Perceived Discrimination,Experiential Avoidance,and Mental Health among Hispanic Adults in Primary Care

Abstract

The Hispanic population is the largest minority group in the United States and frequently experiences racial discrimination and mental health difficulties. Prior work suggests that perceived racial discrimination is a significant risk factor for poorer mental health among Hispanic in the United States. However, little work has investigated how perceived racial discrimination relates to anxiety and depression among Hispanic adults. Thus, the current study evaluated the explanatory role of experiential avoidance in the relation between perceived racial discrimination and anxiety/depressive symptoms and disorders among Hispanic adults in primary care. Participants included 202 Spanish-speaking adults (M_age = 38.99, SD = 12.43, 86.1% female) attending a community-based Federally Qualified Health Center. Results were consistent with the hypothesis that perceived racial discrimination had a significant indirect effect on depression, social anxiety, and anxious arousal symptoms as well as the number of mood and anxiety disorders through experiential avoidance. These findings suggest future work should continue to explore experiential avoidance in the association between perceived racial discrimination and other psychiatric and medical problems among the Hispanic population.

Keywords

experiential avoidance Hispanic mental health perceived discrimination primary care

The Hispanic population is among the largest minority group in the United States (Stepler & Brown, 2016). There is consistent empirical evidence that Hispanic in the United States are exposed to frequent and clinically significant types of racial discrimination (Stuber et al., 2003; Trivedi & Ayanian, 2006). Such racial discrimination is important from a public health perspective because greater rates of discrimination are related to numerous negative consequences. For instance, perceived racial discrimination is associated with poorer physical health and greater health complaints among Hispanic persons (Kessler et al., 1999; Pérez et al., 2008; Williams et al., 2003). Other work has documented that racial discrimination among Hispanic adults is linked to less treatment-seeking behavior (Hausmann et al., 2008; Lauderdale et al., 2006; Ryan et al., 2008). In terms of mental health, higher rates of racial discrimination or perceived discrimination among Hispanic individuals are consistently related to globally higher rates of psychiatric symptoms (Araújo & Borrell, 2006; Finch et al., 2000; Moradi & Risco, 2006; Williams et al., 1997).

The most common psychiatric symptoms among Hispanic individuals are anxiety and depression (Martín-Santos et al., 2008; Meeske et al., 2013; Pina & Silverman, 2004; Pole et al., 2005). Although not always consistent (Huang et al., 2006; Ortega & Rosenheck, 2000), research has indicated that anxiety and depression are correlated with higher personal impairment among Hispanic relative to non-Hispanic Whites (Moitra et al., 2014; Polo et al., 2011). Additionally, the impact of anxiety and depression may be underestimated among Hispanic individuals, as some research has found that this group may be more apt to somaticize emotional experiences (Escobar et al., 1983; Mezzich & Raab, 1980; Varela et al., 2007). Thus, physical health complaints could overshadow underlying anxiety or depressive symptoms (Mezzich & Raab, 1980). Although the public health impact of anxiety and depression among Hispanic individuals is well-established, there is a need to better link such research to racial discrimination among this group. Specifically, more research is needed on the cognitive-affective processes that may underpin the association between perceived racial discrimination and anxiety and depression among Hispanic persons.

One promising transdiagnostic factor for psychological distress is experiential avoidance (Hayes et al., 1996). Experiential avoidance reflects the tendency to be consistently (i.e., inflexibly) unwilling to remain in contact with aversive internal experiences, including thoughts, emotions, and physical sensations (Hayes et al., 1996). Such unwillingness to experience aversive internal sensations is believed to be associated with deliberate and automatic efforts to alter the form, frequency, or contexts that occasion these experiences (Hayes et al., 1996). Research largely among non-Hispanic Whites over the past two decades has found that experiential avoidance is a transdiagnostic construct. That is, it reflects a broad-band vulnerability to the individual difference level (Blackledge & Hayes, 2001; Hayes et al., 1996). Importantly, experiential avoidance is distinct from other transdiagnostic factors, including emotion regulation (Kashdan et al., 2006) and the tendency to experience negative affect (Gámez et al., 2011). Experiential avoidance may be a central mechanism in the etiology and maintenance of psychological distress (see review by Chawla & Ostafin, 2007) and a core therapeutic target for psychological health (see review by Ruiz, 2010). For instance, work has found that experiential avoidance is associated with anxiety broadly (Kashdan et al., 2008), as well as social anxiety and depression symptoms (Kashdan et al., 2010), and generalized anxiety disorder (Roemer et al., 2005). More recent longitudinal work suggests that experiential avoidance is a relatively stable trait-like construct, with state-like fluctuations related to the presence of emotional and fear-related disorders (Spinhoven et al., 2014). Experiential avoidance also appears to be related to the emergence and trajectory of anxiety/depression symptoms in late adolescence (Mellick et al., 2019). While most work on experiential avoidance and its mental health correlates has been conducted with non-Hispanic Whites, there is growing evidence that the phenomenon may affect all racialized and ethnic groups. For instance, experiential avoidance is related to greater anxiety and depression among racialized and ethnic minorities in general (Zvolensky et al., 2016) as well as among Hispanic individuals specifically (Bakhshaie et al., 2017; Raines et al., 2018).

