“No Complaining, No Crying”: A Qualitative Study of the Strong Black Woman Schema in the Breast Cancer Context

Abstract

Background

Black women have the highest mortality from breast cancer compared with other racial/ethnic groups. Black women with breast cancer also evidence compromised quality of life in some domains. Culturally relevant aspects of their experience are understudied.

Purpose

The goal of this qualitative study was to examine the relevance of the Strong Black Woman schema in the cancer context.

Methods

Three Gatherings (i.e., culturally curated focus groups) were conducted with Black women who had been diagnosed with breast cancer and recruited from cancer-related listservs and events. A five-person team conducted reflexive thematic analysis of Gathering transcripts.

Results

The 37 participants ranged in age (30 to 94 years) and in diagnosis duration (2 months to 29 years). Reflexive thematic analysis yielded six themes that characterized the women’s experience: historical legacy of the Strong Black Woman, navigating intersecting Strong Black Woman identities, everyday challenges encountered on the battlefield by Strong Black Women, Strong Black Woman in action during the breast cancer journey, the complexities of seeking and accepting support, and the liberated Strong Black Woman. The schema’s negative consequences included the oncologic team and others expecting the participants to be strong and not to need support. Expectations to suppress emotions and continue caring for others to the neglect of the self also were evident. Positive consequences included engaging in self-advocacy in the oncologic context and redefining strength to include expressing emotions and accepting help.

Conclusions

The Strong Black Woman schema is highly relevant in the breast cancer context and could be addressed in culturally centered interventions.

Black women diagnosed with breast cancer who took part in Gatherings (i.e., culturally curated focus groups) described experiences consistent with the historically-grounded Strong Black Woman schema. In particular, women spoke of needing to be strong, suppressing emotions, declining support, and continuing to care for others to the neglect of self while facing breast cancer within a society that continues to oppress Black women through stigma, marginalization, and mistreatment.

Introduction

Breast cancer is a leading cause of death for Black women in the USA, with the mortality rate exceeding that of White, Native American, Latina, and Asian American women [1]. Specifically, data from 2020 reveal that Black women have 40% higher mortality from breast cancer—but 4% lower incidence—than White women [1]. This alarming relative burden of mortality in Black women is attributable only in part to breast cancer diagnosis at a later stage and distinct tumor characteristics (e.g., triple-negative breast cancer). Indeed, survival across all breast cancer stages and subtypes is lower among Black women than White women [1]. Both promoting the survival of Black women diagnosed with breast cancer and enhancing their ability to live well are vitally important. Accordingly, the present qualitative study was designed to illuminate Black women’s unique experiences potentially relevant to quality of life and health. A particular focus was placed on the culturally relevant and historically grounded Strong Black Woman (or Black Superwoman) schema [2–7] as a potentially important factor in women’s experience of breast cancer.

With regard to the body of knowledge on Black women’s experience of breast cancer, reviews and recent research suggest that they are disadvantaged (relative to non-Latina White women) with regard to specific quality of life parameters, which can persist at least through 2 years after diagnosis. Differences include lower physical health-related quality of life and functioning and greater perceived stress, fear of dying, unmet supportive care needs, and financial distress [8, 9]. Findings regarding emotional well-being are mixed [9–11], and spiritual quality of life [12] appears more robust for Black women than non-Latina White women breast cancer survivors. Husain et al. [13] offered evidence for barriers to Black women’s high-quality survivorship, including (i) lack of regular cancer surveillance (in large part owing to financial hardship); (ii) lack of health promotion to prevent cancer recurrence; (iii) inadequate management of late effects (e.g., lymphedema); and (iv) insufficient care coordination.

Contributors to Black women survivors’ well-being and health are understudied. Demographic factors and cancer-related factors do not appear to be strong predictors, although Black women younger than 50 years appear more at risk for compromised quality of life than older women [9, 10, 12], as is the case more generally [14]. Some evidence suggests that psychosocial and systemic factors also are associated with lower quality of life in Black women survivors, although insufficient attention is devoted to their unique experience and biopsychosocial contributors [8, 9].

Importantly, Black women have multiple stigmatized identities which contribute to their unique experiences [15]. Historically and currently, Black people, women, and people with a cancer diagnosis have been stigmatized, marginalized, and mistreated in the USA and elsewhere (e.g., individual and systemic anti-Black racism, sexism, cancer stigma) [16]. The complexity of the experiences in Black women with breast cancer cannot be deeply understood by studying only one of these identities [15]. Rather, understanding how being Black, being a woman, and being a cancer survivor intersect to contribute to unique experiences and challenges is critical [15]. The Strong Black Woman schema [2–7] is a construct that could bear on Black women’s identities in the breast cancer context.

