15 African American Women and Mental Well-Being: The Triangulation of Race, Gender, and Socioeconomic Status
Keith and Brown present a conceptual model for understanding the way in which the interrelationships among race, gender, and socioeconomic status (SES) influence mental well-being for African American women. Mental well-being is affected by social, cultural, and psychological factors as well as by physical health and health behavior; in turn these factors are influenced by one's social status (i.e., race, gender, SES). African American women are subject to both racism and sexism, which diminish their educational attainment, personal and household incomes, occupational status, wealth accumulation, and opportunities for socioeconomic advancement. Consequently, African American women have fewer resources than their White counterparts and are far more limited in their capacity to cope with crises and adversities. Stressors such as poverty and economic hardship also challenge the adaptive abilities of many African American women. They are less likely to be married and, if they are married, more likely to be employed and responsible for more household chores than White married women. Parenthood often is another source of stress as many African American women are single parents. The particular set of roles that African American women must fulfill may also expose them to more stressful life circumstances. Combining employment and parenthood roles increases the likelihood that they will experience role overload and role conflict, especially when coping resources are limited. A key argument made by Keith and Brown is that there is a strong connection between mental and physical health. African American women have poorer physical health with higher rates of diabetes, hypertension, HIV infection, and lupus, which lead to higher mortality rates than White women. Additionally, African American women are less likely to use health care, which may be due to a lack of access. However, the extended social networks of African American women may provide important sources of social support. What other types of social support would help African American women cope with the many sources of stress in their lives?
Introduction
African American women are disproportionately challenged by a host of social conditions that are linked to higher risk for poor mental health, including low incomes, high levels of poverty and unemployment, single motherhood, poor physical health, and residence in economically disadvantaged neighborhoods where these problems are compounded (Murry et al., 2008; Schulz et al., 2000). Yet, even in the face of such overwhelming threats to their emotional well-being, African American women are remarkably resilient, with research revealing a complex portrait of mental health advantages and disadvantages relative to other race and gender groups. These complexities are illustrated by a few examples drawn from our analysis of data from the National Comorbidity Study Replication (NCS-R), a survey designed to evaluate the prevalence and correlates of mental disorders in the United States (see Kessler & Merikangas, 2004). On the one hand, the percentage of African American women who have experienced a major mental disorder at some point in their lives is similar to that of African American men, but lower than the percentages for White men and women. An examination of specific disorders also shows that African American women report lower lifetime prevalence of major depressive disorder and drug and alcohol disorders than White women. On the other hand, data from the NCS-R indicate that African American women are more likely to have experienced a mental disorder in the past year than either Black men or Whites, and they have higher rates of posttraumatic stress disorder (PTSD) than White women. Further, most studies have found that, compared to men of both races and White women, African American women have lower life satisfaction and are more likely to exhibit general psychological distress and depressive symptoms that do not meet the criteria for a diagnosis of mental disorder (Brown & Keith, 2003; Bratter & Eschbach, 2005). These patterns of similarities and differences point to an amalgamation of strengths and vulnerabilities that culminate in a differential risk profile for African American women's mental well-being that requires explanatory models specific to them.
This chapter presents a discussion of societal factors that affect mental health and illness among African American women, which we contend are more salient than biological or genetic factors. The discussion is guided by the diagram depicted in Figure 15.1, which illustrates that structural location as defined by the triangulation of race, gender, and class can influence mental well-being directly or indirectly by impinging on other more proximate processes. As used here, the term mental well-being refers to the full array of mental states, ranging from indicators of mental health such as life satisfaction to mental illnesses/disorders such as major depression (see Chapter 7 in this volume).
Figure 15.1. Conceptual framework of African American women's mental well-being.
The Primacy of Race, Gender, and Class
Race, gender, and class converge in the lives of African American women to create a unique set of circumstances that shape their emotional well-being. In American society, being Black and female is less valued than being White and male. Simultaneously occupying two devalued statuses influences how African American women see themselves, how they are perceived by others, and how others respond to them. African American women are often viewed by the larger society as socially inferior, unattractive, and unfeminine, and they are stereotyped as domestic workers, mammies, promiscuous, and welfare mothers (Collins, 2000; Greene, 1996). These images, often internalized by Black women themselves in ways that make them vulnerable to psychological distress and mental illness, emanate from the racism and sexism that African American women encounter on a daily basis.
