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Is stress exposure enough? Race/ethnic differences in the exposure and appraisal of chronic stressors among older adults

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Is stress exposure enough? Race/ethnic differences in the exposure and appraisal of chronic stressors among older adults

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Content IS STRESS EXPOSURE ENOUGH?
RACE/ETHNIC DIFFERENCES IN THE EXPOSURE AND APPRAISAL OF
CHRONIC STRESSORS AMONG OLDER ADULTS

By

Lauren L. Brown

Jennifer Ailshire, PhD, Faculty Mentor and Chair
Eileen Crimmins, PhD, Committee Member
Elizabeth Zelinski, PhD Committee Member

A Dissertation submitted to the Graduate School,
University of Southern California in partial fulfillment of the requirements
for the degree of Doctor of Philosophy (Gerontology)
August 2018

1
TABLE OF CONTENTS
Abstract……………………………………………………………………………………………4
Acknowledgements………………………………………………………………….……………7
CHAPTER 1- Introduction………………………………………………………………………10
References………………………………………………………………………..………21
CHAPTER 2- Paper 1…………………………………………………………………..………..28
‘Disentangling the Stress Process: Race/Ethnic Differences in the Exposure and
Appraisal of Chronic Stressors among Older Adults’
Introduction………………………………………………………………………………30
Methods………………………………………………………………………..…………35
Results……………………………………………………………………………………38
Discussion……………………………………………………………………..…………42
References……………………………………………………………………..…………49
Tables/Figures……………………………………………………………...….…………57
CHAPTER 3- Paper 2…………………………………………………………………..………..63
‘Is Exposure Enough? Race/Ethnic Differences in Chronic Stress Exposure, Appraisal &
Mental Health among Older Adults’
Introduction………………………………………………………………………………65
Methods…………………………………………………………………………..………72
Results……………………………………………………………………………………75
Discussion……………………………………………………………………………..…78
References………………………………………………………………………..………83
Tables/Figures………………………………...……………………………………….…88
2
CHAPTER 4- Paper 3……………………………………………………………………………96
‘Race/Ethnic Disparities in Exposure to Chronic Stressors Varies by Age among Older
Adults’
Introduction………………………………………………………………………………98
Methods…………………………………………………………………………………103
Results………………………………………………..…………………………………105
Discussion………………………………………………………………………………108
References………………………………………………………………………………114
Tables/Figures……………………………...………………...…………………………120
CHAPTER 5- Conclusion………………………………………………………………………125
Limitations……………………………………………………...………………………130
Future Directions……………………………………………………………………….131
References………………………………………………………………………………132

3
ABSTRACT
The current project examines the experience of chronic stressors, specifically the
exposure and appraisal of chronic stress, as separate but principal mechanisms contributing to
mental health disparities in older adulthood. The differential exposure and vulnerability
hypotheses have been the dominant frameworks in examining stress to better understand
race/ethnic differences in health. These theories suggest that minorities, and blacks in particular,
are more exposed to stressors and are more vulnerable to the effects of stress on health due to
their disadvantaged social status. Research has shown that stress exposure is linked to worse
physical and mental health. However, most of the stress and health literature at the population
level fails to consider how race/ethnicity uniquely shapes chronic stress exposure and subsequent
stress appraisal on mental health outcomes in a nationally representative sample of diverse older
adults. Further, demographic health disparities research has been unable to establish whether
stress exposure and stress appraisal are differentially linked to race and ethnic differences in
mental health in mid- and late-life.
This project aims to advance the science of health disparities by using a racially diverse
nationally representative sample of older adults from the Health and Retirement Study (N=6,878)
to: 1) examine racial/ethnic differences in the number of reported chronic stressors across five
domains (health, financial, residential, relationship and caregiving), and their appraised
stressfulness; 2) determine whether chronic stress exposure and appraisal are differentially
related to mental health outcomes and 3) examine age variation in race/ethnic differences in the
number of reported chronic stress exposures across the five key domains.
Results show older blacks and Hispanics report the highest levels of chronic stress
exposure and are twice as likely as whites to experience financial strain and housing related
4
stress. Despite experiencing a greater number of stressors, blacks and Hispanics are less likely to
be upset by exposure to stressors than whites. Hispanics were less upset by relationship strain
while blacks were less upset across every domain (health, financial, residential, relationship and
caregiving) of chronic stress. Results also show that greater chronic stress exposure and appraisal
are significantly associated with more anxiety and depressive symptoms Yet, race and stress
appraisal interactions show that when blacks rate their stress as not upsetting they report fewer
depressive symptoms than whites. Comparatively, when blacks consider their stress exposure as
either somewhat or very upsetting they report significantly more depressive symptoms relative to
whites. Finally, in considering age differences in stress exposure, results show fewer chronic
stressors are reported by adults 70+, compared to adults 54-69 years. Yet, analysis of age
interactions show that the decline in total stress burden found with age is only true among white
older adults. Domain specific results show whites report less exposure to every stress domain
except for health problems after age 70. Blacks report similar amounts of stress before and after
age 70 with the exception that they report less employment strain than younger blacks. Hispanic
groups report similar stress burdens before and after age 70 as whites after adjusting for SES.
This distinction between exposure and appraisal based measures of stress shed light on
important pathways that may differentially contribute to mental health disparities among these
groups. Further, race/ethnic disparities in stress exposure may reflect differential experiences of
age-related declines in chronic stress exposure. The results inform long-standing debates over
whether stress exposure alone is enough to incite race and ethnic differences in health or whether
appraising a stressor as stressful is equally necessary in the manufacturing of health disparities.
Additionally, this research identifies the unique social, economic, and psychological challenges
minority populations face in maintaining mental and physical wellbeing in old age by
5
acknowledging aspects of the stress process that may vary due, in part, to the higher stress
burdens they face.

6
ACKNOWLEDGEMENTS
This work was supported by the National Institute on Aging (NIA) of the National
Institutes of Health, Multidisciplinary Training Grant award in Gerontology (grant number
T32AG0037).
I am thankful for the many people who have made this dissertation possible and whose
support throughout graduate school has been invaluable. My deepest gratitude is to my chair and
mentor, Dr. Jennifer Ailshire. It is because of her generous dedication and mentorship that I have
grown into a confident social scientist. Dr. Ailshire, since first meeting her, has pushed me to be
myself on every step of this journey, validating my uniqueness even when I doubted myself. She
patiently maintained faith in my abilities and potential, through my successes as well as times of
discouragement and self-doubt. She has taught me how to think critically about my research,
how to use data responsibly and for the betterment of society, and how to stand before a
classroom and tell a good story. Dr. Ailshire has helped me to discover my voice, she has never
drowned out my ideas, even if she did not see exactly what I saw at the time. Her support and
guidance have meant the world to me and I hope to continue to learn from her wisdom in the
years to come.
I also owe immense thanks to the other members of my dissertation committee. I am
thankful to Dr. Eileen Crimmins for her boundless practical advice, for trusting my abilities and
for always challenging me to consider the multiple perspectives embedded in a given problem.
She is an example of what it takes to survive the male dominated sciences and laid the
groundwork for the rest of us to come behind her. Dr. Crimmins also provided invaluable
funding which freed up my time during the program to focus on my own work. Without this, my
experience in the program would have been much different and words cannot express how
7
grateful I am to have been lucky enough to focus on the work that is important to me. Dr.
Elizabeth Zelinski helped lay the foundations for my dissertation in her grant writing class,
encouraged me to think transdisciplinary, and has never failed to remind me to find the humor in
life. Dr. Zelinski reminds me that your own uniqueness is your gift you should always share with
the world, especially after tenure.
I would like to acknowledge my family and friends who made my writing breaks actual
mini vacations. To my mother, you have always been the woman I aspire to be. Your character,
work ethic, and tenderness reminds me that ‘when they go low we go high.’ To my father, your
life experiences and work ethic motivate my life’s work and your strength and resilience have
inspired and carried me through the darkest nights. To my brother, who never fails to make me
laugh and who understands me without a word being exchanged, I want the world to better for
you and this work was created with the hope that your future is better and brighter than black
men who have come before you. And Aunt Marva, thank you for always being you and being my
role model for how to say no in order to love and honor yourself.
To my girlfriends: Ali, Jessi, Kai, Kelly, Christabel, Crystal, Renesha, Jane, Shavon,
Veronica, Zoe, Tahira, Lindsay, y’all are life. You guys make me gut laugh and make life worth
living. Thank you for supporting and encouraging me now and always.
Finally, I also want to thank my peers Yuan Zhang and Catherine Perez. Yuan is my
brain-storming partner and has taught me so much about thinking through my data problems. I
aspire to see numbers like she does one day. She and I taught our first class together, practiced
our presentations on each other, and became teammates through this PhD program, all of which I
know improved the quality of my work. And to Catherine, who became my instant teammate and
friend as soon as we met because she loves to work and play as hard as I do. Cannot tell you how
8
much I appreciate these two women and the companionship we built going through this program
together. Time with you two in the office are memories I will cherish for life.

9
CHAPTER 1- INTRODUCTION
Blacks have worse physical health than whites in older adulthood. Blacks rate their health
worse (Farmer & Ferraro, 2005), live a greater proportion of life with disability (Hayward &
Heron, 1999), have higher rates of many of the leading causes of death such as cancer and heart
disease (National Center for Health Statistics, 2016; Siegel, Miller, & Jemal, 2016), and have
shorter life expectancies (Cunningham et al., 2017) relative to any other demographic group in
the US. Stress theory has been the dominant framework used to explain race differences in
morbidity and mortality since, due to their more socially disadvantaged social positions, blacks
are exposed to more daily adversities and as a result experience greater stress burdens. Stress, in
this context, is defined as a demand or threat that an individual experiences and does not have the
sufficient resources to meet the demands or mitigate the threats (Lazarus & Folkman, 1984). In
the short-term, a stressful experience is associated with higher cortisol and other glucocorticoids,
higher blood pressure reactivity and heart rate variability, corticotropin releasing hormone levels,
as well as inflammatory and immunologic processes (Massey, 2004). This stress response, if
sustained overtime, aggregates to contribute to higher allostatic load and biological dysregulation
(Geronimus, Hicken, Keene, & Bound, 2006; McEwen, 1998), leading to greater vulnerability to
disease, accelerated aging, and premature death (J. P. Harrell, Hall, & Taliaferro, 2003). Stress
theory not only suggests individuals disproportionately exposed to stressors are at higher risk of
poor physical health due to this physiological cascade but stress exposure also places them at
higher risk for mental health disparities. Brown and colleagues (1999) argue blacks should look
worse than whites on mental health outcomes due to their disadvantaged social status and excess
exposure to stressors (Williams, Yan, Jackson, & Anderson, 1997) suggesting stress exposure as
one pathway linking race and ethnicity to mental health outcomes.
10
However, stress is not a uniform experience and people react differently to adversity.
Some individuals may not feel as much, or any, stress associated with ongoing problems. Prior
stress research at the population level has faced methodical limitations in investigating race
based health disparities by only examining differences in stress exposure and their connection to
physical and mental health. However, race/ethnicity may uniquely shape stress exposure as well
as stress appraisal processes (S. P. Harrell, 2000). Importantly, this dissertation aims to answer
longstanding questions about whether it is the stress exposure that matters and/or individuals
perceptions or appraisal of that stressor that impact mental health outcomes. If an individual
appraises a stress exposure as not upsetting, does it impact their health and wellbeing? This has
important implications for health disparities research because we may be overestimating the
health importance of certain stress exposures, particularly for blacks, who may view exposure to
stressors differently relative to their white counterparts (Brown et al., 1999). Furthermore, and
relatedly, if some individuals are not as bothered by their stress exposure it suggests there are
potential coping mechanisms that are being employed to overcome ongoing adversities.
Identifying the ways in which minority groups cope with stress could help to inform discussions
about potential mechanisms for reducing health disparities. This project aims to advance the
science of health disparities by using a more comprehensive assessment of chronic stress, which
incorporates both exposure and appraisal across multiple domains, to improve our understanding
of the stress process and the manufacturing of health inequity for older racial/ethnic minority
groups.
Differential stress exposure: an explanation for race/ethnic differences in health
Exposure to stress is patterned by an individual’s social environment (Baum, Garofalo, &
Yali, 1999) and is not merely the result of random occurring circumstances (Harrell, 2000). To
11
understand race based health disparities, it is therefore essential to understand the stress process
and its connection with health. Race, within this context, is a category of experiences that reflects
a particular set of exposures and reactions within social and physical environments (Williams et
al., 1997; Williams, Spencer, & Jackson, 1999). Important within aging research, the
accumulation of differential exposures and experiences associated with these categorizations
over the life course produce racial disparities in health that become more pronounced at the end
of life (Mezuk et al., 2013). Accordingly, the differential stress exposure hypothesis posits that
racial minorities, and African Americans in particular, look worse on major health outcomes
because they are exposed to greater levels of stress (G. W. Brown & Harris, 1978; Kessler, 1979).
Although the differential exposure argument is instrumental, this hypothesis is limited in
perspective since it fails to consider appraisal processes in understanding the impact of stress on
outcomes. Individuals do not experience stress in a vacuum. They experience stress in the
context of different personal and environmental resources that shape the stressfulness of a life
experience. The stress process (L. I. Pearlin, Menaghan, Lieberman, & Mullan, 1981) even
indicates that an environmental demand triggers negative emotional and physiological responses
that increase risk of poor health only if the demand is perceived to be stressful (Cohen, Kessler,
& Gordon, 1995). Moreover, the stressfulness of a situation is determined, in part, by the
meaning it has for an individual which is importantly linked to that individual’s personal and
social history (Cohen, Kamarck, & Mermelstein, 1983; Williams et al., 1997). For example, the
emotional effects of ongoing caregiving strain will undoubtedly differ depending on the
availability of financial resources to cope with the responsibilities, the ability to take time off
work to care for that person, and the meaning of caregiving for that individual. Further, the
caregiving literature has consistently found that African Americans do not view caregiving as
12
burdensome as their white counterparts, largely due to differences in culture including familial
obligations to care for others and collectivist values (Roth, Dilworth-Anderson, Huang, Gross, &
Gitlin, 2015). Consequently, attributions related to the stress exposure should be distinguished
from those relevant to the individual stress appraisal since they may be entirely different (Harrell,
2000).
In order to incorporate elements of the subjective stress experience within the health
disparities literature, the differential vulnerability hypothesis posits that, where there are equal
levels of stress, blacks react more strongly to stressors since more vulnerable groups have fewer
social and personal resources to buffer the negative effects of stress on health. Individuals with
the dual burden of socioeconomic disadvantage and race related stressors may be at even greater
risk since they have limited access to psychosocial and material coping mechanisms (Myers,
2009) the most disadvantaged racial groups in any society are expected to report higher distress
levels than those from the majority groups (or those along the continuum of race) primarily due
to a lack of socioeconomic resources (Kagee & Price, 1995). However, though greater
vulnerability to stress among African Americans might be anticipated on the basis of their
socially disadvantaged status in our society, prior research has also shown that despite higher
levels of morbidity, mortality and stress exposure, the base-line levels of nonspecific
psychological distress and stress related psychopathology (e.g. major depression and anxiety
disorders) is statistically similar between African Americans and whites, and adjusted levels
show that African Americans report less distress and psychopathology than non-Hispanic whites
(Bratter & Eschbach, 2005). Simply, African Americans have surprising less stress related
psychopathology and stress theories have been unable to explain this black-white paradox in
mental health.
13
Methodological limitations in health disparities and stress literature
Beyond the lack of theoretical explanations for the black-white paradox in mental and
physical health, the stress and health disparities literature, primarily in younger populations, has
two significant shortcomings. First, prior population level research has suggested that using
stressful life event measures tend to substantially under-estimate differences between African
Americans and non-Hispanic whites in exposure to stress (Turner & Avison, 2003). Chronic and
ongoing stressors are understudied yet critical within health disparities literature as they may be
more consequential for mental and physical health than acute stressors or (Turner & Avison,
2003) major life events (L. I. Pearlin, 2010) since mounting evidence suggests that people may
not biologically or psychologically habituate to chronic stress (Herbert & Cohen, 1993; Lepore,
1995). Further, chronic stressors are capable of exerting powerful effects on the health and
wellbeing of older adults since these types of adversities tend to surface within major social
domains such as financial stability, employment and family, all of which are of vital importance
to both the larger society and individuals (L. I. Pearlin, Schieman, Fazio, & Meersman, 2005).
Thus, prior work has gradually made the case that these ongoing stress exposures that remain
problematic over an extended period of time ought to be positioned at the center of life course
stress models (L. I. Pearlin, 1983; Wheaton, 1994).
Second, much of the work examining race differences in stress that does focus on chronic
stressors only examines the extent to which stress exposure is related to higher rates of disease
among some groups, while less work has looked at the appraisal of that stress exposure.
Evidence suggests that multidimensional measures of stress account for dramatically higher
proportions of observed variation in health outcomes (Turner, Wheaton, & Lloyd, 1995; Turner
& Lloyd, 1999; Wheaton, 1994), making the case for use of both exposure and appraisal to help
14
explain race based health disparities. Further, demographic health disparities research has been
unable to establish precisely whether stress exposure or stress appraisal is the link between stress
and race differences in health in mid- and late-life, bringing about old debates on whether stress
exposure is detrimental if it is not considered stressful. This shortcoming persists largely because
stress measures at the population level refer only to exposure to acute or event based stress and
assume this stress exposure is experienced uniformly across the population. Stress measurement
at the population level, such as such as death of a spouse or living in poverty, implies that
exposure to stressors in and of itself is the precipitating cause of pathology or illness. Yet, stress
models agree that the degree to which a situation is perceived as threatening elicits a stress
response that ultimately impacts health suggesting we should be measuring an individual’s
appraisals of the situation. In this way, measurement decisions at the population level have
confirmed the potentially shallow or even incorrect relationship between stress exposure and
health without considering the individual variability in the appraisal of those stress exposures.
Recent work has attempted to improve the measurement of chronic stress given that there
is general agreement that context and appraisal are critical for a full appreciation of life stressors
on health. Some researchers have only recently taken to asking respondents to rate the
stressfulness of these ongoing issues directly. As a result, there are now measures that emphasize
perception and thus come closer to actually measuring the outcome of stress, rather than the
exposure itself (Wheaton, Young, Montazer, & Stuart-Lahman, 2013). For example, the
Perceived Stress Scale (PSS) includes items such as “In the last month, how often have you felt
nervous and ‘stressed’?” or “In the last month, how often have you felt confident about your
ability to handle your personal problems?” However, this often limits researchers as well since
they are general or global assessments of stress appraisal and do not provide specific information
15
about the type or domain of the stress exposure. Thus, due to the insufficiency built into these
measures, there remains a gap in the literature since prior work has not evaluated both exposure
to stress and the subjective evaluation of how stressful an ongoing stressor is. The proposed
research fills this gap in measuring the objective chronic stress exposure and the subjective stress
components, thus providing a better understanding of the relationship between stress exposure,
stress appraisal and racial inequalities in health.
Race/ethnicity, aging and stress
Prior research and theory have suggested that older adults are exposed to fewer stressors
than younger adults (Turner et al., 1995). Most of this research is based on older adults reporting
a decrease in stressful life events—for example, the risk of job loss or divorce (Vasunilashorn et
al, 2014). . This approach to conceptualizing stress exposure as event based or episodic in older
adulthood ignores a more pervasive form of stress that is likely more consequential for the health
of elderly populations. Additionally, prior research on emotional reactivity to daily stress
suggests that older adults may be more affected by experiences of stress compared to their
younger counterparts. Older adults tend to report reduced exposure to everyday stressors, but
when they do report a stressor they experience similar stress-related increases in negative affect
as their younger counterparts (Mroczek & Kolarz, 1998; Mroczek, 2001; Stawski, Sliwinski,
Almeida, & Smyth, 2008); although this finding has not been consistent across study
methodologies (e.g. Uchino, Berg, Smith, Pearce, & Skinner, 2006). Older adults are thought to
prioritize positive emotions, potentially allowing older adults’ the ability to reappraise negative
situations based on their lived experience. However, they may still be equally or at even greater
risk of being vulnerable to the effects of stress on health when they experience ongoing or
chronic stress (Charles & Carstensen, 2010; Stawski et al., 2008). Chronic stressors are ongoing
16
and last for an unforeseen amount of time, posing severe threats for the health and wellbeing of
older adults since they may have access to fewer coping resources and may not biologically or
psychologically adapt to chronic stress (Herbert & Cohen, 1993; Lepore, 1995). Chronic stress
may be a particularly important kind of stress for capturing the ongoing experience or lingering
stress and the experience of distress that, if unaddressed, may result in anxiety and depression.
Thus, examining connections between stress exposure, appraisal and mental health among older
adults is critical in order to determine how the stress experience might be distinct in older
adulthood.
Prior studies of event based stress exposure among older adults are also particularly
problematic since they primarily evaluate the stress experience of older whites. However, older
blacks and Hispanics report higher levels of stress, including exposure to chronic stressors,
relative to whites (Pearlin, 2010), one major pathway contributing to race/ethnic mental and
physical health disparities. Thus, research showing declines in event based stressed among older
whites may not capture the stress experience for older racial/ethnic minority populations.
Folkman and Lazarus (1984) hold a contextual theory of aging and propose that it is not that
stress exposure declines in older adulthood, but that different types of stressors are encountered
as individuals age which may be more relevant for older minority groups. Some studies have
found that, at least for certain types of stressors, older adults generally experience an increase in
exposure. Thus, chronic stress exposure may vary across the older adult life course for different
race/ethnic subgroups making it important to investigate age differences in the race/ethnic
disparity of chronic stress exposure among older adults. Additionally, stress may not be
declining with age for older minorities groups, it may be that the stress is declining in some areas
(i.e. work related strain) and surfacing in another (i.e. housing insecurity).
17
The present study
Because most empirical evidence only measures stress exposure to acute events and
derived from primarily non-Hispanic white participants, it is unclear whether relationships
between chronic stress exposure, appraisal, and mental health described in the existing literature
apply to older racial/ethnic minorities. To address this limitation, the proposed research will
examine how race differences in stress exposure and stress appraisal are differentially related to
mental health in a diverse sample of aging older adults, thereby identifying the unique
underlying mechanisms that link chronic stress to racially embedded health inequalities. Chapter
2 (paper 1) examines race/ethnic differences in both chronic stress exposure and appraisal.
Chapter 3 (paper 2) determines whether race/ethnic differences in both chronic stress exposure
and stress appraisal are associated with anxiety and depressive symptoms. Chapter 4 (paper 4)
examines age variation in race/ethnic differences in chronic stress exposure. Finally, chapter 5
concludes with a review of major findings and the implications for stress and health disparities
research.
Informed by psychology, sociology, and biology, this project proposes a framework that
promotes innovative research that moves beyond simply documenting social disparities in health
by posing specific hypotheses about the interrelationships among social contexts, stress exposure,
stress appraisal, coping and health. This model builds on the stress process framework (McLeod,
2012; L. Pearlin, Lieberman, Menaghan, & Mullan, 1981; Thoits, 2010), the Environmental
Affordances model (Mezuk et al., 2013), and the biopsychosocial model (Crimmins, Hayward, &
Seeman, 2004) suggesting that the social environment, and specifically race, can pattern stress
exposure, stress appraisal, and as a result, mental health in older adulthood. Importantly, this
work differentiates between chronic stress exposure and appraisal processes, suggesting that each
18
may have a different relationship first with an individual’s social position and finally with mental
health outcomes. Additionally, group variations in appraisal of stress may help explain, at least
partially, why blacks and whites exposed to similar stressors do not necessarily suffer the same
deleterious mental health consequences. Thus, this dissertation argues for the inclusion of both
stress exposure and appraisal in nationally representative surveys since both may be linked
directly with mental health outcomes.
Innovation
The proposed research will examine how race differences in stress exposure and stress
appraisal are differentially related to mental health in a diverse aging sample of older adults,
thereby identifying the unique underlying mechanisms that link chronic stress to racially
embedded health inequalities. This work is innovative for four principal reasons. First, the HRS
data offers a novel approach to examining chronic stress and differences in late life health. This
study incorporates a more comprehensive stress assessment to understand demographic race
differences in health outcomes. As a result, this study is uniquely positioned to advance the
science of health disparities and to inform future interventions aimed at reducing race-based
differences in health. Second, it is the first study to examine race differences in chronic stress
appraisal and chronic stress exposure, in connection with mental health since respondents were
simultaneous asked about chronic stress exposure and appraisal in a population based sample of
ethnically and socioeconomically diverse older adults. This data gives a more nuanced
understanding of how the appraisal of ongoing chronic stress uniquely contributes to national
differences in mental health. Third, it is the first study to disentangle the type of chronic
stressor(s) that are perceived as most stressful by whites, blacks, and Hispanics separately, while
also being able to determine which exposures or appraisals are most consequential for mental
19
health outcomes. Most prior stress research treats stress exposure and appraisal as global
constructs or summary measures without considering the varying magnitudes of each stressor
and their appraised stressfulness in contributing to race differences in health. Finally, this work
addresses key methodological issues in health disparities research by developing a stress and
health model that more accurately depicts the stress experience for minority groups. This work
uses a multidisciplinary framework and builds on the stress process model, the Environmental
Affordances model, and the Biopsychosocial model (Crimmins & Seeman, 2004) to more
carefully map social stress mechanisms that link race/ethnicity to health disparities.

