones, 2007; Hausmann, Jeong, Bost, & Ibrahim, 2008; Hausmann,Kressin, Hanusa, & Ibrahim, 2010).


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1020 Journal of Aging and Health 24(6)

Within this growing body of research, the measurement of perceived dis-crimination is consistently noted as a limitation to better understanding itseffects on health (Blank, Dabady, & Citro, 2004; Brown, 2001; Krieger, 1999;Paradies, 2006; Williams & Mohammed, 2009). Previous reviews have cata-logued perceived discrimination measures by conceptual dimensions, expo-sure time frame, length, and administration type (Kressin, Raymond, &Manze, 2008; Paradies, 2006), assessed their psychometric properties (Bastos,Celeste, Faerstein, & Barros, 2010), and considered their appropriateness forassessing health care discrimination (Kressin et al., 2008). The applicability ofmeasures for research within theoretical frameworks evoked in the racial/ethnic health disparities literature, however, is less discussed.

The purpose of this article is to describe three theoretical frameworks— stress-process, life course, and the Public Health Critical Race (PHCR)

praxis—that hold promise for explaining mechanisms by which perceiveddiscrimination may affect the health of older adults, and to consider howthese perspectives shape our understanding of the content and utility of dif-ferent measures. These frameworks incorporate complementary and some-times parallel concepts when describing the biopsychosocial factors that helpexplain racial/ethnic disparities in health. We discuss how discrimination

would need to be measured to conduct research using each of these frame-works and review four well-known measures of perceived discrimination interms of their applicability. In addition to identifying measurement issues instudying mechanisms by which discrimination affects health, our approachalso illustrates the process of reviewing measures for appropriateness to par-ticular research questions, including potential modifications that might beneeded (Stewart, Thrasher, Goldberg, & Shea, 2012).

Theoretical Considerations for the Study ofPerceived Discrimination and Racial/EthnicHealth Disparities Among Older AdultsStress-Process Models

Conceptual models of the relationship between stress and health posit thatchronic stress generates psychological and physiological responses thataccumulate over time to produce poor health outcomes. Chronic stressors are

persistent and ongoing whereas acute stressors are those occurring relativelyinfrequently, such as negative life events (Cohen et al., 1998). Numerousstudies have concluded that stress has a negative effect on an individual’s




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well-being (Lazarus & Folkman, 1984; Leventhal & Nerenz, 1983;Segerstrom & Miller, 2004). The effects of chronic stressors are consideredmore deleterious than acute stressors because of an increased likelihood oflong-term changes in physiological responses that may lead to increaseddisease risk (Cohen, Janicki-Deverts, & Miller, 2007; McEwen, 1998); ourfocus is thus everyday discrimination , chronic and relatively mundane expe-riences of unfair treatment (Williams et al., 1997). Stress-process modelssuggest that membership in social categories such as racial/ethnic minoritygroups, low socioeconomic status, and old age may make individuals morelikely to experience stressors such as discrimination (Dilworth-Anderson,Williams, & Gibson, 2002; Pearlin, Mullan, Semple, & Skaff, 1990; Sonet al., 2007). For example, Black and American-born Hispanic adults livingin Chicago had a higher prevalence of high scores across eight stressdomains (including multiple types of discrimination) and greater clusteringof high stress scores after controlling for socioeconomic status than Whitesand foreign-born Hispanics (Sternthal et al., 2011). Frameworks used to helpexplain health disparities such as allostatic load (McEwen & Seeman, 1999),weathering (Geronimus, 1992), and embodiment (Krieger, 2005) considerthe health effects of chronic social stressors in general whereas Clark and

colleagues (Clark, 2004; Clark, Anderson, Clark, & Williams, 1999) describea stress-process model specific to the health effects of perceived racism (dis-crimination attributed to race/ethnicity).

