Abstract
Background:
Caregiving has been associated with high blood pressure (BP) in middle-aged and older women, but this relationship is understudied among younger Black women, a population at high risk for hypertension. We examined the associations of caregiving stress and caregiving for high-needs dependents with incident hypertension among reproductive-age women in the Jackson Heart Study (JHS), a cohort of community-dwelling Black adults.
Methods:
We included 453 participants, 21–44 years, with BP <140/90 mmHg and not taking antihypertensive medication at baseline (2000–2004). Caregiving stress over the past 12 months was assessed via a single item in the Global Perceived Stress Scale. Caregiving for a high-needs dependent status was assessed via a question on hours per week spent caregiving for children (≤5 years or disabled), or older adults. Incident hypertension was defined as systolic BP ≥140 mmHg, diastolic BP≥ 90 mmHg, or self-report of taking antihypertensive medication at follow-up exams in 2005–2008 and 2009–2013.
Results:
Over a median follow-up of 7.4 years, 43.5% of participants developed hypertension. Participants with moderate/high versus no/low caregiving stress had higher incidence of hypertension (51.7% vs. 40.6%). Higher caregiving stress was associated with incident hypertension after adjustment for sociodemographic and clinical factors, health behaviors, and depressive symptoms (hazard ratio [HR] 1.39, 95% CI (1.01–1.94). Being a caregiver for a high-needs dependent was not associated with incident hypertension (adjusted HR 0.88, 95%CI [0.64–1.21]).
Conclusions:
Higher caregiving stress among reproductive-age Black women was associated with incident hypertension. Hypertension prevention approaches for this high-risk population may include caregiving stress management strategies.
Keywords: hypertension, caregiving, stress, reproductive-age, women, Black women
Graphical Abstract
INTRODUCTION
Hypertension is a major risk factor for cardiovascular disease (CVD), a leading cause of death among women.1 Reproductive-age Black women have a higher prevalence of hypertension when compared to women from other races and ethnic backgrounds in the United States.2–5 Although the prevalence of hypertension among women 20–44 years old is lower compared to older women, the cumulative burden of CVD risk over the lifespan is high, especially as over half (53.6%) of non-Hispanic Black women with hypertension in this age group have uncontrolled blood pressure (BP).6 Studies show that the rates of hypertension and CVD are high and increasing among Black women in their 30s and 40s.7,8 Identifying factors that contribute to hypertension among reproductive-age Black women may inform strategies to reduce the lifetime burden of hypertension and CVD.
Chronic psychosocial stress increases hypertension risk and contributes to disparities in hypertension and CVD.9–13 Caregiving is a source of chronic stress that is particularly relevant to women. Women comprise the majority of informal caregivers and are more adversely impacted by caregiving than men, including in loss of productivity and loss or reduction of employment opportunities.14–16 Caregiving is associated with an elevated sympathetic nervous system response and hypertension among middle-aged and older women.17–19 The effects of caregiving on hypertension in women of reproductive age have been less explored, particularly among reproductive-age Black women.20 This knowledge gap may hinder the development of hypertension and CVD prevention strategies in this population by failing to address a common stressor.
We examined the associations of caregiving stress and caregiving of high-needs dependents with incident hypertension among reproductive-age female participants in the Jackson Heart Study (JHS). We hypothesized that participants experiencing higher caregiving stress have a higher incidence of hypertension than those with lower caregiver stress. Additionally, we hypothesized that caregivers of high-needs dependents (e.g., children ≤5 years, disabled children, or older adults) have a higher incidence of hypertension than those who were not caregivers to high needs dependents.
METHODS
Data availability
This was a secondary analysis of pre-existing variables in the Jackson Heart Study. Jackson Heart Study data may be requested from the Biologic Specimen and Data Repository Information Coordinating Center (BioLINCC) repository, https://biolincc.nhlbi.nih.gov/studies/jhs/, and the database of Genotypes and Phenotypes (dbGaP), https://www.ncbi.nlm.nih.gov/gap/. Additionally, investigators with a manuscript proposal or ancillary study proposal that has been approved by study committees may request data directly from the Jackson Heart Study Coordinating Center, https://www.jacksonheartstudy.org/Research/Study-Data/Data-Access.
