nature publishing group
Racism and Hypertension: A Review of the Empirical
Evidence and Implications for Clinical Practice
Elizabeth Brondolo1, Erica E. Love2, Melissa Pencille1, Antoinette Schoenthaler3 and Gbenga Ogedegbe3
Background
Despite improved hypertension (HTN) awareness and treatment,
racial disparities in HTN prevalence persist. An understanding of
the biopsychosocial determinants of HTN is necessary to address
racial disparities in the prevalence of HTN. This review examines the
evidence directly and indirectly linking multiple levels of racism
to HTN.
Methods
Published empirical research in EBSCO databases investigating the
relationships of three levels of racism (individual/interpersonal,
internalized, and institutional racism) to HTN was reviewed.
Results
Direct evidence linking individual/interpersonal racism to HTN
diagnosis is weak. However, the relationship of individual/
interpersonal racism to ambulatory blood pressure (ABP) is more
consistent, with all published studies reporting a positive relationship
of interpersonal racism to ABP. There is no direct evidence linking
Racial disparities in hypertension (HTN) continue to be a
pressing problem in the United States. There is consistent
evidence that black Americans are more likely than white
Americans to develop HTN. Prevalence rates for black adults
range from 30.6 to 40.5%; whereas the rates for white range
from 24.4 to 29%.1–5 There is also evidence of racial dispari-
ties in blood pressure (BP) control (control rates: blacks 44.1–
65.2%; whites 55.6–86.3%),5–9 although not all studies have
found race differences.10,11
These disparities exist despite the fact that black Americans
are more likely to be aware of their HTN12 and in some cases
are more likely to receive treatment for HTN than are white
Americans.7,8 Even when black Americans are as or more
adherent to antihypertensive treatment than are whites6,13
disparities in BP control are manifest. To address the high
prevalence of HTN among black Americans, it may be useful
to identify other variables, including different psychosocial
1Department of Psychology, St Johns University, Jamaica, New York, USA;
2Department of Clinical Trials, NYU School of Medicine, New York, New York, USA;
3Center for Healthful Behavior Change, Division of General Internal Medicine,
Department of Medicine, NYU School of Medicine, New York, New York, USA.
Correspondence: E. Brondolo (brondole@stjohns.edu)
Received 14 June 2010; first decision 16 July 2010; accepted 25 December 2010
© 2011 American Journal of Hypertension, Ltd.
AMERICAN JOURNAL OF HYPERTENSION
STATE OF THE ART
internalized racism to BP. Population-based studies provide some
evidence linking institutional racism, in the forms of residential racial
segregation (RRS) and incarceration, to HTN incidence. Racism shows
associations to stress exposure and reactivity as well as associations
to established HTN-related risk factors including obesity, low levels of
physical activity and alcohol use. The effects vary by level of racism.
Conclusions
Overall the findings suggest that racism may increase risk for HTN;
these effects emerge more clearly for institutional racism than
for individual level racism. All levels of racism may influence the
prevalence of HTN via stress exposure and reactivity and by fostering
conditions that undermine health behaviors, raising the barriers to
lifestyle change.
Keywords: ambulatory blood pressure; blood pressure; hypertension;
racial discrimination; racism
American Journal of Hypertension, advance online publication 17 February 2011;
doi:10.1038/ajh.2011.9
stressors, that might serve as potential individual-level and
environmental risk factors that disproportionately affect black
Americans, and to understand the ways in which these vari-
ables may operate to increase HTN prevalence.
Racism has been hypothesized to serve as a psychosocial
stressor contributing to the excess rates of HTN among black
Americans.14–18 The goal of this review is to provide a detailed
evaluation of the evidence linking individual/interpersonal,
internalized, and institutional racism to HTN and to known
risk factors for HTN, including obesity, fitness, and alcohol
use, as well as psychosocial stress. We hope to provide an evi-
dence base that can inform further examination of the role of
racism in the development and course of HTN.
We specifically investigate the effects of racism on black
Americans, because the majority of published research on the
relation of racism to HTN has focused on black Americans. It
is important to note, though, there are also significant dispari-
ties for other ethnic groups.3,6,19,20
Constructs and Definitions
Most broadly, racism has been defined as “the beliefs, attitudes,
institutional arrangements, and acts that tend to denigrate indi-
viduals or groups because of phenotypic characteristics or ­ethnic
group affiliation.”16 Racism or ethnic discrimination can be
1
2
Table 1 | Interpersonal, internalized, and institutional racism and blood pressure
Author Sample Racism measure Blood pressure measure Potential covariates Findings
Interpersonal racism
  Barksdale et al.50 211 Black men and PRS27 Mean SBP None used in the analysis No relation
women, convenience
sample
  Broman56 312 African American Questionnaire assessing “experiences of Self-reported Age, sex, education, No relation
adults randomly discrimination or being prevented from doing hypertension family income,
selected something, have been hassled or made to feel employment status
inferior because you are Black” in any of five
STATE OF THE ART

