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. Author manuscript; available in PMC: 2026 Apr 27.
Published in final edited form as: Psychoneuroendocrinology. 2025 Nov 17;184:107696. doi: 10.1016/j.psyneuen.2025.107696

Superwoman Schema, Motherhood Status, and Subclinical Atherosclerosis Among African American Women

Lori S Hoggard 1, Te-ojah Dennison-Morgan 2, Jordan Parker 3, Raphiel J Murden 4, Zachary T Martin 5, Jelaina Shipman-Lacewell 6, Christy L Erving 7, Nicole D Fields 8, Shivika Udaipuria 9, Reneé H Moore 10, Viola Vaccarino 11, Arshed A Quyyumi 12, Mindy Lee Coccari 13, Tené T Lewis 14
PMCID: PMC13110375  NIHMSID: NIHMS2155704  PMID: 41344043

Abstract

Background:

Cardiovascular disease (CVD) is the leading cause of death among women in the United States, with African American women facing markedly higher rates of CVD-related morbidity and mortality than women of other racial/ethnic backgrounds. African American women’s heightened risk for CVD has been linked to their disproportionate exposure to social stressors. In the present study, we examine how Superwoman Schema (SWS) is related to carotid intima media thickness (IMT) among African American women as well as the moderating role of motherhood status.

Methods:

Data are from the Mechanisms Underlying the Impact of Stress and Emotions (MUSE) on African American Women’s Health Study, a cohort of 422 AA women residing in the greater Atlanta metropolitan area. The women completed demographic questions (e.g., motherhood status) and psychosocial assessments, including the 35-item SWS scale. IMT scans were also performed during the visit.

Results:

After adjustment for sociodemographic (e.g., age) and CVD risk (e.g., blood pressure) factors, the results revealed that Resistance to Vulnerability was associated with lower IMT among non-mothers.

Conclusions:

The results indicate that African American women’s culturally rooted tendency to embody strength, independence, self-reliance, ambition, and care for others may serve as a compensatory mechanism influencing CVD risk, with the associations varying by motherhood status

Keywords: Superwoman Schema, carotid intima-media thickness, cardiovascular risk, African American women, intersectionality, motherhood

1. Introduction

Cardiovascular disease (CVD) is the leading cause of death among women in the United States. African American women face markedly higher rates of CVD-related morbidity and mortality than women of other racial/ethnic backgrounds (Burroughs et al., 2019; Carnethon et al., 2017). These higher rates cannot be fully attributed to socioeconomic status or common clinical risk factors (Jolly et al., 2010). In response, the American College of Cardiology’s Cardiovascular Disease in Women Committee and Health Equity Task Force have called for urgent action to address the persistent cardiovascular health inequities affecting African American women (Ogunniyi et al., 2022)

African American women’s heightened risk for CVD has been linked to their disproportionate exposure to social stressors (Bromfield et al., 2020; Felix et al., 2019; Woods-Giscombe, 2010). Central among these social stressors is systemic racism, which is woven into the fabric of American institutions and cultural norms, shaping systems (e.g., health care, education, housing, the criminal justice system, and media) and giving rise to persistent experiences of interpersonal racism (Harrell, 2000). In parallel, gender inequity functions as a patriarchal system that allocates power and opportunity along gendered lines (hooks, 1989). Positioned at the intersection of these oppressive, interlocking forces, African American women face racism, sexism, racialized sexism, and gendered racism (Cole, 2009; Collins, 2000; Crenshaw, 1989, 1991) that likely contribute to their pronounced vulnerability to CVD.

African American women’s historical and ongoing subjugation to enmeshed oppressive systems (Collins, 2000) has contributed to the development of the Superwoman Schema (SWS; Woods-Giscombé, 2010). SWS—a culturally rooted framework—captures African American women’s collective psychosocial responses to intersecting systems of racialized and gendered oppression. Specifically, SWS highlights patterns of socialization that emphasize obligations to suppress emotions (Suppression of Emotions), manifest strength (Manifesting Strength), resist vulnerability and dependence (Resistance to Vulnerability), succeed despite scarce resources (Succeeding Despite Limited Resources), and help others (Obligation to Help Others), often at the cost of personal health and well-being. Originating during slavery, the Superwoman role embodied resilience in the face of dehumanizing conditions, as African American women simultaneously assumed the roles of caregiver, provider, and protector to ensure familial survival in a violently oppressive era (Beauboeuf-Lafontant, 2003; Shorter-Gooden, 2009).

