CLINICAL SCHOLARSHIP

An Integrative Review of Relationships Between Discrimination

and Asian American Health
Sarah B. Nadimpalli, RN, BSN, MA1 , & M. Katherine Hutchinson, PhD, RN, FAAN2
1 Upsilon, Doctoral Candidate, New York University, College of Nursing, New York, NY
2 Upsilon, Associate Professor, New York University, College of Nursing, New York, NY

Key words Abstract

Nursing, discrimination, racism, health
outcomes, Asian American, health disparities
Correspondence
Sarah B. Nadimpalli, New York University,
College of Nursing, 726 Broadway, 10th Floor,
New York, NY, 10003. E-mail: sb3354@nyu.edu
Accepted February 25, 2012
doi: 10.1111/j.1547-5069.2012.01448.x
Purpose: Many ethnic minorities in the United States experience dispropor-
tionate rates of adverse health outcomes or health disparities. Factors such as
socioeconomic status do not fully explain how these disparities are generated
and maintained. Research has demonstrated that chronic experiences of dis-
crimination are harmful to the health of African Americans and Latinos. How-
ever, there is a dearth of research examining Asian Americans experiences
with discrimination and health disparities. The purpose of this integrative re-
view was to summarize the current literature examining discrimination and
the mental and physical health of Asian Americans.
Design and Methods: Combinations of search terms related to discrim-
ination, health, and Asian Americans were used to search five electronic
databases. Inclusion criteria were primary research studies, published in En-
glish between 1980 and 2011, Asian American adults, and discrimination ex-
amined in relationship to a physical or mental health outcome. The search
initially yielded 489 results; 14 quantitative studies met inclusion criteria.
Findings and Conclusions: Quantitative studies in this review revealed
several significant associations between discrimination and health outcomes in
Asian Americans. Discrimination was significantly associated with depressive
symptoms in seven studies. Three studies found associations between dis-
crimination and physical health, including cardiovascular disease, respiratory
conditions, obesity, and diabetes. Although the literature was limited by
self-reported data, cross-sectional designs, and inconsistent definitions and
measurement of discrimination, the findings suggest that discrimination is
a significant contributor to poorer health and health disparities for Asian
Americans. The findings clearly demonstrate the need for further nursing
research in this area to inform evidence-based practice and social policy.
Clinical Relevance: Patient care providers can recognize discrimination as a
significant stressor or purveyor of illness and explore ways to facilitate coping
and resilience with their Asian American patients. Community-based partic-
ipatory research approaches can be implemented by clinicians, academicians,
and Asian American community partners to address the issue of discrimination
and Asian American health outcomes.

Health disparities pose complex social, economic, and tal disorders (U.S. Department of Health and Human
personal problems for minorities in the United States Services [USDHHS], 2001). Studies have linked socioe-
(US). In a seminal report, the U.S. Surgeon General conomic status, gender, and genetic factors with stress-
identified racial discrimination as a risk factor for men- related illnesses and subsequent poorer health outcomes

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(Trinh-Shevrin, Islam, & Rey, 2009; Williams, Yu, &
Jackson, 1997). However, these factors do not fully ex-
plain racial and ethnic health disparities (Williams et al.,
1997). Recent studies have found significant relation-
ships among discrimination, stress response, and health
among African Americans and Latinos (Krieger & Sid-
ney, 1996; Paradies, 2006). However, Asian Americans
have been largely overlooked in the discrimination and
health disparities literature (Gee, Ro, Gavin, & Takeuchi,
2008; Paradies, 2006); an in-depth examination of how
discrimination impacts the health of Asian Americans is
warranted.
Background and Signicance
Disparities and Asian American Health
By 2050, the Asian American population is expected to
increase from 15.5 million to 40.6 million (Oh, Koeske, &
Sales, 2002). Asian Americans are one of the most het-
erogeneous ethnic minority groups in the US and in-
clude more than 14 diverse subgroups (Trinh-Shevrin
et al., 2009). Indian, Chinese, Filipino, Korean, and Viet-
namese groups account for the majority of Asians in the
US (U.S. Census Bureau, 2007); Thais, Cambodians, and
Pakistanis represent some of the smaller Asian American
groups in the US (U.S. Census Bureau, 2007). Each Asian
American subgroup has its own unique characteristics
and immigration history (Trinh-Shevrin et al., 2009). For
example, Chinese, Koreans, and Filipinos have been
immigrating to the US since the nineteenth century,
whereas South Asians (Indians, Pakistanis) and South-
east Asians (Cambodians, Vietnamese) have only been
coming to the US in substantial numbers within the past
four decades (Trinh-Shevrin et al., 2009). Asian Ameri-
cans reside all across the US; the areas with the largest
Asian populations include California (35.2%), New York
(10%), and Texas (5.8%; U.S. Census Bureau, 2005).
