A Qualitative Understanding of Midlife Sources of Stress and Support in African-American Women

Abstract

African-American women suffer from disproportionate adverse health outcomes compared to women of other ethnicities living in the United States. It is suggested in the literature that chronic stress can be an antecedent to health disparity. The purpose of this study was to evaluate changes in perceived stress from late pre-menopause to post-menopause and to identify significant life stressors perceived by a cohort of African-American women. Retrospective and current data were used to evaluate perceived stress over time, sources of stress, and resources in a cohort of 15 African-American women. Mixed methodologies were utilized. Perceived stress scores were consistent over time. Six themes were identified in responses about stress: finances, caring for family members, relationships, personal health and aging, race and discrimination, and raising children. Understanding the role that unique life stressors play in the lives of African-American women is essential in anticipating the need for assistance and in implementing preventive strategies.

Background & Significance

Chronic perceived stress is a precursor to disease and symptom expression. Chronic perceived stress results in physiological changes that can make individuals more vulnerable to disease over time and it has been proposed as a factor in health disparities (Carlson & Chamberlain, 2005; Janssen et al., 2012; Zhao et al., 2015). Health disparities, according to the Department of Health and Human Services, are defined as differences in health outcomes across population subgroups (USDHHS, 2014). Despite advances in medicine, healthcare, resources, and technology, it would appear that health disparities persist in the United States and around the world. Psychosocial and environmental stressors, in addition to lifestyle choices, are factors that can influence health status and long-term health outcomes. Therefore, the evaluation of how perceived stress may impact individuals during certain life stages is recommended during routine healthcare.

Mid-Life Women: An Examination of Health Status and Health Outcomes

As life expectancy continues to increase, it is important to examine midlife health status, particularly as it relates to women. In fact, women in particular, are more vulnerable to certain health problems during midlife as a result of normal aging and menopause (Seib, Whiteside, Humphreys et al., 2014). Midlife is a time during which most health-care providers implement preventive care plans and aggressively screen for potential health problems (e.g., breast cancer, cardiac disease, osteoporosis). Preventive guidelines are based on generalized health risks and, therefore, it is not surprising that despite aggressive implementation of preventive screenings and preventive measures, health disparities persist. For example, African-American women continue to suffer from higher breast cancer mortality rates despite standardized guidelines for screening, surveillance, and treatment (CDC, 2014).

Mid-Life Women and Co-Existing and Environmental Factors

Other than in sociological and psychological research, limited focus has been given to co-existing environmental and social factors that may increase risk for acquiring certain health conditions. Women commonly endure a wide range of stressors and role changes during midlife including, but not limited to, raising grandchildren, empty nest syndrome, employment changes, or caring for an elderly parent (Seib, Whiteside, Lee, et al., 2014). A firm understanding of stressors commonly experienced among contemporary midlife African-American women is necessary to mitigate health disparities and promote early intervention.

Purpose of the Study

The purpose of this two-phase study was to evaluate the changes in perceived stress from late pre-menopause to post menopause and to identify the most significant life stressors perceived in a cohort of African-American women.

Theory

This study was guided by the theory of allostasis. Allostasis is defined as “stability through change” and refers to adaptation that occurs in response to life stressors (Carlson & Chamberlain, 2005, p. 308). The concept of allostasis was developed by Sterling and Eyer to describe how social and environmental factors influence health disparities (Carlson & Chamberlain, 2005). Further development of the framework and theory of allostasis by McEwen and Wingfield (2003) allows for a deeper understanding of the effects of cumulative wear and tear on the body’s systems in response to stressors and repeated adaptation (Geronimus, Hicken, Keene, & Bound, 2006; McEwen & Wingfield, 2003). Failure to adapt and maintain internal balance leads to infection, illness, or symptom expression (McEwen, 2012).

The theory of allostasis uses a systematic framework to understand the long-term effects of stress. Symptom expression and adverse health outcomes may occur from continual exposure and adjustment to chronic stressors. Everyday social and psychological stressors such as discrimination and bias have been shown to affect health outcomes (Chae et al., 2014; Giurgescu et al., 2015). Identification of key stressors for specific population groups is a key step prior to exploration of outcomes, thereby providing a practical basis for future research and intervention. The data obtained in this study may enable health-care providers and researchers to initiate tailored interventions intended to manage perceived stress in African-American mid-life women.