Overview of the Jackson Heart Study
The JHS is a longitudinal cohort study exclusively focused on the cardiovascular health of African American adults, 21 year or older, in the US. The study methods have been published elsewhere.21,22 Briefly, 5,306 non-institutionalized Black adults were enrolled from 3 Jackson, Mississippi metropolitan area counties (Hinds, Madison, Rankin). Three exams have been completed to date, Exam 1 in 2000–2004, Exam 2 in 2005–2008, and Exam 3 in 2009–2013, with Exam 4 currently underway.
All JHS participants provided written informed consent at each visit. The study was approved by the Institutional Review Boards of Jackson State University, Tougaloo College, and the University of Mississippi Medical Center in Jackson. This study is a secondary analysis of existing JHS data. JHS data is available upon a reasonable request from the JHS Coordinating Center.
Study Sample
The current analysis included JHS female participants between the ages of 21–44 years without hypertension at Exam 1 based on Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High BP (JNC 7) criteria, systolic BP <140 mm Hg, diastolic BP < 90 mm Hg and no self-reported use of antihypertensive medication, as this BP clinical practice guideline during the study period.23 Figure 1 shows the sample inclusion process.
Figure 1.
Flow diagram for the inclusion of reproductive-age women Jackson Heart Study participants (age 21–44years) without hypertension for the current analysis
Abbreviations: JHS – Jackson Heart Study; DBP- diastolic blood pressure; SBP-systolic blood pressure
Data Collection
The data used in the current analysis included sociodemographic and clinical characteristics, medical and family history, health behaviors, and psychosocial measures collected at Exam 1. We also analyzed clinic BP measurement data collected at Exams 1, 2 and 3.
Caregiving Stress
Caregiving stress was determined from a single question in the Global Perceived Stress Scale (GPSS) at Exam 1. The GPSS assesses perceived chronic stress in eight domains (job, relationships, neighborhood, caregiving, legal problems, medical problems, discrimination, and meeting basic needs) over the past year. 24 The caregiving stress question was: “Over the past 12 months, how much stress did you experience, related to caring for others? (This would include caring for an elderly parent or relative, caring for children, etc.)” Responses were measured on a 4-point Likert scale, ranging from (1) “not stressful” to (4) “very stressful”. To simplify interpretation of results, a priori we decided to dichotomize responses to “no/low caregiving stress” and “moderate/high caregiving stress.”
High-needs Dependents Caregiving Status
Caregiving status was assessed using a single question in the physical activity questionnaire at Exam 1: “During the past year (12 months) how much time did you spend caring for children under 5 years of age or for a disabled child, or elderly person?” Respondents who indicated that they spent ≥1 hour per week caring for these high-need dependents were categorized as “caregivers of high-needs dependents”, with respondents spending <1 hour per week in these caregiving activities categorized as “not caregivers of high-needs dependents.” This group included participants who were caregivers for individuals who were not defined by the JHS as having high-needs, and participants who were not caregivers.
