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. Author manuscript; available in PMC: 2025 Mar 1.
Published in final edited form as: Soc Sci Med. 2024 Feb 17;345:116699. doi: 10.1016/j.socscimed.2024.116699

Financial Responsibility, Financial Context, and Ambulatory Blood Pressure in Early Middle-Aged African-American Women

Tené T Lewis 1, Rachel Parker 2, Christy L Erving 3, Shivika Udaipuria 1, Raphiel J Murden 2, Nicole D Fields 1, Bianca Booker 1, Reneé H Moore 4, Viola Vaccarino 1,5
PMCID: PMC11014723  NIHMSID: NIHMS1968505  PMID: 38412624

Background

In the United States (US), hypertension and elevated blood pressure (BP) in midlife are major contributors to later life heart disease and stroke (Gerber et al., 2021; Seshadri et al., 2001). This may be especially true for women, as recent findings indicate that cardiovascular disease (CVD) events occur in women at lower BP thresholds than those observed in men, with particularly pronounced differences prior to age 52 (Ji et al., 2021). Among women, rates of hypertension and elevated BP are highest in African-American women compared to women of all other racial/ethnic groups (Virani et al., 2021), with some of the most striking differences observed in midlife (Geronimus et al., 2007; Levine et al., 2011). These excess rates of elevated BP in African-American women have been documented for decades (Geronimus et al., 2007; Gillum, 1996; Levine et al., 2011), and are not fully explained by body mass index (BMI) (Levine et al., 2011), other traditional CVD risk factors (Levine et al., 2011), or genetics (Powell-Wiley, 2021; Rao et al., 2021). Consequently, additional factors likely play a role.

A number of researchers have argued that the high rates of elevated BP and hypertension observed in African-American women relative to women of other racial/ethnic backgrounds may be due in part to contextual inequalities that uniquely shape the African-American female experience in the US (Albert, 2019; Lewis, 2023). National statistics indicate that compared to African-American men, White men, and White women, African-American women are the least likely to be married or part of a dual-earner couple (Centers for Disease Control, 2016; Elliott & Simmons, 2011) and have historically been the most impacted by the wage gap—i.e. earning fewer cents on the dollar each year (U.S. Bureau of Labor Statistics, 2015). In addition to this, African-American women have the highest rates of single parenthood compared to all other race-gender groups in the US (Gould & Wilson, 2020; Wilson, 2017). These factors are believed to be largely driven by discriminatory practices (e.g., un- and underemployment) (Fryer et al., 2013) and policies (e.g., incarceration) (Alexander, 2020; Edwards et al., 2019) that disproportionately impact African-American men relative to men of other racial/ethnic backgrounds, and diminish their life opportunities and ability to provide economic support to African-American women.

These dynamics impact the socioeconomic context of African-American women’s lives, and create an environment in which African-American women may have a disproportionately high level of financial responsibility for themselves and others in their household. However, while numerous studies have examined linkages between a range of socioeconomic status (SES)-related factors and elevated BP and other precursors to CVD events, findings focused on traditional measures of SES in the form of income and/or education have yielded inconsistent results in African-American women (Gruenewald et al., 2009; Lewis et al., 2005; Petrov et al., 2020; Spikes et al., 2022). This suggests that other SES-related factors may be important to consider. Yet we are aware of no studies that have examined whether financial responsibility (i.e., being the primary breadwinner) is associated with elevated BP in this at-risk group.

This is surprising because African-American women bear a strikingly high level of financial responsibility compared to women from all other racial/ethnic groups. For example, national statistics indicate that among US households with a child under age 18, African-American mothers are more likely than White, Native American, Hispanic, Asian/Pacific-Islander, and “Other” race mothers to be breadwinners, with 74% of African-American mothers occupying this role (Institute for Women’s Policy Research, 2020). This phenomenon is not limited to specific geographic regions or contexts, as data indicate that in every single US state African-American mothers with a child under 18 represent the highest percentage of female breadwinners compared to their White and Hispanic counterparts (Institute for Women’s Policy Research, 2016).

Despite this, to our knowledge research that has examined household responsibilities and elevated BP (or any physical health outcome) in women has primarily focused on the non-financial, traditionally “gendered” aspects of household responsibilities in the form of housework and/or childcare --in cohorts of white women (Brisson et al., 1999; Gilbert-Ouimet et al., 2017; Graff et al., 2024). Moreover, while at least one small study of N=113 adults examined “paying bills/keeping records/managing finances” as a potential contributor to elevated BP in a cohort including an unspecified number of African-American women (Thurston et al., 2011), that study defined paying bills as a household chore to be completed, rather than the individual actually being the largest financial contributor to the bills. Thus, despite the high prevalence and clear relevance of financial responsibility in the lives of African-American women, studies examining financial responsibility as a potential contributor to elevated BP, or health outcomes more generally among African-American women appear to be almost non-existent.