More Asian women than men have immigrated to the
US, and Asian American women now comprise a sig-
nificant proportion of the U.S. workforce (Trinh-Shevrin
et al., 2009). Gender equality has become a pressing issue
for many Asian American women because their work and
family roles may conflict in their lives in modern Ameri-
can society (Trinh-Shevrin et al., 2009).
The US has an unpleasant early history of denying
Asian Americans citizenship, housing, and the right to
vote (Okihiro, 2001); despite progress in eliminating for-
mal sanctions, many Asian American immigrants still
face discrimination while seeking better occupational, ed-
ucational, and economic opportunities (Okihiro, 2001;
Trinh-Shevrin et al., 2009). Since the 1960s, the model
minority myth, suggesting that Asians have achieved suc-
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cess in educational and economic spheres, has failed to
recognize their vulnerability to social problems such as
discrimination (Trinh-Shevrin et al., 2009). A 2007 study
found that 56.1% of Asian and Pacific Islander Ameri-
cans (n = 2,095) reported they had been discriminated
against due to their race, skin color, or nationality (Gee,
Spencer, Chen, & Takeuchi, 2007). Recent events such as
the terrorist attacks on September 11, 2001, have made
South Asians, along with Arabs and Muslims, particularly
vulnerable to damaging stereotypes, acts of violence, and
social hostility (New York City Commission on Human
Rights, 2003). While South Asian Americans experiences
with discrimination have been clearly documented, little
attention has been paid to how discrimination may be
affecting their health. In addition, little is known about
how Asian Americans experiences with discrimination
and associated health disparities may vary across sub-
groups, by region and by gender.
Problem of Discrimination and Health
Relationships between experiences of self-reported dis-
crimination (SRD) and poorer physical and mental health
outcomes have been found (Krieger & Sidney, 1996;
Paradies, 2006), with most studies focusing on African
Americans (Krieger & Sidney, 1996; Paradies, 2006). SRD
has been positively correlated with depression, smok-
ing, psychological distress, hypertension, cholesterol, and
hemoglobin A1C (Krieger & Sidney, 1996; Paradies,
2006; Piette, Bibbins, & Schillinger, 2006). Associations
between SRD and hypertension in African Americans
persist across class and gender lines, even after controlling
for socioeconomic status and other covariates (Krieger &
Sidney, 1996).
In a study with Latino Americans, discrimination was
correlated with poorer general health, depression, and
symptoms, even after the imposition of statistical con-
trols (Flores et al., 2008). One study found positive as-
sociations between discrimination and depression among
Mexican immigrants (Finch, Kolody, & Vega, 2000),
while another found significant relationships with ele-
vated systolic blood pressure and poorer physical health
among adult Latinos (Ryan, Gee, & Laflamme, 2006).
Given these findings in African Americans and Latinos,
there is a need for similar studies among lesser-studied
ethnic minority groups such as Asian Americans.
Purpose and Research Question
The purpose of this integrative review was to sum-
marize the current research literature examining the
relationships between SRD and the mental and physical
health of Asian Americans. The research question was:
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What is the state of the science on relationships be-
tween discrimination and health outcomes among Asian
Americans?
Concept Denitions
Specific definitions were utilized to appropriately
conceptualize discrimination, physical health outcomes,
and mental health outcomes in this review. Personally
mediated or interpersonal discrimination was defined as
the behavioral manifestation of racism that incorporates
both racist attitudes and behaviors (Jones, 2000). Phys-
ical health outcomes were defined as a description or
measurement of the physical or physiological health of an
individual at a particular point in time against identifiable
standards (World Health Organization, 1998). Mental
health outcomes were defined as mental health prob-
lems, when mental health-related signs and symptoms do
not fully meet diagnostic criteria for mental disorders but
are still considered problematic (USDHHS, 1999). Health
outcomes were considered to be distinct from health
behaviors or generalized appraisals of quality of life.
