Group Title: BMC Public Health
Title: The Influence of active coping and perceived stress on health disparities in a multi-ethnic low income sample
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Title: The Influence of active coping and perceived stress on health disparities in a multi-ethnic low income sample
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Language: English
Creator: Watson, Jennifer
Logan, Henrietta
Tomar, Scott
Publisher: BMC Public Health
Publication Date: 2008
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Abstract: BACKGROUND:Extensive research has shown that ethnic health disparities are prevalent and many psychological and social factors influence health disparities. Understanding what factors influence health disparities and how to eliminate health disparities has become a major research objective. The purpose of this study was to examine the impact of coping style, stress, socioeconomic status (SES), and discrimination on health disparities in a large urban multi-ethnic sample.METHODS:Data from 894 participants were collected via telephone interviews. Independent variables included: coping style, SES, sex, perceived stress, and perceived discrimination. Dependent variables included self-rated general and oral health status. Data analysis included multiple linear regression modeling.RESULTS:Coping style was related to oral health for Blacks (B = .23, p < .05) and for Whites there was a significant interaction (B = -.59, p < .05) between coping style and SES for oral health. For Blacks, active coping was associated with better self-reported health. For Whites, low active coping coupled with low SES was significantly associated with worse oral health. Coping style was not significantly related to general health. Higher perceived stress was a significant correlate of poorer general health for all ethnoracial groups and poorer oral health for Hispanics and Blacks. SES was directly related to general health for Hispanics (.B = .27, p < .05) and Whites (B = .23, p < .05) but this relationship was mediated by perceived stress.CONCLUSION:Our results indicate that perceived stress is a critical component in understanding health outcomes for all ethnoracial groups. While SES related significantly to general health for Whites and Hispanics, this relationship was mediated by perceived stress. Active coping was associated only with oral health.
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Research article

The influence of active coping and perceived stress on health
disparities in a multi-ethnic low income sample
Jennifer M Watson* t, Henrietta L Logant and Scott L Tomart


Address: Department of Community Dentistry and Behavioral Science, The University of Florida, Gainesville, USA
Email: Jennifer M Watson* jwatson@dental.ufl.edu; Henrietta L Logan Hlogan@dental.ufl.edu; Scott L Tomar Stomar@dental.ufl.edu
* Corresponding author tEqual contributors


Published: 29 January 2008
BMC Public Health 2008, 8:41 doi: 10.1 186/1471-2458-8-41


Received: 28 August 2007
Accepted: 29 January 2008


This article is available from: http://www.biomedcentral.com/1471-2458/8/41
2008 Watson et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.



Abstract
Background: Extensive research has shown that ethnic health disparities are prevalent and many
psychological and social factors influence health disparities. Understanding what factors influence
health disparities and how to eliminate health disparities has become a major research objective.
The purpose of this study was to examine the impact of coping style, stress, socioeconomic status
(SES), and discrimination on health disparities in a large urban multi-ethnic sample.
Methods: Data from 894 participants were collected via telephone interviews. Independent
variables included: coping style, SES, sex, perceived stress, and perceived discrimination.
Dependent variables included self-rated general and oral health status. Data analysis included
multiple linear regression modeling.
Results: Coping style was related to oral health for Blacks (B = .23, p < .05) and for Whites there
was a significant interaction (B = -.59, p < .05) between coping style and SES for oral health. For
Blacks, active coping was associated with better self-reported health. For Whites, low active coping
coupled with low SES was significantly associated with worse oral health. Coping style was not
significantly related to general health. Higher perceived stress was a significant correlate of poorer
general health for all ethnoracial groups and poorer oral health for Hispanics and Blacks. SES was
directly related to general health for Hispanics (.B = .27, p < .05) and Whites (B = .23, p < .05) but
this relationship was mediated by perceived stress.
Conclusion: Our results indicate that perceived stress is a critical component in understanding
health outcomes for all ethnoracial groups. While SES related significantly to general health for
Whites and Hispanics, this relationship was mediated by perceived stress. Active coping was
associated only with oral health.


Background
Extensive research has shown that ethnic/racial health dis-
parities are prevalent in the United States. Mortality and
morbidity rates are consistently higher among minority
groups than among non-minority groups [1]. These dis-
parities range from the prevalence of specific diseases to


access to life saving preventive measures [2]. Understand-
ing what factors influence health disparities and how to
eliminate health disparities has become a major research
objective [3].