situations. Any positive response indicated

discrimination
  Cozier et al.58 59,000 Black women, Questionnaire assessing self-reported exposure to Self-reported Age, BMI, birthplace, Positive relation for
targeted sampling, types of personally mediated racism (i.e., received antihypertensive use or type of neighborhood, women born outside
snowball recruit poorer service, treated as not intelligent, people act hypertensive status with education the United States and
afraid, treated as dishonest, people act as if they are use of a diuretic born in predominately
better than) and “institutional racism” (i.e., unfair white neighborhoods
treatment on the job, in housing, and by police) only
 Din-Dzietham et al.57 356 Black adults, Author developed measure. Questions include Nurse measured SBP and Age; marital status SES; No relation
population-based “whether the participants had personally DBP and self-reported BMI; coping, abilities
sample experienced any racist or discriminatory encounters physician-diagnosed high
in general, work and medical settings blood pressure at two or
more visits
  Dressler52 186 Black, random Four items assessing the degree to which BP measurements taken BMI, age, sex, skin color No relation
selection, participants perceived that pay raises and other at home with aneroid
4 communities work-related issues were based on race sphygmomanometer
  James et al.55 132 Black men, Three questions about race as a hindrance or help Two measures of resting Age, education, quetlet No direct relationship
probability sample, to job BP taken during interview index, # cigarettes, time
1 community of day
  James et al.49 89 Minority adults Organizational Prejudice-Discrimination Scale49 Mean SBP and DBP Self-esteem; collective Positive relation
(18.1% Black) esteem; value differences
convenience sample with peers & supervisors;
of employees expressiveness
  Krieger59 101 Black and white Interview questions: Have you ever experienced Mean SBP and DBP Age Negative relation,
women, random discrimination, been kept from doing something, or not significant when
sample been hassled or made to feel inferior (at school, at adjusted for age
work, getting a job, at home, getting medical care)
because of your race?
 Krieger and Sidney48 4,086 Black and white, Self-administered questionnaire: five sets of Mean SBP and DBP Age; social class; annual U-shaped relation,
targeted recruitment questions which addressed whether they had ever family income, education, effects vary by gender
experienced discrimination, been prevented from marital status and social class
doing something or been hassled or made to feel
inferior in several situations based on race or color
(at school, getting a job, at work, getting housing,
getting medical care, on the street or in a public
setting and from the police or in the courts)
Table 1 | Continued on next page

AMERICAN JOURNAL OF HYPERTENSION

Race, Racism, and Hypertension
 Table 1 | Continued
Author Sample Interpersonal racism measure Blood pressure measure Potential covariates Findings
  Peters54 162 Black adults, RaLES;26,125 KRDQ59 Mean SBP and DBP Age, trait anger, trait No relation
convenience sample anxiety, anger expression
  Poston et al.47 221 Black medical PRS27 Mean SBP Birthplace, BMI, age No relation
professionals, born in
United States or Africa
Race, Racism, and Hypertension

  Ryan et al.51 666 Black or Latino(a) BRFSS reactions to race module—three questions Mean BP Ethnicity, age, gender, U-shaped relation—
adults (190 Black), “How often do you feel discomfort, or anger by the tobacco use, exercise, both the lowest and
snowball sampling ways others treat you in your everyday life because BP meds, BMI, income, highest levels of

AMERICAN JOURNAL OF HYPERTENSION

of your race? do you feel that “racial discrimination education, employment, exposure had higher
diminishes your ability to achieve your goals fully?” insurance BP than individuals
“You have been receiving less than the best health with moderate
care because of your race?” exposure
  Brondolo et al.62 357 Black and Latino Perceived Ethnic Discrimination Questionnaire- ABP-day and night Age, race, gender, BMI, PR positively
adults, 245 with Community Version24 cynicism/hostility, associated with
nighttime readings, individual-level measures nighttime SBP and
convenience sample of SES, also observation DBP, inversely related
level measures of caffeine to BP dipping
and alcohol, posture,
smoking
  Hill et al.66 40 Black students, PRS,27 racism in academic settings, public setting, ABP-day and night Gender, BMI PR in academic setting
convenience sample racist statements positively associated
with daytime DBP and
nighttime DBP. No
effects for SBP
 Smart Richman 61 Black and white adults, Everyday unfair treatment (discrimination) ABP-day and night Sex, age, race, SES, BMI, UT/D positive relation
et al.65 convenience sample (no questions on attribution to race) hostility, neuroticism, to overall DBP. Time
and observational level trend: for high UT/D
variations in posture (vs. low) increase
over the day, shallow
decreasing slope
during night
  Singleton et al.63 52 Black adults, PRS,27 overall, exposure in public places, racist ABP-day and night No information Racism in public
convenience sample statements settings positively
related to nighttime
SBP and DBP. No
effects for daytime BP
  Tomfohr et al.64 91 Black and white adults, Everyday unfair treatment (discrimination), no ABP-two days and two Age, gender, race, UT/D is associated
convenience sample questions on attribution to race68 nights BMI, defensiveness/ with less nighttime
social desirability SES, dipping of SBP and
and average BP, hostility, DBP. No interactions
marital status, weekly with race. UT/D
consumption of alcoholic mediates race
beverages, and smoking. differences in dipping.
Table 1 | Continued on next page
STATE OF THE ART

