# ind_items

secondary_title_index: sociology compass
title_index:
       racial microaggressions: bridging psychology and sociology and future research considerations     

full_text_index:
       received: 31 october 2019  revised: 30 april 2020  accepted: 8 may 2020  doi: 10.1111/soc4.12803  article  racial microaggressions: bridging psychology and sociology and future research considerations silvia dominguez1 1    david g. embrick2  department of sociology, northeastern  university, ma  abstract  department of sociology and africana  this article reviews racial microaggressions, specifically psy-  studies institute, university of  chology and sociology's historical trajectory in informing  2  connecticut, ma  existing literatures and disciplines, in its connections to  correspondence  meso and macro levels of systemic racism. in doing so, we  david g. embrick, university of connecticut,  contend that a sociological understanding of racial micro-  mansfield, connecticut, usa. email: david.embrick@uconn.edu  aggressions presents opportunities to better understand the cumulative and deleterious effects of racial violence on racialized groups. furthermore, we argue that beyond bridging the disciplines of psychology and sociology to allow for more interdisciplinary analyses of racial microaggressions will help to move conversations in ways that more meaningfully capture the monstrosity of white supremacy and its cumulative deleterious effects of daily racial terrorism at all levels of society.  “my own bottom line is this: since it is usually impossible for me to be conscious more than 30 minutes without thinking of my race, all my professional life can be described as an effort to live as a black in the usa.” chester pierce1  1    i n t ro du ct i o n  our aims in this review are to provide a timeline overview of racial microaggressions scholarship that is centered on the earlier works of chester pierce, philomena essed, and derald wing sue, three major contributors who constitute much of the insight, theoretical groundwork, and research in this area. we then consider some of the major empirical research that have formed the bulk of scholarship in the last 20 years, much of which we argue are largely extensions of sue's racial typology framework. finally, our hope is to provide rationale for future research on racial microaggressions that is more interdisciplinary—that is, that accounts for the individual, interpersonal and psychological, †  authorship is alphabetical and considered to be equally weighted in this article.  sociology compass. 2020;14:e12803. https://doi.org/10.1111/soc4.12803  wileyonlinelibrary.com/journal/soc4   2020 john wiley & sons ltd  1 of 14  
  2 of 14  dominguez and embrick  acts of discrimination as well as structural and institutional causes of racism. we make no claims to cover every single research that has been done with regards to racial microaggressions. rather, we take what follows as major contributors to this area. to be clear, ours is not the first review of microaggressions literature, although ours is one of the few that is specific to racial microaggressions—and the need for more sociological analyses. for example, lilienfeld (2017)2 published a review that took to task what he argued was the rapid rise of an underdeveloped concept. he not only called for the abandonment of the term microaggression, but also concluded with “18 suggestions for advancing the scienfice status of the mrp3...” (138) although lilienfeld noted that his goal was to outline the shortcomings of mrp, the bulk of his review read like a public calling-out of derald wingfield sue et al. this is not surprising given sue's influence since the mid-2000s on microaggressions. any cursory examination of research on racial microaggressions in the past few decades will undoubtedly produce at least three interesting revelations. first, while widely acclaimed psychiatrist pierce (1970) is often given credit for being the undisputed father of the term “microaggression,” his research and other scholarly contributions in this area are seldom detailed, and even more rarely interrogated for his insights, many of which we contend are taken for granted today. although not a sociologist, many of pierce's observations are sociological in nature, or at the very least bridge a multitude of disciplines together in conversations that allow for more complexity in better understanding how people of color are affected by everyday racism. second, noticeably missing from the 1980s through the early part of the 2000s are sociological observations of racial microaggressions that took seriously both meso and macro-level structural factors that either produced and/or maintained various forms of racial violence; much of contemporary scholarship written by sociologists tend to be theoretically anchored by psychological theories of racial microaggressions that more often than not minimize the importance of racialized social structures. there are notable exceptions, with increasing frequency, from the fields of education and health sciences. yet, glaringly missing from the scholarship on racial microaggressions are conversations that include historically (and currently) stigmatized and/or marginalized voices of the academic community, for example, afro-centrist/futurist, critical latino/a studies, du bosian thought, or colonial/post-colonial and settler colonial theories. finally, while a number of scholars (smith, allen, & danley, 2007) have argued on the serious implications of racial microaggressions in terms of the cumulative health disparities on people of color, discussions are often limited to interpersonal interactions, or cross-sectional studies along the life course. when considering everyday racial violence along the full life course, and at the individual, institutional, and societal levels, the multiplier effects of racial violence produce a different story—one in which living in a racialized social system (bonilla-silva, 1997) as a person of color may be much more toxic to one's health than our current data suggests. one often argued shortcoming of current scholarship has to do with the term itself. the “micro” in microaggressions is a diminutive that does not fully capture the cumulative harm that repeated violence does to a person. thus, daily exposure to racial violence—interpersonal, institutional, or societal—has far greater health implications, for example, for people of color, than is typically realized. indeed notable scholars such as elijah anderson and johnny eric williams have publicly expressed their discontents with the term microaggressions in its obfuscation of white supremacy.4 as we have argued previously (embrick, dominguez, & karsak, 2017), research (both theoretical and empirical) attesting to the deleterious effects of racial microaggressions have been limited to understanding the phenomenon as individual or psychological acts of discrimination and does not fully appreciate the cumulative nature of daily racial violence. the dominance of psychologists, psychiatrists, and educational psychologists, in current studies of racial microaggressions, leads to an overemphasis on coping strategies as the mechanism for thinking about how to best deal with the stressors that result from racial microaggressions (grier-reed, 2010). adding a sociological component of racism to the conversation allows us to rethink the concrete realities of racial aggressions as not “micro” but as everyday acts of racial violence. it also allows us to interrogate the structural conditions that foster daily racial violence. and it also allows us to relocate some of our energies to thinking about how best to dismantle the root causes of racism (and those affected by it), rather than trying to figure out how to bandage the victims of racial violence. in this respect, the term racial microaggression does not fully capture the essence and harm of everyday racial violence towards people of color.  
  dominguez and embrick  3 of 14  in the rest of this article, we do the following: first, we explore the various definitions of racial microaggressions, paying special attention to its origination with chester pierce and the significant contributions of philomena essed and derald wing sue. next, we unpack the concept of racial microaggressions as its been used broadly in the social sciences, particularly with respect to the theoretical frameworks of racial battle fatigue (rbf) and critical race theory (crt). finally, we conclude with suggestions as to how in rethinking racial microaggressions we might move forward in ways that not only challenge existing scholarship—of which this is far from our intent—but allow us to fully grasp the consequences of what it means to be a person of color in a racialized social system (bonilla-silva, 1997).  2  r a c i a l m i c r o a g g r e s s i o ns    2.1  the concept of microaggressions originated in psychiatric and psychological    practice and represents a way to understand microaggressions at the individual level. racial microaggression is often defined as racial slights, often subtle, that serves as markers of belonging—that is, who belongs and who does not. in this respect, it may not matter that the perpetrator of racial slights is aware or unaware of how their responses may be hurtful. but the message is often more clear to those who do not fit into normative whiteness—you are not welcome here, you do not belong here, or some iteration of the two.  2.1.1    chester pierce: the father of microaggressions  leading practitioner and harvard university psychiatrist chester pierce was a trailblazer whose contributions we argue are still waiting to be recognized. although pierce is known for his scholarship on racism, societal tensions, sports medicine, and the discriminatory aspects of the media, three of his greatest contributions was the development of a type of stress specific to the lives of blacks called the mundane extreme environmental stress (mees); a concept that explains how racism is promulgated called microaggressions; and a concept that explains what is taken away from blacks through microaggressions, including: space, time, energy, and motion (stem). dr. pierce developed all these concepts from what he heard repeatedly from his patients. in addition, dr. pierce proposed that racism should be considered a mental health problem while pointing out the similarities in objective and consequences shared between racism, terrorism, and torture. unlike many of his psychiatrist and psychologist colleagues, pierce differed in his acute awareness of the macro-structural levels of racism that informed racial attitudes and encouraged racial discrimination. microaggressions—in 1970, pierce published a book chapter titled “offensive mechanisms” in which he took a psychiatric well-known concept of defense mechanisms deemed crucial in the reduction or avoidance of shame and guilt, permitting the individual to function without being overwhelmed by anxiety, and turned it on its head. while protesting the lack of concern with what he called, offensive mechanisms (which he saw as being about aggression and violence), pierce argued that part of the role of social psychiatrists was to study offensive mechanisms and resulting offensive maneuvers. “for it is from feelings of superiority that one group of people proceeds to brutalize, degrade, abuse and humiliate another group of individuals” (p. 265). according to pierce (1995, p. 281), one of gravest offensive mechanisms were microaggressions and pierce defined them as such: “subtle, innocuous, preconscious, or unconscious degradations, and putdowns, often kinetic but capable of being verbal and/or kinetic. in and of itself a microaggression may seem harmless, but the cumulative burden of a lifetime of microaggressions can theoretically contribute to diminishing mortality, augmented morbidity, and flattened confidence.”  
  4 of 14  dominguez and embrick  for pierce, microaggressions create mini disasters in the lives of blacks. he noted, “...one must not look for the gross and obvious, this subtle, cumulative mini assault is the substance of today's racism.” (pierce, 1974, p. 616) a disaster is a serious disruption of normal functioning that last a short time but exceeds their capacity and coping resources. individuals must offset this excessive loss, and this becomes cumulative without ever fully compensating. more interesting were the ways in which pierce acknowledged racism as part of the formula for explaining the root causes of microaggressions and the importance of the daily and cumulative injuries suffered by his patients. he was further aware that the superiority feelings accompanying contemptuous condescension toward a target group were so rampant in our society that he argued it was virtually impossible for any negotiation between blacks and whites to take place without the auspices of such offensive tactics (265). the realities and importance of fully understanding how microaggressions affected black lives were such as pierce argued that their cumulative effect was of “unimaginable magnitude.” pierce conceptualized microaggressions to occur in the interaction between blacks and whites and proposed that superiority stemming from racism could manifest as micro-offenses which “minimize the social importance of black achievement so that blacks see themselves as useless, unlovable and unable” (268). microaggressions, thus, allow for blacks to be denied equality in education and employment while also being more overtly terrorized by police departments in black neighborhoods. pierce implicated us culture as making microaggressions automatic and even obligatory on the part of whites. furthermore, he argued that while these mechanisms may be seen as conscious, unconscious, or preconscious to white people, to blacks they are salient and automatic. pierce envisioned microaggressions as a public health issue due to its magnitude and lasting damaging effects on blacks. what is at play: space, time, energy, and movement (stem)—according to pierce (1970), “dominance-submission dynamics depend heavily on psychological as well as physical manipulations by the victimizers (106).” the victim must confirm the superiority of the aggressor whose goal is to have total unquestionable obedience “in the service of the convenience, aggrandizement, entertainment, and pride of the offender (ibid).” it is through this process of constant submission that the offender takes away the space, time, energy, and movement (stem) of the victim. it erodes the opportunities for pride. the person will be free of victimization when she regains control of space, time, energy, and movement. for example, blacks are subject to arrest when they cross boundaries from black to white neighborhoods. blacks are also discouraged away from white spaces that are alien and antagonistic to blacks. time is compromised when blacks are deterred from white spaces that require circumventing and adding time. energy is compromised when blacks must spend time thinking over microaggressions and wondering what to do with those assaults. movement is compromised as blacks must stay away from white spaces and when attention is called on to them as suspicious. these are just some examples of how stem correlates with microaggressions. regaining control of stem means that the individual no longer must play the inferiority role. what it creates: mees—the ongoing daily onslaught of discriminatory stress5 in such a variety of forms inflicted on blacks during their lifetime in the us is tremendous. daily microaggressions are occurring in schools, jobs, media, books, gyms, clubs, restaurants, street, courts, and politics. blacks are subject to being described by anyone in the street who deputizes themselves to report them as suspicious and bringing police to interact which brings extreme vulnerability (see anderson, 2011, 2015; embrick, weffer-elizondo, & dominguez, 2019). many black people are petrified of being shot at any time by a police officer (embrick, 2015a, 2015b; hughey, 2015), or being refused employment following a devaluing microaggression and wondering why people you have trained are now in positions not available to you (embrick & henricks, 2013). the stress involved is extreme and mundane. pierce understood this because he lived it personally. he also experienced this through his patients and historical accounts of black towns being destroyed and its residents killed. this extreme stress impacts the psyche and worldview of blacks. its cumulative consequence results in limited opportunities, poor mental and physical health, and decreased life expectancy. pierce called this (mees)6 and this has become a type of stress specific to the reality of african americans. grace carrol and william smith both sociologists, are among a multitude of scholars who have taken mees further in studies. william smith, in particular has argued that mees results in what he has coined rbf. according to pierce, cumulative nature of racism and microaggressions compromises the stem of blacks and leads to mees.  
  dominguez and embrick  2.1.2    5 of 14  philomena essed: everyday racism and intersectionality  studying the theoretical underpinnings of racial microaggressions must begin with notable social scientist philomena essed, who pioneered the understanding of everyday racism. essed, the daughter of surinamese parents, spent her youth in surinam and the netherlands where her family settled and where essed did her studies in anthropology and later social sciences. essed wrote several books but the important ones for understanding racial microaggressions are everyday racism: reports from women of two cultures (essed, 1990) and understanding everyday racism: an interdisciplinary theory (essed, 1991). the original writings were in dutch a decade earlier. essed made a number of contributions on racism in the us and the netherlands and in particular by looking at the experiences of racism on black women. she formulated links between the micro and macro in order to explain racism that was quotidian yet stemming from structure. although essed did not use the language of microaggressions in teasing out the pervasiveness of everyday racism. writing in roughly the same time period, both essed and pierce share striking similarities with one another in their understanding of the cumulative effects of being exposed to daily racial violence. whereas pierce describes the structural links to microaggressions in the global sociocultural ideologies and mechanisms of white supremacy, essed looks for a theoretical macro–micro link while considering three types of racism: cultural, institutional, and individual. pierce describes how microaggressions are sustained in everyday interactions between blacks and the white world. essed criticizes the mainstream neglect of racism scholars who identify racism as a societal issue, but do not pay attention to the pervasive experiences of daily racism in the lives of blacks. like pierce, essed bases her theory on blacks' subjective experience. while pierce used the experiences of his patients to develop microaggressions as a concept, essed considers blacks to be sophisticated in their understanding of racism based on their daily experiences. pierce argues that microaggressions work by constraining space, time, energy, and motion (stem). essed wrote that racism worked by: inferiorization; social or spatial distancing, and social or physical aggression. as we can see, there are many parallels between these two contemporaries. essed defines everyday racism as a process in which (a) socialized racist notions are integrated into meanings that make practices immediately definable and manageable, (b) practices with racist implications becoming themselves familiar and repetitive, and (c) are actualized and reinforced through these routines or familiar practices in everyday situations. essed contends that racism is vicariously spread among blacks which adds to its everyday occurrence. to essed, racism is fully integrated in routine everyday practices. in setting out to better connect micro and macro levels of racism, essed wrote, “to understand the specific nature of temporary basis, it is assumed to proceed from the level of individual attitudes to the larger economic, political, ideological processes in a society.” (20). for essed, traditional sociological approaches have defined macrostructure's aspects of racism more or less independent of the practices in daily life. essed criticized aversive, symbolic, and modern racism as inefficient theories to understand racism while ignoring what she perceived to be a progressive culturalization of racism. she saw cultural pluralism replacing the “melting pot” integration processes and instead, pushing the genetic and culture of poverty arguments.7 essed blamed cultural pluralism for complaints of reverse discrimination due to its leveling of all groups as being equal. she also criticized the move from “race” to “ethnicity” as a way to avoid taking responsibility for racism. in this way, she argues, ethnic identity becomes an instrument of control. furthermore, essed argued that racial and ethnic conflict are maintained through three main processes: (a) marginalization, a form of oppression; (b) containment, a form of repression; and (c) problematization, the ideological constructions legitimizing exclusion and repression of opposition. these are three major forms of racism which are ideologically structured and situationally construed (1991, p. 10). essed relied on two major theoretical attempts at integrating micro and macro dimensions of a system. one is the aggregation hypothesis proposed by randall collins in his (collins, 1981) essay on “micro-translation as a theory-building strategy,” where he argues that microsociological reality is composed of aggregates of microsituations. the other attempt is the representation hypothesis, the brain child of cicourel (1981) who argued that macro social facts, or structures, are produced by interactions. both the aggregation and representation hypothesis rely on routine  
  6 of 14  dominguez and embrick  and repetition in practices that culminate in social structures. essed departs from these theories giving greater weight to the mutual interdependence of macro and micro dimensions of racism. to this she contends, “structures of racism don't exist external to agents—they are made by, agents—but specific practices are by definition racist only when they activate existing structural racial inequality in the system” (39). as it pertains to microaggressions, it is important to make distinctions between overt and covert racism. in covert expressions of racism, essed believes that negative intentions cannot be inferred from the act themselves. the definition of the situation seems negotiable. “the relation between racist ideology and racist practices is determined by the historical, material, and political context and the degree to which ideologies are saturated in the cognition of agents” (1991, p. 47). the fact that negative intentions are questionable in prejudicial encounters is found again in some of the ambiguity that sue (2010a) has written about and that we know affects the individual as much as having the certainty of negative intention. essed formulated her thinking by studying the experiences of racism on women. an intersectionality analysis informs us that as women they were likely to experience more intense negative treatment than most men. essed noted that when she asked women about incidents of discrimination, they did not respond affirmatively but did so during a more elaborate conversation. essed argues that racism often appeared in implicit form and it involved what many considered trivial injustices. in order for the women to answer affirmatively, they would need to keep in mind and tally the numerous, often minor, painful accidents which are normally tolerated or repressed. she noted (1990, p. 58), “women do not want to be seen as a bother, so they minimize their uncomfortability.” of course, these are internalized patriarchal narratives that make women not want to be seen as a bother. yet, they were very much seen a bother by men who disrespected them intensely, often cutting their options for further development.  2.2  racial microaggressions in the 2000s    the early part of the 2000s saw an explosion in interest and research, particularly in the field of psychology, on microaggressions, much of which extended pierce's concept in tackling everyday racism outside of the black/white binary, as well as across other forms of oppression: sexism, trans/homophobia, ageism, ableism, for example. that said, interestingly, it was also during this time period that much of the research published largely ignored or minimized the central contributions of chester pierce and philomena essed; although it is true that efforts were made across the board to at minimal acknowledge pierce as the person who coined the term microaggressions.  2.2.1    derald wing sue: racial microaggressions in everyday life  although rapidly changing, much of the racial microaggressions scholarship since the early 2000s has been dominated by psychologist derald wing sue. his seminal collaborative article (2007) and two books, microaggressions in everyday life: race, gender and sexual orientation (2010a) and an edited volume, microaggressions and marginality: manifestation, dynamic, and impact (2010b) were published within a span of 3 years. since then, hundreds of articles have been written using his racial taxonomy, making sue one of the leading spokespersons for microaggressions. derald wing sue began his career as a therapist in california before becoming a professor of counseling and clinical psychology. initially concerned with the lack of psychological understanding of asians in the united states, sue, along with his brother stanley, founded the asian psychological association in 1972. sue's initial concerns were with multiculturalism and racial aspects to be considered in psychological practice, and this has remained a driving force in sue's work. in fact, his books on multicultural counseling have been required reading by psychology courses for years. along with this practice focus, sue's interest in microaggressions came out in 2007 with a publication in the american psychologist titled, “racial microaggressions in everyday life: implications for clinical practice,” cowritten with christina m. capodilupo, gina c. torino, jennifer m. bucceri, aisha m. b. holder, kevin l. nadal, and  
  dominguez and embrick  7 of 14  marta esquilin. sue and his collaborators based their microaggressions work on symbolic (sears, 1988) and aversive racism (dovidio, gaertner, kawakami, & hodson, 2002). symbolic racism is based on a set of beliefs that blacks violate cultural values like individualism and the belief in working hard to get ahead in life. other values that feed negative perceptions are based on morality, capacity of self-restraint, and family traditionalism. the term racism is applicable because the belief that blacks violate cherished values is often strongly associated with negative feelings or antipathy toward blacks, while symbolic highlights the fact that the roots of the symbolic racism belief system are in these abstract, moral values, rather than in concrete self-interest or personal experiences. this allows blacks to be targeted as an abstract collectivity rather than as specific individuals. aversive racism is a type of ambivalence developed by individuals who sympathize with the victims of past injustices and at times support public policies that promote racial equality. aversive racists identify more clearly with a liberal political agenda and regard themselves as nonprejudiced and nondiscriminatory while unavoidably possessing negative feelings about blacks. the aversive racist is unaware of these negative feelings about blacks due to their beliefs in egalitarian values. as a result, negative racial attitudes can be expressed indirectly. finally, aversive racists keep and reinforce negative evaluations of people of color by a persistent avoidance of interaction with other racial and ethnic groups. this avoidance is easily achievable given segregation in housing and employment settings. both symbolic and aversive racism point out how pervasive racism is, how subtle it has become, how it calls on abstract collectivity and not individualized differences and how ambivalent many whites are when it comes to their racism which escapes into interactions with black or others (as abstract collectives) which result in a microaggression.  2.2.2    sue's racial taxonomy8  sue's racial taxonomy is predicated on three specific forms of microaggressions: microassaults, microinsults, and microinvalidations. microassaults are most similar to old-fashion racism at the individual level. they are conscious and deliberate. microinsults are communications that convey rudeness and insensitivity to ethnic and racial heritage or identity. these exchanges communicate less than worthiness as in being in a job because of affirmative action. finally, microinvalidations “are characterized by communication that excludes, negates or nullify the psychological thoughts, feelings or experiential reality of a person of color” (sue et al., 2007, p. 274). sue (2010a) argues that microinvalidations may be the most insidious form of microaggressions because it cuts down opportunities for people of color and negate the significance of identity in the lives of people of color. sue's taxonomy has been the basis of the majority of research on microaggressions. in a review of all microaggression studies from 2007 to 2014, which included 73 studies, wong and company found that 72 of the studies used sue's taxonomy and most were done using college students and faculty as data (wong, derthick, david, saw, & okazaki, 2014). sue (2010b) also writes about the psychological dynamics of microaggressions as including four different components. first, sue believes that there is a clash of realities between the dominant group and socially devalued group explained as differences in socialization that foster implicit bias through cultural conditioning. the results of the conditioning become encoded in the emotional and neurological matter (boysen & vogel, 2008). second, there are two layers of resistance that accompany the invisibility of unintentional bias and discrimination; the perpetrator's unawareness of his prejudices and his need to preserve his image as someone who is unbiased and a righteous person. third, the perceived minimal harm of microaggressions in which literature speaks to the contrary with biological, emotional, cognitive, and behavioral consequences. finally, there is a catch 22 of responding, which leads to the questioning of objective, “did he mean what i think he meant?” (attributional ambiguity), “i do not know how to respond” (indecisiveness about the response), “he is denying my reality” (denying experiential reality), and “this is hopeless” (impotence of actions). in addition, sue identifies nine common themes, falling into three categories: alien in one's own land, the ascription of intelligence, colorblindness, the assumption of criminality, denial of racism, myth of meritocracy, pathologizing cultural norms, second-class citizenship, and environmental invalidation.  
  8 of 14  dominguez and embrick  in later writings on marginality and oppression, sue (2010a) states that persecution can occur through imposition or deprivation. imposition is the act of imposing unwanted and inaccurate realities onto people of color. deprivation is the denial of the opportunity structure to people of color or accomplishments made by people of color. much of history has erased what people of color have accomplished like the fact that women of color were among the first human computers (i.e., doing the logistical calculations by hand) and among the first to work with what became computers in nasa.  2.2.3    applications of sue's racial taxonomy  much of the research that follow sue's taxonomy have used quantitative methods that count on people's capacity to recall individual's experience with microaggressions. following the review article by wong et al. (2014) which criticized recall-based studies, ong and burrow (2017) answered the call and attempted to go further by using methodologies to find macroaggressions longitudinally as they occur via the utilization of diaries. they published an article in perspectives on psychological science in 2017 with a longitudinal focus. but the aims of their article really centered on issues of methods that did not really touch upon sue's conceptualization of microaggressions.  2.2.4    avoidance of structure  sue demonstrates an ambivalence and a lack of follow-through in the conceptualization when it comes to environmental microaggressions regarding how structural it becomes. in 2007, sue explained that environmental microaggressions are macro-level microaggressions, which are more apparent at the systemic and environmental levels. examples might include colleges or universities with buildings that are all named after cis-white heterosexual, upper-class males; television shows and movies that feature predominantly white programs, without representation of people of color; the overcrowding of public schools; or the overabundance of liquor stores in communities of color. hence, a lack of inclusion and representation in institutions are microaggressions. yet, what of the policybased reasons for low-quality schools or zoning policies that allow for a high number of liquor stores to be concentrated in some neighborhoods—where and how would that fit in? sue, capodilupo, and holder (2008, p. 331) considered microaggressions as implicating an “unconscious worldview of white supremacy that directly assails the racial reality of black americans.” here he briefly touches upon the importance of considering white supremacy. in a piece published in 2010, sue argued that the term “environmental microaggressions” refers to “numerous demeaning and threatening social, educational, political, or economic indications that are transferred individually, institutionally, or societally to marginalized groups.” (25) although sue teases by including additional layers of complexity in this definition, he nonetheless shies away from naming a culprit or binding agents like a racialized system of domination or neoliberal capitalism. it is as if these problems existed on their own, or were produced by an invisible hand. more recently, sue and company published an article in a (sue, 2019) special issue on racial trauma in american psychologist where they address the harmful impact of macroaggressions. while the authors make some attempt at acknowledging institutional and structural racism, it is short lived and not fully fleshed out. because the work on environmental microaggressions remains incomplete, there is an absence of research testing this concept within the taxonomy. sue has undoubtedly put down a foundation for the concept of microaggressions that is adequate for the branches of psychology that are individualized and interpersonally based. he has conceptualized around the different motivations and the interpersonal interaction between perpetrator and victim. much of sue's work still under construction has to do with expanding the common themes, which have grown and diversified with lgbt and other minority groups which all seem to be more specific to their status themes.  
  dominguez and embrick  9 of 14  however, the further conceptualization of environmental microaggressions and the invisible hand is a limitation for many sociologists interested in studying racial microaggressions.  2.3  enter the crt framework    the crt framework emerged out of critical legal studies in the 1980s that needed to address racism in law schools and other us legal instititons. leading legal scholars such as derrick bell, kimberle crenshaw, and richard delgado spearheaded the movement to better understand the relationship between law, power, racism, and emancipation. the tenets of crt maintain that white supremacy and racial power are maintained over time and affect legal processes in favor of the dominant group in society. as crt became more popular as a racial framework, scholars in other disciplines such as sociology and education saw crt as a way to better understand and conceptualize the ongoing amount of racism affecting people of color in the united states. microaggression scholars utilizing crt as a foundation for their work have mostly concentrated on health and education disparities as a consequence of racial microaggressions. central to their motivations is to separate themselves from derald wing sue, who, as a psychologist, is best known for microaggressions, and who is followed by scholars from many other disciplines including sociologists who have chosen to accept and rely on sue's racial taxonomy. proponents of crt as the central framework from which to interrogate racial microaggressions include smith (2004) and his work on rbf and solorzano (1998). contrary to sue's framework, which barely pays attention to pierce, smith, and solorzano rely heavily on chester pierce's previous work on microaggressions, although to varying degrees. both smith and solorzano incorporate (mees) in their scholarship, although smith (2004) goes a bit further by incorporating space, time, energy, and motion or (stem). pierce maintained that blacks are bombarded constantly with oppressive agents, environments, and situations which constrain their space, time, energy, and motion. smith's rbf can thus be viewed as a synthesis between pierce's work and crt.  2.3.1    rbf and racial microaggressions  in 2004, william smith developed the rbf framework, placing racial microaggressions within a historical, sociological, and psychological context, explaining the long- and short-term effects of resisting and struggling against racialized stressors. for smith, racial microaggressions can range from racial slights, recurrent indignities and irritations, unfair treatment, stigmatization, hypersurveillance, and contention situation to personal attacks on blacks' wellbeing. rbf is based on combat stress disorder, injury of posttraumatic disorder diagnosed with military personnel who have been to extreme stressful violence-ridden situations (pierce, 1975, 1995; smith, 2004). smith argues that while the military soldier is exposed to a high-level of hypervigilance in a context of life-threating conditions developing combat stress-related disorders, african-americans develop racial fatigue syndrome from constant threats that attack the dignity and character in a racially hostile environment resulting in coping that depletes psychological and physiological resources needed for other critical, creative, and productive areas of life. in addition to (mees) and (stem), rbf incorporates individualism, black misandry, and john henryism in its conceptualization of microaggressions. individualism or collectivism is necessary to understand the effect of the culture and society on people of color. the united states significantly values individualism, a trait consistent with the white anglo-saxon culture. individuality is in itself the basic unit of analysis and survival (hui & villareal, 1989). at the basis of this belief is that individuals are independent of another. this focus on individualism has being heightened via neoliberalism, which sees collectivism as a danger and individuals as being solely responsible for their demise and well-being. as anthropologist jose molina states, “you are the problem, but lucky for you, you are also the solution.” race scholars believe this focus on individualism is responsible for divergent beliefs among whites and people of  
  10 of 14  dominguez and embrick  color in terms of racism and keeps the extreme levels of oppressive beliefs, context, and environment affecting blacks and other people of color (bobo, 2000; bobo & hutchings, 1996; bobo & kluegel, 1993). possessing an individualistic ideology becomes a significant problem for those offering human services and policymakers who focus attention on proximate risk factors while ignoring social conditions and more distant factors that cause disease, mental health problems, educational deficiencies, and race-based stress (noguera, 2003). among many, individualism becomes a racial code word that excuses white privilege and white supremacy while victimizing further blacks and other people of color (hymowitz, 2005). rbf also incorporates black misandry into microaggressions, identified by smith (2010) as the hating of black men represented in gendered forms of racism. finally, rbf looks at the impact of behavioral stressors on blacks in the psychosocial construct, coined “john henryism.” john henry lives in the american folklore as a black man who died of a heart attack after winning a competition against a steam-powered steel-driving machine. he epitomizes the value of hard work and determination in the face of overwhelming odds, setting up the expectations that rbf should and can be coped with; the key element being that through hard work stressors can be contained. in sum, pierce, smith, and others see all these factors imbedded in rbf as curtailing the life chances and decreasing the life expectancy of blacks.  2.3.2    crt and racial microaggressions  solorzano (1998) is notable in his use of microaggressions as a tool in crt to understand educational disparities. as solorzano (1998, p. 122) states, “critical race theory in education challenges the dominant discourse on race and racism as they relate to education by examining how educational theory, policy, and practice are used to subordinate certain racial and ethnic groups.” the basic crt model that solorzano (1997, 1998) uses consists of five elements that interrogate: (a) the centrality of race and racism and their intersectionality with other forms of subordination; (b) a challenge to dominant ideology; (c) a commitment to social justice; (d) the centrality of experiential knowledge; and (e) the transdisciplinary perspective. solorzano explains that these components of crt are specific to the study of educational disparities due to discrimination. solorzano incorporates stereotype threat in his formulations of microaggressions, a concept for which steele and aronson (1995) is well known. solorzano, ceja, and yosso (2000, p. 62) state, “any exploration of racial microaggressions concept must include an examination of the cumulative nature of racial stereotypes and their effects.” steele and aronson sees stereotype threat to be responsible for people of color disappointing performance in tests, and this occurs when words that represent racial differences or race come up in questions, people of color become afraid of living up to the stereotype and that stress results in poor performance. because stereotype threat has been most validated in education activities, solorzano predicts that racial microaggressions in educational environments are based on stereotype threat. in later years, huber and solorzano (2015) would moved further in their conceptualization of microaggressions by adding visual and institutional microaggressions. they define visual microaggressions as, “systemic, every day visual assaults based on race, gender, class, sexuality, language, immigration status, phenotype, accent, or surname that emerge in various mediums such as textbooks, children's books, advertisements, film and television, dance and theater performance, and public signage and statuary” (223). through this framework, they studied the historical image of the mexican banditry as it appears in children's books and advertisements. by 2015, solorzano and perez huber are defining microaggressions as (a) verbal and nonverbal assaults directed towards people of color, often carried out in subtle, automatic or unconscious forms; (b) layered assaults, based on race and its intersections with gender, class, sexuality, language, immigration status, phenotype, accent, or surname; and (c) cumulative assaults that take a psychological, physiological, and academic toll on people of color. solorzano and perez huber consider racial microaggressions as a useful tool to study the everyday experiences of racism, which they say are inextricably linked to institutional racism (i.e., structures and processes), and ideologies of white supremacy that maintain racial subordination.  
  dominguez and embrick  11 of 14  in sum, solorzano et al. have included racial microaggression questions as a tool to accompany crt and stereotype threat as a synergetic way to study visual and institutional microaggressions as they play a significant role in educational disparities. in doing so, they demonstrate that racial microaggressions are much more than just insults. the use of crt has further allowed scholars to expand further in conceptualizing microaggressions as an intimate subordinating aspect of the racialized system of domination. this perspective, therefore, helped to move the discussion about subtle forms of racism in academic and nonacademic circles from the realm of individual interactions to an institutional realm. as such, it offers scholars interested in the subtler aspects of discrimination with an opportunity to study microaggressions more holistically.  2.3.3    sociologists enter the conversation  the past five or so years have seen many more sociologists entering into the debates and conversations of racial microaggressions, either expanding on racial groups affected, or using innovative methods in interrogating the power of racial microaggressions. on the former, we have seen more scholarship looking at indigenous groups (senter & ling, 2017), latinx (ballinas, 2017), and pacific islanders (vila & brunsma, 2014), for example. hughey et al. (2015), using an experimental vignette design, found that exposure to microaggressions are correlated with racial attitudes associated with various forms of repression of people of color. moreover, zambrana et al. (2017), using a mixedmethods approach, found that faculty of color in historically white institutions regularly encounter racial discrimination from colleagues and administrators. while this news is refreshing, the number of social scientists still neglecting the structural and institutional side of the racial microaggressions equation is far too many.  3 c o n c l u s i o n : t h e n e e d fo r m o r e i n t e rs e c t i o n a l a n d interdisciplinary analysis our objectives in this review were to highlight the significant contributions of chester pierce, philomena essed, and derald wing sue in microaggressions and racial microaggressions research. in doing so, we also considered the shortcomings in this area, much of which has been the result of the failures to fully realize the usefulness of a more interdisciplinary approach that fully captures the deleterious effects of daily racial micoaggressions on people of color at the individual, interpersonal and psychological levels, as well as structural and institutional levels of racism. in witnessing the trajectory of scholarship in this area, with some exceptions (see again smith, 2004; solorzano, 1998), we see minimal engagement in the earlier works of pierce and essed, with much research extending sue's racial taxonomy. the result, we argue, has been a stagnation in scholaroship that realizes, or captures, the full dangers that people of color face daily when exposed to everyday racism in society. as we have argued above, when considering everyday racial violence along the full life course, and at the individual, institutional, and societal levels, the multiplier effects of racial violence produce a very different story, one that may be much more alarming that we currently believe. in line with pierce's observations, racial microaggressions, contrary to its moniker (read: micro), is as harmful to people of color as how we think about torture and terrorism— toxic, deadly, potentially excruciatingly painful. better understanding the cumulative effects of racial microaggressions may help us to better understand racial health disparities such as black mothers maternal mortality, the rates of heart disease among blacks, and more. while we have advocated for more sociological insight to better understanding racial microaggressions, a better way moving forward would be to recognize the glaring obmission of scholarship that include historically (and currently) stigmatized and/or marginalized voices of the academic community, for example, afro-centrist/futurist, critical latino/a studies, du bosian thought, or colonial/post-colonial and settler colonial theories.  
  12 of 14  dominguez and embrick  finally, inspired by earlier works produced by philomena essed, particulary her research on everyday racism, we must recognize that the consequences of racial microaggressions do not affect all people in the same ways. we live intersectional lives and the multiplier effects of daily microaggressions are further compounded by our positions in society racially, ethnically, sexually, economically, and so forth. men of color face daily challenges coping with racial microaggressions as black men in a white supremacist society, and those stressors accumulate over time. but, as essed (1990) has noted, women of color face the additional scrutiny, discrimination, and daily microaggressions of living in a patriarchal society. if we start thinking about racial microaggressions along an intersectional and interdisciplinary approach, we might suddenly find ourselves grappling with a larger picture of the realities of the lives and costs of being a person of color in a racialized social system. orcid silvia dominguez  https://orcid.org/0000-0002-8965-0696  david g. embrick  https://orcid.org/0000-0002-4380-053x  endnotes 1 this quote from chester pierce was given at a psychiatric association conference in 1986; pierce presented his thinking about extreme mundane stress and its consequences in a lecture named, “unity in diversity: thirty-three years of stress.” 2 we note that some scholars have rebuked lilienfeld's review for its limitations in understanding the fundamental basics of racism in the u.s. for example, williams (2019a) contends that lilienfeld is misguided in his understanding of microaggressions and racism, in general. 3 mrp refers to microaggressions research project; lilienfeld (2017, p. 140) defines mrp as “the broad line of research focused on microaggressions and their potential impact on the behavior of recipients.” 4 for more information, see williams (2019b) [whitepaper]. “racial micro-aggressions: another means to obfuscating systemic white racism.” 5 we understand discriminatory stress as stressors (physical, physiological, and mental) that cumulate as a result of discrimination (real or perceived, overt or subtle). 6 for more on mees, see pierce (1975). the mundane extreme environment and its effect on learning. learning disabilities: issues and recommendations for research. in s. brainard (ed.), learning disabilities: issues and recommendations for research. washington, dc: national institute of education.  for a good overview of cultural pluralism, “melting pot,” and other classical assimilation theories, see steinberg's (2001) book, the ethnic myth: race, ethnicity, and class in america. new york, ny: beacon press.  7  8  it is worth noting that sue's racial taxonomy was developed through his observations, rather than systemactic empirical data.  re fe r enc e s anderson, e. (2011). the cosmopolitan canopy: race and civility in everyday life. new york, ny: w.w. norton & company. anderson, e. (2015). the white space. sociology of race and ethnicity, 1(1), 10–21. ballinas, j. (2017). where are you from and why are you here? microaggressions, racialization, and mexican college students in a new destination. sociological inquiry, 87(2), 385–410. bobo, l. (2000). race and beliefs about affirmative action: assessing the effects of interests, group threat, ideology, and racism. in d. o. sears, j. sidanius, & l. bobo (eds.), racialized politics: the debate about racism in america. chicago, il: the university of chicago press. bobo, l., & hutchings, v. l. (1996). perceptions of racial group competition: extending blumer's theory of group position to a multiracial social context. american sociological review, 61(6), 951–972. bobo, l., & kluegel, j. r. (1993). opposition to race-targeting: self-interest, stratification ideology, or racial attitudes? american sociological review, 58(4), 443–464. bonilla-silva, e. (1997). rethinking racism: toward a structural interpretation. american sociological review, 62(3), 465–480. boysen, g. a., & vogel, d. l. (2008). the relationship between level of training, implicit bias, and multicultural competency among counselor trainees. training and education in professional psychology, 2(2), 103–110. cicourel, a. v. (1981). language and the structure of belief in medical communication. studia linguistica: a journal of general linguistics, 35(1–2), 71–85.  
  dominguez and embrick  13 of 14  collins, r. (1981). on the microfoundations of macrosociology. the american journal of sociology, 86(5), 984–1014. dovidio, j. f., gaertner, s. e., kawakami, k., & hodson, g. (2002). why can't we just get along? interpersonal biases and interracial distrust. cultural diversity and ethnic minority psychology, 8(2), 88. embrick, d. g. (2015a). we will never forget (never again): massacre of the charleston 9, murders of brown and black bodies, and 21st century amerikkka. issues in race & society: an interdisciplinary global journal, 3(1), 1–10. embrick, d. g. (2015b). two nations, revisited: the lynching of black and brown bodies, police brutality, and racial control in 'post-racial' amerikkka. critical sociology, 41(6), 835–843. embrick, d. g., dominguez, s., & karsak, b. (2017). more than just insults: rethinking sociology's contribution to scholarship on racial microaggressions. sociological inquiry, 87(2), 193–206. embrick, d. g., & henricks, k. (2013). discursive colorlines at work: how epithets and stereotypes are racially unequal. symbolic interaction, 36(2), 197–215. embrick, d. g., weffer-elizondo, s., & dominguez, s. (2019). sanctuaries of white supremacy: art institutes and the boundaries of white spaces and whiteness. the international journal of sociology and social policy, 39(11/12), 995–1009. essed, p. (1990). everyday racism: reports from women of two cultures. claremont, ca: hunter house inc., publishers. essed, p. (1991). understanding everyday racism: an interdisciplinary theory. london, uk: sage publications ltd. grier-reed, tabitha l. (2010). the african american student network: creating sanctuaries and counterspaces for coping with racial microaggressions in higher education settings. the journal of counseling, education and development, 49(2), 181–188. huber, l. p., & solorzano, d. g. (2015). racial microaggressions as a tool for critical race research. race ethnicity and education, 18(3), 297–320. hughey, m. w. (2015). the five i's of five-o: racial ideologies, institutions, interests, identities, and interactions of police violence. critical sociology, 41(6), 857–871. hughey, m. w., rees, j., goss, d. r., rosino, m. l., & lesser, e. (2015). making everyday microaggressions: an exploratory experimental vignette study on the presence and power of racial microaggressions. sociological inquiry, 87(2), 303–336. hui, c. h., & villareal, m. j. (1989). individualism-collectivism and pyschological needs: their relationships in two cultures. journal of cross-cultural psychology, 20(3), 310–323. hymowitz, k. s. (2005). the black family: 40 years of lies; rejecting the moynihan report caused untold, needless misery. city journal. retrieved from. https://www.city-journal.org/html/black-family-40-years-lies-12872.html lilienfeld, s. o. (2017). microaggressions: strong claims, inadequate evidence. perspectives on psychological science, 12(1), 138–169. noguera, p. a. (2003). the trouble with black boys: the role and influence of environmental and cultural factors on the academic performance of african american males. urban education, 38(4), 431–459. ong, a. d., & burrow, a. l. (2017). microaggressions and daily experience: depicting life as it is lived. perspectives on psychological science, 12(1), 173–175. pierce, c. (1970). offensive mechanisms. in f. b. barbour (ed.), the black seventies. boston, ma: porter sargent publisher. pierce, c. (1974). psychiatric problems of the black minority. in s. arieti (ed.), american handbook of psychiatry. new york, ny: basic books. pierce, c. (1975). the mundane extreme environment and its effect on learning. in s. brainard (ed.), learning disabilities: issues and recommendations for research. washington, dc: national institute of education. pierce, c. (1995). stress analogs of racism and sexism: terrorism, torture, and disaster. in c. willie, p. rieker, b. kramer, & b. brown (eds.), mental health, racism, and sexism. pittsburgh, pa: university of pittsburgh press. sears, d. o. (1988). symbolic racism. in eliminating racism (vol. 1988, pp. 53–84). new york, ny: springer. senter, l., & ling, d. a. (2017). 'it's almost like they were happier when you were down': microaggressions and overt hostility against native americans in a community with gaming. sociological inquiry, 87(2), 256–281. smith, w. a. (2004). black faculty coping with racial battle fatigue: the campus racial climate in a post-civil rights era. in d. cleveland (ed.), a long way to go: conversations about race by african american faculty and graduate students. new york, ny: peter lang. smith, w. a., allen, w. r., & danley, l. l. (2007). 'assume the position... you fit the description': psychosocial experiences and racial battle fatigue among african american male college students. american behavioral scientist, 51(4), 551–578. smith, w. a. (2010). toward an understanding of black misandric microaggressions and racial battle fatigue in historically white institutions. in v. c. polite (ed.), the state of the african american male in michigan: a courageous conversation. east lansing: michigan state university press. solorzano, d., ceja, m., & yosso, t. (2000). critical race theory, racial microaggressions, and campus racial climate: the experiences of african american college students. journal of negro education, 69(1/2), 60–73. solorzano, d. g. (1997). images and words that wound: critical race theory, racial stereotyping, and teacher education. teacher education quarterly, 24(3), 5–19.  
  14 of 14  dominguez and embrick  solorzano, d. g. (1998). critical race theory, race and gender microaggressions, and the experience of chicana and chicano scholars. international journal of qualitative studies in education, 11(1), 121–136. steele, c. m., & aronson, j. (1995). stereotype threat and the intellectual test performance of african americans. journal of personality and social psychology, 69(5), 797–811. steinberg, s. (2001). the ethnic myth: race, ethnicity, and class in america. new york, ny: beacon press. sue, d. w. (2010a). microaggressions in everyday life: race, gender, and sexual orientation. new york, ny: john wiley & sons. sue, d. w. (ed.). (2010b). microaggressions and marginality: manifestation, dynamics, and impact. new york, ny: john wiley & sons. sue, d. w., alsaidi, s., awad, m. n., glaeser, e., calle, c. z., & mendez, n. (2019). disarming racial microaggressions: microintervention strategies for targets, white allies, and bystanders. american psychological association, 74(1), 128–142. sue, d. w., christina, m. c., gina, c. t., jennifer, m. b., aisha h., kevin, l. n., and marta e. (2007). racial microaggression in everyday life: implications for clinical practice. american psychologist 62, 271–287. sue, d. w., capodilupo, c. m., & holder, a. m. b. (2008). racial microaggressions in the life experiences of black americans. professional psychology research and practice, 39(3), 329–336. vila, l. k., & brunsma, d. l. (2014). microaggressions and the experiences of asian americans and pacific islanders at predominantly white institutions: a critical literature review. in r. v. robertson (ed.), the plight of students of color at predominantly white institutions: a critical reader. new york, ny: kendall hunt publishing. williams, j. e. (2019b, whitepaper). racial micro-aggressions: another means to obfuscating systemic white racism. williams, m. t. (2019a). microaggressions: clarification, evidence, and impact. perspectives on psychological science, 15, 3–26. wong, g., derthick, a. o., david, e. j. r., saw, a., & okazaki, s. (2014). the what, the why, and the how: a review of racial microaggressions research in psychology. race and social problems, 6(2), 181–200. zambrana, r. n., wingfield, a. h., lapeyrouse, l. m., davila, b. a., hoagland, t. l., & valdez, r. b. (2017). blatant, subtle, and insidious: urm faculty perceptions of discriminatory practices in predominantly white institutions. sociological inquiry, 87(2), 207–232.  author biographi es  dr. silvia dominguez is an interdisciplinary scholar with degrees in sociology, psychology, forensic social work, and social welfare policy. she specializes in areas addressing the welfare of women, children, and minorities both in the united states and abroad, with additional emphasis on sexual violence, race relations, social networks, mental health, and immigration. she currently serves as an associate professor of sociology in the department of sociology and anthropology at northeastern university. dr. david g. embrick holds a joint position as associate professor in sociology and africana studies at the university of connecticut. formally, he spent a decade as faculty in the sociology department at loyola university chicago. he received his ph.d. from texas a&m university in 2006. he is a former american sociological association minority fellow; past-president of the southwestern sociological association and the association for humanist sociology. currently, he serves as founding co-editor of sociology of race and ethnicity, the latest asa sponsored journal of the section on racial and ethnic minorities.  how to cite this article: dominguez s, embrick dg. racial microaggressions: bridging psychology and sociology and future research considerations. sociology compass. 2020;14:e12803. https://doi.org/10.1111/ soc4.12803  
  copyright of sociology compass is the property of wiley-blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. however, users may print, download, or email articles for individual use.  