Experiential avoidance may be one transdiagnostic mechanism that could explain, in part, the association between perceived racial discrimination and anxiety/depressive disorders among Hispanic individuals. Indeed, perceived racial discrimination is consistently linked to heightened levels of negative affect (Gee & Payne-Sturges, 2004; Geronimus et al., 2015; LaVeist et al., 2003; Williams et al., 2003). Consistent with a fear-avoidance model of emotional processing (Hayes et al., 1996; Vlaeyen & Linton, 2000), Hispanic individuals who experience such personal discomfort may be more likely to be motivated to escape or avoid the immediate situation (e.g. avoiding broader social and economic participation with a racist society), which may provide short-term relief from distress. Yet, such ‘experiential avoidance’ should theoretically promote greater anxiety and depression over time because the temporary relief from distress reinforces avoidant behavior (Hayes et al., 1996). Further, some efforts to escape or avoid threatening stimuli may actually promote the intensity and severity of the emotions and thoughts being avoided (Wegner & Zanakos, 1994). When such experiential avoidance tactics are employed consistently and across all situations, they are highly associated with greater psychological distress (Lynch et al., 2001). Thus, following a positive feedback process, perceived racial discrimination may reward escape and avoidance behavior (i.e., experiential avoidance) by mitigating the acute aversiveness of the emotional experience.

The current investigation tested whether experiential avoidance explains, in part, the relation between perceived racial discrimination and anxiety/depressive symptoms and disorders among Spanish-speaking Hispanic adults in primary care. Hispanic individuals tend to present with somatic complaints in relation to psychological distress (e.g., Varela et al., 2007) and evidence suggests that Hispanic persons frequently seek mental health services from primary care settings compared to other resources (Bridges et al., 2012; Vega & Lopez, 2001). Therefore, it is pertinent to investigate these relations among a sample of Spanish-speaking Hispanic adults in a primary care setting. It was hypothesized that experiential avoidance would explain, in part, the relations between perceived racial discrimination and anxiety and depression.

Method

Participants

Participants for the current study were 202 Spanish-speaking adults (M_age = 38.99, SD = 12.43, 86.1% female) attending a community-based Federally Qualified Health Center (FQHC). Participants were eligible to participate if they demonstrated Spanish-language fluency (to ensure comprehension of self-report measures and interviews administered in Spanish) as evidenced by the ability to read, write, and communicate in Spanish, and were between 18 to 64 years old. Participants were excluded if they exhibited limited mental competency and/or inability to provide informed, voluntary, written consent, or if they endorsed current or past psychotic-spectrum symptoms via structured interview screening. Most participants were Mexican/Mexican American (54.5%), followed by 24% Central American, 8.6% American, 5.2% South American, 1.7% Cuban, 0.4% Puerto Rican, 0.9% Dominican, and 2.6% of participants identified as “Other”. On average, individuals reported earning an annual income rate of < $30,000 annually, and an average of 19 (SD = 13.61) years living within the US. Further, 57.1% of individuals reported being in a committed relationship (married or cohabitating), 46.9% reported being unemployed, and an average of 10.63 (SD = 3.78) years of education. In terms of psychiatric diagnoses, results from the MINI International Neuropsychiatric Interview (MINI; Sheehan et al., 1997) diagnostic interview indicated that 15.3% of individuals met criteria for Major Depressive Disorder, 3.5% for Panic Disorder, 3.5% for Agoraphobia, 3.5% for Social Anxiety Disorder, 1.0% for Obsessive-Compulsive Disorder, 3.0% for Post-Traumatic Stress Disorder, and 0.5% for Generalized Anxiety Disorder.