Methods
Literature Search
The literature search methods recommended by Whit-
temore and Knafl (2005) were used to conduct searches
in March and April 2011. Several combinations of search
terms related to discrimination (racism, bias), health (de-
pression, blood pressure), and Asian Americans were
used in the following electronic databases: Anthropology
Plus, Cochrane Database of Systematic Reviews, PubMed,
Web of Science, PsycInfo, the Cumulative Index to Nurs-
ing and Allied Health Literature (CINAHL), and Excerpta
Medica Database (EMBASE). The search was limited to
primary research studies published between 1980 and
2011; a broad 30-year range was used because only a
small number of studies were anticipated and a secondary
interest was examining trends.
The sample inclusion criteria for this review were
primary research or secondary analysis research study;
sample that included or focused exclusively on Asian
American adults (18 years or older); study conducted
within the US; study that explored discrimination in
association with either a mental health or a physical
health outcome; and published in English. Exclusion cri-
teria included not a primary research study or secondary
analysis; sample that included children or adolescents;
study conducted outside of the US; studies that focused
on health behaviors but not health outcomes; and non-
English. Studies that were limited to health behavior
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Discrimination and Health
outcomes were excluded because this review was specif-
ically focused on physical and mental health outcomes.
Search Results and Data Evaluation
Collectively, the five search engines identified a total
of 489 studies. Articles were screened and omitted for
the following reasons: 31 were duplicates; and 414 were
not primary research studies or met one of the other
exclusion criteria based on title and abstract review. The
44 studies that remained were then evaluated consider-
ing the inclusion criteria; of these, 30 were eliminated
because they correlated SRD with health behaviors or
quality of life, or included multi-ethnic samples. Research
design, purpose, setting, samples, instruments, control
variables, analysis methods, and findings were extracted
for each of the remaining 14 articles and organized in a
data matrix. Another matrix was created to appraise the
strength of the studies using the critical appraisal tech-
niques of Polit and Beck (2012) as well as the Strength-
ening the Reporting of Observational Studies in Epidemi-
ology (STROBE) methodology (von Elm et al., 2007).
The data from these matrices are summarized in Table 1.
Synthesis and Analysis
To answer the research question, 14 articles were
analyzed for overall quality, emergent themes, strengths,
and limitations (Polit & Beck, 2012). After synthe-
sizing results from the 14 articles, several themes
emerged: (a) defining and conceptualizing discrimina-
tion; (b) operationalizing and measuring discrimination;
(c) identifying relationships between discrimination and
health outcomes; and (d) limitations in the literature.
Dening and Conceptualizing Discrimination
Six studies (Bernstein, Park, Shin, Cho, & Park, 2011;
Gee et al., 2006; Gee, Ro, Gavin, & Takeuchi, 2008; Lam,
2007; Mossakowski, 2003, 2007) did not provide a defini-
tion for discrimination. Eight studies defined discrimina-
tion (DeCastro, Gee, & Takeuchi, 2008; Gee, 2002; Gee,
Spencer, Chen, & Takeuchi, 2007; Gee, Spencer, Chen,
Yip, & Takeuchi, 2007; Hahm, Ozonoff, Gaumond, & Sue,
2010; Lee, 2005; Yip, Gee, & Takeuchi, 2008; Yoo, Gee &
Takeuchi, 2009). Five of these eight studies (Gee, 2002;
Gee, Spencer, Chen, & Takeuchi, 2007; Hahm et al.,
2010; Yip et al., 2008; Yoo et al., 2009) incorporated
and explicated the specific, action-based, behavioral
component of racism in their conceptualization of
discrimination.
