Adult African-Americans in the United States are less likely than Adult Whites to seek outpatient treatment for mental health problems, significantly less likely to use specialized mental health services and are more likely to leave mental health programs prematurely (Alegria et al., 2002; Neighbors et al., 2007; Snowden, 2001; Sue, Zane, & Young, 1994). They also report lower satisfaction with the care they receive (Jackson et al., 2007), are more likely to receive emergency care (Hu, Snowden, Jerrell, & Nguyen, 1991), and are more likely to seek help for mental health problems at more severe stages of illness than Whites (Cooper et al., 2003). These differences in use are associated with lower self-reported physical and mental health (Fenton, Jerant, Bertakis, & Franks, 2012), higher 30-day hospital readmission rates (Boulding, Glickman, Manary, Schulman, & Staelin, 2011), and higher likelihoods of relapse or recurrence of depression due to incomplete mental health program adherence (Melfi et al., 1998).
Since the 1990s, a growing body of research has examined the causes and effects of health disparities in African-American populations, with a more recent focus on mental health and factors affecting health service utilization. The above mentioned studies have focused on: general health service usage trends; the effects of implicit racial bias on clinical interactions; trust and mistrust; and on the effects of the physical environment on creating fear and uncertainty in communities, as well as their connections and influences to and on each other. Despite this widening pool, the literature does not examine the connections between physical disorder in neighborhoods, trust, and lower rates of mental health service utilization in African-American communities. To address this gap, I conducted a literature review to: (1) evaluate the current literature on these subjects; (2) summarize major findings related to the topics; and (3) draw recommendations for policymakers, researchers and health care practitioners. I use neighborhood disorder, perceived discrimination, centrality of identity, and mistrust as organizational signposts to present the results of my review.
Neighborhood disorder has long been identified as an important component in understanding the connection between neighborhoods and mental health outcomes (Wandersman & Nation, 1998; Wilson & Kelling, 1982). Along with concentrated poverty and low neighborhood cohesion, the presence of neighborhood disorder has been linked to greater mental distress and increased levels of crime (Sampson, Morenoff, & Gannon-Rowley, 2002). According to the Neighborhood Disorder Model, which examines the presence of physical and social signs of neighborhood disorder and decay, there is a connection between repeated exposure to ¡°physical incivilities¡± (including abandoned houses, signs of vandalism, litter, worn down buildings and other signs of neglect) and feelings of fear, stress and anxiety (Halpern, 1995). Those fears were found to be significantly linked to higher levels of depression and anxiety over time (Taylor, Perkins, Shumaker, & Meeks, 1991).
Culture plays a key role in mediating neighborhood effects on urban health outcomes. Geronimus (2000) points to the synthesis of the memory of urban decay, currently visible ¡°dramatic deterioration¡± of neighborhood structures, and lived experience as being a crucial factor in explaining the connection between neighborhood structures and community health outcomes. She also suggests that historical cultural experiences along with visible deterioration and/or disorder might function as reminders of past stress and stressors. These reminders may trigger migration away from an area, recognition of institutional disinvestment and feelings of discomfort, and disquiet among the people who live there (Perkins & Taylor, 1996; Ross, 2000; Sampson & Raudenbush, 1999).
Finally, the physical layout of neighborhoods has been identified as a critical factor in determining health outcomes. Kissane (2010) observed that people often do not visit social service or mental health organizations that are located too far away from them. She found that people often created their own cognitive maps, mentally noting which areas of their community were too far away, too alien, or too dangerous to be worth visiting. The creation of those different areas often depended on individual perceptions of distance, familiarity, disorder and safety. Since many community mental health programs were based out of the social service organizations studied, the physical arrangement of the study area acted as a barrier between participants and recommended health services.
Perceived Discrimination and Centrality of Identity
African-Americans occupy a special place in American society. Having spent centuries experiencing either the memory or reality of slavery, we have become particularly attuned to recognizing manifestations of discrimination and racism in everyday life. These can include instances of individual-level racism, such as verbal or physical insults, refusals of service, demonstrations of low standards of achievement relative to the dominant culture, or of institutional racism, such as general neglect, pervasive neighborhood disorder, avoidance, and political or structural bias disfavoring African-Americans (US Commission on Civil Rights, 1999). These racially dependent manifestations and their recognition likely play some role in creating disparate health outcomes for African-Americans. Since it is difficult to record outright acts of discrimination as they occur, most research conducted on discrimination and its effects focuses on recording and measuring instances of perceived racism (Pascoe & Richman, 2009), which, though unverifiable, can be characterized as a form of stress. According to the literature, there is a link between how much and what kind of perceived discrimination people experience and the quality of their general health and health care access (Armbruster, Gerstein, & Fallon, 1997; Dovidio, et al., 2008; Pascoe & Richman, 2009; Richman, Bennett, Pek, Siegler, & Williams, 2007; Sellers, Copeland-Linder, Martin, & Lewis, 2006).