Covariates
Covariates included key sociodemographic and clinical characteristics, health behaviors, and psychological factors that are each associated with hypertension and CVD risk.27 All items were assessed during Exam 1 by self-report except kidney function, BP, and BMI, which were based on measurements obtained during Exam 1. Exam 1 data was collected at the same time, including exposure and covariate data. Sociodemographic characteristics included age, employment, family income, and marital status. Employment status was categorized as “full time/part-time”, or “unemployed”. Family income was calculated based on household income and family size and was categorized as “low”, income < the US poverty level, “middle”, income 1 to <3.5 times the poverty level, “upper”, income ≥3.5 times the poverty level.25 Marital status was dichotomized as married versus unmarried, which includes individuals who are divorced, widowed, never married or separated. Clinical characteristics included body mass index (BMI) in kg/m2, parental history of hypertension, history of diabetes, history of reduced kidney function (estimated Glomerular Filtration Rate [eGFR] <60ml/min/1.73 m2, calculated by CKD-EPI formula).26 We did not include diabetes (n=23) and reduced kidney function (n=1) in the adjusted models given the low number of participants in the sample with these conditions. Health behaviors included smoking and alcohol use. Current smoking status was categorized as “yes/no”. Alcohol use was defined as average weekly consumption of alcoholic beverages.27,28 Depressive symptoms were assessed per the Center for Epidemiologic Studies Depression Scale (CES-D), which comprises 20 questions scored on a 1–4 Likert scale, ranging from “rarely or none of the time” to “most or all of the time”.29
Blood Pressure Measurement
A description of the BP measurement techniques in the JHS study have been previously published.30,31 In brief, two BP measurements in the clinic were obtained by trained study staff. The first measurement was taken after five minutes of rest. The two BP measurements were taken one minute apart. During Exam 1 and partially through Exam 2, BP measurements were performed by using a random-zero sphygmomanometer (Hawksley and Sons, Ltd, London, UK). Starting in Exam 2 and continuing in Exam 3, a semiautomatic oscillometric device (Omron HEM- 907XL; Omron Healthcare, Inc, Lake Forest, IL) was employed. The random-zero BP measurements were calibrated to the semiautomated device using regression methods.31 Hypertension at baseline was defined by systolic BP (SBP) ≥140 mmHg, diastolic BP (DBP) ≥90 mm Hg, or self-reported use of antihypertensive medication.
Incident Hypertension
Incident hypertension was defined as the first follow-up exam, Exam 2 or Exam 3, at which the participant had SBP ≥140 mmHg, DBP ≥90 mmHg, or self-reported use of antihypertensive medication. For the current study, we followed participants from baseline to the first examination at which they had incident hypertension, or the last study visit they attended for those who did not develop hypertension.
Statistical Analysis
Baseline characteristics were summarized using means and proportions stratified by caregiving stress and by caregiving status, caregivers of high needs-dependents (yes/no). We calculated the percentage of each subgroup that developed hypertension. We calculated HRs for incident hypertension associated with caregiving stress (moderate/high stress vs. no/low stress), and in separate models, with caregiving status (caregivers of high-needs dependents vs. participants who were not caregivers of high-needs dependents [a group that may include caregivers of groups not deemed “high needs” and non-caregivers]), using interval-censored Cox regression models adjusting for age, income, marital status, employment status, parental history of hypertension, BMI, baseline SBP, baseline DBP (model 1). Model 2 included additional adjustment for health behaviors (smoking status, weekly alcohol use), and model 3 further included adjustment for depressive symptoms (CES-D). Among the covariates used in the adjusted models, 7 had missing values. Of these, 5 had less than 1% missing data. Depression and income had more than 10% but less than 30% missingness. We used multiple imputation for these missing values, specifically we used multiple imputation with full conditional description. The event indicator (i.e. incident hypertension status) and the Nelson-Aalen estimator of the cumulative hazard (T) were included in the imputation model. The standard errors and confidence limits were estimated by pooling results using Rubin’s rules.32 We evaluated the validity of the proportional hazards assumption in our interval-censored Cox regression models by fitting an Accelerated Failure Time model with a Weibull distribution. We ascertained the missing at random (MAR) assumption, necessary to justify the use of multiple imputation, in two ways. First, we used Little’s test to test whether data in our covariates was Missing Completely at Random (MCAR), and we also performed logistic regression models to identify covariates associated with missingness. P-value of <0.05 was considered statistically significant. All statistical analyses were performed using R (version 4.3.0). Multiple-imputation was performed using R mice package, interval-censored Cox proportional hazards regression model was performed using the R survreg function.
