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The relation between race, ethnicity and health has been recognised as having an important role to the understanding of social inequalities in health. A review of population-based studies shows that, in developed countries minority ethnic groups identifiable by darker skin colour have increased mortality and prevalence of poor self-perceived health, physical diseases and mental health problems (Nazroo, 2003). Although other factors also contribute to racial disparities in health, more recent studies clearly indicate that racism plays a key role to the understanding of the relations between race, ethnicity and health outcomes, particularly mental health problems (Nazroo, 2003; Williams, Neighbors, & Jackson, 2003). Several studies described a consistent increased frequency of depression or depressive symptoms among adults who perceived racial discrimination (Kessler, Michelson, & Williams, 1999; Noh et al., 1999; Finch, Kolody, & Vega, 2000; Karlsen & Nazroo, 2002; Karslen et al., 2005) or among adolescent populations (Johnson, 1994; Whitbeck et al., 2001; Szalacha et al., 2003; Wong, Eccles, & Sameroff, 2003). Explanations for these findings are still under discussion: one hypothesis is that racism is a risk factor for depression because of the stress from unfavourable life conditions or social exclusion prevailing among most ethnic minorities, while the other assumes that racism is a psychological pathogen by itself, a consequence of living under stigma, segregation and discrimination (Nazroo, 2003). Low socioeconomic status is the most consistent predictor of common mental disorders such as anxiety, minor depressive states and stress (Dohrenwend et al., 1992) and since racial discrimination is strongly related to poverty, socioeconomic status needs to be taken into account when this hypothesis is examined. In support of the second hypothesis, observational (Kessler et al., 1999) or experimental (Jones et al., 1996) studies suggested that discrimination comprises a specific and important origin of stress that is responsible for mental health problems (Meyer, 2003).
Results from recent research also reveal that effects of racial discrimination on health may be mediated by low self-esteem (Mossakowski, 2003), social support networks and coping strategies (Noh & Kaspar, 2003). Individuals who reported perceived racial discrimination are more likely to have symptoms of internalised conflicts, a more common response among girls and young individuals, that may lead to an enhanced acceptance of dominant norms and rules of a given group, which may result in hate against oneself or cause depressive feelings (Whitbeck et al., 2001).
Considering that childhood and adolescence are both crucial phases in the life course, when sexual, cultural and social identities are formed, it is plausible that social exclusion and experienced or perceived racial discrimination at that age may cause even more intense damages to mental health (Wong et al., 1993). The sense of group belonging (alikeness), adjustment and peer acceptance (Williams-Morris, 1996) are also developed in these life stages. Several studies on race or ethnicity and depression among children and adolescents have been reported (Roberts, Roberts, & Chen, 1997; Rickert, Wiemann, & Berenson, 2000), but they have not addressed the racism experience and perception as a relevant variable on the association between race and mental health in young age groups. An exception is Johnson’s (1994) finding of a strong association between racial discrimination and depressive symptoms among Native American children.
Brazil, the country that holds the largest number of Afrodescendents in the world, has been for a long time described as a racial democracy (Heringer, 2002). Nevertheless, the growth and strengthening of black movements in the last decades led to a renewed interest in the social impact of racial discrimination, not always open or visible, even to the victims themselves. Epidemiologic studies on race, ethnicity and depression in Brazilian populations are scarce and do not focus on children or adolescents. Census data have shown that individuals considered to be black, mulattoes or mestizo hold unfavourable social and health indicators across different regions of the country (Heringer, 2002; Chor & Araujo-Lima, 2005). With the purpose of contributing to a better understanding of this issue, in a setting where the majority of the population is black, in this paper the hypothesis that having black skin colour and perceived experience of racial discrimination are positively associated with major depression and depressive symptoms among adolescents is tested, taking into consideration age, sex, and socioeconomic status.
