Black Midlife Women Research Articles

Intervention Fidelity in a Virtual Community Participatory Research Trial.

The objective of this report is to describe approaches used to ensure fidelity in the B-SWELL feasibility trial. A virtual randomized feasibility trial was conducted. Intervention fidelity was evaluated in accordance with Borrelli's five principles of fidelity: design, training, delivery, receipt, and enactment. In addition to the rigorous oversight by the research team, tools were developed or adapted for the virtual trial. Tools used in the trial included a Visual Analog Attendee Engagement Tool, weekly feedback surveys, audio recordings, a facilitator's checklist, an overall satisfaction survey, and a technology survey. Using Borrelli's framework for treatment fidelity, the researchers noted high ratings from the overall satisfaction survey, designed to assess ongoing participant satisfaction with the intervention materials and continued enactment. The tools successfully guided the intervention process from design to enactment. Adherence to Borrelli's principles of fidelity enables rigorous oversight of an intervention and its delivery. The growing use of technology to deliver programmed interventions requires that tools be adapted and created to monitor fidelity. Validation of the research-developed and -adapted tools is recommended in a larger trial.

Cardiovascular Health, Race, and Decline in Cognitive Function in Midlife Women: The Study of Women's Health Across the Nation.

Cognitive decline may progress for decades before dementia onset. Better cardiovascular health (CVH) has been related to less cognitive decline, but it is unclear whether this begins early, for all racial subgroups, and all domains of cognitive function. The purpose of this study was to determine the impact of CVH on decline in the 2 domains of cognition that decline first in White and Black women at midlife. Subjects were 363 Black and 402 White women, similar in baseline age (mean±SD, 46.6±3.0 years) and education (15.7±2.0 years), from the Chicago site of the Study of Women's Health Across the Nation. Cognition, measured as processing speed and working memory, was assessed annually or biennially over a maximum of 20 years (mean±SD, 9.8±6.7 years). CVH was measured as Life's Essential 8 (blood pressure, body mass index, glucose, non-high-density lipoprotein cholesterol, smoking, physical activity, diet, sleep). Hierarchical linear mixed models identified predictors of cognitive decline with progressive levels of adjustment. There was a decline in processing speed that was explained by race, age, and the 3-way interaction of race, CVH, and time (F1,4308=8.8, P=0.003). CVH was unrelated to decline in White women but in Black women poorer CVH was associated with greater decline. Working memory did not decline in the total cohort, by race, or by CVH. In midlife Black women, CVH promotion may be a target for preventing the beginnings of cognitive decline, thereby enhancing independent living with aging.

Abstract P233: Leveraging Community-Engaged Research Methods to Improve Recruitment and Retention of Midlife Black Women in Cardiovascular Research

Introduction: Midlife Black women (ages 45-64) are more likely to die of a cardiovascular disease (CVD)-related cause compared to White women of the same age and less likely to be optimally controlled for upstream chronic conditions like hypertension or dyslipidemia. Black women are also 58% less likely than White women to identify heart disease as their greatest health risk. Recruitment and retention of Black women in research trials has been historically difficult, contributing to the paucity of interventions designed to address the unique sociocultural factors that contribute to the existing health disparities. The Midlife Black Women’s Stress Reduction and Wellness intervention (B-SWELL) was created to lower stress and increase CVD awareness and adoption of healthy lifestyle behaviors to lower CVD risk in midlife Black women. Hypothesis We hypothesized that a theoretically based intervention co-developed with midlife Black women from the community would yield a culturally appropriate and appealing intervention, resulting in high retention, low attrition, and high satisfaction. Methods: Mixed methods and community-engaged methods were used in the preliminary research that supported the B-SWELL feasibility trial. Each step (i.e., conceptualization, development, intervention design and delivery) was viewed through a Black Feminist lens, giving voice to midlife Black women. The B-SWELL materials and content were co-developed with an existing community research advisory board (C-RAB) and midlife Black women from the community to produce a culturally tailored and targeted product that was rated highly by experts. A randomized feasibility study was conducted. Recruitment was led by the C-RAB and other community partners. Satisfaction was measured using a 9-item tool ranging from 1 (strongly disagree) to 5 (strongly agree) and a maximum score of 45. Narrative feedback responses were also obtained. Results: Recruitment (N=52) was completed within 30 days and attrition was low (8%). Four participants withdrew prior to the start of the feasibility trial. The remaining 48 participants completed the trial, and none were lost to follow up. Participant satisfaction ratings were high with a mean of 41. Narrative feedback responses were positive. Participant responses indicated an increase in CVD awareness and motivation to adopt healthier behaviors: “Sisterhood is very important to Black women's health." “Never too late in your life to make changes and better choices.” “I need to be a cheerleader and I need to be checked on as well". Conclusions: Theoretically based interventions that employ community-engaged methods have potential to increase recruitment and retention of midlife Black women in research studies. We recommend integration of community-engaged methods at each level of development and for delivery of interventions targeted to at-risk subpopulations like midlife Black women.

