Experiences of the Flint Water Crisis Among Reproductive-Age Michigan Women in Communities Outside of Flint: Differences by Race and Ethnicity.

We sought to understand how women in Michigan communities outside of Flint experienced the Flint water crisis, an avoidable public health disaster widely attributed to structural racism. Using survey data from 950 Michigan women aged 18-45 from communities outside of Flint, we examined racial and ethnic differences in personal connections to Flint, perceived knowledge about the water crisis, and beliefs about the role of anti-Black racism in the water crisis factors that could contribute to poor health via increased psychological stress. We found that White (OR = 0.32; 95% CI: 0.22, 0.46) and Hispanic (OR = 0.21; 95% CI: 0.09, 0.49) women had lower odds than Black women of having family or friends who lived in Flint during the water crisis. Compared to Black women, White women were less likely to be moderately or very knowledgeable about the water crisis (OR = 0.58; 95% CI: 0.41, 0.80). White women (OR = 0.26; 95% CI: 0.18, 0.37), Hispanic women (OR = 0.38; 95% CI: 0.21, 0.68), and women of other races (OR = 0.28; 95% CI: 0.15, 0.54) were less likely than Black women to agree that the water crisis happened because government officials wanted to hurt Flint residents. Among those who agreed, White women (OR = 0.47; 95% CI: 0.30, 0.74) and women of other races (OR = 0.33; 95% CI: 0.12, 0.90) were less likely than Black women to agree that government officials wanted to hurt people in Flint because most residents are Black. We conclude that the Flint water crisis was a racialized stressor, with potential implications for the health of reproductive-age Black women.

Vicarious structural racism and infant health disparities in Michigan: The Flint Water Crisis.

Building on nascent literature examining the health-related effects of vicarious structural racism, we examined indirect exposure to the Flint Water Crisis (FWC) as a predictor of birth outcomes in Michigan communities outside of Flint, where residents were not directly exposed to lead-contaminated water. Using linear regression models, we analyzed records for all singleton live births in Michigan from 2013 to 2016, excluding Flint, to determine whether birth weight (BW), gestational age (GA), and size-for-gestational-age (SzGA) decreased among babies born to Black people, but not among babies born to White people, following the highly publicized January 2016 emergency declaration in Flint. In adjusted regression models, BW and SzGA were lower for babies born to both Black and White people in the 37 weeks following the emergency declaration compared to the same 37-week periods in the previous 3 years. There were no racial differences in the association of exposure to the emergency declaration with BW or SzGA. Among infants born to Black people, GA was 0.05 weeks lower in the 37-week period following the emergency declaration versus the same 37-week periods in the previous 3 years (95% CI: -0.09, -0.01; p = 0.0177), while there was no change in GA for infants born to White people following the emergency declaration (95% CI: -0.01, 0.03; p = 0.6962). The FWC, which was widely attributed to structural racism, appears to have had a greater impact, overall, on outcomes for babies born to Black people. However, given the frequency of highly publicized examples of anti-Black racism over the study period, it is difficult to disentangle the effects of the FWC from the effects of other racialized stressors.

Healthcare Stereotype Threat and Health Outcomes Among LGB Individuals.

BACKGROUND/PURPOSE: Health disparities between sexual minorities and heterosexuals are well documented and have been explained by differential access to healthcare as well as exposure to discrimination. The current research examines the role that healthcare stereotype threat, or the fear of being judged by healthcare providers based on negative group stereotypes, plays in the health of LGB individuals. METHODS: LGB individuals (N = 1507) in three age cohorts were recruited via random digit dialing to participate in a larger study on sexual minority health. Participants completed measures assessing healthcare stereotype threat, lifetime health diagnoses, life satisfaction, and number of bad physical health days and personal distress in the past 30 days. RESULTS: Healthcare stereotype threat was associated with higher psychological distress and number of reported bad physical health days. Additionally, the Younger and Middle cohorts reported more stereotype threat than the Older cohort, but reported significantly higher levels of life satisfaction in the face of this threat than those in the Older cohort. CONCLUSIONS: Healthcare stereotype threat was related to poorer mental and physical health among LGB individuals; this was true when these outcomes were assessed over the past 30 days but not when they were assessed in general. Cohort differences in healthcare stereotype threat suggest potential important within group variation that needs further investigating. The research broadens the contexts to which stereotype threat is relevant and establishes a stressor related to LGB health.

Discrimination and Depressive Symptoms Among African American Men Across the Adult Lifecourse.

