Exploring stress and coping among black women in early midlife with elevated blood pressure in a safety-net health system: a qualitative focus group protocol

Abstract

Introduction

Black women in early midlife experience disproportionate exposure to stress and elevated cardiovascular risk, including hypertension. Despite this, few stress management interventions are designed with and for this population. This study aims to explore the lived experiences of stress and coping among black women in early midlife with elevated blood pressure to inform the codesign of a culturally relevant, multilevel stress management intervention.

Methods and analysis

We will conduct one-time, semistructured focus groups with black women aged 35–50 who have elevated blood pressure, recruited from a large safety-net health system. Data will be analysed using a constructivist grounded theory approach, with inductive theme development supported by line-by-line, focused and theoretical coding. The Social Determinants of Cardiovascular Disease framework will serve as a sensitising guide to multilevel contextual factors rather than a prescriptive coding structure. An artificial intelligence (AI)-assisted analytic component will complement human-led analysis by supporting preliminary theme exploration and enhancing transparency.

Ethics and dissemination

Approved by the Indiana University Institutional Review Board (Protocol #21785). All participants will provide written informed consent. Findings will be shared via peer-reviewed publications, conference presentations and lay summaries for stakeholders.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• Uses a qualitative design informed by constructivist grounded theory to capture lived experiences of stress and coping.

• Incorporates participatory principles to ensure cultural relevance and stakeholder engagement.

• Guided by the Social Determinants of Cardiovascular Disease framework to address multilevel stressors.

• Includes an artificial intelligence (AI)-assisted analytic component to enhance transparency and reflexivity.

• Findings will be context specific and may not be generalisable beyond black women in early midlife with elevated blood pressure.

Introduction

Black women in early midlife face a unique and disproportionate burden of chronic stress exposure, shaped by intersecting experiences of racism, sexism and role strain across work, family and community.¹,³ These stressors may be further compounded by societal expectations of strength and resilience, which may discourage help-seeking and emotional expression and contribute to the internalisation of stress.⁴,⁸ Emerging evidence suggests that black women may also exhibit heightened physiological stress reactivity, which compounds the effects of frequent stress exposure and contributes to adverse cardiovascular outcomes.⁹ Contextual stressors, including racial discrimination, neighbourhood disadvantage and financial strain, further exacerbate this burden and have been linked to poor sleep, psychological distress and elevated blood pressure.⁹,¹⁴ These stress-related pathways are particularly concerning, given that black women have among the highest prevalence of hypertension globally, with disparities emerging as early as young adulthood and becoming increasingly pronounced by the mid-30s.¹⁵,¹⁷ Addressing stress and coping in this population is, therefore, essential for reducing long-term cardiovascular risk and advancing health equity.

Despite the well-established link between stress and cardiovascular health,¹⁸ stress management interventions are rarely designed with input from black women and often fail to address the multilevel nature of stress. Existing interventions tend to focus on individual-level strategies, such as mindfulness or cognitive–behavioural therapy and are often developed and tested in predominantly white samples.¹⁹ Moreover, few interventions incorporate culturally affirming components, and black adults remain under-represented in stress intervention trials.²⁰

Recent calls from the American Heart Association and the National Institutes of Health emphasise the need for culturally tailored, multilevel interventions that address both individual and contextual stressors. The Social Determinants of Cardiovascular Disease framework highlights how structural, environmental and psychosocial factors interact to shape cardiovascular outcomes.²¹ For black women, such structural and social factors can exacerbate stress exposure and reactivity, processes consistently linked to elevated blood pressure and psychological distress.^{12 22 23} To develop interventions that are both effective and culturally relevant, it is essential to understand how black women experience and navigate these stressors in their daily lives. This study uses constructivist grounded theory to explore the lived experiences of stress and coping among black women in early midlife with elevated blood pressure, with the goal of generating insights to inform the codesign of a culturally relevant, multilevel stress management intervention.

In addition to stress exposure, coping resources, such as social support, mastery and religious involvement, play a complex role in shaping health outcomes. These resources do not uniformly buffer the effects of stress and may, in some cases, amplify stress-related health risks, particularly when resilience is expected but not supported.³ Addressing stress and coping in this population is, therefore, essential for reducing long-term cardiovascular risk and advancing health equity.

Study objectives

The objectives of this study are threefold. First, we aim to explore the lived experiences of stress and coping among black women in early midlife with elevated blood pressure. Second, we seek to identify individual and contextual factors that shape these experiences and the strategies used to manage stress. Third, we will gather insights that can inform the future codesign and pilot testing of a culturally relevant, multilevel stress management intervention.

Methods

Design

This qualitative study will use one-time, 90-min semistructured focus groups to explore stress and coping experiences. The study is informed by user-centred design and participatory principles, emphasising the voices and perspectives of black women.