Additional analyses
We conducted a post-hoc analysis to examine the associations between caregiving stress, high-needs dependents caregiving status, and incident hypertension, stratified by age groups, to determine if younger participants (<35 years) were more or less likely to be impacted by caregiving stress and high-needs caregiving status compared to older participants (35–44 years). We examined whether the associations between caregiving stress, high-needs dependents caregiving status, and incident hypertension were present when using the current BP guideline (i.e., the 2017 American College of Cardiology/American Heart Association [ACC/AHA] BP guideline). Specifically, we performed sensitivity analyses of JHS female participants, age 21–44 years, who had SBP<130 mmHg, DBP<80 mmHg, and not taking antihypertensive medications, at Exam 1.4 Incident hypertension was defined as SBP ≥130 mmHg, DBP ≥80 mmHg, or self-report of taking antihypertensive medications, at the first follow-up exam.
RESULTS
Baseline characteristics
Four hundred and fifty-three participants met eligibility criteria for the primary analysis. Participants with moderate/high caregiving stress (N=118, 26.0%) were more likely to smoke, and to consume alcohol than participants with no/low caregiving stress (N=335, 74.0%) (Table 1). Those with moderate/high caregiving stress had higher depressive symptoms than those with no/low caregiving stress. Caregivers of high-needs dependents (N=214, 47.2%) were younger, had a higher BMI, were more likely to have a parental history of hypertension, reported higher caregiving stress, and were more likely to have low family income than participants who were not caregivers for high-needs dependents (N=239, 52.8%) (Table 2).
Table 1.
Baseline characteristics stratified by caregiving stress
| Characteristics | Caregiving stress |
P-values | |
|---|---|---|---|
| No/low (N=335) | Moderate/high (N=118) | ||
|
| |||
| Age, mean (SD) | 37.9 (5.5) | 37.7 (5.7) | 0.797 |
| BMI kg/m2, mean (SD) | 33.1 (9.2) | 32.6 (7.6) | 0.610 |
| SBP (Exam 1), mean (SD) | 115 (10.8) | 115 (10.7) | 0.959 |
| DBP (Exam 1), mean (SD) | 73 (7.5) | 73 (7.0) | 0.712 |
| Diabetes, N (%) | 17 (5.1) | 6 (5.1) | 1.000 |
| eGFR reduced, (<60ml/min/1.73 m2), N (%) | 1 (0.3) | 0 (0.0) | 1.000 |
| Parental hypertension history (yes), N (%) | 260 (77.8) | 86 (72.9) | 0.333 |
| Current smoking, N (%) | 25 (7.5) | 18 (15.4) | 0.021 |
| Alcohol consumption (drinks/week), mean (SD) | 0.7 (2.4) | 1.7 (7.1) | 0.019 |
| CES-D (depressive symptoms), mean (SD) | 11.6 (8.6) | 14.4 (9.2) | 0.009 |
| Caregiver (high-needs dependents), N (%) | 148 (44.2) | 66 (55.9) | 0.036 |
| Family income, N (%) | 0.706 | ||
| Low | 55 (19.3) | 24 (22.6) | |
| Middle | 160 (56.1) | 59 (55.7) | |
| Upper | 70 (24.6) | 23 (21.7) | |
| Employment status, N (%) | 0.403 | ||
| Employed part-time/full time | 289 (86.3) | 106 (89.8) | |
| Unemployed | 46 (13.7) | 12 (10.2) | |
| Marital status, married, N (%) | 161 (48.2) | 64 (54.2) | 0.308 |
Abbreviations: BMI-body mass index, CES-D - Center for Epidemiologic Studies Depression, DBP- diastolic blood pressure, eGFR – estimated glomerular filtration rate, SBP- systolic blood pressure
Table 2.