Data analysed in this study come from the baseline of a cohort study about work conditions and health carried out with a sample of individuals living in Salvador, capital city of Bahia State, Brazil in the year 2000. In this historical urban area, there were approximately 2.7 million inhabitants, mostly poor, black or mulatto. The study population comprises children and adolescents 10 to 21 years of age. Households were selected by a random single-stage area sampling design, based on predefined sub-areas of the city official urban plan. Sample size was defined based on parameters related to the main hypotheses of the cohort study. From 32 selected sub-areas needed to obtain the required number of individuals, three had no households and were excluded. In the remaining 29 areas, all households were visited and one family member provided general sociodemographic information about each family member. Further visits were scheduled to complete individual interviews for data collection on other sociodemographic characteristics, ethnicity, work conditions, and several health outcomes, including depression, suicidal ideas and low self-esteem. Interviewers were trained and answers checked for internal consistency by supervisors. A sub-sample of families was visited for double checking. When applicable, missing information was obtained by phone interviews. Research instruments were based on a conceptual map developed in accordance with the existing literature, theoretical models and personal experiences of the epidemiology and the ethnographic staff members, social movement leaderships, labour unions and health professionals. The language and operational feasibility of instruments were appropriately tested in a pilot study, and the study protocol approved by Internal Review Boards from the University of Texas, Health Science Center at Houston and the Federal University of Bahia.
Skin colour assessment was made by the interviewer using a 7-categories classification: black, white, mulatto, brown (moreno), yellow, indigenous, other. Because of small numbers, black and mulattoes were analysed as black, and all remaining groups considered non-black. The experience of racial prejudice was assessed by means of answers given to the following questions: 1) ‘Have you ever been impeded access to social clubs, shopping malls, carnival groups (a very popular aggregate of people who dress in similar costumes to outdoor carnival parties) or hotels?’, and when the answer was positive, ‘Did you consider that it happened to you because of your skin colour?’; 2) ‘Do you think your skin colour makes it difficult to have access to loans or other bank services?’ 3) ‘Have you ever noticed that you have been targeted by racial prejudice? 4) ‘Have you ever had difficulties getting a job because of your skin colour?’ Positive answers were coded as 1 and negative as 0. An individual score was calculated by summing up corresponding values, which was analysed dichotomously: at least a positive answer ¼ 1 and no positive answers ¼ 0.
Mental health was assessed using the Patient Health Questionnaire, PHQ, developed by Spitzer et al. (1999), which was translated to Portuguese, after evaluation of adequacy with back translation and tested for reliability as compared to psychiatric diagnosis. An overall agreement of 70.6% and a Kappa Index of 0.25 were estimated. Major depression diagnosis was based on the criteria recommended by DSM-III-R and DSM-IV (Spitzer et al., 1999). Suicidal ideas, suicide planning and feeling unhappy or unhealthy were registered from answers given to specific questions with answers yes/ no. To assess self-esteem a list of assertions was read to each study participant: ‘I feel a worthless person’; ‘I feel that I have nothing that makes me proud of’; ‘I feel that I am useful’; ‘I feel that I’m not capable to do anything right’; ‘I feel that my life is not very useful’; to which they were asked to choose one of the following alternative answers: 0) never; 1) rarely; 2) sometimes; 3) frequently, and 4) almost always. This check list was developed by Roberts et al., (1997).
Age was analysed in three categories (10–14, 15–17 and 18–21 years of age) and as a continuous variable for modelling. Other covariates were sex, socio-economic status (based on the total number of a list of goods and assets of the family categorised as low: less than two items; medium - three to five items; and high - over five items); having paid jobs, and type of family categorised as nuclear (both parents), single parent, and other type. Lack of social support was defined from answers given to questions corresponding to two questions about availability of people to help in emergency situations or to take care of children, elders or ill individuals in the family, which answers were classified as always, several times, a few times and never. Because of sparse data answers lack of social support were analysed as yes (at least one positive answer to a few times or never) and no for the remaining.
Prevalences were estimated and compared using the Pearson Chi Square using a .05 significance level. Prevalence ratios were used to estimate associations, calculated from unconditional logistic regression parameters. Potential effect modifiers were skin colour and self-esteem, analysed by means of maximum likelihood ratio tests for modelling fitting for corresponding product terms. Adjustment variables were selected based on empirical or theoretical evidence of the relevant role for the hypotheses under study, such as age, sex, and socioeconomic status left in the final models. The Delta Method was used to calculate confidence intervals for prevalence ratios (Oliveira et al., 1997). Data entry was conducted by two distinct individuals using EPIINFO-6.0 (CDC, 1995) which allows for double checking and correction of mistakes. The statistical analysis was performed with SAS 8.11 (SAS, 1999/ 2000). Adjustment for the sampling design was performed to the final estimates but did not change considerably non-adjusted estimates.