       


secondary_title_index: religions
title_index:
       spiritual crisis as a unique causal predictor of emotional and characterological impairment in atheists and agnostics: numinous motivations as universal psychological qualities     

full_text_index:
       religions article  spiritual crisis as a unique causal predictor of emotional and characterological impairment in atheists and agnostics: numinous motivations as universal psychological qualities ralph l. piedmont 1, *, jesse fox 2 1 2 3  *  and marion e. toscano 3  center for professional studies, 9603 deereco road, #5334, timonium, md 21094, usa department of counselor education, stetson university, deland, fl 32723, usa; jfox2@stetson.edu natural & health sciences and education faculty, mount mary university, milwaukee, wi 53222-4597, usa; toscanom@mtmary.edu correspondence: mrmagic328@comcast.net    received: 31 july 2020; accepted: 13 october 2020; published: 24 october 2020  abstract: while there is a tremendous literature documenting the positive value of religious and spiritual (r/s) constructs on an array of psychosocial outcomes (e.g., health, resilience, coping ability), spiritual crisis (sc) reflects the negative side of the numinous in a way that stresses the value and importance of r/s constructs for psychological functioning. this study examined whether numinous constructs are more relevant to theists or represent universal psychological qualities. using an mturk-based sample comprising both theists and atheists (n 1399; 800 women and 595 men, four gave no response), the predictive ability of sc on both affective and characterological distress was examined using both regression and sem analyses. the results indicated that both theists and atheists understood the numinous in similar ways and that scores on sc were of equal incremental predictiveness for both groups. sem analyses supported the causal model that understood sc to be a unique and independent (from the personality domains of the five-factor model) predictor of these clinical outcomes. these findings stress the value of the numinous for understanding all clients and that psychological assessment needs to systematically address numinous constructs in order to ensure comprehensive treatment of psychological impairment. keywords: spiritual crisis; numinous motivations; numinous motivation inventory; atheists  1. introduction “indeed, if religion is a human universal, then we should expect to see it everywhere, reinvented and repackaged in secular guises all around us. this renders the scientific study of ‘religion’ more difficult but also much more compelling”. (grassie 2010, p. 47) religious and spiritual crises (rc/sc) are very important constructs in the psychology of religion and spirituality (prs)1 . while there is a tremendous literature documenting the positive value of religious and spirituality (r/s) constructs on an array of psychosocial outcomes (e.g., health,  1  the constructs of “religious crisis” (rc) and “spiritual crisis” (sc) are related terms in that both capture feelings of rejection and inadequacy from a larger, transcendent reality. however, there are important differences between the two. piedmont (2020) and piedmont and wilkins (2020) have proposed that spirituality and religiousness, while strongly related, represent different psychological constructs. spirituality represents an intrinsic, operant source of motivation that is very similar to other personality traits; it is an inherited quality. religiousness, on the other hand, represents a learned set of values and beliefs, something that is acquired through socialization. while both are sources of motivation, they are mediated by  religions 2020, 11, 551; doi:10.3390/rel11110551  www.mdpi.com/journal/religions  
  religions 2020, 11, 551  2 of 20  resilience, coping ability; koenig et al. 2001; plante and sherman 2001), sc reflects the negative side of the numinous in a way that stresses the value and importance of r/s constructs for psychological functioning. sc represents an extreme level of existential condemnation—the personal belief that an individual is unworthy or of little value within the larger scheme of life itself—that one’s existence has completely failed to be of benefit to life. the resulting feelings of emptiness and existential rejection can lead to tragic consequences, like suicide, depression, and characterological impairments (fox and piedmont 2020; piedmont 2017; piedmont et al. 2007; piedmont and wilkins 2020). the profound impact of sc on functioning raises an important question, “is sc an issue only for those who believe in the existence of a god or is there something more fundamental, and universal, that is operating?” if sc is only relevant for theists, then the construct represents a limited dynamic that is merely an epiphenomenon of religious belief. however, if sc represents a more fundamental, universal quality, then an exciting possibility exists for both expanding our understanding of intrapsychic dynamics as well as identifying a new, broad causal pathway to psychological impairment. the purpose of this report is to address this question head-on by examining the utility and predictive power of this construct in samples of both theists and non-theists. 1.1. the role of the numinous in the psychology of religion and spirituality (prs) 1.1.1. god-centric approach the dominant model for understanding r/s constructs is god-centric, in that r/s variables are only relevant and important to individuals who are theists. the role of god is important to this perspective because without such a belief, r/s constructs have little value or relevance. further, many constructs are based on theological traditions and perspectives grounded specifically in the western religious context of mono-theism and the abrahamic traditions (judaism, christianity, and islam; e.g., christian experience inventory (alter 1989); god image inventory (lawrence 1991)). while this approach may provide a clear direction for identifying qualities and behaviors that may be of importance to understanding r/s sentiments, it does serve to parochialize the larger implications of these constructs. reinforcing this approach is the assumption that spirituality emerges out of religion, making it a facet of religious belief (pargament 1999). thus, at the center of r/s research is a belief in a transcendent god and it is the personal attachment to this god that creates the spiritual and religious sentiments of the person. pargament (1999, p. 12) has defined spirituality and religiousness as “a search for the sacred.” what is essential to this definition, according to pargament, is the role of the sacred in making motivations spiritual, “at the heart of the sacred lies god, divine beings, or a transcendent reality” (pargament 2007, p. 33). this definition makes a distinction between personal ethics or guiding philosophies of life and r/s beliefs: there are those motivations that are spiritual because of their god-centric perspective and those that are not spiritual because god is not involved (see also hill et al. 2000, p. 65). this approach prevents the prs from succumbing to a vague, boundaryless, spiritualism where anything is seen as spiritual. this empties the construct of any practical meaning and impedes its differentiation from something that is not spiritual. for instance, veganism can be part of spiritual outlook on life, but veganism by itself is not by definition spiritual. moreover, by differentiating a sacred core (the essence of spirituality) vs. a sacred ring (symbols of the sacred core, i.e. religions), it makes the study of the prs less confined to one religious perspective and opens up the possibility of  different psychological systems (see piedmont et al. (2009) for data which support this view). practically, these constructs ought to predict similar outcomes for people. the difference, though, is that rc examines this sense of rejection as a result of one’s abandonment from the god of one’s understanding and/or from one’s religious community. sc understands this rebuff as stemming from a personal feeling of condemnation and rejection by one’s own sense of ultimate value and worthiness. the former construct requires a belief in a god while the latter does not.  
  religions 2020, 11, 551  3 of 20  multiple, valid perspectives. though not entirely universal, it is less exclusive than researching the sacred through the lens of one religion or assuming a priori privilege of one tradition (e.g., christian). there are, at the same time, several limitations to this perspective. first, it makes prs a rather boutique area of research because of its focus on a very select group of people: those who are theists or those very closely associated like polytheists. while this includes a large number of people, it does exclude people of faith from religions that do not necessarily contain a western concept of “god” (e.g., shintoists, buddhists, janists, etc.). this perspective also minimizes nontheists and nonreligious individuals, who are also mostly unincluded in the research literature (leach and sato 2013). there is the perspective that without a notion of god, there is no spirituality, thus non-believers cannot avail themselves of the benefits of spirituality. it is as if such individuals are unable to create meaning systems that are as developed and psychologically useful as those of believers. second, this approach faces a crisis of utility according to the secularization hypothesis, which states that as individuals and societies embrace secularization (non-religious political institutions, industrialization, science, and modern medicine) religions will lose their relevance (voas 2019; voas and chaves 2016). is the implication of secularization, then, that with people moving out of religious affiliations or not acquiring them (pew research center 2015), mean that the prs is therefore less salient and of increasingly limited value for psychotherapy? this question strikes to the heart of the prs conceptualized from the perspective of the god-centric approach and poses a significant threat to the utility of the field. finally, by casting our constructs as reflecting god-based theologies, there are real ethical concerns as to whether social scientists are being cast as shills for religion. for example, when research shows a positive association between religious attendance and better blood pressure levels (e.g., (koenig et al. 2001)), should therapists recommend to their hypertensive patients to attend church services? should therapists encourage atheists and other nonbelievers to become believers in order to improve their health status? while some in this field may find this useful (e.g., koenig 1999), it may create ethical issues centering on coercion and discrimination (sloan et al. 2001). even when the practice of counseling and psychotherapy includes a respect for worldview differences between clinicians and clients, such as spiritually integrated psychotherapy (pargament 2007), a god-centric approach does not offer a framework for applying the psychological benefits of religion beyond group level interpretation. while this perspective may be less coercive than the one above, findings from research using this approach are really ethically limited to applications with clients who are followers of religions. it makes no ethical sense, for instance, to assess religious coping in a client who is atheist, even though a strong research base exists demonstrating the utility of religious coping for promoting psychological health. 1.1.2. the universal approach there is a growing acknowledgement that r/s issues are really the particular expressions of universal existential human motivations (grassie 2010; piedmont and wilkins 2020). from this perspective, all people confront a similar array of issues surrounding personal needs for meaning, worthiness, and finitude (tillich [1952] 2000). as such, spiritual issues and concerns are addressed by all people, although the responses to these concerns may be quite varied (comte-sponville 2006; grassie 2010). piedmont (2015); piedmont and wilkins (2020) has developed an ontological model that outlines the origins, role, and functioning of numinous dynamics. numinous motivations are those psychological qualities that underlie peoples’ interest in religious and spiritual issues. numinous constructs are what propel the “search for the sacred” noted by pargament (2007). this ontological model stresses the unique, exceptional nature of the numinous and is based on three observations: (a) r/s are universal aspects of human functioning, being significant factors in all cultures and across all ages; (b) there are individual differences in the extent to which individuals are sensitive to these qualities, indicating that these qualities are both inherent to people and evidence individual-difference properties akin to other personality-type constructs; and (c) r/s dynamics are unique to the human species; there are no animal models for these constructs. the existence of these qualities is rooted in  
  religions 2020, 11, 551  4 of 20  the core of our humanity. piedmont argued that r/s constructs (i.e., numinous motivations) find their origins within the neo-cortex, that aspect of brain functioning that is responsible for the unique cognitive powers that characterize humans. for piedmont, the numinous represents those psychological qualities that uniquely define the human species (piedmont n.d.; piedmont and wilkins 2020). these motivators are what make r/s so important to all humans. it also provides an understanding of r/s constructs that promotes interpretive value and clinical significance. piedmont identified three core numinous motivations: infinitude (i; our need to find personal durability for our strivings in life), meaning (m; the need to develop purpose and direction for our lives), and worthiness (w; finding personal acceptance of self within a transcendent perspective). what is important is that all of these qualities are strictly psychological in nature. there is no need for appeal to specific theologies or religious denominations in order to understand the value and role of these constructs. as noted above, our numinous motivations are what make r/s so important to us as a species. having this ontological model provides direction and clarity to defining what is and is not a r/s construct (see piedmont and wilkins (2020) for a complete presentation of this model and its clinical applications). the value of this universal approach is that it offers the opportunity to expand the social science’s understanding of the mental world because these qualities operate independently of other aspects of the psychic system (e.g., personality). as a new dimension of functioning, their role in psychological process may provide new perspectives on disorders that seem resistant to standard interventions. there may also be the potential for new types of interventions based on the numinous that can be useful for addressing a wide array of psychosocial issues. 1.2. developing and applying universal numinous constructs piedmont and wilkins (2020) presented a rigorous empirical model for developing numinous constructs which is based on nine assumptions about the underlying nature of these motivations. the end goal of this process is the creation of a psychological scale that contains concepts and perspectives found in many religions but presented using non-theistic language. further, such a scale would be independent of already existing psychological constructs and universally relevant. the non-denominational language in scale items makes the completion of the measure easier and more appropriate for non-theists. working from this perspective, piedmont (2017, in press) has developed the numinous motivation inventory (nmi) which he considers to be a second-generation measure of the numinous. based on findings from previous research, the nmi attempts to provide a more accurate assessment of the numinous with consequently higher predictive validities. as a measure of universal motivations, scores on the scale ought to be equally reliable and valid across denominational status. the emerging data on this scale appears to support the value of both the ontological and empirical models upon which it is based (piedmont n.d.; piedmont and wilkins 2020). of particular interest to this study is the numinous facet of worthiness (w). piedmont (2017, p. 12) provided the following description of this construct: while we recognize our own imperfections and failings, ultimately each of us assesses our worth and value within the entire universe as we conceive and understand it. this creation of ours exists as its own reality that calls on us to make a statement of our own worth and value. in return we seek acceptance as being worthy. we seek acceptance from the totality of our entire sense of meaning, despite our own perceived unacceptability. there is security in feeling worthy, there is emptiness in feeling condemned. for those who score high on this scale, there is a feeling of personal security and comfort in being which leads to a larger, overall sense of well-being. for those who score low, there is an experience of existential condemnation that is difficult to overcome. piedmont and wilkins (2020) provided data showing how low scores are associated with suicidal ideation and continual thoughts of death. worthiness represents the core qualities of what is commonly referred to as religious crisis (piedmont  
  religions 2020, 11, 551  5 of 20  2020) or spiritual struggle (fox and piedmont 2020). this construct has shown itself to be a very powerful predictor of emotional distress and maladjustment (ano and vasconcelles 2005; exline 2013; exline et al. 2000; wilt et al. 2016). working with the religious crisis (rc) scale from piedmont’s first generation measure of the numinous, the assessment of spirituality and religious sentiments (aspires) scale (piedmont 2020), piedmont et al. (2007) demonstrated that sc was a significant predictor of characterological impairment, even after the predictive effects of the domains of the five-factor model (ffm; digman 1990) of personality were partialed out. fox and piedmont (2020) examined the predictive value of rc in regards to the experience of depression, anxiety, and stress. several important findings were observed. first, rc was a significant, unique predictor of these measures of affective dysphoria; it evidenced significant incremental predictive power over the ffm domains. this suggested that rc and neuroticism were complementary predictors of emotional distress. second, using structural equation modeling, fox and piedmont evaluated three different causal models that varied the role of rc on the outcomes (see figure 1). the results indicated that understanding rc as an independent, causal agent was found to be the best model. two important conclusions were drawn from these data. first, the numinous represents a human-specific motivation that is independent of other, evolved psychological drives. it also indicated that there may be a second pathway leading to psychological problems other than neuroticism. the numinous may have a significant role to play in creating wellness and distress. second, the causal modeling analysis demonstrated that the reason why rc is correlated with such dysphoria is because it serves as an independent causal input into the psychic system. the field of prs has never provided any explanation of the nature of its constructs (e.g., piedmont 2014), leaving critics to see them as merely stand-in variables for already existing psychological constructs (funder 2002; buss 2002; van wicklin 1990). these findings showed such perspectives as missing the essential nature of these motivations. 1.3. the current study the data to date have indicated that numinous constructs are independent of existing psychological motivations and operate as causal agents in the psychological system. there is one further essential test for piedmont’s ontological model: are numinous motivations really universal? an extensive literature has already emerged demonstrating the cross-cultural and cross-religious generalizability of numinous motivations (e.g., chen 2011; joshanloo 2012; piedmont and leach 2002; rican and janosova 2010); numinous constructs have been found to be reliable and valid with christians, jews, muslims, hindus, and other indigenous religious groups. however, all of these studies included religious believers. it could be argued that the conceptual and theological differences between these faith traditions are not as large as one would believe them to be (grassie 2010). therefore, any belief in a transcendent, eternal being/reality brings with it exposure to similar numinous concepts. the current study provides a more rigorous test of the universality of numinous motivations: an examination of the numinous with atheists and agnostics. these are individuals who are not members of any religious tradition. while some may have been denominationally affiliated at some point in their pasts and therefore have some familiarity with numinous concepts, as atheists/agnostics these individuals have rejected current religious ideas and practices, seeing them as being irrelevant and/or sophistic. these individuals are quite distinct from believers who have made a personal commitment to these beliefs and practices and the transcendent perspective they proffer. therefore, if the numinous is very much a theologically-derived concept, then it should hold little value for atheists and agnostics. if this is true, then we would expect to find the factor structure of the nmi to be different with this group than with believers. we would further expect that the nmi would be of little predictive value for atheists in comparison to believers and would evidence no causal predictiveness. however, if the numinous is truly universal, then atheists and believers alike ought to understand the nmi constructs similarly and scores ought to predict the outcomes with comparable effect sizes. finally, the numinous would evidence itself as being an independent causal predictor of  
  religions 2020, 11, 551  6 of 20  both affective and characterological impairment for both groups. this will be done by demonstrating that worthiness will evidence significant, incremental predictive power over the dimensions of the five-factor model (ffm) of personality (digman 1990; mccrae 2010). these dimensions have been shown to comprehensively represent those individual difference variables traditionally considered to be personality (piedmont 1998). finding evidence of universality will bring a sense of parsimony to research in this area by demonstrating that all r/s constructs (whether denominationally based or not) have a common foundation in a core set of motivations. further, because numinous motivations are independent of established individual-differences variables, it may represent a whole new class of psychological processes in need of exploration and development. because the numinous is a core aspect of functioning that is unique to humans, plumbing its depths promises to yield new insights into our ultimate nature and the identification of new modalities for encouraging change, growth, and resilience. 2. method 2.1. participants participants were selected from the normative sample of the nmi (piedmont 2017) which consisted of 1626 individuals. for the purposes of this study these individuals were assigned to either the believer or atheist/agnostic groups based on their religious affiliation. not included were those who indicated they were buddhists, pagans or earth-based, or were spiritual but not religious (n 227), resulting in an overall usable sample of 1399 volunteers (800 women and 595 men, 4 gave no response) ranging in age from 18 to 81 (m 37.15, sd 12.02). the sample was restricted to just us residents for whom english was their first language. concerning ethnicity, 75% were caucasian, 7% were african-american, 7% asian, 6% hispanic, 3% multiethnic, with the remaining 2% being american indian, arabic, native hawaiian, and other. regarding education level, 75% had a college degree or college experience; 17% had a graduate or post-graduate degree, 8% had a high school diploma and less than 1% had less than high school education. concerning occupation 12% of the sample were in education, with the remaining participants coming from a wide array of careers (e.g., 11% health care, 12% information technology, 7% administration, and 6% retail). the believer (bel; n 908) and atheist/agnositic (a/a; n 491) groups were composed as follows: in the bel group, there were 824 christians (e.g., catholics, baptists, episcopal, evangelical, lutheran, pentecostal, presbyterian), 22 hindus, two american-indians of indigenous faith, 27 jews, 18 muslims, and 20 who indicated “other faith tradition.” in comparing these two groups, no significant difference was noted on an education level. however, there were differences in terms of age (a/a m 34.36 vs. bel m 38.65; t(1397)  6.46, p 0.001) with the a/a group being slightly younger; gender (χ2 (1; n 1395) 8.99, p 0.003) with more women than expected in the bel group and more men in the a/a group; and ethnicity (χ2 (1; n 1399) 29.05, p 0.001) with more african-americans in the bel group than expected and more caucasians in the a/a group. 2.2. measures 2.2.1. the international personality item pool-50 (ipip-50) developed by goldberg (1992) is a 50-item inventory of the ffm of personality. the scale measures each dimension of the ffm using 10 items, including (a) emotional stability (es), (b) extraversion (e), (c) imagination (openness; o), (d) agreeableness (a), and (e) consciousness (c). participants read each statement and respond by indicating how it describes them from very inaccurate (1) to very accurate (5). the ipip-50 is in the public domain and has demonstrated comparable psychometric qualities to commercial inventories of the ffm (goldberg et al. 2006; mlac ic and goldberg 2007). alpha coefficients for the current study are reported in table 1.  
  religions 2020, 11, 551  7 of 20  2.2.2. the depression, anxiety, and stress scale-21 (dass-21) developed by (lovibond and lovibond 1995; brown et al. 1997), the depression, anxiety, and stress scale-21 (dass-21) is a brief measure of symptoms common to psychological distress. the instrument consists of three factors (depression, anxiety, and stress) comprised of seven items emblematic of each form of psychological distress. participants read through each symptom and respond from “did not apply to me at all” (0) to “applied to me very much or most of the time” (3) over the course of the previous week. in a non-clinical sample of the u.s. general population, sinclair et al. (2012) reported the following means and standard deviations for each scale of the dass-21: depression 5.70 (8.2), anxiety 3.99 (6.3), stress 8.12 (7.6), and total score 17.80 (20.2). alpha coefficients for the current study are reported in table 1. 2.2.3. numinous motivation inventory (nmi) developed by piedmont (2017) this 22-item scale assesses numinous qualities of the individual. there are three facet scales: infinitude (i), an intrinsic drive to acquire substance and continuity in one’s life in the face of one’s own mortality (item: i believe that this life is only one stage in a larger, eternal process); meaning (m), captures the extent to which individuals have created an ultimate sense of personal meaning that they place their ultimate trust in and towards which they devote their lives (item: i am guided by my personal philosophy and/or faith); worthiness (w), the extent to which individuals experience acceptance and worth, despite personal foibles and imperfections, from their perceeived understanding of life (item: i value myself). items are responded to on a 1 (strongly disagree) to 5 (strongly agree) likert-type scale. items are balanced to control for acquiescence effects. piedmont (2017) demonstrated the independence of these scales from established personality dimension (e.g., the five-factor model of personality (ffm) dimensions), their incremental validity over the ffm in predicting an array of psychosocial outcomes (e.g., resilience, self-compassion, positive and negative affect). reliabilities for this scale are presented in table 1. 2.2.4. personality inventory for the dsm-5 brief form (pid-5) developed by krueger et al. (2012), this 25-item scale is intended to capture personality-related dimensions that underlie the diagnostic and statistical manual-5’s (dsm-5; american psychiatric association 2013) personality disorders (pds). items are responded to on a 0 (very false) to 3 (very true) likert-type scale. there are five dimensions assessed: negative affect (na): the frequent and intense experiences of high levels of negative emotions; detachment (detach): the avoidance of socioemotional experiences including both social withdrawal and restricted affective experiences; antagonism (antag): tendency of individuals to put themselves at odds with others; disinhibition (inhib): an orientation towards immediate gratification and impulsiveness that is driven by thoughts, feelings, and external stimuli; and psychoticism (psychotic): the expression of culturally incongruent odd, eccentric, or unusual behaviors and cognitions. krueger et al. (2012) provide initial evidence of validity. reliabilities for these scales in the current study are presented in table 1. 2.3. procedure loyola university maryland’s institutional research board approved this study. all of the measures were digitized and loaded into a qualtrix survey. that survey was then uploaded onto amazon’s mturk platform, an online platform for soliciting research participants. the data presented here are part of a larger study (piedmont 2017). participants were paid 1.25 for completion of the survey, with the money being directly credited to their respective amazon accounts by amazon. for the purposes of this study, we requested only us-based workers for whom english was their first language. the presentation of the measures was counterbalanced to control for any order effects. further, three attention check items were included. any participant who failed to select the appropriate response for any of these items was deleted from the final data set.  
  religions 2020, 11, 551  8 of 20  3. results the data were screened for missing data and there were none. this is because each item had to be completed before one could move on to the next. moreover, for workers to be paid, they are required to answer all items. data were then analyzed for multivariate outliers using procedures outlined by tabachnick et al. (2007) and no cases were identified. examinations for univariate outliers and non-normal distributions indicated that the data were appropriate for parametric analyses. 3.1. descriptive statistics table 1 provides the descriptive statistics across all scales separately by belief group. mean level scores on the ipip-50 are consistent with other us samples (e.g., robertson et al. 2017), although the current sample is slightly lower on extraversion. alpha reliabilities for these scales were comparable to those found by robertson et al. scores on the pid-5 can range from 0 to 15, thus the scores observed in this sample are in the middle of that range. values this high indicate some minor levels of distress. alphas are all consistent with previous data. scores on the dass appear slightly higher than college students (e.g., fox and piedmont 2020), paralleling the pid-5 results, suggesting higher levels of emotional distress. alphas are consistent with previous studies. a comparison of mean level scores across the two belief groups indicated significant differences on all scales. as such, cohen’s d values are reported as the basis for understanding these differences. according to cohen (1987) effect size interpretations for d are 0.20 small, 0.50 medium, and 0.80 large. as can be seen in table 1, all but two differences fall in the “small” range. thus, the observed differences can be attributed more to sample size than to any substantive factor. the exceptions are found on the nmi scales of infinitude and worthiness. here, there are large differences between the two groups, with the a/a group scoring lower. interestingly, the worthiness scale shows only a small difference effect. in terms of worthiness, the item content may appear more personally relevant than the other two scales. table 1. descriptive statistics by faith orientation and overall alpha reliabilities for study variables.  scale ipip-50 emotional stability extraversion openness agreeableness conscientiousness nmi infinitude worthiness meaning pid-5 negative affect detachment antagonism disinhibition psychotic dass stress anxiety depression total score  atheists/agnostics (n 491)  believers (n 908)  cohen’s d  α  m  sd  m  sd  31.68 27.34 38.43 37.27 36.21  9.53 9.03 6.40 7.42 7.24  33.89 28.98 37.35 39.33 37.27  9.10 8.68 6.55 6.67 7.19  0.24 0.19 0.17 0.30 0.15  0.91 0.90 0.83 0.87 0.85  20.04 34.51 11.42  7.70 8.38 3.73  31.69 36.94 17.47  7.00 7.19 4.59  10.61 0.32 10.41  0.94 0.93 0.85  10.71 9.98 8.07 8.46 9.16  3.63 30.47 3.02 3.41 3.38  10.09 8.89 7.70 8.00 8.65  3.62 3.37 2.94 3.25 3.47  0.17 0.32 0.12 0.14 0.15  0.85 0.81 0.79 0.81 0.82  11.90 7.64 11.33 30.87  9.47 8.66 10.92 26.66  10.38 7.04 8.40 25.82  9.04 8.02 9.36 24.34  0.17 0.07 0.29 0.20  0.90 0.88 0.93 0.95  ipip-50 international personality item pool, ffm 50 item version; nmi numinous motivation inventory; pid-5 personality inventory for dsm-5; dass depression, anxiety, and stress scale.  
  religions 2020, 11, 551  9 of 20  3.2. factor structure given the mean level differences between the two belief groups on the nmi, the question arises as to whether the groups understand the items to the scales in similar ways. to examine this, the nmi items for each group were subjected to a principal components analyses where three factors were extracted and obliquely rotated. differences in factor structure would indicate that the two groups understand the items in psychologically different ways. table 2 provides the pattern loadings for the two samples. table 2. comparison of the pattern loadings for the numinous motivation inventory (nmi) items between atheists/agnostics and other faith traditions. nmi item i1 i2 i3 i4 i5 i6 i7 i8 w1 w2 w3 w4 w5 w6 w7 w8 w9 m1 m2 m3 m4 m5 congruence coefficients  factor 1  factor 2  factor 3  a/a  bel  a/a  bel  a/a  bel  0.74 0.89 0.81 0.88 0.84 0.82 0.77 0.66 0.06  0.02 0.06  0.04 0.00 0.03  0.02 0.03  0.02  0.17  0.05 0.20  0.01 0.23  0.84 0.83 0.75 0.87 0.68 0.56 0.52 0.41 0.18 0.09 0.07  0.05 0.05 0.02  0.05 0.06  0.17 0.21 0.08  0.03 0.18  0.12  0.06 0.05 0.15 0.06  0.04  0.07  0.06  0.11 0.80 0.84 0.81 0.84 0.79 0.85 0.80 0.82 0.80 0.13  0.04  0.28 0.03 0.06  0.06 0.09 0.24 0.06 0.05  0.07 0.02 0.05 0.75 0.79 0.81 0.81 0.75 0.78 0.78 0.78 0.78 0.01 0.04 0.10 0.08 0.11   0.11  0.11  0.14  0.13 0.11 0.09 0.17 0.19  0.06 0.07  0.03  0.02  0.07  0.01 0.05 0.00 0.16 0.73 0.80 0.56 0.70 0.42   0.16 0.01 0.01  0.03 00.30 0.29 0.40 0.48  0.12  0.07  0.03  0.03  0.02 0.02 0.03 0.05 0.23 0.71 0.81 0.84 0.70 0.55  0.94  0.99  0.95  congruence coefficients 1.00 0.99 0.98 0.99 0.96 0.93 0.90 0.83 0.98 0.98 1.00 1.00 1.00 1.00 1.00 1.00 0.98 0.86 0.98 0.90 0.96 0.76 0.96  w worthiness; i infinitude; m meaning; a/a—atheists/agnostics; bel believers. note. loadings greater than or equal to 0.40 are in bold.  two points of interest emerge from table 2. first, the three-factor putative structure to the nmi is clearly recovered in both groups. interestingly, the only infelicity in these data are found for the believer group where two infinitude items have secondary loadings on the meaning dimension. for the a/a group, all items load on their intended factor with appropriate magnitudes. second, congruence coefficients (ccs; gorsuch 1983) were calculated to determine the extent to which the two sets of loadings are identical. ccs provide values between zero and one, with values of 0.90 or above indicating that the two sets of loadings are the same. the last column of table 2 provides ccs for each nmi item. the loadings of each item across all three factors are compared in both groups. as can be seen, the ccs for 19 of the 22 items indicate that they load similarly across the two groups. the bottom row provides ccs for each factor, determining whether the pattern loadings in each group for each factor are similar, which was found here. lastly, the last cc (0.96) in bottom row provides an overall measure of agreement across both items and factors, essentially testing whether the overall matrices of loadings are the same, which these findings indicate. thus, despite whatever mean level differences in scores observed between the two groups, both groups generate identical factor structures.  
  religions 2020, 11, 551  10 of 20  3.3. predictive analyses the personality scales and the three nmi scales were correlated with the clinical outcome scales and the results are presented in table 3. as expected, the personality dimension of es was significantly correlated with the outcome scales in both groups and to similar magnitudes (m correlation for a/a group 0.576; m correlation for bel group 0.552). neuroticism is a broad-based predictor of affective lability. of interest are the correlations between the two groups on worthiness. all the clinical scales correlate significantly with w and are of similar magnitude across the two groups (m correlation for a/a group 0.534; m correlation for bel group 0.559). again, despite mean level differences on the nmi between the two groups, scores for both groups on w correlate, with similar magnitude, with the clinical scales. table 3. correlations between personality, worthiness, and the depression, anxiety, and stress scale (dass) and personality inventory for dsm-5 (pid-5) scales separately by faith status. predictors  outcomes a/as (n 491) pid-na pid-detach pid-antag pid-disinhib pid-psychotic dass-stress dass-anxiety dass-depression dass-total score believers (n 908) pid-na pid-detach pid-antag pid-disinhib pid-psychotic dass-stress dass-anxiety dass-depression dass-total score  w  i  m  es  e  o  a  c   0.49 ***  0.68 ***  0.31 ***  0.42 ***  0.48 ***  0.56 ***  0.54 ***  0.68 ***  0.65 ***  0.04  0.04 0.05 0.10 * 0.10 * 0.01 0.06  0.07  0.01  0.01 0.03 0.16 *** 0.17 *** 0.17 *** 0.07 0.12 ** 0.01 0.07   0.79 ***  0.48 ***  0.31 ***  0.37 ***  0.50 ***  0.74 ***  0.59 ***  0.68 ***  0.73 ***   0.21 ***  0.47 *** 0.07  0.04  0.12 **  0.16 ***  0.15 ***  0.26 ***  0.21 ***   0.16 ***  0.28 ***  0.13 **  0.21 ***  0.16 ***  0.15 ***  0.23 ***  0.17 ***  0.20 ***   0.20 ***  0.50 ***  0.45 ***  0.28 ***  0.32 ***  0.24 ***  0.23 ***  0.27 ***  0.27 ***   0.38 ***  0.32 ***  0.22 ***  0.56 ***  0.43 ***  0.40 ***  0.35 ***  0.40 ***  0.42 ***   0.52 ***  0.65 ***  0.45 ***  0.48 ***  0.53 ***  0.56 ***  0.52 ***  0.69 ***  0.65 ***   0.12 ***  0.22 ***  0.32 ***  0.25 ***  0.17 ***  0.12 ***  0.18 ***  0.21 ***  0.19 ***   0.15 ***  0.17 ***  0.22 ***  0.19 ***  0.15 ***  0.15 ***  0.16 ***  0.18 ***  0.18 ***   0.77 ***  0.50 ***  0.34 ***  0.41 ***  0.50 ***  0.68 ***  0.51 ***  0.61 ***  0.65 ***   0.24 ***  0.39 *** 0.04  0.02  0.16 ***  0.18 ***  0.12 ***  0.24 ***  0.19 ***   0.19 ***  0.24 ***  0.19 ***  0.19 ***  0.07 *  0.14 ***  0.16 ***  0.19 ***  0.18 ***   0.24 ***  0.51 ***  0.54 ***  0.43 ***  0.42 ***  0.29 ***  0.30 ***  0.34 ***  0.34 ***   0.40 ***  0.38 ***  0.43 ***  0.58 ***  0.46 ***  0.40 ***  0.38 ***  0.38 ***  0.42 ***  * p 0.05. ** p 0.01. *** p 0.001, two-tailed. pid-na pid-5 negative affect; pid-detach pid-5 detachment; pid-antag pid-5 antagonism; pid-disinhib pid-5 disinhibition; pid-psychotic pid-5 psychoticism; dass depression, anxiety, and stress scale; a/a atheists/agnostics; w worthiness; i infinitude; m meaning.  the above findings demonstrates that the numinous is indeed related to these psychological outcomes. however, in order to demonstrate that the numinous represents an independent and unique predictor or distress, an important question need to be answered, “to what extent do these associations with worthiness represent unique effects or are merely artifacts of the nmi scales’ overlap with the content of the ffm scales?” while conceptualized to be independent dimensions, to the extent that the nmi scales have content that overlaps with emotional stability on the ipip-50, then such associations reflect this contaminated content. in order to answer this question, a series of nine hierarchical regression analyses were conducted for each group, systematically using one of the clinical scales as the outcome (i.e., four using the dass and five using the piq-5). on step 1 of the analysis, the five personality dimensions were entered simultaneously. on step 2, the three nmi scales were then entered using a forward entry technique. a partial f-test was conducted to determine whether any of the nmi scales had significant, incremental predictive validity over the ffm domain scores. further, an inspection of the beta weights will allow for a determination of the relative unique predictive contributions of these scales. the results are for the dass are presented in table 4.  
  religions 2020, 11, 551  11 of 20  table 4. incremental validity of the nmi scales over the five-factor model (ffm) domains in predicting emotional distress on the dass for atheist/agnostics and other faith traditions. overall r2  ffm r2  nmi r2  predictors (beta)  0.59 0.42 0.60 0.62  0.57 *** 0.37 *** 0.49 *** 0.56 ***  0.02 *** 0.05 *** 0.12 *** 0.07 ***  es ( 0.62) e (0.09) w ( 0.22) es ( 0.42) w ( 0.28) m (0.08) es ( 0.41) o (0.11) w ( 0.47) i ( 0.07) es ( 0.52) w ( 0.36)  0.53  0.49 ***  0.04 ***  anxiety  0.36  0.31 ***  0.05 ***  depression overall dass  0.56 0.56  0.42 *** 0.48 ***  0.14 *** 0.09 ***  es ( 0.51) o (0.05) c ( 0.08) w ( 0.27) es ( 0.31) e (0.08) a ( 0.08) c ( 0.12) w ( 0.30) es ( 0.32) w ( 0.49) es ( 0.42) a ( 0.06) c ( 0.09) w ( 0.39)  measure atheists/agnostics (n 491) stress anxiety depression overall dass believers (n 907) stress  dass depression, anxiety, stress scale; es emotional stability; e extraversion; o openness; a agreeableness; c conscientiousness; w worthiness; i infinitude; m meaning. *** p 0.001.  as can be seen, the personality dimension of es was a consistent significant predictor of all dass scales in both groups. the findings are consistent with the correlational data. the obtained r2 values indicate that the personality scales explain a large amount of variance in the dass scales. however, it is also important to note that the nmi scales also contributed a significant amount of additional explanatory variance in each of the dass scales (from 2% to 14% additional variance, a quite substantial amount, hunsley and meyer 2003). two points of interest in table 4. first, worthiness was a consistent predictor for each dass scale, the other nmi scales had less relevance. surprisingly, additional nmi scales were found to predict only in the a/a group. apparently, infinitude and meaning provide additional predictive power for understanding emotional dysphoria only for atheists and agnostics. second, the magnitude of incremental predictiveness found for the nmi is similar between the two groups (a/a group mean r2 0.07; bel group mean r2 0.08). the nmi scales have comparable relevance for understanding emotional distress for believers and non-believers. table 5 presents the regression results with the pid-5. these scales capture dysfunctional personality dimensions related to the ffm and represent a more personologically diverse set of constructs than the dass. there are three points of interest. first, emotional stability was a consistent predictor of all pid-5 scales, although it is not always the largest predictor (e.g., c was most relevant for inhibition, a was most relevant for antagonism, e and a were strongest for detachment). worthiness was also a consistent significant predictor for all analyses except for antagonism in the a/a group, where m emerged as significant. interestingly, worthiness was the strongest predictor for detachment in both groups, being twice as large as any of the ffm domains. second, as found with the dass, the nmi’s unique predictive contribution was comparable in strength across the two groups, again underscoring the equal relevance of these numinous constructs for both believers and non-believers. the content of the nmi contains information that is relevant and appropriate for all people; responses do not require any specific theological orientation or metaphysical world view for scores to be meaningful. 3.4. sem analyses while worthiness (w) is a unique, significant predictor of both emotional and characterological impairment, it is not clear why this association exists. is it because w has a causal impact on the experience of impairment or because w represents another facet of negative affect that is a consequence of levels of es? in order to determine the answer to this ultimate question of utility, a series of causal models were examined. figure 1 presents three different models that postulate varying causal roles for w consistent with piedmont and wilkins (2020) ontological model of the numinous. model 1 positions w as an independent predictor of distress from the ffm. here, w is its own causal motivation that works  
  religions 2020, 11, 551  12 of 20  additively with personality to impact levels of emotional dysphoria. the remaining models present w as an outcome of personality (model 2) or an outcome of both personality and the experience of impairment (model 3). further, these models are evaluated separately for the two belief groups to determine if w’s role may vary. would w be a causal agent only for believers? would it have a different psychological role to play with non-believers? would its role vary across the type of impairment being evaluated: affective vs. characterological? using the sem software linear structural relations (lisrel version 8.73), these different models were examined in the current data set and the results are presented in table 6. table 5. incremental validity of the nmi scales over the ffm domains in predicting characterological dysfunction on the pid-5 for atheist/agnostics and other faith traditions. measure  overall r2  ffm r2  nmi r2  predictors (betas)  atheists/agnostics (n 491) psychotic  0.38  0.34 ***  0.04 ***  inhibition  0.39  0.36 ***  0.03 ***  antagonism detachment  0.33 0.57  0.32 *** 0.46 ***  0.01 * 0.11 ***  es ( 0.28) o (0.08) a ( 0.18) c ( 0.20) w ( 0.20) m (0.11) i (0.08) es ( 0.10) e (0.10) a ( 0.13) c ( 0.42) w ( 0.17) m (0.10) es ( 0.26) e (0.26) a ( 0.48) m (0.10) es ( 0.11) e ( 0.22) o (0.10) a ( 0.24) w ( 0.46) es ( 0.77)  negative affect believers (n 907) psychotic  0.63  0.63 ***  - - -.- -  0.45  0.41 ***  0.04 ***  inhibition  0.46  0.43 ***  0.03 ***  antagonism  0.44  0.42 ***  0.03 ***  detachment  0.54  0.45 ***  0.09 ***  negative affect  0.62  0.61 ***  0.01 *  es ( 0.25) o (0.22) a ( 0.24) c ( 0.22) w ( 0.27) es ( 0.13) e (0.15) o (0.07) a ( 0.20) c ( 0.39) w ( 0.23) es ( 0.14) e (0.23) o (0.07) a ( 0.43) c ( 0.16) w ( 0.19) i ( 0.06) es ( 0.17) e ( 0.18) o (0.07) a ( 0.26) c ( 0.06) w ( 0.39) es ( 0.68) c ( 0.07) w ( 0.12)  pid-5 personality inventory for the dsm-5; es emotional stability; e extraversion; o openness; a agreeableness; c conscientiousness; w worthiness; i infinitude; m meaning. * p 0.05. *** p 0.001.  table 6. results of sem analyses for three causal models comparing atheists/agnostics and believers on measures of emotional and characterological impairment. outcome  dass  pid-5  groups  x2  df  x2 /n  rmsea  srmr  aic  a/as (n 491) model 1 model 2 model 3  27.19 78.47 43.95  6 10 9  4.53 7.85 4.88  0.085 0.12 0.089  0.019 0.025 0.027  105.19 148.47 115.95  believers (n 907) model 1 model 2 model 3  34.28 56.22 125.9  6 8 10  5.7 7.1 12.59  0.072 0.082 0.11  0.015 0.024 0.024  112.28 130.22 195.9  a/as (n 491) model 1 model 2 model 3  28.07 62.5 50.86  8 9 13  3.51 6.94 3.91  0.072 0.11 0.077  0.023 0.04 0.033  144.07 176.5 156.86  believers (n 907) model 1 model 2 model 3  19.89 42.43 55.03  9 11 15  2.21 3.85 3.67  0.037 0.056 0.054  0.013 0.016 0.021  133.89 152.43 157.03  dass depression, anxiety, and stress scale; pid-5 personality inventory for dsm-5; a/a atheists and agnostics; rmsea root mean square error of approximation; srmr standardized root mean residual; aic akaike information criterion.  