20
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27
CHAPTER 2

Title: Disentangling the Stress Process: Race/Ethnic Differences in the Exposure and Appraisal
of Chronic Stressors among Older Adults

Authors:
Lauren Brown, MPH
1
, Uchechi Mitchell, PhD, MSPH
2
, Jennifer Ailshire, PhD
1
1. Leonard Davis School of Gerontology, University of Southern California
2. Division of Community Health Sciences, School of Public Health, University of Illinois at
Chicago

Corresponding Author:
Lauren Brown, MPH

USC Davis School of Gerontology
University of Southern California
3715 McClintock Ave.
Los Angeles, CA 90089
Phone number: 951-990-4969
Email: laurenlb@usc.edu

28
Abstract
Exposure to stressors is differentially distributed by race/ethnicity with minority groups reporting
a higher stress burden than their white counterparts. However, in order to really understand the
extent to which some groups bear a disproportionate stress burden we need to consider
race/ethnic differences in stress appraisal, specifically how upsetting stressors may be, in
addition to stress exposure. We examine racial/ethnic differences in both the number of reported
chronic stressors across 5 domains (health, financial, residential, relationship and caregiving) and
their appraised stressfulness among a diverse sample of older adults. Data come from 6,567
adults ages 52+ from the 2006 Health and Retirement Study. Results show older blacks, US and
foreign born Hispanics report more chronic stress exposure than whites and are two to three
times as likely to experience financial strain and housing related stress. Socioeconomic factors
fully explain the Hispanic-white difference in stress exposure, but black-white differences
remain. Despite experiencing a greater number of stressors, blacks and US born Hispanics are
less likely to be upset by exposure to stressors than whites. US born Hispanics are less upset by
relationship-based stressors specifically, while blacks are less upset across all stress domains in
fully adjusted models. Foreign born Hispanics are only less upset by caregiving strain. The
distinction between exposure and appraisal based measures of stress may shed light on important
pathways that differentially contribute to race/ethnic physical and mental health disparities.

29
Introduction
Stress process frameworks (Pearlin, Menaghan, Lieberman, & Mullan, 1981) have
positioned stress exposure as a foundational component in the manufacturing of social
inequalities in health. Chronic stressors maintain a dominant theoretical role within these
frameworks due to their ongoing and recurrent nature, which forces individuals to adapt over
extended periods of time (Pearlin, 2010; Wheaton, Young, Montazer, & Stuart-Lahman, 2013).
Despite this attention, an understanding of the complexity of the chronic stress process is largely
missing from the empirical stress literature. For example, stress is often measured using a count
of acute or event based stressors, and this approach to conceptualizing stress exposure overlooks
three key features of the stress experience: 1) that stressors can be ongoing, with no foreseeable
end; 2) the multiple life domains in which stressors can originate; and 3) whether a stressor is
perceived as upsetting. Importantly, there is a lack of research examining how the stress
experience, including appraisal based measures, differs according to social characteristics that
shape exposure to stress.
A persistent quandary among stress researchers is that racial/ethnic minorities tend to
report more exposure to stressors compared to whites, but don’t exhibit the expected increase in
psychological distress. Researchers have found seemingly paradoxical evidence showing lower
rates of stress-related psychopathology, such as depressive and anxiety disorders, among blacks
relative to non-Hispanic whites, despite large disparities in stress exposure in mid and late life
(Mezuk et al., 2013). Similarly, researchers have noted a healthy immigrant effect despite greater
exposure to multiple hardships and stressors among the foreign born population. For instance,
Hispanic immigrants have comparable or even better mental health than whites (Gallo, Penedo,
Espinosa de los Monteros, Karla, & Arguelles, 2009). Although it may seem counterintuitive for
30
groups experiencing more stressors to have similar, or better mental health, these patterns may
reflect important differences between experiences of acute and chronic stressors and between
exposure and appraisal that have yet to be fully examined in the stress disparities literature.
The objective of the current study is to examine race/ethnic differences in stress burden
using a framework that integrates exposure to stressors that are chronic in nature with appraisals
of how upsetting these stressors are perceived to be. Additionally, this study focuses both on
total stress exposure as well as domain specific stressors. This is the first study to examine
race/ethnic differences in stress among older adults that characterizes chronic stress in terms of
both exposure and appraisal and across multiple life domains in which stress can be experienced.
Background
Stress process models(G. W. Brown & Harris, 1978; Kessler, 1979b; Pearlin et al., 1981)
have sought to consider the extent to which exposure to life strains are unequally distributed in
the population, offering a major pathway linking race/ethnicity to health disparities. Accordingly,
the differential exposure hypothesis posits that racial and ethnic minorities, and blacks in
particular, look worse on major health outcomes since they are exposed to greater levels of stress
(G. W. Brown & Harris, 1978; Kessler, 1979a). Similarly, the stress process model suggests
social and economic stratification result in varying exposure to stressors, which explain
population differences in health (Pearlin, 1989). Race and ethnicity, in this context, are
classifications that reflect a set of experiences and stress exposures within social and physical
environments (Williams, Spencer, & Jackson, 1999; Williams, Yan, Jackson, & Anderson, 1997).
Empirical research rooted in these models demonstrate that the degree to which individuals are
exposed to a set of objective life stressors is patterned by their race/ethnicity(Sternthal, Slopen,
& Williams, 2011; Thoits, 2010; Turner & Avison, 2003). Race/ethnic differences in stress
31
exposure have been linked to structural and societal inequities including segregation, unequal
levels of education, employment, wealth, and incarceration. In turn, these race/ethnic differences
in stress exposure explain, in part, race/ethnic differences in health (Hatch & Dohrenwend, 2007;
Sternthal et al., 2011).
Despite the foundational importance of empirical evidence establishing race/ethnic
patterns in stress exposure (Sternthal et al., 2011; Thoits, 2010; Turner & Avison, 2003), there
remain important methodological deficiencies in the measurement of stress in nationally
representative samples. First, stress is often conceptualized in these studies as acute stressors or
checklists of negative life events like job loss or divorce. However, many acute stressful life
events ultimately develop into chronic strains that can be distressing (Avison & Turner, 1988).
Thus the conceptualization of stress as a count of acute or event based experiences may provide
an incomplete picture of the spectrum of stress exposures that contribute to total stress burden.
Blair Wheaton (1994) argued for the expansion of the "stress universe" to include chronic
stressors, traumatic events, and a host of stressors that went far beyond acute or stressful life
events. The Stress Domain Hypothesis(Turner, Wheaton, & Lloyd, 1995) suggested it was
essential to distinguish acute or life events from chronic strains, focusing on the elaboration of
types and sources of stress to more fully specify the stress universe and better approximate total
burden. Turner, Wheaton, and Lloyd (1995) demonstrated unequivocally that consideration of
the stress universe was required to accurately understand differential exposure to stressors,
particularly for understanding race/ethnic differences in stress exposure. Despite these calls for
an expanded conceptualization of the total stress burden, we still lack empirical studies of the
total stress burden that incorporate chronic stressors, particularly in research of
racially/ethnically diverse older U.S. adults.
32
Chronic stressors, or ongoing strains that are persistent and enduring, are understudied
yet critical since they often prevent individuals from ever biologically or psychologically
habituating, putting them in a constant state of arousal that is built into the social environment
(Herbert & Cohen, 1993; Lepore, 1995; Pearlin, 2010). Markedly, chronic stressors tend to
surface within major social domains such as financial stability, employment and family, all of
which are of vital importance to both the larger society and individuals (Pearlin, Schieman, Fazio,
& Meersman, 2005). Critical and chronically stressful life domains, like financial and housing
instability, that cannot be easily remedied, particularly in old age, denote opportunities for
intervention, outreach, and social supports. Understanding the race/ethnic patterning of chronic
stress across these major life domains in older adults may be central to prevention and mediation
efforts since chronic stress burdens are likely charting how life course trajectories and health of
minority groups come to differ in old age (Pearlin, 2010).
An additional methodical limitation in much of the empirical work examining race/ethnic
differences in stress is that most stress measures in nationally representative surveys only focus
on objectively verifiable exposures and life situations such as the death of a spouse or living in
poverty, and overlook the appraisal processes through which stressors operate to impact more
distal outcomes (Lazarus & Folkman, 1984; Park & Folkman, 1997; Pearlin, 1989; Thoits, 1995).
These studies rely on the assumption that standardized lists of stressors are perceived similarly
by individuals or members of different groups. However, all major conceptualizations of the
stress process acknowledge that responses to stressors depend on their meanings to the person
which is importantly linked to that individuals personal and social history (Cohen, Kamarck, &
Mermelstein, 1983; Lewis, Diamond, & Forman, 2015; Williams, Mohammed, Leavell, &
Collins, 2010). Individuals do not experience stress in a vacuum but rather in the context of
33
different personal and environmental resources that shape the stressfulness of a life experience.
For example, the emotional effects of ongoing caregiving strain will undoubtedly differ
depending on the availability of financial resources to cope with the responsibilities, the ability
to take time off work to care for that person, and the meaning of caregiving for that individual.
Additional evidence from the caregiving literature suggests there is racial/ethnic variation in
perceptions of caregiving as a stressor. African Americans have been shown to view caregiving
as less burdensome than their white counterparts, largely due to differences in culture including
familial expectations and active coping styles that confer attitudes of resilience (Roth, Dilworth-
Anderson, Huang, Gross, & Gitlin, 2015). Consequently, attributions related to the stress
exposure should be distinguished from those relevant to the individual’s perceptions of stress
since stress exposure may not manifest uniformly across groups (Amirkhan, 1994; Harrell, 2000).
Prior theoretical work in the sociological literature has attempted to incorporate concepts
of group differences in the subjective experience of stress suggesting that minority status may be
related to higher levels of stress appraisals since minority status is associated with a greater
overall stress burden and fewer socioeconomic resources to buffer the negative consequences of
stress (G. W. Brown & Harris, 1978; Kessler, 1979b). Individuals with the dual burden of
socioeconomic disadvantage and race-related stressors may be at even greater risk of reporting a
higher number of stress exposures, greater severity or hardship in the type of stressor, and
heightened stress appraisal since they have limited access to material coping mechanisms (Myers,
2009). For example, two studies examining race differences in exposure and susceptibility to
stressful life events found both greater exposure and perceived stress among low SES nonwhites
(Kessler, 1979a; Ulbrich, Warheit, & Zimmerman, 1989). This work on race/ethnicity, stress
exposure and appraisal is limited in that it often treats minority groups homogeneously, however,
34
these interrelationships may play out differently among US born, foreign born Hispanics and
blacks. Additionally, this work is limited in that minority status, despite being related to
experiences of prejudice, discrimination, greater stress exposure and lower SES, is also a source
of psychosocial resources, such as a collective racial identity (Sellers & Shelton, 2003) and
larger and more supportive religious and social networks(Mouzon, 2017; Thoits, 1995), that can
protect against the effects of these stressors (Kessler & Neighbors, 1986). Thus, it may be that
racial/ethnic minorities are more prone to stress exposure, have less access to resources related to
SES, but have access to other psychosocial resources that leave them better able to manage both
the emotional and physical consequences of adversity in later life relative to their white peers.
Empirical stress research, however, is yet to fully investigate the race/ethnic patterning of
appraisal into chronic stress measurement at the population level.
In light of this gap in the literature, the present study examines racial/ethnic differences in
both the number of reported chronic stressors and their stress appraisal in a diverse sample of
older adults. We also examine the domains or types of chronic stressors that drive race/ethnic
differences in both stress exposure and appraisal. Based on the differential stress exposure
hypothesis, we expect racial and ethnic minorities, specifically black and both foreign and US
born Hispanic older adults, will report experiencing more ongoing chronic stressors across all
domains of chronic stress and will appraise these exposures as more stressful or upsetting than
their white peers.
Methods
Data come from the nationally representative Health and Retirement Study (HRS), an
ongoing biennial study of U.S. adults age 51 and older that began in 1992 with the aim of
improving our understanding of the social, economic, environmental, and behavioral factors
35
associated with aging and the health of older adults. In 2006, the HRS began collecting data on
chronic stress using a self-administered questionnaire (SAQ) given to a random half-sample of
non-institutionalized respondents who were selected for a face-to-face interview. The SAQ had a
90% completion rate, leaving 7,167 cohort eligible SAQ respondents (Smith et al., 2013). We
excluded 137 respondents who did not identify as white, black or Hispanic. Finally, 463
respondents (6.6%) were excluded who were missing on stress measures resulting in a final
analytic sample of 6,567 adults with complete data on all measures assessed.
Ongoing Chronic Stress
We measure total chronic stress exposure (Aldwin, Sutton, Chiara, & Spiro, 1996; Troxel,
Matthews, Bromberger, & Sutton-Tyrrell, 2003) using a count of the number of chronic stressors
respondents reported experiencing (range: 0-7) during the last twelve months or longer. We
include the following stressors based on respondents self reports (yes/no): ongoing health
problems (in yourself), physical or emotional problems (in spouse or child), problems with
alcohol or drug use (in family member), financial strain, housing problems, problems in a close
relationship, and helping at least on sick/limited/frail family member or friend on a regular basis.
An item about assessing ongoing problems in the workplace was excluded from our analysis
since more than 60% of respondent are retired or out of the labor force.
We also created a stress appraisal scale by averaging across responses of how upsetting
each of the seven stressors was among respondents who experienced at least one stressor (range:
1-3; α=0.75). Respondents who reported exposure to a chronic stressor could rate that stressor as
1= not upsetting, 2= somewhat upsetting, or 3= very upsetting. Stress appraisal was
dichotomized as somewhat or very upsetting versus not upsetting when examined by domain.