Measures

Sociodemographic Form

The sociodemographic form collected information regarding age, sex, years in the US, relationship status, employment status, level of education, and place of birth.

MINI International Neuropsychiatric Interview (MINI; Sheehan et al., 1997)

The MINI is a clinician-administered diagnostic assessment. This semi-structured interview provides reliable DSM-IV diagnoses within a short time frame, which is applicable to primary care settings (Lecrubier et al., 1997). The MINI has demonstrated sound inter-rater and test-retest reliability and validity (Sheehan et al., 1997). The validity of the Spanish version of the MINI has been established (Bobes, 1998) and successfully employed among Spanish-speaking samples (e.g., Zvolensky et al., 2017). Further, the interviews were administered in Spanish by Spanish-speaking staff who were formally trained in MINI diagnostic interviewing. Interviewers were supervised by an independent doctoral-level rater. Approximately 12% of the MINI interview videos (including audio) were randomly checked through a trainer-review process; no cases of diagnostic coding disagreement were noted. For this study, the total number of current mood and anxiety disorders per MINI for each individual was used as a criterion variable.

Social, Attitudinal, Familial, and Environmental Acculturation Stress Scale (SAFE; Mena et al., 1987)

The SAFE was utilized to operationalize an individual's perceived racial discrimination. This 24-item measure measures stressors associated with acculturation in a variety of contexts (e.g., social, attitudinal, familial, and environmental), as well as perceptions of discrimination by individuals of acculturating populations. Within the Hispanic community, this measure has shown to be valid and reliable (Hovey & Magaña, 2000). Items are rated on a 5-point Likert scale (1 = not stressful to 5 = extremely stressful). For the current study, as in past work (Negi, 2013), items that directly tapped into stress associated with discrimination and stigma were used. Such items were "Because of my ethnicity, people exclude me from participation in activities”, followed by, "Many people stereotype my culture or ethnic group, and they treat me as if they are in the righ", then, "When I look for work, I feel limited due to my ethnicity/ race", and lastly, "I feel uncomfortable when people laugh at people from my ethnic group”. As in past work (Negi, 2013), a composite score was made by summing the perceived discrimination items and this score was then used as the predictor variable. This scale evidenced excellent internal consistency (Cronbach's α = 0.95).

Acceptance and Action Questionnaire (AAQ; Bond et al., 2011)

The AAQ is a 10-item self-measure designed to measure experiential avoidance. The AAQ is rated on a 7-point Likert scale from (1 = never true to 7 = always true). The current study utilized the Spanish-language version of this questionnaire (Ruiz et al., 2013), which has been successfully employed among Spanish-speaking samples in past work (Bakhshaie et al., 2017; Zvolensky et al., 2015). The AAQ demonstrated good internal consistency (Cronbach's α = 0.83).

Inventory of Depression and Anxiety Symptoms (IDAS; Watson et al., 2007)

The IDAS is a 64-item self-report measure used to assess a variety of distinct affect symptoms and disorders within the dimensions of depression and anxiety. This measure inquires over an individual's previous two-week period and contains 10 specific symptom-based subscales. Each item rated on a 5-point Likert scale ranging from (1 = not at all to 5 = extremely). Subscales of the IDAS have shown strong internal consistency, convergent and discriminant validity with psychiatric diagnoses and self-report measures as well as short-term retest reliability among samples of both community, and psychiatric participants, respectively (Watson et al., 2007). The IDAS Spanish version has been utilized in past work and demonstrates sound psychometric properties (Zvolensky et al., 2015). Specifically, the general depression subscale (20 items; e.g., “I felt exhausted” [Cronbach's α = 0.89]), the social anxiety (5 items; e.g., “I found it difficult to make eye contact with people” [Cronbach's α = 0.90]) as well as the anxious arousal (8 items; e.g., “I felt pain in my chest” [Cronbach's α = 0.98]) subscales were used.

Procedure

Participants attended a community-based primary health care clinic that serves a Hispanic population. Individuals provided informed written consent (in Spanish) prior to participation in study procedures. After providing consent, participants completed a semi-structured clinical interview (MINI) and self-report measures. All measures were administered in Spanish, including the semi-structured interview. Where no translated versions of a measure existed (i.e. SAFE), the measure was translated into Spanish by a native Spanish-speaking doctoral-level researcher and followed a quality assurance form. The translated measure was then reviewed by bilingual research staff and approved by the Institutional Review Board at the University of Houston. Participants were compensated with $20. The University of Houston Institutional Review Board approved the study protocol.