As defined in the literature on the psychology of African American women, the Strong Black Woman schema encompasses perceived obligations to present an image of strength, suppress emotions, prioritize caregiving over self-care, resist support from other people, and attain success with insufficient resources [17]. These facets were adaptive and even essential to survival during Black women’s enslavement in the USA [4], in that enslaved Black women who did not suppress emotions and prioritize caregiving potentially faced the consequences of being beaten, sold, or killed. Said to serve a protective function, the Strong Black Woman schema “is a suit of armor, a protective covering worn by Black women to mitigate damage from a hostile world that constantly assaults their character with degrading images and stereotypes …” [4] (p. 34). Historic and current internalization of the imposed schema appears to carry present-day negative consequences. In Black women not diagnosed with cancer, identification with the schema is associated with compromised quality of life and lower engagement in health-promoting behaviors, including uptake of cancer screening [3, 18–20].

The Strong Black Woman schema has received little research attention in Black women with breast cancer, despite its potentially compelling relevance. Specifically, breast cancer survivors who identify with the schema may feel pressured to decline support, appear stoic, maintain their caregiving for others, and “motor through” the experience relatively alone. Consequences of the Strong Black Woman schema for Black cancer survivors’ well-being and health are unknown. Accordingly, the primary research questions in the current qualitative study were: Is the Strong Black Woman schema relevant for Black women diagnosed with breast cancer and if so, how? This study was conducted as part of Project SOAR (Speaking Our African American Realities), a community-academic research partnership [21].

Methods

Participants

Black women diagnosed with breast cancer were recruited to take part in a “Gathering” (i.e., a culturally curated focus group) in which they were invited to share their unique experiences as Black women with a history of breast cancer. Eligibility criteria were self-identification as being: (i) an African American woman (or a Black woman living in the USA); (ii) diagnosed with breast cancer (any stage, any diagnosis duration); (iii) at least 21 years old; and (iv) able to communicate in English.

Procedure

Project SOAR flyers included a brief description of the study’s purpose (i.e., “to understand the unique experiences of African American women and their views on the Strong Black Woman concept as it applies during their breast cancer experience”) and eligibility criteria. Gatherings were described as “a half-day Gathering, where you and a small group of other African American women with breast cancer will engage in … a discussion about your views on the Strong Black Woman concept and your unique experiences with breast cancer”). The flyers were distributed electronically (e.g., email listservs) and in person at local breast cancer events. Participants enrolled in the present study via email, over the phone, and in person. All procedures and methods were approved by the University of California, Los Angeles (UCLA) Institutional Review Board, and the Journal Article Reporting Standards for Qualitative Research (JARS) [22] were followed.

Prior to the performance of the Gatherings, the senior (A.L.S.) author, a White woman and psychological scientist who studies well-being and health in adults affected by cancer, provided guidance to the first two authors on best practices in conducting focus groups [23, 24]. The first author (T.D.), a Black woman and 18-year breast cancer survivor, is co-founder and president of a nonprofit organization for Black women with breast cancer (Carrie’s TOUCH; carriestouch.org) and a certified cancer coach. The second author (K.J.M.) is a Black woman and social psychological scientist (then a doctoral student) who served as Project SOAR coordinator. Other authors are psychology doctoral students (Y.K.P. and P.O.), a then-postdoctoral scholar (J.H.J.K.), and a radiation therapist and breast cancer community advocate (K.D.D.).

The culturally curated focus group [21] is an approach developed for Project SOAR by authors T.D., A.L.S., and K.J.M. in community-partnered research, in which the team agreed that Black women taking part in the Gatherings should benefit directly from their contributions to every aspect of the research. Therefore, enhancements included creating an all-Black space that was outside oncologic treatment/academic sites, breaking bread together and providing time for connection, and offering a speaker/experience intended to inspire. Three Gatherings were conducted between March and June of 2019 in three California cities in private homes (Sacramento, n = 13; Los Angeles, n = 7) or a church (Oakland, n = 17). Each Gathering occurred from 9:30 am to 2 pm. According to the empirical literature, three focus groups are sufficient for arriving at developed themes, especially with a semistructured guide [25].

The first and second authors were present for the duration of each Gathering, consistent with the goal of creating an all-Black, all-woman space. When participants arrived, they were provided with a written information sheet, including permission to audio-record the Gathering, and gave oral consent. They then completed a demographic questionnaire, were offered breakfast, took part in an icebreaker activity, engaged in the audio-recorded, semistructured group interview, had lunch together, heard a guest speaker who offered an inspiring message/activity, and were provided $50 compensation as they exited. See [21] for details on participants’ reactions to this culturally curated approach to focus groups and [26] for Supplementary Materials for the semistructured interview guide. The interview guide was developed by authors T.D., A.L.S., and K.J.M. over a number of discussions on the Strong Black Woman schema and drew from the authors’ experiential (T.D. and A.L.S.), scholarly (T.D., A.L.S., and K.J.M.), and methodologic (A.L.S.) expertise. Lasting approximately 2 hr, the semistructured group interviews were led by the first author with the assistance of the second author. After noting ground rules (e.g., confidentiality, use of elected first names) and querying whether participants had heard of the Strong Black Woman (Black Superwoman) concept, the first author asked women to write their definition of the concept and if comfortable, share it with the group. Next, the scholarly definition of the schema [4, 17] was presented, and women were asked whether and in what ways they identified with the schema. Several subsequent questions regarded perceptions and experiences of the Strong Black Woman schema and its relevance to participants’ experiences as women diagnosed with breast cancer. For example, questions included: “Do you think others, such as your family, friends, or medical team expect you to be a Strong Black Woman during your breast cancer journey? If yes, who and how?", “How many people have asked you to stop being a Strong Black Woman during treatment? If so, how did you respond?”, and “How many of you feel that being a Strong Black Woman influences your well-being and health as a woman diagnosed with breast cancer? In positive ways, negative ways, or both?” (with discussion of positive/negative effects).