The current analysis was designed to examine associations between financial responsibility and elevated 48-hour ambulatory BP in a cohort of African-American women, aged 30–46, from diverse SES backgrounds. We intentionally focused on “early” middle age because prior studies have found that this is when increases in BP are steepest for African-American women, relative to other race-gender groups (Geronimus et al., 2007; Shen et al., 2017; Thomas et al., 2018). Further, this life stage has been identified as that of “established adulthood” in which women are most likely to be juggling the multiple demands of work, high-intensity parenthood (for young children and adolescents), and (for some) marriage/partnerships (Mehta et al., 2020). Thus, early middle age may be a time of life when financial responsibility emerges, and becomes salient in the lives of African-American women.

We hypothesized that having primary financial responsibility for one’s household would be associated with higher BP over 48 hours, independent of household size and traditional indicators of SES such as education and income. We further hypothesized that associations would be most pronounced for African-American women who were single parents, and/or low SES, due to the potentially greater demands of financial reponsibility on women in these subgroups. We also included single African-American women who were not parents, as qualitative research has documented that irrespective of parental status, single African-American women frequently report finding financial responsibility problematic because they have no one to fall back on in an economic crisis (H. J. Jones et al., 2016; C. King, 2021). Additionally, we explored associations by marital/live-in partner status, given the possibility that African-American women in a two-adult household might be financially or emotionally buffered from the negative impact of financial responsibility on BP. Finally, we examined whether any of our hypothesized associations were independent of financial strain and depressive symptoms, given that both have potential relevance to financial responsibility and their relationship with elevated BP and hypertension is already known (Davidson et al., 2000; Gavrilova & Zawadzki, 2021; Steptoe et al., 2005).

Methods

Participants

Participants were from the Mechanisms Underlying the impact of Stress and Emotions on African-American Women’s Health (MUSE) cohort. MUSE recruited early middle-aged African-American women from the greater metropolitan Atlanta, GA area, using residential lists representative of a wide range of census tracts. Initial eligibility criteria included: aged 30–45 at screening, self-identification as an African-American woman and premenopausal with at least one ovary. Exclusion criteria included: being pregnant or lactating; having a history of clinical CVD (e.g., myocardial infarction, angina, cerebral ischemia or history of revascularization), most chronic conditions that influence CVD (e.g., autoimmune disease, HIV/AIDS, renal disease), current psychiatric disorder treatment, current illicit drug abuse, and current overnight shift-work (due to alterations in circadian rhythms). Prior research has documented the lack of substantive health gains observed in African-American women of higher, compared to lower, SES backgrounds (Assari, 2020; Din-Dzietham & Hertz-Picciotto, 1998; Lewis et al., 2005). Consequently, in order to more adequately understand factors contributing to risk across the SES spectrum in African-American women, participants were recruited such that 50% of women had incomes above, versus below, the median income in GA ($50,000) at the time of enrollment.

A total of N=422 women enrolled in the cohort. Of these, N=8 were missing ABP data due to equipment failures (N=2), arm circumferences larger than the largest XL cuff size (N=3), refusal (N=1) and undetermined (N=1). Of the remaining N=414 women, an additional 2 did not have data on financial responsibility and 13 had missing or unavailable (e.g., responded don’t know/refused on income) data on sociodemographics, BMI, smoking, or depressive symptoms, resulting in N=399 participants. Of these, N=54 reported being unemployed, with N=3 missing employment data. Because of conceptual concerns around the plausibility of having primary financial responsibility while being unemployed, and consistent with prior studies of household responsibilities and ABP (Brisson et al., 1999; Gilbert-Ouimet et al., 2017; Thurston et al., 2011), these women were excluded from analyses. However, we also ran sensitivity analyses with these women included, with employment status (yes/no) as a covariate. Because we had approximately 5.5% missing/unavailable data, we also ran sensitivity analyses comparing results from our complete case analysis to those using multiple imputation methods. Because a number of researchers have argued that imputing outcomes produces biased estimates (Austin et al., 2021; White et al., 2011), and because some of our ABP data was not missing at random, we initially performed multiple imputation with chained equations (MICE) (White et al., 2011) to construct 5 different datasets that imputed any missing exposure and covariates. Following this, we utilized multiple imputation then deletion (MID) (von Hippel, 2007), where all missing values (including outcomes) were imputed, but participants with missing data on ABP were excluded before conducting analysis. MID has been shown to produce fairly robust estimates that are more efficient than other approaches. Findings from MICE and MID yielded estimates that were slightly smaller, but fairly similar to those from our initial approach (Appendix, Tables 1–4); thus, we utilized our original models with 94.5% of available data.

Procedures

Between 2016–2019, all women completed an in-person visit, where trained study staff obtained resting BP, height, weight, and other clinical data. Face-to-face interviews were then conducted to collect detailed information on demographic and psychosocial characteristics. Following this, participants were fit with an ABP monitor, which was worn for 48 hours. All procedures were approved by the Institutional Review Board, and all participants provided written, informed consent.