Data analytic plan

Analyses were conducted using SPSS version 24. Firstly, bivariate correlations among variables were examined. Then, the proposed analysis was conducted using bootstrapping techniques through the PROCESS Macro (Hayes & Preacher, 2013), a computational tool for observed variable analysis using IBM SPSS version 24.0. Ten thousand bootstrap re-samplings were conducted to detect the indirect effects of the proposed predictor on dependent variables through experiential avoidance (i.e., the product of the beta coefficients of path A and path B). As a non-parametric method, bootstrapping estimates the sampling distribution of an estimator based on resampling with replacement. The indirect effect was computed for each of the samples, resulting in an empirically generated sampling distribution (Hayes & Preacher, 2013). Separate analyses were conducted for each dependent variable, with perceived discrimination as the predictor and experiential avoidance as the proposed explanatory variable in each analysis (see Figure 1). We adjusted for age, sex, relationship status and years in the US, as past work has found these variables to be related to mental health among Hispanic groups (Noonan et al., 2016; Winkleby et al., 1995; Zvolensky et al., 2014). Completely standardized point estimates were used as a measure of effect size for the current study. Effect sizes of .01, .09, and.25 refer to small, medium, and large effects, respectively (Preacher & Kelley, 2011). Percent mediation (P_M)) is the percent for which the indirect effect accounts for the total effect and was also calculated for each model. Further, theoretical models for each criterion variable were compared with an alternative model. Specifically, the predictor and mediator were reversed, such that perceived discrimination was tested as a mediator of the associations between experiential avoidance and each criterion variable (Judd & Kenny, 2010; Kraemer et al., 2008; Preacher & Hayes, 2008).

Figure 1.

Proposed model: Experiential avoidance as the proposed mediator of the relationship between perceived discrimination and depression, social anxiety, anxious arousal, and the number of mood and anxiety disorders.

Results

Bivariate correlations

Bivariate correlations are presented in Table 1. Perceived discrimination was positively correlated with experiential avoidance (r = 0.28), depression (r = 0.33), social anxiety (r = 0.28), anxious arousal (r = 0.31), and number of mood/anxiety disorders (r = 0.26). Experiential avoidance was also positively associated with depression (r = 0.53), social anxiety (r = 0.43), anxious arousal (r = 0.45), and number of mood/anxiety disorders (r = 0.29).

Table 1.

Descriptive statistics and bivariate correlations between study variables.

	1	2	3	4	5	6	7	8	9	10	Mean (SD) or %
1. Age^a	1	0.090	0.252**	−0.203**	0.148*	0.025	0.092	−0.020	0.025	0.067	38.99 (12.43)
2. Sex^a		1	.039	−0.024	0.039	0.082	0.040	0.005	−0.020	0.070	86.1% Female
3. Yrs-US^a			1	−0.074	0.112	0.011	0.076	0.131	0.056	0.029	19.07 (13.6)
4. Marital^a				1	0.043	0.081	0.122	0.045	0.052	0.149*	57.1% with partner
5. Exp avoidance^c					1	0.282**	0.531**	0.425**	0.449**	0.291**	30.18 (8.72)
6. Perceived discrimination^b						1	0.338**	0.284**	0.313**	0.260**	6.59 (3.02)
7. Depression^d							1	0.680**	0.719**	0.453**	22.28 (7.66)
8. Social anxiety^d								1	0.773**	0.419**	4.20 (2.18)
9. Panic^d									1	0.473**	8.27 (4.37)
10. Mood and anxiety disorders^d										1	0.38 (0.78)

Note: N = 202; p <.01, * p <.05;

= Covariate

= Explanatory variable

= Predictor

= Outcome

Sex = % Female (coded as, 1 = Male and 2 = Female); Age = age in years; Yrs-US = Number of years living in the US; Exp avoidance = Experiential avoidance as measured by the Acceptance and Action Questionnaire (Bond et al., 2011); Perceived discrimination = Discrimination measured by the Social, Attitudinal, Familial, and Environmental Scale (Mena et al., 1987); Depression, social anxiety and panic = total scores of these three subscales as measured by the Inventory of Depression and Anxiety Symptoms (Watson et al., 2007); Mood and anxiety disorders = Composite score of mood and anxiety disorders present in the sample.