3
4
Table 1 | Continued
Author Sample Racism measure HTN measure Potential covariates Findings
Internalized racism
  Tull et al.89 Age and body mass Nadanolitization scale31 Mean SBP and DBP or Perceived stress No relation
matched samples of presence of score, defeated coping
African-Caribbean, hypertension style
STATE OF THE ART

nondiabetic women aged

25–60. Twenty-seven
with high internalized
racism and twenty-six
with low internalized
racism
Author Sample Racism measure HTN measure Potential covariates Findings
Institutional racism
  Fang et al.96 All residents of NYC Contrast between largely black and largely white Death registration Age, education, No relation
drawn from census 1990 areas (largely black ≤75% black, largely white ≤75% information from NYC unemployment, birth in
and death registrations white), plus Harlem DOH, cause of death is South of US
from 1988 to 1994 reported by a physician
(ICD - 9.401–404)
 Grady and Ramirez92 91,748 Records of black Local spatial segregation index Presence of chronic HTN Age, marital status, place Positive relationship:
and white mothers drawn or pregnancy-related HTN of birth, education, higher segregation,
from NYC Department Medicaid use, poverty greater risk of
of Health Vital chronic and
records pregnancy HTN
  Mobley et al.109 Sample of 2001–2002 The degree to which members of each race/ethnic 10-year CHD risk Individual characteristics: Negative relation
data of 2,692 women group are exposed more to one another than to calculated by an age, smoking status,
enrolled in the members of other racial/ethnic groups algorithm using gender, education, race/ethnicity
WISEWOMAN program age, total and high Built Environment
of the Centers of Disease density lipoprotein (HDL), characteristics: land use
Control and Prevention cholesterol, SBP, Smoking mix, per 1,000 residents—
status, diabetesstatus number of fitness
facilities, full size grocery
stores, fast food places,
restaurants, minimarts.
Socioecological
characteristics: robbery
arrests per 1,000 residents
Table 1 | Continued on next page

AMERICAN JOURNAL OF HYPERTENSION

Race, Racism, and Hypertension
Race, Racism, and Hypertension STATE OF THE ART

c­ onsidered as a form of social ostracism. Phenotypic or cultural

ABP, ambulatory BP; BMI, body mass index; BP, blood pressure; BRFSS, Behavior Risk Factor Surveillance System; CHD, chronic heart disease; DBP, diastolic BP; HTN, hypertension; KRDQ, Krieger Racial Discrimination Questionnaire;
characteristics are used to render individuals outcasts, making
them targets of social exclusion, unfair treatment, and harass-
Positive relation

Positive relation
ment; and consequently, either directly or indirectly, depriving
No relation
Findings

them of social and economic opportunities and threatening per-

sonal safety.21 Detailed reviews concerning the conceptualiza-
tion and measurement of racism are available elsewhere.16,18,22

risk factors, behavioral risk

Racism can occur on multiple levels: individual/inter-
insurance status, regular
marital status, presence
Sex, age, race/ethnicity,

of children, BMI, health

Demographics, clinical personal, internalized, and institutional.22,23 Individual-

None used in analysis
Potential covariates

medical care status,

immigration status,
education, income,

exercise frequency

level racism includes episodes of race-based maltreatment

that are perpetrated by individuals and targeted at other
factors, SES

individuals.17,22 In the context of an interpersonal exchange,

these exchanges are considered interpersonal racism, which
has been defined as “directly perceived discriminatory inter-
actions between individuals whether in their institutional
Self-reported diagnosed

roles or as public and private individuals.”22 Individual-level

Incident hypertension

racism is typically assessed with self-report surveys inquiring

2000 Census—neighborhood composition, percent Mean SBP and DBP

about exposure to acts perceived as discriminatory, unfair, or

PRS, Perceived Racism Scale; RaLES, Racism and Life Experiences Scale; RRS, residential racial segregation; SBP, systolic BP; SES, socioeconomic status.
HTN measure