The stress associated with perceived discrimination has a negative effecton physical and mental health (Pascoe & Richman, 2009; Williams &Mohammed, 2009), but the relationship may not be a direct one. The originalstress and coping model (Lazarus & Folkman, 1984) suggests that an indi-vidual’s overall level of stress and consequent psychological reactions is

influenced by an interaction between an initial assessment of stressfulness(appraisal ) and availability of resources to mitigate the stressor ( coping ).Appraisals of stressful events are often stronger predictors of health out-comes than the frequency of those events (Gonyea, O’Connor, Carruth, &Boyle, 2005). Worse appraisals of stress and a low sense of control are asso-ciated with poorer health and well-being (Jang et al., 2008; Watson, Logan,& Tomar, 2008). However, there is little empirical evidence to date that thestressfulness of perceived discrimination is related to health because mostexisting studies use measures that lack an appraisal component. This is afruitful area for further study.

The way that individuals’ cope with perceived discrimination may alsoaffect its relationship to health. Research has found that perceived discrimi-nation is associated with both emotional (Brondolo et al., 2005; Hamilton,




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Agarwal, Carter, & Crandell, 2010) and behavioral (Hamilton et al., 2010;Mwendwa et al., 2011; Rankin, David, & Collins, 2011) coping. Furthermore,discrimination-related coping can be independently related to both poorhealth outcomes such as higher lipid levels (Mwendwa et al., 2011) and alsomediate the relationship between perceived discrimination and poor healthoutcomes such as preterm birth (Rankin et al., 2011). For perceived discrimi-nation, seeking social support can be considered a coping strategy along withapproach and avoidance coping, problem-focused coping, and emotion-focused coping (Brondolo, Brady Ver Halen, Pencille, Beatty, & Contrada,2009). Assistance received from an individual’s support network can be con-ceptualized in ways ranging from the size of an individual’s support networkto an individual’s satisfaction with the assistance that he or she is receiving.Satisfaction with social support has been shown to be related to better out-comes in older adults (Clay, Roth, Wadley, & Haley, 2008). As psychosocialresources that contribute greatly to group and individual differences in resil-ience to stressors (Clay et al., 2008; Goode, Haley, Roth, & Ford, 1998), thestudy of the health effects of perceived discrimination among older adultswould benefit from greater attention to coping and social support.

Some implications for addressing stress-process concepts in discrimina-

tion measures include the following:

• Assess chronicity of reported discrimination experiences. A measurethat includes a count of reported discrimination experiences doesnot necessarily address chronicity if it is not a potentially ongo-ing experience over weeks, months, or years. Negative life events(e.g., being fired from a job, being stopped by a police officer) areacute stressors even if they occur more than a couple of times over a

lifetime. Although both types are important, measures should placegreater emphasis on experiences of discrimination that are ongoing(e.g., regular race-related harassment by coworkers).

• Assess stressfulness of reported discrimination (appraisal) . An indi-vidual’s appraisal of its stressfulness is a critical component of theexperience of discrimination and a key domain of the stress-processmodel that is included in some but not most existing discriminationmeasures (Landrine, Klonoff, Corral, Fernandez, & Roesch, 2006).To be responsive to this model, measures should have respondentsrate the stressfulness of each reported experience.

• Assess coping strategies for reported discrimination experiences. Specific coping strategies may be effective for reducing the stressassociated with perceived discrimination on some dimensions but




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have no effect on others. Therefore, for individuals who report per-ceived discrimination, it is important to assess how they dealt withthe event (Brondolo et al., 2009).

Life Course ModelsHealth research among older adults requires study of conditions that affectindividuals over their entire life span (Dannefer, 2003; Ferraro & Shippee,2009; Ory & Chesney, 2002), such as exposure to discrimination (Anderson etal., 2004; Glymour & Manly, 2008). Life course perspectives on health areideally suited to this task (Fuller-Iglesias, Smith, & Antonucci, 2010), althoughapplication to racial/ethnic health disparities research is relatively recent(Lynch, 2008). The life course perspective can be traced to Glen Elder’s con-ceptualization of human development and aging as a product of transitions,turning points, and durations over the changing social contexts of individuallives (Elder & Johnson, 2003). The life course is composed of multiple, inter-dependent trajectories or pathways that describe changes over time in indi-vidual experience in a specific life sphere (e.g., work, family). Aging-relatedexperiences over the life course arise from the interaction between human

agency and social structure, varying within individuals and across groups(Elder & Johnson, 2003; Settersten, 2003).

