A daily diary examination of the influence of intersectional stigma on blood pressure

Hypertension is the most important modifiable risk factor for cardiovascular disease (CVD), the leading cause of death and disability in adults worldwide. Stigmatized populations, such as people of color and sexual minority (e.g., gay/lesbian, bisexual) adults, have a higher prevalence of hypertension that is largely attributed to greater exposure to stigma; a fundamental cause of health disparities. However, prior research on the effects of stigma on blood pressure (BP) has primarily focused on enacted stigma (i.e., personally experienced discrimination) to the exclusion of other forms of stigma, such as anticipated (i.e., expectation of encountering discrimination) and vicarious (i.e., hearing/witnessing people like you being the target of discrimination) stigma. Most research in this area has focused on the impact of stigma on BP due to a single stigmatized identity. This current approach ignores intersectional stigma (i.e., stigma that is not attributed to a specific identity), which obscures the experiences of groups that face stigma due to multiple stigmatized identities. Given these limitations, we posit that researchers have previously underestimated the impact of stigma on BP. We have compelling pilot data showing that, independent of enacted stigma, greater reports of daily intersectional anticipated and vicarious stigma are associated with higher home systolic BP (SBP; a stronger predictor of future CVD events than in-office SBP) among adults. The goal of this 1-week daily diary study is to estimate the influence of intersectional anticipated and vicarious stigma on home BP. We will conduct the first study to robustly examine mechanisms linking daily and chronic anticipated and vicarious stigma with BP in individuals’ real-world environments. We will recruit a diverse sample of 400 adults (ages 18-64) without diagnosed hypertension or CVD. Participants will complete a structured interview followed by 1 week of: (1) twice-daily structured electronic diaries that will assess daily anticipated, vicarious, and enacted stigma, (2) collection of saliva samples to assess salivary stress biomarkers, (3) continuous wrist-worn actigraphy, and (4) twice-daily home BP monitoring. Our specific aims are to: (1) Determine the influence of intersectional anticipated and vicarious stigma on mean home SBP and mediators of these associations (e.g., salivary cortisol, anxiety) and (2) Examine differences in intersectional anticipated and vicarious stigma and mean home SBP across stigmatized identities (e.g., ethnoracial, sexual identity) and the intersections between them. We will also explore moderators (e.g., social support, identity centrality) of the influence of intersectional anticipated and vicarious stigma on mean home SBP. This study will provide the first evidence of mechanisms by which anticipated and vicarious stigma influence BP. If we find that anticipated and/or vicarious stigma influence BP—even in the absence of enacted stigma—it will shift how we think about the design of interventions for CVD risk reduction. This study is a critical step for identifying mechanistic targets for future interventions and policies to reduce the adverse effects of anticipated and vicarious stigma on cardiovascular health.