Examining discrimination as a determinant of health

Center scholar Wilson Figueroa discusses his research on minority stressors and implications for practice and policy 

April 14, 2022 | Lisa A. Frazier | health equity & access


Center for HOPES Research Scholar Wilson Figueroa is wrapping up recruitment and data collection for his study on the effects of daily minority stressors in queer persons of color. The primary aim of the Examining Race, gender Identity, and Sexual orientation for health Equity (RISE) Study is to examine the effects of individual, interpersonal, and structural stressors on physiological markers of stress among queer people of color, including the effects on diurnal cortisol. Dr. Wilson Figueroa

Dr. Figueroa was awarded one of the College of Public Health’s highly competitive 2021 racial justice seed grants to fund this pilot study, which combines survey and biometric data to examine daily minority stress among a sample of racially diverse queer adults residing in Franklin County, Ohio. This work builds on previous findings that demonstrated minority stress was uniquely related to cortisol in a sample of mostly White queer young adults.

We talked with Figueroa about how the RISE Study contributes to health equity research by examining the role of discrimination in minority health outcomes. Figueroa also explained how, through rigorous design, methods, and analysis, health outcomes research can advance equity and justice in public health, health care practice, and health policy.


Discrimination and ‘daily stressors’

Thanks in large part to the work of social epidemiologists and other public health champions, Americans now largely acknowledge that social, economic, and policy factors shape health at least as much as health care and genetics. Daily stressors are one construct that researchers have used to investigate these social determinants of health. Daily stressors refer to the distressing demands of habitual transactions with one’s environment, including in physical, emotional, social, and institutional spaces. Common examples include the demands of managing personal finances, family relationships, traffic/commuting, and work deadlines.

While we generally associate stress with an individual experience, broader societal patterns like systemic bias produce group-based daily stress. Minority daily stressors refer to the distressing habitual demands associated with navigating one’s environment as a member of one or more minoritized or marginalized identity groups.

Compared to cis-gender, heterosexual, and White people, Black Americans (straight and queer) and those who identify as LGBTQ+ experience worse health outcomes, including higher rates of depression, anxiety, and cardiovascular disease. The relative load of daily stressors, including interpersonal and structural discrimination, offers one explanation for these disparities. “There are well documented health disparities in this population and one pathway by which these health disparities may develop is dysregulation of biological process as a result of experiencing chronic stress,” explains Dr. Figueroa. The cumulative effects of internalized, interpersonal, and structural discrimination contribute to chronic stress.

Figueroa says that the layered, intersecting discrimination experienced by Black queer individuals makes them a particularly important population for studying daily minority stress. “Racial minorities experience unique stressors independent of their sexual orientation,” like racialized policing and systemic discrimination in education, employment, and housing. “This ‘double burden’ may contribute to the health disparities we see in LGBTQ people of color, particularly Black queer individuals.”

Graphical representation of RISE Study logic model

RISE Study simple logic model

But the daily stress of discrimination associated with minority group identity is only one side of the coin. Group identity may also confer connectedness to one’s community (both queer and racial) and social support. Therefore, a secondary aim of the RISE Study is to examine resiliency factors that might be protective against the experience of daily stressors, including discrimination. Identifying protective factors may suggest interventions to mitigate the effects of discrimination and other minority stressors.


Advancing equity through representation in research

Unfortunately, consistent with broader scientific trends, research on daily minority stressors has not been racially inclusive. “The majority of studies that have examined stress or that have included biomarkers have consisted mainly of White cis gay males,” says Figueroa. “If we want our work to be representative of the entire LGBTQ population, we have to recruit more diverse samples.” Pursuing representation in research is thus essential to improvement of the evidence base, leading to improved knowledge about determinants of health across a wider range of society, and increased generalizability of findings about stressors.

Dr. Figueroa’s study design is innovative because it combines survey and biometric data. In addition to measuring diurnal cortisol levels as markers of stress, RISE Study participants answer a panel of questions about their experiences of health, discrimination, and social support. These responses provide important context to biomarkers and formalize the inclusion of participants’ experiences as data in the study.