Experiences of perceived discrimination have been linked to lower expectations of institutional interactions, lower rates of mental health service-seeking behavior and utilization (Richman, et al., 2007), lower levels of perceived wellbeing (Williams, Yu, & Anderson, 1997), higher levels of psychological distress (Broman, Mavaddat, & Hsu 2000), depression and anxiety (Klonoff, Landrine, & Ullman, 1999), and mood disorders (Kessler, Mickelson, & Williams, 1999). Further, perceived discrimination seems to be largely mediated by the racial identities of the individuals experiencing it, as the more central individuals hold their racial or ethnic identity to be (and the more they believe other groups hold that identity in low regard), the more likely they are to report experiencing discrimination (Sellers, et al., 2006). This suggests that the way people interpret their racial and sociocultural position plays a role in what they are able to see or acknowledge experiencing.
Certain types of discrimination, though not explicit, appear to be common for African-Americans to perceive. According to the Nelson (2002), writing in the Unequal Treatment report for the Institute of Medicine, ¡°there is considerable empirical evidence that even well-intentioned whites who are not overtly biased and who do not believe that they are prejudiced typically demonstrate unconscious implicit negative racial attitudes and stereotypes¡± (p. 4). In a study conducted by Richeson and Ambady (2003), it was found that White participants who were told that they were in a position of power over Black participants revealed more racial bias than if they were placed in a subordinate position, suggesting that racially disparate interactions featuring African-Americans in a position of lower power have the potential to be fraught with racial bias. In another study by Stepanikova, Triplett, and Simpson (2011), researchers discovered that possessing implicit anti-Black biases had a negative effect on generosity towards African-Americans. It appears that African-Americans are able to detect at least some degree of implicit (that is, not outright) bias, as Black patients reported having less positive reactions to doctors who tested as possessing low levels of explicit racial bias and high levels of implicit racial bias than to those possessing either low or high levels of both explicit and implicit bias (Penner, et al., 2010). Black participants reacted the most strongly when there was a disparity between their doctors¡¯ self-reported bias and their perceived actions.
In another experimental study, Merritt, Bennett, Williams, Edwards, and Sollers (2006) exposed participants to either a blatantly racist encounter or to the same encounter with no mention of race. They found that participants in the non-racially explicit encounter showed a higher cardiovascular response than those in the overtly racist condition, suggesting that individuals possess the ability to detect and react to racism even in the absence of blatant racial reference and that their reactions might depend on the degree of racial undertones. Further, Richeson and Shelton (2005) discovered that Black judges were better at accurately predicting both the implicit and explicit nonverbal racial attitudes of White individuals than White judges in short, interracial interactions, suggesting that subtle forms of racial bias are visible to African-American observers after relatively short periods of exposure.
Perceptions of discrimination or bias can have tangible effects on the health and treatment of African-Americans. Hagiwara et al. (2013) found that non-Black doctors with higher levels of implicit racism in their study spoke at greater length than doctors with lower levels of implicit bias. Black patients with higher levels of perceived discrimination were found to speak more than those with lower levels. Smaller physician-patient talk time ratios (where patients spoke more than doctors) were found to be connected to decreased likelihoods of patients following through with their treatment plans. This points to a connection between perceived racism and patient adherence to medical treatment plans, which holds the potential to have adverse effects on the overall health of African-American patients. Also, since perceptions of discrimination depend partially on the history of individuals, this highlights the importance of perceived past discrimination in the construction of current health behaviors.
Dovidio and Fiske (2012) explored how unexamined racial biases in clinical interactions can contribute to health care disparities. They found that poor African-Americans are stereotypically seen as possessing both low warmth and low competence, a combination that typically incites feelings of disgust and contempt from outside observers. The authors argue that emotions predict behavior, with disgust and contempt predicting both passive and active harm, including neglect, demeaning, attacking, and fighting the observed group. This can create both group-level invisibility and pervasive social harm. It can also produce perceptions of racism in the observed group, leading to adverse health behaviors. Pascoe and Richman (2009) found that some risky health behaviors, including not utilizing available community health resources, might act as active coping strategies against the harms of perceived racism. Since active coping strategies against stressors may be more effective than passive ones in minimizing the effects of stress, groups experiencing a higher lifetime load of discrimination may actively avoid coming into contact with institutions that they believe may display any kind of racial bias. This, in turn, may result in decreased service utilization for groups experiencing high levels of perceived discrimination.
