Racial Regard and Physical Health Among Low-Income Black Caregivers of Children With and Without Asthma

Abstract

The purpose of this study was to examine the associations between child health, parent racial regard, and parent physical health in 87 African American and Black parents/caregivers of children with and without asthma from a low-income, under-resourced urban area. Participants completed the Private and Public Regard subscales of the Multidimensional Inventory of Black Identity (MIBI) and 12-item Short Form Health Survey (SF-12). Parents of children with asthma reported having poorer physical health, while those with higher public and private racial regard reported better physical health. The association between public regard and physical health was surpassed by an interaction of child asthma status and public regard: as public regard decreased, so did physical health, but only for parents raising a child with asthma. Findings suggest that the stresses associated with raising a child with chronic illness and perceiving lower public racial regard may together confer additional risk for poor physical health in African American and Black parents.

Keywords

racial regard child asthma chronic illness caregiver health

Racial disparities in health have been well-documented, with Black Americans experiencing poorer health than non-minoritized White Americans (National Center for Health Statistics, 2018). Racial disparities are evident in disease morbidity and mortality and across illnesses, and although efforts to address disparities have increased in recent years, Black Americans continue to be subjected to a higher burden of poor physical health (U.S. Department of Health and Human Services, 2017). The etiology of health disparities is complex and often considered to result from a confluence of individual, contextual, and systemic factors. Thus, research is needed that addresses multiple factors.

Racial Regard

Racial identity is one individual factor that is important to the physical health of Black individuals. The Multidimensional Model of Racial Identity (MMRI; Sellers et al., 1998) conceptualizes racial regard as containing two unique but related dimensions: private and public regard (Sellers et al., 1997). Private regard refers to how individuals personally view their race, including how they feel about Black individuals as well as their feelings toward their own membership in that racial group. Public regard, in contrast, refers to how individuals believe others in society view their race (Sellers et al., 1997).

Both public and private regard have been linked to health outcomes in Black individuals. Specifically, lower regard for one’s racial group has been associated with worse overall health status (Lewis et al., 2018). There are many proposed explanations for why this may be the case, including explanations centered on how regard may foster different health strategies. For example, lower public and private regard have been associated with poorer health behaviors, such as less physical activity (Lewis et al., 2018). Similarly, awareness of negative racial stereotypes held by the public has predicted fewer self-care behaviors and more substance use (Jerald et al., 2017). Supporting these results, recently published research has indicated that Black individuals may be more sedentary and experience more sleep problems following experiences of discrimination (Fuller-Rowell et al., 2021; Nam et al., 2021).

Beyond those explanations, it is also likely that individuals’ racial regard reflects larger systemic issues such as stress associated with racism and experiences of racial discrimination. For instance, research supports the association between perceived discrimination and physical health through both an increased stress response and engagement in negative health behaviors (e.g., Pascoe & Smart Richman, 2009). From a biopsychosocial perspective, this association between exposure to risk factors (i.e., experiences of racism) and health outcomes is mediated by individuals’ perception, as well as moderated by sociodemographic, constitutional, and psychological/behavioral factors (e.g., Clark et al., 1999). Theoretically, private regard may both reflect perceptions and serve as a protective factor in the way that coping mechanisms do (Clark et al., 1999). Public regard may represent a broader construct related to both objective experiences of racism and perceptions of those experiences. No matter the mechanisms of effect, past studies converge to highlight the importance of racial regard for Black individuals’ physical health.