Four of the 14 studies (Gee, 2002; Gee et al., 2008; Yip
et al., 2008; Yoo et al., 2009) used the term perceived
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Table 1. Summary of Articles

Discrimination and outcome variables

Author (year) Population, sample size, gender of interest Limitations

Bernstein et al. (2011) Korean immigrants of New York City;
n = 304; 56.6% female
De Castro et al. (2008) Filipinos living in Honolulu, HI, or San
Francisco, CA; n = 1,652; 51.7% male
Gee (2002) Chinese Americans living in California;
n = 1,503; N/A
Gee et al. (2006) Filipinos; n = 2,241; 50.7% female
Gee, Spencer, Chen, & Asian Americans included in the
Takeuchi (2007) National Latino and Asian American
Survey (NLAAS); n = 2,047; 53% female
Gee, Spencer, Chen, Diverse sample of Asian Americans
Yip, et al. (2007) included in the NLAAS; n = 2,095;
52.2% female
Gee et al. (2008) Diverse, nationally representative
sample of Asian Americans (NLAAS);
n = 1,956; 52.4% female
Hahm et al. (2010) Asian Americans as included in the
NLAAS; n = 2,095; analysis according
to gender
Lam (2007) Vietnamese American undergraduate
students in Southern California;
n = 122; 39% male
Lee (2005) Korean American undergraduate
students at the University of Texas;
n = 84; 51% male
Mossakowski (2003) Filipino Americans; n = 2,109; 49%
male
Mossakowski (2007) Filipino American Community
Epidemiological study; n = 2,129; 49%
male
Yip et al. (2008) Asian Americans (NLAAS); n = 2,047;
N/A
Yoo et al. (2009) Chinese, Vietnamese, and Korean
Americans; n = 717; 56.2% female
Acculturative stress, depressive
symptoms
Chronic health conditions
Physical and mental health conditions
Chronic health conditions, social
support
Mental disorders
Chronic health conditions
(cardiovascular and respiratory
conditions)
Higher BMI, obesity
Discrimination, depressive disorders
and suicidal ideation; physical health
problems
Collective self-esteem and
psychological distress
Depressive symptoms
Depression
Depression
Psychological distress, ethnic identity
Chronic health conditions
Limited generalizability, exclusive
self-report measures
Constructs not clearly dened, no
power analysis, self-report
Limited generalizability, measures,
and denitions
Study based on self-report,
cross-sectional design
Constructs not clearly dened or
measured; self-report, clustered Asian
subgroups
Temporal precedence issues,
clustered several, diverse clustered
Asian subgroups
Cross-sectional, reliability and validity
unreported
Cross-sectional, temporal precedence
issues, clustered Asian subgroups in
analysis
Lacked control variables, limited
generalizability, no power analysis
Small sample size, limited
generalizability
Limited generalizability
Limited discrimination measure &
generalizability
Limited discrimination measure
Clustered Asian subgroups in analysis

BMI = body mass index; N/A = not available.

discrimination. This designation was based on the no-
tion that discrimination must first be perceived before it
can be reported, yet all perceptions of discrimination may
not be reported. SRD has been proposed as the most ac-
curate terminology to use in discrimination and health
studies (Krieger, 1999; Paradies, 2006). Five of the stud-
ies in the current review (Bernstein et al., 2011; DeCastro
et al., 2008; Gee, Spencer, Chen, & Takeuchi, 2007; Gee,
Spencer, Chen, Yip, et al., 2007; Gee et al., 2008) utilized
the terminology self-reported discrimination or SRD.
While three of these studies (DeCastro et al., 2008; Gee,
Spencer, Chen, & Takeuchi, 2007; Gee, Spencer, Chen,
Yip, et al., 2007) clearly defined and operationalized SRD,
two of the studies (Bernstein et al., 2011; Gee et al.,
2008) did not. The provision of conceptual definitions
lent clarity and trustworthiness to the studies; in contrast,
the absence of conceptual definitions and clarity perpet-
uated confusion regarding measurement and conclusions
in those studies.
Operationalizing and Measuring Self-reported
Discrimination
A variety of instruments were used to measure
SRD. Six studies (Gee, 2002; Lee, 2005; Lam, 2007;
Mossakowski, 2007; Yip et al., 2008; Yoo et al., 2009)
used very brief (one to three items) measures. Five stud-
ies (Gee, Spencer, Chen, & Takeuchi, 2007; Gee, Spencer,

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Chen, Yip, et al., 2007; Gee et al., 2008; Hahm et al.,
2010; Bernstein et al., 2011) used Williams et al.s (1997)
Everyday Discrimination Scale (EDS), and three studies
(DeCastro et al., 2008; Gee et al., 2006; Mossakowski,
2003) used the EDS with one, two, or three additional
items added to it.
The Everyday Discrimination Scale. The EDS is a
nine-item instrument that elicits self-reported responses
about the frequency of unfair, chronic, and routine ex-
periences of discrimination. Examples of EDS items are:
(a) Have you ever been treated with less courtesy than
others? and (b) Have you received poorer services than
others in restaurants or stores? (Bernstein et al., 2011).
Response choices are provided using some variation of a
frequency scale; usually these choices range from never
to almost every day (Bernstein et al., 2011; Gee,
Spencer, Chen, & Takeuchi, 2007; Gee, Spencer, Chen,
Yip, et al., 2007; Gee et al., 2008; Hahm et al., 2010).