Much of the quantitative research informed by intersectionality has relied on intercategorical approaches—comparing across social groups (Bauer & Scheim, 2019; Harnois & Bastos, 2019). Yet, the intracategorical complexity approach focuses on within-group health heterogeneity at one or more marginalized intersectional locations (e.g., race, gender; Harari & Lee, 2021). The development of the SWS framework and corresponding measure has enabled an intracategorical focus on African American women’s health (Erving et al., 2024; Harari & Lee, 2021), allowing for investigations of how SWS heterogeneity among African American women may be linked to CVD risk.

A fledgling literature suggests that SWS is potentially adverse for African American women’s cardiovascular health. Among early middle-aged African American women, higher Total SWS and Obligation to Help Others were associated with elevated systolic blood pressure and augmentation index (Martin et al., 2024). Extending these findings, Blevins et al. (2025) reported that greater endorsement of Total SWS, along with Manifesting Strength, Suppression of Emotions, and Resistance to Vulnerability, was positively associated with aortic pulse wave velocity–a measure of aortic stiffness and strong predictor of future CV events and all-cause mortality–particularly among African American women with lower levels of environmental mastery (Vlachopoulos, Aznaouridis, & Stefanadis, 2010). Succeeding Despite Limited Resources—often framed as perseverance—has also been linked to poorer vascular function among African American women (Martin et al., 2023). These findings underscore the relevance of SWS for understanding African American women’s cardiovascular health, while also highlighting the need for further research examining its associations with a broader range of subclinical indicators of CVD risk. Informed by these prior analyses and using the same cohort of early middle-aged African American women as Martin et al. (2024) and Blevins et al. (2025), the present study examines the associations between Total SWS (and SWS subscales) and carotid intima media thickness (IMT), a biomarker of CVD risk (Bots et al., 1997; Lorenz et al., 2007), among African American women. Indeed, prior studies have documented that psychosocial stressors are positively associated with carotid IMT (Thurston et al., 2017; Troxel et al., 2003).

The association between the endorsement of SWS and carotid IMT may be moderated by motherhood status, as motherhood for African American women is an identity laden with both historical trauma and contemporary role expectations (Collins, 2000; Turner & Avison, 2003). During the era of chattel slavery, African American women were systematically denied reproductive autonomy, and their pregnancies and children were commodified as economic assets to enslavers (Collins, 2000; Morgan, 2018). These conditions of reproductive exploitation contributed to the development of the Strong Black Woman (SBW) ideal and, ultimately, SWS, as a means of asserting agency and survival amid systemic oppression (Abrams et al., 2019; Collins, 2000; Harris-Lacewell, 2001). In modern contexts, African American mothers are frequently expected to perform multiple and often competing roles, including caregiver, provider, partner, community worker, and educator—responsibilities that may intensify the internalization of Superwoman characteristics (Giurgescu et al., 2013). These intersecting pressures may increase psychological strain, physiological burden, and amplify CVD risk among African American women who strongly endorse SWS.

In the present study, we examine how SWS is related to carotid IMT. We hypothesized that Total SWS will be associated with higher carotid IMT, expecting that this association would be driven by Obligation to Help Others. We also examined whether motherhood status would moderate the relation between SWS and carotid IMT. We hypothesized that the association between Total SWS and carotid IMT would be stronger among mothers; we also hypothesized that the association between Obligation to Help Others and carotid IMT would be stronger among mothers. We also examine Manifesting Strength, Suppression of Emotions, Resistance to Vulnerability, and Succeeding Despite Limited Resources in secondary analyses.

2. Method

2.1. Participants

Participants were from the Mechanisms Underlying Stress and Emotions (MUSE) in African American Women’s Health Study (McKinnon et al., 2022; Lewis et al., 2023). Women were recruited via consumer residential lists and voter registration records from a range of census tracts in the greater Atlanta, GA metropolitan area from December 2016 through March 2019. An introductory brochure was sent via mail, followed by a telephone call for prescreening. Eligibility criteria included: self-identification as a Black/African American woman; aged 30–45 (at screening); pre-menopausal; not pregnant or lactating; and having a uterus and at least one ovary. Ineligibility criteria included: history of clinical CVD (e.g., myocardial infarction, angina, intermittent claudication, cerebrovascular disease, or coronary revascularization); chronic illness known to influence atherosclerotic disease (e.g., HIV, kidney disease); current treatment for psychiatric disorders; and current illicit drug use or alcohol abuse. A total of 422 women were enrolled in the study.

