The Missing Link in Contemporary Health Disparities Research: A Profile of the Mental and Self-Rated Health of Multiracial Young Adults

Abstract

This study compared the mental and self-rated health of monoracial and multiracial young adults using data from Wave 3 of the National Longitudinal Adolescent to Adult study. Our analytic sample consisted of 10,535 men and women ages 18–25 that self-identified as monoracial (Asian, Black, Native American, and White) or multiracial (White-Nonwhite and Nonwhite-Nonwhite). We find that when comparing aggregated racial groups, multiracials have poorer mental health than monoracials. However, differences emerge when multiracials are disaggregated into their two primary pairings of White-Nonwhite and Nonwhite-Nonwhite and compared to monoracials collectively and individually. We find that White-Nonwhites have poorer mental and self-rated health relative to monoracials generally and Whites specifically. In contrast, Nonwhite-Nonwhites have greater self-esteem and self-rated health than Whites as well as the aggregated monoracial group. Our findings highlight the complexities of examining multiracial health without researchers using consistent multiracial categories and reference groups. The results are discussed using three new perspectives that are introduced to explain health disparities between monoracial and multiracial persons.

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Health Sociology Review
ISSN: 1446-1242 (Print) 1839-3551 (Online) Journal homepage: https://www.tandfonline.com/loi/rhsr20
The missing link in contemporary health
disparities research: a profile of the mental and
self-rated health of multiracial young adults
Byron Miller, Sara Rocks, Savanah Catalina, Nicole Zemaitis, Kia Daniels &
Jaime Londono
To cite this article: Byron Miller, Sara Rocks, Savanah Catalina, Nicole Zemaitis, Kia Daniels
& Jaime Londono (2019): The missing link in contemporary health disparities research: a profile
of the mental and self-rated health of multiracial young adults, Health Sociology Review, DOI:
10.1080/14461242.2019.1607524
To link to this article: https://doi.org/10.1080/14461242.2019.1607524
Published online: 29 Apr 2019.
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The missing link in contemporary health disparities research: a
profile of the mental and self-rated health of multiracial young
adults
Byron Miller, Sara Rocks, Savanah Catalina, Nicole Zemaitis, Kia Daniels and
Jaime Londono
Department of Society, Culture, and Language, University of South Florida St. Petersburg, St. Petersburg, FL,
USA
ABSTRACT
This study compared the mental and self-rated health of monoracial
and multiracial young adults using data from Wave 3 of the National
Longitudinal Adolescent to Adult study. Our analytic sample
consisted of 10,535 men and women ages 18–25 that self-
identified as monoracial (Asian, Black, Native American, and White)
or multiracial (White-Nonwhite and Nonwhite-Nonwhite). We find
that when comparing aggregated racial groups, multiracials have
poorer mental health than monoracials. However, differences
emerge when multiracials are disaggregated into their two primary
pairings of White-Nonwhite and Nonwhite-Nonwhite and
compared to monoracials collectively and individually. We find that
White-Nonwhites have poorer mental and self-rated health relative
to monoracials generally and Whites specifically. In contrast,
Nonwhite-Nonwhites have greater self-esteem and self-rated
health than Whites as well as the aggregated monoracial group.
Our findings highlight the complexities of examining multiracial
health without researchers using consistent multiracial categories
and reference groups. The results are discussed using three new
perspectives that are introduced to explain health disparities
between monoracial and multiracial persons.
ARTICLE HISTORY
Received 24 June 2018
Accepted 10 April 2019
KEYWORDS
Multiracial; monoracial;
mental health; self-rated
health
Introduction
Health researchers have demonstrated there are significant racial disparities in mental and
self-rated health (Barnes, Keyes, & Bates, 2013; Miller & Kail, 2016; Shahabi et al., 2016).
Previous studies have primarily focused on people identifying with one racial group
(monoracial) and research on those that identify with two or more racial groups (multi-
racial) have largely focused on adolescents (Cooney & Radina, 2000; Tashiro, 2005; Udry,
Li, & Hendrickson-Smith, 2003). As a result, much less is known about the health of multi-
racial adults compared to their monoracial peers.
Although some findings are mixed, prior research generally shows that multiracials
have greater depression symptomatology, lower self-esteem, and lower self-rated health
© 2019 Informa UK Limited, trading as Taylor & Francis Group
CONTACT Byron Miller bamille3@mail.usf.edu Department of Society, Culture, and Language, University of South
Florida St. Petersburg, 262 Davis Hall, St. Petersburg, FL 33701
,
USA
HEALTH SOCIOLOGY REVIEW
https://doi.org/10.1080/14461242.2019.1607524