36
Sociodemographic variables
Race/ethnicity was self reported and respondents were classified as non-Hispanic white,
non-Hispanic black, and Hispanic. We further differentiate between US born and foreign born
Hispanics as we expect stress experience may differ among Hispanics according to foreign born
status. We include sociodemographic and socioeconomic factors that might be related to
race/ethnic differences in stress exposure and appraisal. Age is measured as a continuous
variable in years. Gender was dichotomized as male or female. Educational attainment was
measured using number of years of completed schooling. Employment status was categorized as
currently employed either full or part time, unemployed/not in the labor force, and retired. Total
household income is logged transformed and wealth (assets minus debts) is quartiled because
these variables were highly skewed. Marital status was categorized as married/partnered,
divorced/separated, widowed, and never married.
Analytic Strategy
We first determined the prevalence of chronic stress exposure and corresponding
negative stress appraisal in each of the five domains by race/ethnicity. Next, we used Poisson
regression models to examine race/ethnic differences in total chronic stress exposure. We also
examined race/ethnic differences in exposure across chronic stress domains using logistic models.
We then examine race/ethnic differences in appraisal or how upsetting stress exposures are
among those who reported experiencing any stress exposure. The stress appraisal scale is
normally distributed so we used ordinary least squares (OLS) regression to estimate race/ethnic
differences in appraisal. We also examine race/ethnic differences in appraisal across chronic
stress domains using logistic regression. All analyses are weighted using the self-administered
questionnaire sample weights, which adjust for differential probability of selection and response
37
rates and produce estimates representative of the older U.S population. We account for the
complex sample design using the SVY suite of commands in Stata 14.
Results
Table 1 presents weighted demographic and socioeconomic characteristics for the full
sample and by race/ethnicity. The mean age in the sample was 66.3 (range: 52-104). Women
make up about 54% of the sample, 85% were white and the mean level of education was 13
years (range: 0-17). The mean logged household income for the sample was 10.7 and the wealth
distribution of the sample is similar to and reflects its majority white composition. Nearly 51%
were retired and 69% were married or partnered. When looking at the sample characteristics by
race/ethnicity, whites on average were older, more educated, and had higher incomes and wealth
than their black, foreign born, and US Hispanic counterparts. Whites and US born Hispanics
were more likely to be married than blacks and foreign born Hispanics. A little over half of
Hispanics in the sample were foreign born and reported higher levels of unemployment than their
white, black, and US born Hispanic counterparts.
Table 2 shows the average total chronic stress exposure and appraisal, the prevalence of
domain specific stress exposure, and the percentage of those who reported being somewhat/very
upset (versus not upset) within each stress domain by race/ethnicity. There were significant
race/ethnic differences in both total chronic stress exposure and appraisal. On average, blacks
had the highest level of ongoing chronic stress exposure (2.7) and whites had the lowest level
(2.1). Among those who reported stress exposure, the average stress appraisal was highest for
whites and foreign born Hispanics (1.7) and lowest for blacks and US born Hispanics (1.6),
which is approximately the mid-point between not being upset and being somewhat upset.
38
Ongoing health problems were the most prevalent chronic stress domain, with more than
60% of older adults reporting problems in this domain across race/ethnic groups. Relationship
strain was reported as the most upsetting type of chronic stressor and was experienced by about
half of older adults across race/ethnicity. Compared to whites, older minorities (blacks, US and
foreign born Hispanics) had a higher percentage of exposure to every chronic stress domain, with
the exception that US born Hispanics had a lower rate of relationship stress relative to whites.
Notably, the biggest differences in exposure were in housing and financial strain where blacks
reported nearly double the rate of ongoing financial strain (59.6%) and almost three times more
likely to report residential strain (23.2%) compared to whites. Yet, blacks report being upset by
caregiving, relationship, residential, and financial stress at a lower rate than both whites and US
born Hispanics. Foreign born Hispanics were less upset by caregiving strain relative to all other
groups.
To determine race/ethnic differences in total chronic stress exposure, Table 3 shows
results from Poisson regression models. Model 1 shows race/ethnic differences in exposure after
adjusting for age and gender. To determine if SES or demographic measures account for
race/ethnic differences in exposure, Model 2 adds education, income, wealth, employment and
marital status. Results show that blacks are more likely to report being exposed to a greater
number of ongoing chronic stressors compared to whites (Model 1: IRR=1.26, SE=0.04;
p<0.001) when controlling for age and gender. After adjusting for SES and demographic
measures the black-white disparity was reduced but remains significant (IRR= 1.09; SE=0.03;
p<0.01). US born (Model 1: IRR= 1.10; SE=0.06, p<0.10) and foreign born Hispanics (Model 1:
IRR= 1.18; SE=0.07, p<0.01) also report higher levels of stress exposure compared to whites,
however, the difference between whites and both US (Model 2: IRR= 0.98, SE= 0.06, p>0.10)
39
and foreign born Hispanics (Model 2: IRR= 1.03, SE= 0.04, p>0.10) diminished after adjusting
for income and wealth.
While we find that, overall, blacks and Hispanics report more stress exposure, we are
interested in whether this increased exposure is due to greater likelihood of exposure across
every domain or if specific domains are driving these race/ethnic differences. Thus, we examined
separate models for each stress domain using logistic regression models that predicted the
likelihood of having any ongoing chronic stress exposure in health, financial, residential,
relationship and caregiving domains adjusting for age and gender. We then plot the predicted
probabilities from each model in Figure 1. Figure 1 shows that older blacks have a higher
probability of reporting ongoing health problems (69%; OR 1.43, p<0.01), financial (58%, OR:
2.40, p<0.001), residential (23%, OR: 3.24, p<0.001), and relationship strain (53%, OR: 1.20,
p<0.05) relative to older whites, all of which are likely driving the overall black-white
differences in total stress exposure found in Table 3. US born Hispanics have a higher
probability of reporting financial (44%, OR: 1.33, p<0.10) and residential strain (18%, OR: 2.52,
p<0.001) than whites but are less likely to report relationship strain (42%, OR: 0.78, p<0.10).
Foreign born Hispanics report higher probabilities of health problems (68%, OR: 1.37, p<0.10),
financial (50%, OR: 1.77, p<0.01) and residential strain (14%, OR: 1.75, p<0.05) relative to
whites. Race/ethnic differences in ongoing health problems and financial strain were fully
explained by accounting for SES differences between the groups while black-white and US born
Hispanic-white differences in residential strain remained.
In Table 4 we show OLS regression models examining race/ethnic differences in stress
appraisal among respondents reporting exposure to at least one chronic stressor. In these models,
to isolate race/ethnic differences in appraisal from differences in exposure we also account for
40
the total number of chronic stress exposures reported. Model 1 shows that blacks, on average,
report being less upset by their chronic stress exposure compared to whites (β= -0.10; SE=0.03,
p<0.01). This difference between blacks and whites increased after adjusting for SES and
demographic measures in model 2 (β= -0.13; SE=0.03, p<0.001). US born Hispanics were also,
on average, less upset by chronic stress exposure relative to whites (M1: β= -0.10; SE=0.06;
p<0.10) and differences remained after controlling for SES and demographic characteristics (M2:
β= -0.11; SE=0.05; p<0.10). These race/ethnic differences remained after adjusting for
psychological distress and recent experience of major acute stressors, suggesting these results are
not confounded by feelings of distress or other sources stress.
Since chronic stressors within certain domains may be experienced as particularly
stressful by race/ethnicity, Figure 2 graphs the predicted probabilities of reporting chronic stress
exposure as upsetting across each domain for whites, blacks, US born and foreign Hispanics
separately. Predicted probabilities come from logistic regression models that predicted the
likelihood of reporting ongoing chronic stress exposure as somewhat or very upsetting versus not
upsetting in health, financial, residential, relationship and caregiving domains adjusting for age,
gender, and total chronic stress exposure. Most strikingly, blacks consider financial (47%; OR:
0.75, P<0.05), relationship (61%; OR: 0.49, P<0.001) and caregiving (27%; OR: 0.52, P<0.01)
stress exposure less upsetting than whites. After adjusting for SES and demographic measures,
blacks were less upset across every chronic stress domain including health (49%; OR: 0.68,
P<0.01) and residential (38%; OR: 0.55, P<0.05) strain relative to whites. US (69%; OR: 0.62,
P<0.10) and foreign (72%; OR: 0.57, P<0.10) born Hispanics report being less upset than whites
by ongoing relationship strain and foreign born Hispanics were less upset than whites by
41
caregiving strain (18%; OR: 0.29, P<0.001). Yet, US and foreign born Hispanic-white
differences in relationship strain were attenuated after adjusting for SES measures.
Discussion
In this study, the first to examine both stress exposure and appraisal in a nationally
representative and diverse sample of older adults, we found that older blacks and Hispanics, in
particular foreign born Hispanics, are more likely to be exposed to a greater number of ongoing
chronic stressors relative to whites. Our findings are consistent with those reported in prior
research on race/ethnic differences in overall stress exposure(e.g. Sternthal et al., 2011; Turner &
Lloyd, 1995). However, despite having higher chronic stress burdens, we found that racial and
ethnic minorities do not report higher stress appraisal. After accounting for cumulative chronic
stress exposure, demographic characteristics, and socioeconomic status, the average stress
appraisal was lower among blacks and Hispanics, and in particular US born Hispanics, relative to
whites. This study, therefore, presents novel findings highlighting the importance of considering
both exposure and appraisal in determining race/ethnic differences in the stress burden of older
adults.
Importantly, we also found variability in race/ethnic differences in both exposure and
appraisal by stress domain. For instance, blacks and Hispanics were more likely to be exposed to
housing and financial strain compared to whites, and this seemed to largely account for the
greater stress exposure of older minorities. Excess financial and housing hardship among
racial/ethnic minorities in older adulthood likely reflects the cumulative effects of structural and
societal inequities including segregation, English language proficiency, unequal educational
attainment, longer periods of unemployment and underemployment, lower wages, pensions, and
accumulation of wealth over the life course (Landrine & Corral, 2009; Williams et al., 2010).
42
Older blacks also report exposure to health problems at a greater rate than older whites, though
differences in socioeconomic status appear to explain this black-white gap. Likewise, blacks
reported more relationship strain relative to whites, which is consistent with research showing
blacks simultaneously experience high levels of social support and strain (Neighbors, 1997). A
better understanding of the domain specific chronic stressors underlying race/ethnic differences
in cumulative stress exposure is a significant step forward for prevention and intervention efforts
aimed at reducing or mitigating the effects of stress as well as inform our theoretical models that
link race/ethnicity to stress.
While we show that blacks and Hispanics are disproportionately exposed to chronic stress,
the factors that account for differences in stress exposure vary among these groups. Hispanic-
white disparities in stress exposure tended to be smaller relative to black-white differences and
were largely accounted for by differences in SES. For foreign born Hispanics, socioeconomic
disadvantage and ethnicity or immigrant status may represent a dual disadvantage that, when
combined, place individuals at greater risk of chronic stress exposure (Myers, 2009). Higher SES
may act as a protective factor, shielding Hispanics from health, financial, residential and
caregiving strain. Education for Hispanics may function as an equalizer, perhaps conferring
advantages in English language proficiency, putting them on par with whites in terms of
occupation, earnings, housing, and wealth accumulation. However, disproportionate stress
exposure among older blacks remains even after accounting for SES. As a result of a history of
race-residential segregation, blacks are much more likely to live in disadvantaged environments.
Segregation is considered a fundamental cause of differences in health status between blacks and
whites because it shapes socioeconomic conditions at the individual, household and
neighborhood levels, ultimately determining blacks’ socioeconomic mobility and
43
residential/environmental risk factors (Phelan & Link, 2015). Thus, for many older African
Americans, education, income, and even wealth do not necessarily translate into less stress
exposure due to the unique conditions of living in black neighborhoods. High SES, for instance,
does not confer the same protections from housing security for blacks as it does for whites and
Hispanics. This is a key way in which the aging experience is different for blacks (Landrine &
Corral, 2009; Turner & Avison, 2003) and may account for differences in stress exposure and
coping. Non-equivalence or the benign function of SES among older blacks suggests the need to
identify other protective factors that can mitigate or prevent chronic stress exposure among this
group (Williams et al., 2010). These findings emphasize the varying ways SES differently
influences stress exposure across racial/ethnic minority groups in older adulthood.
Despite domain-specific variation in black-white differences in stress exposure, blacks
are less likely to be upset than whites across all stress domains in fully adjusted models.
Furthermore, black-white differences in appraisal increased after adjusting for SES, suggesting
socioeconomic resources may be particularly important for older black adults’ experience of
stress. Average stress appraisal was also lower among Hispanics compared to whites, but this
difference was primarily driven by US Hispanics being less likely to be upset by ongoing
relationship problems. Additionally, foreign born Hispanics, considered both relationships and
caregiving to be less upsetting relative to whites. Both foreign born and US born Hispanics had
some overlap in their experience of chronic stress, but we found unique differences in stress
exposure and appraisal between these two groups, suggesting there are distinct stress experiences
among Hispanics based on nativity that would be missed if Hispanics were treated as a
homogenous group.
44
This study found race/ethnic differences in stress appraisal that have not been shown
previously, and suggests total stress burden may be better understood by measuring both
exposure and appraisal. Importantly, the distinction between exposure and appraisal based
measures of stress may shed light on critical pathways that differentially contribute to race/ethnic
physical and mental health disparities (Lewis et al., 2015; Williams et al., 2010). Prior research
has shown appraisal-based measures of stress perform better as predictors of mental and physical
health than does exposure-based measures of stress (Hayman, Lucas, & Porcerelli, 2014) likely
because, in traditional psychological stress process models, subjective assessments of stress
impact the ways in which individuals respond to stressors. Consequently, examining race/ethnic
differences in stress appraisal may represent a key component in understanding behavioral and
coping responses to stress, and ultimately race/ethnic health disparities.
There are a few hypotheses that may explain why minority groups would appraise
chronic stress as less upsetting relative to whites, despite reporting greater chronic stress
exposure. First, minority status is a source of unique psychosocial resources and positive coping
strategies (Jackson, Knight, & Rafferty, 2009), such as religious participation (Chatters, Taylor,
Jackson, & Lincoln, 2008) and social support (Thoits, 2010; Thomas, 2016), which might
minimize or influence the perception of certain experiences as stressful. Thus, when measuring
respondents' stress appraisal, it may reflect this stress buffering or modifying response of these
protective resources with lower subjective perceptions of stress (Dohrenwend, 2006). Second,
and more relevant for older adults, there is a life course dynamic that is overlooked in stress
processes frameworks that may be important when examining aging populations. Earlier and
more frequent exposure to stressors may position older minority groups to be more accustomed
to dealing with stress or enable them to develop more effective, context-specific coping (Lewis
45
et al., 2015; Williams et al., 2010). Underlying this hypothesis is the idea that groups who are
exposed to a high stress burden earlier in life are better able to manage both the emotional and
physical consequences of social stressors and adversity later in life.
Finally, minority groups may be collectively and actively reframing the meaning or
significance of chronic stress exposure in an attempt to reduce its adverse mental or emotional
impact. Individuals and minority groups do not always conform to dominant interpretations of
their life circumstances as is generally assumed in stress literature. They may instead develop
alternative interpretations that allow them to construct their own meaning of what is generally
thought of as a stressful experience (McLeod, 2012). This adaptation may also represent a
common pathway by which people have responded to different cultural and life histories.
Measuring stress appraisal in these groups may highlight ways in which racial/ethnic minorities
observe their chronic stress burden and simultaneously adapt, thereby recognizing their
resourcefulness, coping and agency.
In considering stress appraisal in older adults it is important to note that emotional
reactivity declines with age and this may influence how upsetting experiences are perceived to be.
According to the socioemotional selectivity theory and positivity effect, older adults regulate
their emotional states to optimize wellbeing resulting in greater focus on positive information
and diminished attention on negative information (Carstensen, Isaacowitz, & Charles, 1999;
Mroczek, 2001). Consequently, older adults, in the appraisal process, may trivialize many
stressors. However, this may also suggest that when older adults do report upsetting or stressful
experiences they are likely highly salient or of significant importance.

46
Limitations
There are some limitations in the way stress exposure and appraisal are conceptualized.
First, while we use a measure of appraisal that has been utilized in other studies (Aldwin et al.,
1996), the retrospective nature of the questions means respondents may be reporting the
stressfulness of ongoing chronic situations that are no longer or less problematic. Individuals
may be reporting stress exposure during any time in the past 12 months, but at the time of the
interview may be feeling less bothered by the stressor. Respondents maybe relying on memory to
report their stress response and retrospective reporting can be biased. Additionally, selective
mortality among blacks and Hispanics may mean we have a select group of individuals who cope
well with or respond well to stressors and may be more likely to survive to old age. Importantly,
we are measuring chronic stress using a cross-section snapshot, but the relationship between
race/ethnicity, stress exposure and appraisal may vary over time. Finally, although we examined
a variety of stressors, the “stress universe” includes a wider array of race based or related
stressors (e.g., vicarious discrimination, incarceration, intersectional stressors) and additional
research on race/ethnic differences in the stress processes is needed that attends to these stressors
as well (see T. H. Brown & Hargrove, 2018).
The stress experience consists of both exposure to stressors and subjective appraisals, yet
prior stress work at the population level has not evaluated differences in appraisal among a
diverse sample of older adults. Our findings show that appraisals of objectively equivalent
stressors differ systematically by race/ethnicity. The separation of chronic stress exposure from
stress appraisals highlights that minority groups report ongoing chronic stress exposure, but they
may experience these stress exposures differently. Studies that do not take the subjective
meaning of stress into account may miss an important pathway through which social stress
47
affects wellbeing. Future research should evaluate the extent to which social characteristics and
subsequent life experiences influence an individuals interpretations of an otherwise objective life
circumstances. Additionally, future research should explore heterogeneity within racial/ethnic
groups (e.g., gender, skin tone, place, sexuality). By doing so, this work has the potential to
enrich models of the stress process through which social arrangements and race/ethnicity
contribute to differences in health.