Abstract P374: Understanding the Mediating Role of Allostatic Load on the Relationship Between Long-Term Financial Strain and Subclinical CVD Among Black Women: The Study of Women's Health Across the Nation (SWAN)

Introduction: Black adults are disproportionately burdened by poor cardiovascular health, and Black women bear the brunt of this disparity. Cardiovascular disease (CVD) disparities among Black women have been attributed to chronic exposure to psychosocial stressors and the cumulative “wear and tear” of these stressors on the body (i.e., allostatic load). Financial strain has been linked to both higher allostatic load and CVD risk. We aimed to determine whether allostatic load (AL) mediates the relationship between financial strain and cumulative CVD risk among Black women. Methods: This study utilized longitudinal data from the Black participants in the Study of Women's Health Across the Nation (SWAN). We conducted a causal mediation analysis with fourfold decomposition to determine if the relationship between long-term financial strain and subclinical CVD was mediated by AL. The study outcome was defined as the presence of any indicator of subclinical CVD from carotid ultrasounds conducted in visit 12/13: carotid artery intima-media thickness (cIMT) ≥ 75 th percentile of the study sample, carotid adventitial diameter (cAD) ≥ 75 th percentile of the study sample, or plaque index (a measure of number and size of plaques) >2. Long-term financial strain was defined as reporting “money problems” or “difficulty paying for basics” at >50% of the 6 most recent visits prior to the carotid ultrasound. AL was calculated using a validated summary score method based on 10 component measures from visit 12: systolic and diastolic blood pressure, serum glucose, BMI, triglycerides, C-reactive protein, HDL-C, total cholesterol, waist-to-hip ratio, and dehydroepiandrosterone sulfate. AL was considered “high” if the score was ≥75 th percentile of the study sample. Results: Of the 390 Black women in our sample [Mean (SD) age at subclinical CVD visit = 60.0 (2.7)], 42.3% had subclinical CVD (24.9% with cIMT or cAD, 9.7% with plaque), 56.9% reported long-term financial strain, and 38.0% had high AL. Both long-term financial strain (β=0.132, p <0.01) and high AL (β=0.134, p <0.01) were associated with a significantly higher likelihood of subclinical CVD. However, causal mediation analysis indicated that the effect of long-term financial strain on subclinical CVD was not mediated by AL (β=0.004, p =0.66). Conclusions: Though higher AL is associated with higher CVD risk among Black women, it did not mediate the causal relationship between long-term financial strain and CVD risk in these midlife women. Future research should examine the pathways by which financial strain and AL influence premature cardiovascular weathering among midlife Black women and explore potential large-scale interventions.

Discrimination and Cognition in Midlife Black Women: The Roles of Social Support and Spirituality.

Black women are at high risk for discrimination and cognitive impairment in late life. It is not known if discrimination is a risk factor for cognitive decline in Black women and if so, what factors are protective against the adverse cognitive effects of discrimination. Using the biopsychosocial model of gendered racism, we determined if discrimination is associated with poorer cognition in midlife Black women and if social support and/or spirituality would protect against the deleterious effects of discrimination on cognition. Participants were midlife Black women (N = 669) from the Study of Women's Health Across the Nation. Discrimination was measured by the Everyday Discrimination scale. Cognitive outcomes included episodic memory, processing speed, and working memory. Total social support, emotional support, instrumental support, and spirituality were assessed as protective factors. Contrary to expectations, structural equation modeling indicated that discrimination was associated with better immediate recall. For women with more emotional support, greater discrimination was associated with better immediate recall than for women with lower emotional support. Spirituality was not a significant moderator in the association between discrimination and cognition. Discrimination had unexpected positive associations with learning and attention-based cognitive skills for midlife Black women. Discrimination might enhance vigilance, which could be facilitated by higher levels of emotional support. There is an opportunity for clinical and public health interventions for cognitive health and discrimination focused on Black women to better incorporate emotional support as a coping resource.