Analysis

Audio-recordings of the semistructured Gatherings were transcribed by a transcription service, and all authors first listened together to the three recordings in order to ensure accuracy and completeness, as well as to appreciate the sessions’ emotional tone and nuance. Authors K.J.M., Y.J.P., and P.O. imported the content into NVivo 12 [27] for analysis. Under the supervision of author J.H.J.K., reflexive thematic analysis [28] was conducted with a critical realist, contextualist approach. Reflexive thematic analysis is a theoretically flexible approach in which researchers code and conceptualize patterns of shared meaning in the data, while striving to reflect on their assumptions during the process [29]. Unlike other forms of thematic analysis such as coding reliability approaches (e.g., [30]) and codebook approaches (e.g., [31]), reflexive thematic analysis notes the researchers’ active role in knowledge production and views their perspectives as a resource [32] therefore acknowledging that the findings are contextual [33]. Another strength of reflexive thematic analysis is that the produced themes do not stop at categorical summarization but describe how the coded data are united in shared meaning [29, 32]. Reflexive thematic analysis was best suited for the research team’s perspectives about qualitative knowledge production and end goals for the analysis. Multiple coders are not required for reflexive thematic analysis, but if multiple coders are used the purpose is to enhance reflexivity via collaboration rather than consensus [33].

The authors decided to have multiple coders to enhance reflexivity, and this involved sense-checking ideas and exploring multiple interpretations of the data. Reflexive thematic analysis involves six recursive phases of (i) familiarizing with the data, (ii) generating initial codes, (iii) searching for candidate themes, (iv) reviewing themes, (v) defining and naming themes, and (vi) producing the report [28]. Initial coding was completed in two waves, seeking both semantic and latent meanings. First, inductive or “bottom up” (i.e., data-driven) coding was completed for full consideration of women’s experiences. Then, deductive “top down” coding (i.e., focused coding centering on the research question) was performed for additional content specific to the research questions. Inclusion of ideas was determined by the extent of relevance to the Strong Black Woman schema and participants’ experiences with cancer, rather than being defined by other means such as counts.

To enhance rigor of analyses and represent participants’ experiences with openness [34, 35], the importance of self-reflexivity was emphasized prior to and throughout immersion in the data. The coders and J.H.J.K. discussed their backgrounds, biases, and possible impact on analyzing the data; they kept memos of their reactions toward the data to establish an audit trail for how interpretations developed. Authors K.J.M., Y.K.P., P.O., and K.D.D. independently generated initial codes and then worked collaboratively to reconcile codes and identify candidate themes with J.H.J.K., who reviewed the data, the coding process, and the data coding through reading and discussion throughout. Codes and themes were reviewed weekly with peer debriefing alongside reflexivity discussions. Codes and themes were revised iteratively, until themes were refined and agreed to be a good representation of the data.

Results

Of the 57 women who called or emailed to learn about the study, 37 (65%) took part. Participants ranged in age from 30 to 94 years (M = 59.27) and had received a breast cancer diagnosis on average 8.8 years previously (range = 2–343 months). As displayed in Table 1, half the sample reported annual household incomes of at least $75,000. Nearly 50% had a college or more advanced degree. Self-reported stage of breast cancer at diagnosis (or current stage if different from first diagnosis) ranged from 0 to 3, and six women did not know the stage.

Table 1.

Demographic Characteristics of Project SOAR Participants

Characteristic	M (SD) or n (%)
Age (years)
Mean (SD)	59.27 (14.27)
Range	30–94
Months since first breast cancer diagnosis
Mean (SD)	105.62 (96.89)
Range	2–343
Breast cancer stage (n (%))
0	3 (8.11)
1	12 (32.43)
2	9 (24.32)
3	7 (18.92)
4	0
Unsure	6 (16.22)
Annual household income (%)
Less than $25,000	4 (10.81)
$25,000–49,999	10 (27.03)
$50,000–74,999	2 (5.41)
$75,000–99,999	4 (10.81)
>$100,000	12 (32.43)
No response	5 (13.51)
Educational experience (%)
Some high school	1 (2.70)
High school graduate	1 (2.70)
Technical/vocational	2 (5.41)
Some college	15 (40.54)
College graduate	8 (21.62)
Post-college graduate	10 (27.03)
Gathering location (%)
Oakland	17 (45.95)
Los Angeles	7 (18.92)
Sacramento	13 (35.14)
Health insurance
Commercial Insurance	13 (35.14)
Managed Care Plan (HMO, etc.)	14 (37.84)
Medicaid/Medi-Cal	6 (16.22)
Medicare	9 (24.32)
Tricare	1 (2.70)
Veterans Affairs (V.A.)	1 (2.70)

Note. This demographic information and table appear in other Project SOAR manuscripts. Participants were asked to select their health insurance from the above choices and had the option to select multiple choices. Thus, percentages include participants who may have selected multiple categories.