Parenting a Child with Asthma

From a risk and resilience perspective, beyond examining the risk that lower racial regard carries, it is important to consider the simultaneous impact and potential interactive effect of contextual risk factors on health (Luthar et al., 2000). For example, Clark et al. (1999) propose several moderating factors that may amplify or lessen the association between risk factors and health outcomes, such as family history of disease, socioeconomic status, and self-esteem. Parents of children with chronic illness are (a) at increased odds of developing chronic health conditions themselves, (b) more likely to report activity limitations and poorer overall health, and (c) at increased risk for overall mortality (Brehaut et al., 2009; Cohn at al., 2020). Pediatric asthma is of particular interest given its disproportionate impact on Black children (Akinbami et al., 2014). This disparity can be explained in part by systemic factors such as residential segregation; areas with a higher proportion of Black families are also likely to have higher concentrations of poverty and poor housing (Alexander & Currie, 2017). Further, individuals living in high-poverty areas often experience worse asthma morbidity due, in part, to limited access to healthcare (Everhart et al., 2020). These factors, along with the daily responsibility of caring for a child with asthma, can also contribute to caregiver stress, which has been shown to negatively impact caregiver health (Sampson et al., 2013). Thus, Black parents and caregivers of children with asthma may carry unique risk for stress and subsequent poor health.

Current Study

While the link between racial regard and health has been supported, research to date has focused largely on individual characteristics and has not yet examined this association in the context of additional, family-based risk factors. Thus, prior literature is limited in its implications for parents and caregivers as child characteristics may also impact parent/caregiver health. Given that both racial regard and raising a child with asthma have been implicated in physical health outcomes for Black parents, coupled with the large number of Black parents raising children with asthma, understanding how these factors work in concert may add to understanding physical health disparities. Such knowledge could be used to underscore the deleterious effects of systemic racism as well as inform more tailored, nuanced, family-based interventions for improving the physical health of Black caregivers. Thus, this study focused specifically on Black caregivers and explored the health risks conferred by lower racial regard and being the caregiver of a child with asthma living in a low-income, urban area. We hypothesized an interaction in which caregiver health would be lowest in the context of both low racial regard and being the caregiver of a child with asthma.

Method

Participants

Participants were drawn from a larger study examining risk and protective factors among families living in low-income areas. Families were identified as potentially eligible from electronic health records. Families from high-poverty zip codes (i.e., >20% of the population lived below the federal poverty line) were then called and screened for eligibility over the phone. Inclusion criteria included being the caregiver of a child 5–12 years of age and the ability to speak and understand English. The current study included 88 caregivers who self-reported their race as “African American or Black”; 42 (48%) were caregivers of a child with physician-diagnosed asthma and 45 were caregivers of a child without asthma. The majority of participants were biological mothers (88.5%), single parents (69%), and had an income at or below the poverty threshold (80.5%). See Table 1 for complete sample demographics.

Table 1.

Participant Demographic Characteristics.

Variable	n	%
Caregiver type
Biological mother	77	88.5
Biological father	4	4.6
Grandmother	4	4.6
Other	2	2.3
Child sex
Male	43	49.4
Female	44	50.6
Caregiver education
Below high school	30	34.5
High school or GED	28	32.2
Beyond high school	28	32.2
Single parent^a	60	69.0
Income at/below poverty threshold^a	70	80.5
Child diagnosed with asthma^a	42	48.3

Note. Caregivers were 37.63 years on average (SD = 10.20), and children were 8.85 years on average (SD = 1.97).

^aIndicates the number of participants meeting this criterion.

Procedure

Participants visited a community-based research center at a university in the Southeastern United States. After obtaining informed consent and youth assent, the caregiver and child completed a battery of questionnaires and tasks for the larger study that were presented in the same order. Families received fifty dollars and a small prize (for the child) for their time. This study was approved by the Institutional Review Board. The measures used in this study took approximately 20 minutes to complete.

Measures

Demographics

Caregivers reported their racial/ethnic background, age, educational level, relationship to child, family income level, and child’s age and sex. They also reported whether a physician had diagnosed their child with asthma (coded as 1 = present, 0 = absent).