Co-Designing a Program to Lower Cardiovascular Disease Risk in Midlife Black Women.

Midlife Black women suffer disproportionately from heart disease and stroke in comparison to White women of similar age and demographic. Risk for cardiovascular disease (CVD) and stroke is largely considered to be modifiable yet CVD prevention and awareness campaigns have been less effective among Black women. Decreased awareness of personal CVD risk is associated with delays in the presentation of women to the emergency room or health care providers for symptoms of myocardial infarction. The Midlife Black Women’s Stress and Wellness (B-SWELL) program was designed to increase awareness about CVD risk factors, stress, and healthy lifestyle behaviors among midlife Black women. In partnership with an existing Community Research Advisory Board (C-RAB), materials were developed and culturally adapted for the B-SWELL program. Following successful development of the B-SWELL materials, a trial of the B-SWELL program was conducted with a sample of midlife Black women recruited from the community. The program was co-facilitated by members of the C-RAB. We outline the strategies used to successfully co-create and trial the B-SWELL program materials and reflect on the strengths and challenges associated with the development of a culturally tailored heart disease prevention program using community participatory methods.

Establishing Validity of the Midlife Black Women's Stress-Reduction Wellness Program Materials Using a Mixed Methods Approach.

Content validation is an integral part of intervention development and should be established before initiation of trials. In collaboration with a community research advisory board, the objective of this study was to analyze expert ratings and qualitative feedback for the Midlife Black Women's Stress-Reduction Wellness (B-SWELL) intervention materials. The B-SWELL intervention is a culturally tailored 8-week intervention designed to lower cardiovascular disease risk in midlife Black women by leveraging stress reduction and promoting the adoption of the American Heart Association's Life's Simple 7 healthy lifestyle behaviors. Using a mixed methods approach, 12 experts consisting of midlife Black women (n = 6), researchers (n = 3), and integrative health specialists (n = 3) rated the B-SWELL materials for content accuracy, topic relevance, stress relevance, cultural appropriateness, feasibility, usefulness, ease of use, and appeal using a 5-point Likert scale (1, strongly disagree, to 5, strongly agree). Qualitative narrative data were integrated with the ratings. Combined expert ratings for the B-SWELL materials were high (range, 4.43-4.66). Group ratings differed, with midlife Black women having the highest mean ratings for both the individual B-SWELL modules and the overall binder (4.71 and 4.97, respectively), followed by researchers (4.56 and 4.73, respectively) and integrative health specialists (4.11 and 4.40, respectively). Qualitative data provided insight into deficiencies, supporting refinements of the B-SWELL materials. The B-SWELL materials exhibited strong evidence of content and face validity. Researchers and clinicians are encouraged to establish content validity before implementation of culturally appropriate interventions aimed at high-risk populations.