48
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56

Full Sample Whites Blacks
US Born
Hispanics
Foreign
Born
Hispanics
(n=6,567) (n=5,294) (n=809) (n=228) (n=236)
% % % % %
Age in yrs [mean(SE)] 65.3(0.2) 65.6(0.3) 63.8(0.5) 62.1(1.0) 63.8(1.2)
Female 53.7 53.2 59.9 50.8 53.9
Education in yrs [mean(SE)] 13.0(0.1) 13.4(0.1) 11.8(0.2) 11.0(0.4) 8.9(0.5)
HH Income [mean(SE)] 10.7(0.0) 10.8(0.0) 10.0(0.1) 10.2(0.1) 9.4(0.2)
HH Wealth
1st quartile 24.3 19.2 56.0 46.1 52.0
2rd quartile 25.2 25.3 25.9 26.5 17.9
3rd quartile 25.1 27.0 11.8 15.3 20.4
4th quartile 25.4 28.5 6.4 12.1 9.8
Employment Status
Currently Employed 38.1 38.3 33.9 42.3 41.0
Retired 51.2 52.7 52.1 38.7 24.2
Not in the Labor Force 10.6 9.0 13.9 19.1 34.7
Marital Status
Married 69.1 71.4 49.1 71.0 61.7
Divorced/Separated 12.2 10.8 22.5 15.4 16.3
Widowed 15.1 14.7 21.1 9.2 15.0
Never Married 3.6 3.1 7.2 4.4 7.0
Note: Household (HH) income is logged
Table 1. Descriptive statistics for the full sample and by race/ethnicity, Health and Retirement
Study, 2006
57

White Black
US Born
Hispanics
Foreign Born
Hispanics
χ
2
% % % %
Summary stress measures [mean(SE)]
Chronic stress exposure 2.1(0.0) 2.7(0.1) 2.4(0.1) 2.5(0.1) 11.8**
Chronic stress appraisala 1.7(0.0) 1.6(0.0) 1.6(0.1) 1.7(0.0) 37.2***
Health
Exposed 60.6 67.7 61.5 66.4 3.0*
Upseta 56.5 56.5 55.4 66.7 1.6
Financial
Exposed 36.9 59.6 46.8 52.3 30.5***
Upseta 54.0 50.4 57.6 64.0 1.8
Residential
Exposed 8.3 23.2 19.4 14.0 52.4***
Upseta 52.5 47.5 63.6 44.4 1.0
Relationship
Exposed 48.2 53.7 43.8 52.1 2.6+
Upseta 75.5 67.5 71.5 68.9 3.6*
Caregiving
Exposed 35.4 39.5 36.3 38.4 1.1
Upseta 41.4 30.9 45.0 19.7 4.4**
+p<0.10 *p<0.05 **p<0.01 ***p<0.001
Upset = Somewhat/very upset vs. not upset
a Among those who reported any stress exposure (n= 5,519)
Table 2. Bivariate associations between race/ethnicity, chronic stress exposure and stress appraisal,
Health and Retirement Study, 2006 (n=6,567)
58

Independent Variables
IRR SE IRR SE
Race/Ethnicity (ref=white)
Black 1.26 0.04 *** 1.09 0.03 **
US born Hispanic 1.10 0.06 + 0.98 0.06
Foreign born Hispanic 1.18 0.05 *** 1.03 0.04
Age (yrs) 0.99 0.00 *** 0.99 0.00 ***
Female 1.09 0.03 *** 1.07 0.03 **
Education (yrs) 1.01 0.00 +
HH Income 0.96 0.01 **
HH Wealth (ref=1st quartile)
2rd quartile 0.79 0.02 ***
3rd quartile 0.71 0.02 ***
4th quartile 0.66 0.02 ***
Employment Status (ref=employed)
Retired 1.12 0.03 ***
Not in labor force 1.13 0.05 *
Marital Status (ref=married)
Divorced/Separated 0.95 0.03
Widowed 0.92 0.03 *
Never Married 0.82 0.04 **
Intercept 3.78 0.25 *** 7.28 0.95 ***
+p<0.10 *p<0.05 **p<0.01 ***p<0.001
Table 3. Poisson regression models predicting exposure to chronic stress by
race/ethnicity, Health and Retirement Study, 2006 (n=6,567)
Model 1 Model 2
59
Figure 1. Predicted probabilities of stress exposure by race/ethnicity and chronic stress
domain

Notes: +p<0.10 *p<0.05 **p<0.01 ***p<0.001
From logistic models adjusted for age and gender.

60

Independent Variables β SE β SE
Race/Ethnicity (ref=white)
Black -0.10 0.03 ** -0.13 0.03 ***
US born Hispanics -0.10 0.06 + -0.11 0.05 +
Foreign born Hispanic -0.03 0.05 -0.04 0.05
Age (yrs) 0.00 0.00 0.00 0.00 **
Female 0.12 0.02 *** 0.09 0.02 ***
Chronic stress exposure (0-7) 0.08 0.01 *** 0.08 0.01 ***
Education (yrs) 0.00 0.00
HH Income 0.00 0.01
HH Wealth (ref=1st quartile)
2rd quartile -0.08 0.03 **
3rd quartile -0.04 0.03
4th quartile -0.01 0.04
Employment Status (ref=employed)
Retired 0.08 0.02 ***
Not in labor force 0.10 0.03 **
Marital Status (ref=married)
Divorced/Separated 0.08 0.03 **
Widowed 0.10 0.03 **
Never Married 0.00 0.06
Intercept 1.50 0.09 *** 1.67 0.15 ***
+p<0.10 *p<0.05 **p<0.01 ***p<0.001
Table 4. Regression models predicting chronic stress appraisal by race/ethnicity, Health
and Retirement Study, 2006 (n=5,519)
Model 1 Model 2
61

Figure 2. Predicted probabilities of stress appraisal (% upset) by race/ethnicity and
chronic stress domain

Notes: +p<0.10 *p<0.05 **p<0.01 ***p<0.001
From logistic models (somewhat/very upset vs not upset) adjusted for age, gender, and
total chronic stress exposure.

62
CHAPTER 3

Title: Is Exposure Enough? Race/Ethnic Differences in Chronic Stress Exposure, Appraisal &
Mental Health among Older Adults

Authors:
Lauren Brown, MPH
1
, Jennifer Ailshire, PhD
1
1. Leonard Davis School of Gerontology, University of Southern California

Corresponding Author:
Lauren Brown, MPH

USC Davis School of Gerontology
University of Southern California
3715 McClintock Ave.
Los Angeles, CA 90089
Phone number: 951-990-4969
Email: laurenlb@usc.edu

63
Abstract
Exposure to stressors is differentially distributed by race/ethnicity with minority groups reporting
higher stress burdens than their white counterparts. Prior research and theory have suggested that
exposure to objectively stressful events contributes to race/ethnic mental health disparities in
older adulthood. Yet, in order to understand the extent to which some groups bear a
disproportionate stress and mental health burden we need to consider race/ethnic differences in
stress appraisal, specifically how upsetting they may be, in addition to stress exposure. We
examine racial/ethnic differences in the number of reported chronic stressors across 5 domains
(health, financial, residential, relationship and caregiving), their appraised stressfulness and their
varying association with anxiety and depression among a diverse sample of older adults. Data
come from 5,372 adults ages 54+ from the 2006 Health and Retirement Study. Fully adjusted
race stratified models show that exposure and appraisal significantly and independently
predicted anxiety and depressive symptoms for both whites and blacks. Yet, race and stress
appraisal interactions show that when blacks rate their stress as not upsetting they report fewer
depressive symptoms than whites. Comparatively, when blacks consider their stress exposure as
either somewhat or very upsetting they report significantly more depressive symptoms relative to
whites. These findings suggest the varying importance of stress appraisal for whites and blacks
and suggest stress appraisal measures a different and independent construct from stress exposure.
The distinction between exposure and appraisal based measures of stress shed light on important
pathways in which stress differentially contributes to race/ethnic mental health disparities.

64
Introduction
Stress theories have positioned stress exposure as a foundational component in the
manufacturing of social inequalities in health. The differential exposure hypothesis posits that
racial and ethnic minorities, and blacks in particular, look worse on major health outcomes since
they are exposed to greater levels of stress (G. W. Brown & Harris, 1978; Kessler, 1979b).
Similarly, the stress process model suggests social and economic stratification result in varying
exposure to stressors, which explain population differences in health (L. I. Pearlin, 1989).
National surveys have embedded theories centering on differential stress exposure into how we
measure stress in populations with the bulk of empirical evidence demonstrating that race/ethnic
differences in health are determined by the degree to which individuals are exposed to a set of
objective life stressors. However, this work entirely overlooks the stress appraisal process or an
individual’s evaluation of how upsetting a given stress exposure is. In contrast, psychological
stress models emphasize that experiencing the same event can be stressful for some individuals
but not for others (Cohen, Kessler, & Gordon, 1995; Cohen, Gianaros, & Manuck, 2016). In
psychological models of stress, the appraisal process is a primary mechanism through which
stress exposure operates to impact more distal health outcomes (McEwen, 1998). Further
evidence suggests blacks may respond to stressors differently than whites, suggesting the stress
experience depends on culture, individual meaning, and the context in which the stressor
exposure occurs (Brown, Mitchell, & Ailshire, 2018). Importantly, there is a lack of research in
the health disparities literature that has examined whether both race/ethnic variability in stress
exposure and appraisal differently impact health and wellbeing in old age.
A persistent quandary among stress researchers is that racial/ethnic minorities tend to
report more exposure to stressors compared to whites, but don’t exhibit the expected increase in
65
psychological distress. For instance, researchers have found seemingly paradoxical evidence
showing lower rates of stress-related psychopathology, such as depressive and anxiety disorders,
among blacks relative to non-Hispanic whites, despite large disparities in stress exposure and
physical health in mid and late life (Mezuk et al., 2013). Although it may seem counterintuitive
for groups experiencing more stressors to have similar, or better, mental health these patterns
may reflect important differences between experiences of acute and chronic stressors and
between exposure and appraisal that have yet to be fully examined in the stress disparities
literature. The limitations in the stress literature, and with stress measurement focused primarily
on exposure, may be why prior work has been unable to explain the mental/physical health
paradox in blacks relative to whites (Williams, Yan, Jackson, & Anderson, 1997). This paper
will examine how race differences in chronic stress exposure and stress appraisal are
differentially related to anxiety and depressive symptoms in older whites and blacks. Importantly,
this work will use a more comprehensive measurement of chronic stress while also examining
exposure and appraisal across five life domains: health, financial, residential, relationship and
caregiving strain to determine the impact of these stressors on black and white older adults’
mental health.
Background
Much of the empirical work examining race/ethnic differences in stress in nationally
representative surveys only focuses on objectively verifiable exposures and life situations such as
the death of a spouse or living in poverty (Lazarus & Folkman, 1984; Park & Folkman, 1997;
Pearlin, 1989; Thoits, 1995). For example, the focus of prior research examining the relationship
between race, stress and mental health in older adults has used check lists of negative life events
(see Kraaij, Arensman, & Spinhoven, 2002 for a review). These studies rely on the assumption
66
that standardized lists of events that researchers have conceptualized as stress are perceived
similarly by individuals or members of different groups. Yet, even the earliest definitions of
stress by Lazarus and Folkman (1984) indicate that the degree to which a situation is perceived
as threatening and elicits stress is a psychological process that is a function of the individual’s
appraisals of the stress experience. All major subsequent conceptualizations of the stress process
also acknowledge that responses to stressors depend on their meanings to the person which is
linked to an individual’s personal and social history (Cohen, Kamarck, & Mermelstein, 1983;
Williams et al., 1997). Individuals do not experience stress in the context of different personal
and environmental resources that shape the stressfulness of a life experience. Yet, the empirical
work examining the stress process has embedded potentially shallow or incorrect relationships
between stress exposure and health, suggesting stress is experienced uniformly across race/ethnic
groups. Incorporating context and appraisal in stress measurement are critical for a full
appreciation of life stressors on health and wellbeing.
If stress exposure is hypothesized to be a major contributor to race/ethnic differences in
health in older adulthood, it would follow that stress appraisal measures may contribute to our
understanding of the manufacturing of health inequity. Stress exposure, theoretically, should lead
to endorsement that that exposure is stressful, or an imbalance between the demands of a stressor
and the resources of the individual to deal with the stressor. Therefore, stress has at least two
components: 1) exposure to the stressor and 2) the perceived demands of the stressor or ability to
cope, leading to a corresponding appraisal of whether or not the stressor is distressing. In light of
this understudied appraisal processes, the differential vulnerability hypothesis aims to
incorporate race/ethnicity and perceived stressfulness into health disparities literature. The
differential vulnerability hypothesis posits that, where there are equal levels of stress exposure,
67
minority groups and blacks in particular, react more strongly to stressors since more vulnerable
groups have fewer social and personal resources to buffer the negative effects of stress on health
(Brown & Harris, 1978; Kessler, 1979a). Individuals with the dual burden of socioeconomic
disadvantage and race-related stressors may be at even greater risk since they have limited access
to psychosocial and material coping mechanisms (Myers, 2009). For example, two studies
examining race differences in exposure and vulnerability to stressful life events found both
greater exposure and psychological distress among low SES nonwhites (Kessler, 1979; Ulbrich,
Warheit, & Zimmerman, 1989). These theories and a handful of prior studies would suggest that
racial/ethnic minorities are disproportionately exposed to various social stressors (e.g. poverty,
discrimination) that place them at higher risk of poor mental health.
However, minority status, despite being related to experiences of prejudice,
discrimination, greater stress exposure and lower SES, is also a source of psychosocial resources,
such as a collective racial identity (Sellers & Shelton, 2003) and larger and more supportive
religious and social networks (Mouzon, 2017; Thoits, 1995) that can protect against the effects of
chronic stressors (Kessler & Neighbors, 1986). Thus, it may be that racial/ethnic minorities are
more prone to stress exposure, have less access to resources related to SES, but have adapted
better coping mechanisms and have access to other psychosocial resources that leave them better
able to manage both the emotional and physical consequences of adversity in later life relative to
their white peers. Prior empirical evidence has shown that older blacks appraise stress as less
upsetting (Brown et al., 2018) and report less general and domain specific distress. For example,
the caregiving literature suggests there is racial/ethnic variation in perceptions of caregiving as a
stressor. The emotional effects of ongoing caregiving strain will undoubtedly differ depending
on the availability of financial resources to cope with the responsibilities, the ability to take time
68
off work to care for that person, and the meaning of caregiving for that individual. African
Americans have been shown to view caregiving as less burdensome than their white counterparts,
largely due to differences in culture (Roth, Dilworth-Anderson, Huang, Gross, & Gitlin, 2015).
Status based characteristics, including race, affect the psychological and behavioral responses to
stress. Blacks facing chronic adversity may be driven to reorganize their outlook on life (Epel,
2009). In the course of coping with chronic stress, people often develop cognitive shifts or
changes in their mental filter that promote a more beneficial stress appraisal process.
Consequently, attributions related to the stress exposure should be distinguished from those
relevant to the individual’s perceptions of stress since stress exposure may not manifest
uniformly across groups (Amirkhan, 1994; Harrell, 2000). More stress exposure but lower stress
appraisal may result in minorities and blacks in particular exhibiting less stress related
psychopathology, a potential explanation for the white-black paradox in mental health. Stress
exposure and appraisal measure different constructs particularly in minority older adults who
have adapted to stress exposure differently than their white counterparts?.
Appraising acute events as stressful is a common reaction to environmental adversity and
elicits a stress response that subsides in a relatively short amount of time that is unlikely to pose
long-term risk. Chronic stressors, or ongoing strains that are persistent and enduring, are less
understood since these strains may put older adults in a constant state of arousal that is built into
the social environment, often preventing them from ever biologically or psychologically
habituating (Herbert & Cohen, 1993; Lepore, 1995; L. I. Pearlin, 2010). Chronic stress may be a
particularly important kind of stress for capturing the prolonged experience of stress exposure
that, if unaddressed, may result in anxiety and depression. Since chronic stressors tend to surface
within major social and role domains such as financial stability, employment and family, they
69
can illicit a prolonged stress response, leading to psychiatric illnesses such as depression and
anxiety disorders. Prior work has suggested chronic stressors rather than life events were found
to be of primary importance in explaining the social distribution of psychopathology (Turner,
Wheaton and Lloyd 1995), making them central to investigating race/ethnic differences in
anxiety and depression. Further, chronic stress exposure and appraisal may have unique
relationships with anxiety and depression since not all individuals exposed to stress will develop
anxiety or depressive symptoms. Perhaps because those who appraise their stress as not
distressing or successfully cope with chronic stress do not end up developing psychopathology,
which may also vary by race/ethnicity.
Unlike other physical comorbidities, both anxiety and depression are based on subjective
reactions or appraisals to an individual’s conditions that they interpret as threatening or
distressing. Therefore, anxiety and depressive symptoms are often influenced by factors that
shape both an individuals’ stress exposure and appraisal, chief among them perceptions and
interpretations of their reality. Anxiety and depression are related conditions that the social stress
literature often treats as interchange outcomes. Still anxiety and depression are very different
experiences with different relationships to both stress exposure and race/ethnicity. Work by
Aneshensel (1992) demonstrates how studies that use a single outcome can misrepresent the
extent of group differences in mental health when different groups have distinct reactions to
stress. While the literature suggests that depression may be the result of long-term anxiety
(among other factors), a threat appraisal without the belief that effective coping responses are
available is experienced as stress which engenders emotional responses including worry, fear and
anxiety (Cohen et al., 2016). The degree to which stressors are depressing, on the other hand, are
that they erode an individual’s self concept, diminishing self esteem and mastery. People
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typically endorse depressive symptomology since they have diminished resources in the face of
chronic strains, precisely when they need it the most (Pearlin, Lieberman, Menaghan, & Mullan,
1981). Thus, examining race differences in chronic stress exposure, appraisal and anxiety and
depressive symptoms cross-sectionally can help us understand how chronic stress exposure and
appraisal are differently linked to mental health, and potentially inform the ways in which whites
and blacks experience stress and how these stressors differently manifest in mental health
disparities in older adulthood.
Despite the well-documented association between stress exposure and health, prior work
has yet to connect appraisal measures to mental health in diverse nationally representative
samples of older adults. No comprehensive body of research examines the role of chronic stress
exposure and appraisal as independent mechanisms in producing population differences in
depression and anxiety symptoms. Thus, we examine whether stress exposure and appraisal have
independent effects on anxiety and depressive symptoms among black and white older adults.
We also examine the domains of chronic stress that are associated with more anxiety and
depressive symptoms for blacks and whites. We are testing how stressors exert their inimical
effects on mental health and why these effects are stronger for some people than others, with the
possibility that stress appraisal may exert a protective influence on mental health if an individual
perceives stress as not upsetting in the presence of general and specific chronic stressors. This
work may help us understand the mechanisms that link chronic stress exposure and appraisal to
anxiety and depressive symptomology but may also inform efforts to improve or understand
resilience in the face of chronic strain among older adults

71
Methods
Data come from the nationally representative Health and Retirement Study (HRS), an
ongoing biennial study of U.S. adults age 51 and older that began in 1992 with the aim of
improving our understanding of the social, economic, environmental, and behavioral factors
associated with aging and the health of older adults. In 2006, the HRS began collecting data on
chronic stress using a self-administered questionnaire (SAQ) given to a random half-sample of
non-institutionalized respondents who were selected for a face-to-face interview. The SAQ had a
90% completion rate, leaving 6,865 cohort eligible SAQ respondents (Smith et al., 2013). We
excluded 122 respondents who did not identify as white, black or Hispanic. Finally, 452
respondents (6.7%) were excluded who were missing on stress measures resulting in a final
analytic sample of 6,291 adults with complete data on all measures assessed.
Anxiety
The HRS used five items from the widely used Beck Anxiety Inventory (BAI) in the
SAQ (Brenes, et al; 2005). The Beck Inventory has been shown to distinguish symptoms of
anxiety from depression and to be valid for use in older populations. Respondents were asked
how often did they feel this way during the past week: fear of the worst happening, nervous,
hands trembling, fear of dying, felt faint. Respondents could choose 1= never, 2= hardly ever, 3=
some of the time, or 4= most of the time and respondents were told “The best answer is usually
the one that comes to your mind first.” Responses to the items are averaged to form an index of
anxiety (range= 1 to 4) and respondents were considered missing if more than two of the four
items had missing values.