Theories of cumulative advantage/disadvantage and inequality describehow resources and risk exposures (negative or hazardous stimuli) build overtime and are socially stratified (Dannefer, 2003; Ferraro, Shippee, & Schafer,2009). These theories arose from Merton’s ideas about the how the advan-taged use their resources to accrue more advantage, known as the Mattheweffect (Merton, 1968; Rigney, 2010). Advantage not only reduces exposure to

risks but also provides opportunities through access to networks, resources,and prestige (Dannefer, 2003; Merton, 1968; Rigney, 2010). Disadvantageincreases exposure to risk and constrains access to networks, resources, and

prestige (Dannefer, 2003; Ferraro et al., 2009). An example of this process isresearch showing that education confers less benefit to the health of Blacksthan Whites and this discrepancy in benefit widens over time (Shuey &Willson, 2008). Cumulative disadvantage or inequality thus is not only anoutcome but also a process that produces inequalities across the life course(Dannefer, 2003; Ferraro & Shippee, 2009).

Public health researchers drew concepts from life course sociology andcumulative advantage/disadvantage/inequality theories to develop the fieldof life course epidemiology, which considers how the timing and cumulativeexposure to risks and protective factors influence health outcomes across




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groups (Alwin & Wray, 2005; Ben-Shlomo & Kuh, 2002; Kuh, Ben-Shlomo,Lynch, Hallqvist, & Power, 2003; Lynch & Davey Smith, 2005). There isstrong conceptual and empirical support for the contention that childhoodconditions influence adult outcomes including health (Ben-Shlomo & Kuh,2002; Furumoto-Dawson, Gehlert, Sohmer, Olopade, & Sacks, 2007;Glymour & Manly, 2008; Hertzman, 2004; Lynch & Davey Smith, 2005).Age at migration, for example, is one life course factor that may influence theaccumulation of disadvantage and increased risk for ill health among elderlyMexican migrants (de Oca, Garcia, Saenz, & Guillen, 2011).

Three models describe the different (though overlapping) pathways bywhich exposure to risk and protective factors accumulate over time and inter-act to influence health (Ben-Shlomo & Kuh, 2002; Hertzman, 2004). In alatent effect (chains of risk) model, early exposures to risk and protectivefactors are the primary determinants of future health outcomes. The cumula-tive model suggests that combined, repeated exposure to risk and protectivefactors across the life course produces a greater effect than exposure at justone point in the life course on future health outcomes. The pathway modelsuggests that early experiences set individuals on a life trajectory, modifiable

by intervening factors, which produce future health outcomes. Such models

as originally conceptualized may not fully capture the interactive nature ofthe social forces that help produce racial/ethnic health disparities (Colen,2011; Glymour, Ertel, & Berkman, 2010). However they are an importantstarting point when exploring exposures (e.g., discrimination) that cluster bysocial characteristics such as race/ethnicity, age, gender, and socioeconomicstatus over the life course (Colen, 2011; Furumoto-Dawson et al., 2007;Glymour et al., 2010; Hertzman, 2004; Hicken, Gragg, & Hu, 2011).

The life course perspective has important inferences for the study of dis-

crimination and health among older adults. One is that the stress and othernegative consequences of discrimination can be conceptualized as risks thataccumulate over time. As the life spans of older adults are by definition long,life course models help to more fully account for the many exposures theyhave had that contribute to present health but that may be missed by cross-sectional assessments. Discrimination experienced in the past (e.g., everoccurred in one’s life) may have different effects on health than recentlyexperienced discrimination (e.g., in the past year; Landrine & Klonoff, 1996),as is seen with distal stressors that have an effect on health independent fromthe influence of more proximal stressors (Ensel & Lin, 1996). Life courseepidemiology also describes factors that are potentially relevant to the studyof perceived discrimination and the health of older adults: (a) the location ofan individual in time and the place ( context ) in which the discrimination




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Public Health Critical Race Praxis

