Midlife Black women bear a disproportionate burden of health disparities related to chronic diseases (U.S. Census Bureau, 2012). For these women, the incidences of hypertension and obesity exceed all other U.S. groups (American Heart Association, 2016). Forty percent of midlife Black women have been diagnosed with hypertension and another 49% are estimated to have cardiovascular disease (CVD) (Garth, 2015). Black women are twice as likely as White women to experience a stroke and more likely to die at an earlier age (American Heart Association, 2016), as Black women older than 60 have the greatest incidence of heart failure (Loehr, Rosamond, Chang, Folsom, & Chambless, 2008). The higher rates of obesity among Black women place them at greater risk for type 2 diabetes, hypertension, and CVD (Plank-Bazinet et al., 2016). Cancer deaths are also significantly higher for Black women. For example, White women are more likely to be diagnosed with breast cancer, but Black women have a higher mortality rate from breast cancer and die at younger ages (Plank-Bazinet et al., 2016). Due to the existing health disparities experienced by Black women across the lifespan, it is predicted that Black women will have the poorest health outcomes of all U.S. groups by 2060 (U.S. Census Bureau, 2012).
Multiple factors impact these existing health disparities (Sampson et al., 2016). The intersection between race, social status, environment, gender, genetic, and epigenetic factors is complex (Saban, Mathews, DeVon, & Janusek, 2014). Increased awareness about the impact of social and environmental factors resulted in the advent of personalized medicine and recognition that interventions must be tailored and targeted to high-risk populations (Sampson et al., 2016). However, as no single intervention has proven effective for minimizing health disparities related to the pervasive and ingrained social inequities endured by U.S. Black women, multifaceted yet tailored approaches have been recommended (Brown et al., 2018).
Chronic life stress is one such health determinant that has been explored for its contribution to chronic illness (Wagner et al., 2012). Chronic stress is associated with a 40% to 60% increased risk for CVD (Steptoe & Kivimaki, 2012). Stress triggers physiological and cellular changes as well as changes in behavior. For example, chronic life stress can impact participation in preventive screenings and healthy lifestyle behaviors, thus influencing the manner in which self-care is prioritized (Angus et al., 2007; Black & Woods-Giscombe, 2012). Daily chronic stressors, such as discrimination, require consistent coping efforts and energy expenditure that, over time, predispose midlife Black women to illness (Angus et al., 2007). The stress associated with racism can be encountered in every aspect of life, creating a state of persistent hypervigilance that has negative effects on the psychological and physical state of a person. Midlife Black women may experience persistent stress resulting from the simultaneous exposure of racism and sexism, as well as from the gendered expectations of being the primary familial caregiver and supporter of others and the community alike (Kasper et al., 2008).
The Strong Black Woman Syndrome (also known as Superwoman or Sojourner syndrome) is a theoretical framework used to understand the intersecting effects of gender, race, and class on the health and well-being of Black women. The framework also explains the coping mechanisms developed by Black women in response to the extremely oppressive conditions associated with racism (Beauboeuf-Lafontant, 2009). These coping mechanisms cultivate strength and resilience among Black women but also lead to weathering, a deterioration of health due to chronic active coping (Lekan, 2009). As such, midlife Black women have been identified as a high-risk population for stress-related health conditions, reporting long-term exposure to multiple, competing stressors and higher levels of stress than White women (Groer & the Women's Health Research Group at the University of South Florida College of Nursing, 2010). Thus, stress management is an ideal complement to the adoption of healthy lifestyle behaviors and treatment regimens recommended for midlife Black women (Schneider et al., 2012).
The current study aimed to develop a stress management wellness intervention for midlife Black women. This article describes the beginning steps toward development of an intervention. Community engagement through focus groups was essential to identify the key sources of stress that will serve as the building blocks of the intervention. The voices of the midlife Black women who participated are highlighted.
Study Design and Sample
The current focus group study was designed to gather data to inform the development of a framework for a stress management wellness intervention targeted and tailored to midlife Black women. A convenience sample comprising 12 midlife Black women was recruited using purposive sampling and referral. Recruitment flyers were distributed at social gatherings and professional meetings for Black women. Women met inclusion criteria if they self-identified as Black American, were between the ages of 40 and 64, resided in the greater Cincinnati area, were English-speaking, and voiced interest in contributing to the development of a stress management intervention. Focus group discussions were held to explore the sources and experiences of stress for midlife Black women in Cincinnati and to generate ideas for intervention. Total enrollment was limited to 12 to optimize group dynamics and dialogue throughout the project, and to accommodate for attrition (Stewart & Shamdasani, 2015). One participant withdrew, resulting in a final sample size of 11.