72
Depression
The HRS uses the abbreviated version of the Center for Epidemiologic Studies –
Depression Scale (CES-D; Radloff, 1977) with eight yes/no items from the original 20-item
CES-D and has been validated for use with older adults (Beekman et al., 1997). Respondents
were asked if they had experienced the following items in the past week: depressed, everything
was an effort, restless sleep, happy, lonely, enjoyed life, sad, and could not get “going.” Two
items (happy, enjoyed life) are reverse-scored and responses were summed (range= 1 to 8).
Ongoing Chronic Stress
We measure total chronic stress exposure (Aldwin, Sutton, Chiara, & Spiro, 1996; Troxel,
Matthews, Bromberger, & Sutton-Tyrrell, 2003) using a count of the number of chronic stressors
respondents reported experiencing (range: 0-7) during the last twelve months or longer. We
include the following stressors based on respondents self reports (yes/no): ongoing health
problems (in yourself), physical or emotional problems (in spouse or child), problems with
alcohol or drug use in family member, financial strain, housing problems, problems in a close
relationship, and helping at least on sick/limited/frail family member or friend on a regular basis.
An item about assessing ongoing problems in the workplace was excluded from our analysis
since more than 60% of respondent are retired or out of the labor force.
We also created a stress appraisal scale by averaging across responses of how upsetting
each of the seven stressors was among respondents who experienced at least one stressor (range:
1-3; α=0.75). Respondents who reported exposure to a chronic stressor could rate that stressor as
1= not upsetting, 2= somewhat upsetting, or 3= very upsetting. Stress appraisal was
dichotomized as somewhat or very upsetting versus not upsetting when examined by domain.
Sociodemographic variables
73
Race/ethnicity was self reported and respondents were classified as non-Hispanic white,
non-Hispanic black, and Hispanic. We further differentiate between US born and foreign born
Hispanics as we expect stress experience may differ among Hispanics according to foreign born
status. We include sociodemographic and socioeconomic factors that might be related to
race/ethnic differences in stress exposure and appraisal. Age is measured as a continuous
variable in years. Gender was dichotomized as male or female. Educational attainment was
measured using number of years of completed schooling. Employment status was categorized as
currently employed either full or part time, unemployed/not in the labor force, and retired. Total
household income is log transformed and wealth (assets minus debts) is quartiled because these
variables were highly skewed. Marital status was categorized as married/partnered,
divorced/separated, widowed, and never married.
Analytic Strategy
We first used OLS regression models to examine 1) race/ethnic differences in anxiety, 2)
the predictive capacity of stress exposure on anxiety, and 3) adding an interaction term between
race/ethnicity and stress exposure in a three model progression. In the same three model
progression, we then examine race and stress appraisal, or how upsetting stress exposures are
among those who reported experiencing any stress exposure, as independent predictors of
anxiety and added an interaction term between race/ethnicity and appraisal. We then use the
same model progression for race, stress exposure and appraisal on depression. Finally, using chi
squared tests, we also examine race differences anxiety and depression for respondents who
reported domain specific stress exposure and reporting that stress domain as somewhat or very
upsetting. All analyses are weighted using the self-administered questionnaire sample weights,
which adjust for differential probability of selection and response rates and produce estimates
74
representative of the older U.S population. We account for the complex sample design using the
SVY suite of commands in Stata 13.1.
Results
Table 1 presents weighted demographic and socioeconomic characteristics for the full
sample and by race/ethnicity. The mean age in the sample was 66.4 (range: 54-104). Women
make up about 55% of the sample, 84% were white and the mean level of education was 13.2
years (range: 0-17). The mean logged household income for the sample was 10.7 and the wealth
distribution of the sample is similar to and reflects its majority white composition. Nearly 56%
were retired and 68% were married or partnered. When looking at the sample characteristics by
race/ethnicity, whites on average were older, more educated, and had higher incomes and wealth
than their black counterparts. On average, blacks had a higher level of ongoing chronic stress
exposure (2.7) relative to whites (2.1), but they also had a lower average stress appraisal (1.6) or
considered their stress as less upsetting than their white peers (1.7). Blacks, however, did have
higher average anxiety and depressive symptomology than their white peers but these differences
weren’t significant.
To determine race/ethnic, stress exposure, and appraisal differences in anxiety, Table 2
shows results from OLS regression models. First, Model 1 shows race/ethnicity and chronic
stress exposure independently predicting anxiety after adjusting for age and gender. To
determine if SES or demographic measures account for race/ethnic or stress exposure differences
in anxiety, Model 2 adds education, income, wealth, employment and marital status. Model 3
adds an interaction between race/ethnicity and stress exposure to examine if differences in
anxiety symptoms vary by race and exposure to stressors. Results show that higher chronic stress
exposure is positively linked to anxiety symptoms (Model 1: β =0.14, SE=0.01; p<0.001) and
75
blacks report more anxiety symptoms compared to whites (Model 1: β =0.11, SE=0.03; p<0.001)
when controlling for age and gender. After adjusting for SES and demographic measures, results
remain stable for chronic stress exposure (Model 2: β =0.13, SE=0.00; p<0.001) while black-
white differences in anxiety are attenuated (Model 2: β =1.26, SE=0.04; p<0.001). Model 3
shows race/ethnic and stress exposure interactions are not significant in fully adjusted models
(Model 3: β =0.03, SE=0.01; p>0.05). Figure 1 graphs the interaction from model 3 showing
race/ethnic differences in anxiety by the number of stress exposures. In general, anxiety
symptoms increase with the number of reported chronic stress exposures. Yet, while blacks have
more chronic stress exposure and more anxiety symptoms, there is not a significant difference in
anxiety symptoms for blacks with increases in stress exposure.
Table 2 also shows the same three model progression in predicting anxiety symptoms, but
now we examine stress appraisal, adjusting for total chronic stress exposure. Results show that,
on average, stress appraisal is positively associated with anxiety symptoms (Model 1: β =0.19,
SE=0.02; p<0.001) net of chronic stress exposure and results are robust after adjusting for
sociodemographic measures in model 2 (Model 2: β =0.18, SE=0.02; p<0.001). However, Model
3 shows that the race by stress appraisal interaction was not significant suggesting increases in
anxiety symptoms with higher levels of stress appraisal are not different for whites and blacks.
Figure 2 graphs the interactions, showing race/ethnic differences in anxiety by stress appraisal or
considering stress not upsetting, somewhat or very upsetting. As stress appraisal increases, the
black-white differences in anxiety symptoms increase but these differences were not significant.
Next we examined race/ethnic, stress exposure and appraisal differences in depressive
symptoms in Table 3 using the same model progression. Model 1 shows that chronic stress
exposure is positively associated with depressive symptoms (Model 1: β =0.36, SE=0.02;
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p<0.001) and blacks report higher levels of depressive symptoms compared to whites (Model 1:
β =0.53, SE=0.10; p<0.001). After adjusting for our demographic and SES measures, chronic
stress exposure remains robust (Model 2: β =0.32, SE=0.02; p<0.001) and race differences were
attenuated (Model 2: β =0.11, SE=0.09). Model 3 shows the race and chronic stress exposure
interaction is not significant (Model 3: β =0.05, SE=0.06) and Figure 3 graphs the interaction
term suggesting race differences in depressive symptoms increases with the number of stress
exposures, yet those differences were not significant.
Table 4 also shows OLS models predicting depression by race and stress appraisal,
adjusting for chronic stress exposure. Model 1 demonstrates, similar to our findings on anxiety,
that appraisal is significantly associated with depressive symptoms (Model 1: β =0.84, SE=0.05;
p<0.001) and older blacks report more depressive symptoms relative to whites (Model 1: β =0.59,
SE=0.11; p<0.001). Model 2 shows race (Model 2: β =0.18, SE=0.09; p<0.05) and stress
appraisal (Model 2: β =0.80, SE=0.05; p<0.001) differences in depressive symptoms persist after
adjusting for SES and demographic measures. Different from our findings on anxiety, Model 3
shows that the race by stress appraisal interaction is significant (Model 3: β =0.43, SE=0.16;
p<0.01). Figure 4 graphs the interaction from model 3 showing black-white differences in
depressive symptoms increases with higher stress appraisal or considering stress exposure
somewhat or very upsetting. Whites who reported chronic stress exposure as somewhat upsetting
reported an average of about 1.7 depressive symptoms in fully adjusted models while blacks who
consider their stress exposure as somewhat upsetting reported an average of 2.1 depressive
symptoms. This gap in depressive symptoms increased for those who considered their stress very
upsetting since blacks report an average of 3.3 depressive symptoms while whites reported an
average of 2.5 in fully adjusted models.
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Finally, we examined mean anxiety and depressive symptoms by chronic stress domain
for whites and blacks separately to determine what types of stressors are associated with high
levels of anxiety and/or depression. We present mean anxiety and depressive symptoms for those
who report being exposed to the stressor and for those who report the stressor as somewhat/very
upsetting (versus considering it not upsetting). Overall, blacks report more anxiety and
depressive symptoms with exposure to financial and residential strain. Similarly, blacks who
considered financial and residential stressors as somewhat or very upsetting reported
significantly more anxiety and depressive symptoms than their white peers. Additionally, blacks
who considered caregiving as an upsetting stressors reported more anxiety and depressive
symptomology.
Discussion
This the first study to examine race differences in chronic stress exposure and appraisal in
connection with mental health in a diverse sample of older adults. Most empirical evidence only
focuses on race differences in stress exposure, however this paper is innovative in that it provides
a more nuanced understanding of how race differences in the appraisal of ongoing chronic
stressors uniquely contribute to national differences in anxiety and depressive symptoms among
older adults. It is also the first study to disentangle the type or domain of chronic stressor(s) that
are most consequential for mental health outcomes. Consistent with prior research, we found that
stress exposure is an important predictor of both anxiety and depressive symptoms for older
adults. This seemed to be a dose response effect, demonstrating that as stress exposure increased
so did anxiety and depressive symptoms for older blacks and whites. Blacks reported more
chronic stress exposure and, as a result, report more anxiety and depressive symptoms, yet the
interaction between race and stress exposure was not significant suggesting that stress exposure
78
operates similarly for blacks and whites where both groups exhibit more anxiety and depressive
symptoms when they are exposed to more chronic stress. Thus, being exposed to chronic stress
is one mechanism contributing to anxiety and depressive symptoms in older adulthood.
Findings also show that appraisal is an important predictor of mental health in older
adulthood, even when controlling for chronic stress exposure. Chronic stress appraisal
significantly predicted anxiety and depressive symptoms for both blacks and whites. While
blacks appraise their stress as less upsetting compared to whites, race and stress appraisal
interactions show that stress appraisal does not operate differently for whites and blacks in
predicting anxiety symptoms. However, stress appraisal may operate more strongly among
blacks in its impact on depressive symptoms. Race and stress appraisal interactions show that
when blacks rate their stress as not upsetting they report fewer depressive symptoms than whites.
Comparatively, when blacks consider their stress exposure as either somewhat or very upsetting
they report significantly more depressive symptoms relative to whites. At the largest gap, blacks
report an average of 3.3 depressive symptoms if stress is very upsetting while whites reported an
average of 2.5 depressive symptoms, after adjusting for SES and demographic measures. Thus,
older blacks may be protected from the negative mental health effects of chronic strain when
they consider it not upsetting but be more vulnerable when they consider their strain either
somewhat or very upsetting relative to whites.
When examining exposure and appraisal by chronic stress domain, we found that, in
general, those who report experiencing any stress exposure reported lower average anxiety and
depressive symptomology than those who reported stress exposure and considered it upsetting
across all domains. Additionally, there were important Black-white differences in depressive and
anxiety symptomology. First, blacks exposed to financial strain report significantly higher
79
depressive symptomology than whites who report financial strain. Similarly, blacks exposed to
residential strain report both higher anxiety and depressive symptoms relative to whites. In
considering appraisal, blacks who considered finical strain upsetting reported both more anxiety
and depressive symptoms than whites who considered it upsetting. The same was true of
residential and caregiving strain. This potentially reflects the fact that older blacks who report
exposure to financial, residential, and caregiving strain are experiencing this strain at a greater
severity, resulting in worse mental health outcomes. It may also reflect the fact that when blacks
consider their stress as upsetting it has more severe or adverse implications for their mental
health outcomes. The vulnerability hypothesis suggests blacks may be more susceptible to the
effects of stress since they have few resources to buffer the negative effects of stress on health.
Thus, this evidence seems to support the hypotheses that blacks are more vulnerable to the
deleterious mental health effects of financial, residential, and caregiving strain.
This paper is novel in building a case for stress appraisal as an understudied but
important predictor of mental health in older adulthood. This is especially the case for older
blacks whom consider chronic stress as somewhat or very upsetting since they report higher
depressive symptoms regardless of age, gender, SES, or marital status. These findings suggest
chronic stress exposure and appraisal processes independently contribute to mental health
outcomes in blacks and whites and they may also have implications for the black-white mental
health paradox. The paradox, or the finding that, in general, blacks tend to have similar or better
mental health than whites, may be the result of blacks appraising their stress as less upsetting to
reduce the chronic stressors impact on mental health. Blacks maybe actively coping with stress
exposure, resulting in generally lower stress appraisal (Brown et al., 2018) and as a result, fewer
anxiety and depressive symptoms comparted to whites.
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One hypothesis that has emerged in the literature to explain the black-white paradox in
mental health is access to racially salient positive resources (i.e. religiosity, social support, racial
identity) that may buffer the effects of stress on health. Although recent studies suggest that
neither religious involvement nor family relationships (Mouzon, 2017) nor relationships of
choice (Mouzon, 2010) appear to serve as positive coping mechanisms to explain the black–
white paradox in mental health, it is highly plausible that given a prolonged history of
marginalization, blacks have developed other positive coping mechanisms that may account for
their apparent emotional resilience. That is, when blacks do not consider things stressful that
have generally thought to be stressful, they may be using positive coping resources and as a
result show less mental health symptomology. Someone who was able to cope with a stressor
may report perceiving it as less severe upon reflection even if it was an intense stressor at the
time of the experience. Importantly, these hypotheses engage race specific stress coping
mechanisms that are important to consider when trying to better understand the black-white
paradox in health.
This study has a few limitations in the way we measure and conceptualize stress exposure
and appraisal. First, while we use a measure of appraisal that has been utilized in other studies
(Aldwin et al., 1996), the retrospective timing in which the questions are asked require
respondents to report the stressfulness of these ongoing chronic situations, even if it isn’t
impacting them in that moment. Individuals may be reporting stress exposure from the past 12
months but at the point of the interview maybe feeling less bothered by the stressor. Thus,
respondents are relying on memory to report their stress response. Additionally, selective
mortality among blacks and foreign born Hispanics may mean we have a select group of
individuals who cope well or who respond well to stressors and may be more likely to survive to
81
old age. Importantly, we are measuring chronic stress cross-sectionally when the relationship
between race/ethnicity, stress exposure and appraisal and mental health may vary over time.
Finally, in measuring the “stress universe,” it would be appropriate to note the importance of
including a wider array of race based or related stressors (e.g., vicarious discrimination,
incarceration, intersectional stressors) in future research on race/ethnic differences in the stress
processes.
This paper addresses key methodological issues in the stress and health disparities
research by developing a stress and health model that more accurately depicts the stress
experience for minority groups. Importantly, we consider both chronic stress exposure and
appraisal as principal mechanism that impact race/ethnic health disparities. This work uses a
multidisciplinary framework and builds on the stress process model (McLeod, 2012; Pearlin et
al., 1981; Thoits, 2010), to more carefully map social stress mechanisms that link race/ethnicity
to mental health disparities. Whether a person perceives a situation as a threat is crucial in
determining the mental health consequences of stress. The ability to adjust, habituate, or cope to
repeated stress may also be determined by the way one perceives a situation (McEwen, 1998).
Social determinants of mental health are interconnected systems of stratification by
race/ethnicity that often also shape stress exposure and appraisals, yet appraisal processes can
mitigate or exaggerate the mental health impacts of chronic stress exposure.