than monoracials (Bratter & Gorman, 2011; Cooney & Radina, 2000; Milan & Keiley,
2000). The inconclusive results are partially due to the fact that there are a multitude of
possible multiracial combinations but no standard categorisation of multiracials or the
monoracial groups to whom they are compared. For example, some studies compare
the health of all multiracials to all monoracials and others compare various White-Non-
white and Nonwhite-Nonwhite pairings to Whites or racial minorities (Campbell &
Eggerling-Boeck, 2006; Lau, Lin & Flores, 2012). Furthermore, it is also important to con-
sider that the highest prevalence for having any mental illnesses among adults are reported
by those who identify as multiracial as well as those 18–25 years of age (National Institute
of Mental Health, 2017). Thus, there is still a limited understanding of the health profile
for multiracial adults.
Researchers use several theories including the fundamental causes, minority stress, and
stress process theories to explain racial disparities in health (Link & Phelan, 1995; Meyer,
2003; Pearlin, 1989; Tillman & Miller, 2017). This body of literature also establishes that
health outcomes are affected by both biological and social factors. The aforementioned
theoretical perspectives have been generally applied to monoracial individuals however,
although multiracials have unique racial identities and social experiences that may con-
tribute to differential health outcomes between monoracial and multiracial persons. As
such, the development of new theoretical insights that incorporate multiracials into the
racial disparities in health literature can provide researchers and practitioners with a
crucial new link for interconnecting race and the social determinants of health.
Racial disparities in mental and self-rated health
Epidemiological studies using data collected from a nationally representative sample of
non-institutionalized persons finds that nearly 20% of adults in the United States meet
the DSM-IV diagnostic criteria for some type of mental, behavioural, or emotional disorder
(SAMHSA, 2017). This means millions of adults are adversely affected in their ability to
think, cope with stressful experiences, interact with others, and generally enjoy their lives
(World Health Organization, 2014). However, a number of studies show a robust associ-
ation between race and mental illnesses including depression (Ali et al., 2017; Lee, et al.,
2014; NIMH, 2017), self-esteem (Fisher et al., 2017; Gonzales-Backen et al., 2015), and
life satisfaction (Shahabi et al., 2016). There are also significant racial differences in self-
rated health (Miller & Kail, 2016; Sarkin et al., 2013), which is a general indicator of an indi-
vidual’s perceived mental, physical, and social well-being (WHO, 1948).
To better comprehend the underlying mechanisms that contribute to the observed
racial disparities, a clearer understanding is needed of the role race plays in health out-
comes. Although race is often conceptualised according to a person’s biological and phys-
ical characteristics (LaVeist, 1996), many social scientists view race as a social construct
used to divide groups without any biological basis (Omi & Winant, 1994). Racial identity
also tends to be a proxy for other factors that effect health including an individual’s socio-
economic status, social environments, and coping resources (LaVeist, 2005; Williams &
Collins, 2001). Such race-based psychosocial determinants can be considered fundamental
causes of racial disparities in health because they shape a person’s exposure to, and the
impact of, many illnesses and risk factors that affect well-being (Link & Phelan, 1995;
Williams & Collins, 2001).
2B. MILLER ET AL.

Racial disparities in health have also been explained using the stress process theory.
This approach posits that people in different social statuses (e.g. racial groups) tend to
be exposed to dissimilar stressors and have disparate access to coping resources that
can help mediate health disparities or buffer health outcomes from the adverse effects
of stress. Differences in stress exposure and resources to cope with stressful life events,
in turn, contribute to health disparities between people with different social statuses
(Pearlin et al., 1981; Turner, Wheaton, & Lloyd, 1995). Accordingly, racial differences
in social experiences largely contribute to racial disparities in health.
Multiracial health disparities
Despite the extensive evidence indicating the racial disparities in health, greater inclusion
of multiracial adults is needed in this literature. Most research on the mental and self-rated
health of multiracials has focused on adolescents and generally shows that they report sig-
nificantly higher levels of depression but lower levels of self-esteem and self-rated health
than monoracials (Campbell and Eggerling-Boeck 2006; Fisher et al. 2017; Tabb et al.,
2017; Udry, Li, and Hendrickson-Smith 2003). Yet, few studies have examined the
mental health of multiracial adults even though the frequency of mental illness among
adults is inversely related to age with the youngest (ages 18–25) having the highest preva-
lence (NIMH, 2017). Moreover, multiracial adults have a higher prevalence of mental
illness (30%) than any other racial group (NIMH, 2017).
Although there is tremendous diversity in the racial groups with which multiracials
self-identify, the vast majority (75%) identify as White-Nonwhite (e.g. White-Asian)
and the remaining 25% as Nonwhite-Nonwhite (e.g. Black-Native American) (Humes,
Jones, and Ramirez, 2011; Pew Research Center 2015). However, unlike monoracials,
there is no ‘standard’multiracial group used by researchers because multiracial is a ubi-
quitous term used to capture the numerous categorizations of people that self-identify
as such. Differences in categorisation may partially contribute to the mixed findings
yielded in the current multiracial health research and makes how researchers categorise
multiracials just as important as the group(s) to which their health is compared.
For example, some studies compare all multiracials to all monoracials, but others
compare specific multiracials to Whites, other minorities, or both. However, aggregating
multiracials into one general category does not account for any potential differences in the
social experiences of White-Nonwhite or Nonwhite-Nonwhite multiracials that may con-
tribute to health disparities between these groups. In contrast, comparing aggregated or
specific multiracial groups to only Whites or Whites and one minority group does not
reveal how their health compares to other racial minority groups thereby making it
difficult to accurately assess the well-being of multiracials relative to monoracials. Accord-
ingly, Shih and Sanchez (2005) argue that such varied study designs highlight the com-
plexities faced by researchers investigating the link between multiracial identity and
mental health, and suggest it may be premature to conclude that multiracials face an elev-
ated risk of mental illness compared to monoracials.
Researchers have applied a number of theories to the multiracial population for
explaining health disparities between monoracial and multiracial people. For instance,
the minority stress process theory suggests that people with marginalised social statuses
like multiracials are exposed to more social stressors like racism and discrimination
HEALTH SOCIOLOGY REVIEW 3