Study Participants' Protection
This focus group study was approved by the University of Cincinnati Institutional Review Board. The primary investigator (PI; H.J.J.) obtained written consent from each participant prior to the first focus group session. Ground rules for the focus group sessions were established by participants in the initial session and posted for each subsequent session. Flip charts, reviewer notes, and audio recordings were used for data collection. Audio recordings were professionally transcribed. All study data were stored in locked cabinets in the PI's office, separate from demographic data.
A total of five 90-minute focus group sessions were held at the University of Cincinnati College of Nursing over a period of 3 months. Attendance at each focus group session ranged from six to nine participants, with each participant attending at least two sessions. Sessions were scheduled based on majority group consensus. Refreshments were provided, and participants received a monetary gift card at the end of each session. Although the focus group discussion guide comprised multiple questions centered on stress and stress management strategies, the guiding question for the current study report was: “What stresses you out?”
A variety of strategies were used to guide the focus groups, encourage participation, maintain the effectiveness of the group sessions, and reach saturation. Reflection and member checking were used to ensure methodological rigor and for accuracy and clarification of statements and meaning. For example, at the start of each session, the previous sessions were summarized, and large flip chart sheets were attached to the walls listing the ideas generated from prior sessions. Participants were provided the opportunity to add to the content and/or provide clarification.
Triangulation and member checking techniques were used during the study to assure credibility of the data. Transcribed group discussions were analyzed using thematic coding. A line-by-line analysis generated codes and sub-codes of stressors. Codes were independently labeled by each of the research team members. Each team member reviewed the focus group discussion guide, moderator notes, and audiotapes in their entirety. Stress categories were organized into larger concepts and then examined on the basis of similarities and differences across codes and sub-codes. Following individual coding and thematic analyses of the data, the team convened for discussion of variable interpretations and themes until consensus was reached.
The final sample comprised 11 midlife Black women ranging in age from 41 to 54 years (mean age = 48 years). The level of education attained ranged from high school graduate to professional degree and annual incomes ranged between $35,000 and $150,000. All participants reported that they were currently employed and only one reported a lapse in health care coverage in 2016. Of 11 participants, seven were single or divorced and the remaining were married or in long-term relationships. Ten participants were parents.
Key primary stressors were identified through shared experiences: workplace, parenting, finances, and social media. Two underlying stressors were also identified that were strongly related to the Strong Black Woman persona: gendered racism and discrimination and life imbalance. Each stressor is described to reveal the complexity of the life stressors experienced by midlife Black women in the current study.
Workplace Stress. The workplace was reported by all participants as a stressor. Examples of workplace stress included stressful interactions with coworkers and treatment based on preconceived ideas related to the color of their skin and/or gender. One participant shared her experience of perceived subordinate treatment by White female co-workers:
White women would come and confide their problems in me and we would talk about it…and what I found was that they weren't talking to the other White women in the organization about their problems because they had an image to uphold.
Another participant shared her experience in the workplace where she believed unequal treatment was based on gender rather than race. She proposed that education and demonstrable skills diminished the race-based biases yet the gender-based biases of inferiority remained.
I had more of a gender bias than I did a racial bias. And I think from the racial bias, they knew it wouldn't stick because I was [always prepared].
However, most agreed that gender and racial biases were prevalent as stressors. One such example was:
…So, it's like this assumption that I am less than because I am Black and I'm a woman.
Another participant shared:
I think sometimes the expectation is that you don't know what you're doing. You're already judged before you go in there about your business plan or your finances…
Parenting Stress. Parenting was an important stressor, especially for those raising young Black men. Current events and societal issues were reported to increase the need for close supervision of their children.
...I don't think that the stress that they had to go through raising Black boys was as prevalent as what we see on [television] today. So, it has made me become a “paranoid parent.” I don't let them walk the streets. I don't let them just walk out and wear hoodies everywhere. I have to not always say no but I over think it…
An additional parenting-related stressor was the media and news coverage of the police-related shootings and racial tensions present during the time of the focus groups sessions. During summer 2016, concurrent with this study, several highly publicized murders of young Black men heightened the sensitivities and collective stress in U.S. Black communities around police violence and Black men in particular. The residual impact was that Black mothers felt particularly insecure and stressed at the current events.
