‘We must educate healthcare providers’ about Black women’s experience

Medical News Today has interviewed Prof. Cheryl Giscombé, an expert on stress-related health disparities among African Americans, about a source of pressure that many African American women experience: the obligation to project an image of strength or that of fulfilling a ‘superwoman’ role.
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In 2010, Prof. Cheryl Giscombé, Ph.D., published a paper entitled Superwoman Schema: African American Women’s Views on Stress, Strength, and Health in the journal Qualitative Health Research. In it, she explained:
Qualitative Health Research
“Researchers have suggested that health disparities in African American women, including adverse birth outcomes, lupus, obesity, and untreated depression, can be explained by stress and coping. The Strong Black Woman/Superwoman role has been highlighted as a phenomenon influencing African American women’s experiences and reports of stress.” 
MNT reached out to Prof. Giscombé — who is the Melissa and Harry LeVine Family Professor of Quality of Life, Health Promotion and Wellness at the University of North Carolina at Chapel Hill — in an attempt to find out more about how this role affects Black women. 
Prof. Giscombé
We spoke to Prof. Giscombé — who is also a social and health psychologist and a psychiatric-mental health nurse practitioner — about her past and current research, and how she developed the superwoman schema.
We also talked about how the superwoman role affects the mental (and physical) health of African American women, whether there are any benefits to the role, and what are some interventions that could help offset its adverse effects — both on an individual and a societal level.
We have lightly edited the interview for clarity. 
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MNT: Could you kindly define the notion of the superwoman schema for our readers and tell us a bit about what prompted you to research it?
Prof. Giscombé:  Yes, thank you for asking. So, the superwoman schema is a conceptual framework that I developed based on research with African-American women across various age groups and educational backgrounds to understand better how to conceptualize stress and coping in African American women. 
I have been interested in the effects of stress on health behaviors and health outcomes for a number of years, since I was an undergraduate in college, and probably before.
I was quite concerned when I saw that there seemed to be inadequate measures, inadequate ways to evaluate stress that were often void of the gender and/or race-specific nuances that may influence how African American women experience and cope with stress. 
So, I became interested in this — really, I became interested in emotional suppression first. So, if women felt like they could not express their emotions, how might that impact their health? And then I became interested in this concept of strength — if they feel obligated to present an image of strength. 
So, through qualitative research with African American women, the superwoman schema conceptual framework was developed, and we identified [its] five characteristics:
a perceived obligation to present an image of strength
a perceived obligation to suppress emotions 
a perceived obligation to resist help or to resist being vulnerable to others  […]
[a] motivation to succeed despite limited resources
[p]rioritization of caregiving
Basically, prioritization of caregiving is a role of caregiving that really is the prioritization of caregiving over self-care, that’s what it ends up being, and that’s how the women describe it.
The superwoman schema is a conceptual framework. […] When I talked to people, they were generally talking about the characteristics that I described. But, from the research, we also identified antecedents and motivations for it — because it’s not like women just woke up one day and decided, “I’m going to feel obligated to do these things.”
They talked about historical factors, societal factors, lessons from their foremothers, how they saw their moms cope, their grandmothers cope and deal with stress.
They talked about how showing your emotions could be seen as a sign of weakness and make you more vulnerable, how asking for help could make you be disappointed. Because, first of all, when we ask for help, people may then want you to do a favor for them and not a good favor — you know how people do take advantage of you if you let them help you?
And not only that, [but also] if you allowed people to help you, women felt that it was inefficient, often because they could probably do a better and quicker job themselves, and so they defaulted to taking care of things on their own versus asking for help. 
So, there were a number of reasons [for taking on the superwoman role], including historical oppression, gender- and race-related oppression and abuse. Many of the [women] talked about a history of experiencing verbal, physical, and sexual abuse.
And the themes were similar across age groups. We interviewed women in college; we interviewed women with no college and some who hadn’t even completed a high-school education. We interviewed women who had completed college and women who had terminal degrees (law degrees, Ph.D. degrees) and young adult women from age 18 [to women in their 60s]. 
So it was a broad range, yet the themes were very similar across ages and educational backgrounds.
MNT: Could you tell us more about the relationship with racial discrimination and historical racism and how they contributed to the superwoman role and the perceived pressures of this role?
Prof. Giscombé: In particular, some women talked about not wanting to be perceived as “low on the totem pole.” That’s a quote from a group of women, and particularly the women from what we call a lower SES [socioeconomic status].
And [they spoke about] trying to dispel stereotypes about Black women by, what one might consider over-performing, so making sure you’re taking care of your family, your community.