  dass depression, anxiety, and stress scale; pid-5 personality inventory for dsm-5; a/a religions atheists 2020, 11, and 551 agnostics; rmsea root mean square error of approximation; srmr standardized 13 of 20  root mean residual; aic akaike information criterion.  model 1 : worthiness as unique predictor of dass and pid-5  model 2: w and dass/pid-5 as outputs of personality  model 3: w as an output of personality and dass/pid-5 figure 1. proposed structural models linking worthiness, personality, and psychological distress. figure 1. proposed structural models linking worthiness, personality, and psychological distress. dass depression, anxiety, and stress scale; pid-5 personality inventory for dsm-5; w worthiness; dass depression, anxiety, and stress scale; pid-5 personality inventory for dsm-5; w es emotional stability; e extraversion; o openness; a agreeableness; c conscientiousness. worthiness; es emotional stability; e extraversion; o openness; a agreeableness; c conscientiousness. the first observation is that the pattern of results were similar for both belief groups. second, a  similar causal pattern was found for both the emotional and characterological scales. the experience of emotional dysphoria, whether temperament-based or situationally-induced, was similarly impacted by numinous motivations. specifically, low scores on w represented a core sensitivity to the experience of emotional difficulties. third, model 1 which presented w as a unique causal predictor of distress, was the best fitting model across all the fit statistics examined using criteria proposed by hu and bentler (1999) as well as kline (2016; i.e., χ2/n 5; rmsea and srmr 0.08). of particular interest  
  religions 2020, 11, 551  14 of 20  is the akaike information criterion (aic). this index is used when non-nested models are being compared. the aic examines the parsimony and level of fit for each model in terms that can be directly compared. the model with the lowest aic is seen as the best fitting model. in table 6, the aic analysis indicated that model 1 fit best in all four analyses. these results supported viewing w as a motivational construct which can potentially impact the psychological equilibrium of individuals independently of any personality dispositions. the standardized weights (lambdas) for the six contributing factors as portrayed in model 1 are presented in table 7. there are two points of interest. first, the nmi w scale made a significant, unique contribution to the experience of affective and characterological dysregulation. understood as a unique causal agent, w had a moderately sized impact on the clinical outcome variables. its contribution compared favorably to the effect for es. second, there was an interesting differential pattern of predictiveness in these data. when considering the dass, w played an important, though smaller, role than es. for the a/a group, w’s contribution was 69% that of es (i.e., 0.38/ 0.55), while for the bel group, it was 95% (i.e., 0.36/ 0.38). however, when considering the personality disorder outcome, w was a stronger predictor than personality, being 1 12 times stronger in the a/a group (i.e.,  0.49/ 0.32) to almost two and a half times stronger in the bel group ( 0.39/ 0.16). these findings support viewing the numinous as a core, organizing praxis to our psychological systems: w was a better predictor of characterological style than it was of context dependent emotional experiences. table 7. standardized loadings (lambdas) for the numinous and personality constructs on the dass and pid-5 from model 1. standardized path coefficients (lambdas)  outcome a/a dass pid-5 bel dass pid-5  w  es  e  o  a  c   0.38  0.49   0.55  0.32  0.03 0.24   0.09 0.06   0.03  0.27   0.07  0.21   0.36  0.39   0.38  0.16  0.01 0.03   0.05 0.08   0.07  0.26   0.07  0.25  a/a atheists/agnostics; bel believers; dass depression, anxiety, and stress scale; pid-5 personality inventory for the dsm-5; w worthiness; es emotional stability; e extraversion; o openness; a agreeableness; c conscientiousness for understanding emotional and characterological dysregulation.  4. discussion the results of this study provide strong support for the basic assumptions of piedmont’s (piedmont 2015; piedmont and wilkins 2020) ontological model of numinous motivation. first, this study replicated previous research by fox and piedmont (2020) that demonstrated the unique predictive role of religious crisis on emotional dysphoria. using a different sample and measure of religious crisis, the unique role of the numinous on ratings of depression, anxiety, and stress were replicated here. further, the current study also replicated findings by piedmont et al. (2007) that demonstrated the unique causal role of the numinous for understanding characterological impairment. when properly developed measures of the numinous are used (i.e., scales which have demonstrated uniqueness from and incremental validity over measures of the five-factor model (ffm) of personality; see piedmont and wilkins 2020), numinous motivations are being shown increasingly to represent important psychological aspects of the individual that have significant, substantive implications for understanding emotional and characterological dysregulation. 4.1. the universal relevance of the numinous the current study further supports piedmont’s ontological model by directly examining a key hypothesis: the universal nature of the numinous. the numinous appears to represent a core, species-defining aspect of human psychological functioning whose effects can be found in all people,  
  religions 2020, 11, 551  15 of 20  irrespective of any religious affiliation or theological preference. despite representing a sample that is representative of the secularization hypothesis (atheists and agnostics), the data in this study can be taken as counter evidence to the claim that when religion ceases to be a relevant construct of personal identity that numinous issues dissipate as a matter of course. on the contrary, the current findings clearly demonstrated the utility of the numinous for understanding both emotional dysphoria and characterological impairment for both believers and atheists/agnostics. as shown in this paper, both believers and non-believers understood the nature of numinous motivations in similar ways and scores on the nmi were shown to predict their clinical outcomes. of importance, the magnitude of prediction for the nmi was comparable for both groups, underscoring the equal relevance of numinous constructs across different faith orientations. it is also important note that while the nmi scales added significant incremental predictive validity over the ffm, in one instance the nmi was a stronger predictor than the ffm. table 5 documented that worthiness (w) was a stronger predictor of detachment than es, for both groups. given the underlying relational nature of content on the w scale, this finding provides additional construct evidence for this scale. it also underscores the relevance of numinous motivations for expanding our understanding of characterological defects. in fact, the strong predictiveness of w on detachment suggests that any clinical understanding of this construct would be woefully inadequate without a consideration of the numinous. table 5 also provided additional support for our contention that the dimension of w represents aspects of maladaptation that are independent of the personality domain of neuroticism (low es). numinous motivations represented a distinct aspect of psychological functioning not contained by established personality models, like the ffm. the findings observed with the negative affect scale provided additional support for this perspective. while table 3 showed that es correlated over 0.75 with the pid-na scale in both groups, it is interesting to note that in table 5 no nmi scale, particularly w, added much, if any, incremental predictiveness to this clinical outcome. for the a/a group, the nmi is completely independent and in the bel group it added only a very small amount of additional variance (i.e., 1%). these findings support the hypothesis that the numinous and emotional dysphoria are separate constructs, with different psychological dynamics. that both predict common clinical outcomes demonstrates the need to broaden current models of psychopathology to include the numinous. it is interesting to note in table 7 the pattern of predictiveness across the two outcome domains. while scores on the w scale evidenced similar levels of predictiveness for the two study groups, w was a stronger predictor of characterological impairment than emotional dysphoria, for both groups, while the reverse was true on the dass. clearly, w correlated more strongly with characterological outcomes than context dependent emotional states. this finding suggests that w does represent an intrinsic, stable, personological quantity. taken as a whole, these findings should provide reassurance to researchers and clinicians that aspects of the numinous reflect important qualities of the mental life of all individuals. further, an assessment of these qualities will provide non-redundant insights into the psychological status of clients that will have significant implications for treatment. 4.2. clinical next steps because numinous constructs bring an entirely new dimension of analysis for clinical work, some overview of how to apply the current findings in treatment seems warranted. collecting information regarding a client’s numinous status at the beginning of treatment, along with measures of personality and psychological functioning, is ideal for gathering a comprehensive understanding of the psycho-social strengths and weaknesses of the client. this assessment could be done in one of two ways (or both). one could employ a validated measure of the numinous, like the nmi, or information could be gathered during the clinical intake phase. usually, when clients first appear for treatment they are screened across a number of relevant clinical dimensions, such as history of treatment, type of presenting problem and its duration, cognitive functioning, and psychosocial status. unfortunately,  
  religions 2020, 11, 551  16 of 20  most screenings do not include much of an assessment of numinous functioning. while it may be more typical to query whether someone is a believer or not, or whether they consider themselves religious or not, little is done to move deeper into this domain. the comprehensive psycho-spiritual clinical interview (cpsci; piedmont and wilkins 2020) was designed to offer an initial screening that is all inclusive. this interview format was designed to be efficient and useful for clinical work by promoting a multidimensional understanding of the client. it contains four areas of examination: the presentation, how the client appears physically and cognitively; the problem, which examines the current presenting problem and psychiatric history; the person, which assesses a number of personologically relevant dimensions; and the predicament, which provides an assessment of the numinous dimensions of the client. one particularly useful feature of the cpsci is that it includes normed scales that allow for a more inferential understanding of the client. for example, on the predicament section, there are a number of items that capture aspects of the numinous, like the nmi dimensions of infinitude (i), meaning (m), and worthiness (w). therapists can check those elements for each of the dimensions that are descriptive of the client. aside from being individually reflective of numinous issues, aggregating ratings across these items will create a scale score, and the normative data for each of these measures allows for a deeper understanding of where clients stand on these dimensions (see piedmont and wilkins 2020). treatment approaches to effectively resolving numinous concerns are less established. however, the available research may suggest that numinous concerns are less powerfully effected through secular psychotherapy. in a meta-analysis by captari et al. (2018), they noted when treatment approaches explicitly incorporate clients’ religious and spiritual perspectives, they have been found to be equally efficacious on psychological outcomes compared to secular psychotherapy, and superior on numinous related outcomes. it is possible that this dynamic is due in part to the fact that the world’s religions focus so intently on the numinous. their sheer staying power, which spans across thousands of years, can partly be attributed to the fact that they offer humanity compelling means of addressing problems related to infinitude, worthiness, and meaning. while they are diverse in how they do this, they hold in common highly developed sets of philosophical insights into the nature of what it means to be human, elaborate and cohesive meta-narratives that gives meaning to the human journey, and tried and true practices for exercising numinous motivations to their fullest potential across the lifespan (grassie 2010). the next question for researchers and clinicians to explore, then, is how the insights of the world’s religions, and their apparently well tested methods of addressing numinous concerns through their particular means, can be generalized to non-religious patients. treatment samples studied so far have not been inclusive of these groups when examining the numinous and they have not been well tested on measurement models that are universal. as more people in the west embrace secularization, there would appear to be a gap between numinous motivations, when they are frustrated or left unmet, and effective means of adequately addressing them in ways conducive to atheists’ and agnostics’ frameworks of meaning. it is possible that the treasures of the world religions may yet still be of relevance to those who no longer belong to them. how they may be applied to the numinous concerns of atheist and agnostics in psychotherapy represents the cutting edge of the prs. 4.3. measurement considerations while numinous motivations represent universal aspects of the mental lives of people, most measures of r/s phenomena are quite religiously focused (see hill and hood 1999). these scales frequently employ very specific religious language that reflects particular theologies and denominational approaches. while such items may be of maximum relevance to adherents of these different denominations, they are much less useful when given to those who do not share such sentiments. thus, it is not unexpected that atheists and agnostics have played a very limited role in research in this area. after all, if one does not believe in any transcendent realities, then measures that assess such  
  religions 2020, 11, 551  17 of 20  qualities would be of little or no relevance. further, non-believers may be put off by such instruments because the item content is irrelevant to them, thus making their scores unreliable. in assessing numinous constructs, it is important that items reflect non-religious content, ensuring its broad relevance. the nmi is considered a second generation measure (piedmont, in press) because it capitalizes on both a developed ontological model and over 25 years of research using the assessment of spirituality and religious sentiments (aspires) scale (piedmont 2020). while the aspires worked very well and was found useful with respondents from all faith traditions, including atheists and agnostics (toscano et al. 2017), there was always a concern that even in a scale that attempted to be non-religious, religious material was present (e.g., references to god, higher power/being). this would create issues for respondents who were either unfamiliar with the religious terminology or found it irrelevant. toscano et al. (2017) demonstrated that the aspires was a significant predictor of purpose in life and affect for both believers and atheists. however, the magnitude of prediction was substantially less in the atheist group. the nmi was designed to remove much of this theistic-type language and replace it with secular, existential verbiage, thereby preventing potential religious-oriented demand characteristics in the items from obstructing genuine responses to the underlying latent numinous constructs (e.g., i, w, and m). the results of this study demonstrated the success of this new instrument. as these findings showed, the predictive power of the nmi was almost identical in the two groups; scores from atheists and agnostics on worthiness were equally reliable and equally predictive of all the clinical outcomes. researchers wishing to plumb the psychological depths of r/s constructs with non-believers or with adherents of faith communities that do not ascribe to a belief in a transcendent being (e.g., buddhists, janists, shintoist, etc.) will need to redact their scales of such content in favor of broader concepts. 4.4. limitations three particular issues need consideration. first, while the sampling method was able to access a national sample of adults, all the data examined in this study was self-report based. while a useful source of information, reliance on a single information source raises concerns over common method bias. self-report scores will always correlate with each other to some degree because it is the same person answering each scale. unique subject characteristics in response style will create spurious associations across instruments. it is unclear to what extent this occurred in the current study. future research needs to include other data sources (e.g., observer ratings) as a check on the accuracy of these findings. further, observer data has its own predictive validity and provides its own unique insights into the target of the rating. while most r/s scales do not have validated rating versions, both the aspires and nmi do, although they were not used in this study. a second issue concerns the sem findings. it must be remembered, that sem analyses do not demonstrate causality in the data, only an experiment can do that. what sem does, is examine the viability of the putative causal pathways that are specified in the tested model. showing that the data fit a particular model only indicates that the underlying causal assumptions are consistent with the observed data. in working with clinical outcome variables, it is ethically challenging to apply experimental designs, thus sem becomes a useful technique for approximating the viability of a particular model. thus, the models tested here await future replications using experimental designs where appropriate. however, that the current findings replicate several, previous studies gives enhanced confidence in the accuracy of the presented model. finally, whereas the mturk worker model did provide a broad sample, including workers from all 50 us states, demographically the participants were overwhelming european-american (75%) and well educated, most having a college degree of higher (57%). whereas the system was useful in obtaining a variety people from different occupations, income levels, and religious affiliations, the results must be interpreted within the racial and educational limits of our sample. because mturk is a useful platform for collecting large samples, we recommend that future research of this type make the  
  religions 2020, 11, 551  18 of 20  effort to recruit larger samples than ours so that a demographically representative subset of useful size can be culled from the total. 5. conclusions there is much to be excited about by these data. it is becoming increasingly clear that numinous motivations represent aspects of psychological functioning not contained by traditional models of personality and psychopathology. when speaking about humanity’s higher nature, maslow (1971) noted that there could be motivational pathologies that emerge when self-actualized individuals were deprived of key elements of their ultimate self, such as feelings of despair and feeling unneeded. these negative feelings may be at the heart of psychological problems that are not yet studied scientifically. with the numinous emerging as a conceptually clear, empirically robust construct, an opportunity for expanding our psychological knowledge is at hand. disorders that currently remain refractive to contemporary treatment approaches (e.g., moral injury, body image dysphoria, suicide) may become more tractable when viewed from a numinous perspective. the numinous is a universal quality of value in learning about every client. as discussed in this paper, there are technologies that are available for clinicians to use in their practice to explore for themselves the potential interpretive value of these constructs for promoting healing, growth, and resilience in their clients. author contributions: conceptualization, r.l.p., j.f. and m.e.t.; formal analysis, r.l.p. and m.e.t.; funding acquisition, r.l.p.; investigation, r.l.p.; methodology, r.l.p.; project administration, r.l.p. and m.e.t.; writing—original draft, r.l.p.; writing—review & editing, r.l.p. and j.f. all authors have read and agreed to the published version of the manuscript. funding: this research received a faculty development grant to piedmont from the department of pastoral counseling at loyola university maryland. conflicts of interest: ralph l. piedmont receives royalties from the sale of the numinous motivation inventory.  references alter, margaret g. 1989. an empirical study of christian religious maturity: its implications for parish ministry. pastoral psychology 37: 153–60. [crossref] american psychiatric association. 2013. diagnostic and statistical manual of mental disorders, 5th ed. arlington: american psychiatric association. ano, gene g., and erin b. vasconcelles. 2005. religious coping and psychological adjustment to stress: a meta-analysis. journal of clinical psychology 61: 461–80. [crossref] [pubmed] brown, timothy a., bruce f. chorpita, william korotitscw, and david h. barlow. 1997. psychometric properties of the depression anxiety stress scales (dass) in clinical samples. behaviour research and therapy 35: 79–89. [crossref] buss, david m. 2002. sex, marriage, and religion: what adaptive problems do religious phenomena solve? psychological inquiry 13: 201–3. captari, laura e., joshua n. hook, william hoyt, don e. davis, stacey e. mcelroy-heltzel, and everett l. worthington jr. 2018. integrating clients’ religion and spirituality within psychotherapy: a comprehensive meta-analysis. journal of clinical psychology 74: 1938–51. [crossref] [pubmed] chen, tianzhi p. 2011. cross-cultural psychometric evaluation of the aspires in mainland china. ph.d. dissertation, loyola university maryland, baltimore, md, usa. unpublished. cohen, jacob. 1987. statistical power analysis for the behavioral sciences, revised ed. hillsdale: lawrence erlbaum associates. comte-sponville, andre. 2006. the little book of atheist spirituality. new york: penguin books. digman, john m. 1990. personality structure: emergence of the five-factor model. annual review of psychology 41: 417–40. [crossref] exline, julie juola. 2013. religious and spiritual struggles. in apa handbook of psychology, religion, and spirituality. edited by kenneth i. pargament. washington, dc: american psychological association, vol. 1. exline, julie juola, ann marie yali, and william c. sanderson. 2000. guilt, discord and alienation: the role of religious strain in depression and suicidality. journal of clinical psychology 56: 1481–96. [crossref]  
  religions 2020, 11, 551  19 of 20  fox, jesse, and ralph l. piedmont. 2020. religious crisis as an independent causal predictor of psychological distress: understanding the unique role of the numinous for intrapsychic functioning. religions 11: 329. [crossref] funder, david c. 2002. why study religion? psychological inquiry 13: 213–14. goldberg, lewis r. 1992. the development of markers for the big-five factor structure. psychological assessment 4: 26–42. [crossref] goldberg, l., j. johnson, h. eber, r. hogan, m. ashton, c. clonger, and association of research in personality. 2006. the international personality item pook and the future of public-domain personality measures. journal of research in personality 40: 84–96. [crossref] gorsuch, richard l. 1983. factor analysis, 2nd ed. hillsdale: lawrence erlbaum associates. grassie, william. 2010. the new science of religion: exploring spirituality from the outside in and bottom up. new york: palgrave macmillan. hill, peter c., and ralph w. hood jr. 1999. measures of religiosity. birmingham: religious education press. hill, peter c., kenneth pargament ii, ralph w. hood jr., michael e. mccullough, james p. swyers, david b. larson, and brian j. zinnbauer. 2000. conceptualizing religion and spirituality: points of commonality, points of departure. journal for the theory of social behavior 30: 51–77. [crossref] hu, li-tze, and peter m. bentler. 1999. cutoff criteria for fit indices in covariance structure analysis: conventional criteria versus new alternatives. structural equation modeling 6: 1–55. [crossref] hunsley, john, and gregory j. meyer. 2003. the incremental validity of psychological testing and assessment: conceptual, methodological, and statistical issues. psychological assessment 15: 446–55. [crossref] joshanloo, mohsen. 2012. investigation of the factor structure of spirituality and religiosity in iranian shiite university students. international journal of psychology 47: 211–21. [crossref] [pubmed] kline, rex b. 2016. principles and practice of structural equation modeling, 4th ed. new york: guilford press. koenig, harold g. 1999. the healing power of faith. new york: simon and schuster. koenig, harold g., michael e. mccullough, and david b. larson. 2001. handbook of religion and health. new york: oxford university press. krueger, robert f., jaime derringer, kristian e. markon, david watson, and andrew e. skodol. 2012. initial construction of a maladaptive personality trait model and inventory for dsm-5. psychological medicine 42: 1879–90. [crossref] lawrence, richard thomas. 1991. the god image inventory: the development, validation, and standardization of a psychometric instrument for research, pastoral and clinical use in measuring the image of god. ph.d. dissertation, the catholic university of america, washington, dc, usa. unpublished. leach, mark m., and tetsuo sato. 2013. a content analysis of the psychology of religion and spirituality journal: the initial four years. psychology of religion and spirituality 5: 61–68. [crossref] lovibond, peter f., and sydney h. lovibond. 1995. manual for the depression anxiety stress scales, 2nd ed. sydney: psychology foundation of australia. maslow, abraham harold. 1971. the farther reaches of human nature. new york: viking press. mccrae, robert r. 2010. the place of the ffm in personality psychology. psychological inquiry 21: 57–64. [crossref] mlac ic , boris, and lewis goldberg. 2007. an analysis of a cross-cultural personality inventory: the ipip big five factor markers in croatia. journal of personality assessment 88: 168–77. [crossref] pargament, kenneth i. 1999. the psychology of religion and spirituality? yes and no. international journal for the psychology of religion 9: 3–12. [crossref] pargament, kenneth i. 2007. spiritually integrated psychotherapy: understanding and addressing the sacred. new york: guilford press. pew research center. 2015. religious landscape study. available online: http://www.pewforum.org/religiouslandscape-study/ (accessed on 15 july 2020). piedmont, ralph l. 1998. the revised neo personality inventory: clinical and research applications. new york: plenum press. piedmont, ralph l. 2014. looking back and finding our way forward: an editorial call to action. psychology of religion and spirituality 6: 265–67. [crossref] piedmont, ralph l. 2015. a psychological ontology for understanding spirituality. paper presented at the conference on values and the meaning of life, poznan, poland, september 15. piedmont, ralph l. 2017. the numinous motivation inventory: preliminary technical manual. timonium: author.  
  religions 2020, 11, 551  20 of 20  piedmont, ralph l. 2020. assessment of spirituality and religious sentiments: technical manual, 3rd ed. timonium: author. piedmont, ralph l., and mark m. leach. 2002. cross-cultural generalizability of the spiritual transcendence scale in india: spirituality as a universal aspect of human experience. american behavioral scientist 45: 1886–99. [crossref] piedmont, ralph l., catherine j. hassinger, janelle rhorer, martin f. sherman, nancy c. sherman, and joseph e. g. williams. 2007. the relations among spirituality and religiosity and axis ii functioning in two college samples. research in the social scientific study of religion 18: 53–73. piedmont, ralph l., joseph w. ciarrochi, gabriel s. dy-liacco, and joseph e. g. williams. 2009. the empirical and conceptual value of the spiritual transcendence and religious involvement scales for personality research. psychology of religion and spirituality 1: 162–79. [crossref] piedmont, ralph l., and teresa a. wilkins. 2020. understanding the psychological soul of spirituality: a guidebook for research and practice. new york: routledge. piedmont, ralph l. n.d. the numinous motivation inventory: a second generation measure of spirituality. in the oxford handbook of psychology and religion, 2nd ed. edited by lisa miller. new york: oxford, unpublished. plante, thomas g., and allen c. sherman. 2001. faith and healthy: psychological perspectives. new york: the guilford press. rican, pavel, and pavlina janosova. 2010. spirituality as a basic aspect of personality: a cross-cultural verification of piedmont’s model. the international journal for the psychology of religion 20: 2–13. [crossref] robertson, theresa m., awa jangha, ralph l. piedmont, martin f. sherman, and joseph e. g. williams. 2017. factor structure and personality disorder correlates of responses to the 50-item ipip big five factor marker scale. journal of social research and policy 8: 5–17. sinclair, s. j., c. j. siefert, j. m. slavin-mulford, m.b. stern, m. renna, and m. a. blais. 2012. psychometric evaluation and mormative data for the depression, anxiety, and stress sscales-21 (dass-21) in a nonclinical sample of u.s. adults. evaluation & the health professions 35: 259–79. [crossref] sloan, richard p., emilia bagiella, and tia powell. 2001. without a prayer: methodological problems, ethical challenges, and misrepresentations in the study of religion, spirituality, and medicine. in faith and health: psychological perspectives. edited by thomas plante. new york: guilford, pp. 339–54. tabachnick, barbara g., linda s. fidell, and jodie b. ullman. 2007. using multivariate statistics, 5th ed. boston: pearson education. tillich, paul. 2000. the courage to be, 2nd ed. new haven: yale university press. first published 1952. toscano, marion. e., ralph. l. piedmont, and cynthia. e. canner. 2017. understanding spiritual transcendence as a human universal: assessing ultimate meaning in atheists and agnostics. paper presented at the annual convention of the association of spiritual, ethical, and religious values in counseling, richmond, va, usa, july 21. van wicklin, john f. 1990. conceiving and measuring ways of being religious. journal of psychology and christianity 9: 27–40. voas, david. 2019. the power of the nones: why secularization matters. paper presented at the deanna kaplan (covener) religious nones [symposium]. annual meeting of the society for the scientific study of religion, st. loius, mo, usa, october 25–27. voas, david, and mark chaves. 2016. is the united states a counterexample to the secularization thesis? american journal of sociology 121: 1517–56. [crossref] wilt, joshua a., joshua b. grubbs, julie j exline, and kenneth i. pargament. 2016. personality, religious and spiritual struggles, and well-being. psychology of religion and spirituality 8: 341–51. [crossref] publisher’s note: mdpi stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.  2020 by the authors. licensee mdpi, basel, switzerland. this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license (http://creativecommons.org/licenses/by/4.0/).  
       


title_index: the predictive relationship of
full_text_index:
       pr  ev  ie w    7kh 3uhglfwlyh 5hodwlrqvkls ri 5holjlrxv 7udxpd dqg 6slulwxdo exvh rq 0hdqlqj pdnlqj 7uxvw dqg 'hsuhvvlrq    'lvvhuwdwlrq 0dqxvfulsw   6xeplwwhg wr 1ruwkfhqwudo 8qlyhuvlw\  6fkrro ri 6rfldo dqg %hkdylrudo hdowk  lq 3duwldo )xoiloophqw ri wkh  5htxluhphqwv iru wkh 'hjuhh ri  '2&725 2) 3 ,/2623    e\  & (5 / / 11 -2 16721           /d -rood &doliruqld  0d\             approval page the predictive relationship of religious trauma and spiritual abuse on meaning-making, trust, and depression  by cheryl lynn johnston  approved by the doctoral committee: 09/09/2021 13:03:32 pdt  degree held  date  phd  09/09/2021 13:54:53 mst  degree held  date  ph.d.  09/09/2021 14:02:35 mst  ie w  mary blackwell dissertation chair: insert name  phd  pr  ev  committee member: patrick insertmcnamara name  verace committee member: daimon insert name degree held  date     evwudfw 7khuh lv olplwhg xqghuvwdqglqj ri wkh lpsdfw ri uholjlrxv wudxpd dqg vslulwxdo dexvh rq v\vwhpv ri phdqlqj pdnlqj wuxvw dqg ghsuhvvlrq 7kh jhqhudo vrflhwdo sureohp lv wkh kljk shufhqwdjh ri shrsoh h[shulhqflqj uholjlrxv wudxpd ru vslulwxdo dexvh 7kh vshflilf sureohp uhiohfwhg lq wkh olwhudwxuh surpswlqj wkh qhhg iru wklv vwxg\ zdv d odfn ri xqghuvwdqglqj ri wkh lpsdfw ri uholjlrxv wudxpd dqg vslulwxdo dexvh rq phdqlqj pdnlqj wuxvw dqg ghsuhvvlrq zklfk lv qhhghg wr lqirup sv\fkrwkhudshxwlf wuhdwphqw iru wkh dgghg hohphqw ri uholjlrxv wudxpd dqg vslulwxdo dexvh zkloh exloglqj rq h[lvwlqj lqvljkw lqwr wkh uhodwlrqdo frpsoh[lwlhv ri ehwud\do shu ehwud\do wudxpd  ie w  wkhru\ 7kh sxusrvh ri wklv uhvhdufk zdv wr h[dplqh wkh suhglfwlyh uhodwlrqvkls ri uholjlrxv wudxpd dqg vslulwxdo dexvh rq phdqlqj pdnlqj wuxvw dqg ghsuhvvlrq 8vlqj d txdqwlwdwlyh fruuhodwlrqdo uhvhdufk phwkrg dgxowv ryhu zkr h[shulhqfhg d wudxpdwlf ru dexvlyh lqflghqw  ev  zlwk irupdol]hg uholjlrq dqg ru lq d vslulwxdo frqwh[w zhuh uhfuxlwhg wkurxjk gluhfw hpdlo vrfldo phgld dqg zhevlwh dgyhuwlvlqj 7kh gdwd zhuh dqdo\]hg xwlol]lqj fruuhodwlrqdo dqg pxowlsoh uhjuhvvlrq dqdo\vlv wr ghwhuplqh wkh uhodwlrqvkls ehwzhhq wkh suhglfwru yduldeohv ri uholjlrxv  pr  wudxpd dqg vslulwxdo dexvh dqg wkh fulwhulrq yduldeohv phdqlqj pdnlqj wuxvw dqg ghsuhvvlrq 7kh fxuuhqw ilqglqjv ghprqvwudwhg d srvlwlyh fruuhodwlrqdo uhodwlrqvkls ehwzhhq uholjlrxv wudxpd dqg v\vwhpv ri phdqlqj pdnlqj 5holjlrxv wudxpd zdv srvlwlyho\ fruuhodwhg zlwk suhvhqfh ri phdqlqj u q s dqg vhdufk iru phdqlqj u q s 6slulwxdo dexvh zdv srvlwlyho\ fruuhodwhg zlwk wkh suhvhqfh ri phdqlqj u q s %rwk uholjlrxv wudxpd u q s dqg vslulwxdo dexvh u q s zhuh ghwhuplqhg wr kdyh d fruuhodwlrqdo uhodwlrqvkls zlwk ghsuhvvlrq vxssruwlqj sulru uhvhdufk 5holjlrxv wudxpd ghprqvwudwhg d suhglfwlyh uhodwlrqvkls zlwk ghsuhvvlrq 7klv vwxg\ dgguhvvhv wkh olplwhg xqghuvwdqglqj ri wkh lpsdfw ri uholjlrxv wudxpd dqg vslulwxdo dexvh rq phdqlqj l     pdnlqj wuxvw dqg ghsuhvvlrq zklfk lv qhhghg wr lqirup sv\fkrwkhudshxwlf wuhdwphqw iru wkh dgghg hohphqw ri uholjlrxv wudxpd dqg vslulwxdo dexvh 5hfrpphqgdwlrqv iru sudfwlfh zhuh wr dvvhvv iru hohphqwv ri uholjlrxv wudxpd vslulwxdo dexvh dqg ehwud\do zkhq lqfuhdvhg ghsuhvvlyh v\pswrpv duh suhvhqw wr lpsuryh sv\fkrorjlfdo dgmxvwphqw dqg ixqfwlrqlqj 5hfrpphqgdwlrqv iru ixwxuh uhvhdufk lqfoxghg uhfruglqj dgglwlrqdo ghprjudsklf gdwd dorqj zlwk uholjlrxv diiloldwlrq wr exlog xsrq wkh xqghuvwdqglqj ri srvvleoh phgldwlqj idfwruv         pr  ev    ie w    ll      fnqrzohgjhphqwv , kdyh pdq\ shrsoh wr wkdqn dv , uhiohfw rq wkh surfhvv ri wklv glvvhuwdwlrq , kdyh uhfhlyhg vr pxfk vxssruw dqg hqfrxudjhphqw iurp vr pdq\ wkdw lw zrxog eh lpsrvvleoh wr qdph wkhp doo , zrxog olnh wr wkdqn p\ glvvhuwdwlrq fkdlu 'u 0du\ %odfnzhoo zkr surylghg ph frqvwdqw hqfrxudjhphqw jxlgdqfh dvvlvwdqfh zlwk wkh surfhvv dv zhoo dv wkh ghyhorsphqw ri uhvhdufk txhvwlrqv phwkrgrorj\ dqg ryhudoo lqydoxdeoh lqvljkw rx fkdoohqjhg ph wr frqwlqxh wr jurz p\ fulwlfdo wklqnlqj vnloov dqg \rxu srvlwlyh dwwlwxgh dqg ihhgedfn uhvxowhg lq p\ zrun ulvlqj wr d pxfk kljkhu ohyho , zrxog dovr olnh wr wkdqn p\ frpplwwhh phpehuv 'u 0f1dpdud dqg 'u 9hudfh iru surylglqj pxfk zlvgrp dqg lqvljkw iru zklfk , dp judwhixo , dp eohvvhg zlwk pdq\ iulhqgv vwxghqwv dqg fr zrunhuv zkr kdyh fkhhuhg ph rq  ie w  hqfrxudjhg ph wr nhhs jrlqj zkhq , ihow olnh txlwwlqj dqg , dp iruhyhu judwhixo , pxvw jlyh d vshfldo wkdqn \rx wr 7rql iru wkh 6dwxugd\ pruqlqj phhwlqjv wkh vwdwlvwlfv glvfxvvlrqv dqg phwkrgrorj\ zrunvkrsv zlwkrxw zklfk wklv zrxog kdyh ehhq vr pxfk pruh gliilfxow ovr wr doo ri p\ vwxghqwv zkr kdyh vwd\hg zlwk ph rq wklv mrxuqh\ dv , kdyh wkhluv , dp eh\rqg wkdqnixo iru wkh hqfrxudjhphqw dqg vxssruw  ev  , zdqw wr wkdqn p\ zlih iru sxwwlqj xs zlwk doo ri wkh plvvhg hyhqwv vxuo\ uhvsrqvhv odwh zulwlqj qljkwv dv zhoo dv zudqjolqj doo ri rxu fkloguhq¶v lvvxhv frqfhuqv dqg hphujhqflhv dv , ghyrwhg vr pxfk wlph dqg hqhuj\ wr wklv surfhvv ,w zrxog qrw kdyh ehhq srvvleoh zlwkrxw khu  pr  oryh vxssruw dqg frqilghqfh , fdqqrw vd\ ,¶yh hqmr\hg hyhu\ sduw ri wklv surfhvv exw , kdyh jurzq lpphqvho\ dqg lw kdv pdgh ph d vwurqjhu ehwwhu shuvrq lq wkh hqg , krsh wr frqwlqxh wr jurz lq p\ nqrzohgjh dqg kdyh d phdqlqjixo dqg srvlwlyh lpsdfw lq wkh frppxqlw\ dv zhoo dv wkh olyhv ri rwkhuv      lll      7deoh ri &rqwhqwv &kdswhu ,qwurgxfwlrq 6wdwhphqw ri wkh 3ureohp 3xusrvh ri wkh 6wxg\ 7khruhwlfdo ru &rqfhswxdo )udphzrun 1dwxuh ri wkh 6wxg\ 5hvhdufk 4xhvwlrqv  \srwkhvhv 6ljqlilfdqfh ri wkh 6wxg\ 'hilqlwlrqv ri .h\ 7hupv 6xppdu\  ie w  &kdswhu /lwhudwxuh 5hylhz  ev  %hwud\do 7udxpd 7khru\ 5holjlrxv 7udxpd dqg 6slulwxdo exvh 0hdqlqj pdnlqj diwhu exvh 'hsuhvvlrq diwhu exvh 7uxvw diwhu exvh 6xppdu\ &kdswhu 5hvhdufk 0hwkrg  pr  5hvhdufk 0hwkrgrorj\ dqg 'hvljq 3rsxodwlrq dqg 6dpsoh 0dwhuldov ,qvwuxphqwdwlrq 'dwd &roohfwlrq dqg qdo\vlv  vvxpswlrqv /lplwdwlrqv 'holplwdwlrqv (wklfdo vvxudqfhv 6xppdu\ &kdswhu )lqglqjv 9dolglw\ dqg 5holdelolw\ ri wkh 'dwd 5hvxowv 'hvfulswlyh 6wdwlvwlfv iru 6wxg\ 9duldeohv 5hvhdufk txhvwlrq rqh 5hvhdufk txhvwlrq wzr 5hvhdufk txhvwlrq wkuhh (ydoxdwlrq ri wkh )lqglqjv 6xppdu\ ly     &kdswhu ,psolfdwlrqv 5hfrpphqgdwlrqv dqg &rqfoxvlrqv ,psolfdwlrqv 5hfrpphqgdwlrqv iru 3udfwlfh 5hfrpphqgdwlrqv iru )xwxuh 5hvhdufk &rqfoxvlrqv 5hihuhqfhv  sshqglflhv  sshqgl[ 6wxg\ 4xhvwlrqqdluh  sshqgl[ % 5hfuxlwphqw )o\hu 3rvwlqj  sshqgl[ & 6wxg\ ,qylwdwlrq /hwwhu  sshqgl[ ' &rqvhqw /hwwhu   pr  ev  ie w                                 y     /lvw ri 7deohv  pr  ev  ie w  7deoh 'hvfulswlyh 6wdwlvwlfv iru 5holjlrxv 7udxpd 6slulwxdo exvh 'hsuhvvlrq 0hdqlqj pdnlqj dqg 7uxvw 7deoh 6wxg\ 0hdqv &rpsduhg wr 3ulru 5hvhdufk 6fdoh 'hyhorsphqw 0hdqv 7deoh &ruuhodwlrq 0dwul[                                         yl     /lvw ri )ljxuhv   ie w  )ljxuh 1rupdo 3uredelolw\ 3orw iru 7uxvw dv phdvxuhg e\ wkh *76 )ljxuh 1rupdo 3uredelolw\ 3orw iru 'hsuhvvlrq dv phdvxuhg e\ wkh 0 '6 )ljxuh 1rupdo 3uredelolw\ 3orw iru 3uhvhqfh ri 0hdqlqj dv phdvxuhg e\ wkh 0 '6 )ljxuh 1rupdo 3uredelolw\ 3orw iru 6hdufk iru 0hdqlqj dv phdvxuhg e\ wkh 0 '6 )ljxuh 6fdwwhusorw iru 7uxvw dv phdvxuhg e\ wkh *76 )ljxuh 6fdwwhusorw iru 'hsuhvvlrq dv phdvxuhg e\ wkh 0 '6 )ljxuh 6fdwwhusorw iru 0hdqlqj pdnlqj 3uhvhqfh 6xevfdoh dv phdvxuhg e\ wkh 04/ )ljxuh 6fdwwhusorw iru 0hdqlqj pdnlqj 6hdufk iru 0hdqlqj 6xevfdoh dv phdvxuhg e\ wkh 04/      pr  ev    yll     &kdswhu ,qwurgxfwlrq 7kh sudfwlfh ri uholjlrq dqg vslulwxdolw\ lq phulfdq olih surylghv shuvrqdo vrfldo dqg frjqlwlyh uhvrxufhv wkdw vhuyh dv exiihuv zkhq vxiihulqj d wlph ri vwuhvv eh\wd 5rxwohgjh  &duhv &xvlfn -xqj 5holjlrq dqg vslulwxdolw\ krog d irxqgdwlrqdo srvlwlrq lq wkh zruogylhz ri pdq\ phulfdqv 6rqj 0lq xk &kdh (ljkw\ shufhqw ri  phulfdq dgxowv uhsruwhg vrph ghjuhh ri vslulwxdo ru uholjlrxv diiloldwlrq %xqjh )rupdo uholjlrxv lqvwlwxwlrqv duh sodfhv ri frppxqlw\ wkrxjkw wr eh d vrxufh ri vwuhqjwk dqg frpiruw dqg vhuyh dv d sodfh zkhuh wkh h[lvwhqwldo txhvwlrq ri zkr dp ," pd\ eh dqvzhuhg eh\wd  ie w  5rxwohgjh  7kh frqfhsw ri vslulwxdolw\ lv h[sodlqhg dv wkh lqglylgxdo v xqghuvwdqglqj dqg phwkrg ri olylqj zlwklq d iudphzrun ri phdqlqj dqg ydoxh kpdgl xvvlq 0rkdppdg  ev  'rhkulqj d\qhv hw do 0d[zhoo 6plwk )uh\g 6rqj hw do 6rqj hw do h[dplqhg wkh uhohydqfh ri vslulwxdo zhoo ehlqj dv irxqgdwlrqdo lq rqh v uhodwlrqvkls zlwk vhoi hqylurqphqw *rg dqg frppxqlw\ wkdw surylghv d vhqvh ri frpsohwhqhvv  pr  6lploduo\ d\qhv hw do glvfxvvhg d surirxqg vhqvh ri sxusrvh frkhuhqfh dqg vljqlilfdqfh uhvxowlqj iurp uholjlrxv ru vslulwxdo eholhi v\vwhpv zklfk surylgh dq xqghuvwdqglqj ri wkh vxuylyru v uhvsrqvh wr d glvdvwhu d uhdssudlvdo ri *rg ru wkh 6dfuhg dqg d vhqvh ri phdqlqj lq wkh h[lvwhqwldo vhoi 5holjlrq dqg vslulwxdolw\ dfw dv frslqj phfkdqlvpv wkdw exlog rq d v\vwhp ri phdqlqj pdnlqj kpdgl hw do d\qhv hw do 3hrsoh riwhq ghyhors d vhqvh ri phdqlqj zkhq wkh olyhg h[shulhqfhv pdwfk wkhlu jrdov dqg eholhiv iru wkrvh shrsoh uholjlrxv dqg vslulwxdo eholhiv duh fuxfldo wr wkh phdqlqj lq olih kpdgl hw do whq hw do d\qhv hw do  'rhkulqj uhsruwhg uholjlrxv frslqj looxvwudwhv zlgh udqjlqj dvshfwv ri uholjlrq dqg      vslulwxdolw\ dqg krz