2.2. Procedures

Participants completed an in-person visit, where study staff collected height, weight, resting blood pressure, and additional clinical data. Carotid ultrasound to assess IMT was then performed. Following this, demographic and psychosocial characteristics were assessed via face-to-face interview. All procedures were approved by the Emory University Institutional Review Board, and all participants provided written, informed consent. Of the 422 women enrolled in the study, 407 (96% of the cohort) had complete data on Superwoman Schema (SWS). The remaining 4% (N = 15) had a missing response to at least one question on the 35-item SWS scale. Among this group, if a given participant responded to at least 80% of the items on the SWS scale (i.e., answered at least 29 of the 35 questions), we used person-mean-substitution (Huisman, 2000) to impute the remaining 1–6 items. Person-mean substitution was only performed for N = 12 women. Women who skipped 7 or more questions on the 35-item SWS scale (N = 3) were excluded from all analyses. A total of 8 women were missing carotid IMT data. An additional 11 were missing covariate data (e.g., for household income, 7 responded “Don’t Know” or refused to respond, and 2 were missing; 1 was missing systolic blood pressure (SBP) data. Thus, the final sample included 401 participants.

2.3. Measures

2.3.1. Intima Media Thickness Outcome

Certified vascular sonographers at Emory University obtained duplex ultrasound bilateral carotid images using a Mindray M7 system equipped with a linear transducer (L12-4s). Bilateral clips of the 10 mm segment of the common carotid artery (CCA) just proximal to the bifurcation at 3 angles (anterior, lateral and posterior) were obtained. Each clip included four QRS complexes. The clips were saved and streamed to the University of Pittsburgh Ultrasound Research Lab for later reading. Vascular Research Tools 5 (Medical Imaging Applications, LLC, Coralville, IA) was used to measure IMT of the near and far walls of the CCA. Carotid IMT measurements were made by electronically tracing the lumen-intima interface and the media-adventitia interface from images obtained in end-diastole (upstroke of R wave). The mean IMT of the near and far walls of the CCA segment was used in analyses and was measured in mm.

2.3.2. Superwoman Schema

The Superwoman Schema Scale (SWS) comprises 35-items that capture five subscales: 1) Obligation to Present An Image Of Strength , 2) Obligation to Suppress Emotions , 3) Resistance to Being Vulnerable , 4) Intense Motivation to Succeed , and 5) Obligation to Help Others (Woods-Giscombé et al., 2019). Subscale definitions, number of items, sample items, and the Cronbach’s alphas can be found in Table 1. Response options entailed: Not true for me (0), true for me rarely (1), true for me sometimes (2), and true for me all the time (3). To create the Total SWS score, we averaged all 35 items to create a composite score for each respondent (possible range for Total SWS: 0-3). Higher values reflect greater Total SWS endorsement. Moreover, we calculated an average score for each subscale (range: 0-3), which is ideal as the average score allows us to compare across subscales with differing numbers of items. Higher scores reflect greater endorsement of the various SWS dimensions. Total SWS and the five SWS subscales had high internal consistency reliability .

Table 1:

Superwoman Schema Scale

Subscale Conceptualization Sample Item No. of Items Cronbach’s α
Obligation to Present an Image of Strength Experiencing difficulty or being reluctant to display emotions I have to be strong 6 .82
Obligation to Suppress Emotions Being expected to be strong for close others and being perceived as strong I keep my feelings to myself 7 .86
Resistance to Being Vulnerable Being independent and self-reliant Asking for help is difficult for me 7 .86
Intense Motivation to Succeed Having an intense drive to succeed despite not everything needed to be successful No matter how hard I work, I feel like I should do more 6 .75
Obligation to Help Others Feeling a responsibility to ensure other’s needs are met There is no time for me, because I am always taking care of others 9 .88
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2.3.3. Motherhood Status

Motherhood status was self-reported. Women who reported having a child(ren), raising/caring for a child(ren)—including a grandchild(ren) and a stepchild(ren)—and/or being pregnant were identified as mothers (no/yes).