Ambulatory blood pressure monitoring

OnTrak model 90227 ABP monitors (SpaceLabs; Issaquah, WA) were used to obtain ABP readings over 48 consecutive hours. Women were taught proper application/removal techniques and trained to remove the device only to shower/bathe. Each monitor was pre-programmed to record BP every 30-minutes between 8am to 10pm (daytime) and every hour between 10pm and 8am (nighttime). Fixed time windows were chosen a priori to avoid potential recall bias in self-reported sleep/wake time. This type of bias may be especially relevant for the MUSE cohort, as prior studies have found a high degree of night-to-night variability in sleep timing for African-American men and women compared to other racial/ethnic groups (Huang & Redline, 2019; Knutson et al., 2007). Following completion, monitors were retrieved by study staff and readings were downloaded with Sentinel Software from Spacelabs.

Financial Responsibility

Prior studies have assessed financial responsibility, or breadwinning, in the context of a heterosexual marital relationship and typically define breadwinning as a wife earning 60% or more of the couple’s total household income (Springer et al., 2019; Winslow-Bowe, 2006). However, because the current study focused on African-American women, who are less likely to be married than women from other racial/ethnic backgrounds, we aimed to assess financial responsibility in a manner that was more reflective of their lived experience, and not contingent on the income of another adult. Financial responsibility was assessed with a single item created for the purposes of this study: “Are you the primary breadwinner in your family (that is, are you the biggest financial contributor to most of the bills)?” This measure was dichotomous in nature (yes/no), which is in keeping with prior research in this area (Springer et al., 2019; Winslow-Bowe, 2006).

BP Outcomes

Outcome variables were: 1) The average of all systolic BP (SBP) and diastolic BP (DBP) readings obtained across the 48-hour period, separated into daytime and nighttime values based on the timing of assessments. We chose to examine daytime and nighttime BP separately because some studies have found that nighttime BP values are predictive of clinical events independent of daytime BP values (Boggia et al., 2007; Hansen et al., 2011). Additionally, although some prior studies examined BP non-dipping (frequently defined as the percent difference between daytime and nighttime values) as a relevant outcome, recent studies have found that assessments of daytime and nighttime BP values have higher levels of reproducibility than assessments of BP non-dipping (Abdalla et al., 2015; Muntner et al., 2019). Consequently, the current study focused on four continuous BP outcomes: daytime SBP, nighttime SBP, daytime DBP, and nighttime DBP.

Covariates

Sociodemographic and behavioral/clinical covariates were chosen based on their associations with BP in prior studies (Beatty Moody et al., 2016; Spruill et al., 2016; St-Onge et al., 2020; Steptoe et al., 2005; Wu et al., 2018). Sociodemographics including age, marital/live-in partner status (i.e., married/living with partner versus unmarried/not living with partner), education (high school or less, some college, and ≥college), annual self-reported family income ($35,000, $35,000-$49,999K, $50,000-$74,999K, ≥ $75,000) and family size (number of individuals living in the household) were self-reported. Single parenthood (yes/no) was determined based on self-reported partner status and self-reported parental status. Body mass index (BMI) was calculated as weight/height (kg/m2) and modeled continuously. Current smoking and anti-hypertensive medication use were self-reported and modeled as yes/no. We assessed two separate measures of financial strain, one designed to capture recent financial adjustments, and another designed to assess more extreme financial concerns, i.e., the actual inability to pay bills. Financial adjustments were measured by the 12-item financial adjustments scale, which assesses the presence or absence of specific actions taken to lessen overall financial burden in the prior 12 months. Sample items include “…postponed medical or dental care to save money;” “reduced household utility use to save money;” “changed food shopping or eating habits to save money;” and “postponed major household purchases because of financial need;” among others (Conger & Elder, 1994; Cutrona et al., 2015). Endorsed items were summed, resulting in a possible range of 0–12, with higher scores indicative of greater financial strain. The 2-item Can’t Make Ends Meet scale was used to assess more extreme financial concerns such as “During the last month, how much difficulty have you had paying your bills?” Responses were scored on a 5-point Likert scale and summed as in prior studies (Whitbeck et al., 1991), resulting in a possible range of 0 to 10. Depressive symptoms were measured using the 21-item Beck Depression Inventory (BDI), which assesses both cognitive and somatic symptoms of depression.(Beck et al., 2015) Possible scores on the BDI range from 0 to 63, with higher scores indicating more severe depression. Both financial strain measures and depressive symptoms were modeled continuously.