...It's just been very stressful trying to explain to them why our Black boys are pulled over, why our Black men are being killed. I can't even conceptualize getting my oldest from 15 to age 25 without something happening. So that's my No. 1 stress right now...
One participant shared her experiences as a mother of a child who has special needs and the challenges that she faces within the Black community.
…I'm a parent of a special needs child who is 14 years old. He has Asperger's syndrome. And the stresses that go along with that are just way beyond. Because I worry about everything; what he's going to be able to do. Is he going to be able to make it when his father and I are gone? What's going to happen to him?... And so, the stresses that come from special needs, particularly in the Black communities, sometimes issues with mental illness are not always seen as something that's real and tangible, but it is. And it's really hard.... So that is a big stress and it really weighs on me.
Financial Stress. Although women in the sample reported a wide range in income, financial stressors were widely acknowledged as they sought to provide for their children, maintain households, and plan for the future. Factors affecting their financial struggles included co-parenting conflicts, single parenting, and balancing the expectations of others within the reality of their circumstance.
One participant stated:
But the reality is we had the big thing where we had the crash in the economy…I was laid off…And so I had to accept that a choice that I made to go into education was something that contributed to me not living the lifestyle that I had been accustomed to living prior to now.
In reference to her ex-husband, another participant stated:
...it was always a fight to get whatever was needed. ...I didn't expect to pay it by myself but a lot of times I'd have to because they [the children] were going to be okay with or without him.
Social Media Stress. The report of social media as a stressor was frequent among this group of women. Constant exposure and access to cable television, 24-hour news stations, social media, and e-mails was reported to leave some participants feeling overstimulated and overburdened. In addition to the impact of social media on their children as noted above, participants found social media to be a personal stressor because they experienced the adverse effects on their work and social lives.
One participant stated:
...That also comes with being a professional person. I had the same issue at [work] with our e-mail that's open to the public. People can get it. They went into the president's e-mail. So, we find ourselves having conversations in the department...If you're on Facebook®, [you are] wondering how things are going to be interpreted. And this is supposed to be a place where you think you can relax with friends, but you don't know who's watching or if something is going to leak out.
Another participant stated:
…I think that the television is a huge stressor...And I think the other thing about television is that a lot of people use the television to even base how they're gonna live their life. And then you have to look at how it was created, why it was created, what type of shows are put on it. What I'm finding for me is that if I don't stay grounded and I let all those outside influences get internal then I'm a mess. And so I have to turn it all off. I'm finding that I have to go out to nature and get back to basic stuff.
Two stressors emerged in relation to the Strong Black Woman persona: gendered racism and discrimination and life balance. Each stressor is significant and warrants exploration to deepen the understanding of stress in the lives of midlife Black women.
Gendered Racism and Discrimination. Women in this sample expressed that the manner in which they were discriminated against was indeed different from women of other ethnicities and also men. One woman shared the following:
I think it's because Black women, we're not allowed to fail. We're not allowed to fail because you make one mistake and it's the worst thing ever. It's the worst thing ever. But when you're not a minority, you get that second chance.
Another woman commented:
The problem I have is with White men who are beneath me and they think they should have my job because they're in the White boys club.
Life Imbalance. Like many contemporary American women, the midlife Black women in this sample juggled family, work, and community commitments. As midlife women, participants in the current study had established roots in their communities and obligations that extended outside of themselves. However, the time and effort associated with juggling multiple roles in environments that were not “friendly” were taking a toll, leaving them without time to care for or pamper themselves.
One participant stated:
...I didn't have the time to address my own psychosocial needs because I'm a single mom taking care of two kids.... I'd probably have posttraumatic stress but could not get the treatment…
Another participant stated:
…We put ourselves in situations to say: okay, I will pick [my son] up from school, and I'll drop off [my daughter], and then I'll go and pick up this, and then I'll have dinner made, and then I'll throw the laundry in and I'll come back and then I'll be ready to get on my back when you come home. And then I'm not supposed to have an attitude…
Some participants also suggested that the midlife transition added a layer of difficulty that further increased their stress.