And that’s the other thing. These women weren’t just discussing these characteristics in response to their own stressors, but they were responding to the stressors facing their community, their children, the Black males. 
And they felt that there was some obligation and responsibility to perform [or behave] in these ways or to believe these things and then act upon them based on what they saw going on in their community — their relationships with men, protecting their children, [and} being the “backbone” of the African American community. So they saw this as part of their role. 
I call it the superwoman schema because of the psychological and cognitive components of this [phenomenon], where this may be a way of thinking that has grown over time. It may be subconscious — although, of course, talking about it brought it to women’s consciousness.
But when I interviewed women, [it was interesting to see] how they talked about it.
They became enlightened as they talked about it. So, I remember one of the participants talking about her grandmother and what she remembered seeing her grandmother do and not do […], work all day and do things on her own. 
And she talked about how yet [she] never saw her cry, and the more she talked, the more she recognized “Wow, she did model this for me, and maybe unintentionally I picked it up! I never saw her cry, yet she ended up having heart disease, and she had diabetes […].”
So, women came to those realizations as they talked about their experiences and their foremothers in particular.
So, racism directly [contributed to these pressures], but also the effects of racism on society, on Black society. And what that causes people to have to do in their daily lives to survive and thrive. So, direct racism but also indirect [racism contributed to creating the superwoman role].
MNT: In some of our previous articles, we often came across the so-called ‘spillover effects’ of experiencing racism, whether it’s via police brutality or interpersonal discrimination or systemic discrimination. Could this pressure to overperform and place caretaking duties first be an example of one such spillover effect, for example, in situations where young Black males are at the receiving end of police violence, and so on?
Prof. Giscombé: Yes, definitely. So, either direct or vicarious experiences [of racism] and also trying to fill in the gaps generated through racism that your foreparents experienced, which could cause less economic stability. 
And this is [true] even in the higher educated, higher SES groups. Even a high income family may not have the financial foundation that a high income family from, say, a European American group might have. That’s not to say that all European Americans are high income, but there’s different access to resources and that different access to resources affects what one can do, even when they do have resources.
So it’s a number of those factors. In my research, I also study this concept called network stress, and we’ve learned that it’s just as important to study network stress as it is to study individually experienced stress. 
So maybe you’ve never had financial strain, or you’re not having health issues. But if your loved ones are, we found that Black women who report that their loved ones are experiencing stressors [are] carrying those stressors and responding to them emotionally as if it’s their own stress. That can compound the stress experience and this desire to preserve family, community, as well as self. 
But what we are finding also is that [s]trength in and of itself may not be so bad! [T]he superwoman schema, in general, is a double-edged sword because it can contribute to resilience and survival and get you through tough times.
So, […] I don’t encourage the idea that the superwoman schema is bad or strength is bad — sometimes, emotional suppression can even be quite appropriate, and resisting being vulnerable can be quite appropriate. 
But when you think about, perhaps a combination of those things — so, if you feel obligated to be strong, but you have no one to express your emotions to safely, or if you feel obligated to be strong and you can’t be vulnerable with anyone, and you’re prioritizing caregiving of others, and you haven’t made time for self-care, the combination of those factors, those characteristics may be what’s challenging. And that’s the kind of thing we’re trying to tease apart.
I did research with Dr. Amani Allen [from the] University of California, Berkeley, and we looked at superwoman schema and allostatic loads — so, risk factors for cardiometabolic conditions — and we looked at it in the context of exposure to racism, [and the research revealed that] strength could be protective in certain situations. 
research
allostatic loads
[I]’ve developed a psychometrically valid questionnaire to measure superwoman schema, along with my colleagues, including Drs. Allen, Angela Rose Black, Teneka Steed, Yin Li, and others. We were able to look at each characteristic (strength, suppression, resistance to vulnerability, motivation to succeed, and the prioritization of caregiving), and we’re seeing some differences in how those different characteristics relate to things, such as sleep quality, physical activity or sedentary behavior, depressive symptoms, and perceived stress. 
questionnaire
We need to do more work in this area, but we are learning that it’s not all similar, and we’ll be doing more work to test what I just suggested — looking at the combination of different characteristics to see what might actually make women most vulnerable and in what context. 
And, actually, I will be conducting a study funded by NIH [the National Institutes of Health] to look at intervening. I also do mindfulness and self-care interventions with African Americans.
So, our next study will look at how a culturally relevant, mindfulness-based interventions target characteristics of superwoman schema that may be less adaptive. How might that help improve women’s stress levels and their risk for chronic health conditions?