Statistical analyses

Descriptive statistics were utilized to characterize study participants overall, and differences by financial responsibility status were analyzed using analysis of variance tests for continuous variables and Chi-Squared tests for categorical variables. Multivariable linear regression models were conducted to examine associations between financial responsibility and ABP outcomes. Model 0 was age-adjusted only, to examine associations prior to adjusting for other sociodemographic indicators potentially relevant for financial responsibility. Model 1 added adjustments for marital/live-in partner status, education, family income and family size (for family income) and Model 2 added terms for BMI and smoking, as standard BP risk factors. Model 3 added a separate term for anti-hypertensive medication use, as in prior studies (Edmondson et al., 2018; Gilbert-Ouimet et al., 2017). Finally, Model 4 adjusted for financial strain (e.g., financial adjustments and can’t make ends meet separately) and Model 5 adjusted for depressive symptoms. In order to determine whether financial responsibility was a particularly strong correlate of BP for women who were single parents and/or were of low SES, additional models tested for interactions between financial responsibility status (i.e., being “the biggest contributor to the bills”) and single parenthood, and financial responsibility status and SES (above versus below $50,000). Exploratory analyses examined interactions between financial responsibility and marital/live-in partner status and supplemental analyses included women who reported being unemployed. All analyses were conducted in SAS V9.4, and a two-sided p-value of < .05 was considered statistically significant.

Results

Participant Characteristics

Participant characteristics for the overall cohort and by financial responsibility status are presented in Table 1. On average women were 37.43 (SD=4.26) years of age and from a range of SES backgrounds, with incomes ranging from below $35,000 to above $75,000, and 48.12% of the cohort reporting a college education. Approximately 37% of women were married/had a live-in partner, and 41% were single parents. With respect to hypertension risk factors, approximately 10% of women were current smokers, and the average BMI was above the threshold for obesity, at 32.65 (SD=8.03). Daytime BPs were, on average, in the normal range. Mean nighttime BPs were in the normal (Ravenell et al., 2017) to elevated range (Muntner et al., 2019), based on recent thresholds (Whelton et al., 2018). Approximately 17% of women reported anti-hypertensive use. The majority of women in the cohort (67.8%) reported financial responsibility for their households (i.e., that they were the biggest financial contributor to the bills).

Table 1.

Participant Characteristics by Financial Responsibility Status

Overall Financial Responsibility

N=345		 Yes
N=234 (67.83%)		 No
N=111 (32.17%)
P-value
Age, M (SD) 37.52 (4.36) 37.70 (4.17) 37.14 (4.73) 0.2646
Education, % (N)
 HS or less 98 (28.41%) 68 (29.06%) 30 (27.03%) 0.2109
 Some College 71 (20.58%) 42 (17.95%) 29 (26.13%)
 College or higher 176 (51.01%) 124 (52.99%) 52 (46.85%)
Income, % (N)
 $<35K USD 80 (23.19%) 69 (29.49%) 11 (9.91%) <.0001
 $35K-$49,999K 68 (19.71%) 56 (23.93%) 12 (10.81%)
 $50K-$74,999K 80 (23.19%) 54 (23.08%) 26 (23.42%)
 ≥$75K 117 (33.91%) 55 (23.50%) 62 (55.86%)
Married/Live-in Partner, % (N) 122 (35.36%) 46 (19.66%) 76 (68.47%) <.0001
 
Single Parent, % (N) 144 (41.74%) 123 (52.56%) 21 (18.92%) <.0001
Family Size, M (SD) 3.42 (1.65) 3.07 (1.59) 4.15 (1.52) <.0001
Current Smoker, % (N) 32 (9.28%) 23 (9.83%) 9 (8.11%) 0.6067
 
BMI, kg/m2 M, (SD) 32.36 (7.83) 32.48 (7.93) 32.11 (7.66) 0.6865
 
Ambulatory Blood Pressure, M (SD)
 DT SBP 121.40 (12.10) 122.89 (12.51) 118.24 (10.57) 0.0008
 NT SBP 111.00 (11.38) 112.38 (11.45) 108.10 (10.71) 0.0010
 DT DBP 77.55 (8.63) 78.49 (9.11) 75.55 (7.15) 0.0013
 NT DBP 68.33 (8.42) 69.23 (8.51) 66.43 (7.92) 0.0037
 
Anti-HTN use, % (N) 54 (15.65%) 41 (17.52%) 13 (11.71%) 0.1653
Can’t Make Ends Meet 2.79 (2.12) 2.84 (2.17) 2.68 (2.02) 0.4976
Financial Adjustments 1.94 (1.94) 2.03 (2.05) 1.73 (1.68) 0.1736
Depressive Symptoms, M (SD) 5.42 (6.06) 5.50 (6.20) 5.24 (5.77) 0.7138
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Abbreviations: DT=Daytime; NT=Nighttime; SBP=Systolic Blood pressure; DBP=Diastolic blood pressure

As shown in Table 1, women reporting primary financial responsibility for their households were similar to their counterparts who did not report primary financial responsibility in terms of age and educational level. Yet, those reporting primary financial responsibility had lower total household incomes, were less likely to be married/have a live-in partner, reported a smaller household size, and were more likely to be single parents than women who did not report that they were the biggest financial contributor to the bills. There were no significant differences between groups in rates of current smoking, average BMIs, reports of financial strain, or depressive symptoms. However, women reporting financial responsibility were marginally more likely to be on anti-hypertensive medications, and had significantly higher levels of both daytime and nighttime BPs than their counterparts who did not report primary financial responsibility (Table 1).