wkhvh eholhi v\vwhpv surprwh frslqj ru h[dfhuedwh wkh vxiihulqj ri wkrvh zkr hqgxuhg wudxpd dqg olih fulvhv ,q uhvsrqvh wr wudxpdv ri glvdvwhuv ru ylrohqfh wkh vxuylyruv vhqvh ri sxusrvh dqg h[lvwhqwldo irxqgdwlrq pd\ eh lpsdfwhg qhjdwlyho\ ru ehfrph d vrxufh ri vwuhqjwk kpdgl hw do whq hw do d\qhv hw do  rzhyhu wkhuh duh wlphv zkhq wkh rssrvlwh ri frpiruw dqg frqvrodwlrq duh h[shulhqfhg dw wkh kdqgv ri wkrvh wuxvwhg dv *rg v uhsuhvhqwdwlyhv du]\fnd lhwhn )ru wkrvh zkr duh eholhyhuv lq *rg wkh vkduhg h[shulhqfh ri ehwud\do vwljpd frqixvlrq dqg wudxpd pd\ kdyh pdjqlilhg phdqlqj dv d uhvxow ri wkh uholjlrxv ru vdfuhg fkdudfwhu ri wkh dexvhu &dvkzhoo  ie w  6zlqgoh 5rvpdulq 3luxwlqvn\ ssho .dsodq 3hofrylw] 7kh vxuylyru ri uholjlrxv wudxpd dqg vslulwxdo dexvh pd\ lqwhuwzlqh wkh frqfhsw ri *rg zlwk wkh dexvhu zklfk dggv wkh glphqvlrq ri ehwud\do ru dedqgrqphqw e\ *rg dqg wkhuhe\ lqfuhdvhv wkh srzhu  ev  gliihuhqwldo ghshqglqj xsrq wkh uhodwlrqvkls wr wkh dexvhu &dvkzhoo 6zlqgoh .ohvw 7dpdldq %rxjkqhu 0d[zhoo   exvh dqg qhjohfw duh erwk wudxpdwlf h[shulhqfhv wkdw glvuxsw wkh vwdelolw\ rughu dqg  pr  shdfh ri hyhu\gd\ olih zklfk diihfwv wkh shufhswlrq dqg vhqvh ri vhoi wkh vhqvh ri wkh zruog wkh vhqvh ri rwkhuv dqg wkh vhqvh ri *rg wkdw zdv eholhyhg ehiruh wkh wudxpdwlf h[shulhqfh 6rqj hw do 7khuh lv wkhq d glvuxswlrq lq phdqlqj pdnlqj lqiolfwhg lq wkh qdph ri uholjlrq wkdw gluhfwo\ lpsdfwv phqwdo dqg sk\vlfdo zhoo ehlqj ohdglqj wr lqfuhdvhg v\pswrpv ri ghsuhvvlrq glvwuhvv plvwuxvw dqg lqwhuqdo frqiolfw eh\wd 5rxwohgjh ex 5dl\d hw do &dvkzhoo 6zlqgoh 0f&ruplfn &duuroo 6lpv &xuulhu 6lprqlh 0dqghom 1ryvdn 6lprqlh hw do irxqg sv\fkrorjlfdo gdpdjh pd\ eh lqiolfwhg zkhq uholjlrxv wh[wv ydoxhv dqg urohv duh glvwruwhg dqg vxevhtxhqwo\ xvhg lq vxfk d pdqqhu wkdw mxvwlilhv ru jorulilhv dq dffxvdwlrq lqvxow ru ylrohqw dfw zklfk kdv d gluhfw lpsdfw rq phqwdo dqg      sk\vlfdo zhoo ehlqj 7kh wkuhdw ri *rg v sxqlvkphqw lv fdvw ryhu wkrvh ylfwlpv zkr duh lq fryhuw ru ryhuw dexvlyh uhodwlrqvklsv dqg duh riwhq sdlqwhg dv wkh vlqqhu ex 5dl\d hw do 1ryvdn :rrg &rqoh\ :lqhoo frqwhqghg wudxpd zkhq frqihuuhg zlwk wkh txdolilhu ri uholjlrxv wudxpd lv vxiihuhg gxh wr d frpelqdwlrq ri wkh whdfklqjv ri wkh uholjlrq dv zhoo dv wkh hprwlrqdo dqg sv\fkrorjlfdo dexvh zklfk duh dw wlphv frpsrxqghg e\ sk\vlfdo dqg vh[xdo dexvh jlyhq wkh sdwuldufkdo dqg uhsuhvvlyh qdwxuh ri wkh uhvwulfwlyh uholjlrxv hqylurqphqw 3hrsoh zkr vxiihuhg wklv w\sh ri uholjlrxv wudxpd duh olnho\ wr kdyh ehhq wdxjkw wr glvwuxvw wkh phqwdo khdowk frppxqlw\ wkxv frpsrxqglqj wkh lvrodwlrq :lqhoo  ie w  7kh fxuuhqw olwhudwxuh uhiohfwv wkdw dq\ hiiruw wr xqghuvwdqg wkh hiihfw ri wudxpd dqg wudxpdwlf h[shulhqfhv ixoo\ pxvw lqfoxgh hohphqwv ri lqwhushuvrqdo ehwud\do dqg wkh lpsdfw ri lqvwlwxwlrqdo ehwud\do dv lw uhodwhv wr phqwdo khdowk 6plwk )uh\g 7kh frqvwuxfw ri wuxvw  ev  sulpdulo\ zkdw wkh ghilqlwlrq ri ehwud\do lqfoxghv 0d[zhoo lv qrw lpsolflwo\ phqwlrqhg ru phdvxuhg zlwklq fxuuhqw uholjlrxv wudxpd dqg vslulwxdo dexvh uhvhdufk whq hw do fdoohg iru ixwxuh uholjlrxv wudxpd dqg vslulwxdo dexvh uhvhdufk edvhg rq d glyhuvh vdpsoh wkdw  pr  hqjdjhv lq wkh exloglqj ru vwuhqjwkhqlqj ri wkhru\ 0xfk ri wkh olwhudwxuh uhylhzhg vdpsohg olplwhg srsxodwlrqv ru ghprjudsklfv zklfk udqjhg iurp fklogkrrg wudxpd vxuylyruv qrz vxuyh\hg dv froohjh vwxghqwv 6plwk )uh\g wr fdqfhu sdwlhqwv kpdgl hw do wr wkrvh zkr duh gldjqrvhg zlwk ,9 6plwk 'dzvrq 5rvh %odqfkdug %xwohu 7khvh vwxglhv duh lqglfdwlyh ri vhohfwlyh vdpsolqj zklfk grhv qrw wudqvodwh wr wkh eurdghu sxeolf ex 5dl\d hw do vxjjhvwhg dgglwlrqdo vwxglhv duh qhhghg wr lghqwli\ dq\ olqn ehwzhhq uholjlrxv wudxpd dqg vslulwxdo dexvh phdqlqj pdnlqj wuxvw dqg ghsuhvvlrq 7khuh duh olplwhg vwxglhv zlwk vshflilhg wkhruhwlfdo iudphzrunv phqwlrqhg frqfhuqlqj wkh lpsdfw ri uholjlrxv dqg vslulwxdo dexvh ex 5dl\d hw do 'rhkulqj d\qhv hw do      6wdwhphqw ri wkh 3ureohp 7kh jhqhudo vrflhwdo sureohp lv wkh kljk qxpehu ri shrsoh h[shulhqflqj uholjlrxv wudxpd ru vslulwxdo dexvh 2dnoh\ .lqprqg xpskuh\v :lqhoo &xuuhqw uhvhdufkhuv 2dnoh\ hw do hvwlpdwhg wkh suhydohqfh ri vslulwxdo dexvh wr eh kljk lq d vwxg\ ri uhvsrqghqwv uhsruwhg shuvrqdo h[shulhqfhv ri uholjlrxv dexvh dqg vslulwxdo wudxpd 7kh udplilfdwlrqv ri uholjlrxv wudxpd dqg vslulwxdo dexvh lqyroyh dq lqfuhdvhg vhqvh ri jxlow kljkhu udwhv ri ghsuhvvlrq d glvuxswhg v\vwhp ri phdqlqj pdnlqj dqg gliilfxow\ frslqj eh\wd 5rxwohgjh ex 5dl\d hw do &dvkzhoo 6zlqgoh 0f&ruplfn hw do  ie w  6lprqlh hw do du]\fnd lhwhn  7kh vshflilf sureohp uhiohfwhg lq wkh olwhudwxuh surpswlqj wkh qhhg iru wklv vwxg\ zdv d odfn ri xqghuvwdqglqj ri wkh lpsdfw ri uholjlrxv wudxpd dqg vslulwxdo dexvh rq phdqlqj pdnlqj  ev  wuxvw dqg ghsuhvvlrq zklfk lv qhhghg wr lqirup sv\fkrwkhudshxwlf wuhdwphqw iru wkh dgghg hohphqw ri uholjlrxv wudxpd dqg vslulwxdo dexvh 6shflilfdoo\ uhvhdufk zdv fdoohg iru wr ghwhuplqh wkh uhodwlrqvkls ehwzhhq uholjlrxv wudxpd dqg vslulwxdo dexvh rq phdqlqj pdnlqj  pr  wuxvw dqg ghsuhvvlrq lq rughu wr ghyhors dghtxdwh lqwhuyhqwlrqv whq hw do 0d[zhoo  2dnoh\ hw do whu .xloh (kulqj 7lvkhopdq )rqwhv :roi .hssoh  6xfk lqirupdwlrq lv qhhghg wr lqirup sv\fkrwkhudshxwlf wuhdwphqw iru uholjlrxv wudxpd dqg vslulwxdo dexvh 1ryvdn 6lprqlh hw do 3xusrvh ri wkh 6wxg\ 7kh sxusrvh ri wklv txdqwlwdwlyh fruuhodwlrqdo uhvhdufk zdv wr h[dplqh wkh suhglfwlyh uhodwlrqvkls ri uholjlrxv wudxpd dqg vslulwxdo dexvh rq phdqlqj pdnlqj wuxvw dqg ghsuhvvlrq 7kh wdujhw srsxodwlrq zdv dgxowv zlwklq wkh 8qlwhg 6wdwhv zkr lghqwlilhg d wudxpdwlf ru dexvlyh h[shulhqfh zlwk lqvwlwxwlrqdo uholjlrq 7kh vdpsoh lqfoxghg d plqlpxp ri shrsoh zklfk phw      wkh uhtxluhg vdpsoh vl]h iru srzhu 3duwlflsdqw uhfuxlwphqw zdv fduulhg rxw yld io\hu lqylwdwlrq wr sduwlflsdwh yld hpdlo srvwhg rq )dfherrn lq ydulrxv rqolqh phvvdjh jurxsv /lqnhg,q dqg 7zlwwhu 'dwd zdv froohfwhg yld 4xdowulfv dq rqolqh vxuyh\ sodwirup 7kh suhglfwru yduldeoh ri uholjlrxv wudxpd zdv phdvxuhg zlwk wkh 6wuxfwxuhg 7udxpd 5hodwhg ([shulhqfhv dqg 6\pswrpv 6fuhhqhu iru gxowv *udvvr )howrq 5hlg 4xlqrqhv wkh wwlwxghv 7rzdug *rg 6fdoh :rrg hw do dqg wkh 0hdvxuhv ri %hwud\do 3rzhuohvvqhvv dqg 6wljpd *levrq /hlwhqehuj 7kh suhglfwru yduldeoh ri vslulwxdo dexvh zdv phdvxuhg zlwk wkh 5holjlrxv dqg 6slulwxdo 6wuxjjohv 6fdoh ([olqh hw do 7kh fulwhulrq yduldeoh ri phdqlqj pdnlqj zdv  ie w  phdvxuhg xwlol]lqj wkh lwhp vxuyh\ xwlol]lqj d srlqw /lnhuw w\sh vfdoh ri wkh 0hdqlqj lq /lih 4xhvwlrqqdluh 6whjhu hw do 7kh fulwhulrq yduldeoh ri wuxvw zdv phdvxuhg zlwk wkh *hqhudo 7uxvw 6fdoh dpdjlvkl dpdjlvkl 7kh fulwhulrq yduldeoh ri ghsuhvvlrq zdv phdvxuhg  ev  zlwk wkh 0rglilhg xqj 'hsuhvvlrq 6fdoh .qljkw :ddo 0dqqlqj 6shduv 'dwd zhuh froohfwhg hqwhuhg lqwr 6366 frghg dqg ghvfulswlyh dqdo\vhv frpsohwhg dqg wkh lqihuhqwldo dqdo\vlv dvvxpswlrq whvwv zhuh frpsohwhg 'hvfulswlyh gdwd dqdo\vhv lqfoxghg wkh fdofxodwlrq ri  pr  vwdqgdug ghyldwlrqv yduldeoh phdqv dqg judskv iru hdfk ri wkh vwxg\ yduldeohv ,qihuhqwldo dqdo\vhv lqfoxghg pxowlsoh uhjuhvvlrq dqdo\vlv lq ghwhuplqlqj wkh suhglfwlyh uhodwlrqvkls ri wkh h[shulhqfh ri uholjlrxv wudxpd dqg vslulwxdo dexvh suhglfwru yduldeohv rq phdqlqj pdnlqj wuxvw dqg ghsuhvvlrq fulwhulrq yduldeohv 7khruhwlfdo ru &rqfhswxdo )udphzrun %hwud\do 7udxpd 7khru\ krogv d sodfh lq wkh uhvhdufk ri wklv vxemhfw wr xqghuvwdqg wkh lpsolfdwlrqv ri dxwkrulw\ iljxuhv dqg ylrodwlrqv ri wuxvw dv zhoo dv gdpdjhg phdqlqj pdnlqj v\vwhpv \hw pruh uhvhdufk zdv lqglfdwhg wr h[dplqh wkh pdq\ dvshfwv uhodwhg h[solflwo\ wr uholjlrxv dqg vslulwxdo dexvh 0d[zhoo 6plwk )uh\g 0d[zhoo fdoohg iru      ixuwkhu uhvhdufk zlwk lqglylgxdov zkr vhoi lghqwli\ dv ylfwlpv ri uholjlrxv ru vslulwxdo dexvh lq wkh 8qlwhg 6wdwhv 7kh fdoo iru vxfk uhvhdufk lv wr hvwdeolvk d edvholqh iru xqghuvwdqglqj wkh glvuxswlrq ri phdqlqj pdnlqj wkurxjk wkh ohqv ri ehwud\do wudxpd wkhru\ 0d[zhoo 6plwk dqg )uh\g ghwhuplqhg ehwud\do wudxpd rffxuv zkhq ylrohqfh pdowuhdwphqw ru dexvh lv shushwudwhg e\ d wuxvwhg lqglylgxdo ru e\ rqh zkrp wkh ylfwlp ghshqghg %hwud\do wudxpd lv d frpsoh[ vwuhvvru olqnhg wr pdunhg srru khdowk rxwfrphv dqg lqfuhdvhg ghsuhvvlrq dqg dq[lhw\ 0d[zhoo 6plwk )uh\g 0d[zhoo uhodwhg %hwud\do 7udxpd 7khru\ wr fklogkrrg dqg ghyhorslqj d khdowk\ irxqgdwlrq ri dq dwwdfkphqw v\vwhp 7kh vdph  ie w  v\vwhp lq zklfk vxuylydo dqg wkh xqghuvwdqglqj ri wkh qhfhvvlw\ ri vrfldo frqwudfwv wr kdyh hvvhqwldo qhhgv phw lv exlow 0d[zhoo 6plwk )uh\g 2qh hohphqw ri wkh sv\fkrorjlfdo gdpdjh uhfrjql]hg lv wkh eolqgqhvv wr ehwud\do zkhq wkh riihqghu lv vrphrqh  ev  wuxvwhg vxfk dv d sdvwru ru vrphrqh wkh ylfwlp uholhv rq iru vxuylydo olnh d sduhqw 0d[zhoo  6plwk )uh\g %hwud\do 7udxpd 7khru\ pd\ eh xwlol]hg dfurvv d eurdg vshfwuxp iurp lqvwlwxwlrq grzq wr wkh lqglylgxdo dv lw lv wkh ehwud\do lwvhoi wkdw lv uhodwlyh wr wkh  pr  uhodwlrqvkls ehwzhhq wkh ylfwlp dqg shushwudwru .ohvw hw do ,qvwlwxwlrqdo ehwud\do lqfoxghv wkh frqfhsw ri uholjlrq ru uholjlrxv eholhiv dv d wuxvwhg lqvwlwxwlrq 7klv w\sh ri ehwud\do kdv ehhq vkrzq wr frpsolfdwh wkh wudxpdwlf h[shulhqfh dqg lqfuhdvh wkh olnholkrrg ri srvwwudxpdwlf vwuhvv glvrughu 6plwk )uh\g ,w kdv ehhq vxjjhvwhg wkdw wkh hohphqw ri ehwud\do ohdgv wr glvvrfldwhg sv\fkrorjlfdo glvwuhvv uhvxowlqj lq fkurqlf khdowk sureohpv exw vxevwdqwldwlrq uhtxluhv dgglwlrqdo uhvhdufk wr exlog xsrq wkh wkhru\ derxw uholjlrxv dqg vslulwxdo lqvwlwxwlrqv 0d[zhoo 6plwk )uh\g  gglwlrqdo wkhrulhv h[solfdwhg wkh hpsor\phqw ri 6whskhq 3rujhv sro\ydjdo wkhru\ ghyhorshg rq wudxpd dqg dfxwh vwuhvv uhvsrqvhv wkdw pd\ eh plwljdwhg xwlol]lqj erg\ dzduh      fdoplqj whfkqltxhv wr vkliw iurp ihdu jxlow dqg ru vkdph wr d fdop dqg frpsdvvlrqdwh rulhqwlqj v\vwhp zlwk wkh xvh ri uholjlrxv sudfwlfhv vxfk dv ydulhg euhdwklqj whfkqltxhv frppxqdo fkdqwlqj dqg rwkhu djh rog froohfwlyh phwkrgv wr vkliw dxwrqrplf vwdwhv 'rhkulqj 'rhkulqj vxjjhvwhg wkh qhfhvvlw\ ri lqfuhdvhg uhvhdufk rq wkh uroh wkdw hylghqfh edvhg vslulwxdo fduh sudfwlfhv pd\ dvvlvw sdwlhqw v pdqdjhphqw dqg frslqj zlwk vhulrxv looqhvv  wwdfkphqw 7khru\ pd\ eh xwlol]hg wr xqghuvwdqg wkh hohphqw ri lqdelolw\ wr ghyhors d vslulwxdo frqqhfwlrq uhvxowlqj iurp d fklogkrrg lq zklfk d vhfxuh lqwhuqdo irxqgdwlrq zdv qhyhu ghyhorshg vslulwxdo ru rwkhuzlvh 6rqj hw do 7kh ([lvwhqwldo &ulvlv 7khru\ lv vlplodu wr  ie w  %hwud\do 7udxpd 7khru\ exw lqyroyhv pruh hprwlrqdo frpsrqhqwv vxfk dv ghvsdlu dq[lhw\ jxlow orqholqhvv ihdu hprwlrqdo sdlq wkh frjqlwlyh frpsrqhqwv ri glvwxuehg ghflvlrq pdnlqj d vhqvh ri sxusrvh orvv ri jrdov d uhdol]dwlrq ri pruwdolw\ dqg orvv ri ydoxhv %xwhqdlwh 6rqgdlwh  ev   0rfnxv 7khvh duh qrw pxwxdoo\ h[foxvlyh frpsrqhqwv krzhyhu wkh euhdgwk ri lpsdfw rq ixqfwlrqlqj lv vljqlilfdqw 1dwxuh ri wkh 6wxg\   txdqwlwdwlyh phwkrg zdv xwlol]hg wr lghqwli\ sdwwhuqv lq wkh gdwd dqg surylgh d phdqv wr  pr    duwlfxodwh idfwv surgxfhg iurp txdqwlildeoh gdwd 7klv irup ri uhvhdufk lv iuhtxhqwo\ xvhg lq vrfldo vflhqfhv wr h[dplqh wkh lpsolfdwlrqv ri d skhqrphqrq dqg lwv hiihfw rq wkh vdpsoh srsxodwlrq %xuuhoo *urvv 7kh uhvhdufk jrdo zdv wr surylgh gdwd iru xqghuvwdqglqj krz wkh yduldeohv lqioxhqfh rqh dqrwkhu wr surylgh d eurdghu xqeldvhg h[sodqdwlrq ri wkh gdwd zlwk wklv lq plqg txdqwlwdwlyh uhvhdufk phwkrgrorj\ zdv vhohfwhg    fruuhodwlrqdo ghvljq zdv vhohfwhg dv lw lv wkh uhvhdufk phwkrgrorj\ wkdw vhhnv wr  lghqwli\ d uhodwlrqvkls ehwzhhq wzr ru pruh yduldeohv wr lghqwli\ krzhyhu lw grhv qrw hvwdeolvk fdxvh dqg hiihfw 0huwhqv glvfxvvhg wkh xvh ri fruuhodwlrqdo vwdwlvwlfv wr whvw wkh vwuhqjwk      ri wkh uhodwlrqvkls ehwzhhq d yduldeoh dqg dq rxwfrph 7klv phwkrg lv lqglfdwlyh ri d vxlwdeoh ghvljq wr phdvxuh wkh lpsdfw ri uholjlrxv wudxpd dqg vslulwxdo dexvh rq dq lqglylgxdo loo dqg 3dujdphqw ghvfulehg wkh gliilfxow\ lq phdvxulqj wkh lpsdfw ri uholjlrxv wudxpd dqg vslulwxdo dexvh rq frslqj phfkdqlvpv 7kh phdvxuh ri uholdelolw\ dqg ydolglw\ duh hvvhqwldo frqvlghudwlrqv zkhq dwwhpswlqj wr phhw wkh vflhqwlilf vwdqgdugv iru phdvxuhphqw lq wkh sv\fkrorj\ ri uholjlrq dqg vslulwxdolw\ loo dqg 3dujdphqw uhiohfwhg zkhq vdpsolqj glyhuvh srsxodwlrqv d vfdoh wkdw lv jurxqghg lq wkhru\ kdv pruh uholdelolw\ dqg juhdwhu ydolglw\ 7kh xwlol]dwlrq ri wkh vxuyh\ phwkrg zklfk lqyroyhv froohfwlqj gdwd gluhfwo\ iurp d srsxodwlrq dw  ie w  d vshflilhg wlph surylghg dq dgydqwdjh ri dffhvv wr odujh glyhuvh srsxodwlrqv %dghu dqg )lqnh  qrwhg uholjlrxvqhvv dqg vslulwxdolw\ fkdqjh ryhu wlph zklfk fdq fdxvh idlwk pd\ eh xqghuvwrrg dv d surfhvv ri phdqlqj pdnlqj uhvxowlqj iurp wkh reoljdwlrq wr fuhdwh dqg dgkhuh wr  dssursuldwh vxuyh\ wrrov  ev  doljqlqj sulqflsohv ru ydoxhv 7kxv pdnlqj lw lpshudwlyh wkdw wkh uhvhdufkhu vhohfw wkh  7kh suhglfwru yduldeoh ri uholjlrxv wudxpd zdv phdvxuhg zlwk wkh 6wuxfwxuhg 7udxpd  pr  5hodwhg ([shulhqfhv dqg 6\pswrpv 6fuhhqhu iru gxowv *udvvr hw do wkh wwlwxghv 7rzdug *rg 6fdoh :rrg hw do dqg wkh 0hdvxuhv ri %hwud\do 3rzhuohvvqhvv dqg 6wljpd *levrq /hlwhqehuj 7kh suhglfwru yduldeoh ri vslulwxdo dexvh zdv phdvxuhg zlwk wkh 5holjlrxv dqg 6slulwxdo 6wuxjjohv 6fdoh ([olqh hw do 7kh fulwhulrq yduldeoh ri phdqlqj pdnlqj zdv phdvxuhg xwlol]lqj wkh lwhp 0hdqlqj lq /lih 4xhvwlrqqdluh 6whjhu hw do 7kh fulwhulrq yduldeoh ri wuxvw zdv phdvxuhg zlwk wkh *hqhudo 7uxvw 6fdoh dpdjlvkl   dpdjlvkl 7kh fulwhulrq yduldeoh ri ghsuhvvlrq zdv phdvxuhg zlwk wkh 0rglilhg  xqj 'hsuhvvlrq 6fdoh .qljkw hw do       7kh vwxg\ srsxodwlrq zdv dgxowv zlwklq wkh 8qlwhg 6wdwhv zkr lghqwlilhg d wudxpdwlf ru dexvlyh h[shulhqfh zlwk d irupdol]hg uholjlrq 7kh vdpsoh lqfoxghg d plqlpxp ri shrsoh zklfk phw wkh uhtxluhg vdpsoh vl]h iru srzhu 3duwlflsdqw uhfuxlwphqw zdv fduulhg rxw yld io\hu lqylwdwlrq wr sduwlflsdwh yld hpdlo srvwhg rq )dfherrn lq ydulrxv rqolqh phvvdjh jurxsv /lqnhg,q dqg 7zlwwhu 'dwd zdv froohfwhg yld 4xdowulfv dq rqolqh vxuyh\ sodwirup 'dwd zhuh dqdo\]hg zlwk pxowlsoh uhjuhvvlrq dqdo\vlv 7klv vwxg\ dlphg wr h[sdqg xsrq xqghuvwdqglqj wkh uhodwlrqvkls ehwzhhq uholjlrxv wudxpd dqg vslulwxdo dexvh zlwk phdqlqj pdnlqj wuxvw dqg ghsuhvvlrq  ie w  5hvhdufk 4xhvwlrqv  54 rz gr uholjlrxv wudxpd dqg vslulwxdo dexvh suhglfw phdqlqj pdnlqj"    54 rz gr uholjlrxv wudxpd dqg vslulwxdo dexvh suhglfw wuxvw"    54 rz gr uholjlrxv wudxpd dqg vslulwxdo dexvh suhglfw ghsuhvvlrq"   \srwkhvhv  ev    pdnlqj  pr   5holjlrxv wudxpd dqg vslulwxdo dexvh suhglfw qr fkdqjh lq v\vwhpv ri phdqlqj   d 5holjlrxv wudxpd dqg vslulwxdo dexvh suhglfw glvuxswhg v\vwhpv ri phdqlqj pdnlqj  5holjlrxv wudxpd dqg vslulwxdo dexvh suhglfw qr fkdqjh lq wkh delolw\ wr wuxvw  d 5holjlrxv wudxpd dqg vslulwxdo dexvh suhglfw ghfuhdvhg delolw\ wr wuxvw  5holjlrxv wudxpd dqg vslulwxdo dexvh suhglfw qr fkdqjh lq wkh ohyho ri ghsuhvvlrq  d 5holjlrxv wudxpd dqg vslulwxdo dexvh suhglfw dq lqfuhdvhg ohyho ri ghsuhvvlrq 6ljqlilfdqfh ri wkh 6wxg\   7klv vwxg\ lv vljqlilfdqw ehfdxvh wkh uhvxowv dgg wr xqghuvwdqglqj wkh uhodwlrqvkls ehwzhhq  uholjlrxv wudxpd dqg vslulwxdo dexvh wr phdqlqj pdnlqj wuxvw dqg ghsuhvvlrq 5holjlrxv eholhiv      dqg uholjlrxv dxwkrulw\ iljxuhv pdlqwdlq d frpsoh[ srvlwlrq zlwklq wkh idplo\ dqg vrfldo olih dqg wkh uroh sod\hg e\ vxfk iljxuhv pd\ vhhp olnh d phdqv wr d shuvrqdo frqqhfwlrq wr *rg zklfk zkhq orvw gxh wr vrph irup ri ehwud\do vxfk dv sk\vlfdo vh[xdo ru hprwlrqdo dexvh lv wudxpdwlf &dvkzhoo 6zlqgoh 0durwwd :dowhuv 6whyhqv u]rxpdqldq *uhhqedxp 6fkzde 'dohqehuj 7klv vwxg\ surylghg uhvhdufk wr lghqwli\ dq\ olqn ehwzhhq uholjlrxv wudxpd dqg vslulwxdo dexvh zlwk phdqlqj pdnlqj wuxvw dqg ghsuhvvlrq dv fdoohg iru e\ ex 5dl\d hw do dqg exlogv rq wkh xqghuvwdqglqj ri wkh lpsolfdwlrqv ri glvuxswlrq lq phdqlqj pdnlqj v\vwhpv zkhq lqwhusuhwhg wkurxjk wkh ohqv ri ehwud\do wudxpd wkhru\ 0d[zhoo  ie w  7klv vwxg\ v uhvxowv lqirup folqlfldqv iru sudfwlfdo dssolfdwlrq dqg vwuhqjwkhq wkh irxqgdwlrqdo wkhruhwlfdo xqghuvwdqglqj ri uholjlrxv wudxpd dqg vslulwxdo dexvh 5hvxowv lqglfdwhg d vljqlilfdqw fruuhodwlrqdo uhodwlrqvkls ehwzhhq uholjlrxv wudxpd dqg vslulwxdo dexvh dqg wkh v\vwhpv ri  ev  phdqlqj pdnlqj dqg ohyho ri ghsuhvvlrq 7kh lpsruwdqfh ri frqwlqxhg vwxg\ dqg ixuwkhu ghyhorsphqw ri folqlfdo dvvhvvphqw dqg lqwhuyhqwlrq lv vxssruwhg lq wklv vwxg\ 'hilqlwlrqv ri .h\ 7hupv  pr  'hsuhvvlrq 'hsuhvvlrq lv d phglfdo looqhvv wkdw ghfuhdvhv rqh v delolw\ wr ixqfwlrq dw krph dqg zrun gxh wr v\pswrpv wkdw lqfoxgh h[wuhph ihholqjv ri vdgqhvv dqg ru orvv ri lqwhuhvw lq dfwlylwlhv zhljkw jdlq ru orvv wrr pxfk ru wrr olwwoh vohhs ihholqjv ri zruwkohvvqhvv ru jxlow gliilfxow\ frqfhqwudwlqj dqg vxlflgdo wkrxjkwv 3duhnk 0hdqlqj pdnlqj 0hdqlqj pdnlqj lqfoxghv erwk vslulwxdo dqg sv\fkrorjlfdo frpsrqhqwv ri krz rqh shufhlyhv wkh zruog rqh v sodfh lq wkh zruog dqg d vhqvh ri sxusrvh )udqno 0durwwd :dowhuv 5holjlrxv wudxpd 5holjlrxv wudxpd pd\ eh ghilqhg dv d vshfwuxp ri frqglwlrqv uhvxowlqj iurp d wudxpdwlf h[shulhqfh shufhlyhg e\ wkh vxuylyru wr eh fdxvhg e\ uholjlrxv      sudfwlfhv uholjlrxv frppxqlwlhv uholjlrxv whdfklqjv v\perov dqg ru wkh glylqh ehlqj wr wkh h[whqw wkdw wkh vxuylyru v delolw\ wr sduwlflsdwh lq uholjlrxv olih 3dqfkxn 6slulwxdo dexvh 6slulwxdo dexvh pd\ eh ghilqhg dv wkh frqwuro ru rssuhvvlrq lq d vslulwxdo frqwh[w lq zklfk wkh dexvh lqfoxghv hohphqwv ri h[sorlwdwlrq pdqlsxodwlrq ghflvlrq pdnlqj fhqvruvkls hqirufhg frqiruplw\ h[shfwdwlrqv ri rehglhqfh plvxvh ri vfulswxuh zlwk wkh lqwhqw ri ehkdylrudo frqwuro pdqlsxodwlrq lvrodwlrq iurp rwkhuv dqg wkh looxvlrq wkdw wkh dexvhu krogv d glylqh srvlwlrq 2dnoh\  7uxvw 7uxvw lv ghilqhg dv d zloolqjqhvv wr eh rshq wr wkh frqvhtxhqfhv ri rwkhuv dfwlrqv  ie w  0d\hu 'dylv 6fkrrupdq 7uxvw dulvhv iurp vrflhwdo dwwlwxghv ri wkh vxuurxqglqj zruog dqg rwkhu shrsoh -dvlhovnd 5rjr]d dmhqnrzvnd 5xvvd 6xppdu\  7klv fkdswhu surylghg lqwurgxfwru\ lqirupdwlrq derxw wkh fxuuhqw vwxg\ 7kh jhqhudo  ev    sureohp lv wkh qxpehu ri shrsoh wr h[shulhqfh uholjlrxv wudxpd ru vslulwxdo dexvh 2dnoh\ hw do  :lqhoo 7kh vshflilf sureohp dgguhvvhg zdv d odfn ri xqghuvwdqglqj ri wkh lpsdfw  pr  ri uholjlrxv wudxpd dqg vslulwxdo dexvh rq phdqlqj pdnlqj wuxvw dqg ghsuhvvlrq zklfk lv qhhghg wr lqirup sv\fkrwkhudshxwlf wuhdwphqw iru wkh dgghg hohphqw ri uholjlrxv wudxpd dqg vslulwxdo dexvh ffruglqjo\ wkh fxuuhqw vwxg\ v sxusrvh zdv wr h[dplqh wkh suhglfwlyh uhodwlrqvkls ri uholjlrxv wudxpd dqg vslulwxdo dexvh rq phdqlqj pdnlqj wuxvw dqg ghsuhvvlrq ,q rughu wr dfklhyh wklv sxusrvh d txdqwlwdwlyh fruuhodwlrqdo uhvhdufk phwkrg zdv hpsor\hg 7kh vshflilf vdpsoh frpsulvhg dgxowv zkr lghqwlilhg dv kdylqj d wudxpdwlf ru dexvlyh h[shulhqfh zlwk d irupdol]hg uholjlrq 3duwlflsdqw uhfuxlwphqw zdv fduulhg rxw yld io\hu lqylwdwlrq wr sduwlflsdwh yld hpdlo srvwhg rq )dfherrn lq ydulrxv rqolqh phvvdjh jurxsv /lqnhg,q dqg 7zlwwhu 'dwd zdv froohfwhg yld 4xdowulfv dq rqolqh vxuyh\ sodwirup 5holjlrxv      wudxpd zdv phdvxuhg e\ wkh 6wuxfwxuhg 7udxpd 5hodwhg ([shulhqfhv dqg 6\pswrpv 6fuhhqhu iru gxowv *udvvr hw do wkh wwlwxghv 7rzdug *rg 6fdoh :rrg hw do dqg wkh 0hdvxuhv ri %hwud\do 3rzhuohvvqhvv dqg 6wljpd *levrq /hlwhqehuj 6slulwxdo dexvh zdv phdvxuhg zlwk wkh 5holjlrxv dqg 6slulwxdo 6wuxjjohv 6fdoh ([olqh hw do 7kh fulwhulrq yduldeohv zhuh phdqlqj pdnlqj wuxvw dqg ghsuhvvlrq 0hdqlqj pdnlqj zdv phdvxuhg zlwk wkh 0hdqlqj lq /lih 4xhvwlrqqdluh 6whjhu hw do 7uxvw zdv phdvxuhg zlwk wkh *hqhudo 7uxvw 6fdoh dpdjlvkl dpdjlvkl dqg ghsuhvvlrq zdv phdvxuhg zlwk wkh 0rglilhg xqj 'hsuhvvlrq 6fdoh .qljkw hw do 7kh vhyhq lqvwuxphqwv zhuh frpelqhg lqwr rqh vwxg\  ie w  txhvwlrqqdluh 0xowlsoh olqhdu uhjuhvvlrq dqdo\vhv zhuh xvhg wr ghwhuplqh wkh suhglfwlyh uhodwlrqvkls ri uholjlrxv wudxpd dqg vslulwxdo dexvh zlwk phdqlqj pdnlqj wuxvw dqg ghsuhvvlrq 7kh qh[w fkdswhu lqfoxghv dq h[dplqdwlrq ri wkh olwhudwxuh uhodwhg wr wkh yduldeohv dqg   pr  ev  uhodwlrqvklsv ri lqwhuhvw lq wklv vwxg\       &kdswhu /lwhudwxuh 5hylhz 7kh sxusrvh ri wklv txdqwlwdwlyh fruuhodwlrqdo uhvhdufk zdv wr h[dplqh wkh suhglfwlyh uhodwlrqvkls ri uholjlrxv wudxpd dqg vslulwxdo dexvh rq phdqlqj pdnlqj wuxvw dqg ghsuhvvlrq 7klv olwhudwxuh uhylhz suhvhqwv d irxqgdwlrqdo h[dplqdwlrq ri wkh fxuuhqw xqghuvwdqglqj ri wkh hiihfwv ri uholjlrxv wudxpd dqg vslulwxdo dexvh 5hvhdufkhuv vxjjhvwhg juhdwhu h[dplqdwlrq lv qhhghg lq rughu wr xqghuvwdqg wkh uhodwlrqvkls dqg hiihfwv ri uholjlrxv wudxpd dqg vslulwxdo dexvh rq phdqlqj pdnlqj wuxvw dqg ghsuhvvlrq wr ghyhors dghtxdwh lqwhuyhqwlrqv whq hw do 0d[zhoo 2dnoh\ hw do whu .xloh (kulqj 7lvkhopdq )rqwhv :roi  ie w   .hssoh 7khuhiruh wkh sxusrvh ri wklv txdqwlwdwlyh fruuhodwlrqdo uhvhdufk zdv wr h[dplqh wkh suhglfwlyh uhodwlrqvkls ri uholjlrxv wudxpd dqg vslulwxdo dexvh rq phdqlqj pdnlqj wuxvw dqg ghsuhvvlrq  ev  7r idflolwdwh wkh dqdo\vlv ri wkh uhohydqw yduldeohv dq h[kdxvwlyh vhdufk ri wkh olwhudwxuh zdv frqgxfwhg wkurxjk wkh iroorzlqj gdwdedvhv (%6&2 krvw 3ur4xhvw &hqwudo 3v\f uwlfohv 3ur4xhvw 5holjlrq 3ur4xhvw 5hvhdufk /leudu\ 3v\fkldwu\ 2qolqh 6djh 6flhqfh 'luhfw  pr  3v\f,1)2 6rfldo 6flhqfhv &lwdwlrq ,qgh[ 6sulqjhu /lqn dqg 7d\oru dqg )udqflv 2qolqh .h\zrugv xvhg lqfoxghg uholjlrxv wudxpd vslulwxdo dexvh phdqlqj pdnlqj wuxvw ghsuhvvlrq ghsuhvvlrq dqg uholjlrq ghsuhvvlrq dqg vslulwxdolw\ phdqlqj pdnlqj dqg dexvh wuxvw wuxvw dqg vslulwxdolw\ fohuj\ dexvh uholjlrxv dexvh vslulwxdo wudxpd ehwud\do ehwud\do wudxpd dqg ehwud\do wudxpd wkhru\ 3xeolfdwlrq \hduv ri vhohfwhg duwlfohv zhuh sulpdulo\ uhvwulfwhg wr wkrvh idoolqj ehwzhhq dqg uwlfohv ghvljqdwhg dv vfkroduo\ dqg ru shhu uhylhzhg rqo\ kdyh ehhq lqfoxghg 7kh iroorzlqj vhfwlrqv duh uhsuhvhqwhg lq wklv olwhudwxuh uhylhz ehwud\do wudxpd wkhru\ uholjlrxv wudxpd dqg vslulwxdo dexvh phdqlqj pdnlqj wuxvw dqg ghsuhvvlrq       %hwud\do 7udxpd 7khru\ -hqqlihu )uh\g sursrvhg wkh frqfhsw ri vrfldo ehwud\do dv dq dvshfw ri wkh wudxpdwlf h[shulhqfh lq wkh frqwh[w ri khu ehwud\do wudxpd wkhru\ )uh\g )uh\g 'h3ulqfh  )uh\g 'h3ulqfh *ohdyhv 6plwk )uh\g d wkhru\ lqlwldoo\ ghyhorshg wr frqfhswxdol]h wkh ixqfwlrq ri wudxpdwlf dpqhvld ffruglqj wr )uh\g ehwud\do wudxpd uhihuhqfhv wudxpdwlf h[shulhqfhv vxfk dv pdowuhdwphqw ru dexvh shushwudwhg e\ dq dwwdfkphqw iljxuh ru rwkhu lqglylgxdo ri dxwkrulw\ rq zkrp wkh ylfwlp ghshqgv iru edvlf qhfhvvlwlhv 7kh ehwud\do wudxpd wkhru\ krogv wkdw fkloguhq kdyh dq hyroxwlrqdulo\ edvhg frjqlwlyh eldv wr  ie w  flufxpyhqw surfhvvlqj hylghqfh lqglfdwlyh ri ehwud\do e\ d wuxvwhg fduhjlyhu )uh\g )uh\g dqg 'h3ulqfh pdlqwdlqhg kxpdqv duh kljko\ vhqvlwlyh wr ehwud\do \hw vhsdudwlqj iurp wkh ehwud\hu pd\ eh ghwulphqwdo li wkh ehwud\hu lv d iljxuh ri dwwdfkphqw vxfk dv d sduhqw  ev  vleolqj ru dxwkrulw\ iljxuh ,w wkhq ehfrphv qhfhvvdu\ wr vhjuhjdwh wkh nqrzohgjh ri wkh ehwud\do iurp rqh v frqvflrxv dzduhqhvv dv d phdqv ri suhvhuylqj wkh dwwdfkphqw uhodwlrqvkls )uh\g 'hsulqfh 6plwk )uh\g 7kh irufh surpswlqj vhohfwlyh dzduhqhvv lv wkh qhfhvvlw\  pr  wr dyrlg wkh nqrzohgjh ri wkh ehwud\do vxfk dv )dwkhu kxuwv ph zklfk glvuxswv wkh dwwdfkphqw vhhnlqj ehkdylru rq zklfk vxuylydo lwvhoi ghshqgv )uh\g ([sodlqlqj ixuwkhu )uh\g hw do  vwdwhg %hwud\do 7udxpd 7khru\ lv rqh dssurdfk wr frqfhswxdol]h wudxpd ixuwkhu dqg gluhfwv dwwhqwlrq wr wkh lpsruwdqfh ri vrfldo uhodwlrqvklsv dv jxlgdqfh lq xqghuvwdqglqj srvw wudxpdwlf rxwfrphv lqfoxglqj hohphqwv ri uhgxfhg uhfdoo owkrxjk %hwud\do 7udxpd 7khru\ v ruljlqdo irfxv zdv rq ehwud\do eolqgqhvv dqg uhgxfhg uhfdoo lw kdv vlqfh h[sdqghg dqg ghyhorshg wr lqfoxgh juhdwhu uhvsrqvhv vxfk dv ghsuhvvlrq dqg dq[lhw\ )uh\g hw do  lvwrulfdoo\ gldjqrvwlf qrvrorj\ kdv qrw lqfoxghg wkh hohphqw ri ehwud\do *rph] /hzlv 1roo 6plgw %luuhoo 0d[zhoo ghilqhg ehwud\do dv d srlqw lq d      uhodwlrqvkls zkhuh wkh edodqfh ri srzhu ehwzhhq wzr sduwlhv lv glvuxswhg e\ rqh sduw\ idyrulqj wkhlu rzq lqwhuhvwv dw wkh h[shqvh ri wkh rwkhuv 7kh lpsruwdqfh ri glvwlqjxlvklqj ehwzhhq lqwhqwlrqdolw\ ru udqgrp rffxuuhqfhv ri ehwud\do wkhq vhuyhv wr ehwwhu looxvwudwh wkh ohyho ri kdup h[shulhqfhg e\ wkh ylfwlp ri wkh ehwud\do 0d[zhoo 3v\fkrdqdo\vw 5lfkdug *duwqhu  lqwhusuhwhg ehwud\do wr eh d «ylrodwlrq ri lpsolflw ru h[solflw wuxvw ,w lv e\ ghilqlwlrq dq lqwhushuvrqdo h[shulhqfh « ,q ehwud\do vhhplqjo\ xqeuhdndeoh erqgv duh eurnhq dqg wuhdfkhu\ lv lqwurgxfhg lqwr wkh prvw sulydwh shuvrqdo dqg wuxvwlqj uhodwlrqvklsv 7kh ehwud\hg lqglylgxdo ihhov mdjjhg  ie w  dzu\ iudfwxuhg uhfnohvvo\ kxuw s  7kh ehwud\do wkhq fdq eh ylhzhg dv dq h[lvwhqwldo h[shulhqfh suhvhqwlqj dv wkh khduw ri wkh qdwxuh dqg hiihfw ri wkh wudxpd 0d[zhoo %dfk ghvfulehg zkhq wuxvw lv orvw zlwk vrphrqh  ev  forvh lw pd\ ihho dv li d sxqfk kdv ehhq wkurzq fuhdwlqj olwhudo sdlq frpelqhg zlwk kxploldwlrq zklfk h[dfhuedwhv d vhqvh ri jxlow dqg vkdph ehfdxvh rqh vkrxog kdyh nqrzq ehwwhu 7kh wudxpd ri ehwud\do lqfoxghv dv rwkhu wudxpd riwhq grhv d vxgghq fkdqjh iurp ehlqj uhod[hg dqg  pr  frpiruwdeoh wr d vwdwh ri iljkw ru ioljkw wkh hqylurqphqw fkdqjhg iurp iulhqgo\ wr xqiulhqgo\ %dfk *rph] hw do srlqwhg wr wkh lpsruwdqfh ri uhfrjql]lqj wkh hohphqw ri rqh ehlqj ohiw srzhuohvv e\ ehwud\do zlwklq wkh frqwh[w ri d ghshqghqw uhodwlrqvkls surirxqgo\ diihfwv dq hvvhqwldo phfkdqlvp ri kxpdq vxuylydo wkh rulhqwdwlrq wr frqqhfw zlwk rwkhuv 2qh vljqlilfdqw dgglwlrq wr wkh uhfhqw gldjqrvwlf wh[w ri wkh phulfdq 3v\fkldwulf vvrfldwlrq v 3 'ldjqrvwlf dqg 6wdwlvwlfdo 0dqxdo ri 0hqwdo 'lvrughuv )liwk (glwlrq '60 3 lv wkh vlqjxodu olqh dgghg wr wkh srvwwudxpdwlf vwuhvv glvrughu 376' gldjqrvlv uhdgv 7kh glvrughu pd\ eh hvshfldoo\ vhyhuh ru orqj odvwlqj zkhq wkh vwuhvvru lv lqwhushuvrqdo dqg lqwhqwlrqdo  3 s *rph] hw do vwdwhg zlwkrxw dghtxdwh uhfrjqlwlrq ri ehwud\do wudxpd    reproduced with permission of copyright owner. further reproduction prohibited without permission.  
       


secondary_title_index: psychoneuroendocrinology
abstract_index:
       discrimination has consistently been associated with multiple adverse health outcomes. like other psychosocial stressors, discrimination is thought to impact health through stress-related physiologic pathways including hypothalamic-pituitary-adrenal (hpa) axis activation, dysregulation of inflammation responses, and accelerated cellular aging. given growing attention to research examining the biological pathways through which discrimination becomes embodied, this systematic review and meta-analysis synthesizes empirical evidence examining relationships between self-reported discrimination and four biomarker outcomes (i.e., cortisol, c-reactive protein (crp), interleukin-6 (il-6), and telomere length) among studies that have used the everyday discrimination scale. we conducted a systematic review of studies discussing self-reported, everyday, or chronic discrimination in the context of health by searching medline / pubmed (national library of medicine, ncbi), psycinfo (apa, ebsco) and web of science
  core collection (clarivate). twenty-five articles met the criteria for meta-analysis, with several reporting on multiple outcomes. discrimination was associated with elevated crp levels (r = 0.11; 95% ci: 0.01, 0.20, k = 10), though not cortisol (r = 0.05; 95% ci: −0.06, 0.16, k = 9), il-6 (r = 0.05; 95% ci: −0.32, 0.42, k = 5), or telomere length (r = 0.03; 95% ci: −0.01, 0.07, k = 6). we identify several points of consideration for future research including addressing heterogeneity in assessment of biomarker outcomes and the need for longitudinal assessments of relationships between discrimination and biomarker outcomes.     

authors_index:
       lawrence, jourdyn a.     kawachi, ichiro     white, kellee     bassett, mary t.     priest, naomi     masunga, joan gakii     cory, hannah j.     mita, carol     williams, david r.     

title_index:
       a systematic review and meta-analysis of the everyday discrimination scale and biomarker outcomes     

full_text_index:
       hhs public access author manuscript author manuscript  psychoneuroendocrinology. author manuscript; available in pmc 2023 march 09. published in final edited form as: psychoneuroendocrinology. 2022 august ; 142: 105772. doi:10.1016/j.psyneuen.2022.105772.  a systematic review and meta-analysis of the everyday discrimination scale and biomarker outcomes jourdyn a. lawrencea,b,c,*,1, ichiro kawachia, kellee whited, mary t. bassetta,c, naomi prieste,f, joan gakii masungag,h, hannah j. coryb,i,2, carol mitaj, david r. williamsa,k adepartment of social and behavioral sciences, harvard t.h. chan school of public health,  boston, ma, usa  author manuscript  bpopulation health sciences, harvard graduate school of arts and sciences, cambridge, ma,  usa cfrancois-xavier bagnoud (fxb) center for health and human rights, harvard t.h. chan school  of public health, boston, ma, usa ddepartment of health policy and management, university of maryland school of public health,  college park, md, usa ecentre for social research and methods, australian national university, canberra, australian  capital territory, australia fmurdoch children’s research institute, parkville, victoria, australia  author manuscript  gcenter for bioethics, harvard medical school, boston, ma, usa hdepartment of global health and social medicine, harvard medical school, boston, ma, usa idepartment of nutrition, harvard t.h. chan school of public health, boston, ma, usa jcountway library, harvard medical school, boston, ma, usa kdepartment of african and african american studies, harvard university, cambridge, ma, usa  abstract  author manuscript  discrimination has consistently been associated with multiple adverse health outcomes. like other psychosocial stressors, discrimination is thought to impact health through stressrelated physiologic pathways including hypothalamic-pituitary-adrenal (hpa) axis activation, dysregulation of inflammation responses, and accelerated cellular aging. given growing attention  this is an open access article under the cc by-nc-nd license (http://creativecommons.org/licenses/by-nc-nd/4.0/). *  correspondence to: department of social and behavioral sciences, harvard t.h. chan school of public health, 677 huntington avenue, boston, ma 02115, usa. jlawrence@hsph.harvard.edu (j.a. lawrence). 1present address: francois-xavier bagnoud (fxb) center for health and human rights, harvard t.h. chan school of public health, 651 huntington avenue, 7th floor, boston, ma 02115 2present address: division of epidemiology and community health, university of minnesota school of public health, 1300s 2nd street, suite 300, minneapolis, mn 55455 conflicts of interest the authors have no conflicts of interest to declare.  appendix a. supporting information supplementary data associated with this article can be found in the online version at doi:10.1016/j.psyneuen.2022.105772.  
  lawrence et al.  page 2  author manuscript  to research examining the biological pathways through which discrimination becomes embodied, this systematic review and meta-analysis synthesizes empirical evidence examining relationships between self-reported discrimination and four biomarker outcomes (i.e., cortisol, c-reactive protein (crp), interleukin-6 (il-6), and telomere length) among studies that have used the everyday discrimination scale. we conducted a systematic review of studies discussing selfreported, everyday, or chronic discrimination in the context of health by searching medline / pubmed (national library of medicine, ncbi), psycinfo (apa, ebsco) and web of science core collection (clarivate). twenty-five articles met the criteria for meta-analysis, with several reporting on multiple outcomes. discrimination was associated with elevated crp levels (r 0.11; 95% ci: 0.01, 0.20, k 10), though not cortisol (r 0.05; 95% ci: 0.06, 0.16, k 9), il-6 (r  0.05; 95% ci: 0.32, 0.42, k 5), or telomere length (r 0.03; 95% ci: 0.01, 0.07, k 6). we identify several points of consideration for future research including addressing heterogeneity in assessment of biomarker outcomes and the need for longitudinal assessments of relationships between discrimination and biomarker outcomes.  author manuscript  keywords social discrimination; c-reactive protein; inflammation; telomere length; stress  1.  introduction  author manuscript author manuscript  in addition to the inequitable access to opportunities, resources, and power due to structural oppression at structural, cultural, and institutional levels, discrimination acts as the behavioral expression of oppression, resulting in inequitable treatment for marginalized groups (priest et al., 2020a; tajfel and turner, 2004). as one of the most frequently assessed domains of discrimination, self-reported discrimination is often conceptualized as a stressor that adversely affects health, with a large proportion of the literature examining the impacts of self-reported racial discrimination (dolezsar et al., 2014; gilbert and zemore, 2016; goosby et al., 2018; krieger, 2014; lewis et al., 2015, 2014; pascoe and smart richman, 2009; williams et al., 2019a, 2019b; williams and mohammed, 2009). the study of discrimination as a type of psychosocial stressor that adversely affects health and as a contributor to race/ethnic disparities in health has grown in the last two decades (krieger, 2014). a recent review documented 29 reviews of the literature that were published between 2013 and 2019 which examined relationships between discrimination and mental and physical health outcomes (williams et al., 2019b). most early research on the relationship between discrimination and health documented associations with mental health, indicators of health behavior, or self-reported measures of physical health (williams and mohammed, 2009). however, research has begun to elucidate the biological pathways through which societal and psychosocial stressors, like discrimination, are embodied to affect health (cuevas et al., 2020; priest, 2021). a growing body of evidence suggests that experiences of discrimination may affect physical and mental health through multiple biological pathways (clark et al., 1999; epel, 2009; lewis et al., 2015). the conceptual model of allostatic load, developed by mcewen and stellar, suggests that frequent exposure to psychosocial stressors – such as discrimination  psychoneuroendocrinology. author manuscript; available in pmc 2023 march 09.  
  lawrence et al.  page 3  author manuscript author manuscript  – results in the activation of multiple axes involved in the stress response, e.g., the neuroendocrine system (hpa axis, sympathetic-adreno-medullar axis), the autonomic nervous system, immune and inflammatory processes, and metabolism (mcewen, 2000; mcewen and stellar, 1993; seeman et al., 2001). as a result of societal processes of social marginalization and devaluing, individuals from marginalized groups experience increased exposure to discrimination which is posited to be embodied through the activation of hpa axis (i.e., cortisol) and inflammation (i.e., interleukin-6 and c-reactive protein) cascades or accelerated cellular aging (i.e., shortened telomere length). these outcomes capture distinct, but inter-related processes through which discrimination may affect health. these systems interact with each other, suggesting a coordinated physiological response to stress. for example, chronic elevation of hpa axis and inflammation mediators result in interactions which yield chronic elevations in blood pressure that can contribute to adverse cardiovascular outcomes such as heart attacks and stroke (mcewen, 2008). much of the literature supports this framework, with researchers identifying relationships between discrimination and increased hpa axis activation, (clark et al., 1999) dysregulation of inflammatory responses, (cuevas et al., 2020) and accelerated cellular aging. (epel, 2009) studies have also found biomarkers associated with these pathways (e.g., cortisol, crp, telomere length) to have documented associations with increased morbidity across several health outcomes and mortality (cuevas et al., 2020; mcewen, 2008, 2012).  author manuscript  indeed, closer examination of the relationship between discrimination and biomarkers provides an opportunity to advance our mechanistic understanding of how chronic experiences of differential treatment become embodied or “get under the skin” to contribute to poor psychological and physiological health (krieger, 2005; mcewen, 2012). the use of biomarkers measures also circumvents the issue of common source bias that may arise when both the exposure (discrimination) and health outcome are self-reported. however, a comprehensive assessment of the association between experiences of discrimination and biomarkers of physiologic stress, inflammation, and accelerated aging has not been performed to date.  author manuscript  studies assessing biological pathways are a small proportion of the total literature on discrimination but are increasing in recent years. a recent systematic review of discrimination and systemic inflammation identified 28 articles published since 2009 (cuevas et al., 2020). these measures were not included in previous meta-analyses of the health implications of discrimination. prior meta-analyses have examined the relationship between discrimination and health across several measures of discrimination, with much heterogeneity in the timing and type of discrimination experienced (paradies et al., 2015; pascoe and smart richman, 2009; pieterse et al., 2012). results from previous meta-analyses suggest that the associations between discrimination and health outcomes vary by instruments used to assess discrimination (dolezsar et al., 2014; paradies et al., 2015). reducing heterogeneity in meta-analysis by limiting variations across measures of discrimination, for example, is also important statistically when combining estimates across studies in meta-analysis (bourabain and verhaeghe, 2021; imrey, 2020). the larger literature on stress and health suggests that incidents of racial discrimination, like other self-reported stressors, can be classified into several types of stressful life experiences  psychoneuroendocrinology. author manuscript; available in pmc 2023 march 09.  
  lawrence et al.  page 4  author manuscript  (williams and mohammed, 2009). similar to research on stress and health, interpersonal experiences of discrimination can be divided into acute major discriminatory life events (e.g. being unfairly fired from a job), chronic discrimination in major domains life (e.g. at work, school, or in one’s neighborhood), traumatic discriminatory experiences (e.g. being beaten by the police) and more minor but ongoing events, somewhat analogous to daily hassles in the larger stress literature (williams and mohammed, 2009). different measures of discrimination assess various aspects of these stressful experiences. the everyday discrimination scale (eds) captures only the latter class of relatively minor, but recurrent instances of discrimination (williams et al., 1997). enhancing our understanding of the ways in which discrimination can affect health requires greater research attention to understanding how specific types of discrimination are related to health outcomes. social identity theory provides a framework that allows for an understanding of how social contexts and identities facilitate differential treatment, devaluing, and withholding of resources by members of the “in-group” can result in the disadvantage that members of marginalized groups face. (tajfel and turner, 2004) in this context, marginalized groups are more likely to encounter experiences of discrimination, which have long been theorized to be “assaults to [b]lack dignity and [b]lack hope [that] are incessant and cumulative” in their adverse impacts on health (pierce, 1974). understanding the everyday encounters of discrimination marginalized groups face facilitates an understanding of how recurrent exposure to differential treatment becomes embodied and how the eds remains a strong predictor of the onset and progression of adverse health outcomes (kershaw et al., 2016a; lewis et al., 2006; williams et al., 2003).  author manuscript author manuscript  a sufficient number of studies have been conducted utilizing the eds to permit a review of the association of discrimination with biomarkers (i.e., hpa axis, inflammation, and cellular aging). to the authors’ knowledge, this is the first meta-analysis that examines the association of discrimination on stress-related biomarkers among studies that have used the same measure. accordingly, this paper sought to synthesize existing literature, provide deeper insight into methodological and measurement challenges, and identify future research directions. 1.1.  study objectives  author manuscript  this systematic review and meta-analysis examined the relationship between experiences of discrimination and molecular biomarker outcomes, with quantitative focus on interleukin-6 (il-6), crp, cortisol, and leukocyte telomere length, among studies that have used the eds to measure exposure to discrimination. we characterized the existing body of literature that has included the eds – highlighting study design and methodology, sample characteristics, operationalization of the eds, and outcomes examined. we examined relationships between the eds and individual biomarker measures of stress, inflammation, and cellular aging (e.g., telomere length) – to increase the comparability of findings across studies that have used the same assessment of exposure to discrimination. specifically, the overarching research aims of the systematic review were to: 1.  meta-analyze associations between the eds and stress-related biomarkers. we hypothesize that increased discrimination is associated with adverse levels of  psychoneuroendocrinology. author manuscript; available in pmc 2023 march 09.  