Objectives: A lifecourse framework was used to examine the association between major and everyday measures of perceived discrimination and depressive symptoms among African American men and to evaluate whether these relationships differed for young, middle-aged, and older men. Method: The association between both major and everyday discrimination and depressive symptoms, as measured by the Center for Epidemiologic Studies Depression (CES-D) scale, was assessed among 296 African American men in the 2011-2014 Nashville Stress and Health Study (NSAHS) using ordinary least squares regression. Interactive associations between major and everyday discrimination and age patterns in the discrimination-depressive symptoms relationship were also investigated. Results: Everyday, but not major discrimination was associated with depressive symptoms among African American men. This relationship was stronger among middle-aged men and diminished among older men. However, major discrimination, but not everyday discrimination, was associated with depressive symptoms of older men (age 55+), with greatest depressive symptomatology among those reporting both forms of discrimination. Discussion: Everyday discrimination is a more consistent predictor, relative to major discrimination, of depressive symptoms among African American men across the lifecourse, although there were age and/or cohort differences. Findings also demonstrate the synergistic, or additive, impact of multiple forms of discrimination on mental health.

Stress, self-regulation, and context: Evidence from the Health and Retirement Survey.

Health-related behaviors, such as smoking, alcohol use, exercise, and diet, are major determinants of physical health and health disparities. However, a growing body of experimental research in humans and animals also suggests these behaviors can impact the ways our bodies respond to stress, such that they modulate (that is, serve as a means to self-regulate or cope with) the deleterious impact of stressful experiences on mental health. A handful of epidemiologic studies have investigated the intersection between stress and health behaviors on health disparities (both mental and physical), with mixed results. In this study we use a novel instrument designed to explicitly measure the self-regulatory motivations and perceived effectiveness of eight health-related self-regulatory behaviors (smoking, alcohol, drug use, overeating, prayer, exercise, social support, talking with a councilor) in a subset of the Health and Retirement Study (N=1,354, Mean age=67, 54% female). We find that these behaviors are commonly endorsed as self-regulatory stress-coping strategies, with prayer, social support, exercise, and overeating used most frequently. The likelihood of using particular behaviors as self-regulatory strategies varied significantly by sex, but not by race/ethnicity, education, or wealth. We also find that greater stress exposure is associated with higher likelihood of using these behaviors to self-regulate feelings of emotional distress, particularly health-harming behaviors like smoking, alcohol, and overeating. These findings provide an important link between sociological and psychological theoretical models on stress and empirical epidemiological research on social determinants of health and health disparities.

Maternal Social Disadvantage and Newborn Telomere Length in Archived Dried Blood Spots from the Michigan Neonatal Biobank.

Telomeres are the protective caps at the ends of eukaryotic chromosomes. Short telomere length is associated with morbidity and mortality among adults and may mark the biological impact of social experiences. Using archived dried blood spots from the Michigan Neonatal Biobank, this study examined markers of maternal social disadvantage (educational attainment, receipt of public assistance, marital status, and race/ethnicity) from linked birth certificates as predictors of telomere length at birth in a sample of 192 singleton neonates born to non-Hispanic black, non-Hispanic white, and Latina mothers aged 20-35 years. Consistent with two recent studies in newborns, but counter to the idea that maternal social disadvantage is associated with shorter offspring telomere length, we found that infants born to black mothers had longer telomeres than those born to white mothers (b = 0.12, SE = 0.06, p = .05). However, black/white differences in newborn telomere length varied by receipt of public assistance. Among newborns whose mothers received WIC and/or Medicaid, there were no significant black/white differences in telomere length (b = 0.09, SE = 0.08, p = .25). In contrast, among those whose mothers did not receive public assistance-just 6 out of 69 infants born to black mothers versus 41 out of 69 infants born to white mothers-we found that babies born to black mothers had longer telomere length than babies born to white mothers (b = 0.37, SE = 0.16, p = .03). The interaction between black race/ethnicity and receipt of public assistance did not reach the conventional threshold for statistical significance (b = -0.22, SE = 0.15, p = .13), suggesting that this finding may be due to chance. No other markers of maternal social disadvantage were related to infant telomere length. Although replication of these results in a larger sample with more infants born to black mothers with relatively high socioeconomic status is needed, this study offers preliminary support for the hypothesis that race/ethnic differences in newborn telomere length depend on social context.

Age-Based Reproductive Healthcare Stereotype Threat (HCST) as a Stressor Affecting Prenatal Mental Health in Pregnant Women of Advanced Maternal Age: Measurement, Process, Outcomes, and Interactions with Ethnicity/Race, SES, and Other Social Identities.