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Previous research has shown that self-rated health is
strongly and consistently associated with morbidity and is
frequently shown to be as good as or better than a physical
examination in predicting mortality [4]. Self-rated health
is often considered a more comprehensive measure of
health than simple rates of mortality and morbidity and
health disparities have been clearly demonstrated using a
single global measure of health [5].

Oral health has become a critical area in health disparities
research as evidenced by the first-ever Surgeon General's
Report on Oral Health [6]. Poor oral health causes signif-
icant pain, diminishes overall quality of life, and is con-
sidered an integral part of general health. For example,
recent research findings have pointed to possible associa-
tions between chronic oral infections and diabetes, heart
and lung diseases, stroke, low birth weight, and premature
births [6]. Furthermore, individuals with lower income
and members of some racial and ethnic minority groups
experience a disproportionate level of oral health prob-
lems [6].

Many factors including socioeconomic status (SES),
chronic stress levels, discrimination, coping style, ethno-
racial group membership, and sex are strongly associated
with general and oral health disparities, but the causal
mechanisms remain unclear [7,8]. A strong association
has been found between chronic stress and poorer health
[9-11]. In addition, coping strategies that emphasize
actively engaging in problem solving strategies, i.e. "active
coping", have frequently been associated with better
health outcomes, e.g. [12,13] but studies of health out-
comes among Blacks have suggested otherwise [14-17].
The John Henryism Hypothesis (JHH) posits that for
Blacks, active coping accompanied by chronic psychoso-
cial stress is associated with elevated risk for negative
health outcomes among those without sufficient socio-
economic resources [15,18]. For example, studies sup-
porting the JHH typically demonstrate that for Blacks in
small, poor, mostly rural communities, high active coping
coupled with low SES results in higher hypertension and
cardiovascular reactivity [14,15,19,20]. JHH combines
psychological and social factors many minorities face to
begin to explain health disparities, but the generalizability
and the precise parameters for the phenomena are still
speculative. However, the JHH has only been applied to
samples of African American adults and it is unclear if it
would apply similarly to other racial or ethnic groups such
as Hispanics or to more general health indicators.

In order to better understand the influence of active cop-
ing on health in minorities it is critical that active coping
be examined in conjunction with common psychological
and social stressors known to be related to health in a
large multi-ethnic non-rural sample. It is critical that cul-


turally sensitive measures of active coping, socioeconomic
status, and discrimination applicable to both minority
and non-minority individuals be used to gain a clear
understanding of how these factors interact and relate to
health. In addition, a critical and often neglected area -
self-rated oral health should be included as a sensitive
marker of both social and biological aspects of health [6].

This study addressed important gaps in the stress and cop-
ing literature. Specifically, this study investigated how
stress and coping influence not just general health, but
oral health as well. In addition, it expanded the JHH
hypothesis to a racial/ethic population other than African
Americans (Hispanics) to discern whether active coping
combined with increased stress was deleterious to general
and oral health. The purpose of this study was to assess
the impact of active coping on health as well as how the
relationship between active coping and health was influ-
enced by common psychological stressors (perceived
stress) and social stresses (discrimination, SES) in an
urban multi-ethnic sample. Specifically, our hypothesis
was that high active coping coupled with low socioeco-
nomic status would predict low self-rated health in all eth-
nic groups. We hypothesized that perceived stress would
relate to general and oral health for all ethnic groups, but
perceived discrimination would only relate to general and
oral health for minority populations. We also hypothe-
sized that SES would be inversely related to health for all
ethnic groups.

Methods
Data Source
Data for this study were collected as part of a larger study
designed to test the effectiveness of an oral cancer aware-
ness billboard campaign in Florida [21]. Baseline data
were collected in Miami-Dade and Duval counties in Sep-
tember and October 2001. A follow-up survey was com-
pleted in the same counties in July to September 2002.
Miami-Dade County is located in southern Florida and
contains 2.3 million residents, 57.3% of whom are His-
panic or Latino in origin and 20.3% who are black or Afri-
can American. Duval County, which includes the city of
Jacksonville, is located in the northeastern part of the
state. Duval County contains 792,434 residents, 4.1% of
who are of Hispanic or Latino origin and 27.8% of who
are black or African American. Data used in this analysis
are from the follow-up survey (N = 894). The study was
reviewed and approved by the University of Florida
Health Science Center Institutional Review Board and fol-
lowed human subject guidelines for research. Verbal
informed consent was obtained from each participant.