2.3.4. Ever Pregnant: Supplemental Analyses

Whether a woman had ever been pregnant was self-reported (no/yes).

2.4. Covariates & data analytic plan

Covariates were chosen based on prior research (Lewis et al., 2019; Cundiff et al., 2015; Wendell et al., 2017). Resting SBP was measured using an automated sphygmomanometer after 15 minutes of seated rest (feet flat on the floor, arm supported at heart level), with the average of at least two measurements being used. Age and partner status (married/living with partner vs. not) were self-reported. Education was self-reported in years and as highest degree status and then categorized into: high school or less, some college or occupational training, and college or higher. Family income was self-reported into predefined ranges and collapsed into: <$35,000, $35,000–$49,999, $50,000–$74,999, ≥$75,000/year. Family size was reported as the number of individuals in the household. Body Mass Index (BMI) was calculated as weight/height2 (kg/m2) and modeled continuously. Current smoking, antihypertensive medication use, and medical insurance coverage were self-reported as no/yes. Depressive symptoms were assessed with the 21-item Beck Depression Inventory (Beck et al., 1961) and modeled continuously.

All analyses were conducted using IBM SPSS Version 29.01. Descriptive statistics were first computed. A series of analysis of variance (ANOVA) models were conducted to compare mothers and non-mothers on main study variables and covariates. We employed the PROCESS macro (Hayes, 2013; Model 1) to examine the associations between SWS (and each SWS dimension: Resistance to Vulnerability, Obligation to Help Others, Suppression of Emotions, Manifesting Strength, and Succeeding Despite Limited Resources) and carotid IMT and to test the interactions between SWS (and each SWS dimension) and motherhood status. For Total SWS and each SWS dimension, Model 1 included the interaction term (SWS x Motherhood Status) as well as age as a covariate. Model 2 adjusted for additional key sociodemographic variables, including marital/live-in partner status, educational attainment, family income, and family size. Model 3 further adjusted for clinical and behavioral covariates known to be linked to carotid IMT, including BMI, SBP, use of antihypertensive medication, current smoking status, insurance coverage, and depressive symptoms. The Total SWS and dimension variables were mean-centered to reduce multicollinearity in interaction terms. Interaction terms were computed by multiplying centered SWS scores (Total and dimensions) with motherhood status (coded 0 = non-mother, 1 = mother). In Supplemental Analyses (section 3.5), we used PROCESS Model 1, to test whether the women have ever been pregnant moderated the association between Total SWS (and SWS dimensions) and carotid IMT. All significant interactions were probed ( 0 vs. 1) using simple slopes analyses and plotted to visualize differential associations of SWS with IMT by motherhood status. Statistical significance was set at p < .05 for all tests, and 95% confidence intervals were reported for the unstandardized regression coefficients. Given the exploratory nature of this study and the novel application of the SWS subscales to cardiovascular outcomes, no formal correction for multiple comparisons (e.g., Bonferroni adjustment) was applied. Applying such corrections in an exploratory context can be overly conservative and may increase the likelihood of Type II error, potentially obscuring meaningful associations. Therefore, findings are interpreted as preliminary and hypothesis-generating, with emphasis placed on the pattern and magnitude of associations rather than on statistical significance alone

3. Results

3.1. Preliminary Results

Descriptives are reported in Table 2. On average, mothers (M =38.14, SD =4.14) were approximately one year older than non-mothers (M =37.14, SD = 4.62), F(1, 397) = 130.23, p < .001, η2p = .011. Mothers and non-mothers also differed on family size, with mothers (M =4.11, SD =1.64) reporting a larger family size than non-mothers, on average (M =2.07, SD = 1.36), F(1, 397) = 4.21, p = .04, η2p = .247. Moreover, relative to non-mothers (M =1.81, SD = .48), mothers more strongly endorsed Total SWS (M =1.96, SD = .50), F(1, 397) = 7.01, p = .008, η2p = .017. Obligation to Help Others endorsement was also higher among mothers (M =1.79, SD = .69) than non-mothers (M =1.72, SD = .68), F(1, 397) = 14.96, p < .001, η2p = .036. Similarly, Manifesting Strength endorsement was also higher among mothers (M =2.30, SD = .61) than non-mothers, (M =2.11, SD = .66), F(1, 397) = 6.59, p = .011, η2p = .016. Finally, mothers exhibited higher carotid IMT than (M =.62, SD = .08) than non-mothers (M =.60, SD = .08), F(1, 397) = 7.15, p = .008, η2p = .018.