(Bostwick et al., 2014; Meyer, 2003) that are linked to deleterious health outcomes (Miller,
Rote, & Keith, 2013; Slotman et al., 2017). Multiracials specifically report experiencing dis-
crimination and microaggressions related to their blended racial identities from people
that doubt their self-identity or view multiracial identities as abnormal, which can lead
to negative attitudes, adverse self-perceptions, and other issues with emotional adjustment
(Greif, 2015; Johnston & Nadal, 2010; Sanchez, 2010). Overall, the application of this
theory may help explain differences in well-being between monoracials and multiracials
but we are not aware of a sociological perspective that incorporates multiracials into the
racial disparities in health literature.
Racialized experiences of multiracial persons
Racial disparities in health are not only affected by biological reasons like gene mutations
or changes in cell functioning but also social factors like self-identity and social experi-
ences (Link & Phelan, 1995; Pearlin, 1989; Ponticelli, 1998; Williams & Collins, 2001).
In terms of race, skin tone and group affiliation are two salient factors that both greatly
affect social experiences and identity (Keith and Herring 1991; Maxwell et al., 2015).
Bonilla-Silva (2004) suggested society currently has a ‘tri-racial divide’consisting of
Whites, Honorary Whites, and Collective Blacks, whereby multiracials are categorised
as either White or Honorary White. However, this classification overlooks the fact that
many multiracials such as Halle Berry and President Barack Obama are categorised as
Black due to their skin tone, self-identification, or the ‘one-drop rule’that classifies
people with any African heritage as Black (Wolfe, 2015). We therefore modified Bonilla
Silva’s tri-racial divide to propose three perspectives on the social experiences of multira-
cials that may particularly impact their health: (1) The White Experience; (2) The Min-
ority Experience; and (3) The Blended Race Experience.
The White Experience
This perspective refers to multiracials that self-identify as either White-Nonwhite (e.g.
White-Asian or White–Black) or monoracial White despite having parents with
different racial backgrounds. An individual’s choice of racial identity may be related to
the fact that they look like, or are socialised to associate with being, a member of the mono-
racial White group (Helms, 1990; Wolfe, 2015). Accordingly, this group of multiracials are
likely to have social experiences that are similar to monoracial Whites including white pri-
vilege and white consciousness. As a result, White-Nonwhite multiracials that have the
White experience are likely to report health outcomes that are similar to Whites (i.e. no
statistical differences) but significantly different from Nonwhite minorities.
The Minority Experience
This approach refers to multiracials that identify as White-Nonwhite, with two Nonwhite-
Nonwhite minority groups (e.g. Black-Asian or Native-Asian), or as a monoracial min-
ority (e.g. Asian or Black). The racial identification of these individuals may be related
to phenotype or socialisation factors whereby many multiracial persons with a brown
skin tone have long been socially categorised as Black. For example, due to the one-
drop rule, brown-skinned multiracials (regardless of their racial combinations) are
likely to have experiences akin to monoracial Blacks. Similarly, multiracials that solely
4B. MILLER ET AL.

identify with other minority groups are likely to have social experiences that reflect being a
member of that particular group (e.g. Asian or Native American). These multiracials are
therefore likely to have health outcomes that are comparable to Nonwhites but signifi-
cantly different from Whites.
The Blended Race Experience
This viewpoint refers to people that clearly self-identify as being a member of a multiracial
group that has its own racial experiences that are distinct from monoracials. Such experi-
ences may be related to family socialisation (James, Coard, Fine, & Rudy, 2018) as well as
the degree to which multiracials feel connected with their family. These individuals may
also experience microaggressions and macroaggressions for identifying as multiracial,
which in turn can negatively impact their health. In contrast, some multiracials may be
able to symbolically switch their racial identity according to the race of the people with
whom they are interacting (Wilton, Sanchez, & Garcia, 2013). Such identity shifting may
allow multiracials to draw on various psychosocial resources that protect their mental
health or filter out emotionally detrimental social experiences. Therefore, this group of mul-
tiracials may have health outcomes that are either similar to, or significantly different from,
monoracials.
Few studies have examined the well-being of multiracial adults and the extant multira-
cial health literature has presented mixed results, partly due to inconsistent multiracial cat-
egorizations. There also is no current sociological perspective that includes multiracials to
explain racial differences in health between monoracial and multiracial persons. There-
fore, the purpose of the present study is to contribute to the racial disparities in health lit-
erature by exploring the impact using different categorizations has on the health outcomes
of multiracial young adults relative to their monoracial peers. Using data from Wave 3 of
the National Longitudinal Study of Adolescent to Adult Health, we pose the following
research questions:
Q
1
: Do monoracials collectively have better or worse mental and self-rated health than
multiracials?
Q
2
: Do both White-Nonwhite and Nonwhite-Nonwhite multiracials have similar or worse
mental and self-rated health than monoracials collectively?
Q
3
: Do individual monoracial groups have better or worse mental and self-rated health
than multiracials?
Q
4
: Do White-Nonwhite and Nonwhite-Nonwhite multiracials have similar or worse
mental and self-rated as other racial minorities compared to Whites?
Methods
Data and sample
The present study uses data from Wave 3 of the National Longitudinal Study of Adoles-
cent to Adult Health (Add Health). The Add Health is a school-based study of a nation-
ally representative sample of adolescents in grades 7–12 in the United States with Wave 1
beginning in 1994–1995. The Add Health used a multistage, stratified, school-based,
cluster sampling design that involves four waves of data collection and several data
HEALTH SOCIOLOGY REVIEW 5

collection components. See Bearman, Jones and Udry (1997) for more details on the Add
Health Study.
The present study uses Wave 3 data, collected from 2001 to 2002. Although this data is
somewhat dated, it is one of the only nationally representative data sets that has the
measures available to examine the mental and self-rated health of multiracial persons
ages 18–25. This investigation compares the mental and self-rated health profiles of multi-
racial young adults with White-Nonwhite (e.g. White-Asian) and Nonwhite-Nonwhite
(e.g. Black-Native American) identities to monoracial persons. To conduct these compari-
sons, our analytic sample was limited to individuals that self-identified with the Asian,
Non-Hispanic Black, Native American, and Non-Hispanic White racial groups. Individ-
uals that identified as Hispanic were excluded from the sample because they are classified
as an ethnic group and not a race (Humes et al., 2011). The final analytic sample consists of
10,098 monoracial and 437 multiracial young adults (N= 10,535).
Independent variables
Race is a self-reported measure that categorises respondents as monoracial or multiracial.
Respondents that identified themselves as monoracial were coded into one of four
mutually exclusive categories: Asian, Native American, Non-Hispanic Black, and Non-
Hispanic White. Respondents that identified themselves as multiracial were coded as Non-
white-Nonwhite if they self-identified as Black-Native American, Black-Asian, Native
American-Asian, and Black-Native American-Asian. Respondents that identified them-
selves as; White-Asian, White–Black, White-Native American, White-Asian-Black,
White-Asian-Native American, and White-Asian-Black-Native American were coded as
White-Nonwhite.
Gender is a self-reported measure that categorises respondents as either female (1) or
male (0). Age is measured continuously in years ranging from 18 to 25. Education is
based on the respondent’s highest educational attainment and is then coded into five
mutually exclusive categories: ‘less than high school;’‘high school graduate;’‘associate
degree;’‘bachelor degree;’and ‘more than a bachelor degree.’
Dependent variables
Depression symptomatology was measured using a nine-item index with scores ranging from
0to27(α= .84) modified from Radloff’s(1977) CES-D 20-item index where scores range
from 0 to 60 (αranging from .85 to .90). Responses to items 1 through 7 were coded so
that the range of values was from 0 = never or rarely; 1 = sometimes; 2 = a lot of the time;
and 3 = most of the time or all of the time, and responses to items 8 and 9 were reverse
coded whereby 3 = never or rarely and 0 = most of the time or all of the time.
Self-Esteem was a four-item index ranging from 4 to 20 (α=.78) modified from Rosen-
berg’s(1965) 10-item index where scores range from 0 to 30 (αranging from .77 to .88).
Responses to the items were coded such that 5 = strongly agree; 4 = agree; 3 = neither agree
nor disagree; 2 = disagree; and 1 = strongly disagree.
Life Satisfaction is a one-item measure. ‘How satisfied are you with your life as a whole?’
Ranging from 1 to 5 where 5 = very satisfied; 4 = satisfied; = neither satisfied nor dissa-
tisfied; 2 = dissatisfied; and 1 = very dissatisfied.
6B. MILLER ET AL.