Another way to study the health effects of perceived discrimination is to usethe PHCR. PHCR is not a behavior-change theory aimed at predicting causalrelationships. Rather it is an antiracism methodology that outlines strategiesand provides tools for systematically and rigorously applying critical racetheory, which originated in the field of jurisprudence (Crenshaw, Gotanda,Peller, & Thomas, 1995), to the study of health inequities (Ford &Airhihenbuwa, 2010). There are four phases to PHCR research: (a) accu-rately assessing contemporary patterns of racial relationships; (b) consider-ing how racial biases may inadvertently influence the immediate project(e.g., investigators’ a priori assumptions); (c) conceptualizing and measuringracism-related factors; and (d) intervening on the causes of observed dis-

parities. PHCR is rooted in social justice; therefore, research based on the praxis aims not only to reflect methodological rigor—for example, in devel-oping meaningful measures of concepts such as discrimination, racism, andrace—but also to ensure that concerns of racial equity undergird the research

process (Ford & Airhihenbuwa, 2010).A key concept of PHCR is race consciousness . Race consciousness means

to be aware of and to explicate the ways in which racism may be operating.This approach contends that is impossible to identify the root causes of racial/ethnic disparities without explicitly investigating racism’s potential contribu-tions to them. Race consciousness challenges the notion of colorblindness,which pervades the early 21st century and views racism as having minimalrelevance to contemporary disparities (Bonilla-Silva, 2006; Winant, 2004).Color blindness attributes racial disparities fundamentally to socioeconomicfactors or to people’s behaviors, whereas race consciousness emphasizes the

mechanisms by which racism contributes to the disparities. PHCR studies dem-onstrate race consciousness in all aspects of the research process—from formu-lating research questions, to carrying out research in minority communities inways that are respectful and empowering of them, to drawing on communitiesto interpret study findings. This approach therefore suggests that traditionalstudies of racial/ethnic disparities risk conflating race effects with racismeffects. That is, because race is socially constructed, differences observed

between racially defined groups generally reflect inequities stemming fromracism, not race or racial differences. To be consistent with PHCR, disparitiesresearch should clearly explain the relationship linking any observed racial dif-ferences to the racism mechanisms hypothesized to generate them.

Three other PHCR concepts are particularly relevant to studies of dis-crimination and health among older adults: ordinariness; the need for racism




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measures to reflect the time periods of interest; and intersectionality. First,racism is an ordinary and integral aspect of the social environment in raciallystratified societies such as the United States. This perspective, called ordi-nariness , challenges the widely held but contestable notion that racism expo-sures are rare, intentional, and discrete (Bonilla-Silva, 2006). Second, as withlife course models, PHCR stresses that discrimination measures appropri-ately reflect the ways that discrimination functions during the time of interestto the study. Overt forms of discrimination such as segregated hospitals werecommon prior to 1965 and, therefore, are relevant when assessing olderadults’ cumulative or early life experiences. In contrast, more subtle forms ofdiscrimination (e.g., not being offered the same follow up care that other

patients are offered) are common today. While the same term, discrimination,may describe both of these, the underlying nature of the exposures differs.Finally, intersectionality posits that individuals inhabit multiple, overlappingsocial statuses and more than one status may be marginalized or stigmatized(e.g., Black gay men). The effects of stressors on people who occupy multipleminority social categories (e.g., racial minority and sexual minority) may besynergistic, exceeding the independent effects of membership in each cate-gory (Meyer, 2003).

Some implications for addressing PHCR concepts in discrimination mea-sures include the following:

• Employ race consciousness . A measure that explicitly assessesracism exposures is race conscious; however, the opposite is notnecessarily true. That is, just because a measure does not explic-itly assess racism does not necessarily mean it is not race conscious

because race consciousness may lead to some other way (i.e., other

than explicitly asking about racism) of assessing racism expo-sures. Another implication of taking a race conscious approach isthe importance of using measures that reflect how discriminationactually functions “in the real world.” Historical research or policyanalysis can inform the development of measures so that they mean-ingfully capture salient racial patterns in society. For instance, civilrights laws prohibit discrimination in hiring on the basis of race.Minorities, therefore, may be hired at comparable rates as their non-minority counterparts, but experience subtle forms of discriminationin which they are afforded few opportunities for promotion. Accord-ingly, measures should assess the subtle forms of discrimination(e.g., being hired but not promoted on the job) that more accuratelycapture the ways that discrimination is likely to operate currently.




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• Address the ordinariness of racism . Discrimination measures thatoperationalize racism exposures as ubiquitous, chronic, everydaystressors (e.g., being followed while shopping because of race)reflect this ordinariness concept.