Table 2:

Descriptive Statistics (N=401)

Overall (n = 401) Non-mothers (n = 104) Mothers (n = 297)
Mean ± SD or %
Carotid Intima Media Thickness (mm) .61 ± .08 .60 ± .08 .62 ± .08
Superwoman Schema
 Total (score; range: .46-2.86) 1.92 ± .50 1.81 ± .48 1.96 ± .50
 Obligation to Help Others (score; range 0-3) 1.72 ± .68 1.72 ± .68 1.79 ± .69
 Manifesting Strength (score; range 0-3) 2.25 ± .63 2.11 ± .66 2.30 ± .61
 Suppression of Emotions (score; range 0-3) 1.65 ± .68 1.62 ± .64 1.66 ± .70
 Succeeding Despite Limited Resources (score; range .33-3) 2.23 ± .51 2.16 ± .57 2.26 ± .50
 Resistance to Vulnerability (score; range 0-3) 1.91 ± .69 1.84 ± .69 1.93 ± .68
Motherhood Status
 Not a Parent (referent) 25.9%
 Parent 74.1%
Covariates
Age (years) 37.89 ± 4.28 37.14 ± 4.62 38.14 ± 4.14
Partner Status
 Not Married or Living with a Partner 63.6% 84.6% 56.2%
 Married/Living with a Partner 36.4% 15.4% 43.8%
Annual Household Income (USD)
 < $35,000 24.7% 20.2% 26.3%
 $35,000 - $49,999 21.2% 22.1% 20.9%
 $50,000 - $74,999 23.4% 28.8% 21.5%
 $75,000 or more 30.7% 28.8% 31.3%
Family Size 3.58 ± 1.81 2.07 ± 1.36 4.11 ± 1.64
Education
 High school or less 30.7% 19.2% 34.7%
 Some college or occupational training 20.9% 17.3% 22.2%
 College or higher 48.4% 63.5% 43.1%
Insurance Status
 Not insured 15.7% 19.2% 14.5%
 Insured 84.3% 80.8% 85.5%
Smoking Status
 Non-smoker 90.3% 93.3% 89.2%
 Smoker 9.7% 6.7% 10.8%
Antihypertensive Medication Use
 No 83.5% 87.5% 82.2%
 Yes 16.5% 12.5% 17.8%
Body Mass Index (BMI) 32.71 ± 8.29
Depressive Symptoms (score; range: 0-39) 5.82 ± 6.65
Systolic Blood Pressure (mm Hg) 118.91 ± 14.49
Supplemental Analysis Variable
Ever pregnant
 No 19% 72.1% .3%
 Yes 81% 27.9% 99.7%
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Source: Mechanisms Underlying Stress and Emotions (MUSE) in African American Women’s Health Study

3.2. Total SWS

In age-adjusted linear regression models (Table 3; Model 1), Total SWS was not associated with carotid IMT, b= −0.026(0.015), p = .08, 95% CI [−0.056, 0.003]. After adjustment for marital/live-in partner status, education, family income, and family size (Table 3; Model 2), this association remained non-significant, b= −0.028(0.015), p = .06, 95% CI [−0.058, 0.001]. After further adjustment for BMI, SBP, use of antihypertension medicine, current smoking, insurance status, and depressive symptoms (Table 3; Model 3), the association remained non-significant, b=−0.028(0.015), p = .06, 95% CI [−0.057, 0.002]. Please see Table 3 for the estimates for non-mothers and mothers.

Table 3.