SBW Strong Black Woman; SOAR Speaking Our African American Realities.

As summarized in Fig. 1, six themes characterized the data with regard to the primary qualitative research questions: Is the Strong Black Woman schema relevant for Black women diagnosed with breast cancer and if so, how? In what follows, the themes are described and illustrated with representative, anonymized quotes from participants. From the NVivo content, the author team selected quotes representative of the themes and included the speaker’s cancer diagnosis duration in order to illustrate its span across participants (the study was not intended to examine the data as a function of participants’ sociodemographic or cancer-related factors).

Fig. 1.

Themes generated from reflexive thematic analysis on the relevance of the Strong Black Woman schema for Black women diagnosed with breast cancer (N = 37). SBW Strong Black Woman.

Theme 1: Historical Legacy of the Strong Black Woman

All 37 participants had heard of the Strong Black Woman concept and provided a definition, in which the schema’s historical legacy was evident:

A Strong Black Woman is a concept that refers to Black women having to bear the brunt of emotionally damaging experiences and still keep pushing through life. Experiences, such as Black men being lynched, castrated, giving birth and having babies ripped from your arms and kids being shot by the police. We have to bear it all and still keep going. (Maxine, 2-month survivor)

Strong Black Woman, Black women are the backbone of our race, we work, have children, care for everyone, and forgetting to take time for herself. (Brenda, 10-year survivor)

Commenting on their own histories, participants noted the importance and impact in their lives of women (e.g., mother, grandmother) who had characteristics of the Strong Black Woman, as well as having seen examples in their social groups, in society, and throughout Black history. These examples included women who had modeled both the schema’s positive facets (e.g., supporting others) and negative facets (e.g., emotional suppression):

It [being a Strong Black Woman] just is expected. To be, because I was, you know brought up by a single mom and then I’ve two older sisters and we’re all strong, we did what mama did. Mama didn’t cry. Mama kept going. (Ramona, 10-year survivor)

Growing up we’re just taught certain things. And, so, when we get up here, we’ve seen our mothers do and they’ve been in abusive relationships so we think that that’s okay. And then we try to be the good mother, the good wife, the good everybody. And we never put ourselves first. (Juanita, 6-year survivor)

I’m grateful that I have a tradition of women in my family as well as others, secondary moms and others in my life, who, from a childhood, that I can recall being strong. Being very positive, being very supportive and just being influencers. And so growing up that way, I think I’ve kind of carried on that. (Gail, 21-year survivor)

Participants also pointed to how the historical legacy and modeling of the Strong Black Woman had influenced their own approach when they were diagnosed with breast cancer:

So, when I got diagnosed, I wasn’t going to tell anybody, then I told them I wasn’t going to get any treatment. I was just going to let it ride its cycle out. And then they took over. My sisters and my mother took over … but it was hard to let somebody have me, when I’ve been doing for me and my two kids by myself for so long. It was hard being told not to be that Strong Black Woman … I felt weak. (Ramona, 10-year survivor)

Across all examples of women who embodied the Strong Black Woman schema, participants identified resilience (i.e., withstanding and persevering in the midst of adversity) as a key characteristic, both historically and in the present day. Participants described the relevance of the schema generally and in the breast cancer context:

I always go back to my favorite quote of Zora Neale Hurston, it says, “Black women have been socialized to be the pack mules of the world.” (Marjorie, 21-year survivor)

My grandmother was diagnosed with breast cancer, she was in her eighties … She would drive an hour and a half each way, to the doctor. She drove herself, she was in her eighties, okay? … That is the definition of a Strong Black Woman … I got some of my strength from her. [The strength] comes from behind me too. (Sandy, 13-year survivor)

Theme 2: Navigating Intersecting Strong Black Woman Identities

Women described their unique experiences through their intersecting identities: a strong person, a Black person, a woman, and someone diagnosed with breast cancer. As Strong Black Women with breast cancer, participants reported experiencing stress caused by discrimination and placing additional and, at times, unreasonable expectations on themselves. Navigating the societally imposed burdens of their intersecting identities was emotionally taxing for women:

Like, we have some innate stresses that just come with just being a Black woman. Like, just to exist. You know, some things that we already have to deal with that are separate from—those are just our everyday stresses. You know, that are different from other races of women, and then on top of that, then it’s the things that we put on top of ourselves and then it’s the things that come hit us like a Mack truck, like breast cancer. And worries and dealing with just the stresses of being alive, discrimination and racism and things like that. (Maxine, 2-month survivor)

The idea of a Black woman, someone who doesn’t need help or support, and can take more pain, ridicule, heartbreak, violence, et cetera, than the average person, without love, reassurance, support, dedication, they’re often not seen. (Renee, 1-year survivor)

Some women described pursuing an idealized version of strength rather than focusing on their own health and well-being:

You do and you do and you continue to do, no matter what. (Marjorie, 21-year survivor)