Of course, improved representation is not just scientifically valuable. Broadening representation in research is also a responsibility to historically marginalized communities themselves. “Aside from cost, the biggest challenge to conducting research with LGBTQ people of color is recruitment,” says Figueroa. A long, consistent history of pervasive racism and abuse in health and medical research has resulted in justified mistrust of scientific investigators. Figueroa views confronting that history as an essential investment. “It takes a great deal of effort on our part to work with the community, to gain their trust, and to give them a sense that this research is necessary to understand the health disparities experienced by their community.”

Drs. Figueroa & Zoccola with their poster

Drs. Figueroa (left) and Zoccola (right) pose with their research poster   

Pursuing inclusiveness in research is deeply personal for Figueroa, whose parents are first-generation immigrants. “As a queer person of color, I have always been interested in stressors unique to minority groups,” he says. As an undergraduate student at the University of California Irvine, Figueroa was inspired to pursue a career in stress research by Drs. Sally Dickerson and Peggy Zoccola. (Photos from the 2022 American Psychosomatic Society conference courtesy Wilson Figueroa)

Dr. Zoccola quickly became his closest mentor and now, colleague. “She saw a lot of promise in me, so she gave a me many opportunities to advance quickly and really helped me be prepared for graduate school and research in general,” which Figueroa credits with building his confidence in his ability to work in the academy. “Both my parents only finished through the 8th grade,” he says, “so I didn’t have the role models that most of my peers had when it came to education and research.”

Zoccola, Figueroa, and Taylor

Three generations of researchers working together. From left: Zoccola, Figueroa, and doctoral student Courtney Taylor

Figueroa followed Zoccola to Ohio University to earn his masters and doctoral degrees in psychology. Zoccola’s mentorship has made all the difference for Figueroa. Aware that sexual and gender minorities were underrepresented in the research, Figueroa says that Zoccola encouraged him to pursue the issues and populations he was most interested in, “even if it meant doing most of the groundwork myself.” The advice to rigorously pursue what he’s passionate about continues to fuel Figueroa’s career as he carries out research in service to improving the health of his community.


Advancing health equity in policy & practice

Ultimately, Figueroa’s objective is for his research to improve population health and health equity in the LGBTQ community, particularly among queer people of color. “The main goal of this work is to understand pathways that may lead to health disparities in this population so that we can target points of intervention,” says Figueroa, underscoring the connection between research, practice, and policy in the health sciences. By examining the pathways between discrimination and disparities in health outcomes, research on daily stressors helps elucidate the origins and mechanisms of health inequities. Findings can therefore inform a wide range of public policies, practice guidelines, and population-level health interventions aimed at mitigating the deleterious effects of discrimination.

RISE study logoFigueroa says that the contributions of the RISE Study are just one step in this larger goal. Improving equity through collective actions requires, among other things, continuing to expand representation and agency in research. “In order to better understand stress and subsequent health outcomes in this population,” he says, “we need to engage in qualitative work (i.e., interviews, focus groups) so that we can hear in the communities’ own words how stress influences their health. We need to further diversify our samples by purposefully targeting older LGBTQ adults, trans and non-binary individuals, and individuals in hard-to-reach rural areas.” Figueroa also notes that countering the deprivation narrative in minoritized communities is imperative because effective interventions may come in the form of leveraging existing resources. “I want to bring focus to resiliency in this community and how resiliency factors may also positively influence health outcomes in this population.”

His long-term objectives illustrate that for health policy scholars like Figueroa, closing the loop on the relationship between structural stressors and health is also critical to the long-term impact of public health research. Explicitly and systematically interrogating the effects institutionalized racism, homo- and trans-phobia, and other forms of discrimination on disparities in health is essential to advancing both the health sciences and health equity itself. Policy – that is, the purposeful collective actions we take in our society and institutions – is a determinant of health itself. We applaud scholars like Figueroa who are part of a movement in health outcomes research to embrace that reality.