Superwoman Schema, Carotid Intima Media Thickness, and in Early Middle-Aged African American Women (N=401)

SWS Predictor Model 1 Model 2 Model 3
b (SE) p b (SE) p b (SE) p
Non-Mothers (n =104)
Total Superwoman Schema −.026 (.015) .08 −.028 (.015) .06 −.028 (.015) .06
Obligation to Help Others −.017 (.011) .13 −.019 (.012) .10 −.022 (.011) .05
Resistance to Vulnerability −.022 (.010) .04 −.023 (.010) .03 −.023 (.010) .02
Manifesting Strength .002 (.011) .85 .002 (.011) .85 .007 (.011) .54
Suppressing Emotions −.020 (.011) .08 −.021 (.011) .06 −.020 (.011) .08
Motivation to Succeed .015 (.013) .26 −.016 (.013) .23 −.015 (.013) .25
Mothers (n =297)
Total Superwoman Schema .006 (.008) .51 .005 (.009) .52 .006 (.009) .48
Obligation to Help Others .006 (.006) .37 .005 (.006) .41 .004 (.006) .57
Resistance to Vulnerability .006 (.006) .34 .006 (.006) .33 .006 (.006) .33
Manifesting Strength .002 (.007) .76 .002 (.007) .73 .005 (.007) .48
Suppressing Emotions −.0001 (.006) .99 −.0003 (.006) .96 .001 (.006) .92
Motivation to Succeed .0003 (.009) .97 .0001 (.009) .99 .003 (.008) .72
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Note. The b coefficient for Resistance to Vulnerability represents the change in carotid IMT (mm) associated with a 1-unit increase in Resistance to Vulnerability endorsement score. Model 1: Interaction term and adjustment for age; Model 2: adjusted for age, interaction term, marital status, education, family income, and family size. Model 3: adjusted for age, interaction term, marital status, education, family income, family size, BMI, clinic systolic blood pressure, use of anti-hypertension medicine, current smoking, insurance status, and depressive symptoms. BMI = Body Mass Index.

3.3. SWS Dimensions

After multivariate adjustment for demographic (age, marital/live-in partner status, education, family income, and family size) and cardiovascular risk factors (BMI, SBP, use of antihypertension medicine, current smoking, insurance status, and depressive symptoms), there was no association of Obligation to Help Others, for Manifesting Strength, Suppression of Emotions, and Succeeding Despite Limited Resources with IMT (see Table 3).

Conversely, in age-adjusted linear regression models (Table 3; Model 1), Resistance to Vulnerability was negatively associated with carotid IMT, b= −0.022(0.01), p = .04, 95% CI [−0.042, −0.001]. Specifically, a unit increase in Resistance to Vulnerability endorsement was associated with a 0.022 unit decrease in carotid IMT. After adjustment for marital/live-in partner status, education, family income, and family size (Table 3; Model 2), this association remained significant, b=−0.023(0.01), p = .03, 95% CI [−0.043, −0.002]. After further adjustment for BMI, SBP, use of antihypertension medicine, current smoking, insurance status, and depressive symptoms (Table 3; Model 3), the association remained significant, b=−0.023(0.01), p = .025, 95% CI [−0.043, −0.003], with a unit increase in Resistance to Vulnerability endorsement being associated with a 0.023 unit decrease in carotid IMT.

3.4. The Potential Moderating Role of Motherhood on Overall SWS and SWS Dimensions

Motherhood status moderates the relation between Total SWS and carotid IMT (see Figure 1), b=.034(.017), p = .04, 95% CI [.001, .066]. Among women who are not mothers, the association between Total SWS and carotid IMT was not significant but trended in the inverse direction, b=−0.028(0.015), t=−1.86, p=0.06, 95% CI [−.057, .002]. Among mothers, Total SWS was not associated with carotid IMT, b=0.006(0.009), t=0.712, p=0.48, 95% CI [−.011, .023].

Figure 1.

Figure 1.

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Graph for Total SWS by Motherhood Status Interaction on Carotid IMT.

Note. Low, moderate, high values of Total SWS represent one standard below and above the mean as well as at the mean.

Analyses showed that motherhood status moderates the relation between Obligation to Help Others and carotid IMT (see Figure 2), b=.026(.013), p =.04, 95% CI [.001, .051]. Among women who are not mothers, the association between Obligation to Help Others and carotid IMT was not significant but trended in the inverse direction, b=−0.022(0.011), t=−1.92, p=0.05, 95% CI [−.047, .0002]. Among mothers, Obligation to Help Others was not associated with carotid IMT, b= 0.004(0.006), t=0.477, p=0.570, 95% CI [−.009, .016].

Figure 2.

Figure 2.

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Graph for Obligation to Help Others by Motherhood Status Interaction on Carotid IMT.

Note. Low, moderate, high values of Obligation to Help Others represent one standard below and above the mean as well as at the mean.