hypertension

disrespectful (i.e., refs. 24–27). Self-report surveys assess the

subset of experiences of ethnicity-related maltreatment that
are directly perceived by the target and are generally labeled
­perceived ­racism or ethnic discrimination.
Internalized racism is defined as “the acceptance, by mar-
3,105 participants aged Hispanic, percent immigrant, percent non-black in

ginalized racial populations, of the negative societal beliefs

3,014 Telephone surveys 2000 Census—percent of blacks in census tract

and stereotypes about themselves.”28 The internalization of

negative stereotypes about ones’ own group may develop in
response to repeated exposure to ethnicity-based maltreat-
RRS/institutional racism measure

ment, as a function of cultural communications of attitudes

toward stigmatized groups, and from familial or other sociali-
zation processes, as well as other mechanisms.29,30 In studies
History of incarceration

of BP among black individuals, internalized racism has been

assessed with a self-report scale (i.e., Nadanolitization scale)31
that measure the degree of agreement with typical stereotypes
18 and over from various census tract

about the black individuals.

Institutional racism refers to specific policies and/or pro-
cedures of institutions (i.e., government, business, schools,
churches, etc.) which consistently result in unequal treatment
men and women in North

or outcomes for particular groups, even though other non-

Nashville and Nashville/
done using a sample of
Probability sample of

race-related factors may also be associated with the disparate

outcomes.32,33 Policies resulting in unequal treatment can be
cities in Chicago

considered as a form of racism, despite the absence of evidence

Davidson, TN

of deliberate racial prejudice on the part of the policy-makers.

Sample

This is the case when majority-group policy-makers are less

aware of or responsive to the consequences of these policies
for minority stakeholders.34 In general, research on the rela-
Table 1 | Continued

tionship of institutional racism to HTN has focused on the

Morenoff et al.94

  Schlundt et al.93

relationship of BP to the tangible outcomes of these policies,

  Wang et al.97

including access to education or health care, residential seg-

regation, incarceration, among other outcomes.35,36 Two out-
Author

comes that have been specifically studied in relation to HTN

include residential racial segregation (RRS) and incarceration.
 