Racism is a system of inequality based on race that encompasses discriminatory treatment and beliefs about the inferiority or superiority of some groups relative to others. Although racism is most often perpetrated by non-African Americans, racism internalized by African Americans can also have deleterious effects on their mental well-being (Taylor, Henderson, & Jackson, 1991). Sexism is a system of inequality based on gender that encompasses discriminatory treatment and beliefs about the superiority and privileges of men. African American women are targets of sexist behaviors from men of all races and from women who have internalized sexist perspectives (Collins, 2003). Experiences of racism and sexism can be overt or covert, institutionalized or individualized, but all shape the social context in which African American women must strive to live emotionally healthy lives. African American women are vulnerable to the overlapping effects of racism and sexism in ways that no other race–gender group in the United States must endure, making their lives both “raced” and “gendered.” Neither African American men nor women of other racial and ethnic groups face the same race- and gender-based threats to their mental well-being that occur at the societal, community and neighborhood, and individual levels (Zsembik, 1995).
As depicted in Figure 15.1, the race and gender status of African American women affects their socioeconomic status (SES), a concept that captures both level of economic resources and opportunities for enhancing one's material well-being. The racism and sexism to which African American women are simultaneously exposed diminish their educational attainment, personal and household incomes, occupational status, wealth accumulation, and opportunities for socioeconomic advancement. Consequently, they have fewer resources than their White counterparts and are far more limited in their capacity to cope with crises and adversities.
The educational achievement of African American women tends to be lower than that of White women. In 2004, 80.8% of African American women aged 25 and older had 4 or more years of high school, and 18.5% had completed 4 or more years of college. In comparison, 90.1% of White women 25 years and older had completed at least 4 years or more of high school, and 24.4% had completed 4 or more years of college (U.S. Census Bureau, 2004a). However, although African American women have less education than their White counterparts, they have higher levels of education than African American men. In 2000 among African Americans 15 years and older, 41.1% of African American women had obtained at least some postsecondary education or more in comparison to 37.4% of African American men (U.S. Census Bureau, 2000). The widening gender gap in educational attainment has important implications for the mental well-being of African American women because it affects the availability of eligible mates, the politics of male–female relationships, and family and marital stability.
Occupation, a second indicator of SES, is important to mental health because it brings financial rewards, offers opportunities to exercise skills and creativity, and is a source of self-fulfillment (Kohn & Schooler, 1983). A job that is personally satisfying contributes much to one's overall life satisfaction (Riley & Keith, 2003). African American women, however, are disproportionately employed in occupations that are less satisfying, offer little control over work tasks, are physically and mentally taxing, expose them to hazardous conditions, and are characterized by poor social relationships (Leigh & Lindquist, 1999). Data from the Current Population Survey (U.S. Census Bureau, 2004b) showed that only 31.2% of all employed African American women held professional or managerial positions; 32% held sales or administrative positions; and approximately 27.3% held service positions, with many of those still in domestic or domestic-like work that requires deference and “knowing one's place.” In contrast, 41.5% of White women held professional or managerial positions, 36% were in sales or administrative jobs, but only 16.7% held service positions.
Racism and sexism are also reflected in the income and benefits that African American women receive, as well as in differences in household wealth. The median annual income for African American women in 2005 was $29,588 in comparison to $34,190 for White women, $34,433 for Black men and $46,808 for White men (Webster & Bishaw, 2006). Although African American women holding bachelor's degrees earn more than similar White women, those without college degrees earn less than their White counterparts (Alon & Haberfeld, 2007). With regard to employee benefits, African American women working full time are less likely to have employer-provided retirement plans than their White counterparts (Herz, Meisenheimer, & Weinstein, 2000). As a group, African American women's economic disadvantages persist over the life course, culminating in lower retirement incomes than African American men and Whites (Hogan & Perrucci, 2007). Racial differences in net worth or wealth, defined as the difference between assets and liabilities, also point to African American women's economic vulnerability. In 2002, the median household net worth excluding home equity of all White householders was $87,056 compared to $5,446 for all African American householders, and this gap widened between 2000 and 2002 as net worth increased among Whites but declined among African Americans (Gottschalck, 2008). With fewer interest-earning assets, African Americans have fewer resources available for paying expenses in times of economic hardship such as job loss or illness.