82
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87

Full Sample Whites Blacks
(n=5,764) (n=4,991) (n=773) Chi2
% % %
Age [mean(SE)] 66.4(0.3) 66.7(0.3) 64.5(0.5) 73.8***
Female 54.7 54.0 60.9 9.0**
Education [mean(SE)] 13.2(0.0) 13.3(0.1) 11.7(0.2) 4.9*
HH Income [mean(SE)] 10.7(0.0) 10.8(0.0) 10.0(0.1) 4.2*
HH Wealth 96.7***
1st quartile 22.0 18.5 55.6
2nd quartile 25.1 25.0 26.3
3rd quartile 25.9 27.3 11.8
4th quartile 27.0 29.2 6.3
Employment Status 5.4**
Currently Employed 34.8 35.1 31.9
Retired 55.7 55.9 53.9
Not in the Labor Force 9.5 9.0 14.2
Marital Status 31.5***
Married 68.4 70.5 48.8
Divorced/Separated 12.0 10.9 22.4
Widowed 16.5 15.9 22.5
Never Married 3.1 2.8 6.4
Stress Exposure [mean(SE)] 2.2(0.0) 2.1(0.0) 2.7(0.1) 1.2
Stress Appraisal [mean(SE)]a 1.7(0.0) 1.7(0.0) 1.6(0.0) 29.2***
Anxiety Symptoms [mean(SE)] 1.6(0.0) 1.5(0.0) 1.7(0.0) 2.3
Depressive Symptoms [mean(SE)] 1.4(0.0) 1.3(0.0) 2.0(0.1) 0.1
+p<0.10 *p<0.05 **p<0.01 ***p<0.001
Note: HH income is logged
a Among those who reported any stress exposure (n= 4,846)
Table 1. Weighted descriptive statistics for the full sample and by race/ethnicity, Health
and Retirement Study, 2006
88

Independent Variables
β SE β SE β SE β SE β SE β SE
Chronic stress exposure (0-7) 0.14 0.01 *** 0.13 0.00 *** 0.13 0.00 *** *** 0.14 0.01 *** 0.13 0.01 *** 0.13 0.01 ***
Race/Ethnicity (ref=white)
Black 0.11 0.03 *** 0.04 0.03 -0.04 0.05 0.15 0.03 *** 0.07 0.03 * -0.04 0.09
Race/Ethnicity X exposure
Black X exposure 0.03 0.01 +
Stress Appraisal (1-3) 0.19 0.02 *** 0.19 0.02 *** 0.18 0.02 ***
Race/Ethnicity X appraisal
Black X appraisal 0.07 0.06
Age 0.00 0.00 *** 0.00 0.00 0.00 0.00 0.00 0.00 *** 0.00 0.00 0.00 0.00
Female 0.06 0.02 *** 0.04 0.02 * 0.04 0.02 * 0.04 0.02 ** 0.02 0.02 0.02 0.02
Education -0.02 0.00 *** -0.02 0.00 *** -0.02 0.00 *** -0.02 0.00 ***
HH Income -0.01 0.01 -0.01 0.01 -0.01 0.01 -0.01 0.01
HH Wealth (ref=1st quartile)
2nd quartile -0.05 0.02 * -0.05 0.02 * -0.05 0.03 + -0.04 0.03 +
3rd quartile -0.06 0.02 * -0.06 0.02 * -0.06 0.02 * -0.06 0.02 *
4th quartile -0.07 0.03 ** -0.08 0.03 ** -0.08 0.03 ** -0.07 0.03 **
Employment Status (ref=employed)
Retired 0.10 0.03 ** 0.09 0.03 ** 0.10 0.04 * 0.09 0.04 *
Not in labor force 0.05 0.02 * 0.05 0.02 * 0.05 0.02 * 0.05 0.02 *
Marital Status (ref=married)
Divorced/Separated 0.01 0.03 0.00 0.03 -0.01 0.03 -0.01 0.03
Widowed 0.04 0.02 + 0.05 0.02 + 0.03 0.03 0.04 0.03
Never Married 0.06 0.06 0.06 0.06 0.08 0.07 0.08 0.07
Intercept 0.95 0.05 *** 1.62 0.11 *** 1.63 0.11 *** 0.57 0.07 *** 1.27 0.12 *** 1.28 0.12 ***
+p<0.10 *p<0.05 **p<0.01 ***p<0.001
Model 3
(+interaction)
Table 2. Regression models predicting anxiety symptoms, Health and Retirement Study, 2006
Model 1 Model 2 Model 1
Stress Exposure (n=5,764)
Model 2
Model 3
(+interaction)
Stress Appraisal (n=4,846)
89
Figure 1. Predicted means of anxiety symptoms by race and stress exposure from fully adjusted
models

90
Figure 2. Predicted means of anxiety symptoms by race and stress appraisal from fully adjusted
models

2.5
2
"'
E
1.5
0
....
Q.
E
>
11'1
>
....
41
·;c
1
c
<(
0.5
0
Not Upsetting Somewhat Upsetting
Stress Appraisal
• White
• Black
Very Upsetting
91

Independent Variables
β SE β SE β SE β SE β SE β SE
Chronic stress exposure (0-7) 0.36 0.02 *** 0.32 0.02 *** 0.32 0.02 *** 0.32 0.03 *** 0.28 0.03 *** 0.28 0.03 ***
Race/Ethnicity (ref=white)
Black 0.53 0.10 *** 0.11 0.09 -0.02 0.16 0.59 0.11 *** 0.18 0.09 * -0.52 0.24 *
Race/Ethnicity X exposure
Black X exposure 0.05 0.06
Stress Appraisal (1-3) 0.84 0.05 *** 0.80 0.05 *** 0.76 0.05 ***
Race/Ethnicity X appraisal
Black X appraisal 0.43 0.16 **
Age 0.01 0.00 *** -0.01 0.00 -0.01 0.00 0.02 0.00 *** 0.00 0.00 0.00 0.00
Female 0.25 0.05 *** 0.03 0.05 0.03 0.05 0.15 0.05 ** -0.04 0.05 -0.03 0.05
Education -0.08 0.01 *** -0.08 0.01 *** -0.08 0.01 *** -0.08 0.01 ***
HH Income -0.06 0.04 -0.06 0.04 -0.05 0.04 -0.05 0.04
HH Wealth (ref=1st quartile)
2nd quartile -0.21 0.11 + -0.21 0.11 + -0.19 0.11 + -0.18 0.11
3rd quartile -0.19 0.10 + -0.19 0.10 + -0.18 0.11 -0.17 0.11
4th quartile -0.29 0.10 ** -0.29 0.10 ** -0.31 0.09 ** -0.30 0.09 **
Employment Status (ref=employed)
Retired 0.58 0.13 *** 0.58 0.13 *** 0.56 0.15 *** 0.54 0.15 ***
Not in labor force 0.25 0.07 *** 0.25 0.07 *** 0.24 0.07 ** 0.24 0.07 **
Marital Status (ref=married)
Divorced/Separated 0.51 0.10 *** 0.51 0.10 *** 0.47 0.10 *** 0.47 0.10 ***
Widowed 0.60 0.08 *** 0.60 0.08 *** 0.56 0.09 *** 0.56 0.09 ***
Never Married 0.61 0.23 *** 0.61 0.23 *** 0.65 0.24 ** 0.65 0.24 **
Intercept -0.57 0.20 ** 2.43 0.44 *** 2.46 0.44 *** -1.94 0.19 *** 1.06 0.43 * * 1.11 0.43 *
+p<0.10 *p<0.05 **p<0.01 ***p<0.001
Model 3
(+interaction)
Table 3. Regression models predicting depressive symptoms, Health and Retirement Study, 2006
Stress Exposure (n=5,764)
Model 1 Model 2
Model 3
(+interaction) Model 1 Model 2
Stress Appraisal (n=4,846)
92
Figure 3. Predicted means of depressive symptoms by race and stress exposure from fully
adjusted models

3.5
3
2.5
Ill
E
.....
0
Q.
2
E
>
11'1
41
• White >
'iii
Ill
1.5
41
• Black
...
Q.
41
0
1
0.5
0
0 1 2 3 4 5 6 7
Stress Exposure
93
Figure 4. Predicted means of depressive symptoms by race and stress appraisal from fully
adjusted models

3.5
3
2.5
Ill
E
0
.....
Q.
2
E
>
11'1
41
>
'iii
Ill
1.5
41
....
Q.
41
0
1
0.5
0
Not Upsetting Somewhat Upsetting
Stress Appraisal
• White
• Black
Very Upsetting
94

White Black χ
2
White Black χ
2
mean(SE) mean(SE) mean(SE) mean(SE)
Health
Exposed 1.6(0.0) 1.9(0.0) 0 1.6(0.0) 2.5(0.1) 0
Upseta 1.8(0.0) 2.0(0.1) 0.3 2.1(0.1) 3.1(0.2) 0.24
Financial
Exposed 1.7(0.0) 1.9(0.0) 1.6 1.8(0.1) 2.4(0.2) 5.2*
Upseta 1.9(0.0) 2.1(0.0) 8.3** 2.3(0.1) 3.1(0.2) 5.9*
Residential
Exposed 2.0(0.0) 2.1(0.1) 4.1* 2.7(0.2) 3.0(0.3) 6.1*
Upseta 2.1(0.1) 2.3(0.1) 4.4* 3.3(0.3) 3.5(0.5) 3.9*
Relationship
Exposed 1.7(0.0) 1.9(0.0) 0.6 1.6(0.0) 2.4(0.1) 1.2
Upseta 1.7(0.0) 2.0(0.0) 0.2 1.8(0.1) 2.8(0.2) 1.1
Caregiving
Exposed 1.6(0.0) 1.9(0.0) 0.2 1.4(0.1) 2.3(0.2) 0.2
Upseta 1.7(0.0) 1.9(0.1) 6.4* 1.8(0.1) 2.3(0.3) 3.4+
+p<0.10 *p<0.05 **p<0.01 ***p<0.001
a Among those who reported any stress exposure (n= 5,276)
Upset = Somewhat/very upset vs. not upset
Table 4. Mean anxiety and depressive syptoms by chronic stress exposure and stress
appraisal for whites and blacks, Health and Retirement Study, 2006 (n=5,764)
Anxiety Symptoms Depressive Symptoms
95
CHAPTER 4

Title: Race/Ethnic Disparities in Exposure to Chronic Stressors Varies by Age among Older
Adults

Authors:
Lauren Brown
1
, Jennifer Ailshire
1
1. Leonard Davis School of Gerontology, University of Southern California

Corresponding Author:
Lauren Brown, MPH

USC Davis School of Gerontology
University of Southern California
3715 McClintock Ave.
Los Angeles, CA 90089
Phone number: 951-990-4969
Email: laurenlb@usc.edu

96
Abstract
Chronic stress exposure may vary across the older adult life course. Prior research has
suggested stress exposure declines with age yet racial/ethnic minorities tend to report more stress
exposure than whites. Stress exposure is linked to physical and mental health disparities making
it important to investigate age differences in the race/ethnic disparity in chronic stress exposure
among older adults. We examine age variation in race/ethnic differences in the number of
reported chronic stressors in six key domains: health, financial, residential, employment,
relationship, and caregiving. Data come from 6,593 white, black, US and foreign born Hispanic
adults age 54+ from the psychosocial subsample of the 2006 Health and Retirement Study.
Multivariate results show fewer chronic stressors are reported by adults 70+ compared to adults
54-69 years (β=-0.18, p<0.001). Blacks (β=0.23, p<0.001) and foreign born Hispanics (β=0.13,
p<0.01) report higher chronic stress burdens than whites. Age and race interactions show that
total stress burden is lower among older whites age 70+ compared to younger white adults.
Domain specific results show older whites report less exposure to every domain of stress
exposure except for health problems after age 70. Blacks report similar amounts of stress after
age 70 with the exception that they report less employment strain (8.3% CI: 5.5, 11.2) than
younger blacks. Results were similar after adjustment for sociodemographic characteristics.
Hispanic groups report similar stress burdens as whites after adjusting for SES, despite reporting
double the exposure to financial strain after age 70 compared to their same aged white peers.
Thus, race/ethnic disparities in stress may reflect differential experiences of age-related declines
in chronic stress exposure.

97
Introduction
Prior research and theory have suggested that older adults are exposed to fewer stressors
than younger adults (Turner, Wheaton, & Lloyd, 1995). Most of this research is based on older
adults reporting a decrease in stressful life events—for example, the risk of job loss or divorce
(Vasunilashorn, Lynch, Glei, Weinstein, & Goldman, 2014). Older adults may no longer
experience stress related to the loss or transition out of roles related to work, retirement, and
adult children’s departure from the home of in later life (Rauschenbach, Krumm, Thielgen, &
Hertel, 2013). However, stress in these studies is often measured using a count of acute or event
based stress exposures. This approach to conceptualizing stress exposure as event based or
episodic in older adulthood ignores a more pervasive form of stress that is likely more
consequential for the health of elderly populations. Chronic stressors are ongoing and last for an
unforeseen amount of time, posing severe threats for the health and wellbeing of older adults
since they may have access to fewer coping resources and may not biologically or
psychologically adapt to chronic stress (Herbert & Cohen, 1993; Thoits, 2010). Prior studies of
event based stress exposure among older adults are particularly problematic since they primarily
evaluate the stress experience of older whites. However, older blacks and Hispanics report higher
levels of stress, including exposure to chronic stressors, relative to whites(L. Brown L., Mitchell,
& Ailshire, 2018), one major pathway contributing to race/ethnic mental and physical health
disparities. Thus, research showing declines in event based stress among older whites may not
capture the stress experience for older racial/ethnic minority populations. Chronic stress
exposure may vary across the older adult life course for different race/ethnic subgroups making it
important to investigate age differences in the race/ethnic disparity of chronic stress exposure
among older adults.
98
Background
Due to transitions and role changes like retirement and access to old age safety nets like
Social Security and Medicare, older adults are thought to be less inclined to experience stressors
than young adults, especially those that characterize the work environment (Turner et al., 1995).
In parallel, older adults may no longer have parental responsibilities once adult children become
independent. Yet, older adults are not just passively exposed to fewer stressors as the result of
age related transitions. According to socioemotional selectivity theory, they are thought to
strategize to decrease stress burden and to avoid or limit stress exposure due to age-related
advantages in emotional intelligence and emotional regulation strategies (Charles & Carstensen,
2010; E. Chen & Matthews, 2001; Chen, Peng, Xu, & O’Brien, 2018; Löckenhoff & Carstensen,
2004; Sliter, Chen, Withrow, & Sliter, 2013). Based on their accumulated life experience, or
wisdom, older adults may be able to actively avoid exposure to situations that elicit a stress
response (Blanchard-Fields, Chen, & Norris, 1997; Blanchard-Fields, 2007). The life span
literature theorizes that as people grow older, they have fewer problems in their close
relationships, purposefully reducing contact with acquaintances as a means of decreasing the
likelihood of negative encounters. As a result of role transitions and actively avoiding stress
exposure, it is commonly held that older adults are exposed to less stress than younger adults.
“Stress” in this context refers to any threat or challenge to homeostasis (McEwen, 2013),
yet these studies examining age differences in stress mostly rely on life events or checklists when
stress really includes a broad range and type of exposures. This conceptualization of stress as
acute or event based, while easy to measure, functions as incomplete measures of the spectrum
of stress exposures. Chronic and ongoing stressors are critical in conceptualizing the ‘stress
universe’ among older adults. When older adults cannot avoid or circumvent stressful situations
99
(e.g., chronic health problems), they are often shown to suffer from worse physical and mental
health consequences than younger adults due to increased physiological vulnerabilities and few
resources to buffer the effects of these exposures (Charles & Carstensen, 2010). Investigating
chronic stress may offer important insights into the lived experiences of older adult populations
since chronic stress can act as background or ambient strain that characterizes or is embedded in
living, economic, and family environments (Baum, Garofalo, & Yali, 1999).
Evidence and theory showing that fewer stressors are experienced at older ages is also
limited in that it has mostly been shown among white populations. However, this experience of a
decline in stress exposure with age may be unique to white populations and may not apply
universally to racial/ethnic subgroups. Critiques of the stress literature have also emphasized that
the current approaches to the assessment of stress are not comprehensive and do not capture
some of the stressful life experiences of poor populations in general and racial minority
populations in particular (Aneshensel, 1992). Older minorities are more likely to still be working
and have less access to pensions, savings or to resources that might protect from chronic stress
exposure in older adulthood. The differential exposure hypothesis posits that racial/ethnic
minorities, and blacks in particular, look worse on major health outcomes since they are exposed
to greater levels of stress (G. W. Brown & Harris, 1978; Kessler, 1979). Similarly, the stress
process model suggests social and economic stratification, including race/ethnicity and
socioeconomic status, result in varying exposure to stressors which explain population
differences in health (Pearlin, 1989). Empirical research has demonstrated that the degree to
which individuals are exposed to a set of objective life stressors, including chronic strains, is
patterned by their race/ethnicity (Sternthal, Slopen, & Williams, 2011; Thoits, 2010; Turner &
Avison, 2003). In addition, race/ethnic disparities in social, material and personal resources that
100
may help buffer or avert stress exposure in old age for whites, may contribute to higher stress
burdens for minorities in old age.
Folkman and Lazarus (1980) hold a contextual theory of aging and propose that it is not
that stress exposure declines in older adulthood, but that different types of stressors are
encountered as individuals age which may be more relevant for older minority groups. Some
studies have found that, at least for certain types of stressors, older adults generally experience
an increase in exposure. In particular, events involving death and illness of spouses, children, and
peers occur with increasing frequency, as one might expect because of loss-related events
associated with aging (George & Lynch, 2003). Older adults may have lower levels of exposure
to work-related stress yet report more health-related stressors. An individual’s position and social
stratification in the adult life course is an additional intersection that must be considered in
examining changes in stress exposure with age. Cumulative disadvantage theory posits that a
lifetime of education, income, and wealth differences between blacks and whites produce larger
differences in socioeconomic status (SES) at the end of life. Racial residential segregation is a
prime example of a societal structure that importantly restricts socioeconomic opportunity and
mobility (Massey, 1993) that likely follows racial/ethnic minorities into older adulthood,
differentially patterning their stress exposure in old age. Thus, while older minorities may report
less work-related stress exposure, it does not protect them from the cumulative effects of
disadvantage that would expose them to a disproportionate stress burden, especially financial and
housing strain, that likely do not disappear at end of life.
Chronic stressors, especially for older minority communities, tend to surface within
major social domains such as financial stability, employment and family, all of which are of vital
importance to both the larger society and individuals (Pearlin, Schieman, Fazio, & Meersman,
101
2005). Chronic financial strain may be a particularly pertinent domain of stress for
racial/ethnically diverse older adults because most live on fixed incomes that they often find to
be insufficient, with less access to personal wealth, pensions or savings (Keister, 2000). Critical
and chronically stressful life domains, like financial and housing instability, that cannot be easily
remedied, particularly in old age, denote opportunities for intervention, outreach, and social
supports. Understanding the race/ethnic patterning of chronic stress across major life domains in
older adulthood may be central to prevention and mediation efforts since chronic stress burdens
are likely charting how life course trajectories and health of minority groups come to differ in old
age (Pearlin, 2010) . Thus, we aim to examine the age patterning of race/ethnic differences in
stress exposure and aim to identify the stress domains most salient to minority populations whose
stress experiences may be unique in older adulthood.
This paper will examine the varying experience of chronic stress with age for white,
black, US and foreign born Hispanic older adults. Specifically, we examine age differences in
total chronic stress burden among race/ethnic subgroups for older adults less than 70 years old
and those 70+. Importantly, we also investigate race/ethnic and age variation across six different
domains of chronic stress: health, financial, residential, employment, relationship, and caregiving.
Based on socioemotional selectivity theories of aging, we expect reports of chronic stress
exposure to decline with age. However, based on the differential stress exposure hypothesis, we
expect racial/ethnic minorities, specifically black and both Hispanic subgroups, will report
experiencing more ongoing chronic stressors across all domains in older adulthood relative to
their white peers and will also report less decline in chronic stress exposure with age.