AMERICAN JOURNAL OF HYPERTENSION 5

 STATE OF THE ART
Residential segregation refers to “the degree to which
groups of people categorized on a variety of scales (race, eth-
nicity, income) occupy different space within urban areas.”37
We focus on race-based residential segregation (RRS), which
is likely to be a function of a number of both historical and
current actions on the part of institutions (i.e., real estate
­developers, lending organizations, employers) as well as the
actions of individuals within neighborhoods.37 RRS also serves
as a proxy for the extent to which black individuals are ostra-
cized by other groups.38 Across all income groups, blacks tend
to live in more racially segregated areas than do whites, but
RRS is most pronounced among individuals with low ­levels
of income and education.35 Strategies for conceptualizing and
quantifying RRS have been well reviewed elsewhere.37,39,40
Examples of measures include the index of dissimilarity and
the proportion of black residents in a given area, a measure
used in most ­studies of HTN despite some limitations to its
interpretability.37,41
Rates of incarceration in the criminal justice system can also
be regarded as an index of institutional racism.42,43 In compar-
ison to whites, most evidence suggests that black Americans
are more likely to be incarcerated, even when controlling for
a wide range of case and jurisdiction-related variable.42 These
differences have developed in part, because of stereotypes
about the propensity of black Americans to be violent, as well
as legal and policing policies and practices.42,43
This review extends our prior work and examines studies of
adults linking each level of racism to HTN diagnosis or to BP
levels (with BP levels serving as a proxy for a documented diag-
nosis of HTN).14,44 To obtain all relevant studies, we searched
all EBSCO-host-related databases, including MEDLINE and
Psych Info using the terms: racism, racial discrimination, eth-
nic discrimination, institutional racism, internalized racism,
self-stereotyping, residential segregation, racial segregation,
racial residential segregation, and incarceration combined
with BP, cardiovascular response, reactivity, HTN, and health.
All papers were searched for any additional relevant refer-
ences. Papers available through August 2010 were included.
Table  1 includes the details of all reviewed studies for each
level of racism.
To further understand the mechanisms through which rac-
ism may affect HTN, we also investigate the relationship of
racism to obesity, low levels of fitness, and excess alcohol con-
sumption. Each has been documented to be associated with
increased HTN prevalence.20,45 Reductions in these risk fac-
tors have been associated with improvements in BP, and they
are frequent targets of physician recommendations.45
We include data on psychosocial stress as a risk ­factor,
although the relationship is not as well documented or
accepted as lifestyle-related risk factors. Events and conditions
are perceived as stressful when they are appraised as ­salient and
6
Race, Racism, and Hypertension
threatening, and present demands for coping that are ­perceived
to exceed the individual’s resources.46 Both ­systematic and
conceptual reviews suggest that chronic, but not acute stres-
sors are more likely to be associated with increased risk for
HTN.47,48
All levels of racism can result in acute stress exposure,
but racism is widely regarded as a chronic stressor.16,21,49
Interpersonal racism takes the form of discrete events, includ-
ing both overt and covert episodes of race-related maltreat-
ment. These acute events can become chronic stressors if
they occur frequently and/or if the experience has persistent
negative effects. For example, the acute effects of race-related
maltreatment may be maintained if the targeted individual
experiences constraints on his or her ability to resolve the
situation or cope with its aftermath.21,46 Institutional racism
is associated with conditions (e.g., residential segregation,
incarceration) that present additional obstacles or sustained
demands that can act as chronic stressors.
Racism and Htn: Examining the Associations
of Interpersonal, Internalized, and Institution‑
alized Racism To Htn Diagnosis Or Bp Levels and
Htn‑Related Risk Factors
Individual/interpersonal racism
The bulk of the research on racism and HTN has investigated
the effects of individual-level or interpersonal racism.15,17
Most studies employed within-group designs to investigate the
degree to which the intensity of exposure to racism affects risk
for HTN within black individuals. In our prior review,14 we
indicated limited direct relationships of racism to HTN diag-
nosis. The subsequent publications support this conclusion.
To date there have been 12 observational studies (described in
13 papers) which included black adults and which examined the
relationship between self-reported exposure to interpersonal
racism and resting BP level (e.g., a mean of two or three read-
ings taken under standardized conditions)47–55 or self-reported
or physician-diagnosed hypertensive status.48,56–58 Seven stud-
ies did not find a direct relationship between perceived rac-
ism and BP when the investigators examined the sample as a
whole.47,50,52–54,56,57 Two studies have found a negative relation-
ship either among older participants54 or among the participant
group as a whole.59 There are two ­studies that report a U-shaped
relationship of racism to HTN, in which, depending on partici-
pants’ race, gender, and social class, there were elevated BP lev-
els in those experiencing high levels of racism or no racism vs.
moderate levels of racism.48,51 There are only two studies that
reported a positive relationship between self-reported racism
and either BP level or self-reported diagnosis of HTN either
in the group overall49 or in one subgroup (i.e., non-US born
women).58 However, one of these ­studies included a small sam-
ple (n = 89), only 18% of whom were black.49
AMERICAN JOURNAL OF HYPERTENSION
Race, Racism, and Hypertension
In contrast, the data from ambulatory BP (ABP) monitoring
studies are more consistent. ABP, and in particular nocturnal
ABP, is regarded as a more reliable predictor of target organ
damage than are clinic measures.60 Ambulatory monitoring
also captures BP reactivity to daily events. The six studies of
adults all reported positive relationships between perceived
racism/discrimination and either daytime ABP,61 nighttime
ABP or BP dipping,62–65 or both.66