Methodology

Design

This current study was a two-phase study. Phase I was a secondary analysis using mixed-methods to evaluate the changes in perceived stress from late pre-menopause to post menopause. Phase II was a qualitative content analysis designed to identify the most significant premenopausal and post-menopausal life stressors perceived in a cohort of African-American women. It was derived from the University of California San Francisco (UCSF) Midlife Women’s Health Study that consisted of a multicultural sample (European American, Latin American, and African-American) of community-dwelling women living in the San Francisco Bay Area. In the larger parent study, women across a spectrum of racial/ethnic groups were used. However, in this current study only the African-American participants were used.

UCSF Women’s Health Study

The University of California San Francisco (UCSF) Midlife Women’s Health Study was conducted from 1996 to 2005 and consisted of a multicultural sample (European American, Latin American, and African-American) of community-dwelling women living in the San Francisco Bay Area. Women included in the study were between 40 and 50 years of age and still experiencing regular menstrual periods. Women who self-identified as having major health problems, or who were taking hormone therapy at initiation of the study, were excluded (Choi et al., 2012). Details of recruitment and protocol for the parent study were previously reported (Choi et al., 2012; Gilliss et al., 2001).

At baseline, there were 93 African-American women in the parent study and attrition during the first 2 years was less than 10%. Health assessments were obtained every 6 months through 1 year post-hysterectomy, 1 year post-initiating hormone therapy, or 1 year after the last menstrual period (Gilliss et al., 2001). Participants were followed for up to 3 years in Phase I and an additional 2 years in Phase II. The study concluded in 2005.

Institutional Review Board Approval

The UCSF Committee on Human Research (CHR) approved both the parent study and this ancillary study and informed consent was obtained prior to data collection.

Sample

The sample for this study consisted of 15 African-American participants (N= 15) from the parent study who gave permission to be re-contacted at a later date. Inclusion criteria for this study required the participants to have completed at least two time points in the parent study and being post menopausal in the current study. The participants were recruited through mailings and follow-up phone calls. The mailings included study information, a copy of the consent form, and questionnaires. Additional study details and questions were discussed by phone. The women who were deemed eligible for participation and who agreed to participate were asked to bring the completed questionnaire to their scheduled in-person visit. Meetings with the researcher took place at the Clinical and Translational Science Institute (CTSI) Clinical Research Center located in the UCSF Medical Center.

Data Analysis

This study was designed to include both qualitative and quantitative data about perceived stress and other psychosocial determinants of health in a cohort of women across midlife (before and after menopause). Quantitative methods were used to evaluate the changes in perceived stress scores from late pre-menopause to post-menopause and to provide a demographic description of the participants. Content analysis of the narrative data was used to identify the most significant life stressors perceived in this cohort of women.

Quantitative Statistical Analysis

Quantitative data from Phase I and II was analyzed to demographically describe this sample set. Descriptive analyses, repeated measures analysis of variance (ANOVA), and paired t-tests were used to compare perceived stress scores in pre- and post-menopause using multiple time points and to evaluate associations between PSS-10 scores and descriptive characteristics associated with health status.

Qualitative Content Analysis

Content analysis allows examination of text data using a systematic process of coding and identification of themes (Hsieh & Shannon, 2005). Two members of the research team conducted a content analysis of responses to the open-ended questions (Table 1). Open-ended questions were asked in Phase II of the study to facilitate detailed responses about pre- and post-menopausal stressors in the lives of participating women, alleviating and aggravating factors, and management strategies. Written responses were read multiple times for clarity and understanding; key words and concepts were identified and categorized to identify themes (See Table 1).

Table 1.

Open-Ended Questions

Please comment on the primary source of stress that has been present through your life: a) before you had children or before menopause and b) after your children left home or after menopause. Is there something more you would like to share about your experiences with stress in your life? What do you do or think to relieve your stress? What do you think makes your stress worse?

Instrumentation

The Self-Report Questionnaire

Items in the questionnaire booklet included demographic questions, the Perceived Stress Scale (PSS-10), a discrimination survey, self-report of major health problems in the past year, and open-ended questions about stressors in their lives and personal management strategies.