Self-Rated Health –is a one-item measure. ‘In general, how is your health?’Ranging
from 1 to 5 where 5 = excellent; 4 = very good; 3 = good; 2 = fair; and 1 = poor.
Statistical analyses
To compare the differences in the means between the multiracial and monoracial samples,
chi-square tests were used for the categorical variables and one-tailed t-tests used for the
continuous variables. Second, the multivariate analyses use ordinary least squares (OLS)
analysis to predict racial differences in depression symptomatology, self-esteem, life satis-
faction, and self-rated health between monoracial and multiracial young adults. Coeffi-
cient estimates are adjusted for the complex sampling design of the Add Health study
by using the ‘svy’commands in Stata SE, version 14 (StataCorp, 2015).
Descriptive results
Table 1 presents the descriptive statistics for the variables used in the analyses to assess
differences in means between the monoracial and multiracial young adults. In terms of
race, 96% of the sample was monoracial and 4% multiracial, which is in-line with 2010
census estimates (Humes et al., 2011). Among the multiracial sample, 86% self-identified
as White-Nonwhite and 14% identified as Nonwhite-Nonwhite whereas 77%, 16%, 2%,
and 4% of monoracials identified as White, Black, Native American, and Asian respect-
ively. In terms of well-being, multiracials have significantly greater depression symptoma-
tology (5.05 vs. 4.51) and slightly lower self-esteem (16.64 vs. 16.88) than their monoracial
counterparts. However, there were no statistical differences in the life satisfaction or self-
rated health reported by multiracial and monoracial young adults. The sample also had an
equal percentage of males and females in the monoracial and multiracial groups with no
differences in the average age of monoracial (21.38 years) and multiracial (21.39 years)
young adults but there were marginal differences in educational attainment.
Table 2 presents the results of the multivariate analyses that examined the racial dispar-
ities in mental and self-rated health outcomes when broadly comparing monoracial and
multiracial young adults. The findings presented in Panel A answer the first research ques-
tion and indicate that, when comparing the aggregated monoracial and multiracial groups,
monoracial people report having less depression symptomatology (β=−0.53, p< .001),
higher self-esteem (β= 0.24, p< .10), and greater life satisfaction (β= 0.18, p< .01) than
multiracials. There were no significant differences in self-rated health between monoracial
and multiracial persons.
The results presented in Panel B answered the second research question by compar-
ing the health of the two multiracial groups to the aggregated monoracial group. We
find clear health disparities whereby multiracials that identify as Nonwhite-Nonwhite
have greater self-esteem (β= 0.68, p< .05) and self-rated health (β= 0.20, p< .05) than
monoracials. In contrast, White-Nonwhite multiracials have greater depression sympto-
matology (β= 0.54, p< .10), lower self-esteem (β=−0.38, p< .05), lower life satisfaction
(β=−0.16, p< .05), and lower self-rated health (β=−0.11, p< .10) than monoracials. It
is interesting to note that no differences in self-rated health were found when compar-
ing the two aggregated groups in Panel A, but disparities are revealed when disaggregat-
ing multiracials into their two primary pairings in Panel B. Moreover, we find that
HEALTH SOCIOLOGY REVIEW 7

White-Nonwhite people have poorer mental and self-rated health than Whites but Non-
white-Nonwhite multiracials have better mental health and similar self-rated health as
their White peers.
Results from the ordinary least squares analyses comparing the mental and self-rated
health of individual monoracial groups to the aggregated multiracial group are
Table 1. Bivariate comparison of means for the analytic sample, by racial identity.
Variable Names
Multiracial
(n= 437)
Monoracial
(n= 10,098)
Total
(N= 10,535)
% / Mean SD % / Mean SD % / Mean SD
Health Outcomes
Depression* 5.05 4.12 4.51 4.05 4.54 4.05
Self-Esteem* 16.64 2.34 16.88 2.28 16.88 2.28
Life Satisfaction 3.99 .88 4.17 .80 4.16 .80
Self-Rated Health 3.93 .85 3.99 .87 3.99 .87
Race
Monoracial
White –– .77 .42 .74 .44
Black –– .16 .37 .15 .36
Native American –– .02 .15 .02 .15
Asian –– .04 .20 .04 .20
Multiracial
White-Nonwhite .86 .34 –– .03 .18
Nonwhite-Nonwhite .14 .34 –– .01 .07
Sex
Female .50 .50 .50 .50 .50 .50
Male .50 .50 .50 .50 .50 .50
Age 21.29 1.62 21.39 1.65 21.39 1.65
Education*
Less than High School .12 .32 .10 .30 .10 .30
High School Graduate .74 .44 .76 .43 .76 .43
Associate’s Degree .07 .25 .06 .23 .06 .23
Bachelor’s Degree .07 .25 .08 .28 .08 .27
More than Bachelor Degree .01 .10 .00 .07 .00 .07
Note: *p< .05. Significance measured using chi-square tests for categorical variables and one-tailed t-tests for continuous
variables. Some percentages do not total 100 due to rounding.
Table 2. OLS regressions predicting the mental and self-rated health of monoracial and multiracial
young adults.
Depression Self-esteem Life satisfaction Self-rated health
Panel A: (N= 10,535)
Monoracial −0.53**
(−0.26)
0.24*
(−0.14)
0.18***
(−0.06)
0.06
(−0.05)
Constant 3.10***
(−0.84)
17.37***
(−0.46)
4.18***
(−0.15)
4.31***
(−0.16)
R-squared 0.03 0.02 0.01 0.03
Panel B: (N= 10,535)
Nonwhite-Nonwhite 0.48
(−0.60)
0.68**
(−0.32)
−0.29
(−0.18)
0.20**
(−0.10)
White-Nonwhite 0.54*
(−0.29)
−0.38**
(−0.15)
−0.16**
(−0.06)
−0.11*
(−0.06)
Constant 2.58***
(−0.80)
17.62***
(−0.46)
4.35***
(−0.14)
4.38***
(−0.15)
R-squared 0.03 0.02 0.01 0.03
Note: Unstandardised beta coefficients (β) presented and standard errors in parentheses.
*p<0.05, ** p< 0.01, and *** p< 0.001
Multiracial is the reference group for Panel A.
Monoracial is the reference group for Panel B.
All models adjusted for gender, age, and educational attainment.
8B. MILLER ET AL.