Baseline characteristics stratified by caregiver status of high-needs dependents.
| Characteristics | Caregivers of high-needs dependents |
||
|---|---|---|---|
| Yes (N=214) | No (N=239) | P-values | |
|
| |||
| Age, mean (SD) | 36.9 (5.8) | 38.6 (5.1) | 0.001 |
| BMI kg/m2, mean (SD) | 34.2 (9.8) | 31.8 (7.6) | 0.005 |
| SBP (Exam 1), mean (SD) | 115 (10.7) | 115 (10.9) | 0.853 |
| DBP (Exam 1), mean (SD) | 72 (7.6) | 74 (7.1) | 0.018 |
| Diabetes, N (%) | 14 (6.5) | 9 (3.8) | 0.259 |
| eGFR reduced (<60ml/min/1.73 m2), N (%) | 1 (0.5) | 0 (0.0) | 0.472 |
| Parental hypertension history (yes), N (%) | 173 (81.2) | 173 (72.4) | 0.036 |
| Current Smoking, N (%) | 26 (12.3) | 17 (7.1) | 0.089 |
| Alcohol consumption (drinks/week), mean (SD) | 0.9 (3.2) | 1.0 (4.8) | 0.704 |
| CES-D (depressive symptoms), mean (SD) | 12.3 (7.7) | 12.5 (9.7) | 0.842 |
| Stress caring for others, N (%) | 0.036 | ||
| No/Low Stress | 148 (69.2) | 187 (78.2) | |
| Moderate/high Stress | 66 (30.8) | 52 (21.7) | |
| Family income, N (%) | 0.001 | ||
| Low | 47 (25.4) | 32 (15.5) | |
| Middle | 107 (57.8) | 112 (55.3) | |
| Upper | 31 (16.8) | 62 (30.1) | |
| Employment status, N (%) | 0.383 | ||
| Employed part-time/full-time | 183 (85.5) | 212 (88.7) | |
| Unemployed | 31 (14.5) | 27 (11.3) | |
| Marital status, married, N (%) | 105 (49.1) | 120 (50.4) | 0.847 |
Abbreviations: BMI-body mass index, CES-D - Center for Epidemiologic Studies Depression, DBP- diastolic blood pressure, eGFR – estimated glomerular filtration rate, SBP- systolic blood pressure
Association between caregiving stress, caregiver status, and incident hypertension
Over a median follow-up of 7.4 years (25–75 percentile 5.4 – 8.2 years), 43.5% (N=197) of participants developed hypertension. Among participants with moderate/high caregiving stress, 51.7% (N=118) developed hypertension, compared to 40.6% (N=335) of participants with no/low caregiver stress. Moderate/high caregiving stress was associated with incident hypertension after each level of adjustment (Table 3). In addition, 41.1% (N=214) of caregivers of high-needs dependents developed hypertension, compared to 45.6% (N=239) of participants who were not caregivers of high-needs dependents. Being a caregiver for high-needs dependents was not associated with incidence of hypertension after multivariable adjustment. The association between caregiving stress and incident hypertension among participants who were and were not caregivers for high-needs dependents, separately, are presented in Table S1.
Table 3.