102
Methods
Data come from the nationally representative Health and Retirement Study (HRS), an
ongoing biennial study of U.S. adults age 51 and older that began in 1992 with the aim of
improving our understanding of the social, economic, environmental, and behavioral factors
associated with aging and the health of older adults. In 2006, the HRS began collecting data on
chronic stress using a self-administered questionnaire (SAQ) given to a random half-sample of
non-institutionalized respondents who were selected for a face-to-face interview. The SAQ had a
90% completion rate, leaving 6,865 cohort eligible SAQ respondents (Smith et al., 2013). We
excluded 122 respondents who did not identify as white, black or Hispanic. Finally, 150
respondents were excluded who were missing on all chronic stress questions resulting in a final
analytic sample of 6,593 adults with complete data on all measures assessed.
Ongoing Chronic Stress
We measure total chronic stress exposure (Troxel, Matthews, Bromberger, & Sutton-
Tyrrell, 2003) using a count of the number of chronic stressors respondents reported
experiencing (range: 0-8) during the last twelve months or longer. We include the following
stressors based on respondents self reports (yes/no): ongoing health problems (in yourself),
physical or emotional problems (in spouse or child), problems with alcohol or drug use in family
member, problems in the workplace, financial strain, housing problems, problems in a close
relationship, and helping at least on sick/limited/frail family member or friend on a regular basis.
Sociodemographic variables
Race/ethnicity was self reported and respondents were classified as non-Hispanic white,
non-Hispanic black, and Hispanic. We further differentiate between US born and foreign born
Hispanics as we expect stress experience may differ among Hispanics according to foreign born
103
status. We include sociodemographic and socioeconomic factors that might be related to
race/ethnic differences in stress exposure and appraisal. Age is measured in years and
categorized into two groups: 54-69 and 70+. Gender was dichotomized as male or female.
Respondents were categorized as either foreign born or US born. Educational attainment was
measured using number of years of completed schooling and dichotomized as high school degree
or less (less than 12 years) and some college or higher (13 or more years). Employment status
was categorized as currently employed either full or part time, unemployed/not in the labor force,
and retired. Total household income and wealth (assets minus debts) is categorized into quartiles
because these variables were highly skewed. Marital status was categorized as married/partnered,
divorced/separated, widowed, and never married.
Analytic Strategy
We first determined the average total chronic stress burden and prevalence of stress
exposure within each of the five domains by race/ethnicity and age. Next, we used Poisson
regression models to examine age and race/ethnic differences in total chronic stress burden. To
examine if age differences in chronic stress burden varied by race/ethnicity we added
race/ethnicity and age interactions. We then include, in a subsequent model, social and economic
characteristics to determine whether race/ethnic and age differences are attributed to other factors
related to chronic stress exposure. Using estimates from fully adjusted model, we graph mean
chronic stress burden for each race/ethnic group before and after age 70. We also examined
race/ethnic and age differences in stress exposure across chronic stress domains using logistic
models. All analyses are weighted using the self-administered questionnaire sample weights,
which adjust for differential probability of selection and response rates and produce estimates
104
representative of the older U.S population. We account for the complex sample design using the
SVY suite of commands in Stata 13.1.
Results
Table 1 presents weighted demographic and socioeconomic characteristics for the full
sample and by race/ethnicity. Around 65% of the sample was 54-69 years of age while 35% were
70+ (range: 54-104). Women make up about 55% of the sample, 84% were white and 53% had
the equivalent of a high school diploma or less education. Nearly 55% of the sample were retired
and 68% were married or partnered. When looking at the sample characteristics by race/ethnicity,
whites on average were older, more educated, and had higher incomes and wealth than their
black, foreign born, and US Hispanic counterparts. Whites and US born Hispanics were more
likely to be married than blacks and foreign born Hispanics. Nearly half of Hispanics in the
sample were foreign born and reported higher levels of unemployment than their white, black,
and US born Hispanic counterparts.
Table 2 shows the average total chronic stress burden and the prevalence of domain
specific stress exposure within each stress domain by race/ethnicity and age. There were
significant race/ethnic and age differences in total chronic stress burden. On average, younger
blacks ages 54-69 had the highest burden of ongoing chronic stress exposure (2.9) and older
whites and US born Hispanics ages 70+ had the lowest burden (1.9). Older blacks ages 70+ had a
comparatively high stress burden (2.7) relative to their 70+ aged peers and had higher stress
burdens than younger whites and US born Hispanics (ages 54-69). When examining the
prevalence of domain specific chronic stress exposure by race/ethnicity and age, older blacks
ages 70+ report around double the exposure to financial (53.5%), residential (24.7%), and
employment strain (8.0%) relative to their older 70+ white peers. Older US and Foreign born
105
Hispanics ages 70+ report less relationship strain relative to both their white and black
counterparts. And older US born Hispanics (70+) report less exposure to ongoing health
problems than their same aged white, black, and foreign born Hispanic peers.
We next assessed age differences in total chronic stress burden by race/ethnicity. Table 3
shows results from Poisson regression models. Model 1 includes age, race/ethnicity, and model 2
adds interactions between race/ethnicity and age adjusting for gender. To determine if SES or
demographic measures account for race/ethnic and age differences in total stress burden, Model
3 adds education, income, wealth, employment and marital status. Results from Model 1 show
that fewer stressors are reported by adults 70+ compared to the young-old (β=-0.23, SE=0.02;
p<0.001). Blacks (Model 1: β=0.22, SE=0.03; p<0.001) and foreign born Hispanics (Model 1:
β=0.12, SE=0.06; p<0.05) are more likely to report higher chronic stress burdens compared to
whites. Interactions between race/ethnicity and age suggest there is a black-white disparity in
chronic stress burden with age, noting significantly higher burdens for blacks ages 70+ (Model 2:
β=0.18, SE=0.06; p<0.01). Race/ethnic and age patterns in total chronic stress burden did not
differ between whites and US born Hispanics; the interaction between age and both foreign born
and US born Hispanic ethnicity was small and not statistically significant. After adjusting for
SES and demographic measures the black-white disparity remained stable and significant (β=
0.17; SE=0.06; p<0.01). The difference between whites and foreign born Hispanics found in
Model 1 diminished (Model 2: β= -0.02, SE= 0.07, p>0.05) after adjusting for income and
wealth.
To visualize the age patterning in total chronic stress burden by race/ethnicity, we plot
the predicted means from Model 3. Figure 1 demonstrates that among whites, there is a
significant decline in total chronic stress burden after age 70. This figure clearly shows that this
106
decline in total stress burden after age 70 only applies to whites. Blacks, both younger and older
than 70, report a similar chronic stress burden. There is a decline in stress after 70 for both
Hispanic subgroups but these differences are not significant. The relationship between
race/ethnicity and stress exposure may change with age, thus we did investigate four year change
in chronic stress exposure since one more wave of data were available, however, there was not a
significant amount of change in chronic stress burden in a four year window.
While we find that, overall, the decline in total chronic stress burdens after age 70 only
applies to older whites, we are interested in whether this lower burden after age 70 is due to less
likelihood of exposure across every domain or if specific domains are driving these age
differences. It is also equally important to examine the domains of stress that are persistent for
older minorities after age 70 where older whites are reporting declines in the same domains.
Thus, in Table 4, we examined separate models for each stress domain using logistic regression
that predicted the probability of reporting any ongoing chronic stress exposure by race/ethnicity
and age in health, financial, residential, employment, relationship and caregiving domains
adjusting for gender. White older adults report significantly less exposure across every domain of
chronic stress (financial, residential, employment, relationship and caregiving) except for
ongoing health problems. Conversely, older blacks report similar stress burdens after age 70 as
they do before age 70, with the exception that they report less exposure to employment strain
(8.3% CI: 5.5, 11.2) than their younger black counterparts (18%, CI: 13.7, 22.3). Older blacks
ages 70+ have a higher probability of reporting ongoing financial (53%, CI:45.6, 59.9),
residential (25%, CI:18.7, 30.3), employment (8.3%, CI: 5.5, 11.2) and relationship strain (51%,
CI: 43.6, 57.4 ) relative to their same aged 70+ white peers, all of which are likely driving the
overall black-white differences in total stress burden found in Table 3 (model 1). Younger blacks
107
ages 54-69 only reported more exposure relative to their aged matched white peers to ongoing
health problems.
When considering Hispanic subgroups, US born Hispanics reported similar total chronic
stress burdens relative to whites regardless of age. Yet when broken down by stress domain, US
born Hispanics did report significantly higher exposure to financial strain (41%, CI: 27.6, 53.3)
after age 70 relative to their aged matched white peers. US born Hispanics also reported some
decline in stress at older ages among two domains including less exposure to residential and
employment strain after aged 70 relative to their younger US born Hispanic counterparts.
Foreign born Hispanics, however, report an overall higher stress burden relative to whites before
controlling for SES measures, primarily driven by more exposure to health problems at ages 54-
69 (69%, CI: 60.5, 76.8) and financial strain both before (55%, CI: 43.5, 67.3) and after age 70
(44%, CI: 34.9, 53.9). Similar to blacks, foreign born Hispanics only report less exposure to
employment strain after age 70 (4%, CI: 0.3, 6.8) relative to their younger foreign born Hispanic
counterparts <70 (18%, CI: 8.4, 27.8).
Discussion
According to prior theory and evidence, older adults are generally thought to be exposed
to fewer stressors as they age. This paper investigating the race/ethnic variation in chronic stress
with age among older adults finds that lower stress burdens are reported by adults ages 70+
compared to the younger adults ages 54-69. We also find that both blacks and foreign born
Hispanics report higher chronic stress burdens than whites. However, age interactions show that
age related declines in total chronic stress burden after age 70 are only reported among whites.
Older blacks ages 70+ report similar chronic stress burdens as blacks 54-69 years old, while
older whites ages 70+ are reporting less chronic stress exposure. Importantly, total stress burden
108
is similar among blacks and whites ages 54-69, suggesting that race/ethnic differences in chronic
stress exposure are actually driven by black-white differences at older ages. Consistent with
cumulative disadvantage theory, older blacks 70+ are subject to aggregate effects of structural
and societal inequities including segregation, unequal educational attainment, longer periods of
unemployment and underemployment, lower wages, pensions, and accumulation of wealth over
the life course (Landrine & Corral, 2009; Williams, Mohammed, Leavell, & Collins, 2010).
Older blacks are not beneficiaries of the age related declines in chronic stress exposure originally
postulated by stress research and shown here among whites. These findings add to our
understanding of the importance of persistent stress, especially among older blacks, and their
contribution to race/ethnic differences in stress exposure.
Prior stress theory put forward by Folkman and Lazarus (Folkman & Lazarus, 1980) has
suggested that older adults might not experience an overall decline in stress exposure but that
different types of stressors are encountered with age. In probing the black-white disparities in
chronic stress at older ages, we found that investigating domain specific changes in chronic
stress paint a more complex story of changes in stress exposure with age. White older adults
report significantly less exposure across every domain of chronic stress including financial,
residential, employment, relationship and caregiving strain; except they report stable exposure to
ongoing health problems. Older blacks, however, report similar stress burdens after age 70 as
they do before age 70, with the exception that they report less exposure to employment strain
than their younger black counterparts. Compared to their same aged white peers, older blacks
ages 70+ have a higher probability of reporting ongoing financial, residential, employment and
relationship strain, all of which are driving the overall black-white differences in total stress
burden. At a time when social roles are shifting and economic opportunity dwindles, black elders
109
over 70 are still faced with financial and housing instability at similar rates as younger blacks
who may be better positioned to work and alleviate these types of strains. Some researchers have
argued that physiological changes in health combined with cultural and social changes in older
adulthood (e.g., retirement) may erode existing psychological coping resources (e.g., feelings of
self-mastery) as well as financial resources to deal with chronic strains like housing insecurity.
As their physical and psychological resources decline, older blacks may become more vulnerable
to the effects of chronic life strains that persist well into older adulthood (Geronimus, Hicken,
Keene, & Bound, 2006; Turner & Avison, 2003). Race/ethnic differences in chronic stress
exposure across different domains in old age may shed light on critical pathways that
differentially contribute to race/ethnic physical and mental health disparities, inform intervention
efforts aimed at alleviating race/ethnic differences in stress exposure at the end of life, and help
inform our theoretical models that link race/ethnicity and age to stress exposure.
In examining Hispanic subgroups, total chronic stress burden appears very similar
between foreign born and US born Hispanics. Yet, disaggregating these two groups by age and
chronic stress domain reveal intergroup variability that demonstrate these groups have
considerably different chronic stress experiences. US born Hispanics, overall, had similar
chronic stress burdens relative to whites after adjusting for SES characteristics despite reporting
double the exposure to financial strain after age 70 compared to their same aged white peers. US
born Hispanics reported some decline in stress at older ages among two domains including less
exposure to residential and employment strain after aged 70 relative to their younger US born
Hispanic counterparts. Financial hardship among US born Hispanics after age 70 reflect
cumulative disadvantage at older ages and the varying hardships unique to aging minority
communities that are often not characteristic of the aging experiences of older whites.
110
Foreign born Hispanics, however, report an overall higher stress burden relative to whites
before controlling for SES measures. Foreign born Hispanics report more exposure to health
problems at ages 54-69 and financial strain both before and after age 70, driving overall foreign
born Hispanic-white differences. While US born Hispanics report some decline in chronic stress
exposure with age, Foreign born Hispanics look more similar to blacks in examining age related
declines. They only report less exposure to employment strain after age 70 relative to their 54-69
foreign born Hispanic counterparts. Socioeconomic disadvantage, ethnicity, immigrant status,
and English language proficiency may represent compounded disadvantages that, when
coexisting, put foreign born Hispanics at greater risk of chronic stress exposure (Myers, 2009)
than their US born counterparts. Foreign born and US born Hispanics show some overlap in their
experience of chronic stress, reflecting overlap in some social positions, but there are unique
differences among foreign born Hispanics that suggest this groups has a distinct stress
experiences that would be missed if Hispanics were considered as one race/ethnic group.
Despite having access to social security, a shared stressor among older minority adults
ages 70+ uniting the experience of chronic stress across race/ethnic subgroups is financial strain.
Grappling with difficult and ongoing circumstances stemming from their locations in the social
and economic structures of society, minority older adults are often denied (at double the rates of
whites) the financial security we believe to be ubiquitous and necessary in older adulthood.
Minority groups, on average, have lower incomes across the life course, ultimately resulting in
lower amounts of social security, savings, pensions, and wealth across in old age (Williams &
Sternthal, 2010). Both foreign and US born Hispanic-white differences in financial strain were
attenuated after adjusting for SES. However, black-white differences in financial and housing
persisted after adjusting for SES. This emphasizes the importance of measuring financial and
111
housing strain as separate indicators, differentiating these experiences from simply reporting low
levels of education, income and wealth. Although low income or wealth often generates financial
and housing strain, this is not always the case. Financial and housing strain can emerge among
those with more considerable assets when financial demands exceed the resources available to
meet those demands. This is particularly relevant in capturing financial wellbeing among older
adults who may have fixed incomes and assets that do not adequately meet their needs.
Additionally, many immigrant groups and blacks live in segregated neighborhoods as a result of
historical racism in the housing and financial sectors. Segregation is considered a fundamental
cause of differences in health status and likely shapes the environment for chronic stressors
related to finical and housing strain to thrive in, giving its residents few resources to buffer or
counteract the experience of economic hardship.
This study is the first to examine age differences in chronic stress exposure by
race/ethnicity and stress domain, yet this study has some limitations. First, we used cross-
sectional data and thus did not study changes in chronic stress with age. Although our findings
suggest race/ethnic differences vary across age, we do not know whether there are intra-
individual declines in chronic stress exposure with age. Longitudinal data should investigate
change in chronic stress exposure over the adult life course in order to evaluate intra-individual
change in chronic stress burden with age. Second, when looking at stress among our subgroups
we have smaller sample sizes among racial/ethnic minorities groups and these groups report
greater variability in chronic stress exposure than our white subgroup, especially for the Hispanic
subgroups. Thus, with larger samples of racial and ethnic minorities we might detect significant
stress differences with age among these groups.
112
Stress theory, predominantly based on white populations, suggests that acute or event
based stressors decrease with age. Our findings show age related declines in chronic stress and
higher stress burdens for blacks and foreign born Hispanics relative to whites. Yet, upon further
probing, we found chronic stress exposure only declined with age for whites. Race/ethnic
disparities in stress reflect differential experiences of age-related declines in chronic stress
exposure. Black-white differences in chronic stress may be due to high stress burdens among
blacks 70+. Future research should investigate older adults capacity to cope with chronic strain.
If it is true that physical, material and psychological resources dissipate with age, then social
resources such as social support may take on added importance in later life. Structural sources of
chronic stress for older minorities (i.e., financial and housing strain) have the potential to
influence health disparities by both acting as a source of stress and by truncating the
opportunities older adults have to cope with these ongoing strains (Bird, Rieker, & Moyer, 2008;
Phelan & Link, 2015).