Strong Black Woman takes care of everything, family, kids, spouses, parents, job, finances, cooking, cleaning, and making sure everyone is okay. She gets little help because it’s expected that she can do everything, it’s because she has no choice, though it takes its toll in stress … I remember saying to somebody once, and I don’t know if I was saying it half-jokingly, but there was still some meaning to it. I said, “I’d have a nervous breakdown if I had time. I just don’t have time.” I was like, well you don’t have time to stop. I mean, it’s like you don’t have a choice. (Nora, 14-year survivor)

Women also described how experiencing breast cancer diagnosis and treatment at times represented an affront to their perceptions of their own strength:

You know if you’re grounded in your life being a Strong Black Woman, there isn’t an on and off switch … when you get your diagnosis and you’re living through that, that’s what you are, that’s who you are. But then you’re fighting the disease itself and the treatment. And so while in your head, you may say, “I’m a Strong Black Woman, but the chemo may have a different strategy.” And it’s a struggle. It’s a struggle around who you are and how you’ve lived your lifestyle and then this foreign treatment that is just brutal. And depending how you react to it, is like you’re not strong. You’re just fighting to stay alive. (Florence, 2-year survivor)

I would get chemo on Thursdays, work from home Fridays, recover, go back on Monday. And it wasn’t even financial for me-Because, you know, I was okay, but I just … I didn’t want to seem like that invalid … I look back on it now and I’m like, had I embraced the help—Had I embraced, taken advantage of the opportunity to heal—I feel I just kind of like, do it on my back and said whatever, I’m just going through it. I just really wish I would have done some things differently. Because I had it. I had the support. (Janet, 5-year survivor)

I never doubted that I wouldn’t get through it [breast cancer]. And I think that was just that Strong Black Woman in me that says, “You handled a lot in your life. So, okay, what we going to do about it?” But the hardest part was accepting that it was okay to be weak. It was okay to ask for help. (Tanya, 10-year survivor)

Also in line with the Strong Black Woman schema, participants described actively suppressing their emotions or being hesitant to express them:

No complaining, no crying. (Ramona, 10-year survivor)

In dealing with your health, you just keep a positive attitude, and you let your fam—you’re not a crybaby, you’re strong and let your family see you standing up, and being a strong person in handling your problem, the breast cancer. (Lauren, 21-year survivor)

Women also noted needing to find a safe space to be emotional as a Black woman in society:

Coming into the Women’s Cancer Resource Center was my way out. (Tanya, 10-year survivor)

That strong thing you try to just hang on in there. And then when someone looks at you and cares, that’s when it’s like you can let some of this go. You know, give it to them for a minute. Let them pick you up. (Tamara, 7-year survivor)

Theme 3: Everyday Challenges Encountered on the Battlefield by Strong Black Women

Participants described the demands, expectations, and assumptions that accompany being a Black woman, in general and with regard to their experience of cancer. They described expectations imposed by others to put up a strong front and continue to be responsible for everything, while also encountering assumptions that they are “too strong.”

And [the oncologist] says, “You don’t look sick.” And I said, I—I, you know, and it startled me a little bit, I said, “Well, I don’t want to be sick and I don’t want to feel sick.” (Janet, 5-year survivor)

She [the Strong Black Woman] gets little help because it’s expected that she can—can do everything, it’s because she has no choice. (Tina, 28-year survivor)

But I just think that there’s a lot missing [from the current definition of the Strong Black Woman] in terms of really specifics of how much responsibility is expected … Well how about the expectations of what a Strong Black Woman is? It’s not just the image, she is literally expected to do everything. Cook. Clean. Pay the bills. You name it. (Nora, 14-year survivor)

Participants faced negative perceptions and stereotypes associated with Black women. These stereotypes, assumptions, and expectations arose from multiple sources, such as medical staff, friends, and family, and in distinct contexts, such as medical settings and personal relationships over the cancer trajectory. As a result, women reflected on how such assumptions and expectations did not allow them to be vulnerable or to be perceived as needing support.

I think a lot of times there is no support because people don’t think you need it. I mean it’s not that we’re declining support, in some cases, there isn’t any there or you know, or they just assume that you don’t need it. (Nora, 14-year survivor)

[A Strong Black Woman] can handle anything, does not need anyone, almost an expectation to do all on your own. (Evelyn, 22-year survivor)

The Strong Black Woman thing. I think over the years I have come to see that as a negative stereotype. And in my mind I said, “No, I’m not gonna do that.” Because you know, it’s like you got no feelings, you’re not allowed to have feelings, you’re not allowed to be vulnerable or anything. But as I listened … there is some strength there. And it helps you get through. (Kellie, 3-year survivor)

Theme 4: Strong Black Woman in Action During the Breast Cancer Journey

Women described a variety of behaviors that personified strength during the cancer experience. These behaviors underlie positive and negative facets of the Strong Black Woman schema. They spoke of being strong for themselves (e.g., self-advocacy, care for self):

When I went in there [oncologist’s/doctor’s office], I’d been to the Cancer Society, and I had all my facts, and so well I want this aggressive type of treatment, and, you know, they [medical team] were just kind of taken aback like, “Oh, you know what you want.” You know? And they were really surprised … (Tina, 28-year survivor)