• Assess intersectionality . Measures that attribute unfair treatment toonly one basis (e.g., race) may not account for the interlocking waysthat other social categories (e.g., gender, immigrant status) com-

pound the perceptions and experiences of discrimination. For example, unfair treatment attributed to language and perceived immigrantstatus may be of particular relevance to Latinos (Perez, Fortuna, &Alegria, 2008) and Asian/Pacific Islanders (Gee, Ro, Shariff-Marco,& Chae, 2009). It may be difficult to determine the extent to which

perceptions and exposures to discrimination related to language useare distinct from those tied to perceived immigrant status or race/ethnicity. Although people may not always know which aspect(s)of their identity matter most for a particular discriminatory experi-ence, allowing respondents to choose more than one attribute fortheir experiences helps to address intersectionality.

• Operationalize discrimination measures so that they are specific

to the time period(s) of interest to the study . For older adults, bothovert and subtle discrimination should be assessed as their livesencompass historical periods when one or the other was more preva-lent. As with the life course perspective, operationalizing discrimi-nation measures so that they are appropriate for and specific to thetime period(s) of interest is necessary to understand the underlyingmechanisms by which discrimination contributes to disparities.

• Understand how racial/ethnic minority groups differ in their expe-

riences of discrimination. PHCR urges researchers to be cautiouswhen choosing between group-specific discrimination measures ormeasures designed to be used across diverse groups. Some forms ofdiscrimination operate universally across groups (e.g., exclusion ofgroup members) but others may be group-specific (e.g., the process

by which the systematic exclusion occurs) and reflect unique his-tories and circumstances. For example, Asian Americans are morelikely to be stereotyped as immigrants and African Americans morelikely to be stereotyped as criminals. Although both groups sharethe experience of being stereotyped, the implications may differdepending on the stereotype. Differences and similarities in the waydiscrimination operates across groups may also influence responsesto race-specific items. For example, describing the phenomenon as




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racial/ethnic discrimination rather than unfair treatment attributed torace/ethnicity can affect the prevalence of self-reported discrimina-tion, which participants report discrimination, and the relationship

with health outcomes (Bastos et al., 2010; Brown, 2001; Shariff-Marco et al., 2011; Williams & Mohammed, 2009).

Using Theory to Select andModify Measures of Perceived DiscriminationIn this section we describe how four well-known discrimination measures— the Everyday Discrimination Scale, Experiences of Discrimination Scale,Schedule of Racist Events, and Index of Race-Related Stress—addressselected concepts from stress-process, life course, and PHCR frameworks(Table 1). These measures were chosen because of differences in how theyaddress selected concepts: chronicity, appraisal , and coping for stress-

process models; trajectories and sensitive periods for life course models;

Table 1. Integration of Selected Theoretical Concepts Within Four DiscriminationMeasures Used in Racial/Ethnic Health Disparities Research

EverydayDiscrimination

ScaleExperiences ofDiscrimination

Scheduleof RacistEvents

Index ofRace-Related

Stress

Stress-processmodel

Chronicity: Was theexperience routine andongoing?

•

Appraisal: How stressfulwas the discrimination?

• •

Coping: How doindividuals deal withdiscrimination?

• • •

Life course Trajectories: Howdo experiences ofdiscrimination changeover time?

Sensitive Periods: Howis discriminationexperienced at differenttimes (e.g., childhood)?

•

PublicHealthCriticalRacepraxis

Ordinariness: Isdiscriminationconceptualized asroutine?

Intersectionality: Aremultiple social statusesaddressed?

• • •

•

•




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ordinariness and intersectionality for studies employing PHCR praxis.Conceptual gaps offer opportunities for researchers, if desired, to modifyexisting perceived discrimination measures by incorporating new items thataddress missing dimensions or changing items to refocus content (Stewartet al., 2012). Although researchers do not need to consider all issues forevery study, it is important to identify those most relevant to their ownresearch questions.