All but one study (Gee et al., 2008) employing the EDS
reported strong reliability coefficients (0.860.91; Bern-
stein et al., 2011; DeCastro et al., 2008; Gee et al., 2006;
Gee, Spencer, Chen, & Takeuchi, 2007; Gee, Spencer,
Chen, Yip, et al., 2007; Hahm et al., 2010; Mossakowski,
2003). One study employing the EDS (Gee, Spencer,
Chen, Yip, et al., 2007) reported validity measurements
with an exploratory factor analysis supported by a one-
factor structure (eigenvalue = 4.87; factor loadings =
0.670.79). However, in half the studies using the EDS,
race-based discrimination was not specified. Participants
could have attributed discrimination to such other factors
such as gender, language proficiency, or other non-race-
based forms of discrimination (DeCastro et al., 2008; Gee
et al., 2006; Gee, Spencer, Chen, Yip, et al., 2007; Hahm
et al., 2010).
Other measures. Among the six studies that used
single-item or brief measures to assess SRD (Gee, 2002;
Lam, 2007; Lee, 2005; Mossakowski, 2007; Yip et al.,
2008; Yoo et al., 2009), all clearly evoked race-based re-
sponses for SRD. One study (Yip et al., 2008) reported
a relatively strong internal reliability coefficient of 0.83.
However, given the limitations of brief measures, binary
(yes or no) scales, and lack of reported reliability and va-
lidity, the strength and accuracy in measuring the con-
struct of discrimination was questionable (Gee, 2002;
Lam, 2007; Lee, 2005; Yip et al., 2008; Yoo et al., 2009).
Identifying Relationships Between
Discrimination and Health Outcomes
Discrimination and mental health problems.
Nine studies in this review (Bernstein et al., 2011; Gee,
2002; Gee, Spencer, Chen, Yip, et al., 2007; Hahm et al.,
2010; Lam, 2007; Lee, 2005; Mossakowski, 2003, 2007;
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Discrimination and Health
Yip et al., 2008) revealed 18 significant relationships be-
tween SRD and mental health problems among Asian
Americans. Notably, there were no negative findings in
any of the relationships between SRD and mental health
problems tested. Discrimination was significantly (p <
.05) associated with depression or depressive symptoms
in seven studies (Bernstein et al., 2011; Gee, Spencer,
Chen, & Takeuchi, 2007; Hahm et al., 2010; Lam, 2007;
Lee, 2005; Mossakowski, 2003, 2007). Other mental
health outcomes significantly associated with SRD in-
cluded psychological distress, anxiety, and other men-
tal health problems (Gee, 2002; Gee, Spencer, Chen, &
Takeuchi, 2007; Hahm et al., 2010; Lam, 2007).
Although these studies provide support for relation-
ships between SRD and adverse mental health outcomes
among Asian Americans, some findings were more trust-
worthy than others. For example, four studies (Bern-
stein et al., 2011; Gee, Spencer, Chen, & Takeuchi, 2007;
Hahm et al., 2010; Mossakowski, 2003) utilized the EDS
to measure SRD and found significant relationships be-
tween SRD and an aspect of depression. Gee, Spencer,
Chen, and Takeuchi (2007) conducted a study with a
large random sample of 2,047 Asian Americans, and
found that SRD was associated with a 120% increase in
odds of ever having been diagnosed with a depressive
disorder (Beta = 1.72; confidence interval [1.29, 2.30]).
However, Gee, Spencer, Chen, and Takeuchi did not dif-
ferentiate between experiences of diverse Asian Amer-
ican subgroups and may have received biased SRD re-
sponses based on recruitment of secondary responders
within households. However, Gee, Spencer, Chen, and
Takeuchis study of SRD and depression was rigorous and
compelling since it used the EDS, employed multivariate
analysis, included important control variables, and had a
high response rate (primary = 73.7%).
Two studies utilizing the EDS (Bernstein et al., 2011;
Mossakowski, 2003) found relationships between SRD
and depression among specific Asian American sub-
groups. Bernstein et al. used convenience sampling tech-
niques to recruit Korean immigrants (mean age = 46.7)
for their study. However, the sample was diverse in
terms of age, number of years in the US, English pro-
ficiency, and education (53.3% college educated). Sim-
ilarly, Mossakowski (2003) used a random selection
technique to recruit 2,109 Filipinos in her study on SRD,
depression, ethnic identity, and depressive symptoms.