Participants also described being strong for others (e.g., taking care of others, being a community leader):

But what came up was that my mom was diagnosed with ovarian cancer a month after I was diagnosed. And it’s just funny because I think about how strong I was and how [I] didn’t want anybody to help me. I was trying to drive. I was camping. I was doing this and doing that and just trying to run the house. Everything but going to work. I mean, literally I was cleaning up and everything … I even let family members come stay with me that was displaced, so we had five more family members, including kids, in my house. And I was trying to take care of them too … So now she’s [my mom] in the house by herself and she’s diagnosed with ovarian cancer. And I’m going through my breast cancer. And I’m looking at her trying to do everything and I’m asking her, “What’s your plan for treatment? Who are you going to have care for you?” … So I kept asking, “Who you gonna have, who you gonna have?” Because I felt like she needed somebody. But I didn’t feel like I needed nobody. I was looking at my mom, like, “You can’t be that Strong Black Woman, but I can be her. I can do everything.” (Charlotte, 10-month survivor)

It [the definition of a Strong Black Woman] feels like it’s me, even though going through this [breast cancer] journey, ‘cause I continued to keep my grandson, you know, because I didn’t want my son and his wife to have to find a baby sitter or worry about that or pay people. So even when I was going through, I still continued to keep my grandson. Or always managed to find someone to keep him. (Frances, 7-month survivor)

I wanted to be an advocate and let people know about breast cancer … (Brenda, 10-year survivor)

Women reported several catalysts for their strength during breast cancer. Specifically, they expressed having no other choice but to be strong. Emphasizing a responsibility to survive for their families, women therefore ensured they were receiving the correct oncologic treatments:

… it’s family, as a single parent, what choice did I have but to lead the charge, and not put the burden on them. I didn’t want the onus on them, that it’s, is she gonna be here tomorrow, or is she gonna die? I never let that thought enter their minds. (Tina, 28-year survivor)

Theme 5: The Complexities of Seeking and Accepting Support

Women who identify with the Strong Black Woman schema are likely to resist support [16]. During their journeys with breast cancer, however, women discussed their path to the realization and acceptance of needing help and being vulnerable:

Our families expect a lot from us. And what it [my breast cancer diagnosis] also taught me is that I allowed them to expect a lot from myself. That I didn’t allow them to see me as weak. You know, it was my children that said to me that all we saw was this … Because I could not talk to them about how I was feeling because they couldn’t handle the weak part of me. I finally said I don’t want to babysit your feelings, right. I need to be able to come into an avenue of which if I want to cry, I can cry. If I want to be sad, it’s okay. If I want to be in that dark space, let me be in that dark space. And feel safe about being in that dark space because I’m going to come out of it. But I still have to kind of go inward in order for me to come outward. And I think I’m glad that as time has gone by, my immediate family has seen that. (Tanya, 10-year survivor)

I feel with the declined support in the beginning of my [breast cancer] journey, I just thought, “Okay, I can do this. I don’t need any help.” But, as I progressed, I learned that my friends and family are there for me and I want to utilize my resources, you know, to help me with my mental behavioral health, just be able to process and cope, so utilizing my friends and family was really, really beneficial. So, I started to accept support and not decline it like I did in the beginning. (Sheila, 13-year survivor)

Participants described ups and downs of seeking help after the cancer diagnosis, such as receiving “help” that actually was not what they wanted or needed:

I think probably the one thing that was kind of a dual street is that when you go to your church or you tell so many of your friends that may be church members, they always tell you to pray. Well we all know about praying, but you need a little bit more than that. (Wendy, 1-year survivor)

The people that I thought were supposed to be my support, I couldn’t be around [them] because they’d cry all the time. (Sandy, 13-year survivor)

Participants also described the intricacies of spiritual support and spirituality, which will be covered in a separate paper.

Theme 6: The Liberated Strong Black Woman

Many women noted beneficial aspects of identifying as a Strong Black Woman, both before and after the breast cancer diagnosis. Some of these benefits included defining “strength” as including self-advocacy and self-care.

… So the strong part for me was, that I had to get better for me first …Because if I don’t get better for me, I can’t do anything for all those people out there (Juanita, 6-year survivor)

Participants found that being a Strong Black Woman included extending support to other breast cancer survivors.