Abstract 9394: Establishing Validity of a Midlife Black Women's Wellness Program

Introduction: Expert ratings and qualitative feedback are essential for establishing validity of materials developed for interventions. Validation of intervention content should be established prior to initiation of trials. In collaboration with a community research advisory board, the purpose of this study was to analyze expert ratings and qualitative feedback for the Midlife Black Women’s Stress Reduction Wellness (B-SWELL) intervention materials. Methods: The B-SWELL is a culturally tailored 8-week program that leverages stress reduction to lower cardiovascular disease (CVD) risk in midlife Black women by promoting the adoption of the AHA’s Life’s Simple 7 healthy lifestyle behaviors (LS7). Using community participatory methods, the LS7 metrics and B-SWELL binder were culturally tailored and targeted to midlife Black women. A multilevel mixed methods approach was used to establish content and face validity for the B-SWELL binder made up of eight modules. Twelve experts consisting of midlife Black women (n=6), researchers (n=3), and integrative health specialists (n=3) were purposefully recruited to rate each B-SWELL module and the overall binder for content accuracy, topic relevance, stress relevance, cultural appropriateness, feasibility, usefulness, ease of use, and appeal using a 5-point Likert scale (1 strongly disagree to 5 strongly agree). Open ended questions were integrated with ratings to obtain insight into areas needing improvement. Results: Combined mean expert ratings for individual B-SWELL modules were high with means ranging between 4.43 and 4.66. Group ratings differed for individual B-SWELL modules and the B-SWELL binder with midlife Black women having the highest mean ratings (4.71, 4.97), followed by researchers (4.56, 4.73), and integrative health specialists (4.11, 4.40). Narrative data provided details to guide refinement. Conclusions: The B-SWELL intervention materials exhibited strong evidence of content and face validity. Testing feasibility of the B-SWELL intervention in a future study is warranted, ultimately leading to a well-powered randomized control clinical trial to test efficacy of the B-SWELL in lowering CVD risk in midlife Black women through adoption of the LS7 healthy lifestyle behaviors.

Stress Reduction Strategies Used by Midlife Black Women to Target Cardiovascular Risk.

Midlife black women are at a high risk for cardiovascular disease and experience higher morbidity and mortality rates. Chronic life stress contributes to the existent cardiovascular-related disparities for midlife black women. The purpose of this qualitative study was to describe stress reduction strategies relevant to midlife black women, identify barriers, and generate ideas for the development of a stress reduction wellness intervention for midlife black women. A community advisory board consisting of 11 midlife black women from the Midwest was established and charged with exploring life stress and stress-related issues for women like themselves. The community advisory board was led through a series of focus group discussions using open-ended questions focused on stress reduction strategies used by midlife black women, what kept them from incorporating stress reduction strategies into their daily routines, and what would be helpful in a stress reduction routine. Discussions were audiotaped, transcribed, coded, and analyzed using content analysis. Stress reduction strategies identified included exercise, faith and prayer, self-care, sisterhood, volunteerism, and mindfulness. Barriers to adopting stress reduction behaviors included time, finances, physical limitations, health status, health insurance, and guilt. Suggested modes of delivery for an intervention included informative lectures and coaching, demonstration, team sessions, social media, and continued access. Findings from this study were consistent with those from a preliminary study focused on midlife black women from the West Coast. Recommendations will inform development of a stress reduction wellness intervention for midlife black women.

Leveraging Community Engagement to Develop Culturally Tailored Stress Management Interventions in Midlife Black Women.

Chronic stress is a social health determinant associated with many persistent health conditions and health disparities for midlife Black women. Midlife Black women in the United States are exposed to multiple, competing stressors, increasing their risk for adverse health outcomes. The objective of the current study was to illicit information about the key life stressors experienced by midlife Black women. Focus groups were conducted using a convenience sample of midlife Black women (N = 11, age range = 41 to 54 years). Coding and thematic analysis identified four primary sources of stress: workplace, parenting, finances, and social media. Gendered racism and discrimination and life imbalance emerged as underlying stressors linked to the Strong Black Woman persona. This persona prioritizes resilience and self-reliance while suppressing self-care. The stressors identified will inform the development of an intervention and should be considered when providing care for midlife Black women. [Journal of Psychosocial Nursing and Mental Health Services, 57(3), 32-38.].

Abstract 9509: Heart Fat, but Not Peri-Aortic Fat Depots Were Significantly Associated With Presence and Severity of Coronary Calcification in Women at Midlife: The Study of Women’s Health Across the Nation (SWAN) Ectopic Cardiovascular Fat Ancillary Study