The use of the EDS and inclusion of control variables in
multivariate regression models were strengths, and signif-
icant links between SRD and depressive symptoms were
found (Beta = 0.173; p < .001). However, diversity in
participants by age, education, and nativity status ham-
pered a more nuanced understanding of relationships be-
tween SRD and depressive symptoms.
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Other studies with specific Asian American subgroups
lacked appropriate control variables, relied on conve-
nience samples, and used less sophisticated statistical
analyses. For example, Lam (2007) recruited a con-
venience sample of 122 Vietnamese college students
through Vietnamese American student organizations.
Thus, students who participate in university activities
may not represent more hidden, and perhaps vulnera-
ble, Vietnamese Americans. Additionally, the analyses of
bivariate correlations between SRD and depression (r =
0.29, p < .01) and SRD and anxiety (r = 0.29, p < .01)
are difficult to trust without the inclusion of control vari-
ables. Similar to Lam, Lee (2005) used convenience sam-
pling techniques to recruit students connected to Korean
organizations, did not include any control variables, and
drew conclusions solely based on bivariate correlations.
In the nine studies that explored relationships between
SRD and mental health problems (Bernstein et al., 2011;
Gee, 2002; Gee, Spencer, Chen, & Takeuchi, 2007; Hahm
et al., 2010; Lam, 2007; Lee, 2005; Mossakowski, 2003,
2007; Yip et al., 2008), several (Gee, Spencer, Chen, &
Takeuchi, 2007; Hahm et al., 2010; Yip et al., 2008) clus-
tered together diverse Asian American subgroups. Several
studies (Paradies, 2006; Williams et al., 1997) suggest
that experiences of SRD may vary according to social and
demographic characteristics, and by diverse ethnic groups
and subgroups. Nonetheless, 18 significant correlations
were found between SRD and depression, depressive
symptoms, psychological symptoms, psychological dis-
tress, anxiety, and other mental health problems in
the nine studies examining SRD and mental health
problems.
Discrimination and physical health outcomes.
Three of the studies in this review (Gee, Spencer, Chen,
Yip, et al., 2007; Gee et al., 2008; Hahm et al., 2010)
found positive correlations between SRD and physical
health outcomes, including cardiovascular conditions,
respiratory conditions, pain, obesity, headaches, and dia-
betes (p < .05). However, associations between SRD and
pain, being overweight, and diabetes were not found. All
studies testing relationships between SRD and physical
health outcomes (Gee, Spencer, Chen, Yip, et al., 2007;
Gee et al., 2008; Hahm et al., 2010) used regression anal-
ysis and controlled for factors such as educational level,
English language proficiency, gender, and age.
Importantly, two of the three studies correlating
SRD with poorer physical health (Gee, Spencer, Chen,
Yip, et al., 2007; Gee et al., 2008) controlled for social
desirability. Social desirability controls account for par-
ticipants who respond in ways that seek approval or seek
to avoid disapproval (Gee, Spencer, Chen, Yip, et al.,
2007). Controlling for social desirability in studies on
discrimination and health may be especially important
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for Asian Americans and their subgroups. Saving face
has been found to be a dominant cultural trait of Asian
Americans (Lee & Mjelde-Mossey, 2004). Thus, Asian
Americans may underreport discrimination for fear of
portraying themselves in a negative light.
Finally, among studies analyzing relationships between
SRD and physical health outcomes (Gee, Spencer, Chen,
Yip, et al., 2007; Gee et al., 2008; Hahm et al., 2010), SRD
responses for diverse Asian American subgroups were
combined for analysis. In conclusion, studies that have
used reliable, valid, and multi-item measurements such
as the EDS, and controlled for several factors in their
analysis, provide trustworthiness and support for associ-
ations found between SRD and specific physical health
outcomes.
Discrimination and overall health. In five stud-
ies analyzing relationships between SRD and composite
reports of mental or physical health or a combination
of both (DeCastro et al., 2008; Gee, 2002; Gee et al.,
2006; Gee, Spencer, Chen, Yip, et al., 2007; Yoo et al.,
2009), four studies found positive associations (p < .05).
In the sole study with nonsignificant results (Gee, 2002),
a single dichotomous (yes or no) question was used to
measure SRD in a large Chinese American sample (n =
1,503). The weak measure may have failed to detect re-
lationships between SRD and health.