Participants

Participants will be a convenience sample of black women between the ages of 35 and 50 who are fluent in English and have at least one electronic medical record in the past 12 months indicating a systolic blood pressure of ≥140 mm Hg. Eligible patients will be identified through lists generated by Eskenazi Health’s electronic medical record system. Using this list, a member of the research team (ARB) will contact potential participants by phone to describe the study and assess interest. No prior relationships with participants will be established before recruitment. We aim to recruit approximately 24 women across four focus groups of six participants each. Sampling will be guided by the principle of information saturation, continuing until no new themes emerge from the data.

Patient and public involvement

Patients or members of the public were not formally involved in the development of this protocol. However, the study is informed by participatory principles and aims to incorporate patient perspectives in future phases through codesign of the stress management intervention. Findings from the focus groups will directly shape intervention content and delivery strategies. Plans for dissemination will include sharing lay summaries with participants and community stakeholders.

Data collection

Focus groups will be conducted virtually. Only the facilitator (ARB) will be present during the virtual focus groups; no non-participants will attend. Each session will follow a semistructured guide designed to elicit rich, open-ended responses across five key domains: lived experience of stress; coping strategies and resources; barriers to effective stress management; preferences for stress management tools and interventions and systemic stressors across multiple levels, including individual, interpersonal, community and institutional contexts. These domains are informed by the Social Determinants of Cardiovascular Disease framework, which emphasises the role of structural, environmental and psychosocial factors in shaping cardiovascular outcomes.²¹ This approach allows for consistency across groups while also providing flexibility to explore emergent themes and participant-driven insights. Field notes will be taken by the facilitator (ARB) during and immediately after each focus group to capture contextual details, non-verbal observations and reflections relevant to the analysis. BNS will also review the audiovisual recordings after each focus group to provide additional non-verbal contextual details. The complete focus group interview guide is provided in online supplemental file 1. The focus group interview guide was drafted and reviewed for content, clarity and sequencing, and underwent internal pilot testing among the research team to refine the wording and flow of questions. The guide was not pilot tested with participants prior to data collection.

Data analysis

We will use constructivist grounded theory to analyse the data.²⁴ This approach emphasises the coconstruction of meaning between participants and researchers and is well suited for developing theory grounded in lived experience. The analysis will begin with initial coding, where transcripts are examined line-by-line to identify actions, processes and meanings. These initial codes will then be synthesised into broader categories through focused coding. Throughout this process, we will engage in memo writing to document analytic decisions, emerging ideas and reflections on the data. Theoretical coding will be used to identify relationships between categories and to begin constructing a conceptual framework that reflects participants’ experiences. Constant comparison will be employed across transcripts and categories to refine the emerging theory and ensure that it remains grounded in the data. NVivo will be used to support data management and coding. Two members of the research team (BNS and ARB) will code the data independently, followed by team discussions to reconcile analytic decisions and enhance coding consistency. The analysis will be iterative, with early findings informing subsequent data collection and interpretation, allowing for responsiveness to new insights as they emerge. Themes will be derived inductively through constructivist grounded theory methods, beginning with line-by-line initial coding, followed by focused and theoretical coding. The Social Determinants of Cardiovascular Disease framework will inform the analytic process by sensitising the research team to multilevel contextual factors, but it will not prescribe or constrain theme development. In this approach, the framework guides interpretation while themes ultimately emerge from the data rather than being predetermined.

In addition to the human-led grounded theory approach described above, we will incorporate an artificial intelligence (AI)-assisted analytic component to enhance transparency and explore the utility of large language models in qualitative research. This complementary process will not replace researcher interpretation but will serve as an adjunct to support preliminary theme development, pattern detection and reflexive dialogue. Details of this approach, including prompt design principles, analytic phases and ethical safeguards, are provided below.

Integration of AI in qualitative analysis

To support preliminary theme development and explore the utility of AI in qualitative research, we will use Microsoft Copilot (‘Copilot’) to assist with thematic analysis of focus group transcripts. Prompts will be designed following the framework proposed by Zhang et al,²⁵ which emphasises structured input, methodological alignment, role playing and transparency. Copilot will be instructed to analyse transcripts using constructivist grounded theory and the Social Determinants of Cardiovascular Disease framework, with attention to individual, interpersonal, community and institutional stressors.²¹

Informed by Costa et al,²⁶ we conceptualise AI as a coresearcher capable of contributing to pattern detection, reflexivity and interpretive insight. This approach acknowledges that knowledge can be created across human and non-human actors. Copilot will be engaged through Chain-of-Thought prompting, a technique that prompts the AI to document its reasoning process in sequential steps.²⁷ Hayes’s dialogical model of AI-assisted analysis²⁸ will inform our second analytic phase, in which copilot will be prompted to explore contradictions, surface subtle patterns and suggest theoretical connections. While AI will support iterative refinement of categories, collaborative coding and abductive reasoning, the research team will maintain interpretive authority and ethical oversight throughout the process. AI-generated outputs will be reviewed and refined iteratively, with particular attention paid to the alignment between emergent themes and the analytic framework.