Participants
The sample frame for the survey included households
with a land line telephone located within low to moderate


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income areas within each of the two counties; median
household income for the targeted census tracts ranged
from $7,243 to $97,453, with a median of $33,252. The
inclusion criteria for participation in the study were to be
at least 18 years of age and to speak either English or Span-
ish. Random digit dialing was used to select a probability
sample of households. Approximately 25% of the tele-
phone interviewers were Black and 55% were females.
Each interview lasted approximately 27 minutes. To com-
plete 894 surveys, 8,863 telephone numbers were selected
of which 699 were for businesses, institutions, or group
quarters and were ineligible to participate. Because of
technical problems (e.g., fax number, answering
machines with no message), 3,386 telephone numbers
were excluded. There were 132 telephone numbers that
reached households in which physical, mental or lan-
guage barriers made potential respondents ineligible.
There were 1,200 persons who refused to participate or
did not complete the telephone survey. No eligible
respondent was available (including no answer or always
busy) at 2,552 telephone numbers (See Table 1). Further
details on the survey design and content have been pub-
lished previously [21].

Measures
Self-rated general health and oral health
Self-rated general health and self-rated oral health were
the key dependent variables in this study. Participants
were asked to indicate how they rated their health in gen-
eral and their dental or oral health on a 5-point scale from
1 ("Excellent") to 5 ("Poor"). This method of assessing
global general and oral health has been shown to be a
valid assessment of health and also has the advantage of
permitting respondents to integrate multiple aspects of
their health in their rating [4,22-27]. It offers positive
response categories (excellent/good) rather then limiting
people to only reporting health problems [28]. In order to
maintain consistency with large epidemiologic studies
that used single global measures of self-rated health,
"Excellent" and "Very Good" were combined into a single

Table I: Final Phone Call Dispositions.


Category N

Completed Interviews 894
Eligible No Interview
Refusal/less than 50% complete 1200
Non Contact
Ineligible Respondents
Physical/Mental/language barriers 132
Unknown Eligibility
NO answer/Always busy 2552
Not Eligible
Business/institutions/group quarters 699
Fax/Data line 3386


category [5]. Items were reverse-coded so that higher
scores indicated better health.

Demographic Information
Demographic items were derived from the Behavioral
Risk Factor Surveillance System Survey [29]. Participants
indicated their sex (male, female), ethnicity (Hispanic/
Latino) and race (White, Black or African-American,
Asian, Pacific Islander, American Indian/Native American,
Other). For purposes of this analysis, three racial/ethnic
groups were used: Hispanics, non-Hispanic blacks, and
non-Hispanic whites. Hereafter, non-Hispanic blacks are
referred to as Blacks and non-Hispanic whites are referred
to as Whites.

SES
A modified version of the MacArthur Scale of Subjective
Social Status [30] was used to assess the respondents'
social status. Subjective social status has been character-
ized as a person's belief about his or her location in a sta-
tus order and takes into account multidimensionality of
SES simultaneously. It has been shown to assess aspects of
social status that are typically not captured by more tradi-
tional SES measures such as income or education [31].
Respondents were asked to "think of a ladder with 10
rungs as representing where people stand in the United
States. At the top of the ladder (10) are the people who are
the best off those who have the most money, the most
education and the most respected jobs. At the bottom (1)
are the people who are the worst off who have the least
money, least education, and the least respected jobs or no
job..." They were then asked to place themselves on this
ladder, at this time in their lives, relative to other people
in the United States by selecting a number from 1 to 10.
The midpoint of the scale (5) was used to divide partici-
pants into low SES vs. high SES.

Discrimination
Discrimination was assessed by using "The Everyday Dis-
crimination Scale" [32]. This is a 9 item measure assesses
chronic and routine experiences of unfair treatment and
has been shown to have reasonable internal consistency
(Cronbach's alpha = .88) [32]. It can be easily utilized
with all ethnic and racial groups because it does not focus
on race or color discrimination solely but rather more typ-
ical occurrences of unfair treatment. For instance, partici-
pants rate their day-to-day experience of how often they
experience unfair treatment; are treated will less courtesy
than others. Mean scores were calculated for participants
that had valid data on at least 2/3 of the items and higher
scores indicate higher discrimination.