Poverty rates are nearly three times higher for African American women than for White women. In 2003, more than one-quarter (26.4%) of African American women lived in poverty, compared to only 9.1% of White women (U.S. Census Bureau, 2004c). Further, in 2003, 36.8% of all families headed by African American women fell below the poverty line, compared to only 20.4% of families headed by White women (U.S. Census Bureau, 2004d). For many African American women, daily life is a continuous struggle to supply such basic necessities as food and shelter. Poverty and low income increase the likelihood that African American women will also be exposed to classism, or prejudice and discrimination against the poor. Work by Russell (1996) indicated that the devaluation and stigmatization associated with classism can potentially affect the mental well-being of African American women by further undermining their self-concept and their relationship with others. Moreover, social class hierarchies within the Black community leave many poor African American women, especially mothers, isolated from cross-class interactions and communal support. Classism, along with racism and sexism, can have a devastating impact on the lives of African American women.
As shown in Figure 15.1, the triangulation of race, gender, and SES is a primary factor that is critical to African American women's well-being. Each system of inequality may operate independently to affect well-being, but their combined effects are more powerful. Further, these intersecting social forces may affect African American women’s mental well-being indirectly though several pathways: (1) other social statuses; (2) social, cultural, and psychological factors; (3) physical health and biological and genetic factors; and (4) health behaviors and health care.
Other Social Statuses: Age, Marriage, Parenthood, and Employment
The mental well-being of African American women varies by age, marital status, household headship, parenthood, and employment. Although some studies have shown that depressive symptoms are more prevalent among younger adults than midlife adults and those just entering old age, depression increases at ages 70 and older (George, 1999). These findings may reflect the differing challenges faced across the life course, along with changes in sociocultural context and SES that occur over time. Younger women are heavily involved in balancing the demands of intimate relationships, childbearing and child rearing, and establishing careers or stable employment. Many midlife women and the “young elderly” may be at a point where children have left the home, they are in reasonably good health, have reached a point of economic stability, and have developed effective strategies for coping with a host of problematic life circumstances. As African American women age, however, they must confront declining physical health, loss of independence, and another form of discrimination – ageism.
Marriage, a highly valued status in American society, generally brings emotional, instrumental, and economic forms of support, which are beneficial to the mental health of African American women (Brown, 1996; Tucker, 2003). African American women are less likely to marry than White women, and if ever married, they are more likely to be divorced or widowed. In 2004, 30.3% of African American women aged 15 and older were married, compared to 55.3% of White women (U.S. Census Bureau, 2004e). Further, 42.5% of African American women were never married, 9.2% were widowed, and 18% were separated or divorced. Among White women, 21.5% were never married, 10.4% were widowed, and 12.8% were separated or divorced. Major factors contributing to lower marriage rates among African American women are Black male joblessness, incarceration, and economic marginality (Harknett & McLanahan, 2004; Tucker, 2003), circumstances that in large part derive from the racial discrimination experienced by Black men. More than other ethnic groups, African American men and women believe that economic stability is critical for marital success (Haynes, 2000; Tucker & Mitchell-Kernan, 1995), and many opt for alternative domestic arrangements that result in fewer resources with which to deal with life problems (Miller & Browning, 2000). In particular, Black men's lack of adequate finances may strain relationship quality and lead to separation and divorce. Even among married women, the benefits of marriage may not be the same as they are for White women. More likely to be employed than married White women, Black women still perform most of the traditional chores of cooking and cleaning and are more likely to feel overworked than men (Broman, 1988). Most important, African American women must cope with the effects of racism on their husbands’ earning ability and mental well-being, sometimes at the cost of their own (Beauboeuf-Lafontant, 2007).
Parenthood can be psychologically challenging for African American women in large part because they are more likely than White women to be mothers, to be raising children without men, and to be doing so under financially stressful conditions (Page & Steven, 2005). In 2003, the birth rate for African American women aged 15 to 44 was 15.7 per 1,000, but only 13.6 per 1,000 for White women (Martin, Hamilton, et al., 2005). Among unmarried women, the birth rates were 67.8 per 1,000 African American women and 30.1 per 1,000 for White women. Some nonmarital births occur in cohabiting unions, but such births are less likely among young Black women (Schoen, Landale, & Daniels, 2007). Single mothers who head households must assume primary responsibility for meeting all household needs, including housing, food, clothing, and transportation, as well as ministering to the emotional and nurturing needs of household members. According to the U.S. Census Bureau (2004f), in 2004 African American women householders constituted approximately 44.7% of the total number of Black family households. In contrast, White women householders with no spouse present constituted approximately 13.2% of the total White family households. On average, the households headed by Black women are larger and often multigenerational, so that they may include minor children, sometimes adult children as well as older adults, and often nonrelatives or pseudo-kin. Among female householders with no spouse present, 59.7% of households headed by African American women had three or more members in comparison to 45.2% of those headed by Whites (U.S. Bureau of the Census, 2004g).