Because of the differences in perceptions of discrimination between Black and White individuals, groups possessing different racial identities are likely to cultivate markedly different views on the presence of racial bias (Dovidio et al., 2008). African-Americans are less trusting of their own physicians than Whites (Doescher, Saver, Franks, & Fiscella, 2000), more likely to believe that race negatively affects the quality and type of health care they receive (Johnson, Saha, Arbelaez, Beach, & Cooper, 2004), and are likely to report that discrimination occurs regularly in interactions with White doctors, with 57% of Black respondents in a national survey reporting that discrimination occurs ¡°often¡± or ¡°very often¡± in African-Americans¡¯ interactions with White physicians (Malat & Hamilton, 2006). Since about 75% of African-American patients¡¯ medical interactions occur with a provider of a different race (Chen, Fryer, Phillips, Wilson, & Pathman, 2005), there is likely some link between individual perceptions of racial bias in medical encounters and the creation and encouragement of mistrust between African-Americans and a largely non-Black medical system.
There is evidence that trust affects utilization of health services. LaVeist, Isaac and Williams (2009) found that the Medical Mistrust Index (MMI) was effective in both measuring mistrust of health care organizations and in predicting underutilization of health services. Mistrust was associated with failure to take medical advice, failure to keep follow-up appointments, postponing and receiving needed care, and failure to fill prescriptions. Further, Boulware, Cooper, Ratner, LaVeist, and Powe (2003) found that patterns of trust in the American health care system differ along racial lines. They found that non-Hispanic Black respondents were less trusting of their physicians than non-Hispanic White respondents, as well as more likely to hold concerns about personal privacy and harmful experimentation in hospitals.
Musa, Schulz, Harris, Silverman, and Thomas (2009) found that African-Americans had significantly less trust than Whites in their own physicians and in both formal and informal health information sources. Lower trust was associated with decreased utilization of preventive services, including routine checkups, prostate tests and mammograms. The authors concluded that African-Americans¡¯ relatively high distrust of their physicians likely contributed to health disparities through the mechanism of reducing utilization of preventive services. Armstrong, Dean, Micco, Pyeritz, and Bernhardt (2008) identified two different kinds of mistrust, values and competence, with ¡°the former [referring] to the values that are thought to be necessary in the health care system, such as respect, honesty, caring, dependability, and confidentiality, while the latter represents the technical skills needed for successful health care¡± (as cited in Shoff & Yang, 2012, p. 2). Shoff and Yang (2012) found that African-Americans have greater values distrust than Whites, with the association between race and distrust of values weakened by increasing levels of neighborhood stability. The more ¡°unstable¡± a neighborhood was perceived to be, the greater the connection became between respondents¡¯ race and distrust. This suggests some connection between signs of instability in a neighborhood, such as physical and social disorder, and the encouragement or discouragement of trust.
After reviewing the literature on neighborhood effects, perceived discrimination, mistrust and their effects on health service utilization, a possible pathway between observing physical disorder in a neighborhood and the outcome of decreased mental health service use for African-Americans becomes visible. Physical disorder of neighborhoods may be interpreted as perceived discrimination (mediated by centrality of racial identity), which then manifests as mistrust, resulting in decreased mental health service utilization for African-Americans. This pathway is visually represented in Figure 1. Individuals living in neighborhoods may see the poor shape of buildings and structures around them, assume that the poor shape is a result of discrimination (with the assumed form of that discrimination depending on the racial and cultural identity of the observer), and decide that they are unable to trust parts of a system that does a poor job of caring for their neighborhood environment with care for their own bodies and minds.
That perceived discrimination could act as an antecedent to decreased health service utilization for African-Americans is not a new idea, but only recently have researchers begun examining the precise connections between physical disorder and mental health service utilization. In addition, there has been very little literature published that focuses on the connections between trust, mistrust, and the physical configuration of African-American communities. Future research should focus on what factors in the physical environment inspire distrust, how physical disorder may be interpreted as mistrust and how neighborhood effects can be mitigated to reduce disparities in health service usage between African-Americans and other racial groups. A very small portion of the literature examined in this review utilized ethnographic methods in collecting data on trust, neighborhood effects, service utilization and their connections. A future focus on this kind of data collection may provide more detailed information on the pathways between neighborhood disorder and decreased service use than traditional quantitative measures.
Underutilization of mental health services by African-Americans in the U.S. continues to be widespread among adults. This literature review summarizes findings from major research studies on the effects of neighborhood disorder, perceived discrimination, and mistrust on mental health and health care usage. It is my hope that it can highlight paths for future research in these areas and serve as a starting point to inform future health utilization interventions.
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About the Author
Rayven Plaza is a graduate student at the Silberman School of Social Work at Hunter College. She holds a BA and MA in Cultural Anthropology from the University of North Carolina at Chapel Hill and Columbia University (respectively) and will return to Columbia as a doctoral student in Social Policy & Policy Analysis in the fall of 2014. Rayven can be reached at email@example.com.