  lawrence et al.  page 5  author manuscript  biomarker measures (i.e., shorter telomere length; higher il-6, crp, and cortisol levels). 2.  2.  descriptively map the mediators (e.g., smoking, excess drinking) of the associations between discrimination and molecular biomarkers across studies that have used the eds. this provides context as to what factors have been considered as mediating variables in studies assessing discrimination and biomarker outcomes.  methods this meta-analysis followed the preferred reporting items for systematic reviews and meta-analysis (prisma) and the meta-analysis of observational studies in epidemiology (moose) guidelines and criteria (moher et al., 2009; stroup et al., 2000).  author manuscript  2.1.  search strategy studies discussing self-reported, everyday, or chronic discrimination in the context of health were identified by searching medline / pubmed (national library of medicine, ncbi), psycinfo (apa, ebsco) and web of science core collection (clarivate). controlled vocabulary terms (i.e., mesh; thesaurus of psychological index terms) were included when available and appropriate. the search strategies were designed and executed by a research librarian (cm) at the countway library of medicine at harvard university. publication date was limited to studies published in 1997 or later. no language restriction was applied. the exact search terms used for each of the databases are provided in the supplementary materials (supplemental table 1). reference lists of identified papers were examined for additional relevant articles for inclusion.  author manuscript  2.2.  inclusion criteria for consideration of inclusion, studies must have used quantitative methodology reporting an estimate of the relationship between the eds and a disease-related molecular biomarker (e.g., telomere length, il-6) (broza et al., 2019; epel, 2009; laterza et al., 2007). as such, studies using qualitative methods were not included. all collection methods for molecular biomarkers were included (e.g., blood, saliva, hair, urine) (broza et al., 2019). all study designs were eligible (i.e., cross-sectional, longitudinal, case-control, and experimental). given that the eds was first utilized in 1997, (williams et al., 1997) studies were eligible for inclusion if published in 1997 or later.  author manuscript  exclusion restrictions were not placed upon study populations, such that studies including participants from any age group, racial/ethnic/cultural identity, ability, and other sociodemographic factors were included. 2.2.1.  exposure self-reported discrimination was measured using the eds, which includes the frequency of self-reported discrimination in the respondent’s day-to-day life (williams et al., 1997) the original scale includes nine-items: “in your day-to-day life, how often do any of the following things happen to you?” (1) you are treated with less courtesy than other people  psychoneuroendocrinology. author manuscript; available in pmc 2023 march 09.  
  lawrence et al.  page 6  author manuscript  are; (2) you are treated with less respect than other people are; (3) you receive poorer service than other people at restaurants or stores; (4) people act as if they think you are not smart; (5) people act as if they are afraid of you; (6) people act as if they think you are dishonest; (7) people act as if they’re better than you are; (8) you are called names or insulted; and (9) you are threatened or harassed. responses for each item include “almost every day,” “at least once a week,” “a few times a month,” “a few times a year,” less than once a year,” and “never”. respondents reporting “a few times a year” or more frequent experiences of discrimination may be asked a follow up question: “what do you think is the main reason for these experiences?” participants can select one or more of the following attributions: (1) your ancestry or national origins; (2) your gender; (3) your race; (4) your age; (5) your religion; (6) your height; (7) your weight; (8) some other aspect of your physical appearance; (9) your sexual orientation; (10) your educational or income level.  author manuscript  a short form of the eds was developed for the chicago community adult health study (ccahs) (sternthal et al., 2011) in which respondents were asked: “”in your day-to-day life, how often have any of the following things happened to you?” (1) you are treated with less courtesy or respect than other people; (2) you receive poorer service than other people at restaurants or stores; (3) people act as if they think you are not smart; (4) people act as if they are afraid of you; (5) you are threatened or harassed. the follow-up question and response categories of the shortened eds are the same as the original. other adapted versions of the scale were considered eligible for inclusion if they were not major adaptations beyond the original scope of the eds (e.g., studies that created summary scores that joined the eds with other measures or studies that only include one item from the eds were not included).  author manuscript  2.2.2. outcomes—all stress-related biomarker outcomes were eligible for inclusion. these included il6, crp, cortisol, dhea (dehydroepiandrosterone, also dhea-s), dna methylation, e-selectin, fibrinogen, nerve growth factor, alpha amylase, hsp-70 (heat shock protein-70), hba1c levels, and telomere length. several outcomes were only examined in one or two articles and were excluded from the meta-analysis but are included in our narrative synthesis of the findings (n 5, fig. 1). for example, dna methylation was only assessed as an outcome in two identified studies. the three remaining outcomes meeting the inclusion criteria were only assessed in one manuscript each. 2.3.  screening  author manuscript  search results were imported into endnote x9, and duplicate entries were removed. the endnote library was exported into covidence (veritas health innovation, 2017), a webbased systematic review software. two reviewers (jl, gm) independently conducted title and abstract screening to assess studies for eligibility (inter-reviewer reliability (κ) 0.78, indicating good agreement). full texts of studies considered for inclusion were obtained. discrepancies between reviewers regarding study inclusion was resolved by discussion with a third reviewer (hc)  psychoneuroendocrinology. author manuscript; available in pmc 2023 march 09.  
  lawrence et al.  page 7  author manuscript  and/or consensus (jl, gm) [κ 0.74]. the study selection process is outlined in full in fig. 1. 2.4.  data extraction and analysis  author manuscript  data from identified studies were independently extracted into an excel document by one reviewer (jl) with another reviewer randomly checking 20% of the extracted data (hc). inconsistencies were resolved by consensus and/or discussion with a third reviewer (gm). extracted data included information regarding the eds (e.g., version used, operationalization) and biomarker assessed, demographic characteristics of participants (e.g., age, gender, educational attainment), study attributes (e.g., study design, location [country and region], period and duration of study (if relevant), sample size), most and minimally adjusted estimates, covariates adjusted for, psychometric properties of the scale (if assessed), mediators (if explicitly mentioned) and potential sources of bias (e.g., attrition, missing data). for articles using the same dataset to examine relationships with the same outcome, we extracted data from papers with the most information reported (e.g., both minimally and fully adjusted models reported). if multiple papers included the same amount of information, the earliest publication was included in the meta-analysis. minimally adjusted estimates include data from the least adjusted model reported or correlations between eds and biomarkers. fully adjusted estimates include data from the most adjusted model reported with all covariates included. efforts were made to contact study authors for additional information; however, if only one estimate was available, it was used as both the minimally and most adjusted estimate.  author manuscript  most studies reported regression coefficients. to incorporate regression coefficients into the present meta-analysis, we use a derived formula developed by peterson and brown to estimate correlation coefficients (r) (peterson and brown, 2005). after extracting over 1500 β and r values, the authors fit several models to assess the relationships between the two measures. they found that r 0.98β 0.05λ yielded the best fit, where β is the coefficient reported and λ is an indicator variable that is 0 when β is negative and 1 when β is positive (peterson and brown, 2005). after testing this efficacy of this formula against several alternatives, the authors found little difference between results. however, the authors note that this imputation is best used among β estimates within the interval of 0.50–0.50, given an observed tight joint distribution of β and r values in that range. given that most estimates from eligible studies were within that range, we imputed r values from reported β values in eligible studies where r values were not reported using r 0.98β 0.05λ.  author manuscript  estimates were coded such that greater experiences of discrimination are associated with poorer outcomes (negative for telomere length, positive for inflammation and stress biomarkers (e.g., il-6)). weighted correlation sizes were calculated using large-sample approximation to compute sampling variance (viechtbauer, 2010). random effects models were fit utilizing the minimally adjusted associations reported using the “metafor” package (viechtbauer, 2010) available in r (r core team, 2013). random effect models essentially relax the assumption of fixed-effect models, which assume that there is one ”true” effect estimated in all studies  psychoneuroendocrinology. author manuscript; available in pmc 2023 march 09.  
  lawrence et al.  page 8  author manuscript  and that variations only occur due to chance (i.e., variations in samples) (borenstein et al., 2010). instead, random effects models assume a distribution of correlation sizes allowing for variations in the correlation size across studies, where factors beyond sampling variation may influence the association (e.g., age of sample) (borenstein et al., 2010). cochran’s q test was conducted to test for heterogeneity. forest plots are presented to illustrate studyspecific and overall correlation sizes by outcome and 95% cis. sensitivity analyses included estimating the weighted correlation sizes using the most adjusted estimates reported in eligible articles. 2.5.  quality assessment  author manuscript  study quality was assessed in terms of potential for bias. similar to paradies et al. (2015), we use sampling procedure, data type (e.g., cross-sectional, longitudinal), and instrument (i.e., full scale, short form), and covariates included in a narrative assessment of study quality. funnel plots were created to illustrate potential publication bias and asymmetry was tested using egger’s tests (egger et al., 1997).  3.  results database searches on 03/24/2020 yielded 2803 references, resulting in 1867 unique references for screening. relevant outcomes were found in 33 articles included in the narrative review and 25 studies were identified for inclusion in the quantitative synthesis of associations in the present study. the number of studies excluded from the quantitative analysis, with reasons, are provided in detail in fig. 1. overall descriptive data for the articles included in the quantitative assessment are summarized in supplemental table 2.  author manuscript  most studies were published between 2016 and march 2020, with all articles having publication dates between 2010 and 2020. nearly all articles examined associations among populations in the united states, with one assessing associations among a sample in new zealand. nearly 36% of studies implemented representative sampling procedures, with 64% of studies reporting non-representative sampling methods. many articles reported findings from cross-sectional analyses (72%) with the remainder being longitudinal (24%) or other (4%).  author manuscript  sample sizes ranged from 49 to 12,624, with a total sample of 37,763 respondents included across all eligible studies. all articles reported some information on participant age (e.g., average age of population), race/ethnicity, and sex; however, two did not report the number of participants within each racial/ethnic group in the analytic samples. articles were mostly conducted among adults (nearly 99% of the sample size), though populations under 18 were included in three articles, yielding 419 young adult or adolescent participants ( 18 years of age) to the total sample. one study did not report the age range of study participants to discern whether young adults could have been included in the study population. data on participant educational attainment was reported in 19 studies. the full version of the eds was employed in most articles (n 17), with fewer using the short-form (n 5) or a modified version of the eds (n 3). attribution of experiences was assessed in 7 studies, with most assessing attributions of experiences to both racial and  psychoneuroendocrinology. author manuscript; available in pmc 2023 march 09.  
  lawrence et al.  page 9  author manuscript  non-racial reasons (n 4). the remaining three studies that captured attributions assessed only racial or non-racial attributions. operationalization of the eds remained consistent across studies with most measuring experiences as the sum (n 11) or the average (n 10) of the frequency of experiences. other means of operationalizing the eds included a count of yes responses to experiences, dichotomizing beyond a certain threshold. how the measure was operationalized was unclear in one analysis. among studies that examined the reliability of the eds, it exhibited very good reliability using a cronbach’s alpha cutoff of greater than 0.80 in 18 of the 25 articles. cortisol and crp were the most frequently assessed biomarker outcomes (n 9 and n 10, respectively), followed by telomere length (n 6) and il-6 (n 5). approximately 16% (n  4) of articles reported associations between the eds and multiple biomarker outcomes.  author manuscript  supplemental table 3 presents the summary of study and sample characteristics by outcome. weighted correlation sizes from the most adjusted associations reported between the eds and each biomarker outcome are presented in figs. 2, 3, 4, and 5. 3.1.  cortisol  author manuscript  nine studies examined relationships between discrimination and cortisol. most frequently, the eds was operationalized as the mean (n 4) or sum of frequencies (n 3). another study used the count of yes responses, though one study did not clearly specify how the measure was operationalized. studies were primarily cross-sectional (n 7) and conducted among adults (n 6). black participants comprised nearly 29.4% of the cortisol study population, followed by latinx/hispanic (18.6%) and asian (7.7%) participants; however, white participants (38.6%) comprised the largest proportion of the study population across all 9 studies. native hawaiian, pacific islander, or maori, multiracial, and individuals categorized as “other” racial groups together comprised the remaining 5.7% of the pooled study population.  author manuscript  assessments of cortisol varied across studies. given the evidence of changes in cortisol levels throughout the day, (levine et al., 2007; weitzman et al., 1971) some studies assessed salivary cortisol by collecting multiple samples per day at different time points ( 4) over several days ( 3) (doane and zeiders, 2014; fuller-rowell et al., 2012; huynh et al., 2016; zeiders et al., 2014). others collected two saliva samples (morning and evening) over two consecutive days thayer and kuzawa, 2015), three salivary samples in one day, (incollingo rodriguez et al., 2019) salivary samples before, during and after exposure to a stress task (lucas et al., 2017) and the average of duplicate samples collected in one afternoon (ratner et al., 2013). another study assessed cortisol concentration through hair cortisol, using 3 cm of hair closest to the scalp to assess retrospective cortisol levels (lehrer et al., 2020). in the main analysis, the reported assessment of cortisol levels varied, with articles assessing associations between the eds and waking cortisol levels in five studies, baseline cortisol, average cortisol from one measurement, total daily cortisol, and hair cortisol concentration. five studies reported both minimally and fully adjusted estimates, while the remaining reported only unadjusted (n 2) or adjusted (n 2).  psychoneuroendocrinology. author manuscript; available in pmc 2023 march 09.  
  lawrence et al.  page 10  author manuscript  the mean correlation coefficient for associations between eds and cortisol was r 0.05 [95% ci: 0.06, 0.16, k 9; q 19.83, df 8, p 0.011] (fig. 2a), suggesting no observed association with cortisol levels. patterning in the direction of responses was observed, where larger studies showed null or negative associations while smaller studies typically had associations indicating greater cortisol levels with increased discrimination. minimally adjusted models included four correlations and models that accounted for factors including age, race, sex or gender, bmi, socioeconomic indicators (i.e., household income, educational attainment, material deprivation), health behaviors (i.e., exercise, food, alcohol and caffeine consumption, cigarette use), daytime sleep, daily wake and sleep time, psychological factors (i.e., stress level, emotional stability), and medication (i.e., cortisol medication, other medication use) or medical history (i.e., c-section delivery).  author manuscript  several studies reported estimates between the eds and cortisol outcomes using the same measure (i.e., cortisol awakening response [car], waking levels). to minimize the impact of heterogeneity in the measurement of cortisol on the pooled estimate, we estimated mean correlation sizes for studies that examined the car (doane and zeiders, 2014; fullerrowell et al., 2012; huynh et al., 2016; incollingo rodriguez et al., 2019; zeiders et al., 2014) (defined as the change in cortisol from waking to a defined time period after waking) and waking cortisol levels (doane and zeiders, 2014; fuller-rowell et al., 2012; huynh et al., 2016; thayer and kuzawa, 2015; zeiders et al., 2014). among studies that evaluated the relationship between the eds and waking cortisol, the mean correlation size was r 0.01 (fig. 2b, 95% ci: 0.18, 0.19). whereas the mean correlation size among studies reporting associations between the eds and car was r 0.00 (fig. 2b, 95% ci: 0.22, 0.22). these findings suggest that discrimination is not associated with cortisol levels, specifically waking and the cortisol awakening response.  author manuscript  sensitivity analyses were conducted using the most or fully adjusted estimates reported in each study. the mean correlation size did not differ greatly across fully adjusted estimates (r 0.06; 95% ci: 0.06, 0.18) compared to the minimally adjusted models. associations between discrimination and car (r 0.02; 95% ci: 0.24, 0.29) and waking cortisol (r  0.00; 95% ci: 0.19, 0.18) remained null. beyond covariates included in the minimally adjusted models, fully adjusted models also included factors such as psychological factors (i.e., neuroticism risk, public and private esteem), average hours of sleep, medication (i.e., contraceptive use), waist-to-hip ratio, and attributions of discrimination. 3.2.  c-reactive protein (crp)  author manuscript  among the ten eligible studies assessing the association between discrimination and crp, the eds was frequently implemented as the sum (n 5) or mean (n 4) of the frequencies of experiences of discrimination. one study operationalized the eds as the sum of the experiences (lewis et al., 2010). nine of the ten studies reported the racial/ethnic composition of the analytic samples, with 38% identifying as black, 7% as latinx/hispanic, 2% as asian and 52% as white/european. a small percentage of participants were classified as “other” race (1%). most studies were cross-sectional in design (50%) and conducted among adult populations (n 9). crp was assessed consistently, with most studies using blood/serum levels of crp (n 9) and one using a measure of salivary crp levels.  psychoneuroendocrinology. author manuscript; available in pmc 2023 march 09.  
  lawrence et al.  page 11  author manuscript  the pooled correlation size for the associations between discrimination and crp was r  0.11 [95% ci: 0.01, 0.20; k 10; q 69.90, df 9, p 0.001]. correlation sizes appear to be larger in smaller studies, though larger studies also show relationships between discrimination and crp. minimally adjusted estimates included one unadjusted correlation and models which accounted for factors such as age, race/ethnicity, lifetime experiences of discrimination, measures of socioeconomic status (e.g., income, educational attainment, employment status), bmi and medications (e.g., statin use, hormone replacement therapy, anti-inflammatory use). three articles did not report unadjusted associations, (beatty moody et al., 2014; saban et al., 2018; zahodne et al., 2019) though one only accounted for age, bmi and statin use in the adjusted estimate reported (saban et al., 2018).  author manuscript  supplemental fig. 2 illustrates the reported associations and mean correlation size using the most adjusted estimates reported. significant associations were observed [r 0.09; 95% ci: 0.01, 0.17, k 10]. these associations remain considering the covariates included in the most adjusted models reporting these associations. one paper only reported a minimally adjusted association (correlation), however other articles accounted for factors such as race, age, sex, bmi, measures of socioeconomic status (e.g., financial strain, educational attainment, income), psychological factors (e.g., depressive symptoms, cynicism) and lifetime experiences of discrimination, health behaviors (e.g., physical activity, smoking, alcohol consumption), measures of physiological functioning (e.g., blood pressure, cholesterol and triglyceride levels, hba1c, vital capacity, adiponectin), health conditions (e.g., heart attack, other vascular diseases, diabetes), and medications (e.g., statin use, anti-hypertensives, diabetes management medications). the similarities in mean correlation sizes from the most and minimally adjusted estimates reported suggest that the relationship between discrimination and crp is robust to covariate adjustment and may not be strongly mediated by health behaviors (e.g., smoking, drinking).  author manuscript  3.3.  interleukin-6 (il-6) among the 5 studies examining il-6, the eds was operationalized as the sum of frequencies (n 3) or mean of frequencies (n 2). white/european participants comprised over 80% of the sample across studies reporting data on race/ethnicity (n 4). measurement of il-6 levels was captured through blood (n 3) or saliva (n 3). one study assessed both blood and salivary il-6 levels, though only the adjusted association was reported for the blood il-6 outcomes (saban et al., 2018). eligible studies used in the meta-analysis were all cross-sectional in design and conducted among adult populations.  author manuscript  the mean weighted correlation size between discrimination and il-6 suggests discrimination may not be correlated with elevated il-6 levels (r 0.05; 95% ci:  0.32, 0.42, k 5; q 47.01, df 4, p 0.001). minimally adjusted estimates included an unadjusted correlation (n 1) and models (n 4) that accounted for factors such as race/ethnicity, gender, age, measures of socioeconomic status (i.e., income, educational attainment, employment status), medication use (i.e., anti-inflammatory, hormone replacement therapy), and time. larger correlation sizes were observed among two smaller studies; while one association went in the opposite direction, indicating an inverse relationship between discrimination and il-6 levels.  psychoneuroendocrinology. author manuscript; available in pmc 2023 march 09.  
  lawrence et al.  page 12  author manuscript  additionally, when assessed by measurement of il-6 (i.e., plasma, salivary), we find the direction of the mean correlation size for the minimally adjusted estimates to be similar among both measures (r 0.03; 95% ci: 0.03, 0.09 and r 0.06; 95% ci: 0.99, 1.12 for plasma and salivary measures, respectively). however, the confidence interval is larger among studies using salivary measures of il-6, possibly indicating greater variability in estimates derived from salivary samples. these assessments should be interpreted with caution given the small sample size for these assessments (k 3 for each) and that one study reported only fully adjusted associations between discrimination and plasma il-6 levels.  author manuscript  supplemental analysis of the most adjusted estimates reported resulted in a stronger correlation between increased experiences of discrimination and il-6 levels [r 0.07; 95% ci: 0.28, 0.42, k 5], however, the confidence interval is wide and crosses the null. examining the forest and tree plot, we observed null associations in studies of varying sample sizes (two, relatively large and one small), though the remaining two studies find lower and elevated il-6 levels to be associated with increased discrimination. the observed null associations may be a function of covariates included in each model. in most adjusted models, several studies accounted for what could be potential mediators or moderators of the relationship between discrimination and il-6 levels. covariates included age, race, marital status, measures of socioeconomic status (i.e., income, employment status, educational attainment), psychological factors (i.e., measures of depression, anxiety, reactivity), perceived social status, reported childhood trauma, medication use (i.e., cholesterol, blood pressure, diabetes, hormone replacement), public and private esteem, bmi, and alcohol consumption.  author manuscript  mediators.—one study explicitly assessed bmi as a potential mediator of the relationship between discrimination and il-6 in a sample of men and women (kershaw et al., 2016b). among women, the authors found the positive relationship between everyday discrimination and il-6 to be attenuated by bmi. however, the inability to establish temporality given the cross-sectional analysis does not provide insight as to whether bmi is subsequent to exposures to discrimination or whether it may increase experiences of discrimination (kershaw et al., 2016b). 3.4.  telomere length  author manuscript  three of the six eligible studies operationalized the eds as the sum of reported frequency of discrimination. assessments also included the mean of frequency of experiences of discrimination (n 2) and a dichotomized assessment of if a respondent ever experienced everyday discrimination and attributed it to a personal characteristic (yes/no). the racial/ethnic breakdown of analytic samples were provided in 5 of the 6 studies, with white participants comprising 60% of the overall study populations. black participants comprised approximately 33% of the overall sample size, followed by latinx/hispanic participants (7.4%). asian, native hawaiian/pacific island, multiracial or “other” racial/ ethnic individuals were not represented in the studies eligible for inclusion. all eligible studies used quantitative polymerase chain reaction (qpcr) to assess and quantify telomere length, which is optimal for large studies given the small sample needed to replicate dna and assess telomere length (montpetit et al., 2014). additionally, all studies utilized  psychoneuroendocrinology. author manuscript; available in pmc 2023 march 09.  
  lawrence et al.  page 13  author manuscript  leukocyte samples to ascertain telomere length. three studies examined associations between discrimination and telomere length using the ratio of telomeric length of dna to a single-copy control gene (t/s ratio) which is correlated with telomere length, (hailu et al., 2020; liu and kawachi, 2017; lu et al., 2019) while others converted the t/s ratio to kilobase or base pairs to compare differences in length (beatty moody et al., 2019; geronimus et al., 2015; sullivan et al., 2019).  author manuscript  everyday discrimination was not associated with telomere length when minimally adjusted models were assessed (r 0.03; 95% ci: 0.01, 0.07, k 6; q 7.26, df 5, p 0.202). examining the forest and tree plot, we observe that most studies indicate a null association, with larger studies finding discrimination to be associated with longer telomere length. minimally adjusted estimates included unadjusted regression coefficients (n 2), estimates from an age-adjusted model (n 1), and two adjusted estimates that accounted for age, race, sex, measures of socioeconomic status (i.e., poverty-to-income ratio; educational attainment); and psychosocial stress (i.e., safety stress, physical environment, and negative social interactions). supplemental analyses of fully adjusted estimates exhibited similar associations. the mean correlation size using the most adjusted estimates reported were not statistically significant [r 0.02; 95% ci: 0.02; 0.06]. models accounted for factors such as age, race, sex, measures of socioeconomic status (i.e., poverty-to-income ratio; educational attainment); and psychosocial stress (i.e., safety stress, physical environment, negative social interactions, perceived stress); psychological factors (i.e., depression, reaction type); smoking status; bmi; health conditions (e.g., diabetes, hypertension, myocardial infarction, cancer), census region of birth; childhood health; lifetime substance use and physical activity.  author manuscript  mediators.—two studies explicitly examined potential mediators of the relationship between discrimination and telomere length. work by liu and kawachi assessed whether physical activity, smoking status, and having a bmi 30 kg/m2 mediated the relationship between discrimination and telomere length (liu and kawachi, 2017). the authors found evidence that suggested these factors mediate the relationship between everyday discrimination and telomere length, observing attenuated associations when these factors were included in regression analyses. sullivan et al. examined whether depressive symptoms and perceived stress mediated the relationship between discrimination and telomere length (sullivan et al., 2019). the authors found that observed associations between everyday discrimination and telomere length among black and white women remained after accounting for mediating variables, with correlation sizes remaining larger (i.e., shorter telomere length) for black women; though no associations were observed among men.  author manuscript  across three of the four analyzed outcomes, between study heterogeneity was high and statistically significant as measured by the cochran’s q test. results from the q-test reject the null hypothesis of the “true” effect being the same across studies and only differing due to sampling variability, indicating that other factors may influence biomarker outcomes.  psychoneuroendocrinology. author manuscript; available in pmc 2023 march 09.  
  lawrence et al.  3.5.  page 14  quality assessment  author manuscript author manuscript  the limited availability of longitudinal assessments of the relationship between the eds and biomarker outcomes leaves us unable to assess the temporality of associations. across all outcomes, most studies were cross-sectional (77.8%, 50%, 100%, and 100% for cortisol, crp, il-6, and telomere length respectively). several studies utilized nonrepresentative sampling procedures (n 7, 7, 3, and 1 for cortisol, crp, il-6, and telomere length, respectively). this may raise concerns regarding potential bias such that correlation sizes may be estimated from samples that may not be generalizable, however they do provide context to the experiences of individuals from similar backgrounds (i.e., communities with similar sociodemographic characteristics). however, most studies assessing representative samples contributed greater weights to the estimated mean correlation size given the small variances across all outcomes. most studies used the full eds or short form (n 8, 10, 4, 4), with few utilizing modified versions. among studies reporting the cronbach’s alpha (n 22), α was greater than or equal to 0.70 suggesting acceptable or better internal consistency of the measure. studies reporting adjusted models accounted for several socioeconomic, demographic, and health-related covariates that may confound the relationship between discrimination and biomarker outcomes. adjusted models sometimes accounted for potential mediators of the relationship (i.e., perceived stress) that may have partially accounted for the effect of discrimination. 3.6.  assessment of publication bias  author manuscript  funnel plots (fig. 6) and egger’s tests were used to evaluate the possibility of publication bias. among studies that examined cortisol, eligible studies tended to have smaller standard errors, but eligible studies had positive, negative, and null associations. results from the egger’s test to assess funnel plot asymmetry in funnel plots were not statistically significant (t 1.91, df 7, p 0.098), suggesting that the funnel plot for cortisol is not imbalanced (i.e., no publication bias). assessment of the funnel plot for crp outcomes appears to be asymmetric. eligible studies tend to have small standard errors or larger correlation sizes. results from the egger’s test were statistically significant (t 4.57, df 8, p 0.002), suggesting potential publication bias. fewer studies examined il-6 and telomere length. the funnel plot for il-6 appears to be relatively symmetric, with eligible studies having variations in correlation size and standard error. one study was included that documented associations in the opposite direction for il-6 (i.e., lower il-6 levels for increased report of discrimination). eligible studies examining telomere length had varying directions (i.e., null, and positive associations reported). the egger’s test for il-6 was not statistically significant, suggesting that publication bias may not be a concern (t 0.30, df 3, p 0.785); however, egger’s test for telomere length was significant (t 3.00, df 4, p 0.040) indicating the possibility of publication bias. these results should be interpreted with caution as the egger’s test has limited power when used in a small sample of studies.  author manuscript  3.7.  narrative review five studies that were relevant to our review but were not included in the meta-analysis are narratively synthesized here. friedman et al. found that everyday discrimination was associated with greater e-selectin levels, an indicator of inflammation response, among  psychoneuroendocrinology. author manuscript; available in pmc 2023 march 09.  
  lawrence et al.  page 15  author manuscript  men, but not women in a sample of adults in the midlife in the united states study (midus) (friedman et al., 2009). using data from a community sample of adults with poorly controlled type 2 diabetes, potter et al. found that everyday discrimination attributed to weight was associated with elevated hba1c levels (potter et al., 2015). relationships between everyday discrimination and dna methylation, an indicator of stress, were assessed in two studies (santos et al., 2018; van der laan et al., 2020). among a sample of latina mothers, santos et al. found that everyday discrimination was inversely associated with dna methylation (less methylation with increased discrimination), (santos et al., 2018) while van der laan et al. found everyday discrimination to be positively associated with dna methylation among participants in the research on obesity and diabetes among african migrants (rodam) study (van der laan et al., 2020) saban and colleagues examined the relationship between several social factors – including everyday discrimination – and heat shock protein-70 (hsp-70), another stress-related biomarker, in a small sample of black and white women with atherosclerosis (saban et al., 2014) the authors did not observe an association between discrimination and hsp-70 levels, though this association should be examined in a larger study population.  author manuscript  4.  discussion  author manuscript  though previous meta-analyses have examined the relationship between discrimination and several health outcomes, variations in the measurement of discrimination have made cross-study comparisons difficult. evidence from the most recent meta-analysis suggests that the relationship between discrimination and health outcomes vary according to the measure of discrimination used (paradies et al., 2015). this current systematic review and metaanalysis is the first to standardize the measure of discrimination to assess the association of discrimination and health by restricting the analysis to studies that have used the everyday discrimination scale. these findings also contribute to the literature by estimating the pooled correlation coefficient across studies that have examined the relationship between discrimination and molecular biomarkers of stress, inflammation, and cellular aging.  author manuscript  we found that most eligible studies operationalized the eds as the mean or sum of reported frequency (n 21 of 25). our findings also suggest that increased self-report of discrimination is associated with higher crp levels, though we did not observe evidence of associations between discrimination and cortisol, il-6, or telomere length when using the eds. we also observed patterns in the magnitude of associations by sample size. for example, larger positive correlation sizes were observed among two smaller studies examining associations between the eds and il-6 while more modest positive correlations were observed among two larger studies. one small study had a large negative association, which may have influenced the null finding for il-6. null associations between discrimination and cortisol and telomere measures were not surprising as neither of these biomarkers have been consistently associated with other types of stress (chida and steptoe, 2009; fogelman and canli, 2018; korous et al., 2017; mathur et al., 2016). however, we identified associations between discrimination and crp, consistent with associations observed in other systematic reviews and meta-analyses of self-report measures and stress tasks (cuevas et al., 2020; steptoe et al., 2007). the  psychoneuroendocrinology. author manuscript; available in pmc 2023 march 09.  
  lawrence et al.  page 16  author manuscript  correlation of discrimination with higher crp, but not il-6 suggests that more studies are needed on the latter, given that il-6 stimulates the production of crp (papanicolaou et al., 1998). this may also reflect a need to examine alternative measures of cumulative and chronic inflammation, such as glycoprotein acetyls (glyca), instead of acute phase inflammatory markers (priest, 2021). however, studies have identified both il-6 and crp to have independent relationships with several adverse health outcomes and risk factors (bermudez et al., 2002; pradhan et al., 2001).  author manuscript  we noted three factors (1) heterogeneity in outcome measurement; (2) study design; and (3) sample demographics that could have contributed to our mixed findings. first, the observed findings between discrimination and cortisol, il-6, and telomere length may be influenced by several factors related to outcome measurement. specifically, eligible studies differed in their operationalization of biomarker outcomes. among studies that examined cortisol, differences in both the number of samples captured and cortisol outcomes assessed (e.g., momentary cortisol, hair cortisol concentration) were observed. for example, heterogeneity may be introduced by including hair cortisol in this analysis given that hair samples capture cortisol levels over a period ranging from several weeks to months (iob and steptoe, 2019). additionally, cortisol levels fluctuate throughout the day, typically with higher levels at waking and lower during the evening (levine et al., 2007; weitzman et al., 1971) and are sensitive to the method of collection (i.e., blood, saliva) (levine et al., 2007). collecting sufficient data to understand individual cortisol fluctuations and utilizing measures of diurnal cortisol may be useful contributions to future research (adam et al., 2017).  author manuscript  we also observed differences in how inflammation was assessed among eligible studies assessing il-6. il-6 samples were collected through blood (n 3) or saliva (n 3), with one study assessing both. while the mean correlation size across studies that used either measure was similar (r 0.03; r 0.06, plasma and saliva respectively), we observed a wider confidence interval across studies using salivary assessments. this could reflect greater variability in salivary assessments of il-6; however, the intervals may also be wide given the limited number of studies available. these differences suggest consideration of the means of assessment of inflammatory markers. this is especially relevant given that salivary assessments of inflammation may capture oral rather than systemic inflammation (priest et al., 2020b). previous research has concluded that plasma and salivary samples of inflammatory biomarkers (i.e., il-6, crp) may not be strongly correlated, and that blood samples – though relatively invasive – are preferred to salivary measures to assess systemic inflammation (cullen et al., 2015; williamson et al., 2012).  author manuscript  optimal assessments of telomere length are still being explored. all eligible studies used qpcr to assess telomere length which has several strengths that have been summarized in detail elsewhere (montpetit et al., 2014). these strengths include that qpcr requires a small sample of dna, is easily implemented in large studies, and has a reference to compare samples to. however, this method is sensitive to the quality of the dna sample and the reference is not standardized which makes cross-study comparisons difficult (montpetit et al., 2014). additionally, qpcr provides an estimate of the telomere amplification product (t) as compared to that of a reference single-copy gene (s) (aviv et al., 2011; montpetit et al., 2014). this is used to create a t/s ratio that correlates with average telomere  psychoneuroendocrinology. author manuscript; available in pmc 2023 march 09.  
  lawrence et al.  page 17  author manuscript  length, but does not yield a base pair estimate (montpetit et al., 2014). while qpcr has been widely accepted as an approach to assess telomere length, other techniques exist to determine telomere length (montpetit et al., 2014). these include flow-fluorescence in situ hybridization (fish) and southern blot, which is often referred to as the golden standard (aviv et al., 2011). the fish method is labor intensive and is likely not useful for large scale epidemiologic studies, as obtaining needed samples can be difficult compared to qpcr and southern blot (aviv et al., 2011; montpetit et al., 2014). however, both qpcr and southern blot yield reproducible results though the measurement error is greater in qpcr analyses (aviv et al., 2011). both qpcr and southern blot come with a set of tradeoffs that should be explored regarding their ability to impact cross-study comparisons. across all biomarkers used, differences in sample types and quality, frequency of measurement, as well as methodology used highlight a need to identify “gold standard” measures of biomarker levels and implement consistency in biomarker operationalization across studies.  author manuscript author manuscript  second, study design may have influenced our findings. several studies employed nonrepresentative sampling. this may reflect populations that are more or less likely to report experiences of discrimination and are willing to have their biomarkers sampled (e.g., have a blood draw) which is likely to introduce further selection bias. while these findings may not be generalizable to a broader population, they still provide insight into the experiences of individuals and communities with similar characteristics. the preponderance of cross-sectional studies in our review limits the ability to establish a temporal order between exposure to discrimination and biomarker changes, although the use of biomarkers reduces the possibility of reverse causality (i.e., people are generally unaware of their levels of circulating inflammatory biomarkers and hence biomarkers are unlikely to influence reports of discrimination). the longitudinal assessment of experiences of discrimination also makes it possible to examine trajectories of experiences over time and the cumulative impacts of discrimination on biomarker outcomes. priorities for future research on discrimination and health include the need for more longitudinal assessments and representative sampling, particularly of marginalized groups that may be most susceptible to experiencing discrimination and the differential health, social, and economic burden of such experiences.  author manuscript  though not quantifiable in the present analysis given the limited number of studies, findings from individual studies suggest there may be heterogeneity in the associations of discrimination and biomarkers according to race/ethnicity, gender, and/or sexual orientation (doyle and molix, 2016; kershaw et al., 2016b; ratner et al., 2013; saban et al., 2018). specifically, studies that examined associations among marginalized groups observed more nuanced associations than the average correlation obtained from our pooled estimates. for example, lehrer et al. found that everyday discrimination was associated with hair cortisol concentration among black participants, though not white participants (lehrer et al., 2020). differential relationships among marginalized groups may be obscured in assessments where their experiences are not centered or when included in study populations where those groups are less represented. these relationships should be explored in future research. additionally, while the literature on discrimination and health is global and spans across the lifecourse, (paradies, 2006; williams et al., 2019b) assessments of the association between discrimination and biomarkers that use the eds have been predominantly carried out in the psychoneuroendocrinology. author manuscript; available in pmc 2023 march 09.  
  lawrence et al.  page 18  author manuscript  united states (n 24) and among adult populations. associations between discrimination and biomarkers should be examined in other national contexts and lifecourse periods to assess comparability. while the underlying mechanisms may not differ, cross-context studies can help to elucidate causal mechanisms and effect modifiers useful to understanding relationships between discrimination and health. associations between discrimination and biomarkers across the lifecourse may vary at different periods (i.e., early life, adolescence, mid-life, older age). relatedly, items in the eds may not perform the same in different countries and populations. for example, to extend the use of the measure, the eds has recently been adapted for aboriginal and torres strait islander peoples to capture experiences and attributions relevant to indigeneity in australia (thurber et al., 2021).  author manuscript author manuscript  it should also be noted that there is a body of literature that suggests that psychosocial factors and coping strategies may influence reports and impacts of experiences of discrimination (berjot and gillet, 2011; brondolo et al., 2009; pascoe and smart richman, 2009). unhealthy coping strategies (e.g., suppressing responses) or “negative” psychosocial factors have maintained fairly consistent associations with worsened health impacts of discrimination, (brondolo et al., 2009; himmelstein et al., 2015; krieger and sidney, 1996; nuru-jeter et al., 2009) though findings regarding the overall health impacts of active or health-promoting coping strategies and positive psychosocial factors have been mixed (brondolo et al., 2009; james, 1994; pascoe and smart richman, 2009). while insight into how individual-level coping behaviors and resources is useful and can inform individuallevel interventions, the focus should extend beyond the individual-level. though these measures may be useful in understanding how marginalized people respond to and cope with discrimination – and should be further explored – focus on individual coping strategies without intervening on the structural and cultural factors that pattern these experiences may do little to mitigate adverse health outcomes and sustain wellbeing (bailey et al., 2020, 2017; homan, 2019; james, 1994).  author manuscript  our search found that crp, cortisol, il-6, and telomere length were outcomes that were assessed with reasonable frequency. however, in addition to studies in the meta-analysis, the narrative review revealed a broader range of biomarkers for future research. in addition to those identified in our narrative synthesis of relevant papers, several inflammatory markers such as il-1β, tnf-α, and inflammatory mechanisms such as the conserved transcriptional response to adversity (ctra) have been identified in a recent review of the relationship between discrimination and inflammation (cuevas et al., 2020). measures such as glyca may be more accurate measures of cumulative inflammation and have been associated with several chronic and acute health outcomes in adults (priest, 2021). this literature suggests that future research should examine relationships between discrimination and these understudied indicators of biological functioning to better understand and intervene upon the health implications of societal conditions and contexts. while future research should increase focus on relationships between discrimination and biomarkers (as well as potential interventions), it should also consider whether these associations differ when other measures of discrimination are used (e.g., experiences of discrimination, (krieger, 1990; krieger and sidney, 1996) major experiences of discrimination scale, (williams et al., 1997) or schedule of racist events (sre) (landrine  psychoneuroendocrinology. author manuscript; available in pmc 2023 march 09.  
  lawrence et al.  page 19  author manuscript author manuscript author manuscript  and klonoff, 1996)). studies using the experiences of discrimination (eod) scale have found positive associations with il-6 levels (giurgescu et al., 2016). a cross-sectional analysis by chae and colleagues found the main effect of eod on telomere length to be null in a sample of black men (chae et al., 2014), though, in a recent longitudinal assessment, they found evidence of greater 10-year telomere shortening among a sample of black adults in the cardia study (chae et al., 2020). differences in findings of these assessments may reflect differences in 1) study design (i.e., cross-sectional vs. longitudinal) or 2) study population (e.g., middle-aged black men in the bay area vs. a broader sample of middle-aged black adults across 4 cities). research examining the relationship between discrimination using the sre and cytokine levels (i.e., indicators of inflammation) found increased discrimination to be associated with elevated cytokines (brody et al., 2015; simons et al., 2021). an eligible study also assessed associations between discrimination and telomere length using the major experiences of discrimination scale finding null associations (hailu et al., 2020). it seems that the direction of relationships is relatively consistent across measures, though these are comparisons to individual studies. however, each measure captures different domains and frequencies in which discrimination occurs and offers considerations of different policy suggestions and interventions to mitigate their impacts. future research estimating the pooled correlation size between various indicators of discrimination and biomarker outcomes across studies that use measures that capture different forms, severity, and specific attributions of discrimination could contribute to understanding how discrimination adversely affects indicators of health status across the continuum of disease. it may also be useful to understand whether these associations differ among measures of discrimination that do not rely on the willingness of an individual to report compared to those which require self-report (krieger et al., 2010). additionally, this work can contribute to an evidence base that emphasizes the importance of policy and programs in tandem with research to intervene prior to the development of diseases to prevent and reduce disease burden among marginalized groups.  author manuscript  the present meta-analysis is not without its limitations. in examining the relationship between discrimination and biomarkers using the eds, we rely on a measure of discrimination that captures general experiences of unfair and differential treatment. while useful, the eds is distinct from measures that capture discrimination occurring within institutional contexts (e.g., the eod scale), those that capture specific forms of oppression (e.g., the sre), measures that capture discrimination as a result of an individual’s multiple marginalized identities (e.g., multiple discrimination scale (bogart et al., 2010)), and those capturing experiences which result in material, opportunity, and political deprivation irrespective of whether an individual was aware of such experiences and reported them as discriminatory or harmful (bailey et al., 2017; krieger, 2011, 2012; williams and mohammed, 2009). additionally, we only include findings from published manuscripts, which may differ from associations reported in unpublished works. specifically, results from the egger’s test suggests publication bias among studies that assessed crp, though not for cortisol, telomere length, or il-6. this may reflect a trend of not publishing null findings for crp and may also reflect the need for more research on il-6, telomere length, and cortisol given the smaller number of studies identified. we estimated mean correlation sizes from minimally adjusted associations reported in each article, however we also examine  psychoneuroendocrinology. author manuscript; available in pmc 2023 march 09.  
  lawrence et al.  page 20  author manuscript  associations reported in most adjusted models to account for potential confounders of the association. the biomarkers included in our review are linked with each other, resulting in a cascade of physiological responses to stress. for example, chronic inflammation (measured through il-1β and il-6) may lead to shortened telomeres, (baylis et al., 2014) acting as a potential mediator between discrimination and telomere length. however, our review did not consider the complex, inter-relationships between biomarkers representing different systems. instead, we have focused on summarizing the associations with individual components of the stress response, as well as reveal gaps in the evidence.  author manuscript author manuscript  this study also has several strengths. it quantifies the relationship between discrimination and molecular biomarkers, which provide evidence for some of the pathways that discrimination may become embodied. we also examine the relationship among studies that use the same measure of discrimination, the eds, thus increasing the comparability across studies. the eds is a widely used measure in both domestic and international contexts. full, abbreviated, or modified versions of the eds are included in many major epidemiologic studies in the united states and elsewhere (see for example: (bild et al., 2002; heeringa and connor, 1995; jackson et al., 2004; radler, 2014; rosenberg et al., 1995; steptoe et al., 2013; taylor et al., 2005; williams et al., 2004)). the frequent inclusion of eds in cross-national studies to examine the implications of discrimination on health allows for the systematic examination of the strength of associations between discrimination and health using a standardized exposure. additionally, the utility of the eds in capturing, reasonably accurately, the experiences of discrimination has been documented across a wide range of populations, with good internal consistency and validity (gonzales et al., 2016; kim et al., 2014; krieger et al., 2005; lewis et al., 2012). we also evaluate, where possible, the relationship between discrimination and biomarkers among studies that have utilized similar means of outcome assessment (i.e., car, waking cortisol, blood, and salivary il-6) to further increase the comparability across studies.  author manuscript  overall, our results provide information on the relationships between discrimination and several molecular biomarkers. the number of studies was limited, but we did find associations consistent with discrimination having an adverse effect, though evidence can be strengthened. there is a need of research using a broader range of biomarkers to better characterize the relationships between discrimination and physiological indicators. this study identifies associations between discrimination and biological indicators that have been identified as possible precursors to adverse health outcomes using a consistent measure of discrimination. we also provide considerations for future research utilizing biomarker outcomes to strengthen ongoing efforts.  supplementary material refer to web version on pubmed central for supplementary material.  psychoneuroendocrinology. author manuscript; available in pmc 2023 march 09.  
  lawrence et al.  page 21  author manuscript  funding this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.  references  author manuscript author manuscript author manuscript  adam ek, quinn me, tavernier r, mcquillan mt, dahlke ka, gilbert ke, 2017. diurnal cortisol slopes and mental and physical health outcomes: a systematic review and meta-analysis. psychoneuroendocrinology 83, 25–41. [pubmed: 28578301] aviv a, hunt sc, lin j, cao x, kimura m, blackburn e, 2011. impartial comparative analysis of measurement of leukocyte telomere length/dna content by southern blots and qpcr. nucleic acids res. 39 e134–e134. [pubmed: 21824912] bailey zd, feldman jm, bassett mt, 2020. how structural racism works — racist policies as a root cause of u.s. racial health inequities. n. engl. j. med. 384, 768–773. [pubmed: 33326717] bailey zd, krieger n, agenor m, graves j, linos n, bassett mt, 2017. structural racism and health inequities in the usa: evidence and interventions. lancet 389, 1453–1463. [pubmed: 28402827] baylis d, ntani g, edwards mh, syddall he, bartlett db, dennison em, martin-ruiz c, von zglinicki t, kuh d, lord jm, aihie sayer a, cooper c, 2014. inflammation, telomere length, and grip strength: a 10-year longitudinal study. calcif. tissue int. 95, 54–63. [pubmed: 24858709] beatty moody dl, brown c, matthews ka, bromberger jt, 2014. everyday discrimination prospectively predicts inflammation across 7–years in racially diverse midlife women: study of women’s health across the nation. j. soc. issues 70, 298–314. [pubmed: 25342861] beatty moody dl, leibel dk, darden tm, ashe jj, waldstein sr, katzel li, liu hb, weng np, evans mk, zonderman ab, 2019. interpersonal-level discrimination indices, sociodemographic factors, and telomere length in african-americans and whites. biol. psychol. 141, 1–9. [pubmed: 30553820] berjot s, gillet n, 2011. stress and coping with discrimination and stigmatization. front. psychol. 2. bermudez ea, rifai n, buring j, manson je, ridker pm, 2002. interrelationships among circulating interleukin-6, c-reactive protein, and traditional cardiovascular risk factors in women. arterioscler. thromb. vasc. biol. 22, 1668–1673. [pubmed: 12377747] bild de, bluemke da, burke gl, detrano r, diez roux av, folsom ar, greenland p, jacobsjr dr, kronmal r, liu k, nelson jc, o’leary d, saad mf, shea s, szklo m, tracy rp, 2002. multi-ethnic study of atherosclerosis: objectives and design. am. j. epidemiol. 156, 871–881. [pubmed: 12397006] bogart lm, wagner g, galvan fh, banks d, 2010. conspiracy beliefs about hiv are related to antiretroviral treatment nonadherence among african american men with hiv. j. acquir immune defic. syndr. 53, 648–655. [pubmed: 19952767] borenstein m, hedges lv, higgins jp, rothstein hr, 2010. a basic introduction to fixed-effect and random-effects models for meta-analysis. res. synth. methods 1, 97–111. [pubmed: 26061376] bourabain d, verhaeghe p-p, 2021. the conceptualization of everyday racism in research on the mental and physical health of ethnic and racial groups: a systematic review. j. racial ethn. health disparities 8, 648–660. [pubmed: 32740800] brody gh, yu t, miller ge, chen e, 2015. discrimination, racial identity, and cytokine levels among african-american adolescents. j. adolesc. health 56, 496–501. [pubmed: 25907649] brondolo e, brady ver halen n, pencille m, beatty d, contrada rj, 2009. coping with racism: a selective review of the literature and a theoretical and methodological critique. j. behav. med. 32, 64–88. [pubmed: 19127420] broza yy, zhou x, yuan m, qu d, zheng y, vishinkin r, khatib m, wu w, haick h, 2019. disease detection with molecular biomarkers: from chemistry of body fluids to nature-inspired chemical sensors. chem. rev. 119, 11761–11817. [pubmed: 31729868] chae dh, nuru-jeter am, adler ne, brody gh, lin j, blackburn eh, epel es, 2014. discrimination, racial bias, and telomere length in african-american men. am. j. prev. med. 46, 103–111. [pubmed: 24439343]  psychoneuroendocrinology. author manuscript; available in pmc 2023 march 09.  