presented in Table 3. The findings presented in Panel A show that, compared to multi-
racials, Whites have less depression symptomatology (β=−0.72, p< .01) and higher life
satisfaction (β= 0.20, p< .01). In contrast, Native Americans have greater depression
than multiracials (β= 0.72, p< .10) but Blacks have higher self-esteem (β= 0.66,
p< .001). There were no statistically significant differences in the mental or self-rated
health between Asians and multiracials. These findings answer the third research ques-
tion and indicate health disparities between monoracials and multiracials vary by the
specific monoracial group of comparison.
The results presented in Panel B address the fourth research question by including both
multiracial groups in the analysis to compare the health of individual minority groups
to Whites. Among monoracial persons, Blacks have greater depression symptomatology
(β= 0.67, p< .001), greater self-esteem (β= 0.48, p< .001), and lower life satisfaction
(β=−0.14, p< .001) than Whites. Native Americans also have greater depression
(β= 1.44, p< .001) as well as lower self-rated health (β=−0.20, p< .01) than Whites.
Asians similarly reported having greater depression (β= 1.18, p< .001), lower life satisfac-
tion (β=−0.11, p< .01), and lower self-rated health (β=−0.11, p< .01) when compared to
Whites. Among multiracials, those who identified as Nonwhite-Nonwhite have greater
self-esteem (β= 0.74, p< .05), greater self-rated health (β= 0.19, p< .05), and lower life
satisfaction (β=−0.32, p< .05) than Whites but there were no significant differences in
Table 3. OLS regressions predicting the mental and self-rated health of monoracial and multiracial
young adults.
Depression Self-esteem Life satisfaction Self-rated health
Panel A: (N= 10,535)
Asian 0.46
(−0.42)
0.00
(−0.20)
0.10
(−0.08)
−0.04
(−0.0*)
Black −0.05
(−0.29)
0.66***
(−0.15)
0.06
(−0.07)
0.07
(−0.06)
Native American 0.72*
(−0.42)
0.00
(−0.21)
0.12
(−0.10)
−0.13
(−0.10)
White −0.72***
(−0.27)
0.17
(−0.15)
0.20***
(−0.06)
0.07
(−0.05)
Constant 3.36***
(−0.79)
17.51***
(−0.44)
4.13***
(−0.15)
4.31***
(−0.16)
R-squared 0.04 0.02 0.02 0.03
Panel B: (N= 10,535)
Asian 1.18***
(−0.36)
−0.18
(−0.15)
−0.11**
(−0.05)
−0.11**
(−0.06)
Black 0.67***
(−0.18)
0.48***
(−0.08)
−0.14***
(−0.03)
0.00
(−0.03)
Native American 1.44***
(−0.38)
−0.17
(−0.16)
−0.08
(−0.07)
−0.20**
(−0.08)
Nonwhite-Nonwhite 0.67
(−0.61)
0.74**
(−0.33)
−0.32*
(−0.18)
0.19**
(−0.10)
White-Nonwhite 0.73**
(−0.29)
−0.32**
(−0.16)
−0.19***
(−0.06)
−0.12**
(−0.06)
Constant 2.64***
(−0.75)
17.70***
(−0.43)
4.33***
(−0.14)
4.38***
(−0.15)
R-squared 0.04 0.02 0.02 0.03
Note: Unstandardised beta coefficients (β) presented and standard errors in parentheses.
*p< 0.05, **p< 0.01, and ***p< 0.001
Multiracial is the reference group for Panel A.
White is the reference group for Panel B.
All models adjusted for gender, age, and educational attainment.
HEALTH SOCIOLOGY REVIEW 9