PURPOSE OF REVIEW: Reproductive health, and pregnancy more specifically, is the first critical link between generations. Beginning with this first critical link, pregnancy acts as a domino, affecting the expression of genes and determining the lifespan mental and physical health and reproductive potential of offspring and, likely, of subsequent generations. Given the powerful intergenerational domino that is pregnancy, the development of innovative models to enhance reproductive health and outcomes is an invaluable public health investment. RECENT FINDINGS: While U.S. pregnancy and birth outcomes have improved dramatically since the 1960s- including substantial progress within the past 15 years, largely catalyzed by the Healthy People initiative-group-based disparities remain. What's more, social change and medical advancements have led to an evolving window of female reproductive age. Despite becoming more common, being an older expectant mother remains a stigmatized social identity. The concept of healthcare stereotype threat (HCST) is introduced in relation to reproductive health. Stereotype threat is a situational predicament in which an individual who possesses a stigmatized social identity fears confirming negative group-based stereotypes. HCST is a healthcare-specific form of stereotype threat, arising out of stereotypes that are salient in healthcare settings. It is hypothesized that the experience of age-based reproductive HCST is an overlooked stressor affecting prenatal mental and physical health among women of advanced maternal age. SUMMARY: The hypothesized process of age-based reproductive HCST is described; outcomes and consequences are discussed; interactions with ethnicity/race, SES, and other aspects of social identity are considered; and strategies for prevention and intervention are explored, including active and passive shifts in three areas: (1) internally, in both providers and patients; (2) in the external environment, or the physical healthcare setting itself; and (3) within interpersonal interactions that occur within healthcare settings, particularly between physicians and patients. Implications for gynecological, infertility, and obstetric care and improving the reproductive outcomes of older women are discussed.

Healthcare Stereotype Threat in Older Adults in the Health and Retirement Study.

INTRODUCTION: Healthcare stereotype threat is the threat of being personally reduced to group stereotypes that commonly operate within the healthcare domain, including stereotypes regarding unhealthy lifestyles and inferior intelligence. The objective of this study was to assess the extent to which people fear being judged in healthcare contexts on several characteristics, including race/ethnicity and age, and to test predictions that experience of such threats would be connected with poorer health and negative perceptions of health care. METHODS: Data were collected as part of the 2012 Health and Retirement Study (HRS). A module on healthcare stereotype threat, designed by the research team, was administered to a random subset (n=2,048 of the total 20,555) of HRS participants. The final sample for the present healthcare stereotype threat experiment consists of 1,479 individuals. Logistic regression was used to test whether healthcare stereotype threat was associated with self-rated health, reported hypertension, and depressive symptoms, as well as with healthcare-related outcomes, including physician distrust, dissatisfaction with health care, and preventative care use. RESULTS: Seventeen percent of respondents reported healthcare stereotype threat with respect to one or more aspects of their identities. As predicted, healthcare stereotype threat was associated with higher physician distrust and dissatisfaction with health care, poorer mental and physical health (i.e., self-rated health, hypertension, and depressive symptoms), and lower odds of receiving the influenza vaccine. CONCLUSIONS: The first of its kind, this study demonstrates that people can experience healthcare stereotype threat on the basis of various stigmatized aspects of social identity, and that these experiences can be linked with larger health and healthcare-related outcomes, thereby contributing to disparities among minority groups.

Stereotype threat among black and white women in health care settings.

The first of its kind, the present experiment applied stereotype threat-the threat of being judged by or confirming negative group-based stereotypes-to the health sciences. Black and White women (N = 162) engaged in a virtual health care situation. In the experimental condition, one's ethnic identity and negative stereotypes of Black women specifically were made salient. As predicted, Black women in the stereotype threat condition who were strongly identified as Black (in terms of having explored what their ethnic identity means to them and the role it plays in their lives) reported significantly greater anxiety while waiting to see the doctor in the virtual health care setting than all other women. It is hypothesized that stereotype threat experienced in health care settings is one overlooked social barrier contributing to disparities in health care utilization and broader health disparities among Black women.

Race and socioeconomic differences in obesity and depression among Black and non-Hispanic White Americans.