Perceived Stress Scale (PSS-10 item)

This instrument is a 10-item version of the PSS (PSS-10) and is a widely used self-report measure of perception of stress. The 10 items are rated on a scale of 0 – 4 with a maximum score of 40. Higher levels of stress correspond with higher scores. The PSS-10 has been validated in a variety of sample populations and languages. Due to its generality, results from the PSS cannot be attributed to any specific subculture of a population (Cohen, Kamarck, & Mermelstein, 1983). Cronbach alpha for the PSS-10 in Phase I of the parent sample was 0.88.

Results

Quantitative Analysis

The post-menopausal women in this sample had a mean age of 61 ± 1.36 (SD) and varied in education and income (refer to Table 2). Most of the women were highly educated with a median income of over $57,000. All of the women reported experiencing discrimination due to race, social class, or gender. Four women reported sexual harassment in the past year (See Table 2).

Table 2.

Current Sample Demographics N = 15

Post menopause	Mean (SD)
Age	60.93 (1.49)
Education	n (%)
- Less than high school	1 (7.1)
- High school or GED	1 (7.1)
- Some some college	2 (14.3)
- College graduate/Professional degree	10 (71.5)
Marital Status	n (%)
- Married	6 (42.9)
- Living with partner/ significantly involved	2 (14.3)
- Single/Divorced	5 (35.7)
- Widowed	1 (7.1)
Income	n (%)
- < $ 30,999	3 (21.4)
- $31 – 50,999	1 (7.1)
- $51 – 80,999	2 (14.3)
- > $ 81,000	7 (50.0)
	1 missing

The mean PSS-10 score in this sample was 17 ± 6.74 (SD) in Phase I and 18.1 ± 6.17 (SD) currently. Current mean PSS-10 scores were correlated with education (r = −.350) and with income (r = −.501). Pre-menopausal and post-menopausal scores on the PSS-10 were highly correlated (r = .687). Repeated measures ANOVA indicated stability in mean pre-menopausal PSS-10 scores over 3 time points; within-subject differences were not significant (F = 1.09, p = .352). A paired t-test was performed comparing the mean PSS-10 scores pre-menopause to post-menopause and the difference was not significant (t = −.482, p = .638) (See Table 3).

Table 3.

Individual PSS-10 Scores by Menopause Stage N =15

Participant	Mean PSS score (Time 4, 5, 6) Pre-menopause	Current PSS score Post-menopause
Claudette	21	16
Valerie	9	10
Laura	29	23
Carla	15	16
Yvonne	29	22
Adele	21	25
Bonnie	10	8
Anita	19	22
Inez	5	15
Camille	14	28
Joan	14	13
Alicia	22	22
Opal	19	24
Jeanne	5	8
Noel	—	19

Content Analysis

Phase II consisted of four open-ended questions, which were found at the end of the Self-Report Questionnaire. The participants in this sample reported a variety of stressors via written responses to the open-ended questions. The content analysis of their responses revealed six categories of stress before and after menopause: finances, caring for family members, relationships, personal health and aging, race and discrimination, and raising children. Finances and caring for family members were the most prevalent stressors. The identities of the participants were protected in the description of this analysis using pseudo-names.

Finances

The participating women overwhelmingly expressed concerns about finances. Prior to menopause, finance-related stress was attributed to child rearing, school, or other career goals. Participants who were single mothers were more concerned about the financial support of their children and providing a safe and nurturing environment. For example, Adele (age 62, PSS score 25) stated:

“[I] struggled to raise two children alone. Always working two jobs. But I persevered!”

Employment was an underlying concept noted within the responses. For the participating women, employment represented independence, success, and the ability to provide for the family. The women in this cohort were, overall, well educated and with that came the added stress and responsibility related to their respective jobs. Carla (age 62, PSS score 16) shared her experience:

“[Stress included] discrimination on the job, [I was] passed over for promotion, [and there was a] lack of opportunities.”

After menopause, the reported financial concerns were focused on securing retirement and health-care costs as stated by Joan (age 62, PSS score 13):

“Primarily, I [have been] concerned about medical coverage…”

Retirement or changes in job status are common in midlife and are often associated with additional stress and life adjustments as expressed by Laura (age 61, PSS score 23):

“After menopause, the primary source of stress has been loss of working life, income, and career due to [work-related] injuries.”

Some women also remained the primary source of financial support for their children, grandchildren, or extended family members despite a fixed or limited income as expressed by Adele:

“My children did not make very good choices…I ended up raising my daughter’s 3 sons...”