So, we don’t want to take it all away; we just want to help women — if they had those [superwoman characteristics] at appropriate times, but they engage in self-care […], maybe that’s the [missing] piece.
Like, okay, say you do these things when appropriate, yet you also make time to exercise, meditate, eat properly, take time away from being a caregiver, put that role down from time to time — will that be what [offsets] superwoman schema characteristics [and not make them turn into] risk factors for mental health, distress, or other chronic health issues? So, we’re looking at that, and it’s really exciting, and we’re trying to tailor it specifically for African American women.
MNT: Can you tell us more about these interventions?
Prof. Giscombé: [O]ne of our latest papers is on mindfulness meditation, and this one was actually with both African American men and women who have prediabetes.
mindfulness meditation
And [the participants] found it culturally acceptable, but they also gave us some feedback on how to make it even more relevant. [W]e did interviews with everyone, and then we did focus groups with African American women.
And that’s where we found out that even when they’re exposed to mindfulness and appreciate it, they greatly appreciate mindfulness, they saw the benefits, they knew it could help them in their lives — taking the time to practice at home [was hard].
The superwoman schema characteristics were getting in the way […]. They talked about how they loved being able to take a break from their regular lives and learn about mindfulness, and not only learn about mindfulness but engage in groups with other African American women in support of one another. 
Yet, they said they want more tools to know how to integrate the feeling and the activities that they did in our intervention. 
They wanted more tools to figure out how to break down their behavior patterns of being at home. So, they couldn’t actually integrate it and sustain it because they weren’t able to. They would get home, and they weren’t practicing because they were cooking, or taking care of people, or working, you know, and just not figuring out completely how to take time for themselves because they feel guilty.
I haven’t mentioned that yet, but they talked about feeling guilty: “when I take time for myself, that makes me feel like I should be doing something for somebody else. There’s so much to do for other people, that when I take time for myself, I feel guilty.” 
So, they talked about appreciating the intervention — and not only appreciating the intervention but appreciating the fact that they learned that they had prediabetes because then that was a reason [for self-care]. And their family members said, “yes, go, you need to do this,” so they finally felt like they had an “excuse” — it’s incredible that you need an excuse to take care of yourself.
So even when we asked them things like, well, in our next intervention […], if you’re a mom, do you want us to provide childcare on site? they said, “No, we don’t want to bring our children; we want this to be our time.” So, they know that’s what they need; they just need help creating the architecture in their lives to do it. 
And that’s what we aim to do in our next step. It’s not enough to give them the tools; we have to help them figure out how to integrate those tools.
MNT: Speaking of maternal health, I spoke to Prof. Tiffany Green about untreated postpartum depression (PPD) being more prevalent amongst women of color. She pointed out that income disparities or educational levels do not fully explain these differences (in fact, she said a higher educational level correlates with more, not less, racial discrimination in some studies). Do you think some aspects of the superwoman schema might explain why some women are less likely to seek or receive treatment for conditions like PPD? 
postpartum depression (PPD)
Prof. Giscombé: I’m so glad you asked, and I agree completely with Dr. Green and what she shared with you. Women’s perinatal health was actually [o]ne of my first areas of research, under the mentorship of Dr. Marci Lobel (in addition to stress and cardiovascular outcomes) but in my doctoral program that is exactly what inspired me to do this work on superwoman schema — trying to understand why African American women have stress-related birth outcomes and why the disparity continues to exist among higher educated, higher-income women.
In my research, I always attempt to recruit across SES groups, because if we only recruit low SES groups, we might assume that it’s SES, you know, and a lot of research is done with “African American women,” but you’ll often see “low-income African American women” and that’s the sample that was selected.
Sometimes, people don’t even know that higher SES Black women exist, number one, and they might assume that once you’re higher SES, then you don’t have these issues. But [w]e have these data that demonstrate that these birth outcome disparities exist despite higher SES and might even be greater in these higher SES groups [and] racism exposure [may be higher]. 
And, [i]f you think about it, there’s a couple of factors going on. Higher SES African Americans tend to be in more integrated environments, and often, they’re the only one or one of few. They also may be more likely to be separated from their family of origin, so they may have moved away. Or even if they haven’t moved away, they spend more time in their work environments. And [t]heir family may not understand their new roles, possibly.
Because it might be that they have been the first, or they might just be unique. So, they are in two worlds, and there’s definitely research and literature about that — the two worlds that you could be living in. 