From a total of 2361 individuals from 10 to 21 years of age, 1049 reported having a paid job, or were responsible for unpaid domestic family chores for at least eight hours a week, which made them eligible for individual interviews. Approximately 76 refused to participate (7.2%) so reducing the study population to 973 subjects. The study population was mostly composed of females (68.9%), individuals 18 to 21 years (54.1%), from low socioeconomic status (58.1%), nuclear families (56.6%), and who reported having social support (92.4%). The majority was identified as having black skin colour (64.9%). The overall proportion of subjects that recall a racist experience was estimated as 19.4%, higher among individuals of black skin colour (25.4%) than non-black (8.5%) (X2 , p < .0001). No other statistically significant differences were found (Table 1). As expected, a higher proportion of individuals rated as black (84.7%) were aware of situations of racial prejudice as compared to the non-black group (15.3%) (Table 1).
The prevalence of major depression was 10.4%, higher among those who reported racial discrimination (17.5%) than in the referent group (8.7%), a statistically significant difference (Prevalence Ratio, PRcrude ¼ 2.01; 95% CI: 1.37–2.96) (Table 2). Eating (39.3%) and anhedonia symptoms (32.4%) were the most prevalent symptoms, in contrast with low frequency estimates of suicidal plans (6.5%) and low self-esteem (8.2%). Consistently, the majority of depressive symptoms used to assess clinical diagnosis of major depression (PHQ) was more common in the group aware of racial discrimination (p < .05), except for ‘feeling tired or having little energy’, ‘poor appetite or overeating’ and ‘trouble concentrating on things’. In the group of other depressive symptoms, it is worth noticing the high prevalence of suicidal behaviour was more likely to be reported by adolescents who recall a racial prejudice situation (PRcrude ¼ 1.57 95%CI: 1.05–2.35 for suicidal ideas, and PRcrude ¼ 1.87, 95%CI: 1.07–3.00 for suicide planning. Feelings of unhappiness or being unhealthy also were more common in the group who report experience of racism, as compared to those who did not report. Interestingly, low self-esteem was not statistically significantly associated with racial discrimination.
The logistic regression analysis showed that being coded by the interviewer as black was not associated with major depression or depressive symptoms for either crude or adjusted estimates (Table 3). However, perceived racial discrimination was positively associated with major depression with crude estimate (PRcrude ¼ 1.96 95%CI: 1.33–2.89) or after adjustment for potential confounding effects of age, sex or socioeconomic status (PRadjusted ¼ 1.97 95%CI: 1.33–2.91. The introduction of skin colour and self-esteem in the model did not change substantially the association (PRadjusted ¼ 1.76 95%CI: 1.18–2.62) (Table 4). Similar results were found for each depressive symptom even after adjustment for all covariates, except for suicidal ideas and planned suicide whose correspondent prevalences did not differ according to racial discrimination after adjustment for self-esteem (Table 4). Self-esteem was not associated with reported experience of racism, nor changed the direction or magnitude of the association with major depression based on maximum likelihood ratio tests. No relevant changes were observed between crude and adjusted estimates of the association between skin colour or perceived racial discrimination with major depression or any depressive symptom considered.
Here in the article it has been shown that -To add to a superior comprehension of this issue, in a setting where most of the populace is dark, in this paper the speculation that having dark skin shading and seen understanding of racial separation are decidedly connected with significant misery and burdensome side effects among young people is tried, mulling over age, sex, and financial status.
The investigation populace was generally made out of females (68.9%), people 18 to 21 years (54.1%), from low financial status (58.1%), family units (56.6%), and who revealed having social help (92.4%). The larger part was distinguished as having dark skin shading (64.9%). The general extent of subjects that review a bigot experience was assessed as 19.4%, higher among people of dark skin shading (25.4%) than non-dark (8.5%) (X2 , p < .0001). No other factually huge contrasts were discovered (Table 1).
Be that as it may, saw racial segregation was decidedly connected with significant sadness with unrefined gauge (PRcrude ¼ 1.96 95%CI: 1.33–2.89) or after change for potential jumbling impacts of age, sex or financial status (PRadjusted ¼ 1.97 95%CI: 1.33–2.91. The presentation of skin shading and confidence in the model didn't change significantly the affiliation (PRadjusted ¼ 1.76 95%CI: 1.18–2.62
Article Summary I Read the article below and provide feedback by writing a 2 page summary....
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