Caring for family members

Many of the women were responsible for taking care of siblings or other family members early in their youth, as did Adele:

“ I experienced a great deal of stress being the oldest daughter with several siblings. I was an extension of my mother.”

Post menopause, the women reported assuming responsibility for elderly parents or ailing family members. Caring for grandchildren, children, or an aging parent is not uncommon in a matriarchal role, but the added responsibility and daily demands can be overwhelming. Adele stated:

“I am currently helping with the care of my brother who has cancer. Stress seems to be a big part of my life.”

And Bonnie (age 63, PSS score 25) shared:

“[I provide] care/support for an elderly parent [and] a close family member.”

Relationships

The women expressed that relationships were often significant sources of stress. Before menopause many women alluded to the stress of romantic relationships, getting married, and making decisions as a couple. Yvonne (age 62, PSS score 22) stated:

“[Stress came with] partnering to raise children and fear for their long-term work.”

Other comments spoke to the presence (or lack of) support received from spouses or significant others as with Inez (age 62, PSS score 22):

“[I experienced stress from] marital conflicts over parenting styles.”

Post-menopause, the women also spoke of the importance of family dynamics and the likelihood of stress caused by conflict between family members.

Personal health and aging

Aging and health-related themes were prevalent among the women’s responses about post-menopause. Midlife is often a time during which issues of health and mortality become more relevant. There are multiple social, family, and personal circumstances that may complicate existing issues or magnify their importance. For example, Claudette (age 59, PSS score 16) noted:

“The empty nest was hard to deal with. Nobody to [fuss over] meant focusing on myself.”

A wide variety of issues were noted among the women in this cohort, as well as a wide variety of responses to the challenges they presented:

“[I experienced stress related to]…social isolation due to difficulty using the new technology, the physical and emotional effects of aging and being post-menopausal…worried about finances and who will take care of me when I am very old.” (Laura)

Racism, sexism, and discrimination

Race and gender issues persist within the United States and around the world. Therefore, it is not a surprise that the women in this sample cited race and gender-based discrimination as sources of stress. Social and environmental stressors such as these may persist throughout life and be affected by socioeconomic issues. Yvonne commented:

“I think race is the hidden in plain view stressor in USA life. I am Black and that has caused me stress working in a White world. Equal or perhaps worse is the fight to have my voice heard as a woman.”

Women of color endure discrimination on many levels: race, ethnicity, gender, and age (Moody-Ayers, Stewart, Covinsky, & Inouye, 2005). The women in this cohort shared personal experiences and expressed concern for their children’s future and well-being within a racist society.

“[My stress is made worse by] work environment, news of injustices for African Americans, [and concern for] the safety of [my] family.” (Alicia, age 58, PSS score 22)

Raising children

Intermingled within the issues of finances, relationships, and discrimination were the issues associated with raising children. Every aspect of their lives affected their ability to care for their children and provide them with opportunities for success. This issue was prevalent despite socioeconomic status or situation. The heart-felt concerns written by Joan effectively summarized the interconnectedness of every aspect of the lives of these women:

“I was a single parent...and I was concerned if I had died [while] my child was a minor, how she would be taken care of. I wonder[ed] as I was raising my daughter if the divorce would have lasting effects in her life.”

Opal (age 62, PSS score 24) commented:

“[I experienced stress] as a mother of two bi-racial sons.”

Stress management

The women were also asked to comment on their stress-relieving tactics and resources as a part of the study. They generously provided insight into personal remedies for managing stress. “Exercise,” “praying,” “taking time to participate in hobbies or activities” they enjoy, and maintaining relationships were the most common ways to alleviate stress. Although their individual approaches varied, many expressed an understanding of the value of nurturing their mind, body, and soul. For example, Joan stated:

“ I am a result-oriented person and recognized that you are not in this world alone and must reach out to others to aid in positive outcomes,”

And Laura shared:

“ I am in counseling weekly. I exercise and focus very hard on good nutrition and lifestyle choices. I also sing and do story-telling to give me spiritual and creative outlets to channel stress.”