Analyses also revealed that motherhood status moderates the relation between Resistance to Vulnerability and carotid IMT (see Figure 3), b=.029(.012), p = .013, 95% CI [.006, .052]. Among women who are not mothers, higher endorsement of Resistance to Vulnerability was associated with lower carotid IMT, b=−0.023(0.01), t=−2.257, p=0.02, 95% CI [−.043, −.003]. Among mothers, endorsement of SWS Resistance to Vulnerability was not associated with carotid IMT, b= 0.006(0.006), t=0.975, p=0.33, 95% CI [−.006, .019].

Figure 3.

Figure 3.

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Graph for Resistance to Vulnerability by Motherhood Status Interaction on Carotid IMT. Note. Low, moderate, high values of Resistance to Vulnerability represent one standard below and above the mean as well as at the mean.

Motherhood status did not moderate the associations between carotid IMT and Manifesting Strength, Suppression of Emotions, or Succeeding Despite Limited Resources.

3.5. Supplemental Analyses

Given that pregnancy induces progressive increases in carotid IMT from the first to the third trimester of pregnancy that is reflective of adaptive remodeling of the arterial wall (Ghossein-Doha et al., 2023; Skow et al., 2017), we sought to ascertain whether the moderating influence of motherhood status may have been observed as a function of whether a women has ever been pregnant. Analyses revealed that whether the women have ever been pregnant did not moderate the relation between Total SWS and carotid IMT, b=.017(.021), p = .41, 95% CI [−.024, .058]. These supplemental analyses also revealed that whether the women have ever been pregnant did not moderate the relation for Manifesting Strength, Suppression of Emotions, Resistance to Vulnerability, Succeeding Despite Limited Resources, or Obligation to Help Others.

4. Discussion

The present study examined the associations between SWS and subclinical CVD risk, as indexed by carotid IMT, and the potential moderating capacity of motherhood status among a sample of African American women in early midlife. Contrary to our first hypothesis, total SWS endorsement was not significantly associated with carotid IMT. Our findings align with Blevins et al. (2025), who observed no direct association between Total SWS and aortic pulse wave. In contrast, Martin et al. (2024) reported that higher Total SWS endorsement was associated with elevated systolic blood pressure, suggesting that while SWS may relate to some indicators of vascular function, its associations with subclinical measures such as carotid IMT may be less robust or more context dependent.

Analyses of four of the five individual SWS dimensions—Obligation to Help Others, Manifesting Strength, Suppression of Emotions, and Succeeding Despite Limited Resources—yielded similarly null findings. These findings are contradictory to those of Blevins et al. (2025), who documented that Succeeding Despite Limited Resources is positively associated with pulse wave velocity, and Martin et al. (2024), who reported that Obligation to Help Others is associated with greater SBP. These discrepancies may reflect differences in the cardiovascular outcomes examined, as SWS dimensions may be more strongly linked to hemodynamic rather than subclinical indicators of CVD risk, especially during early middle adulthood. Indeed, IMT is largely influenced by age. Conversely, Resistance to Vulnerability was significantly negatively associated with carotid IMT across all models, even after adjusting for sociodemographic and clinical covariates, including blood pressure, smoking, and depressive symptoms. It is plausible that resistance to being vulnerable and being dependent on others may be associated, at least to some extent, with slight structural changes in the arterial wall (i.e., thickening) that are detectable in carotid IMT among African American women.

Notably, the direct association above was only observed among non-mothers. We found some support for our second hypothesis, as the association between Total SWS endorsement and carotid IMT was moderated by motherhood status. Among non-mothers, the inverse association between endorsement of Total SWS and carotid IMT approached significance, whereas no significant association was observed among mothers. To discern whether the moderating effect was driven by having ever been pregnant, we conducted supplemental analyses which revealed that having ever been pregnant did not moderate the association between Total SWS (or any SWS dimensions) and carotid IMT. Thus, the moderating capacity of motherhood status may not be driven by pregnancy-induced increases in carotid IMT in our cohort of women. In terms of the individual SWS dimensions, among non-mothers, the inverse association between Obligation to Help Others and carotid IMT approached significance, whereas no association was found among mothers. Finally, Resistance to Vulnerability was inversely associated with carotid IMT among non-mothers and unrelated to carotid IMT among mothers. These findings highlight the possibility that certain aspects of SWS—particularly those emphasizing caregiving in the context of immediate and extended family and the broader community, prosocial responsibility, and emotional fortitude—may be psychologically compensatory for African American women who are not navigating the additional demands and societal expectations associated with motherhood. Specifically, African American women who are not mothers may be able to enact cultural values (e.g., collectivism, community uplift) while also having more control (relative to mothers) over how, when, and whom they help without cumulative stress associated with parenting obligations. In contrast, for mothers, the cumulative strain of fulfilling culturally imposed Superwoman roles alongside the demands of motherhood may diminish the potential buffering effects of these characteristics on CVD risk.