The juggling act is getting harder.... Before [midlife], I had it together...and I'm starting to drop some balls; some balls are starting to drop.
Another participant also commented:
I wanted to talk about the sandwich generation, a stressor for me. Right now, my parents are in their 70s. I'm in my 50s and then I have a college student who I'm trying to get out of [college]; got 1 more year. Then I've got a high schooler that will be a senior next year and I'm trying to figure out where she's going to go to school. And my mother was recently sick.
The Strong Black Woman persona emerged from the focus group discussions and contextualized what may otherwise be considered common stressors. Participants agreed that maintaining a “strong” persona has enabled them to endure hardships that women of other ethnicities do not endure. Each participant shared stories of struggle and took great pride in her accomplishments and ability to remain strong through adversity. They acknowledged that there are positive and negative aspects to their strength. Their sacrifice created opportunity and clear benefits for those whom they loved and supported. However, their willingness to take on multiple responsibilities resulted in self-neglect and inner conflict.
…We put ourselves as Black women in these areas to handle the stuff that we're handling, and then we complain about it…because we have been reared to take on and to say okay, “Yes, we'll do it, I can handle that”; I've got an S on my chest.
The idea of the Strong Black Woman was so ingrained that some women went to great lengths to uphold an image worthy of the title. Images of strength, success, and the ability to provide for their children and families were relevant not only in the workplace, but also among other Black individuals. In reference to her experience with seeking help for financial troubles, one woman stated:
...I was so ashamed about what people were going to think...because sometimes with help also comes judgment.
Another participant commented:
...we fail to seek assistance...sometimes you have to step back and recognize you might be a little bit in over your head and you need some help.
Participants in the current study reported that they used silence as a protective strategy to limit scrutiny and judgment by others. In other words, they kept their struggles and problems to themselves. However, they also recognized that their silence decreased their likelihood to seek the help and support they needed. One participant stated:
We can't expose all of our stress. This is the thing. We feel that we can't expose all of our stress. There's inter- and intra-judgment amongst [Black women]. So, you can't say…I got laid off, I lost my house, I lost my car, I lost this and had to move here, I've got to do this. I can't tell you that. I can't tell her that and I can't tell her that.
Another participant stated:
If you look in the Scripture, you just can't tell everything to everybody. And you're right; there are different people that are in your life for different reasons. I know my girlfriends who I can call in the middle of the night. Even when I was having problems with my [daughters], because I talk about my [daughters], but it wasn't easy.
The women reported a sense of scrutiny from coworkers, particularly if they were White and/or male, and there was a sense of isolation if they were employed in a mostly White organization. In this way, the women indicated they were further silenced and forced to endure the isolation dictated by their circumstance, culture, and politics. One participant commented:
...A certain segment of the Black community is pushed really, really hard to achieve to be the best at this, be the best at that. So, what happens when you are isolated? When you have pushed so hard to get to the top, to achieve something that a majority of Blacks don't achieve, and then you're right here. There's nobody there with you.
The current study detailed the sources of stress (stressors) from the perspective of a representative sample of midlife Black women in Cincinnati. Stressors included work, parenting, finances, social media, gendered racism and discrimination, and life imbalance. Workplace stressors manifested as overt racist and discriminatory acts as well as microaggressions. Contemporary Black women must manage societal images and reconcile them with their personal beliefs. Often times these stereotypes, along with socialized expectations, are encountered in the workplace, reinforcing the presumed subordination of Black women and the expectation of service roles to keep Black women ‘in their place’ (Hall, Everett, & Hamilton-Mason, 2011). It takes particular skill and effort to manage and resist these societal images in the workplace. It has been proposed that certain images of Black women persist as a mechanism of ideological oppression (Beauboeuf-Lafontant, 2009).
The stress associated with social media outlets was unique in that it is representative of the fast-paced, technology-dependent world in which we live and has not been encountered by previous generations. Racist images in the mainstream media that perpetuate stereotypes and prejudice are not new; however, women reported additional stress from contemporary outlets of social media, such as Facebook, which offered continuous and often unfiltered news streams and opinions.