Stress
Stress was assessed by utilizing Cohen's Perceived Stress
Scale (PSS). The PSS is a 14-item scale and is one of the


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most widely used psychological instruments for measur-
ing the perceptions of stress [33]. Items were designed to
assess how unpredictable, uncontrollable and over-
whelming respondents find their lives and higher scores
indicate higher stress. The PSS was designed for use with
community samples with at least a junior high school
level of education [33].

Active Coping
Active coping was assessed by using the John Henry Active
Coping Scale (JHAC). JHAC is a culturally sensitive 12-item
scale that assesses a strong personality predisposition to
cope actively with psychosocial stressors in one's environ-
ment. Participants indicated on a 5-point Likert scale
(from 1 = "Completely False" to 5 = "Completely True")
how much they agreed with each specific statement (e.g.
"I've always felt that I could make of my life pretty much
what I wanted to make of it; I am rarely disappointed by
the results of my hard work). Higher scores indicate more
active coping. No test-retest reliability coefficient of the
scale has been published and internal consistency of the
scale assessed via Cronbach's alpha range from mid-70s to
mid-80s [16,18].

JHAC is scored by summing each participant's responses.
If three or fewer items were missing then the average of the
non-missing responses was substituted for the missing
response. Scores can range from 12 to 60. In keeping with
the methodology proposed by James and colleagues,
[15,18,34] scores were dichotomized at the median for
each racial/ethnic group to categorize respondents into
low and high John Henry active coping groups.

Data Analysis
We first generated univariate statistics to describe demo-
graphic characteristic of the sample participants, JH, SES,
discrimination, and stress. Pearson correlation coeffi-
cients were used to examine the bivariate relationships
among active coping, SES, stress, and discrimination.
Hierarchical linear regression models were used to ana-
lyze the relationship between active coping, stress, sex,
SES, and self-rated health. Age was strongly associated
with oral and general health, and was therefore included
as a covariate in multivariable models.

We performed stratified analysis by race/ethnicity (Black,
White, and Hispanic) to determine the association
between active coping and self-rated general and oral
health. To fully explore the relationship between active
coping and self-rated health and to test potential interac-
tion effects we ran a series of linear regression models that
examined interaction terms and main effects for active
coping, sex, and SES. We examined the additional impact
of stress and discrimination on self-rated general health
and oral health.


The John Henryism Hypothesis (JHH)
We ran a series of multiple regression models that exam-
ined the impact of JH, SES and sex on self-rated health.
First, we ran main effect models. Then to specifically
assess the John Henryism Hypothesis we examine two-
way interactions between JH and SES and JH and Sex. We
then ran a model that examined the 3-way interaction
between JH, SES and sex for self-rated health.

Stress and Discrimination
We conducted analyses to determine the additional
impact of discrimination and perceived stress. We first ran
a model to examine whether discrimination and stress
were significantly related to self-rated health even after
accounting for significant effects in the first models (e.g.
JH, SES, or sex). We then examined whether JH interacted
with either of those constructs. If no interaction terms
were statistically significant, we ran a simplified model
including only significant effects. This series of modeling
was also conducted for self-rated oral health.

Results
Participants with complete data on all independent varia-
bles were included in this analysis (n = 812). Overall,
more than one-half of the sample was female, 29% were
White, 47% were Black, and 24% were Hispanic. Table 2
provides the distribution of the main independent and
dependent variables of interest, stratified by race/ethnic-
ity. Forty-eight percent of the overall sample reported
excellent or very good health, and 38% of the participants
reported excellent or very good oral health. Black and
White participants reported similar levels of oral and gen-
eral health while Hispanic participants reported the low-
est oral and general health ratings. The minimum age in
the sample was 18 and the maximum age was 91. Age dif-
fered significantly among the ethnic/racial groups and
was also significantly correlated with general health (r = -
243, p < .001 and oral health (r = -.161, p < .001) and was
therefore included as a covariate in all analyses. Cron-
bach's alpha for the perceived stress scale was .68 and for
the discrimination scale was .87 in this sample. There
were significant but modest correlations between all of
the variables (JH, stress, SES) except the correlation
between JH and discrimination was weak and not signifi-
cant (See Table 3). These findings suggest that although
there is some overlap, these variables measure different
constructs.

General Health
Table 4 presents parameter estimates from the preliminary
models for each ethnic/racial group.

Blacks
The JHH was not supported in the Black sample. Sex
approached significance (B = .163; p = .052) when


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Table 2: Selected characteristics of study participants, by race/ethnicity.