Obesity and depression often co-occur; however, the association between these conditions is poorly understood, especially among racial/ethnic minority groups. Using multinomial logistic regression and data from the National Survey of American Life, the relationships between race, ethnicity, and sociodemographic factors to the joint classification of body mass index categories and depression among African Americans, Caribbean Blacks, and non-Hispanic Whites were examined. Differential risk for the combination of obesity and depression by sociodemographic status was found. Being African American, female, young, married, or having low income or education increases the risk for obesity without depression. Risk factors for obesity with depression include being female, young, married and having a low income. Race was not a significant predictor of obesity with depression relative to normal weight without depression status. However, racial differences were observed among the non-depressed. Non-depressed African Americans were more likely than non-depressed Whites or Caribbean Blacks to be obese.

A comparison of skin tone discrimination among African American men: 1995 and 2003.

This study investigated perceptions of skin tone discrimination among adult African American men. Research suggests that through negative African American stereotypes, out-group members (Whites) perceive light-skinned African Americans favorably and dark-skinned African Americans unfavorably. However, it is unclear how treatment by in-group members (other African Americans) uniquely affects men. Using data from the 1995 Detroit Area Study and the 2003 National Survey of American Life, we investigated these relationships among African American men representing a wide range of socioeconomic groups. We found that African American men's perceptions of out-group and in-group treatment, respectively, were similar across time. Light-skinned men perceived the least out-group discrimination while dark-skinned men perceived the most out-group discrimination. In appraisals of skin tone discrimination from in-group members, medium-skinned men perceived the least discrimination while both light- and dark-skinned men perceived more in-group discrimination. Additionally, men of lower social economic groups were more affected by skin tone bias than others. Future research should explore the influence of these out- and in-group experiences of skin tone discrimination on social and psychological functioning of African American men.

"White Box" Epidemiology and the Social Neuroscience of Health Behaviors: The Environmental Affordances Model.

Crucial advances have been made in our knowledge of the social determinants of health and health behaviors. Existing research on health disparities, however, generally fails to address a known paradox in the literature: While blacks have higher risk of medical morbidity relative to non-Hispanic whites, blacks have lower rates of common stress-related forms of psychopathology such as major depression and anxiety disorders. In this article we propose a new theoretical approach, the Environmental Affordances Model, as an integrative framework for the origins of both physical and mental health disparities. We highlight early empirical support and a growing body of experimental animal and human research on self-regulatory health behaviors and stress coping that is consistent with the proposed framework. We conclude that transdisciplinary approaches, such as the Environmental Affordances Model, are needed to understand the origins of group-based disparities to implement effective solutions to racial and ethnic group inequalities in physical and mental health.

Cardiovascular disease among Black Americans: comparisons between the U.S. Virgin Islands and the 50 U.S. states.

OBJECTIVES: Consistent findings show that black Americans have high rates of cardiovascular disease (CVD) and related behavioral risk factors. Despite this body of work, studies on black Americans are generally limited to the 50 U.S. states. We examined variation in CVD and related risk factors among black Americans by comparing those residing within the U.S. Virgin Islands (USVI) with those residing in the 50 U.S. states and Washington, D.C. (US 50/DC) and residing in different regions of the US 50/DC (Northeast, Midwest, South, and West). METHODS: Using data from the 2007 and 2009 Behavioral Risk Factor Surveillance System, we compared CVD and CVD risk factor prevalence in non-Hispanic black people (≥20 years of age) in the USVI and US 50/DC, examining the relative contributions of health behaviors, health insurance, and socioeconomic status (SES). RESULTS: Accounting for age, sex, education, health insurance, and health behaviors, US 50/DC black Americans were significantly more likely than USVI black people to report ever having a stroke and coronary heart disease, and to be hypertensive, diabetic, or obese. While there was heterogeneity by region, similar patterns emerged when comparing the USVI with different regions of the US 50/DC. CONCLUSION: USVI black people have lower CVD and risk factor prevalence than US 50/DC black people. These lower rates are not explained by differences in health behaviors or SES. Understanding health in this population may provide important information on the etiology of racial/ethnic variation in health in the U.S. and elsewhere, and highlight relevant public health policies to reduce racial/ethnic group disparities.

Is ignorance bliss? Depression, antidepressants, and the diagnosis of prediabetes and type 2 diabetes.