Two studies correlating SRD with overall health (De-
Castro et al., 2008; Gee et al., 2006) measured specific
types of SRD: discrimination encountered at work and
acute forms of discrimination. In addition to measuring
SRD with the EDS, DeCastro et al. measured work-related
discrimination in relationship to health conditions in a
large Filipino sample (n = 1,652). Despite using a two-
item scale without reported reliability or validity, DeCas-
tro et al. found work-related discrimination to be more
positively associated with health conditions than every-
day discrimination (Beta = 0.06, p = 0.05). Using the
EDS, Gee et al. (2006) differentiated between acute and
chronic forms of SRD and found associations between
acute SRD and poorer health to be insignificant (p > .05).
Gee et al. (2006) also found that chronic, everyday dis-
crimination was associated with reports of poorer health
in Honolulu but not in San Francisco. Despite the limi-
tations, these studies (DeCastro et al., 2008; Gee, 2002;
Gee et al., 2006; Gee, Spencer, Chen, Yip, et al., 2007;
Yoo et al., 2009) found relationships between SRD and
poorer overall health.
Limitations of the Literature
Dependence on cross-sectional designs. All of the
studies in this integrative review utilized cross-sectional
designs, correlating SRD at one point in time with
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measures of self-reported health. This is a significant
shortcoming of the literature since cross-sectional designs
do not demonstrate causality, in part because there is no
temporal ordering of the variables (Creswell, 2009). For
example, it is impossible to discern whether SRD con-
tributed to depressive symptoms or whether depression
contributed to perceptions of discrimination.
Reliance on self-report measures. All of the stud-
ies in this review measured discrimination and health
outcomes via self-report. Although self-report methods
are useful, their accuracy and validity hinge on respon-
dents abilities to recall, perceive, and communicate pre-
cisely (Polit & Beck, 2012). Because discrimination is a
sensitive and highly subjective experience, the accuracy
and congruency with which respondents report discrim-
ination is unclear. In addition, studies suggest that Asian
Americans who are not highly acculturated, are recent
immigrants, or do not speak English are likely to report
SRD experiences that differ from those who are highly
acculturated, speak English, and are perhaps more ed-
ucated (Gee, Spencer, Chen, & Takeuchi, 2007; Hahm
et al., 2010; Oh et al., 2002).
Measures of health outcomes based solely on self-
report are likely to be even more problematic. Studies of
African American and Latino experiences with discrim-
ination and health have included direct, physiological
health outcomes such as blood pressure and hemoglobin
A1C (Krieger & Sidney 1996; Piette et al., 2006). None
of the studies with Asian Americans in this review in-
cluded direct physiologic measures of health. A major
strength of collecting direct, physiological data is its objec-
tivity (Polit & Beck, 2012). Compounding the limitations
of self-report, four of the studies (Gee, Spencer, Chen, &
Takeuchi, 2007; Gee, Spencer, Chen, Yip, et al., 2007;
Gee, 2008; Yip et al., 2008) included a social desirability
measure to assess for favorable response biases.
Issues related to sampling. As stated throughout,
diversity within and between samples in this review im-
pedes generalizability to the Asian American population.
Six studies (Gee, Spencer, Chen, & Takeuchi, 2007; Gee,
Spencer, Chen, Yip, et al., 2007; Gee et al., 2008; Hahm
et al., 2010; Yip et al., 2008; Yoo et al., 2009) clustered
several Asian American subgroups together, prohibiting
specific analysis of SRD and health consequences accord-
ing to Asian American subgroup. Four studies (Bernstein
et al., 2011; Gee et al., 2006; Lam, 2007; Lee, 2005) an-
alyzed differences in SRD and health outcomes accord-
ing to geographical locations. Three studies (Lam, 2007;
Lee 2005; Yip et al., 2008) stratified analysis of SRD and
health outcome by age, and two studies (Hahm et al.,
2010; Lee, 2005) stratified their analysis based on gen-
der. Finally, two studies (Yip et al., 2008; Yoo et al., 2009)
stratified their analysis by U.S. born versus foreign born
Journal of Nursing Scholarship, 2012; 44:2, 127135.
C 2012 Sigma Theta Tau International
Discrimination and Health
and time spent in the US, respectively. Given the variety
of ways samples were stratified for analysis, specific, nu-
anced relationships between SRD and health according to
Asian American subgroup, age, geographic location, and
gender are limited in this review.
Nine of the studies in this review came from two
sampling frames limiting this review: (a) five were sec-
ondary data analyses of the national NLAAS, and (b) four
were secondary data analysis of the 19981999 Filipino
American Community Epidemiological Survey (FACES).