Introduction: Increasing evidence demonstrates a role of cardiovascular fat in the pathogenesis of CAD. It is unknown whether heart and vascular fat depots are related to atherosclerotic burden in women transitioning through menopause, a time of increasing CAD risk. Hypothesis: We hypothesize that volumes of epicardial (EAT), pericardial (PAT), total heart (TAT=EAT+PAT) and peri-aortic (PVAT) adipose tissues are associated with presence and severity of coronary artery calcification (CAC) in a sample of white and black midlife women. Methods: CAC and cardiovascular fat depots were quantified by electron beam CT. Outcomes were presence of CAC (none vs. any: Agatston score >0), and severity of CAC (CAC Agatston score). Logistic and tobit regression were used. Final models were adjusted for age, race, study site, menopausal status, obesity (BMI ≥30 Kg/m 2 ), systolic blood pressure, lipids, homeostasis model assessment insulin resistance index, current smoking, physical activity, comorbidity (history of hypertension, stroke, angina, heart attack or diabetes) and medication use (cholesterol lowering, antihypertensive or antidiabetic medications). Results: The study included 509 women (37.9% black; 58.4% pre-/early perimenopausal, 41.6% late peri-/postmenopausal) aged 46-59 years with data on any of the 4 fat depots. CAC was found in 47.4% of the participants. Odds ratios (95% CI) from final logistic regression models showed that higher volumes of EAT (2.43 (1.22, 4.86), PAT (1.57 (1.04, 2.37), and TAT (2.43 (1.22, 4.87), were significantly associated with higher odds of presence of CAC. Similarly, tobit regression models showed that higher volumes per 1 log-unit increase of EAT (β (SE): 28.0 (10.7)), PAT (16.5 (6.6)), and TAT (30.0 (10.7)), were significantly associated with greater severity of CAC in final adjusted models. PVAT was not associated with either CAC presence or severity in final models. Conclusions: Heart fat (EAT, PAT and TAT), but not peri-aortic fat were independently associated with greater presence and severity of CAC in women at midlife, suggesting that local cardiovascular fat depots may contribute to CAD in midlife women. Future work is warranted to understand the underlying mechanistic pathways.

Abstract P327: Associations Between Ectopic Cardiovascular Fat Depots and Aortic Calcification Vary by Race and Menopausal Status in Women at Midlife: The Study of Women’s Health Across the Nation (SWAN) Ectopic Cardiovascular Fat Ancillary Study

Objective: Mounting evidence demonstrates a role of ectopic cardiovascular fat (ECF), which surrounds the heart and vasculature, in the pathogenesis of cardiovascular disease (CVD). It is unknown whether ECF depots are related to atherosclerotic burden in women transitioning through menopause, a time of increasing CVD risk. We evaluated the cross-sectional associations between volumes of epicardial (EAT), pericardial (PAT), total heart (TAT; TAT=EAT+PAT) and perivascular (peri-aortic) (PVAT) adipose tissues and aortic calcification (AC) in a sample of white and black midlife women. Effect modifications by race and menopausal status were also examined. Design: Data were obtained from the SWAN ectopic cardiovascular fat ancillary study. AC and ECF depots were quantified by electron beam computed tomography. Outcomes were presence of AC among all women, and extent of AC among women with an Agatston score >0. Logistic and linear regression were used as appropriate. Final models were adjusted for age, race, study site, menopausal status, body mass index (BMI), systolic blood pressure, lipids and insulin resistance. Results: The study included 257 women (32.7% Black; 58.7% pre-/early peri-menopausal and 41.3% late peri-/postmenopausal) aged 46-58 years with data on any of the 4 ECF depots (EAT, PAT and TAT: n=227, PVAT: n=191). AC was found in 184 (71.6%) participants. Pre-/early peri menopausal women had less EAT (median (Q1, Q3): 35.0 (28.4, 51.7) cm 3 vs. 43.5 (32.9, 58.3) cm 3 , P = 0.02) and TAT (median (Q1, Q3): 42.5 (33.2, 64.5) cm 3 vs. 50.3 (38.9, 74.3) cm 3 , P = 0.05) than late peri-/postmenopausal women, respectively. In final models, only EAT (OR (95%CI): 3.29 (1.14, 9.54)) was associated with higher odds of presence of AC. Interactions with race or menopausal status were not significant. Relationships between ECF depots (EAT,PAT and TAT) and extent of AC varied by race (all P <0.05); in that higher volumes of EAT, PAT and TAT were associated with greater AC in black compared with white women in final models. Irrespective of race or menopausal status, higher volumes of PVAT (β (SE): 1.60 (0.63), P= 0.01, per 1 log-unit increase in PVAT) were associated with greater extent of AC in the fully adjusted model. In black women only, the associations of PAT and TAT with extent of AC varied by menopausal status (all P <0.05) independent of age, BMI and other CVD risk factors: late peri-/postmenopausal women had significantly more AC than pre-/early peri-menopausal women for each 1-log unit increase in PAT (β (SE): 1.57 (0.66), P=0.02) and TAT (β (SE): 2.29 (1.04), P=0.03). Conclusion: ECF depots are associated with aortic calcification in women at midlife and the associations vary by race and menopausal status. Perhaps ECF plays a role in the higher risk of CVD reported in women after menopause.