Being employed outside the home is essential to maintaining African American women's mental well-being as well as their family's quality of life, particularly because Black women are often the major breadwinners in their households, whether or not there are spouses or partners living with them. Historically, African American women have been more likely to engage in paid work than White women, but as the economy has shifted from manufacturing to services, Black–White differences have narrowed. Among women in the labor force in 2004, 55.5% of African American women were employed compared to 56.1% of White women (U.S. Department of Labor, Bureau of Labor Statistics, 2005). In contrast to these employment figures, unemployment was higher among African American women (9.8%) than for White women (4.7%). These unemployment figures reflect racial and gender dynamics in the labor force that make maintaining gainful employment more difficult for African American women. In her longitudinal analysis of labor force dynamics among women, Reid (2002) found that African American women left full-time employment at a higher rate than White women because they were more likely to be laid off, to work in seasonal or temporary jobs, and to specify other reasons for leaving work, including low wages, poor work conditions, and to obtain better jobs. Kennelly's (1999) analysis of data from employers surveyed in the Atlanta area documented that stereotyping of all Black working-class women as single mothers had negative effects on hiring practices and evaluations of job performance. Given that younger cohorts of working-class African American women have less labor market experience relative to younger White and Hispanic women, attaining stable employment and wages may become even more problematic in the future (Alon & Haberfeld, 2007).
Social, Cultural, and Psychological Influences: Life Stressors and Coping Resources
Any number of social, cultural, and psychological factors may enhance or diminish mental well-being. Among the social factors that diminish well-being among African American women are stressors resulting from the triangulation of racism, sexism, and low SES (Allen & Britt, 1983; Schulz, Gravlee, et al., 2006). Stressors such as poverty and economic hardship challenge the adaptive abilities of many African American women. The particular set of roles that African American women must fulfill may also expose them to more stressful life circumstances. Combining employment and parenthood roles increases the likelihood that they will experience role overload and role conflict, especially when coping resources are limited. A nontrivial number of African American women hold demanding jobs, are raising children without the support of the father, and are engaged in multiple caregiving roles for grandchildren, aging relatives, adult children, and other kin who may be unemployed, ill, or disabled. Consequently, these women are at high risk for role overload. Discrimination or unfair treatment at the interpersonal level is another stressor that is heavily implicated in African American women's well-being (Ryff, Keyes, & Hughes, 2003). Whether these encounters constitute major events such as being denied a bank loan or chronic, everyday events like being treated with less courtesy or respect, personal discrimination undermines mental well-being (Schulz, Gravlee, et al., 2006; Schulz, Israel, et al., 2006).
It is important to note that upwardly mobile and middle-class African American women are not exempted from exposure to stressors and strains, although certainly possessing greater economic resources provides them with some protection. Professional African Americans, both female and male, experience a myriad of strains and frustrations, including underemployment in which their skills are underutilized and concentration in jobs that are expendable because they primarily provide services to Blacks and other minority clients (Collins, 1997). Tokenism, the stress associated with being the only or one of a few African Americans in a work setting, can result in heightened pressure to perform and the expenditure of energy to combat negative stereotypes (Jackson & Stewart, 2003). As noted previously, African American women in the corporate sector are especially likely to experience the isolation that comes from tokenism, given their small numbers and the absence of collegial support. Notable also is that professional and middle-class African American women are strained from the marginality that results from being split between African American and Euro-American culture. Many African American women experience a profound schism between their professional lives and their personal lives and may be treated with suspicion and be rejected by less affluent African Americans (Chisholm, 1996; Jackson & Stewart, 2003).