I think it’s [cancer] made me appreciate life … I was always a very giving person, but it was always within my family. It was my mother, my father, my nieces, my nephews, my sisters, my brothers. I was always the person that everybody went to, okay. But, I really didn’t have as much time to do other things. Well now you name it, I’m there. I’m volunteering, I’m doing work, I’m speaking, I woulda never had time for that before. I still don’t have time, I still have a full-time job but the reality is being that Strong Black Woman is actually part of my breast cancer journey. (Nora, 14-year survivor)

Women described how their ideas of strength were changed by their experience with cancer. Although women often recognized their strength prior to the diagnosis, many women stated that breast cancer was a catalyst for their change in perspective. Furthermore, women’s experiences with breast cancer demonstrated to them that strength can be embodied in multiple ways. Their experiences allowed them to solidify their own definition of strength (e.g., accepting help from others), such that it did not have to be in line with societal definitions of strength generally or the Strong Black Woman schema specifically:

Coming from being a former athlete, I was more of a tomboy growing up and I always hung out with my dad. As I got older, I thought being a strong woman was being tough and being fearless and whatever the case may be, because of being an athlete. Until I got on this [cancer] journey. There’s no comparison … The piece I would add [to the Strong Black Woman definition] would be compassion. (Roxanne, 4-year survivor)

So once when my friend told me I needed to let other people take care of me, I stood back and I said, “Can I do that?” And so now when somebody wanna come in my kitchen and do my dishes I say “Go ahead” and they say, “OK you’ve done enough,” I say “OK.” But it took me years to learn how to let someone take care of me and that’s a lesson that, as Black women, we have to learn how to let other people take care of us, and when we look in the mirror at ourselves, we have to be confident enough that we can say I’m beautiful the way I am. I can let you take care of me and I can still be independent … that’s something we have to learn, though. (Juanita, 6-year survivor)

Discussion

In this qualitative study of whether and how the Strong Black Woman schema is relevant in the breast cancer context, all 37 participants had heard of the schema, and their experience often aligned with the schema’s facets. The six themes derived from the reflexive thematic analysis [28] appeared to apply both broadly to participants’ lives and to their experiences of breast cancer. Acknowledging that Project SOAR participants had been informed that the Gatherings would address the schema’s relevance, the authors were struck by the high level of participants’ voiced similarity of experiences pertinent to the schema. The thematic content contributes to the conclusion that the Strong Black Woman schema indeed is relevant and consequential in the lives of Black American women diagnosed with breast cancer.

As reflected in the first theme—Historical Legacy of the Strong Black Woman—women described an awareness of the schema’s grounding in enslavement [4]. They cited their female ancestors’ and their own mothers’ forbearance, emotional suppression, self-denial, and perseverance in the face of externally imposed impediments and race-related trauma. Participants reported learning the attributes themselves through the example of older women in their lives and bringing those attributes into their breast cancer experience. As such, understanding how the schema contributes to Black women’s health and well-being in the breast cancer context, as well as other clinically relevant settings, gains even greater import.

Navigating intersectional identities and everyday discrimination also were relevant in participants’ experience of breast cancer. Social inequalities constituting “interlocking systems of oppression” [36], and particularly gendered racism [15, 18, 37], were active in participants’ lives. The toll of continuing to care for others during breast cancer, to the neglect of caring for the self, was prominent. The imposed expectation that the Strong Black Woman can “do everything” without needing help left participants feeling no choice but to “… continue to do, no matter what” (Marjorie, 21-year survivor). Women also described their daily realities of racism and discrimination, also experienced during their oncologic care (see [26] for a qualitative analysis of the participants’ experience in the medical system).

Participants spoke of how the Strong Black Woman schema, whether externally imposed or externally imposed and then internalized, had primarily negative influences on their cancer experience. In noncancer samples of Black women, endorsement of the schema or its specific facets often is related to indicators of poorer psychological health such as depressive symptoms and anxiety [38–43]. Potential mediators of the schema’s relationship with psychological and physical health are receiving study, including maladaptive perfectionism, low self-compassion, high self-silencing, low collective coping, high coping through disengagement/avoidance, low perceived emotional support, and high social isolation [38, 39, 41–43]. Although rarely studied, distinct facets of the schema appear to have differential associations with markers of physical health (e.g., hypertension) [44] or to condition the relationships of racial discrimination or racial identity with health indices such as cellular aging and allostatic load [45, 46]. None of these cross-sectional studies was conducted in Black women diagnosed with cancer, however. Psychological and physical health concomitants of the Strong Black Woman schema and other culturally relevant constructs (e.g., ethnic pride) warrant continued investigation in the context of cancer, as do the malleable mechanisms through which such factors carry their effects.

Although facets of the Strong Black Woman schema [6, 17] were present in women’s narratives about their cancer experiences, not all experiences were negative. Participants spoke of the value of being strong in their advocacy for high-quality oncologic treatment and in offering support to other women with cancer, for example [47, 48]. This finding suggests that particular facets of the schema may serve adaptive functions during the breast cancer experience, much like Strong Black Woman facets have been protective historically for Black women in the USA. At least initially, the externally imposed and often internalized expectation that they should not need support prompted participants’ ambivalence toward or rejection of help once they were diagnosed with cancer. Some women, however, noted the comfort of finding others, and especially other Black breast cancer survivors, with whom to share emotional experiences. Also catalyzed by the cancer experience, some women came to a transformed definition of strength, such as the ability to accept help and engage in self-advocacy.