  lawrence et al.  page 22  author manuscript author manuscript author manuscript author manuscript  chae dh, wang y, martz cd, slopen n, yip t, adler ne, fuller-rowell te, lin j, matthews ka, brody gh, spears ec, puterman e, epel es, 2020. racial discrimination and telomere shortening among african americans: the coronary artery risk development in young adults (cardia) study. health psychol. 39, 209–219. [pubmed: 31928029] chida y, steptoe a, 2009. cortisol awakening response and psychosocial factors: a systematic review and meta-analysis. biol. psychol. 80, 265–278. [pubmed: 19022335] clark r, anderson nb, clark vr, williams dr, 1999. racism as a stressor for african americans: a biopsychosocial model. am. psychol. 54, 805. [pubmed: 10540593] cuevas ag, ong ad, carvalho k, ho t, chan swc, allen j, chen r, rodgers j, biba u, williams dr, 2020. discrimination and systemic inflammation: a critical review and synthesis. brain behav. immun. cullen t, thomas aw, webb r, hughes mg, 2015. the relationship between interleukin-6 in saliva, venous and capillary plasma, at rest and in response to exercise. cytokine 71, 397–400. [pubmed: 25464926] doane ld, zeiders kh, 2014. contextual moderators of momentary cortisol and negative affect in adolescents’ daily lives. j. adolesc. health 54, 536–542. [pubmed: 24321894] dolezsar cm, mcgrath jj, herzig aj, miller sb, 2014. perceived racial discrimination and hypertension: a comprehensive systematic review. health psychol. 33, 20. [pubmed: 24417692] doyle dm, molix l, 2016. minority stress and inflammatory mediators: covering moderates associations between perceived discrimination and salivary interleukin-6 in gay men. j. behav. med. 39, 782–792. [pubmed: 27534538] egger m, smith gd, schneider m, minder c, 1997. bias in meta-analysis detected by a simple, graphical test. bmj 315, 629–634. [pubmed: 9310563] epel es, 2009. telomeres in a life-span perspective: a new “psychobiomarker”? curr. dir. psychol. sci. 18, 6–10. fogelman n, canli t, 2018. early life stress and cortisol: a meta-analysis. horm. behav. 98, 63–76. [pubmed: 29289660] friedman em, williams dr, singer bh, ryff cd, 2009. chronic discrimination predicts higher circulating levels of e-selectin in a national sample: the midus study. brain behav. immun. 23, 684–692. [pubmed: 19171188] fuller-rowell te, doan sn, eccles js, 2012. differential effects of perceived discrimination on the diurnal cortisol rhythm of african americans and whites. psychoneuroendocrinology 37, 107– 118. [pubmed: 21689889] geronimus at, pearson ja, linnenbringer e, schulz aj, reyes ag, epel es, lin j, blackburn eh, 2015. race-ethnicity, poverty, urban stressors, and telomere length in a detroit community-based sample. j. health soc. behav. 56, 199–224. [pubmed: 25930147] gilbert pa, zemore se, 2016. discrimination and drinking: a systematic review of the evidence. soc. sci. med. 161, 178–194. [pubmed: 27315370] giurgescu c, engeland cg, templin tn, zenk sn, koenig md, garfield l, 2016. racial discrimination predicts greater systemic inflammation in pregnant african american women. appl. nurs. res. 32, 98–103. [pubmed: 27969060] gonzales kl, noonan c, goins rt, henderson wg, beals j, manson sm, acton kj, roubideaux y, 2016. assessing the everyday discrimination scale among american indians and alaska natives. psychol. assess. 28, 51–58. [pubmed: 26146948] goosby bj, cheadle je, mitchell c, 2018. stress-related biosocial mechanisms of discrimination and african american health inequities. annu. rev. sociol. 44, 319–340. hailu em, needham bl, lewis tt, lin j, seeman te, roux ad, mujahid ms, 2020. discrimination, social support, and telomere length: the multi-ethnic study of atherosclerosis (mesa). ann. epidemiol. 42, 58–63 e52. [pubmed: 32070634] heeringa sg, connor jh, 1995. technical description of the health and retirement survey sample design. ann arbor: university of michigan. himmelstein ms, young dm, sanchez dt, jackson js, 2015. vigilance in the discrimination-stress model for black americans. psychol. health 30, 253–267. [pubmed: 25247925]  psychoneuroendocrinology. author manuscript; available in pmc 2023 march 09.  
  lawrence et al.  page 23  author manuscript author manuscript author manuscript author manuscript  homan p, 2019. structural sexism and health in the united states: a new perspective on health inequality and the gender system. am. sociol. rev. 84, 486–516. huynh vw, guan sa, almeida dm, mccreath h, fuligni aj, 2016. everyday discrimination and diurnal cortisol during adolescence. horm. behav. 80, 76–81. [pubmed: 26853614] imrey pb, 2020. limitations of meta-analyses of studies with high heterogeneity. jama netw. open 3 e1919325–e1919325. [pubmed: 31922554] incollingo rodriguez ac, tomiyama aj, guardino cm, dunkel schetter c, 2019. association of weight discrimination during pregnancy and postpartum with maternal postpartum health. health psychol. 38, 226–237. [pubmed: 30762402] iob e, steptoe a, 2019. cardiovascular disease and hair cortisol: a novel biomarker of chronic stress. curr. cardiol. rep. 21, 116–116. [pubmed: 31471749] jackson js, torres m, caldwell ch, neighbors hw, nesse rm, taylor rj, trierweiler sj, williams dr, 2004. the national survey of american life: a study of racial, ethnic and cultural influences on mental disorders and mental health. int. j. methods psychiatr. res. 13, 196–207. [pubmed: 15719528] james sa, 1994. john henryism and the health of african-americans. kershaw kn, lewis tt, diez roux av, jenny ns, liu k, penedo fj, carnethon mr, 2016a. self-reported experiences of discrimination and inflammation among men and women: the multiethnic study of atherosclerosis. health psychol. 35, 343–350. [pubmed: 27018725] kershaw kn, lewis tt, diez roux av, jenny ns, liu k, penedo fj, carnethon mr, 2016b. selfreported experiences of discrimination and inflammation among men and women: the multi-ethnic study of atherosclerosis. health psychol. 35, 343–350. [pubmed: 27018725] kim g, sellbom m, ford k-l, 2014. race/ethnicity and measurement equivalence of the everyday discrimination scale. psychol. assess. 26, 892. [pubmed: 24708076] korous km, causadias jm, casper dm, 2017. racial discrimination and cortisol output: a metaanalysis. soc. sci. med. 193, 90–100. [pubmed: 29028560] krieger n, 1990. racial and gender discrimination: risk factors for high blood pressure? soc. sci. med. 30, 1273–1281. [pubmed: 2367873] krieger n, 2005. embodiment: a conceptual glossary for epidemiology. j. epidemiol. community health 59, 350–355. [pubmed: 15831681] krieger n, 2011. ecosocial theory of disease distribution: embodying societal & ecologic context, epidemiology and the people’s health: theory and context. oxford university press, pp. 202– 235. krieger n, 2012. methods for the scientific study of discrimination and health: an ecosocial approach. am. j. public health 102, 936–944. [pubmed: 22420803] krieger n, 2014. discrimination and health inequities. int. j. health serv. 44, 643–710. [pubmed: 25626224] krieger n, carney d, lancaster k, waterman pd, kosheleva a, banaji m, 2010. combining explicit and implicit measures of racial discrimination in health research. am. j. public health 100, 1485– 1492. [pubmed: 19965567] krieger n, sidney s, 1996. racial discrimination and blood pressure: the cardia study of young black and white adults. am. j. public health 86, 1370–1378. [pubmed: 8876504] krieger n, smith k, naishadham d, hartman c, barbeau em, 2005. experiences of discrimination: validity and reliability of a self-report measure for population health research on racism and health. soc. sci. med. 61, 1576–1596. [pubmed: 16005789] landrine h, klonoff ea, 1996. the schedule of racist events: a measure of racial discrimination and a study of its negative physical and mental health consequences. j. black psychol. 22, 144–168. laterza of, hendrickson rc, wagner ja, 2007. molecular biomarkers. drug inf. j. 41, 573–585. lehrer hm, goosby bj, dubois sk, laudenslager ml, steinhardt ma, 2020. race moderates the association of perceived everyday discrimination and hair cortisol concentration. stress 1–9. levine a, zagoory-sharon o, feldman r, lewis jg, weller a, 2007. measuring cortisol in human psychobiological studies. physiol. behav. 90, 43–53. [pubmed: 17055006]  psychoneuroendocrinology. author manuscript; available in pmc 2023 march 09.  
  lawrence et al.  page 24  author manuscript author manuscript author manuscript author manuscript  lewis tt, aiello ae, leurgans s, kelly j, barnes ll, 2010. self-reported experiences of everyday discrimination are associated with elevated c-reactive protein levels in older african-american adults. brain behav. immun. 24, 438–443. [pubmed: 19944144] lewis tt, cogburn cd, williams dr, 2015. self-reported experiences of discrimination and health: scientific advances, ongoing controversies, and emerging issues. annu. rev. clin. psychol. 11, 407–440. [pubmed: 25581238] lewis tt, everson-rose sa, powell lh, matthews ka, brown c, karavolos k, sutton-tyrrell k, jacobs e, wesley d, 2006. chronic exposure to everyday discrimination and coronary artery calcification in african-american women: the swan heart study. psychosom. med. 68, 362–368. [pubmed: 16738065] lewis tt, williams dr, tamene m, clark cr, 2014. self-reported experiences of discrimination and cardiovascular disease. curr. cardiovasc risk rep. 8, 365–365. [pubmed: 24729825] lewis tt, yang fm, jacobs ea, fitchett g, 2012. racial/ethnic differences in responses to the everyday discrimination scale: a differential item functioning analysis. am. j. epidemiol. 175, 391–401. [pubmed: 22306556] liu sy, kawachi i, 2017. discrimination and telomere length among older adults in the united states. public health rep. 132, 220–230. [pubmed: 28147207] lu d, palmer jr, rosenberg l, shields ae, orr eh, devivo i, cozier yc, 2019. perceived racism in relation to telomere length among african american women in the black women’s health study. ann. epidemiol. 36, 33–39. [pubmed: 31387775] lucas t, wegner r, pierce j, lumley ma, laurent hk, granger da, 2017. perceived discrimination, racial identity, and multisystem stress response to social evaluative threat among african american men and women. psychosom. med. 79, 293–305. [pubmed: 27806018] mathur mb, epel e, kind s, desai m, parks cg, sandler dp, khazeni n, 2016. perceived stress and telomere length: a systematic review, meta-analysis, and methodologic considerations for advancing the field. brain behav. immun. 54, 158–169. [pubmed: 26853993] mcewen bs, 2000. allostasis and allostatic load: implications for neuropsychopharmacology. neuropsychopharmacology 22, 108–124. [pubmed: 10649824] mcewen bs, 2008. central effects of stress hormones in health and disease: understanding the protective and damaging effects of stress and stress mediators. eur. j. pharm. 583, 174–185. mcewen bs, 2012. brain on stress: how the social environment gets under the skin. proc. natl. acad. sci. usa 109 (suppl 2), 17180–17185. [pubmed: 23045648] mcewen bs, stellar e, 1993. stress and the individual: mechanisms leading to disease. arch. intern. med. 153, 2093–2101. [pubmed: 8379800] moher d, liberati a, tetzlaff j, altman dg, 2009. preferred reporting items for systematic reviews and meta-analyses: the prisma statement. ann. intern. med. 151, 264–269. [pubmed: 19622511] montpetit aj, alhareeri aa, montpetit m, starkweather ar, elmore lw, filler k, mohanraj l, burton cw, menzies vs, lyon de, jackson-cook ck, 2014. telomere length: a review of methods for measurement. nurs. res. 63, 289–299. [pubmed: 24977726] nuru-jeter a, dominguez tp, hammond wp, leu j, skaff m, egerter s, jones cp, braveman p, 2009. “it’s the skin you’re in”: african-american women talk about their experiences of racism. an exploratory study to develop measures of racism for birth outcome studies. matern child health j. 13, 29–39. [pubmed: 18463971] papanicolaou da, wilder rl, manolagas sc, chrousos gp, 1998. the pathophysiologic roles of interleukin-6 in human disease. ann. intern. med. 128, 127–137. [pubmed: 9441573] paradies y, 2006. a systematic review of empirical research on self-reported racism and health. int. j. epidemiol. 35, 888–901. [pubmed: 16585055] paradies y, ben j, denson n, elias a, priest n, pieterse a, gupta a, kelaher m, gee g, 2015. racism as a determinant of health: a systematic review and meta-analysis. plos one 10, e0138511. [pubmed: 26398658] pascoe ea, smart richman l, 2009. perceived discrimination and health: a meta-analytic review. psychol. bull. 135, 531. [pubmed: 19586161]  psychoneuroendocrinology. author manuscript; available in pmc 2023 march 09.  
  lawrence et al.  page 25  author manuscript author manuscript author manuscript author manuscript  peterson ra, brown sp, 2005. on the use of beta coefficients in meta-analysis. j. appl. psychol. 90, 175–181. [pubmed: 15641898] pierce c, 1974. psychiatric problems of the black minority. in: caplan g (ed.), american handbook of psychiatry, volume ii. basic books, new york, pp. 512–523. pieterse al, todd nr, neville ha, carter rt, 2012. perceived racism and mental health among black american adults: a meta-analytic review. j. couns. psychol. 59, 1–9. [pubmed: 22059427] potter l, wallston k, trief p, ulbrecht j, juth v, smyth j, 2015. attributing discrimination to weight: associations with well-being, self-care, and disease status in patients with type 2 diabetes mellitus. j. behav. med. 38, 863–875. [pubmed: 26133488] pradhan ad, manson je, rifai n, buring je, ridker pm, 2001. c-reactive protein, interleukin 6, and risk of developing type 2 diabetes mellitus. jama 286, 327–334. [pubmed: 11466099] priest n, 2021. how does the social environment become embodied to influence health and health inequalities? brain behav. immun. 94, 23–24. [pubmed: 33607234] priest n, chong s, truong m, alam o, dunn k, o’connor m, paradies y, ward a, kavanagh a, 2020a. racial discrimination and socioemotional and sleep problems in a cross-sectional survey of australian school students. arch. dis. child. 105, 1079–1085. [pubmed: 32723755] priest n, truong m, chong s, paradies y, king tl, kavanagh a, olds t, craig jm, burgner d, 2020b. experiences of racial discrimination and cardiometabolic risk among australian children. brain behav. immun. 87, 660–665. [pubmed: 32119900] r core team, 2013. r: a language and environment for statistical computing. radler bt, 2014. the midlife in the united states (midus) series: a national longitudinal study of health and well-being. open health data 2, e3. [pubmed: 25558376] ratner kg, halim ml, amodio dm, 2013. perceived stigmatization, ingroup pride, and immune and endocrine activity: evidence from a community sample of black and latina women. social psychological and personality. science 4, 82–91. rosenberg l, adams-campbell l, palmer jr, 1995. the black women’s health study: a follow-up study for causes and preventions of illness. j. am. med. women’s. assoc. (1972) 50 56–58. [pubmed: 7722208] saban kl, hoppensteadt d, bryant fb, devon ha, 2014. social determinants and heat shock protein-70 among african american and non-hispanic white women with atherosclerosis: a pilot study. biol. res. nurs. 16, 258–265. [pubmed: 23749050] saban kl, mathews hl, bryant fb, tell d, joyce c, devon ha, witek janusek l, 2018. perceived discrimination is associated with the inflammatory response to acute laboratory stress in women at risk for cardiovascular disease. brain behav. immun. 73, 625–632. [pubmed: 30012518] santos hp jr., nephew bc, bhattacharya a, tan x, smith l, alyamani ras, martin em, perreira k, fry rc, murgatroyd c, 2018. discrimination exposure and dna methylation of stress-related genes in latina mothers. psychoneuroendocrinology 98, 131–138. [pubmed: 30144780] seeman te, mcewen bs, rowe jw, singer bh, 2001. allostatic load as a marker of cumulative biological risk: macarthur studies of successful aging. proc. natl. acad. sci. 98, 4770–4775. [pubmed: 11287659] simons rl, lei m-k, klopack e, zhang y, gibbons fx, beach srh, 2021. racial discrimination, inflammation, and chronic illness among african american women at midlife: support for the weathering perspective. j. racial ethn. health disparities 8, 339–349. [pubmed: 32488825] steptoe a, breeze e, banks j, nazroo j, 2013. cohort profile: the english longitudinal study of ageing. int j. epidemiol. 42, 1640–1648. [pubmed: 23143611] steptoe a, hamer m, chida y, 2007. the effects of acute psychological stress on circulating inflammatory factors in humans: a review and meta-analysis. brain behav. immun. 21, 901–912. [pubmed: 17475444] sternthal mj, slopen n, williams dr, 2011. racial disparities in health: how much does stress really matter? du bois rev. soc. sci. res. race 8, 95–113. stroup df, berlin ja, morton sc, olkin i, williamson gd, rennie d, moher d, becker bj, sipe ta, thacker sb, 2000. meta-analysis of observational studies in epidemiology: a proposal for reporting. jama 283, 2008–2012. [pubmed: 10789670]  psychoneuroendocrinology. author manuscript; available in pmc 2023 march 09.  
  lawrence et al.  page 26  author manuscript author manuscript author manuscript author manuscript  sullivan s, hammadah m, al mheid i, shah a, sun yv, kutner m, ward l, blackburn e, zhao j, lin j, bremner jd, quyyumi aa, vaccarino v, lewis tt, 2019. an investigation of racial/ethnic and sex differences in the association between experiences of everyday discrimination and leukocyte telomere length among patients with coronary artery disease. psychoneuroendocrinology 122– 128. tajfel h, turner jc, 2004. the social identity theory of intergroup behavior. psychology press, pp. 276–293. taylor ha jr., wilson jg, jones dw, sarpong df, srinivasan a, garrison rj, nelson c, wyatt sb, 2005. toward resolution of cardiovascular health disparities in african americans: design and methods of the jackson heart study. ethn. dis. 15. s6–4. thayer zm, kuzawa cw, 2015. ethnic discrimination predicts poor self-rated health and cortisol in pregnancy: insights from new zealand. soc. sci. med. 128, 36–42. [pubmed: 25589034] thurber ka, walker j, batterham pj, gee gc, chapman j, priest n, cohen r, jones r, richardson a, calear al, williams dr, lovett r, 2021. developing and validating measures of self-reported everyday and healthcare discrimination for aboriginal and torres strait islander adults. int. j. equity health 20, 14. [pubmed: 33407521] van der laan lc, meeks kac, chilunga fp, agyemang c, venema a, mannens m, zafarmand mh, klipstein-grobusch k, smeeth l, adeyemo a, henneman p, 2020. epigenome-wide association study for perceived discrimination among sub-saharan african migrants in europe - the rodam study. sci. rep. 10, 4919. [pubmed: 32188935] veritas health innovation, 2017. covidence systematic review software. veritas health innovation melbourne, vic. viechtbauer w, 2010. conducting meta-analyses in r with the metafor package. j. stat. softw. 36, 1–48. weitzman ed, fukushima d, nogeire c, roffwarg h, gallagher tf, hellman l, 1971. twenty-four hour pattern of the episodic secretion of cortisol in normal subjects. j. clin. endocrinol. metab. 33, 14–22. [pubmed: 4326799] williams dr, herman a, kessler rc, sonnega j, seedat s, stein dj, moomal h, wilson cm, 2004. the south africa stress and health study: rationale and design. metab. brain dis. 19, 135–147. [pubmed: 15214513] williams dr, lawrence ja, davis ba, 2019a. racism and health: evidence and needed research. annu. rev. public health 40, 105–125. [pubmed: 30601726] williams dr, lawrence ja, davis ba, vu c, 2019b. understanding how discrimination can affect health. health serv. res. 54, 1374–1388. [pubmed: 31663121] williams dr, mohammed sa, 2009. discrimination and racial disparities in health: evidence and needed research. j. behav. med. 32, 20–47. [pubmed: 19030981] williams dr, neighbors hw, jackson js, 2003. racial/ethnic discrimination and health: findings from community studies. am. j. public health 93, 200–208. [pubmed: 12554570] williams dr, yu y, jackson js, anderson nb, 1997. racial differences in physical and mental health: socio-economic status, stress and discrimination. j. health psychol. 2, 335–351. [pubmed: 22013026] williamson s, munro c, pickler r, grap mj, elswick rk, 2012. comparison of biomarkers in blood and saliva in healthy adults. nurs. res. pract. 2012, 246178. [pubmed: 22619709] zahodne lb, kraal az, sharifian n, zaheed ab, sol k, 2019. inflammatory mechanisms underlying the effects of everyday discrimination on age-related memory decline. brain behav. immun. 75, 149–154. [pubmed: 30367930] zeiders kh, hoyt lt, adam ek, 2014. associations between self-reported discrimination and diurnal cortisol rhythms among young adults: the moderating role of racial–ethnic minority status. psychoneuroendocrinology 50, 280–288. [pubmed: 25262035]  psychoneuroendocrinology. author manuscript; available in pmc 2023 march 09.  
  lawrence et al.  page 27  author manuscript author manuscript fig. 1.  study identification and selection process.  author manuscript author manuscript psychoneuroendocrinology. author manuscript; available in pmc 2023 march 09.  
  lawrence et al.  page 28  author manuscript author manuscript  fig. 2.  associations between eds and (a) all cortisol outcomes; (b) cortisol awakening response (car); and (c) waking levels (minimally adjusted).  author manuscript author manuscript psychoneuroendocrinology. author manuscript; available in pmc 2023 march 09.  
  lawrence et al.  page 29  author manuscript fig. 3.  associations between eds and c-reactive protein (crp, minimally adjusted).  author manuscript author manuscript author manuscript psychoneuroendocrinology. author manuscript; available in pmc 2023 march 09.  
  lawrence et al.  page 30  author manuscript author manuscript fig. 4.  author manuscript  associations between eds and (a) interleukin-6 (il-6) across all studies; (b) plasma samples; and (c) salivary samples (minimally adjusted).  author manuscript psychoneuroendocrinology. author manuscript; available in pmc 2023 march 09.  
  lawrence et al.  page 31  author manuscript fig. 5.  associations between eds and telomere length (minimally adjusted).  author manuscript author manuscript author manuscript psychoneuroendocrinology. author manuscript; available in pmc 2023 march 09.  
  lawrence et al.  page 32  author manuscript author manuscript fig. 6.  funnel plots for a) cortisol; b) crp; c) il-6; and d) telomere length.  author manuscript author manuscript psychoneuroendocrinology. author manuscript; available in pmc 2023 march 09.  
       


secondary_title_index: psychoneuroendocrinology
abstract_index:
       discrimination has consistently been associated with multiple adverse health outcomes. like other psychosocial stressors, discrimination is thought to impact health through stress-related physiologic pathways including hypothalamic-pituitary-adrenal (hpa) axis activation, dysregulation of inflammation responses, and accelerated cellular aging. given growing attention to research examining the biological pathways through which discrim­ination becomes embodied, this systematic review and meta-analysis synthesizes empirical evidence examining relationships between self-reported discrimination and four biomarker outcomes (i.e., cortisol, c-reactive protein (crp), interleukin-6 (il-6), and telomere length) among studies that have used the everyday discrimination scale. we conducted a systematic review of studies discussing self-reported, everyday, or chronic discrimination in the context of health by searching medline / pubmed (national library of medicine, ncbi), psycinfo (apa, ebsco) and web of science core collection (clarivate). twenty-five articles met the criteria for meta-analysis, with several reporting on multiple outcomes. discrimination was associated with elevated crp levels (r = 0.11; 95% ci: 0.01, 0.20, k = 10), though not cortisol (r = 0.05; 95% ci: − 0.06, 0.16, k = 9), il-6 (r = 0.05; 95% ci: − 0.32, 0.42, k = 5), or telomere length (r = 0.03; 95% ci: − 0.01, 0.07, k = 6). we identify several points of consideration for future research including addressing heterogeneity in assessment of biomarker outcomes and the need for longitudinal assessments of relationships between discrimination and biomarker outcomes.     

authors_index:
       lawrence, jourdyn a.     kawachi, ichiro     white, kellee     bassett, mary t.     priest, naomi     masunga, joan gakii     cory, hannah j.     mita, carol     williams, david r.     

title_index:
       a systematic review and meta-analysis of the everyday discrimination scale and biomarker outcomes     

full_text_index:
       psychoneuroendocrinology 142 (2022) 105772  contents lists available at sciencedirect  psychoneuroendocrinology journal homepage: www.elsevier.com/locate/psyneuen  a systematic review and meta-analysis of the everyday discrimination scale and biomarker outcomes jourdyn a. lawrence a, b, c, *, 1, ichiro kawachi a, kellee white d, mary t. bassett a, c, naomi priest e, f, joan gakii masunga g, h, hannah j. cory b, i, 2, carol mita j, david r. williams a, k a  department of social and behavioral sciences, harvard t.h. chan school of public health, boston, ma, usa population health sciences, harvard graduate school of arts and sciences, cambridge, ma, usa francois-xavier bagnoud (fxb) center for health and human rights, harvard t.h. chan school of public health, boston, ma, usa d department of health policy and management, university of maryland school of public health, college park, md, usa e centre for social research and methods, australian national university, canberra, australian capital territory, australia f murdoch children’s research institute, parkville, victoria, australia g center for bioethics, harvard medical school, boston, ma, usa h department of global health and social medicine, harvard medical school, boston, ma, usa i department of nutrition, harvard t.h. chan school of public health, boston, ma, usa j countway library, harvard medical school, boston, ma, usa k department of african and african american studies, harvard university, cambridge, ma, usa b c  a r t i c l e i n f o  a b s t r a c t  keywords: social discrimination c-reactive protein inflammation telomere length stress  discrimination has consistently been associated with multiple adverse health outcomes. like other psychosocial stressors, discrimination is thought to impact health through stress-related physiologic pathways including hypothalamic-pituitary-adrenal (hpa) axis activation, dysregulation of inflammation responses, and accelerated cellular aging. given growing attention to research examining the biological pathways through which discrim ination becomes embodied, this systematic review and meta-analysis synthesizes empirical evidence examining relationships between self-reported discrimination and four biomarker outcomes (i.e., cortisol, c-reactive protein (crp), interleukin-6 (il-6), and telomere length) among studies that have used the everyday discrimination scale. we conducted a systematic review of studies discussing self-reported, everyday, or chronic discrimination in the context of health by searching medline / pubmed (national library of medicine, ncbi), psycinfo (apa, ebsco) and web of science core collection (clarivate). twenty-five articles met the criteria for meta-analysis, with several reporting on multiple outcomes. discrimination was associated with elevated crp levels (r 0.11; 95% ci: 0.01, 0.20, k 10), though not cortisol (r 0.05; 95% ci: 0.06, 0.16, k 9), il-6 (r 0.05; 95% ci: 0.32, 0.42, k 5), or telomere length (r 0.03; 95% ci: 0.01, 0.07, k 6). we identify several points of consideration for future research including addressing heterogeneity in assessment of biomarker outcomes and the need for longitudinal assessments of relationships between discrimination and biomarker outcomes.  1. introduction  oppression, resulting in inequitable treatment for marginalized groups (priest et al., 2020a; tajfel and turner, 2004). as one of the most frequently assessed domains of discrimination, self-reported discrimi nation is often conceptualized as a stressor that adversely affects health, with a large proportion of the literature examining the impacts of  in addition to the inequitable access to opportunities, resources, and power due to structural oppression at structural, cultural, and institu tional levels, discrimination acts as the behavioral expression of  * correspondence to: department of social and behavioral sciences, harvard t.h. chan school of public health, 677 huntington avenue, boston, ma 02115, usa. e-mail address: jlawrence@hsph.harvard.edu (j.a. lawrence). 1 present address: francois-xavier bagnoud (fxb) center for health and human rights, harvard t.h. chan school of public health, 651 huntington avenue, 7th floor, boston, ma 02115 2 present address: division of epidemiology and community health, university of minnesota school of public health, 1300s 2nd street, suite 300, minneapolis, mn 55455 https://doi.org/10.1016/j.psyneuen.2022.105772 received 2 september 2021; received in revised form 1 march 2022; accepted 17 april 2022 available online 21 april 2022 0306-4530/ 2022 the authors. published by elsevier ltd. this is an open access article under the cc by-nc-nd license (http://creativecommons.org/licenses/bync-nd/4.0/).  
  j.a. lawrence et al.  psychoneuroendocrinology 142 (2022) 105772  self-reported racial discrimination (dolezsar et al., 2014; gilbert and zemore, 2016; goosby et al., 2018; krieger, 2014; lewis et al., 2015, 2014; pascoe and smart richman, 2009; williams et al., 2019a, 2019b; williams and mohammed, 2009). the study of discrimination as a type of psychosocial stressor that adversely affects health and as a contributor to race/ethnic disparities in health has grown in the last two decades (krieger, 2014). a recent review documented 29 reviews of the litera ture that were published between 2013 and 2019 which examined re lationships between discrimination and mental and physical health outcomes (williams et al., 2019b). most early research on the relation ship between discrimination and health documented associations with mental health, indicators of health behavior, or self-reported measures of physical health (williams and mohammed, 2009). however, research has begun to elucidate the biological pathways through which societal and psychosocial stressors, like discrimination, are embodied to affect health (cuevas et al., 2020; priest, 2021). a growing body of evidence suggests that experiences of discrimi nation may affect physical and mental health through multiple biolog ical pathways (clark et al., 1999; epel, 2009; lewis et al., 2015). the conceptual model of allostatic load, developed by mcewen and stellar, suggests that frequent exposure to psychosocial stressors – such as discrimination – results in the activation of multiple axes involved in the stress response, e.g., the neuroendocrine system (hpa axis, sympathetic-adreno-medullar axis), the autonomic nervous system, immune and inflammatory processes, and metabolism (mcewen, 2000; mcewen and stellar, 1993; seeman et al., 2001). as a result of societal processes of social marginalization and devaluing, individuals from marginalized groups experience increased exposure to discrimination which is posited to be embodied through the activation of hpa axis (i.e., cortisol) and inflammation (i.e., interleukin-6 and c-reactive protein) cascades or accelerated cellular aging (i.e., shortened telomere length). these outcomes capture distinct, but inter-related processes through which discrimination may affect health. these systems interact with each other, suggesting a coordinated physiological response to stress. for example, chronic elevation of hpa axis and inflammation mediators result in interactions which yield chronic elevations in blood pressure that can contribute to adverse cardiovascular outcomes such as heart attacks and stroke (mcewen, 2008). much of the literature supports this framework, with researchers identifying relationships between discrimination and increased hpa axis activation, (clark et al., 1999) dysregulation of inflammatory responses, (cuevas et al., 2020) and accelerated cellular aging. (epel, 2009) studies have also found bio markers associated with these pathways (e.g., cortisol, crp, telomere length) to have documented associations with increased morbidity across several health outcomes and mortality (cuevas et al., 2020; mcewen, 2008, 2012). indeed, closer examination of the relationship between discrimina tion and biomarkers provides an opportunity to advance our mecha nistic understanding of how chronic experiences of differential treatment become embodied or “get under the skin” to contribute to poor psychological and physiological health (krieger, 2005; mcewen, 2012). the use of biomarkers measures also circumvents the issue of common source bias that may arise when both the exposure (discrimi nation) and health outcome are self-reported. however, a comprehen sive assessment of the association between experiences of discrimination and biomarkers of physiologic stress, inflammation, and accelerated aging has not been performed to date. studies assessing biological pathways are a small proportion of the total literature on discrimination but are increasing in recent years. a recent systematic review of discrimination and systemic inflammation identified 28 articles published since 2009 (cuevas et al., 2020). these measures were not included in previous meta-analyses of the health implications of discrimination. prior meta-analyses have examined the relationship between discrimination and health across several measures of discrimination, with much heterogeneity in the timing and type of discrimination experienced (paradies et al., 2015; pascoe and smart  richman, 2009; pieterse et al., 2012). results from previous meta-analyses suggest that the associations between discrimination and health outcomes vary by instruments used to assess discrimination (dolezsar et al., 2014; paradies et al., 2015). reducing heterogeneity in meta-analysis by limiting variations across measures of discrimination, for example, is also important statistically when combining estimates across studies in meta-analysis (bourabain and verhaeghe, 2021; imrey, 2020). the larger literature on stress and health suggests that incidents of racial discrimination, like other self-reported stressors, can be classified into several types of stressful life experiences (williams and mohammed, 2009). similar to research on stress and health, interpersonal experi ences of discrimination can be divided into acute major discriminatory life events (e.g. being unfairly fired from a job), chronic discrimination in major domains life (e.g. at work, school, or in one’s neighborhood), traumatic discriminatory experiences (e.g. being beaten by the police) and more minor but ongoing events, somewhat analogous to daily hassles in the larger stress literature (williams and mohammed, 2009). different measures of discrimination assess various aspects of these stressful experiences. the everyday discrimination scale (eds) captures only the latter class of relatively minor, but recurrent instances of discrimination (williams et al., 1997). enhancing our understanding of the ways in which discrimination can affect health requires greater research attention to understanding how specific types of discrimination are related to health outcomes. social identity theory provides a framework that allows for an understanding of how social contexts and identities facilitate differential treatment, devaluing, and withholding of resources by members of the “in-group” can result in the disadvantage that members of marginalized groups face. (tajfel and turner, 2004) in this context, marginalized groups are more likely to encounter experi ences of discrimination, which have long been theorized to be “assaults to [b]lack dignity and [b]lack hope [that] are incessant and cumulative” in their adverse impacts on health (pierce, 1974). understanding the everyday encounters of discrimination marginalized groups face facili tates an understanding of how recurrent exposure to differential treat ment becomes embodied and how the eds remains a strong predictor of the onset and progression of adverse health outcomes (kershaw et al., 2016a; lewis et al., 2006; williams et al., 2003). a sufficient number of studies have been conducted utilizing the eds to permit a review of the association of discrimination with biomarkers (i.e., hpa axis, inflammation, and cellular aging). to the authors’ knowledge, this is the first meta-analysis that examines the association of discrimination on stress-related biomarkers among studies that have used the same measure. accordingly, this paper sought to synthesize existing literature, provide deeper insight into methodological and measurement challenges, and identify future research directions. 1.1. study objectives this systematic review and meta-analysis examined the relationship between experiences of discrimination and molecular biomarker out comes, with quantitative focus on interleukin-6 (il-6), crp, cortisol, and leukocyte telomere length, among studies that have used the eds to measure exposure to discrimination. we characterized the existing body of literature that has included the eds – highlighting study design and methodology, sample characteristics, operationalization of the eds, and outcomes examined. we examined relationships between the eds and individual biomarker measures of stress, inflammation, and cellular aging (e.g., telomere length) – to increase the comparability of findings across studies that have used the same assessment of exposure to discrimination. specifically, the overarching research aims of the systematic review were to: 1. meta-analyze associations between the eds and stress-related bio markers. we hypothesize that increased discrimination is associated 2  
  j.a. lawrence et al.  psychoneuroendocrinology 142 (2022) 105772  national origins; (2) your gender; (3) your race; (4) your age; (5) your religion; (6) your height; (7) your weight; (8) some other aspect of your physical appearance; (9) your sexual orientation; (10) your educational or income level. a short form of the eds was developed for the chicago community adult health study (ccahs) (sternthal et al., 2011) in which re spondents were asked: “”in your day-to-day life, how often have any of the following things happened to you?” (1) you are treated with less courtesy or respect than other people; (2) you receive poorer service than other people at restaurants or stores; (3) people act as if they think you are not smart; (4) people act as if they are afraid of you; (5) you are threatened or harassed. the follow-up question and response categories of the shortened eds are the same as the original. other adapted ver sions of the scale were considered eligible for inclusion if they were not major adaptations beyond the original scope of the eds (e.g., studies that created summary scores that joined the eds with other measures or studies that only include one item from the eds were not included).  with adverse levels of biomarker measures (i.e., shorter telomere length; higher il-6, crp, and cortisol levels). 2. descriptively map the mediators (e.g., smoking, excess drinking) of the associations between discrimination and molecular biomarkers across studies that have used the eds. this provides context as to what factors have been considered as mediating variables in studies assessing discrimination and biomarker outcomes. 2. methods this meta-analysis followed the preferred reporting items for sys tematic reviews and meta-analysis (prisma) and the meta-analysis of observational studies in epidemiology (moose) guidelines and criteria (moher et al., 2009; stroup et al., 2000). 2.1. search strategy studies discussing self-reported, everyday, or chronic discrimination in the context of health were identified by searching medline / pubmed (national library of medicine, ncbi), psycinfo (apa, ebsco) and web of science core collection (clarivate). controlled vocabulary terms (i.e., mesh; thesaurus of psychological index terms) were included when available and appropriate. the search strategies were designed and executed by a research librarian (cm) at the countway library of medicine at harvard university. publication date was limited to studies published in 1997 or later. no language restriction was applied. the exact search terms used for each of the databases are provided in the supplementary materials (supplemental table 1). reference lists of identified papers were examined for additional relevant articles for inclusion.  2.2.2. outcomes all stress-related biomarker outcomes were eligible for inclusion. these included il6, crp, cortisol, dhea (dehydroepiandrosterone, also dhea-s), dna methylation, e-selectin, fibrinogen, nerve growth factor, alpha amylase, hsp-70 (heat shock protein-70), hba1c levels, and telomere length. several outcomes were only examined in one or two articles and were excluded from the meta-analysis but are included in our narrative synthesis of the findings (n 5, fig. 1). for example, dna methylation was only assessed as an outcome in two identified studies. the three remaining outcomes meeting the inclusion criteria were only assessed in one manuscript each.  2.2. inclusion criteria  2.3. screening  for consideration of inclusion, studies must have used quantitative methodology reporting an estimate of the relationship between the eds and a disease-related molecular biomarker (e.g., telomere length, il-6) (broza et al., 2019; epel, 2009; laterza et al., 2007). as such, studies using qualitative methods were not included. all collection methods for molecular biomarkers were included (e.g., blood, saliva, hair, urine) (broza et al., 2019). all study designs were eligible (i.e., cross-sectional, longitudinal, case-control, and experimental). given that the eds was first utilized in 1997, (williams et al., 1997) studies were eligible for inclusion if published in 1997 or later. exclusion restrictions were not placed upon study populations, such that studies including participants from any age group, racial/ethnic/ cultural identity, ability, and other sociodemographic factors were included.  search results were imported into endnote x9, and duplicate entries were removed. the endnote library was exported into covidence (ver itas health innovation, 2017), a web-based systematic review software. two reviewers (jl, gm) independently conducted title and abstract screening to assess studies for eligibility (inter-reviewer reliability (κ)  0.78, indicating good agreement).  2.2.1. exposure self-reported discrimination was measured using the eds, which includes the frequency of self-reported discrimination in the re spondent’s day-to-day life (williams et al., 1997) the original scale in cludes nine-items: “in your day-to-day life, how often do any of the following things happen to you?” (1) you are treated with less courtesy than other people are; (2) you are treated with less respect than other people are; (3) you receive poorer service than other people at restau rants or stores; (4) people act as if they think you are not smart; (5) people act as if they are afraid of you; (6) people act as if they think you are dishonest; (7) people act as if they’re better than you are; (8) you are called names or insulted; and (9) you are threatened or harassed. re sponses for each item include “almost every day,” “at least once a week,” “a few times a month,” “a few times a year,” less than once a year,” and “never”. respondents reporting “a few times a year” or more frequent experiences of discrimination may be asked a follow up question: “what do you think is the main reason for these experiences?” participants can select one or more of the following attributions: (1) your ancestry or  fig. 1. study identification and selection process. 3  
  j.a. lawrence et al.  psychoneuroendocrinology 142 (2022) 105772  2.5. quality assessment  full texts of studies considered for inclusion were obtained. dis crepancies between reviewers regarding study inclusion was resolved by discussion with a third reviewer (hc) and/or consensus (jl, gm) [κ 0.74]. the study selection process is outlined in full in fig. 1.  study quality was assessed in terms of potential for bias. similar to paradies et al. (2015), we use sampling procedure, data type (e.g., cross-sectional, longitudinal), and instrument (i.e., full scale, short form), and covariates included in a narrative assessment of study qual ity. funnel plots were created to illustrate potential publication bias and asymmetry was tested using egger’s tests (egger et al., 1997).  2.4. data extraction and analysis data from identified studies were independently extracted into an excel document by one reviewer (jl) with another reviewer randomly checking 20% of the extracted data (hc). inconsistencies were resolved by consensus and/or discussion with a third reviewer (gm). extracted data included information regarding the eds (e.g., version used, oper ationalization) and biomarker assessed, demographic characteristics of participants (e.g., age, gender, educational attainment), study attributes (e.g., study design, location [country and region], period and duration of study (if relevant), sample size), most and minimally adjusted estimates, covariates adjusted for, psychometric properties of the scale (if assessed), mediators (if explicitly mentioned) and potential sources of bias (e.g., attrition, missing data). for articles using the same dataset to examine relationships with the same outcome, we extracted data from papers with the most information reported (e.g., both minimally and fully adjusted models reported). if multiple papers included the same amount of information, the earliest publication was included in the meta-analysis. minimally adjusted estimates include data from the least adjusted model reported or correlations between eds and biomarkers. fully adjusted estimates include data from the most adjusted model reported with all covariates included. efforts were made to contact study authors for additional information; however, if only one estimate was available, it was used as both the minimally and most adjusted estimate. most studies reported regression coefficients. to incorporate regression coefficients into the present meta-analysis, we use a derived formula developed by peterson and brown to estimate correlation co efficients (r) (peterson and brown, 2005). after extracting over 1500 β and r values, the authors fit several models to assess the relationships between the two measures. they found that r 0.98β 0.05λ yielded the best fit, where β is the coefficient reported and λ is an indicator variable that is 0 when β is negative and 1 when β is positive (peterson and brown, 2005). after testing this efficacy of this formula against several alternatives, the authors found little difference between results. however, the authors note that this imputation is best used among β estimates within the interval of 0.50–0.50, given an observed tight joint distribution of β and r values in that range. given that most esti mates from eligible studies were within that range, we imputed r values from reported β values in eligible studies where r values were not re ported using r 0.98β 0.05λ. estimates were coded such that greater experiences of discrimination are associated with poorer outcomes (negative for telomere length, positive for inflammation and stress biomarkers (e.g., il-6)). weighted correlation sizes were calculated using large-sample approximation to compute sampling variance (viechtbauer, 2010). random effects models were fit utilizing the minimally adjusted asso ciations reported using the “metafor" package (viechtbauer, 2010) available in r (r core team, 2013). random effect models essentially relax the assumption of fixed-effect models, which assume that there is one ”true” effect estimated in all studies and that variations only occur due to chance (i.e., variations in samples) (borenstein et al., 2010). instead, random effects models assume a distribution of correlation sizes allowing for variations in the correlation size across studies, where factors beyond sampling variation may influence the association (e.g., age of sample) (borenstein et al., 2010). cochran’s q test was conducted to test for heterogeneity. forest plots are presented to illustrate study-specific and overall correlation sizes by outcome and 95% cis. sensitivity analyses included estimating the weighted correlation sizes using the most adjusted estimates reported in eligible articles.  3. results database searches on 03/24/2020 yielded 2803 references, resulting in 1867 unique references for screening. relevant outcomes were found in 33 articles included in the narrative review and 25 studies were identified for inclusion in the quantitative synthesis of associations in the present study. the number of studies excluded from the quantitative analysis, with reasons, are provided in detail in fig. 1. overall descrip tive data for the articles included in the quantitative assessment are summarized in supplemental table 2. most studies were published between 2016 and march 2020, with all articles having publication dates between 2010 and 2020. nearly all articles examined associations among populations in the united states, with one assessing associations among a sample in new zealand. nearly 36% of studies implemented representative sampling procedures, with 64% of studies reporting non-representative sampling methods. many articles reported findings from cross-sectional analyses (72%) with the remainder being longitudinal (24%) or other (4%). sample sizes ranged from 49 to 12,624, with a total sample of 37,763 respondents included across all eligible studies. all articles reported some information on participant age (e.g., average age of population), race/ethnicity, and sex; however, two did not report the number of participants within each racial/ethnic group in the analytic samples. articles were mostly conducted among adults (nearly 99% of the sample size), though populations under 18 were included in three articles, yielding 419 young adult or adolescent participants ( 18 years of age) to the total sample. one study did not report the age range of study participants to discern whether young adults could have been included in the study population. data on participant educational attainment was reported in 19 studies. the full version of the eds was employed in most articles (n 17), with fewer using the short-form (n 5) or a modified version of the eds (n 3). attribution of experiences was assessed in 7 studies, with most assessing attributions of experiences to both racial and non-racial rea sons (n 4). the remaining three studies that captured attributions assessed only racial or non-racial attributions. operationalization of the eds remained consistent across studies with most measuring experi ences as the sum (n 11) or the average (n 10) of the frequency of experiences. other means of operationalizing the eds included a count of yes responses to experiences, dichotomizing beyond a certain threshold. how the measure was operationalized was unclear in one analysis. among studies that examined the reliability of the eds, it exhibited very good reliability using a cronbach’s alpha cutoff of greater than 0.80 in 18 of the 25 articles. cortisol and crp were the most frequently assessed biomarker out comes (n 9 and n 10, respectively), followed by telomere length (n 6) and il-6 (n 5). approximately 16% (n 4) of articles re ported associations between the eds and multiple biomarker outcomes. supplemental table 3 presents the summary of study and sample characteristics by outcome. weighted correlation sizes from the most adjusted associations reported between the eds and each biomarker outcome are presented in figs. 2–5. 3.1. cortisol nine studies examined relationships between discrimination and cortisol. most frequently, the eds was operationalized as the mean 4  
  j.a. lawrence et al.  psychoneuroendocrinology 142 (2022) 105772  fig. 2. associations between eds and (a) all cortisol outcomes; (b) cortisol awakening response (car); and (c) waking levels (minimally adjusted).  fig. 3. associations between eds and c-reactive protein (crp, minimally adjusted).  (n 4) or sum of frequencies (n 3). another study used the count of yes responses, though one study did not clearly specify how the measure was operationalized. studies were primarily cross-sectional (n 7) and conducted among adults (n 6). black participants comprised nearly 29.4% of the cortisol study population, followed by latinx/hispanic (18.6%) and asian (7.7%) participants; however, white participants (38.6%) comprised the largest proportion of the study population across all 9 studies. native hawaiian, pacific islander, or ma ori, multiracial, and individuals categorized as “other” racial groups together comprised the remaining 5.7% of the pooled study population. assessments of cortisol varied across studies. given the evidence of changes in cortisol levels throughout the day, (levine et al., 2007; weitzman et al., 1971) some studies assessed salivary cortisol by col lecting multiple samples per day at different time points ( 4) over several days ( 3) (doane and zeiders, 2014; fuller-rowell et al., 2012; huynh et al., 2016; zeiders et al., 2014). others collected two saliva samples (morning and evening) over two consecutive days thayer and kuzawa, 2015), three salivary samples in one day, (incollingo rodriguez et al., 2019) salivary samples before, during and after exposure to a stress task (lucas et al., 2017) and the average of duplicate samples collected in one afternoon (ratner et al., 2013). another study assessed  cortisol concentration through hair cortisol, using 3 cm of hair closest to the scalp to assess retrospective cortisol levels (lehrer et al., 2020). in the main analysis, the reported assessment of cortisol levels varied, with articles assessing associations between the eds and waking cortisol levels in five studies, baseline cortisol, average cortisol from one mea surement, total daily cortisol, and hair cortisol concentration. five studies reported both minimally and fully adjusted estimates, while the remaining reported only unadjusted (n 2) or adjusted (n 2). the mean correlation coefficient for associations between eds and cortisol was r 0.05 [95% ci: 0.06, 0.16, k 9; q 19.83, df 8, p 0.011] (fig. 2a), suggesting no observed association with cortisol levels. patterning in the direction of responses was observed, where larger studies showed null or negative associations while smaller studies typically had associations indicating greater cortisol levels with increased discrimination. minimally adjusted models included four correlations and models that accounted for factors including age, race, sex or gender, bmi, socioeconomic indicators (i.e., household income, educational attainment, material deprivation), health behaviors (i.e., exercise, food, alcohol and caffeine consumption, cigarette use), day time sleep, daily wake and sleep time, psychological factors (i.e., stress level, emotional stability), and medication (i.e., cortisol medication, 5  