Financial Responsibility and Daytime and Nighttime Blood Pressure

Results from linear regression analyses examining associations between financial responsibility and daytime BP are shown in Table 2. In age-adjusted linear regression analyses (Model 0), reporting financial responsibility was associated with higher levels of both daytime SBP (β=4.42, S.E.=1.36, p=.0013), and DBP (β=2.82, S.E.=.98, p=.004). Associations remained significant after adjusting for sociodemographic factors that might impact financial responsibility in the form of marital/live-in partner status, education, household income, and household size (Model 1). Findings remained significant after additional adjustments for smoking, BMI (Model 2) and anti-hypertensive medication use (Model 3), as well as financial strain and depressive symptoms (Models 4–5). The full results showing all coefficients for Model 5 are presented in the Appendix, Tables 5–6. There were no significant interactions observed between financial responsibility and single parenthood for daytime SBP (p=.44) or DBP (p=.12). There were also no significant interactions between financial responsibility and high versus low SES for daytime SBP (p=.31) or daytime DBP (p=.27). Exploratory analyses examining associations between financial responsibility and marital/live-in partner status also yielded null results for daytime SBP (p=.89) and daytime DBP (p=.65).

Table 2.

Financial Responsibility and ABP in Early Middle-Aged African-American Women, N=345

Daytime ABP Nighttime ABP
SBP DBP SBP DBP
β (S.E.) p-value β (S.E.) p-value β (S.E.) p-value β (S.E.) p-value
Model 0 4.42 (1.36) 0.0013 2.82 (0.98) 0.0043 4.10 (1.29) 0.0016 2.69 (0.96) 0.0052
Model 1 4.91 (1.63) 0.0028 3.44(1.18) 0.0039 4.53(1.55) 0.0037 2.96 (1.16) 0.0111
Model 2 4.33 (1.60) 0.0072 3.28(1.19) 0.0061 3.88(1.50) 0.0099 2.75 (1.16) 0.0178
Model 3 4.22 (1.55) 0.0068 3.20(1.14) 0.0054 3.79(1.45) 0.0096 2.68 (1.13) 0.0178
Model 4 4.22 (1.55) 0.0070 3.15(1.14) 0.0062 3.79(1.46) 0.0098 2.66 (1.13) 0.0192
Model 5 4.30 (1.55) 0.0059 3.20(1.14) 0.0054 3.85(1.46) 0.0085 2.70(1.13) 0.0175
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Model 0: Age-adjusted only

Model 1: Adjusted for age, marital status, education, family income and family size

Model 2: Model 1 covariates + BMI, smoking

Model 3: Model 2 covariates + anti-hypertensive medication

Model 4: Model 3 covariates + financial strain.

Model 5: Model 4 covariates + depressive symptoms

Findings for nighttime BP were similar to those for daytime BP (Table 2). In models adjusted for age only (Model 0), reporting financial responsibility was associated with higher levels of nighttime SBP (β=4.10, S.E.=1.29, p=.002), and DBP (β=2.69, S.E.=.96, p=.005). Significant associations persisted after adjusting for additional sociodemographics (Model 1), smoking, BMI (Model 2), anti-hypertensive medication use (Model 3), financial strain (Model 4) and depressive symptoms (Model 5). There were no significant interactions between financial responsibility and single parenthood for nighttime SBP (p=.64) or nighttime DBP (p=.50). Similarly, there were no significant interactions between financial responsibility and low versus high SES for nighttime SBP (p=.41) or nighttime DBP (p=.36). There were also no significant interactions observed between financial responsibility and marital/live-in partner status for nighttime SBP (p=.74) or nighttime DBP (p=.60) in additional, exploratory analyses.

Sensitivity Analyses including Unemployed Women

Models including unemployed women (total N=396) are presented in the Appendix in Table 7. In brief, financial responsibility was associated with daytime SBP (β=3.68, S.E.=1.26, p=.004) and DBP (β=2.24, S.E.=.91, p=.014) in age-adjusted analyses (Model 0). Findings remained significant after adjusting for sociodemographics, with an additional term for employment status (Supplemental Table 2; Model 1) for both SBP (β=4.43, S.E.=1.53, p=.004) and DBP (β=3.24, S.E.=0.91, p=.014). Associations remained significant in subsequent models.