Association between caregiving stress, caregiving status (high-needs dependents), and incident hypertension (N=453)
| Caregiving Stress | Caregiver of high-needs dependents | |||
|---|---|---|---|---|
| No/low | Moderate/high | No | Yes | |
|
|
||||
| Percent developing hypertension | Percent developing hypertension | |||
| 40.6% | 51.7% | 45.6% | 41.1% | |
|
|
||||
| Hazard ratio (95%CI) | Hazard ratio (95%CI) | |||
| Model 1 | 1 (ref) | 1.49 (1.08–2.05) | 1 (ref) | 0.89 (0.65–1.21) |
| Model 2 | 1 (ref) | 1.41 (1.02–1.95) | 1 (ref) | 0.87 (0.63–1.20) |
| Model 3 | 1 (ref) | 1.39 (1.01–1.94) | 1 (ref) | 0.88 (0.64–1.21) |
Model 1 covariates: age, income (low), marital status (yes), employment status (full/part-time), parental history of hypertension (yes), BMI, baseline SBP, baseline DBP
Model 2 covariates: Model 1+current smoker (yes), weekly alcohol use (mean)
Model 3 covariates: Model 2+CES-D score (mean)
Abbreviations: BMI-body mass index, CES-D – Center for Epidemiologic Studies, DBP- diastolic blood pressure, eGFR – estimated glomerular filtration rate, SBP- systolic blood pressure
Over half of participants < 35 years (N=98) with moderate/high caregiving stress developed hypertension (51.9%), in contrast to those with no/low caregiving stress (23.9%) (Table S2). After adjustment for clinical and sociodemographic characteristics, higher caregiving stress was associated with incident hypertension HR 2.64 (95%CI 1.04– 6.72) but this effect was attenuated after further adjustment (HR 2.15 95% CI 0.74 – 6.25 after full adjustment). Among participants ≥ 35 years (N=355), 51.6% of participants with moderate/high caregiving stress developed hypertension in the follow-up period, but this did not substantially differ compared to those with no/low caregiving stress, (45.1%) (Table S3). There was no evidence of an association between caregiving stress and incident hypertension after adjustment for covariates.
Analyses with hypertension defined using the 2017 ACC/AHA BP guideline
Three hundred and sixty-nine participants met the eligibility criteria for the sensitivity analysis (Figure S1). Characteristics of participants by caregiving stress and caregiving status are provided in Tables S4 and S5, respectively. Over a median follow-up of 7.2 years (25th-75th percentile 5.0–8.1 years), 57.8% of participants developed hypertension. Among participants with moderate/high caregiving stress, 61.7% developed hypertension, compared to 56.4% of participants with no/low caregiving stress. Among high-needs dependents caregivers, 59.8% developed hypertension, compared to 55.9% of participants who were not caregivers for high-needs dependents. The fully adjusted HR for incident hypertension was 1.24 (95% CI, 0.89–1.72) comparing moderate/high versus no/low caregiving stress, and was 1.30 (95%CI, 0.95–1.76) comparing participants who were versus who were not caregivers for high-needs dependents (Table S6). We present the association between caregiving stress and incident hypertension, for participants who were caregivers for high-needs dependents and not caregivers for high-needs dependents, separately, in Table S7.
Half of participants < 35 years (N=85) with moderate/high caregiving stress developed hypertension (50.0%), compared to 41.5% of those with no/ low caregiving stress. Among participants ≥ 35 years (N=284), 64.9% of those with moderate/high caregiving stress developed hypertension, compared to 61.0% of those with no/low caregiving stress. There was no evidence of associations between caregiving stress, high-needs caregiving status and incident hypertension after multivariable adjustment in either age group. (Table S8)
DISCUSSION
The results of the current analysis support our hypothesis that reproductive-age women who experience higher caregiving stress have a higher incidence of hypertension than those with lower caregiving stress. Over half of participants reporting moderate/high caregiving stress developed hypertension. After adjustment for relevant sociodemographic, clinical, behavioral and psychosocial variables, caregiving stress remained associated with incident hypertension in this reproductive-age cohort.
The findings from the current study are consistent with prior studies, primarily based on middle-age and older female caregivers, that demonstrated adverse effects of caregiving stress on CVD-related risk.18,33,34 They are also consistent with the AHA’s Life’s Essential Eight model, which describes psychological health, including stress, as a foundational component of cardiovascular health.35 Given the high lifetime risk of CVD among reproductive-age women overall and especially among minoritized reproductive-age women, tailored stress management programs that address sources of stress relevant to this population are needed. 35,36 Furthermore, identifying and alleviating root causes contributing to caregiving strain require further study in order to better inform tailored stress reduction strategies. For example, if lack of affordable childcare is a source of caregiving stress, then navigation and linkage to childcare resources could comprise one component of an intervention. Alternatively, if the source of caregiving strain comes from challenges in interpersonal communication between caregiver and dependent (e.g., parent and younger child, or caring for an elderly relative), an intervention may include parenting/caregiving classes or education related to interpersonal communication.