Everyday Discrimination ScaleOne of the most commonly used measures in public health research on per-ceived discrimination and health is the Everyday Discrimination Scale(Williams et al., 1997), which assesses “chronic, routine, and relativelyminor experiences of unfair treatment.” The measure asks respondents the

basis to which they attribute the unfair treatment (e.g., race/ethnicity, gender,socioeconomic status). The Everyday Discrimination Scale was designed foruse across racial/ethnic groups. It was originally tested with primarilyAfrican American and White samples, but has demonstrated good internalconsistency in other racial/ethnic groups (Gee, Ryan, Laflamme, & Holt,

2006; Gee, Spencer, Chen, & Takeuchi, 2007; Perez et al., 2008). An example of its use in aging research is a study that found that reports of everydaydiscrimination were associated with elevated diastolic blood pressure amongAfrican Americans but not Whites (Lewis et al., 2009).

Stress-process models. The Everyday Discrimination Scale was specificallydesigned to assess chronic instances of unfair treatment, experiences thatoccur consistently over time. A key limitation to using this measure withstress-process models, however, is that there are no items to appraise the

stressfulness of the chronic experiences. Thus, a potential modification wouldinclude such rating for each reported unfair treatment, e.g., “how stressful isthis experience to you in general?” on a scale of 0 to 3 with 0 being not at allstressful and 3 being very stressful. Finally, the full version of the measureincludes items addressing the strategies used to cope with discrimination.

Life course models. Everyday Discrimination Scale items have no specifictime frame associated with them, as respondents are asked if any of thechronic events “ever” happened to them. For application in life course studiesof discrimination, a potential modification would be to address changes overtime in the experiences of discrimination, that is, trajectories of perceiveddiscrimination. The Jackson Heart Study Discrimination Instrument (Sims,Wyatt, Gutierrez, Taylor, & Williams, 2009), partly based on the Everyday




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Discrimination Scale, includes an item comparing the frequency of unfairtreatment from early life to present time. Another possible modificationwould be to frame each experience during a specific time period (e.g., child-hood up to age 18, past year). This could help pinpoint sensitive periods .

Public Health Critical Race praxis (PHCR). The ubiquity and chronicity ofeveryday racism that undergirds the PHCR concept of ordinariness (Delgado& Stefancic, 2001) is reflected in the Everyday Discrimination Scale. Asrespondents may choose multiple options for attribution, the measure may beused to explore the intersecting effects of discrimination due to co-occurringsocial categories. The PHCR approach views racism as operating differentlyacross groups and so a potential modification would be adding follow-upquestions to obtain additional information about the nature of discriminationexposures and whether subtle differences exist across groups.

Experiences of Discrimination ScaleThe Experiences of Discrimination Scale (Krieger & Sidney, 1996) was oneof the first measures developed specifically for public health research anddemonstrates psychometric equivalence across racial/ethnic groups (Krieger,

Smith, Naishadham, Hartman, & Barbeau, 2005). Like the EverydayDiscrimination Scale, the Experiences of Discrimination Scale was designedfor use with racially diverse samples. The attribution for each experience isset at “race, ethnicity, or color” with no other options. An example of its usein aging research is a study that found that perceived discrimination was asso-ciated with more patient-reported problems with care among AfricanAmerican and White military veterans with diabetes (Hausmann et al., 2010).

Stress-process models. The items describe experiences in a variety of set-

tings that are acute and chronic; adding more of the latter would strengthenits application to the chronicity concept. The measure does not include anyway to appraise the stressfulness of each reported experience but does askhow participants generally cope with unfair treatment.

Life course models. A limitation of the Experiences of Discrimination Scalefor life course research is that no specific time frame is provided for reports ofdiscrimination. Adding items that assess changes over time in the experiencesof discrimination would address the concept of trajectories . However, themeasure does address sensitive periods to some extent through two questionsabout how worried participants were about racial discrimination as a child (upto 18 years old) and is thus one of the few perceived discrimination measuresto address early childhood experiences. A measure by Parker-Dominguez and




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colleagues (Dominguez, Dunkel-Schetter, Glynn, Hobel, & Sandman, 2008)loosely based on Experiences of Discrimination, addressed lifetime exposureto discrimination with items referring to specific periods of the life course toaid recall (as a child aged 16 and younger and as an adult aged 16 and older).