Indirect effects

Depression

In relation to depression, the c path was significant (see Table 2; b = 0.84, SE = 0.18, p < .001, 95% CI [0.50, 1.19]). There was also a significant indirect effect of perceived discrimination through experiential avoidance on depression (b = 0.46, SE = .10, p < .001, 95% CI [0.19, 0.59], P_m = .05), completely standardized point estimate (β = 0.14). After accounting for the effects of experiential avoidance, the direct effect (c’ path) of perceived discrimination was a significant direct effect (b = 0.50, SE = 0.17, p = .01, 95% CI [0.16, 0.81]).

Table 2.

Mediation results.

Y	Model	B	SE	t	p	Lower CI	Upper CI
Depression	Discrimination --> depression (c)	0.84	0.18	4.38	<.001	0.5	1.19
Depression	Discrimination --> depression(c’)	0.5	0.17	2.95	.01	0.16	0.81
	EA--> discrimination--> depression (a*b)	0.06	0.03	−	−	0.01	0.12
	Discrimination-->EA-->depression (a*b)	0.46	0.1	−	−	0.19	0.59
Social anxiety	Discrimination --> social anxiety (c)	0.21	0.05	3.94	.001	0.10	0.31
Social anxiety	Discrimination --> social anxiety (c’)	0.12	0.05	2.33	.02	0.02	0.22
	EA-->discrimination--> social anxiety (a*b)	0.01	0.01	−	−	0.02	0.04
	Discrimination-->EA-->social anxiety (a*b)	0.09	0.03	−	−	0.04	0.16
Anxious arousal	Discrimination--> anxious arousal (c)	0.45	0.1	4.38	.001	0.25	0.66
Anxious arousal	Discrimination--> anxious arousal (c’)	0.28	0.10	2.74	.01	0.08	0.47
	EA--> Discrimination--> anxious arousal (a*b)	0.03	0.02	−	−	0.01	0.08
	Discrimination-->EA-->anxious arousal (a*b)	0.18	0.06	−	−	0.08	0.34
Number of mood and anxiety disorders	Discrimination --> #mood/anx disorders (c)	0.06	0.02	3.47	.006	0.03	0.1
Number of mood and anxiety disorders	Discrimination --> #mood/anxiety disorders (c’)	0.05	0.02	2.53	.012	0.01	0.08
	EA-->Discrimination-->#mood/anxiety disorders (a*b)	0.01	0.003	−	−	0.00	0.01
	Discrimination-->EA-->#mood/anxiety disorders (a*b)	0.02	0.01	−	−	0.01	0.04

Note: N = 202. The standard error and 95% CI for the indirect effects (a*b) are obtained through bootstrapping 10,000 re-samples. a path = Effect of X on M; b paths = Effect of M on Y; c’ paths = Direct effect of X on Y controlling for M; c paths = Total effect of X on Y. Exp avoidance = Experiential avoidance as measured by the Acceptance and Action Questionnaire (Bond et al., 2011); Perceived discrimination = Discrimination measured by the Social, Attitudinal, Familial, and Environmental Scale (Mena et al., 1987); Depression, social anxiety and panic = total scores of these three subscales as measured by the Inventory of Depression and Anxiety Symptoms (Watson et al., 2007); Mood and anxiety disorders = Composite score of mood and anxiety disorders present in the sample.

Social anxiety

For social anxiety, the c path was also significant (see Table 2; b = 0.21, SE = 0.05, p = .001, 95% CI [0.10, 0.31]). The indirect effect of perceived discrimination via experiential avoidance was significant (b = 0.09, SE = 0.03, bootstrapped 95% CI [0.04, 0.16], P_M = .04), completely standardized point estimate (β = 0.12). After accounting for the effects of experiential avoidance, the direct effect (c’ path) of perceived discrimination was (b = 0.12, SE = 0.05, p = .02, 95% CI [0.02, 0.22]).

Anxious arousal

In relation to perceived discrimination and anxious arousal, the c path was significant (see Table 2; b = 0.45, SE = 0.10, p < .001, 95% CI [0.25, 0.66]). There was also a significant indirect effect of perceived discrimination through experiential avoidance, on anxious arousal shown (b = 0.18, SE = 0.06, bootstrapped 95% CI [0.08, 0.34], P_M = .04), completely standardized point estimate (β = 0.12). Lastly, after accounting for the effects of experiential avoidance, the direct effect (c’ path) of perceived discrimination remained significant (b = 0.28, SE = 0.10, p = .01, 95% CI [0.08, 0.47]).