Public and Private Racial Regard

The Multidimensional Inventory of Black Identity (MIBI; Sellers et al., 1997, 1998) was used to assess racial regard. Participants indicated how much they agreed with each statement on a scale from strongly disagree (1) to strongly agree (7). Items were summed to create the two six-item subscales used in this study, with higher scores reflecting more positive regard. The Private Regard score reflects the extent to which an individual feels positive about being Black and toward other Black individuals. The Public Regard score indicates the extent to which the participant perceives that others feel positively towards Black individuals. Sample items include “I feel good about Black people” (Private Regard) and “In general, others respect Black people” (Public Regard). The Private Regard subscale has been correlated with relationships with other Black individuals, supporting convergent validity (Sellers et al., 1997). Multiple studies have investigated the factor structure of the MIBI, which have indicated strong support for the Public Regard subscale and mixed support for the Private Regard subscale (Vandiver et al., 2009). Like prior evaluations that have yielded adequate reliability (Cronbach’s alphas ≥ .7; Vandiver et al., 2009), in this study both subscales showed adequate internal consistency: Public Regard (sample Cronbach’s α = .69) and Private Regard (α = .72).

Overall Physical Health

The Physical Health score (6 items) of the 12-item Short Form Health Survey (SF-12) was used to measure caregiver physical health (Ware et al., 1996). The SF-12 is a self-report measure of the impact of health on a participant’s daily life. Caregivers reported how they felt in various situations over the last 4 weeks, via items such as, “Does your health limit you in climbing several flights of stairs?” Higher scores indicate better physical health. Cronbach’s alpha for this sample was .77. Larson et al. (2008) investigated the psychometric properties of the SF-12 in a sample of African American and Black individuals living in low-income communities. Cronbach’s alpha for the sample was .8. Additionally, correlations between each individual item and the scale were all ≥ .40, indicating support for item-convergent validity. The Physical Heath scores in this sample were also lower in individuals with obesity and diabetes compared to those without. Finally, items on the Physical Health scale had stronger correlations with the overall Physical Health scale than the Mental Health scale, providing evidence for discriminant validity (Larson et al., 2008).

Statistical Analyses

The Process Macro (version 3.5; Hayes, 2018), an ordinary least squares approach to regression-based interaction analysis using bootstrapping, and SPSS version 26, were used to test the hypothesized interaction between racial regard and asthma status on caregiver physical health. A priori alpha level was set to .05. Effect sizes for f² range from .02, .15, and .35 and are interpreted as small, medium, and large, respectively (Aiken & West, 1991). Public and private racial regard were used as the predictor variables and asthma status (present/absent) was used as the moderator. One outlier case was removed prior to analysis, leaving a final sample size of 87. Following the removal of that case, assumptions of normality, linearity, and multicollinearity were met. Missing data were handled via listwise missing value deletion. Covariate testing for differences in caregiver health based on demographic variables was conducted using ANOVA or correlational analysis. Two models (model 1: public regard x asthma status; model 2: private regard x asthma status) were computed in Process (Model 1) using 5000 bias-corrected bootstraps to test for interaction effects on the outcome variable (caregiver physical health). The MIBI subscale scores (Private and Public Regard) were mean centered prior to analysis. A post hoc power analysis in G*Power 3 (Faul et al., 2009) revealed power of .83 to detect a small-medium effect (f² = .1) at an alpha of .05 with a sample size of 87 (.02 = small effect, .15 = medium effect, .35 = large effect; Aiken & West, 1991). Significant interaction effects were plotted for interpretation.

Results

Descriptive statistics and correlations among study variables can be found in Table 2. Caregiver age was the only demographic variable significantly associated with parent health [r (86) = −.22, p = .04], and was included as a covariate in subsequent regression models. Better caregiver health was correlated with child asthma status [r (86) = −.23, p = .03] as well as parents’ public [r (86) = .29, p =.008] and private [r (86) = .26, p =.02] racial regard.

Table 2.

Descriptive Statistics and Correlations Among Study Variables and Family Sociodemographic Characteristics.