Although the NLAAS utilized multistage probability
sampling techniques to obtain a large, nationally repre-
sentative sample (n = 2,047), the subsequent analyses did
not control for variations by Asian American subgroup
or area of residence (Gee, Spencer, Chen, & Takeuchi,
2007; Gee, Spencer, Chen, Yip, et al., 2007; Gee et al.,
2008; Hahm et al., 2010; Yip et al., 2008). In contrast,
the FACES dataset allowed for a more specific, nuanced
study because it surveyed one Asian subgroup and re-
ported results separately for San Francisco and Honolulu
(DeCastro et al., 2008; Gee et al., 2006; Mossakowski,
2003, 2007).
Gaps in the Literature
This literature review found inconsistencies in con-
ceptualization, measurement, associations tested, study
designs, and samples used in studies of SRD and Asian
American health outcomes. Discrimination was not
conceptualized and operationalized consistently; discrim-
ination was defined in different ways, and race-based
measures were inconsistently used. Thus, when studies
do not clearly define and measure race-based SRD, rela-
tionships between SRD and health may be ambiguous.
Second, although stress was often considered a common
pathway through which discrimination undermined
health, the literature on discrimination and health
indicates that exposure to hazards and economic depri-
vation may also explain links between SRD and poorer
health (Krieger, 1999; Paradies, 2006). Considering
alternative explanations in relationships between SRD
and health outcomes may contribute to a more nuanced
understanding of the phenomenon.
All of the measures in the reviewed studies relied on
self-report. Further research is needed that includes ob-
jective, direct measures of physical health. In addition, a
variety of instruments were used to measure SRD; some
(e.g., the EDS) were stronger than others. Even though
the EDS is a frequently used, reliable, and valid instru-
ment, it measures discrimination in the broader, social
context and considers two specific domains (restaurants,
stores) in which discrimination may occur (Williams
133
Discrimination and Health
et al., 1997). Evaluating SRD in additional domains in
which it occurs may provide a better understanding of
where Asian Americans are most at risk. In addition to
assessing SRD, it may also be useful to evaluate struc-
tural, institutional forms of discrimination or, in the lab-
oratory setting, introduce real-time racist stimuli and
measure subsequent physiological responses (Paradies,
2006).
Given the findings of this review, it is strongly
suggested that qualitative studies be undertaken to
illuminate personal experiences of SRD, thereby encour-
aging a richer contextual analysis of SRD. Given that
all of the studies in this review were cross-sectional,
longitudinal studies are needed to provide temporal
ordering between predictor and outcome variables and
bolster support for relationships between SRD and health
outcomes. In addition, more rigorous designs including
comparison or control groups (e.g., White groups) would
further our understanding of the relationship between
SRD and health outcomes.
Conclusions and Implications
Despite the stated limitations of the existing literature,
discrimination may be an understudied social determi-
nant of health and health disparities for Asian Americans.
Consistent with the research findings among African
American and Latino populations, a positive trend was
found between SRD and poorer health outcomes for
Asian Americans. The findings of this review support
that discrimination, a form of inequality, appears to
exert harmful health effects for Asian Americans. Thus,
research further explicating the relationships between
SRD and Asian American health outcomes is needed.
Further research is also needed into the discrimination
experiences of Asian American subgroups and differences
within and between those subgroups according to age,
gender, immigration histories, education, and language
capabilities.
Future studies of discrimination among Asian Amer-
icans should include specific physical health outcomes
as well as more specific measures of mental health
outcomes. In addition, research should seek to identify
the mediators and moderators of SRD effects on health.
Direct patient care providers should recognize SRD as
a significant stressor or purveyor of illness and explore
ways to facilitate coping and resilience with their Asian
American patients. Lastly, Asian Americans should be
engaged to offer insight into the problem of SRD and
assist in the development of action and research and
solutions. Through continued research, policy change,
provider action, and community engagement, the impact
134
Nadimpalli & Hutchinson
of discrimination may be ameliorated to promote health
and wellness in the Asian American community.
Clinical Resources
r National Partnership for Action to End Health
Disparities, http://minorityhealth.hhs.gov/npa/
r The Science of Research on Discrimination
and Health; February, 201, http://conference.
novaresearch.com/SRDH/
r Healthy People 2020. The Social Determi-
nants of Health, http://healthypeople.gov/2020/
topicsobjectives2020/overview.aspx?topicid=39
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