OBJECTIVE: To examine the association between clinically identified and undiagnosed prediabetes and Type 2 diabetes with depression and antidepressant medication use. METHODS: Data come from the National Health and Nutrition Examination Study (2005 and 2007), a population-based cross-sectional survey. Analysis is limited to adults aged 30 and older (n = 3,183, Mean age = 52.1 year). Depression syndrome was measured by the Patient Health Questionnaire-9. Participants were categorized using fasting glucose levels as normoglycemic (glucose <100 mg/dL), undiagnosed prediabetes (glucose 100-125.9), clinically identified prediabetes (glucose 100-125.9 plus clinician diagnosis), undiagnosed Type 2 diabetes (glucose >126), and clinically identified Type 2 diabetes (glucose >126 plus clinician diagnosis or use of antidiabetic medications). Health behaviors included smoking, poor diet, excessive alcohol use, and obesity. Health promotion behaviors included efforts to change diet, lose weight, and increase physical activity. RESULTS: Clinically identified diabetes was associated with 4.3-fold greater odds of depression, but undiagnosed diabetes was not significantly associated with depression. This relationship was more pronounced for prediabetes. Clinically identified diabetes was associated with 1.8-fold greater odds of antidepressant use, but undiagnosed diabetes was not significantly associated with antidepressant use. Health behaviors were not consistently related to depression syndrome. CONCLUSION: The relationship between diabetes status and depression and antidepressant use depends on whether the diabetes has been clinically identified. Findings are consistent with the hypothesis that the relationship between diabetes and depression may be attributable to factors related to disease management. Previous reports linking antidepressants and diabetes may be attributable to clinical ascertainment bias.

Maternal familism predicts birthweight and asthma symptoms three years later.

There are marked ethnic and socioeconomic differences in birthweight and childhood asthma, conditions which may be linked causally or via a third variable. Cultural resources are often credited with diminished health disparities in infancy and childhood among subsets of poor and minority populations; yet direct empirical tests of this hypothesis are needed. In this study, ethnicity, lifespan family socioeconomic position (FSEP), and the cultural resource of familism were compared as predictors of birthweight and expression of asthma symptoms (AE) by age three. Familism and lifespan FSEP were assessed in 4633 socioeconomically disadvantaged African Americans, White Americans, and Latinas upon giving birth, as was offspring birthweight. AE was assessed in offspring through age three. Asthma diagnosis by age three was likelier in very low (≤ 1500 g) and low (≤ 2500 g) birthweight infants compared to infants born at average (2501-3999 g) or larger (≥ 4000 g) birthweights. Asthma risk associated with lower birthweight was higher for Latinos (17-35%) and African Americans (19-23%) than for White Americans (13-14%). As predicted, maternal familism was higher among White Americans than among African Americans and Latinas, an effect that was largely driven by ethnic disparities in lifespan FSEP. Familism predicted continuous birthweight (p = .003) and AE (p = .001) by age three independently of ethnicity and lifespan FSEP accounting for appropriate control variables, including maternal biomedical risk, maternal acculturation, parental marital status, and infant sex. There was a 71-g gain in birthweight for every one-unit increase in familism. The protective effect of familism on AE by age three was strongest for participants of lower lifespan FSEP. Maternal familism is one cultural resource that may reduce reproductive and intergenerational health disparities in both U.S.- and foreign-born Americans. Consistent with our previous work, familism and other nonmaterial resources covary with material resources. Nevertheless, culture is distinguishable from lifespan FSEP and ethnicity, and has health implications beyond associations to ethnicity, lifespan FSEP, and related biomedical and sociodemographic factors.

Reconsidering the role of social disadvantage in physical and mental health: stressful life events, health behaviors, race, and depression.

Prevalence of depression is associated inversely with some indicators of socioeconomic position, and the stress of social disadvantage is hypothesized to mediate this relation. Relative to whites, blacks have a higher burden of most physical health conditions but, unexpectedly, a lower burden of depression. This study evaluated an etiologic model that integrates mental and physical health to account for this counterintuitive patterning. The Baltimore Epidemiologic Catchment Area Study (Maryland, 1993-2004) was used to evaluate the interaction between stress and poor health behaviors (smoking, alcohol use, poor diet, and obesity) and risk of depression 12 years later for 341 blacks and 601 whites. At baseline, blacks engaged in more poor health behaviors and had a lower prevalence of depression compared with whites (5.9% vs. 9.2%). The interaction between health behaviors and stress was nonsignificant for whites (odds ratio (OR = 1.04, 95% confidence interval: 0.98, 1.11); for blacks, the interaction term was significant and negative (ß: -0.18, P < 0.014). For blacks, the association between median stress and depression was stronger for those who engaged in zero (OR = 1.34) relative to 1 (OR = 1.12) and ≥2 (OR = 0.94) poor health behaviors. Findings are consistent with the proposed model of mental and physical health disparities.

Communalism predicts prenatal affect, stress, and physiology better than ethnicity and socioeconomic status.