Caregiving for high needs dependents was not associated with incident hypertension in the current analysis. Black women experience higher caregiver burden compared to their White counterparts, spending more time performing informal caregiving tasks, yet paradoxically report lower levels of caregiver stress.16,37,38 Among caregivers of high-needs dependents included in the analysis, 31% reported moderate/high caregiving stress. The divergence between time spent caregiving and caregiver stress levels among Black women caregivers has been attributed to sociocultural and social support coping mechanisms, such as spirituality and high- effort coping (including emotional suppression as described in the “Strong Black Woman” schema and the Motherwork framework).38,39
In our sensitivity analysis using 2017 ACC/AHA criteria for hypertension, the risk for hypertension was higher among those with caregiving stress and who were caregivers for high-needs dependents. Although not statistically significant, the findings support the notion that caregiving strain and caregiving status may play a role in BP progression.
In the current study, 43.5% of reproductive-age JHS women participants developed hypertension using JNC 7 criteria and 57.8% developed hypertension using 2017 ACC/AHA criteria over a median 7-year time frame. These rates are high in the context of the cohort’s young age. While many studies have examined the prevalence of hypertension in reproductive- age women across race and ethnicity, few have examined the incidence of hypertension among reproductive-age Black women. Estimating the incidence of hypertension and how different factors contribute to it is important to optimize timing and delivery of interventions to slow BP progression and prevent hypertension and attendant sequalae in this high-risk population. The current findings suggest that hypertension prevention efforts including lifestyle interventions among young Black women should start early. Notably, in our cohort, younger (<35 years) women with moderate/high caregiving stress developed hypertension at significantly higher rates compared to same age participants with no/low caregiving stress, and with similar rates to our cohort’s older participants (aged 35–44 years). As psychological health is a foundational factor for CV health,35 stress management may be considered as an integral component in any lifestyle interventions.
Strengths and limitations
This study has several major strengths. First, we focused on reproductive-age women, where the effects of caregiving and caregiving stress are not well-explored. Second, we focused on younger Black women, who are substantially underrepresented in the CVD literature but carry disproportionate lifetime risk of CVD. Other strengths include the availability of multi- faceted data, including standardized measurement of BP, objective and subjective caregiving variables, and robust clinical and sociodemographic information, allowing for a comprehensive adjustment for relevant covariates. In addition, the longitudinal design allowed us to examine progression to hypertension in this cohort.
Despite the strength of our analyses, there are some limitations. We were not able to disaggregate types of caregiving. Participants who were not caregivers to high-needs dependents included those who were not caregivers and those who were caregivers to other groups (e.g., children >5 years, non-elderly spouses). Also, we could not distinguish by type of high-needs caregiving (e.g., caring for children compared to caring for elderly, compared to caring for both children and elderly) and data related to the number of high needs dependents per caregiver was not available. As different types of caregiving confer different physical and emotional stressors,40 it is possible that this information would have allowed us to explore such associations in a more nuanced way. We did not have information on change in caregiving roles over time and therefore could not account for this, which may have possibly concealed some effects of caregiving on hypertension. However, it is notable that caregiving stress, even at one time point, was independently associated with incident hypertension after the follow-up period. This finding underscored the long-lasting effects of stress on health. Because all baseline data was collected at the same time, data pertaining to participants’ health behaviors, e.g., smoking, alcohol use, prior to assessment of their perceived stress was not available. While health behaviors can be coping mechanisms for stress, we did not have the data to evaluate this potential mechanism. We note that higher caregiving stress was independently associated with incident hypertension with adjustment for all covariates. We did not account for changes in health behaviors, such as smoking, which may have changed over time and may be temporally associated with caregiving stress, because caregiving stress was only assessed at baseline. However, we note that while improvement in health behaviors, like smoking, may reduce hypertension risk, former smokers still have a higher risk of hypertension compared to never smokers.4 In addition, we used two assessments of hypertension status, JHS Visit 2 and 3. It is possible that participants could have developed hypertension outside of the JHS visit windows. Furthermore, we cannot exclude residual confounding from additional measured and unmeasured covariates. Despite these limitations, this study has critical implications for informing, timing, and delivery of CV prevention efforts among younger women.