Gendered racism and discrimination and life imbalance stress were additional barriers that limited women's opportunities for assistance. These two underlying stressors were persistent, adding a level of complexity to the primary stressors identified. This additional stress associated with racism and discrimination has been shown to increase the vulnerability of midlife Black women to the effects of everyday stressors (Groer & the Women's Health Research Group at the University of South Florida College of Nursing, 2010). Gendered racism is experienced through simultaneous oppression and microaggressions due to race and gender (Szymanski & Lewis, 2015). Examples of race- and gender-based oppressive acts and microaggressions permeated the dialogue, and the underlying meaning of these acts were not lost on the women in the current study. This stressor is one of the driving forces behind the Strong Black Woman, pushing these individuals deeper into the persona and further away from the life balance they desire. This is perhaps the trademark of the Strong Black Woman: making personal sacrifices to accommodate the needs of others.
The stressors related to the Strong Black Woman image and coping revealed in the current study represent factors that have historically contributed to the culture of stress experienced by midlife Black women. The Strong Black Woman refers to the idea that Black women have an impenetrable strength (Beauboeuf-Lafontant, 2009). Maintaining an image (or mask) of strength in the face of racism, discrimination, and interpersonal conflict has helped Black women endure and succeed. For that reason, the Strong Black Woman has remained a paradoxical concept that is both a benefit and detriment to these women's health. Strength is a positive attribute, yet the silence characteristic of the Strong Black Woman persona should be of particular concern to those who care for these women, including family, friends, and professional health care providers. Strength demands an appearance of invulnerability, which enforces self-silence (Beauboeuf-Lafontant, 2009). Silence suppresses feelings and dampens the natural urge for self-expression. Midlife Black women may not freely express their experiences with stress or their need for assistance, perpetuating the image of strength and the need for self-reliance, but also perpetuating self-isolation. Issues related to the Strong Black Woman persona should be taken into consideration when providing care for midlife Black women, as they may reveal areas in need of additional support and referral.
Although this article identifies and contextualizes salient stressors that may contribute to the health status and health outcomes for midlife Black women, there are limitations worthy of discussion. The sample of participants was recruited from the greater Cincinnati area, which may improve the sustainability of a community-based intervention but limit the geographical generalizability. The overall sample was small; however, the attendance at each focus group ranged from six to nine participants, an optimal size to promote dialogue and obtain data saturation.
Implications for Intervention
Midlife Black women encounter multiple and competing stressors over time, often to the extent that the experience becomes normalized. Despite the striking health disparities that exist for this population of women, midlife Black women may minimize stress-related health issues and symptoms, resulting in delayed diagnosis and treatment. The stressors identified in this article will be included in the development of a culturally tailored stress management program targeting midlife Black women. Participants in the current study are representative of midlife Black women from the greater Cincinnati area and a wide range of socioeconomic backgrounds. Participants had a unique perspective and understanding of the circumstances and challenges facing midlife Black women; thus, they are motivated to play a role in research that can influence the health and well-being of their friends, family, and neighbors and will ensure the authenticity of the intervention.
In addition to providing stress management and coping strategies for the stressors most prevalent in the lives of midlife Black women, the proposed intervention will also convey understanding about the impact of the Strong Black Woman persona. Based on the data obtained, each stressor will be contextualized and personalized to target unhealthy behaviors related to the Strong Black Woman persona. It is the current authors' intention to create a tailored stress management intervention to complement the health and wellness advice provided by health care providers. The authors recognize that many providers lack the time (and sometimes interest) to explore the social and environmental stressors affecting the lives and health of their patients. The authors also acknowledge the reality that Black women encounter racism and discrimination from the very people entrusted with their health: nurses, physicians, and other members of the health care team. Subtle and overt acts of racism by health care providers further marginalize this population of women, decreasing the chance that they will seek assistance. This proposed intervention has the potential to empower women by uncovering the very issues that illicit stress through education, support, and coping strategies. The availability of an intervention that complements and enhances proposed treatment regimens (or lack thereof) is greatly needed to offset the impact of these stressors on the health of Black women, improve individual health, and decrease disparities (Warnecke et al., 2008).
The midlife Black women in the current study have agreed to continue their participation as members of a community advisory board charged with informing the development of a stress management intervention targeted to midlife Black women. A key to successful intervention is inclusion of the targeted population and viewing the phenomenon from the perspective of those in the lived experience. Community engagement is considered essential when developing interventions in underrepresented populations, such as Black women, and to improve recruitment and retention rates (Johnson, Joosten, Wilkins, & Shibao, 2015). It is important that the voices of midlife Black women be used to inform the development of the intervention from inception to implementation.
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