Variable	1	2	3	4	Mean (SD)	Range	Skewness	Kurtosis
(1) Private regard					6.07 (0.83)	3.67–7.00	−0.762	−0.168
(2) Public regard	.39**				4.12 (1.13)	1.33–7.00	−0.059	0.233
(3) Caregiver health	.26*	.29**			45.03 (10.05)	15.25–57.65	−0.781	−0.263
(4) Child asthma status	.03	.03	−.23*
(5) Caregiver age	.15	.15	−.22*	.04
(6) Caregiver education	.05	.18	.16	−.23*
(7) Single-parent household	.12	.07	−.04	−.05
(8) Family income	−.17	.20	.12	−.13

Note. N = 87. * = p < .05; ** p < .01; child asthma status 0 = absent, 1 = present.

As shown in Table 3, the overall public regard regression model accounted for 26.3% (R²=.263) of the variance in caregiver health scores [F (4, 76) = 6.81, p <.001] and the overall private regard regression model accounted for 17.8% (R²=.178) of the variance in caregiver health scores [F (4, 76) = 4.12, p =.005]. The interaction between public regard and asthma status accounted for a small but statistically significant additional variance in caregiver perceptions of their physical health (△R²= .05, p = .023; f² = .05). The conditional effect of public regard on caregiver physical health was significant for caregivers of children with asthma (β = 5.39, 95% C.I. = 2.69, 8.08) but not for caregivers of children without asthma (β = 0.94, 95% C.I. = −1.76, 3.63; see Figure 1). The interaction between private regard and asthma status did not account for additional variance in health scores (△R² = .003, p = .607; f² = .0001).

Table 3.

Results of Interaction (Regression) Analyses Predicting Caregiver Health Controlling for Caregiver Age.

Variable	Coefficient	Standard error	t-value	p-value	95% CI [upper and lower]
Public regard
Public regard	0.937	1.354	0.692	.491	[−1.759, 3.634]
Asthma status	−5.733	2.143	−2.675	.009	[−10.001, −1.465]
Public regard X asthma status	4.448	1.916	2.321	.023	[.631, 8.265]
Caregiver age	−0.213	0.107	−2.002	.049	[−.425, −.001]
Private regard
Private regard	3.006	1.915	1.569	.121	[−.808, 6.819]
Asthma status	−5.505	2.264	−2.431	.017	[−10.015, −.995]
Private regard X asthma status	1.497	2.901	0.516	.607	[−4.280, 7.274]
Caregiver age	−0.237	0.112	−2.118	.038	[−.459, −0.014]

Note. N = 87. Reported coefficients are unstandardized.

Figure 1.

Conditional association between public regard and caregiver physical health according to child asthma status. Note. sample size = 87. There was a statistically significant positive association between public regard and physical health for caregivers of children with asthma (solid line) but not caregivers of children without asthma (dashed line).

Discussion

The present study examined associations between racial regard and physical health in a group of African American and Black caregivers of children with and without asthma living in a low-income, urban area. Specifically, the purpose of this study was to evaluate the impact of public and private regard on caregiver health and the potential interactive effect of child asthma status. Findings concur red with previous research showing that caregivers of children with asthma have worse physical health than caregivers of children without asthma (Brehaut et al., 2009; Cohn et al., 2020). Additionally, higher racial regard has been associated with better physical health (e.g., diet, physical activity), as well as psychological well-being in Black adults (Lewis et al., 2018). Our results extend these findings to caregivers of children with asthma living in low-income, urban areas.

However, the bivariate association between public regard and parent physical health was surpassed by the interactive, or combined effect of child asthma status and public regard. In line with our hypothesis, there was a positive association for public regard and caregiver physical health specifically for caregivers of children with asthma (Figure 1). From a risk-protection perspective (e.g., see Luthar et al., 2000), one interpretation is that the health disadvantage associated with lower public regard was heightened in the context of higher contextual stress (i.e., raising a child with asthma). Stated differently, the risk associated with raising a child with asthma was attenuated by higher public racial regard. These results are concurrent with past research showing that both caregiving for a chronically ill individual and experiencing discrimination are associated with a higher allostatic load, which in turn is associated with poorer physical health (Guidi et al., 2021).