depression. Multiracials with a White-Nonwhite identity however, have greater depression
(β= 0.74, p< .05), lower self-esteem (β=−0.32, p< .05), lower life satisfaction (β=−0.19,
p< .01), and lower self-rated health (β=−0.12, p< .01) than Whites. These overall
findings indicate that, like other racial minority groups, White-Nonwhite multiracials
face an elevated risk of having poorer mental and self-rated health than Whites but
young adults that identify as Nonwhite-Nonwhite do not face the same risks.
Discussion
Despite being one of the fastest growing racial groups, few studies have examined the
mental and self-rated health of multiracial adults. The present study addresses this
issue using a sample of monoracial and multiracial young adults (ages 18–25) from
the nationally representative Add Health study and makes several contributions to
advance the racial disparities in health research. First, we explored multiple mental
and self-rated health outcomes to present an overall profile of the well-being of multi-
racial young adults. Second, differences in study design and conceptualizations of mul-
tiracial in prior studies have contributed to mixed and inconsistent findings for
multiracial health (Shih & Sanchez, 2005). Therefore, we demonstrate how different
categorizations of multiracial persons influence differences in findings and suggest con-
ceptualising multiracials as a collective minority group consisting of the two primary
categories of White-Nonwhite and Nonwhite-Nonwhite persons. Lastly, we propose
three new perspectives to explain the racial disparities in health observed between mul-
tiracial and monoracial people.
Our findings reveal that when using an aggregated measure with one general category
encompassing all multiracials and another for monoracials, monoracial persons have
better mental health in terms of less depression, higher self-esteem, and higher life satis-
faction, and self-rated health, which supports prior research (Cooney & Radina, 2000;
Fisher et al. 2014; Lau et al., 2012). However, our study extends previous research by
demonstrating the importance of disaggregating multiracials according to the racial
groups with whom they identify because their mental and self-rated health varies signifi-
cantly by their racial identity. Specifically, discovering that Nonwhite-Nonwhite persons
had greater self-esteem and self-rated health than monoracials whereas White-Nonwhites
had greater depression, lower self-esteem, lower satisfaction, and lower self-rated health is
a significant finding suggesting there are meaningful racial disparities in health among
different multiracial pairings that are related to the racial groups with whom they self-
identify (Bratter & Gorman, 2011; Lau et al., 2012; Udry et al., 2003). Moreover, these
differences indicate that multiracials that only identify with racial minority groups may
actually have better health than monoracials but multiracials that partially identify as
White have poorer mental and self-rated health.
When comparing the aggregated multiracial group to individual monoracial groups,
our findings demonstrate that not all racial groups have equally different mental and
self-rated health outcomes from multiracials (Bratter & Gorman, 2011; Udry et al.,
2003). Moreover, when compared to Whites as commonly done in many racial disparity
studies, the disaggregated Nonwhite-Nonwhite multiracial group had greater self-esteem
and self-rated health than Whites whereas the White-Nonwhite multiracial group had
lower self-esteem, life satisfaction, and self-rated as well as greater depression
10 B. MILLER ET AL.

symptomatology. Put another way, multiracials with minority identities may have better
health than Whites and those with a partially White identity have worse health. This
suggests that all multiracials may not face an elevated risk of mental illness (Shih and
Sanchez, 2005) and using an analytical strategy comparing the two primary multiracial
groups reveals much more detail about the health disparities between multiracials and
monoracials than comparing both groups in aggregate.
Discovering that White-Nonwhite multiracial young adults have significantly
poorer mental and self-rated health than Whites was a surprising finding that did
not support the proposed White Experience perspective. The observed health dispar-
ities may be related to differences in self-identity, since some multiracial individuals
tend to struggle with their identity in combination with perceiving elevated levels
of social stressors like racial discrimination that are positively related to depression
symptomatology (Ahn et al., 2017;Choietal.,2006; Slotman et al., 2017). Similarly,
the lower self-rated health of White-Nonwhite multiracial young adults may reflect
rating one’s health negatively in terms of social health due to racial discrimination
related to their identity in the absence of chronic diseases (Landrine et al., 2015).
Thus, differences in life experiences related to exposure to social stressors such as
microaggressions may be significant factors that influence the mental health disadvan-
tages reported by White-Nonwhite multiracial individuals. The observed outcomes
also fall more closely inline with the proposed Minority Experience and suggests it
is more likely that multiracials who self-identify as monoracial White may actually
have the White Experience but those that only partially identify as White do not
have the same experiences. This position is supported by the fact that the population
of multiracial adults rises from 3% to 7% when the racial background of an individ-
ual’s parents and grandparents are also accounted for resulting in a ‘multiracial iden-
tity gap’(Pew Research Center, 2015), which further adds to the complexity of
understanding the health of multiracials.
Conversely, we find that Nonwhite-Nonwhite multiracials have lower life satisfac-
tion but greater self-esteem and self-rated health than Whites. The differences in life
satisfaction are not surprising given that monoracial Whites are more likely to
report having greater life satisfaction than racial minorities because they are, on
average, better offinanumberofwaysinalmostallaspectsoflife(Barger,Donoho,
&Wayment,2009). The findings for self-esteem suggest that like Blacks (Gray-Little
&Hafdahl,2000; Zeigler-Hill, Wallace, & Myers 2012), Nonwhite-Nonwhite multira-
cial persons might also have a self-esteem advantage over Whites that may at least par-
tially stem from their ability to attribute negative social experiences to prejudice or
racial discrimination rather than something personal about their appearance, behav-
iour, or characteristics as well as placing less importance on the stigmatised attributes
of multiracial persons and instead subjectively emphasising their more positive charac-
teristics (Crocker & Major 1989; Zeigler-Hill et al., 2012). Since self-esteem is based on
aperson’s intrinsic view of how they value themselves or others in their group
(Bachman et al., 2011), our findings suggest that Nonwhite-Nonwhite multiracials
highly value their culture(s) and may have a stronger self-identity than Whites. In
terms of self-rated health, given that it is a general measure of a person’s perceived
mental, physical, and social well-being (WHO, 1948), our findings suggest Non-
white-Nonwhite multiracials perceive their overall health to be better than Whites
HEALTH SOCIOLOGY REVIEW 11