Public Health Critical Race praxis (PHCR). The Experiences of Discrimina-tion Scale encompasses routine forms of racism and thus reflects the ordi-nariness concept of PHCR. Offering other options for attribution in additionto race/ethnicity could help address intersectionality . Although the experi-ences of discrimination are specifically attributed to race, PHCR suggestsracism does not operate similarly across groups and therefore researchersusing Experiences of Discrimination Scale should carefully interpret findingsas they apply to specific groups. Follow-up questions could be used to obtainadditional information about the nature of discrimination exposures andwhether subtle differences exist across groups.

Schedule of Racist EventsThe Schedule of Racist Events (Landrine & Klonoff, 1996) was specificallydesigned for African Americans, and items attribute the reported experiences

to respondents’ Blackness. The measure assesses the frequency with whichAfrican Americans encountered racial discrimination in the past year andover their lifetimes as well as the stress associated with any reported events.The General Ethnic Discrimination Scale (Landrine et al., 2006) is a modi-fied version that changed the attribution for each experience from “becauseyou are Black” to “because of your race/ethnicity.” An example of the use ofthe Schedule of Racist Events in aging research is a study that found thatgreater perceived racism was associated with depression among older

African Americans with diabetes (Wagner & Abbott, 2007).Stress-process models. The Schedule of Racist Events was specifically con-ceptualized within the stress-coping framework (Landrine et al., 2006). Theitems describe experiences that are both chronic and acute; dropping some of theformer or adding more of the latter would strengthen its application to the chro-nicity concept. Respondents who report ever having an experience are asked tonote its frequency and appraise its stressfulness. The measure does not includeitems on the coping strategies of respondents to experiences of racism.

Life course models. Adding items that assess changes over time in the experi-ences of discrimination would address the concept of trajectories . Because theSchedule of Racist Events asks whether an experience ever happened as wellas if it happened within the past year, a potential modification for its use in life




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course research would be to incorporate assessment of experiences within spe-cific time periods (e.g., childhood up to age 18) to address sensitive periods .

Public Health Critical Race praxis (PHCR). Both the Schedule of RacistEvents and the General Ethnic Discrimination Scale reflect the PHCR con-cept of ordinariness by assessing routine forms of racism. According toPHCR, however, racism does not operate in the exact same way across allracially or ethnically defined groups so investigators must carefully interpretfindings as they apply to specific groups when using the General Ethnic Dis-crimination Scale. Follow-up questions to obtain additional informationabout the nature of discrimination exposures and whether subtle differencesexist across groups. Intersectionality could be addressed by adding multipleoptions (“choose all that apply”) in addition to race/ethnicity for attributionsfor perceived discrimination.

Index of Race-Related StressThe Index of Race-Related Stress (Utsey, 1999; Utsey & Ponterotto, 1996)assesses stress experienced by African Americans in daily encounters. It wasdeveloped with the idea that experiences of racism by African Americans are

“cumulative, whereby new encounters are interpreted on the basis of pastexperiences with racism, knowledge of others’ experience with racism, andknowledge about the systemic nature of racism” (Utsey & Ponterotto, 1996,

p. 490).The measure has subscales on cultural racism, institutional racism,individual racism, and collective racism. An example of its use in agingresearch is a study that found that institutional racism-related stress wasassociated with self-reported psychological health among older AfricanAmericans (Utsey, Payne, Jackson, & Jones, 2002).

Stress-process models. The Index of Race-Related Stress was specificallydeveloped within the stress-process coping framework (Utsey & Ponterotto,1996) and incorporates both acute and chronic experiences; dropping someof the former or adding more of the latter would strengthen its application tothe chronicity concept. Respondents are asked to appraise the stressfulness ofeach experience but not about coping strategies.

Life course models. A limitation of the Index of Race-Related Stress for lifecourse research is that no specific time frame is provided for reports of dis-crimination. Adding items that assess changes over time in the experiences ofdiscrimination would address the concept of trajectories . A potential modifi-cation would be to frame each experience during a specific time period (e.g.,




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childhood up to age 18, past year) to assess sensitive periods when experi-ences of discrimination may have had a particularly strong impact.