Variable



Sex
Female
Male

Socioeconomic Status a
Low ( I-5)
High (GT 5)


White


(n = 238)
%


Median
52 e


John Henryism (range 12-60) b


Age
Self-Rated General Health (range 1-4) c
Self-Rated Oral Health (range 1-4) c
Perceived Discrimination (range 1-6) d
Perceived Stress (3-40) d


Mean (SD)
47.53(17.5) f
03.32(00.82)e
03.13(00.91) e
02.18(00.95) e
22.58(05.87)e


Black

(n = 378)
%

57.5
42.5


49.9
50.1


Median
52'

Mean (SD)
42.13(15.62) e
03.28(00.85) e
03.03(00.96) e
02.61(01.08)'
22.25(06.20) f


Hispanic

(n = 196)
%


Median
51 e

Mean (SD)
41.68(15.27)e
03.04(00.94) f
02.90(00.98) f
02.23(01.07) e
23.91(06.09)e


P value e


.011


< .001
.001
.046
< .001
.010


a Perceived SES in the United states based on respondents rating of how they compare to others in terms of income, education and job status.
Higher scores indicate higher SES.
b ohn Henryism Active Coping assesses predisposition to cope actively with psychosocial stressors in one's environment, higher scores indicated
more active coping.
c Based on participants' ratings of their general and oral health, higher scores indicated better health.
d Higher scores indicate higher discrimination or higher perceived stress.
eAnalyses were chi square for categorical variables and ANOVA for continuous variables, different subscripts in row indicate a significant difference
between groups for ANOVA analyses.


accounting for the effects of perceived stress and discrimi-
nation. Perceived stress and discrimination were both sig-
nificantly related to general health. The final model
included sex, perceived discrimination and perceived
stress. Black males (x = 3.42) reported significantly higher
health ratings than did Black females (x = 3.19). For both
Black men and Black women, higher stress and higher per-
ceived discrimination was significantly related to worse
health (See Table 5 for final models).

Hispanics
The JHH was not supported in the Hispanic sample. The
only significant effect was a main effect for SES with low
SES participants indicating worse health (x = 2.92) than
high SES participants (x = 3.19). When examining the
impact of perceived stress and perceived discrimination

Table 3: Correlationsa among JH, SES, and Perceived
Discrimination (n = 812).


Variable

Discrimination
Perceived stress
JH


SES b Discrimination Perceived Stress


-.140 *
-.250 *
.105 *


.206 *
-.063


-.227*


a Pearson correlation coefficients.
b SES is a Dichotomous variable (low/high)
* P< .01


only perceived stress was significantly related to general
health. When perceived stress was included in the model
for Hispanics, SES was no longer significantly related to
health status. Therefore, the final model included only
perceived stress with higher perceived stress being signifi-
cantly related to worse health.

Whites
The JHH was not supported in the White sample. The only
significant effect was a main effect for SES, with low SES
participants reporting worse health (x = 3.17) than high
SES participants (x = 3.43). When examining the impact
of stress and discrimination only perceived stress was sig-
nificantly related to general health. Mirroring the results
for our Hispanic sample, when stress was included in the
model, SES was no longer significantly related to self-
rated health status. Therefore, the final model included
only stress with higher stress being significantly related to
worse health.

Oral Health
Table 4 presents parameter estimates from the preliminary
models for each ethnic/racial group.

Blacks
The JHH was not supported for oral health in the Black
sample. However, active coping was significantly related


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Table 4: Preliminary multiple linear regression model parameter estimates for self-rated general and oral health, by race/ethnicity
adjusted for age.


Variables




GENERAL HEALTH
John Henryism (JH), Sex, SES
JH x Sex x SES
JH x Sex
JH x SES
Main Effects
JH
Sex (male)
SES
Perceived Stress and Discrimination
JH x Perceived Stress
JH x Perceived Discrimination
Main Effects
Perceived Stress
Perceived Discrimination
Sex
JH
SES
ORAL HEALTH
JH x Sex x SES
JH x Sex
JH x SES
Main Effects
JH
Sex (male)
SES
Perceived Stress and Discrimination
JH x Perceived Stress
JH x Perceived Discrimination
Main Effect
Perceived Stress
Perceived Discrimination
Sex
JH
SES

a Unstandardized Coefficients.
b SES is a dichotomous variable (low/high)
* p < .05** p < .01