Interestingly, while there was a combined effect of public regard and child asthma status on caregiver health, this effect was not evident for private regard. This may be partially explained by the association between experiences of discrimination and health. If public regard reflects both experiences of racism and perceptions, then Black individuals with lower public regard may experience greater distress in response to racial discrimination than those with higher public regard (Lee & Ahn, 2013) and/or may perceive more threat associated with broader systems. This could result in compounded distress for parents of children with chronic illness who are likely to have more interactions with the healthcare system. Recent literature has highlighted that internalized racism may moderate the association between experiences of discrimination and markers of health (i.e., sleep problems; Fuller-Rowell et al., 2021). Considering the nuanced interplay of these constructs would be valuable for future research focused on racial public regard, contextual risk factors, and health.

There are several limitations to this preliminary study. Notably, our sample size was relatively small and included African American and Black caregivers from urban, low-income areas, limiting the generalizability of these results. In addition, measures were presented to all participants in the same sequence, increasing the risk of order effects; future research could mitigate this risk by randomly changing the order of measures and/or items. Moreover, data regarding other individual and contextual risk and protective factors were not collected or included in the analyses. It would be interesting to examine these results with inclusion of other stressors such as parents’ own chronic illness, exposure to discrimination, and access to healthcare. Further, we did not evaluate race centrality in these analyses. While poor private regard may influence self-evaluation and stress, it is possible this association depends on how central race is to one’s identity. Finally, while the MIBI is a commonly used scale, evidence of convergent validity for the Public Regard subscale and discriminant validity for both racial regard subscales is sparse. Future research using these subscales might consider including evaluation of these psychometric properties.

Nonetheless, these results underscore the importance of individuals’ racial regard, which is likely a reflection of the stresses and threat resulting from racism and associated marginalization and discrimination in the United States. Findings supplement previous research on the role of racial regard in physical health among Black individuals and extend findings to two specific populations: individuals living in low-income, urban areas and caregivers/parents. Further, this study is the first to explore how racial regard may interact with child health risk factors for poorer parent physical health. Future research with larger samples should examine processes of effect longitudinally and assess potential explanatory constructs such as stress. In addition, it would be valuable to consider how racial regard---perhaps particularly public regard---arises from, and influences, caregivers’ interactions with broader systems. For example, healthcare providers may need to consider and validate the symptoms, concerns, and lived experiences of Black caregivers to improve their trust and adherence to health changes and treatments for themselves and their children. Findings highlight the importance of considering culturally relevant individual factors, such as racial regard, in intervention efforts focused on caregiver physical health.

Our findings also have important implications for the field of Black psychology. In particular, we suggest that within the context of the COVID-19 pandemic and an intense period of social unrest at the national level (Hawkins, 2021), more attention is needed specifically on how public and private racial regard among Black caregivers have been impacted. For instance, the pandemic has continued to highlight health disparities driven by social inequities (Gray et al., 2020), which likely have negatively impacted racial regard among Black individuals. Thus, research might be needed to enhance racial regard among individuals of color, and specifically, caregivers who are tasked with caring for children with chronic conditions. It is also possible that prevention efforts are needed that focus on promoting healthy behaviors among Black caregivers, especially those experiencing lower racial regard. Our results suggest the need to focus on physical health specifically among Black caregivers of children with asthma. Qualitative research might be one way to begin developing more sustainable and caregiver-informed, feasible initiatives to promote healthy behaviors, especially within the context of racial regard.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported in part by a grant from the VCU Presidential Research Quest Fund to the second and last authors, and CTSA award UL1TR000058 from the National Center for Advancing Translational Sciences to VCU.

Author’s Note

Jessica Greenlee is now at the University of Wisconsin, Madison, and Akea Robinson is now at the George Washington University.

ORCID iD

Rachel L. Holder

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