  j.a. lawrence et al.  psychoneuroendocrinology 142 (2022) 105772  fig. 4. associations between eds and (a) interleukin-6 (il-6) across all studies; (b) plasma samples; and (c) salivary samples (minimally adjusted).  fig. 5. associations between eds and telomere length (minimally adjusted).  other medication use) or medical history (i.e., c-section delivery). several studies reported estimates between the eds and cortisol outcomes using the same measure (i.e., cortisol awakening response [car], waking levels). to minimize the impact of heterogeneity in the measurement of cortisol on the pooled estimate, we estimated mean correlation sizes for studies that examined the car (doane and zeiders, 2014; fuller-rowell et al., 2012; huynh et al., 2016; incollingo rodri guez et al., 2019; zeiders et al., 2014) (defined as the change in cortisol from waking to a defined time period after waking) and waking cortisol levels (doane and zeiders, 2014; fuller-rowell et al., 2012; huynh et al., 2016; thayer and kuzawa, 2015; zeiders et al., 2014). among studies that evaluated the relationship between the eds and waking cortisol, the mean correlation size was r 0.01 (fig. 2b, 95% ci: 0.18, 0.19). whereas the mean correlation size among studies reporting associations between the eds and car was r 0.00 (fig. 2b, 95% ci: 0.22, 0.22). these findings suggest that discrimination is not associated with cortisol levels, specifically waking and the cortisol awakening response.  sensitivity analyses were conducted using the most or fully adjusted estimates reported in each study. the mean correlation size did not differ greatly across fully adjusted estimates (r 0.06; 95% ci: 0.06, 0.18) compared to the minimally adjusted models. associations between discrimination and car (r 0.02; 95% ci: 0.24, 0.29) and waking cortisol (r 0.00; 95% ci: 0.19, 0.18) remained null. beyond cova riates included in the minimally adjusted models, fully adjusted models also included factors such as psychological factors (i.e., neuroticism risk, public and private esteem), average hours of sleep, medication (i.e., contraceptive use), waist-to-hip ratio, and attributions of discrimination. 3.2. c-reactive protein (crp) among the ten eligible studies assessing the association between discrimination and crp, the eds was frequently implemented as the sum (n 5) or mean (n 4) of the frequencies of experiences of 6  
  j.a. lawrence et al.  psychoneuroendocrinology 142 (2022) 105772  discrimination. one study operationalized the eds as the sum of the experiences (lewis et al., 2010). nine of the ten studies reported the racial/ethnic composition of the analytic samples, with 38% identifying as black, 7% as latinx/hispanic, 2% as asian and 52% as white/ european. a small percentage of participants were classified as “other” race (1%). most studies were cross-sectional in design (50%) and con ducted among adult populations (n 9). crp was assessed consistently, with most studies using blood/serum levels of crp (n 9) and one using a measure of salivary crp levels. the pooled correlation size for the associations between discrimi nation and crp was r 0.11 [95% ci: 0.01, 0.20; k 10; q 69.90, df 9, p 0.001]. correlation sizes appear to be larger in smaller studies, though larger studies also show relationships between discrimination and crp. minimally adjusted estimates included one unadjusted correlation and models which accounted for factors such as age, race/ethnicity, lifetime experiences of discrimination, measures of socioeconomic status (e.g., income, educational attainment, employ ment status), bmi and medications (e.g., statin use, hormone replace ment therapy, anti-inflammatory use). three articles did not report unadjusted associations, (beatty moody et al., 2014; saban et al., 2018; zahodne et al., 2019) though one only accounted for age, bmi and statin use in the adjusted estimate reported (saban et al., 2018). supplemental fig. 2 illustrates the reported associations and mean correlation size using the most adjusted estimates reported. significant associations were observed [r 0.09; 95% ci: 0.01, 0.17, k 10]. these associations remain considering the covariates included in the most adjusted models reporting these associations. one paper only reported a minimally adjusted association (correlation), however other articles accounted for factors such as race, age, sex, bmi, measures of socio economic status (e.g., financial strain, educational attainment, income), psychological factors (e.g., depressive symptoms, cynicism) and lifetime experiences of discrimination, health behaviors (e.g., physical activity, smoking, alcohol consumption), measures of physiological functioning (e.g., blood pressure, cholesterol and triglyceride levels, hba1c, vital capacity, adiponectin), health conditions (e.g., heart attack, other vascular diseases, diabetes), and medications (e.g., statin use, antihypertensives, diabetes management medications). the similarities in mean correlation sizes from the most and minimally adjusted estimates reported suggest that the relationship between discrimination and crp is robust to covariate adjustment and may not be strongly mediated by health behaviors (e.g., smoking, drinking).  minimally adjusted estimates to be similar among both measures (r 0.03; 95% ci: 0.03, 0.09 and r 0.06; 95% ci: 0.99, 1.12 for plasma and salivary measures, respectively). however, the confidence interval is larger among studies using salivary measures of il-6, possibly indicating greater variability in estimates derived from salivary samples. these assessments should be interpreted with caution given the small sample size for these assessments (k 3 for each) and that one study reported only fully adjusted associations between discrimination and plasma il-6 levels. supplemental analysis of the most adjusted estimates reported resulted in a stronger correlation between increased experiences of discrimination and il-6 levels [r 0.07; 95% ci: 0.28, 0.42, k 5], however, the confidence interval is wide and crosses the null. examining the forest and tree plot, we observed null associations in studies of varying sample sizes (two, relatively large and one small), though the remaining two studies find lower and elevated il-6 levels to be associ ated with increased discrimination. the observed null associations may be a function of covariates included in each model. in most adjusted models, several studies accounted for what could be potential mediators or moderators of the relationship between discrimination and il-6 levels. covariates included age, race, marital status, measures of socio economic status (i.e., income, employment status, educational attain ment), psychological factors (i.e., measures of depression, anxiety, reactivity), perceived social status, reported childhood trauma, medi cation use (i.e., cholesterol, blood pressure, diabetes, hormone replacement), public and private esteem, bmi, and alcohol consumption. mediators. one study explicitly assessed bmi as a potential mediator of the relationship between discrimination and il-6 in a sample of men and women (kershaw et al., 2016b). among women, the authors found the positive relationship between everyday discrimination and il-6 to be attenuated by bmi. however, the inability to establish temporality given the cross-sectional analysis does not provide insight as to whether bmi is subsequent to exposures to discrimination or whether it may increase experiences of discrimination (kershaw et al., 2016b). 3.4. telomere length three of the six eligible studies operationalized the eds as the sum of reported frequency of discrimination. assessments also included the mean of frequency of experiences of discrimination (n 2) and a dichotomized assessment of if a respondent ever experienced everyday discrimination and attributed it to a personal characteristic (yes/no). the racial/ethnic breakdown of analytic samples were provided in 5 of the 6 studies, with white participants comprising 60% of the overall study populations. black participants comprised approximately 33% of the overall sample size, followed by latinx/hispanic participants (7.4%). asian, native hawaiian/pacific island, multiracial or “other” racial/ethnic individuals were not represented in the studies eligible for inclusion. all eligible studies used quantitative polymerase chain reac tion (qpcr) to assess and quantify telomere length, which is optimal for large studies given the small sample needed to replicate dna and assess telomere length (montpetit et al., 2014). additionally, all studies uti lized leukocyte samples to ascertain telomere length. three studies examined associations between discrimination and telomere length using the ratio of telomeric length of dna to a single-copy control gene (t/s ratio) which is correlated with telomere length, (hailu et al., 2020; liu and kawachi, 2017; lu et al., 2019) while others converted the t/s ratio to kilobase or base pairs to compare differences in length (beatty moody et al., 2019; geronimus et al., 2015; sullivan et al., 2019). everyday discrimination was not associated with telomere length when minimally adjusted models were assessed (r 0.03; 95% ci:  0.01, 0.07, k 6; q 7.26, df 5, p 0.202). examining the forest and tree plot, we observe that most studies indicate a null association, with larger studies finding discrimination to be associated with longer telomere length. minimally adjusted estimates included unadjusted  3.3. interleukin-6 (il-6) among the 5 studies examining il-6, the eds was operationalized as the sum of frequencies (n 3) or mean of frequencies (n 2). white/ european participants comprised over 80% of the sample across studies reporting data on race/ethnicity (n 4). measurement of il-6 levels was captured through blood (n 3) or saliva (n 3). one study assessed both blood and salivary il-6 levels, though only the adjusted association was reported for the blood il-6 outcomes (saban et al., 2018). eligible studies used in the meta-analysis were all cross-sectional in design and conducted among adult populations. the mean weighted correlation size between discrimination and il-6 suggests discrimination may not be correlated with elevated il-6 levels (r 0.05; 95% ci: 0.32, 0.42, k 5; q 47.01, df 4, p 0.001). minimally adjusted estimates included an unadjusted correlation (n 1) and models (n 4) that accounted for factors such as race/ ethnicity, gender, age, measures of socioeconomic status (i.e., income, educational attainment, employment status), medication use (i.e., antiinflammatory, hormone replacement therapy), and time. larger corre lation sizes were observed among two smaller studies; while one asso ciation went in the opposite direction, indicating an inverse relationship between discrimination and il-6 levels. additionally, when assessed by measurement of il-6 (i.e., plasma, salivary), we find the direction of the mean correlation size for the 7  
  j.a. lawrence et al.  psychoneuroendocrinology 142 (2022) 105772  regression coefficients (n 2), estimates from an age-adjusted model (n 1), and two adjusted estimates that accounted for age, race, sex, measures of socioeconomic status (i.e., poverty-to-income ratio; educational attainment); and psychosocial stress (i.e., safety stress, physical environment, and negative social interactions). supplemental analyses of fully adjusted estimates exhibited similar associations. the mean correlation size using the most adjusted esti mates reported were not statistically significant [r 0.02; 95% ci:  0.02; 0.06]. models accounted for factors such as age, race, sex, measures of socioeconomic status (i.e., poverty-to-income ratio; educational attainment); and psychosocial stress (i.e., safety stress, physical environment, negative social interactions, perceived stress); psychological factors (i.e., depression, reaction type); smoking status; bmi; health conditions (e.g., diabetes, hypertension, myocardial infarction, cancer), census region of birth; childhood health; lifetime substance use and physical activity. mediators. two studies explicitly examined potential mediators of the relationship between discrimination and telomere length. work by liu and kawachi assessed whether physical activity, smoking status, and having a bmi 30 kg/m2 mediated the relationship between discrimi nation and telomere length (liu and kawachi, 2017). the authors found evidence that suggested these factors mediate the relationship between everyday discrimination and telomere length, observing attenuated as sociations when these factors were included in regression analyses. sullivan et al. examined whether depressive symptoms and perceived stress mediated the relationship between discrimination and telomere length (sullivan et al., 2019). the authors found that observed associ ations between everyday discrimination and telomere length among black and white women remained after accounting for mediating vari ables, with correlation sizes remaining larger (i.e., shorter telomere length) for black women; though no associations were observed among men. across three of the four analyzed outcomes, between study hetero geneity was high and statistically significant as measured by the cochran’s q test. results from the q-test reject the null hypothesis of the “true” effect being the same across studies and only differing due to sampling variability, indicating that other factors may influence biomarker outcomes.  3.6. assessment of publication bias funnel plots (fig. 6) and egger’s tests were used to evaluate the possibility of publication bias. among studies that examined cortisol, eligible studies tended to have smaller standard errors, but eligible studies had positive, negative, and null associations. results from the egger’s test to assess funnel plot asymmetry in funnel plots were not statistically significant (t 1.91, df 7, p 0.098), suggesting that the funnel plot for cortisol is not imbalanced (i.e., no publication bias). assessment of the funnel plot for crp outcomes appears to be asym metric. eligible studies tend to have small standard errors or larger correlation sizes. results from the egger’s test were statistically signif icant (t 4.57, df 8, p 0.002), suggesting potential publication bias. fewer studies examined il-6 and telomere length. the funnel plot for il6 appears to be relatively symmetric, with eligible studies having vari ations in correlation size and standard error. one study was included that documented associations in the opposite direction for il-6 (i.e., lower il-6 levels for increased report of discrimination). eligible studies examining telomere length had varying directions (i.e., null, and posi tive associations reported). the egger’s test for il-6 was not statistically significant, suggesting that publication bias may not be a concern (t 0.30, df 3, p 0.785); however, egger’s test for telomere length was significant (t 3.00, df 4, p 0.040) indicating the possibility of publication bias. these results should be interpreted with caution as the egger’s test has limited power when used in a small sample of studies. 3.7. narrative review five studies that were relevant to our review but were not included in the meta-analysis are narratively synthesized here. friedman et al. found that everyday discrimination was associated with greater eselectin levels, an indicator of inflammation response, among men, but not women in a sample of adults in the midlife in the united states study (midus) (friedman et al., 2009). using data from a community sample of adults with poorly controlled type 2 diabetes, potter et al. found that everyday discrimination attributed to weight was associated with elevated hba1c levels (potter et al., 2015). relationships between everyday discrimination and dna methylation, an indicator of stress, were assessed in two studies (santos et al., 2018; van der laan et al., 2020). among a sample of latina mothers, santos et al. found that everyday discrimination was inversely associated with dna methylation (less methylation with increased discrimination), (santos et al., 2018) while van der laan et al. found everyday discrimination to be positively associated with dna methylation among participants in the research on obesity and diabetes among african migrants (rodam) study (van der laan et al., 2020) saban and colleagues examined the relationship be tween several social factors – including everyday discrimination – and heat shock protein-70 (hsp-70), another stress-related biomarker, in a small sample of black and white women with atherosclerosis (saban et al., 2014) the authors did not observe an association between discrimination and hsp-70 levels, though this association should be examined in a larger study population.  3.5. quality assessment the limited availability of longitudinal assessments of the relation ship between the eds and biomarker outcomes leaves us unable to assess the temporality of associations. across all outcomes, most studies were cross-sectional (77.8%, 50%, 100%, and 100% for cortisol, crp, il6, and telomere length respectively). several studies utilized nonrepre sentative sampling procedures (n 7, 7, 3, and 1 for cortisol, crp, il-6, and telomere length, respectively). this may raise concerns regarding potential bias such that correlation sizes may be estimated from samples that may not be generalizable, however they do provide context to the experiences of individuals from similar backgrounds (i.e., communities with similar sociodemographic characteristics). however, most studies assessing representative samples contributed greater weights to the estimated mean correlation size given the small variances across all outcomes. most studies used the full eds or short form (n 8, 10, 4, 4), with few utilizing modified versions. among studies reporting the cronbach’s alpha (n 22), α was greater than or equal to 0.70 sug gesting acceptable or better internal consistency of the measure. studies reporting adjusted models accounted for several socioeconomic, de mographic, and health-related covariates that may confound the rela tionship between discrimination and biomarker outcomes. adjusted models sometimes accounted for potential mediators of the relationship (i.e., perceived stress) that may have partially accounted for the effect of discrimination.  4. discussion though previous meta-analyses have examined the relationship be tween discrimination and several health outcomes, variations in the measurement of discrimination have made cross-study comparisons difficult. evidence from the most recent meta-analysis suggests that the relationship between discrimination and health outcomes vary accord ing to the measure of discrimination used (paradies et al., 2015). this current systematic review and meta-analysis is the first to standardize the measure of discrimination to assess the association of discrimination and health by restricting the analysis to studies that have used the everyday discrimination scale. these findings also contribute to the 8  
  j.a. lawrence et al.  psychoneuroendocrinology 142 (2022) 105772  fig. 6. funnel plots for a) cortisol; b) crp; c) il-6; and d) telomere length.  literature by estimating the pooled correlation coefficient across studies that have examined the relationship between discrimination and mo lecular biomarkers of stress, inflammation, and cellular aging. we found that most eligible studies operationalized the eds as the mean or sum of reported frequency (n 21 of 25). our findings also suggest that increased self-report of discrimination is associated with higher crp levels, though we did not observe evidence of associations between discrimination and cortisol, il-6, or telomere length when using the eds. we also observed patterns in the magnitude of associa tions by sample size. for example, larger positive correlation sizes were observed among two smaller studies examining associations between the eds and il-6 while more modest positive correlations were observed among two larger studies. one small study had a large negative asso ciation, which may have influenced the null finding for il-6. null associations between discrimination and cortisol and telomere measures were not surprising as neither of these biomarkers have been consistently associated with other types of stress (chida and steptoe, 2009; fogelman and canli, 2018; korous et al., 2017; mathur et al., 2016). however, we identified associations between discrimination and crp, consistent with associations observed in other systematic reviews and meta-analyses of self-report measures and stress tasks (cuevas et al., 2020; steptoe et al., 2007). the correlation of discrimination with higher crp, but not il-6 suggests that more studies are needed on the latter, given that il-6 stimulates the production of crp (papanicolaou et al., 1998). this may also reflect a need to examine alternative mea sures of cumulative and chronic inflammation, such as glycoprotein acetyls (glyca), instead of acute phase inflammatory markers (priest, 2021). however, studies have identified both il-6 and crp to have in dependent relationships with several adverse health outcomes and risk factors (bermudez et al., 2002; pradhan et al., 2001). we noted three factors (1) heterogeneity in outcome measurement; (2) study design; and (3) sample demographics that could have contributed to our mixed findings. first, the observed findings between  discrimination and cortisol, il-6, and telomere length may be influenced by several factors related to outcome measurement. specifically, eligible studies differed in their operationalization of biomarker outcomes. among studies that examined cortisol, differences in both the number of samples captured and cortisol outcomes assessed (e.g., momentary cortisol, hair cortisol concentration) were observed. for example, het erogeneity may be introduced by including hair cortisol in this analysis given that hair samples capture cortisol levels over a period ranging from several weeks to months (iob and steptoe, 2019). additionally, cortisol levels fluctuate throughout the day, typically with higher levels at waking and lower during the evening (levine et al., 2007; weitzman et al., 1971) and are sensitive to the method of collection (i.e., blood, saliva) (levine et al., 2007). collecting sufficient data to understand individual cortisol fluctuations and utilizing measures of diurnal cortisol may be useful contributions to future research (adam et al., 2017). we also observed differences in how inflammation was assessed among eligible studies assessing il-6. il-6 samples were collected through blood (n 3) or saliva (n 3), with one study assessing both. while the mean correlation size across studies that used either measure was similar (r 0.03; r 0.06, plasma and saliva respectively), we observed a wider confidence interval across studies using salivary as sessments. this could reflect greater variability in salivary assessments of il-6; however, the intervals may also be wide given the limited number of studies available. these differences suggest consideration of the means of assessment of inflammatory markers. this is especially relevant given that salivary assessments of inflammation may capture oral rather than systemic inflammation (priest et al., 2020b). previous research has concluded that plasma and salivary samples of inflamma tory biomarkers (i.e., il-6, crp) may not be strongly correlated, and that blood samples – though relatively invasive – are preferred to salivary measures to assess systemic inflammation (cullen et al., 2015; wil liamson et al., 2012). optimal assessments of telomere length are still being explored. all 9  
  j.a. lawrence et al.  psychoneuroendocrinology 142 (2022) 105772  eligible studies used qpcr to assess telomere length which has several strengths that have been summarized in detail elsewhere (montpetit et al., 2014). these strengths include that qpcr requires a small sample of dna, is easily implemented in large studies, and has a reference to compare samples to. however, this method is sensitive to the quality of the dna sample and the reference is not standardized which makes cross-study comparisons difficult (montpetit et al., 2014). additionally, qpcr provides an estimate of the telomere amplification product (t) as compared to that of a reference single-copy gene (s) (aviv et al., 2011; montpetit et al., 2014). this is used to create a t/s ratio that correlates with average telomere length, but does not yield a base pair estimate (montpetit et al., 2014). while qpcr has been widely accepted as an approach to assess telomere length, other techniques exist to determine telomere length (montpetit et al., 2014). these include flow-fluorescence in situ hybridization (fish) and southern blot, which is often referred to as the golden standard (aviv et al., 2011). the fish method is labor intensive and is likely not useful for large scale epide miologic studies, as obtaining needed samples can be difficult compared to qpcr and southern blot (aviv et al., 2011; montpetit et al., 2014). however, both qpcr and southern blot yield reproducible results though the measurement error is greater in qpcr analyses (aviv et al., 2011). both qpcr and southern blot come with a set of tradeoffs that should be explored regarding their ability to impact cross-study com parisons. across all biomarkers used, differences in sample types and quality, frequency of measurement, as well as methodology used high light a need to identify “gold standard” measures of biomarker levels and implement consistency in biomarker operationalization across studies. second, study design may have influenced our findings. several studies employed non-representative sampling. this may reflect pop ulations that are more or less likely to report experiences of discrimi nation and are willing to have their biomarkers sampled (e.g., have a blood draw) which is likely to introduce further selection bias. while these findings may not be generalizable to a broader population, they still provide insight into the experiences of individuals and communities with similar characteristics. the preponderance of cross-sectional studies in our review limits the ability to establish a temporal order between exposure to discrimination and biomarker changes, although the use of biomarkers reduces the possibility of reverse causality (i.e., people are generally unaware of their levels of circulating inflammatory biomarkers and hence biomarkers are unlikely to influence reports of discrimination). the longitudinal assessment of experiences of discrimination also makes it possible to examine trajectories of experi ences over time and the cumulative impacts of discrimination on biomarker outcomes. priorities for future research on discrimination and health include the need for more longitudinal assessments and representative sampling, particularly of marginalized groups that may be most susceptible to experiencing discrimination and the differential health, social, and economic burden of such experiences. though not quantifiable in the present analysis given the limited number of studies, findings from individual studies suggest there may be heterogeneity in the associations of discrimination and biomarkers ac cording to race/ethnicity, gender, and/or sexual orientation (doyle and molix, 2016; kershaw et al., 2016b; ratner et al., 2013; saban et al., 2018). specifically, studies that examined associations among margin alized groups observed more nuanced associations than the average correlation obtained from our pooled estimates. for example, lehrer et al. found that everyday discrimination was associated with hair cortisol concentration among black participants, though not white participants (lehrer et al., 2020). differential relationships among marginalized groups may be obscured in assessments where their ex periences are not centered or when included in study populations where those groups are less represented. these relationships should be explored in future research. additionally, while the literature on discrimination and health is global and spans across the lifecourse, (paradies, 2006; williams et al., 2019b) assessments of the association between discrimination and biomarkers that use the eds have been  predominantly carried out in the united states (n 24) and among adult populations. associations between discrimination and biomarkers should be examined in other national contexts and lifecourse periods to assess comparability. while the underlying mechanisms may not differ, cross-context studies can help to elucidate causal mechanisms and effect modifiers useful to understanding relationships between discrimination and health. associations between discrimination and biomarkers across the lifecourse may vary at different periods (i.e., early life, adolescence, mid-life, older age). relatedly, items in the eds may not perform the same in different countries and populations. for example, to extend the use of the measure, the eds has recently been adapted for aboriginal and torres strait islander peoples to capture experiences and attribu tions relevant to indigeneity in australia (thurber et al., 2021). it should also be noted that there is a body of literature that suggests that psychosocial factors and coping strategies may influence reports and impacts of experiences of discrimination (berjot and gillet, 2011; brondolo et al., 2009; pascoe and smart richman, 2009). unhealthy coping strategies (e.g., suppressing responses) or “negative” psychoso cial factors have maintained fairly consistent associations with wors ened health impacts of discrimination, (brondolo et al., 2009; himmelstein et al., 2015; krieger and sidney, 1996; nuru-jeter et al., 2009) though findings regarding the overall health impacts of active or health-promoting coping strategies and positive psychosocial factors have been mixed (brondolo et al., 2009; james, 1994; pascoe and smart richman, 2009). while insight into how individual-level coping be haviors and resources is useful and can inform individual-level in terventions, the focus should extend beyond the individual-level. though these measures may be useful in understanding how marginal ized people respond to and cope with discrimination – and should be further explored – focus on individual coping strategies without inter vening on the structural and cultural factors that pattern these experi ences may do little to mitigate adverse health outcomes and sustain wellbeing (bailey et al., 2020, 2017; homan, 2019; james, 1994). our search found that crp, cortisol, il-6, and telomere length were outcomes that were assessed with reasonable frequency. however, in addition to studies in the meta-analysis, the narrative review revealed a broader range of biomarkers for future research. in addition to those identified in our narrative synthesis of relevant papers, several inflam matory markers such as il-1β, tnf-α, and inflammatory mechanisms such as the conserved transcriptional response to adversity (ctra) have been identified in a recent review of the relationship between discrimination and inflammation (cuevas et al., 2020). measures such as glyca may be more accurate measures of cumulative inflammation and have been associated with several chronic and acute health outcomes in adults (priest, 2021). this literature suggests that future research should examine relationships between discrimination and these understudied indicators of biological functioning to better understand and intervene upon the health implications of societal conditions and contexts. while future research should increase focus on relationships between discrimination and biomarkers (as well as potential interventions), it should also consider whether these associations differ when other measures of discrimination are used (e.g., experiences of discrimina tion, (krieger, 1990; krieger and sidney, 1996) major experiences of discrimination scale, (williams et al., 1997) or schedule of racist events (sre) (landrine and klonoff, 1996)). studies using the experi ences of discrimination (eod) scale have found positive associations with il-6 levels (giurgescu et al., 2016). a cross-sectional analysis by chae and colleagues found the main effect of eod on telomere length to be null in a sample of black men (chae et al., 2014), though, in a recent longitudinal assessment, they found evidence of greater 10-year telo mere shortening among a sample of black adults in the cardia study (chae et al., 2020). differences in findings of these assessments may reflect differences in 1) study design (i.e., cross-sectional vs. longitudi nal) or 2) study population (e.g., middle-aged black men in the bay area vs. a broader sample of middle-aged black adults across 4 cities). research examining the relationship between discrimination using the 10  
  j.a. lawrence et al.  psychoneuroendocrinology 142 (2022) 105772  sre and cytokine levels (i.e., indicators of inflammation) found increased discrimination to be associated with elevated cytokines (brody et al., 2015; simons et al., 2021). an eligible study also assessed associations between discrimination and telomere length using the major experiences of discrimination scale finding null associations (hailu et al., 2020). it seems that the direction of relationships is rela tively consistent across measures, though these are comparisons to in dividual studies. however, each measure captures different domains and frequencies in which discrimination occurs and offers considerations of different policy suggestions and interventions to mitigate their impacts. future research estimating the pooled correlation size between various indicators of discrimination and biomarker outcomes across studies that use measures that capture different forms, severity, and specific attri butions of discrimination could contribute to understanding how discrimination adversely affects indicators of health status across the continuum of disease. it may also be useful to understand whether these associations differ among measures of discrimination that do not rely on the willingness of an individual to report compared to those which require self-report (krieger et al., 2010). additionally, this work can contribute to an evidence base that emphasizes the importance of policy and programs in tandem with research to intervene prior to the devel opment of diseases to prevent and reduce disease burden among marginalized groups. the present meta-analysis is not without its limitations. in examining the relationship between discrimination and biomarkers using the eds, we rely on a measure of discrimination that captures general experiences of unfair and differential treatment. while useful, the eds is distinct from measures that capture discrimination occurring within institu tional contexts (e.g., the eod scale), those that capture specific forms of oppression (e.g., the sre), measures that capture discrimination as a result of an individual’s multiple marginalized identities (e.g., multiple discrimination scale (bogart et al., 2010)), and those capturing expe riences which result in material, opportunity, and political deprivation irrespective of whether an individual was aware of such experiences and reported them as discriminatory or harmful (bailey et al., 2017; krieger, 2011, 2012; williams and mohammed, 2009). additionally, we only include findings from published manuscripts, which may differ from associations reported in unpublished works. specifically, results from the egger’s test suggests publication bias among studies that assessed crp, though not for cortisol, telomere length, or il-6. this may reflect a trend of not publishing null findings for crp and may also reflect the need for more research on il-6, telomere length, and cortisol given the smaller number of studies identified. we estimated mean correlation sizes from minimally adjusted associations reported in each article, however we also examine associations reported in most adjusted models to account for potential confounders of the association. the biomarkers included in our review are linked with each other, resulting in a cascade of physiological responses to stress. for example, chronic inflammation (measured through il-1β and il-6) may lead to shortened telomeres, (baylis et al., 2014) acting as a potential mediator between discrimination and telomere length. however, our review did not consider the complex, inter-relationships between biomarkers rep resenting different systems. instead, we have focused on summarizing the associations with individual components of the stress response, as well as reveal gaps in the evidence. this study also has several strengths. it quantifies the relationship between discrimination and molecular biomarkers, which provide evi dence for some of the pathways that discrimination may become embodied. we also examine the relationship among studies that use the same measure of discrimination, the eds, thus increasing the compa rability across studies. the eds is a widely used measure in both do mestic and international contexts. full, abbreviated, or modified versions of the eds are included in many major epidemiologic studies in the united states and elsewhere (see for example: (bild et al., 2002; heeringa and connor, 1995; jackson et al., 2004; radler, 2014; rosenberg et al., 1995; steptoe et al., 2013; taylor et al., 2005; williams  et al., 2004)). the frequent inclusion of eds in cross-national studies to examine the implications of discrimination on health allows for the systematic examination of the strength of associations between discrimination and health using a standardized exposure. additionally, the utility of the eds in capturing, reasonably accurately, the experi ences of discrimination has been documented across a wide range of populations, with good internal consistency and validity (gonzales et al., 2016; kim et al., 2014; krieger et al., 2005; lewis et al., 2012). we also evaluate, where possible, the relationship between discrimination and biomarkers among studies that have utilized similar means of outcome assessment (i.e., car, waking cortisol, blood, and salivary il-6) to further increase the comparability across studies. overall, our results provide information on the relationships be tween discrimination and several molecular biomarkers. the number of studies was limited, but we did find associations consistent with discrimination having an adverse effect, though evidence can be strengthened. there is a need of research using a broader range of bio markers to better characterize the relationships between discrimination and physiological indicators. this study identifies associations between discrimination and biological indicators that have been identified as possible precursors to adverse health outcomes using a consistent measure of discrimination. we also provide considerations for future research utilizing biomarker outcomes to strengthen ongoing efforts. funding this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. conflicts of interest the authors have no conflicts of interest to declare. acknowledgements n/a. appendix a. supporting information supplementary data associated with this article can be found in the online version at doi:10.1016/j.psyneuen.2022.105772. references adam, e.k., quinn, m.e., tavernier, r., mcquillan, m.t., dahlke, k.a., gilbert, k.e., 2017. diurnal cortisol slopes and mental and physical health outcomes: a systematic review and meta-analysis. psychoneuroendocrinology 83, 25–41. aviv, a., hunt, s.c., lin, j., cao, x., kimura, m., blackburn, e., 2011. impartial comparative analysis of measurement of leukocyte telomere length/dna content by southern blots and qpcr. nucleic acids res. 39 e134-e134. bailey, z.d., feldman, j.m., bassett, m.t., 2020. how structural racism works — racist policies as a root cause of u.s. racial health inequities. n. engl. j. med. 384, 768–773. bailey, z.d., krieger, n., age nor, m., graves, j., linos, n., bassett, m.t., 2017. structural racism and health inequities in the usa: evidence and interventions. lancet 389, 1453–1463. baylis, d., ntani, g., edwards, m.h., syddall, h.e., bartlett, d.b., dennison, e.m., martinruiz, c., von zglinicki, t., kuh, d., lord, j.m., aihie sayer, a., cooper, c., 2014. inflammation, telomere length, and grip strength: a 10-year longitudinal study. calcif. tissue int. 95, 54–63. beatty moody, d.l., brown, c., matthews, k.a., bromberger, j.t., 2014. everyday discrimination prospectively predicts inflammation across 7–years in racially diverse midlife women: study of women’s health across the nation. j. soc. issues 70, 298–314. beatty moody, d.l., leibel, d.k., darden, t.m., ashe, j.j., waldstein, s.r., katzel, l.i., liu, h.b., weng, n.p., evans, m.k., zonderman, a.b., 2019. interpersonal-level discrimination indices, sociodemographic factors, and telomere length in africanamericans and whites. biol. psychol. 141, 1–9. berjot, s., gillet, n., 2011. stress and coping with discrimination and stigmatization. front. psychol. 2.  11  
  j.a. lawrence et al.  psychoneuroendocrinology 142 (2022) 105772  bermudez, e.a., rifai, n., buring, j., manson, j.e., ridker, p.m., 2002. interrelationships among circulating interleukin-6, c-reactive protein, and traditional cardiovascular risk factors in women. arterioscler. thromb. vasc. biol. 22, 1668–1673. bild, d.e., bluemke, d.a., burke, g.l., detrano, r., diez roux, a.v., folsom, a.r., greenland, p., jacobsjr, d.r., kronmal, r., liu, k., nelson, j.c., o’leary, d., saad, m.f., shea, s., szklo, m., tracy, r.p., 2002. multi-ethnic study of atherosclerosis: objectives and design. am. j. epidemiol. 156, 871–881. bogart, l.m., wagner, g., galvan, f.h., banks, d., 2010. conspiracy beliefs about hiv are related to antiretroviral treatment nonadherence among african american men with hiv. j. acquir immune defic. syndr. 53, 648–655. borenstein, m., hedges, l.v., higgins, j.p., rothstein, h.r., 2010. a basic introduction to fixed-effect and random-effects models for meta-analysis. res. synth. methods 1, 97–111. bourabain, d., verhaeghe, p.-p., 2021. the conceptualization of everyday racism in research on the mental and physical health of ethnic and racial groups: a systematic review. j. racial ethn. health disparities 8, 648–660. brody, g.h., yu, t., miller, g.e., chen, e., 2015. discrimination, racial identity, and cytokine levels among african-american adolescents. j. adolesc. health 56, 496–501. brondolo, e., brady ver halen, n., pencille, m., beatty, d., contrada, r.j., 2009. coping with racism: a selective review of the literature and a theoretical and methodological critique. j. behav. med. 32, 64–88. broza, y.y., zhou, x., yuan, m., qu, d., zheng, y., vishinkin, r., khatib, m., wu, w., haick, h., 2019. disease detection with molecular biomarkers: from chemistry of body fluids to nature-inspired chemical sensors. chem. rev. 119, 11761–11817. chae, d.h., nuru-jeter, a.m., adler, n.e., brody, g.h., lin, j., blackburn, e.h., epel, e. s., 2014. discrimination, racial bias, and telomere length in african-american men. am. j. prev. med. 46, 103–111. chae, d.h., wang, y., martz, c.d., slopen, n., yip, t., adler, n.e., fuller-rowell, t.e., lin, j., matthews, k.a., brody, g.h., spears, e.c., puterman, e., epel, e.s., 2020. racial discrimination and telomere shortening among african americans: the coronary artery risk development in young adults (cardia) study. health psychol. 39, 209–219. chida, y., steptoe, a., 2009. cortisol awakening response and psychosocial factors: a systematic review and meta-analysis. biol. psychol. 80, 265–278. clark, r., anderson, n.b., clark, v.r., williams, d.r., 1999. racism as a stressor for african americans: a biopsychosocial model. am. psychol. 54, 805. cuevas, a.g., ong, a.d., carvalho, k., ho, t., chan, s.w.c., allen, j., chen, r., rodgers, j., biba, u., williams, d.r., 2020. discrimination and systemic inflammation: a critical review and synthesis. brain behav. immun. cullen, t., thomas, a.w., webb, r., hughes, m.g., 2015. the relationship between interleukin-6 in saliva, venous and capillary plasma, at rest and in response to exercise. cytokine 71, 397–400. doane, l.d., zeiders, k.h., 2014. contextual moderators of momentary cortisol and negative affect in adolescents’ daily lives. j. adolesc. health 54, 536–542. dolezsar, c.m., mcgrath, j.j., herzig, a.j., miller, s.b., 2014. perceived racial discrimination and hypertension: a comprehensive systematic review. health psychol. 33, 20. doyle, d.m., molix, l., 2016. minority stress and inflammatory mediators: covering moderates associations between perceived discrimination and salivary interleukin-6 in gay men. j. behav. med. 39, 782–792. egger, m., smith, g.d., schneider, m., minder, c., 1997. bias in meta-analysis detected by a simple, graphical test. bmj 315, 629–634. epel, e.s., 2009. telomeres in a life-span perspective: a new “psychobiomarker”? curr. dir. psychol. sci. 18, 6–10. fogelman, n., canli, t., 2018. early life stress and cortisol: a meta-analysis. horm. behav. 98, 63–76. friedman, e.m., williams, d.r., singer, b.h., ryff, c.d., 2009. chronic discrimination predicts higher circulating levels of e-selectin in a national sample: the midus study. brain behav. immun. 23, 684–692. fuller-rowell, t.e., doan, s.n., eccles, j.s., 2012. differential effects of perceived discrimination on the diurnal cortisol rhythm of african americans and whites. psychoneuroendocrinology 37, 107–118. geronimus, a.t., pearson, j.a., linnenbringer, e., schulz, a.j., reyes, a.g., epel, e.s., lin, j., blackburn, e.h., 2015. race-ethnicity, poverty, urban stressors, and telomere length in a detroit community-based sample. j. health soc. behav. 56, 199–224. gilbert, p.a., zemore, s.e., 2016. discrimination and drinking: a systematic review of the evidence. soc. sci. med. 161, 178–194. giurgescu, c., engeland, c.g., templin, t.n., zenk, s.n., koenig, m.d., garfield, l., 2016. racial discrimination predicts greater systemic inflammation in pregnant african american women. appl. nurs. res. 32, 98–103. gonzales, k.l., noonan, c., goins, r.t., henderson, w.g., beals, j., manson, s.m., acton, k.j., roubideaux, y., 2016. assessing the everyday discrimination scale among american indians and alaska natives. psychol. assess. 28, 51–58. goosby, b.j., cheadle, j.e., mitchell, c., 2018. stress-related biosocial mechanisms of discrimination and african american health inequities. annu. rev. sociol. 44, 319–340. hailu, e.m., needham, b.l., lewis, t.t., lin, j., seeman, t.e., roux, a.d., mujahid, m.s., 2020. discrimination, social support, and telomere length: the multi-ethnic study of atherosclerosis (mesa). ann. epidemiol. 42, 58–63 e52. heeringa, s.g., connor, j.h., 1995. technical description of the health and retirement survey sample design. ann arbor: university of michigan. himmelstein, m.s., young, d.m., sanchez, d.t., jackson, j.s., 2015. vigilance in the discrimination-stress model for black americans. psychol. health 30, 253–267. homan, p., 2019. structural sexism and health in the united states: a new perspective on health inequality and the gender system. am. sociol. rev. 84, 486–516.  huynh, v.w., guan, s.a., almeida, d.m., mccreath, h., fuligni, a.j., 2016. everyday discrimination and diurnal cortisol during adolescence. horm. behav. 80, 76–81. imrey, p.b., 2020. limitations of meta-analyses of studies with high heterogeneity. jama netw. open 3 e1919325-e1919325. incollingo rodriguez, a.c., tomiyama, a.j., guardino, c.m., dunkel schetter, c., 2019. association of weight discrimination during pregnancy and postpartum with maternal postpartum health. health psychol. 38, 226–237. iob, e., steptoe, a., 2019. cardiovascular disease and hair cortisol: a novel biomarker of chronic stress. curr. cardiol. rep. 21, 116-116. jackson, j.s., torres, m., caldwell, c.h., neighbors, h.w., nesse, r.m., taylor, r.j., trierweiler, s.j., williams, d.r., 2004. the national survey of american life: a study of racial, ethnic and cultural influences on mental disorders and mental health. int. j. methods psychiatr. res. 13, 196–207. james, s.a., 1994. john henryism and the health of african-americans. kershaw, k.n., lewis, t.t., diez roux, a.v., jenny, n.s., liu, k., penedo, f.j., carnethon, m.r., 2016a. self-reported experiences of discrimination and inflammation among men and women: the multi-ethnic study of atherosclerosis. health psychol. 35, 343–350. kershaw, k.n., lewis, t.t., diez roux, a.v., jenny, n.s., liu, k., penedo, f.j., carnethon, m.r., 2016b. self-reported experiences of discrimination and inflammation among men and women: the multi-ethnic study of atherosclerosis. health psychol. 35, 343–350. kim, g., sellbom, m., ford, k.-l., 2014. race/ethnicity and measurement equivalence of the everyday discrimination scale. psychol. assess. 26, 892. korous, k.m., causadias, j.m., casper, d.m., 2017. racial discrimination and cortisol output: a meta-analysis. soc. sci. med. 193, 90–100. krieger, n., 1990. racial and gender discrimination: risk factors for high blood pressure? soc. sci. med. 30, 1273–1281. krieger, n., 2005. embodiment: a conceptual glossary for epidemiology. j. epidemiol. community health 59, 350–355. krieger, n., 2011. ecosocial theory of disease distribution: embodying societal & ecologic context, epidemiology and the people’s health: theory and context. oxford university press, pp. 202–235. krieger, n., 2012. methods for the scientific study of discrimination and health: an ecosocial approach. am. j. public health 102, 936–944. krieger, n., 2014. discrimination and health inequities. int. j. health serv. 44, 643–710. krieger, n., carney, d., lancaster, k., waterman, p.d., kosheleva, a., banaji, m., 2010. combining explicit and implicit measures of racial discrimination in health research. am. j. public health 100, 1485–1492. krieger, n., sidney, s., 1996. racial discrimination and blood pressure: the cardia study of young black and white adults. am. j. public health 86, 1370–1378. krieger, n., smith, k., naishadham, d., hartman, c., barbeau, e.m., 2005. experiences of discrimination: validity and reliability of a self-report measure for population health research on racism and health. soc. sci. med. 61, 1576–1596. landrine, h., klonoff, e.a., 1996. the schedule of racist events: a measure of racial discrimination and a study of its negative physical and mental health consequences. j. black psychol. 22, 144–168. laterza, o.f., hendrickson, r.c., wagner, j.a., 2007. molecular biomarkers. drug inf. j. 41, 573–585. lehrer, h.m., goosby, b.j., dubois, s.k., laudenslager, m.l., steinhardt, m.a., 2020. race moderates the association of perceived everyday discrimination and hair cortisol concentration. stress 1–9. levine, a., zagoory-sharon, o., feldman, r., lewis, j.g., weller, a., 2007. measuring cortisol in human psychobiological studies. physiol. behav. 90, 43–53. lewis, t.t., aiello, a.e., leurgans, s., kelly, j., barnes, l.l., 2010. self-reported experiences of everyday discrimination are associated with elevated c-reactive protein levels in older african-american adults. brain behav. immun. 24, 438–443. lewis, t.t., cogburn, c.d., williams, d.r., 2015. self-reported experiences of discrimination and health: scientific advances, ongoing controversies, and emerging issues. annu. rev. clin. psychol. 11, 407–440. lewis, t.t., everson-rose, s.a., powell, l.h., matthews, k.a., brown, c., karavolos, k., sutton-tyrrell, k., jacobs, e., wesley, d., 2006. chronic exposure to everyday discrimination and coronary artery calcification in african-american women: the swan heart study. psychosom. med. 68, 362–368. lewis, t.t., williams, d.r., tamene, m., clark, c.r., 2014. self-reported experiences of discrimination and cardiovascular disease. curr. cardiovasc risk rep. 8, 365-365. lewis, t.t., yang, f.m., jacobs, e.a., fitchett, g., 2012. racial/ethnic differences in responses to the everyday discrimination scale: a differential item functioning analysis. am. j. epidemiol. 175, 391–401. liu, s.y., kawachi, i., 2017. discrimination and telomere length among older adults in the united states. public health rep. 132, 220–230. lu, d., palmer, j.r., rosenberg, l., shields, a.e., orr, e.h., devivo, i., cozier, y.c., 2019. perceived racism in relation to telomere length among african american women in the black women’s health study. ann. epidemiol. 36, 33–39. lucas, t., wegner, r., pierce, j., lumley, m.a., laurent, h.k., granger, d.a., 2017. perceived discrimination, racial identity, and multisystem stress response to social evaluative threat among african american men and women. psychosom. med. 79, 293–305. mathur, m.b., epel, e., kind, s., desai, m., parks, c.g., sandler, d.p., khazeni, n., 2016. perceived stress and telomere length: a systematic review, meta-analysis, and methodologic considerations for advancing the field. brain behav. immun. 54, 158–169. mcewen, b.s., 2000. allostasis and allostatic load: implications for neuropsychopharmacology. neuropsychopharmacology 22, 108–124.  12  