Other statements included the following:

“[I am] engaged in outside activities with friends and co-workers...[ I have] personal hobbies and am interested in the arts.” (Bonnie)

“Exercise, walk, write, make things.” (Yvonne)

“God. Prayer. Faith.” (Claudette)

“Educate yourself: I learned a lot from the first midlife study.” (Carla)

Activities or situations that worsen stress were shared as well, and they were congruent with the strategies used to relieve their stress:

“My stress becomes worse when I lose my focus on God.” (Jeanne, age 60, PSS 8)

“Being tired or hungry, trying to appease others, not taking care of myself.” (Yvonne)

“Not getting the help you know you need.” (Noel, age 60, PSS 19)

“Feeling the need to fix everything.” (Adele)

Discussion

Previous researchers have found that pre-menopausal African-American women experience higher levels of perceived stress but few have studied post-menopausal women (Giurgescu et al., 2013, Zhao et al., 2015). Our sample of 15 African-American post-menopausal women had high levels of perceived stress, as demonstrated by their PSS-10 scores, however these scores varied little from their pre-menopausal values. Sources of stress may have changed over time but their perceived level of stress did not. This sample of women was overwhelmingly affected by the personal demands in their lives. Family roles and responsibilities coupled with societal roles were recurring concepts. Many had assumed the role of matriarch and were caring for parents, grandchildren, and/or extended family members despite having already raised their children. Race and gender played a part in their lives and was instrumental in their stress, particularly at work. Health issues were relevant during post-menopause and the importance of maintaining good health was a recurring concept. Some women expressed that their health status played a role in their perceived level of stress.

Interpersonal relationships were deemed valuable commodities in the lives of these women and these relationships were found to be both a source of stress and stress relief. Interpersonal conflict resulted in great stress when the women felt they needed to “appease others” or when the relationship kept them from caring for “self” or resulted in “limited time” and “not being heard.” Exercise, diet, meditation, and prayer were common strategies used to reduce stress and to cope with the feelings associated with stress.

Although contemporary midlife women of different ethnic backgrounds have been shown to encounter similar life stressors, race-based differences in the level of perceived stress experienced with particular stressors have been documented (Vines, Ta, Esserman, & Baird, 2009). Personal characteristics influence the appraisal of stressors in our lives. The stability of the PSS-10 scores from pre- to post-menopause in this cohort speaks to the continued high stress in this sample. That the scores were not higher in post-menopause might speak to inherent personal characteristics or learned coping styles in this cohort. Previous literature suggests socialization is a key factor in coping and the appraisal of stress (Vines et al., 2009). The uniqueness of this cohort of women is noted in the simultaneous experience of discrimination, racism, and contemporary midlife issues. Cultural differences in the form of matriarchal roles and expectations also possibly mediate and moderate the responses to stress.

Strengths and Limitations of the Study

This two-phased study has both strengths and weaknesses. Although the sample size is acceptable for qualitative analysis, it is not optimal for quantitative analysis. The nature of the qualitative data collection and analysis limited our ability to draw forth an in-depth analysis of the themes or to formulate theory. The responses were written and therefore, it was not possible to use techniques to further explore thoughts expressed by these women or to develop identified concepts. In addition, our findings are not generalizable to all African-American women, or to all mid-life women.

The strengths of this study included the use of comparative time points and the use of mixed methodology. Incorporation of multiple time points allowed for the evaluation of perceived stress scores over time. Utilization of both qualitative and quantitative methods allowed for a deeper understanding of the experience of stress before and after menopause for this cohort of African-American women.

Conclusions

For this cohort of African-American women, stress remained a constant throughout mid-life. The manner in which we conceptualize the stressors in our lives impacts our responses and overall ability to cope (Lazarus & Folkman, 1984). It is impossible to foresee the long-term effects of stress, however research suggests that coping styles and attitudes are instrumental in preventing adverse health outcomes. Taking steps to modify the manner in which life stress is perceived may prevent adverse health outcomes, thereby decreasing disparity.

The women in this study expressed proactive attitudes and recognized the benefits of relieving their stress. Studies have shown promise in the use of stress-reducing strategies for certain observed health disparities in African-American women such as low birth weight and heart disease (Cooper, Thayer, & Waldstein, 2013; Jallo, Ruiz, Elswick, & French, 2014; Woods-Giscombe & Gaylord, 2014). Recognition of the unique stressors encountered by midlife women and the key periods during which they may occur is paramount in this effort. Health-care providers should take time to address social and psychological issues that arise during mid-life in an effort to assist women in navigating through life’s challenges. Acknowledgement and validation of a woman’s experience is an intervention in itself that can help to build a strong provider-patient relationship. Open provider-patient communication can allow for recognition of problem stressors and can facilitate effective interventions.