Discussion

In this cohort of early middle-aged African-American women from diverse SES backgrounds, having primary financial responsibility for one’s household (i.e., being the biggest financial contributor to the bills) was associated with elevated levels of both daytime and nighttime SBP and DBP, independent of age, and other sociodemographic factors relevant to finances such as household size, household income, and education. Associations persisted after adjusting for known risk factors for elevated BP in the form of smoking and BMI, and were also independent of anti-hypertensive medication use. Moreover, financial responsibility was associated with elevated BP independent of self-reported financial strain-- including financial adjustments as well as more extreme financial circumstances, such as the inability to make ends meet. Observed findings were also independent of depressive symptoms. Importantly, our fully-adjusted findings revealed an estimated difference of 4.30 mm/Hg in daytime SBP and 3.85 mm/Hg in daytime DBP between women reporting primary financial responsibility, compared to those who did not. These differences are only slightly lower (for SBP) and/or fairly comparable (for DBP) to the 5 mm/Hg reduction in SBP, and the 3 mm/Hg reduction in DBP shown to produce meaningful associations with later life CVD events in meta-analytic results from over 52 pharmacologic clinical trials (Canoy et al., 2022; Rahimi et al., 2021a; Rahimi et al., 2021b). Thus, our associations also have some clinical relevance.

Our findings are consistent with prior research that has documented associations between general family, or household, responsibilities and elevated ABP in predominantly female cohorts of employed adults (Brisson et al., 1999; Gilbert-Ouimet et al., 2017; Thurston et al., 2011), particularly in the context of overall job stress and strain (Brisson et al., 1999; Gilbert-Ouimet et al., 2017). However, the current study extends this work in important ways, as these studies primarily defined household responsibilities as childcare, chores (e.g., laundry, cooking, cleaning), and to a lesser extent, paying bills/keeping records/managing finances, with almost no mention of overall financial responsibility (i.e., earning the largest proportion of the money that contributes to the bills). Therefore, to our knowledge, this study is the first to examine associations between having primary financial responsibility for one’s household and ABP, or any objectively-assessed physical health outcome, with a unique emphasis on African-American women.

Previous studies have primarily examined associations between financial responsibility in the form of breadwinner status and mental health outcomes (T. L. King et al., 2020; Springer et al., 2019; Vink et al., 2021). But the majority of this research has focused on White women, and to a lesser extent, White men. It has also been largely predicated on the notion that female (in comparison to male) breadwinning would be associated with poor mental health in men, due to violations of traditional gender norms of the male as breadwinner (T. L. King et al., 2020; Springer et al., 2019). However, findings have been mixed, with some studies finding that male breadwinning was associated with poor mental health for White men and neutral mental health for White women (T. L. King et al., 2020), others finding associations between female breadwinning and poor mental health in both groups (Vink et al., 2021), and still others finding no differences in mental health outcomes based on male or female breadwinning status (Springer et al., 2019). At least one prior study has examined breadwinning status and self-reported physical health among men in a predominantly White cohort of N=1,095 older married couples from the Health and Retirement Study. The authors found that men whose wives were breadwinners early in their marriages (i.e., 1960’s-1970’s) reported poorer physical health 30 years later than their White male counterparts who were themselves breadwinners throughout the entirety of their marriages (Springer et al., 2019). Thus, breadwinning was actually protective against poor self-reported health outcomes for White men.

Because much of the prior literature on breadwinning status has focused on White adults, it is based on the assumption that women have only entered the labor force in recent decades, and examines female breadwinner status primarily in the context of partnership (more specifically marriage), with an individual of equal or higher earning potential. This literature has questionable applicability to African-American women as historical data documents relatively high levels of labor force participation for African-American women as early as 1880, following the end of chattel slavery in the US (Banks, 2019; Bedell, 1953; J. Jones, 2009). Additionally, research suggests that throughout history African-American women often were large financial contributors to their households, even when married or in dual-earner partnerships (Boushey, 2009; Landry & Jendrek, 1978), primarily due to discriminatory labor practices that resulted in high rates of un- and under-employment for African-American men (J. Jones, 2009). Financial responsibility is therefore not viewed as a violation of gender role norms for African-American women, as empirical research suggests that both African-American men and women have historically expected that African-American women would have to work, and have some degree of financial responsibility for themselves and/or their families (Blee & Tickamyer, 1995; Landry & Jendrek, 1978; Orbuch & Custer, 1995; Scott Carter et al., 2009), out of economic necessity. A number of researchers have argued that this in direct contrast to other racial/ethnic groups, where work was historically viewed as a potential option, rather than a necessity, for women (Orbuch & Custer, 1995; Scott Carter et al., 2009). Financial responsibility for African-American women is further complicated by the aforementioned wage gap (U.S. Bureau of Labor Statistics, 2015), as well as high levels of occupational segregation, even at high levels of education (Banks, 2019) relative to other race-gender groups. In this respect, the overall context of financial responsibility, or breadwinning, has been different for African-American women compared to White women (and White men). Hence, our examination of financial responsibility in African-American women represents an important advance in the literature, as it focuses on a particularly relevant exposure, in a uniquely impacted group.