There are substantial variations in the quality of these stud-
ies of HTN diagnosis, clinic BP or ABP. Only four of the
studies employed population-based or randomly selected
samples.55–57,59 As shown in Table 1, some studies employed
measures with a small number of items inquiring about dis-
crimination in general or experiences of discrimination in spe-
cific venues (i.e., such as work or medical care),48,52,55,56,59 and
very little psychometric information was provided about these
measures. Others studies included measures that have been
subjected to extensive psychometric testing (e.g., Perceived
Racism Scale, Everyday Discrimination, or the Perceived Ethnic
Discrimination Questionnaire-Community Version).47,49,50,54
The studies of ABP (vs. those of BP level or HTN diagnosis)
were more likely to include measures with known and good
psychometric properties. However, it is important to note that
neither the more limited scales, nor those with good psycho-
metric properties yielded positive effects in studies of clinic BP
or HTN status. In contrast, the same scales (i.e., the Perceived
Racism Scale, Everyday Discrimination/Unfair treatment)
were associated with ABP, even in studies with much smaller
samples.61–66
As is the case with all self-report measures, scores on meas-
ures of perceived racism may contain some error. The scales
measuring perceived racism cannot distinguish between the
target’s perceptions of racial bias in cases in which these per-
ceptions are accurate (i.e., the perpetrators’ actions were moti-
vated by racial bias) vs. those in which the target’s perceptions
are a function of misperceptions or misattributions to discrimi-
nation. To attempt to control for intrapersonal factors such
as hostility or neuroticism that might influence the percep-
tions of racism (and potentially HTN), but may develop from
nonracism-­related factors (e.g., temperament, family function-
ing,  etc.), some investigators have included measures of per-
sonality characteristics as covariates.62,65 Three ABP studies in
which measures of negative-affect related traits (e.g., hostility or
neuroticism) were included as covariates find that the effects of
perceived racism on ABP remain robust and significant.62,64,65
Measures of perceived racism which inquire about dis-
crimination in a variety of venues could elicit answers reflect-
ing perceptions of institutional racism (i.e., perceptions of
being mistreated as a function of institutional policies) rather
than experiences of interpersonal maltreatment. Racism
may also affect an individual’s access to economic and social
AMERICAN JOURNAL OF HYPERTENSION
STATE OF THE ART
resources, and in turn affect HTN risk through deprivation.
Consequently, most investigators included measures of indi-
vidual level or neighborhood socioeconomic status (SES) as a
partial control for the effects of these environmental or insti-
tutional variables. In studies in which the effects of SES were
explicitly evaluated,67 the inclusion of SES as a control variable
did not eliminate the effects of perceived racism/discrimina-
tion on ABP.62 However, some studies suggest that SES mod-
erates the effects of racism on BP, although the direction of
effects is not consistent and additional work is needed.48,55,57
Individual-level racism may also have health effects in cir-
cumstances in which the targeted individual is unaware of
the exposure.68,69 Some investigators have advocated the use
of measures of unfair treatment or discriminatory behavior
(e.g.,  the Everyday Unfair Treatment Scale68,69) which assess
exposure to interpersonal experiences that are likely to be a
function of racial discrimination, without requiring participants
to attribute the maltreatment to racial bias. These scales can be
considered as a measure of the construct “­everyday unfair treat-
ment” rather than racial discrimination per se, because individ-
uals can perceive themselves as targeted for unfair treatment for
many reasons (i.e., including their social class or ­gender). Some
investigators have included additional questions about the attri-
butions for the maltreatment; however, none of the studies of
HTN or ABP in adults included these items.
All studies of HTN and clinic BP employed measures directly
referring to race. All ABP studies included measures assessing
experiences of unfair or discriminatory treatment in ­everyday
life (i.e., Everyday Unfair Treatment, Perceived Racism
Scale, and Perceived Ethnic Discrimination Questionnaire-
Community Version). Four of these studies included meas-
ures which explicitly refer to race as a cause for the unfair
treatment (i.e., Perceived Racism Scale and Perceived Ethnic
Discrimination Questionnaire-Community Version),61–63,66
whereas two other studies included measures of unfair treat-
ment that did not explicitly refer to race.64,65 Associations of
unfair treatment/discrimination to ABP among blacks were
found using either type of measure of unfair treatment.
Interpersonal racism and risk factors for HTN. Although two
recent studies reported no concurrent relationship of racism
to body mass index,70,71 another prospective investigation
reported that increases in interpersonal racism were positively
associated with weight gain over a period of 8 years.72 To our
knowledge there have been no studies of the relationship of indi-
vidual-level racism and the intake of specific nutrients such as
sodium or potassium. Perceived racism has been associated with
greater risk for any level of alcohol use (but not binge or heavy
drinking) among black Americans.73 Prospective studies also
indicate a relationship of perceived discrimination to increases
in alcohol use, partially mediated by ­discrimination-related
7
 STATE OF THE ART
changes in psychological distress.74 The one study specifically
examining physical activity in a large population-based sample,
did not find a relationship with racism.75
In contrast, there is substantial, clear and consistent evidence
that individual-level racism is associated with indices of psycho-
logical distress (e.g., negative affect, anger, depression, and anx-
iety), as well as personality characteristics (e.g., ­hostility, trait
negative mood) that increase the experience of distress.15,17,76,77
Racism may also influence cardiovascular responses to stress
exposure. BP reactivity to stress has been identified as an inde-
pendent predictor of the development of HTN.78,79 Several
studies report that perceived individual-level racism predicts
the magnitude of BP reactivity to laboratory-induced stres-