Black


(n = 375)


a Beta

.164
.169
-.277

.089
.152
.023


-.006
.046

-.024 *
-.081*
.163
.023
-.062
(n = 376)
.075
-.024
-.113

.229*
-.057
.111

.003
.1 17

-.03 I**
-.015
-.069
.15 1
.030


Hispanic

(n = 194)

Beta

.561
-.016
.358

.153
.019
.280*

-.013
-.169

-.052**
.032
-.001
.095
.115
(n = 194)
.544
.112
-.074

.068
.044
.229

-.008
-.048

-.038**
.031
.005
.005
.115


White

(n = 233)

Beta

-.012
-.411
-.349

.16 1
-.0 11
.245 *

-.002
-.077

-.038**
.009
-.045
.083
.13 1
(n = 233)
.597
-.438
-.679*


-.307**


.015
-.166

-.019
-.070
-.301*
.150
.333**


to oral health as a main effect. Black participants with
high active coping reported better oral health (x = 3.15)
than those with low active coping (x = 2.93). When exam-
ining the impact of stress and discrimination only per-
ceived stress was significantly related to oral health.
However, when stress was included in the model, active
coping was no longer significantly related to self-rated
oral health. Therefore, the final model included only
stress with higher stress being significantly related to
worse oral health. (See Table 5 for final models).

Hispanics
The JHH was not supported for oral health in the Hispanic
sample. Perceived stress was the only variable significantly


related to oral health for Hispanics. Therefore, the final
model included only stress with higher stress being signif-
icantly related to worse health

Whites
When examining the JHH in Whites there was a signifi-
cant interaction between active coping and SES (B = -.595,
p = .011) however, it was participants with low active cop-
ing and low SES that reported significantly worse oral
health than participants with high active coping and low
SES. Sex was the only other variable significantly related to
oral health with White males (x = 2.97) reporting signifi-
cantly lower oral health ratings than White females (x =




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Table 5: Final multiple linear regression n
estimates for self-rated general and oral h
adjusted for age.


Variables

GENERAL HEALTH
Blacks (n = 375)
Sex (Male)
Perceived Stress
Perceived Discrimination
Hispanics (n = 194)
Perceived Stress


Whites (n = 233)
Perceived Stress

ORAL HEALTH

Blacks (n = 375)
Perceived Stress


odel parameter for Whites and Hispanics, this relationship was moder-
ealth, by race/ethnicity ated by stress. It may be that low SES is a proxy for higher
stress because lower SES (lack of economic resources,
Beta a p-value lower education and lower occupation) is associated with
higher stress. These results point to the importance of
incorporating measures of stress into health disparities
research.
.164 .048
-.024 <.001 Perceived discrimination was significantly related to gen-
eral health only for Black participants. Increased discrim-

-.056 < .001 nation relates to higher stress levels and has been
regularly associated with poorer health [9-11]. The fact
that discrimination was associated with self-rated health
-.042 < .001 status only among Black participants may be due in part
to the location of the survey. A majority of Miami-Dade
County's population is comprised of residents of Hispanic
or Latino origin (57.3%), and discrimination may be less
-.034 < .001 common in such circumstances.


Hispanics (n = 194)
Perceived Stress

Whites (n = 233)
Sex
SES b x John Henryism (JH)
REF High JH and Low SES
Low JH and Low SES
LowJH and High SES
High JH and High SES


-.040 <.001


.757 <.001


a Unstandardized Coefficients.
b SES is a dichotomous variable (low/high)

3.22). Therefore, the final model included only the signif-
icant interaction between active coping and SES and sex.

Discussion
This study assessed active coping and health, taking into
account the influence of known psychological and social
correlates of general and oral health in a low-income, eth-
nically diverse sample. Overall, perceived stress was the
strongest correlate of general and oral health and often
accounted for a significant amount of the variance associ-
ated with SES. Sex of the participant was related to general
health only for Black participants and oral health for
white participants. The main hypothesis for this study was
not supported, as active coping coupled with low SES did
not relate to worse self-rated general or oral health in any
of the ethnic/racial groups.