In keeping with prior literature that focuses explicitly on breadwinner status in the context of marriage/romantic partnership, we explored whether associations between financial responsibility and BP differed for African-American women who reported being married/in a live-in relationship versus those who were single. The interaction between reporting financial responsibility and being married/in a live-in relationship was non-significant, suggesting that the impact of financial responsibility on daytime and nighttime BP was comparable whether women were in a (potentially) dual-earner relationship or not. We also examined whether having financial responsibility was more strongly associated with BP in African-American women who were single parents, or who reported household incomes less (versus more) than $50,000 per year. However, these interactions were also non-significant. Thus, findings indicate that having financial responsibility may be problematic for African-American women’s BP whether they are single or partnered, single parents versus not, or of relatively high versus low income.

Our findings that financial responsibility was associated with elevated BP in African-American women across a range of financial contexts were somewhat surprising, as we hypothesized that associations would be most pronounced among those African-American women who were in situations (e.g., single parenthood, low income, not in a potential dual-earner partnership) that might promote financial instability, or financial hardship more broadly. But this was not the case in our cohort. Interestingly, women reporting primary financial responsibility for their households did not report more financial adjustments, or more difficulty making ends meet than their counterparts without primary financial responsibility. Moreover, our observed estimates of the association between financial responsibility and elevated BP were relatively unchanged after adjusting for these two measures of financial strain. Taken together, these findings suggest that having financial responsibility may impact elevated BP in African-American women via pathways that are not solely due to financial resources.

In addition to controlling for a range of relevant financial stressors, we were even able to account for depressive symptoms in our analyses; but it also did not appreciably change our results. Nonetheless other psychosocial stressors might play a role. It is possible that being financially responsible represents a form of role strain, i.e., “the felt difficulty of fulfilling role obligations” (Goode, p. 483)(Goode, 1960) for African-American women. Role strain, or stress, has been linked to elevated BP and other markers of CVD risk among women in prior studies (Berkman et al., 2015; Hauenstein et al., 1977; Janssen et al., 2012; Orden et al., 1995; Orth-Gomér & Leineweber, 2005; Stewart et al., 2019). However, this research has largely focused on the stressors that occur from either occupying multiple roles (e.g., worker and mother, worker, mother and spouse/partner) (Orth-Gomér & Leineweber, 2005) or having stressors from one role (e.g., employee) spill over into, or create conflict with another role (mother or spouse/partner) (Berkman et al., 2015). Even prior studies of household responsibilities in the form of chores and childcare and ABP in women found that household responsibilities were most deleterious for elevated BP when job strain was high (Brisson et al., 1999; Gilbert-Ouimet et al., 2017), indicating that the combination of the two is what was most problematic for BP. Yet, our findings suggest that simply having the role of primary breadwinner—even when single—may be a source of strain, or stress for African-American women.

We did not include a measure of general perceived stress in our cohort, but it is also plausible that African-American women reporting financial responsibility also experienced a greater amount of perceived life stress overall, compared to their counterparts who did not have primary financial responsibility for their households. Anecdotal accounts from African-American women report that there is a notable lack of discussion about “the struggles, the difficulties, the resentment, [and] the fear” around being the primary breadwinner (C. King, 2021), and consistent with this sentiment, empirical studies of this phenomenon are limited. Future studies that not only inquire about the presence or absence of primary financial responsibility, but also query women about the perceived stressfulness and/or difficulties surrounding this role are needed.

Further, although our study controlled for measures of financial strain, or the presence of financial adjustments and/or difficulties, we did not include measures of financial threat (Marjanovic et al., 2013). Financial threat is defined in the extant literature as worry, uncertainty and/or preoccupation about the security and stability of one’s finances, comparable to a measure of appraisal, or perceived stress specific to one’s finances. It is possible that for African-American women, merely having primary financial responsibility leads to worry or anxiety about being able to meet financial obligations, independent of socioeconomic resources and financial strain. Worry and anxiety more broadly have been linked to elevated BP (Joseph et al., 2021; Räikkönen et al., 1999), with some evidence suggesting that worry about finances in particular may be relevant for overall cardiovascular health (Kubzansky et al., 1997). Other components of financial threat, such as preoccupation with thoughts about financial security or stability, may represent a form of rumination or psychological vigilance (Smith et al., 2000). Both rumination and vigilance have been linked to autonomic arousal and elevations in BP in laboratory (Ottaviani et al., 2016; Smith et al., 2000) and community-based studies (Birk et al., 2019; Ottaviani et al., 2016). Thus, it is conceivable that financial threat is one potential pathway through which financial responsibility impacts elevated BP, possibly via worry/anxiety, rumination or vigilance. However, additional research on the psychological, as well as physiological mechanisms linking financial responsibility to elevated BP is warranted.