Number of mood/anxiety disorders

In relation to number of mood and anxiety disorders, the c path was significant (see Table 2; b = 0.06, SE = 0.02, p = .006, 95% CI [0.03, 0.10]). There was also a significant indirect effect of perceived discrimination through experiential avoidance on number of mood/anxiety disorders (b = 0.02, SE = 0.01, bootstrapped 95% CI [0.01, 0.04], P_m = .02), completely standardized point estimate (β = 0.06). After accounting for the effects of experiential avoidance, the direct effect (c’ path) of perceived discrimination was a significant direct effect (b = 0.05, SE = 0.02, p = .012, 95% CI [0.01, 0.08]).

Specificity analyses

To further strengthen the interpretation of results, alternative models were tested by reversing the proposed mediator for each of the three models (Preacher & Hayes, 2004); specifically, experiential avoidance was the predictor, perceived discrimination was the indirect variable, and all three dependent variables remained the same. The indirect effects of the alternative models was significant for depression (b = 0.06, SE = 0.03, bootstrapped 95% CI [0.01, 0.12], P_M = 0.01; see Table 2), completely standardized point estimate (β = 0.06), social anxiety (b = 0.01, SE = 0.01, 95% CI [0.02, 0.04], P_M = 0.01), completely standardized point estimate (β = 0.05), and anxious arousal (b = 0.03, SE = 0.02, 95% CI [0.01, 0.08], P_M = 0.01), completely standardized point estimate (β = 0.06). Additionally, the indirect effect of the alternative model for number of mood and anxiety disorders was also significant (b = 0.01, SE = 0.003, bootstrapped 95% CI [0.00, 0.01], P_M = 0.01), completely standardized point estimate β = 0.05).

Discussion

Perceived racial discrimination is a highly common risk factor for anxiety and depression and poorer mental health in general among Hispanic individuals (Berg et al., 2011; Finch et al., 2000; Flores et al., 2008). Yet, there is highly limited empirical data on the processes by which perceived racial discrimination is related to anxiety and depression among Hispanic adults (Alvidrez, 1999; Bledsoe, 2008). Therefore, the present study examined whether experiential avoidance explains, in part, the relation between perceived racial discrimination and anxiety/depressive symptoms and disorders among Hispanic adults in primary care.

Findings from the investigation indicated that perceived racial discrimination exerted a significant indirect effect through experiential avoidance in terms of depression, social anxiety, and anxious arousal symptoms as well as number of mood and anxiety disorders. The indirect effects for experiential avoidance were statistically small, with effect size estimates ranging from 6% for number of mood/anxiety disorders to 12% for social anxiety and anxious arousal, and 14% for depression. Importantly, the indirect effects were evident after adjusting for age, sex, relationship status, and years in the US. Such findings are in line with the theoretical perspective that experiential avoidance may represent a transdiagnostic mechanism underlying the relation between perceived racial discrimination (Chawla & Ostafin, 2007; Kashdan & Rottenberg, 2010) and anxiety/depressive symptoms and disorders among Hispanic persons.

Inspection of the specificity tests indicated that bi-directional relations may be evident between the studied variables. Specifically, experiential avoidance may be associated with increased perceived racial discrimination, which in turn, is related to anxiety/depression. Broadly, such results, in conjunction with the findings of the first set of mediational tests, suggest that these two constructs – perceived racial discrimination and experiential avoidance – are important explanatory variables among Hispanic individuals. Still, it is important to highlight that the effect size for experiential avoidance as the explanatory variable was greater across all models (effect size range 6–14%) tested than that for perceived racial discrimination with effect sizes ranging from 5% to 6%. Such data suggest that there may be a relatively greater degree of validity to experiential avoidance as a mechanistic variable in the present tests. Based upon these novel findings, there is a need to replicate and extend the current results using prospective and laboratory-based research designs. This type of additional work could help explicate the temporal ordering of the observed relations. Theoretically, it is possible that recurrent racial discrimination may increase experiential avoidance as a coping strategy for dealing with such toxic personal experiences (Chawla & Ostafin, 2007). Yet, in a non-mutually exclusive manner, it also may be that greater experiential avoidance may increase the probability of threat processing (Forsyth et al., 2003), thereby heightening perceptions of racial discrimination. Both perspectives would yield a similar affective experience: greater risk for more severe anxiety and depression.