  j.a. lawrence et al.  psychoneuroendocrinology 142 (2022) 105772 seeman, t.e., mcewen, b.s., rowe, j.w., singer, b.h., 2001. allostatic load as a marker of cumulative biological risk: macarthur studies of successful aging. proc. natl. acad. sci. 98, 4770–4775. simons, r.l., lei, m.-k., klopack, e., zhang, y., gibbons, f.x., beach, s.r.h., 2021. racial discrimination, inflammation, and chronic illness among african american women at midlife: support for the weathering perspective. j. racial ethn. health disparities 8, 339–349. steptoe, a., breeze, e., banks, j., nazroo, j., 2013. cohort profile: the english longitudinal study of ageing. int j. epidemiol. 42, 1640–1648. steptoe, a., hamer, m., chida, y., 2007. the effects of acute psychological stress on circulating inflammatory factors in humans: a review and meta-analysis. brain behav. immun. 21, 901–912. sternthal, m.j., slopen, n., williams, d.r., 2011. racial disparities in health: how much does stress really matter? du bois rev. soc. sci. res. race 8, 95–113. stroup, d.f., berlin, j.a., morton, s.c., olkin, i., williamson, g.d., rennie, d., moher, d., becker, b.j., sipe, t.a., thacker, s.b., 2000. meta-analysis of observational studies in epidemiology: a proposal for reporting. jama 283, 2008–2012. sullivan, s., hammadah, m., al mheid, i., shah, a., sun, y.v., kutner, m., ward, l., blackburn, e., zhao, j., lin, j., bremner, j.d., quyyumi, a.a., vaccarino, v., lewis, t.t., 2019. an investigation of racial/ethnic and sex differences in the association between experiences of everyday discrimination and leukocyte telomere length among patients with coronary artery disease. psychoneuroendocrinology 122–128. tajfel, h., turner, j.c., 2004. the social identity theory of intergroup behavior. psychology press, pp. 276–293. taylor jr., h.a., wilson, j.g., jones, d.w., sarpong, d.f., srinivasan, a., garrison, r.j., nelson, c., wyatt, s.b., 2005. toward resolution of cardiovascular health disparities in african americans: design and methods of the jackson heart study. ethn. dis. 15. s6-4. thayer, z.m., kuzawa, c.w., 2015. ethnic discrimination predicts poor self-rated health and cortisol in pregnancy: insights from new zealand. soc. sci. med. 128, 36–42. thurber, k.a., walker, j., batterham, p.j., gee, g.c., chapman, j., priest, n., cohen, r., jones, r., richardson, a., calear, a.l., williams, d.r., lovett, r., 2021. developing and validating measures of self-reported everyday and healthcare discrimination for aboriginal and torres strait islander adults. int. j. equity health 20, 14. van der laan, l.c., meeks, k.a.c., chilunga, f.p., agyemang, c., venema, a., mannens, m., zafarmand, m.h., klipstein-grobusch, k., smeeth, l., adeyemo, a., henneman, p., 2020. epigenome-wide association study for perceived discrimination among sub-saharan african migrants in europe - the rodam study. sci. rep. 10, 4919. veritas health innovation, 2017. covidence systematic review software. veritas health innovation melbourne, vic. viechtbauer, w., 2010. conducting meta-analyses in r with the metafor package. j. stat. softw. 36, 1–48. weitzman, e.d., fukushima, d., nogeire, c., roffwarg, h., gallagher, t.f., hellman, l., 1971. twenty-four hour pattern of the episodic secretion of cortisol in normal subjects. j. clin. endocrinol. metab. 33, 14–22. williams, d.r., herman, a., kessler, r.c., sonnega, j., seedat, s., stein, d.j., moomal, h., wilson, c.m., 2004. the south africa stress and health study: rationale and design. metab. brain dis. 19, 135–147. williams, d.r., lawrence, j.a., davis, b.a., 2019a. racism and health: evidence and needed research. annu. rev. public health 40, 105–125. williams, d.r., lawrence, j.a., davis, b.a., vu, c., 2019b. understanding how discrimination can affect health. health serv. res. 54, 1374–1388. williams, d.r., mohammed, s.a., 2009. discrimination and racial disparities in health: evidence and needed research. j. behav. med. 32, 20–47. williams, d.r., neighbors, h.w., jackson, j.s., 2003. racial/ethnic discrimination and health: findings from community studies. am. j. public health 93, 200–208. williams, d.r., yu, y., jackson, j.s., anderson, n.b., 1997. racial differences in physical and mental health: socio-economic status, stress and discrimination. j. health psychol. 2, 335–351. williamson, s., munro, c., pickler, r., grap, m.j., elswick, r.k., 2012. comparison of biomarkers in blood and saliva in healthy adults. nurs. res. pract. 2012, 246178. zahodne, l.b., kraal, a.z., sharifian, n., zaheed, a.b., sol, k., 2019. inflammatory mechanisms underlying the effects of everyday discrimination on age-related memory decline. brain behav. immun. 75, 149–154. zeiders, k.h., hoyt, l.t., adam, e.k., 2014. associations between self-reported discrimination and diurnal cortisol rhythms among young adults: the moderating role of racial–ethnic minority status. psychoneuroendocrinology 50, 280–288.  mcewen, b.s., 2008. central effects of stress hormones in health and disease: understanding the protective and damaging effects of stress and stress mediators. eur. j. pharm. 583, 174–185. mcewen, b.s., 2012. brain on stress: how the social environment gets under the skin. proc. natl. acad. sci. usa 109 (suppl 2), 17180–17185. mcewen, b.s., stellar, e., 1993. stress and the individual: mechanisms leading to disease. arch. intern. med. 153, 2093–2101. moher, d., liberati, a., tetzlaff, j., altman, d.g., 2009. preferred reporting items for systematic reviews and meta-analyses: the prisma statement. ann. intern. med. 151, 264–269. montpetit, a.j., alhareeri, a.a., montpetit, m., starkweather, a.r., elmore, l.w., filler, k., mohanraj, l., burton, c.w., menzies, v.s., lyon, d.e., jackson-cook, c.k., 2014. telomere length: a review of methods for measurement. nurs. res. 63, 289–299. nuru-jeter, a., dominguez, t.p., hammond, w.p., leu, j., skaff, m., egerter, s., jones, c. p., braveman, p., 2009. “it’s the skin you’re in”: african-american women talk about their experiences of racism. an exploratory study to develop measures of racism for birth outcome studies. matern child health j. 13, 29–39. papanicolaou, d.a., wilder, r.l., manolagas, s.c., chrousos, g.p., 1998. the pathophysiologic roles of interleukin-6 in human disease. ann. intern. med. 128, 127–137. paradies, y., 2006. a systematic review of empirical research on self-reported racism and health. int. j. epidemiol. 35, 888–901. paradies, y., ben, j., denson, n., elias, a., priest, n., pieterse, a., gupta, a., kelaher, m., gee, g., 2015. racism as a determinant of health: a systematic review and metaanalysis. plos one 10, e0138511. pascoe, e.a., smart richman, l., 2009. perceived discrimination and health: a metaanalytic review. psychol. bull. 135, 531. peterson, r.a., brown, s.p., 2005. on the use of beta coefficients in meta-analysis. j. appl. psychol. 90, 175–181. pierce, c., 1974. psychiatric problems of the black minority. in: caplan, g. (ed.), american handbook of psychiatry, volume ii. basic books, new york, pp. 512–523. pieterse, a.l., todd, n.r., neville, h.a., carter, r.t., 2012. perceived racism and mental health among black american adults: a meta-analytic review. j. couns. psychol. 59, 1–9. potter, l., wallston, k., trief, p., ulbrecht, j., juth, v., smyth, j., 2015. attributing discrimination to weight: associations with well-being, self-care, and disease status in patients with type 2 diabetes mellitus. j. behav. med. 38, 863–875. pradhan, a.d., manson, j.e., rifai, n., buring, j.e., ridker, p.m., 2001. c-reactive protein, interleukin 6, and risk of developing type 2 diabetes mellitus. jama 286, 327–334. priest, n., 2021. how does the social environment become embodied to influence health and health inequalities? brain behav. immun. 94, 23–24. priest, n., chong, s., truong, m., alam, o., dunn, k., o’connor, m., paradies, y., ward, a., kavanagh, a., 2020a. racial discrimination and socioemotional and sleep problems in a cross-sectional survey of australian school students. arch. dis. child. 105, 1079–1085. priest, n., truong, m., chong, s., paradies, y., king, t.l., kavanagh, a., olds, t., craig, j. m., burgner, d., 2020b. experiences of racial discrimination and cardiometabolic risk among australian children. brain behav. immun. 87, 660–665. r core team, 2013. r: a language and environment for statistical computing. radler, b.t., 2014. the midlife in the united states (midus) series: a national longitudinal study of health and well-being. open health data 2, e3. ratner, k.g., halim, m.l., amodio, d.m., 2013. perceived stigmatization, ingroup pride, and immune and endocrine activity: evidence from a community sample of black and latina women. social psychological and personality. science 4, 82–91. rosenberg, l., adams-campbell, l., palmer, j.r., 1995. the black women’s health study: a follow-up study for causes and preventions of illness. j. am. med. women’s. assoc. (1972) 50 56–58. saban, k.l., hoppensteadt, d., bryant, f.b., devon, h.a., 2014. social determinants and heat shock protein-70 among african american and non-hispanic white women with atherosclerosis: a pilot study. biol. res. nurs. 16, 258–265. saban, k.l., mathews, h.l., bryant, f.b., tell, d., joyce, c., devon, h.a., witek janusek, l., 2018. perceived discrimination is associated with the inflammatory response to acute laboratory stress in women at risk for cardiovascular disease. brain behav. immun. 73, 625–632. santos jr., h.p., nephew, b.c., bhattacharya, a., tan, x., smith, l., alyamani, r.a.s., martin, e.m., perreira, k., fry, r.c., murgatroyd, c., 2018. discrimination exposure and dna methylation of stress-related genes in latina mothers. psychoneuroendocrinology 98, 131–138.  13  
       


title_index: out
full_text_index:
       theory and methods  coding the everyday discrimination scale: implications for exposure assessment and associations with hypertension and depression among a cross section of mid-life african american women eli michaels, 1 marilyn thomas,1 alexis reeves,1 melisa price,2 rebecca hasson,3,4 david chae,5 amani allen6  additional material is published online only. to view please visit the journal online (http://dx.doi.org/10.1136/jech-2018-211230).  for numbered affiliations see end of article. correspondence to eli michaels, division of epidemiology, university of california berkeley school of public health, berkeley, ca 94720, usa; e likmichaels@berkeley.edu received 26 june 2018 revised 8 february 2019 accepted 16 february 2019 published online first 20 march 2019   author(s) (or their employer(s)) 2019. no commercial re-use. see rights and permissions. published by bmj. to cite: michaels e, thomas m, reeves a, et al. j epidemiol community health 2019;73:577–584.  abstract background studies suggest that racial discrimination impacts health via biological dysregulation due to continual adaptation to chronic psychosocial stress. therefore, quantifying chronicity is critical for operationalising the relevant aetiological exposure and hence maximising internal validity. using one of the most common discrimination scales in the epidemiological literature, we develop a novel approach for more accurately assessing chronicity and compare it with conventional approaches to determine whether coding influences differential exposure classification and associations with hypertension and depression among african american women. methods data are from a socioeconomically diverse cross section of 208 mid-life african american women in northern california (data collection: 2012–2013). racial discrimination was assessed using the everyday discrimination scale (α 0.95), and was coded using two conventional approaches: (1) situation-based coding: number of different situations ever experienced; (2) frequency-based coding: sum of likert scale responses ranging from ’never’ to ’almost everyday’; and (3) a new chronicity-based coding approach: sum of responses, weighted to capture annual chronicity (eg, ’a few times a month’ 3 12 36 /year). outcomes are hypertension and depressive symptomatology (10-item center for epidemiologic studies-depression scale). findings exposure classification differed by coding approach, by up to 41%. there was a positive association between racial discrimination and hypertension prevalence for chronicity coding only (prevalence ratio 1.61, 95% ci 1.03 to 2.49). for depressive symptoms, a dose–response relationship of similar magnitude was observed for all three coding approaches. conclusion scale coding is an important methodological consideration for valid exposure assessment in epidemiological research. coding can impact exposure classification and associations with important indicators of african american women’s mental and physical health.  introduction african american women experience higher rates of numerous adverse mental and physical health outcomes compared with other groups1–5 and a  growing body of evidence implicates racial discrimination as a driver of these inequities.4 6–11 racial discrimination, commonly reported by african american women, is hypothesised to impact health through repeated biological adaptation to chronic psychosocial stress.7 12 13 when chronic, psychosocial stress can cause ongoing activation of the body’s stress response processes, resulting in the overcirculation of stress hormones, which, over time, can lead to multisystem dysregulation and increased risk of poor health.14 quantifying chronicity, therefore, is critical for operationalising the aetiologically relevant exposure and hence maximising validity among studies examining racial discrimination as a predictor of health. the everyday discrimination scale (eds)—one of the most commonly used measures of discrimination in the epidemiological literature6 9—is well suited to measure chronicity. the eds was developed as a subjective measure to capture self-reported frequency of routine, relatively subtle discriminatory experiences in everyday social situations. first, respondents are asked: ‘in your day-to-day life, how often have any of the following things happened to you?’ examples include: ‘people treat you with less respect’ and ‘people act as if they’re afraid of you.’ second, respondents identify the reason for the unfair treatment (eg, gender, race, ethnicity).9 responses are typically coded on a 6-point likert scale ranging from ‘never’ to ‘almost everyday.’15–17 while the eds has been consistently and positively associated with adverse mental health outcomes among african americans,9 15 18 19 findings for physical health outcomes are less consistent.6 8 for example, racial discrimination is often conceptualised as a risk factor for hypertension (ht).12 20 21 however, studies examining the association between racial discrimination—including studies using the eds—and blood pressure outcomes show mixed results.16 17 20–27 one potential explanation for mixed findings across studies using the eds is inconsistency in scale properties and the coding strategy used. these differences produce distinct exposures that may differentially impact health. for example, the two most common approaches to coding the eds—‘situation-based’ and ‘frequency-based’ coding28—differentially weight the survey response options, which  michaels e, et al. j epidemiol community health 2019;73:577–584. doi:10.1136/jech-2018-211230  577  
  theory and methods  figure 1 situation-based coding item weighting structure, everyday discrimination scale. may carry implications for assessing the chronicity of discrimination experiences. in situation-based coding, each survey item is dichotomised: ‘never’ 0 and ‘ever’ 1.18 22 25 28 as shown in figure 1, situation-based coding collapses everyone who experienced any discrimination into one category (ie, responses from ‘less than once a year’ through ‘almost everyday’ are combined), obscuring the chronicity of reports. responses are summed across the items to generate a score ranging from 0 to 10, capturing the number of different situations ever experienced. in frequency-based coding,15–17 22–24 28 each response is given a value according to the likert scale (‘never’ 1 to ‘almost everyday’ 6). responses are summed across items to produce  figure 3 chronicity-based coding item weighting structure, everyday discrimination scale.  a score ranging from 10 to 60. figure 2 illustrates that although frequency-based coding preserves distinctions between doses of the exposure, it assumes a monotonic change between each response. in reality, each successive response represents increasingly chronic experiences, which the frequency-based coding approach fails to capture. in summary, the two common approaches to coding the eds may underestimate the chronicity of everyday racial discrimination experiences. given that racial discrimination is hypothesized to harm health via repeated physiologic adaptation to chronic psychosocial stress, underestimating chronicity may lead to misclassification of the aetiologically relevant exposure. such exposure misclassification may threaten internal validity and stall progress toward understanding the potential impact of chronic racial discrimination on racial health inequities.  study aims  figure 2 frequency-based coding item weighting structure, everyday discrimination scale. 578  we develop a novel approach to coding the eds, which weights each response to more accurately reflect the chronicity of eds experiences (figure 3). we then compare our new coding scheme to the conventional situation and frequency-based approaches to determine whether coding: (a) produces differential exposure classification and (b) influences the association of eds with ht and depressive symptomatology among african american women. ht and depression are both stress-related conditions that disproportionately impact african american women, making them salient outcomes to examine in relation to racial discrimination within this population.1 3 moreover, these are two of the most commonly studied outcomes in the discrimination and health literature, which will allow us to compare our findings to existing work. we hypothesise that the association between the eds and each study outcome will be differential based on coding approach; and that findings will be most pronounced using chronicity-based coding due to refined exposure assessment in relation to the hypothesised pathway to health (ie, repeated physiologic adaptation to chronic psychosocial stress).  michaels e, et al. j epidemiol community health 2019;73:577–584. doi:10.1136/jech-2018-211230  
  theory and methods materials and methods study and recruitment  data are from the african american women’s heart and health study, an exploratory, cross-sectional study examining associations between social and environmental stressors and mental and physical health among a community sample of 208 african american women in northern california. we specifically recruited african american women to explore the unique health implications associated with navigating the intersection of multiple marginalised social identities (ie, race and gender) in us society.13 recruitment and data collection took place from march 2012 to march 2013. study procedures are described in detail elsewhere.29 briefly, we used purposive sampling to maximise heterogeneity of sociodemographic factors and risk of experiencing racial discrimination. women were eligible if they (1) self-identified african american, (2) female sex since birth, (3) aged 30–50, (4) us born, (5) parent(s)/primary caregiver(s) are us-born african american, and (6) could read/write english. exclusion criteria included: (1) pregnant or lactating, (2) self-reported as physician-diagnosed inflammatory or autoimmune disease.  missing data  systolic (sbp) and diastolic blood pressure (dbp) had the highest fraction of missing information (4.8%). we performed multiple imputation of missing values based on socioeconomic, psychosocial, and health status characteristics.30 we excluded one respondent prior to imputation because data were missing for the majority of predictors (n 207). relative variance increase was  10% for all models and relative efficiency was high ( 98%).31  study measures  data collection included a computer-assisted self-survey, in-person interview, and physical examination. resting dbp and sbp was calculated as the average of three consecutive readings using an automated oscillometric monitor.32 ht was defined as: (a) sbp 140 mm hg, and/or (b) dbp 90 mm hg, and/or (c) self-reported current cardiovascular medication usage.33 depressive symptomatology was assessed using the 10-item center for epidemiologic studies-depression scale (ces-d), which captures frequency of self-reported depressive symptoms in the past month (range: 0–30, α 0.83).34–36 racial discrimination was assessed using the 10-item everyday discrimination scale (eds).9 because of the within-group design and focus on racially based discrimination, we used a modified version of the eds, which asks: ‘in your day-to-day life, how often have the following things happened to you because of your race, ethnicity, or skin color?’ six response options range from ‘never’ to ‘almost everyday’ (online supplementary file 6). we used three coding approaches to examine the potential effect of coding on exposure classification and associations with health outcomes (table 1). (1) situation-based coding—we dichotomised each eds item to ‘never’ 0 and ‘ever’ (collapsing those reporting ‘less than once a year’ or greater into one category) 1. items were summed (range: 0–10) to reflect the total number of situations ‘ever’ experienced (α 0.89). (2) frequency-based coding—we scored responses according to the original likert scale (range: ‘never’ [1] to ‘almost everyday’ [6]) and summed responses across items (range: 10–60, α 0.95). (3) chronicity-based coding—we recoded each eds response to reflect the total number of reported discrimination experiences, standardised on the total number of days per year. ‘never’  table 1 eds survey response weighting structure, summary and tertile ranges, and description by coding approach, african american women’s heart and health study, northern california, 2012–2013 (n 207) situation-based frequencycoding based coding  chronicitybased coding   never  0  1  0   less than once a year  1  2  0.5   a few times a year  3  3   a few times a month  4  36  eds response   at least once a week  5  104   almost everyday  6  260 0–2600  summary score range  0–10  10–60   lower tertile range  0–7  10–22  0–24   middle tertile range  8–9  23–35  24.5–448   upper tertile range  10  36–60  482–2600  description  number of situations ‘ever’ experienced  likert scale total annual summary score number of eds experiences  owing to the granularity of the chronicity coding, not all possible values of annual eds experiences are represented. eds, everyday discrimination scale.  was coded 0. ‘less than once a year’ was coded as the midpoint between 0 and 1 time per year 0.5 /year. ‘a few’ is generally interpreted as 2–4, so we selected the midpoint 3. therefore, we coded ‘a few times a year’ as 3 /year and ‘a few times a month’ as 3 12 months 36 /year. we coded ‘at least once a week’ as 2 52 weeks 104 /year and ‘almost everyday’ as 5 52 weeks 260 /year. recoded items were summed to represent the total number of eds experiences annually (range: 0–2600, α 0.95). to facilitate comparisons between coding approaches, we collapsed the three eds measures into tertiles reflecting low, moderate and high exposure (table 1).16 covariate selection was outcome specific and guided by directed acyclic graphs (see online supplementary files 4 s; 5).37 confounders included: age, body mass index (bmi), neuroticism,38 39 education, marital/partnership and employment status. bmi was calculated as weight (kg)/height (m)2. age was confirmed via driver’s license/state id. all other covariates were self-reported. to minimise df, we modelled age and neuroticism continuously and dichotomised all other covariates.  analysis  we generated alpha statistics and performed a polychoric principal component analysis (pca) to evaluate internal consistency and scale dimensionality under each eds coding approach. all three coding iterations demonstrated a unidimensional data structure with high internal consistency, indicating recoding did not compromise the integrity of this previously validated scale. we used goodman-kruskal’s gamma40 and cohen’s kappa41 statistics to assess concordance/agreement in eds exposure classification (low, moderate, high) between the three coding approaches, coded categorically. we also used pearson’s correlation coefficients to describe the strength of association between the continuous scales. we fit multivariable modified poisson regression models with robust ses to estimate ht prevalence ratios and 95% cis as a function of each eds measure.42 the prevalence ratio is a more appropriate and conservative measure of association than the  michaels e, et al. j epidemiol community health 2019;73:577–584. doi:10.1136/jech-2018-211230  579  
  theory and methods table 2 sample characteristics, african american women’s heart and health study, northern california, 2012–2013 (n 207) variable  n (%) or mean (sd)  poverty status, n (%)  100% federal poverty level  168 (81)   100% federal poverty level  39 (19) 138 (67)   high school diploma  69 (33)  health insurance status, n (%)  insured  152 (73)   not insured  55 (27)  employment status, n (%)  employed  114 (55)   not employed  93 (45) 61 (30)   not married/partnered  146 (71)  body mass index (bmi), n (%)*  bmi 18.5 and 25  28 (14)   bmi 18.5 or 25  179 (87) 164 (79)   currently taking cv meds  43 (21)  age (years), mean (sd)  42 (5.9)  neuroticism, mean (sd)†  122 (20)  diastolic blood pressure (dbp), mean (sd)‡  80 (12)  clinically diagnosable hypertension, n (%)‡  low on sbp and dbp and not taking cv meds  132 (64)   high on sbp or dbp or taking cv meds  75 (36)  ces-d score, mean (sd)  12 (6.3)  34 (16)  0.90  0.75 (0.001)  0.97 (0.009)  situation versus frequency  64 (31)  0.76  0.54 (0.001)  0.88 (0.031)  situation versus chronicity  85 (41)  0.48  0.39 (0.001)  0.78 (0.044)  eds exposure classification by coding approach  owing to rounding, some percentages do not sum to 100%. *seven cases (3.38%) missing. †four cases (1.93%) missing. ‡ten cases (4.83%) missing. ces-d, center for epidemiologic studies-depression.  or when the outcome is not rare ( 10%), as was the case with ht in our sample.42 logistic regression models yielded similar results, although with inflated ors due to the prevalent outcome (results not shown). next, we fit multivariable linear regression models to estimate the association between each eds measure and ces-d. all models used low eds (bottom tertile) as the reference category. we report models unadjusted and controlling for confounders specific to the exposure–outcome relationship. all analyses were performed using stata ic v.13.43  results sample sample characteristics are displayed in table 2. the mean (sd) sbp was slightly elevated (122 [20]), whereas dbp was in the normal range (80 [12]). accordingly, 36% of the sample was hypertensive, less than the national prevalence of 46%.1 the mean (sd) ces-d score was approximately 12 [6], slightly above the recommended cut-off of 10 for depression.35 580  frequency versus chronicity  internal consistency was high for all three coding approaches (α 0.89, 0.95 and 0.95 for the situation, frequency and chronicity-based coding approaches, respectively). our pca revealed a largely unidimensional data structure for all three approaches. for situation-based coding, the eigenvalue for the first component was 6.35 (63.5% of variance explained). the eigenvalue for the second component was 1.37. all other eigenvalues were 1. for both frequency and chronicity-based coding, the eigenvalue for the first component was 7.57 (75.7% of variance explained). all other eigenvalues were 1.  3 (0.8)  systolic blood pressure (sbp), mean (sd)‡  goodmankruskal’s gamma (γ) (ase)†  eds internal consistency and dimensionality by coding approach  cardiovascular (cv) medication usage, n (%)  not currently taking cv meds  cohen’s kappa (κ) (p)*  *cohen’s kappa statistics test for agreement in exposure classification (low, moderate, high) between everyday discrimination scale (eds) measures.41 †goodman-kruskal’s gamma statistics test for agreement in exposure classification (low, moderate, high) between eds measures, accounting for ordinal data structure with ties.40 ase, asymptotic se.  marital/partnership status, n (%)  married/partnered  discordance n (%)  pearson’s correlation coefficient (r)  coding approaches compared  educational attainment, n (%)  high school diploma  table 3 discordance n (%), pearson’s correlation coefficient (r), goodman-kruskal’s gamma statistics (γ) and cohen’s kappa statistics (κ) comparing everyday discrimination scale exposure classification (low, moderate, high) by coding approach, african american women’s heart and health study, northern california, 2012–2013 (n 207)  respondent distribution across low, moderate and high eds levels was differential by coding approach (online supplementary file 7–s). table 3 summarises the number (%) of respondents for whom exposure assessment was discordant (eg, classified as low eds using one coding approach and moderate or high using another), pearson’s correlation coefficients, kappa statistics,41 and gamma40 statistics for exposure classification agreement. the frequency and chronicity-based approaches yielded the most concordant exposure classification and highest correlation/agreement, whereas the situation and chronicity-based approaches were most discordant and showed the lowest correlation/agreement.  associations between eds and study outcomes by coding approach  table 4 displays associations between each eds measure and prevalence of ht. no association was observed using the situation or frequency-based coding approach. in contrast, we found a positive association using chronicity-based coding: moderate (vs low) levels of eds were associated with a 60% higher estimated prevalence of ht. table 5 displays the results for depressive symptomatology. we observed a consistent dose–response association between eds and ces-d, irrespective of coding approach.  michaels e, et al. j epidemiol community health 2019;73:577–584. doi:10.1136/jech-2018-211230  
  theory and methods table 4 modified poisson regression with robust error variances for association between everyday discrimination scale and hypertension by coding approach, african american women’s heart and health study, northern california, 2012–2013 (n 207) model 1: number of eds ‘situations’ ever experienced  model 2: ‘frequency’ of eds experiences (likert summary score)  model 3: annual ‘chronicity’ of eds experiences  model 1a: unadjusted  model 1b: fully adjusted  model 2a: unadjusted  model 2b: fully adjusted  model 3a: unadjusted  model 3b: fully adjusted  eds*  pr (95% ci)  pr (95% ci)  pr (95% ci)  pr (95% ci)  pr (95% ci)  pr (95% ci)  moderate  0.97 (0.61 to 1.56)  1.00 (0.63 to 1.60)  1.14 (0.74 to 1.76)  1.23 (0.81 to 1.88)  1.52 (0.96 to 2.39)  1.61 (1.04 to 2.49)  high  1.12 (0.74 to 1.70)  1.09 (0.72 to 1.65)  1.01 (0.63 to 1.61)  1.00 (0.63 to 1.61)  1.14 (0.69 to 1.90)  1.10 (0.66 to 1.84)  constant  0.36 (0.27 to 0.48)  0.37 (0.20 to 0.68)  0.35 (0.26 to 0.48)  0.34 (0.18 to 0.64)  0.30 (0.21 to 0.44)  0.31 (0.17 to 0.57)  model a: unadjusted. model b: adjusts for age, body mass index, education ( high school [hs] diploma), marital/partnership status and employment status. *referent group ‘low’ eds. eds, everyday discrimination scale; pr, prevalence ratio.  discussion  accurate exposure assessment is fundamental to validity in epidemiological research and measurement decisions should be based on the hypothesised biological mechanism linking the exposure and outcome.37 we developed a novel approach to coding the eds for more accurately assessing the chronicity of everyday racial discrimination, a psychosocial stressor that is hypothesised to impact health via repeated stress adaptation. we compared our coding approach with conventional strategies to determine whether risk profiles and associations with health outcomes varied by coding approach. as hypothesised, the three coding schemes produced differential exposure classifications and associations with study outcomes. however, eds coding was more instrumental for associations with ht than with depressive symptomatology. evidence of association between the eds and ht is mixed;16 17 22–26 44 our findings suggest this may be partially attributed to differences in coding approach, and hence chronicity assessment. one prior cross-sectional analysis showed inconsistent associations between eds and ht among african americans when comparing situation vs frequency-based coding strategies.16 the present study corroborates the finding of differential associations based on coding, and extends this work by developing and testing a novel chronicity-based coding approach. that an association between eds and ht was observed only using chronicity-based coding could be due to more accurate exposure assessment in relation to the proposed biological pathways to health. specifically, chronicity may be underestimated by the frequency-based approach and entirely ignored by the  situation-based approach. in both cases, non-differential exposure misclassification may bias results towards the null,37 both here and in other studies seeking to measure chronic exposure to racial disrimination as a social determinant of health. the chronicity coding approach provides a more accurate exposure assessment, potentially reducing misclassification of chronic racial discrimination experiences. findings may also help identify the mechanisms linking racial discrimination with cardiovascular functioning. specifically, accurate chronicity measurement was crucial for modelling this association, which is consistent with stress theory and proposed biological pathway (ie, repeated stress adaptation).7–9 12 14 the finding of higher ht prevalence among those reporting moderate, but not high, eds parallels other work showing an inverse u-shaped relationship between racial discrimination and health among african americans.5 16 23 44 there are several plausible interpretations for this finding. first, appraisal and coping may differ by chronicity.5 45 46 those reporting moderate levels of eds may possess fewer and/or less adaptive racism-specific coping strategies compared with those reporting high levels. consequently, each encounter may be appraised as more stressful, resulting in exaggerated blood pressure reactivity, which over time may increase ht risk.20 second, acknowledging and reporting more chronic eds may be indicative of a problack bias, greater race centrality and/or engagement in system-blame versus self-blame, all of which have been shown to buffer the effects of racial discrimination on health.8 23 44 47 finally, those reporting high eds may have a blunted blood pressure response due to a lack of physiological adaptation to chronic psychosocial  table 5 linear regression for association between everyday discrimination scale depressive symptomatology (ces-d) by coding approach, african american women’s heart and health study, northern california, 2012–2013 (n 207) model 4: number of eds ‘situations’ ever experienced  model 5: ‘frequency’ of eds experiences (likert model 6: annual ‘chronicity’ of eds summary score) experiences  model 1a: unadjusted  model 1b: fully adjusted  model 2a: unadjusted  model 2b: fully adjusted  model 3a: unadjusted  model 3b: fully adjusted  eds*  β (95% ci)  β (95% ci)  β (95% ci)  β (95% ci)  β (95% ci)  β (95% ci)  moderate  2.74 (0.65 to 4.82)  1.16 ( 0.69 to 3.01)  3.15 (1.14 to 5.17)  1.75 ( 0.05 to 3.54)  3.47 (1.45 to 5.49)  2.01 (0.21 to 3.81)  high  3.89 (1.90 to 5.88)  2.37 (0.63 to 4.11)  4.75 (2.72 to 6.79)  3.03 (1.23 to 4.83)  4.96 (2.93 to 6.98)  2.85 (1.10 to 4.69)  constant  9.72 (8.40 to 11.04)  8.75 (6.88 to 10.61)  9.13 (7.72 to 10.54)  8.39 (6.50 to 10.28)  8.89 (7.45 to 10.32)  8.34 (6.42 to 10.25)  p for trend†  0.000  0.008  0.000  0.001  0.000  0.003  model a: unadjusted. model b: adjusts for age, neuroticism, marital/partnership status, education ( high school [hs] diploma) and employment status. *referent group ‘low’ eds. †p value (two sided) associated with beta coefficient when eds tertiles are modelled ordinally (vs categorically). ces-d, center for epidemiologic studies-depression; eds, everyday discrimination scale.  michaels e, et al. j epidemiol community health 2019;73:577–584. doi:10.1136/jech-2018-211230  581  
  theory and methods stress.14 future research should explore these potential psychosocial and biological mediators to further explicate the mechanisms through which eds impacts health. unlike with ht, the association between eds and depressive symptomatology was robust to coding. after adjusting for potential confounders, we saw a dose–response relationship using all three approaches. findings are consistent with an extensive literature demonstrating a positive association between the eds and depression, regardless of coding strategy used across studies.15 18 19 our study demonstrates that capturing chronicity is not critical for modelling the association between everyday racial discrimination and depression, suggesting there are other mechanisms at play that could be explored in future work. finally, results provide preliminary evidence of the construct and criterion validity for our new eds coding scheme. because frequency-based coding captures eds with more granularity than situation-based coding, we would expect the chronicity-based coding (the most granular assessment) to be more similar to frequency than situation-based coding both in terms of exposure classification and associations with study outcomes. indeed, we found the highest correlation/agreement between chronicity and frequency-based approaches (convergent validity) and the lowest correlation/agreement between chronicity and situation-based coding approaches (discriminant validity). relatedly, scale internal consistency and unidimensionality were more robust for the frequency and chronicity coding approaches than for the situation-based approach. this finding provides further evidence that the nature of the exposure may differ when items are dichotomised (situation-based approach) compared with when the gradient in experiences are retained (frequency and chronicity-based approaches). the shape of association between eds and ht was similar between the frequency and chronicity-based coding approaches, while dissimilar from the situation-based approach (construct validity). while the frequency and chronicity-based coding approaches were highly correlated and showed similar patterns of results, findings of association with ht were most robust using the chronicity-based approach, suggestive of criterion validity based on the proposed pathway to health. thus, although the frequency and chronicity-based coding are highly correlated, the latter provides a more nuanced exposure assessment, which may explain the more robust findings under this approach. next steps for future research include conducting a more formal exploratory and/or confirmatory factor analysis using these three coding approaches, testing these coding schemes on different health outcomes and more diverse study populations, and exploring whether sociodemographic (eg, age, race, gender, socioeconomic status), coping (eg, active vs passive) or other psychosocial factors (eg, social support) modify the scale validity, reliability and health associations differentially by coding approach. moreover, given previous evidence of differential validity and reliability of the eds by race and by gender,48 49 future research may also consider comparing psychometric properties of the three coding approaches stratified by these factors, a subanalysis that was not possible in this within-group study of african american women. this study had several limitations. data are from a non-representative sample of african american women living in northern california, and findings are not generalisable to the african american population as a whole. however, recruitment sought to maximise heterogeneity of exposure to discrimination and key covariates such as income and education, and characteristics of our sample are similar to the demographics of the source population, improving external validity.50 the sociodemographic 582  composition of our sample shares similarities with other national data sets; however, there are also important differences (eg, participants in the present study had similar levels of education but lower prevalence of poverty compared with national samples of african americans).51–53 previous work suggests that racial discrimination may manifest differently at various socioeconomic levels.19 29 54 these findings should therefore be replicated in larger national samples to ensure generalisability and interrogate whether the optimal coding approach differs based on the study sample’s socioeconomic make-up. while findings cannot be generalised to other gender or racial groups, the purpose of the study was to understand relationships between psychosocial stressors and mental/physical health among african american women, a particularly vulnerable group across numerous health indicators.1–5 additionally, the within-group study design uniquely facilitates an assessment of racial discrimination—rather than race—as the exposure of interest, a critical step toward understanding the drivers of racial health inequity.55 future research should explore these coding schemes in relation to health outcomes among african american men. cross-sectional data preclude causal inference; ht and depressive symptomatology could influence racial discrimination reporting. however, other studies have shown longitudinal associations between self-reported discrimination and incident ht17 and depressive symptomatology,18 indicating the potential directionality of these associations. future research should apply these coding schemes to longitudinal data and test associations with disease progression. we also adjusted for neuroticism, a confounder of the association between racial discrimination and depression.8 39 neuroticism confounded the association between eds and depressive symptomatology for situation and frequency-based, but not chronicity-based, coding approaches (results not shown). future research should explore whether reporting bias manifests differently depending on scale coding. in developing the ‘chronicity’ weighting structure, we made assumptions about the meaning of each response (eg, ‘a few’ 3). to assess potential measurement error, we conducted a sensitivity analysis under various assumptions (eg, ‘a few’ 2 or 4).  what is already known on this subject  racial discrimination is believed to harm the health of african  americans through repeated and ongoing adaptation to chronic psychosocial stress. the everyday discrimination scale, one of the most commonly used measures of racial discrimination in the epidemiological literature, has been consistently associated with mental health outcomes among african americans; whereas associations with physical health outcomes are mixed.  what this study adds  scale coding is an important methodological consideration  that has implications for exposure assessment and validity in epidemiological research. accurately assessing chronicity may be pivotal for operationalising the aetiologically relevant exposure among studies examining racial discrimination as a social determinant of cardiovascular health.  michaels e, et al. j epidemiol community health 2019;73:577–584. doi:10.1136/jech-2018-211230  
  theory and methods results were largely unchanged, underscoring the robustness of this coding. chronicity coding is novel and cannot be directly compared with other studies. however, all three eds iterations in our sample demonstrated high internal consistency and a unidimensional data structure, similar to other studies using the scale.9 28 48 49 while distribution-based cut-points are sample specific, the tertile ranges shown in table 1 facilitate reproducibility. finally, although logistical constraints limited the sample to n 208, all models were powered 0.80.  and health disparities. mt was partially supported by grant ul1gm118985 from the national institute of general medical sciences, and by a ford foundation predoctoral fellowship administered by the national academies of sciences, engineering, and medicine. disclaimer the funders had no involvement in the study design, data collection, analysis and interpretation of the data, writing of the report, nor the decision to submit the paper for publication. competing interests none declared. patient consent for publication obtained. ethics approval the study was approved by the committee for the protection of human subjects at the university of california, berkeley. provenance and peer review not commissioned; externally peer reviewed.  conclusions  different approaches to coding the eds produce distinct exposures that vary in their associations with important indicators of african american women’s mental and physical health. coding differences were more influential for associations with ht than with depressive symptomatology, which may help explain a puzzling pattern in the discrimination and health literature: consistent evidence for mental health outcomes, but inconsistent findings for physical, and particularly for cardiovascular, health outcomes.6 future research using the eds should explicate hypothesised mechanisms and code the scale accordingly. if the proposed pathway is through the chronic accumulation of discrimination experiences, then the chronicity-based coding approach may be most appropriate. this may be particularly relevant for strengthening internal validity in studies examining the association between racial discrimination and blood pressure outcomes among african american women. author affiliations 1 division of epidemiology, university of california berkeley school of public health, berkeley, california, usa 2 division of community health sciences, university of california berkeley school of public health, berkeley, california, usa 3 university of michigan school of kinesiology, ann arbor, michigan, usa 4 nutritional sciences, university of michigan school of public health, ann arbor, michigan, usa 5 department of human development and family studies, auburn university college of human sciences, auburn, alabama, usa 6 divisions of epidemiology and community health sciences, university of california berkeley school of public health, berkeley, california, usa correction notice this article has been corrected since it first published. the data collection year range has been corrected in the methods section, a value has been corrected in table 1, and erronous text removed. acknowledgements we thank dr maureen lahiff, phd, for her thoughtful feedback on coding decisions and model selection, ms suzanne dufault, mph, for her assistance with the principal component analysis, and the many undergraduate, graduate and postdoctoral students working as volunteer research assistants on the african american women’s heart and health study. contributors em, first author, reviewed the literature, conceptualised the scientific question, designed and executed all statistical analysis (and takes responsibility for the integrity and validity of the analysis), and took primary responsibility for drafting the manuscript. mt assisted with the design of the analysis, data interpretation and drafting the manuscript. ar assisted with data interpretation and drafting the manuscript. mp assisted with concept and design of the study, was responsible for management of data collection and assisted with manuscript revisions. rh assisted with the design of the study and manuscript revisions. dc helped conceptualise the study and provided assistance with data interpretation and drafting the manuscript. aa, principal investigator, conceptualised the study, coordinated all logistics related to recruitment and data collection, assisted with the design of the analysis, data interpretation and drafting the manuscript. funding this work was supported by research grants from: university of california, berkeley (ucb) hellman fund, ucb population center, ucb research bridging grant, ucb experimental social science laboratory, robert wood johnson health and society scholars program (ucb site), uc center for new racial studies, and the ucb institute for the study of societal issues. em was partially supported by grant gtdr14301469 from the susan g komen foundation. aa was also partially supported by grant p60md006902 from the national institute on minority health  data sharing statement per irb approval, the data are restricted for transmission to those outside of the primary investigative team. all codes needed to replicate scale recoding and analysis will be provided and can be made publicly available.  references  1 mozaffarian d, benjamin ej, go as, et al. heart disease and stroke statistics-2016 update: a report from the american heart association. circulation 2016;133:e38–60. 2 statistics ncfh. health, united states, 2015: with special feature on racial and ethnic health disparities 2016. 3 neighbors hw, caldwell c, williams dr, et al. race, ethnicity, and the use of services for mental disorders: results from the national survey of american life. arch gen psychiatry 2007;64:485–94. 4 geronimus at, hicken m, keene d, et al. "weathering" and age patterns of allostatic load scores among blacks and whites in the united states. am j public health 2006;96:826–33. 5 slaughter-acey jc, sealy-jefferson s, helmkamp l, et al. racism in the form of micro aggressions and the risk of preterm birth among black women. ann epidemiol 2016;26:7–13. 6 paradies y. a systematic review of empirical research on self-reported racism and health. int j epidemiol 2006;35:888–901. 7 clark r, anderson nb, clark vr, et al. racism as a stressor for african americans. a biopsychosocial model. am psychol 1999;54:805–16. 8 harrell jp, hall s, taliaferro j. physiological responses to racism and discrimination: an assessment of the evidence. am j public health 2003;93:243–8. 9 williams dr, jackson js, et al. racial differences in physical and mental health: socioeconomic status, stress and discrimination. j health psychol 1997;2:335–51. 10 williams dr, mohammed sa. racism and health i: pathways and scientific evidence. am behav sci 2013;57. 11 williams dr, neighbors hw, jackson js. racial/ethnic discrimination and health: findings from community studies. am j public health 2008;98(9 suppl):s29–s37. 12 williams dr, neighbors h, racism nh. racism, discrimination and hypertension: evidence and needed research. ethn dis 2001;11:800–16. 13 nuru-jeter a, dominguez tp, hammond wp, et al. "it’s the skin you’re in": africanamerican women talk about their experiences of racism. an exploratory study to develop measures of racism for birth outcome studies. matern child health j 2009;13:29–39. 14 mcewen bs, stress mbs. stress, adaptation, and disease. allostasis and allostatic load. ann n y acad sci 1998;840:33–44. 15 hunte her, king k, hicken m, et al. interpersonal discrimination and depressive symptomatology: examination of several personality-related characteristics as potential confounders in a racial/ethnic heterogeneous adult sample. bmc public health 2013;13. 16 roberts cb, vines ai, kaufman js, et al. cross-sectional association between perceived discrimination and hypertension in african-american men and women: the pitt county study. am j epidemiol 2008;167:624–32. 17 cozier y, palmer jr, horton nj, et al. racial discrimination and the incidence of hypertension in us black women. ann epidemiol 2006;16:681–7. 18 schulz aj, gravlee cc, williams dr, et al. discrimination, symptoms of depression, and self-rated health among african american women in detroit: results from a longitudinal analysis. am j public health 2006;96:1265–70. 19 hudson dl, neighbors hw, geronimus at, et al. racial discrimination, john henryism, and depression among african americans. j black psychol 2016;42:221–43. 20 dolezsar cm, mcgrath jj, herzig ajm, et al. perceived racial discrimination and hypertension: a comprehensive systematic review. health psychol 2014;33:20–34. 21 brondolo e, love ee, pencille m, et al. racism and hypertension: a review of the empirical evidence and implications for clinical practice. am j hypertens 2011;24:518–29. 22 lewis tt, barnes ll, bienias jl, et al. perceived discrimination and blood pressure in older african american and white adults. j gerontol a biol sci med sci 2009;64:1002–8.  michaels e, et al. j epidemiol community health 2019;73:577–584. doi:10.1136/jech-2018-211230  583  
  theory and methods 23 chae dh, nuru-jeter am, adler ne. implicit racial bias as a moderator of the association between racial discrimination and hypertension: a study of midlife african american men. psychosom med 2012;74:961–4. 24 sims m, diez-roux av, dudley a, et al. perceived discrimination and hypertension among african americans in the jackson heart study. am j public health 2012;102 suppl 2:s258–s265. 25 brown c, matthews ka, bromberger jt, et al. the relation between perceived unfair treatment and blood pressure in a racially/ethnically diverse sample of women. am j epidemiol 2006;164:257–62. 26 moody dlb, chang y-f, pantesco ej, et al. everyday discrimination prospectively predicts blood pressure across 10 years in racially/ethnically diverse midlife women: study of women’s health across the nation. ann behav med 2018. doi:10.1093/abm/ kay069. [epub ahead of print: 21 sep 2018]. 27 albert ma, ravenell j, glynn rj, et al. cardiovascular risk indicators and perceived race/ethnic discrimination in the dallas heart study. am heart j 2008;156:1103–9. 28 krieger n, smith k, naishadham d, et al. experiences of discrimination: validity and reliability of a self-report measure for population health research on racism and health. soc sci med 2005;61:1576–96. 29 allen am, thomas md, michaels ek, et al. racial discrimination, educational attainment, and biological dysregulation among midlife african american women. psychoneuroendocrinology 2019;99:225–35. 30 rubin db. multiple imputation for nonresponse in surveys. john wiley & sons, 2004. 31 statacorp l. stata multiple-imputation reference manual, 1985. 32 pickering tg, hall je, appel lj, et al. recommendations for blood pressure measurement in humans and experimental animals: part 1: blood pressure measurement in humans: a statement for professionals from the subcommittee of professional and public education of the american heart association council on high blood pressure research. circulation 2005;111:697–716. 33 james pa, oparil s, carter bl, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the eighth joint national committee (jnc 8). jama 2014;311:507–20. 34 radloff ls. the ces-d scale: a self-report depression scale for research in the general population. appl psychol meas 1977;1:385–401. 35 andresen em, malmgren ja, carter wb, et al. screening for depression in well older adults: evaluation of a short form of the ces-d (center for epidemiologic studies depression scale). am j prev med 1994;10:77–84. 36 kohout fj, berkman lf, evans da, et al. two shorter forms of the ces-d (center for epidemiological studies depression) depression symptoms index. j aging health 1993;5:179–93. 37 savitz da. interpreting epidemiologic evidence: strategy for study design and analysis: oxford. uk: oxford university press, 2003.  584  38 john op, srivastava s. the big five trait taxonomy: history, measurement, and theoretical perspectives. handbook of personality: theory and research 1999. , 1999: 2, 102–38. 39 huebner dm, nemeroff cj, davis mc. do hostility and neuroticism confound associations between perceived discrimination and depressive symptoms? j soc clin psychol 2005;24:723–40. 40 goodman la, kruskal wh. measures of association for cross classifications. journal of the american statistical association 1954;49:732–64. 41 cohen j. a coefficient of agreement for nominal scales. educ psychol meas 1960;20:37–46. 42 barros ajd, hirakata vn. alternatives for logistic regression in cross-sectional studies: an empirical comparison of models that directly estimate the prevalence ratio. bmc med res methodol 2003;3. 43 statacorp l. stata data analysis and statistical software. 10, 2007. 44 krieger n, sidney s. racial discrimination and blood pressure: the cardia study of young black and white adults. am j public health 1996;86:1370–8. 45 la f. stress, appraisal, and coping. 1. new york, 1984. 46 sapolsky rm. why zebras don't get ulcers. new york: wh freeman, 1994. 47 laveist ta, sellers r, neighbors hw. perceived racism and self and system blame attribution: consequences for longevity. ethn dis 2001;11:711–21. 48 lewis tt, yang fm, jacobs ea, et al. racial/ethnic differences in responses to the everyday discrimination scale: a differential item functioning analysis. am j epidemiol 2012;175:391–401. 49 clark r, coleman ap, novak jd. brief report: initial psychometric properties of the everyday discrimination scale in black adolescents. j adolesc 2004;27:363–8. 50 bureau u. american community survey. raleigh-durham-chapel hill, nc combined statistical area, 2013. 51 alegria m, jackson js, kessler rc, et al. collaborative psychiatric epidemiology surveys (cpes), 2001-2003 [united states. inter-university consortium for political and social research distributor, 2016. 52 williams dr, gonzalez hm, neighbors h, et al. prevalence and distribution of major depressive disorder in african americans, caribbean blacks, and non-hispanic whites: results from the national survey of american life. arch gen psychiatry 2007;64:305–15. 53 assari s. high income protects whites but not african americans against risk of depression. healthcare 2018;6. 54 krieger n. methods for the scientific study of discrimination and health: an ecosocial approach. am j public health 2012;102:936–44. 55 nuru-jeter am, michaels ek, thomas md, et al. relative roles of race versus socioeconomic position in studies of health inequalities: a matter of interpretation. annu rev public health 2018;39:169–88.  michaels e, et al. j epidemiol community health 2019;73:577–584. doi:10.1136/jech-2018-211230   2019 author(s) (or their employer(s)) 2019. no commercial re-use. see rights and permissions. published by bmj.  
       