sors.80–85 However, others studies found no direct relation-
ship of individual-level racism to BP reactivity or recovery, and
report that the effects of racism emerged only when moderated
by other characteristics (e.g., support or hostility).80,82,86
Interpersonal racism is more consistently related to perceived
stress and negative emotions than to lifestyle-related factors,
including physical activity or obesity. It is worth noting that
some,50,57 although not all,54 studies of racism and HTN found
that stress reactions to racism were associated with HTN diag-
nosis or BP level, even when exposure to race-based maltreat-
ment was not. However, there are still very limited data.
Internalized racism
To our knowledge, there is only one study directly assessing
the effects of internalized racism, assessed with a modified ver-
sion of the Nadanolitization scale on BP in Afro-Caribbean
women. The authors did not find a direct relationship of inter-
nalized racism to resting BP.87
The measure of internalized racism (i.e., the Nadanolitization
scale) assesses the belief that members of one’s group have
characteristics that correspond to common stereotypes about
the group. This may or may not be related to self-­stereotyping
(i.e., the degree to which the individual has incorporated
these stereotypes into his or her self-concept). New research
is employing methods from cognitive psychology, including
variations on the Implicit Association Test, to assess noncon-
scious self-stereotyping.88
Internalized racism and HTN risk factors. Internalized racism
does not show a relationship with body mass index,87 but is
more closely associated with abdominal obesity, with three of
four studies reporting a significant positive relationship.89–91
One study suggests that internalized racism is associated with
perceived stress among black women.87
Institutional racism
The data linking racial residential segregation to HTN is
mixed. RRS has been associated with greater risk for HTN
8
Race, Racism, and Hypertension
among both black and white mothers, such that mothers
­living in more racially segregated areas (e.g., areas in which
there were high percentages of black individuals and in which
residents were less likely to interact with others who were not
black) were more likely to report having chronic HTN and to
be at risk for pregnancy-related HTN, controlling for neigh-
borhood poverty and other factors.92 Another study reported
that the percentage of black individuals living in an area was
correlated with the percentage of individuals with HTN, but
did not control for other facets of the neighborhood in which
black individuals predominate, including higher density and
lower cost of housing, variables independently associated
with HTN.93
In contrast, two population-based studies of black adults did
not find any relationship of the proportion of blacks ­living in
the neighborhood to prevalence of HTN among black adults94
controlling for other neighborhood risks.95 Fang et al. reports
that for black adults, there was no effect of residential area on
HTN-related mortality.96 Finally, a large population-based
study of black women from communities varying in size, seg-
regation, and other factors found that racial segregation, as
assessed by an index evaluating the likelihood that individu-
als would interact with others of another ethnicity or race,
was negatively associated with a measure of 10-year risk for
coronary heart disease in which HTN was one factor used to
­comprise the measure.64
To our knowledge, there is only one study specifically exam-
ining the link between incarceration and HTN.97 The inves-
tigators report that a history of incarceration was associated
with HTN prevalence and new incidences of HTN because
incarceration across both black and white adults drawn from
a national sample of young adults drawn from the Coronary
Artery Risk Development in Young Adults (CARDIA) study.
The effects were strongest for black men, the group most likely
to have been incarcerated, but interactions of race and incar-
ceration were not significant.
There is substantial evidence that black Americans live in
more disadvantaged communities than other groups.34 The
limited available evidence suggests that neighborhood disad-
vantage may mediate the relationship of RRS to HTN.40 Low
levels of neighborhood economic resources, including hous-
ing quality and affluence have been associated with increased
prevalence of HTN,98,99 as have perceptions of social stress in
the community, including crime, perceptions of safety, marital
instability, and crowding.100–103 There may also be additional
environmental factors influencing racial disparities in HTN,
given the wide geographic disparities in rates of HTN among
both blacks Americans.104 Efforts to intervene to reduce HTN
will require an understanding of the specific circumstances or
deprivations that are most closely associated with HTN and
which mediate the effects of RRS on HTN.40
AMERICAN JOURNAL OF HYPERTENSION
Race, Racism, and Hypertension
Institutional racism and HTN risk factors. Data from most,105–
108 but not all109 studies suggest that living in neighborhoods
with higher levels of RRS is associated with a higher prevalence
of obesity. The data on the association of neighborhood afflu-
ence to obesity is clear: rates of obesity are higher in neighbor-
hoods with low vs. high SES.37,110
To our knowledge, there is no direct evidence that RRS
is independently linked to higher rates of alcohol abuse or
dependence. However, there is evidence that economically
disadvantaged neighborhoods and those with higher ­levels of
neighborhood stress are associated with a higher rate of alco-
holism.111–113 The available data on RRS suggest that indi-
viduals living in more segregated communities are less likely
to be physically active.114 RRS has been associated with both
objective indices of stress (e.g., crime),115 subjective reports of
neighborhood stress,116 and fewer community resources for
stress reduction (e.g., parks, recreational ­facilities, etc.).117
A portion of these neighborhood effects on HTN risk fac-
tors may be a function of the barriers to obtaining healthy
foods and accessing recreational facilities, combined with
greater access to liquor stores.110,118–121 In one experimental
study in which very low income individuals from low income
neighborhoods were randomly assigned to live in new, higher
income neighborhoods revealed decreases in obesity (but not
HTN) over a 5-year period.122 Similarly, in the Yonkers project,