and this differs from results of previous research that examined specificmultiracial
pairings (Bratter & Gorman, 2011). Instead of supporting the expected Minority
Experience, these are very interesting findings that support the Blended Race Experi-
ence. Using the Blended Race Experience perspective helps interpret our findings
because some multiracial people can integrate their multiple racial identities into
one identity (Gibbs, 1987)andsuchidentity shifting may explain why multiracial indi-
viduals that identify as Nonwhite-Nonwhite have better health than their monoracial
counterparts whereby they switch their identity according to the group of people
that they are interacting with (Wilton, Sanchez, & Garcia, 2013). Identity shifting
can be used as part of one’s impression management strategies for protecting the
self-worth of stigmatised people (Zeigler-Hill et al., 2012). The ability to shift racial
identities, in turn, can reduce or buffer multiracial individuals from the adverse
effects of stressful events related to their discriminatory experiences, which have
been found to be associated with significantly lower self-rated health (Alvarez-
Galvez, 2016).
Limitations
One limitation to the present study is the data were collected in 2001 and may not
fully reflect the experiences and well-being of today’syoungadults.Wedobelieve
however, that there is utility in examining data of this age because we are not
aware of any other publicly available data set with the measures to make such ana-
lyses and understanding how racial identity affects the well-being of multiracial
young adults can give researchers and practitioners some much needed insight into
the health outcomes for one of the fastest growing demographics of our population.
Dohrenwend (1998) suggested researchers should gather more data on diverse groups
to better understand racial differences in health outcomes. Accordingly, more data is
needed on the growing multiracial population to advance the contemporary racial
disparities research.
Another limitation is that by employing a cross-sectional analysis, there may be issues
with social-selection such that people with poorer health select to identify as multiracial.
Multiracial persons tend to experience more negative social and emotional well-being
when their mother identifies as a racial minority (Schlabach, 2013), so there may also
be issues related to the racial group with whom a multiracial person chooses most to ident-
ify with that impact their health. For example, an individual who identifies as White–Black
may identify more with Whites than Blacks, which may lead to different life experiences
and subsequent health disparities than a White–Black person that identifies more with
Blacks than Whites. We were also unable to control for the effects of social-selection or
social-causation because half of the outcome measures we use at Wave 3 are excluded
in previous waves of data. Lastly, our findings are not generalisable to all multiracial com-
binations since our analyses exclude multiracials with specific racial identities such as
White-Asian or Asian-Black-Native American. However, we further show there are sig-
nificant health disparities among multiracials and using the two primary categories of
White-Nonwhite and Nonwhite-Nonwhite is one way to begin gathering more consistent
research for this minority group and thereby address some of the issues raised by Shih and
Sanchez (2005).
12 B. MILLER ET AL.

Future directions
The present study adds new insight into the racial disparities in health by demonstrating
that the mental and self-rated health outcomes of young adults (ages 18–25) significantly
vary by specific multiracial combinations when compared to their monoracial peers. Our
findings demonstrate the way researchers categorise multiracial people can significantly
challenge our understanding of race and racial disparities in health (Roberts & Gelman,
2015). Furthermore, exploring the health of the growing multiracial population will
become more paramount for health researchers and practitioners in the near future as
the biracial baby boom (Cruz & Berson, 2001) is likely to continue and it is predicted
that by the year 2040 minorities will constitute the majority of the nation’s adolescent
population (Fox et. al., 2007).
As such, we believe our proposed Racialized Experiences of Multiracial Persons perspec-
tive would benefit future researchers examining racial disparities in health because our
model recognises how the identity and social experiences of individuals with mixed racial
backgrounds may influence their health outcomes. Racial identity is a complex multidimen-
sional construct, and our model addresses one of the missing links in contemporary health
disparities research by providing a framework for understanding the role self-identification
plays in the health outcomes of multiracial individuals. Furthermore, there is tremendous
diversity within the multiracial population and although it can be further developed, our
model establishes the basis for a theoretical framework that provides a rationale to categor-
ise the plethora of multiracial experiences into three fundamental perspectives; the white
experience, the minority experience, and the blended race experience.
Our study also highlights the need to understand the role skin tone plays in racial iden-
tity particularly for intra-racial classifications. For example, lighter skin equates to greater
purity within some Native American cultures as well as greater self-esteem among Blacks
(Hochschild, 2005; Thompson & Keith, 2001). Therefore, future research should examine
how the health of multiracial people is related to an individual’s skin tone. Skin tone may
also impact self-identity, particularly for White-Nonwhite and Black-Nonblack multira-
cials that may identify as monoracial White or Black because of their appearance
despite having parents from different racial groups. As such, future research should use
parent’s racial identity to account for the multiracial identity gap and its effect on racial
disparities in health. Future studies should also examine whether or not there are differ-
ences in the social stressors to which different multiracial and monoracial groups are
exposed as well as the psychosocial resources each has available to help them cope with
stressful life events. Therefore, more funding from policy makers can significantly help
researchers and practitioners gain a better understanding of the association between
race and health disparities as well as develop treatments that can help improve the lives
of the millions of multiracial minorities.
Acknowledgment
This research uses data from Add Health, a program project directed by Kathleen Mullan Harris
and designed by J. Richard Udry, Peter S. Bearman, and Kathleen Mullan Harris at the Univer-
sity of North Carolina at Chapel Hill, and funded by grant P01-HD31921 from the Eunice
Kennedy Shriver National Institute of Child Health and Human Development, with cooperative
funding from 23 other federal agencies and foundations. Special acknowledgment is due Ronald
HEALTH SOCIOLOGY REVIEW 13

R. Rindfuss and Barbara Entwisle for assistance in the original design. Information on how to
obtain the Add Health data files is available on the Add Health website (http://www.cpc.unc.
edu/addhealth). No direct support was received from grant P01-HD31921 for this analysis.
Disclosure statement
No potential conflict of interest was reported by the authors.
Funding
This work was supported by Eunice Kennedy Shriver National Institute of Child Health and
Human Development [grant number P01-HD31921].
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Organization as adopted by the International Health Conference, New York, 19–22 June,
1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the
World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.
World Health Organization. (2014). Mental health: A state of well-being. Retrieved from http://
www.who.int/features/factfiles/mental_health/en/
Zeigler-Hill, V., Wallace, M. T., & Myers, E. M. (2012). Racial differences in self-esteem revisited:
The role of impression management in the black self-esteem advantage. Personality and
Individual Differences,53, 785–789. doi:10.1016/j.paid.2012.06.007
HEALTH SOCIOLOGY REVIEW 17