While AI facilitates scalability and transparency, its contributions are bounded by limitations in contextual understanding and nuance. As such, all coding decisions will be critically evaluated by the research team to preserve the depth and reflexivity central to qualitative inquiry. To support transparency and reproducibility, the detailed prompt design checklist proposed by Zhang et al²⁵ and the full Chain-of-Thought prompt template are included as appendices (online supplemental files 2 and 3).

Ensuring rigour

To ensure methodological rigour, we will employ multiple strategies throughout the research process. First, we will maintain reflexivity by documenting researcher assumptions, positionality and reflections in analytic memos. A formal positionality statement will be included in the final manuscript to acknowledge the social identities, lived experiences and insider–outsider dynamics of the research team. This is essential, given the racialised and gendered nature of the topic and the potential influence of researcher identity on data collection, interpretation and power relations.

Drawing on Goundar’s guidance,²⁹ we recognise that researcher positionality is shaped by factors, such as race, gender, professional role and lived experience, all of which can influence how researchers access participants, pose questions and interpret findings. In this study, the lead researcher (BNS) is a PhD-level faculty member with expertise in lifespan development, particularly behavioural interventions that promote cognitive and physical health in middle-aged and older adults. While not a member of the study population (but sharing the same gender identity as the participants), the researcher’s professional role and institutional affiliation may influence how participants perceive the research and their willingness to participate. We will reflect on these dynamics throughout the study, particularly the potential for perceived authority or institutional power to affect rapport and disclosure. To mitigate this, we will emphasise voluntary participation, clarify the researcher’s role and avoid recruiting individuals with direct academic or supervisory ties to the research team. These reflections will be documented in analytic memos and addressed in the final positionality statement to ensure transparency and ethical integrity. The researcher responsible for participant recruitment and facilitation of focus groups (ARB) is a research specialist who is highly experienced in implementing behavioural interventions. Additionally, the researcher shares the same racial and gender identity as the study population, which may influence participants’ comfort level and willingness to disclose information.

To ensure rigour, we will employ multiple strategies throughout the analysis, including constant comparison to keep emerging categories grounded in the data, team discussions to enhance coding consistency and assessment of intercoder reliability using NVivo. We will provide thick description in reporting, maintain an audit trail to document analytic decisions and incorporate member checking by inviting a subset of participants to review preliminary themes and interpretations. Raw transcripts will not be returned to participants; instead, member checking will focus on participant review of preliminary themes. Finally, we will engage in peer debriefing with qualitative experts and community stakeholders to validate findings and enhance credibility.

Data availability

The focus group guide, final codebook and analytic framework will be available in the Open Science Framework (OSF) repository at https://osf.io/u54jv. Due to confidentiality considerations, raw transcripts will not be shared.

Ethics and dissemination

This study has received approval from the Indiana University Institutional Review Board (Protocol #21785). All participants will provide written informed consent and may decline to answer any question or withdraw at any time without consequence. Study findings will be disseminated through peer-reviewed publications, scientific conference presentations and community-facing products. Non-identifiable materials, including the focus group guide and final codebook, will be made available on OSF. Raw transcripts will not be shared due to confidentiality considerations. Lay summaries will be distributed to participants, Eskenazi Health partners and other community stakeholders to support future stress management intervention codesign activities.

Strengths, limitations and discussion

This study has several notable strengths. It uses a qualitative design informed by constructivist grounded theory, incorporates participatory principles to ensure cultural relevance and applies the Social Determinants of Cardiovascular Disease framework to address multilevel stressors. The integration of an AI-assisted analytic component represents an innovative approach to enhancing transparency and reflexivity; for example, AI-supported pattern detection can help identify subtle connections during early coding. These features position the study to generate culturally relevant insights that will inform the codesign of a multilevel stress management intervention. However, findings will be context specific and may not be generalisable beyond black women in early midlife with elevated blood pressure. Recruitment from a single safety-net health system may further limit transferability. While AI-assisted analysis offers potential benefits, its contributions are bounded by limitations in contextual understanding and nuance, requiring careful oversight by the research team.

In conclusion, this protocol addresses a critical gap in cardiovascular intervention research by centring the lived experiences of black women in early midlife. Findings from this work have the potential to advance cardiovascular health equity and guide future research on tailored strategies to reduce stress-related risk in marginalised populations.