Black Women in Menopausal Transition

To describe the experience of menopausal symptoms of midlife Black women in the United States. Qualitative online forum using a feminist perspective. Internet communities for midlife women and Blacks. Twenty midlife Black women recruited using a quota sampling method. A 6-month online forum was conducted with seven discussion topics on menopausal symptoms. The discussion topics were posted sequentially on the forum site, and the women posted messages at their convenience over 6 months. The data were analyzed using thematic analysis. The identified themes were raised to be strong, accepting a natural aging process, silent and without knowledge, and our own experience. The women tried to be strong during their menopausal transitions while dealing with other important family matters. The women did not report their menopausal symptoms and were silent about or downplayed their symptoms, but many emphasized the importance of education about menopausal symptoms and highlighted their own lack of knowledge. These women generally did not talk about their symptoms because they believed that nobody except other Black midlife women could understand their menopausal experience. Health care providers need to develop a mechanism to deliver the necessary knowledge about menopausal symptoms and management strategies to Black midlife women in their health care practices.

Physical Activity and Reduced Intra‐abdominal Fat in Midlife African‐American and White Women

The purpose of our study was to determine whether self-reported physical activity (PA), including recreational, household, and exercise activities, is associated with intra-abdominal fat (IAF) in community-dwelling white and black midlife women. We performed a cross-sectional study of 369 women from the Chicago site of the Study of Women's Health Across the Nation (SWAN) ancillary study, the SWAN Fat Patterning Study. PA level was the independent variable, and IAF, assessed by computerized tomography (CT) scan, was the dependent variable. Measures were obtained at SWAN Fat Patterning Baseline visit between August 2002 and December 2005. Linear regression models explored the association between PA and IAF. The first model included IAF as the outcome and total score PA as the main predictor, adjusting for total percent fat mass, age, and ethnicity. The second model included education, parity, sex hormone-binding globulin (SHBG) level, and depressive symptoms, measured by Center for Epidemiological Studies-Depression (CES-D) scale. Each 1-point higher total PA score was associated with a 4.0 cm(2) lower amount of IAF (P = 0.004), independent of total percent fat mass, age, ethnicity, SHBG level, educational level, CES-D, and parity. Associations did not differ between white and black women. This study demonstrates a significant negative association between PA and IAF independent of multiple covariates in midlife women. Our findings suggest that motivating white and black women to increase PA during midlife may lessen IAF, which may have a positive impact on subsequent development of diabetes and cardiovascular disease.

The Effects of Social Activism on the Occupational Experience, Locus of Control, and Well-Being of Black Midlife Women

The purpose of this study was to address the confluence of social activism, occupational experience, and overall well-being in midlife Black college-educated women. The participants included 205 Black women who graduated from a historically Black university between the years of 1958 and 1968. This study of educated Black midlife women resulted in a number of suggestive findings. The structural equation model supported the relationship between social activism and occupational experience in this sample of women.

Empowerment of women students through educational achievement: A narrative enquiry

Education is the basic tool for empowering women, and this is particularly striking among women from deprived economic and social backgrounds. Narratives of women's lives indicate different statuses of self-development, which are further complicated by issues of race, class and socioeconomic position. This paper presents the stories of four black midlife women with a view to examining how women from a background of extreme deprivation construct and give meaning to the story of their educational history and its contribution to their self-identity. Data was collected through written life histories and interviews and analysed according to two narrative models. The findings illustrate how the women made sense of trauma and difficult life transitions, describe their ultimate empowerment through educational and professional achievement, and illustrate the use and value of narrative enquiry in research in education.