113
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Full Sample Whites Blacks
US born
Hispanics
Foreign born
Hispanics
(n=6,593) (n=5,264) (n=846) (n=228) (n=255) Chi2
% % % % %
Age 9.3 ***
54-69 65.5 63.7 72.3 82.8 73.1
70+ 34.5 36.3 27.7 17.2 27.0
Female 54.5 53.9 66.5 50.6 57.1 3.7 *
Education
High school or less 52.6 49.2 66.5 70.9 79.9 32.4 ***
HH Income 24.3 ***
1st quartile 23.1 19.1 45.2 34.4 51.3
2nd quartile 22.3 21.9 23.9 22.7 27.5
3rd quartile 25.4 26.6 18.2 27.5 13.6
4th quartile 29.1 32.4 12.7 15.4 7.6
HH Wealth 39.8 ***
1st quartile 24.5 18.9 56.0 45.2 55.9
2nd quartile 24.9 25.0 26.1 28.0 15.1
3rd quartile 25.1 27.1 12.0 14.9 21.1
4th quartile 25.5 28.9 6.0 11.9 7.9
Employment Status 23.0 ***
Currently Employed 34.4 34.4 30.9 40.1 35.9
Retired 54.6 56.4 54.5 39.9 24.3
Not in the Labor Force 11.1 9.2 14.6 20.0 39.8
Marital Status 13.3 ***
Married 68.0 70.1 49.2 71.3 62.6
Divorced/Separated 12.0 10.7 21.7 14.8 14.3
Widowed 16.6 16.4 22.9 9.5 13.9
Never Married 3.4 2.8 6.2 4.4 9.1
Total Chronic Stress Burden 2.3(0.0) 2.2(0.0) 2.8(0.1) 2.5(0.1) 2.6(0.1) 25.3 ***
+p<0.10 *p<0.05 **p<0.01 ***p<0.001
Table 1. Weighted descriptive statistics for the full sample and by race/ethnicity, Health and Retirement Study,
2006
120

Whites Blacks
US born
Hispanics FB Hispanics Chi2
% % % %
Total Chronic Stress Burden [mean(SE)]
54-69 2.4(0.0) 2.9(0.1) 2.6(0.1) 2.8(0.2) 16.2**
70+ 1.9(0.0) 2.7(0.1) 1.9(0.2) 2.0(0.1) 5.1
Health
54-69 57.4 66.9 63.6 68.7 4.2**
70+ 69.8 73.9 60.8 70.2 1.2
Financial
54-69 40.9 62.6 47.9 55.4 18.0***
70+ 26.8 53.3 40.7 44.7 27.6***
Residential
54-69 8.8 22.8 20.5 17.3 27.3***
70+ 7.0 24.7 8.5 8.6 24.8***
Employment
54-69 21.2 17.7 19.8 18.1 0.7
70+ 3.6 8.0 6.2 3.6 4.7**
Relationship
54-69 51.3 54.3 44.2 54.5 1.5
70+ 41.4 50.7 33.9 34.6 3.3*
Caregiving
54-69 37.1 40.8 36.9 41.3 0.8
70+ 30.3 38.9 27.4 33.3 2.0
+p<0.10 *p<0.05 **p<0.01 ***p<0.001
Table 2. Descriptive statistics showing the prevalence of stress exposure by
race/ethnicity and age, Health and Retirement Study, 2006 (n=6,593)
121

Independent Variables
β SE β SE β SE
Age (ref=54-69) 0 .
70+ -0.23 0.02 *** -0.25 0.02 *** -0.21 0.03 ***
Race/Ethnicity (ref=white)
Black 0.22 0.03 *** 0.17 0.04 *** 0.04 0.04
US Born Hispanic 0.08 0.05 0.09 0.05 + -0.03 0.06
Foreign Born Hispanic 0.12 0.06 * 0.14 0.07 + -0.02 0.07
Female 0.07 0.03 * 0.07 0.02 * 0.06 0.03 *
Race/Ethnicity X age
Black X 70+ 0.18 0.06 ** 0.17 0.06 **
US Born Hispanic X 70+ -0.09 0.12 -0.07 0.12
Foreign Born Hispanic X 70+ -0.09 0.11 -0.09 0.11
High school or less (ref=college+) -0.06 0.02 **
Income (ref=1st quartile)
2nd quartile -0.05 0.04
3rd quartile -0.12 0.04 **
4th quartile -0.17 0.06 **
Wealth (ref=1st quartile)
2st quartile -0.22 0.03 ***
3rd quartile -0.31 0.03 ***
4th quartile -0.39 0.03 ***
Employment Status (ref=employed)
Retired -0.07 0.03 *
Not in labor force -0.02 0.05
Marital Status (ref=married)
Divorced/Separated -0.07 0.04 +
Widowed -0.13 0.03 ***
Never Married -0.26 0.05 ***
Intercept 0.84 0.02 *** 0.85 0.02 *** 1.28 0.04 ***
+p<0.10 *p<0.05 **p<0.01 ***p<0.001
Model 1
Model 2
(+raceXage)
Model 3
(+demographics)
Table 3. Poisson regression models of total chronic stress burden, Health and Retirement Study, 2006 (n=6,593)
122
Figure 1. Predicted mean chronic stress burden by race/ethnicity and age

0
0.5
1
1.5
2
2.5
3
3.5
Whites Blacks US born
Hispanics
Foreign born
Hispanics
Total Chronic Stress Burden
54-69 yrs 70+ yrs
123

Table 4. Race/ethnic and age differences in the predicted probability of reporting domain specific chronic stress exposure, Health and
Retirement Study, 2006 (n= 6,593)
Whites Blacks US born Hispanics
Foreign born
Hispanics
PP CI PP CI PP CI PP CI
Health
54-69 57.5 (55.1, 59.8) 66.7 (60.9, 72.5) 63.8 (53.3, 74.2) 68.7 (60.5, 76.8)
70+ 69.7 (67.7, 71.6) 73.7 (68.2, 79.2) 60.7 (48.9, 72.6) 70.0 (58.9, 81.2)
Financial
54-69 41.1 (38.8, 43.4) 62.3 (58.3, 66.3) 48.1 (39.9, 56.4) 55.4 (43.5, 67.3)
70+ 26.7 (24.1, 29.2) 52.8 (45.6, 59.9) 40.5 (27.6, 53.3) 44.4 (34.9, 53.9)
Residential
54-69 8.9 (8.0, 9.8) 22.7 (19.0, 26.4) 20.6 (16.3, 24.8) 17.3 (8.2, 26.3)
70+ 7.0 (6.0, 8.0) 24.5 (18.7, 30.3) 8.5 (1.1, 15.8) 8.6 (1.7, 15.5)
Employment
54-69 21.0 (19.7, 22.3) 18.0 (13.7, 22.3) 19.5 (13.4, 25.7) 18.1 (8.4, 27.8)
70+ 3.6 (2.8, 4.5) 8.3 (0.1, 11.2) 6.3 (-0.1, 12.7) 3.6 (0.3, 6.8)
Relationship
54-69 51.4 (49.4, 53.3) 54.2 (49.5, 58.8) 44.3 (36.9, 51.7) 54.5 (43.7, 65.2)
70+ 41.3 (39.7, 42.9) 50.5 (43.6, 57.4) 33.8 (21.2, 46.5) 34.5 (23.5, 45.5)
Caregiving
54-69 37.3 (34.9, 39.6) 40.5 (35.7, 45.3) 37.2 (27.2, 47.2) 41.3 (33.9, 48.7)
70+ 30.1 (28.5, 31.8) 38.4 (30.7, 46.1) 27.2 (13.0, 41.5) 33.2 (22.8, 43.6)
Predicted probabilities come from separate logistic models adjusted for gender

124
CHAPTER 5- CONCLUSION
The main objective of this work was to examine 1) race/ethnic differences in chronic
stress exposure and appraisal, 2) determine if race/ethnic differences in stress exposure and
appraisal matter for mental health outcomes, and 3) examine age variation in race/ethnic
differences in stress exposure. In the first paper, ‘Disentangling the Stress Process: Race/Ethnic
Differences in the Exposure and Appraisal of Chronic Stressors among Older Adult’s’, findings
show that similar to prior work on race/ethnic differences in overall stress exposure (Sternthal,
Slopen, & Williams, 2011; Turner & Lloyd, 1995), older blacks and Hispanics, in particular
foreign born Hispanics, are more likely to be exposed to a greater number of ongoing chronic
stressors relative to whites. This difference seems to be driven largely by the fact that blacks and
Hispanics were more likely to be exposed to housing and financial strain compared to whites.
Despite experiencing a greater number of stressors, blacks and Hispanics are less likely to be
upset by exposure to stressors than whites. Hispanics were less upset by relationship and
caregiving strain while blacks were less upset across every stress domain. In paper 2, ‘Is
Exposure Enough? Race/Ethnic Differences in Chronic Stress Exposure, Appraisal & Mental
Health among Older Adults’, we found that stress exposure is an important predictor of both
anxiety and depressive symptoms for older adults, demonstrating that as stress exposure
increased so did anxiety and depressive symptoms for older blacks and whites. Stress appraisal
was also an important predictor of anxiety and depressive symptoms with symptomology
increasing with higher stress appraisal. Yet, results show that stress appraisal may operate more
strongly on depressive symptoms for blacks compared to whites when they appraise their stress
as upsetting. In contrast, when blacks said their stress was not upsetting they reported fewer
depressive symptoms relative to whites. In paper 3, ‘Race/Ethnic Disparities in Exposure to
125
Chronic Stressors Varies by Age among Older Adults’, we found older blacks ages 70+ report
similar chronic stress burdens as blacks 54-69 years old, while older whites ages 70+ are
reporting less chronic stress exposure than their younger white counterparts suggesting that
race/ethnic differences in chronic stress exposure are actually driven by black-white differences
at older ages. Hispanic groups report similar stress burdens as whites regardless of age and after
adjusting for SES, despite reporting double the exposure to financial strain after age 70
compared to their same aged white peers.
This work represents a significant contribution to the literature since chronic stress
exposure has been positioned as a foundational component in the manufacturing of race/ethnic
health disparities in later life, yet less is known about the mechanisms that actually link exposure
to health and health disparities. Further, this work challenges dominant stress theory that has
largely only focused on stress exposure and has only been studied in non-Hispanic whites. This
project, instead, focuses on the ways in which the chronic stress experience is different for
racial/ethnic minority groups in older adulthood. These findings acknowledge the unique
hardships minorities face in achieving health and wellbeing in old age, while also acknowledging
their resourcefulness in dealing with these chronic stressors. Importantly, this project is
innovative in measuring and quantifying stress appraisal in racial/ethnic minority groups,
highlighting the ways in which they observe their chronic stress burden and simultaneously adapt,
thereby recognizing their resourcefulness, coping and agency. Using the Health and Retirement
Survey, a nationally representative socioeconomically and ethnically diverse sample of older
adults, also strengthens this work. Additionally, this work incorporates a more comprehensive
measure of the chronic stress experience allowing for us to examine stress exposure and
126
appraisal as well as across five domains: health, financial, housing, relationship, and caregiving
strain.
In considering the larger implications that this work may have in the measuring, reporting,
and understanding of race/ethnic health disparities, this work may help us understand the black-
white mental health paradox. The black-white paradox in mental health refers to the surprising
finding that blacks exhibit better mental health than whites despite chronic exposure to
psychosocial stressors such as poverty and racial discrimination. The limitations within in the
stress literature, and with stress measurement in particular, may be why prior work has been
unable to explain the mental/physical health paradox in African Americans relative to whites.
Methodologically, stress measurement in diverse, nationally representative samples has not
advanced past checklists of negative events or global measures of perceived stress. Measuring
and quantifying race/ethnic differences in stress appraisal gives us a better understanding of how
the stress experience is unique for minority groups and may help us understand mental and
physical health disparities at the end of life. Examining stress appraisal processes may shed light
on black-white differences in anxiety and depression.
However, it is important to note that other methodological explanations have been
offered for the white-black paradox, although none have garnered wide acceptance or are backed
by substantial empirical evidence. First, some scholars have attributed this paradox to
measurement error, or the idea that mental health measurement tools are culturally biased and do
not capture mental health in blacks. For example, there are complex and often inconsistent
results across mental health outcomes. Some studies using general psychosocial distress or
diagnosed psychiatric disorder find blacks report worse mental health. Studies that use a count of
symptoms have even shown mixed findings, including the Health and Retirement Study. Most
127
past researchers have assessed depressive symptoms using the CES-D scale, with some finding
that blacks are more likely than whites to endorse somatic symptoms (e.g., poor appetite,
everything is an effort; Iwata & Buka, 2002), and interpersonal items on the scale (e.g., people
were unfriendly to me; Cole, Kawachi, Maller, & Berkman, 2000; Rosenfield & Smith, 2009).
Conversely, whites are more likely than blacks to endorse mood symptoms such as feeling lonely
or sad (Iwata, Turner, & Lloyd, 2002; Iwata & Buka, 2002). Thus, the underrepresentation of
interpersonal and somatic items on measurement instruments (or the overrepresentation of mood
symptoms) could artificially reduce rates of mental health problems among blacks.
Yet, in contrast to some of the methodological hypotheses offered, three main theoretical
hypotheses have emerged to attempt to explain the paradox: 1) minority status is a source of
psychosocial resources and positive coping strategies (Jackson, Knight, & Rafferty, 2010), such
as religious participation (Chatters, Taylor, Jackson, & Lincoln, 2008) and social support (Thoits,
1995), that protect against the adverse mental health effect of these stressors; 2) earlier and more
frequent exposure to adversity may render blacks more accustomed to dealing with stress or
perhaps have developed more effective, context-specific coping resources (Williams, Yan,
Jackson, & Anderson, 1997); and 3) the Environmental Affordances Model that suggests blacks
engage in poor health behaviors to mitigate the immediate symptoms of psychological stress but
contribute to poor physical health (Mezuk et al., 2013). Yet, these explanations remain untested
or lack sufficient data and thus leave the black-white differences in mental and physical health
unresolved.
An underlying commonality in all the theoretical hypotheses outlined above is the
suggestion that blacks cope differently, or perhaps better, with adversity or stress. This is a
critical distinction that aligns with the finding that blacks do not appraise stress in the same way
128
whites do. Thus, this dissertation supports the idea that blacks may cope differently with stress
and may shed light on the important physical and mental health paradox within the health
disparities literature (Williams et al., 1997). Status based characteristics, including race, affect
the psychological and behavioral responses to stress. African Americans facing chronic adversity
may be driven to reorganize their outlook on life (Epel, 2009). In the course of coping with
chronic stress, people often develop cognitive shifts or changes in their mental filter that promote
a more beneficial stress appraisal process. In the psychology literature, these cognitive shifts
have been termed psychological thriving. Thriving includes a range of positive or protective
resources (i.e. social support, religiosity, racial identity) that minorities may use to buffer stress
appraisal in the face of a chronic stressor. In this way, African Americans may promote a
collective state of lower appraised stressfulness, however exposure may still exert a stress effect
(Epel, 2009). If older blacks are coping differently with stress, specifically in considering the
exposure to stressors as less stressful than whites, then based on the findings of this dissertation,
appraisal may offer an explanation for black-white differences in mental health.
An additional strength of this work is that it identifies financial strain and housing
insecurity as two dominate stressors for older minority groups. Older minorities report two to
three times the rate of financial and housing hardship compared to whites, likely reflecting the
cumulative effects of structural and societal inequities including segregation, English language
proficiency, unequal educational attainment, longer periods of unemployment and
underemployment, lower wages, pensions, and accumulation of wealth over the life course
(Landrine & Corral, 2009; Williams, Mohammed, Leavell, & Collins, 2010). Controlling for
SES largely eliminated these disparities for Hispanic subgroups. Yet, high SES does not protect
blacks from things we would normally think are related to SES like financial and housing
129
security, uncovering some of the ways in which the aging experience is different for blacks
(Landrine & Corral, 2009; Turner & Avison, 2003). Non equivalence or the benign function of
SES among older blacks suggests the need to identify other protective factors that can mitigate or
prevent chronic stress exposure among this group (Williams et al., 2010). These findings
emphasize the varying ways SES differently influences stress exposure across racial/ethnic
minority groups in older adulthood. Moreover, understanding the race/ethnic patterning of
chronic stress across these major life domains in older adults may be central to prevention and
mediation efforts since chronic stress burdens are likely charting how life course trajectories and
health of minority groups come to differ in old age (Pearlin, 2010).
Limitations
Despite the potential contributions of this work, limitations exist do to the nature of the
data set as well as what is feasible within the time frame. First, though the selection of chronic
stressors covers five domains of stress, the present study does not include measures of race-based
chronic stressors such as discrimination or acculturation stress (Brown et al., 1999; Sellers &
Shelton, 2003). Explicit examination of the role of race specific stressors among minorities is
essential to advance future research on stress and health in diverse populations. Second, the
cross-sectional nature of the study restricts time order and causality-based conclusions. This does
not allow us to rule out the possibility that higher levels of anxiety and depression may
exacerbate stress appraisal. Yet it is possible in future work to consider the effects of chronic
stress on more distal health outcomes. Finally, this discussion focuses on the potential health
effects of long term stressors yet it cannot be assumed that ongoing chronic stress is separate or
distal from other types of stress that an individual may experience. While we did robust checks,
controlling for other types of stressors, these stressors may have overlapping or simultaneous
130
effect on health, thus this provides future opportunity within the HRS to create a more accurate
picture of an individual’s entire stress experience.
Future directions
I plan to extend this work by investigating the resources that can be utilized to reduce
both stress exposure and appraisal, and the subsequent impact on health. Informed by a novel
health disparities framework, this work highlights a resource/resilience narrative wherein
community and individual level resources interact to promote healthy aging in historically
disadvantaged populations. Health disparities research has largely overlooked factors that
promote health and well-being among aging minorities, focusing instead on the many
disadvantages that lead to poor health. Since older blacks and Hispanics report around double the
exposure to ongoing financial and housing strain relative to whites, it’s even more important to
find mitigating factors that may reduce both stress exposure and the resulting stressfulness or
impact of these exposures. A major purpose of this work is to find social and economic resources
that improve senior housing security for older minority communities where the need is
exceptionally salient. Housing stability is healthcare, and maybe one way to markedly reduce
health inequity. By focusing on the factors that promote health and well-being against the most
pervasive stressors in minority populations, I aim to identify resources that can be used to
formulate more comprehensive theoretical models of health disparities as well as policy solutions
to eliminate racial/ethnic differences health.

131
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134

Abstract (if available)

Abstract The current project examines the experience of chronic stressors, specifically the exposure and appraisal of chronic stress, as separate but principal mechanisms contributing to mental health disparities in older adulthood. The differential exposure and vulnerability hypotheses have been the dominant frameworks in examining stress to better understand race/ethnic differences in health. These theories suggest that minorities, and blacks in particular, are more exposed to stressors and are more vulnerable to the effects of stress on health due to their disadvantaged social status. Research has shown that stress exposure is linked to worse physical and mental health. However, most of the stress and health literature at the population level fails to consider how race/ethnicity uniquely shapes chronic stress exposure and subsequent stress appraisal on mental health outcomes in a nationally representative sample of diverse older adults. Further, demographic health disparities research has been unable to establish whether stress exposure and stress appraisal are differentially linked to race and ethnic differences in mental health in mid- and late-life. ❧ This project aims to advance the science of health disparities by using a racially diverse nationally representative sample of older adults from the Health and Retirement Study (N=6,878) to: 1) examine racial/ethnic differences in the number of reported chronic stressors across five domains (health, financial, residential, relationship and caregiving), and their appraised stressfulness

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Asset Metadata

Creator Brown, Lauren Leigh (author)

Core Title Is stress exposure enough? Race/ethnic differences in the exposure and appraisal of chronic stressors among older adults

School Leonard Davis School of Gerontology

Degree Doctor of Philosophy

Degree Program Gerontology

Publication Date 08/06/2018

Defense Date 04/20/2018

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag anxiety,chronic stress,coping, diverse aging,Depression,health and retirement study,Mental Health,minority aging,OAI-PMH Harvest,Stress

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Advisor Ailshire, Jennifer (committee chair), Crimmins, Eileen (committee member), Zelinski, Elizabeth (committee member)

Creator Email laurenlb@usc.edu,lrnleebrwn@gmail.com

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