low income minority families who were randomly assigned to
be able to move to middle class neighborhoods reported less
alcohol abuse than did families unable to move.123
Summary
Black individuals remain at higher risk for the development
of HTN than do white individuals, despite improvements in
awareness and treatment. There is evidence that racism appears
to affect risk for HTN, but the effects are complex. Among black
Americans, interpersonal racism is associated with ABP,61–
63,66,124 and in particular nocturnal BP, although it does not
appear to be reliably associated with resting measures of BP or
HTN diagnosis.47,50,52–54,56,57,59 There is mixed evidence link-
ing RRS, an index of institutional racism, to HTN prevalence
and BP levels,92,93 and emerging evidence that prison incarcer-
ation is associated with HTN prevalence.97 It is not clear if the
effects of RRS are attributable to the degree of racial isolation
or the degree of deprivation associated with the neighborhood,
as neighborhood SES is inversely associated with HTN inci-
dence.98,99 There is no evidence directly linking internalized
racism to BP, but there have been very few studies.
Racism may influence the incidence of HTN by ­increasing
the incidence of HTN-related risk factors. There is limited
­evidence that interpersonal racism is associated with the
development of obesity.72 RRS is associated with higher levels
of obesity93 and lower levels of fitness.114 Both interpersonal
AMERICAN JOURNAL OF HYPERTENSION
STATE OF THE ART
racism and neighborhood deprivation and stress have been
linked to alcohol use, but more data are needed on the effects
of internalized racism and RRS. All levels of racism are associ-
ated with perceived stress, and individual-level racism, in par-
ticular, is associated with distress21 and stress reactivity.125
Conclusions
Taken together, the evidence suggests that institutional and
interpersonal racism are likely to contribute to the develop-
ment of HTN, although multiple mechanisms and trajectories
may be involved. Individual-level racism, and potentially inter-
nalized racism, may act in part by increasing the frequency,
magnitude, duration, and psychophysiological effects of stress
exposure. The harsh or impoverished environments that are a
function of institutional racism may add additional stress and
raise barriers to achieving a healthy lifestyle.
The relationship of perceived racism to BP emerges more
clearly, when the measures inquire about episodes of interper-
sonal maltreatment vs. global judgments of exposure to dis-
crimination. This may reflect problems with the reliability of
global discrimination measures or the strategies for measur-
ing BP. However, it is also possible that the findings reflect the
aspects of individual-level racism (i.e., stressful interpersonal
maltreatment) that are most closely associated with BP.
Exposure to race-related maltreatment has been shown to be
positively related to increased rates of negative interpersonal
interactions in general.73,77 If the effects of perceived racism
on BP are mediated through exposure to daily interpersonal
maltreatment, the effects of racism on BP may not be apparent
during brief conditions involving rest (or neutral or positive
interactions with medical personnel). Instead, the effects of
racism may be more likely to emerge when BP is assessed dur-
ing everyday events, including episodes of interpersonal con-
flict. This is consistent with the finding that perceived racism/
discrimination is more closely related to ABP than to resting
clinic BP. The importance of ongoing interpersonal conflict to
BP is underscored by our recent report that the level of daily
interpersonal harassment predicted masked HTN (i.e., clinic
normotension plus elevated ABP) in a sample of black and
Latino(a) adults.126 Further study of the effects of racism on
psychobiological responses to interpersonal relationships is
needed, as is research on coping strategies that might moder-
ate or buffer these effects.
Institutional racism is associated with conditions includ-
ing neighborhood poverty, segregation, and incarceration
that provide limited access to health promoting resources
and ­constraints on the development and/or deployment of
health promoting coping strategies.110 This suggests that
resources and coping may mediate the relationship of institu-
tional ­racism to HTN. Yet, experimental data suggest that the
ways in which these variables act as mediators is complex. For
9
 STATE OF THE ART
e­ xample, ­moving to a less impoverished area was associated
with decreases in obesity and alcohol abuse, but was not asso-
ciated with changes in hypertensive status.122,123
Research is needed to understand the specific community-
level variables that affect HTN incidence. It is possible that
multiple environmental factors (e.g., high levels of stress expo-
sure plus limited access to healthy foods) must be present to
trigger the onset of HTN. Alternatively, environmental vari-
ables may exert an effect on risk for HTN only in the presence
of genetic vulnerability. Different levels of racism may inter-
act to compound risk by impairing coping. For example, the
negative mood states that are a persistent effect of exposure to
interpersonal racism may undermine the motivation needed to
overcome the effects of institutional racism, including environ-
ments with few resources for healthy living.62 Risk factors may
operate differently over the course of development. The early
life effects of racism, including the well-documented effects of
racism on birth weight,127,128 may set the stage for increased
vulnerability to the additional challenges presented by chronic
interpersonal maltreatment or neighborhood poverty.
Despite progress, research on racism and HTN is still in its
early stages. To more fully understand the relationship of rac-
ism to HTN, it will be important to identify the ways each level
of racism acts as a stressor or as a barrier to health promotion.
These continued efforts will be necessary to identify targets for
prevention and intervention.
Acknowledgments: This publication was made possible by prior support to
E.B. from grant R01HL68590 and ongoing support to G.O. from the following
grants: P60MD003421; R01HL087301; and R01HL078566. The contents of
this work are solely the responsibility of the authors and do not represent
the official views of NIH.
Disclosure: The authors declared no conflict of interest.
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