Regarding the relatability of the present findings, the sample was somewhat more highly educated than the population of Black women; nearly half had a college degree, whereas the figure is 36% in the USA [49]. Participants’ average age was similar to Black women’s median age (i.e., 59 years) at breast cancer diagnosis [50]. Confidence in the findings’ validity is enhanced by the cultural curation of the Gatherings to offer a trustworthy environment for Black women diagnosed with breast cancer to share their experiences openly (see [21]). Indeed, despite the participants varying widely in sociodemographic and cancer-related characteristics, with an age range of 30 to 94 years and cancer diagnosis duration of 2 months to 29 years, the authors were struck by the power of the Gatherings as a vehicle for supportive exchanges and acknowledgment of common ground with regard to the Strong Black woman schema in breast cancer. Women often spoke in the voice of the collective rather than the individual and took part in a chorus of connection expressed through “mm-hmm” and other mutual affirmations. Women were informed in advance that the schema would be addressed in the Gatherings, which could have attracted participants for whom the schema is salient and contributed to the high level of agreement on how the schema had influenced the cancer experience across their diverse sociodemographic and cancer-related circumstances. Research conducted with large samples of Black women cancer survivors across the cancer trajectory will advance the understanding of the schema’s influence on important psychological and physical health outcomes.

In light of the relevance and impact of the Strong Black Woman schema in the breast cancer context illuminated in the present research, development of schema-relevant interventions to enhance Black women’s well-being and health after a breast cancer diagnosis is vital. A 2015 review of psychosocial interventions for Black women with breast cancer revealed only five randomized controlled trials with a sufficient sample size for analysis [51], and few trials have been published since that time [52]. The reviewers concluded that cognitive behavioral strategies, culturally sensitive approaches, and enhanced support appeared beneficial in enhancing the quality of life of Black breast cancer survivors [51]. None of the trials incorporated facets of the Strong Black Woman schema as intervention targets, although doing so has been advocated [6].

The authors recently conducted reunions with Gathering participants to address their relevant experiences since the initial Gatherings, share Project SOAR findings, and welcome input. The women suggested approaches involving all-Black, all-woman, facilitated group meetings (in person and/or virtually) to allow acknowledgment and sharing of feelings, personal stories, and effective strategies tied to the Strong Black Woman schema’s influences on their lives as cancer survivors who are Black American women. Although endorsement of the Strong Black Woman schema is associated with a lower self-reported propensity to seek psychological services [20], inclusion of culturally centered content such as the Strong Black Woman schema could increase the appeal of interventions to promote well-being and health in Black women diagnosed with breast cancer.

Funding

The research was supported by the California Breast Cancer Research Program (Co-PI Denyse and Stanton; 24AB 1800) and the Breast Cancer Research Foundation (Stanton; BCRF-21-153, BCRF-22-153). Martin and Owoyemi were supported by the National Institute of Mental Health under the National Institutes of Health (NIH; T32MH15750; PI: Dunkel Schetter). Kim was supported by the National Cancer Institute under the NIH (K99CA246058; PI: Kim).

Compliance with Ethical Standards

Authors’ Statement of Conflict of Interest and Adherence to Ethical Standards Authors Tammie Denyse, Kimberly J. Martin, Jacqueline H.J. Kim, Yrvane K. Pageot, Praise Owoyemi, K. Denise DeLuz, and Annette L. Stanton declare that they have no conflict of interest.

Authors’ Contributions Tammie Denyse, PhD(Hon), MDiv (Conceptualization: Lead; Funding acquisition: Equal; Investigation: Lead; Methodology: Equal; Writing – original draft: Equal; Writing – review & editing: Equal), Kimberly J Martin, PhD (Data curation: Lead; Formal analysis: Lead; Investigation: Supporting; Methodology: Supporting; Project administration: Equal; Writing – original draft: Supporting; Writing - review & editing: Equal), Jacqueline HJ Kim, PhD (Formal analysis: Lead; Writing – review & editing: Equal), Yrvane K Pageot, MA (Formal analysis: Equal; Investigation: Supporting; Writing – review & editing: Supporting), Praise L Owoyemi, MA (Formal analysis: Equal; Investigation: Supporting; Writing – review & editing: Supporting), K Denise DeLuz, RT (Formal analysis: Equal; Investigation: Supporting; Writing – review & editing: Supporting), and Annette L. Stanton, PhD (Conceptualization: Equal; Funding acquisition: Equal; Investigation: Supporting; Methodology: Lead; Resources: Equal; Software: Lead; Supervision: Equal; Writing – original draft: Equal; Writing – review & editing: Equal)

Transparency Statement The study and analytic plan are not registered. Currently, the data are not available while manuscripts are in progress and at this time, we do not intend to make the qualitative data and coding available on an electronic platform. Our two reasons for this decision are: (i) we did not make such an intention explicit in the Gatherings informed consent form and do not feel free to make the Gatherings transcripts available without women’s informed consent (we do not have current contact information for all participants); and (ii) some of the women’s qualitative responses, even when anonymized, are such that other people who know a participant (including oncologic professionals) might be able to tell her identity through the combination of her breast cancer story, speech pattern, and speech content. We have perused the literature on sharing of qualitative data, and opinions are mixed. In light of the understandable lack of trust some Black American women have in research and researchers, we believe the privacy and trust of this relatively small group of breast cancer survivors are of utmost importance, and we do not want to jeopardize the relationship with Gatherings participants in any way.