Appendices
Appendix A. OLS regressions predicting the mental and self-rated health of
monoracial and multiracial young adults (full models)
Depression Self-esteem Life satisfaction Self-rated health
Panel A: (N= 10,535)
Monoracial −0.53**
(−0.26)
0.24*
(−0.14)
0.18***
(−0.06)
0.06
(−0.05)
Female 0.97***
(−0.10)
−0.40***
(−0.06)
−0.02
(−0.02)
−0.18***
(−0.02)
Age 0.07*
(−0.04)
−0.02
(−0.02)
−0.01
(−0.01)
−0.01**
(−0.01)
Less than HS 1.42***
(−0.18)
−0.55***
(−0.11)
−0.13***
(−0.04)
−0.27***
(−0.04)
Associate degree −0.81***
(−0.18)
0.31***
(−0.12)
0.17***
−(0.04)
0.15***
(−0.03)
Bachelor degree −1.11***
(−0.19)
0.47***
(−0.10)
0.24***
(−0.04)
0.30***
(−0.04)
More than bachelor −1.87***
(−0.52)
0.82*
(−0.44)
0.21
(−0.16)
0.25
(−0.16)
Constant 3.10***
(−0.84)
17.37***
(−0.46)
4.18***
(−0.15)
4.31***
(−0.16)
R-squared 0.03 0.02 0.01 0.03
Panel B: (N= 10,535)
Nonwhite-Nonwhite 0.48
(−0.60)
0.68**
(−0.32)
−0.29
(−0.18)
0.20**
(−0.10)
White-Nonwhite 0.54*
(−0.29)
−0.38**
(−0.15)
−0.16**
(−0.06)
−0.11*
(−0.06)
Female 0.98***
(−0.10)
−0.40***
(−0.06)
−0.02
(−0.02)
−0.18***
(−0.02)
Age 0.07*
(−0.04)
−0.03
(−0.02)
−0.01
(−0.01)
−0.01**
(−0.01)
Less than HS 1.42***
(−0.18)
−0.55***
(−0.11)
−0.14***
(−0.04)
−0.27***
(−0.04)
Associate degree −0.81***
(−0.18)
0.31***
(−0.12)
0.17***
−(0.04)
0.15***
(−0.03)
Bachelor degree −1.11***
(−0.19)
0.47***
(−0.10)
0.24***
(−0.04)
0.30***
(−0.04)
More than bachelor −1.87***
(−0.52)
0.83*
(−0.44)
0.21
(−0.16)
0.25
(−0.16)
Constant 2.58***
(−0.80)
17.62***
(−0.46)
4.35***
(−0.14)
4.38***
(−0.15)
R-squared 0.03 0.02 0.01 0.03
Note: Unstandardised beta coefficients (β) presented and standard errors in parentheses.
*p< 0.05, **p< 0.01, and ***p< 0.001.
Reference groups: White, male, and high school graduate.
18 B. MILLER ET AL.

Appendix B. OLS regressions predicting the mental and self-rated health
of monoracial and multiracial young adults (full models)
Depression Self-esteem Life satisfaction Self-rated health
Panel A: (N= 10,535)
White −0.72***
(−0.27)
0.17
(−0.15)
0.20***
(−0.06)
0.07
(−0.05)
Black −0.05
(−0.29)
0.66***
(−0.15)
0.06
(−0.07)
0.07
(−0.06)
Native American 0.72*
(−0.42)
0.00
(−0.21)
0.12
(−0.10)
−0.13
(−0.10)
Asian 0.46
(−0.42)
0.00
(−0.20)
0.10
(−0.08)
−0.04
(−0.08)
Female 0.98***
(−0.10)
−0.41***
(−0.06)
−0.02
(−0.02)
−0.18***
(−0.02)
Age 0.06
(−0.04)
−0.03
(−0.02)
−0.01
(−0.01)
−0.01**
(−0.01)
Less than HS 1.34***
(−0.18)
−0.57***
(−0.11)
−0.13***
(−0.04)
−0.26***
(−0.04)
Associate degree −0.75***
(−0.17)
0.35***
(−0.12)
0.16***
(−0.04)
0.15***
(−0.03)
Bachelor degree −1.05***
(−0.18)
0.50***
(−0.10)
0.23***
(−0.04)
0.30***
(−0.04)
More than bachelor −1.84***
(−0.52)
0.85*
(−0.43)
0.20
(−0.16)
0.25
(−0.16)
Constant 3.36***
(−0.79)
17.51***
(−0.44)
4.13***
(−0.15)
4.31***
(−0.16)
R-squared 0.04 0.02 0.02 0.03
Panel B: (N= 10,535)
Black 0.67***
(−0.18)
0.48***
(−0.08)
−0.14***
(−0.03)
0.00
(−0.03)
Native American 1.44***
(−0.38)
−0.17
(−0.16)
−0.08
(−0.07)
−0.20**
(−0.08)
Asian 1.18***
(−0.36)
−0.18
(−0.15)
−0.11**
(−0.05)
−0.11**
(−0.06)
Nonwhite-Nonwhite 0.67
(−0.61)
0.74**
(−0.33)
−0.32*
(−0.18)
0.19**
(−0.10)
White-Nonwhite 0.73**
(−0.29)
−0.32**
(−0.16)
−0.19***
(−0.06)
−0.12**
(−0.06)
Female 0.98***
(−0.10)
−0.41***
(−0.06)
−0.02
(−0.02)
−0.18***
(−0.02)
Age 0.06
(−0.04)
−0.03
(−0.02)
−0.01
(−0.01)
−0.01**
(−0.01)
Less than HS 1.34***
(−0.18)
−0.57***
(−0.11)
−0.13***
(−0.04)
−0.26***
(−0.04)
Associate degree −0.75***
(−0.17)
0.35***
(−0.12)
0.15***
(−0.04)
0.15***
(−0.03)
Bachelor degree −1.05***
(−0.18)
0.50***
(−0.10)
0.23***
(−0.04)
0.30***
(−0.04)
More than bachelor −1.84***
(−0.52)
0.86**
(−0.43)
0.20
(−0.16)
0.26
(−0.16)
Constant 2.64***
(−0.75)
17.70***
(−0.43)
4.33***
(−0.14)
4.38***
(−0.15)
R-squared 0.04 0.02 0.02 0.03
Note: Unstandardised beta coefficients (β) presented and standard errors in parentheses.
*p< 0.05, **p< 0.01, and ***p< 0.001.
Reference groups: Multiracial, male, and high school graduate.
HEALTH SOCIOLOGY REVIEW 19