Although not the primary aim of the current study, it is noteworthy that experiential avoidance and perceived racial discrimination shared only 7% of variance. These data suggest that these psychological constructs are non-overlapping and empirically distinct from one another. Yet, because both experiential avoidance and perceived racial discrimination were consistently associated with anxiety/depression at the bi-variate level among the studied Hispanic sample (see Table 1), these data underscore the clinical and theoretical utility in continued efforts to understand the processes by which these factors confer affective vulnerability among this health disparities population.

The findings from the present investigation may serve to conceptually inform the utilization of targeted assessment batteries and the development of specialized intervention strategies for Hispanic adults in primary care. At the most basic level, the current data suggest it would be clinically important to assess for perceived racial discrimination and experiential avoidance in primary care settings. In this regard, clinicians should strive to ensure they are knowledgeable and comfortable asking their patients about experiences of racial discrimination in a culturally sensitive manner. Further, to decrease the relative risk for anxiety and depression in such settings, there may be utility in developing integrated therapeutic and culturally adapted protocols for Hispanic individuals with higher levels of acculturative stress and experiential avoidance. Here, there may be clinical utility in drawing from past work on Acceptance and Commitment Therapy (ACT) that has shown to decrease experiential avoidance and improve mental health (Lillis & Hayes, 2007; Luoma et al., 2007; Villatte et al., 2016; Woidneck et al., 2012), including among Hispanic groups (Hinton et al., 2011). It may be useful to integrate ACT with psychoeducation about perceived racial discrimination in one integrated protocol that is focused on the Hispanic population (Hayes et al., 2011). Such an approach may offer clinical benefits for anxiety and depression among this health disparities group.

The current investigation has some limitations. First, causal relations cannot be determined from the present research design. Therefore, future research should build from the current findings and use prospective and laboratory methodologies to further understand the interplay between perceived racial discrimination and experiential avoidance in relation to anxiety and depression. Second, most of the sample were female. Although females compared to males are more apt to seek medical care in the Hispanic population (Burgess et al., 2008; Flores & Vega, 1998; Hofstede, 2001), there is a needed to have more sex-balanced samples in future research. For example, some work has shown that gender differences in terms of type of health service used exist with women being more likely to use primary care services (Koopmans & Lamers, 2007). Additional empirical evidence suggests that a high proportion of Hispanic women (77.3%), relative to Hispanic men (63.5%) report any physician office visit within a given year (Manuel, 2018). Accordingly, future work may seek to understand the impact of gender and role expectations (Hawkins et al., 2017) and other culturally-relevant factors which may serve as deterrents or barriers for Hispanic males in terms of seeking care, including machismo, denial, and fatalism (Hunter et al., 2007; Macnaughton, 2008). Further, it may be an important next step to investigate how sociocultural protective and risk factors, such as stoicism, familism, and active coping styles, may modulate the observed associations in the present study; prior work has shown that such factors are important to understanding sickness behavior across sex and racial/ethnic groupings (Shattuck et al., 2020). Finally, the sample was comprised primarily of Mexican- and Central-American participants and the role of immigration and geopolitical experience among this group were not modeled except for the number of years in the U.S. Accordingly, there is a need for future research to more comprehensively explore the generalizability of the present findings to larger samples from South America and further characterize immigration experience.

Together, the current investigation sheds novel insight into the nature of perceived racial discrimination in terms of anxiety and depression among Hispanic adults in primary care. The findings highlight the role of experiential avoidance in the association between perceived discrimination and mental health among Hispanic persons. Based upon these findings, future research could usefully further explore the role of experiential avoidance in the relations between perceived racial discrimination and other psychiatric and medical problems among Hispanic individuals.

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) received no financial support for the research, authorship and/or publication of this article.

ORCID iD

Michael J. Zvolensky

Michael Zvolensky, PhD: Dr Zvolensky is a Distinguished Professor in the Department of Psychology at University of Houston and Director of the Anxiety and Health Research Laboratory and Substance Use Treatment Clinic. He has published over 700 peer-reviewed articles and books/book chapters on the co-occurrence of anxiety and stress-related psychopathology with substance use disorders, health behavior problems, and physical illness (e.g., chronic pain). His work is globally aimed at eliminating inequalities in psychopathology, addictive, and other health risk behaviors through translational research.