The authors examined the relevance of communalism, operationalized as a cultural orientation emphasizing interdependence, to maternal prenatal emotional health and physiology and distinguished its effects from those of ethnicity and childhood and adult socioeconomic status (SES). African American and European American women (N = 297) were recruited early in pregnancy and followed through 32 weeks gestation using interviews and medical chart review. Overall, African American women and women of lower socioeconomic backgrounds had higher levels of negative affect, stress, and blood pressure, but these ethnic and socioeconomic disparities were not observed among women higher in communalism. Hierarchical multivariate regression analyses showed that communalism was a more robust predictor of prenatal emotional health than ethnicity, childhood SES, and adult SES. Communalism also interacted with ethnicity and SES, resulting in lower blood pressure during pregnancy for African American women and women who experienced socioeconomic disadvantage over the life course. The effects of communalism on prenatal affect, stress, and physiology were not explained by depressive symptoms at study entry, perceived availability of social support, self-esteem, optimism, mastery, nor pregnancy-specific factors, including whether the pregnancy was planned, whether the pregnancy was desired after conception, or how frequently the woman felt happy to be pregnant. This suggests that a communal cultural orientation benefits maternal prenatal emotional health and physiology over and above its links to better understood personal and social resources in addition to economic resources. Implications of culture as a determinant of maternal prenatal health and well-being and an important lens for examining ethnic and socioeconomic inequalities in health are discussed.

Community perspectives: mixed-methods investigation of culture, stress, resilience, and health.

Despite well-documented ethnic and socioeconomic disparities, our understanding of child, maternal and family health is based disproportionately on White middle-class populations in the United States. The National Institute of Child Health and Human Development funded the Community Child Health Network (CCHN) in 2004, a partnership of five academic institutions and community organizations, to collaborate in the design and conduct of a study to foster new understandings of these disparities. Reported here are findings from a pilot study conducted at one site to inform CCHN regarding community views of stress, coping resources, family and health. Mixed-methods (qualitative and quantitative) interviews were conducted with 54 adult participants recruited from public healthcare clinics to obtain both their self-reports and their reports of their communities' perspectives. Findings include the pervasiveness of experiences of racism and gender differences in support seeking and coping behavior. There was little recognition of some common health conditions, such as low birth weight and preterm birth, which disproportionately affect poor and minority communities. Many indicators of strength and resilience in individuals, families, and the communities at large emerged in these interviews. Communities were described as valuing achievement and upward mobility. Participants also indicated an intuitive understanding of effective parenting and of the roles of nature (genetics) and nurture (environment and behavior) in determining child health. The results inform intervention and stress research in underrepresented communities.

Racial identity and depression among African American women.

This study examines direct, interactive, and indirect effects of racial identity and depression in a sample of 379 African American women. Results indicated that higher racial private and public regard were associated with lower depression. The relationship between private regard and depression was moderated by racial centrality, such that higher private regard was more strongly related to lower depression when women's race was a central part of their self-concept. Finally, results indicated that self-esteem fully mediated the relationship between private regard and depression and partially mediated the relationship between public regard and depression. The authors discuss the results in relation to reflected appraisal, the insulation hypothesis, and identity theory.

Socioeconomic position, health behaviors, and C-reactive protein: a moderated-mediation analysis.

OBJECTIVE: We sought to understand the link between low socioeconomic position (SEP) and cardiovascular disease (CVD) by examining the association between SEP, health-related coping behaviors, and C-reactive protein (CRP), an inflammatory marker and independent risk factor for CVD, in a U.S. sample of adults. DESIGN: We used a multiple mediation model to evaluate how these behaviors work in concert to influence CRP levels and whether these relationships were moderated by gender and race/ethnicity. MAIN OUTCOME MEASURES: CRP levels were divided into two categories: elevated CRP (3.1-10.0 mg/L) and normal CRP (< or =3.0 mg/L). RESULTS: Both poverty and low educational attainment were associated with elevated CRP, and these associations were primarily explained through higher levels of smoking and lower levels of exercise. In the education model, poor diet also emerged as a significant mediator. These behaviors accounted for 87.9% of the total effect of education on CRP and 55.8% the total effect of poverty on CRP. We also found significant moderation of these mediated effects by gender and race/ethnicity. CONCLUSION: These findings demonstrate the influence of socioeconomically patterned environmental constraints on individual-level health behaviors. Specifically, reducing socioeconomic inequalities may have positive effects on CVD disparities through reducing cigarette smoking and increasing vigorous exercise.