4.1. Limitations and Future Directions

While this study has several strengths, it is not without limitations. First, our effect sizes were small, suggesting that SWS dimensions may not be strongly linked to structural or subclinical indicators of CVD risk, especially relative to hemodynamic indicators of CVD risk during early middle adulthood. Thus, the physiological correlates of SWS may differ across specific cardiovascular risk markers and the present work highlights the need for additional research examining multiple indices of subclinical cardiovascular health. Second, our findings may not generalize beyond African American women residing in the Atlanta metropolitan area. However, Atlanta provides a valuable context for this research given its large, socioeconomically diverse Black population (U.S. Census Bureau, 2020). It may be beneficial for future research to examine the extent to which SWS endorsement is linked to carotid IMT among African American women residing in rural areas, which generally have fewer institutional and infrastructural resources than urban areas, particularly in the domains of health care, education, and economic development (Hart et al., 2005). Third, we did not gather information on the gender of the participants’ children, which may have limited our ability to capture important nuances in the experiences of African American mothers. It would be helpful for future research to assess the gender/sex or gender identities of the children of African American women, especially in a longitudinal manner, as gender has been increasingly recognized as a fluid identity. Finally, caregiving was examined exclusively in the context of motherhood and child-rearing; other caregiving roles, such as eldercare, which may involve distinct psychosocial and physiological stressors, were not assessed. Future research might examine whether similar physiological associations emerge among early middle-aged African American women across diverse caregiving contexts.

4.2. Conclusions

The present study adopts an intra-categorical focus, allowing for nuanced, within-group examinations of African American women’s risk for CVD. The findings from this study suggest that African American women’s cultural disposition to be self-reliant, independent, strong, and ambitious while simultaneously being nurturing and self-sacrificing may be a compensatory factor in the context of CVD risk, depending on their other intersectional identities including their motherhood status.

Acknowledgements

The MUSE study was funded by R01 HL130471. R. Murden, L Hoggard, and C Erving were funded by supplements to R01 HL158141. TT Lewis received additional funding from K24 HL163696. Erving received support from P2CHD042849, Population Research Center, awarded to the Population Research Center at The University of Texas at Austin by the Eunice Kennedy Shriver National Institute of Child Health and Human Development. J Shipman-Lacewell received support from T32 HL130025. ZTM, JSL, and NDF were supported by NIH T32 HL130025 to VV.

Footnotes

Data are available upon request from the senior author. We did not preregister the research in an independent, institutional registry.

Contributor Information

Lori S. Hoggard, Department of Psychology, College of Humanities and Social Sciences, North Carolina State University, Raleigh, NC.

Te-ojah Dennison-Morgan, Department of Psychology, College of Humanities and Social Sciences, North Carolina State University, Raleigh, NC.

Jordan Parker, Department of Psychology, College of Life Sciences, University of California Los Angeles, Los Angeles; CA.

Raphiel J. Murden, Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA.

Zachary T. Martin, Department of Exercise Physiology, College of Health Sciences and Professions, Ohio University, Athens, OH.

Jelaina Shipman-Lacewell, Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA.

Christy L. Erving, Department of Sociology, Population Research Center, College of Liberal Arts, The University of Texas at Austin, Austin, TX.

Nicole D. Fields, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL.

Shivika Udaipuria, Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA.

Reneé H. Moore, Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA.

Viola Vaccarino, Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA Department of Medicine, School of Medicine, Emory University, Atlanta, GA.

Arshed A. Quyyumi, Department of Medicine, School of Medicine, Emory University, Atlanta, GA.

Mindy Lee Coccari, Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, PA.

Tené T. Lewis, Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA.

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