It is important to note that we did not have information about exactly who women were financially responsible for. We were able to control for household size, but this does not account for adult children living outside of the home that African-American women may provide with financial resources. Additionally, although being the “biggest financial contributor to the bills” might assume only immediate household expenses, research suggests that African-American adults are more likely than their White counterparts to provide financial stupport for family members (especially parents and siblings) outside of their immediate households (Higginbotham & Weber, 1992; O’Brien, 2012) and this may be particularly true for women without children (Marsh, 2023). Thus, identifying the potential range of financial responsibilities that African-American women have, both within and outside of their immediate households, and how these varying types of financial responsibility might impact BP will be an important consideration for future research.

Our study has several limitations that should be noted. First, the cross-sectional nature of the analysis makes it difficult to determine temporality, although a reverse causation pathway is highly unlikely. Additionally, because our study is one of the first to examine financial responsibility outside of the context of a marital, or dual earner relationship, we used a newly-created, single-item, dichotomous measure of financial responsibility. While prior studies have also used dichotomous measures, and the prevalence of financial responsibility in our cohort is highly plausible given national trends, it is also possible that our measure is an un- or over-estimate of financial responsibility and that a continuous measure would have yielded different results. Future studies would greatly benefit from a validated, and more nuanced measure of financial responsibility. Another important limitation is that our cohort was focused on African-American women, and while this is an important group to examine with respect to financial responsibility, findings may not generalize to other race-gender groups. Moreover, by design, we recruited approximately equal numbers of both high and low SES African-American women, consequently college-eduated women were overrepresented in our cohort (50%, compared to 35.9% nationally) (Nichols & Schak, 2018). However research suggests that high SES African-American women in particular are disproportionately likely to have a high level of financial responsibility (O’Brien, 2012; Sacks et al., 2020); thus their inclusion allows us to examine a salient, yet understudied exposure in a highly impacted group. Finally, our participants are from a single metropolitan area in the Southeast. Although rates of elevated BP and CVD among African-American women are the highest in the southeastern US (Zheng et al., 2021), it is unclear whether findings would generalize to other geographic regions.

There are also several important strengths to this study. African-American women are underrepresented and understudied in CVD research, and to our knowledge, this is the first study of its kind. Moreover, our cohort featured considerable within-group heterogeneity, which allowed us to examine how a range of contexts relevant for financial responsibility among African-American women (e.g. single parenthood, low SES, married/partnered status) might impact associations between financial responsibility and elevated BP. We also focused on midlife, a critical life stage with respect to both elevated BP and financial responsibility among women. Finally, BP was assessed using the gold standard in BP assessment, ABP monitoring, which we were able to assess over the course of 48-hours, further increasing the internal validity and precision of our results.

In conclusion, our findings suggest that having primary financial responsibility for one’s household may be an important driver of BP in early middle-aged African-American women, independent of a range of factors that might increase financial vulnerability. Specifically, we examined social (education, income, marital/partnered status), psychological (financial adjustments, can’t make ends meet, depressive symptoms), and potential contextual factors (single parenthood, marital/partnered status) that might pattern our results. Yet none of these factors appreciably altered our fairly robust associations. Given the historical and current salience of financial responsibility in the lives of African-American women, we view this study as an initial, but important, first step that will ideally lay the foundation for additional research that further elucidates the underlying mechanisms.

Future longitudinal studies that examine prospective associations between financial responsibility, a range of potential psychosocial and behavioral mediators, and increases in BP in African-American women over time are needed. Factors such as role strain, the combination of household chores and financial responsibility, along with resentment and/or overall stress associated with financial responsibility represent particularly promising avenues for future research. Additionally, research on the potential positive aspects of financial responsibility, including increased self-efficacy and independence (Buchanan & Selmon, 2008; C. King, 2021) as well as their association with BP and cardiovascular health is warranted.

Further, although the lack of research on this topic suggests that recommendations for interventions might currently be premature, ample evidence indicates that financial responsibility in African-American women has been heavily shaped by historical and structural factors over which African-American women have limited control, including wage discrimination, occupational segregation and restrictive family leave policies (Banks, 2019). Thus, policy-level interventions targeting these factors may ultimately benefit African-American women’s overall health. Finally, given sociodemographic shifts in US society as a whole, such as lower educational attainment for men and increasing single-hood for women from all racial/ethnic backgrounds (Pew Research Center, 2021), it is likely that the overall prevalence of financial responsibility among women will increase for all groups. Thus, understanding its relevance for women’s elevated BP and cardiovascular health more broadly may be of mounting importance in future decades.

Supplementary Material

Supplement

Acknowledgements

The MUSE study was funded by grants R01 HL130471 and R01 HL158141. TT Lewis received additional funding from K24 HL163696. R Parker and N Fields were funded by T32 HL130025.

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