So you may be exposed to more discrimination, you may be isolated, and you may not have a community, and your community may not be as rich with people that you can completely trust and rely upon. We need to continue to dig deeper to see if that’s really the case, but those things have been hypothesized.
As I said in the research on Black women and birth outcomes, their measures of stress were void of race and gender factors. I came across literature and articles in Essence magazine, for example, where I saw this type of superwoman — what I now call superwoman schema — described in words shared by Black women. I thought, “We’re not measuring that in our research! How can I get at that?”
And my hypothesis is that it is a factor [in conditions like PPD]. Also, if you have more means, you may be more likely to feel obligated to give back — to the people coming behind you, meaning the people you’re mentoring, to your family at home, people might [look up to you]. 
Even if it’s not giving back financially, it’s giving back through your knowledge and your resources, and that’s a gift to be able to do that. But it also creates another job. And there’s less time for downtime.
[J]ohn Henry-ism is also a factor that has been explored in Black men and also Black women — of course, Black men also experience similar phenomena […]. But I was particularly interested in Black women because of the birth outcomes and because of the different ways that they are expected to or expect themselves to care for others in their communities.
explored
MNT: Before we draw to a close, is there anything that I haven’t asked that you would like our readers to know?
I would say yes, and it relates to kind of what we were just saying before. I think many people, many women operate on this idea that, to whom much is given, much is required. So if one has something to give, then they want to give it. They want to share. They don’t want to hold it.
Yet, we haven’t learned as much about how to care for ourselves and these disparities, these inequities in health — diabetes, birth outcomes, obesity, cardiovascular disease, lupus, numerous things — we can address them, that’s the exciting part!
So, what’s exciting is that so many people are now entering the dialogue about self-care, and mindfulness is becoming more [popular], people are more curious about that […].
I think that will be important, but what will be critical is, as I mentioned before, helping people make space for those things.
The other thing is helping healthcare providers and healthcare systems understand these things because it’s one thing for people who have the wherewithal to engage in self-care, meditation, exercise, etc., […] yet, we also have to [get] the medical community, the healthcare community [u]p to speed and keep them up to speed. 
Because other factors in these [health] disparities that we see are bias, assumptions, lack of understanding of the Black experience, lack of understanding of what you’re seeing or what you’re looking at, when a Black woman, for example, enters your hospital or emergency room or clinic.
And so, a lot of my work also focuses on educating providers to provide culturally sensitive, culturally humble, and culturally relevant care. And we’ve unfortunately recently seen [i]n the media, [stories] about African American women who’ve lost their lives because of the treatment that they received in perinatal care.
But those are just examples of many experiences that African American women and others face when they engage with the healthcare system, and there’s a lack of understanding or even a lack of an attempt to understand the context of their lives and how that’s influencing how they show up in care. Or what their symptoms look like. 
So, we have to educate Black women and their families also — because that’s another thing; if Black women are educated, and they start taking better care of themselves, their families need to also understand that there may be a new attitude happening — but we must also educate healthcare providers — nurses, physicians, nurse practitioners, psychologists, physicians assistants, speech and respiratory therapists, social workers, and other professionals. 
One of the greatest joys [I had was] maybe about a year ago, [when] I was invited to speak to an organization of healthcare and hospital executives [that] determine patient flow, […] so much about how physicians and nurses and nurse practitioners and others operate in the patient care setting (we have to understand that side of health and healthcare as well to tackle health disparities).
So, they wanted to hear about the superwoman schema, [a]nd they wanted to understand how that influences the lives of their patients, their stress, and coping in general. So that is important work that researchers and policymakers should attend to — to improve these outcomes that are unacceptable. 
As we work to promote equitable care for African Americans, attention also needs to be placed on other groups (Native Americans, Hispanic/Latinx populations, Asian Americans, LGBTQIA populations, and those with disabilities). As we address inequities in one group, we can apply what we learn, and what we do to help optimize care and create equity for all groups.
[S]tructures, policy, work policy [are all important]. I’m working on a paper now on workplace meditation and the feasibility of workplace programs. [The responsibility to stay healthy] can’t just be on the individual. Because they are in a context, they are in a structure; we’re in a society that is supporting inequities.
So, we can start with the individual because awareness is important, they can try to strive for improving their lives, focus on the providers, the healthcare systems, and we need to focus on workplace settings because we spend most of our time at work — and other policies. 
So, it is a multifaceted so-called socio-ecological framework where you’re dealing with the individual, the family, the community, and all of these institutions that impact health. So, it’s a lot of work, but it’s exciting.