There are significant disparities by socioeconomic status (SES) and race in self-reports of stress. Individuals of low (vs. high) SES and black and U.S.-born Hispanic individuals (in comparison to whites) report higher levels of stress. Members of racial and ethnic minority groups report greater exposure to discrimination (Sternthal, Slopen, & Williams, 2011). There are also social class and racial disparities in exposure to specific objective threats to safety and financial security across the lifespan, including greater exposure to violence and barriers to occupational advancement (Browning et al., 2017; Pager, Western, & Padulla, 2009). As important, there are also significant race and class disparities in access to a wide range of personal, social, educational and material resources across the lifespan (P. Taylor, Kochhar, Fry, Velasco, & Motel, 2011). For black, Hispanic, and Native American individuals, neighborhood disadvantage across the lifespan compounds the deprivation of poverty at the individual level (Drake & Johnson-Reid, 2014; Sarche & Spicer, 2008; Thorpe, Brandon, & LaVeist, 2008). Without sufficient resources, even minor demands are more stressful. Racial and ethnic discrimination compounds these effects by increasing threat exposure and creating barriers to the development of the resources needed to respond to these threats (Brondolo, Libretti, Rivera, & Walsemann, 2012; R. Clark, Rodney, Anderson, Clark, & Williams, 1999; Krieger, 2014; Lewis, Cogburn, & Williams, 2015).
Stressors related to social and economic disadvantage have demonstrable downstream effects on a wide range of psychological, neurobiological, physiological and behavioral processes related to health.
On a psychological level, the stressors associated with social and economic disadvantage have effects on the way individuals think and feel about themselves and others, potentially generating new threats, heightening appraisals of threat and undermining the personal resources needed to respond to the threats (Brondolo, Ng, Pierre, & Lane, 2016; Gallo & Matthews, 2003; Kraus, Piff, Mendoza-Denton, Rheinschmidt, & Keltner, 2012). On a neurobiological level, stressors associated with disadvantage can affect the development of the brain structures and processes necessary to support effective self-regulation and stress recovery (Hofmann, Schmeichel, & Baddeley, 2012). On a physiological level, threat appraisals elicit activation of neuroendocrine, immune and autonomic systems throughout the body (Gianaros & Wager, 2015). Frequent, intense or persistent activation of these systems may alter their self-regulatory capacities, leading to impairments in stress recovery, including notable disruptions to sleep. On a behavioral level, stressors and their downstream effects on psychobiological stress systems may also shape health behaviors, driving obesity and substance use in particular (J. S. Jackson et al., 2010). Processes at any one level influence those at another, potentially exacerbating or prolonging the effects of stress.
Efforts to reduce health disparities have included a wide range of individual, dyadic, family and community-level approaches. On an individual and dyadic level, promising approaches include culturally adapted cognitive behavior stress management interventions and mindfulness approaches (Burnett-Zeigler, Schuette, Victorson, & Wisner, 2016; Lechner et al., 2013), as well as training to improve children's cognitive control competencies (Diamond & Lee, 2011), parent–child interactions (Mortensen & Mastergeorge, 2014) and patient–provider communication (Havranek et al., 2012). Systemic interventions have attempted to decrease discrimination at work or school (Paluck & Green, 2009), reduce violence by improving economic access (Massetti & David-Ferdon, 2016) or police–community engagement (Graziano, Rosenbaum, & Schuck, 2014), increase access to healthy foods and recreational facilities and facilitate engagement in health care through the use of community partners (Victor et al., 2011), among other approaches derived from community-based participatory research (see reviews by A. R. Clarke et al., 2013; Glik et al., 2016). The literature on disparity-reduction interventions is still growing, and the findings indicate both positive outcomes and concerns about potential challenges and side effects. There is also a growing recognition that there are important personal, situational, institutional and regional moderators of outcomes (Abrams, 2010; D. R. Williams & Mohammed, 2013).
Health disparities research has grown rapidly and provided greater understanding of the role of specific stressors in influencing stress processes and/or health outcomes. However, there has been limited research examining the ways in which factors at one level (i.e., at the national, community, family, or individual level) drive stress exposures at other levels. Additionally, there is a need for further research clarifying potential bidirectional relationships among stressors, stress processes and health outcomes. This type of research can help develop a clearer understanding of the antecedents and consequences of stress exposure. Relations among stressors and outcomes have largely but not exclusively been studied in relatively narrowly defined populations, making it difficult to understand the degree to which stress effects generalize across health disparity populations. Although disparities in stress exposure and stress processes have been identified, there is a need for more explicit tests of the hypothesis that disparities in stress account for disparities in health.
Further, interventions have also focused on specific threats or gaps in resources, but further research is needed to determine if these interventions modify stress processes and have replicable effects on health outcomes. Unintended consequences of these interventions have been identified, and a clearer understanding of the personal and contextual factors that explain variations in outcomes is still needed.