Residential and physical environments are additional social influences on the mental well-being of African American women. The combination of race, gender, and low SES tends to circumscribe the choice of residential settings available to them, increasing the likelihood that they will reside in economically deprived rural areas or in equally deprived inner-city, segregated neighborhoods characterized by substandard housing, inadequate services, poor quality schools, and threats to personal safety. Residents in such locales are exposed to acute and chronic stressors that diminish optimal mental well-being as well as physical health (Cutrona et al., 2000; Hill, Ross, & Angel, 2005). Living in substandard housing is associated with exposure to environmental hazards such as asbestos insulation, lead poisoning, pest infestation, and adverse health effects from housing decay, inadequate ventilation, air and noise pollution, and faulty heating, wiring, and plumbing systems (Zsembik, 1995). These socially and economically deprived physical environments offer African American women limited access to jobs, transportation, grocery stores, health care, and other goods and services. Poor inner-city neighborhoods offer few if any recreational and cultural amenities such as the parks, playgrounds, fountains, jogging and bicycle paths, libraries, museums, and arboretums that are available in more affluent neighborhoods (Zsembik, 1995). Even when such amenities exist, they are often not well maintained or safe, given higher rates of crime in inner-city neighborhoods. Moreover, even African American middle-class women are more likely to live in highly segregated, poor neighborhoods than White or other women (Pattillo-McCoy, 1999).
Racism, sexism, and classism also contribute to increasing African American women's vulnerability to sexual harassment (Hine, 1995; Wyatt & Riederle, 1995), domestic violence, sexual assault, and physical injuries (Marsh, 1993; Leigh & Lindquist, 1999). They are more likely than White women to find themselves in life-threatening situations where they are the victims of homicide (Stevens et al., 1999). African American women are often the victims of the internalized rage of Black men against their own mistreatment. This violence has resulted in the highest reported spousal homicide rates to be those against Black women. According to Leigh and Lindquist (1999), African American women often are unwilling to call the police for fear that the police will brutalize the men who have battered them. Keeping silent about the violence perpetrated on them undermines African American women's emotional well-being, perhaps as much as the violence itself (Barbee, 2003).
The cultural values, beliefs, and practices that undergird the Black community can have a positive or negative impact on the mental well-being of African American women. Culture influences one's perceptions of the world, shapes interpretations of life experiences, and affects responses to stressors. It also provides a sense of identity, along with norms and customs pertaining to social interaction. Given the historical background of African Americans in the United States, African American culture is an amalgamation of an African heritage and Euro-American culture, among other influences. However, there is also great cultural diversity among African Americans (V. Green, 1978; Williams, Lavizzo-Mourey, & Warren, 1994). The cultural background of contemporary African Americans represents nearly every region of the globe from Africa, Europe, the Caribbean, to South America, as well as varying degrees of urbanicity (urban, small city, rural) and regional locations within the United States (north, south, east, and west). Although aspects of culture at times may be a powerful source for promoting mental well-being, at other times and under other circumstances aspects of culture can be detrimental. A few examples make this differential impact clear.
Involvement in extended family and friendship networks is among the characteristics of African American culture that can enhance the mental well-being of African American women (Akbar, 1991). Sharing close personal relationships with kin, friends, and co-workers provides opportunities to receive social support and to derive satisfaction from giving support to others (Brown & Monye, 1995; Lawton et al., 1992). Extended family and friends have traditionally provided African American women with the emotional and material resources needed to cope with family, job, and other demands. These networks of kin and pseudo-kin play especially critical roles in relieving the work and family role strain of young or poor women (Billingsley, 1992) and in caring for older women when they become ill and are no longer able to manage day-to-day activities (Dilworth-Anderson, Williams, & Gibson, 2002). Changing demographics and economic opportunities in African American communities are raising questions whether the extended family will continue to fulfill its traditional support functions (Benin & Keith, 1995). Especially notable is the declining extended family child care, even among families headed by single African American women (Brewster & Padavic, 2002).
African American women's spirituality and involvement in religious and community organizations are additional positive cultural influences on their mental well-being. African American women have high levels of church attendance (Fitchett et al., 2007), and involvement in church activities has traditionally been linked to their participation in civil rights, neighborhood, community action, political, and economic organizations (Gilkes, 2000). Participation in voluntary organizations has been a source of empowerment that has helped them combat the oppression associated with race, gender, and poverty (Collins, 2000). Like the extended family, church membership is an important source of emotional support and facilitates the exchange of goods and services (R. J. Taylor, Chatters, & Levin, 2004). Further, both church and nonchurched African American women use prayer and bible reading to effectively cope with a variety of stressors, including chronic poverty, illness, caregiving, and neighborhood problems (R. J. Taylor et al., 2004). Praying and reading religious material are thought to have positive effects on mental health by fostering emotions such as hope and forgiveness.