PERSPECTIVES
The incidence of hypertension among reproductive-age Black women was high, underscoring the need to mitigate CVD risk among this population. In addition, those experiencing higher caregiving stress were more likely to develop hypertension compared to those with low/no caregiving stress. Caregiver strain as a source of chronic stress may contribute to CV risk among reproductive-age Black women. Strategies to address caregiving stress require further study, including its incorporation in stress management programs as an important component of CVD risk mitigation in this population.
Supplementary Material
NOVELTY AND RELEVANCE.
WHAT IS NEW?
In the Jackson Heart Study, which enrolled Black adults, 43.5% of female participants aged 21–44 years developed hypertension over a median follow-up of 7.4 years.
Caregiving is associated with high blood pressure in middle-aged and older women, but less is known about this relationship in younger women.
Higher caregiver stress was associated with a higher incidence of hypertension among this reproductive-aged cohort.
WHAT IS RELEVANT?
Reproductive-age Black women experience high hypertension prevalence, a major risk factor for CVD, but hypertension incidence among this population is underexplored.
CLINICAL/PATHOPHYSIOLOGICAL IMPLICATIONS
Study implications include consideration of caregiver strain as a source of chronic stress that may contribute to cardiovascular risk among reproductive-age Black women.
Acknowledgements:
We would like to thank the staff and participants in the Jackson Heart Study.
Funding:
The Jackson Heart Study (JHS) is supported by contracts from the National Heart, Lung, and Blood Institute (NHLBI) and the National Institute for Minority Health and Health Disparities (NIMHD) and is conducted in collaboration with Jackson State University (HHSN268201800013I), Tougaloo College (HHSN268201800014I), the Mississippi State Department of Health (HHSN268201800015I) and the University of Mississippi Medical Center (HHSN268201800010I, HHSN268201800011I and HHSN268201800012I). Additionally, this work is supported by additional funding from the NHLBI (R01HL117323).
Disclaimer:
The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the National Heart, Lung, and Blood Institute; the National Institute for Minority Health and Health Disparities; the National Institutes of Health; or the US Department of Health and Human Services.
LIST OF ABBREVIATIONS
- AHA/ACC
American Heart Association/American College of Cardiology
- BP
Blood Pressure
- BMI
Body Mass Index
- CES-D
Center for Epidemiologic Studies Depression Scale
- CVD
Cardiovascular disease
- DBP
Diastolic blood pressure
- GED
General Education Diploma
- eGFR
Estimated Glomerular Filtration Rate
- GPSS
Global Perceived Stress Scale
- JHS
Jackson Heart Study
- JNC7
Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure
- SBP
Systolic blood pressure
Footnotes
Financial Disclosures: Authors have no financial disclosures to report.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
This was a secondary analysis of pre-existing variables in the Jackson Heart Study. Jackson Heart Study data may be requested from the Biologic Specimen and Data Repository Information Coordinating Center (BioLINCC) repository, https://biolincc.nhlbi.nih.gov/studies/jhs/, and the database of Genotypes and Phenotypes (dbGaP), https://www.ncbi.nlm.nih.gov/gap/. Additionally, investigators with a manuscript proposal or ancillary study proposal that has been approved by study committees may request data directly from the Jackson Heart Study Coordinating Center, https://www.jacksonheartstudy.org/Research/Study-Data/Data-Access.