Public Health Critical Race praxis (PHCR). The Index of Race-Related Stressfocuses on the daily microaggressions of racism and thus reflects the conceptof ordinariness . The measure is specific to African Americans, whichaddresses the PHCR claim that racism operates differently across racial/ethnic groups. Intersectionality could be addressed by adding multipleoptions (“choose all that apply”) in addition to race/ethnicity for attributionsfor perceived discrimination.

DiscussionExisting discrimination measures have significantly contributed to ourunderstanding of the determinants of racial/ethnic health disparities. The fourmeasures reviewed in this article have been used successfully in researchamong older adults, and two have been validated in community-dwellingsamples of older adults—Everyday Discrimination Scale (Taylor et al.,2004) and Index of Race-Related Stress (Utsey et al., 2002). These measuresalso incorporate (to varying degrees) features that enable them to use con-

cepts from theoretical approaches relevant to research on the health effectsof discrimination.

However, no discrimination measure has yet been specifically developedwith an aging perspective that addresses older adults’ unique developmentaland social circumstances. We recommend that aging researchers use cogni-tive interview pretesting (Napoles-Springer, Santoyo-Olsson, O’Brien, &Stewart, 2006) and other pretesting methods with their selected discrimina-tion measure (modified or unmodified) to ensure that the items are under-

standable but more importantly applicable to the older adults in their study.Moody-Ayers and colleagues, for example, modified the Perceived RacismScale to eliminate items identified in pretesting as not relevant to the olderAfrican Americans with type II diabetes in their study (Moody-Ayers,Stewart, Covinsky, & Inouye, 2005). Although we have suggested examplesof modifications that address some conceptual gaps related to the stress-

process, life course, and PHCR praxis frameworks, some changes couldalter—sometimes radically—the measure developers’ original purpose (e.g.,changing a group-specific measure to one that would be used in diversegroups; Stewart et al., 2012). The ideal solution, of course, would be todevelop discrimination measures specifically designed and validated for usein health disparities research among diverse older adults.




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Conclusion

Advancing research on the health effects of perceived discrimination in olderadults will require thoughtful consideration of the measurement implications oftheoretical frameworks relevant to the study of racial/ethnic health disparities.Researchers have a wide variety of perceived discrimination measures fromwhich to choose, and employing the perspective of stress-process, life course,and/or the PHCR praxis frameworks may assist in the selection of the mostappropriate measure for their study. Although we highlighted these particularframeworks, the process of evaluating the conceptual appropriateness of a spe-cific measure described in this article can be used with any theory. Such consid-erations will help us to better understand how discrimination experienced overa lifetime contributes to racial/ethnic health disparities among older adults.

Authors’ Note

The content is solely the responsibility of the authors and does not necessarily repre-sent the official views of the National Institute on Aging or the National Institutes ofHealth.

AcknowledgmentsThe authors would like to thank Steve Wallace, Patricia Sawyer, Liana Richardson,and the anonymous reviewers for their helpful comments on this article, as well asDevynn Taylor for manuscript preparation assistance.

Declaration of Conflicting Interests

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

Funding

All authors were supported through the Resource Centers for Minority AgingResearch program of the National Institute on Aging: Angela D. Thrasher throughGrant number 3P30-AG015272-14S3 to the UCSF Center for Aging in DiverseCommunities; Olivio J. Clay through Grant number 3P30-AG031054-02S1 to theUAB Deep South Resource Center for Minority Aging Research; Chandra L. Fordthrough Grant number P30-AG021684 to the UCLA Center for Healthy Aging inMinority Elders; and Anita L. Stewart through Grant number P30-AG15272 to theUCSF Center for Aging in Diverse Communities.




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Note

1. We consider discrimination to be an action or behavior that causes harm regard-less of perception by the target individuals or groups. In this article, we are

primarily concerned with perceived discrimination and its consequences whendiscussing theoretical linkages between discrimination and health, as well as

self-reported discrimination when discussing implications for measurement. Thelatter is perceived discrimination that has been formally or informally acknowl-edged to others (e.g., submission of a grievance at work, answering a confidentialsurvey, or discussed with friends and family). A long line of social-psychologicalresearch has explored factors that promote or inhibit reporting of discrimination,for example, Crocker & Major (1989).

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theory-guided selection of discrimination measures for racial/ ethnic health disparities research...

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