Andrew Rogers, MA: Andrew Rogers, MA, is a clinical psychology graduate student in the Department of Psychology at the University of Houston. Mr Rogers researches the intersection of chronic pain and substance use. His published work focuses specifically on chronic pain and opioid use, and identifying how transidagnostic vulnerability factors (i.e. pain-related anxiety, emotion dysregulation, anxiety sensitivity) may be targeted in treatment to reduce overall disease burden and health disparities.

Nubia A. Mayorga, MA: Nubia Mayorga, MA, is a current PhD candidate in the clinical psychology program at the University of Houston. Ms Mayorga's research interests evaluate the role minority stressors play within the processes of addictive behaviors and substance misuse as well as identifying what individualized factors may serve as resilience or risk factors. Her published works aim to build a strong foundation and understanding of mental health outcomes and behaviors among racial and ethnic minority groups.

Justin Shepherd, MA: Justin M. Shepherd, MA, is a doctoral student in the clinical psychology program at the University of Houston. He has charted a line of work focused on risk and protective factors of addictive behavior in relation to clinically relevant treatment and negative health-related outcomes. In particular, his work aims to elucidate malleable mechanistic factors (e.g., anxiety sensitivity, pain-related anxiety) that underlie relations between tobacco use and negative mental and physical health outcomes, particularly among underserved and vulnerable populations.

Jafar Backshaie, MD PhD: Jafar Bakhshaie, MD PhD, is a clinical psychologist and clinical and research fellow at the Integrated Brain Health Clinical and Research Program at the Massachusetts General Hospital (MGH). Dr Bakhshaie received his MD from the Tehran University of Medical Sciences and his PhD (with a minor in biostatistics) from the University of Houston clinical psychology program. He also completed a clinical research fellowship at the Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine. He is currently serving as lead clinician in an NIH-funded multi-site feasibility RCT, involving a mind-body toolkit aimed to facilitate recovery among orthopedic injury patients with catastrophic thinking about pain. His current work is focused on the development of web-based mind-body interventions for various clinical populations with comorbid medical and mental illnesses such as individuals with comorbid orthopedic pain and emotional distress.

Monica Garza, PhD: Dr Monica Garza, PhD is a Clinical Psychologist at Legacy Community Health Clinic in Houston, TX. Her published works focus on understanding mental health disorders such as anxiety, depression, and suicidal behaviors among Latinos in primary care, as well as other racial and ethnic minority groups.

Andres Viana, PhD: Andres G. Viana, PhD, is the Director of the Child Temperament, Thoughts, and Emotions Laboratory and an associate professor of psychology in the Department of Psychology at University of Houston. Dr Viana researches temperamental and cognitive-affective mechanisms implicated in anxiety, trauma, and substance use comorbidity. He is currently the Principal Investigator on a NIAAA-funded study examining sociocultural mechanisms implicated in the alcohol-anxiety comorbidity among Latinx drinkers. The overarching goal of Dr Viana's program of research is to advance knowledge regarding the causes of emotional disorders and to improve existing treatments.

Melissa Ochoa-Perez, MD: Dr Ochoa-Perez is a psychiatrist at Legacy Community Health Clinic in Houston, TX. Dr Ochoa-Perez received her MD from Baylor College Of Medicine. Her specialties include adult and child/adolescent psychiatry. Her published works focus on mental health problems within economically disadvantaged populations.

Chad Lemaire, MD: Dr Chad Lemaire, MD, is a psychiatry specialist in Houston, TX. He currently practices at Legacy Community Health Montrose Clinic. Dr Lemaire received his MD from Baylor College Of Medicine. His published works focus on mental health behavior problems such as anxiety, posttraumatic stress, emotion dysregulation, and acculturative stress among Latinos in primary care.

Ana Ruiz, B.S, is a research coordinator at UTHealth Harris County Psychiatric Center. Her primary research interest is examining the factors that contribute to health disparities in the Latinx population. She is also interested in exploring the biological underpinnings of certain psychiatric disorders. Ruiz’ published works focus on elucidating the risk factors that contribute to severe mental illness in underserved communities.

Natalia Peraza, BS: Natalia Peraza, BS, is a project assistant at the USC Health, Emotion, & Addiction Laboratory at the University of Southern California. Her research interests include understanding the comorbidity of mental health disorders and addictive behaviors and identifying populations that may be at greater risk for maladaptive mental health and substance use problems. Ms Peraza's published works aim to highlight factors that contribute to problematic substance use and mental health outcomes.

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