However, some features of African American culture can be sources of distress for African American women. On the one hand, family and friend relationships can be positive and supportive, making one feel loved and cared for. On the other hand, they can be demanding and a source of strain that is detrimental to mental well-being (Lincoln, Chatters, & Taylor, 2003; Okun & Keith, 1998). Involvement with family members can be particularly stressful if they have chronic, financial, physical, or emotional problems. Problematic relationships with family members may take a particularly heavy emotional toll on African American women, who appear to be much more deeply embedded in social networks than are African American men.
African American cultural stereotypes and socialization practices may also affect African American women’s perceptions and expectations of themselves. Socialized differently than White women (Ladner, 1972), they are expected to be mothers, to be independent, to be caregivers, and to assume all manner of extended-family obligations. Although the enactment of multiple roles may serve as positive influences on the mental well-being of many African American women, it may have deleterious effects for others. Beauboeuf-Lafontant (2007) has argued that the cultural image of the “strong Black woman” has served to establish a highly valued ideal that poses an alternative to the denigrating stereotypes generated by the larger society and a feminine norm that stands in direct contrast to that of White women as weak and delicate. Many African American women, however, cannot live up to the ideal, or they do so at the expense of their mental well-being. Her interviews with African American women revealed that, in trying to live up to the strength mandate, they engage in a form of self-silencing whereby depression and distress go unrecognized or unvoiced or are not deemed legitimate by others.
An additional source of distress for African American women is the continuing social preferences in their communities and in the larger society for lighter skin color, long straight hair, and Eurocentric facial features (Hunter, 2005). Arguably the social value given to the beauty of “Blackness” is greater now than in the past, but African American women are still confronted with Euro-American standards of beauty (St. Jean & Feagin, 1998). Greene, White, and Whitten (2000) noted that excessive concern with length and texture of hair, especially among young African American girls, may have negative consequences for social adjustment. For African American women of all ages, hair and skin color are linked to complex social, political, and economic issues that impinge on their self-esteem, perceived attractiveness, life satisfaction, and overall quality of life (Hunter, 2005; M. S. Thompson & Keith, 2001).
Physical Health and Mental Well-Being
The conceptual framework presented in Figure 15.1 also contends that there are substantial interactions between physical health and mental well-being. Poor health can be emotionally upsetting, especially if the condition is disabling or life threatening or requires a drastic change in lifestyle. Some research has shown that physical illness is accompanied by anxiety (C. L. Cohen et al., 2006) as well as by depressive symptoms (Furner et al., 2006). African American women have poorer health than White women (D. R. Williams, 2002), and it is also likely that their mental health is more affected by their poorer health status. For example, chronic diseases such as hypertension, diabetes, HIV/AIDS, and lupus are more prevalent among African American than White women (Leigh & Lindquist, 1999; National Center for Health Statistics [NCHS], 2007). With higher death rates from heart disease, cancer, stroke, AIDS, and diabetes, African Americans women have an overall mortality rate that is 30% higher than the rate for White women, and they live 4.3 fewer years on average (NCHS, 2007).
Geronimus coined the term “weathering” to suggest that African American women's excessive disease rates reflect a faster aging process that stems from the cumulative burden of social and economic adversities (Geronimus et al., 2006). She and her colleagues tested the weathering hypothesis by calculating allostatic load, a health measure that includes physiological risk factors for chronic disease such as blood pressure, cholesterol, and various other biological markers obtained from blood samples. Allostatic load is thought to capture the body's reaction to stressors. Their research revealed that, compared to Whites and African American men, poor African American women had the highest allostatic load scores followed by nonpoor African American women. This study and others that noted higher disability among women suggested that African American women seem to carry a heavy disease burden despite their longer life expectancy relative to men.
In the face of physical illness and disability, African American women are much more likely than White women to continue working and fulfilling household responsibilities (D. R. Brown, 1988). An illustration of the multiple demands that many African American women face even when confronted with a life-threatening illness came from a focus group of women recently diagnosed with breast cancer. One participant said the following:
Could not even think about it (breast cancer) because of taking care of my mother…there was just too much happening. It was a shock when I found out.…I was in denial. I can't believe this is happening. I'm taking care of too many people, you know…the grandkids…my mother, and I don't really even have the time.