Our results suggest that overall perceived stress may be a
critical component in understanding health outcomes for
low income Black, Hispanic and White adults. Perceived
stress was significantly related to reports of general health
for all ethnoracial groups and was significantly related to
self-rated oral health for Black and Hispanic participants.
While SES was significantly associated with general health


Sex was significantly related to general health only for
Black participants. For Blacks, the relationship between
sex and health was not moderated by stress. Research has
shown that men and women cope differently in response
to stress, and that those differences ultimately can influ-
ence physiology and health [35]. Previous researchers
have hypothesized that Black women's more diverse roles
may be a protective factor for health, while Black men
who do not have as pronounced a family role suffer due
to economic disparities [16]. Our results indicate that the
multiple roles Black women are required to fill may actu-
ally be detrimental to their overall health possibly due to
the stress of trying to balance numerous critical roles.

It is interesting that coping style was related solely to oral
health and not to general health. Although the John Hen-
ryism Hypothesis (JHH) was not supported by our data, it
is possible that, although the sample size was large, we did
not have adequate statistical power to detect such interac-
tion effects. The JHH has generally been linked to condi-
tions that lead to worse health such as high blood pressure
or cardiovascular reactivity [14,15]. This relationship
makes intuitive sense in that active coping with limited
resources can increase activity in the parasympathetic
nervous system which could increase heart rate and blood
pressure. Our measure of general health was more global
than physiological markers such as blood pressure. How-
ever, coping did relate to oral health for Blacks and Whites
but again not in the way hypothesized by the JHH. There
is no reason to expect that active coping with stressors
would be independently related to poorer health [12,361].
Our finding that Blacks with active coping strategies
reported better health is consistent with an extensive liter-
ature on the benefit of active coping to psychological and
physical health [12,36]. High active coping may be critical
in oral health as several active self-care strategies (e.g.


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daily tooth brushing and flossing) have been found to
dramatically improve oral health. Oral health is a critical
component of general health and our results show that
key psychological factors (e.g. stress and coping) and
social factors (discrimination and SES) impact global
measures of oral and general health differently.

The strengths of this study include comprehensive assess-
ment of factors that have been shown to influence health
disparities, such as ethnoracial group membership, sex,
discrimination, SES and active coping. In addition, this
study expanded on past research by examining the JH con-
struct among Hispanics, another U.S. ethnic group that
experiences health disparities. This study utilizes an
encompassing and culturally relevant measure of SES and
discrimination. Finally, health outcomes were assessed
utilizing a comprehensive measure of both general and
oral health. Oral health is often neglected in disparities
research but is an essential factor in overall health [6].

Limitations of this study include reliance on self-reported
data, the absence of physiological or clinical measures of
oral or general health, and a cross-sectional study design.
Because they were not measured, it was also not possible
to rule out other unmeasured psychological variables such
as neuroticism or depressive symptoms as responsible for
the observed association between self rated health indica-
tors and perceived stress. Despite the potential biases
inherent in self-rated measures, obtaining objective meas-
ures of discrimination and stress would be extremely dif-
ficult and the association between self-rated health status
and excess mortality has been well-established [4,5,261. In
addition, moving toward a more all-encompassing assess-
ment of health allows for a more comprehensive under-
standing of health disparities [26]. Finally, although this
sample was diverse in regards to ethnicity/race, all partic-
ipants resided in one of two cities in Florida.

Conclusion
This study examined several known correlates of health
status and factors related to health disparities among a
large multi-ethnic sample and also expanded the study of
these variables to oral health. Active coping was positively
related to oral health only, while perceived stress was an
important correlate of both general and oral health.
Although SES related to general health for Hispanics and
Whites, this relationship was mediated by perceived
stress. These results point to the importance measuring
perceived stress directly rather than relying on SES as a
proxy for stress. Coping styles or perceptions of stress can
differ greatly among individuals in identical situations.
Simultaneously assessing general health, oral health, and
several critical psychological and social variables within a
large multi-ethnic sample provides an important step in
understanding the complex etiology of health disparities


in the United States. Future research should include longi-
tudinal studies to help clarify the temporal relation of
these factors.

Competing interests
The authors) declare that they have no competing inter-
ests.

Authors' contributions
HL and ST made substantial contributions to the concep-
tion, design and acquisition of the data. HL, ST, JW all par-
ticipated in the data analytic plan and interpretation of
data. JW performed all data analysis and initial drafts of
the manuscripts. HL, ST and JW all participated in review-
ing and revising the manuscript.

Acknowledgements
This research was supported by grants from the American Cancer Society
ROG 02 230 01; Centers for Disease Control and Prevention, Prevention
Research Centers Oral Health Network UAB/CDC U48 CCU 4-9679-02;
and the National Institute of Health RO IDE 16226. No other financial sup-
port, commercial or federal was provided for this research.

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