Lipscomb and colleagues (2006) observed that African American women and other minority workers continue to work when ill or injured because they are overrepresented in jobs that have no or limited paid sick and vacation time. In addition, minority workers are more likely to have worker's compensation claims denied and to fear job loss after illness or injury.
The conceptual model presented in Figure 15.1 assumes that biological and genetic factors may potentially affect African American women's mental well-being. The relationship between biological or genetic factors and mental well-being is the subject of intense investigation. For example, researchers have identified genetic factors that predispose individuals to major depressive disorder (Malhi, Moore, & McGuffin, 2000). Studies have also linked genetic factors to antisocial behavior among women (Goldstein, Prescott, & Kendler, 2001), and the genetic epidemiology of Alzheimer's disease was shown to differ between African Americans and Whites (Froehlich, Bogardus, & Inouye, 2001). To date, however, there is no evidence that any biological or genetic factor is uniquely associated with the mental well-being of African American women. Further research is needed to determine the extent to which the interplay among race, gender, biology, and genetics affects mental well-being, with careful attention given to social and environmental effects on biology.
Health Behaviors and Access to Health Care
Figure 15.1 posits that health behaviors have implications for the mental well-being of African American women. Health-promoting behaviors such as getting enough regular exercise and eating a balanced, nutritious diet are generally assumed to have positive effects on mental health (Fox, 1999). Current research is documenting a negative association between obesity and mental health (Carpenter et al., 2000; Roberts et al., 2003), although the causal sequence remains unclear. Findings from these investigations are particularly important for African American women, given their greater prevalence of obesity. According to the National Center for Health Statistics (2007), 51.6% of African American women aged 20 and older are obese, compared to 30.7% of White women. Baltrus and colleagues (2005) found that, in association with their lower childhood SES, African American women had greater body weight initially and gained more weight than men or White women over the 34-year time period of their study. Thompson (1996) contended that eating problems begin as survival strategies to cope with traumas stemming from sexual abuse, racism, classism, sexism, and poverty. Some writers have suggested that body size norms are more flexible and large body size is less stigmatized in African American culture (see Lovejoy, 2001), but others have found that concerns about weight and body image are distressing especially to African American girls (see Grandberg et al., 2008). Other lifestyle behaviors such as cigarette smoking, use of alcohol and illicit drugs, and engaging in risky sexual behavior may also impinge on the mental well-being of African American women. Although African American women are less likely to use alcohol and cigarettes and have a lower lifetime use of illicit drugs than White women (Wiemann, Berenson, & San Miguel, 1994), their use of these substances may help alleviate the distress associated with race, gender, and class oppression (Hummer, 1996; Leigh & Lindquist, 1999; Thompson, 1996). Health behaviors are not just a matter of individual preferences and choices but are also influenced by racism, sexism, socioeconomic instability, targeted marketing, education, and cultural values (F. Ahmed et al., 1994; Cooper & Simmons, 1985; Hummer, 1996).
Access to health care is critical for mental well-being because it contributes to healthier, longer lives (Hummer, 1996). Quality health care for African American women requires access and utilization of mental health services that are culturally appropriate and sensitive to the social context of their lives (Chisholm, 1996), as well as access and use of primary care. Indeed, primary care physicians often serve as the gatekeepers to mental health services, particularly in managed care organizations. Access to both primary care and mental health services may be restricted by lack of health insurance coverage. Even the insured may incur out-of-pocket expenses because of restrictions on services, especially mental health services. Additional barriers to mental health care for African American women include factors such as cultural beliefs, stigma, and lack of understanding of the nature and treatability of mental illness (U.S. Department of Health and Human Services, 2001).
Summary
The conceptual framework presented in this chapter provides a basis for linking what we know about the lives of African American women and research on mental well-being. The model emphasizes the primacy of race, gender, and SES and how these forces converge to transform more proximate influences on mental health. It recognizes that the various components combine in different ways for different African American women, encompassing their diversity. Some African American women are poor and some are middle class; some are mothers, but others are not. Despite this heterogeneity, the reality of race, gender, and SES means that they share many common experiences.
